ABSTRACT
Sentinel lymph node biopsy (SLNB) at upfront surgery is the gold-standard surgical method for axillary lymph node staging in early stage breast cancer: the technique provides adequate information regarding axillary status, with similar oncological safety and lower morbidity compared to axillary dissection, despite the false negative rates. Neoadjuvant chemotherapy (NACT), traditionally used for locally advanced breast cancer, plays an important role in the treatment of early stage breast cancer, making downstaging possible in axillary lymph node and breast cancer, thus minimizing the impact of surgery and reducing morbidity, as well as enabling patients with residual disease to be selected for adjuvant treatment. In this respect, the role of SLNB has proved controversial, particularly in view of the lack of data from randomized clinical trials on this subject. Currently, the de-escalation of axillary surgery after NACT is mainly based on retrospectives studies and false negative rates. This paper reviews current evidence on the management of axillary surgery following NACT under different circumstances, with suggested recommendations in each scenario: clinically negative nodes at diagnosis and SLNB after NACT, clinically positive nodes at diagnosis and SLNB after NACT, positive SLNB following NACT and finally the possibility of omitting axillary surgery in good responders.
Subject(s)
Breast Neoplasms , Sentinel Lymph Node Biopsy , Humans , Female , Sentinel Lymph Node Biopsy/methods , Neoadjuvant Therapy/methods , Lymphatic Metastasis , Neoplasm Staging , Lymph Node Excision/methods , Lymph Nodes/pathology , Breast Neoplasms/drug therapy , Breast Neoplasms/surgery , Breast Neoplasms/pathologyABSTRACT
BACKGROUND: Triple-negative breast cancer (TNBC) is a heterogenous subtype involving different patterns of behavior and clinical course, demanding a complex, individualized sequence of treatment. The knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology regarding TNBC were evaluated and a consensus regarding management and treatment was reached. METHODS: Affiliates completed a survey involving 44 objective questions. In addition, a specialist meeting was held with 27 experts and 3 ad hoc consultants. The panelists completed the survey before and after brainstorming. Answers achieving 70% of agreement were considered consensual. The chi-square test was used to compare answers between panelists and affiliates and the Kappa coefficient to calculate agreement. RESULTS: Consensus among the panelists increased from 26 (59.1%) to 32 questions (72.7%) following brainstorming (p = 0.17), including 7/10 questions on systemic treatment. Among the affiliates, consensus was achieved for 24 questions (54.5%), resulting in moderate agreement (κ = 0.445). Neoadjuvant chemotherapy should be indicated for almost all cases (except cT1a-b N0) and should include platinum agents. When indicated, immunotherapy is part of the standard of care. The panel reaffirmed the concept of no ink on tumor as indicative of adequate margins and the possibility of sentinel lymph node biopsy for cN1 patients who become cN0 following neoadjuvant therapy. Controversies remain on combining immunotherapy with capecitabine/olaparib in pertinent cases. CONCLUSION: Expert consensus was achieved for > 70% of the questions, with moderate agreement between panelists and affiliates. Educational interventions on systemic breast cancer treatment affected decision-making in 60% of the questions.
