Marcelo Bello

Male breast cancer: Overall survival in a single institution.

93 Background: Male breast cancer is an uncommon disease and the therapy is mainly based on what is know from female breast cancer. OBJECTIVE To investigate the clinicopathologic characteristics of male breast cancer and the overall survival in a single institution. METHODS The clinical data and survival status of 75 male breast cancer treated in a Brazilian public cancer hospital from 2000 to 2009 were collected. The association with clinicopathological characteristics and overall survival was analyzed using Kaplan-Meier curves and the Cox proportional hazards regression (enter method) was used to assess survival differences after adjusting for confounders. The study was approved by National Cancer Institute Research and Ethics Committee (number 128/11). RESULTS The median patient age was 64 years (range 33-86). Estrogen receptor (ER) was positive in 58 (77.3%) patients, while progesterone receptor (PR) were positive in 47 (62.7%). Histology type was ductal infiltrant carcinoma for 57 (76.0%) and 51 (68.0%) patients underwent surgery. The median follow-up period was 43,1 months (range 2.7-147.8). The median survival from the diagnosis of breast cancer was 97.0 months (95%CI 53.6 -140.4) with a 61.7% 5-year overall survival (OS). In the final Cox regression model, independent factors associated with increased risk of death were metastasis at diagnosis (HR = 18.1; 95%CI: 5.9-55.2), ≥ 65 years old (HR = 4.3; 95%CI: 1.7-10.5); tumor stages ≥ IIb (HR = 3.5; 95%CI: 1.3-9.7) and smoking (HR = 1.6; 95%CI: 1.04-2.6). CONCLUSIONS Invasive ductal carcinoma is the main pathologic type. The median survival from the diagnosis of breast cancer was 97.0 months and metastasis at diagnosis, patient age, tumor stage and smoking are independent prognostic factors.

Carcinoma microinvasor de mama: resultados em longo prazo

Objective: Microinvasive breast carcinoma (MBC) is an uncommon breast carcinoma subtype although an increase of screening mammography in recent decades has resulted in a higher incidence of ductal carcinoma in situ (DCIS), as well as invasive carcinomas at early stages. The objective of this research study was to review 115 cases of MBC from Brazilian National Cancer Institute between the years 2000 and 2010. Methods: The clinical presentation, diagnosis, type of treatment, clinical progression and the relevance of the axillary nodal status were analyzed. Results: The average patient age was 56 years old. Radiographic findings of calcifications on MBC lesions (68%) were similar to the findings seen on DCIS. Positive axillary metastasis was seen in 9.6% of the cases. After a follow up of on average eight years, one case of local recurrence and four cases of distal recurrence were seen. Overall survival was 95.6% and disease-free survival was 96.5%. Conclusion: Despite the possibility of nodal metastasis in our study, MBC has a favorable prognosis and it is associated with a low axillary nodal metastasis risk. Knowledge of clinical presentation and radiological findings of DCIS lesions may draw a physicians attention to the possibility of local microinvasion and the appropriate approach for each patient Objetivo: O carcinoma microinvasor de mama (CMM) e um subtipo incomum de carcinoma mamario; no entanto, o uso intensificado do rastreio mamografico nas ultimas decadas resultou no aumento da incidencia de carcinoma ductal in situ (CDIS) bem como no aumento da incidencia de carcinoma invasor de estagios iniciais. O objetivo deste estudo foi revisar uma serie de 115 casos de CMM do Instituto Nacional de Câncer no periodo de 2000 a 2010. Metodos: Foram avaliadas a apresentacao clinica, o diagnostico, o tipo de tratamento, a evolucao clinica e a necessidade de conhecimento do status axilar. Resultados: A media de idade das pacientes foi de 56 anos. A aparencia radiologica das calcificacoes encontrada nas lesoes de CMM (68%) mimetizou os achados vistos no CDIS. Axila positiva foi encontrada em 9,6% dos casos. Apos um seguimento medio de oito anos, foi observado um caso de recidiva loco regional e quatro casos de recidiva a distancia. A sobrevida global foi de 95,6% e a sobrevida livre de doenca, de 96,5%. Conclusao: Apesar do potencial de metastase nodal no nosso estudo, o CMM possui um bom prognostico e e associado ao baixo risco de metastase para linfonodos axilares. O conhecimento da clinica e da radiologia de lesoes com CDIS podera alertar ao medico sobre a possibilidade de microinvasao e orientacao do manejo adequado para cada paciente.

