Gustavo Antonio de Souza

Intravenous leiomyomatosis of the uterus. A report of three cases.

Three cases of intravenous leiomyomatosis (IVL) of the uterus, a rare benign smooth-muscle tumor, are described. A preoperative diagnosis of IVL was not made in any of the patients, all of which presented with a pelvic mass with the presumptive diagnosis of leiomyoma. Surgical exploration confirmed the presence of uterine mass and two of the three cases showed extra-uterine extension into the ovarian or uterine veins. Histological examination demonstrated a fascicular pattern of bland spindle-shaped smooth-muscle cells, which extended to veins inside the myometrium or to extrauterine veins. This was confirmed by immunohistochemical stain for desmin and factor VIII. Despite their histological benignity, these lesions have a tendency to metastasize and are closely related to the conditions called “benign metastasizing leiomyoma” and “intracaval mass and cardiac extension”. The primary treatment of IVL is hysterectomy and excision of any extrauterine tumor, when technically feasible. Anti-estrogenic therapy has been suggested as potentially useful in controlling of unresectable tumor. According to the literature, the follow-up must be long and periodic postoperative ultrasonic or magnetic nuclear resonance imaging studies may be useful in detecting growth of residual intravascular tumor.

Concomitant Cisplatin Plus Radiotherapy and High–Dose-Rate Brachytherapy Versus Radiotherapy Alone for Stage IIIB Epidermoid Cervical Cancer: A Randomized Controlled Trial

PURPOSE The benefits of chemoradiotherapy (CRT) for cervical cancer compared with radiation (RT) alone seem to diminish in later-stage disease. However, these modalities have not been directly compared for disease-free interval (DFI) and overall survival (OS) of women with stage IIIB cervical cancer. PATIENTS AND METHODS We conducted a randomized controlled clinical trial comparing DFI and OS of 147 women with stage IIIB squamous cervical cancer who received either cisplatin plus RT (CRT) or RT alone (72 patients in the CRT group and 75 patients in the RT-only group). RESULTS The CRT group had significantly better DFI (hazard ratio [HR], 0.52; 95% CI, 0.29 to 0.93; P = .02). However, patients in the CRT group did not have significantly better OS than those in the RT-only group (HR, 0.67; 95% CI, 0.38 to 1.17; P = .16). Toxicity was graded according to criteria of the Radiation Therapy Oncology Group. The organs affected (excluding hematologic effects) did not differ significantly between groups. Also, late toxicity events and organs affected were not significantly disproportionate between the study groups. CONCLUSION For stage IIIB cervical cancer, the addition of cisplatin offers a small but significant benefit in DFI, with acceptable toxicity.

Exercícios para membros superiores durante radioterapia para câncer de mama e qualidade de vida

PURPOSE To assess the influence of physiotherapy performed during radiotherapy (RT) on the quality of life (QL) of women under treatment for breast cancer. METHODS This was a randomized clinical trial conducted on 55 women under RT treatment, 28 of whom were assigned to a group submitted to physiotherapy (PG) and 27 to the control group receiving no PG (CG). The physiotherapy technique used for PG was kinesiotherapy for the upper limbs using 19 exercises actively performed, with a series of ten rhythmic repetitions or stretching movements involving flexion, extension, abduction, adduction, internal and external shoulder rotation, separate or combined. QL was evaluated using the Functional Assessment of Cancer Therapy-Breast (FACT-B), at the beginning and at the end of RT and six months after the end of RT. The physiotherapy sessions were started concomitantly with RT, 90 days after surgery, on average. RESULTS There was no difference between subgroups regarding the following subscales: physical well-being (p=0.8), social/family well-being (p=0.3), functional well-being (p=0.2) and breast subscale (p=0.2) at the three time points assessed. A comparison of the emotional subscale applied at the three evaluations demonstrated a better behavior of PG as compared to CG (p=0.01), with both groups presenting improvement on the breast subscale between the beginning and the end of RT (PG p=0.0004 and CG p=0.003). There was improvement in FACT-B scores at the end of RT in both groups (PG p=0.0006 and CG p=0.003). However, at the sixth month after RT, this improvement was maintained only in PG (p=0,005). QL assessed along time by the FACT B (p=0.004) and the Trial Outcome Index (TOI) (sums of the physical and functional well-being subscales and of the breast subscale) was better for PG (p=0.006). There was no evidence of negative effects associated with the exercises. CONCLUSIONS The execution of exercises for the upper limbs was beneficial for QL during and six months after RT.

