Indiana University-Purdue University Indianapolis (IUPUI) / Endometrial cancer is the most common gynecologic cancer in the United States, and patients with early-stage endometrioid adenocarcinoma have a favorable prognosis. Over the past decade, the gynecologic oncology community has debated whether potential harms of systematic lymph node dissection (LND) outweigh potential benefits for these patients. To minimize number of nodes removed, sentinel lymph node dissection (SLND) is under investigation as an alternative. However, ongoing uncertainty of LND/SLND best practices may result in variations in disease management and discrepant outcomes. Methods Three retrospective cohort studies examined LND/SLND use in patients with endometrioid adenocarcinoma. Two examined temporal and geographic variations, respectively, utilizing the Surveillance, Epidemiology, and End Results (SEER) 18 dataset for the years 2004 through 2015. The third used the SEER-Medicare dataset from 2003 through 2016 to quantify and compare the risk of developing 6-month post-surgical lymphedema, lymphocele, hemorrhage, ileus, infection, thrombosis, and all-cause death by number of lymph nodes removed (0, 1-4, 5-9, or 10+). Results Time trend analyses found LND increased from 2004 through 2008, followed by a significant decline through 2015. SLND was rare and did not increase significantly. Significant geographic variation existed for LND use but not SLND. Per 1,000 patients, analyses of 6-month post-surgical complications found 6.5 experienced lymphedema, 3.9 experienced lymphocele, 15.7 experienced hemorrhage, 28.7 experienced ileus, 37.1 experienced infection, 18.6 experienced thrombosis, and 19.8 died. Controlling for size of primary tumor, tumor grade, comorbidities, race/ethnicity, age at diagnosis, adjuvant chemotherapy, and radiotherapy, adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) showed greater risk for ileus (HR: 1.53; 95% CI: 1.24-1.90), infection (HR: 1.52; 95% CI: 1.25-1.83), and thrombosis (HR: 1.41; 95% CI: 1.09-1.82) when comparing removal of 10+ nodes versus 0 nodes. Conclusion Overall, these studies found significant temporal and geographic variation in LND, as well as increasing risk of post-surgical complications associated with increasing numbers of lymph nodes removed. Should continued research into SLND find strong evidence that it effectively detects cancer spread, patients may benefit through decreased risk of post-surgical ileus, infection, and thrombosis.

Introdução: Atualmente a ressecção hepática é o melhor tratamento para metástases de câncer colorretal. Diversos fatores prognósticos foram estudados e muitos estudos têm demonstrado que metástases nos linfonodos hilares constituem um fator prognóstico adverso. Este estudo avaliou a frequência e as características do envolvimento linfonodal hilar microscópico, através de linfadenectomia sistemática, com pesquisa de micrometástases em pacientes submetidos à hepatectomia por metástases colorretais. Métodos: Os critérios de exclusão foram: irressecabilidade detectada no pré e intraoperatório, condições clínicas e fatores intraoperatórios que exigiam menor tempo cirúrgico, metástases linfonodais macroscópicas confirmadas por exame de congelação e menos de três linfonodos no produto da linfadenectomia. De 38 pacientes iniciais, 28 foram submetidos ressecção hepática em associação com linfadenectomia sistemática do hilo, apresentando três ou mais linfonodos dissecados. Os linfonodos negativos ao método convencional de hematoxilina e eosina foram avaliados através de cortes seriados com intervalos de 100 m associada à imunoistoquímica com anticorpos contra pancitoqueratinas humanas AE1/AE3. Resultados: Em média, 6,18 linfonodos foram dissecados por paciente. A linfadenectomia aumentou o tempo operatório em 48 minutos, no entanto, não houve morbimortalidade associada a este procedimento. Dois pacientes (7,2%) apresentaram metástase linfonodal microscópica ao exame convencional com hematoxilina e eosina. Quando aplicado os cortes seriados associados à imunoistoquímica, três pacientes adicionais (10,8%) foram identificados como portadores de micrometástases linfonodais. Conclusão: A frequência global de metástases microscópicas, incluindo micrometástases foi de 18%. Não houve correlação estatística entre outros fatores prognósticos e a presença de metástases microscópicas. A linfadenectomia