Técnicas de imagen para la valoración del estado ganglionar axilar en el cáncer de mama

The axillary lymph node status is the most important prognostic factor in breast cancer, and the axillary dissection as the gold standar for staging. It requires radical surgery, which is accompanied by importants postoperaive problems. Axillary lymph nodes can be imaged with a wide variety of available diagnostic radiological test (ultrasonography, mammography, computed tomography and magnetic resonance imaging). In these anatomic imaging, the limph nodes whit metastatic disease appear dense, enlarged or spiculated. Difficulties arise, not in visualization of the axillary lymph nodes, but in reliably separating normal from those involved with metastatic disease. Radionucleide studies and positron emisión tomography provide biochemical information, but are limited by resolution constrains

Lesiones mamarias no palpables: Biopsia por congelación

Introducción: El interés prioritario del examen microscópico intraoperatorio de una biopsia de mama es la obtención del diagnóstico histológico; pero en el caso de lesiones malignas, también es importante el conocer el estado de los márgenes de resección quirúrgica, con objeto de realizar en un sólo acto quirúrgico el tratamiento definitivo. Material y Métodos: Se revisan 215 biopsias por congelación correspondientes a lesiones mamarias no palpables (LNP), practicadas bajo control de arpón marcador; seguidas posteriormente durante 36 meses. El espécimen obtenido, una vez marcado en sus bordes (orientación de la pieza) fue teñido con tinta china y radiografiado. Tras ser cortado de forma seriada, fue nuevamente radiografiado, lo que permitió seleccionar el/los cortes que serán sometidos a estudio morfológico por congelación. Resultados: el 53,9% de las LNP biopsiadas correspondían a microcalcificaciones, 31,6 densidades anormales y 14,6 presentaban densidades anormales asociadas a microcalcificaciones. En 110 casos se trató de carcinomas. En 11 casos la biopsia por congelación no permitió un diagnóstico definitivo que debió diferirse hasta el estudio en parafina. No existieron falsos positivos, y en 5 casos (2,3%) el diagnóstico definitivo difirió del intraoperatorio. En otros 5 casos el estudio en parafina advirtió de la afectación de los bordes de resección siendo precisa una nueva intervención quirúrgica. Conclusiones: La biopsia por congelación en el caso de LNP permite no sólo el diagnóstico morfológico, sino en la mayoría de los casos asegurar el estado de los márgenes de resección evitando una nueva intervención quirúrgica.Background: The priority in the examination of breast biopsies is to obtain a histologic diagnosis, but in NPL it is also important to know the whether the surgical margins are involved, so that definitive surgery may be carried out. Methods: A review of 215 consecutive needle-located biopsies was carried out. Median follow-up was 36 months. The surgical specimen was dyed, radiographed and serially sectioned. After a further radiography, the section of tissue with the lesion area closer to the resection margin was histopathologically studied by freezing. Results: 53.9% of NPL were calcifications, 31.6% were abnormal density, and 14.6% presented density asso- ciated with calcifications. 110 cases were carcinomas. 11 cases were classified as "non diagnostic" with frozen section and the diagnosis was deferred to permanent sections. A false-negative diagnosis was made in 5 cases (2.3 %); there were no false-positive diagnoses. In 5 cases the margin involvement was evidenced with paraffin study, and a second operation was needed to perform wider margin excisions. Conclusions: The intraoperative frozen section of NPL provides an accurate diagnosis even with small speci- mens, thus avoiding a second surgical procedure

Técnicas de biopsia para el diagnóstico de lesiones mamarias no palpables

Facing a non-palpable mammary lesion requiring a diagnostic biopsy, consideration must be given to the most suitable guiding method for obtaining the latter. Three methods are employed at present: stereotaxy (basically in cases of microcalcifications), echography (above all in the nodules), and magnetic resonance (for lesions not made visible through the previous systems). The next step is to select the most suitable biopsy technique. The most classical and reliable technique is the surgical biopsy with prior marking using a metallic harpoon, but, besides its high cost, it has the drawback of being an aggressive technique for the diagnosis of a benign pathology. Numerous systems of puncture have been developed as alternatives. Puncture with a fine needle is technically simple to carry out and can provide good results in the mammary nodules, but the existence of positive and negative false results has progressively limited its use. As an alternative, the systems of biopsy with a broad needle have made it possible to obtain multiple cylinders with a high diagnostic reliability, above all in the case of mammary nodules. However, their use in microcalcifications continues to show negative false results. The arrival of systems of vacuum-assisted biopsy has made it possible to obtain cylinders of greater quality, above all in cases of microcalcifications. Finally, the systems of percutaneous resection biopsy by means of cannulas with a diameter of 22 mm make it possible to completely extract lesions of a size below that of the cannula, with a reliability similar to that of the surgical biopsy

