Sérgio Bighetti

Differential diagnosis of axillary masses.

Axillary masses are uncommon alterations when detected as an isolated finding. We evaluated 31 patients with isolated axillary masses. Patients with alterations of the breasts or the upper limbs or with ipsilateral chest lesions were excluded from the study. Nine patients had occult breast cancer, 5 of them in the contralateral breast. Seven had metastatic lymph nodes of non-ductal origin, and 1 had carcinoma of apocrine cells with metastasis to the axilla. Four patients had benign lymphadenopathy which disappeared spontaneously, and 4 others had ruptured infundibular follicular cyst, nodular fibromatosis, inflammatory tuberculous and inflammatory rheumatoid lymphadenitis. Five had an ectopic breast (2 with a fibroadenoma and 3 with fibrocystic changes). One patient had an axillary lipoma. The mean age of patients with malignant pathology was 55.1 ± 10.9 years, and the mean age of patients with a benign pathology was 43.1 ± 14.7 (P <0.01). Chest X-ray and bilateral mammography are useful when the cause of the mass cannot be determined by taking a detailed history of neoplastic or infectious antecedents, by careful physical examination of the skin of the arms, trunk and neck, or by palpation of the breasts and thyroid. Fine needle aspiration biopsy distinguishes between benign and malignant pathologies. In cases of indeterminate neoplasia, complete axillary dissection for diagnosis is indicated.

Tumor-infiltrating CD4+ T lymphocytes in early breast cancer reflect lymph node involvement

BACKGROUND The role of immune system in the pathogenesis and progression of breast cancer is a subject of controversy, and this stimulated us to investigate the association of the immunophenotype of tumor-infiltrating lymphocytes in early breast cancer with the spread of tumor cells to axillary lymph nodes. METHODS Tumor samples from 23 patients with early breast cancer from the Department of Gynecology and Obstetrics of Ribeirão Preto Medical School (USP) were obtained at the time of biopsy and submitted to an enzyme-digestion procedure for the extraction of tumor-infiltrating lymphocytes. The lymphocytes extracted were analyzed by dual-color flow cytometry with monoclonal antibodies in these combinations: CD3 FITC/CD19 PE, CD3 FITC/CD4 PE, CD3 FITC/CD8 PE, and CD16/56 PerCP, which are specific for immunophenotyping of T and B lymphocytes, helper and cytotoxic T lymphocytes, and natural killer (NK) cells. The mean percentage of these cells was used for comparing groups of patients with or without lymph node metastasis. RESULTS The mean value for T-lymphocyte infiltration was 24.72 +/- 17.37%; for B-lymphocyte infiltration, 4.22 +/- 6.27%; for NK-cell infiltration, 4.41 +/- 5.22%, and for CD4(+) and CD8(+) T-lymphocyte infiltration, 12.43 +/- 10.12% and 11.30 +/- 15.09%, respectively. Only mean values of T- and CD4(+) T-lymphocyte infiltration were higher in the group of patients with lymph node metastasis, while no differences were noted in the other lymphocyte subpopulations. CONCLUSION The association of tumor-infiltrating CD4(+) T lymphocytes with lymph node metastasis suggests a role for these cells in the spread of neoplasia to lymph nodes in patients with early breast cancer.

Lymphocyte subpopulations in patients with advanced breast cancer submitted to neoadjuvant chemotherapy.

Aims and background There is an enhanced immune response in patients with breast cancer after the use of chemotherapy. The objective of this study was therefore to investigate alterations in the number of peripheral lymphocytes in patients with breast cancer after neoadjuvant chemotherapy (NC) and the relationship with prognosis. Methods Thirty women were analyzed. Their UICC staging was IIb (only T3N0 included) and III (N3 not included). Sample analysis was performed using flow cytometry before the first cycle and 18 to 21 days after the last cycle of NC. The lymphocyte subsets studied were: T (CD3, CD4, CD8), B (CD19, CD23), natural killer (NK) (CD56, CD16), and interleukin-2 (CD25). CD3, CD56, CD8, and CD16 lymphocytes were analyzed with double marking. After x = 3.8 ± 1.3 cycles of 5-fluorouracil, epirubicin and cyclophosphamide (FEC), 16 patients showed a complete or partial response (group 1). After three cycles 14 showed no response or tumor progression (group 2). A control group of healthy women was used for pretreatment analysis. Results Before NC there was a significant increase in B lymphocytes and NK cells in comparison to the control group. After NC there was a significant percentage increase in CD3, CD4, CD8, CD25 and CD3+CD56+ cells and a decrease in CD19, CD23, CD56, CD16 and CD16+CD8+ cells. There was a significant fall in the absolute number of CD4, CD19, CD23, CD56, CD16 and CD16+CD8+ lymphocytes and an increase in GD3+CD56+ lymphocytes. Before NC the ratio CD4/CD8 in group 1 was 2.25 ± 0.5 and in group 2 it was 1.79 ± 0.5 (P <0.05). Conclusions Patients with advanced breast cancer showed increases in B and NK lymphocytes. Neoadjuvant chemotherapy (FEC) caused an increase in CD3+CD56+ and a decrease in B lymphocytes. Patients with an increased CD4/CD8 ratio have a better chance of responding to neoadjuvant chemotherapy.

