Neoplasia Lobular da mama: revisão / Lobular neoplasia of the breast: review

A neoplasia lobular da mama se refere às lesões caracterizadas pela hiperplasia lobular atípica e pelo carcinoma lobular in situ. A neoplasia lobular não é apenas um fator de risco, mas um precursor não obrigatório para desenvolvimento de carcinoma invasivo. O carcinoma lobular in situ do tipo pleomórfico é subtipo de neoplasia lobular com comportamento agressivo, com alto grau nuclear e pode mimetizar o carcinoma ductal in situ de alto grau. O manejo e o seguimento das pacientes portadoras de neoplasia lobular é controverso, especialmente, quando o diagnóstico é feito através da core biopsy. Os estudos moleculares e genômicos têm sido capazes de identificar genes que podem ser dirimir dúvidas quanto à sua patogênese e permitir abordagem que permite abordagens terapêuticas mais seguras e adequadas. Esta revisão procura estabelecer o conceito mais atual sobre a abordagem da neoplasia lobular da mama.

Lobular neoplasia of the breast refers to lesions featuring atypical lobular hyperplasia and lobular carcinoma in situ. Recent evidence suggests that lobular neoplasia is not only a risk factor, but is also a non-obligate precursor for invasive carcinoma. Pleomorphic lobular carcinoma in situ is a subtype of lobular neoplasia with agressive behaviour, that has high-grade nuclei and may simulate high-grade ductal carcinoma in situ. The management and follow-up of patients diagnosed with lobular neoplasia is a current issue of debate, specially when the diagnostic is given by core biopsy. Molecular and genomic studies have identified genes that may be important in understanding its pathogenesis and may lead to news therapeutic interventions.

Detección inmunohistoquímica de la expresión de la oncoproteína c-erbB-2 en tumores ductales y lobulillares de mama / Immunohistochemical detection of c-erbB-2 oncoprotein expression in human breast ductal and lobular tumors

El cáncer de mama es una de las enfermedades importantes en la mujer y se le dedican grandes esfuerzos científicos y económicos existiendo el propósito de la búsqueda constante de vías de mejor precocidad en el diagnóstico y con ello, mejoramiento del pronóstico. En los rangos etarios de mayor riesgo de presentar esta patología se han descrito varios factores desencadenantes como son los receptores de estrógenos (RE), progesterona (RP) y de la proteína c-erbB-2. Se utilizaron biopsias de cáncer mamario ductal y lobulillar de diagnóstico de rutina, sometidas a reacciones inmunohisto químicas con anticuerpos anti RE, anti RP y específicamente para anti c-erbB-2. El revelado fue a través de kit comercial HRP con AEC y DAB. Las imágenes fueron capturadas con microscopio Olympus CX31, cámara fotográfica digital incorporada y software Micrometrics SE Premium 2011. Los resultados permiten observar reacción positiva en color rojo intenso en las muestras reveladas con AEC y pardo cuando se utilizó DAB, en las células que expresan la marcación y que se distribuyen indistintamente en el sitio del tejido afectado por la patología. Estas técnicas son de uso clínico protocolizado en el diagnóstico de cáncer de mama, por lo cual su estandarización y visualización son de extrema importancia para el laboratorio de histopatología integrado a unidades de patologia mamaria.

Breast cancer is one of the major diseases in women and devote great economic and scientific eforts. The intention of continuing to find ways of better and early diagnosis, and improved prognosis. In the age ranges of increased risk for this disease have been described several triggers such as receptors: estrogen (ER), progesterone (PR), and protein c-erbB-2. Biopses were used ductal and lobular breast cancer diagnostic routine, subjected to immunohistochemical antibodies to ER, PR and specifically anti c-erbB-2. The development was through HRP AEC and DAB commercial kit. Images were captured with Olympus CX31 microscope and digital camera and software built Micrometrics SE Premium 2011. The results allow observed positive reaction in red color in the samples developed with AEC and brown when used DAB in cells expressing the bearing and which are distributed equally at the site of pathology tissue affected. These techniques are protocolized by clinical use in diagnosing breast cancer, so its standardization and visualization are of extreme importance to the histopathology laboratory of integrated units of breast disease.

Es carcinoma lobulillar infiltrante igual a carcinoma ductal infiltrante?: seguimiento a largo plazo / Is lobulillar infiltrante carcinoma equal to ductal infiltrante carcinoma?: long term follow

Comparar carcinoma lobulillar infiltrante y carcinoma ductal infiltrante a largo plazo según estadio, tratamiento quirúrgico, terapia neoadyuvante, adyuvante. Estudiamos en la base de datos de CECLINES 841 pacientes, el lobulillar representa 7,25% (61) y ductal 51,24% (431). El seguimiento global 22 años con promedio de 5 años. La sobrevida global: lobulillar 68,1% vs. 60,9% ductal (P=0,772), por estadio fue: I lobulillar 96,3% ductal 90,5 II 94,4% y 88,4% III 90,5% 83,2% (P=0,023). La expresión de receptores de estrógenos positivos en comparación a los CDI fue 87,7% vs. 74,7%,(P=0,031) sobrevida 96,9% vs. 94,0% (P=0,033). El tratamiento preservador del lobulillar en comparación aductal 57,4% vs. 63,2% (P=0,949) y la sobrevida 85,4% vs. 82,9% (P=0,001). La sobrevida de lobulillar sometidos a quimioterapia primaria, quimioterapia adyuvante, radioterapia y hormonoterapia adyuvante en relación al grupo ductal fue 93,4% vs. 91,3%, 91,5% vs. 89,7%, 92,5% vs. 89,8% 92,5% vs. 88,4%, respectivamente (P<0,05). La sobrevida global es igual, la sobrevida por estadio favorece al lobulillar estos presentan más receptores positivos y sobrevida mejor. La tendencia a tratamiento preservador en lobulillar es mayor encontrando excelentes cifras de sobrevida. Dado el perfil hormonal y sobrevida según receptores las pacientes con lobulillar infiltrante son candidatas a participar en protocolos de hormonoterapia primaria. Generalmente el tratamiento para ambos grupos es similar.

