Factores predictivos de alta carga residual ganglionar axilar post biopsia de ganglio centinela positiva / Predictive factors of high residual burden in axillary lymph node after positive sentinel node biopsy

El estado axilar es un factor pronóstico para los estadios tempranos de cáncer de mama. Existen factores que podrían predecir riesgo de mayor enfermedad axilar. El objetivo es determinar cuáles son los factores predictivos independientes de alta carga residual ganglionar axilar (4 o más GNC comprometidos) luego de la BGC positiva. Estudio analítico, observacional, cohorte retrospectiva de pacientes con tumores T1-2, axila clínicamente negativa, a las que se les realizó cirugía conservadora (CC) y BGC con resultado positivo (marco o micrometástasis) y se les realizó posterior linfadenectomía axilar (LA). Del total de 325 pacientes, 96 tuvieron resultado positivo para metástasis en el ganglio centinela (29,5%) y también se les realizó LA. Se dividió a la población seleccionada en dos grupos según el compromiso de los GNC: baja carga axilar 0-3 GNC positivos, y alta carga axilar 4 o más GNC positivos. Se observaron como factores que demostraron mayor riesgo para alta carga axilar ganglionar residual al grado histológico, ki-67 y la invasión extracapsular en el GC; pero solamente la invasión extracapsular en el GC demostró ser significativa en el análisis multivariado. Probablemente con un mayor número de pacientes otras variables pudieran haber resultado factores de riesgo independiente

Axillary status is a prognostic factor for early stages of breast cáncer. There are predictive factors that might indicate the risk of greater axilary disease. The aim is to determine which are the independent predictive factor sor a high residual axillary nodal burden (four or more non-sentinel lymph nodes involved) after a positive sentinel node biopsy. Retrospective cohort analytic observational study of patients with T1-2 tumors, negative axilla, who underwent breast conserving surgery and sentinel node biopsy with a positive result (macro ­ or micro-metastasis) and later underwent lymph node dissection. Out of the total 325 patients, 96 got a positive result for metástasis in the sentinel lymph node (29.5%) and also underwent lymph node dissection. The selected population was divided into two groups according to the involvement of NSLNs: low axillary burden: 0-3 NSLNs, and high axillary burden: 4 or more positive NSLNs. Among the factors found to have a higher risk of high residual axillary nodal burden were the histologic grade, Ki-67 and the extracapsular invasión of the SLN, but only the extracapsular invasión of the SLN was found to be significant in the multivariate analysis. It is likely that with a higher number of patients, other variables might have been independent risk factors

Ganglio centinela en cáncer de mama. Experiencia en nuestros primeros 100 casos / Sentinel Node in Breast Cancer. Our first 100 cases experience

Introducción Desde los trabajos presentados por Giuliano et al . en 1994 y sus posteriores validaciones, la biopsia del ganglio centinela se ha convertido en el standard de la evaluación axilar en estadios tempranos del cáncer de mama. Es de vital importancia respaldar esta técnica con altas tasas de identificación y de correlación anatomopatológica intraoperatoria/diferida. Objetivos 1) Determinar nuestra tasa de identificación usando solo azul patente. 2) Determinar la correlación entre el estudio intraoperatorio y diferido. 3) Determinar la tasa de recurrencia axilar. Material y método Se reclutaron 100 pacientes con cáncer de mama T1 T2 N0 o cdis extenso de alto grado diagnosticadas por punción con aguja fina (paf) o Core Biopsy. Se utilizó solo Azul Patente al 1%, inyección subareolar, masaje circular por 10 minutos, incisión axilar. Se reconoce como Ganglio Centinela al ganglio o a los ganglios teñidos de azul o con su linfático aferente con colorante. El estudio intraoperatorio se realizó por sección en fresco e impronta citológica. El diferido por coloración con Hematoxilina y Eosina. Las pacientes fueron seguidas por el cirujano actuante y/u oncología clínica. Resultados Se evaluaron 100 pacientes. Nuestra tasa de detección fue del 98%. Los falsos negativos intraoperatorios por impronta citológica fueron del 3%. Luego de un seguimiento promedio de 63,8 meses, no se detectaron recidivas axilares. El número total de Ganglios Centinela positivos fue del 26,5%. El promedio de Ganglios hallados fue de 1,2. Conclusiones La Biopsia de Ganglio Centinela usando Azul Patente como único método es una operación confiable, de bajo costo y al alcance de todo centro con interés de desarrollar dicha técnica.

