Alfredo Carlos S.D. Barros
São Paulo, 5/11/2011
CIRURGIA NA PREVENÇÃO
DO CÂNCER DE MAMA
Núcleo de Mastologia
Hospital Sírio-Libanês Laboratório de Anatomia Médico-Círúrgica (LIM 02) Faculdade de Medicina da USP
CLINICAL CASE
• A.M.S., 40 years-old
• Married, 2 children
• Fammily history
Mother: BC at 47 years
Sister: BC at 38 years
She wants BC prevention. What is your best choice at
this momment ?
a) Mg, US, MRI
b) Genetic testing
c) Tamoxifen
Breast Cancer Risk in Relation to Amount of Tissue
Removed during Breast Reduction Operations in Sweden
Brinton e col.
Cancer 2001; 91: 478 - 83
Removed tissue (two breasts)
g OR 95% CI < 800 1,00 ≥ 800 < 1200 0,45 0,3 – 0,8 ≥ 1200 < 1600 0,40 0,2 – 0,7 ≥ 1600 0,24 0,1 – 0,5 Case-control study
• 31.910 cases of reductive mammaplasty • 1965 – 1993
Evolution
• Breast cancer cases: 161
SURGERY FOR BREAST CANCER
RISK REDUCTION
• Ablation of part of the mammary glandular tissue aiming to
reduce the amount of ducto-lobular units (CIC cells)
susceptible to neoplasic transformation.
NOMENCLATURE
• Mammary adenectomy
• Subcutaneous mastectomy
• Adenomastectomy
• Total skin sparing mastectomy
• Conservative mastectomy
FORMS OF SURGERY TO REDUCE BREAST CANCER RISK
Mastectomy Skin-sparing“MASTECTOMIA” PROFILÁTICA EM MULHERS
DE ALTO RISCO
RESUÇÃO DE RISCO
98,1 6,4 105 Mutação de BRCA 1-2 Rebbeck e col. - 04 100 3 139 Mutação de BRCA 1-2 Meijers – Heijboer e col. - 01ADENECTOMIA MAMÁRIA PROFILÁTICA
•
Síndrome hereditária pro heredograma
•Suscetibilidade genética comprovada
POSSÍVEIS INDICAÇÕES
•
Cancerofobia
•
Hiperplasia atípica – NLIS
•Mama densa
Profilatic mastectomy in BRCA1 and BRCA2 mutation
carries
• Netherlands Cancer Institute • 1995 – 2008
• 147 casos assintomáticos • Mutação
BRCA1...100 BRCA2...47
• Adenectomia mamária após
EF – Mg – US e RM normais Kaas et al. Ann 2010; 251:488-92 1. Peça cirúrgica CDI... 1...0,7% CDIS... 6...41%
Bilateral prophylatic mastectomy in Swedish women at
high risk of breast cancer: a National Survey
• Sweden 1995 – 2005 • 223 high-risk women • 8 hospitals
• Risk model: BOADICEA • Follow-up: 6.6 years • BRCA1-2 mutation: 58% • Median age: 40 years
Anver et al.
Ann Surg 2011; 253:1147-54
Expected cases 12 Observed cases 0 Occult cancers in the specimen 8 4 IDC
4 CDIS
The role of sentinel node biopsy in women undergoing
prophylatic mastectomy
•
Meta-analysis
•6 studies
•
1343 prophylatic mastectomies
•21 occult invasive cancers (1.7%)
•23 positive sentinel nodes (1.9%)
Zhoo WB et al
Can J Surg 2011; 54: 300-6
ADENECTOMIA PROFILÁTICA
RESULTADOS ESTÉTICOS
AVALIAÇÃO ESTÉTICA PELA PACIENTE
Sacchini V, Pinotti JA, Barros ACSD et al. J Am Coll Surg 2006; 2003: 704-14. Nota 0-3 4 – 6 7 – 10 n % n % n % Adenectomia terapêutica (n = 65) 3 5 5 8 53 87 Adenectomia profilática (n = 49) 0 0 3 6 46 94
NIPPLE-SPARING MASTECTOMY FOR BREAST CANCER AND RISK REDUCTION: ONCOLOGIC OR TECHNICAL PROBLEM ?
• Número de procedimentos: 192 • Número de pacientes: 117
Bilateral prophylatic mastectomy in women with
inherited risk of breast cancer – Prevalence of pain,
discomfort, impact on sexuality, quality of life and
feelings of regret two years after surgery
• Karolinska Institute • N = 59 (2004 - 2006)
• Mean follow-up: 29 months
Gahm et al.
Breast 2010; 19:462-9
(%)
Light pain 69 Mild discomfort 71 Reduced sexual sensations 85 Sex negative impact 75 Disagreement and regret 1.8
Contralateral prophylatic mastectomy in associated with
a survival advantage in high-risk women with a personal
history of breast cancer
• Estudo caso-controle • 1971 – 1993
• Mayo Clinic
• 385 casos (E I-II) cirurgia bilateral
385 controles – cirurgia unilateral
• História familiar (1º e 2º grau) • Follow-up mediano: 17,3 anos
Boughey et al.
Ann Surg Oncol 2010;17:2702-9
RESULTADOS
Ca de mama
oposta sobrevida 10 anos
n (%) (%)
Cirurgia
bilateral 2 0,5 83
Population-based study on contralateral prophylatic
mastectomy and survival outcomes of breast cancer
patients
• SEER data-base (EUA) • 1998 – 2003
• Mastectomia unilateral...107.106
Mastectomia profilática
do outro lado...8.902
Bedrosian et al.
J Natl Cancer Inst 2010;102:401-9
Sobrevida em 5 anos
(%)
Cirurgia bilateral 88,5 Cirurgia unilateral 83,7
Population-based study on contralateral prophylatic
mastectomy and survival outcomes of breast cancer
patients
• SEER data-base (EUA) • 1998 – 2003
• Mastectomia unilateral...107.106
Mastectomia profilática
do outro lado...8.902
Bedrosian et al.
J Natl Cancer Inst 2010;102:401-9
TAKE HOME
•
Deve ser explicada e considerada para mulheres
de alto risco hereditário para câncer de mama.
•
Não deve ser indicada para lesões marcadoras de
risco, cancerofobia ou mamas densas.
•
Resultados estéticos bons são obtidos em 80-90%
dos casos.
•
