INTRODUÇÃO: O status linfonodal da axila ainda permanece como importante fator prognóstico em pacientes com câncer de mama invasivo. Muitos estudos já relataram a importância da ultrassonografia axilar e da punção aspirativa por agulha fina (PAAF) na avaliação pré-operatória das pacientes com câncer de mama. Nossos objetivos foram avaliar as características ultrassonográficas dos linfonodos axilares relacionadas à metástase linfonodal e o papel da PAAF na avaliação pré-operatória de pacientes com câncer de mama. Nosso objetivo secundário foi avaliar se, dependendo das características dos tumores, linfonodos sem alterações na ultrassonografia poderiam ter comprometimento metastático. MÉTODOS: Este estudo foi realizado no Instituto de Radiologia e no Instituto do Câncer do HCFMUSP. Foram incluídas 182 pacientes com câncer de mama invasivo recém-diagnosticado, sendo que, destas, apenas 145 realizaram cirurgia - 74 prosseguiram direto para cirurgia e 71 realizaram tratamento neoadjuvante e após cirurgia. Foi realizada avaliação ultrassonográfica da axila ipsilateral ao tumor e punção aspirativa por agulha fina de um linfonodo selecionado pelo radiologista. Os dados ultrassonográficos dos linfonodos e os achados citológicos da PAAF foram correlacionados com os resultados anatomopatológicos da biópsia do linfonodo sentinela ou do esvaziamento axilar. RESULTADOS: Nas 74 pacientes (75 axilas) que não realizaram tratamento neoadjuvante, as características ultrassonográficas do linfonodo associadas à metástase na análise univariada foram espessamento cortical difuso e a obliteração parcial ou completa do hilo gorduroso. A sensibilidade, especificidade, acurácia, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) da ultrassonografia foram, respectivamente, 72,7%, 57,1%, 64,0%, 57,1% e 72,7% (p=0,009), e da PAAF: 36,4%, 97,6%, 70,7%, 92,3% e 66,1% (p < 0,001). Incluindo apenas linfonodos alterados na ultrassonografia, obtivemos, respectivamente, sensibilidade, especificidade, acurácia, VPP e VPN de 50%, 94%, 69%, 92% 59% (p=0,001). Nenhuma PAAF de linfonodo classificado como normal na ultrassonografia teve resultado positivo. Obtivemos, nas análises das curvas ROC, um valor de corte da espessura da cortical de 2,65 mm (p < 0,001) e do tamanho do tumor pré-cirúrgico de 2,45 cm (p=0,042). Na análise multivariada, as seguintes características foram associadas à metástase linfonodal: espessura da cortical (p = 0,005), tamanho do tumor pré-cirúrgico (p = 0,030), status pré-menopausa (p = 0,017), tipo histológico não especial (p = 0,034) e localização do tumor no quadrante superolateral (p = 0,011). Construiu-se um modelo de predição de risco de metástase axilar usando estas características. Nas 71 pacientes que realizaram tratamento adjuvante, a única característica do linfonodo associada à metástase linfonodal foi a forma redonda ou irregular. Os demais resultados deste grupo não podem ser generalizados, pois não é possível separar o efeito do tratamento nesta população. CONCLUSÕES: Linfonodos axilares com espessamento cortical difuso e com obliteração parcial ou completa do hilo gorduroso estão associados à malignidade. A PAAF apresentou-se mais útil nos linfonodos alterados, com sensibilidade de 50%. Pacientes com PAAF positivas devem ser encaminhadas para esvaziamento axilar ou quimioterapia neoadjuvante. Não há benefício da realização da PAAF em linfonodos sem alterações na ultrassonografia / BACKGROUND: The lymph node status of the axilla remains an important prognostic factor in patients with invasive breast cancer. Many studies have already reported the importance of axillary ultrasonography and fine needle aspiration (FNA) in the preoperative evaluation of patients with breast cancer. Our objectives were to evaluate the ultrasound characteristics of axillary lymph nodes related to lymph node metastasis and the role of FNA in the preoperative evaluation of patients with breast cancer. Our secondary objective was to assess whether, depending on the tumor characteristics, lymph nodes that showed no change on ultrasonography could have metastatic involvement. METHODS: This study was conducted at the Institute of Radiology and the Institute of Cancer of HCFMUSP. A total of 182 patients with newly diagnosed invasive breast cancer were included, of whom only 145 had undergone surgery - 74 went straight to surgery and 71 underwent neoadjuvant treatment and after surgery. Ultrasound evaluation of the axilla ipsilateral to the tumor and fine needle aspiration of a lymph node selected by the radiologist were performed. The ultrasound data of the lymph nodes and the cytological findings of FNA were correlated with pathology results from sentinel lymph node biopsy or surgical dissection. RESULTS: In the 74 patients (75 axillae) who did not undergo neoadjuvant treatment, the ultrasound characteristics of the lymph nodes associated with metastasis in the univariate analysis were diffuse cortical thickening and partial or complete fatty hilum obliteration. