Francisco José Cândido dos Reis

Apoptosis induced by neoadjuvant chemotherapy in breast cancer

Aim: To evaluate the relationship between apoptosis induced by chemotherapy and clinical response in breast cancer. Methods: Apoptosis index (AI), mutant p53 and Bcl‐2 protein expression were evaluated in 44 breast tumour samples from patients submitted to neoadjuvant chemotherapy. Objective response (OR) to primary chemotherapy was observed in 37 patients (84%) and no response (NR) in seven. AI was measured by the rate of apoptotic cells identified using morphological criteria. p53 and Bcl‐2 protein expression were evaluated using an immunoperoxidase staining technique. Results: The median AI change observed between pre‐chemotherapy AI and post‐chemotherapy AI was 0.84 in the OR group and 0.01 in the NR group, (rho = 0.4; p = 0.006). There was no change in Bcl‐2 protein expression following chemotherapy. In the OR group, p53 protein expression was positive in 41.6% of patients before and in 22.2% after chemotherapy (difference = 16.6%; p = 0.03). No change was detected in the NR group. Conclusion: A positive correlation was found between the increase in AI and clinical response to neoadjuvant chemotherapy in locally advanced breast cancer.

Chronic pelvic pain: multifactorial influences

RATIONALE Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with diagnosis and treatment being more difficult. From a clinical viewpoint, CPP is defined as non-cyclic, non-menstrual pain lasting at least 6 months and sufficiently severe to interfere with habitual activities and requiring clinical or surgical treatment. Thus, CPP is a syndrome resulting from a complex interaction of the nervous, musculoskeletal and endocrine systems and also influenced by psychological and sociocultural factors. CPP is influenced by emotional aspects with an impact on quality of life, and involving high costs for health services. Its aetiology is not always clear and a cure or significant improvement of symptoms is not always obtained with the treatments employed, with constant frustration of the professionals involved. It can be seen that its treatment is often unsatisfactory, simply providing temporary relief of symptoms. METHODS In the present study, we reviewed the bibliography regarding pelvic pain, with emphasis on emotional aspects and on the importance of a multidimensional approach to the care for these patients. RESULTS AND CONCLUSIONS New investigations are needed to clarify these relations and interventions in a more effective manner. Interdisciplinary care can minimize the impact of the disease, helping the patients to cope with symptoms and improving their quality of life.

Impact of surgical staging in locally advanced cervical cancer and subsequent chemotherapy.

Surgical staging (SS) is the gold standard for determination of the true extent of a patients disease and is an important prognostic factor in cervical cancer. We investigated whether lymph node dissection (LND) prior to chemotherapy (CT) followed by radical surgery (RS) could modified overall (OS) and disease‐free survival (DFS).

Endometriose umbilical sem cirurgia pélvica prévia

PURPOSE: to present a series of cases of umbilical endometriosis in patients in reproductive age, with no previous pelvic surgery. METHODS: four patients aged between 33 and 43 years were included in the study. They all presented umbilical bleeding associated or not with pelvic pain, and medical history varied from two months to four years. Abdominal wall ultrasound was performed for diagnosis support before surgical excision of the umbilical lesions, and histological examination was also performed. RESULTS: the ultrasonographic evaluation of the four patients showed hypoechogenic umbilical lesion suggestive of endometriosis. All patients were submitted to surgical excision and histological examination of the lesions. CA-125 serum levels were measured in three of the patients, but they were within normal ranges (from 6.8 to 10.1 U/mL). In addition to umbilical surgery, laparoscopy was performed in all patients, but only one presented concomitant pelvic endometriosis. In a one-year follow-up, patients maintained asymptomatic and there was no recurrence of the lesions. CONCLUSIONS: umbilical endometriosis is a rare entity, but it may be remembered as a possibility in cases of umbilical nodulations or bleeding, even if there is no previous history of pelvic surgery with endometrial manipulation. Its treatment is always surgical and, in general, it is enough to promote complete elimination of the lesion and of the symptoms.

Modelo Experimental para Endometriose em Coelhas com Seguimento Evolutivo das Lesões

PURPOSE: development of a new experimental model of endometriosis induction in rabbits evaluating its temporal evolution both macro-and microscopically. METHODS: thirty female rabbits were submitted to endometriosis induction through the fixation of a piece of the left uterine horn to the abdominal peritoneum. After four or eight weeks the viability of the lesions was verified by laparoscopy. The lesions were observed endoscopically. The implants were measured and histological analyses were made. The groups were compared for the presence of endometriotic lesion on laparoscopy, presence of adhesions, implant size and histological aspects. For statistical analyses we utilized Students t and Mann-Whitneys tests, with a statistical significance of 5%. RESULTS: endometriotic lesions were identified in all cases submitted to laparoscopy after 4 weeks of induction, 64% of them cystic, and in 80% of the rabbits after eight weeks, 66% of which cystic. The adhesions were present in 71% of the rabbits after 4 weeks (none in the implants) and in 80% of the rabbits after 8 weeks (13% in the implants). The lesions were significantly larger after 8 weeks (p<0,0001). The histological analyses showed 100% of endometrial tissue in both groups. CONCLUSION: this experimental model showed that it is possible to simulate endometriosis in rabbits with a viable and simple technique, also allowing to record the characteristics and development of the implants macro-and microscopically. Although the histological aspects were similar, the lesions after eight weeks were larger than after four, making their manipulation easier.

