Fatores associados ao tempo para submissão ao primeiro tratamento do câncer de mama / Factors associated with time-to-treatment initiation of breast cancer

Resumo Este estudo retrospectivo investigou fatores associados ao tempo para submissão ao primeiro tratamento do câncer de mama entre 12.100 casos assistidos em estabelecimentos de saúde habilitados para a alta complexidade em oncologia no âmbito do SUS localizados no Rio de Janeiro entre 2013 e 2019. Regressão logística multivariada estimou razões de chances e intervalos de 95% de confiança. Foram submetidos ao primeiro tratamento em tempo >60 dias 82,1% dos casos. Entre aqueles sem histórico de diagnóstico anterior, alta escolaridade e estadiamento III e IV exibiram menor probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto tratamento em estabelecimento de saúde não localizado na capital exibiu probabilidade maior. Entre aqueles com histórico de diagnóstico anterior, idade ≥50 anos, raça/cor da pele não branca e estadiamento I exibiram maior probabilidade de submissão ao primeiro tratamento em tempo >60 dias, enquanto alta escolaridade, tratamento em estabelecimento de saúde não localizado na capital e estadiamento IV exibiram probabilidade menor. Em suma, fatores sociodemográficos, clínicos e relacionados ao estabelecimento de saúde estão associados ao tempo para submissão ao primeiro tratamento do câncer de mama.

Abstract The present retrospective study investigated factors associated with time-to-treatment initiation of breast cancer of a cohort of 12,100 cases of health facilities qualified for high complexity in oncology within the scope of the Brazilian Public Health System (SUS) of Rio de Janeiro between 2013 and 2019. Multivariate logistic regression was used to estimate odds ratios and 95% confidence intervals. Of all cases, 82.1% were submitted to the first treatment >60 days. Patients without previous diagnosis history, higher education and in stages III and IV were less likely to have their first treatment >60 days, while treatment at a health facility outside the capital showed a higher probability. Patients with a previous diagnosis history, aged ≥50, non-white race/skin color and in stage I were more likely to be submitted to their first treatment >60 days, while subjects with higher education, treated in a health facility outside the capital and in stage IV showed a lower probability. To summarize, sociodemographic, clinical and health facility-related factors are associated with time-to-treatment initiation of breast cancer.

A nationwide pilot study on breast cancer screening in Peru.

Introduction: A high prevalence of advanced breast cancer (BC) is a common scenario in Latin America. In Peru, the frequency of BC at Stages III/IV is ≈50% despite implementation of a programme for breast cancer screening (BCS) along the country. We carried out a study to assess the feasibility and develop an instrument to evaluate the knowledge, barriers and perception about BCS in a nationwide pilot study in Peru among candidates for BCS. Methods: We conducted a systematic review of 2,558 reports indexed in PubMed, Scopus, Web of Science, Medline-Ovid and EMBASE, regarding to our study theme. In total, 111 were selected and a 51-items survey was developed (eight items about sociodemographic characteristics). Patients were recruited in public hospitals or private clinics, in rural and urban areas of nine departments of Peru. Results: We surveyed 488 women from: Lima (150), Cajamarca (93), Ica (59), Arequipa (56), Loreto (48), Ancash (38), Junín (15), Puerto Maldonado (15) and Huancavelica (14); 27.9% of them were from rural areas. The mean of age was 53.3 years (standard deviation ± 9.1). Regarding education level, 29.8% had primary, 33.2% secondary and 37.0% higher education. In total, 28.7% of women did not know the term 'mammogram' and 47.1% reported never receiving a BCS (36.9% from urban and 73.5% from rural population). In women that underwent BCS, only 67% knew it is for healthy women. In total, 54.1% of patients had low levels of knowledge about risk factors for BC (i.e. 87.5% of women respond that injuries in the breast produce cancer). Cultural, economic and geographic barriers were significantly associated with having a mammogram where 56.9% of participants considered a cost ≤ 7 USD as appropriate. Mammogram was perceived as too painful for 54.9% of women. In addition, women with a self-perception of low-risk for BC and a fatalistic perception of cancer were less likely to have a BCS. Conclusion: We found that it is feasible to conduct a large-scale study in Peru. The results of this pilot study highlight an urgent need of extensive education and awareness about BCS in Peru.

PPV of the Molecular Breast Imaging Lexicon.

BACKGROUND. Molecular breast imaging (MBI) is used for various breast imaging indications. An MBI lexicon has been developed, although the likelihood of malignancy of the lexicon descriptors has not been assessed to our knowledge. OBJECTIVE. The purpose of this article was to evaluate the PPV for malignancy of the MBI lexicon imaging descriptors. METHODS. This retrospective study included MBI examinations performed from August 1, 2005, through August 31, 2017, that were positive (BI-RADS analogous categories 0, 3, 4, 5, or 6) according to the clinical report and had an available reference standard. Examinations were performed using dual-detector cadmium zinc telluride MBI systems after injection of 99mTc sestamibi. Category 3 lesions had pathologic correlation, at least 2 years of imaging follow-up, or final resolution on follow-up imaging as category 1 or 2; category 4 and 5 lesions had pathologic correlation. MBI examinations were reviewed by one of two radiologists to assess lesions on the basis of the published MBI lexicon for type (mass vs nonmass uptake), distribution (if nonmass uptake), uptake intensity, and number of MBI views on which the lesion was seen. PPV for malignancy was summarized. RESULTS. The analysis included 643 lesions (479 benign, 164 malignant; 83 mass, 560 nonmass uptake) in 509 patients (median age, 56 years). PPV was 73.5% (61/83) for masses and 18.4% (103/560) for nonmass uptake. Among the nonmass uptake lesions, PPV was 36.2% (17/47) for segmental, 20.1% (77/384) for focal, 30.8% (4/13) for diffuse, and 4.3% (5/116) for regional or multiple regional distribution. PPV was 5.3% (5/94) for one view, 15.2% (32/210) for two views, 14.6% (13/89) for three views, and 45.4% (113/249) for four views showing the lesion. PPV was 14.0% (43/307) for mild, 22.4% (51/228) for moderate, and 64.8% (70/108) for marked uptake intensity. CONCLUSION. The MBI lexicon lesion descriptors are associated with likelihood of malignancy. PPV was higher for masses, lesions seen on multiple MBI views, and lesions with marked uptake intensity. Among nonmass uptake lesions, PPV was highest for those with segmental distribution. CLINICAL IMPACT. Insight into the likelihood of malignancy associated with the MBI lexicon descriptors can inform radiologists' interpretations and guide potential future incorporation of the MBI lexicon into the ACR BI-RADS Atlas.

