Introduction: Breast cancer is the most common malignant neoplasm in women, after skin cancer, and one of the leading causes of cancer death in women. Diagnosing it as a premalignant lesion or “in situ” becomes challenging in the current conjuncture. Ductal carcinoma in situ (DCIS) is a proliferation of malignant epithelial cells within the breast ducts. These cells have a predilection for the terminal duct lobular unit and are restricted to the basement membrane of the ducts. Through mammographic screening, it is possible to identify DCIS, which is responsible for about 20% of cancers detected by mammography. Objective: The aim of this study was to evaluate the clinical, radiological, anatomopathological, and therapeutic aspects of patients with DCIS of the breast treated at an academic hospital in Federal District, Brazil. Methods: Retrospective, cross-sectional, descriptive, and observational studies were carried out through the analysis of electronic medical records of cases of patients diagnosed with DCIS, treated at the Hospital Regional da Asa Norte (HRAN) (Brasília/Federal District/Brazil), from March 2014 to March 2020. Results: Of the 196 patients surgically treated for breast cancer, only 19 (9.69%) had a diagnosis of DCIS. The mean age was 52.9 years, and the greatest involvement was in the fourth decade, with 28.57% of cases being referred to palpation of a breast lump. Most patients were symptomatic (57.14%). Most mammograms were categorized as BI-RADS IV (47.36%), with clustered microcalcifications being the most frequent finding (42.85%). The concordance rate between preoperative and postoperative biopsies was 61.53%. Most tumors were categorized as luminal B (42.85%) on immunohistochemistry. Only 49.8% of the patients underwent conservative surgery, and the axillary evaluation by sentinel lymph node biopsy (SLNB) was fulfilled in 14.6%. Mastectomy was performed in 50.2% of cases and in this group 94.7%, there was also axillary surgery by SLNB. In 5% had lymph node microinvasion. Half of the analyzed patients underwent radiotherapy after surgery, and 57.14% underwent hormone therapy. Conclusion: The low rate of DCIS in the study (9.69%) and the involvement of the disease in women under 50 years of age lead us to question the scope and accessibility of the mammographic screening program in the Brazilian Health Unified System (SUS) users, treated at the HRAN. We still have high rates of mastectomy and axillary surgery in the treatment of DCIS. Axillary dissection should be discouraged and SLNB carried out in specific cases. Knowing women with DCIS is essential to design interventions with the purpose of directing public policies to the population at risk, enabling early diagnosis, and improving the effectiveness of treatment.
Paget’s disease (PD) of the nipple is a rare cancer that affects the nipple and areola and accounts for between 0.4% and 5% of breast cancers. It was first described in 1877 by the English physician Sir James Paget. It affects women between 60 and 70 years of age and very rarely affects men. In PD, the skin on the nipple and areola becomes thicker. Clinical presentations are usually erythema, desquamation, or eczematous changes in the nipple, features that can progressively progress to erosion, overt destruction, and ulceration of the papilla. Bloody papillary discharge, itching, nipple retraction, and/or a palpable mass may be associated. Cancer cells, called Paget cells, are malignant, large, with clear, abundant cytoplasm and nuclei with prominent nucleoli. Like glandular cells, they appear either as isolated cell in the epidermal tissue or as groups of cells. Most women diagnosed with PD also have ductal adenocarcinoma, either in situ or invasive. The prevalence is 67–100% of cases, which gives a worse prognosis to the patient. Patients with Paget-associated invasive breast disease have lower hormone receptor expression, greater lymph node involvement, and higher human epidermal growth factor receptor type 2 (HER2) expression. An 82-year-old woman sought the mastology outpatient clinic for a follow-up of carcinoma in situ in the right breast 2 years ago, having been submitted to quadrantectomy and hormone therapy with tamoxifen, with no signs of recurrence. She complained of an exudative pruritic lesion on the left nipple that had started 6 months ago. She reported that the lesion started with itching and burning, associated with a spontaneous discharge of serous secretion from the itchy surface of the breast, which improved with the use of “talcum powder.” On physical examination, the presence of a discrete reddened area with a diameter of 3 mm, eczematous, with bloody areas interspersed with serous secretion was observed on the left nipple. Areola lesions and palpable nodules in the left breast were absent. She underwent mammography, which showed symmetrical breasts with fat-replaced parenchyma, absence of nodules, presence of isolated calcifications, and grouping in the superior lateral region of the left breast, categorized as BIRADS II. On ultrasound, a nodule with angled edges, measuring 5×4 mm in the superomedial quadrant of the left breast, which showed nodular enhancement and persistent kinetic curve on magnetic resonance imaging of the breasts. The histopathological study diagnosed moderately differentiated left breast ductal carcinoma, associated with a high-grade solid intraductal carcinoma and PD of the nipple, without the involvement of the areola. Immunohistochemistry revealed the absence of estrogen and progesterone hormone receptors and HER-2 overexpression in both histological types. She underwent mastectomy with sentinel lymph node biopsy that was free of neoplasia. Oncological follow-up with no signs of recurrence. PD, if left untreated, extends to the areola and other regions of the breast. Therefore, clinical suspicion from the first physical examination allows an early diagnosis of extreme importance, which improves the prognosis and allows less aggressive treatments.