Introduction Since Giuliano et al. publications in 1994 and forward validations, sentinel node biopsy (snp) has become the standard procedure for staging the axilla in early breast cancer. Therefore, it is of vital importance to back this technique up by a high rate of identification and high intraoperative/final pathology correlation. Objectives 1) To determine our identification rate by only using Patent Blue dye. 2) To determine the correlation between intraoperative and final pathology results. 3) To determine axillary recurrence. Materials and method A hundred patients have been recruited. Each was diagnosed with T1 T2 N0 Breast Cancer or extense high grade Ductal Carcinoma In situ (dcis) by fine needle aspiration (fna) and/or Core Biopsy. Patent Blue 1% was injected subareolary. In addition, circular massage was performed during 10 minutes and an axillary incision was made. The node or nodes dyed in blue or with coloured lymphatic afferent have been acknowledged as sentinel nodes. The node was analyzed intraoperatively by touch imprint citology. The final study was done with Hematoxilin Eosin coloration. Further follow up was in charge of the surgeon and/or clinical oncologist. Results A hundred patients were assesed. Our identification rate was 98%. The pathology intraoperative false negative rate was 3%. Afer an average of 63,8 months follow up, no axillary recurrence was detected. 26,5% of positive sentinel nodes was found. The average of sentinel nodes found was 1,2. Conclusions snb by using only patent blue dye is a low cost reliable technique, and available for every institution interested in its development.

Ecografía axilar con punción citológica positiva en pacientes con cáncer de mama: Análisis de su utilidad para indicar linfadenectomía axilar en la era del acozog Z0011: Experiencia en la Unidad de Mastología del Hospital Español de Montevideo, Uruguay / Axillary ultrasound with puncture positive cytology in patients with breast cancer: Analysis of its usefulness to indicate axillary lymphadenectomy in the era of acozog Z0011: Experience in the Mastology Unit of the Spanish Hospital of Montevideo, Uruguay

Objetivo Evaluar la validez de la ecografía axilar (ea) con punción citológica para indicar linfadenectomía axilar en pacientes con cáncer de mama, dentro del marco de los criterios propuestos por el estudio acosog Z0011. Material y método Estudio prospectivo, descriptivo. Se presentan los resultados del análisis de 123 pacientes con diagnóstico de cáncer de mama pertenecientes a la Unidad de Mastología del Hospital Español de Montevideo (Uruguay). En todas las pacientes se evaluó la axila con ecografía y, cuando existían ganglios sospechosos, se procedió a realizar punción con aguja fina. Cuando esta modalidad resultó positiva, en todas las pacientes se realizó linfadenectomía axilar de inicio. Cuantificamos la carga tumoral axilar de estas pacientes y analizamos la indicación de linfadenectomía axilar dentro del marco de propuestas del acozog Z0011. Resultados Los resultados obtenidos para predecir alta carga tumoral fueron los siguientes: porcentaje de verdaderos positivos (vp) 88,88%; porcentaje de falsos negativos (fn) 32%; sensibilidad (s) 80%; especificidad 80,95%; valor predictivo positivo (vpp) 88,89%; valor predictivo negativo (vpn) 68%; cociente de probabilidad positivo 4,20; cociente de probabilidad negativo 0,25; pacientes correctamente diagnosticados 80,33%. Discusión Desde hace varios años, la ecografía axilar con punción citológica ha demostrado elevada especificidad para predecir metástasis ganglionares. Publicaciones recientes afirman que la positividad de esta modalidad de estudio evidencia alta carga tumoral axilar y que, por lo tanto, se debe excluir a la paciente de las conductas conservadoras sobre la axila propuestas por el estudio acosog Z0011. Conclusiones Nuestros resultados concuerdan con la literatura internacional: la ecografía axilar con punción citológica es una metodología de elevada especificidad para predecir alta carga tumoral axilar. Esta metodología permite individualizar a aquellas pacientes que deben ser tratadas de inicio con linfadenectomía axilar, inclusive bajo los nuevos postulados del acosog Z0011