Underestimation Rate in the Percutaneous Diagnosis of Radial Scar/Complex Sclerosing Lesion of the Breast: Systematic Review / Taxa de subestimação no diagnóstico percutâneo de cicatriz radiada/lesão esclerosante complexa da mama: Revisão sistemática

Abstract Objective To evaluate the underestimation rate in breast surgical biopsy after the diagnosis of radial scar/complex sclerosing lesion through percutaneous biopsy. Data Sources A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The PubMed, SciELO, Cochrane, and Embase databases were consulted, with searches conducted through November 2020, using specific keywords (radial scar OR complex sclerosing lesion, breast cancer, anatomopathological percutaneous biopsy AND/OR surgical biopsy). Data collection Study selection was conducted by two researchers experienced in preparing systematic reviews. The eight selected articles were fully read, and a comparative analysis was performed. Study selection A total of 584 studies was extracted, 8 of which were selected. One of them included women who had undergone a percutaneous biopsy with a histological diagnosis of radial scar/complex sclerosing lesion and subsequently underwent surgical excision; the results were used to assess the underestimation rate of atypical and malignant lesions. Data synthesis The overall underestimation rate in the 8 studies ranged from 1.3 to 40% and the invasive lesion underestimation rate varied from 0 to 10.5%. Conclusion The histopathological diagnosis of a radial scar/complex sclerosing lesion on the breast is not definitive, and it may underestimate atypical andmalignant lesions, which require a different treatment, making surgical excision an important step in diagnostic evaluation.

Resumo Objetivo Avaliar o grau de discordância entre biópsia percutânea e cirúrgica da mama em pacientes com diagnóstico de cicatriz radiada/lesão esclerosante complexa (CR/LEC) por meio de uma revisão sistemática. Fontes dos dados Foi realizada uma revisão sistemática segundo as recomendações do Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, na sigla em inglês). As bases de dados primárias consultadas foram PubMed, SciELO, Cochrane e Embase, combuscas conduzidas até novembro de 2020, utilizando palavras chaves específicas (cicatriz radiada OU lesão esclerosante complexa, câncer de mama, anatomopatológico de biópsia percutânea E/OU biópsia cirúrgica). Seleção dos estudos A busca dos artigos resultou em um total de 584 estudos, sendo 8 selecionados, os quais incluíam mulheres submetidas a biópsia com diagnóstico histológico de CR/LEC e posteriormente submetidas a exérese cirúrgica para avaliar como desfecho o grau de subestimação de lesões atípicas e malignas. Coleta de dados A seleção dos estudos foi conduzida por dois pesquisadores, com experiência na elaboração de revisão sistemática. Os oito artigos selecionados foram lidos na íntegra e submetidos a uma análise comparativa. Síntese dos dados Cicatrizes radiadas/lesões esclerosante complexas foram associadas com lesões atípicas e malignas após a exérese cirúrgica. O grau de subestimação geral foi calculado pela porcentagem de lesões atípicas e malignas no anatomopatológico após a exérese cirúrgica dentre o total de CR/LEC diagnosticadas, enquanto o grau de subestimação de lesões invasoras foi calculado considerando-se apenas os carcinomas invasivos. O grau de subestimação geral dos estudos selecionados variou de 1,3 a 40%, e o de lesões invasoras de 0 a 10,5%. Conclusão O diagnóstico histopatológico de CR/LEC na mama não é definitivo, podendo subestimar lesões atípicas e malignas, cujo tratamento é distinto, tornando a exérese cirúrgica etapa fundamental na investigação diagnóstica.

Breast imaging hindered during covid-19 pandemic, in Brazil

ABSTRACT OBJECTIVE: To report the decrease in breast imaging after covid-19 pandemic, obtaining the number of mammograms performed in 2019 and 2020. Additionally, to investigate if there was an increase in the proportion of women undergoing mammography for diagnostic purposes, with palpable lesions. METHOD: This is a cross-sectional study, based on the number of mammograms performed by the Brazilian public health services, provided by DATASUS, an open access database. Mammograms from private institutions were not included. This study compares the number of mammograms performed in 2019 and 2020, in women aged 50-69 years, stratified by month, in each federal state, and the presence of palpable lumps (physician-reported). RESULTS: In total, 1,948,471 mammograms were performed in 2019 and 1,126,688 in 2020, for the population studied. These values represent a 42% decline. Monthly, a significant decreased is observed after April 2020. The results varied slightly according to federal state; yet the entire country was affected. Rondônia was the most affected state, with 67% decline. The proportion of women presenting palpable lumps increased from 7.06% on average in 2019 to 7.94% in 2020 (OR = 1.135, 95%CI 1.125-1.145, p = 0,001). DISCUSSION: The number of mammograms performed in 2020 declined considerably. Out of the women who presented for mammogram, the proportion of palpable lumps was significantly higher in 2020. Considering the detection rate of digital mammography, the loss of 800,000 exams means 4,000 undiagnosed breast cancer cases, by the end of 2020.