Compare infiltrante lobulillar carcinoma and ductal carcinoma in long-term follow up as stage surgical treatment, neoadyuvante, adjuvant therapy. We studied in CECLINES data base 841 patients; lobulillar represents 7.25% (61) and 51.24% ductal (431). The overall followup was up to twenty two years with an average of five years. The overall survival for lobulillar was 68.1%and for ductal 60.9% (P=0.772), the survival according to state was: I lobulillar 96.3% ductal 90.5, II 94.4% vs. 88.4 III 90.5 and 83.2 respectively (P=0.023). Estrogen receptors positive expression for lobulillar compared to ductal was 87.7% vs. 74.7%, (P=0.031) and its survival 96.9% vs. 94.0% (P=0.033). The breast conserving surgery for lobulillar compared to ductal was 57.4% vs. 63.2% (P=0.949) survival 85.4% vs. 82.9% (P=0.001). The survival reported for patients with lobulillar who received neoadyuvante chemotherapy adjuvant chemotherapy radiotherapy and adjuvant hormonotherapy compared to ductal was 93.4% 91.3%, 91.5% 89.7%, 92.5% 89.8% 92.5% 88.4%, respectively P<0.05. The overall survival is equal, survival favors. The lobulillar have more positive receptors and survival is better. The tendency to conservative treatment in lobulillar is increasingly. Given the hormonal profile and survival according to estrogen receptors patients with ILC, are probably good candidates to participate in neoadyuvante hormone therapy protocols. Usually the treatment is the same or similar for both groups.

Manejo quirúrgico de cáncer subclínico detectado en mamografía: como densidad nodular: no visible al ultrasonido / Surgical management of subclinical cancer detected in mamography: how nodular density: no visible at ultrasound

Evaluar el manejo quirúrgico del cáncer subclínico detectado en mamografía de pesquisa como densidad nodular, no visible al ultrasonido. Análisis retrospectivo del manejo quirúrgico de tres cánceres subclínicos detectados en la mamografía de pesquisa como densidades nodulares, no visibles al ultrasonido que fueron extirpados mediante radio-localización con arpón. Se evaluó la realización de biopsia de ganglio centinela en segundo acto operatorio al tener la confirmación histológica definitiva o durante la operación inicial. En dos pacientes se le practicó tumorectomía eficaz y en el otro un margen fue cercano requiriendo re-ampliación. Un solo paciente se practicó tumorectomía y biopsia de ganglio centinela en el mismo acto quirúrgico. Dos presentaron carcinoma lobulillar infiltrante uno de ellos multifocal y el otro caso ductal infiltrante. La edad promedio fue: 63 años (Rango 62 a 64 años) El promedio del tamaño de las lesiones fue 0,9 cm. (Rango en cuatro lesiones: 0,7 cm a 1,2 cm). En todas las pacientes se realizó biopsia de ganglio centinela siendo positivo en solo un caso, sin embargo, se practicó disección axilar en todas. En pacientes, cuando se detecta lesiones sospechosas como densidad nodular a la mamografía y no visible al ultrasonido, la radio-localización con arpón representa un método relativamente sencillo y eficaz para la obtención de biopsias y pueden ser practicadas en cualquier centro que disponga de mamógrafo. Sugerimos realizar biopsia de ganglio centinela durante la operación inicial si hay confirmación firme de malignidad.

The purpose of these work is evaluate the surgical management of non-palpable breast cancer diagnosed as a mammographic visible mass on screening, non visible ultrasonographic. Analyzed retrospectively of tree cases with the diagnosis of non palpable breast lesion visible at the screening mammography and non visible at the ultrasound, they were excised after preoperative tumor localization with a wire. The performance of the sentinel lymph node biopsy was evaluated, if it was in the second surgery after the definitive histopathology confirmation. All the three cases underwent wire localization prior to the tumorectomy, in 2 cases the tumorectomy had wide margins, and in the other one they were close. In one patient we did tumorectomy and sentinel lymph node biopsy in the same surgical procedure. Two cases had invasive lobulillar carcinoma, one of them multifocal and in the other case invasive ductal. The average ages were 63 years (62 to 64 years). The averages of the lesion were 0.9 cm (range in four lesions 0.7 to 1.2 cm). In all the patient were performed the sentinel lymph node biopsy, being positive in just one of the cases. In patients the wire radio-localization represents a simple and efficient method to obtain the biopsy and could be performed in any center that counts with a mammographic. We suggest performing the sentinel lymph node biopsy with patent blue during the initial surgery if there is a strong confirmation of malignant.

