Avaliação de microcalcificações mamárias de acordo com as classificações do Breast Imaging Reporting and Data System (BI-RADS TM) e de Le Gal

OBJETIVO: avaliar a acurácia da mamografia para o diagnóstico de microcalcificações mamárias suspeitas, com as classificações do Breast Imaging Reporting and Data System (BI-RADS TM) e Le Gal em comparação com o resultado histopatológico utilizado como padrão-ouro. MÉTODOS: foram selecionados dos arquivos dos blocos cirúrgicos, 130 casos operados com mamografias contendo somente microcalcificações mamárias, inicialmente classificadas como suspeitas sem lesões detectáveis ao exame clínico. Estas foram reclassificadas por dois examinadores, utilizando as classificações de Le Gal e BI-RADS TM, obtendo-se diagnóstico de consenso. As biópsias foram revistas por dois patologistas e foi obtido diagnóstico de consenso. A leitura das mamografias e a revisão das lâminas foram feitas em duplo-cego. As análises estatísticas utilizadas neste estudo foram o teste do chi2, o modelo Fleiss quadrático para VPP e o programa Epi-Info 6.0. RESULTADOS: a correlação entre a análise histopatológica e mamográfica, usando BI-RADS TM e Le Gal, mostrou a mesma sensibilidade de 96,4%, especificidade de 55,9 e 30,3%, valor preditivo positivo (VPP) de 37,5% e 27,5% e acurácia de 64,6 e 44,6%, respectivamente. Quando discriminamos por categorias de BI-RADS TM, obtivemos VPPs: categoria 2, 0%; categoria 3, 1,8%; categoria 4, 31,6% e categoria 5, 60%. Os VPPs pela classificação de Le Gal foram: categoria 2, 3,1%; categoria 3, 18,1 %; categoria 4, 26,4%; categoria 5, 66,7% e não classificável, 5,2%. CONCLUSÕES: observou-se uma maior precisão com a classificação de BI-RADS TM, porém não se conseguiu reduzir a ambigüidade na avaliação das microcalcificações mamárias.

Comparison of nuclear grade and immunohistochemical features in situ and invasive components of ductal carcinoma of breast

PURPOSE:To compare the prognostic and predictive features between in situ and invasive components of ductal breast carcinomas. METHODS:We selected 146 consecutive breast samples with ductal carcinoma in situ (DCIS) associated with adjacent invasive breast carcinoma (IBC). We evaluated nuclear grade and immunohistochemical expression of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), cytokeratin 5/6 (CK5/6), and epidermal growth factor receptor (EGFR) in both components, in situ and invasive, and the Ki-67 percentage of cells in the invasive part. The DCIS and IBC were classified in molecular surrogate types determined by the immunohistochemical profile as luminal (RE/PR-positive/ HER2-negative), triple-positive (RE/RP/HER2-positive), HER2-enriched (ER/PR-negative/HER2-positive), and triple-negative (RE/RP/HER2-negative). Discrimination between luminal A and luminal B was not performed due to statistical purposes. Correlations between the categories in the two groups were made using the Spearman correlation method. RESULTS:There was a significant correlation between nuclear grade (p<0.0001), expression of RE/RP (p<0.0001), overexpression of HER2 (p<0.0001), expression of EGFR (p<0.0001), and molecular profile (p<0.0001) between components in situ and IBC. CK 5/6 showed different distribution in DCIS and IBC, presenting a significant association with the triple-negative phenotype in IBC, but a negative association among DCIS. CONCLUSIONS: Our results suggest that classical prognostic and predictive features of IBC are already determined in the preinvasive stage of the disease. However the role of CK5/6 in invasive carcinoma may be different from the precursor lesions.