Uterine artery embolization for the treatment of symptomatic myomas in Brazilian women

CONTEXT Uterine myomas are benign tumors that mostly occur in women of reproductive age at a frequency ranging from 20 to 25%. The symptoms are increased menstrual flow, pain and compressive signs. New treatments have been proposed and uterine artery embolization is one of them. OBJECTIVE To evaluate the effects of treatment by embolization of the uterine artery, in women with symptomatic myomas. Uterine and dominant myoma volumes and the major symptoms were evaluated before treatment and 12 weeks later. TYPE OF STUDY Open clinical trial. SETTING A tertiary-care womens hospital. PARTICIPANTS The study was conducted on 32 women with symptomatic single or multiple myomas of the uterine body, seen at the outpatient unit from May 2000 to September 2001. MAIN MEASUREMENTS The patients were submitted to gynecological examination and abdominal and endovaginal pelvic ultrasonography, and the examinations were repeated 12 weeks after the first procedure. Uterine artery embolization using PVA (polyvinyl alcohol) particles of 355-700 was performed by catheterization of the right femoral artery in 30 women and by bilateral catheterization in two. RESULTS Before embolization, the mean uterine volume of the 32 women was 455 cm and the mean volume of the dominant myoma was 150 cm . Twelve weeks after embolization, the mean uterine volume was 256 cm and the mean volume of the dominant myoma was 91 cm , with p < 0.01 in both cases. Twelve weeks after the treatment, all the women answered a questionnaire, which showed that 71% had improvement in menstrual regularity, 90% decreased menstrual volume and 81% shortened menstrual duration. The most frequent immediate post-procedure symptoms, established as complications, were pain (100%) and fatigue (34%). One woman had myoma degeneration and was submitted to myomectomy. CONCLUSION The significant reduction in uterine and dominant myoma volume confirms the validity of the treatment of symptomatic myomas by the technique of uterine artery embolization in Brazilian women. There was significant reduction in menstrual flow and duration, as well as better cycle regularity in the women studied. The few adverse effects observed in the sample studied mainly involved pain immediately after embolization.

Protein expression of c-erbB-2 and p53 in normal ducts, ductal carcinoma in situ and invasive carcinoma of the same breast

CONTEXT AND OBJECTIVE Breast cancer is thought to derive from progressively aberrant, non-invasive breast lesions, but it is not known exactly how invasive breast cancer develops from these lesions. The aim of this study was to verify the changes in c-erbB-2 and p53 protein expression between non-neoplastic ducts, ductal carcinoma in situ and invasive ductal carcinoma found in the same breast. DESIGN AND SETTING This was a cross-sectional study at Centro de Atenção Integral à Saúde da Mulher, Campinas, Brazil. METHODS Fifty-six women with invasive ductal carcinoma and ductal carcinoma in situ in the same breast were included. The expression of c-erbB-2 and p53 proteins was assessed in non-neoplastic and neoplastic cells using immunohistochemical techniques. RESULTS The c-erbB-2 protein was absent in non-neoplastic ducts but was present in 46% and 36% of in situ and invasive carcinoma components, respectively. Only 2% of non-neoplastic ducts, and 18% and 16% of ductal carcinoma in situ and invasive carcinoma components, respectively, were positive for p53 protein. No significant difference in c-erbB-2 and p53 protein expression was observed between in situ and invasive components. The nuclear grade agreement between in situ and invasive carcinoma was very good. CONCLUSIONS The invasiveness of ductal carcinoma in situ seems to be independent of the Her-2/neu and TP53 genes. The general features of an occurrence of breast carcinoma are formulated at the outset of carcinogenesis, and the Her-2/neu and TP53 genes are involved.

