Potential Impact of the Z0011 Trial on the Omission of Axillary Dissection: A Retrospective Cohort Study

OBJECTIVE

 To evaluate the number of patients with early-stage breast cancer who could benefit from the omission of axillary surgery following the application of the Alliance for Clinical Trials in Oncology (ACOSOG) Z0011 trial criteria.

METHODS

 A retrospective cohort study conducted in the Hospital da Mulher da Universidade Estadual de Campinas. The study population included 384 women diagnosed with early-stage invasive breast cancer, clinically negative axilla, treated with breast-conserving surgery and sentinel lymph node biopsy, radiation therapy, chemotherapy and/or endocrine therapy, from January 2005 to December 2010. The ACOSOG Z0011 trial criteria were applied to this population and a statistical analysis was performed to make a comparison between populations.

RESULTS

 A total of 384 patients underwent breast-conserving surgery and sentinel lymph node biopsy. