Rosemar Macedo Sousa Rahal

Incidence trend for breast cancer among young women in Goiânia, Brazil

CONTEXT AND OBJECTIVE It has been suggested that there has been a large increase in breast cancer incidence among young women over the last decade. The aim of this study was to describe the incidence of breast cancer among young women up to 39 years of age in Goiânia, between 1988 and 2003, and to compare this with other age groups. DESIGN AND SETTING Retrospective study using the database of the Population-based Cancer Registry of Goiânia, State of Goiás, Brazil. METHODS The incidence was calculated according to age groups: up to 39 years, 40 to 59 years and 60 years and over. Average annual percentage changes (AAPCs) were estimated for the different age groups using Poisson regression. RESULTS Over this period, 3,310 new cases were recorded. The standardized incidence was 2.89/100,000 in 1988 and increased to 6.37/100,000 in 2003 (R(2) = 0.52) for the group aged up to 39 years (p < 0.003). For the group from 40 to 59 years old, the incidence was 14.39/100,000 in 1988 and 41.70/100,000 in 2003 (R(2) = 0.85; p < 0.001). For the group aged 60 years and over, it was 17.62/100,000 and 28.49/100,000, respectively (R(2) = 0.67; p < 0.001). The AAPCs were 5.22%, 5.53% and 4.54% for the age groups up to 39, 40 to 59 and 60 years and over, respectively. CONCLUSIONS The incidence of breast cancer among young women in Goiânia has been increasing significantly, although this change was similar to the increase in other age groups.

Contribution of the Unified Health Care System to mammography screening in Brazil, 2013

Objective To estimate the coverage of opportunistic mammography screening performed via the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System), at the state and regional level, in 2013. Materials and Methods This was an ecological study in which coverage was estimated by determining the ratio between the number of mammograms performed and the expected number of mammograms among the population of females between 50 and 69 years of age. The number of mammograms performed in the target population was obtained from the Outpatient Database of the Information Technology Department of the SUS. To calculate the expected number of mammograms, we considered 58.9% of the target population, the proportion that would be expected on the basis of the recommendations of the Brazilian National Cancer Institute. Results In 2013, the estimated national coverage of mammography screening via the SUS was 24.8%. The mammography rate ranged from 12.0% in the northern region to 31.3% in the southern region. When stratified by state, coverage was lowest in the state of Pará and highest in the state of Santa Catarina (7.5% and 35.7%, respectively). Conclusion The coverage of mammography screening performed via the SUS is low. There is a significant disparity among the Brazilian states (including the Federal District of Brasília) and among regions, being higher in the south/southeast and lower in the north/northeast.

Performance of diagnostic centers in the classification of opportunistic screening mammograms from the Brazilian public health system (SUS)

Objective To evaluate the performance of diagnostic centers in the classification of mammography reports from an opportunistic screening undertaken by the Brazilian public health system (SUS) in the municipality of Goiânia, GO, Brazil in 2010. Materials and Methods The present ecological study analyzed data reported to the Sistema de Informacao do Controle do Câncer de Mama (SISMAMA) (Breast Cancer Management Information System) by diagnostic centers involved in the mammographic screening developed by the SUS. Based on the frequency of mammograms per BI-RADS® category and on the limits established for the present study, the authors have calculated the rate of conformity for each diagnostic center. Diagnostic centers with equal rates of conformity were considered as having equal performance. Results Fifteen diagnostic centers performed mammographic studies for SUS and reported 31,198 screening mammograms. The performance of the diagnostic centers concerning BI-RADS classification has demonstrated that none of them was in conformity for all categories, one center presented conformity in five categories, two centers, in four categories, three centers, in three categories, two centers, in two categories, four centers, in one category, and three centers with no conformity. Conclusion The results of the present study demonstrate unevenness in the diagnostic centers performance in the classification of mammograms reported to SISMAMA from the opportunistic screening undertaken by SUS.

