RESUMO
Sentinel lymph node biopsy (SLNB) at upfront surgery is the gold-standard surgical method for axillary lymph node staging in early stage breast cancer: the technique provides adequate information regarding axillary status, with similar oncological safety and lower morbidity compared to axillary dissection, despite the false negative rates. Neoadjuvant chemotherapy (NACT), traditionally used for locally advanced breast cancer, plays an important role in the treatment of early stage breast cancer, making downstaging possible in axillary lymph node and breast cancer, thus minimizing the impact of surgery and reducing morbidity, as well as enabling patients with residual disease to be selected for adjuvant treatment. In this respect, the role of SLNB has proved controversial, particularly in view of the lack of data from randomized clinical trials on this subject. Currently, the de-escalation of axillary surgery after NACT is mainly based on retrospectives studies and false negative rates. This paper reviews current evidence on the management of axillary surgery following NACT under different circumstances, with suggested recommendations in each scenario: clinically negative nodes at diagnosis and SLNB after NACT, clinically positive nodes at diagnosis and SLNB after NACT, positive SLNB following NACT and finally the possibility of omitting axillary surgery in good responders.
Assuntos
Neoplasias da Mama , Biópsia de Linfonodo Sentinela , Humanos , Feminino , Biópsia de Linfonodo Sentinela/métodos , Terapia Neoadjuvante/métodos , Metástase Linfática , Estadiamento de Neoplasias , Excisão de Linfonodo/métodos , Linfonodos/patologia , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/cirurgia , Neoplasias da Mama/patologiaRESUMO
BACKGROUND: Triple-negative breast cancer (TNBC) is a heterogenous subtype involving different patterns of behavior and clinical course, demanding a complex, individualized sequence of treatment. The knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology regarding TNBC were evaluated and a consensus regarding management and treatment was reached. METHODS: Affiliates completed a survey involving 44 objective questions. In addition, a specialist meeting was held with 27 experts and 3 ad hoc consultants. The panelists completed the survey before and after brainstorming. Answers achieving 70% of agreement were considered consensual. The chi-square test was used to compare answers between panelists and affiliates and the Kappa coefficient to calculate agreement. RESULTS: Consensus among the panelists increased from 26 (59.1%) to 32 questions (72.7%) following brainstorming (p = 0.17), including 7/10 questions on systemic treatment. Among the affiliates, consensus was achieved for 24 questions (54.5%), resulting in moderate agreement (κ = 0.445). Neoadjuvant chemotherapy should be indicated for almost all cases (except cT1a-b N0) and should include platinum agents. When indicated, immunotherapy is part of the standard of care. The panel reaffirmed the concept of no ink on tumor as indicative of adequate margins and the possibility of sentinel lymph node biopsy for cN1 patients who become cN0 following neoadjuvant therapy. Controversies remain on combining immunotherapy with capecitabine/olaparib in pertinent cases. CONCLUSION: Expert consensus was achieved for > 70% of the questions, with moderate agreement between panelists and affiliates. Educational interventions on systemic breast cancer treatment affected decision-making in 60% of the questions.
Assuntos
Neoplasias de Mama Triplo Negativas , Humanos , Neoplasias de Mama Triplo Negativas/diagnóstico , Neoplasias de Mama Triplo Negativas/terapia , Brasil , Terapia Neoadjuvante , Imunoterapia , CapecitabinaRESUMO
PURPOSE: The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC. METHODS: An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery. RESULTS: The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation. CONCLUSIONS: Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.