Objectives Evaluate the validity of ultrasound-guided fine needle aspiration (ugfna) of lymph nodes to determine axillary lymphadenectomy in patients with breast cancer, following the criteria proposed by acosog Z0011. Materials and method A prospective descriptive design was utilized. We present the analysis and results of 123 patients who were treated in the Unidad de Mastología at Hospital Español in Montevideo (Uruguay). All patients underwent axillary ultrasonography in order to evaluate lymphnodes. When suspicious lymph nodes were found, ugfna was performed. Patients who's ugfna yielded positive results were subjected to immediate axillary lymphadenectomy. We then quantified tumoral load and analyzed it according to the guidelines proposed by acosog Z0011. Results The following results were obtained for predicting tumoral load: True Positive Value of 88.88%; False Negative Value of 32%; Sensitivity of 80%; Specificity of 80.95%; Positive Predictive Value of 88.89%; Negative Predictive Value of 68%; Positive Likelihood Ratio of 4.20; Negative Likelihood Ratio of 0.25; accurately diagnosed patients 80.33%. Discussion ugfna has shown to have elevated specificity when predicting lymph node metastases. Recent investigations have shown that positive results of ugfna of lymph nodes determines elevated tumoral load; therefore, conservative treatment proposed by acosog Z0011 should not be followed. Conclusions Our results are comparable to research published internationally. ugfna is a method which has high specificity for the prediction of elevated axillary lymph node tumoral load. ugfna allows the tailoring of treatment for patients which must be treated initially with axillary lymphadenectomy, even under the new evidence put forth by acosog Z0011.

Abordagem cirúrgica axilar no câncer de mama estadiamento clínico T1-T2N0M0: complicações pós-operatórias e sobrevida em uma coorte hospitalar de mulheres do Rio de Janeiro / Auxillary surgical approach in breast cancer clinical stage T1-T2N0M0: postoperative complications and survival in a hospital cohort of women of Rio de Janeiro

As preocupações relacionadas ao prognóstico e qualidade de vida das pacientes com estadiamento precoce sem comprometimento linfonodal têm aumentado, especialmente no que se refere à abordagem cirúrgica axilar, devido ao aumento do diagnóstico precoce e avanços no tratamento do câncer de mama. Enquanto a biópsia do linfonodo sentinela (BLS) tem se mostrado eficiente e mais protetora do que a linfadenectomia axilar (LA) na incidência de complicações, ainda existem preocupações relacionadas a sobrevida das pacientes, principalmente na presença das micrometástases linfonodais. Objetivo: Caracterizar a incidência de complicações pós-operatórias em mulheres com câncer de mama classificação T1-T2N0M0, e determinar a sobrevida global (SG) e livre de doença (SLD) de mulheres diagnosticadas e tratadas no Instituto Nacional de Câncer (INCA) entre 2007 a 2009 segundo a abordagem cirúrgica axilar (BLS e LA). Métodos: Trata-se de um estudo observacional de uma coorte de 933 mulheres com diagnóstico clínico T1-2N0M0 atendidas no Hospital de Câncer III do Instituto Nacional de Câncer, no período de Janeiro de 2007 a Dezembro de 2009, e seguidas por um período de 60 meses. A coleta de dados foi realizada com base na análise do Registro Hospitalar de Câncer, dos prontuários físicos e/ou eletrônicos das pacientes e da ficha de avaliação do Serviço de Fisioterapia do HC-III/INCA. Dentre as informações avaliadas, constaram as características sociodemográficas, clínicas, de hábitos de vida, tratamentos empregados e variáveis de desfecho. As variáveis de desfecho serão àquelas referentes às complicações pós-cirúrgicas no membro superior afetado, status da doença (resposta ao tratamento e recidiva) e de status vital...