Dysregulation of serum miR-1204 and its potential as a biomarker for the diagnosis and prognosis of breast cancer

SUMMARY OBJECTIVE A previous study has reported that miR-1204 exerted oncogenic effects in breast cancer (BC). The purpose of our paper was to evaluate the expressions of tissue and serum miR-1204 in patients with BC and further investigate its biomarker potential. METHODS The expressions of tissue and serum miR-1204 were investigated by qRT-PCR in 144 BC patients and 38 healthy controls. Chi-square tests were conducted to examine the associations between miR-1204 expressions and clinicopathological factors. Then, the associations of miR-1204s level with the survival of BC patients were determined by performing the Kaplan-Meier and multivariate analysis. The receiver operating characteristics (ROC) and area under the OC curve (AUC) were obtained to validate the diagnostic values of miR-1204. RESULTS We found that the expressions of miR-1204 were increased in both tissue and serum samples from BC patients. Multivariate assays identified tissue and serum miR-1204 overexpression as an independent poor prognostic factor. In addition, ROC curve assays indicated that tissue and serum miR-1204 are potential diagnostic markers of BC. CONCLUSIONS Detection of tissue and serum miR-1204 levels could have clinical potential as a novel prognostic/diagnostic biomarker for BC patients.

RESUMO OBJETIVO Um estudo anterior indicou que o miR-1204 exerce efeitos oncogênicos no Câncer de Mama (CM). O objetivo deste trabalho foi avaliar as expressões de miR-1204 sérico e em tecidos em pacientes com CM e investigar o seu potencial biomarcador. METODOLOGIA As expressões de miR-1204 sérico e em tecidos foram investigadas por qRT-PCR em 144 pacientes com CM e 38 controles saudáveis. Testes qui-quadrados foram realizados para examinar as associações entre as expressões de miR-1204 e os fatores clinicopatológicos. Em seguida, as associações entre nível de miR-1204s e sobrevida de pacientes de CM foram determinadas através de análises de Kaplan-Meier e multivariadas. A Curva Característica de Operação do Receptor (ROC) e área sob a curva (AUC) foram obtidas para validar o valor diagnóstico do MIR-1204. RESULTADOS Descobrimos que as expressões do MIR-1204 estavam aumentadas em amostras de tecido e séricas de pacientes com CM. Análises multivariadas identificaram a superexpressão de miR-1204 sérico e em tecidos como um fator independente de prognóstico ruim. Além disso, as curvas ROC indicaram que o miR-1204 sérico e em tecidos é um possível marcador de diagnóstico de CM. CONCLUSÃO A detecção dos níveis MIR-1204 em tecidos e séricos pode ter potencial clínico como um novo biomarcador de prognóstico/diagnóstico para pacientes de CM.

Performance of Computer-Aided Diagnosis in Ultrasonography for Detection of Breast Lesions Less and More Than 2 cm: Prospective Comparative Study.

BACKGROUND: Computer-aided diagnosis (CAD) is used as an aid tool by radiologists on breast lesion diagnosis in ultrasonography. Previous studies demonstrated that CAD can improve the diagnosis performance of radiologists. However, the optimal use of CAD on breast lesions according to size (below or above 2 cm) has not been assessed. OBJECTIVE: The aim of this study was to compare the performance of different radiologists using CAD to detect breast tumors less and more than 2 cm in size. METHODS: We prospectively enrolled 261 consecutive patients (mean age 43 years; age range 17-70 years), including 398 lesions (148 lesions>2 cm, 79 malignant and 69 benign; 250 lesions≤2 cm, 71 malignant and 179 benign) with breast mass as the prominent symptom. One novice radiologist with 1 year of ultrasonography experience and one experienced radiologist with 5 years of ultrasonography experience were each assigned to read the ultrasonography images without CAD, and then again at a second reading while applying the CAD S-Detect. We then compared the diagnostic performance of the readers in the two readings (without and combined with CAD) with breast imaging. The McNemar test for paired data was used for statistical analysis. RESULTS: For the novice reader, the area under the receiver operating characteristic curve (AUC) improved from 0.74 (95% CI 0.67-0.82) from the without-CAD mode to 0.88 (95% CI 0.83-0.93; P<.001) at the combined-CAD mode in lesions≤2 cm. For the experienced reader, the AUC improved from 0.84 (95% CI 0.77-0.90) to 0.90 (95% CI 0.86-0.94; P=.002). In lesions>2 cm, the AUC moderately decreased from 0.81 to 0.80 (novice reader) and from 0.90 to 0.82 (experienced reader). The sensitivity of the novice and experienced reader in lesions≤2 cm improved from 61.97% and 73.23% at the without-CAD mode to 90.14% and 97.18% (both P<.001) at the combined-CAD mode, respectively. CONCLUSIONS: S-Detect is a feasible diagnostic tool that can improve the sensitivity for both novice and experienced readers, while also improving the negative predictive value and AUC for lesions≤2 cm, demonstrating important application value in the clinical diagnosis of breast cancer. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800019649; http://www.chictr.org.cn/showprojen.aspx?proj=33094.