Introduction: Phyllodes tumor (PT) of the breast is an infrequent neoplasm, which corresponds to less than 0.5% of the breast tumors. The age group at the greatest risk in women is between 35 and 55 years of age. They are classified as benign (60%–75%), borderline (15%–20%), and malignant (10%–20%). In their less aggressive form, they behave like benign fibroadenomas (FA), however, with a tendency to recur locally after excision without wide margins. In contrast, they may present a metastatic component in its most aggressive form. In general, they are referred to as voluminous tumors, larger than 5 cm, painless, of firm consistency, with a raised or lobulated surface, well defined, movable, and without compromising the skin or deep tissues. They are associated with inflammatory axillary nodes in 17% and metastatic in about 1%. Systemic spread is rare and primarily affects the lungs, bones, liver, and brain. However, the preoperative diagnosis is very difficult, since its clinical presentation, in imaging examinations and in biopsies, is like to FA, requiring surgical excision of the lesion for diagnostic confirmation. Surgical treatment alone is the first therapeutic choice. In smaller tumors, general segmental surgical resection with margins of at least 1 cm is necessary for local control. In very voluminous tumors, total mastectomy or adenomastectomy is performed, without the need for axillary dissection, due to the low probability of lymphatic metastasis. Adjuvant radiotherapy is controversial, with a reduction in the rate of relapses, but without a reduction in mortality. A 67-year-old patient came to the gynecology emergency deparment reporting an ulcerated lesion in the right breast for 3 months, associated with intense right breast tenderness and local fetid secretion. She reported an involuntary weight loss of 6 kg and a progressive increase in the lesion, which at the time of the consultation affected practically the entire breast. She reported active smoking for 40 years. On physical examination, a necrotic-looking tumor was observed, occupying all quadrants of the right breast, with local fetid secretion. She underwent core biopsy, which resulted in a poorly differentiated, high-grade malignant neoplasm in the breast and skin on the right, with breast neoplasia to immunohistochemical marking of prognostic factors: estrogen receptor (ER) negative, progesterone receptor (PR) negative, KI67 positive 50%, and HER2 negative. She underwent right mastectomy with sentinel lymph node biopsy. The anatomopathological conclusion reported histological aspects of a malignant PT of the breast (cystosarcoma phyllodes). The tumor measured 21×15×9.5 cm, with a high-grade epithelioid appearance and necrosis in 60% of the neoplasm, in addition to the ulcerated skin affected by the malignant lesion, with areola and nipple free of invasion. The margins were free and there was no evidence of vascular invasion. In all, 30 mitotic figures were present in 10 CGA in sarcomatous areas. Two sentinel lymph nodes were isolated and were free of neoplasia. Immunohistochemistry was repeated: KI67 is 45%, HER2, ER, and PR are all negative. The patient was referred for outpatient follow-up at Clinical Oncology, which started adjuvant radiotherapy.
Introduction: Synchronous bilateral breast cancer (SBBC) consists of the simultaneous presence of two primary tumors at diagnosis. There is no consensus on its origin, and it may be a metastasis of a primary lesion or a second independent tumor. The incidence of SBBC has been reported to be approximately 3%. The prognosis of SBBC was considered to be reserved, which is why bilateral mastectomy is the preferred approach. Case report: A 44-year-old patient with no family record of gynecological neoplasm sought care reporting bilateral breast pain and palpable nodular lesions on the breasts. On examination, a hard nodule measuring 10×12 cm was palpated on the left breast (LB) associated with ulcerated areas in the superior lateral quadrant. On the right breast (RB), a mobile nodule was palpable, measuring 8×8 cm with chocolate- -colored nipple discharge. Clinically positive axillary lymph nodes are bilateral. She had a mammogram, which showed a nodule with spiculated contours, measuring 2.5 cm in the SLQ of the LB, with apparent associated dermal retraction and multiple, grouped microcalcifications on RB-BIRADS 5. She underwent core biopsy, which resulted in invasive lobular carcinoma and dermal infiltration, with immunohistochemistry (IHC): positive PR and ER, positive HER2, Ki-67 positive in 40% on LB, and carcinoma invasive ductal, non-special type, with IHC: negative RP and RE, HER2 score 3+, and Ki-67 positive in 60% on RB. She underwent neoadjuvant chemotherapy, followed by bilateral mastectomy with sentinel lymph node biopsy. The anatomopathological (AP) study of the LB surgical specimens revealed residual ductal carcinoma in situ, free margins, and neoplasm-free lymph nodes. The RB’s AP revealed high-grade (comedocarcinoma), intermediate-grade residual intraductal carcinoma, alongside an extensive fibro hyalinized area of the stroma, foci of lobular cancerization, absence of residual invasive component, free margins, and absence of lymph node metastasis. The patient underwent adjuvant radiotherapy and hormone therapy with tamoxifen.
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