sistemática associada à pesquisa de micrometástases ampliou a detecção de envolvimento linfonodal microscópico, contribuindo assim, com o estadiamento de doença extra-hepática / Introduction: Currently, hepatectomy is considered the best treatment of metastatic colorectal cancer. Several prognostic factors have been investigated, and many studies have shown that the involvement of regional lymph nodes at the hepatic hilum represents a negative prognostic factor. The present study investigated the frequency and characteristics of microscopic involvement of hilar lymph nodes, through systematic lymphadenectomy and analysis of micrometastases in patients undergoing hepatectomy due to colorectal metastases. Methods: Exclusion criteria were: no resectable disease detect in the pre or intra-operative; clinics conditions and intraoperative factors what required minor surgical time; macroscopic hepatic lymph node metastases, confirmed by frozen section and less of three lymph nodes resected for patient. Of the 38 patients, 28 underwent hepatic resection in association with systematic lymphadenectomy of the hepatic hilum, with three or more lymph nodes resected for patient. Lymph nodes considered negative by conventional hematoxylin and eosin staining were analyzed by serial sectioning with 100 m intervals and immunohistochemistry with antibodies to cytokeratins AE1/AE3. Results: In average, 6.18 lymph nodes were dissected per patient. Lymphadenectomy increased surgical time by 48 minutes in average, but no morbi-mortality was associated to the procedure. In two of the patients (7,2%), conventional hematoxylin and eosin analysis showed the presence of microscopic lymph node metastases. Immunohistochemistry analysis of serial sections allowed the identification of three other patients with lymph node micrometastases (10,8%). Conclusion: The overall frequency of microscopic metastases, including micrometastases, was 18%. No statistically significant relationships were observed between other prognostic factors and the presence of microscopic metastases. Systematic lymphadenectomy with inclusion of micrometastases protocols improved the detection of microscopic lymph node involvement, resulting in more accurate staging of extrahepatic disease

Le cancer de l’endomètre est le plus fréquent des cancers gynécologiques pelviens. L’envahissement ganglionnaire constitue l’un des principaux facteurs pronostiques mais le rôle des curages ganglionnaires reste débattu.Nous avons construit le score PREGE (Prédiction du Risque d’Envahissement Ganglionnaire dans le cancer de l’Endomètre), à partir d’une base de données de près de 20000 cancers de l’endomètre, après la sélection de caractéristiques individuelles (race et âge) et tumorales définitives, obtenues sur la pièce d’hystérectomie (type, grade et extension locale) significativement associées à l’existence de métastase ganglionnaire. Le score PREGE a été validé sur une base de données multicentrique française (AUC dans les populations de développement et de validation de 0,80 et 0,79 respectivement). Le score était correctement calibré.En utilisant les données préopératoires (IRM et biopsie d’endomètre), les capacités de discrimination du score PREGE étaient conservées. Différents seuils d’intérêt pour la décision clinique ont été définis. Avec un seuil de 100 points, la valeur prédictive négative était de 100%.Dans aucun quantile du score PREGE, la survie spécifique n’était supérieure chez les patientes ayant eu une lymphadénectomie. Toutefois, avec un seuil prédit d’envahissement ganglionnaire supérieur à 20%, nous avons mis en évidence un bénéfice de la lymphadénectomie emportant au moins 10 ganglions.L’utilisation du score PREGE pour la sélection des patientes atteintes d’un cancer de l’endomètre candidates à une lymphadénectomie pourrait permettre de réduire le recours à cette intervention morbide sans altérer la survie spécifique / Endometrial cancer is the most common malignancy of the female genital tract. Lymph node metastasis is one of the most important prognostic factors. However, the therapeutic role of lymphadenectomy is still debated.We developed the score PREGE, able to predict lymph node metastasis based on pathological hysterectomy characteristics in endometrial cancer. Data from almost 20,000 patients who underwent hysterectomy and lymphadenectomy were analyzed and significant prognostic