Granular Cell Tumor: A Rare Breast Lesion.

Granular cell tumors are uncommon, and are usually benign neoplasms that can mimic malignancy on breast imaging tests. These tumors can originate anywhere in the body and the breast accounts for only a few cases of all granular cell tumors. We report a case of a 54-year-old woman with a granular cell tumor of the breast presenting clinically on breast imaging (ultrasound, mammography and magnetic resonance) as a suspicious lesion. Core needle biopsy was performed for tissue diagnosis and was consistent with granular cell tumor that was confirmed in the histopathological report of the surgical specimen following a breast lumpectomy. Given the rarity of this tumor, we present this case to highlight this diagnostic hypothesis, that can be challenging and frequently confused with breast carcinoma.

Os tumores de células granulares são tumores benignos raros que podem mimetizar lesões malignas nos exames de imagem mamária. Podem originar-se em qualquer localização, contudo, os de origem mamária representam uma percentagem mínima de todos os tumores de células granulares. Os autores apresentam um caso de uma mulher de 54 anos de idade com um tumor de células granulares da mama que se apresentou como uma lesão suspeita, tanto clinicamente, como nos exames de imagem de mamografia, ecografia e ressonância magnética. Realizou-se biópsia com agulha grossa, guiada por ecografia, cuja histologia revelou achados consistentes com um tumor de células granulares, que foi confirmado posteriormente pelo exame histológico da peça cirúrgica de tumorectomia. Os autores expõem este caso pela sua raridade e para enfatizar esta hipótese diagnóstica, muitas vezes desafiante, e que mimetiza frequentemente lesões mamárias malignas.

Feasibility of mapping breast cancer with supine breast MRI in patients scheduled for oncoplastic surgery.

OBJECTIVES: To prospectively determine the feasibility of preoperative supine breast MRI in breast cancer patients scheduled for oncoplastic breast-conserving surgery. METHODS: In addition to a diagnostic prone breast MRI, a supplementary supine MRI was performed with the patient in the surgical position including skin markers. Tumours' locations were ink-marked on the skin according to findings obtained from supine MRI. Changes in tumours' largest diameter and locations between prone and supine MRI were measured and compared to histology. Nipple-to-tumour and tumour-to-chest wall distances were also measured. Tumours and suspicious areas were surgically removed according to skin ink-markings. The differences between MRI measurements with reference to histopathology were evaluated with the paired-sample t test. RESULTS: Fourteen consecutive patients, 15 breasts and 27 lesions were analysed. Compared to histology, prone MRI overestimated tumour size by 47.1% (p = 0.01) and supine MRI by 14.5% (p = 0.259). In supine MRI, lesions' mean diameters and areas were smaller compared to prone MRI (- 20.9%, p = 0.009 and - 38.3%, p = 0.016, respectively). This difference in diameter was more pronounced in non-mass lesions (- 31.2%, p = 0.031) compared to mass lesions (- 9.2%, p = 0.009). Tumours' mean distance from chest wall diminished by 69.4% (p < 0.001) and from nipple by 18.2% (p < 0.001). Free microscopic margins were achieved in first operation in all patients. CONCLUSIONS: Supine MRI in the surgical position is feasible and useful in the precise localisation of prone MRI-detected lesions and provides a helpful tool to implement in surgery. Supine MRI more accurately determines tumours' size and location and might have an important role to diminish overestimations. KEY POINTS: • Breath-hold supine breast MRI is feasible using commercially available coils and sequences. • Size and area of lesions on MRI were consistently smaller when measured from the supine position as compared to the prone position. • Supine breast MRI is useful in the precise preoperative localisation of prone MRI-detected lesions. •.

Magnetic resonance imaging-guided vacuum-assisted breast biopsy: experience and preliminary results of 205 procedures.

OBJECTIVE: To demonstrate the frequency of malignancy and histological characteristics of lesions in patients submitted to vacuum-assisted breast biopsy guided by magnetic resonance imaging (MRI). MATERIALS AND METHODS: This was a retrospective study of MRI-guided vacuum-assisted breast biopsies performed between April 2008 and December 2016, in which we analyzed clinical and epidemiological data, as well as the BI-RADS classification and histopathological results. We compared nodules and non-nodular enhancements, in terms of their correlation with malignancy, using chi-square test. RESULTS: Among 215 cases referred for MRI-guided vacuum-assisted breast biopsy, the procedure was contraindicated in 10 cases (5%) and was technically feasible in the remaining 205 (95%). Non-nodular enhancements were observed in 135 cases (66%), and nodules were observed in 70 (34%), with a mean diameter of 2.2 cm (range, 0.5-9.6 cm) and 0.97 cm (range, 0.5-2.2 cm), respectively. Of the 205 lesions analyzed, 43 (21%) were malignant, 129 (63%) were benign, and 33 (16%) were classified as high-risk lesions. The most common histological findings were invasive ductal carcinoma and, in high-risk cases, lobular neoplasia. There was no significant difference between nodules and non-nodular enhancements in terms of the rate of malignancy (p = 0.725). CONCLUSION: In our sample, the overall malignancy rate was 21%. However, to improve the assessment of these results, it is necessary to correlate them with the surgical data and with data from the follow-up of benign cases.