Volume of breast tissue excised during breast-conserving surgery in patients undergoing preoperative systemic therapy

PURPOSE: We aimed to determine whether clinical examination could adequately ascertain the volume of tissue to be resected during breast-conserving surgery after neoadjuvant therapy. METHODS: We reviewed the clinical reports of 279 patients with histologically diagnosed invasive breast carcinomas treated with neoadjuvant therapy followed by surgery or with primary surgery alone. We estimated volumes of excised tissues, the volume of the tumor mass and the optimal volume required for excision based on 1 cm of clear margins. The actual excess of resected volume was estimated by calculating the resection ratio measured as the volume of the resected specimen divided by the optimal specimen volume. The study endpoints were to analyze the extent of tissue resection and to ascertain the effect of excess resected tissue on surgical margins in both groups of patients. RESULTS: The median tumor diameter was 2.0 and 1.5 cm in the surgery and neoadjuvant therapy groups, respectively. The median volume of resected mammary tissue was 64.3 cm³ in the primary surgery group and 90.7 cm³ in the neoadjuvant therapy group. The median resection ratios in the primary surgery and neoadjuvant therapy groups were 2.0 and 3.3, respectively (p<0.0001). Surgical margin data were similar in both groups. Comparison of the volume of resected mammary tissues with the tumor diameters showed a positive correlation in the primary surgery group and no correlation in the neoadjuvant therapy group. CONCLUSION: Surgeons tend to excise large volumes of tissue during breast-conserving surgery after neoadjuvant therapy, thereby resulting in a loss of the correlation between tumor diameter and volume of the excised specimen.

Localization of metastasis within the sentinel lymph node biopsies: a predictor of additional axillary spread of breast cancer?

PURPOSE: To explore the relationship between morphological characteristics and histologic localization of metastasis within sentinel lymph nodes (SLN) and axillary spread in women with breast cancer. METHODS: We selected 119 patients with positive SLN submitted to complete axillary lymph node dissection from July 2002 to March 2007. We retrieved the age of patients and the primary tumor size. In the primary tumor, we evaluated histologic and nuclear grade, and peritumoral vascular invasion (PVI). In SLNs we evaluated the size of metastasis, their localization in the lymph node, number of foci, number of involved lymph nodes, and extranodal extension. RESULTS: Fifty-one (42.8%) patients had confirmed additional metastasis in non-sentinel lymph nodes (NLSN). High histologic grade, PVI, intraparenchymatous metastasis, extranodal neoplastic extension and size of metastasis were associated with positive NLSN. SLN metastasis affecting the capsule were associated to low risk incidence of additional metastasis. After multivariate analysis, PVI and metastasis size in the SLN remained as the most important risk factors for additional metastasis. CONCLUSIONS:The risk of additional involvement of NSLN is higher in patients with PVI and it increases progressively according the histologic localization in the lymph node, from capsule, where the afferent lymphatic channel arrives, to the opposite side of capsule promoting the extranodal extension. Size of metastasis greater than 6.0 mm presents higher risk of additional lymph node metastasis.

Polymorphisms of GSTM1 and GSTT1 genes in breast cancer susceptibility: a case-control study

PURPOSE: This study aimed to evaluate the frequency of homozygous deletion of GSTM1 and GSTT1 genes and their combinations between patients with breast cancer and healthy individuals, associating them with disease susceptibility. METHODS: This is a case-control study in which 49 women diagnosed with breast cancer confirmed by pathological examination and 49 healthy women with no evidence of cancer and no prior family history of breast cancer were invited to participate. All of them answered a questionnaire with epidemiological data and were submitted to blood sample collection. Genomic DNA was extracted from blood, and genotyping was performed by polymerase chain reaction. Data were analyzed with SPSS 20.0. RESULTS: The frequency of null alleles for GSTM1 and GSTT1 was 58.8 and 61.7%, respectively, for patients with breast cancer, and 41.2 and 38.3%, respectively, in control patients. In homozygous deletion of the GSTM1 gene, a significantly higher frequency was found in the breast cancer cases. CONCLUSION: Breast cancer patients presented higher frequency of homozygous deletion of the GSTM1 gene compared with the control group.

