César Cabello

Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer.

Abstract:  This study evaluated the relationship between preservation of the intercostobrachial (ICB) nerve and pain sensitivity of the arm, the total time of the surgery, and the number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. An intervention, prospective, randomized, and double blind study was performed on 85 patients at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to whether the ICB nerve was preserved or not. The surgeries were performed by the same surgeons, utilizing the same technique. The postoperative evaluations were performed at 2 days, 40 days, and 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurologic examination (objective evaluation). The surgical technique presented a feasibility of 100% and preservation of the ICB nerve was related to a significant decrease in the pain sensitivity of the arm, both in the subjective and objective evaluations. After 3 months, in the subjective evaluation, 61% of the patients were asymptomatic in the ICB nerve preservation group, with 28.6% in the nerve section group (p < 0.01). In the objective evaluation, 53.7% of the patients presented normal neurologic examination in the ICB nerve preservation group, with 16.7% in the nerve section group (p < 0.01). No significant difference was observed in the total time of the surgery (p = 0.76) and the number of dissected nodes between the two groups (p = 0.59). Local relapse was not observed in any group after 36 months of follow‐up. These data support that preservation of the ICB nerve is feasible and leads to a significant decrease in the alteration of pain sensitivity of the arm, without interfering with the total time of the surgery, the number of dissected nodes, and local relapse rate. 

Menopause symptoms and quality of life in women aged 45 to 65 years with and without breast cancer.

Objective:To compare the prevalence of menopause symptoms, sexual activity, and quality of life in women with and without breast cancer. Design:A cross-sectional study using one group for comparison was conducted on women aged 45 to 65 years who had not received hormone therapy or tamoxifen during the last 6 months. Participants were recruited from the Menopause and Breast Cancer Outpatient Facilities. One hundred eighty-two women were included, 97 with breast cancer and 85 without breast cancer. Sociodemographic and clinical features and prevalence of menopause symptoms were assessed. The quality of life was assessed by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire. To compare sociodemographic and clinical features between groups, the Students t test or Fisher exact test was used. Multiple logistic regression and linear regression models were used to control for potential confounding variables. Results:The mean age of participants with breast cancer was 53.2 ± 6.2 years, and the mean age of those without cancer was 57.8 ± 4.9 years (P < 0.01). Age at menopause was 47.2 ± 5.1 years and 47.4 ± 4.9 years for women with and without breast cancer (P = 0.76), respectively. Approximately one-fourth of women with breast cancer and 4.7% of women without cancer were premenopausal (P < 0.01). The prevalence of menopause symptoms was similar between the groups. Women with breast cancer reported less sexual activity (51.5%) than women without cancer (62.4%) (P < 0.01). Quality of life scores were good in both groups. There was a significant difference regarding physical functioning, with a median score of 90 for the cancer group and 75 for the group without cancer (P < 0.01). Conclusion:The prevalence of menopause symptoms was similar in women with and without breast cancer. Sexual activity was less frequent in women with breast cancer. Quality of life was good in women from both groups, although women with breast cancer had the highest level of physical functioning.

Quality of Life in Brazilian Breast Cancer Survivors Age 45–65 Years: Associated Factors

Abstract:  The objectives of this study were to evaluate quality of life (QOL) and identify its associated factors in climacteric women with a history of breast cancer. A cross‐sectional study was performed including 75 breast cancer survivors age 45–65 years who had undergone complete oncologic treatment and nonusers of hormone therapy or tamoxifen in the last 6 months. Sociodemographic and clinical characteristics in addition to the prevalence of climacteric symptoms were evaluated. QOL was evaluated by the Medical Outcomes Study 36‐item Short‐Form Health Survey (SF‐36) questionnaire, including eight components that can be condensed into two summaries: a physical component summary (physical functioning, role‐physical, body pain, general health) and a mental component summary (vitality, social functioning, role‐emotional, and mental health). Generalized linear models were used to analyze the data, allowing the identification of factors affecting QOL, adjusting for confounding variables. The mean age of the participants was 53.1 ± 5.9 years. Breast cancer survivors reported good QOL. The most prevalent symptoms were nervousness (69%) and hot flashes (56%). Factors associated with poorer QOL were dizziness, postmenopausal status, and breast‐conserving therapy (physical component), as well as insomnia and being married (mental component). In conclusion, participants demonstrated good QOL. We identified factors that may influence QOL in women with breast cancer, highlighting being married, climacteric symptoms, postmenopausal status, and breast‐conserving therapy. Given the impact of these factors, health professionals and patients must discuss choices for alleviating climacteric symptoms and explanations for the potential repercussions of breast cancer treatment.