Tratamiento conservador del cáncer de mama: valoración de los resultados

Introducción: La asociación de cirugía limitada y radioterapia es el tratamiento de elección para un gran número de mujeres con cáncer de mama; no obstante esta opción terapéutica va asociada a un número no despreciable de recidivas sobre la mama tratada (1-1,5% por año de seguimiento). Material y Métodos: Se analizan 641 casos de mujeres con cáncer de mama, tratados mediante cirugía conservadora de la mama y radioterapia y seguidos durante una media de 50 meses. La técnica consistió preferentemente en la practica de una Resección Segmentaria de mama con vaciamiento axilar, al menos de los niveles I y II (excepto en los CIS a partir de 1997), complementada con la administración de Radioterapia (45-50 Gy sobre la mama y una sobreimpresión de 15-20 Gy). Resultados: La edad media fue de 52.3 años, con extremos en 21 y 82 años El tamaño medio tumoral fue pT: 1,7 cm y el 63,1% de los casos correspondieron a tumores pT1. En 41 casos no se realizó vaciamiento axilar (35 CIS y 6 pT1mic). En 4 casos existió afectación puntual de bordes (componente intraductal) que fueron sometidos a sobreimpresión radioterápica con 20Gy. Tras un seguimiento medio de 50 meses, el 91,4% están libres de enfermedad y en 12 casos (1,9%) se desconocía su estado. Se han producido 13 recidivas (2%) a nivel mamario (2 de ellas en un cuadrante distinto). Conclusiones: El estado de los bordes de resección en un factor fundamental en la cirugía conservadora del cáncer de mama. La resección del tumor debe ser suficientemente amplia e incluir el segmento mamario asiento del tumor, para asegurar un alto índice de control local, sin comprometer el resultado cosmético. El estudio histológico de los bordes de resección permite reducir significativamente la necesidad de una segunda cirugía.Introduction: Conservative surgery combined with radiotherapy is an effective treatment in many cases of breast cancer. Nevertheless this therapy is associated with a not inconsiderable number of recurrences in the remaining breast after excision (1-1.5% recurrences per year of follow-up). Material and Methods: We reviewed 641 cases of breast cancer (age average was 52.3 years (21-82) and tumour size average 1.7 cm, 3% corresponded to pT1 tumours) treated with conservative surgery combined with radiotherapy, average follow-up of 50 months. The technique consisted of segmentectomy and at least level I-II axilary dissection (excluding in situ carcinoma diagnosed since 1997, in which lymphadenectomy was not performed). Adjuvant radiotherapy was also indicated (giving a dose of 45-50 Gy to the breast, and another 15-20 Gy dose was given to tumour size). Results: In 41 cases lymphadenectomy was not performed (35 cases of Tis, and 6 pTmic). In 4 cases, 20 Gy radiotherapy was administered to the tumour excision site because of in situ carcinoma disease in the margins. During follow-up of 50 months, 91.4% of the patients were disease- free; in 12 cases we are not informed of the present status. 13 recurrences (2%) have been found, two of which were in a different quadrant. Conclusions: The status of the surgical margins is an important factor in the practice of conservative surgery. Tumour excision must be broad enough and must include the whole segment in which the tumour is located to obtain local control of the disease, maintaining an acceptable cosmetic appearance. The intraoperative study of specimen margins permits the reduction of cases in which a second operation is needed

Novedades en el tratamiento quirúrgico del cáncer de mama

Adecuate surgical treatment is mandatory in order to achieve cure in patients with breast cancer. Breast surgeons have to choice the best surgical technique over the breast and over the axillary nodes. Two new surgical aproaches have been implemented in the last decade: oncoplastic conservative surgery and sentinel lymph node biopsy. Oncoplastic surgery provides oncologic safety results and good cosmetic outcome. In this paper the technical steps and indications of different oncoplastic techniques in conservative breast surgery are review. Concerning to axillary surgery sentinel lymph node biopsy is the gold standard. However there are several controversial points in sentinel node biopsy referring to indications, identification and histological findings

Secuelas tras inyección ilegal de silicona líquida como técnica de aumento mamario: presentación de 2 casos

The use of liquid silicone for breast augmentation was widespread in the 1960s but was abandoned at the end of the decade due to numerous studies describing the development of a large number of local complications, as well as remote migration of small amounts of silicone. The use of liquid silicone also leads to enormous difficulty in the early diagnosis of breast cancer; these patients are precluded from routine screening programs and must undergo exhaustive periodic examinations. Magnetic resonance imaging has become the most effective test for the early detection of breast cancer in these patients. Indications for subcutaneous mastectomy are the presence of local complications, suspicion of a malignant lesion, or the patient’s desire to prevent both these potential problems