Recaídas locales posterior a tratamiento radical: evaluación de infiltración del complejo areola-pezón / Local recurrence posterior to radical treatment: evaluation of the complex areola nipple infiltration

Experiencia de nuestra institución durante el período 2004-2005 en recidivas locales del cáncer de mama. Se realizó estudio clínico, descriptivo, retrospectivo durante 2004-2005, en pacientes con tratamiento radical y adyuvante con radioterapia, quimioterapia si tuviesen indicación. Algunos recibieron quimioterapia neoadyuvante. 167 pacientes sometidos a mastectomía radical. El diagnóstico histológico correspondió 80 por ciento (128) carcinomas ductales infiltrantes, 4,19 por ciento carcinomas in situ. La localización más frecuente fue la centro-mamaria 35,48 por ciento. El 3,65 por ciento fueron estadio I, 35, 58 por ciento estadio II, 53,65 por ciento estadio III y 6,09 por ciento estadio IV. 57 pacientes (34 por ciento) con quimioterapia neoadyuvante. Se realizaron 161 mastectomía radicales tipo Madden (94,7 por ciento), 2 mastectomía radicales tipo Patey y 4 mastectomía total simple, 2 con ganglio centinela. 29 (17,36 por ciento) presentaron infiltración del complejo areola-pezón. 20 (68,96 por ciento) se localizaron en región centro mamaria. La edad promedio fue 53,6 años, 18 (62,07 por ciento) pacientes se ubicaron en el estadio III (37,93 por ciento), 72,94 por ciento recibió quimioterapia adyuvante. El 61,76 por ciento recibió radioterapia, 15 (51,72 por ciento) pacientes estaban vivas sin enfermedad, 1 está viva con recaída local, 5 vivas con enfermedad sistémica y 6 (20,67 por ciento) fallecieron por enfermedad. El seguimiento promedio fue de 36,14 meses. Cinco pacientes del total (2,9 por ciento) presentaron recaída local. La mastectomía radical es un arma terapéutica primaria, los índices de recaída local son menores en centros especializados. La infiltración del complejo aréola-pezón es más frecuente en la localización centro-mamaria.

The experience in our institution during the period 2004-2005 in local recurrence of breast cancer. Realized study clinical, retrospective, descriptive during 2004-2005, in patients with radical treatment, adjuvant radiation therapy and chemotherapy if exist indication. Some received neoadjuvant chemotherapy. 167 patients underwent radical mastectomy. Histological diagnostic was 80 percent (128) ductal infiltrante carcinoma, 4.19 percent in situ carcinoma. The more frequent localization was mammalian center 35.48 percent. 3.65 percent was stage I, 35.58 percent stage II 53.65 percent, stage III 6.09 percent stage IV. 57 patients (34 percent) with neoadjuvant chemotherapy. We realized 161 radical mastectomy Madden type (94.7 percent), 2 radical mastectomy Patey type and 4 mastectomy total simple 2 with node sentinel. 29 (17.36 percent) had infiltration to the areola nipple zone. 20 (68.96 percent) were localized in center mammalian region. The average age was 53.6 years, 18 patients (62.07 percent) were ubicated in stage III (37.93 percent), 72.94 percent received adjuvant chemotherapy. 61.76 percent received radiation therapy, 15 (51.72 percent) patients were alive without disease, 1 live with local recurrence, 5 staying alive with systemic disease and 6 (20.67 percent) dead by the disease. The control average was 36.14 month. 5 patients of the total (2.9 percent) presented local recurrence. The radical mastectomy is a therapeutically first arm, the local recurrence index are minor in the special centers. The infiltration of the areola-nipple complex is more frequent in the center mammalian region.

A multivariate analysis on prognostic factors for lobular carcinoma of the breast / Uma análise multivariada de fatores prognósticos para o carcinoma lobular de mama

CONTEXT AND OBJECTIVE: Lobular carcinoma is the second most common type of breast neoplasia and has unique clinical and pathological features. Our aim was to evaluate prognostic factors for this type of breast cancer. DESIGN AND SETTING:Retrospective study at a tertiary oncological institution. METHODS: 162 patients diagnosed and treated between January 1985 and January 2002 were included. The inclusion criteria were: absence of previous treatment, histological diagnosis of lobular carcinoma, no previous history of breast cancer and minimum follow-up of 36 months. RESULTS: In univariate analysis, the following factors were statistically significant: clinical stage T (P = 0.0005), clinical stage N (P = 0.0014), neoadjuvant chemotherapy (P = 0.0008), primary tumor size (P < 0.0001), vascular invasion (P < 0.0001), lymphatic invasion (P = 0.0004), neural invasion (P = 0.0004), skin invasion (P < 0.0001), capsular transposition (P = 0.0008), lymph node ratio (P < 0.0001), estrogen receptor expression (P = 0.0186), progesterone receptor expression (P = 0.0286), pathological stage T (P < 0.0001), pathological stage N (P < 0.0001), adjuvant chemotherapy (P < 0.0001) and postoperative hormone therapy (P = 0.0367). After grouping the variables, multivariate analysis was performed. Presence of lymph node metastases, capsular transposition, lymph node ratio and postoperative hormone therapy remained significant. CONCLUSION: In this series, the most important prognostic factors for lobular carcinoma of the breast seemed to relate to lymph node status and presence of capsular transposition. Factors relating to axillary involvement, capsular transposition and hormone therapy were significant for survival.

