Marcio de Almeida Salles

Importância da segunda opinião em patologia cirúrgica mamária e suas implicações terapêuticas

PURPOSE: to evaluate the agreement between histopathologic diagnoses of breast lesions made by general pathologists and by a specialist in breast pathology. METHODS: a cohort retrospective study comparing histopathologic diagnoses of 329 cases of breast lesions received in consultation for a second opinion was carried out. The material received for consultation included slides (152 cases), paraffin blocks (59 cases) or slides and blocks (118 cases). Cases were reviewed and the original diagnoses and diagnoses from a specialist in breast pathology were compared. The main diagnoses, nuclear grade of ductal carcinoma in situ, and the histopathologic grade of invasive mammary carcinomas were evaluated. The kappa index and percentual concordance were used in the statistical analyses. RESULTS: a moderate agreement was observed between the original histopathologic diagnoses and the second opinion (kappa index=0.48; percentual concordance=59.9%). The diagnosis of malignancy was confirmed in 185/225 cases (82.2%) and diagnosis of benign lesions was confirmed in 89/104 cases (85.6%). The highest agreement was observed in the diagnosis of invasive mammary carcinomas (81%) and the highest disagreement was observed among diagnoses of ductal carcinoma in situ with microinvasion (74%), lobular carcinoma in situ (70%), and atypical epithelial hyperplasias (61%). There was a moderate agreement in the nuclear grade of ductal carcinoma in situ (kappa index=0.52; percentual concordance=68.8%), and good concordance in the histologic grade of invasive carcinomas (kappa index=0.61; percentual concordance=74.3). CONCLUSIONS: the results show higher concordance rate in the diagnosis of invasive carcinomas and lower concordance in the diagnosis of ductal carcinoma in situ with microinvasion and premalignant breast lesions, especially lobular neoplasia in situ, and atypical epithelial hyperplasias.

Treinamento e critérios padronizados aprimoram o diagnóstico de lesões pré-malignas da mama

PURPOSE to analyze interobserver variability in the histopathological diagnosis of premalignant breast lesions before and after training with diagnostic standardized criteria. METHODS Slides containing histological sections representative of three kinds of breast lesions (atypical ductal hyperplasia, ductal carcinoma in situ and ductal carcinoma in situ with microinvasion), revised by an international specialist in breast pathology whose diagnoses were considered as golden standard, have been used. The same slides have been evaluated at two different times by five pathologists from the community according to a specific protocol for classifying the lesions. In the first evaluation, the cases were analyzed and classified according to the specific criteria adopted in each service. At the second time, the pathologists were given a tutorial containing diagnostic criteria and representative images, and the lesions were classified again, employing the standardized criteria. Interobserver analysis using percent agreement and weighted Kappa index has been performed. RESULTS There has been a large diagnostic variation among the pathologists in the initial analysis without the use of standardized diagnostic criteria concerning the diagnostic, nuclear grade and histological grade (weighted Kappa indexes related to diagnosis varied from 0.15 to 0.40). In the second evaluation using standardized criteria, there has been a significant improvement in the diagnostic concordance among the five pathologists concerning the diagnosis, nuclear grade and histological grade (weighted Kappa indexes related to diagnosis have varied from 0.42 to 0.80). CONCLUSIONS interobserver concordance related to diagnosis and classification of breast premalignant lesions may be improved with specific training and the use of standardized histopathological criteria.

Consultoria em patologia cirúrgica mamária: variabilidade interobservador no diagnóstico de lesões proliferativas intraductais atípicas