Magnetic resonance imaging-guided vacuum-assisted breast biopsy: experience and preliminary results of 205 procedures / Biópsia a vácuo guiada por ressonância magnética: experiência e resultados preliminares de 205 procedimentos

Abstract Objective: To demonstrate the frequency of malignancy and histological characteristics of lesions in patients submitted to vacuum-assisted breast biopsy guided by magnetic resonance imaging (MRI). Materials and Methods: This was a retrospective study of MRI-guided vacuum-assisted breast biopsies performed between April 2008 and December 2016, in which we analyzed clinical and epidemiological data, as well as the BI-RADS classification and histopathological results. We compared nodules and non-nodular enhancements, in terms of their correlation with malignancy, using chi-square test. Results: Among 215 cases referred for MRI-guided vacuum-assisted breast biopsy, the procedure was contraindicated in 10 cases (5%) and was technically feasible in the remaining 205 (95%). Non-nodular enhancements were observed in 135 cases (66%), and nodules were observed in 70 (34%), with a mean diameter of 2.2 cm (range, 0.5-9.6 cm) and 0.97 cm (range, 0.5-2.2 cm), respectively. Of the 205 lesions analyzed, 43 (21%) were malignant, 129 (63%) were benign, and 33 (16%) were classified as high-risk lesions. The most common histological findings were invasive ductal carcinoma and, in high-risk cases, lobular neoplasia. There was no significant difference between nodules and non-nodular enhancements in terms of the rate of malignancy (p = 0.725). Conclusion: In our sample, the overall malignancy rate was 21%. However, to improve the assessment of these results, it is necessary to correlate them with the surgical data and with data from the follow-up of benign cases.

Resumo Objetivo: Demonstrar a frequência de malignidade e as características histológicas das lesões encontradas em pacientes submetidas a biópsia a vácuo guiada por ressonância magnética (RM). Materiais e Métodos: Estudo retrospectivo, realizado no período de abril de 2008 a dezembro de 2016, de biópsia a vácuo guiada por RM, em que se analisaram dados clinicoepidemiológicos, classificação BI-RADS e resultados histopatológicos. A comparação entre os nódulos e os realces não nodulares e a presença de malignidade foi realizada utilizando-se o teste de qui-quadrado. Resultados: Dos 215 casos com indicação de biópsia a vácuo guiada por RM, 10 (5%) foram contraindicados e os restantes 205 (95%) foram tecnicamente viáveis. Foi observado que 66% eram realces não nodulares (135 lesões) e 34% eram nódulos (70 lesões), medindo, em média, 2,2 cm (0,5-9,6 cm) e 0,97 cm (0,5-2,2 cm), respectivamente. Das 205 lesões analisadas, 43 (21%) eram malignas, 129 (63%) eram benignas e 33 (16%) eram de alto risco. O achado histológico mais frequente nos casos de malignidade foi o carcinoma ductal infiltrante, e nos casos de alto risco, as neoplasias lobulares. Não houve diferenças estatisticamente significantes entre os nódulos e realces não nodulares em relação a malignidade (p = 0,725). Conclusão: Na nossa amostra, a taxa global de malignidade foi de 21%. No entanto, é necessário correlação com dados cirúrgicos e seguimento nos casos benignos, para melhor avaliação dos resultados.

Breast cancer detection method, diagnostic interval and use of specialized diagnostic assessment units across Ontario, Canada. / Cancer du sein : méthode de détection, intervalle diagnostique et recours aux unités d'évaluation diagnostique spécialisées en Ontario (Canada).

INTRODUCTION: Breast cancer is detected through screening or through signs and symptoms. In Canada, mammograms for breast cancer screening are offered in organized programs or independently (opportunistic screening). Province of Ontario breast Diagnostic Assessment Units (DAUs) are facility-based programs that provide coordinated breast cancer diagnostic services, as opposed to usual care, in which the primary care provider arranges the tests and consultations. This study describes breast cancer detection method, diagnostic interval and DAU use across Ontario. METHODS: The study cohort consisted of 6898 women with invasive breast cancer diagnosed in 2011. We used the Ontario Cancer Registry linked to administrative health care databases. We determined the detection method using the Ontario Breast Screening Program (OBSP) data and physician claims. The diagnostic interval was the time between the initial screen, specialist referral or first diagnostic test and the cancer diagnosis. The diagnostic route (whether through DAU or usual care) was determined based on the OBSP records and biopsy or surgery location. We mapped the diagnostic interval and DAU coverage geographically by women's residence. RESULTS: In 2011, 36% of Ontario breast cancer patients were screen-detected, with a 48% rate among those aged 50 to 69. The provincial median diagnostic interval was 32 days, with county medians ranging from 15 to 65 days. Provincially, 48.4% were diagnosed at a DAU, and this ranged from zero to 100% across counties. CONCLUSION: The screening detection rate in age-eligible breast cancer patients was lower than published population-wide screening rates. Geographic mapping of the diagnostic interval and DAU use reveals regional variations in cancer diagnostic care that need to be addressed.

