Avaliação convencional e estesiômetro: resultados controversos na avaliação sensitiva no câncer de mama

This study, clinical, prospective, randomized study was conducted from August 2004 to February 2008 in a convenience sample of 60 women who underwent breast surgery with axillary dissection, divided into two groups (n = 30). The GI (Guidance Kit with different textures, to perform at home) and GII (control). The objective was to analyze the effect of home orientation in patients after surgery for breast cancer complaining of numbness, evaluation, and the conventional esthesiometer. The surface sensitivity was assessed by monofilament Semmes-Weinstein and evaluation using conventional two test tubes with hot water (38 to 43o C) and cold (16 to 27o C), paintbrush, needle. The GI was subjected to 10 sessions and assessments in both 3 times. The M1 (pre intervention), the M2 (post-intervention) after 10 sessions of physical therapy intervention and M3 (washout) after 3 months the second time for assessment. The region targeted for evaluation and intervention was the sensory nerve dermatome intercostobrachial. In the test of Goodman (conventional assessment) there was improvement in both groups, the P1, during the thermal evaluation. The t-test of student (esthesiometer) there was improvement in P2 only in GI (p = 0.003) between points 1 and 2 while the time 3 (p = 0.121 and p = 0.733 respectively). It was concluded that there were divergent and opposite results after examining the effect of home orientation in the nerve dermatome intercostobrachial, evaluation, and the conventional esthesiometer.

Intervención cognitivo-conductual para el control de ansiedad ante la biopsia insicional en pacientes con cáncer de mama

Oncological patients are submitted to invasive exams in order to obtain an accurate diagnosis; these procedures may cause maladaptative reactions (fear, anxiety and pain). Particularly in breast cancer, the most common diagnose technique is the incisional biopsy. Most of the patients are unaware about the procedure and for that reason they may focus their thoughts on possible events such as pain, bleeding, the anesthesia, or the later surgical wound care. Anxiety and pain may provoke physiological, behavioral and emotional complications, and because of this reason, the Behavioral Medicine trained psychologist takes an active role before and after the biopsy. The aim of this study was to evaluate the effect of a cognitive-behavioral program to reduce anxiety in women submitted to incisional biopsy for the first time. There were 10 participants from the Hospital Juárez de México, Oncology service; all of them were treated as external patients. The intervention program focused in psycho-education and passive relaxation training using videos, tape-recorded instructions and pamphlets. Anxiety measures were performed using the IDARE-State inventory, and a visual-analogue scale of anxiety (EEF-A), and the measurement of blood pressure and heart rate). Data were analyzed both intrasubject and intersubject using the Wilcoxon test (p≤0.05). The results show a reduction in anxiety (as in punctuation as in ranges) besides, a reduction in the EEF-A.

A eficácia terapêutica da fisioterapia no linfedema pós cirurgia de cancro da mama

Projeto de Graduação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Licenciada em Fisioterapia

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim: The aim of this study was to evaluate the safety of breast conserving surgery ill patients with breast tumours satisfactorily downstaged after neoadjuvant therapy. Methods: A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group. Results: The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient. Conclusion: Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy. (c) 2008 Elsevier Ltd. All rights reserved.

Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy

Breast screening programmes have facilitated more conservative approaches to the surgical and radiotherapy management of women diagnosed with breast cancer. This study investigated changes in shoulder movement after surgery for primary, operable breast cancer to determine the effect of elective physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were completed preoperatively, at day 5 and at 1 month, 3, 6, 12 and 24 months postoperatively. The CG only received an exercise instruction booklet in comparison to the TG who received the Physiotherapy Management Care Plan (PMCP). Analyses of variance revealed that abduction returned to preoperative levels more quickly in the TG than in the CG. The TG women had 14degrees more abduction at 3 months and 7degrees at 24 months. Functional recovery at 1 month was greater in those randomised to the TG, with a dominant operated arm (OA) or receiving breast-conserving surgery. However, it was not possible to predict recovery over the 2 years postoperatively on the basis of an individual woman's recovery at 1 month postoperatively. The eventual recovery of abduction or flexion range of movement was not related to the dominance of the OA nor to the surgical procedure performed. The PMCP provided in the early postoperative period is effective in facilitating and maintaining the recovery of shoulder movement over the first 2 years after breast cancer surgery.

Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema

The development of secondary arm lymphoedema after the removal of axillary lymph nodes remains a potential problem for women with breast cancer. This study investigated the incidence of arm lymphoedema following axillary dissection to determine the effect of prospective monitoring and early physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were made preoperatively, at day 5 and at 1, 3, 6, 12 and 24 months postoperatively. Three measurements were used for the detection of arm lymphoedema: arm circumferences (CIRC), arm volume (VOL) and multi-frequency bioimpedance (MFBIA). Clinically significant lymphoedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. Using this definition, the incidence of lymphoedema at 24 mo. was 21%, with a rate of 11% in the TG compared to 30% in the CG. The CIRC or MFBIA methods failed to detect lymphoedema in up to 50% of women who demonstrated an increase of at least 200 ml in the VOL of the operated arm compared to the unoperated arm. The physiotherapy intervention programme for the TG women included principles for lymphoedema risk minimisation and early management of this condition when it was identified. These strategies appear to reduce the development of secondary lymphoedema and alter its progression in comparison to the CG women. Monitoring of these women is continuing and will determine if these benefits are maintained over a longer period for women with early lymphoedema after breast cancer surgery.

An interactive web-based tool for breast reduction surgery simulation

In this work, we present a 3D web-based interactive tool for numerical modeling and simulation approach to breast reduction surgery simulation, to assist surgeons in planning all aspects related to breast reduction surgery before the actual procedure takes place, thereby avoiding unnecessary risks. In particular, it allows the modeling of the initial breast geometry, the definition of all aspects related to the surgery and the visualization of the post-surgery breast shape in a realistic environment.

Concurrent or Sequential Adjuvant Hormonoradiotherapy after Conservative Surgery for Early-Stage Breast Cancer: Clinical Results of the CO-HO-RT Phase II Randomized Trial.

Purpose: Letrozole (LET) has recently been shown to be superior to tamoxifen for postmenopausal patients (pts). In addition, LET radiosensitizes breast cancer cells in vitro. We conducted a phase II randomized study to evaluate concurrent and sequential radiotherapy (RT)-LET in the adjuvant setting. We present here clinical results with a minimum follow-up of 24 months. Patients and Methods: Postmenopausal pts with early-stage breast cancer were randomized after conservative surgery to either: A) concurrent RT-LET (LET started 3 weeks before the first day of RT) or B) sequential RT-LET (LET started 3 weeks after the end of RT). Whole breast RT was delivered to a total dose of 50 Gy. A 10-16 Gy boost was allowed according to age and pathological prognostic factors. Pts were stratified by center, adjuvant chemotherapy, boost, and radiation-induced CD8 apoptosis (RILA). RILA was performed before RT as previously published (Ozsahin et al. Clin Cancer Res, 2005). An independent monitoring committee reviewed individual safety data. Skin toxicities were evaluated by two different clinicians at each medical visit (CTCAE v3.0). Lung CT-scan and functional pulmonary tests were performed regularly. DNA samples were screened for SNPs in candidate genes as recently published (Azria et al., Clin Cancer Res, 2008). Results: A total of 150 pts were randomized between 01/05 and 02/07. Median follow-up is 26 months (range, 3-40 months). No statistical differences were identified between the two arms in terms of mean age; initial TNM; median surgical bed volume; post surgical breast volume. Chemotherapy and RT boost were delivered in 19% and 38% of pts, respectively. Nodes received 50 Gy in 23% of patients without differences between both arms. During RT and within the first 6 weeks after RT, 10 patients (6.7%) presented grade 3 acute skin dermatitis during RT but no differences were observed between both arms (4 and 6 patients in arm A and B, respectively). At 26 month of follow-up, grade 2 and more radiation-induced subcutaneous fibrosis (RISCF) was present in 4 patients (3%) without any difference between arm A (n = 2) and B (n = 2), p=0.93. In both arms, all patients that presented a RICSF had a RILA lower than 16%. Sensitivity and specificity were 100% and 39%, respectively.No acute lung toxicities were observed and quality of life was good to excellent for all patients.SNPs analyses are still on-going (Pr Rosenstein, NY). Conclusion: Acute and early late grade 2 dermatitis were similar in both arms. The only factor that influenced RISCF was a low radiation-induced lymphocyte apoptosis yield. We confirmed prospectively the capacity of RILA for identifying hypersensitive patients to radiation. Indeed, patients with RILA superior to 16% did not present late effects to radiation and confirmed the first prospective trial we published in 2005 (Ozsahin et al., Clin Cancer Res).

