Calidad de atención y mejora continua en el abordaje integral del cáncer de mama: Evaluación de indicadores en una Unidad de Mastología / Quality of care and continous improvement in a comprehensive approach of breast cancer management: evaluation of indicators in a breast center

Introducción: las Unidades de Mastología son organizaciones que tienen por objetivo abordar la patología mamaria de manera multidisciplinaria e integral. A nivel mundial se han implementado programas para evaluar la calidad de atención a través del cumplimiento de indicadores propuestos por Sociedades Científicas u organismos gubernamentales. Algunos de estos han sido propuestos y revisados por la Sociedad Europea de Mastología (EUSOMA). Objetivo: evaluar la calidad de atención de la Unidad de Mastología del Hospital Juan A. Fernández a través del análisis de una serie de indicadores propuestos por EUSOMA como estándares de calidad de atención en centros de patología mamaria. Material y método: estudio descriptivo retrospectivo analizando la base de datos de las pacientes con cáncer de mama estadios 0 a III operadas entre 2015 y 2019. Se analizaron 25 indicadores de procesos propuestos por EUSOMA en 2017. Se registraron las características de la población, y el porcentaje de pacientes en las cuales se cumple la condición de cada uno de los indicadores. Se registró si el indicador alcanza o supera el mínimo estándar, o si alcanza o supera el valor ideal. Resultados: se evaluaron 284 pacientes. Se observó el cumplimiento de la mayoría de los estándares propuestos (18 de 25), alcanzando o superando en el 25% de los indicadores evaluados el valor ideal. Se lograron alcanzar los estándares de calidad de atención relacionados con el diagnóstico clínico y preoperatorio, caracterización anatomopatológica completa en carcinoma invasor, evaluación multidisciplinaria, tratamiento quirúrgico primario en carcinoma invasor e in situ. Se alcanzaron los objetivos tendientes a evitar el sobretratamiento quirúrgico en carcinoma invasor y en cirugía conservadora en carcinoma in situ. En relación a los tratamientos adyuvantes, se alcanzaron los estándares relacionados con radioterapia post cirugía conservadora y post mastectomía, así como también el tratamiento con hormonoterapia y quimioterapia. El seguimiento de los pacientes se realizó en tiempo en tiempo y forma de acuerdo al indicador establecido. Existen 3 indicadores de calidad obligatorios en los que no se alcanzó el estándar mínimo: se observó la necesidad de mejorar la accesibilidad a los tratamientos antiHer2neu en neoadyuvancia, y de reducir los tiempos de espera al inicio del tratamiento. Conclusiones: se observó el cumplimiento de la mayoría de los estándares propuestos. Dado que existen indicadores obligatorios en los que no se alcanzó el estándar mínimo, los esfuerzos primarios deberán centrarse prioritaria e inicialmente en diseñar una planificación que permita alcanzar estos objetivos, así como también mantener en el tiempo los valores positivos ya alcanzados. Se pone de manifiesto la necesidad de implementar políticas a nivel sanitario nacional que permitan mejorar la accesibilidad a medicación oncológica. A su vez, destacamos la importancia de definir indicadores propios con valores ajustados a las características de nuestro país y mantener una evaluación periódica de la calidad de atención a través de los mismos.

Introduction: Breast Units are organizations that manage Breast Cancer in a comprehensive and multidisciplinary approach. Worlwide, programs have been developed in order to evaluate quality of care through the achievement of certain standards of care that have been proposed by scientific organizations, medical associations or government health departments. Some of these indicators have beeb proposed by the European Society of Breast Cancer Specialist (EUSOMA). Objective: to evaluate quality of care in the Breast Unit at Hospital Juan A Fernández (Buenos Aires, Argentina) through the analysis of a series of indicators described by EUSOMA as standard of care in breast centers. Material and method: we performed a descriptive, retrospective analysis of our database including patients with breast cancer stage 0 to III that wer treated between 2015 and 2019. We studied 25 quality of care process indicators proposed by EUSOMA in 2017. We registered population characteristics and the percentage of patients in which each indicator mínimum requirements were achieved. We also studied whether our results achieved or were beyond the ideal targets for each indicator. Results: a total of 284 patients were evaluated. The mínimum standard of care was achieved in most of the evaluated indicators (18 of 25) and in 25% of these, our results achieved or exce3ded the ideal requirements. The indicators in which the mínimum or ideal standard of care was accomplished were regarding clinical and preoperative diagnosis anatomopathological characterisation in invasive breast cancer, multidisciplinary approach, primary surgical management in invasive and in situ breast cancer, avoidanc of overtreatement in invasive breast cancer and breast conserving therapy in carcinoma in situ. Regarding adjuvant treatment, the standard of care was achieved in radiotherapy after breast conserving surgery and after mastectomy, endocrine therapy and chemotherapy. The follow up timing was according to the indicator. There were 3 mandatory indicators in which the mínimum standards were not achieved and were regarding accesibility to anti Her2neu agents in neoadjuvant setting, and timing form diagnosis to firts treatment. Conclusions: we observed that out Breast Unit achieved most of the quality of care indicators described by EUSOMA. However, there 3 mandatory indicators where the results were below the mínimum. This is why future efforts should be focused on designing and planning new measures that will allow these objectives to be accomplished, as well as maintaining what has already been achived. Our results also show the imperious need to implement national public health pólices that would grant a better accesiblility to oncologic medications. We also analysed the importance of defining our own local quality of care indicators in relation to our health policies and current situation, as well as the importance of a continuous evaluation of quality of care through these indicators.

