Luiz Claudio Santos Thuler

Post-mastectomy pain syndrome: incidence and risks.

BACKGROUND Post-mastectomy pain syndrome is defined as a chronic pain that persists beyond the normal healing time of 3 months. It is considered a neuropathic condition that arises after surgery for breast cancer. AIM To evaluate the incidence and risk factors of pain syndromes in patients undergoing surgical treatment of breast cancer in the National Cancer Institute. METHODS This study is a prospective cohort of women undergoing surgical treatment for breast cancer from September 2008 to June 2009, followed up until 6 months postoperatively. RESULTS AND CONCLUSIONS One hundred seventy-four women were examined. The mean age was 58 years. The incidence of pain syndrome was 52%. Younger women (<40 years) and those who were submitted to axillary lymph node dissection (with more than 15 lymph nodes excised) have shown a significantly increased risk of pain syndrome after surgery for breast cancer (relative risk (RR) =5.23 95% confidence interval (CI): 1.11-24.64) and (RR=2.01 95% CI: 1.08-3.75).

Drug-induced sleep endoscopy in the identification of obstruction sites in patients with obstructive sleep apnea: a systematic review

INTRODUCTION Obstructive sleep apnea syndrome has multifactorial causes. Although indications for surgery are evaluated by well-known diagnostic tests in the awake state, these do not always correlate with satisfactory surgical results. OBJECTIVE To undertake a systematic review on endoscopy during sleep, as one element of the diagnosis routine, aiming to identify upper airway obstruction sites in adult patients with OSAS. METHODS By means of electronic databases, a systematic review was performed of studies using drug-induced sleep endoscopy to identify obstruction sites in patients with OSAS. RESULTS Ten articles were selected that demonstrated the importance of identifying multilevel obstruction, especially in relation to retrolingual and laryngeal collapse in OSAS. CONCLUSION DISE is an additional method to reveal obstruction sites that have not been detected in awake patients.

The magnitude of the association between smoking and the risk of developing cancer in Brazil: a multicenter study

Objectives To estimate the magnitude of association and identify the aetiological fraction (AF) attributable to smoking in the development of different types of cancers in Brazil. Setting We conducted a case–control study, including 231 102 patients registered in the Cancer Hospital Registries (CHR) in the period from 1998 to 2011. Participants A total of 204 131 cancer cases relating to 30 topographies were compared with 26 971 cases of non-melanoma skin cancer. Primary and secondary outcome measures Smoking exposure was considered at the time of hospital registration. We calculated OR, unadjusted and adjusted for gender, age and alcohol consumption, with 95% CIs. Results After adjustment, the risk of developing cancer associated with smoking was very high (piriform sinus, bronchi and lung, larynx, hypopharynx, oropharynx and oral cavity), high (oesophagus and bladder), moderate (anus and anal canal stomach, nasal cavity, middle ear and paranasal sinuses, pancreas, nasopharynx, other parts of the biliary tract and kidney and low (liver, gall)). There was no association between smoking and cancers of the central nervous system and myeloid leukaemia. For thyroid cancer there was a decreased risk of developing the disease. The AF was higher than 50% for hypopharynx, larynx, bronchi and lung, oropharynx, oral cavity and oesophagus cancers. Conclusions This study confirms a high risk of developing cancer of the hypopharynx, bronchi and lung, larynx, oropharynx and oral cavity, oesophagus and bladder cancer among smokers and establishes the AF attributable to smoking in the development of different types of cancer in Brazil.

Determinants of advanced stage presentation of breast cancer in 87,969 Brazilian women.

BACKGROUND Breast cancer is commonly diagnosed at an advanced stage in Brazil. AIM Analyze the determinants of advanced staging in Brazilian women with breast cancer. METHODS Crosssectional study, including women diagnosed with breast cancer in Brazil, between 2000 and 2009. RESULTS A total of 59,317 women were included, 53.5% being classified as advanced stage (≥IIB). Younger age (18 to 49 years old) (OR=1.61 95% CI 1.51 to 1.72) or between 40 and 49 years old (OR=1.08 95% CI 1.03 to 1.14), having low educational level (OR=1.53 95% CI 1.48 to 1.58), living in less developed geographical regions (OR=1.27 95% CI 1.21 to 1.33), having invasive ductal carcinoma (OR=2.70 95% CI 2.56 to 2.84) and invasive lobular carcinoma (OR=2.63 95% CI 2.42 to 2.86) were associated with advanced breast cancer. CONCLUSION We conclude that future interventions should focus on these high risk groups.