Penrose Drain as a Foreign Body in the Breast

▪ Abstract: Two cases of women who underwent breast nodule exeresis and drainage are described; in both instances a Penrose drain was used and part of the drain, remaining in the surgical cavity after the surgery, acted as a foreign body. The author discusses the reasons why it can happen, as well as the need to take this possibility into account in the differential diagnosis of clinical findings (e.g., nodules) or mammographic alterations (e.g., gross calcification) in the vicinity of a previous surgery scar. ▪

Adjuvant radiotherapy in early stage endometrial cancer

OBJECTIVE To compare the rates of overall survival (OS), disease-free survival (DFS) and toxicity in different techniques of postoperative radiotherapy for stage IA endometrioid adenocarcionoma of endometrium, histological grades 1and 2. METHODS A historical comparison between treatment regimens was performed, and 133 women with a minimum follow-up of 5 years were included. Teletherapy (TELE group), with 22 patients treated from 1988 to 1996, with a 10 MV linear accelerator, average dose 46.2 Gy. Low dose rate brachytherapy (LDRB group) was performed between 1992 and 1995, in 19 women, with an insertion of Cesium 137, at a 60 Gy dose. Fourteen women operated between 1990 and 1996 did not receive radiotherapy (NO RT group). High dose rate brachytherapy was performed in 78 patients (HDRB group), from 1996 to 2004, in five weekly 7 Gy insertions, prescribed at 0.5 cm from the vaginal cylinder. RESULTS The 5-year disease-free survival was 94.6% for the HDRB group, 94.1% for the LDRB group, 100% for the TELE group and NO RT groups (p = 0.681). The 5-year overall survival was 86.6% for the HDRB group, 89.5% for the LDRB group and 90% for the TELE group and NO RT groups (p = 0.962). Grades 3-5 late toxicity was 5.3% in LDRB group and 27.3% for the TELE group (p < 0.001). CONCLUSION Patients submitted to adjuvant teletherapy showed very high toxicity, which contraindicates that treatment for those patients. There may be a role for adjuvant HDRB, but randomized controlled trials are still needed to evaluate its benefit.

Prognostic significance of GRP78 expression patterns in breast cancer patients receiving adjuvant chemotherapy.

This study examined the associations between GRP78 expression and breast cancer recurrence and survival in patients treated with anthracyclines in the adjuvant setting. GRP78 expression was assessed in 106 stage II/III breast cancer patients. Tissue microarray was used to perform immunohistochemistry and to determine the GRP78 expression in endoplasmic reticulum and cell membrane of breast tumors. Four distinct scenarios (low and high thresholds) were developed. For high thresholds, 16% and 40% of our cases were GRP78-positive for endoplasmic reticulum and cell membrane, respectively. For low thresholds, 74% and 87% of our cases were GRP78-positive for endoplasmic reticulum and cell membrane, respectively. In the endoplasmic reticulum high-threshold scenario, GRP78 positive was found to be significantly frequent in T3 tumors (p=0.02), and inversely related to ERBB2 overexpression (p=0.03). There was a lower proportion of GRP78-positive cases among women between 50 and 65 years of age (p=0.02). In the endoplasmic reticulum low-threshold scenario, the proportion of GRP78-positive cases was significantly higher in women younger than 50 years and in those who were premenopausal (p=0.04). No statistically significant difference was found in survival probabilities among the scenarios examined. In our cohort, GRP78 overexpression was not a predictor of overall or disease-free survival of patients receiving anthracycline-based adjuvant chemotherapy.

