Felipe Andrade

Measuring plasma levels of three microRNAs can improve the accuracy for identification of malignant breast lesions in women with BI-RADS 4 mammography

A BI-RADS category of 4 from a mammogram indicates suspicious breast lesions, which require core biopsies for diagnosis and have an approximately one third chance of being malignant. Human plasma contains many circulating microRNAs, and variations in their circulating levels have been associated with pathologies, including cancer. Here, we present a novel methodology to identify malignant breast lesions in women with BI-RADS 4 mammography. First, we used the miRNome array and qRT-PCR to define circulating microRNAs that were differentially represented in blood samples from women with breast tumor (BI-RADS 5 or 6) in comparison to controls (BI-RADS 1 or 2). Next, we used qRT-PCR to quantify the level of this circulating microRNAs in patients with mammograms presenting with BI-RADS category 4. Finally, we developed a machine learning method (Artificial Neural Network - ANN) that receives circulating microRNA levels and automatically classifies BI-RADS 4 breast lesions as malignant or benign. We identified a minimum set of three circulating miRNAs (miR-15a, miR-101 and miR-144) with altered levels in patients with breast cancer. These three miRNAs were quantified in plasma from 60 patients presenting biopsy-proven BI-RADS 4 lesions. Finally, we constructed a very efficient ANN that could correctly classify BI-RADS 4 lesions as malignant or benign with approximately 92.5% accuracy, 95% specificity and 88% sensibility. We believe that our strategy of using circulating microRNA and a machine learning method to classify BI-RADS 4 breast lesions is a non-invasive, non-stressful and valuable complementary approach to core biopsy in women with BI-RADS 4 lesions.

Intraoperative full-dose of partial breast irradiation with electrons delivered by standard linear accelerators for early breast cancer.

Purpose. To assess feasibility, efficacy, toxicity, and cosmetic results of intraoperative radiotherapy (IORT) with electrons delivered by standard linear accelerators (Linacs) during breast conserving surgeries for early infiltrating breast cancer (BC) treatment. Materials and Methods. A total of 152 patients with invasive ductal carcinoma (T ≤ 3.0 cm) at low risk for local relapses were treated. All had unicentric lesions by imaging methods and negative sentinel node. After a wide local excision, 21 Gy were delivered on the parenchyma target volume with electron beams. Local recurrences (LR), survival, toxicity, and cosmetic outcomes were analyzed. Results. The median age was 58.3 years (range 40–85); median follow-up was 50.7 months (range 12–101.5). There were 5 cases with LR, 2 cases with distant metastases, and 2 cases with deaths related to BC. The cumulative incidence rates of LR, distant metastases, and BC death were 3.2%, 1.5%, and 1.5%, respectively. Complications were rare, and the cosmetic results were excellent or good in most of the patients. Conclusions. IORT with electrons delivered by standard Linacs is feasible, efficient, and well tolerated and seems to be beneficial for selected patients with early infiltrating BC.

Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia

Surgery is the first-line treatment for early, localized, or operable breast cancer. Regional anesthesia during mastectomy may offer the prevention of postoperative pain. One potential protocol is the combination of serratus anterior plane block (SAM block) with pectoral nerve block I (PECS I), but the results and potential benefits are limited. Our study compared general anesthesia with or without SAM block + PECS I during radical mastectomy with axillary node dissection and breast reconstruction using evaluations of pain, opioid consumption, side effects and serum levels of interleukin (IL)-1beta, IL-6 and IL-10. This is a prospective, randomized controlled trial. Fifty patients were randomized to general anesthesia only or general anesthesia associated with SAM block + PECS I (25 per group). The association of SAM block + PECS I with general anesthesia reduced intraoperative fentanyl consumption, morphine use and visual analog pain scale scores in the post-anesthetic care unit (PACU) and at 24 h after surgery. In addition, the anesthetic protocol decreased side effects and sedation 24 h after surgery compared to patients who underwent general anesthesia only. IL-6 levels increased after the surgery compared to baseline levels in both groups, and no differences in IL-10 and IL-1 beta levels were observed. Our protocol improved the outcomes of mastectomy, which highlight the importance of improving mastectomy protocols and focusing on the benefits of regional anesthesia.