Assuntos
Antineoplásicos Hormonais/uso terapêutico , Antineoplásicos/uso terapêutico , Neoplasias da Mama/terapia , Infecções por Coronavirus , Mamoplastia , Mastectomia , Terapia Neoadjuvante , Pandemias , Pneumonia Viral , Adulto , Betacoronavirus , Brasil , Neoplasias da Mama/genética , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , COVID-19 , Atenção à Saúde , Gerenciamento Clínico , Feminino , Genes BRCA1 , Genes BRCA2 , Humanos , Masculino , Mastectomia Segmentar , Pessoa de Meia-Idade , Seleção de Pacientes , Pós-Menopausa , Pré-Menopausa , Mastectomia Profilática , Receptor ErbB-2/metabolismo , Receptores de Estrogênio/metabolismo , Receptores de Progesterona/metabolismo , SARS-CoV-2 , Sociedades Médicas , Inquéritos e Questionários , Carga TumoralAssuntos
Antineoplásicos Hormonais/uso terapêutico , Neoplasias da Mama/terapia , COVID-19/complicações , Atenção à Saúde/normas , Mastectomia/estatística & dados numéricos , Terapia Neoadjuvante/estatística & dados numéricos , SARS-CoV-2/isolamento & purificação , Brasil/epidemiologia , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/virologia , COVID-19/transmissão , COVID-19/virologia , Terapia Combinada , Gerenciamento Clínico , Feminino , HumanosRESUMO
The present paper reports on the local treatment of breast cancer from a historical perspective. A search for articles written in English was made in the Medline and EMBASE databases, and 40 papers were selected. Over the past 10 years, various randomized, controlled clinical trials on the local treatment of breast cancer indicated that patients with the same molecular subtype may receive different individualized surgical treatments aimed at optimizing systemic adjuvant therapy. With a view to retaining the gains made in disease-free and overall survival, surgical techniques have advanced from radical surgery to conservative mastectomies, thus reducing sequelae, while adjuvant and neoadjuvant therapies have contributed toward controlling the disease, both distant metastases and local recurrence. Current studies evaluate whether future breast cancer therapy may even succeed in eliminating surgery to the breast and axilla altogether.
Este artigo discute o tratamento local do câncer de mama a partir de uma perspectiva histórica. Uma busca de artigos publicados em inglês foi realizada nas bases de dados Medline e EMBASE, sendo selecionados 40 artigos. Nos últimos 10 anos, vários ensaios clínicos controlados e randomizados sobre o tratamento local do câncer de mama indicaram que pacientes com o mesmo subtipo molecular podem receber diferentes tratamentos cirúrgicos individualizados com o objetivo de otimizar a terapia adjuvante sistêmica. Pretendendo reter os ganhos obtidos na sobrevida livre de doença e na sobrevida global, as técnicas cirúrgicas avançaram progressivamente da cirurgia radical para mastectomias conservadoras, reduzindo sequelas, enquanto as terapias adjuvantes e neoadjuvantes contribuíram para o controle da doença, tanto em relação às metástases distantes quanto à recorrência local. Estudos atuais avaliam se a terapia futura contra o câncer de mama poderá até mesmo eliminar a cirurgia da mama e da axila por completo.
Assuntos
Neoplasias da Mama/terapia , Quimioterapia Adjuvante , Mastectomia Segmentar , Terapia Neoadjuvante , Feminino , Humanos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Abstract The present paper reports on the local treatment of breast cancer from a historical perspective. A search for articles written in English was made in the Medline and EMBASE databases, and 40 papers were selected. Over the past 10 years, various randomized, controlled clinical trials on the local treatment of breast cancer indicated that patients with the samemolecular subtypemay receive different individualized surgical treatments aimed atoptimizing systemic adjuvant therapy. With a view to retaining the gainsmade in diseasefree and overall survival, surgical techniques have advanced from radical surgery to conservative mastectomies, thus reducing sequelae, while adjuvant and neoadjuvant therapies have contributed toward controlling the disease, both distant metastases and local recurrence. Current studies evaluate whether future breast cancer therapy may even succeed in eliminating surgery to the breast and axilla altogether.
