Eduardo Schünemann

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.

Quimioterapia neoadjuvante em câncer localmente avançado do colo do útero

ABSTRACT Purpose: to evaluate neoadjuvant chemotherapy in locallyadvanced cervical cancer as to its acceptability, tolerability,toxicity, surgical complications, operability, response rate,and overall survival in 5 years. Methods: sixty women with locally advanced cervical cancer(stages IIB and IIIB), who were submitted to neoadjuvantchemotherapy, were included. All patients were treated withdoxorubicin-bleomycin-cisplatin. Those who had a goodresponse, allowing a surgical approach, underwent theWertheim-Meigs procedure. After surgery, they were submittedto pelvic radiotherapy. Those that could not be submitted tosurgery after chemotherapy underwent total radiotherapy. Results: the average follow-up was 108 months, and 80% ofthe patients had an overall response to neoadjuvantchemotherapy. In the IIB group, the response rate was 100%,and in the IIIB group it was 60%. The operability rate afterneoadjuvant chemotherapy was 65%. The overall survivalin 5 years was 62%. Comparing the operated group (n=34)with the nonoperated group (n=18), the overall survival in5 years was 82.14 and 16.67%, respectively.

Ethics in sentinel node biopsy in breast cancer: an open question.

The sentinel node concept agrees with the modern principles of surgical oncology in breast cancer, which are related to lymphatic dissection, accurate axillary study, and less traumatic surgery. After publication of many series, it has proven its capacity to correctly stage axilla and select patients who need axillary dissection. The Brazilian Society of Senology established the current norms for its practice. However, the transportation of new surgical techniques from research to practice always occurs with some ethical dilemmas related to its introduction in clinical practice. The aim of this study was to analyze the ethical challenges of the sentinel node technique and problems with its implementation.

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.

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.