PURPOSE To evaluate the agreement about the histopathological diagnosis of intraductal proliferative breast lesions between general pathologists and a specialist in breast pathology. METHODS This was an observational, cross-sectional study of 209 lesions received in consultation at the Breast Pathology Laboratory of the School of Medicine, Federal University of Minas Gerais, from 2007 to 2011, comparing the original diagnosis and the review. We included only cases with a formal request for review and cases in which the original diagnosis or reviewers diagnosis showed proliferative lesions, pure ductal carcinoma in situ, ductal carcinoma in situ associated with microinvasion or associated with invasive carcinoma. The kappa index and percent concordance were used in the statistical analyses. RESULTS A moderate agreement was observed between the original histopathological diagnosis and the second opinion (kappa=0.5; percentual concordance=83%). After the review, the diagnosis of malignancy was confirmed in 140/163 cases (86%) and the diagnosis of benign lesions was confirmed in 34/46 cases (74%). Regarding specific diagnosis, we observed moderate agreement between the original diagnosis and the reviewers diagnosis (136/209 cases; kappa=0.5; percent concordance=65%). The highest disagreement was observed in cases of ductal carcinoma in situ with microinvasion (6/6 cases; 100%). Important discordance was observed in cases of atypical ductal hyperplasia (16/30 cases; 53%) and ductal carcinoma in situ (25/75 cases; 33%). Regarding the histological grade of ductal carcinoma in situ, we observed good agreement between the original diagnosis and the review (29/39 cases; kappa=0.6, percent agreement=74%). CONCLUSION Our data confirm that intraductal proliferative breast lesions, especially atypical ductal hyperplasia, ductal carcinoma in situ and ductal carcinoma in situ with microinvasion show relevant discrepancies in the histopathological diagnoses, which may induce errors in therapeutic decisions.

Contribuição da imuno-histoquímica na avaliação de fatores prognósticos e preditivos do câncer de mama e no diagnóstico de lesões mamárias

OBJETIVO: Fazer analise critica da contribuicao da imuno-histoquimica na avaliacao de fatores preditivos/prognosticos do câncer de mama, na pesquisa de micrometastases em linfonodos sentinela e no diagnostico diferencial de lesoes mamarias. METODOS: Foi realizado estudo observacional retrospectivo de todos os casos de lesoes mamarias e linfonodos sentinelas submetidas a estudo imuno-histoquimico no Laboratorio de Patologia Mamaria da Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG) entre 2001 e 2007. Os casos foram classificados de acordo com a indicacao do estudo imuno-histoquimico em tres categorias: avaliacao de fatores preditivos/prognosticos, pesquisa de celulas epiteliais metastaticas em linfonodos sentinela e definicao diagnostica. RESULTADOS: Foram realizados exames imuno-histoquimicos de 1.294 casos, totalizando 4.101 reacoes com 21 anticorpos diferentes. Na maioria dos casos, a imuno-histoquimica foi realizada para avaliacao de fatores preditivos/prognosticos (1.106 casos, 85,5%), seguido de pesquisa de celulas epiteliais metastaticas em linfonodos sentinelas (134 casos, 10,6%) e diagnostico diferencial de lesoes mamarias (51 casos, 3,9%). Obtiveram-se reacoes de boa qualidade com importante contribuicao do estudo imuno-histoquimico em 1.247 casos (96,4%). Em 47 casos (3,6%), o resultado foi inconclusivo devido a problemas de fixacao (autolise) da fase pre-analitica. CONCLUSAO: Nossos dados confirmam ser o estudo imuno-histoquimico importante ferramenta para avaliacao de fatores preditivos e prognosticos do câncer de mama, pesquisa de micrometastases em linfonodos sentinelas e diagnostico diferencial de lesoes mamarias. A maior utilizacao da imuno-histoquimica foi para avaliacao de fatores preditivos e prognosticos do câncer de mama.

Avaliação de microcalcificações mamárias de acordo com as classificações do Breast Imaging Reporting and Data System (BI-RADS TM) e de Le Gal