Cat scratch disease presenting as axillary lymphadenopathy and a palpable benign mammary nodule mimicking a carcinoma

We present a case involving a 74-year-old woman with cat scratch disease characterized by an enlarged and hard axillary lymph node as well as a palpable breast nodule mimicking a carcinoma. The lymph node and the breast nodule were excised. The pathologic examinations revealed granulomatous lymphadenitis with gram-negative bacilli and an intraductal papilloma. Antibiotic therapy (azithromycin) was prescribed and the patients clinical evolution was excellent.

Primary breast lymphoma presenting as locally advanced breast cancer: a case report

Study carried out at the Instituto de Responsabilidade Social of Hospital Sírio Libanês – São Paulo (SP), Brazil. 1Hospital Sírio-Libanês – São Paulo (SP), Brasil. 2Universidade de São Paulo – São Paulo (SP), Brasil. *Corresponding author: rebecanh@gmail.com Conflict of interests: nothing to declare Received on: 12/19/2016. Accepted on: 05/30/2017 Doenças hematopoiéticas podem ser encontradas na mama e simular uma neoplasia mamária, como leucemia e/ou linfoma. Apesar de os linfomas serem considerados tumores linfonodais, 25-40% acometem sítios extranodais, sendo um deles a mama. Os linfomas primários da mama representam 0,1-0,5% de todas as neoplasias da mama. Podem ter origem primária ou secundária. Os primários normalmente iniciam-se na mama sem acometimento de outros sítios linfonodais. O diagnóstico é feito através do exame físico e anatomopatológico. Relatamos um caso de uma paciente, idosa, de 77 anos, que compareceu em nosso serviço com uma massa progressiva envolvendo toda a mama direita, ulcerada e associada a sinais e sintomas inflamatórios com linfonodos axilares palpáveis. Os exames de imagem foram inespecíficos e não ajudaram no diagnóstico, não tendo sido recomendados para o rastreio dessa neoplasia. O exame anatomopatológico revelou um linfoma de células B difuso infiltrando a mama (linfoma não Hodgkin). Devido à raridade do caso, a etiopatogenia é desconhecida, e o tratamento foi realizado com os esquemas quimioterápicos para linfoma segundo o consenso para linfomas de células B, sendo a base o tratamento com antraciclinas. A paciente realizou seis ciclos de CHOP (ciclofosfamida, doxorrubicina, vincristina e prednisona), com a regressão total da lesão. O uso do rituximabe, bem como a radioterapia, permanecem controversos na literatura, mas a radioterapia é indicada por alguns autores na dose de 30 a 45 GY. Nossa paciente realizou radioterapia da mama e da axila com ausência de remissão da doença, não tendo sido necessário tratamento complementar ou cirurgia da mama.

Idiopathic granulomatous mastitis: diagnosis and follow-up with magnetic resonance imaging

Study carried out at Instituto de Responsabilidade Social do Hospital Sírio Libanês – São Paulo (SP), Brazil. 1Hospital Sírio-Libanês – São Paulo (SP), Brazil. *Corresponding author: felipe.andrade@hsl.org.br Conflict of interests: nothing to declare. Recebido em: 12/19/2016. Aceito em: 05/30/2017 A mastite granulomatosa é uma condição rara e benigna da mama que, em alguns casos, possui etiologia desconhecida de doença inflamatória benigna, a mastite idiopática. Seu diagnóstico normalmente é feito por exclusão. Os exames de imagens têm demonstrado achados inespecíficos que podem sugerir uma doença inflamatória, um carcinoma ou não apresentar alterações. Deve ser realizado um diagnóstico diferencial com outras causas de mastites, sempre alertando para o risco de carcinoma inflamatório. Os exames de imagem servem mais para descartar uma malignidade do que para confirmar a mastite granulomatosa idiopática. Em função de tanto os exames de imagem como o exame físico poderem simular uma lesão maligna da mama, o laudo histopatológico é fundamental para estabelecer o diagnóstico. A sua etiologia permanece desconhecida, portanto, o tratamento é controverso na literatura, com alguns autores recomendando cirurgia, outros a imunossupressão e, por fim, alguns antibióticos. É apresentado o caso de uma paciente de 21 anos com uma lesão suspeita na mama associada à descarga papilar. Durante a investigação, houve um realce de 12 x 6 x 8,5 cm na ressonância magnética associado a sinais inflamatórios na pele e nos linfonodos. O exame anatomopatológico evidenciou um quadro de mastite granulomatosa idiopática. O realce desapareceu completamente após o tratamento conservador com corticoterapia. A mamografia e o ultrassom também podem demonstrar alterações inespecíficas, tais como assimetria focal, massa indefinida ou distorção. Apesar das limitações dos exames de imagem, demonstrou-se, neste relato, que a ressonância magnética pode ser utilizada para monitorar a resposta clínica ao tratamento conservador e o acompanhamento pelo risco de recorrência.