CONTEXTO E OBJETIVO: O carcinoma lobular é o segundo tipo de neoplasia mais frequente na mama e tem características clínicas e patológicas próprias. Nosso objetivo foi avaliar fatores prognósticos para esse tipo de câncer de mama. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo em instituição terciária oncológica. MÉTODOS: 162 pacientes diagnosticadas e tratadas entre janeiro de 1985 e janeiro de 2002 foram incluídas. Os critérios de inclusão foram: ausência de tratamento prévio, diagnóstico histológico de carcinoma lobular, ausência de história prévia de câncer de mama e acompanhamento mínimo de 36 meses. RESULTADOS: Em análise univariada, os seguintes fatores foram estatisticamente significativos: estágio T clínico (P = 0,0005), estágio N clínico (P = 0,0014), quimioterapia neoadjuvante (P = 0,0008), tamanho do tumor primário (P < 0,0001), invasão vascular (P < 0,0001), invasão linfática (P = 0.0004), invasão neural (P = 0,0004), invasão de pele (P < 0,0001), transposição capsular (P = 0,0008), relação linfonodal (P < 0,0001), expressão de receptor estrogênico (P = 0,0168), expressão de receptor de progesterona (P = 0,0286), estágio T patológico (P < 0,0001), estágio N patológico (P < 0,0001), quimioterapia adjuvante (P < 0,0001) e hormonioterapia pós-operatória (P = 0.0367). Agrupando-se as variáveis, realizou-se análise multivariada. Presença de metástases linfonodais, transposição capsular, razão linfonodal e hormonioterapia pós-operatória permaneceram significantes. CONCLUSÃO: Nesta série, os fatores prognósticos mais importantes para carcinoma lobular de mama parecem ser aqueles relacionados com status linfonodal e presença de transposição capsular. Fatores relacionados ao comprometimento axilar, transposição capsular e terapia hormonal foram significativos para sobrevida.

TNM staging and classification (familial and nonfamilial) of breast cancer in Jordanian females.

Purpose : Staging of breast tumor has important implications for treatment and prognosis. This study aims at pinpointing the frequency of each stage among familial and nonfamilial breast cancers. Materials and Methods : Ninety-nine Jordanian females diagnosed with familial and nonfamilial breast cancer between 2000 and 2002 were enrolled in this study All breast cancer cases were staged according to the TNM classification into in situ, early invasive, advanced invasive and metastatic. Results : Forty-three cases were familial breast cancer and 56 were nonfamilial. One female breast cancer was diagnosed with ductal carcinoma in situ (DCIS) cancer. Fifty cases were diagnosed in early stages of invasive breast cancer, of which 31 cases were familial, 29 cases were classified as advanced invasive, where 21 cases were nonfamilial and 19 cases were metastatic stage of breast cancer, with 16 nonfamilial cases. Stage 2b was the most common stage of early invasive cases and represented 48% of the early stage of breast cancer. On the other hand, among cases diagnosed with advanced invasive breast cancer, stage 3a was the most common stage and represented 89.6% of the advanced stage. Interestingly, all cases of stage 3a belonged to TNM stages of T2N2M0 and T3N1M0. The tumor size in all cases of Jordanian females diagnosed with advanced invasive breast cancer exceeded 2 cm in size due to selection bias from symptomatic women in our study. Conclusion : The incidence of nonfamilial breast cancer was slightly higher than that of the familial type amongst studied the Jordanian females studied. The early invasive stage of breast cancer was more common in the familial while the advanced invasive and metastatic breast cancer cases were encountered more often in the nonfamilial type. Our study was based on a small sample and symptomatic women. Therefore, more research with larger population samples is needed to confirm this conclusion.

Factores de riesgo conocidos para cáncer de mama: pacientes con cáncer patología benigna no patología / Knew risk factors to breast cancer: in patients with cancer bening pathology and not pathology

Estudio prospectivo caso-control de factores de riesgo conocidos para cáncer de mama en grupo de pacientes femeninas con cáncer de mama, patología mamaria benigna y sin patología mamaria, para definir criterios clínicos que permitan orientar a los médicos y pacientes. Se incluyeron 515 pacientes con cáncer de mama, 507 con patología mamaria benigna y 505 sin patología mamaria. Se recogieron, con entrevista personal, los siguientes factores de riesgo: historia familiar de cáncer de mama y ovario, exposición a hormonas femeninas (exógena y endógena), antecedentes de patología mamaria benigna. Los resultados significativos al comparar el grupo con cáncer de mama y el grupo sin patología mamaria fueron los siguientes: antecedentes familiares de cáncer de mama y ovario, edad de la menopausia, nuliparidad, edad del primer embarazo a término, número de abortos, lactancia y antecedente de patología mamaria benigna. El modelo de regresión logística demostró que las variables de mayor impacto fueron los antecedentes familiares de cáncer de mama y ovario. Los resultados significativos al comparar el grupo con cáncer de mama y patología mamaria benigna fueron los siguientes: antecedente familiar de cáncer de mama “fuerte”, ingestión de anticonceptivos orales, lactancia, terapia hormonal de reemplazo, antecedente de patología mamaria benigna. El modelo de regresión logística demostró que la variable de mayor impacto fue la lactancia. Aunque algunos factores hormonales tuvieron importancia, la historia familiar de cáncer de mama, ovario, así como lactancia fueron los factores de mayor impacto.

A prospective case-control study was done considering known breast cancer risks factors in a group of female patients with breast cancer, benign breast diseases and without breast disease. The main objective was defining clinical criteria’s that help not only the physicians but also the patients with their parents about the clinical evaluation and the follow-up. Five hundred fifteen patients with breast cancer, 507 with benign breast disease, and 505 without breast disease were included. We registered, through personal interview, the following risk factors: family history of breast and ovarian cancer, exposition to female hormones (exogenous and exogenous) and previous benign breast disease. The significant results when we compared the group of breast cancer with the group without breast disease were as follows: family history of breast and ovarian cancer, age at menopause, null parity, and age at first live birth, number of abortions, lactation and previous benign breast disease. Logistic regression model showed that the most important variables were: family history of breast and ovarian cancer. The significant results when we compared the group of breast cancer with the group of benign breast disease were as follows: “strong” family history of breast cancer, oral contraceptives ingestion, lactation, hormone- replacement therapy and previous benign breast disease. Logistic regression model showed that the most important variable was lactation. Although some hormonal factors were important, family history of breast and ovarian cancer, and lactation were the most important risk factors.