features were selected: final pathological characteristics (histologic type, grade and primary site tumoral extension) and patients’ characteristics (age and race). In a French multicentric cohort, the nomogram showed good discrimination (AUC=0.79 ) and was well calibrated.Lymph node metastasis prediction by the score using preoperative data was as accurate as that obtained using the final tumor characteristics. With a cut-off value of 100 points for the total score, the negative predictive value was 100%.Patients were clustered into quintiles according to their lymph node metastasis probability. The cancer related survival was compared based on whether patients underwent lymphadenectomy. In the five quintile groups, the specific survival rate was significantly higher in the patients who did not undergo lymphadenectomy. However, when lymph node letastatic probabilityexceeded 20%, specific survival was higher in patients in whom at least 10 lymph nodes were removed.PREGE score could be useful to select few patients who will really benefit from lymphadenectomy and avoid lymphadenectomy in most patients with endometrial cancer

Introdução: Atualmente a ressecção hepática é o melhor tratamento para metástases de câncer colorretal. Diversos fatores prognósticos foram estudados e muitos estudos têm demonstrado que metástases nos linfonodos hilares constituem um fator prognóstico adverso. Este estudo avaliou a frequência e as características do envolvimento linfonodal hilar microscópico, através de linfadenectomia sistemática, com pesquisa de micrometástases em pacientes submetidos à hepatectomia por metástases colorretais. Métodos: Os critérios de exclusão foram: irressecabilidade detectada no pré e intraoperatório, condições clínicas e fatores intraoperatórios que exigiam menor tempo cirúrgico, metástases linfonodais macroscópicas confirmadas por exame de congelação e menos de três linfonodos no produto da linfadenectomia. De 38 pacientes iniciais, 28 foram submetidos ressecção hepática em associação com linfadenectomia sistemática do hilo, apresentando três ou mais linfonodos dissecados. Os linfonodos negativos ao método convencional de hematoxilina e eosina foram avaliados através de cortes seriados com intervalos de 100 m associada à imunoistoquímica com anticorpos contra pancitoqueratinas humanas AE1/AE3. Resultados: Em média, 6,18 linfonodos foram dissecados por paciente. A linfadenectomia aumentou o tempo operatório em 48 minutos, no entanto, não houve morbimortalidade associada a este procedimento. Dois pacientes (7,2%) apresentaram metástase linfonodal microscópica ao exame convencional com hematoxilina e eosina. Quando aplicado os cortes seriados associados à imunoistoquímica, três pacientes adicionais (10,8%) foram identificados como portadores de micrometástases linfonodais. Conclusão: A frequência global de metástases microscópicas, incluindo micrometástases foi de 18%. Não houve correlação estatística entre outros fatores prognósticos e a presença de metástases microscópicas. A linfadenectomia sistemática associada à pesquisa de micrometástases ampliou a detecção de envolvimento linfonodal microscópico, contribuindo assim, com o estadiamento de doença extra-hepática / Introduction: Currently, hepatectomy is considered the best treatment of metastatic colorectal cancer. Several prognostic factors have been investigated, and many studies have shown that the involvement of regional lymph nodes at the hepatic hilum represents a negative prognostic factor. The present study investigated the frequency and characteristics of microscopic involvement of hilar lymph nodes, through systematic lymphadenectomy and analysis of micrometastases in patients undergoing hepatectomy due to colorectal metastases. Methods: Exclusion criteria were: no resectable disease detect in the pre or intra-operative; clinics conditions and intraoperative factors what required minor surgical time; macroscopic hepatic lymph node metastases, confirmed by frozen section and less of three lymph nodes resected for patient. Of the 38 patients, 28 underwent hepatic resection in association with systematic lymphadenectomy of the hepatic hilum, with three or more lymph nodes resected for patient. Lymph nodes considered negative by conventional hematoxylin and eosin staining were analyzed by serial sectioning with 100 m intervals and immunohistochemistry with antibodies to