CA 125 and Vascular Endothelial Growth Factor in the Differential Diagnosis of Epithelial Ovarian Tumors

Tumor markers have been investigated in differentiation of benign and malignant tumors. We analyzed CA 125 and vascular endothelial growth factor (VEGF) levels in serum and cyst fluid in patients with epithelial ovarian tumors. Serum and tumor cyst fluid of 50 patients with ovarian epithelial tumors (7 malignant, 3 bordeline and 40 benign) were assayed for VEGF by ELISA and CA 125 levels by chemoluminescence. CA 125 serum levels were significantly higher in patients with malignant and borderline tumors than in patients with benign cysts (p = 0.0005). CA 125 cyst fluid contents were comparable for malignant, borderline and benign ovarian tumors (p = 0.39). Significantly higher levels of VEGF were present in cyst fluid for malignant and borderline tumors compared with benign cysts (p < 0.0001); however, serum levels of VEGF were similar among all patients (p = 0.25). The CA 125 serum levels correlated with matched VEGF cyst fluid levels (r = 0.44, p = 0.0015). Serum CA 125 and cystic VEGF were good methods to differentiate benign and malignant epithelial ovarian tumors. Patients with elevated intracystic VEGF levels presented significantly higher CA 125 serum levels, although the CA 125 intracystic content overlapped. The angiogenesis and enhancement of vascular permeability induced by VEGF represents a new hypothesis for the release of the CA 125 antigen into the circulation in patients with ovarian epithelial neoplasm.

Selection of Criteria for the Treatment of Ovarian Cysts on the Bases of Ultrasound and Cytology

The major objective of the present study was to determine whether leakage of ovarian cyst cells occurs when the cysts are punctured inside a container with saline. Other subjectives were to determine the sensitivity and specificity of cytology in the differentiation between malignant and benign cysts by comparing cytology data with histology data, and also to determine whether ultrasound can provide consistent evidence for predicting whether the cyst is benign or malignant, thus permitting the selection of patients with benign cysts for puncture rather than surgical exeresis. A cytologic study was carried out on the contents of 62 ovarian cysts diagnosed by ultrasound and clinical examination, and excised from 51 patients submitted to exploratory laparotomy. The cyst was excised and immersed in a container with saline outside the surgical field. The cyst was punctured and its contents aspirated through the wall of the container. Five samples were obtained for cytology: (1) presurgical abdominal wash; (2) saline before cyst puncture; (3) fluid from the punctured cyst; (4) saline after cyst puncture, and (5) postoperative abdominal wash. The materials obtained were submitted to centrifugation and slides of the precipitate were prepared for cytology. A total of 248 slides were studied. Slides of cysts with good cellularity were stained with silver to study the nucleolar organizer regions. Analysis using Kappa statistics showed excellent agreement between the cytologic and histologic diagnoses (p < 0.001). The sensitivity of the cytologic study of the cyst was 75% and the specificity 100%, with a positive predictive value of 100%, a negative predictive value of 92%, and 93% accuracy. The present results led us to conclude that cell leakage into physiological saline occurred after puncture and that cytologic study of cysts valuable in the diagnosis of benign and malignant processes.

Tumores pélvicos em mulheres na pós-menopausa

Purpose: to evaluate clinical and ultrasonic findings in patients with pelvic tumors at postmenopause and to correlate them with the final diagnosis. Patients and Methods: thirty-six postmenopausal women with pelvic tumor diagnosis were prospectively evaluated through clinical examination and endovaginal ultrasonography. Clinical follow-up with no surgical procedures was indicated for anechoic cystic tumors with or without thin unique septation and volume under 50 cm3. Needle aspiration was indicated for tumors with the same aspect, and volume of 50 to 100 cm3, whereas exploratory laparotomy was performed in the remaining patients. Diagnosis defined two groups of patients: benign (28) and malignant (8) pathologies. Results: anechoic cystic tumor with or without a thin septum indicates benignity (p = 0.0091). Tumors with solid areas indicate malignancy (p = 0.0024). Ascites correlates with malignancy (p = 0.0278). Heterogeneity, thick capsule, thick septa, and papillary projections predominated in malignancies but without no statistical significance (p > 0,05). Tumor volume indicates malignancy, with a median of 85.2 cm3 in benign tumors and 452.5 cm3 in malignancies (p = 0.0048), with a cutoff at 295 cm3 (sensitivity = 83.3% and specificity = 85.2%). Following this protocol, all malignancies were submitted to surgery and 11 benign tumor patients were treated with a conservative protocol (39.3% of all benign patients). Conclusion: conservative management is an adequate protocol for women with anechoic pelvic tumors with low volume, with or without single thin septum and without ascites. Differentiation between benign and malignant of complex and/or high volume tumors requires complementary investigation.