Carcinoma mamário dentro de fibroadenoma: relato de dois casos / Breast carcinoma within fibroadenoma - two cases reports

O fibroadenoma é um tumor benigno mais comum da mama. Trata-se de neoplasia mista com componentes epiteliais e estromais. As taxas de frequencia de malignização do componente epitelial do fibroadenoma referidas na literatura são muito baixas (0,3%). Na maioria das vezes o carcinoma associado a fibroadenoma apresenta-se no estágio in situ e tem bom prognóstico. O objetivo deste trabalho é descrever dois casos clínicos de carcinoma dentro de fibroadenoma atendidos no Hospital do Câncer – Instituto do Câncer do Ceará (ICC). Primeiro caso: paciente, 51 anos, submetida à excisão local de nódulo à direita. O anatomopatológico evidenciou fibroadenoma associado a carcinoma lobular in situ. Segundo caso: paciente 42 anos mastectomizada à esquerda em 2005, apresentou nódulo em mama direita cuja punção guiada por ultra-sonografia foi compatível com carcinoma. Submeteu-se a quadrantectomia com pesquisa de linfonodo sentinela. O estudo histopatológico demonstrou carcinoma ductal in situ dentro de fibroadenoma e em tecido periférico.

Fibroadenoma is the most common benign tumor of the breast. It is a mixed neoplasm with epithelial and stromal components. Malignancy rates for the epithelial component reported in the literature are very low (0.3%). Usually carcinomas associated with fibroadenomas are in the in situ stage and have a favorable prognosis. The objective of the present paper was to report two clinical cases of carcinoma arising in fibroadenoma in patients attending the Ceará Cancer Institute (Fortaleza, Brazil). Case 1: 51-year old patient submitted to local excision of node in the right breast. The pathoanatomical examination revealed fibroadenoma associated with lobular carcinoma in situ. Case 2: 42-year old patient with left breast mastectomized in 2005 presenting with node in the right breast. Ultrasound-guided biopsy compatible with carcinoma. The patient was submitted to quadrantectomy and sentinel lymph node biopsy. The histopathological examination revealed ductal carcinoma in situ arising in fibroadenoma and peripheral tissues.

Análise da DNA-ploidia em carcinoma lobular de mama / DNA content analysis of breast lobular invasive carcinoma

O carcinoma mamário apresenta elevados números relacionados à incidência e prevalência nas mulheres em vários países. No Brasil, é a neoplasia com um dos maiores índices de mortalidade. O tipo de carcinoma mamário mais freqüente é o ductal invasor seguido do carcinoma lobular. Embora essas neoplasias tenham características próprias, há ainda muitas questões a serem dirimidas. Sabe-se que os carcinomas lobulares apresentam alto risco de desenvolvimento bilateral e recorrência; estão relacionadas à expressão hormonal e têm desfecho lento. Sabe-se que o carcinoma lobular não tem positividade para a proteína E-caderina, cuja ausência de expressão imuno-histoquímica tem sido usada para diferenciá-la do carcinoma ductal. O padrão do conteúdo de DNA no carcinoma lobular tem sido objeto de controvérsias, com trabalhos descrevendo-o como predominantemente diplóide e outros, ao contrário, aneuplóide. O objetivo deste estudo foi analisar os padrões da DNA-ploidia em carcinomas lobulares invasivos de mama, E-caderina negativos, e correlacioná-los com fatores prognósticos de notória importância: expressão da proteína p53, Cerb-B2, receptores de estrógeno, tamanho dos tumores, comprometimento linfonodal, metástases a distância e pós-cirúrgica. Para isso foi realizado um estudo retrospectivo, com 50 casos examinados no Departamento de Anatomia Patológica do Hospital do Câncer A. C. Camargo, São Paulo-SP. Essas mulheres foram tratadas com cirurgia e as que apresentaram comprometimento axilar, receberam terapia adjuvante com quimioterapia, radioterapia e hormônioterapia. As medianas dos tempos de seguimento, com início no tratamento inicial (cirurgia) até o evento foi: grupo que foram a óbito 50 ± 27,6 meses; grupo com perda de seguimento 33 ± 56,0 meses; grupo de censura por interrupção do tempo para análise 79 ± 45,3 meses. A idade média foi de 54 anos (variando de 34 a 80 anos). A análise do conteúdo de DNA mostrou-se predominantemente aneuplóide (63,16 % dos casos). Somente o comprometimento linfonodal mostrou-se significativo (p=0,043) em relação a análise de DNA-ploidia, os demais parâmetros não mostraram associação significativa. Concluímos que a análise do conteúdo de DNA não é um parâmetro relevante para avaliar a agressividade do carcinoma lobular.