Breast-conserving surgery for non-palpable breast cancer: relationship of lumpectomy resection margins measurements between remote perioperative ultrasound and postoperative histopathology

Purpose: Tumour-free resection margins (RMs) are mandatory in breast-conserving surgery. On-site intraoperative ultrasound (US)-guided tumour resection with extemporaneous histopathological assessment of RMs has been described. Remote intraoperative US assessment of RMs is an alternative. The purpose of this study was to evaluate the relationship of lumpectomy RMs measurements between remote intraoperative US and postoperative histopathology.Methods and Materials: In a retrospective IRB-approved review of 100 consecutive lumpectomies performed between October 2009 and April 2011 for presumed non-palpable breast cancer, 71 women (mean age 63.8years) were included. Twenty-nine patients were excluded because of absence of cancer at histopathology and/or incomplete data. Measurements of lumpectomy minimal RMs and tumour maximal diameter obtained on remote intraoperative US and postoperative histopathology were compared.Results: Minimal RMs were 0.35±0.32 (mean±SD) and 0.35±0.32cm on remote intraoperative US and postoperative histopathology, respectively. No significant difference was found between these measurements (p=0.37). Tumour maximal diameter was 1.02±0.51 (mean±SD) and 1.33±0.74cm on remote intraoperative US and postoperative histopathology, respectively. US measurements were significantly smaller (p<0.001). The 71 breast carcinoma (CA) consisted of: invasive canalar (n=49), invasive lobular (n=11), in situ (n=3) and other types of CA (n=8). Twenty-nine patients had intraoperative re-excision (24 without residual CA), while 16 patients were re-operated due to insufficient histopathological RMs (12 without residual CA).Conclusion: Good correlation of minimal RMs between remote intraoperative US and postoperative histopathology warrants use of both techniques in a complementary manner. Remote intraoperative US is helpful in taking rapid decision of re-excision and maintaining low re-operation rate after breast-conserving surgery for non-palpable cancer.

Axillary Sentinel Lymph Node Biopsy for Breast Cancer and Melanoma Patients after Previous Axillary Surgery: A Systematic Review

Objective: Sentinel lymph node biopsy (SLNB) is a validated staging technique for breast carcinoma. Some women are exposed to have a second SLNB due to breast cancer recurrence or a second neoplasia (breast or other). Due to modi- fied anatomy, it has been claimed that previous axillary surgery represents a contra-indication to SLNB. Our objective was to analyse the literature to assess if a second SLNB is to be recommended or not. Methods: For the present study, we performed a review of all published data during the last 10 years on patients with previous axilla surgery and second SLNB. Results: Our analysis shows that second SLNB is feasible in 70%. Extra-axillary SNs rate (31%) was higher after radical lymph node dissection (ALND) (60% - 84%) than after SLNB alone (14% - 65%). Follow-up and com- plementary ALND following negative and positive second SLNB shows that it is a reliable procedure. Conclusion: The review of literature confirms that SLNB is feasible after previous axillary dissection. Triple technique for SN mapping is the best examination to highlight modified lymphatic anatomy and shows definitively where SLNB must be per- formed. Surgery may be more demanding as patients may have more frequently extra-axillary SN only, like internal mammary nodes. ALND can be avoided when second SLNB harvests negative SNs. These conclusions should however be taken with caution because of the heterogeneity of publications regarding SLNB and surgical technique.

Chirurgie du cancer du sein [Breast cancer surgery].

Breast conserving surgery followed by radiation therapy is the treatment of choice for early breast cancer. For patients who choice or need a mastectomy, breast reconstruction provides an acceptable alternative. Breast cancer surgery has been evolving through minimally invasive approaches. Sentinel node biopsy has already remplaced axillary lymph node dissection in the evaluation of the axilla. Local ablation of the tumor may be a valuable alternative to surgery in the future.