Reconstrucción mamaria inmediata en el Instituto Nacional de Oncología y Radiobiología de Cuba / Immediate Breast Reconstruction at the National Institute of Oncology and Radiobiology of Cuba

RESUMEN Introducción: La reconstrucción mamaria inmediata disminuye el impacto psicológico del cáncer de mama y mejora la calidad de vida de las pacientes. Objetivo: Evaluar la simetría en la reconstrucción mamaria inmediata en el Instituto Nacional de Oncología y Radiobiología de Cuba. Método: Se realizó un estudio analítico y prospectivo, de cohorte incidente, en el Servicio de Cirugía Reconstructiva del Instituto Nacional de Oncología y Radiobiología de 2014 al 2017. Se incluyeron 41 pacientes que consintieron participar en el estudio. Se recogieron variables demográficas y onco-reconstructivas. Se utilizó un software creado en la institución para evaluar la simetría mamaria. Los datos se recogieron de la historia clínica. Se aplicaron el test de Chi-cuadrado corregido y la razón de momios para el análisis estadístico. Resultados: El 30,2 por ciento de mujeres reconstruidas pertenecieron al grupo de 30 a 39 años; el 46,3 por ciento tenían sobrepeso. La mejor simetría se encontró con las técnicas oncoplásticas (31,7 por ciento), seguida de la mastectomía ahorradora de piel. La técnica de expansión tisular con la mastectomía presentó mayores complicaciones (63,6 por ciento) y menor simetría. La necrosis parcial de piel fue la mayor complicación en 7,3 por ciento y estuvo relacionadas con las técnicas ahorradoras de piel. Conclusiones: Evaluar de forma objetiva la simetría mamaria permitió conocer la efectividad de las técnicas quirúrgicas reconstructivas. Con las técnicas de cirugía oncoplástica y mastectomía ahorradora de piel se obtuvieron los mejores resultados estéticos y pocas complicaciones. La expansión mamaria inmediata con una mastectomía radical modificada no ofrece ninguna ventaja(AU)

ABSTRACT Introduction: Immediate breast reconstruction reduces the psychological impact of breast cancer and improves the quality of life of patients. Objective: To assess symmetry in immediate breast reconstruction at the of Cuba. Method: An analytical and prospective study of incident cohort was carried out in the reconstructive surgery service at the National Institute of Oncology and Radiobiology (INOR), from 2014 to 2017. Forty-one patients who consented to participate in the study were included. Demographic and oncoreconstructive variables were collected. A software created in the institution was used to assess breast symmetry. The data were collected from the medical histories. The corrected chi-square test and odds ratio were applied for statistical analysis. Results: 30.2 percent of women who received reconstruction belonged to the age group 30-39 years; 46.3 percent were overweight. The best symmetry was found with oncoplastic techniques (31.7 percent), followed by skin-sparing mastectomy. The tissue expansion technique with mastectomy presented greater complications (63.6 percent) and less symmetry. Partial skin necrosis was the major complication, accounting for 7.3 percent of the cases, and was related to skin-sparing techniques. Conclusions: Objectively evaluating breast symmetry allowed us to know the effectiveness of reconstructive surgical techniques. With oncoplastic surgery and skin-sparing mastectomy techniques, the best aesthetic outcomes and few complications were obtained. Immediate breast expansion with a modified radical mastectomy offers no benefit(AU)

Tumor neuroendocrino primario de mama en un hombre / Primary neuroendocrine breast tumor found in a man

El cáncer de mama en hombres es una entidad poco frecuente y muy poco estudiada. Su pronóstico y manejo aun distan de lo ideal y de lo que se ha logrado en cáncer mamario en mujeres. Los tumores neuroendocrinos de la mama son aún más raros. Su comportamiento tiende en la mayoría de los casos a ser incierto y su manejo controversial. El reporte de caso se trata de un paciente masculino de 67 años, con historia de aparición de masa en mama derecha, con diagnóstico inicial de tumor mal diferenciado, con posterior inmunohistoquimica que informa tumor neuroendocrino primario de la mama. El diagnóstico temprano de cáncer de mama en hombres implica un verdadero reto para los sistemas de salud. Debemos conocer más sobre su fisiopatología y factores de riesgo(AU)

The early diagnosis of breast cancer in men represents a real challenge for the health systems. Therefore, our knowledge about its physiopathology and risk factors must be expandedBreast cancer in men is a rare and poorly studied malady. The prognosis and management is far from being ideal and from the achievements of the female breast cancer treatment. Even rare are neuroendocine breast tumors. In most of cases, its behavior is uncertain and its management is controversial. This was the report of a male patient aged 67 years, with history of right breast mass, initially diagnosed as a poorly differentiated tumor with later immunohistochemical test that reported the existence of a primary neuroendocrine breast tumor(AU)

