Giuliano Mendes Duarte

Radioguided surgery using intravenous 99mTc sestamibi associated with breast magnetic resonance imaging for guidance of breast cancer resection.

Abstract:  The purpose of this study was to evaluate the feasibility of surgery radioguided with intravenous 99mTc sestamibi associated with magnetic resonance imaging (MRI) of the breast to detect tumor extent and guide complete tumor resection. A descriptive experimental study was developed with 10 breast cancer patients (stage IIA–IIB) who underwent mastectomy. From 2 to 10 days before surgery, the patients underwent breast MRI with 0.1 mmol/kg of gadolinium and scintimammography with a 740 MBq of 99mTc sestamibi. A region of interest was drawn around the tumor image and an uptake curve as a function of time was plotted to calculate the optimal time to perform radioguided surgery. In the perioperative period, the same dose of 99mTc sestamibi was intravenously injected into the patients. Tumor resection was performed under the guidance of a gamma probe. MRI was used to evaluate the skin and deep fascia involvement and to detect occult tumor foci which were also excised. Subsequently a modified radical mastectomy was performed. Tumor and residual breast were histopathologically examined. In a series of 10 women, all demonstrated 99mTc sestamibi uptake in tumor cells. Eight patients showed no disease in the residual breast, one presented with one foci of invasive ductal carcinoma measuring 0.5 cm in diameter located 5 cm from the tumor bed, and one presented with one foci of ductal carcinoma in situ measuring 0.8 cm at the resection margin. The mean tumor size in the histopathologic assessment was 3.3 cm and in MRI was 5.0 cm. Radioguided surgery using 99mTc sestamibi associated with MRI is a feasible technique that can be employed in tumor resection.

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).

Abstract P4-01-04: Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients

Objective: We investigated immunohistochemical and histological composition of dense and non-dense breast tissue in 18 women undergoing mastectomy as the initial treatment for breast cancer. Materials and Methods: In each mammogram, we localized the dense and the non-dense areas. We used a localization technique based on a linear approximation method with interpolation of mammogram images and breast pictures. The selected areas were retrieved during mastectomy and analyzed. Results: Estrogen and progesterone receptors, Ki-67 and CD-34, were equally expressed in both tissues, as well as the percentage composition of fat. The percentage compositions of brownish spots among dense and non-dense tissues were significantly different (p = 0.0226). The number of terminal ductal lobular units was higher for dense than for non-dense breast tissues (p = 0.0019). In the non-dense breast tissue, there were no proliferative lesions with atypia, while we found flat epithelial atypia in 3 of the dense areas evaluated. Proliferative lesions without atypia and non-proliferative lesions were found in both tissues, but they were more frequent in dense than in non-dense breast tissues (23.5% vs 11.8%, p = 0.0455, and 17.6% vs 2.9%, p = 0.0253, respectively). Fibrosis was more frequently extensive or moderate in dense tissue, while it was predominantly mild in non-dense tissue (p = 0.03). Conclusion: There was no difference in the expression of the estrogen and progesterone receptors, Ki-67 and CD-34, in the dense and non-dense tissue areas in breast-cancer women. In addition, both stroma fibrosis and epithelial proliferation were responsible for higher mammographic density. Citation Format: dos Santos CC, Marshall P, Torresan R, Tinois E, Duarte G, Teixeira S. Immunohistochemical and histological features of mammographic dense and non-dense tissue in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-04.

Claudin-4 Expression Is Associated With Disease-Free Survival in Breast Carcinoma-in-Situ: Mean Follow-up of 8.2 Years