Tumores pélvicos em mulheres na pós-menopausa

Purpose: to evaluate clinical and ultrasonic findings in patients with pelvic tumors at postmenopause and to correlate them with the final diagnosis. Patients and Methods: thirty-six postmenopausal women with pelvic tumor diagnosis were prospectively evaluated through clinical examination and endovaginal ultrasonography. Clinical follow-up with no surgical procedures was indicated for anechoic cystic tumors with or without thin unique septation and volume under 50 cm3. Needle aspiration was indicated for tumors with the same aspect, and volume of 50 to 100 cm3, whereas exploratory laparotomy was performed in the remaining patients. Diagnosis defined two groups of patients: benign (28) and malignant (8) pathologies. Results: anechoic cystic tumor with or without a thin septum indicates benignity (p = 0.0091). Tumors with solid areas indicate malignancy (p = 0.0024). Ascites correlates with malignancy (p = 0.0278). Heterogeneity, thick capsule, thick septa, and papillary projections predominated in malignancies but without no statistical significance (p > 0,05). Tumor volume indicates malignancy, with a median of 85.2 cm3 in benign tumors and 452.5 cm3 in malignancies (p = 0.0048), with a cutoff at 295 cm3 (sensitivity = 83.3% and specificity = 85.2%). Following this protocol, all malignancies were submitted to surgery and 11 benign tumor patients were treated with a conservative protocol (39.3% of all benign patients). Conclusion: conservative management is an adequate protocol for women with anechoic pelvic tumors with low volume, with or without single thin septum and without ascites. Differentiation between benign and malignant of complex and/or high volume tumors requires complementary investigation.

Identification of a Subtype of Poorly Differentiated Invasive Ductal Carcinoma of the Breast Based on Vimentin and E-cadherin Expression

OBJECTIVE  The use of molecular markers can identify a subgroup of tumors with distinct recurrence patterns. The present study aimed to characterize the immunohistochemical expression of vimentin (VIM), of E-cadherin (CDH1), and of cytokeratin 5 (CK5) in patients with invasive ductal carcinomas (IDCs). METHODS  We have constructed a tissue microarray (TMA) from 87 patients with IDC of the breast. Immunohistochemistry (IHC) was performed to study the expression of estrogen and progesterone receptors (ER and PgR), human epidermal growth factor receptor 2 (HER2), VIM, CDH1, CK5, and Ki67. The tumors were classified as luminal A and B (n = 39), HER2 enriched (n = 25), and triple-negative (TNBC) (n = 23), based on the IHC expression. RESULTS  We have observed that luminal A and B tumors lack the VIM+/CDH1-/low phenotype. This phenotype was observed in 16.5% of the HER2+ tumors and in 60% of the TNBC tumors (p = 0.0001). Out of a total of 20 TNBC tumors, the CK5 (basal-like marker) was positive in 11 of them. The VIM+/CDH1-/low phenotype was observed in 5 CK5+ TNBC tumors (45%) and in 7 out of 9 CK5- TNBC tumors (78%) (p = 0.02). The median Ki67 index in the VIM+/CDH1-/low tumors was 13.6 (range: 17.8-45.4) compared with 9.8 (range: 4.1-38.1) in other tumors (p = 0.0007). The presence of lymph node metastasis was less frequent in patients with VIM+/CDH1-/low tumors (23% versus 61%; X2 test; p = 0.01). CONCLUSION  Our findings suggest that the expression of VIM and CDH1 can identify a subset of IDCs of the breast with a mesenchymal phenotype associated with poor prognosis, high-grade lesion, and high mitotic index.

626 THE INFLUENCE OF DEPRESSION AND OF PAIN INTENSITY ON THE SEXUAL FUNCTION OF WOMEN WITH CHRONIC PELVIC PAIN

626 THE INFLUENCE OF DEPRESSION AND OF PAIN INTENSITY ON THE SEXUAL FUNCTION OF WOMEN WITH CHRONIC PELVIC PAIN A. Romão *, P. Souza, O. Poli Neto, J. Rosa-e Silva, F. Reis, R. Gorayeb, G. Romão, A. Nogueira. Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine of Ribeirão Preto-USP, Ribeirão Preto, Brazil; Department of Surgery and Anatomy, University Hospital, Faculty of Medicine of Ribeirão Preto-USP, Ribeirão Preto, Brazil; Department of Neurosciences and Behavioral Sciences, University Hospital, Faculty of Medicine of Ribeirão Preto-USP, Ribeirão Preto, Brazil; Department of Medicine, Federal University of São Carlos, São Paulo, Brazil, São Carlos, São Paulo, Brazil