Comparison of quality of life, satisfaction with surgery and shoulder-arm morbidity in breast cancer survivors submitted to breast-conserving therapy or mastectomy followed by immediate breast reconstruction

OBJECTIVES: This study was designed to compare the prevalence of shoulder-arm morbidity, patient satisfaction with surgery and the quality of life of women submitted to breast-conserving therapy or modified radical mastectomy and immediate breast reconstruction . METHODS: This study was a cross-sectional study of women who underwent breast-conserving therapy (n=44) or modified radical mastectomy and immediate breast reconstruction (n=26). Quality of life was evaluated with the SF-36 Health Survey Questionnaire. RESULTS: No differences were found in the prevalence of lymphedema. The movements that were most commonly affected by these procedures were abduction, flexion and external rotation. When the two groups were compared, however, we only found a statistically significant difference for the prevalence of restricted internal rotation, which occurred in 32 percent of women in the breast-conserving therapy group and 12 percent of those in the modified radical mastectomy and immediate breast reconstruction group (OR: 7.23; p=0.03 following adjustment for potential confounding factors). No difference in quality of life or satisfaction with surgery was found between the two groups. CONCLUSIONS: These data suggest that the type of surgery did not affect the occurrence of lymphedema. Breast-conserving therapy, however, increased the risk of shoulder movement limitation. No differences were found between the two surgical techniques with respect to quality of life or satisfaction with surgery.

Mama fantasma no pós-operatório recente de mastectomia radical modificada / Phantom breast in the recent postoperative of modified radical mastectomy

O objetivo deste estudo foi analisar, prospectivamente, a ocorrência da mama fantasma (MF) e suas características clínicas no pós-operatório recente de mastectomia radical modificada (MRM). Constituíram-se sujeitos do estudo 25 mulheres, com idades entre 32 e 78 anos, portadoras de câncer de mama. O trabalho dividiu-se em duas etapas investigatórias: pré-operatória e pós-operatória recente . Os instrumentos de pesquisa contemplaram pesquisa de dados no prontuário, realização de entrevista estruturada, aplicação de testes e escala, e exames físico e funcional. O estudo das variáveis foi realizado pela análise descritiva. Para se comparar freqüências, utilizaram-se técnicas não paramétricas (Teste Qui-quadrado e Teste Exato de Fisher) e o nível de significância foi de 5 por cento. Destaca-se que 16 mulheres (64 por cento) apresentaram MF descrita como sensação de persistência mamária, prurido, amortecimento, formigamento e peso. Dessas, 13 (81,25 por cento) notaram a MF no primeiro dia de pós-operatório; 11 (68,75 por cento) perceberam a MF na totalidade; 02 (12,50 por cento) apresentaram dor na MF (DMF) e 05 (31,25 por cento) demonstraram resposta positiva em um teste de estimulação da MF com base nos trabalhos de Ramachandran. Não se encontrou significância estatística das variáveis estudadas em relação à presença / ausência da MF. Concluiu-se que a MF não dolorosa é freqüente, que pode ocorrer antes das 48 horas após a amputação e que não se constitui em um problema clínico. Já a freqüência da MF dolorosa foi menor que a esperada, sugerindo que possa ser confundida com as demais algias, as quais podem fazer parte do quadro clínico.

The objective of this study was to analyze, in a prospective way, the occurrence of the phantom breast (PB) and its clinical characteristics in the recent postoperative period of modified radical mastectomy (MRM). Twenty-five women with breast cancer were the subjects of the study, with ages between 32 and 78 years. The work was divided into two inquiry stages: preoperative and recent postoperative. The research instruments included: review of the literature, systematic interview, application of tests and scales and physical and functional examination. The study of the variables was carried out through descriptive analysis. To compare to the frequencies, non-parametric statistical tools were used (Qui-square Test and Accurate Test of Fisher), the level of significance was 5 percent. Sixteen women (64 percent) presented described PB as a persistent sensation of the breast, as well as feelings of itching and weight. Of these, 13 (81.25 percent) noticed the PB on the first postoperative day; 11 (68.75 percent) perceived the PB in its totality; 2 (12.50 percent) presented pain in the PB and 5 (31.25 percent) reported positive results on a stimulation test of the PB based on the work of Ramachandran. No statistical significance was met in the studied variables in relation to the presence/absence of the PB. It was concluded that the no-painful PB is frequent, that it can occur before 48 hours after the amputation and that it does not constitute a clinical problem. The frequency of the painful PB was lower than expected, suggesting that it can be confused with other pains, which can be part of the clinical frame.