Punção biópsia aspirativa (PBA) com agulha fina no diagnóstico diferencial de patologias da mama

A puncao biopsia aspirativa (PBA) e um metodo simples e isento de complicacoes, de grande valor em mastologia. Sua acuracia diagnostica pode sofrer a influencia de diversos fatores, dos quais podemos destacar a experiencia do medico que a realiza. Com o objetivo de verificar a eficacia da PBA realizada por ginecologistas gerais, foram estudadas 341 pacientes correlacionando-se os resultados da PBA com o diagnostico histopatologico da lesao mamaria. Obtivemos sensibilidade de 70,87%, especificidade de 70,58%, valor preditivo positivo de 92,40%, valor preditivo negativo de 89,36% e acuracia de 70,67%. Concluimos que a PBA e de grande auxilio na abordagem das lesoes mamarias e pode ser realizada adequadamente por ginecologistas gerais. O metodo, contudo, pode apresentar erros de diagnostico. Nao recomendamos, portanto, o uso do resultado da PBA como diagnostico definitivo, devendo este resultado ser interpretado no contexto do diagnostico clinico e mamografico da lesao mamaria.

Estudo da correlação entre o estadiamento clínico e as alterações esqueléticas das metástases ósseas do câncer da mama

Forty-eight breast cancer patients with bone metastases were studied aiming to evaluate the correlation between clinical staging of the primary tumor, according to the Cancer Staging American Committee protocol, and the skeletal manifestations of the bone metastases; the assessment parameters were the follow-up period, the number of metastases, the type of the lesions, their localization, and the affected bone region. A correlation was found between the primary lesion staging and the follow-up period, which was reduced when the staging degree increased; no correlation was observed between breast cancer clinical staging and the other parameters.

Hemangiosarcoma of the breast followed by term pregnancy.

Aims and background Primary angiosarcoma of the breast is an unusual neoplasm which is generally associated with a dismal prognosis. Given the poor prognosis and the predominance in the third and fourth decades of life when fertility tends to decrease, reports of term pregnancies after treatment of this disease are rare. Methods and study design We report a case of angiosarcoma of the breast in a 17-year-old patient with a recurrent breast nodule treated by local surgery only. After three years of follow-up without evidence of disease recurrence she became pregnant. Results A girl weighing 2,430 g was delivered at 38 weeks and two days. The patient has been free of disease for five years now. Conclusions Our experience of the present case shows the lack of full information about this tumor. Pregnancy does not seem to interfere negatively with the course of the disease.

Sangramento maciço em cirurgia onco-ginecológica: uso do pack hemostático

Purpose: to introduce the use of the hemostatic pack, a tampon consisting of compresses tied to the bleeding surface and left in place for 48 to 72 h and which is one of the therapeutic alternatives to be used in this situation. Patients and Methods: we evaluated 3 cases of massive bleeding during surgery, with the exchange, on average, of 1.4 blood volumes (1.2-2.4), in terms of hemostatic effectiveness of the pack and of some patient parameters such as age and amount and type of volume infused. Results: the mean age of the patients was 57 years (51, 56 and 64). Only one had been previously irradiated. The bleeding was of venous origin, from the fossa of the obturator nerve, the iliac plexus and the presacral plexus. The volume expander most often used was 0.9% physiological saline solution, followed by blood derivatives and by Ringer lactate. Two patients were submitted to ligation of the hypogastric vein during surgery, with no improvement. The use of hemostatic synthetic material was inefficient in all three cases. In one of the patients, the use of nonabsorbable sutures to close the bleeding area led to a considerable reduction of bleeding, but did not eliminate it completely. One patient died before 24 h had elapsed, with signs and symptoms of heart failure. The other two patients developed acute renal failure and one of them developed aspirative pneumonia during surgical reexploration. Conclusion: massive bleeding is related to high morbidity and mortality. Among the emergency measures used for hemostasis, the pack seems to be the most adequate.