Introduction Claudins are tight junctions associated with breast cancer prognosis. The claudin‐low intrinsic subtype of invasive carcinoma is associated with high‐grade carcinoma, low junction molecule expression, and worse response to chemotherapy. However, it is not known whether the expression of claudins may provide clues as to carcinoma‐in‐situ (CIS) prognosis. The aim of this study was evaluate claudin‐4 expression in CIS and its association with disease‐free survival and histologic type of local recurrence (in situ or invasive). Methods A tissue microarray block, constructed from 137 pure CIS paraffin blocks, was submitted to immunohistochemical staining for claudin‐4, &bgr;‐catenin, E‐cadherin, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and Ki‐67. A claudin‐4 score categorized samples as claudin‐4‐low or ‐high. Clinical and treatment data were obtained from medical records. Results Claudin‐4 expression was evaluated in 86 samples; 88.4% were high and 11.6% low. Mean follow‐up was 98.4 months, and the local recurrence rate was 10.4%. There was a significant difference in disease‐free survival between claudin‐4‐high and ‐low (4.9 and 1.9 years, respectively, P = .02); however, there was no difference between them in histologic type of recurrence (invasive or in situ) (P = .44). Conclusion In our samples, high claudin‐4 expression in CIS was more frequent than low expression. Claudin‐4‐low expression had a worse prognosis in CIS (inferior disease‐free survival), but it was similar to high claudin‐4 in histologic type of local recurrence. Micro‐Abstract Claudin‐4 expression in carcinoma‐in‐situ (CIS) is unknown. In 86 patients with pure CIS and mean follow‐up of 8.2 years, claudin‐4‐high expression was more frequent than claudin‐4‐low. However, claudin‐4‐low was associated with worse disease‐free survival than claudin‐4‐high.

Abstract P3-17-05: Claudin-4 expression is associated with disease free survival in breast carcinoma in situ: Mean follow up of 8.2 years

Introduction: Claudins are tight junction molecules that have been associated with breast cancer prognosis. The claudin-low intrinsic subtype of invasive carcinoma was recently described and associated with high grade carcinoma, low junction molecules expression and worse response to chemotherapy. However, it is not known whether the expression of claudins may provide clues as to carcinoma in situ prognosis. The aim of study was evaluate the association between claudin–4 expression and disease-free survival and histologic type of local recurrence in carcinoma in situ after longer follow up. Methods: A tissue microarray (TMA) block was constructed from 137 pure carcinoma in situ paraffin blocks sampled from patients treated from 1999 to 2009. The TMA was submitted to immunohistochemical staining for claudin-4. A claudin-4 score calculated based on percentage and intensity of expression, categorized samples as: claudin-4-low or claudin–4-high. Clinical data, treatment data, local recurrence data and survival of each patient were reanalyzed from medical records. Kaplan-Meier curves, log-rank and Wilcoxon tests were used to analyze disease-free survival; qui-square and Fisher test were employed to compare others variables; a significance level of 5 % was used. Results: Claudin-4 expression was evaluated in 86 samples, 88.4% were claudin-4-high and 11.6% claudin-4-low. Mean follow up was 8.2 years ( and local recurrence rate was 10.5 %. There was significant difference in the disease-free survival between claudin-4-high and claudin-4-low (4.9 x 1.9 respectively, p= 0.02); however there was no difference between both in histologic type of recurrence, invasive or in situ (p=0.44). Conclusion: In our samples, claudin-4-high expression in carcinoma in situ was more frequent than low expression. Our data showed that claudin-4-low expression had a worse prognosis in carcinomas in situ (inferior disease-free survival) but it was similar to claudin-4-high in histologic type of local recurrence. Citation Format: Duarte GM, Almeida NR, Tocchet F, Espinola J, Pinto T, Barreto CT, Pinto GA, Soares FA, Marshall P, Paiva GR. Claudin-4 expression is associated with disease free survival in breast carcinoma in situ: Mean follow up of 8.2 years [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-05.

Abstract P5-17-10: Claudin -4 expression in carcinoma in situ and its association with local recurrence, clinical and immunohistochemistry characteristics