Subject(s)
Triple Negative Breast Neoplasms , Humans , Triple Negative Breast Neoplasms/diagnosis , Triple Negative Breast Neoplasms/therapy , Brazil , Neoadjuvant Therapy , Immunotherapy , CapecitabineABSTRACT
OBJETIVO: avaliar a eficiência da localização e exérese por cirurgia radioguiada de lesões ocultas mamárias utilizando radiofármaco injetado diretamente no interior das lesões ou até dois centímetros destas com posterior injeção de ar como controle radiológico. MÉTODOS: vinte e nove pacientes com 32 lesões mamárias ocultas, detectadas por mamografia ou ultra-sonografia, classificadas como Bi-Rads® 3, 4 e 5 foram incluídas neste estudo observacional com resultados expressos em percentagens. O radiofármaco utilizado foi o macroagregado de albumina marcado com tecnécio-99m (99mTc-MAA) injetado por orientação mamográfica ou guiado por ultra-sonografia. A injeção do radiofármaco foi seguida pela imediata administração de ar, através da agulha da estereotaxia, visando o controle radiológico da injeção do radiofármaco. A biopsia excisional foi feita com o auxílio do aparelho portátil gamma-probe (detector de radiação gama) e a remoção completa das lesões foi verificada pela radiografia das peças cirúrgicas ou por exame por congelação intra-operatório. RESULTADOS: câncer de mama foi encontrado em 10 por cento (1/10) das lesões BI-RADS® 3, em 31,5 por cento (6/19) das BI-RADS® 4 e em 66,6 por cento (2/3) das BI-RADS® 5. As 29 pacientes corresponderam a 32 espécimes, cirúrgicos. O radiofármaco foi corretamente posicionado em 96,8 por cento (31/32) dos espécimes permitindo remoção de 96,8 por cento das lesões mamárias não palpáveis estudadas. A completa remoção da lesão foi demonstrada pela radiografia das peças em 23 casos (71,8 por cento), pelo estudo intra-operatório por congelação em 21,8 por cento (7/32) e por ambos os métodos em 6,2 por cento (2/32). CONCLUSAO: a cirurgia radioguiada é importante instrumento na remoção de lesões mamárias não palpáveis, tratando-se de método simples, rápido e exeqüível que pode ser implementado na rotina clínica dessas pacientes.
Subject(s)
Female , Adult , Middle Aged , Humans , Breast Diseases , Breast/injuries , Breast Neoplasms/diagnosis , Video-Assisted SurgeryABSTRACT
Paciente de 44 anos com massa axilar pétrea, fixa, indolor, medindo 4cm de diâmetro. À mamografia, evidenciou-se massa hiperdensa em prolongamento axilar esquerdo (categoria IV Bi-Rads); a ultra-sonografia mostrou imagem nodular hipoecóica com área ecogênica central, de contornos parcialmente regulares, medindo 3,4cm x 2,1cm. Apresentava hipervascularização ao doppler colorido sugerindo linfonodo atípico. Estudo histopatológico evidenciou seis linfonodos, medindo, o maior, 2,5cm x 1,6cm, os quais mostravam granuloma de células gigantes, multinucleadas, células epitelióides, necrose central com debris celulares e leucócitos polimorfonucleares. Os achados histopatológicos eram compatíveis com linfadenite granulomatosa, doença da arranhadura do gato. O carcinoma oculto da mama se apresenta com massa axilar suspeita, sendo altamente recomendável estudo histopatológico antes de decisão terapêutica. A doença da arranhadura do gato é causa de linfadenite regional subaguda. É causada pela inoculação da Bartonella henselae através de arranhaduras ou mordidas de gatos. O período de incubação é de três a 30 dias, aos quais se segue o aparecimento de pápulas ou vesículas avermelhadas no sítio de inoculação.
We studied the case of a 44-year-old female patient with a hard, painless and fixed axillary mass with 4cm in diameter. The mammography showed a dense axillary mass, at the axillary tail. Ultrasonography showed a hypoecoic nodule with central ecogenicity and regular borders, measuring 3.4cm x 2.1cm, with hypervascularization in doppler color suggesting atypical lymphonode. The histopathologic study found six lymphonodes, the bigger one measured 2.5cm x 1.6cm with giant cells granuloma, multinuclear cells, epithelioid cells, central necrosis with debris and polymorphonuclear cells, suggesting granulomatosis lymphadenitis, cat scratch disease. Actually, occult breast carcinoma clinically shows an axillary mass and the histopathologic study is highly recommended before the therapeutic decision is made. The etiology of the cat scratch disease is the inoculation of Bartonella henselae by scratch or bite of cats. It causes a regional subacute lymphadenitis with an incubation period from three to 30 days where the acommited site presents with red skin and papules or vesicles.
