Renato Zocchio Torresan

Evaluation of Residual Glandular Tissue After Skin-Sparing Mastectomies

BackgroundThe oncological safety of skin-sparing mastectomy (SSM) has been the object of several studies.MethodsFrom June 2003 to January 2004, 42 breast cancer patients, stage 0 to IIIA, underwent SSM. Before surgery, two lines were drawn on the breast skin, representing SSM and conventional mastectomy incisions. After surgery, the skin flap that would remain after SSM was removed, and immediate breast reconstruction was begun. The presence and amount of remaining glandular breast tissues were histologically evaluated in the skin flap. Terminal ductal lobular units (TDLUs) and residual disease were identified. These data were correlated with other clinical and pathologic parameters by using Fisher’s exact test (P value) and receiver operating characteristic curves.ResultsThe prevalence of residual breast tissue in the sample was 59.5%, and the presence of TDLUs was significantly associated with skin flaps thicker than 5 mm. Residual disease was found in 9.5% of the women and was associated with skin flaps >5 mm thick and the presence of TDLUs. There was no significant association between the presence of TDLUs and residual disease with age, body mass index, menopausal status, clinical and pathologic staging, breast volume, mammographic density, neoadjuvant chemotherapy, type of surgery, and presence of an extensive in situ component. The receiver operating characteristic curve showed that as skin flaps decrease in thickness, TDLUs also decrease.ConclusionsA high prevalence of glandular breast tissue and residual disease in the skin flap was associated with a skin flap thickness >5 mm.

Impact of the preservation of the intercostobrachial nerve in axillary lymphadenectomy due to breast cancer.

Abstract:  This study evaluated the relationship between preservation of the intercostobrachial (ICB) nerve and pain sensitivity of the arm, the total time of the surgery, and the number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. An intervention, prospective, randomized, and double blind study was performed on 85 patients at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to whether the ICB nerve was preserved or not. The surgeries were performed by the same surgeons, utilizing the same technique. The postoperative evaluations were performed at 2 days, 40 days, and 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurologic examination (objective evaluation). The surgical technique presented a feasibility of 100% and preservation of the ICB nerve was related to a significant decrease in the pain sensitivity of the arm, both in the subjective and objective evaluations. After 3 months, in the subjective evaluation, 61% of the patients were asymptomatic in the ICB nerve preservation group, with 28.6% in the nerve section group (p < 0.01). In the objective evaluation, 53.7% of the patients presented normal neurologic examination in the ICB nerve preservation group, with 16.7% in the nerve section group (p < 0.01). No significant difference was observed in the total time of the surgery (p = 0.76) and the number of dissected nodes between the two groups (p = 0.59). Local relapse was not observed in any group after 36 months of follow‐up. These data support that preservation of the ICB nerve is feasible and leads to a significant decrease in the alteration of pain sensitivity of the arm, without interfering with the total time of the surgery, the number of dissected nodes, and local relapse rate. 

Fibroadenoma in axillary supernumerary breast: case report

CONTEXT Supernumerary breast tissue may be affected by the same diseases and alterations that compromise topical breast tissue. Nevertheless, reports of fibroadenoma in supernumerary breast tissue in the axillae are rare. OBJECTIVE To describe a case of fibroadenoma in an axillary supernumerary breast. DESIGN Case report. CASE REPORT A 39-year-old woman was referred to the gynecology and obstetrics outpatient clinic at Hospital Estadual Sumaré, complaining of bilateral axillary masses. The patient reported cosmetic problems and local pain and discomfort. On physical examination, alterations compatible with bilateral axillary accessory breasts, without palpable nodules, were observed. Supplementary examinations (mammography and ultrasonography) revealed a 1.1 cm mass in the right axillary breast. The patient underwent resection of the supernumerary breasts and histopathological examination revealed fibroadenoma of the right axillary breast tissue.

Simple rules for ultrasonographic subcategorization of BI-RADS ® -US 4 breast masses

OBJECTIVES To evaluate an objective method for ultrasonographic (US) subcategorization of BI-RADS(®)-US 4 breast masses based on clear and simple rules in order for woman to benefit from a more complete and homogeneous breast mass analysis. METHODS In this cross-sectional study, we selected 330 women, with 339 US breast masses, classified as BI-RADS(®)-US 4. Three physicians experienced in breast imaging independently reviewed all US images, assessing mass shape, margins, orientation, echo texture and vascularity. These experts further subdivided the masses into subcategories 4a, 4b and 4c, according to simple US rules. Inter-observer agreement was calculated for US features categories and for final subcategory assessment. We also estimated the positive predictive value (PPV) for BI-RADS(®)-US subcategories 4a, 4b and 4c assigned by each of the three observers. RESULTS Pathological examination of all masses confirmed 144 (42%) malignant and 195 (58%) benign tumors. Moderate agreement was obtained for mass shape, margins, vascularity and for final BI-RADS(®)-US 4 subcategory. Substantial agreement was obtained for the description of mass orientation and echo texture. The PPV for subcategories 4a, 4b and 4c were, 17%, 45% and 85%, respectively, for the first observer and 20%, 38% and 79% and 17%, 40% and 85% for the other two observers. CONCLUSION Standardization of a US subcategorization of BI-RADS(®)-US 4 breast masses seems to be feasible, with substantial inter-observer agreement and progressive increase in the PPV in the subcategories 4a, 4b and 4c, provided that clear and simple classification rules are defined.