cytokeratins AE1/AE3. Results: In average, 6.18 lymph nodes were dissected per patient. Lymphadenectomy increased surgical time by 48 minutes in average, but no morbi-mortality was associated to the procedure. In two of the patients (7,2%), conventional hematoxylin and eosin analysis showed the presence of microscopic lymph node metastases. Immunohistochemistry analysis of serial sections allowed the identification of three other patients with lymph node micrometastases (10,8%). Conclusion: The overall frequency of microscopic metastases, including micrometastases, was 18%. No statistically significant relationships were observed between other prognostic factors and the presence of microscopic metastases. Systematic lymphadenectomy with inclusion of micrometastases protocols improved the detection of microscopic lymph node involvement, resulting in more accurate staging of extrahepatic disease

Seit Beginn der 90er Jahre wurden minimal-invasive Operationsmethoden zur Therapie des Bronchialkarzinoms eingeführt, ohne vorher sicherzustellen, daß sie hinsichtlich der onkologischen Sicherheit und Radikalität der konventionellen Operationsmethode ebenbürtig sind. Die vorliegende Arbeit hat daher die Entwicklung einer onkologisch adäquaten thorakoskopischen Lobektomie zur Aufgabe. Die dazu notwendige wissenschaftliche Evaluation erfolgt in mehreren Schritten. Zunächst wird der aktuelle operative Standard der konventionellen Chirurgie beim Bronchialkarzinom in der Literatur dargestellt. Auf dieser Grundlage wird die thorakoskopische Resektion inklusive Lymphadenektomie beim Bronchialkarzinom definiert. Dieser Standard dient als Vorlage für die Entwicklung der minimal-invasiven Chirurgie im Tier- und Leichenmodell. Im ersten Schritt der Phase I wird anhand tierexperimenteller Arbeiten untersucht, ob und unter welchen technischen Voraussetzungen eine thorakoskopische Lobektomie vollständig minimal-invasiv durchführbar ist. Mit den anschließenden chirurgisch-anatomischen Untersuchungen soll festgestellt werden, inwieweit die erarbeitete thorakoskopische Technik den onkologischen Prinzipien, insbesondere der Lymphadenektomie, Rechnung trägt. Diese Phase stellt die Grundvoraussetzung für eine weitere Evaluierung der erarbeiteten Ergebnisse in der Phase II dar. Die Erprobung der erarbeiteten Technik in der Klinik dient der Überprüfung auf Morbidität und Mortalität im Vergleich zur konventionellen Operationsmethode und der Übertragung in randomisierte Studien zum Nachweis relevanter Unterschiede im Frühverlauf (Phase IIIa) und Spätverlauf (Phase IIIb). / Since the beginning of the 1990's, minimal invasive surgery has expanded to include extensive thoracic operations, especially the lobectomy. Implementation of this procedure has been described in numerous publications, however the development occurred unsystematically. So the oncologic radicality and safety of both thoracoscopic lobectomy and lymph node dissection is a debated topic in the literature. Therefore, previous results could not prove that minimal invasive resections by bronchial carcinoma are equivalent to conventional surgical methods with respect to oncological security and radical resectability. For this reason thoracoscopic lobectomy with lymphadenectomy is investigated for radicality and completeness according to the recommendations for scientific evaluation. In a first step the criterias of an oncologic lung resection - lobectomy and lymphadenectomy - are established. This definition is the basis for the following phase I, the animal study and the experimental-anatomic study in a human cadaver model. The task of the animal study is to examine if a lobectomy could be done by thoracoscopic technique completely and on which conditions. Than an experimental-anatomic study in a cadaver model is done to control the extent of the radical thoracoscopic lobectomy with lymphadenectomy by a following thoracotomy. This study is essential for a phase II-trial, the application of the acquired thoracoscopic technique in a pilot study for examination of morbidity and mortality. The comparison of the thoracoscopic and the conventional lobectomy in the pilot study also served to evaluate potential advantages of the minimal-invasive method. These advantages are a strong argument in favour of the introduction of the thoracoscopic method in to the clinic for prospective-randomized trials (phase III a and III B).

