Cleverton Spautz

Oncoplastic principles in breast conserving surgery.

Oncoplastic surgery (OP) represents a major advance in breast cancer surgery. It is based on three principles: ideal oncology surgery with free margins and adequate local control of disease, immediate breast reconstruction and symmetry, with the transposition of plastic surgery techniques into breast cancer surgery. Its original focus was to improve the quality of life of patients undergoing oncological treatments that can be more effective from the aesthetic-functional point of view than the traditional breast conserving techniques. As it happens with all changes of paradigms, it brings new challenges for the traversal formation of all involved in the treatment of breast cancer. Besides that, it opens to new perspectives of surgical research related to the aesthetic results, quality of life and local control, as well as optimization of operative timing and reduction of both adverse effects and costs. The aim of this review was to present the principles of this approach and the main techniques applied, evaluating its indications and limits in conservative breast cancer surgery.

Impact of preoperatory magnetic resonance imaging in oncoplastic surgery

Study carried out at Unidade de Mama do Hospital Nossa Senhora das Graças – Curitiba (PR), Brazil. 1Unidade de Mama, Hospital Nossa Senhora das Graças – Curitiba (PR), Brazil. 2Clínica de Diagnóstico Avançado por Imagem, DAPI – Curitiba (PR), Brazil. *Corresponding author: kfurlan@terram.com.br Conflict of interests: nothing to declare. Received in: 05/14/2017. Accepted in: 05/29/2017 Objetivo: Não há dados sobre o impacto da imagem de ressonância magnética (RM) na cirurgia oncoplástica. O objetivo deste trabalho foi avaliar o impacto da RM no planejamento cirúrgico e nas mudanças de conduta em pacientes com câncer de mama inicial e candidatas a realizar a cirurgia oncoplástica. Métodos: Trata-se de uma coorte prospectiva de 60 pacientes que foram candidatas à cirurgia oncoplástica entre janeiro de 2013 e julho de 2014. Todos elas foram submetidas a uma RM pré-operatória, além de mamografia (MG) e ultrassom (US). Qualquer tumor adicional na RM classificada como BIRADS 4-5 foi biopsiado ou marcado com carvão e ROLL para serem localizados durante a cirurgia. O impacto cirúrgico dos achados adicionais da RM foi avaliado quanto a mudanças para mastectomia ou ressecção mais ampla. Resultados: Das pacientes, 29/60 (48,3%) apresentaram achados adicionais na ressonância magnética, 16/29 (55%) foram tumores multifocais, 1/29 (3,4%) foi multicêntrico, 5/29 (17%) foram tumores contralaterais e 9/29 (31%) apresentaram tamanho de tumor maior que 10 mm na RM. Das 22 pacientes que apresentaram lesões adicionais na RM, 15 (68,2%) apresentaram carcinomas invasivos no exame anatomopatológico definitivo. A sensibilidade da RM foi maior na estimativa do tamanho do tumor. Das pacientes, 12/60 (20%) foram submetidas à mastectomia e 17/60 (28,3%) a ressecções mais amplas. Apenas 5% das pacientes apresentaram margens positivas em todo o grupo. No grupo de pacientes que apresentaram resultados adicionais na RM, apenas 3,4% tiveram margens positivas. Conclusões: A RM é melhor que a MG e o US na avaliação da extensão do tumor e na detecção de tumores multicêntricos, multifocais e bilaterais. Em consequência, contribuiu nesta série para um melhor planejamento cirúrgico na cirurgia oncoplástica com baixa taxa de margens comprometidas e reexcisão.

Resultados do exame intraoperatório do linfonodo sentinela na Unidade de Mama do Hospital Nossa Senhora das Graças em Curitiba