PURPOSE: the aim of this study is to evaluate the accuracy of mammography in the diagnosis of suspicious breast microcalcifications, using BI-RADSTM and Le Gals classifications. METHODS: one hundred and thirty cases were selected with mammograms contain only microcalcifications of file and initially classified as suspicious (categories 4 and 5) without lesions clinical detectable and reclassified by two examiners, getting a consensus diagnosis. The biopsies were reviewed by two pathologists getting also a consensus diagnosis. Both, mammogram and histopathologic analysis were double blinded reviewed. Qui-square test, Fleiss-square statistic and EPI-INFO 6.0 were used in this study. RESULTS: the correlation between histopathological and mammographic analysis using BI-RADSTM and Le Gal classification showed the same sensitivity of 96.4%, specificity of 55.9 and 30.3%, positive predictive value (PPV) of 37.5 and 27.5%, and accuracy of 64.6 and 44.6% respectively. The PPV by BI-RADSTM categories was: category 2, 0%; category 3, 1.8%; category 4, 30.8%; and category 5, 60%. The PPV by Le Gal classification was: category 2, 3.1%; category 3, 18.1%; category 4, 26.4%;category 5, 66.7%, and non classified 5.2%. CONCLUSIONS: the results were better for the classification of BI-RADS™, but it did not get to reduce the ambiguity in assessment of breast microcalcifications.

Ductal carcinoma in situ of the breast: correlation between histopathological features and age of patients

BackgroundThe histopathological subtype, nuclear grade and presence or absence of comedonecrosis are established as critical elements in the reporting of ductal carcinoma in situ (DCIS) of the breast. The aims of this study were to determine the frequencies of morphological subtypes of DCIS, nuclear grade and comedonecrosis; to compare the age of patients with the histopathological characteristics of DCIS, and to assess the agreement of grade between in situ and invasive components in DCIS cases that were associated with invasive carcinoma.MethodsWe evaluated a series of 403 cases of DCIS, pure or associated with invasive mammary carcinoma, consecutively identified from the histopathology files of the Breast Pathology Laboratory, Federal University of Minas Gerais, Brazil, from 2003 to 2008.ResultsDCIS displayed a single growth pattern in most cases (55.1%) and the solid subtype was the most common morphology (42.2% of the total). High-grade DCIS was identified in 293/403 cases (72.7%) and comedonecrosis was present in 222/403 cases (55%). Among DCIS with a single architectural pattern, high grade was more common in the solid subtype (151/168 cases, 89.9%; p < 0.001). Only 32% of tumours with a cribriform pattern had high nuclear grade. Comedonecrosis was more common in the solid morphology than in the cribriform, papillary and micropapillary subtypes (p < 0.001). Patients with high-grade DCIS were younger in relation to patients with low-grade DCIS (p = 0.027) and patients with tumours with comedonecrosis were also younger in comparison to patients with tumours without comedonecrosis (p = 0.003). Fair agreement was observed between in situ and invasive components with regard to grade (weighted kappa = 0.23).ConclusionsThe high nuclear grade and the presence of comedonecrosis were identified more frequently in younger patients and more often correlated with the solid pattern of DCIS.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_227

Carcinoma ductal in situ da mama: critérios para diagnóstico e abordagem em hospitais públicos de Belo Horizonte

PURPOSE: to evaluate the clinical, radiological therapeutic and anatomo-pathological aspects in a series of patients with breast ductal carcinoma in situ (DCIS), attended in three public hospitals in Belo Horizonte (MG). METHODS: 179 cases of DCIS, that were selected from all the patients who had been diagnosed with breast cancer between 1985 and 2000, were studied retrospectively. After reviewing all the tissue sections, it was possible to collect all the clinical data, mammogram and treatment information of 85 cases. RESULTS: most patients were not symptomatic and the diagnosis had been done by mammogram (68.2%), being the microcalcification the most common radiological alteration. There has been a progressive increase in the diagnosis of DCIS along the years, following the introduction of periodical mammographic screening. The initial histopathological diagnosis and the review agreed in 72.9% of cases. In three cases, the original diagnosis of DCIS was not confirmed, being classified as atypical hyperplasia. Mammogram microcalcifications were confirmed in the pathological analysis in 95.6% of cases. Half of the patients was treated with mastectomy. All lymph nodes from axillary dissection were negative for metastases. CONCLUSIONS: The present study is in agreement with the recent literature, which shows an increase in the diagnosis of DCIS since 1990. There has been a great interobserver variation since the initial pathological diagnosis, which tended to malignancy and the present review. There were a great number of radical treatments, such as mastectomy and axillary dissection, which would probably be replaced by conservative treatment and sentinel lymph node biopsy nowadays, according to recent knowledge.