Le facteur pronostic majeur des cancers du col localement avancés (LACC) est le statut ganglionnaire lombo-aortique. Notre travail de thèse a été d'évaluer la lymphadénectomie lombo-aortique (qui représente la technique de référence pour obtenir cette information) à l'ère de la tomographie par émission de positron (TEP) et de la chirurgie par une seule incision (LESS). Les résultats publiés de cette thèse sont: la lymphadénectomie lombo-aortique extrapéritonéale par LESS est faisable. Nous en avons décrit et codifié la technique pour la première fois par une incision iliaque gauche unique ; cette technique que nous avons mise au point est sure, reproductible et équivalente sur le plan carcinologique et ergonomique à la laparoscopie conventionnelle ; la lymphadénectomie lombo-aortique de staging est indispensable dans les LACC compte tenu du taux de faux négatif du TEP-TDM retrouvé dans ce travail de thèse (12% s'élevant à 22 % en cas de fixations ganglionnaires pelviennes suspectes). Nous avons également démontré sur la plus large de la série de littérature que la lymphadénectomie lombo-aortique associée à l'extension des champs d'irradiation en lombo-aortique lors de la radio-chimiothérapie apporte aux patientes présentant des micrométastases une survie identique à celle des patientes négatives histologiquement au niveau lombo-aortique. En revanche, en cas d'atteinte macrométastatique le pronostic demeure péjoratif et nécessite de proposer d'autres options thérapeutiques / In locally advanced cervical cancer (LACC) the most important predictor of disease recurrence is para-aortic nodal status. The aim of our thesis was to evaluate the role of para-aortic lymphadenectomy (the current gold standard to assess para-aortic nodal status) in the era of positron emission tomography (PET) and single incision surgery (LESS). The published results of this thesis are: extraperitoneal para-aortic lymphadenectomy by LESS is feasible and we have described and codified the technique for the first time by a single left iliac incision; the technique we have developed is safe, reproducible and oncologically and ergonomically equivalent to conventional laparoscopy; para-aortic LAD staging is essential in LACC given the false negative rate of PET-CT found in this work (12% increasing to 22% if PET-CT reveals suspicious pelvic lymph nodes). We have also demonstrated, in the largest case series published to date, that para-aortic lymphadenectomy followed by chemoradiation including the pelvis and para-aortic lymph nodes for patients with micrometastatic para-aortic nodal involvement provides an overall survival that is identical to the overall survival of LACC with histologically negative para-aortic lymph nodes. However, in case of macrometastatic disease prognosis remains pejorative and requires other treatment options

Orientador: René Aloísio da Costa Vieira / Resumo: Introdução: O câncer de mama representa o tipo de câncer mais comum entre as mulheres no mundo. A presença e a extensão do envolvimento linfonodal axilar é um importante fator prognóstico, com grande impacto na decisão terapêutica. Por outro lado, a linfadenectomia axilar (LA) associa-se a considerável morbidade. Neste sentido, a biópsia do linfonodo sentinela (BLS) constitui modalidade atualmente aceita para uso em tumores T1 e T2, associados a axila negativa. Fato é que pacientes com tumores T3 e T4 e axila negativa são, muitas vezes, submetidas a LA de maneira desnecessária, visto o limitado número de pacientes em séries publicadas. Assim, o objetivo deste estudo é avaliar a negatividade e segurança da BLS em tumores T3 e T4, associados à axila clinicamente negativa, baseada em série de casos institucionais e revisão sistemática da literatura. Material e métodos: Estudo retrospectivo, observacional de pacientes tratadas de câncer de mama no ambulatório de Mastologia e Reconstrução Mamária do Hospital de Câncer de Barretos (HCB), Fundação Pio XII, nos anos de 2008 a 2015, realizado em pacientes portadoras de tumores T3/T4 e axila clinicamente N0 submetidas a BLS. Realizou-se, também, revisão sistemática da literatura em 5 bases. Utilizou-se a metodologia PICO, considerando P = breast cancer, I = lymph node sentinela, C = T3 and T4 tumors e O = axillary preservation. Para avaliação dos artigos, foi utilizada a metodologia PRISMA. Resultados: Foram analisadas 73 pacientes; de... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: Breast cancer represents the most common type of cancer among women in the world. The presence and extent of axillary lymph node involvement represents an important prognostic factor, with an impact on therapy. On the other hand, axillary lymph node dissection (ALND) is associated with considerable morbidity. In this sense, sentinel lymph node biopsy (SLNB) is currently accepted modality for tumors T1 and T2 with negative axilla (N0). The fact is that many patients with T3-T4 tumors with negative axilla, are often submitted to unnecessarily ALND. There are limited number of patients in published series and selected cases may have axillary preservation. Thus, the objective of this study is to evaluate the negativity and safety of SLNB in T3 and T4 tumors, associated to the clinically N0, based on a series of institutional cases and a systematic review of the literature. Materials and Methods: A retrospective, observational study of patients treated for breast cancer at a tertiary cancer center between 2008 and 2015, with T3 / T4 tumors and N0 who underwent SLNB. A systematic review of literature was also carried out in 5 bases through the PICO methodology, considering: P = breast cancer; I = sentinel lymph node; C = T3 and T4 tumors and O = axillary preservation. Results: We analyzed 73 patients, 9 of whom were cT3 and after surgery they became pT2, 47 pT3 patients and 17 T4b patients. SLNB was identified in all cases and was negative for macrometastasis in 60.3%... (Complete abstract click electronic access below) / Mestre

INTRODUÇÃO: O aprimoramento dos métodos de rastreamento e a conscientização da população geral contribuíram para o diagnóstico cada vez mais precoce do câncer de mama e proporcionou, juntamente com o avanço na terapêutica, altas taxas de sobrevida. O estado do acometimento axilar por metástase é um dos principais fatores prognósticos em pacientes com câncer de mama, particularmente naquelas com diagnóstico em estádio inicial. Na última década, esforços científicos foram direcionados para simplificar a amostragem dos linfonodos axilares, diminuindo a morbidade, mas respeitando os princípios oncológicos. Nesse sentindo, a biópsia do linfonodo sentinela foi considerada o avanço mais importante. Ao se obter um método preditor do estado axilar, que apresente os benefícios da abordagem padrão dissecção axilar e biópsia de linfonodo sentinela porém sem seus efeitos colaterais e que seja facilmente reproduzível, realizaremos um grande avanço na avaliação e terapêutica do câncer de mama inicial. MÉTODOS: Foi realizado estudo transversal retrospectivo com base nos prontuários de pacientes com câncer de mama invasivo, não metastático, com qualquer idade, atendidas entre 1999 e 2007 no Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo e Clínica Professor José Aristodemo Pinotti, cujo estudo histopatológico e imunoistoquímico foi supervisionado por um único médico patologista. Realizamos uma subdivisão imunoistoquímica dos tumores, sendo considerado luminal A os tumores com receptores hormonais positivos e HER 2 negativo; luminal B os com receptores hormonais positivos e HER 2 positivo; HER 2 as pacientes com receptores hormonais negativos e HER 2 positivo e triplo negativo aquelas com receptores hormonais e HER 2 negativos. Correlacionamos esses subtipos com as variáveis clínicas idade e tamanho tumoral para predizer a probabilidade de acometimento linfonodal axilar. RESULTADOS: Duzentos e trinta e nove casos foram analisados. No subtipo luminal A, a possibilidade de metástase foi maior quanto menor a idade da paciente e maior o tamanho do tumor. Essa foi a única associação que apresentou diferença estatisticamente significante. As pacientes que possuíam tumores triplo negativo tiveram, aproximadamente, 90% menos chance de metástase linfonodal que as pacientes com tumor luminal A. CONCLUSÕES: As pacientes com tumor luminal A apresentaram, significativamente, maior probabilidade de metástase linfonodal axilar. As pacientes com de tumores triplo negativo, com idade superior a 55 anos ou tumores menores que 2 cm, revelaram menor probabilidade de metástase axilar / INTRODUTION: The improvement of screening methods and awareness of general population contributed to the increasingly early diagnosis of breast cancer and provided, together with advances in therapy, high survival rates. The status of axillary involvement is a major prognostic factor in patients with breast cancer, particularly those with early stage. In the last decade, research efforts were directed to simplify the sampling of axillary lymph nodes, decreasing the morbidity, but respecting the oncological principles. In this sense, the sentinel lymph node biopsy was considered the most important advance. If we obtain a method to predict the axillary status, with the benefits of the standard approach - axillary dissection and sentinel lymph node biopsy - without its side effects and easily reproducible, we will hold a major advance in the assessment and treatment of early breast cancer. METHODS: We conducted a retrospective cross-sectional study based on records of patients with invasive breast cancer, non metastatic, with any age, treated between 1999 and 2007 in the breast cancer Sector of the Gynecology Discilpine of the Department of Obstetrics and Gynecology, Faculty of Medicine, University of São Paulo and Private Clinic of Professor José Aristodemo Pinotti, whose histopathological studies were supervised by a single pathologist. We performed