Impact of Treatment Type on Overall Survival in Elderly Brazilian Women with Breast Cancer

Objective: To analyze the survival of elderly patients with breast cancer according to the type of treatment used. Methods: A cohort study of women aged 80 or over with breast cancer registered with the Brazilian National Cancer Institute (Instituto Nacional do Câncer - INCA) between 2008 and 2009 was conducted. Prognosis was analyzed according to the cancer treatment performed: surgery, radiotherapy, or hormone therapy. Analysis of the overall 5-year survival rate was performed using the Kaplan - Meier method, and comparisons of curves were undertaken using the log-rank test. For multiple regression analysis, Cox regression was used, adjusting for age and clinical stage, considering values of p < 0.05 as significant. Data were all analyzed using the statistical package SPSS version 20. Results: 70 women with a mean age of 84.0 ± 3.7 years at diagnosis participated in the study. The median follow-up time was 37.1 months (range 0.5–75.5), and 31 deaths (44.3%) occurred during this time. The median survival time was 51.2 months (95% CI, 44.9–57.4), higher in those who underwent surgery (p = 0.012) and those who had hormone therapy (p=0.001). Treatment with surgery reduced the risk of death by 61.7% (HR 0.3; 95% CI, 0.1–0.6; p = 0.001) when adjusted for clinical stage and age at diagnosis. However, there was no significant benefit from radiotherapy (HR 1.2; 95% CI, 0.5–2.5; p = 0.694). Conclusion: Treatment with surgery and hormone therapy increased the survival of our Brazilian patients with breast cancer aged 80 or over.

Breast Sarcoma in a 16 Year-Old Girl

INTRODUCTION: Sarcomas are histologically heterogeneous nonepithelial tumors, which may develop in the connective tissue of the breast, only in around 4, 6 cases per million women/year. They represent less than 1% of all the breast cancers; however their grim prognosis implies an importance in the study of these tumors. Sarcomas usually occur in women over 45 years of age. Furthermore, these malignancies can be classified according to their histology, as fibrosarcoma, angiosarcoma, and pleomorphic sarcoma. The patient appears with a fast growing mass in her breast. The prognosis depends on stage and histological grade, and treatment is mainly surgery. This case report is of a teenager without any family history who developed this rare malignancy. CASE REPORT: APLV, female, 16 years old, white, natural from and resident in Rio de Janeiro, Brazil, student, single, was referred to the senology department for further investigation of breast mass. The patient denied any previous illnesses, contact with Tuberculosis or anything important in the family history. Her physical exam presented with a 20cm tumor occupying the whole left breast, stretching the skin but without infiltrating it, with a hard consistency, and an areas of fluctuation. This area was drained and the liquid was sent to pathology for research for neoplastic cells, Tuberculosis, and other pathogens. The axillary lymph nodes were not palpable. A core-biopsy of the tumor was performed for diagnosis, and the patient was submitted to a breast sonogram and mammography. The cytology showed no signs of disease. The result of the core- biopsy was malignant mesenchymal neoplasm. The sonogram and the mammography showed a large hypoechoic/hyperdense mass occupying all quadrants of the left breast, of about 14 cm, suggesting a solid lesion. The immunohistochemistry research showed fusiform cells neoplasm with intense pleomorphism and necrosis, positive for vimentine, and negative for CD31, CD34, estrogen receptor, progesterone receptor and CK5. The screening for metastatic disease was negative, and the patient was submitted to mastectomy with immediate reconstruction with skin graft. The final result from pathology of the left breast was a malignant mesenchymal neoplasm with necrosis, and pronounced nuclear pleomorphism and high mitotic index. Nipple, skin, and surgical margins free from neoplasm. The patient was followed up at the hospital for one year and she has had a favorable outcome, with good healing and no metastasis so far. DISCUSSION: The diagnosis of breast sarcoma is very rare, and it is usually followed by a poor prognosis for the patient. It is important to report the rare cases in order to further understand and to clarify the aspects of this disease. The patient in this case report, epidemiologically different from the usual breast sarcoma patient, shows that anything is possible in oncology.