Resumo Este artigo discute o tratamento local do câncer de mama a partir de uma perspectiva histórica. Uma busca de artigos publicados em inglês foi realizada nas bases de dados Medline e EMBASE, sendo selecionados 40 artigos. Nos últimos 10 anos, vários ensaios clínicos controlados e randomizados sobre o tratamento local do câncer de mama indicaram que pacientes com o mesmo subtipo molecular podem receber diferentes tratamentos cirúrgicos individualizados como objetivo de otimizar a terapia adjuvante sistêmica. Pretendendo reter os ganhos obtidos na sobrevida livre de doença e na sobrevida global, as técnicas cirúrgicas avançaram progressivamente da cirurgia radical para mastectomias conservadoras, reduzindo sequelas, enquanto as terapias adjuvantes e neoadjuvantes contribuíram para o controle da doença, tanto em relação às metástases distantes quanto à recorrência local. Estudos atuais avaliam se a terapia futura contra o câncer de mama poderá até mesmo eliminar a cirurgia da mama e da axila por completo.
Assuntos
Humanos , Feminino , Neoplasias da Mama/terapia , Mastectomia Segmentar , Quimioterapia Adjuvante , Terapia Neoadjuvante , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Background: Nipple-sparing mastectomy (NSM) has been performed for breast cancer treatment and for women at high risk. NSM provides better aesthetic outcomes; however, its oncological safety is still controversial. Objective: To evaluate the surgical complications, oncological safety and aesthetic satisfaction of breast cancer patients undergoing NSM with immediate breast reconstruction operated by the same medical team in a Breast Cancer Center in Brazil. Method: From 2004 to 2011, an aesthetic satisfaction questionnaire was administered to women undergoing NSM followed by immediate breast reconstruction 30 or 60 days after surgery. Aesthetic satisfaction, complication rates and oncological safety were analyzed. Results: Thirty-six breast cancer patients who underwent NSMs followed by immediate reconstruction answered the questionnaire. Most of them considered their results good (51%) or great (43%) and all patients will recommend NSM as a therapeutic treatment for other women with breast cancer. Only one patient presented infection and loss of the mammary implant, and recurrence rates were satisfactory (5.5%). Conclusion: Our findings showed low complication rate, oncological safety and good aesthetic outcome related to NSM with immediate reconstruction in patients from a Breast Cancer Center in Brazil. Despite the limitations of our study, we support the use of NSM with immediate reconstruction for a better aesthetic outcome with oncological safety.
Introdução: A Mastectomia Poupadora do Mamilo (MPM)tem sido realizada em tratamentos de câncer de mama e em mulheres em situação de risco. A cirurgia traz melhores resultados estéticos; todavia, a sua segurança oncológica ainda é controversa. Objetivo: Avaliar as complicações cirúrgicas, a segurança oncológica e a satisfação estética de pacientes com câncer de mama submetendose à MPM com reconstrução imediata da mama operadas pela mesma equipe médica em um centro de câncer de mama no Brasil. Método: De 2004 a 2011, um questionário de satisfação estética foi administrado a mulheres submetidas à MPM seguida de reconstrução imediata de mama 30 ou 60 dias após a cirurgia. Foram analisadas a satisfação estética, as taxas de complicações e a segurança oncológica. Resultados: Trinta e seis pacientes com câncer que se submeteram a MPMs seguidas de reconstrução imediata responderam ao questionário. A sua maioria considerou os resultados bons (51%) ou ótimos (43%) e todos os pacientes a recomendarão como tratamento terapêutico a outras mulheres com câncer de mama. Apenas uma paciente apresentou infecção e perda do implante mamário, e as taxas de recorrência foram satisfatórias (5,5%). Conclusão: Nossas descobertas mostraram baixa taxa de complicação, segurança oncológica e bom resultado estético relacionado à MPM com reconstrução imediata em pacientes de um centro de câncer de mama no Brasil. Apesar das limitações do nosso estudo, nós apoiamos o uso da MPM com reconstrução imediata para um melhor resultado estético com segurança oncológica.
RESUMO
Fibroadenoma is the most common benign tumor of the breast but giant juvenile fibroadenoma represent only 0.5% of all fibroadenomas and when bilateral are much more rare. We describe the case of a 25 years old girl that presented with bilateral giant juvenile fibroadenomas and was treated by bilateral skin reducing mastectomy using the inferior dermal flap, implant, and free nipple graft.