an immunohistochemical subdivision of the tumors, and considered luminal A tumors with positive hormonal receptors and negative HER 2, luminal B with positive hormonal receptors and positive HER 2, HER 2 patients with negative hormonal receptors and positive HER 2 and the triple-negative those with negative hormonal receptors and HER 2. Those subtypes were correlated with the clinical variables age and tumor size in predicting the likelihood of axillary lymph node involvement. RESULTS: Two hundred and nine cases were analyzed. In the luminal A, the possibility of axillary metastasis was higher in the younger patients and larger tumors. That was the only combination that showed statistically significant difference. The patients who had triplenegative tumors had approximately 90% less chance of lymph node metastasis than patients with tumors luminal A. CONCLUSIONS: The patients with luminal A tumors showed a significantly association with greater likelihood of axillary lymph node metastasis. The patients with triple negative tumors, age over 55 years or tumors smaller than 2 cm showed a lower likelihood of axillary lymph node metastasis

INTRODUÇÃO: O aprimoramento dos métodos de rastreamento e a conscientização da população geral contribuíram para o diagnóstico cada vez mais precoce do câncer de mama e proporcionou, juntamente com o avanço na terapêutica, altas taxas de sobrevida. O estado do acometimento axilar por metástase é um dos principais fatores prognósticos em pacientes com câncer de mama, particularmente naquelas com diagnóstico em estádio inicial. Na última década, esforços científicos foram direcionados para simplificar a amostragem dos linfonodos axilares, diminuindo a morbidade, mas respeitando os princípios oncológicos. Nesse sentindo, a biópsia do linfonodo sentinela foi considerada o avanço mais importante. Ao se obter um método preditor do estado axilar, que apresente os benefícios da abordagem padrão dissecção axilar e biópsia de linfonodo sentinela porém sem seus efeitos colaterais e que seja facilmente reproduzível, realizaremos um grande avanço na avaliação e terapêutica do câncer de mama inicial. MÉTODOS: Foi realizado estudo transversal retrospectivo com base nos prontuários de pacientes com câncer de mama invasivo, não metastático, com qualquer idade, atendidas entre 1999 e 2007 no Setor de Mastologia da Disciplina de Ginecologia do Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo e Clínica Professor José Aristodemo Pinotti, cujo estudo histopatológico e imunoistoquímico foi supervisionado por um único médico patologista. Realizamos uma subdivisão imunoistoquímica dos tumores, sendo considerado luminal A os tumores com receptores hormonais positivos e HER 2 negativo; luminal B os com receptores hormonais positivos e HER 2 positivo; HER 2 as pacientes com receptores hormonais negativos e HER 2 positivo e triplo negativo aquelas com receptores hormonais e HER 2 negativos. Correlacionamos esses subtipos com as variáveis clínicas idade e tamanho tumoral para predizer a probabilidade de acometimento linfonodal axilar. RESULTADOS: Duzentos e trinta e nove casos foram analisados. No subtipo luminal A, a possibilidade de metástase foi maior quanto menor a idade da paciente e maior o tamanho do tumor. Essa foi a única associação que apresentou diferença estatisticamente significante. As pacientes que possuíam tumores triplo negativo tiveram, aproximadamente, 90% menos chance de metástase linfonodal que as pacientes com tumor luminal A. CONCLUSÕES: As pacientes com tumor luminal A apresentaram, significativamente, maior probabilidade de metástase linfonodal axilar. As pacientes com de tumores triplo negativo, com idade superior a 55 anos ou tumores menores que 2 cm, revelaram menor probabilidade de metástase axilar / INTRODUTION: The improvement of screening methods and awareness of general population contributed to the increasingly early diagnosis of breast cancer and provided, together with advances in therapy, high survival rates. The status of axillary involvement is a major prognostic factor in patients with breast cancer, particularly those with early stage. In the last decade, research efforts were directed to simplify the sampling of axillary lymph nodes, decreasing the morbidity, but respecting the oncological principles. In this sense, the sentinel lymph node biopsy was considered the most important advance. If we obtain a method to predict the axillary status, with the benefits of the standard approach - axillary dissection and sentinel lymph node biopsy - without its side effects and easily reproducible, we will hold a major advance in the assessment and treatment of early breast cancer. METHODS: We conducted a retrospective cross-sectional study based on records of patients with invasive breast cancer, non metastatic, with any age, treated between 1999 and 2007 in the breast cancer Sector of the Gynecology Discilpine of the Department of Obstetrics and Gynecology, Faculty