Male breast cancer: clinical-epidemiological characteristics of 1189 Brazilian patients

Abstract Purpose: To describe the clinical-epidemiological features of male patients with breast cancer in Brazil. Methods: Data from male patients with breast cancer treated from 2000 through 2009 were obtained from the Brazilian Hospital Cancer Register databases. Descriptive statistics were performed. Results: A total of 1189 male patients were included. The mean age at diagnosis was 59.6 years (± 13.6). Tumours were categorised as clinical stage I (14.3%), stage II (38.3%), stage III (34.1%) and stage IV (13.3%). The most frequent histological type was invasive ductal carcinoma (83.7%). The first course treatment (alone or combined) consisted of chemotherapy in 53.2%, surgery in 49.2, radiation therapy in 36.8 and hormonal therapy in 21.0%; 3.4% of cases did not receive treatment. Treatment modality varies according to the tumor-node-metastasis (TNM) stage. The inadequate response rate was 15.9%, and 7.4% of patients died after the first course of treatment. Adequate response according to the first-course cancer treatment, after adjusted for clinical stage, was associated with being Caucasian (odds ratio (OR) = 2.50; 95% confidence interval (95% CI): 1.35–4.65) and submitted to chemotherapy (OR = 0.46; 95% CI: 0.28–0.74). Conclusions: Male breast cancer diagnosis is often made in the advanced stage. Consequently, patients were subjected to more aggressive treatments, with poorer clinical response.

Comparison of adenocarcinoma (ACA) and squamous cell carcinoma (SCC) of the uterine cervix in a sub-optimally screened cohort: A population-based epidemiologic study of 51,842 women in Brazil

BACKGROUND Most cancers of the uterine cervix are SCC, but the relative and absolute incidence of ACA has risen in recent years, and ACA now accounts for approximately 20% of invasive cervical cancers in the screened populations worldwide. OBJECTIVE To compare the epidemiological, clinical characteristics, and treatment outcomes of ACA with those of SCC of the cervix in a sub-optimally screened population. METHODS Data from cervical cancer patients with SCC and ACA treated from 2000 through 2009 were obtained from the Brazilian Hospital Cancer Register databases. The summary odds ratios and chi-square tests were estimated. RESULTS A total of 51,842 patients including 45,540 (87.8%) cases of SCC and 6302 (12.2%) of ACA were analyzed. Compared with the ACA patients, the SCC patients were younger and more frequently black and had a higher degree of illiteracy and alcohol and tobacco consumers. The tumor stage at the time of diagnosis was also significantly different between the two groups. However, initial therapeutic response and death rate after the first course of treatment were similar in both groups. CONCLUSIONS Differences between ACA and SCC were observed for all demographic and clinical variables analyzed but not for responses to treatment and death at the end of the first course of treatment. Irrespective of the histological subtype, the quality of screening and treatment must be improved in developing countries, since initial therapeutic response of ACA and SCC is similar.

Alcohol consumption and the risk of cancer in Brazil: A study involving 203,506 cancer patients

This study aims to analyze the association between alcohol consumption and the risk of developing the most common types of cancer in the Brazilian population. It is a case-control study in which the most common types of cancer were considered as cases and non-melanoma skin cancers as controls. Data were routinely obtained by hospital-based cancer registrars. Individuals between 18 and 100 years old, diagnosed between January 1, 2000 and December 31, 2009, with information regarding alcohol consumption, were included. The odds ratio (OR) for each type of cancer was calculated, adjusting for confounding variables. The etiologic fraction (EF) was calculated in cases with statistically significant results. The study included 203,506 individuals (110,550 women and 92,956 men), with an average age of 59 years. A statistically significant association was found between alcohol consumption and increased risk of cancers of the respiratory and digestive systems, prostate, and female breast. The association between alcohol consumption and cancers of the urinary tract, male genital organs, and other neoplasias was not statistically significant. Consumption of alcoholic beverages increased the risk of developing cancer of the nasal cavity, pyriform sinus, oral cavity, oropharynx, nasopharynx, larynx, hypopharynx, lung, esophagus, stomach, liver, pancreas, breast, prostate, colon and rectum, and anus and anal canal.