With increased early detection and advances in treatment of breast cancer, concerns related to the prognosis and quality of life of patients with early stage have increased without lymph node involvement, especially with respect to the axillary approach. However, while the sentinel lymph node biopsy (BLS) it has proved so efficient and more protective than the axillary lymphadenectomy (LA) in the incidence of complications, there are still concerns about the survival of patients, especially in the presence of lymph node micrometastase. Objective: To characterize the incidence of postoperative complications in women with breast cancer classification T1 and T2N0M0, according to axillary surgical approach, and determine overall survival and disease-free survival of women diagnosed and treated at the National Cancer Institute (INCA) between 2007 2009. Methods: Observational study of a cohort of 933 women with clinical diagnosis T1-2N0M0 treated at Hospital Cancer-III of the National Cancer Institute (HC-III / INCA) in 2007-2009, and followed by a period of 60 months. Data collection was based on analysis of the Hospital Registry Cancer, the physical and/or electronic records of patients - HCIII/INCA and clinical evaluation form the Physical Therapy Service of the HC-III/INCA. Among the evaluated information included sociodemographic, clinical, lifestyle habits, implemented treatments and outcome variables. The outcome variables will be those related to post-surgical complications in the affected upper limb, disease status (response to treatment and relapse) and vital status...

Factores asociados a mayor débito de drenaje tras linfadenectomía axilar por cáncer de mama / Factors associated with greater debit drainage after axillary lymphadenectomy for breast cancer

Introduction: axillary lymph node dissection (ALND) is still a usual procedure in the treatment of breast cancer. A drain is normally placed in the surgical bed and maintained several days until obtaining a daily discharge of 30-50 ml, in order to reduce the appearance of seroma. The aim of this study was to analyze possible factors associated with an increased drainage volume. Patients and Methods: a retrospective study of all the patients undergoing ALND for breasts cancer at our institution between 2011 and 2012 was performed. Results: 40 females were included. There were no complications or mortality. Median hospital stay was 2 days. Median day of drainage removal was the 5th postoperative day. Mean total drainage volume was 298.9 +/- 240.1 ml. High blood pressure associated with an increased drainage volume (550 ml vs 217.5 ml; p = 0.001) and a later removal (8th vs 4th day; p = 0.002). Similar happened with age > 65 years (420.8 ml vs 24.6 ml; p = 0.003) and (7th vs 5th day; p = 0.009). The number of metastatic lymph nodes showed a direct correlation with total drainage volume (Pearson 0.503; p = 0.017) and removal day (Spearman 0.563; p = 0.006), similar to the primary tumour size: total drainage volume (Pearson 0.447; p = 0.042) and removal day (Spearman 0.556; p = 0.009). Conclusion: age over 65 years, high blood pressure, number of metastatic lymph nodes and primary tumour size associated with a higher drainage volume and time to remove the drain.

Introducción: la linfadenectomía axilar (LA) sigue siendo un procedimiento frecuente en el tratamiento del cáncer de mama. Habitualmente se coloca un drenaje en el hueco axilar, que se mantiene varios días, hasta que tiene un débito diario de 30-50 ml, con el fin de reducir la aparición de seroma. El objetivo del presente estudio es analizar posibles factores asociados a un mayor volumen de drenaje. Pacientes y Métodos: realizamos un estudio retrospectivo de todas las pacientes intervenidas de LA por cáncer de mama en nuestro centro durante los años 2011 y 2012. Resultados: incluimos 40 mujeres en el estudio. No hubo complicaciones ni mortalidad. La mediana de estancia hospitalaria fue de 2 días. El día mediano de retirada de drenaje fue el 5° postoperatorio. El volumen medio total del drenaje fue 298,9 +/- 240,1 ml. La hipertensión arterial se asocia a un mayor volumen de drenaje (550 ml vs 217,5 ml; p = 0,001) y a una retirada más tardía del mismo (8° día vs 4° día; p = 0,002). Al igual ocurre con la edad > 65 años (420,8 ml vs 24,6 ml; p = 0,003) y (7° vs 5° día; p = 0,009). El número de ganglios metastásicos también se correlaciona con el volumen total de drenaje (coeficiente de correlación de Pearson 0,503; p = 0,017) y con el día de retirada (Spearman 0,563; p = 0,006), lo mismo que el tamaño del tumor primario: volumen total de drenaje (Pearson 0,447; p = 0,042) y día de retirada (Spearman 0,556; p = 0,009). Conclusión: la edad mayor de 65 años, la hipertensión arterial, el número de ganglios metastásicos y el tamaño del tumor primario se asocian con mayor volumen por el drenaje axilar y días necesarios hasta la retirada.