Cardiovascular risk in middle-aged breast cancer survivors: a comparison between two risk models

PURPOSE: It was to assess the risk of cardiovascular disease (CVD) in breast cancer survivors (BCS).METHODS: This cross-sectional study analyzed 67 BCS, aged 45 -65 years, who underwent complete oncological treatment, but had not received hormone therapy, tamoxifen or aromatase inhibitors during the previous 6 months. Lipid profile and CVD risk were evaluated, the latter using the Framingham and Systematic COronary Risk Evaluation (SCORE) models. The agreement between cardiovascular risk models was analyzed by calculating a kappa coefficient and its 95% confidence interval (CI).RESULTS: Mean subject age was 53.2±6.0 years, with rates of obesity, hypertension, and dyslipidemia of 25, 34 and 90%, respectively. The most frequent lipid abnormalities were high total cholesterol (70%), high LDL-C (51%) and high non-HDL-C (48%) concentrations. Based on the Framingham score, 22% of the participants had a high risk for coronary artery disease. According to the SCORE model, 100 and 93% of the participants were at low risk for fatal CVD in populations at low and high risk, respectively, for CVD. The agreement between the Framingham and SCORE risk models was poor (kappa: 0.1; 95%CI 0.01 -0.2) for populations at high risk for CVD.CONCLUSIONS: These findings indicate the need to include lipid profile and CVD risk assessment in the follow-up of BCS, focusing on adequate control of serum lipid concentrations.

Short-term changes in handgrip strength, body composition, and lymphedema induced by breast cancer surgery

PURPOSE: This study investigated short-term changes in body composition, handgrip strength, and presence of lymphedema in women who underwent breast cancer surgery.METHODS: Ninety-five women participated in a cross-sectional study, divided into two groups: Control (n=46), with healthy women, and Experimental (n=49), with women six months after breast cancer surgery . The Experimental Group was subdivided into right total mastectomy (RTM, n=15), left total mastectomy (LTM, n=11), right quadrant (RQ, n=13), and left quadrant (LQ, n=10). It was also redistributed among women with presence (n=10) or absence (n=39) of lymphedema. Presence of lymphedema, handgrip strength, and body composition were assessed.RESULTS: Trunk lean mass and handgrip strength were decreased in the Experimental Group. Total lean mass was increased in the LTM compared to RTM or LQ. Left handgrip strength in LTM was decreased compared to RTM and RQ and in LQ compared to RTM and RQ. Finally, total lean mass, trunk fat mass, trunk lean mass, right and left arm lean mass were increased in women with lymphedema.CONCLUSIONS: Breast cancer survivors have changes in their body composition and in handgrip strength six months after surgery; however, the interaction between the type of surgery and its impact is unclear. Furthermore, women who developed lymphedema in this period showed more significant changes in the body composition, but they were not enough to cause impairment in handgrip strength.

Loss of PTEN expression and AKT activation in HER2-positive breast carcinomas

PURPOSE: To examine the expression of AKT and PTEN in a series of HER2-positive primary invasive breast tumors using immunohistochemistry, and to associate these expression profiles with classic pathologic features such as tumor grade, hormone receptor expression, lymphatic vascular invasion, and proliferation.METHODS: A total of 104 HER2-positive breast carcinoma specimens were prepared in tissue microarrays blocks for immunohistochemical detection of PTEN and phosphorylated AKT (pAKT). Original histologic sections were reviewed to assess pathological features, including HER2 status and Ki-67 index values. The associations between categorical and numeric variables were identified using Pearson's chi-square test and the Mann-Whitney, respectively.RESULTS: Co-expression of pAKT and PTEN was presented in 59 (56.7%) cases. Reduced levels of PTEN expression were detected in 20 (19.2%) cases, and these 20 tumors had a lower Ki-67 index value. In contrast, tumors positive for pAKT expression [71 (68.3%)] were associated with a higher Ki-67 index value.CONCLUSION: A role for AKT in the proliferation of HER2-positive breast cancers was confirmed. However, immunohistochemical detection of PTEN expression did not correlate with an inhibition of cellular proliferation or control of AKT phosphorylation, suggesting other pathways in these mechanisms of control.