Movimento do ombro após cirurgia por carcinoma invasor da mama: estudo randomizado prospectivo controlado de exercícios livres versus limitados a 90º no pós-operatório

PURPOSE: to evaluate the efficacy of a physical exercise protocol in the recovery of shoulder movement in women who underwent complete axillary lymph node dissection due to breast carcinoma, comparing free and restricted amplitude movements. METHODS: 59 women who underwent complete axillary lymph node dissection associated with modified mastectomy (46) or quadrantectomy (13) were included in this clinical, prospective and randomized study. On the first day after surgery 30 women were randomized to do the shoulder movement with free amplitude and 29 women had this amplitude restricted to 90o in the first 15 days. Nineteen exercises were done, three sessions per week, for six weeks. Mean (± standard error) deficits of shoulder flexion and abduction were compared, as well as gross and adjusted incidence rates of seroma and dehiscence. RESULTS: 42 days after surgery, flexion and abduction means were similar in the two groups. Both presented a mean flexion deficit (17.2o and 21.6o, respectively), and abduction deficit (19.7o and 26.6o, respectively). The incidence rates of seroma and dehiscence were neither related to exercise nor to the type of surgery, time of drain permanence, number of dissected or compromised lymph nodes, age or obesity. CONCLUSION: early physiotherapy with free movement of the womens shoulder was associated neither with functional capacity nor with postsurgical complications.

Breast density in women with premature ovarian failure or postmenopausal women using hormone therapy: analytical cross-sectional study

CONTEXT AND OBJECTIVE Studies on postmenopausal women have reported increased risk of breast cancer relating to the type and duration of hormone therapy (HT) used. Women with premature ovarian failure (POF) represent a challenge, since they require prolonged HT. Little is known about the impact of prolonged HT use on these womens breasts. This study aimed to evaluate the effects of one type of HT on the breast density of women with POF, compared with postmenopausal women. DESIGN AND SETTING Cross-sectional study at the Department of Obstetrics and Gynecology, Universidade Estadual de Campinas (Unicamp). METHODS 31 women with POF and 31 postmenopausal women, all using HT consisting of conjugated equine estrogen combined with medroxyprogesterone acetate, and matched according to HT duration, were studied. Mammography was performed on all subjects and was analyzed by means of digitization or Wolfes classification, stratified into two categories: non-dense (N1 and P1 patterns) and dense (P2 and Dy). RESULTS No significant difference in breast density was found between the two groups through digitization or Wolfes classification. From digitization, the mean breast density was 24.1% ± 14.6 and 18.1% ± 17.2 in the POF and postmenopausal groups, respectively (P = 0.15). Wolfes classification identified dense breasts in 51.6% and 29.0%, respectively (P = 0.171). CONCLUSION There was no difference in breast density between the women with POF and postmenopausal women, who had used HT for the same length of time. These results may help towards compliance with HT use among women with POF.