Mammary Duct Ectasia: An Overview

To the Editor: Mammary duct ectasia (MDE) is a benign abnormality characterized by dilatation of the mammary ducts (1). The frequency of MDE may range from 1.1% (2) to 75% (3), according to the diagnostic method used, which might be clinical, histopathological or necropsy-based (2–4). MDE occurs most often in women around menopause (5,6), also being able to occur in younger women (5), children (7), and men (8). Some degree of dilatation of the ducts occurs with aging, and this can be considered as a normal involution of the breast tissue (3,9). The present review was conducted to identify the most relevant information on the different aspects of MDE. Studies were identified by means of a bibliographic search in the following databases: Pubmed, Lilacs, and SciELO, covering the years from 1951 to 2009. The descriptors used to identify the articles were breast, duct, and ectasia. Some authors (10) have described a relationship between abnormal secretion of prolactin and MDE. About the relationship of smoking to MDE, there is divergence in the literature. Some studies have not shown a correlation between smoking and MDE (11,12), whereas others have demonstrated a correlation (6,9,13), indicating that smoking increases by five times the risk of MDE (6). Haagensen (1) described the mechanism of MDE as a dilatation of the retroareolar duct because of the accumulation of debris and lipid material in the duct lumen. An alternative mechanism considered that the process would begin with inflammation surrounding the duct, and would be followed by fibrosis and finally, duct dilatation (14). Some authors have hypothesized that duct ectasia might be because of the bacterial contamination by anaerobic and aerobic agents (6). Other authors (15) studied cultures from mammillary fluids of patients with duct ectasia and compared these with cultures from mammillary swabs from patients without mammillary secretions. The same flora was isolated in both groups, thus dismissing the possibility that ectasia might be an infectious process. The initial phase of duct dilatation is usually asymptomatic, and the ratio of symptoms to incidental findings is 1:2 (4). When symptomatic, the commonest clinical presentation consists of mammillary secretion. This is frequently bilateral, coming through several ducts, and may present colors of light and dark tone ranging from white and light yellow to dark yellow, greenish chestnut, and black (1,9,11,15). Besides mammillary discharge, a patient may present mastalgia, tumors, or alteration in the nipple areola complex (NAC) (4). The diagnosis of MDE usually is clinical, reserving complementary examinations for cases of papillary flow with suspicious characteristics. The mammographic findings can be asymmetric or include calcification, which can simulate a carcinoma (16). Ultrasonography allows duct diameters greater than 5 mm to be diagnosed and measured (17). It should be remembered that ultrasonography is an easily reproducible, noninvasive examination of low cost. Ductography and cytology of mammillary discharges offer a limited role as a diagnostic method for MDE (18). Histologically, the initial phase of MDE is characterized by the presence of dilatation of duct terminals (1). The basal membrane starts to present small openings that further facilitate the migration of histiocytes. The lesioned duct wall and adjacent parenchyma present an intense inflammatory reaction, and a foreign body granulomatous reaction may be generated. Following this, the inflammatory process is replaced by fibrosis (19). Although a rare situation in childhood, an MDE may be manifested as a bloody mammillary discharge (7). In this context, the management of MDE is expectant, as this condition usually resolves spontaneously after 6–9 months (7). Another situation in which MDE is rare is in men. Discharge and mammillary retraction are the forms of clinical presentation, although the presence of an Address correspondence and reprint requests to: Rosemar Macedo Sousa Rahal, MD, PhD, Rua 6-A, N 54, Apto 801 Setor Oeste, 74115-080, Goiânia-Goiás, Brazil, or e-mail: rosems@terra.com.br.

Modified radical mastectomy sparing one or both pectoral muscles in the treatment of breast cancer: intra and postoperative complications

CONTEXT AND OBJECTIVE Modified radical mastectomy is widely utilized in breast cancer treatment. However, no prospective comparison has yet been made between the Madden technique (preservation of the pectoralis minor muscle) and the Patey technique (resection of this muscle). The aim of this work was to compare these two modified radical mastectomy techniques, by analyzing their degrees of difficulty and complications. DESIGN AND SETTING Randomized trial at the Breast Unit of Hospital Araújo Jorge, Goiás; and Faculdade de Medicina da Universidade Federal de Goiás. METHODS 430 patients with breast cancer with an indication for modified radical mastectomy were included in the program, of whom 426 patients were available for analysis (225 allocated to Patey and 201 to Madden). The chi-squared and Student t tests were used for analysis. RESULTS The patients demographics were well balanced between the two groups. The mean duration of the surgical procedures was 105 (+/- 29.9) and 102 minutes (+/- 33), for the Patey and Madden groups, respectively (p = 0.6). Hospitalization duration was 2.3 days for both groups. The mean number of lymph nodes resected was 20.3 (+/- 7.6) for Patey and 19.8 (+/- 8.1) for Madden (p = 0.5). There were no differences in terms of vascular or nerve sections, hematomas or infections. The surgeons reported the same degree of difficulty for the two methods. CONCLUSION The removal of the pectoralis minor muscle did not influence any of the variables studied. Therefore, either technique can be performed, at the surgeons discretion.

Prevalence of bacteria in the nipple discharge of patients with duct ectasia

The aim of this study was to identify the aerobic and the anaerobic microorganisms which can be related to duct ectasia. The patients were divided into two groups. Group 1 comprised 100 patients with coloured nipple discharge (duct ectasia group), and Group 2 (the control group) was composed of 50 patients without nipple discharge. The culture media used were BHI‐PRAS, blood agar, mannitol agar and MacConkey agar. There was a high frequency of bacterial growth in the two groups: 85% in Group 1 and 88% in Group 2. The most prevalent bacteria were Staphylococcus aureus and Staphylococcus epidermidis. There was a statistically significant higher rate of smokers in the duct ectasia group compared with the control group, 25 (25%) patients vs. 5 (10%), respectively (p = 0.03). These findings allow us to put forth the hypothesis that the genesis of duct ectasia may be a non‐infectious inflammatory process.