Respuesta completa y prolongada al tratameinto con pamidronato en metástasis pulmonares de un tumor de células gigantes óseo / Complete and prolonged response to treatment with pamidronate in lung metastases from a giant cell tumor of the bone

A pesar de ser considerado benigno, el tumor de células gigantes (TCG) de hueso con baja frecuencia puede presentar metástasis (MTS) a distancia, mayormente pulmonares. El curso clínico de las MTS, aunque habitualmente indolente, es muy variable. Se comunicaron tanto muertes por progresión de MTS, como su regresión sin mediar tratamiento alguno. Los marcadores pronósticos moleculares están aún en desarrollo. El manejo terapéutico de las MTS pulmonares es controversial. Las principales modalidades de tratamiento fueron tradicionalmente la cirugía, la quimioterapia y observación. En la última década los bifosfonatos (BF) y el denosumab, fueron empleados con éxito en el tratamiento adyuvante y neoadyuvante, pero la efectividad de estos fármacos, especialmente los BF, en pacientes con MTS está estudiada en menor medida. Presentamos un caso de MTS pulmonares múltiples histológicamente verificadas de TCG con respuesta completa al tratamiento con pamidronato que continúa a los 7 años de seguimiento (AU)

Although it is considered benign, on rare occasions giant cell tumor (GCT) of bone may present systemic dissemination, predominantly to the lung. The clinical course of metastasis (MTS), while usually indolent, is unpredictable. Both, deaths from progressive lung MTS and regressions without any treatment were reported. Molecular prognostic biomarkers are under development yet. The management of GCT is controversial. Surgical removal, chemotherapy and observation were traditionally the treatment modalities of choice. In the last decade biphosphonates and denosumab were successfully used in the adjuvant and neoadjuvant/unresectable setting. Nonetheless, the effectiveness of these drugs in metastatic disease is less studied. We submit a case report of complete response of multiple histopathologically confirmed unresectable lung MTS of TCG to the treatment with pamidronate with total follow-up length of 7 years (AU)

Anal squamous carcinoma: a new AIDS-defining cancer? Case report and literature review / Carcinoma de células escamosas do canal anal: a nova neoplasia associada com AIDS?

Squamous anal cell carcinoma is a rare malignancy that represents the 1.5% to 2% of all the lower digestive tract cancers. However, an increased incidence of invasive anal carcinoma is observed in HIV-seropositive population since the widespread of highly active antiretroviral therapy. Human papillomavirus is strongly associated with the pathogenesis of anal cancer. Anal intercourse and a high number of sexual partners appear to be risk factors to develop anal cancer in both sexes. Anal pain, bleeding and a palpable lesion in the anal canal are the most common clinical features. Endo-anal ultrasound is the best diagnosis method to evaluate the tumor size, the tumor extension and the infiltration of the sphincter muscle complex. Chemoradiotherapy plus antiretroviral therapy are the recommended treatments for all stages of localized squamous cell carcinoma of the anal canal in HIV-seropositive patients because of its high rate of cure. Here we present an HIV patient who developed a carcinoma of the anal canal after a long time of HIV infection under highly active antiretroviral therapy with a good virological and immunological response.