Doppler e marcadores séricos maternos na predição de complicações da gestação

OBJECTIVE: To compare the effectiveness of uterine artery Doppler and maternal serum screening in the prediction of pregnancy complications. MATERIALS AND METHODS: Prospective study with 49 primigravidae at their 18th gestational week, when a blood sample was collected for serum dosage by chemiluminescence (alpha-fetoprotein, human chorionic gonadotropin and nitric oxide) and radioimmunoassay (atrial natriuretic peptide). Uterine artery Doppler was performed between the 24th and 26th gestational weeks, for determining the presence or absence of notch in the flow velocity waveform. The non-parametric Mann-Whitney test was utilized for statistical analysis, and the Fisher exact test for analysis of qualitative parameters. RESULTS: Sensitivity, specificity, positive and negative predictive values were, respectively, 8.3%, 97.0%, 50.0% and 74.4% for alpha-fetoprotein; 8.3%, 87.9%, 20.0% and 72.5% for human chorionic gonadotropin; 16.7%, 97.0%, 33.3% and 76.2% for atrial natriuretic peptide; and 16.7%, 93.9%, 50.0% and 75.6% for nitric oxide. The uterine artery Doppler sensitivity was 75.0%, specificity 63.6%, positive predictive value 57.1%, and negative predictive value 87.5%. CONCLUSION: Uterine artery Doppler is an effective method for prediction of pregnancy complications as compared with maternal serum screening in low risk populations.

Estadiamento cirúrgico do câncer de colo de útero localmente avançado

PURPOSE: to assess to what extent the surgical staging differs from the clinical staging among cases of advanced uterine cervix carcinoma, and also to assess the percentage of cases with positive para-aortic ganglia in this group of patients. METHODS: this is a descriptive prospective study in which 36 patients with histological diagnosis of uterine cervix carcinoma considered locally advanced were included (stages IB2, IIB, IIIA and B, and IVA). The cases were submitted to clinical staging, according to FIGO criteria. All patients were to be treated with neoadjuvant chemotherapy. Age ranged from 40 to 73 years, with a mean of 56.2±7.9. The procedure started with pelvic lymphadenectomy followed by para-aortic lymphadenectomy, in case the pelvic lymph nodes were positive on surgical examination. Examination of the abdominal cavity and lymphadenectomy were done either through laparotomy or laparoscopy, chosen at random. In each case, the clinical staging was compared to the surgical staging, considered the gold standard. RESULTS: in the clinical staging (CS), 7 cases were classified as IB2 (tumors larger than 4 cm), 22 cases as CSII and 7 cases as CSIII. The surgical assessment changed the clinical staging as follows: the stage was decreased in six cases, and increased in 13. There was agreement only in 18 cases (50%). The para-aortic lymph nodes were affected in six cases. CONCLUSIONS: clinical staging of locally advanced uterine cervix carcinoma is incorrect in most of the cases. Such inconsistency may lead to excessive treatment in some cases, but about one fourth of the patients with positive para-aortic ganglia would not be adequately treated with the current standard treatment radiotherapy with chemosensitization, which aims at the local regional control of the pelvic disease.OBJETIVO: verificar em que proporcao o estadiamento cirurgico difere do estadiamento clinico entre casos com carcinoma avancado do colo do utero e a porcentagem de casos com gânglios para-aorticos positivos neste grupo de pacientes. METODOS: estudo prospectivo descritivo no qual foram incluidas 36 pacientes com diagnostico histologico de carcinoma de colo de utero considerados localmente avancados (estadios IB2, IIB, IIIAeB e IVA). Foram submetidas a estadiamento clinico conforme as recomendacoes da FIGO. Todas eram candidatas ao tratamento com quimioterapia neoadjuvante. A idade variou de 40 a 73 anos, com media de 56,2±7,9 anos. O procedimento constou de linfadenectomia pelvica seguida de linfadenectomia para-aortica se os linfonodos pelvicos fossem positivos ao exame intra-operatorio. A abordagem da cavidade e linfadenectomia foram efetuados por via laparotomica ou laparoscopica, indicados aleatoriamente. Os casos foram comparados individualmente e para cada estadiamento clinico foram estabelecidos os respectivos achados cirurgicos que foram considerados o padrao-ouro. RESULTADOS: na fase de estadiamento clinico (EC) 7 casos foram classificados como IB2 (tumores com mais de 4 cm), 22 casos como EC II e 7 casos ECIII. A avaliacao cirurgica modificou o estadiamento clinico da seguinte foram: em seis casos o estadio foi diminuido, e em 13 casos os achados levaram a elevacao do estadio. Houve concordância em apenas 18 casos (50%). Em seis casos (16,9%) os linfonodos para-aorticos estavam comprometidos. CONCLUSOES: o estadiamento clinico do carcinoma de colo de utero localmente avancado e incorreto em proporcao alta dos casos. Esta divergencia levaria a indicacao de tratamento excessivo em alguns casos, mas cerca de um quarto das pacientes com gânglios para-aorticos positivos nao seria adequadamente tratado com o tratamento padrao atual radioterapia com quimiossensibilizacao que e dirigida ao controle locorregional da doenca na pelve.