Effectiveness of four inflammatory markers in predicting prognosis in 2374 women with breast cancer

OBJECTIVE To analyze the association between four biomarkers and overall survival in patients with breast cancer (BC). METHODOLOGY This cohort study had a sample of 2374 women over the age of 18, diagnosed and treated in a single reference center for BC in Brazil, during the year 2008-2009. The following pretreatment indices were analyzed: neutrophil-lymphocyte ratio (NLR), a derived neutrophil-lymphocyte ratio (dNLR), absolute neutrophil count (ANC) and platelet-lymphocyte ratio (PLR). A descriptive analysis was performed using median (range) and absolute and relative frequency as categorical variables. Exploratory survival evaluation was performed using the Kaplan-Meier method and the log-rank test for comparison between survival curves, with a statistical significance level of 5%. The variables with p<0.20 were selected for inclusion in a multivariate Cox regression model, considering as statistically significant p<0.05. RESULTS After adjusting for clinical variables, the biomarkers associated with worse overall survival were NLR >5 (HR=1.66 95%CI 1.08-2.55; p=0.021) and PLR >300 (HR=1.82 95%CI 1.10-2.99; p=0.019). When stratified by molecular subtype, the independent markers related to death were PLR >300 for triple negative (HR 3.27 95%CI 1.38-7.76; p=0.007); NLR >5 (HR 2.47 95%CI 1.16-5.28; p=0.019), ANC >7500 (HR 1.84 95%CI 1.17-2.90; p=0.008) and dNLR >3 (HR 2.45 95%CI 1.29-4.66; p=0.006) for luminal. CONCLUSION NLR and PLR are independent markers of prognosis in BC. Further studies are needed in patients with overexpression of HER 2.

Phase II trial of neoadjuvant chemotherapy followed by chemoradiation in locally advanced cervical cancer

OBJECTIVE Cervical cancer is a global public health challenge. Since 1999, platin based chemoradiation (CRT) is the standard treatment for those patients with locally advanced disease. However, this population still has a dismal prognosis and, alternatives approaches such as adjuvant chemotherapy are controversial, especially because of increased toxicity. Neoadjuvant chemotherapy (NACT) could be an option for more intensive treatment with manageable toxicity. METHODS A phase II, prospective, non-randomized trial was conducted at a reference center in Recife, Brazil. Locally advanced cervical cancer patients (Ib2-IVa) were treated with neoadjuvant cisplatin 35mg/m2 and gemcitabine 1000mg/m2 D1 and D8, for 2cycles. Then, they received CRT (50.4Gy) with weekly cisplatin 40mg/m2 followed by brachytherapy. Response rate (RR) and toxicity were the primary endpoints. Progression-free survival (PFS) and overall survival (OS) were secondary endpoints. RESULTS Between Sep/2013 and Oct/2015, 50 patients were initiated on NACT and CRT. RR was 81% at the end of treatment. Hematological and gastrointestinal toxicity were most common. Grade 3/4 toxicity was 20% during NACT and 44% during CRT. Late adverse events were present in 20% of patients. PFS at 1 and 3-years were 73.4% (IC 58.7-83.6) and 53.9% (IC 36.9-68.3), respectively; and, OS at 1 and 3-years were 93.9% (IC 82.4-98.0) and 71.3% (IC 53.3-83.3), respectively. CONCLUSION In our hands NACT in locally advanced cervical cancer patients did not show a meaningful improvement in ORR. Nevertheless, we believe it should be further explored in prospective trials.

Crises epilépticas no período neonatal: análise descritiva de uma população hospitalar

Objective: To investigate their incidence and lethality of neonatal epileptic seizures and their associated condi- tions.