O carcinoma de células escamosas do canal anal é uma malignidade rara que representa 1,5% a 2% de todos os cânceres do trato gastrointestinal inferior. Entretanto, é observada uma incidência aumentada do carcinoma anal invasivo, na população soropositiva para o HIV desde a difusão da terapia antirretroviral altamente ativa. O vírus do papiloma está fortemente associado com a patogênese do câncer anal. Sexo anal e um alto número de parceiros sexuais parecem ser os fatores de risco para desenvolver câncer anal em ambos os sexos. Dor anal, sangramento e lesão palpável no canal anal são as manifestações clínicas mais comuns. O ultrassom endoanal é o melhor método diagnóstico para avaliar o tamanho do tumor, sua extensão e a infiltração para o complexo do músculo esfincteriano. A quimioradioterapia mais terapia antirretroviral é o tratamento recomendado para todos os estádios do carcinoma localizado de células escamosas do canal anal nos pacientes HIV soropositivos, devido a sua alta taxa de cura. Apresentamos um paciente que desenvolveu carcinoma do canal anal depois de um longo tempo de infecção por HIV sob tratamento com a terapia antirretroviral altamente ativa, com boa resposta virológica e imunológica.

Non Hodgkin's lymphoma with cutaneous involvement in AIDS patients: report of five cases and review of the literature

Cutaneous B cell lymphoma (CBCL) is a lymphoproliferative disorder of neoplastic B cell of the skin with a wide range of clinical manifestations. Commonly, the clinical features of CBCL are plaques, nodules, or ulcerative lesions. Skin is one of the common sites for extra-nodal lymphomas in patients with AIDS and B cell type is less common than T cell type. Only recently, the existence of B cell lymphomas presenting clinically in the skin without evidence of extra-cutaneous involvement has been accepted as primary CBCL. Here, we are presenting 5 patients with cutaneous involvement in the setting of HIV/AIDS disease. Two of them were primary cutaneous non-Hodgkin lymphomas. All were CBCL; 3 were immunoblastic, 1 was plasmablastic, and the other was a Burkitt lymphoma. We analyzed the epidemiological, clinical, virological, and immunological characteristics of this group of patients.

Tratamiento conservador con quimioterapia y radioterapia en el cáncer músculo-invasivo de vejiga / Conservative management with chemotherapy and radiotherapy in the treatment of muscle-invading cancer of the bladder

Radical cystectomy for invasive bladder cancer remains the standard of care. However, a large international experience indicates satisfactory result with bladder-sparing approaches (transurethral resection, radiation, and chemotherapy as a trimodality therapy), in selected patients, with a survival rate with an intact bladder of 40%. It would be very useful a direct comparison of surgically, based and chemoradiotherapy based approaches.

Sarcoma de Kaposi asociado al SIDA / Management of aids-related Kaposi's sarcoma

Kaposi's sarcoma is a multicentric neoplasm highly vascularized, and represents the most frequent malignancy among HIV-infected pesons, abeing its estimated incidence 900 thousand times higher among HIV-infected persons than in those who are not...The high incidence of disease in homosexual and bisexual men has implicated environmental and infectious factors. The authors of this reort, describe the epidemiology and pathogenesis, diagnostic evaluation and extension of the disease, and with special consideration on treatment

Carcinoma bronquioloalveolar en un paciente con sida: presentación de un caso y revisión de la literatura / Bronchogenic carcinoma in a patient with HIV infection

Los pacientes con infección por el virus de la inmunodeficiencia humana (HIV) presentan un alto riesgo de desarrollar un carcinoma pulmonar independientemente del antecedente de tabaquismo. Los sujetos seropositivos para HIV con cáncer de pulmón, son más jóvenes en comparación con la población general que padece esta neoplasia y en ellos el subtipo histológico predominante es el adenocarcinoma ... Aquí se hace referencia a un paciente con infección por HIV que desarrolló un infrecuente subtipo de adenocarcinoma pulmonar, el carcinoma bronquioloalveolar.

Oral cavity lymphoma as secondary AIDS-defining neoplasm in a patient on HAART with immune reconstitution

Lymphomas of the oral cavity are a rare complication of advanced HIV/AIDS disease. The clinical appearance of these neoplasms includes masses or ulcerative lesions that involve the oral soft tissue and the jaw as the predominant manifestation. We report the case of a patient with AIDS who developed diffuse large B-cell non-Hodgkin’s lymphoma of the oral cavity during highly active antiretroviral therapy, with undetectable plasma viral load and immune reconstitution.

