A oncoplastia no tratamento conservador do câncer de mama / Oncoplastic and conservative treatment of the breast cancer

Os autores usam técnicas conhecidas de cirurgia plástica da mama para decidir e planejar o mais radical tratamento oncológico com melhores resultados estéticos. Realiza-se a cirurgia oncológica com margens de segurança, o linfonodo-sentinela é pesquisado e, se necessário, faz-se o esvaziamento axilar seguido de mamoplastia bilateral. Sistematizou-se para a abordagem oncoplástica da mama a associação de técnicas de cirurgia plástica com o tipo de mama e a localização do tumor em um de nove quadrados de uma divisão geométrica da mama. Para mamas tipo I e II, a técnica periareolar é usada para a retirada de tumor em qualquer quadrado da mama. Para as mamas do tipo III e IV com tumores localizados em quadrados superiores e laterais, a técnica usada é o quinto pedículo. Tumores localizados no quadrado central mediano têm abordagem pela técnica em ilha com posterior reconstrução do complexo aréolo-mamilar. Para a retirada dos tumores localizados em quadrados inferiores, são usadas as técnicas de Pitanguy ou de Gerardo Peixoto, dependendo do grau de ptose da mama. É imperativo que o profissional, hoje, domine as técnicas oncoplásticas.

The authors systematized oncoplastic surgery techniques for the approach of breast cancer regarding the type of breast and the location of the tumor in one of nine squares. Oncologic surgery is performed by removing the tumor area with safety margins and examining the sentinel lymph nodes when necessary, by axillary emptying at three levels, followed by bilateral mammoplasty. The authors used a geometrical division of the breast and, depending on tumor location and on the type of breast, decided on plastic surgery techniques for the breast and planned the most radical oncologic management with better esthetic results. For breast types I and II, a periareolar technique is used to remove the tumor from any square of the breast. For breast types III e IV with tumors located in lateral and upper squares, the 5th pedicle technique is used. For tumors located in the median central square, the island technique is used, with subsequent reconstruction of the areolo-mammillary complex. For the removal of tumors located in the lower squares the techniques of Pitanguy or Gerardo Peixoto are used, depending on the degree of ptosis of the breast. Today it is imperative for mastologists to dominate the oncoplastic techniques.

Microinvasive carcinoma of the cervix. Analysis of prognostic factors.

INTRODUCTION: Superficially invasive neoplasias of the uterine cervix are a matter of controversy in terms of their definition, prognostic factors and selection of treatment to minimize the risk of recurrences. We reviewed our treatment to determine whether any factors affect this risk. PATIENTS AND METHODS: The present study was conducted on 59 patients seen at our service, 22 of them with early stromal invasion (IA1) and 37 with microinvasive carcinoma (IA2) according to FIGO criteria (1995). Ten patients were submitted to conization as definitive treatment, although for three of them treatment was complemented with Wertheim-Meigs surgery due to recurrence in the remaining cervix. The other 49 patients were submitted to total abdominal hysterectomy. RESULTS: Forty-four patients underwent diagnostic or therapeutic conization, and 14 of them presented involvement of the endocervical margin. Seven patients presented recurrence with involvement of the endocervical margin in five. The age of recurrence ranged from 40 to 70 years, with a mean of 52.3 years, as opposed to a general mean of 42.3 (p<0.05). Angiolymphatic invasion was positively correlated to recurrence and death (p<0.01) as well as depth of invasion. CONCLUSIONS: We conclude that the presence of a cone with an involved endocervical margin represents a high risk of recurrence and that this condition occurs in older patients who are prone to present more extensive lesions. Thus, age should be regarded as an important risk factor. Angiolymphatic invasion and depth of invasion have a poor prognosis in terms of recurrence and death.

Colposcopic scoring system for biopsy decisions in different patient groups.

Colposcopic scoring system have been used for distinguishing low-grade from high-grade cervical lesions. However, none of the previous studies have reported colposcopic scoring systems for biopsy decisions in different patient groups. The purpose of our study was to evaluate the safety of biopsy decisions using the colposcopic score elaborated by Stellato and Paavonen (IL) in 21 nonpregnant HIV infected patients (NP+) and 36 uninfected patients (NP-), 12 HIV infected pregnant patients (P+) and 20 uninfected pregnant patients (P-) in the diagnosis of cervical intraepithelial neoplasias (CIN) and HPV infection. The receiving operator curve was used for the establishment of a cut-off point in the scoring system graduation. The chi-square test was used for the statistical analysis. We obtained a safety cut-off value in the colposcopic scoring system for each patient group: 4.5 for NP+; 4.0 for NP- and 3.5 for P+ and P- patients. The sensitivity and specificity of the colposcopic score for the detection of high-grade lesions for each group were respectively: 87.5 and 92.3% for NP+ patients; 90.9 and 92% for NP- patients; 100 and 87.5% for P+ patients and 100 and 91.7% for P- patients. Our results suggest that the colposcopic scoring system is a practical tool for a colposcopy-guided punch biopsy decision and detection of high-grade cervical lesions in different patient groups. Further studies are needed to prove its clinical utility.

Successful preservation of fertility subsequent to a complete pathologic response of a squamous cell carcinoma of the uterine cervix treated with primary systemic chemotherapy.

This is the first report about a successful pregnancy following treatment for advanced cervical cancer.

Selection of criteria for the treatment of ovarian cysts on the bases of ultrasound and cytology.

The major objective of the present study was to determine whether leakage of ovarian cyst cells occurs when the cysts are punctured inside a container with saline. Other subjectives were to determine the sensitivity and specificity of cytology in the differentiation between malignant and benign cysts by comparing cytology data with histology data, and also to determine whether ultrasound can provide consistent evidence for predicting whether the cyst is benign or malignant, thus permitting the selection of patients with benign cysts for puncture rather than surgical exeresis. A cytologic study was carried out on the contents of 62 ovarian cysts diagnosed by ultrasound and clinical examination, and excised from 51 patients submitted to exploratory laparotomy. The cyst was excised and immersed in a container with saline outside the surgical field. The cyst was punctured and its contents aspirated through the wall of the container. Five samples were obtained for cytology: (1) presurgical abdominal wash; (2) saline before cyst puncture; (3) fluid from the punctured cyst; (4) saline after cyst puncture, and (5) postoperative abdominal wash. The materials obtained were submitted to centrifugation and slides of the precipitate were prepared for cytology. A total of 248 slides were studied. Slides of cysts with good cellularity were stained with silver to study the nucleolar organizer regions. Analysis using Kappa statistics showed excellent agreement between the cytologic and histologic diagnoses (p < 0.001). The sensitivity of the cytologic study of the cyst was 75% and the specificity 100%, with a positive predictive value of 100%, a negative predictive value of 92%, and 93% accuracy. The present results led us to conclude that cell leakage into physiological saline occurred after puncture and that cytologic study of cysts valuable in the diagnosis of benign and malignant processes.

Congenital arrhythmia in a normal newborn.

We describe a case, unique to the best of our knowledge, in which bigeminal supraventricular premature contractions were detected in a normal newborn. These arrhythmias disappeared spontaneously after the twelfth day of life. Since they do not appear to evolve towards paroxysmal supraventricular tachycardia, treatment with antiarrhythmic drugs is not recommended.