Differential Diagnosis of Axillary Masses

Axillary masses are uncommon alterations when detected as an isolated finding. We evaluated 31 patients with isolated axillary masses. Patients with alterations of the breasts or the upper limbs or with ipsilateral chest lesions were excluded from the study. Nine patients had occult breast cancer, 5 of them in the contralateral breast. Seven had metastatic lymph nodes of non-ductal origin, and 1 had carcinoma of apocrine cells with metastasis to the axilla. Four patients had benign lymphadenopathy which disappeared spontaneously, and 4 others had ruptured infundibular follicular cyst, nodular fibromatosis, inflammatory tuberculous and inflammatory rheumatoid lymphadenitis. Five had an ectopic breast (2 with a fibroadenoma and 3 with fibrocystic changes). One patient had an axillary lipoma. The mean age of patients with malignant pathology was 55.1 ± 10.9 years, and the mean age of patients with a benign pathology was 43.1 ± 14.7 ( P <0.01). Chest X-ray and bilateral mammography are useful when the cause of the mass cannot be determined by taking a detailed history of neoplastic or infectious antecedents, by careful physical examination of the skin of the arms, trunk and neck, or by palpation of the breasts and thyroid. Fine needle aspiration biopsy distinguishes between benign and malignant pathologies. In cases of indeterminate neoplasia, complete axillary dissection for diagnosis is indicated.

Survival impact of neoadjuvant treatment in cervical cancer stage IIB

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Background: A few previous studies demonstrated that neoadjuvant chemotherapy, followed by preoperative radiotherapy in diagnosed IIB cervical cancer patients, had similar therapeutic results as the standard protocol with concurrent chemoradiotherapy, considering complete response; overall survival; disease free survival and toxicity; requiring its evaluation as an alternative approach. Methods: One hundred sixteen women with IIB stage cervical cancer stages were submitted to a platinum combined based neoadjuvant chemotherapy followed by chemoradiotherapy with cisplatin. Those who had a good response, allowing a surgical approach, underwent the Wertheim-Meigs procedure. Those that could not be submitted to surgery remained in clinical follow-up. Results: The age of the patients were 22 to 75 years old (48.7±11.4 years). The average follow-up was about 48 months (1–120). The good response to the neoadjuvant treatment was found in 76 patients (65.5%), and surgery was possible in 86 (74%). The pathological complete response was found in 39 (33%), and the partial response in 40%. The global recurrence was diagnosed in 37 (32%) patients. In the operated group (n = 86), the overall-five years survival was 76%, and in the non-operated group (n = 30) was 17,5%. The five years-global survival was 79,2% in “good response” (GR) patients, and 27.4% in that with “no-good response” (NGR) to combined neoadjuvant treatment ( p < 0.01). The free-relapse survival was 79.4% in GR, and 32.5% in NGR group (p < 0.01). Conclusions: Amongst the studied prognostic factors, the most important one for interval of relapse and survival (global and free-relapse) was a good response to the neoadjuvant treatment, and that this treatment had an acceptable toxicity and could be considered in other trials as an option to standard treatment.

No significant financial relationships to disclose.

Combination chemotherapy with gencitabine and cisplatin in anthracycline and taxane pretreated metastatic breast cancer