A biopsia do linfonodo sentinela (LS) e o procedimento padrao para as pacientes com axila clinicamente negativa. O seu exame intraoperatorio ainda gera dificuldades na sua abordagem. Assim, o objetivo deste estudo foi avaliar a eficacia desse exame no câncer de mama. Foram avaliadas 342 pacientes que foram operadas na Unidade de Mama do Hospital Nossa Senhora das Gracas em Curitiba (PR), no periodo de 2000 a 2012. No exame intraoperatrorio eram rea lizados cortes longitudinais, ao longo do maior eixo, a cada 2 ou 3mm. Em seguida eram feitos imprints em cada face de cada fatia e, entao, realizavam se cortes histologicos em criostato em tres niveis. Tanto os imprints quanto os cortes eram corados com azul de toluidina. Em sua maio ria eram tumores T1c (n=151), e 60 (17,5%) delas apresentaram axila comprometida no exame definitivo. A acuracia foi de 92%, o valor preditivo negativo, de 91% e a taxa de falso negativo, de 8%. Nao foram encontrados fatores de risco significativos para falencia da tecnica dentro dos parâmetros estudados.(AU) Sentinel node (SN) biopsy is the standard of care for patients with clinically negative axilla. However, in traoperatory pathological exam remains as a controversial issue. So, the aim of this study was to evaluate its efficacy in 342 breast cancer patients operated at the Hospital Nossa Senhora das Gracas Breast Unit in Curitiba (PR), in the period between 2000 2012. In the intraoperatory evaluation, all SNs were cutted in the major axis, in three levels, combining frozen sections with imprints, using toluidin blue. The majority of patients were T1c (n=151), and 60 (17.5%) had positive axila in the definitive pathology evaluation. Accuracy was 92%, predictive negative value was 91%, and false negative rate was 8%. We did not find any significant risk factor for false negative SN in this series.(AU)

Immediate Breast Reconstruction in Pregnancy and Lactation

It is estimated that 3 % of all breast cancers may be diagnosed in pregnant women, and the incidence of breast cancer in pregnant women is expected to increase owing to the postponement of childbearing. Management of this condition is a challenge because, in contrast to other areas of breast oncology, there are no large randomized trials to guide surgical and clinical practice. Breast reconstruction can be performed following a specific model designed in our breast unit since 2008, where patients are divided into three distinct groups: (1) first trimester—immediate reconstruction in one-step surgery with breast implants and contralateral breast symmetrization by breast reduction or mastopexy, or in two-step surgery with temporary expanders; (2) second and third trimester—temporary expanders; and (3) lactation—temporary expanders, autologous flaps, or breast-conserving therapy. If lactation ceased at least 3 months earlier, it is possible to perform one-step surgery with a definitive implant and contralateral breast symmetrization. In this situation, a breast conservative surgery approach is possible too. With this reconstructive approach it is possible to minimize the effects of mastectomy in this group of patients. It is a transverse model, which considers all aspects: oncologic, obstetric and reconstructive.

Clinical and Pathological Evaluation of 102 Patients with Internal Mammary Node Metastases in a Single Breast Unit

INTRODUCTION: Although incidence of internal mammary node (IMN) recurrence is only 0.1%, and almost all of these patients have systemic disease, it has an important prognostic value when both axillary and IMN are positive. But routine sentinel node (SN) biopsy of IMN is not standard practice and warrants further investigation of patients who may benefit of this procedure. METHODS: 561 patients with invasive carcinomas who underwent to Patey’s mastectomy (between 1987 and 2004) and skin-sparing mastectomy (after 2004) between 1987 and 2012 in HNSG Breast Unit in Curitiba (Brazil) were included in this study, and underwent to a routine IMN biopsy in the second and third intercostal space, together with complete axillary dissection in 3 Berg’s levels. After 1997 only patients with positive SN underwent to this procedure. RESULTS: 102 patients (18%) in this group had positive IMN. The age ranged from 28 to 85 years, with a median of 52 (sd=12) years. 94 (92%) were invasive ductal carcinomas, 6 (6%) invasive lobular carcinomas, 1 (1%) mucinous invasive carcinoma, and 1 (1%) medullary carcinoma. Most of the tumors were T2 (57%) and T3 (21%), and only 3% were T1. Lymphovascular invasion was found in 99 (97%) in this group. 9 (9%) patients had no positive axillary nodes, and for those with both axillary and IMN positive, median of compromised nodes was 9 (sd=12), 22% of IMN positive had 1-3 compromised axillary nodes, 48% had 4-10, and 31% had more than 10. In the follow-up, 57 (56%) died with disease, 22 (22%) were alive without disease, 5 (5%) were alive with disease, and 22 (22%) lost follow-up. CONCLUSIONS: IMN was positive in more advanced and aggressive tumors. Implication of these results to IMN adjuvant radiotherapy needs further investigation.