Breast cancer neoadjuvant endocrine therapy and COVID-19: a renewed breath with future perspectives

In 2020, the COVID-19 pandemic is the major healthcare concern around the world. The infection is especially severe to those with immune system suppression, including patients with cancer. In order to mitigate the negative effects of COVID-19, guidelines have been developed by societies worldwide to review oncology care during this pandemic time. Neoadjuvant endocrine therapy (NET) is a well-stablished option for hormone positive (HR) HER2 negative breast cancer and showed a positive response in breast conservative surgery with substantially less toxicity. Compared to chemotherapy, the NET cost is lower, and its administration is easier, due to less medical visits. Even with remarkable advantages, NET remains taking less place in treatments than it might have. Periods of humanity crisis, such as World Wars and other pandemics, boosted the development of science and established many treatments, which are currently practiced. New data generated during the COVID-19 outbreak can inspire more trials comparing chemotherapy to endocrine therapy within the neoadjuvant setting. The purpose of this letter is to suggest NET as a safe low toxicity treatment strategy for breast cancer, not only to postpone breast cancer surgery during the pandemic, but also to become a standard therapy, a flame kept burning crossing the COVID-19 border.

Breast metastasis of gastric signet ring cell carcinoma mimicking breast lymphangitic carcinomatosis / Metástase mamária de carcinoma gástrico em anel de sinete simulando linfangite carcinomatosa da mama

Introduction: The incidence of breast metastasis from gastric adenocarcinoma is extremely low. Since 1908, 44 cases have been reported in the literature, of which 30 are signet ring cell type. Case report: A 49-year-old patient being investigated for digestive bleeding was found to have left axillary lymphadenopathy, associated with breast asymmetry, associated with breast asymmetry, edema and thickening of the skin. Breast ultrasonography showed a heterogeneous lesion in the left breast. Core biopsy histology was compatible with Lauren diffuse gastric adenocarcinoma with signet ring cells. There was positive immunohistochemical staining for CK7, CK20 and CDX2 and negative for RE, RP and ERB2. Our findings were compatible with gastric adenocarcinoma (lymphatic embolism), favoring the possibility of a secondary neoplasm. At the time of diagnosis, the patient already had radiological signs of multiple metastases. Discussion: Breast metastases of gastric carcinoma differ from primary breast cancer in histopathological features. The clinical manifestations of gastric cancer metastasis vary, but it is known that there is a greater tendency for inflammatory disorders compared to primary tumors. In the metastatic process, breast involvement may be the first event or occur in a context of multiple metastases. Most patients have a one-year survival after diagnosis. There is no gain in survival with breast surgery, but it can alleviate the symptoms in some cases. Conclusion: Gastric cancer with breast metastasis is a rare condition associated with poor prognosis. The diagnosis is based on clinical history, histological findings and immunohistochemical markers, differing from primary tumors of the breast, to provide patients with adequate treatment.

Introdução: A incidência de metástase mamária de adenocarcinoma gástrico é extremamente baixa. De 1908 até o momento, 44 casos foram relatados na literatura, dos quais 30 são do tipo em anel de sinete. Relato do caso: Paciente de 49 anos em propedêutica de sangramento digestivo alto. Apresentava linfadenomegalia axilar esquerda, associada a assimetria mamária, edema e espessamento de pele. Ultrassonografia mamária evidenciou lesão heterogênea em mama esquerda. Histologia de core biopsy da área compatível com adenocarcinoma gástrico tipo difuso de Lauren, com células em anel de sinete. Imuno-histoquímica positiva para pancitoqueratinas CK7, CK20, CDX2 e negativa para RE, RP e ERB2. Achados compatíveis com adenocarcinoma gástrico (embolia linfática), favorecendo a possibilidade de neoplasia secundária. Ao momento do diagnóstico, a paciente já apresentava sinais radiológicos de múltiplas metástases. Discussão: As metástases mamárias do carcinoma gástrico diferem do câncer de mama primário nas características histopatológicas. As manifestações clínicas das metástases de câncer gástrico são variadas, mas é sabido que há tendência maior de alterações inflamatórias que nos tumores primários. No processo metastático, o envolvimento mamário pode ser o primeiro evento ou ocorrer em um contexto polimetastático. A maioria dos pacientes tem sobrevida inferior a um ano. Não há ganho de sobrevida com a cirurgia de mama, mas ela pode aliviar os sintomas em alguns casos. Conclusão: O câncer gástrico com metástase na mama é uma condição rara associada a mau prognóstico. O diagnóstico é baseado em história clínica, achados histológicos e marcadores imuno-histoquímicos, o que diferencia a metástase de um tumor primário da mama, a fim de oferecer aos pacientes o tratamento adequado.

SYSTEMATIC CAVITY SHAVING IN ONCOPLASTIC BREAST SURGERY / Ampliação sistemática das margens cirúrgicas na cirurgia oncoplástica da mama

Introduction: Conservative breast surgery has changed considerably in recent decades. Breast remodeling after conservative surgery is a surgical approach that has good oncological and cosmetic results. The surgical margin of oncological breast surgery has been shown to be a limiting factor, because a considerable percentage of patients undergo additional procedures, which increases costs and morbidity. Objective: To describe the experience of the establishment of systematic cavity shaving in conservative breast surgery and the benefits of this technique. Methods: This is a retrospective study, which evaluated information contained in patient records at the Campinas Breast Institute between 2009 and 2015. Systematic cavity shaving consists of the removal of tissue around the tumor in a thickness of 1 cm, and 2 cm in the other axes. Medial, lateral, cranial, inferior, deep and superficial margins are evaluated. Results: In a total of 94 cases with systematic cavity shaving, 18 (20%) reoperations were avoided. Only two patients required further surgery. Conclusion: It is a simple and reproducible procedure, which does not affect the final aesthetic result, and aims to provide disease-free surgical margins, avoiding reoperation and delayed adjuvant treatment.

Introdução: A cirurgia conservadora da mama tem se modificado consideravelmente nas últimas décadas. O remodelamento mamário pós-cirurgia conservadora apresenta-se como uma forma de abordagem cirúrgica com bons resultados oncológicos e cosméticos. A margem cirúrgica das cirurgias oncológicas da mama tem se mostrado um fator limitante, pois um percentual considerável das pacientes é submetido a novos procedimentos, aumentando os custos e a morbidade. Objetivo: Descrever a experiência da instituição de ampliação sistemática das margens cirúrgicas na cirurgia conservadora de mama e os benefícios dessa técnica. Métodos: Estudo retrospectivo, que avaliou informações contidas em prontuário de pacientes do Instituto de Mama de Campinas, entre os anos de 2009 e 2015. A ampliação sistemática das margens consiste na retirada de tecido em torno do tumor, com espessura de 1 cm e dimensões de 2 cm nos demais eixos. São avaliadas margens medial, lateral, cranial, inferior, profunda e superficial. Resultados: Em um total de 94 casos com realização de ampliação sistemática das margens cirúrgicas, foram evitadas 18 (20%) reoperações. Apenas duas pacientes necessitaram de nova cirurgia. Conclusão: Trata-se de um procedimento simples e reprodutível, que não prejudica o resultado estético final, e que visa oferecer margens cirúrgicas livres de doença, evitando a reoperação e o atraso do tratamento adjuvante.