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Background: Metastatic breast cancer (MBC) anthracycline (A) and taxane (T) resistant has a complicated management.Combination chemotherapy, even in 2nd line, may have advantages over single agent therapy. Gencitabine (G) - cisplatin (C) combinations have been used as synergistic salvage therapy in MBC and it’s another option for patients with important symptoms and aggressive visceral disseminated disease. Methods: This trial analyses the safety and efficacy of G-C in A-T pretreated MBC. Eligibility criteria include: confirmatory pathological analyses; measurable disease; adequate performance status, organ and hematological functions. It was not allowed patients with exclusive bone metastasis. They received IV G 750mg/m2 and C 30mg/m2, both d1 and d8 every three weeks for 6 cycles up to a maximum of 9 cycles. Response evaluation was performed every third cycle and in the end of treatment. Results: From February 2005 through December 2006, 31 patients have been evaluated for response and toxicity from G-C combination. For 20/31 patients this treatment was 2nd line palliative chemotherapy. 26/31 received at least 3 or more cycles (medium 4 cycles) and no one treatment was discontinued due to toxicity. The most frequent site of metastasis was lung (20/31), followed by hepatic in 13 patients, bone in 11, skin in 10, lymph nodes in 7, brain metastasis in 3 and pericardium in only one. Each patient had at least lung or hepatic metastasis and medium of 2 different metastatic sites. According to RECIST criteria, partial response were observed in 8/31, stable disease in 17/31 (55%) and progressive disease in 6 patients. 90% of cycles were given at full dose and at the right time. Hematological toxicity was modest with grade 2–3 (NCI-CTC) leucopenia in 58/140 cycles, grade 1–2 anemia in 40/140, grade 1–2 thrombocytopenia in 27/140 and was none febrile neutropenia. Non hematological toxicity: grade 2 fatigue in 4 patients and grade 2 nausea in 6/31. Following 22 months, global survival was at mean 4.8 months. Conclusions: Combination chemotherapy with gencitabine 750mg/m2 and cisplatin 30mg/m2 both d1 and d8 is feasible and effective in A-T pretreated MBC and demonstrated good tolerance with low intensity of collateral effects.

No significant financial relationships to disclose.

Primary chemotherapy in breast cancer shows excellent clinical and pathological response with docetaxel and epirubicin

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Background: Primary chemotherapy is becoming the standard of care for locally advanced breast cancer. Recently tested regimens using new drugs have been showing better results than usual anthracycline based treatments. Methods: From April 1998 through April 2004, 104 patients (18 stage IIA; 36 stage IIB; 13 stage IIIA; 33 stage IIIB; 4 stage IV) were included in the trial and received three cycles of docetaxel 75 mg/m2 and epirubicin 50 mg/m2 (q3w). Patients with stable or progressive disease were excluded from the trial, receiving alternative treatment. Those with partial response after three cycles but still not suitable for conservative surgery received up to 3 additional cycles. Following completion of the chemotherapy regimen, tumour response was assessed and appropriate surgery performed. Pathological response was evaluated in excised specimens. Results: According to the UICC criteria for clinical evaluation, 79 pts (76%) had objective regression (14 CR and 65 PR); 21 resulted in stabilised disease and 4 showed progression (24%). There was no toxicity in 62 patients, grade I/II in 4 and grade III/IV in seven patient. Ninity-nine patients became eligible for surgery (95%); 60 underwent conservative surgical treatment (60.6%) and in 39 patients a modified radical surgery was done (39.4%). No axyllary involvement were detected in 22 patients, other 23 had 1–3 positive nodes and 54 had 3 or more positives node in axillary dissection. 338 chemotherapy cycles were given, with an average of previously expected 3.25 cycles per patient. Conclusions: Our study demonstrates a high response rate with primary docetaxel and epirubicin chemotherapy in locally advanced breast cancer and high axillary envolvement group, enabling conservative surgery to take place and carrying no significant toxicity. Survival rate was directly linked to pathological response and complete response was associated to highest rate of survival in the group.

No significant financial relationships to disclose.

Microinvasive carcinoma of the cervix. Analysis of prognostic factors

INTRODUCTION

Superficially invasive neoplasias of the uterine cervix are a matter of controversy in terms of their definition, prognostic factors and selection of treatment to minimize the risk of recurrences. We reviewed our treatment to determine whether any factors affect this risk.

PATIENTS AND METHODS

The present study was conducted on 59 patients seen at our service, 22 of them with early stromal invasion (IA1) and 37 with microinvasive carcinoma (IA2) according to FIGO criteria (1995). Ten patients were submitted to conization as definitive treatment, although for three of them treatment was complemented with Wertheim-Meigs surgery due to recurrence in the remaining cervix. The other 49 patients were submitted to total abdominal hysterectomy.

RESULTS

Forty-four patients underwent diagnostic or therapeutic conization, and 14 of them presented involvement of the endocervical margin. Seven patients presented recurrence with involvement of the endocervical margin in five. The age of recurrence ranged from 40 to 70 years, with a mean of 52.3 years, as opposed to a general mean of 42.3 (p<0.05). Angiolymphatic invasion was positively correlated to recurrence and death (p<0.01) as well as depth of invasion.