Análise da DNA-ploidia em carcinoma lobular de mama

O carcinoma mamário apresenta elevados números relacionados à incidência e prevalência nas mulheres em vários países. No Brasil, é a neoplasia com um dos maiores índices de mortalidade. O tipo de carcinoma mamário mais freqüente é o ductal invasor seguido do carcinoma lobular. Embora essas neoplasias tenham características próprias, há ainda muitas questões a serem dirimidas. Sabe-se que os carcinomas lobulares apresentam alto risco de desenvolvimento bilateral e recorrência; estão relacionadas à expressão hormonal e têm desfecho lento. Sabe-se que o carcinoma lobular não tem positividade para a proteína E-caderina, cuja ausência de expressão imuno-histoquímica tem sido usada para diferenciá-la do carcinoma ductal. O padrão do conteúdo de DNA no carcinoma lobular tem sido objeto de controvérsias, com trabalhos descrevendo-o como predominantemente diplóide e outros, ao contrário, aneuplóide. O objetivo deste estudo foi analisar os padrões da DNA-ploidia em carcinomas lobulares invasivos de mama, E-caderina negativos, e correlacioná-los com fatores prognósticos de notória importância: expressão da proteína p53, Cerb-B2, receptores de estrógeno, tamanho dos tumores, comprometimento linfonodal, metástases a distância e pós-cirúrgica. Para isso foi realizado um estudo retrospectivo, com 50 casos examinados no Departamento de Anatomia Patológica do Hospital do Câncer A. C. Camargo, São Paulo-SP. Essas mulheres foram tratadas com cirurgia e as que apresentaram comprometimento axilar, receberam terapia adjuvante com quimioterapia, radioterapia e hormônioterapia. As medianas dos tempos de seguimento, com início no tratamento inicial (cirurgia) até o evento foi: grupo que foram a óbito 50 ± 27,6 meses; grupo com perda de seguimento 33 ± 56,0 meses; grupo de censura por interrupção do tempo para análise 79 ± 45,3 meses. A idade média foi de 54 anos (variando de 34 a 80 anos). A análise ...

Regression of the fibrous disease of the breast in a non-diabetic woman after pregnancy and breastfeeding

Fibrous mastopathy, also known as diabetic mastopathy and lymphocytic mastopathy, may mimic breast cancer at the physical examination, mammography, and ultrasound. We report a case of a woman who presented a non-tender mass clinically suggestive of breast carcinoma; however, the fine-needle aspiration cytology indicated atypia and the core needle biopsy revealed lymphocytic mastopathy. The magnetic resonance imaging of the breast showed a lesion with benign features. It was not demonstrated diabetics mellitus and autoimmune diseases. The patient got pregnant, breastfed, and it was observed the progressive regression of the lesion, with complete disappearance of the solid mass. Three years and three months later, there was no palpable mass at the clinical examination and ultrasound. In conclusion, fibrous mastopathy shall be considered for all breast lesions, regardless of the diagnosis of diabetes mellitus. Once a definitive diagnosis of this pathology is reached, it is recommended clinical, imaging studies and fine-needle aspiration biopsy follow-up of the patient, avoiding unnecessary surgical procedures.

A mastopatia fibrótica, também conhecida como mastopatia diabética e mastopatia linfocítica, pode, ao exame clínico, mamografia e ultra-som, simular um carcinoma mamário. Descrevemos o relato de uma mulher na qual o nódulo foi inicialmente suspeito de carcinoma mamário, mas o diagnóstico pela punção aspirativa com agulha fina foi de atipia, e o com biópsia com agulha grossa foi de mastopatia linfocítica. A ressonância magnética da mama mostrou a lesão com características de benignidade. Não foram demonstradas diabetes mellitus e doenças auto-imunes. A paciente engravidou, amamentou e foi observada regressão progressiva da lesão, com desaparecimento da mesma. A paciente persiste sem lesão na mama ao exame clínico e de ultra-som após acompanhamento de três anos e três meses. Em conclusão, a mastopatia fibrótica deve ser considerada para todas as lesões de mama, mesmo em pacientes sem diabetes mellitus. Quando o diagnóstico definitivo da patologia for realizado, é recomendável o acompanhamento da paciente com estudos clínicos e de imagem e biópsia com agulha fina, evitando-se procedimentos cirúrgicos desnecessários.

Carcinomatosis peritoneal secundaria a carcinoma Lobulillar de mama / Peritoneal carcinomatosis secondary to lobular breast cancer

Introducción: Aunque el cáncer de mama metastatiza con mayor frecuencia en ganglios linfáticos, hueso, pulmón e hígado, también se puede extender hacia el tracto gastrointestinal, peritoneo y órganos ginecológicos. Material y Método: Describimos tres casos de carcinomatosis peritoneal secundaria a la diseminación metastásica de un carcinoma lobulillar infiltrante de mama. En los tres casos el diagnóstico se hizo varios años después del descubrimiento del tumor primario y en dos de ellos se observa remisión de la enfermedad al año y cuatro años respectivamente tras la administración de quimio y hormonoterapia postoperatoria. Conclusión: La carcinomatosis peritoneal en cáncer de mama es poco frecuente, pero cuando aparece casi siempre es secundaria a un carcinoma lobulillar infiltrante con receptores hormonales positivos. Los síntomas son inespecíficos y normalmente existe un intervalo largo desde el diagnóstico inicial del tumor, de ahí que en muchos casos sea difícil diferenciar entre un tumor primario de la cavidad peritoneal y la presencia de metástasis de un carcinoma de mama, no solo a nivel clínico, sino también histológico. El diagnóstico resulta fundamental para el oncólogo, pues con tratamiento quimio y hormo-noterápico se han descrito remisiones parciales o completas del tumor durante períodos prolongados de tiempo.

Quimioterapia no carcinoma lobular invasivo: qual a evidência? / Chemotherapy in lobular invasive breast cancer: is there an evidence?