INTRODUCTION: Le cancer du sein est détecté soit par un examen de dépistage, soit à l'aide de signes et symptômes. Au Canada, les mammographies pour le dépistage du cancer du sein sont offertes dans le cadre de programmes organisés ainsi qu'en contexte indépendant (dépistage opportuniste). Les unités d'évaluation diagnostique (UED) de la province de l'Ontario sont des programmes en établissement qui fournissent des services diagnostiques coordonnés pour le cancer du sein, à la différence des soins habituels où le fournisseur de soins de première ligne organise les examens et les consultations. Cette étude décrit les méthodes de détection, l'intervalle diagnostique et l'utilisation des UED pour le cancer du sein en Ontario. MÉTHODOLOGIE: L'étude a porté sur une cohorte de 6 898 femmes ayant reçu un diagnostic de cancer du sein envahissant en 2011. Nous avons utilisé le Registre d'inscription des cas de cancer de l'Ontario jumelé à des bases de données administratives sur les soins de santé. Nous avons déterminé la méthode de détection à l'aide des données du Programme ontarien de dépistage du cancer du sein (PODCS) et des demandes de règlement des médecins. L'intervalle diagnostique a été défini comme le temps écoulé entre le dépistage initial, l'aiguillage vers un spécialiste ou la première épreuve diagnostique et le diagnostic de cancer lui-même. Le parcours diagnostique (qu'il passe par les UED ou les soins habituels) a été déterminé en fonction des dossiers du PODCS et du lieu de biopsie ou d'intervention chirurgicale. Nous avons cartographié l'intervalle diagnostique et de la couverture des UED en fonction du lieu de résidence des femmes. RÉSULTATS: En 2011, 36 % des cas de cancer du sein en Ontario ont été détectés par dépistage, dont 48 % chez des femmes de 50 à 69 ans. L'intervalle diagnostique provincial médian était de 32 jours, les médianes par comté variant entre 15 et 65 jours. À l'échelle provinciale, 48,4 % des cas ont été diagnostiqués dans une UED, ce pourcentage variant entre 0 et 100 % selon les comtés. CONCLUSION: Le taux de détection au dépistage correspondant aux patientes admissibles du fait de leur âge s'est révélé inférieur au taux de dépistage officiel du cancer du sein pour l'ensemble de la population. La répartition géographique de l'intervalle diagnostique et du recours aux UED révèle des variations régionales dans les soins diagnostiques en oncologie qu'il est nécessaire de corriger.

Caso Clínico: Carcinoma Papilar Sólido de Mama / Case Report: Breast Papillary Solid Carcinoma

INTRODUCCIÓN: El carcinoma papilar sólido de mama es un subtipo poco frecuente de carcinomas mamarios representando el 1 ­ 2 % y principalmente en mujeres postmenopáusicas. Su diagnóstico desde el punto de vista clínico, imagenológico y patológico es difícil. El tratamiento no está estandarizado por el bajo porcentaje de casos reportados, actualmente es aceptada la cirugía conservadora, la radioterapia, existiendo controversia en la hormonoterapia y el vaciamiento axilar, pues las metástasis ganglionares ascienden únicamente al 2 %. Su pronóstico es bueno y la complicación más común es la recidiva local. CASO CLÍNICO: Paciente femenina de 80 años, acudió a consulta por presentar una masa a nivel de mama izquierda al realizarse una autoexploración, donde identificó un nódulo de 2 cm aproximadamente. EVOLUCIÓN: Se realizó una mamografía, ecografía mamaria y la citología mamaria que dio como resultado un tumor, inicialmente se consideró como Phyllodes. Tras el diagnóstico se realizó una lumpectomía, y la patología de la pieza quirúrgica fue de un carcinoma papilar sólido, luego recibió radioterapia y vigilancia médica. CONCLUSIÓN: La autoexploración fue un pilar fundamental en el diagnóstico de este caso y alertó a la paciente a buscar valoración médica. Al tratarse de un caso poco frecuente el diagnóstico definitivo fue la patología.

BACKGROUND: Solid papillary carcinoma of the breast is a rare subtype of mammary carcinomas corresponding to 1 ­ 2 % and mainly in postmenopausal women. It is diagnosis from the clinical, imaging and pathological point of view is difficult. The treatment is not standardized due to the low percentage of cases reported, conservative surgery, radiotherapy is currently accepted, and controversy exists in hormone therapy and axillary emptying, as lymph node metastases amount to only 2 %. It is prognosis is good and the most common complication is local recurrence. CASE REPORT: An 80-year-old female patient attended the consultation by presented a mass at the level of the left breast when performing the self-examination, where identified a 2 cm nodule. EVOLUTION: Mammography, mammary ultrasound and mammary cytology outcome in a tumor, was initially considered as Phyllodes. After the diagnosis a lumpectomy was performed, and the pathology of the surgical piece was of a solid papillary carcinoma, then received radiotherapy and surveillance. CONCLUSIONS: Self-examination was a fundamental pillar in the diagnosis of this case and alerts the patient to seek medical assessment. Being a rare case, the definitive diagnosis was pathology.

Accuracy of contrast-enhanced spectral mammography for estimating residual tumor size after neoadjuvant chemotherapy in patients with breast cancer: a feasibility study.

OBJECTIVE: To assess the feasibility of contrast-enhanced spectral mammography (CESM) of the breast for assessing the size of residual tumors after neoadjuvant chemotherapy (NAC). MATERIALS AND METHODS: In breast cancer patients who underwent NAC between 2011 and 2013, we evaluated residual tumor measurements obtained with CESM and full-field digital mammography (FFDM). We determined the concordance between the methods, as well as their level of agreement with the pathology. Three radiologists analyzed eight CESM and FFDM measurements separately, considering the size of the residual tumor at its largest diameter and correlating it with that determined in the pathological analysis. Interobserver agreement was also evaluated. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value were higher for CESM than for FFDM (83.33%, 100%, 100%, and 66% vs. 50%, 50%, 50%, and 25%, respectively). The CESM measurements showed a strong, consistent correlation with the pathological findings (correlation coefficient = 0.76-0.92; intraclass correlation coefficient = 0.692-0.886). The correlation between the FFDM measurements and the pathological findings was not statistically significant, with questionable consistency (intraclass correlation coefficient = 0.488-0.598). Agreement with the pathological findings was narrower for CESM measurements than for FFDM measurements. Interobserver agreement was higher for CESM than for FFDM (0.94 vs. 0.88). CONCLUSION: CESM is a feasible means of evaluating residual tumor size after NAC, showing a good correlation and good agreement with pathological findings. For CESM measurements, the interobserver agreement was excellent.