Randomized clinical trial on the preservation of the medial pectoral nerve following mastectomy due to breast cancer: impact on upper limb rehabilitation

CONTEXT AND OBJECTIVE Systematic modifications to the surgical technique of mastectomy have been proposed with the objective of minimizing injuries to the pectoral nerves and their effects. The aim of this study was to compare muscle strength and mass of the pectoralis major muscle (PMM) and abduction and flexion of the homolateral upper limb following mastectomy among women with breast cancer undergoing either preservation or sectioning of the medial pectoral nerve (MPN). DESIGN AND SETTING Randomized, double-blind, clinical trial on 30 women with breast cancer who underwent mastectomy between July 2002 and May 2003 in Campinas, Brazil. METHODS The women were allocated to a group, in which the MPN was preserved, or to another group in which it was sectioned. Fishers exact and Wilcoxon tests were used to analyze the data, along with Friedman and ANOVA analysis of variance. RESULTS In the MPN preserved group, 81% of the women did not lose any PMM strength, compared with 31% in the sectioned MPN group (confidence interval, CI = 1.21; relative risk, RR = 2.14; P < 0.03). There were no differences between the groups regarding muscle mass (CI = 0.32; RR = 0.89; P = 0.8), shoulder abduction (CI = 1.36; RR = 0.89; P = 0.28) and shoulder flexion (CI = 1.36; RR = 1.93; P = 0.8). CONCLUSIONS Preservation of the MPN was significantly associated with maintenance of PMM strength, compared with nerve sectioning. No differences in muscle mass or in abduction and flexion of the homolateral shoulder were found between the groups. CLINICAL TRIAL REGISTRATION NUMBER ANZCTR - 00082622.

Mammographic breast density in women with premature ovarian failure: a prospective analysis.

ObjectiveThis study aims to compare breast density between two mammograms in women with premature ovarian failure (POF). MethodsA cohort study evaluated 56 women with POF. Two mammograms performed at least 2 years apart were analyzed. Mammogram films were digitalized, and images were assessed using a computer-assisted method; the percentage of breast image that is radiologically dense is referred to as the percentage of mammographic density (PMD). Age at menarche, age at onset of POF, length of POF, length of estrogen-progestin therapy (EPT), body mass index (BMI), pregnancy, and age at the time of each mammogram were evaluated. ResultsThe mean (SD) age at POF diagnosis was 32.35 (5.95) years. In the first mammogram, the mean (SD) age, BMI, and length of POF were 37.58 (3.72) years, 26.79 (4.86) kg/m2, and 5.25 (4.61) years, respectively. EPT had been used for a mean (SD) of 2.71 (3.12) years. In the second mammogram, the mean (SD) age, BMI, and length of POF were 43.23 (4.98) years, 27.6 (5.39) kg/m2, and 10.5 (5.11) years, respectively. EPT had been used for a mean (SD) of 7.25 (4.6) years. The mean (SD) interval between mammograms was 5.25 (3) years, and the mean (SD) PMD decreased from 27.78% (21.04%) to 17.53% (15.71%) (P = 0.007). Comparing PMD between women taking EPT and those not taking EPT, we observed no significant differences. In both instances, multiparous women had lower PMD than nulliparous women (P < 0.05). BMI, length of POF, and pregnancy were negatively correlated with PMD. ConclusionsBreast density in young women with POF decreases across a period of 5 years, regardless of EPT use. Further studies may elucidate how this result will correlate with decision-making in clinical therapeutics and breast cancer risk in POF.

Selecting postoperative adjuvant systemic therapy for early stage breast cancer: A critical assessment of commercially available gene expression assays

Risk stratification of patients with early stage breast cancer may support adjuvant chemotherapy decision‐making. This review details the development and validation of six multi‐gene classifiers, each of which claims to provide useful prognostic and possibly predictive information for early stage breast cancer patients. A careful assessment is presented of each tests analytical validity, clinical validity, and clinical utility, as well as the quality of evidence supporting its use.