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of ultrasound were respectively 72.7%, 57.1%, 64.0%, 57.1% and 72.7% (p = 0.009) and of the FNA 36.4%, 97.6%, 70.7%, 92.3% and 66.1% (p <0.001). Including only atypical lymph nodes on ultrasonography, we obtained respectively sensitivity, specificity, accuracy, PPV and NPV of 50%, 94%, 69% 92% and 59% (p = 0.001). No FNA of lymph node classified as normal on ultrasonography had a positive result. With ROC curves analysis we obtained a cut-off value of cortical thickness of 2.65 mm (p <0.001) and pre-surgical tumor size of 2.45 cm (p = 0.042). In the multivariate analysis, the following characteristics were associated with lymph node metastasis: cortical thickness (p = 0.005), preoperative tumor size (p = 0.030), premenopausal status (p = 0.017), non-special histological type and tumor location in the upper outer quadrant (p = 0.011). A predictive model of axillary metastasis risk was constructed using these characteristics. In the 71 patients who underwent adjuvant treatment the only feature of the lymph node associated with lymph node metastasis was the round or irregular shape. The other results of this group cannot be generalized since it is not possible to separate the treatment effect in this population. CONCLUSIONS: Axillary lymph nodes with diffuse cortical thickening and with partial or complete fatty hilum obliteration are associated with malignancy. FNA was more useful in atypical lymph nodes, with a sensitivity of 50%. Patients with positive FNA should be referred for axillary surgical dissection or neoadjuvant chemotherapy. There is no benefit of performing FNA in lymph nodes without changes in ultrasound

Objective: In this study, the efficiency of telemedical consulting with regard to fine needle aspirates from space-occupying lesions (SOLs) of the liver is investigated for the first time. Study Design: The study includes fine needle aspirations from 62 patients, 33 with hepatocellular carcinoma (HCC) and 29 with non-hepatic tumors. Using the Internetbased iPath system, the initial pathologist submitted 1–8 images from smears and cell block sections. One consultant assessed the cytological and another one the histological images. Both made their diagnoses independent of each other. A final diagnosis was made by immunochemistry of cell block sections. The cytological images were analyzed retrospectively for the occurrence of the most typical HCC indicators. The number of these indicators was related to the initial diagnoses of the three pathologists, and possible reasons for diagnostic errors were analyzed based on this analysis. Results: The accuracy of the preliminary telemedical diagnoses regarding HCC was 82.0% for the cytological images and 87.7% for the histological images. Most of the false diagnoses occurred in tumors with unusual cytological and histological patterns. Conclusions: Telemedical consulting is a valuable tool to obtain a second opinion. However, for improvement of the diagnosis of HCC, supplementary immunochemical tests are necessary.

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Les masses kystiques latérales du cou (MKLC) bénignes et malignes sont difficiles à différencier cliniquement. L’utilité des modalités d’imagerie et de prélèvement doit être clarifiée. Une revue rétrospective de cas entre 2010 et 2016. Les données d’imagerie ont été récoltées et plusieurs variables propres à la masse furent analysées. Les rapports de cytoponction à l’aiguille fine (CAAF), de la biopsie au trocart (BT) et des examens extemporanés (EE) ont été analysés. La sensibilité, la spécificité, la valeur prédictive positive (VPP) et la valeur prédictive négative (VPN) pour prédire la malignité ont été calculées pour toutes les variables comparées entre les masses kystiques bénignes et malignes. Aucune variable d’imagerie n’a pu différencier les masses kystiques bénignes de malignes. La sensibilité de la CAAF est plus basse que celle de la BT (59% vs 83%; p=0.036) et de l’EE (59% vs 93%; p=0.01). L’EE a une meilleure VPN que la CAAF (92% vs 40%; p<0.001) et que la BT (92% vs 50%; p=0.062). La VPP et la spécificité étaient similaires dans tous les groupes. Les cliniciens ne peuvent pas se fier uniquement à l’imagerie pour différencier les masses bénignes des masses malignes. Vu sa VPP adéquate (92%), la CAAF devrait être utilisée initialement pour tous les patients avec une MKLC. Si la CAAF s’avère négative, la BT devrait être utilisée vu sa meilleure sensibilité. Un examen extemporané devrait toujours suivre une BT négative vu la faible VPN de la BT. Un résultat positif à l’une des trois modalités de prélèvement indique la présence de malignité. / Benign and malignant lateral cystic neck masses (LCNM) are difficult to distinguish clinically. The usefulness of imaging and sampling modalities in clarifying the diagnosis remains unclear. Retrospective review of cases between 2010 and 2016. Imaging data was reviewed and the variables pertaining to the mass were assessed including the following: size, nodal level, fat stranding, extracapsular spread, calcifications, vascularity, necrosis and standardized uptake value. Sampling reports of fine-needle aspiration (FNA), core-needle biopsy (CNB) and frozen section (FS) were also assessed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for predicting malignancy were calculated for all variables and compared between benign and malignant cystic neck masses. Ultrasound was used in 47.2% and CT-Scan in 90.5% of patients. No variables on imaging could definitely differentiate benign from malignant LCNM. FNA had a lower sensitivity then CNB (59% vs 83%; p=0.036) and FS (59% vs 93%; p=0.01). FS had a better NPV when compared to FNA (92% vs 40%; p<0.001) and CNB (92% vs 50%; p=0.062). Specificities and PPV were similar among all groups. Clinicians cannot rely on imaging to differentiate benign from malignant LCNM. Given its adequate PPV (92%), FNA should be used initially on lateral cystic neck masses. Because of its high sensitivity, CNB should be considered if FNA is not diagnostic of malignancy. FS should always follow a CNB not indicative of malignancy, because of the low NPV. Any result diagnostic of malignancy on either FNA, CNB or FS strongly indicates presence of malignancy.