OBJETIVO: Avaliar a viabilidade da utilização da mamografia espectral com meio de contraste (CESM) na avaliação do tumor residual em mulheres com câncer de mama submetidas a quimioterapia neoadjuvante. MATERIAIS E MÉTODOS: Foi avaliada a concordância entre a mensuração do tumor residual na CESM e na mamografia digital (FFDM) com os dados histopatológicos de mulheres submetidas a quimioterapia neoadjuvante entre 2011 e 2013. Após as exclusões, três radiologistas analisaram oito CESMs e FFDMs separadamente. A maior dimensão do tumor residual foi considerada para comparação com os resultados histopatológicos. Concordância e correlação da CESM e FFDM com resultados histopatológicos e a concordância interobservador foram avaliadas. RESULTADOS: A CESM teve sensibilidade, especificidade e valores preditivos positivos e negativos maiores que a FFDM - 83,33%, 100%, 100% e 66% versus 50%, 50%, 50% e 25%, respectivamente. A CESM teve correlação boa e consistente com os achados histopatológicos (coeficiente de correlação = 0,76-0,92; coeficiente de correlação intraclasse = 0,692-0,886). A correlação entre FFDM e os achados histopatológicos não foi estatisticamente significante, com consistência questionável (coeficiente de correlação intraclasse = 0,488-0,598). A concordância entre as dimensões do estudo histopatológico foi mais estreita com a CESM do que com a FFDM. A concordância interobservador foi maior na CESM (0,94) do que na FFDM (0,88). CONCLUSÃO: A CESM é viável e pode ser utilizada para avaliação de tumor residual após quimioterapia neoadjuvante. A CESM tem boa correlação e concordância com o estudo histopatológico e excelente concordância interobservador.

Accuracy of contrast-enhanced spectral mammography for estimating residual tumor size after neoadjuvant chemotherapy in patients with breast cancer: a feasibility study / Acurácia da mamografia espectral com contraste para seguimento de tumor residual pós-quimioterapia neoadjuvante em pacientes com câncer de mama: um estudo de viabilidade

Abstract Objective: To assess the feasibility of contrast-enhanced spectral mammography (CESM) of the breast for assessing the size of residual tumors after neoadjuvant chemotherapy (NAC). Materials and methods: In breast cancer patients who underwent NAC between 2011 and 2013, we evaluated residual tumor measurements obtained with CESM and full-field digital mammography (FFDM). We determined the concordance between the methods, as well as their level of agreement with the pathology. Three radiologists analyzed eight CESM and FFDM measurements separately, considering the size of the residual tumor at its largest diameter and correlating it with that determined in the pathological analysis. Interobserver agreement was also evaluated. Results: The sensitivity, specificity, positive predictive value, and negative predictive value were higher for CESM than for FFDM (83.33%, 100%, 100%, and 66% vs. 50%, 50%, 50%, and 25%, respectively). The CESM measurements showed a strong, consistent correlation with the pathological findings (correlation coefficient = 0.76-0.92; intraclass correlation coefficient = 0.692-0.886). The correlation between the FFDM measurements and the pathological findings was not statistically significant, with questionable consistency (intraclass correlation coefficient = 0.488-0.598). Agreement with the pathological findings was narrower for CESM measurements than for FFDM measurements. Interobserver agreement was higher for CESM than for FFDM (0.94 vs. 0.88). Conclusion: CESM is a feasible means of evaluating residual tumor size after NAC, showing a good correlation and good agreement with pathological findings. For CESM measurements, the interobserver agreement was excellent.

Resumo Objetivo: Avaliar a viabilidade da utilização da mamografia espectral com meio de contraste (CESM) na avaliação do tumor residual em mulheres com câncer de mama submetidas a quimioterapia neoadjuvante. Materiais e métodos: Foi avaliada a concordância entre a mensuração do tumor residual na CESM e na mamografia digital (FFDM) com os dados histopatológicos de mulheres submetidas a quimioterapia neoadjuvante entre 2011 e 2013. Após as exclusões, três radiologistas analisaram oito CESMs e FFDMs separadamente. A maior dimensão do tumor residual foi considerada para comparação com os resultados histopatológicos. Concordância e correlação da CESM e FFDM com resultados histopatológicos e a concordância interobservador foram avaliadas. Resultados: A CESM teve sensibilidade, especificidade e valores preditivos positivos e negativos maiores que a FFDM - 83,33%, 100%, 100% e 66% versus 50%, 50%, 50% e 25%, respectivamente. A CESM teve correlação boa e consistente com os achados histopatológicos (coeficiente de correlação = 0,76-0,92; coeficiente de correlação intraclasse = 0,692-0,886). A correlação entre FFDM e os achados histopatológicos não foi estatisticamente significante, com consistência questionável (coeficiente de correlação intraclasse = 0,488-0,598). A concordância entre as dimensões do estudo histopatológico foi mais estreita com a CESM do que com a FFDM. A concordância interobservador foi maior na CESM (0,94) do que na FFDM (0,88). Conclusão: A CESM é viável e pode ser utilizada para avaliação de tumor residual após quimioterapia neoadjuvante. A CESM tem boa correlação e concordância com o estudo histopatológico e excelente concordância interobservador.

Agreement of Different Methods for Tissue Based Detection of HER2 Signal in Invasive Breast Cancer.