Adequate Margin for Breast-Conserving Surgery: Is There Consensus Among Brazilian Experts?

INTRODUCTION: Breast-Conserving Surgery (BCS) followed by radiotherapy (RT) is the treatment of choice for women with early stage breast cancer. Nevertheless, there is no widely adopted definition of an adequate margin for invasive (IDC) or in situ ductal breast carcinoma (CDIS) in patients undergoing BCS. While it’s well accepted that positive margin is an important predictor of ipsilateral breast tumor recurrence, there is controversy about the required margin extent to provide oncologic safety. The lack of a standard definition among Brazilian surgeons and breast cancer treatment centers causes a very wide variation of re-excision rates. Our aim is to assess the current opinion about definition of negative margins among experts involved with breast cancer treatment in Brazil. METHODS: The questionnaire was sent to all experts in the Brazilian Society of Mastology mailing list. We’ve sent 1800 questionnaires by e-mail, using the Survey Monkey Software. The survey was about what should be considered as negative margin in DCIS and IDC. The response rate was 21. 9% (n= 395). RESULTS: Participants were between 30 and 50 years old in 63. 4% of cases and 62. 2% had over 10 years of professional practice. Free margin in DCIS, were considered negative when the tumor is not touching ink in 11. 6%; 1mm in 23.5%; 2mm in 24. 4%; 5mm in 13. 9% and 26. 6% endorsed 10mm as an adequate margin. In invasive carcinoma, 18. 7% considered negative margin when tumor is not touching ink, followed by 1mm(22. 3%), 2mm(19. 7%), 5mm(11. 9%) and 10mm(27. 3%). Regarding to the cases presented, we obtained the following responses: A 35 year old woman with a lump in the upper outer quadrant of her left breast, submitted to BCS and sentinel node biopsy (SNB). Histopathology showed an IDC, 2.5cm, triple negative, with an 1mm medial margin and sentinel node free from neoplasia. In this case 64. 1% opted for re-excision. If the same patient in the same scenario, but with a positive hormone receptor tumor, only 48. 9% would perform the re-excision. If the patient in the same scenario, with a triple negative tumor, but at the age of 70 years old, only 45. 8% of the participants would re-excise margins. DISCUSSION: This work shows the lack of consensus among experts in Brazil. Other studies have addressed this issue, as Taghian et al, published in 2005 where almost 46% of U. S. respondents required only “no tumor cells touching ink” to consider a margin as negative, while among Europeans only 27. 6% considered this alternative. Azu et al, showed in 2010 great variety of responses concerning to surgical margins. This reflects the diversity of opinions surrounding the issue. In a recent International Expert Panel published in 2010 it was defined “tumor not touching ink” as negative margin for ICD. For DCIS they recommend 2mm as appropriate. CONCLUSION: Despite the international consensus, we still find intense debate on this subject in Brazil. The standardization of an adequate margin is important as it affects the rate of reoperations, the rate of mastectomies and consequently, the costs.