of Medicine, University of São Paulo and Private Clinic of Professor José Aristodemo Pinotti, whose histopathological studies were supervised by a single pathologist. We performed an immunohistochemical subdivision of the tumors, and considered luminal A tumors with positive hormonal receptors and negative HER 2, luminal B with positive hormonal receptors and positive HER 2, HER 2 patients with negative hormonal receptors and positive HER 2 and the triple-negative those with negative hormonal receptors and HER 2. Those subtypes were correlated with the clinical variables age and tumor size in predicting the likelihood of axillary lymph node involvement. RESULTS: Two hundred and nine cases were analyzed. In the luminal A, the possibility of axillary metastasis was higher in the younger patients and larger tumors. That was the only combination that showed statistically significant difference. The patients who had triplenegative tumors had approximately 90% less chance of lymph node metastasis than patients with tumors luminal A. CONCLUSIONS: The patients with luminal A tumors showed a significantly association with greater likelihood of axillary lymph node metastasis. The patients with triple negative tumors, age over 55 years or tumors smaller than 2 cm showed a lower likelihood of axillary lymph node metastasis

Submitted by Jaqueline Silva (jtas29@gmail.com) on 2016-10-25T17:17:35Z No. of bitstreams: 2 Dissertação - Fernanda Dorneles de Morais - 2014.pdf: 4082854 bytes, checksum: db2b8638cb0a746a19314231d5bdcb13 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Jaqueline Silva (jtas29@gmail.com) on 2016-10-25T17:18:02Z (GMT) No. of bitstreams: 2 Dissertação - Fernanda Dorneles de Morais - 2014.pdf: 4082854 bytes, checksum: db2b8638cb0a746a19314231d5bdcb13 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2016-10-25T17:18:02Z (GMT). No. of bitstreams: 2 Dissertação - Fernanda Dorneles de Morais - 2014.pdf: 4082854 bytes, checksum: db2b8638cb0a746a19314231d5bdcb13 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2014-08-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / The aim of this study was to evaluate quality of life (QoL) and late morbidity after axillary lymphadenectomy (AL) or sentinel lymph node biopsy (SLNB) in breast cancer survivors. :This was an analytical, cross-sectional study with 100 participants. Sociodemographic and clinical data were obtained at interviews, from patients’ medical charts and by applying the EORTC QLQ-C30 and QLQ-BR23 questionnaires. In addition, a kinetic analysis was made of the patients’ upper limb function to investigate the presence of possible late morbidities (pain, limited range of motion [ROM], sensory disturbance and lymphedema). Results: The patients who underwent AL worse QoL than those submitted to SLNB in 10 domains. Following AL, there was a greater likelihood of the patient developing: lymphedema (odds ratio [OR]: 17.22; 95% confidence interval [95%CI]: 2.15-137.57), reduced flexion (OR: 6; 95%CI: 2.45-14.68), reduced abduction (OR: 5.67; 95%CI: 2.14–15.00), sensory disturbance (OR: 4.03; 95%CI: 1.71–9.49) and pain (OR: 1.74; 95%CI: 1.16–2.61). Conclusions: These results confirm the benefit of SLNB due to its lower arm morbidity impact on QoL, compared with AL. All morbidities were more common and more likely to occur in the patients submitted the dissection axillary. In addition, the high frequency of limitations in movement and pain in both groups merits particular attention. / O objetivo desse estudo foi avaliar a qualidade de vida (QV) e morbidades após linfadenectomia axilar (LA) ou biópsia de linfonodo sentinela (BLS) em sobreviventes do câncer de mama. Trata-se de um estudo transversal, analítico, composto por 100 participantes. Os dados pessoais, sociodemográficos e clínicos foram obtidos por meio de entrevista, dados dos prontuários e aplicação dos questionários EORTC QLQ C 30 e BR 23. Além disso, foi realizada avaliação cinético funcional dos membros superiores das pacientes para verificar a presença de possíveis morbidades tardias (dor, limitação na amplitude de movimento (ADM), alteração na sensibilidade e linfedema). Resultados: As pacientes que se submeteram à LA apresentaram pior QV do que aqueles submetidos à biópsia de linfonodo sentinela em 10 domínios. Após a LA foi maior a probabilidade de ocorrer linfedema (OR 17,22; IC 95% 2,15-137,57), déficit de flexão (OR 6; IC 95% 2,45-14,68), déficit de abdução (OR 5,67; IC 95% 2,14-15,00), alteração na sensibilidade (OR 4,03; IC 95% 1,71-9,49) e dor (OR 1,74; IC 95% 1,16-2,61). Conclusões: Estes resultados confirmam o benefício da BLS devido ao seu menor impacto na morbidade pós-operatória e na qualidade de vida, em comparação com LA. Todas as morbidades foram mais frequentes e tiveram maior risco de ocorrerem em pacientes submetidos a esvaziamento axilar. Além disso, a alta frequência nas limitações de movimento e dor, em ambos os grupos, merecem atenção especial.