CONCLUSIONS

We conclude that the presence of a cone with an involved endocervical margin represents a high risk of recurrence and that this condition occurs in older patients who are prone to present more extensive lesions. Thus, age should be regarded as an important risk factor. Angiolymphatic invasion and depth of invasion have a poor prognosis in terms of recurrence and death.

Colposcopic scoring system for biopsy decisions in different patient groups

Colposcopic scoring system have been used for distinguishing low-grade from high-grade cervical lesions. However, none of the previous studies have reported colposcopic scoring systems for biopsy decisions in different patient groups. The purpose of our study was to evaluate the safety of biopsy decisions using the colposcopic score elaborated by Stellato and Paavonen (IL) in 21 nonpregnant HIV infected patients (NP+) and 36 uninfected patients (NP-), 12 HIV infected pregnant patients (P+) and 20 uninfected pregnant patients (P-) in the diagnosis of cervical intraepithelial neoplasias (CIN) and HPV infection. The receiving operator curve was used for the establishment of a cut-off point in the scoring system graduation. The chi-square test was used for the statistical analysis. We obtained a safety cut-off value in the colposcopic scoring system for each patient group: 4.5 for NP+; 4.0 for NP- and 3.5 for P+ and P- patients. The sensitivity and specificity of the colposcopic score for the detection of high-grade lesions for each group were respectively: 87.5 and 92.3% for NP+ patients; 90.9 and 92% for NP- patients; 100 and 87.5% for P+ patients and 100 and 91.7% for P- patients. Our results suggest that the colposcopic scoring system is a practical tool for a colposcopy-guided punch biopsy decision and detection of high-grade cervical lesions in different patient groups. Further studies are needed to prove its clinical utility.

Chemotherapy in the treatment of locally advanced cervical cancer and pregnancy

BACKGROUND

Carcinoma of the cervix is the most common malignant tumor associated with pregnancy. The initial stages and premalignant lesions apparently present the same prognosis in pregnant and nonpregnant women; however, there are limited data regarding outcome for locally advanced cervical cancer in pregnancy.

CASE

A 26-year-old woman, gravida 4, para 3, at 14 weeks and 4 days' gestation, was diagnosed with a FIGO stage IIB squamous cell carcinoma of the cervix, treated by primary chemotherapy with cisplatin and bleomycin, until pregnancy resolution at 38 weeks. The newborn infant is currently 3 years old and presents no evidence of abnormalities in neuropsychomotor development.

CONCLUSION

The present case demonstrates that chemotherapy was harmless for the child up to the present time. However, a longer follow-up is needed to determine the safe outcome of this child.

Successful preservation of fertility subsequent to a complete pathologic response of a squamous cell carcinoma of the uterine cervix treated with primary systemic chemotherapy

This is the first report about a successful pregnancy following treatment for advanced cervical cancer.

Hemangiosarcoma of the Breast Followed by Term Pregnancy

Aims and background

Primary angiosarcoma of the breast is an unusual neoplasm which is generally associated with a dismal prognosis. Given the poor prognosis and the predominance in the third and fourth decades of life when fertility tends to decrease, reports of term pregnancies after treatment of this disease are rare.

Methods and study design

We report a case of angiosarcoma of the breast in a 17-year-old patient with a recurrent breast nodule treated by local surgery only. After three years of follow-up without evidence of disease recurrence she became pregnant.

Results

A girl weighing 2,430 g was delivered at 38 weeks and two days. The patient has been free of disease for five years now.

Conclusions

Our experience of the present case shows the lack of full information about this tumor. Pregnancy does not seem to interfere negatively with the course of the disease.

Vaginal hysterectomy for correcting genital prolapse. Long-term evaluation

OBJECTIVE

To determine whether a transvaginal hysterectomy with anterior and posterior repair is effective in the long term in treating uterovaginal prolapse and stress urinary incontinence (SUI).

STUDY DESIGN

Seventy-four patients subjected to vaginal hysterectomy for the treatment of severe genital prolapse, on average five years before the study, were contacted by letter for evaluation. Four of these patients had died, and 47 (67.1%) responded to the letter. The mean age of the patients at the time of reevaluation was 66.1 +/- 10.6 years, and mean parity was 6.6 deliveries.