O carcinoma lobular invasivo é o segundo tipo histológico mais freqüente de câncer de mama, e sua incidência parece estar aumentando. O carcinoma lobular invasivo apresenta características clínicas, biológicas e moleculares distintas das do carcinoma ductal, sendo freqüentemente de baixo grau e quase sempre positivo para receptores de estrógeno. A taxa de resposta à quimioterapia neo-adjuvante do carcinoma lobular invasivo é mais baixa que a do carcinoma ductal invasivo. Apesar disso, a quimioterapia adjuvante é rotineiramente indicada para pacientes com carcinoma lobular invasivo, com base nos mesmos critérios utilizados para carcinoma ductal invasivo. Neste artigo, revisaram-se os estudos randomizados de quimioterapia em câncer de mama localizado e não se encontraram dados suficientes para alicerçar ou banir o uso de quimioterapia em pacientes com carcinoma lobular invasivo. O benefício da quimioterapia sistêmica para pacientes com carcinoma lobular invasivo precoce está pouco claro na literatura. O carcinoma lobular invasivo é uma classe clínica e molecularmente distinta dos cânceres de mama, que deve ser investigada separadamente em estudos prospectivos, para que se possa oferecer o tratamento ideal para pacientes com essa doença.

Invasive lobular carcinoma is the second most frequent histological type of breast cancer, and on whose incidence seems to be increasing. Invasive lobular carcinoma displays unique clinical and biological features, when compared with invasive ductal carcinoma, and a significantly lower response rate to neoadjuvant chemotherapy. However, adjuvant chemotherapy is indicated for patients with invasive lobular carcinoma using the same criteria utilized for invasive ductal carcinoma. In this article, we provide an overview of the randomized trials of neoadjuvant and adjuvant chemotheraphy; at the present time, there is little evidence to support or to withhold chemotherapy for patients with early-stage, invasive lobular carcinoma. We thus suggest that the role of systemic chemotherapy for such patients is currently unclear, and an issue well deserving of more thorough investigation in future trials.

Biopsia por aspiración con aguja fina en lesiones mamarias: experiencia institucional / Fine needle aspiration biopsy of breast lesions: institutional experience

Background. With the advent of new diagnostic technologies and the fear of low diagnostic accuracy, there has been a reduction in the use of fine needle aspiration (FNA) for diagnosis of breast lesions. The objectives of the present study were to establish the diagnostic accuracy and complications associated with FNA of breast lesions. Material and methods. We retrospectively reviewed FNA of breast lesions done in a tertiary referral center in Mexico City from 1999 through 2001. We analyzed demographic, radiologic and pathological variables in order to establish diagnostic accuracy of FNA. The gold standard was considered the histopathologic study of the specimen or the clinical follow-up of benign lesions. Categorical variables were analyzed with the method and statistical significance was considered at p < 0.05. Results. We identified 300 patients with a mean age of 50 years (range, 20-86). Fifty-three percent were postmenopausal. In ninety-three percent of patients, FNA was performed in the outpatient clinic. Nonpalpable lesions were aspirated under ultrasound guidance. Mean size of the lesion was 2.27 cm (range 0.7-10 cm). Thirty-one percent of patients had definite diagnosis of malignancy. The only variables associated with cancer diagnosis were the BTRADS category and the presence of palpable adenopathy. Cancer was diagnosed in 6.5% of lesions categorized as BTRADS 0-3 compared to 56.2% for lesions BTRADS 4-5 (p < 0.0001). Positive predictive value and specificity of FNA were 100%. Sensitivity, negative predictive value and accuracy were 82.6%, 92.8% and 94.7%, respectively. The most common diagnosis of false negative lesions were lobular and papillary carcinomas. There were no significant complications associated with FNA. Conclusions. Diagnostic accuracy of FNA for breast lesions is very high with minimal complications. Positive predictive value of 100% allows to establish therapy based on its results.

Antecedentes. El advenimiento de nuevas tecnologías diagnósticas, así como el temor a baja exactitud diagnóstica, han reducido el papel de la biopsia por aspiración con aguja fina (BAAF) en lesiones mamarias. El objetivo del presente estudio fue el establecer la exactitud diagnóstica y complicaciones de la BAAF en esta indicación. Material y métodos. Estudio retrospectivo de BAAF de lesiones mamarias realizadas en nuestra institución de 1999 a 2001. Se analizaron variables demográficas, radiológicas e histopatológicas para establecer la exactitud diagnóstica. Se definió como estándar diagnóstico al análisis histopatológico del tejido o bien al seguimiento clínico en caso de lesiones benignas dejadas para observación. Las variables categóricas se analizaron con la prueba de . Se estableció como significativa a una p < 0.05. Resultados. Fueron identificados 300 pacientes con una edad promedio de 50 años (20-86). Fueron posmenopáusicas 53.3%. En 93.3% de los casos se realizó BAAF de lesión clínicamente palpable y en el resto de una lesión visible por ultrasonido. El tamaño promedio de la lesión fue de 2.27 cm (0.7-10 cm). De las pacientes, 30.7% tuvieron diagnóstico definitivo de lesión maligna. Las únicas variables asociadas al diagnóstico de cáncer fueron la clasificación radiológica de BI-RADS y la presencia de adenomegalias palpables. La incidencia de cáncer en pacientes con BI-RADS de 0 a 3 fue de 6.5% vs. 56.2% en aquellas con BI-RADS 4 o 5 (p < 0.0001). Tanto el valor predictivo positivo como la especificidad de la BAAF fueron de 100%, con una sensibilidad de 82.6% y valor predictivo negativo de 92.8%, para una exactitud diagnóstica de 94.7%. Las causas más frecuentes de falsos negativos fueron el carcinoma lobulillar infiltrante y el carcinoma papilar. No se presentaron complicaciones significativas en ningún caso asociadas con la BAAF. Conclusiones. La exactitud diagnóstica de la BAAF en lesiones mamarias es muy elevada, con una incidencia mínima de complicaciones. Un valor predictivo positivo de 100% permite basar la terapéutica en sus resultados. El diagnóstico de benignidad por BAAF permite el seguimiento seguro de lesiones mamarias.