Os linfomas da cavidade oral são uma complicação rara da AIDS/HIV avançada. A aparência clínica dessas neoplasias inclui massas ou lesões ulcerativas que envolvem o tecido mole oral e da mandíbula como manifestação predominante. Relatamos um caso de um paciente com AIDS que desenvolveu um linfoma não Hodgkin de células B difuso e extenso da cavidade oral durante a terapia antiretroviral altamente ativa com carga viral plasmática indetectável e reconstituição imune.

Linfomas del tubo digestivo y glándulas anexas en pacientes con SIDA: serie de casos / Non-Hodgkin's lymphomas of the digestive tract and anexal glands in AIDS patients

Introducción: el linfoma no Hodgkin (LNH) es la segunda neoplasia más frecuente en pacientes con SIDA. Una de las principales características de los LNH asociados con el SIDA es la alta frecuencia de compromiso extranodal, incluyendo el tracto astrointestinal, como manifestación inicial de la neoplasia. Métodos: se analizaron de manera retrospectiva las características epidemiológicas, clínicas, virológicas, inmunológicas e histopatológicas de 8 pacientes con diagnóstico de linfomas del tracto gastrointestinal y glándulas anexas (hígado y parótida) asistidos en la División de VIH- /SIDA del Hospital de Enfermedades Infecciosas F J Muñiz de Buenos Aires, Argentina, entre enero de 1997 y diciembre de 2004. Todos los pacientes fueron evaluados por tomografía computarizada y examen de la médula ósea, además de los exámenes endoscópicosde diagnóstico. Resultados: todos los pacientes fueron varones; 4 eran heterosexuales, 2 homosexuales, uno hemofílico y uno adicto a drogas endovenosas. Tres pacientes presentaron coinfección por el virus de la hepatitis C. La mediana de edad fue de 42 años y la mediana de linfocitos T CD4 + fue de 87 células/uL al momento del diagnóstico de la neoplasia. Ningún paciente recibía TARGA al momento del diagnóstico del linfoma. La incidencia global de linfomas (primarios del sistema nervioso central, no Hodgkin sistémicos y de Hodgkin) durante el período de estudio fue de 2,9% (54 casos); 17 pacientes (32%) tuvieron diagnóstico de LNH sistémicos; 10 (58,8%) de ellos tuvieron presentación extranodal al momento del inicio de las mani manifestaciones clínicas y 8 (80%) comprometieron el tubo digestivo y las glándulas anexas (parótida, cavum, esófago, estómago, duodeno, colon derecho en 2 casos e hígado en el restante), como LNH primarios, de alto grado y de fenotipo "B". Todos los pacientes presentaronsíntomas "B" al momento del diagnóstico. De acuerdo con los criterios de estadificación de Lugano, 4 se encontraban en el estadio...

Background: Non-Hodgkin's lymphoma (NHL) is the second most common neoplasm among patients with AIDS. One of the major clinical characteristics of AIDS-associated NHL is the high frequency of extranodal involvement, including the gastrointestinaltract, at initial presentation. Methods: From January 1997 to December 2004, 8 cases of NHL of the digestive tract and anexal glands (liver and parotid gland) were observed at the HIV/AIDS division of the Infectious Diseases F J Muñiz Hospital from Buenos Aires,Argentina. All patients were staged by computed tomography scanning and bone marrow examination, in addition to the endoscopic evaluation. Results: All patients were males; 4 were heterosexual, 2 homosexual, and 1 were a hemophilic and an intravenous drug abuser. The median age was 42 years and the median CD4 T cell count was 87 cells/uL at the time of the diagnosis of neoplasm. No patient was receiving highly active antiretroviral therapy (HAART) at lymphoma diagnosis. The global incidence of AIDS-associated lymphomas (central nervous system lymphomas, non-Hodgkin lymphomas and Hodgkin lymphoma) during the time of study was 2,9% (54 cases); 17 patients(32%) had diagnosis of systemic NHL; 10 (58,8%) of them were extranodal at the onset of clinical symptoms and 8 (80%) involvement the digestive tract and anexal glands (parotid gland, cavum, esophagus, stomach, duodenum, the right colon in 2 patients and the liver), as primary NHL of high grade and "B" phenotype. All patients presented "B" symptoms at the time of diagnosis. Primary duodenal lymphoma was the only Burkittlymphoma of this serie and we detected the Epstein-Barr virus genome in the biopsy smears of this tumor and in the hepatic lymphoma. Four patients were treated with systemic chemotherapy with granulocytic growth factor support plus highly active antiretroviral therapy (HAART); 2 of them (cavum and one of the colon) had a prolonged survival with immune reconstitution during 5 and 6...