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.

Preservação do Nervo Intercostobraquial na Linfadenectomia Axilar por Carcinoma de Mama

Purpose: to evaluate the relationdhip between preservation of the intercostobrachial nerve and pain sensitivity of the arm, total time of the surgery, and number of dissected nodes in patients submitted to axillary lymphadenectomy due to breast cancer. Methods: an intervention, prospective, randomized and double-blind study was performed on 85 patients assisted at the State University of Campinas, Brazil, from January 1999 to July 2000. The patients were divided into two groups, according to the intention of preserving or not the intercostobrachial nerve. The surgeries were performed by the same researchers, utilizing the same technique. The postoperative evaluations were performed within 2 days, 40 days and after 3 months. The pain sensitivity of the arm was evaluated through a specific questionnaire (subjective evaluation) and through a neurological physical examination (objective evaluation). Results: the surgical technique was applied to all patients and the preservation of the intercostobrachial nerve was related to a significant decrease in the alterations of pain sensitivity of the arm, both by the subjective and objective evaluations. After three months, in the subjective evaluation, 61% of the patients were asymptomatic in the intercostobrachial nerve preservation group and 28.6% in the nerve section group (p<0.01). By the objective evaluation, 53.7% of the patients presented normal neurological examination in the intercostobrachial nerve preservation group and 16.7% in the nerve section group (p<0.01). No significant difference was observed regarding total time of surgery (p=0.76) and number of dissected nodes between the two evaluated groups (p=0.59). Conclusions: these data show that the preservation of the intercostobrachial nerve is feasible and leads to a significant decrease in the alterations of pain sensitivity of the arm, without interfering in the total time of surgery and the number of dissected nodes.

Randomized clinical trial on the preservation of the medial pectoral nerve following mastectomy due to breast cancer: impact on upper limb rehabilitation

CONTEXT AND OBJECTIVE Systematic modifications to the surgical technique of mastectomy have been proposed with the objective of minimizing injuries to the pectoral nerves and their effects. The aim of this study was to compare muscle strength and mass of the pectoralis major muscle (PMM) and abduction and flexion of the homolateral upper limb following mastectomy among women with breast cancer undergoing either preservation or sectioning of the medial pectoral nerve (MPN). DESIGN AND SETTING Randomized, double-blind, clinical trial on 30 women with breast cancer who underwent mastectomy between July 2002 and May 2003 in Campinas, Brazil. METHODS The women were allocated to a group, in which the MPN was preserved, or to another group in which it was sectioned. Fishers exact and Wilcoxon tests were used to analyze the data, along with Friedman and ANOVA analysis of variance. RESULTS In the MPN preserved group, 81% of the women did not lose any PMM strength, compared with 31% in the sectioned MPN group (confidence interval, CI = 1.21; relative risk, RR = 2.14; P < 0.03). There were no differences between the groups regarding muscle mass (CI = 0.32; RR = 0.89; P = 0.8), shoulder abduction (CI = 1.36; RR = 0.89; P = 0.28) and shoulder flexion (CI = 1.36; RR = 1.93; P = 0.8). CONCLUSIONS Preservation of the MPN was significantly associated with maintenance of PMM strength, compared with nerve sectioning. No differences in muscle mass or in abduction and flexion of the homolateral shoulder were found between the groups. CLINICAL TRIAL REGISTRATION NUMBER ANZCTR - 00082622.

Nova classificação dos carcinomas da mama: procurando o luminal A

PURPOSE:To compare the distributions of patients with clinical-pathological subtypes of luminal B-like breast cancer according to the 2011 and 2013 St. Gallen International Breast Cancer Conference Expert Panel.METHODS:We studied 142 women with breast cancer who were positive to estrogen receptor and had been treated in Sao Paulo state, southeast Brazil. The expression of the following receptors was assessed by immunohistochemistry: estrogen, progesterone (PR) and Ki-67. The expression of HER-2 was measured by fluorescent in situ hybridization analysis in tissue microarray.RESULTS:There were 29 cases of luminal A breast cancers according to the 2011 St. Gallen International Breast Cancer Conference Expert Panel that were classified as luminal B-like in the 2013 version. Among the 65 luminal B-like breast cancer cases, 29 (45%) were previous luminal A tumors, 15 cases (20%) had a Ki-67 >14% and were at least 20% PR positive and 21 cases (35%) had Ki-67 >14% and more than 20% were PR positive.CONCLUSIONS:The 2013 St. Gallen consensus updated the definition of intrinsic molecular subtypes and increased the number of patients classified as having luminal B-like breast cancer in our series, for whom the use of cytotoxic drugs will probably be proposed with additional treatment cost.

Complex Breast Masses Assessment of Malignant Potential Based on Cyst Diameter

The purpose of this study was to assess whether cyst diameter might contribute to the prediction of malignancy in complex breast masses.

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).