Introduction: Claudins are tight junction molecules and have been associated to breast cancer prognosis. Claudin-low intrinsic subtype of invasive carcinoma was described recently and has been related to high grade carcinoma, low junction molecules expression and worse chemotherapy response. However, it is unknown whether Claudins expression could be associated to carcinoma in situ prognostic. The aim of this study was evaluated the Claudin – 4 expression in carcinoma in situ and its association with local recurrence, clinical and immunohistochemistry characteristics. Methods: A tissue microarray (TMA) block was constructed, using region of interesting, with 137 pure carcinoma in situ paraffin blocks of patients treated in the Women 9s Hospital Prof. Dr. Jose Aristodemo Pinotti – UNICAMP from 1999 to 2009. The TMA was submitted to immunohistochemistry analyze to: Claudin-4, beta-catenin, e-caderin, estrogen receptor (ER), progesterone receptor (PR), HER-2 and Ki-67. It was calculated Claudin-4 score based in percentage and intensity of expression and categorized in: Claudin-4 low and Claudin – 4 high. The clinical data, treatment data (surgery, radiotherapy and tamoxifen use), local recurrence data (date and type) and death of each patient were reviewed in the medical records. The statistical analyze used Kaplan-Meier curve and log-rank test to disease free survival; qui-square and Fisher test to compare others variables; significance level of 5 % was used. Results: It was possible to evaluate Claudin-4 expression in 86 cases, 88.4% were Claudin-4 high and 11.6% Claudin-4 low. The follow up mean was 69 months and local recurrence rate was 10.5 %. There was no significant difference in local recurrence rate between Claudin-4 high and Claudin-4 low (10.0% x 10.5% , p=1.0).The disease free survival was similar between Claudin-4 low and Claudin-4 high (p=0.559). The Claudin- 4 high was significantly more frequent in beta-catenin positive patients (p=0.048). There was no association significantly between Claudin-4 expression and: age (p=0.66), histology type (p=0.75), surgery (p=0.102), radiotherapy (p=0.29), tamoxifen use (p=0.432), ER (p=0.33), PR (p=1.0), HER-2 (p=0.23) and e-caderin (p=0.21). Conclusion: Despite the Claudins are related to invasive carcinoma prognosis, our outcome did not show difference in local recurrence and disease free survival between Claudin-4 low and high in carcinoma in situ. The beta-catenin and claudin-4 expressions were significantly associated. Citation Format: Duarte GM, Toucchet F, Espinola JP, Barreto CR, Paiva Silva GR, Almeida NR, Soares F, Pinto G, Marshall P. Claudin -4 expression in carcinoma in situ and its association with local recurrence, clinical and immunohistochemistry characteristics. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-10.

Abstract P2-13-25: Cytology and histopathology evaluation of sub-nipple tissue during intraoperative and postoperative time to predict neoplastic involvement of the nipple in patients with breast carcinoma

Introduction: The analyses of sub nipple tissue (SNT) have been used by some surgeons to preserve or not the nipple in nipple sparing mastectomy for breast carcinoma. Therefore, the intraoperative study of SNT becomes an important tool. However, it is uncertain if the SNT evaluation can safely predict the nipple involvement for carcinoma. The aim of this study was to evaluate the accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of intraoperative imprint cytology, intraoperative frozen section and postoperative paraffin histopathology of SNT to predict involvement of the nipple in women with breast carcinoma. Methods: It was realized a prospective study with 38 consecutives breast carcinoma women (stage 0, I, II and III) underwent to mastectomy. It was excluded inflammatory carcinoma and clinical evident nipple involvement. After mastectomy, the nipple areolar complex were dissected in an approximate thickness of 5mm simulating nipple-sparing flap dissection. Then, the SNT were dissected and submitted to imprint citology and frozen section during intraoperative time. Subsequently, it were submitted to routine paraffin histopathology analysis. The nipple was examined separately by paraffin histopathology (considered the gold standard). We considered any atypical cells like positive findings in all exams (cytology, frozen and paraffin). Results: The mean of patient’s age was 59 years, the mean of tumor size was 34 mm in clinical exam and 31mm in pathological exam. The clinical and mammographic means of distance from tumor to nipple were 23 and 34 mm, respectively. The imprint citology frozen section and paraffin histopathology of SNT showed: sensitivity 42.9%, 42.9% and 57.1%; specificity 80.6%, 96.8% and 100%; accuracy 73.7%, 86.8% and 92.1%; PPV 33.3%, 75% and 100%; NPV 86.2%, 88.2% and 91.2%, respectively. When we associated both intraoperative exams (imprint cytology and frozen section), the specificity (80.6% x 100%, p=0.01) and accuracy (76.3% x 92.1%, p=0.02) were worse than postoperative exam. The false negative of postoperative analyses was 8.8%. Conclusion: These preliminaries outcomes showed a moderate sensitivity and good specificity of three exams, the low false negative rate of postoperative paraffin exam. Our dates suggest that SNT evaluation is a good method to predict nipple involvement and possibly the postoperative evaluation (histopathology) is better than intraoperative evaluation (imprint cytology and frozen section). Citation Format: Giuliano M Duarte, Maria Virginia Thomazin, Andre Oliveira, Fernado Tocchet, Luciana Moreira, Adriana Worschech, Renato Z Torresan. Cytology and histopathology evaluation of sub-nipple tissue during intraoperative and postoperative time to predict neoplastic involvement of the nipple in patients with breast carcinoma [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-25.