Rol de la linfadenectomía en el manejo quirúrgico del cáncer de mama / Role of lymphadenectomy in the surgical management of breast cancer

La linfadenectomía axilar ha sido siempre un componente tanto de la mastectomía como de la cirugía conservadora de mama, al proveer el estadiaje axilar, así como un control local efectivo, no sin potenciales efectos colaterales. El estado de los ganglios linfáticos axilares es una variable pronóstica significante y permanece como el más potente predictor de recurrencia y supervivencia. Sin embargo, recientemente se debate sobre el interés del potencial rol terapéutico de la terapia local agresiva para el cáncer de mama. Pocos tópicos han permanecido con controversias tan duraderas como el manejo de los ganglios linfáticos axilares en el cáncer de mama, parece que hemos pasado de una época en que la linfadenectomía axilar se consideraba indispensable a otra en la que para algunos autores parece innecesaria. En el momento actual a pesar de más de un siglo de debate nos seguimos preguntando acerca de la posibilidad que la cirugía axilar tenga un beneficio en la supervivencia de los pacientes con cáncer de mama. El siguiente trabajo nos permitirá evidenciar el rol de la linfadenectomía axilar, particularmente a la luz de los ensayos clínicos en curso

Axillary node dissection has always been a component both of mastectomy and breast conservative surgery, providing accurate axillary staging as well as effective regional control, not without potential side effects. Axillary lymph node status is a significant prognostic pathologic variable and remains the most powerful predictor of recurrence and survival. However, recently it debates about the interest in the potential therapeutic role of aggressive local therapy of breast cancer. Few topics have remained as durably controversial as the management of the axillary lymph node dissection in breast cancer, it seems that we have been past time the axillary lymphadenectomy was considered indispensable respect others for some authors. At this moment, despite a century of debate, we still are wondering about the possibility of a survival benefit of the axillary surgery. This study allows us to reflect about the role of axillary lymph node dissection, particularly at light on ongoing clinical trials

Estudo comparativo da eficácia da movimentação precoce do braço no controle do seroma pós-linfadenectomia axilar em mulheres com câncer de mama / A comparative study of the efficacy of early arm mobilization in the control of seroma formation after axillary limphadenectomy in breast cancer surgery

Objetivo: Avaliar a eficácia da movimentação precoce do braço na formação de seroma em mulherescom câncer de mama submetidas à linfadenectomia axilar (LA). Métodos: Estudo prospectivo,consecutivo de 39 mulheres com diagnóstico de câncer de mama unilateral e submetidas àcirurgia. Estas foram divididas aleatoriamente em dois grupos: grupo movimento (GM/n = 19) egrupo-controle (GC/n = 20). No primeiro grupo, as pacientes foram orientadas à movimentaçãoprecoce do braço, com programa específico de movimentos iniciados durante a internação e continuandoem domicílio; no segundo grupo, as pacientes receberam orientações rotineiras da unidade.Os testes de Mann-Whitney e Fisher foram utilizados para a comparação de variáveis entreos grupos. Resultados: Os grupos foram homogêneos quanto a idade e índice de massa corporal(p > 0,05). Não houve diferença estatisticamente significante entre os dois grupos quanto ao tempode permanência do dreno, volume de secreção drenado e incidência de seroma. Porém, houvemenor número de punções de seroma (p = 0,01) e menor volume puncionado de seroma (p = 0,04)no GM. Conclusão: A movimentação precoce do braço favoreceu melhor absorção do seroma eesteve associada à resolução menos invasiva deste.