Efeitos adversos no pós-operatório de cirurgias ginecológicas e mamárias

OBJECTIVES: To analyze the occurrence of adverse effects in the first 24-hour postoperative/postanesthetic period in women undergoing minor gynecologic or minor breast surgeries and to identify main associated factors. METHODS: A cross-sectional study was conducted with 159 women who underwent minor gynecologic or breast surgeries. The women were admitted to the hospital one day before surgery and remained hospitalized for at least 24 hours after surgery. The anesthetic techniques performed were intercostal nerve blockade, spinal anesthesia, and general anesthesia. RESULTS: Tthe most frequent adverse effects were vomiting, nausea and pain that occurred in 40.3% of women. Of these effects, 60% were observed in the first four hours and 80% were observed in up to six hours after surgical intervention. Women submitted to intercostal blockade received earlier postanesthetic release. Spinal anesthesia was most frequently associated with postoperative pain, although with a lower incidence of nausea and vomiting when compared to general anesthesia and intercostal blockade. The incidence of pain was higher in women who smoked. CONCLUSIONS: A six-hour period of postoperative observation appeared to be adequate for assessment of most complications and adverse effects occurring in women who undergo minor gynecologic or minor breast surgeries.OBJECTIVES To analyze the occurrence of adverse effects in the first 24-hour postoperative/postanesthetic period in women undergoing minor gynecologic or minor breast surgeries and to identify main associated factors. METHODS A cross-sectional study was conducted with 159 women who underwent minor gynecologic or breast surgeries. The women were admitted to the hospital one day before surgery and remained hospitalized for at least 24 hours after surgery. The anesthetic techniques performed were intercostal nerve blockade, spinal anesthesia, and general anesthesia. RESULTS The most frequent adverse effects were vomiting, nausea and pain that occurred in 40.3% of women. Of these effects, 60% were observed in the first four hours and 80% were observed in up to six hours after surgical intervention. Women submitted to intercostal blockade received earlier postanesthetic release. Spinal anesthesia was most frequently associated with postoperative pain, although with a lower incidence of nausea and vomiting when compared to general anesthesia and intercostal blockade. The incidence of pain was higher in women who smoked. CONCLUSIONS A six-hour period of postoperative observation appeared to be adequate for assessment of most complications and adverse effects occurring in women who undergo minor gynecologic or minor breast surgeries.

Avaliação da resposta do câncer de mama à quimioterapia: papel da ultra-sonografia e da dopplerfluxometria

Objetivo: comparar os tamanhos dos tumores mamarios localmente avancados por meio de exame clinico, mamografia, ultra-sonografia e dopplervelocimetria associada a ultra-sonografia, avaliados antes e depois da quimioterapia primaria. Metodos: estudo clinico prospectivo e descritivo. Foram incluidas dezoito mulheres com tumor primario clinico maior ou igual a 50 mm que foram submetidas a palpacao, mamografia, ultra-sonografia e dopplervelocimetria, no momento do diagnostico e apos 3 ciclos de quimioterapia. A resposta foi considerada presente quando ocorreu diminuicao clinica maior que 50% e ultra-sonografica maior que 25%, e ausente quando a reducao medida pela clinica fosse inferior 50% e a ultra-sonografica menor que 25%. A analise estatistica utilizada foi descritiva com teste de Wilcoxon na comparacao dos metodos. Resultados: em relacao ao tamanho dos tumores, o metodo cuja medida mais se aproximou do exame anatomopatologico foi o exame clinico na pos-quimioterapia, quando comparado com a ultra-sonografia e a mamografia. A mamografia permitiu avaliacao em 44% dos casos, antes da quimioterapia (8/18). Nos casos em que nao houve resposta a quimioterapia, a dopplervelocimetria demonstrou aumento significativo do fluxo, com a diminuicao dos indices de pulsatilidade e resistencia. Nos casos em que houve resposta (9 casos), com reducao do tamanho tumoral, a dopplervelocimetria nao mostrou alteracoes significativas em relacao aos parâmetros estudados. Conclusao: o exame clinico mostrou-se como melhor metodo de avaliacao da reducao do volume dos tumores tratados com quimioterapia neoadjuvante quando comparado com o exame de ultra-sonografia e a mamografia. A dopplervelocimetria demonstrou que houve aumento do fluxo nos casos com resposta ausente.