Trends in breast cancer surgery at Brazil's public health system

To analyze time trend patterns in Breast Cancer (BC) surgeries performed at Brazils Public Health System, known as SUS from 2008 to 2014.

Variação temporal do tratamento cirúrgico do câncer de mama em um hospital universitário na região Centro-Oeste do Brasil

OBJECTIVE: To assess the types of surgical treatments for breast cancer performed by the Mastology program of the Clinics Hospital, Federal University of Goias (HC-UFG). METHODS: We conducted a cross-sectional, cohort study on the breast operations performed at HC-UFG from January 2002 to December 2009. We evaluated the surgical records for: surgical time and size, surgeon, type of operation, diagnosis, and type of anesthesia. The medical charts were researched for: pathology report of the tumor, lymph node involvement, primary tumor size, staging and performance of neoadjuvant therapies. We excluded operations for the removal of benign breast tumors. The temporal variation was analyzed using Poisson regression, considering the annual percentage change (APC). RESULTS: 403 operations were performed for breast cancer during the study period, with an average of 50.38 operations per year. The most common histological type was invasive ductal carcinoma (72.6%). The mean age of patients was 52 years, and 29% had disease in stages III and IV. The temporal trend revealed a significant increase in tumor size (p <0.01), the clinical stages III and IV (p = 0.01) and the use of neoadjuvant chemotherapy (p = 0.02). There was increase in mastectomies (APC = 9 cases/year, p = .04). There was no increase in cases of breast conservation treatments or of mastectomies with immediate reconstruction. CONCLUSION: In recent years, the HC-UFG has had an increased number of mastectomies as a result of increased incidence of locoregionally advanced breast cancer.

Análise comparativa da técnica da incisão em duplo círculo com as técnicas com incisão periareolar e transareolomamilar de correção cirúrgica da ginecomastia

PURPOSE: to compare the double-circle (DC) technique to other techniques, with periareolar (PA) and transverse nipple-areolar (TNA) incisions, for the surgical correction of gynecomastia. METHODS: we studied the medical files of 34 patients from the Federal University of Goias, submitted to the surgical correction of gynecomastia, from 1999 to 2004. Patients were divided according to the surgical technique used. The parametric numeric variables were compared by Tukey test. The c2 or the Fishers exact test was used for nominal variables. It was considered significant a p value<0.05. RESULTS: the mean age of the patients was 27.9 (+12.5) years. There were 43 gynecomastias, 34 unilateral (79.1%) and nine (20.9%) bilateral. There were 19 breasts operated (44.2%) using DC, 14 (33.6%) using PA incision, and 10 (23.3%), TNA incision. The mean drain usage was five days for DC and one day for the others (p<0.01). The suction drain was used in 19 cases (100%) of DC and two (22%) in TNA. The other patients used drains of Penrose (p<0.01). The mean surgical time was significantly larger for DC (73 minutes) than for PA (45 minutes) and for TNA (48 minutes). DC was used mainly in voluminous gynecomastias (p=0.04). The complications consisted in three (33%) hematomas in TNA (p<0.01) and one (5%) in DC; one (11%) infection in TNA; two (10%) partial necrosis of the nipple in DC; four (21%) enlarged scars in DC (p=0.04); three (16%) hypertrofic scars (p=0.08) in DC; one (2%) inversion of nipple with TNA. CONCLUSIONS: The DC was used often in voluminous gynecomastias. It was a good and secure operation, although it required a more extensive surgical time and had a larger possibility of distended scars.

Complete axillary dissection without drainage for the surgical treatment of breast cancer: a randomized clinical trial

OBJECTIVE: This randomized clinical trial evaluated the possibility of not draining the axilla following axillary dissection. METHODS: The study included 240 breast cancer patients who underwent axillary dissection as part of conservative treatment. The patients were divided into two groups depending on whether or not they were subjected to axillary drainage. ClinicalTrials.gov: NCT01267552. RESULTS: The median volume of fluid aspirated was significantly lower in the axillary drainage group (0.00 ml; 0.00 – 270.00) compared to the no drain group (522.50 ml; 130.00 - 1148.75). The median number of aspirations performed during conservative breast cancer treatment was significantly lower in the drainage group (0.5; 0.0 - 4.0) compared to the no drain group (5.0; 3.0 - 7.0). The total volume of serous fluid produced (the volume of fluid obtained from drainage added to the volume of aspirated fluid) was similar in the two groups. Regarding complications, two cases (2.4%) of wound dehiscence occurred in the drainage group compared to 13 cases (13.5%) in the group in which drainage was not performed, with this difference being statistically significant. Rates of infection, necrosis and hematoma were similar in both groups. CONCLUSION: Safety rates were similar in both study groups; hence, axillary dissection can feasibly be performed without drainage. However, more needle aspirations could be required, and there could be more cases of wound dehiscence in patients who do not undergo auxiliary drainage.