Cirugía derivativa más radioterapia intraoperatoria y externa en el carcinoma de páncreas localizado e irresecable

Presentamos una serie de 25 casos de carcinomas de páncreas localmente avanzados e irresecables, sin metástasis a distancia, tratados con cirugía derivativa, radioterapia intraoperatoria e irradiación externa: 18 tumores de cabeza (16 con ictericia obstructiva) y 7 de cuerpo. Se realizó derivación biliar en 18 y gastroyeyunostomía en 19. La mortalidad operatoria fue nula, con una morbilidad del 16%. A largo plazo se produjeron 3 hemorragias digestivas, 2 ictericias obstructivas, una colangitis y una obstrucción intestinal. Se obtuvo un 72% de control local de la enfermedad y todos los fallecidos por progresión tumoral desarrollaron metástasis hepáticas y/o peritoneales. Presentaban dolor pancreático 22 pacientes y 20 experimentaron remisión del mismo en una a 2 semanas. La analgesia fue definitiva en 12 y reapareció el dolor tardíamente en ocho. La supervivencia media fue de 9 meses (rango 4-24). La revisión de la literatura pone de manifiesto la indicación de la radioterapia externa tanto en el carcinoma de páncreas irresecable y no metastásico como en los resecados. La asociación de radioterapia intraoperatoria tiene, así mismo, un papel importante en cuanto a supervivencia, paliación del dolor y de la progresión local. El 5-fluorouracilo asociado al tratamiento radioterápico prolonga significativamente la supervivencia con una morbilidad razonable

Quimioterapia complementaria del cáncer de mama; experiencia de la Clínica Universitaria de Navarra

Desde 1982 a 1989 se han tratado 68 pacientes con carcinoma de mama. 57 han sido premenopáusicas y 11 postmenopáusicas. El estadio tumoral más frecuente ha sido T2N1 (44,1 %) seguido de T1N1 (20,6 %). La dosis media de quimioterapia recibida ha sido de 91,2 %, 88 % y 94 % para la ciclofosfamida, metotrexate y 5-fluorouracilo respectivamente. El tratamiento ha sido bien tolerado, siendo la toxicidad más frecuente la hematológica (leucopenia). Las pacientes premenopáusicas han presentado un intervalo libre de enfermedad de 89,4 % a 96 meses y las postmenopáusicas de 63,3 % a 68 meses. No se han observado diferencias en el intervalo libre de enfermedad según el tamaño del primario o la positividad del tumor a receptores de estrógeno o progesterona. Los factores pronósticos más importantes de esta serie han sido el número de ganglios axilares afectos y la dosis de quimioterapia recibid

Cáncer de esófago (I): Valoración epidemiológica, clínica y diagnóstica según el tipo histológico

From 1975 to 1991, sixty-eight patients were treated with surgery for esophageal cancer at the Clinica Universitaria de Navarra. This study involves an analysis of epidemiologic and predisposing risk factors in relation with the histologic type of tumor: epidermoid carcinoma vs. adenocarcinoma. The difference in mean age of males (60,5 yrs.) as compared with that of females (48,7 yrs.) was statistically significant (p < 0,05). Likewise, the mean age of patients with epidermoid carcinoma (57,8 yrs.) was significant lower (p < 0,01) as compared with that of those with adenocarcinoma (66,3 yrs.). Smoking and alcoholism were common in the group of patients with epidermoid carcinoma, while Barrett's esophagus and hiatal hernia were frequently seen in patients with adenocarcinoma. Dysphagia was the most frequent symptom both at the start of disease (75%) and with the diagnosis established (96,7%). There was no significant difference in the symptomatology of patients with one type of tumor or the other. The efficacy of ancillary diagnostic procedures such as barium swallow, esophagoscopy, computerized tomography and biopsy were likewise assessed. The most frequent site of tumor was at the middle third, with majority of patients being at clinical stage 1-2 of disease at the time of diagnosi

Técnicas de imagen para la valoración del estado ganglionar axilar en el cáncer de mama

The axillary lymph node status is the most important prognostic factor in breast cancer, and the axillary dissection as the gold standar for staging. It requires radical surgery, which is accompanied by importants postoperaive problems. Axillary lymph nodes can be imaged with a wide variety of available diagnostic radiological test (ultrasonography, mammography, computed tomography and magnetic resonance imaging). In these anatomic imaging, the limph nodes whit metastatic disease appear dense, enlarged or spiculated. Difficulties arise, not in visualization of the axillary lymph nodes, but in reliably separating normal from those involved with metastatic disease. Radionucleide studies and positron emisión tomography provide biochemical information, but are limited by resolution constrains