Variations in the body mass index in Brazilian women undergoing adjuvant chemotherapy for breast cancer

PURPOSE:To evaluate variations in the body mass index in patients undergoing adjuvant chemotherapy for breast cancer, and to associate these changes with patient's age and adjuvant chemotherapy regimen.METHODS:We performed a retrospective cohort study in order to correlate any variation in the body mass index before and after adjuvant chemotherapy with patient's age and adjuvant chemotherapy regimen. Patients who received any form of prior hormone therapy, such as tamoxifen or aromatase inhibitors, were excluded. We selected data for 196 patients with stage I to III breast cancer who were treated by radical or conservative surgery and received adjuvant chemotherapy at the Cancer Institute of the State of São Paulo, Brazil.RESULTS:Before adjuvant chemotherapy, 67.8% of patients were classified as overweight or obese according to their body mass indices. Around 66.3% (95% CI 59.7–73.0) of the patients exhibited an increase in the body mass index after adjuvant chemotherapy. The average age of all patients was 56.3±11.3 years. Participants whose body mass index increased were younger than those with no increase (54.7±11.1 versus 59.3±11.2 years; p=0.007). Patients were treated with the following adjuvant chemotherapy regimens: doxorubicin, cyclophosphamide, and paclitaxel (AC-T, 129 patients, 65.8%); 5-fluoracil, doxorubicin, and cyclophosphamide (36 patients, 18.4%); cyclophosphamide, methotrexate, and 5-fluoracil (16 patients, 8.2%); docetaxel and cyclophosphamide (7 patients, 3.6%); and other regimen (8 patients, 4.1%). The AC-T regimen showed a statistically significant association with increase in the body mass index (p<0.001 by ANOVA).CONCLUSIONS:Most patients with breast cancer showed an increase in the body mass index after adjuvant chemotherapy, especially after the AC-T chemotherapy regimen.

Fatigue and quality of life in breast cancer survivors: a comparative study

PURPOSE: To assess fatigue and quality of life in disease-free breast cancer survivors in relation to a sample of age-matched women with no cancer history and to explore the relationship between fatigue and quality of life.METHODS: A cross-sectional study was conducted in a sample of 202 consecutive disease-free Brazilian breast cancer survivors, all of whom had completed treatment, treated at 2 large hospitals. The patients were compared to age-matched women with no cancer history attending a primary health care center. The Piper Fatigue Scale-Revised and the World Health Organization Quality of Life Instrument (WHOQOL-BREF) were used to measure the fatigue and quality of life, respectively. Socio-demographic and clinical variables were also obtained. The χ2 test, generalized linear model, and Spearman correlation coefficient were used for statistical purposes. The adopted level of significance was 5%.RESULTS: Breast cancer survivors experienced significantly greater total and subscale fatigue scores than comparison group (all p-values<0.05). In addition, survivors reported a poorer quality of life in physical (p=0.002), psychological (p=0.03), and social relationships (p=0.03) domains than comparison group. No difference was found for the environmental domain (p=0.08) for both groups. For survivors of breast cancer and for comparison group, the total and subscale fatigue scores were related to lower quality of life (all p-values<0.01).CONCLUSION: The findings of this study highlight the importance of assessing fatigue and quality of life in breast cancer survivors.