Multiple desmoid tumors in a patient with Gardner's syndrome – Report of a case

INTRODUCTION Desmoid tumor (DT) is a common manifestation of Gardners Syndrome (GS), although it is a rare condition in the general population. DT in patients with GS is usually located in the abdominal wall and/or intra-abdominal cavity. PRESENTATION OF CASE We report a case of a 32 years-old female patient with familial adenomatous polyposis (FAP), who was already submitted to total colectomy and developed multiple DT, located in the abdominal wall and in the left breast. The patient underwent several surgical procedures, with a multidisciplinary team of surgeons. Wide surgical resections of the left breast and the abdominal wall tumors were performed in separate steps. Polypropylene mesh reconstruction and muscle flaps were needed to cover the defects of the thoracic and abdominal walls. After partial necrosis of the adipose-cutaneous flap in the abdomen that required a new skin graft, she had a satisfactory outcome with complete healing of the surgical incisions. DISCUSSION DT is frequent in GS, however, breast localization is very rare, with few cases reported in the literature. Recurrence of DT is not negligible, even after a wide surgical resection. GS patients must be followed up closely, and clinical examination, associated with imaging studies, should be performed to detect any signs of tumor. CONCLUSION DT represents one of the most significant causes of the morbidity and mortality that affects FAP patients following colectomy. In general, the surgical procedures to excise DT are highly complex, requiring a multidisciplinary team.

Bloody Nipple Discharge in Childhood

To the Editor: Bloody nipple discharge (BND) is a relative common symptom in adults. Usually, it is associated with a benign condition, such as the presence of intraductal papilomas or ductal ectasia. It has a well-defined approach, demands clinical and histological investigation, as it can be associated with breast cancer. However, BND occurring during childhood is an extremely rare condition, usually self-limited and associated with ductal ectasia. The approach to BND in children is not well established, as it is in adults, and is based on some literature descriptions of case reports. A 4-year-old girl (premenarche) was admitted to our hospital with a 1-month history of BND from her left breast. The child had no remarkable familial or personal past medical history, including no surgical or trauma history and no use of medications. She had only experienced an episode of acute purpura, which was resolved 3 months before the BND began. There was no history of breast manipulation. The physical examination revealed a tender enlargement of the retroareolar region of the left breast of approximately 1 cm in diameter. There was BND from one duct of the left nipple at expression (Fig. 1). The nipple discharge cytology was negative for atypical cells and contained many red blood cells. Laboratory findings, including prolactin levels, estradiol levels, gonadotropin levels, thyroid-stimulating hormone levels, coagulation status, and blood cell counts, were within normal ranges. The ultrasonographic examination of the breast showed a cystic anechoic lesion of 5 · 4 mm, another cystic lesion (probably a duct) of 9 · 3 mm and another duct of 2.6 mm, all of which were located in the left retroareolar area. The parents were informed of the benignity of the condition and a follow-up of 3 months was scheduled. At 3-months’ follow-up, the physical examination was normal and no BND was observed. Clinical follow-up was scheduled at 6 months. This case report is in accordance with other reported cases in literature regarding BND in childhood (1–13). In this case, there was spontaneous resolution within 4 months. Causes of BND in infancy include nipple trauma, repeated manipulation of the nipple, intraductal papiloma, and ductal ectasia. Ductal ectasia is the main etiology of this bleeding; this is a benign condition caused by dilatation of the terminal collecting ducts beneath the nipple and the areola, inflammatory reactions and, occasionally, periductal fibrosis. There is no clear pathogenic explanation for this phenomenon. A previously reported case of BND, in a premenarcheal girl of 12 years of age who also presented with a solitary breast mass, relates the cause as an infarcted fibroadenoma (1). It is also possible that BND may originate from a nest of active hematopoietic cells. One study analyzed 72 samples of infant breasts (from newborn to 2 years of age) that were collected at necropsy and there was evidence of extramedullary hematopoiesis in the periductal connective tissue until 4 months of age (2). However, many cases have been reported in children of older than 4 months of age and the etiology of BND remains unclear. It has also been observed that some cases of BND in babies are not associated with breast enlargement (3).