Objective: To assess the efficacy of early arm movement in the control of seroma formation in womenwith breast cancer submitted to axillary limphadenectomy (AL). Methods: A consecutive andprospective study of 39 women with the diagnosis of unilateral breast cancer was undertaken. Theywere submitted to surgery and had been randomized in two groups: movement group (MG) andcontrol group (CG). At the first group, patients were oriented to realize early arm movement throughtan specific movement training programme that was initiated during hospitalization period andcontinued at home; the second group received ordinary orientations. Mann-Whitney and Fisher testswere used to compare variables between groups. Results: Both groups were homogeneous regardingage and body mass index (p > 0.05). There were no statistically significant diference between MG and CG about drain permanence time, total drainded volume and incidence of seroma. However, there were a smaller percentage of the number of seroma punctions (p=0.01) and punctioned seroma volume (p=0.04) for MG. Conclusion: Early arm movement favoured a better absorption of seroma and it was associated with a less invasive resolution of seroma.

El por qué de la cirugía conservadora en el cáncer de mama. Nuestra experiencia desde el año 1984 al año 1999 / Why conservative surgery in breast cancer. Our experience from 1984 to 1999

Se presenta una revisión del diagnóstico y tratamiento del cáncer de mama, desde la década del 60. Se destaca el cambio de la cirugía conservadora a partir de estudios clínico-quirúrgico-patológicos, quimioterapia y hormonoterapia; se pone énfasis en el rol de la mujer en la decisión terapéutica. Se describe el origen y la evolución de la técnica quirúrgica Cuadrantectomía con Linfadenectomía Axilar. Los autores relatan su experiencia desde el año 1984 y presentan un estudio sobre la cirugía conservadora, cuadrantectomía y vaciamiento axilar con radioterapia postoperatoria. El estudio incluye 190 pacientes (38-70 años) con las siguientes características: a) diagnóstico clínico y mamográfico; b) diámetro del tumor de hasta 2.5 cm; c) diagnóstico histológico del cáncer; d) edad inferior a 70 años; e) accesibilidad geográfica para completar su tratamiento y seguimiento. El tamaño del tumor fue ≤ a 2.5 cm en la mayoría de las pacientes; en el 60% de los casos se localizó en el cuadrante superior externo; en el 41% hubo adenopatías axilares. Existió recidiva mamaria en el 5.12%, en un período de 20 y 25 meses. La estadificación postoperatoria mostró que el 61.5% de los casos estudiados eran Estadio I. Desarrollaron metástasis el 7.8% y el 2.1 % falleció. Se concluye que la cuadrantectomía, linfadenectomía axilar y radioterapia ocupan el primer lugar en el diagnóstico y tratamiento del cáncer de mama. Para aumentar las tasas de curación del cáncer de mama, se propone mejorar tres áreas: diagnóstico precoz, tratamiento adecuado y educación médica continuada.

A review of breast cancer diagnosis and treatment since the 1960s is presented in this paper. The change in traditional surgery based on clinical, surgical and pathological studies, chemotherapy and hormone therapy, as well as the role of women in therapeutic decisions is emphasized. The origin and evolution of quadrantectomy with axillary lymphadenectomy is described. The authors present their experience since 1984 and a study on traditional surgery, quadrantectomy, and axillary lymphadenectomy with post-surgical radiotherapy. The study includes 190 patients (range 38-70 years) presenting the following characteristics: a) clinical and mammography diagnosis; b) tumor diameter of a maximum of 2.5 cm; c) cancer histological diagnosis; d) less than 70 years of age; e) geographic accessibility to complete treatment and follow-up. Tumor size was ≤to 2.5 cm in most patients; in 60% of the cases the tumor was located in the external upper quadrant; in 41% of the cases there was axillary node enlargement. 5.12% of the patients presented mammary recidivation within 20 and 25 months. Postsurgical staging showed that 61.5% of the cases belonged to Stage I tumors. 7.8% of the patients developed metastasis and 2.1% died. The conclusion of this study is that quadrantectomy, axillary lymphadenectomy, and radiotherapy are the most common procedures in breast cancer diagnosis and treatment. In order to increase breast cancer cure rates, three areas should be improved: early diagnosis, adequate treatment, and permanent medical education.