The Effects of Estradiol, Androgens and the Selective Estrogen Modulators: Ospemifene, Raloxifene and Tamoxifen on Explant Cultures of Human Breast Tissue

The impact of menopausal hormone therapy (MHT) on increasing the risk for breast cancer (BC) remains controversial. To understand MHT-elicited cellular breast effects and the potential risks, included with using this therapy, a further investigation into this controversy is the subject of this thesis. In this thesis, to study the effects of estrogen, progestin, androgens and selective estrogen receptor modulators (SERMs), a modified tissue explant culture system was used. The different types of human breast tissues (HBTs) used in this study were normal HBTs, obtained from reduction mammoplasties of premenopausal women (prem-HBTs) or postmenopausal (postm-HBTs) women and peritumoral HBTs (peritum-HBTs) which were obtained from surgeries on postmenopausal BC patients. The explants were cultured up to three weeks in the presence or absence of estradiol (E2), medroxyprogesterone acetate (MPA), testosterone (T), dihydrotestosterone (DHT) and SERMs - ospemifene (OSP), raloxifene (RAL) and tamoxifen (TAM). The cultured HBTs maintained morphological integrity and responded to hormonal treatment in vitro. E2, MPA or E2/MPA increased proliferative activity and was associated with increased cyclin-D1 and caused changes in the cell cycle inhibitors p21 and p27, whereas the androgens T and DHT inhibited proliferation and increased apoptosis in HBT epithelia and opposed E2-stimulated proliferation and cell survival. The postm-HBTs were more sensitive to E2 than prem-HBTs. The effects of OSP, RAL and TAM on HBT epithelium were antiproliferative. E2, androgens and SERMs were associated with marked changes in the proportions of epithelial cells expressing steroid hormone receptors: E2 increased ERα expressing cells and decreased androgen receptor (AR) positive cells, whereas T and DHT had opposite effects. The OSP, RAL and TAM, also decreased a proportion of ERα positive cells in HBT epithelium. At 100 nM, these compounds maintained the relative number of AR positive cells, present at control level, which may partly explain proliferative inhibition. In conclusion, the proliferative activity of E2, in the epithelium of postm-HBTs, is opposed by T and DHT, which suggests that the inclusion of androgens in MHT may decrease the risk for developing BC.

The Role of an Oncoprotein CIP2A in Breast Cancer

Cancerous inhibitor of PP2A (CIP2A) is an oncoprotein expressed in several human cancer types. Previously, CIP2A has been shown to promote proliferation of cancer cells. Mechanistically, CIP2A is known to inhibit activity of a tumor suppressor protein phosphatase 2A (PP2A) towards an oncoprotein MYC, further stabilizing MYC in human cancer. However, the molecular mechanisms how CIP2A expression is induced during cellular transformation are not well known. Also, expression, functional role and clinical relevance of CIP2A in breast cancer had not been studied before. The results of this PhD thesis work demonstrate that CIP2A is highly expressed in human breast cancer, and that high expression of CIP2A in tumors is a poor prognostic factor in a subset of breast cancer patients. CIP2A expression correlates with inactivating mutations of tumor suppressor p53 in human cancer. Notably, we demonstrate that p53 inactivation up-regulates CIP2A expression via increased expression of an oncogenic transcription factor E2F1. Moreover, CIP2A promotes expression of E2F1, and this novel positive feedback loop between E2F1 and CIP2A is demonstrated to regulate sensitivity to both p53-dependent and -independent senescence induction in breast cancer cells. Importantly, in a CIP2A deficient breast cancer mouse model, abrogation of CIP2A attenuates mammary tumor formation and progression with features of E2F1 inhibition and induction of senescence. Furthermore, we demonstrate that CIP2A expression defines the cellular response to a senescence-inducing chemotherapy in breast cancer. Taken together, these results demonstrate that CIP2A is an essential promoter of breast cancer tumor growth by inhibiting senescence. Finally, this study implicates inhibition of CIP2A as a promising therapy target for breast cancer.

