O CMH é uma doença rara, portanto deve ser tratada como tal. Por esta razão o nosso conhecimento sobre o CMH continua ainda a ter muitas lacunas. São necessários esforços conjuntos que se foquem na prevenção do subtratamento. Torna-se crítica a necessidade crescente de compreender a biologia da doença, particularmente na identificação das diferenças entre o CM no homem e na mulher, e na deliberação das implicações terapêuticas que essas diferenças podem acarretar. Sempre que seja possível investigações e ensaios clínicos sobre o tratamento do CM devem incluir os homens, de forma a construir evidência científica que suporte futuras recomendações de tratamento. Os balanços entre eficácia versus toxicidade da terapêutica endócrina neoadjuvante justifica ensaios clínicos randomizados, preferencialmente internacionais. A avaliação da qualidade de vida dos tratamentos do CMH tem sido negligenciada, mesmo em estudos internacionais. Esperamos que este aspeto da gestão do doente com cancro da mama possa a vir a ter maior preponderância.
O International Male Breast Cancer Program representa um esforço coletivo mundial impressionante que procura recolher dados clínicos a longo prazo e centrar-se em informações biológicas para esta doença rara. Inclusivamente este programa tem uma fase de estudo prospetivo de dados acerca da biologia do CMH, bem como de avaliação de ensaios clínicos em novas terapêuticas. Dada a escassa casuística de cada instituição, só programas de cooperação interinstitucionais podem contribuir para o avanço no conhecimento da biologia, da terapêutica e da repercussão socioeconómica do CMH.
35
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40
Anexos
Tabela 4 Tumor Primário (T)
TX Tumor primário não pode ser avaliado T0 Sem evidência de tumor primário
Tis Carcinoma in situ
Tis (DCIS) Carcinoma ductal in situ
Tis (Paget’s) Doença de Paget do mamilo
SEM associação com carcinoma invasivo e/ou carcinoma in situ (DCIS e/ou LCIS) no
parênquima mamário
subjacente. T1 tumor ≤ 20 mm na sua maior dimensão (no
maior eixo)
T1mi tumor ≤ 1 mm na sua maior
dimensão
T1a tumor >1 mm mas ≤5mm na sua
maior dimensão
T1b tumor >5mm mas ≤10mm
T1c tumor >10mm mas ≤20mm
T2 tumor >20mm mas ≤50mm
T3 tumor >50mm
T4 tumor de qualquer tamanho com extensão direta da parede torácica (inclui costelas, músculos intercostais e músculo serratus anterior) e/ou da pele (ulceração ou nódulos macroscópicos); invasão da derme isolada não se qualifica como T4
T4a extensão à parede torácica;
aderência/invasão ao músculo peitoral na ausência de invasão de estruturas da parede torácica não se qualifica como T4
41
T4b ulceração e/ou nódulos
satélite macroscópicos ipsilaterais e/ou edema (inclui peau d’orange) da pele, que não preenche os critérios para carcinoma inflamatório T4c presença de T4a e T4b T4d carcinoma inflamatório Tabela 5 Gânglios Linfáticos Regionais (N) Clínicos
cNX Gânglios linfáticos regionais não podem ser avaliados (ex foram removidos previamente)
cN0 Sem metástases nos gânglios linfáticos regionais (por examinação clínica e imagiológica)
cN1 Metástases móveis para nível ipsilateral I e II dos gânglios linfáticos axilares
cN1mi Micrometástases
(aproximadamente 200
células, >0.2mm e <2.0mm) cN2 Metástases no nível ipsilateral I e II dos
gânglios linfáticos axilares clinicamente fixas ou aglomeradas; ou gânglios mamários internos ipsilaterais na ausência de metástases nos gânglios linfáticos axilares
cN2a Metástases no nível ipsilateral
I e II dos gânglios linfáticos axilares fixas umas às outras (aglomeradas) ou a outras estruturas
cN2b Metástases apenas nos gânglios
42 na ausência de metástases nos gânglios linfáticos axilares cN3 Metástases nos gânglios linfáticos
infraclaviculares ipsilaterais (nível III axilar) com ou sem envolvimento dos gânglios linfáticos axilares nível I e II; ou nos gânglios linfáticos mamários internos ipsilaterais com metástases nos gânglios linfáticos axilares nível I e II; ou metástases nos gânglios linfáticos supraclaviculares ipsilaterais com ou sem envolvimento nos gânglios linfáticos mamários internos ou axilares
cN3a Metástases nos gânglios
linfáticos infraclaviculares ipsilaterais
cN3b Metástases nos gânglios
linfáticos mamários internos ipsilaterais e nos axilares
cN3c Metástases nos gânglios
linfáticos supraclaviculares ipsilaterais Tabela 6 Gânglios Linfáticos Regionais (N) Patológicos
pNX Gânglios Linfáticos regionais não podem ser avaliados (ex previamente removidos ou não removidos para estudo patológico)
pN0 Sem metástases histologicamente
identificadas nos gânglios linfáticos regionais
pN0(i-) Sem metástases histológicas
43 regionais, imunohistoquímica (IHC) negativa
pN0(i+) Células malignas nos gânglios
linfáticos regionais não >0.2mm [detetadas pela coloração hematoxilina e eosina (H&E) ou IHC incluindo clusters de células tumorais (ICT) isolados]
pN0(mol-) Sem metástases histológicas
nos gânglios linfáticos regionais, resultados moleculares negativos (RT- PCR)
pN0(mol+) Resultados moleculares
positivos (RT-PCR), mas sem metástases nos gânglios linfáticos regionais detetadas por histologia ou IHC
pN1 Micrometástases; ou metástases em 1 a 3 gânglios linfáticos axilares; e/ou nos gânglios mamários internos com metástases detetadas com BGLS mas não clinicamente detetadas
pN1mi Micrometástases (>0.2mm
e/ou >200 células, mas nenhuma >2.0mm)
pN1a Metástases em 1 a 3 gânglios
linfáticos, pelo menos uma metástase >2.0mm
pN1b Metástases nos gânglios
mamários internos com
micrometástases ou
macrometástases detetadas por BGLS mas não clinicamente detetadas
pN1c Metástases em 1 a 3 gânglios
linfáticos e nos gânglios linfáticos mamários internos
44 com micrometástases ou macrometástases detetadas por BGLS mas não clinicamente detetadas