MR Imaging Findings of Infiltrating Lobular Carcinoma of the Breast

Purpose: Invasive lobular carcinoma (ILC) is the second most common malign breast neoplasia. Its classic histological type presents a slow and insidious growth, but no exuberant desmoplastic reaction. Therefore, its clinical and radiological detection is challenging. All the predictive characteristics for malignancy in breast cancer on magnetic resonance (MR) imaging are well established in the literature. However, there are few studies examining the peculiar image aspects of less prevalent histological subgroups such as the pure ILC case. Therefore, this paper assesses the characteristics of MR imaging results from patients with a histologically confirmed diagnosis of pure ILC by comparing them to the characteristics classically described in the literature for breast cancer in general. Methodology: This document is an transversal study done on 43 female patients diagnosed with pure ILC who were treated at the Sirio-Libanes Hospital Mastology Center from January 2006 to August 2014 and who were subjected to pre-surgery and pre-biopsy MR examinations. Results: Lesions presented an average size of 3.2 cm (0,6-10,0 cm). The most common image aspect found was nodules with expansive growth pattern and irregular or spiculated margins. About 91% of patients showed nodules, and 9% showed only a non-mass enhancement (NME). Of patients with NME, the vast majority (77,7%) showed segmental distribution and 22.3% were the focal type. Enhancement kinetics with type I curves were found on 30.3% of lesions. The most prevalent curve type was type II (51.1%), while type III curves were only observed on 18.6% of lesions. In T2-weighted images, nearly half of the cases (41%) showed a distinct low-intensity signal on T2, while the rest showed iso-intense signal. No lesions showed a high signal on T2-weighted images. Other data, such as the presence of macrovascularization and signs of edema and distortion surrounding the tumor were less prevalent and were observed in less than a third of patients. Conclusion: In general, the image characteristics of pure ILCs imitate characteristics classically described for invasive breast cancer; however, a significant portion of ILC cases share less customary image characteristics including the presentation of nonmass enhancement and/or progressive enhancement, a distinct hypointense signal on T2-weighted images, and absence of macrovascularization or edema surrounding the tumor. Knowing these less customary aspects is an extremely important task– especially in cases where abnormalities are evidenced exclusively through MRI.

Radicality effect of adding an interpectoral to a subpectoral approach for dissection of level III axillary lymph nodes in breast cancer.

Aims and background The extent of axillary lymph node dissection for breast cancer treatment is tailored to each patient. When the surgeon assumes that full dissection, including level III, is needed, there are basically two ways for reaching the apical nodes while preserving the pectoralis muscles: a subpectoral approach, below the joined pectoralis muscles, and another that includes an additional interpectoral dissection between the muscles. We conducted a study to evaluate the radicality of dissection using these two approaches. Methods To determine whether the harvest of level III axillary lymph nodes is equivalent with the different approaches, we prospectively studied 75 patients with breast cancer. Careful axillary lymph node dissection was done to as radical an extent as possible, first below the lateral edge of the joined pectoralis muscles (subpectoral approach) and sequentially after opening the space between the muscles (additional interpectoral approach). The number of patients with extra level III nodes retrieved by the addition of an interpectoral dissection as well as the number of complementary nodes obtained in such patients were determined. Results We excised 1701 axillary lymph nodes in 75 patients (mean, 22.7). Using first the subpectoral approach, we resected 259 level III nodes in 68 patients (mean, 3.8); in 56 patients, we removed 132 additional level III nodes using the supplementary interpectoral approach (mean, 2.4). In 7 patients (9.3%), we found at least one metastatic node with the interpectoral approach. Two of these patients had positive level III nodes that were discovered only by addition of the interpectoral dissection. Conclusions The dissection of level III axillary nodes is more radical when an additional interpectoral dissection is performed after a subpectoral approach has been used. The exclusive subpectoral approach frequently leaves residual nodes at the apex of the axilla.