Libyan breast cancer: Health services and biology. Diagnosis delay and prognostic value of DNA pploidy, S-phase fraction, and Ki-67 and Bcl-2 immunohistochemistry

The aim of this study was to investigate the diagnosis delay and its impact on the stage of disease. The study also evaluated a nuclear DNA content, immunohistochemical expression of Ki-67 and bcl-2, and the correlation of these biological features with the clinicopathological features and patient outcome. 200 Libyan women, diagnosed during 2008–2009 were interviewed about the period from the first symptoms to the final histological diagnosis of breast cancer. Also retrospective preclinical and clinical data were collected from medical records on a form (questionnaire) in association with the interview. Tumor material of the patients was collected and nuclear DNA content analysed using DNA image cytometry. The expression of Ki-67 and bcl-2 were assessed using immunohistochemistry (IHC). The studies described in this thesis show that the median of diagnosis time for women with breast cancer was 7.5 months and 56% of patients were diagnosed within a period longer than 6 months. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was also associated with initial breast symptom(s) that did not include a lump, old age, illiteracy, and history of benign fibrocystic disease. The patients who showed diagnosis delay had bigger tumour size (p<0.0001), positive lymph nodes (p<0.0001), and high incidence of late clinical stages (p<0.0001). Biologically, 82.7% of tumors were aneuploid and 17.3% were diploid. The median SPF of tumors was 11% while the median positivity of Ki-67 was 27.5%. High Ki-67 expression was found in 76% of patients, and high SPF values in 56% of patients. Positive bcl-2 expression was found in 62.4% of tumors. 72.2% of the bcl-2 positive samples were ER-positive. Patients who had tumor with DNA aneuploidy, high proliferative activity and negative bcl-2 expression were associated with a high grade of malignancy and short survival. The SPF value is useful cell proliferation marker in assessing prognosis, and the decision cut point of 11% for SPF in the Libyan material was clearly significant (p<0.0001). Bcl-2 is a powerful prognosticator and an independent predictor of breast cancer outcome in the Libyan material (p<0.0001). Libyan breast cancer was investigated in these studies from two different aspects: health services and biology. The results show that diagnosis delay is a very serious problem in Libya and is associated with complex interactions between many factors leading to advanced stages, and potentially to high mortality. Cytometric DNA variables, proliferative markers (Ki-67 and SPF), and oncoprotein bcl-2 negativity reflect the aggressive behavior of Libyan breast cancer and could be used with traditional factors to predict the outcome of individual patients, and to select appropriate therapy.

Nuclear morphometry, apoptotic and mitotic indices, and tubular differentiation in Libyan breast cancer

Aims of this study were to evaluate the relations of nuclear morphometry, mitotic and apoptotic indices, and tubular differentiation with clinicopathological features and survival rate in Libyan women. The data were compared with corresponding results on Finnish, and Nigerian female breast cancer patients. Histological samples of breast cancer (BC) from 131 patients were retrospectively studied. Mitotic activity indices (MAI and SMI), apoptotic index (AI), and fraction of fields with tubular differentiation (FTD) were estimated. Samples were also studied by computerized nuclear morphometry, such as mean nuclear area (MNA). Demographic and clinicopathological features were analyzed from 234 patients. The Libyan BC was dominantly premenopausal, and aggressive in behavior. There were statistically significant correlations between the mean nuclear area, fraction of fields with tubular differentiation, apoptotic index and proliferative indices, and most clinicopathological features. The highest significances were shown between lymph node status and the proliferative and apoptotic indices (p=0.003 with SMI, and p=0.005 with AI). There were significant associations between clinical stage and SMI and AI (p=0.002 and 0.009, respectively). The most significant associations with grade were observed with MNA and FTD (p<0.0001 and 0.001, respectively). The proliferative differences between Libyan, Nigerian and Finnish populations were prominent. These indices in Libyan were lower than in Nigerian, but higher than in Finnish patients. The Libyan patients’ AI is slightly higher than in Nigeria, but much higher than in Finland. The differences between countries may be associated with the known variation in the distribution of genetic markers in these populations. The results also indicated that morphometric factors can be reliable prognostic indicators in Libyan BC patients.