RESULTS

All patients but two presented some degree of genital prolapse at the time of reevaluation, with three cases of total vaginal vault prolapse. White patients (87.2%) predominated over African (black) patients (12.8%). SUI associated with prolapse persisted in 14 of the 20 patients, and 6 others had this complaint after surgical correction (22.2% of previously continent patients).

CONCLUSION

The rate of unsuccessful surgical correction of severe genital prolapse was very high (95.7%), and cure of SUI was low (30%), with SUI actually arising after surgical correction in 25% of continent patients. In addition to parity, there seems to be a racial factor linked to the onset and maintenance of this pathology, with a higher prevalence among white patients.

A morphometric study of maternal smoking on apoptosis in the syncytiotrophoblast

OBJECTIVES

To study syncytiotrophoblast apoptosis in the placenta of smoking and non-smoking pregnant women.

METHODS

Twelve neonates, pregnancies and placentas were available for study. Eight mothers smoked during pregnancy and the remaining four were non-smokers used as control subjects. The main outcome measure was the apoptotic syncytiotrophoblast index for each group. Apoptosis was detected by immunohistochemistry using the TUNEL method and quantitatively measured using a Merz grid. The apoptotic syncytiotrophoblast index was calculated as the ratio of mean apoptotic labeling to percent terminal villus area using high-power field microscopy.

RESULTS

Significant differences in apoptotic syncytiotrophoblast index were observed between the control group (15.06+/-3.72) and the smoker group (1.66+/-1.74) (P < 0.0001, Mann-Whitney test), but no differences were detected in clinical or morphometric data between groups.

CONCLUSIONS

The human placental syncytiotrophoblast undergoes apoptosis and this process is associated with inhibition of apoptosis by the smoking habit. The same way as the presence of trophoblast apoptosis is associated with modifications of the maternal-fetal exchange, the inhibitory effect of the smoking habit on syncytiotrophoblast could be responsible for the poor prognosis of pregnancy in the presence of maternal smoking.

Natural killer cells and interleukin-12 in patients with advanced cervical cancer under neoadjuvant chemotherapy

Patients with advanced cervical cancer have deficient natural killer (NK) cell activity, usually as a consequence of tumor invasion, which results in tumor NK cell sequestration. The reason for the occurrence of such alterations in patients under chemotherapy is unknown. We evaluated the activity and number of NK cells and T cell subpopulations in ten patients before and three weeks after neoadjuvant chemotherapy (CT). The schedule used was cis-platinum (100 mg/m2 per cycle) and bleomycin (15 mg/cycle), repeated every 28 days. Although there were similar levels of NK cells before and after CT in both groups, we observed greater cytotoxicity of peripheral blood lymphocytes and increased levels of CD4+ and CD8+ T cells (P < 0.01) in five patients who presented a good clinical response when compared to the group with a poor response. IL-12, known to increase NK cell activity when added to peripheral blood lymphocyte cultures, markedly increased lytic activity before and after CT only in the group with a good clinical response. These results suggest that NK cells from the poorly responding patient group express less lytic activity per NK cell and are insensitive to IL-12 stimulation, probably as a result of reduced IL-12 receptor expression or a defective intracellular transduction mechanism. The present findings may be useful as a prognostic factor in clinical practice and also provide support for human clinical trials of IL-12 and neoadjuvant CT for the treatment of malignant cervical tumors.

[Use of polimerase chain reaction for neonatal diagnosis of human immunodeficiency virus type 1 (HIV-1) perinatal infection]

The polymerase chain reaction (PCR) was evaluated for its ability to diagnose perinatal HIV-1 infection before the development of signs or symptoms of the disease in thirty-seven infants (median age of 5.5 days) born to HIV-1 infected women. Of 30 children with complete follow up (median of 25 months), 9 (30%) had serological and clinical features of HIV-1 infection and 21 (70%) were uninfected. Among the infected infants, 5/9 (56%) had positive neonatal PCR tests and 4/9 (44%) had negative PCR tests. None of the 21 uninfected children had positive PCR tests. The prognosis of HIV-1 disease in infected infants with a positive neonatal PCR positive test was similar to that of infected infants with a negative PCR test. In spite of not identifying all the infected infants, the PCR test is a useful tool for early diagnosis of HIV-1 perinatal infection, detecting infected newborns during gestation.