Breast cancer is the second leading cause of cancer mortality amongst American women. The HER2 gene encodes a cell surface receptor that affects cell proliferation and has been recognized as a diagnostic factor in treatment selection for invasive breast cancer. Examine accuracy in HER2 detection between manual count, computer assisted, and automated tiling algorithm. 42 randomly selected invasive breast cancer specimens were enumerated by fluorescence in situ hybridization (FISH)for HER2 and CEP17 markers using the Vysis HER2 assay (AbbotLaboratory, North Chicago, IL). Specimens were tested using three methods: Manual, computer assisted nuclei selection (Tissue FISH MetaSystems, Newton, MA), and automated enumeration (MetaSystems, Newton, MA). The greatest bias and widest agreement limits for HER2 and CEP17 were seen in Automatic versus Manual, the gold standard. HER2 values greater than 6 possessed the greatest bias and widest agreement limits. CEP17 comparison showed similar bias and agreement limits for each comparison. Kappa values indicated good agreement for all methods although Tissue FISH and Manual possessed better agreement. Higher agreement at lower HER2 & CEP17 count maybe due to fewer chromosomal aberrations, in which selection of field of views has less variation between methods. Alternatively, increased background signals seen in polyploidy may be responsible for the variations in signal count. Manual and Tissue FISH demonstrated good agreement amongst by both Altman Bland and Cohen's Kappa. While the automatic method has good agreement at lower HER2, the sharp increase in variability at higher HER2 counts illustrates a limitation of the automatic method.

Early detection of breast cancer in Brazil: data from the National Health Survey, 2013 / Detecção precoce do câncer de mama no Brasil: dados da Pesquisa Nacional de Saúde, 2013

ABSTRACT OBJECTIVE To analyze whether the actions of early detection of breast cancer, initiated with the medical request for mammography, differ between users of the Brazilian Unified Health System (SUS) and those who have private health insurance. METHODS From the data collected in the National Health Survey, we estimated the proportions of women who had medical request for mammography according to presence or absence of private health insurance. For assessing the factors related to having mammography medical request, we estimated crude and adjusted odds ratios and respective 95%CI by logistic regression. We also analyzed the main reasons reported for not having performed mammography after medical request, as well as the time between examination and result. RESULTS Of the women interviewed, 66.7% had a medical request for mammography (59.4% among SUS users and 83.9% among those with private health insurance). Having private health insurance, higher education level, and being white were positively associated with having the medical request. Only 5.4% (95%CI 4.8–6.0) of women who received medical request failed to perform mammography – 7.6% were SUS users and 1.7% had health insurance. The most reported reasons for not being able to perform the examination were: not thinking it was necessary; having the test scheduled, but not yet performed; and not being able to schedule it. More than 70% of women received the result with less than one month from its execution. CONCLUSIONS The barriers to access a medical request for mammographic screening for breast cancer are higher among women who depend exclusively on SUS.

RESUMO OBJETIVO Analisar se as ações de detecção precoce para o câncer de mama, iniciadas com o pedido médico de mamografia, diferem entre usuárias do Sistema Único de Saúde (SUS) e aquelas que possuem plano de saúde privado. MÉTODOS A partir dos dados coletados na Pesquisa Nacional de Saúde, foram calculadas as proporções de mulheres que tiveram pedido médico para realização de mamografia segundo ter ou não plano de saúde privado. Para avaliar os fatores relacionados a ter pedido médico de mamografia, foram calculadas odds ratios brutas e ajustadas e os respectivos IC95% por regressão logística. Foram também analisados os principais motivos informados para não ter realizado mamografia após ter o pedido médico, assim como o tempo entre ter realizado o exame e o recebimento do resultado. RESULTADOS Das mulheres entrevistadas, 66,7% tiveram um pedido médico para mamografia (59,4% entre as que eram usuárias do SUS e 83,9% entre as portadoras de plano de saúde privado). Ter plano de saúde privado, maior nível de escolaridade e ser de cor branca se associaram positivamente a ter o pedido médico. Apenas 5,4% (IC95% 4,8–6,0) das mulheres que receberam solicitação médica não conseguiram fazer mamografia – 7,6% eram dependentes do SUS enquanto 1,7% eram portadoras de plano de saúde. Os motivos mais reportados de não conseguir realizar o exame foram: não achar necessário; ter o exame marcado, mas ainda não realizado; e não ter conseguido marcar. Mais de 70% das mulheres receberam o resultado antes de completar um mês da realização. CONCLUSÕES As barreiras de acesso a ter pedido médico para rastreamento mamográfico para o câncer de mama são maiores entre mulheres que dependem exclusivamente do SUS.

Comparison of clinical and pathological characteristics between screen-detected and self-detected breast cancers: a Hong Kong study.

INTRODUCTION: Breast cancer is the leading cause of death of Hong Kong women with increasing incidence. This study aimed to determine any prognostic differences between screen-detected and self-detected cases of breast cancer in a cohort of Hong Kong patients. METHODS: This was a case series with internal comparison carried out in a private hospital in Hong Kong. Approximately 3000 cases of Chinese patients diagnosed with ductal carcinoma in situ or invasive breast cancer were reviewed. RESULTS: The screen-detected group showed better pathological characteristics than the self-detected group. Number of lymph nodes involved, invasive tumour size, and tumour grade were more favourable in the screen-detected group. There was also a lower proportion of patients with pure invasive ductal carcinoma and mastectomy in the screen-detected group. CONCLUSION: This study provides indirect evidence that women in the local population may gain clinical benefit from regular breast cancer screening. The findings need to be validated in a representative population of Hong Kong women.