Manejo conservador de la axila en cáncer de mama operable / Conservative management of the axillary nodes in operable breast cancer

El tratamiento del cáncer de mama (CM), tumor mas frecuente en la mujer, sufrió diferentes modificaciones a lo largo de los dos últimos siglos. Se describe una reseña de las mismas, como así también los cambios en el manejo de la terapéutica axilar. Durante el siglo pasado, se trabajó fundamentalmente en las opcionesterapéuticas para la conservación de la glándula mamaria. Recién en las últimas décadas comienza el planteo de conductas dirigidas al manejo conservador de la axila, sobre todo para minimizar los efectos adversos secundarios a la linfadenectomía axilar completa. La técnica del Ganglio Centinela cobra importancia ya que los canceres de mama, cada vez con mayor frecuencia, son diagnosticados en estadios iniciales, por lo que las probabilidades de tener ganglios axilares negativos son cada vez mayores. Concluimos que la información que brinda el conocimiento del estado de los ganglios axilares es muy importante en la toma de decisiones terapéuticas en pacientes con cáncer de mama, y que la técnica del ganglio centinela podría, en algunos casos, ser un test que predice el status ganglionar axilar, sin necesidad de realizar una linfadenectomía axilar clásica.

Over the years, the treatment of breast cancer has changed dramatically. We briefly describe those changes and also the different therapeutic approaches to the axillary nodes. Over the last century, the primary goal was to avoid radical surgery of the breast. However, during the last decades, the interest was mainly focused on the possibility of treating the axilla in a conservative way, in an effort to minimize the adverse effects of linfadenectomy. The sentinel node technique is of key importance, because nowadays it is possible to diagnose breast cancer at early stages when most of the times the axilla is negative. The early diagnoses of breast cancer make the sentinel node technique a relevant tool at the time of making therapeutic decisions. We believe that the sentinel node technique could predict in many cases the lymph node status without the need of a complete axillary dissection of the axilla in patients with breast cancer.

Prognostic factors in infiltrating lobular carcinoma.

Various prognostic factors viz. clinical details, histologic features including subtypes, elastosis, desmoplasia, in situ carcinoma, perineural and vascular invasion, Nottingham Prognostic Index (NPI), and menopausal status were evaluated in Infiltrating Lobular carcinoma (ILC) in the context of patient survival. 138 patients had presented with ILC over a period of 20 years. Histological subtypes of ILC and vascular invasion played a role in the biologic behaviour of the tumour. Interestingly premenopausal status protected against the risk for relapse, while being postmenopausal, increased the risk. NPI was demonstrated as an independent significant prognostic factor and was a good predictor for relapse. This study underlines the role of the pathologist in determination of the prognostic groups in Infiltrating lobular carcinoma.

Metástasis de carcinoma mamario lobulillar a vesícula biliar: estudio con inmunohistoquímica de receptores hormonales / Mammary lobular carcinoma metastatic to the gallbladder: immunohitochemistry and estrogen/progesterone receptors study

Se presenta un caso de carcinoma mamario lobulillar que cinco años después presenta metástasis a vesícula biliar. La metástasis fue sospechada por el estudio histológico y confirmada por medio de inmunohistoquímica para receptores de estrógenos y progesterona.

Malignant phyllodes tumor in the right breast and invasive lobular carcinoma within fibroadenoma in the other: case report

CONTEXT: The malignant variety of the phyllodes tumor is rare. The occurrence of invasive lobular carcinoma within fibroadenoma is rare as well. DESIGN: Case report. CASE REPORT: A 58-year-old black female patient was referred to the Mastology unit of the Department of Gynecology, Federal University of Sao Paulo / Escola Paulista de Medicina, in February 1990, presenting an ulcerated tumor in the right breast with fast growth over the preceding six months. She was a virgin, with meno-pause at the age of 45 years and had not undergone hormone replacement treatment. The physical examination showed, in her right breast, an ulcerated tumor of 20 x 30 cm which was not adher-ent to the muscle level, multilobular and with fibroelastic consistency. The axillary lymph nodes were not palpable. The left breast showed a 2 x 3 cm painless, movable nodule, with well-defined edges, and fibroelastic consistency. We performed left-breast mammography, which showed several nodules with well-defined edges, the largest being 2 x 3 cm and exhibiting rough calcification and grouped microcalcifications within it. The patient underwent a frozen biopsy that showed a malignant variant of the phyllodes tumor in the right breast and fibroadenoma in the left one. After that, we performed a total mastectomy in the right breast and an excision biopsy in the left one. Paraffin study confirmed the frozen biopsy result from the right breast, yet we observed that in the interior of the fibroadenoma that was removed on the left, there was a focal area of invasive lobular carcinoma measuring 0.4 cm. The patient then underwent a modi-fied radical mastectomy with total axillary lymphadenectomy. None of the 21 dissected lymph nodes showed evidence of metastasis. In the follow-up, the patient evolved asymptomatically and with normal physical and laboratory examination results up to July 1997

Lobular carcinoma in situ in sclerosing adenosis

The initial presentation of breast malignancy as noninvasive carcinoma in an area of sclerosing adenosis is unusual. Especially, lobular carcinoma in situ in sclerosing adenosis sometimes can be a potential source of confusion with invasive lobular carcinoma. We report a case of lobular carcinoma in situ presenting in adenosis exhibiting patterns akin to invasive lobular carcinoma, thus leading to potential misdiagnosis. Overall architecture of the lesion as seen at lower power and immunohistochemistry can be useful to distinguish between sclerosing adenosis with lobular carcinoma in situ and infiltrating lobular carcinoma.