Breast Cancer Survival Rate in a Cohort of Patients Treated in Brazilian National Cancer Institute in Rio de Janeiro, Brazil

BACKGROUND: This study estimates survival rates and its the main prognostic factors related, in women with breast cancer and submitted to local and systemic treatment in brazilian National Cancer Institute between 2001 to 2002. OBJECTIVES: The purpose of this study was to analyze five-year survival and the main prognostic factors among women with breast cancer diagnosed from 2001 to 2002 that had undergone surgical treatment in the Brazilian National Cancer Institute. MATERIAL AND METHODS: The survival curves were obtained in a hospital cohort of breast cancer with 1076 patients diagnosed and treated between 01/08/2001 and 01/12/2002, with median follow up time was 61 months (range 1 to 94 months) and mean patients age was 55, 9 years (standard deviation 13, 1). The Study variables were: age, marital status, tumor-related variables and the treatment-related variables. Survival functions were calculated by the Kaplan- Meier method. RESULTS: Among all patients, 23% performed neoadjuvant chemotherapy, 3% performed neoadjuvant hormone therapy and 2% performed neoadjuvant radiotherapy. A mastectomy was performed in 65%. In 84% of cases, lymphadenectomy was performed at the axillary level III with an average of 17 lymph nodes removed (SD 6. 40) and 46% had positive lymph nodes. Most had advanced pathological stage (57% II and 23% III) and 86% were ductal carcinoma infiltrante. O adjuvant treatment with chemotherapy was performed in 59%, the adjuvant radiotherapy performed in 63% and adjuvant hormone therapy in 68%. Patients were followed for a median 61 months (1-94), 16% of deaths occurred in the period, with average survival time of 82 months (95% CI 81-84) (Figure 1). In Kaplan-Meier analysis, the variables that were statistically associated with better overall survival were initial staging (p <0. 000), negative lymph nodes (p <0. 000), tumor size (p <0. 000), number of lymph nodes removed (p=0. 005), adjuvant chemotherapy (p = 0. 013) and neo-adjuvant (p <0. 000), adjuvant hormone therapy (p = 0. 001), CDI (p = 0. 005), conservative surgery (p <0. 000). CONCLUSION: Overall survival is similar to data found in the literature for staging. The results suggest the need for early diagnosis and treatment.

Incidence complications following sentinel lymph node biopsy or axillary lymph node dissection after breast cancer surgery.

97 Background: To reduce arm morbidity the sentinel lymph node biopsy was implemented in the breast cancer treatment. The aim of this study was to investigate the arm morbidity after sentinel lymph node biopsy or axillary lymph node dissection. METHODS This is a prospective cohort study of women who underwent surgical treatment of breast cancer at a single institution. Arm and shoulder morbidity were measured before, 1 and 6 months after the operation. Analyses were performed to compare morbidity between sentinel lymph node biopsy (SLND) and axillary lymph node dissection (ALND). This study obtained approval from the National Cancer Institute research and ethics committee. RESULTS Were included 203 patients and, during the study, 6 were excluded and there was 23 losses of follow-up. The average age of women was 58 years (DP=13). SLND was made in 31,6% with an average of 3 lymph nodes removed. Among those submitted to ALND, the average lymph node removed was 18 (p<0.0001). After 45 days of surgery, the incidence of arm morbidity was: 23% of shoulder restriction (ALND 22%, SLND 1%, p<0.001); 28% of axillar web syndrome (ALND 24%, SLND 4%, p<0.001); 38% of seroma (ALND 32%, SLND 6%, p<0.001); 5% of arm edema (ALND 4%, SLND 1%, p<0.001). In the final evaluation occurred 6 months after the surgery, it was observed de following incidence: 4% of shoulder restriction (ALND 3%, SLND 1%, p=0.371); 18% of arm pain (ALND 12%, SLND 6%, p=0.460); 18% of axillar web syndrome (ALND 16%, SLND 2%, p<0.002); 5% of arm edema (ALND 4%, SLND 1%, p=0.417). CONCLUSIONS After 45 days of surgery, patients with SLND has less arm morbidity compared with patients submitted to ALND. After 6 months, it was observed less incidence of arm symptoms and only axillary web syndrome were more incident in patients with axillary dissection.