Seroma formation after surgery for breast cancer

Seroma formation is the most frequent postoperative complication after breast cancer surgery. We carried out a study to investigate the effect of various demographic, clinical and therapeutic variables on seroma formation. A retrospective cross sectional study of patients who underwent surgical therapy for breast cancer with either modified radical mastectomy [MRM] or breast preservation [BP] was carried out. The demographic data and clinical information were extracted from case records. Seroma formation was studied in relation to age, type of surgery, tumor size, nodal involvement, preoperative chemotherapy, surgical instrument [electrocautery or scalpel], use of pressure garment, and duration of drainage. The multiple logistic regression analysis was performed to estimate odds ratios. A total of 158 patients with breast cancer were studied. The mean age of the patients was 46.3 years [SD +/- 11.9]. Seventy-three percent underwent modified radical mastectomy and the remaining 27% received breast preservation surgery. Seroma occurred in 35% of patients. In multivariate logistic regression analysis an association of postoperative seroma formation was noted with modified radical mastectomy [OR = 2.83, 95% CI 1.01-7.90, P = 0.04]. No other factor studied was found to significantly effect the seroma formation after breast cancer surgery. The findings suggest that the type of surgery is a predicting factor for serorna formation in breast cancer patients

Two doses of oral sustained-release tramadol do not reduce pain or morphine consumption after modified radical mastectomy: a randomized, double blind, placebo-controlled trial.

BACKGROUND: Tramadol is a weak opioid agonist with antinociceptive effects through its action on the mu-receptor and by inhibiting the neuronal re-uptake of both noradrenaline and serotonin. Tramadol is commonly used for treatment of mild to moderate post-operative pain. An oral form of sustained-release tramadol (SR) was recently formulated for reducing the administration frequency from qid to bid. OBJECTIVE: To evaluate the analgesic efficacy and safety of two doses of oral tramadol SR for the treatment of pain after modified radical mastectomy. STUDY DESIGN: Randomized, double blind, placebo-controlled trial. METHOD: Fifty women were randomly allocated to receive either tramadol SR 100 mg (group T), or placebo tablet (group P) orally approximately 1 hour before surgery with a repeat dose administered 12 hours later by nurses not apprised of the patient groupings. All patients received the standard general anesthesia. Post-operatively, nurses in the research team assessed pain using a visual analog scale 0-100 mm at rest (rVAS) and during arm movements (mVAS) at admission to postanesthesia care unit (PACU) (T0) and 2 (T2), 6 (T6), 12 (T12) and 24 (T24) hours after surgery. Rescue analgesia was provided for 24 hours via a morphine-loaded patient-controlled analgesia (PCA) device at 1 mg bolus with a 5-minute lockout interval. Cumulative morphine consumption and adverse events were recorded. RESULTS: Twenty-five patients with comparable baseline characteristics from each group were studied. The proportions of patients with VAS > 30 (both rVAS and mVAS) at each measurement period were not significantly different between the groups except for the mVAS at T24, where the proportion in group T was higher than group P (48% vs 20%, 95% CI of difference: -53%, -3%, p = 0.04). The median morphine consumption in both groups at T2, T6, T12 and T24 were comparable. No serious adverse effects were observed; however, patients in group T reported nausea and vomiting more than group P (56% vs 24%, p = 0.02). CONCLUSION: Two doses of oral tramadol SR 100 mg had no effect on post-operative pain scores and morphine consumption in patients who underwent modified radical mastectomy. In fact, more patients in the tramadol group reported nausea and vomiting than the placebo group.

Prevalence and risk factors for development of lymphedema following breast cancer treatment.

BACKGROUND: Early detection and multimodality therapy has resulted in an overall improvement of survival among breast cancer patients. Despite a significant shift in the treatment approach from radical mastectomy to breast conservation a significant number of patients develop lymphedema. This study was conducted to evaluate the prevalence and risk factors for development of lymphedema. SETTINGS AND DESIGN: Retrospective analysis for prevalence of lymphedema in a tertiary care regional cancer centre. MATERIAL AND METHODS: Three hundred treated breast cancer patients with a minimum follow up of one year were evaluated for the prevalence and risk factors for lymphedema. Lymphedema was assessed using a serial circumferential measurement method. More than 3 cm difference in circumference is considered as clinical significant lymphedema. Univariate and multivariate analysis were performed for evaluating the risk factors by using the Chi square test and Cox logistic regression analysis. RESULTS: The prevalence of clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema. The prevalence of lymphedema was 13.4 % in patients treated with surgery only where as the prevalence was 42.4% in patients treated with surgery and radiotherapy. Stage of the disease, body surface area > 1. 5 m2, presence of co-morbid conditions, post operative radiotherapy and anthracycline based chemotherapy were significant risk factors in univariate analysis where as axillary irradiation and presence of co-morbid conditions have emerged as independent risk factors in multivariate analysis (P < 0.001). CONCLUSION: Post treatment lymphedema continues to be a significant problem following breast cancer therapy. Presence of co-morbid conditions and axillary radiation significantly increases the risk of lymphedema. A combination of axillary dissection and axillary radiation should be avoided whenever feasible to avoid lymphedema.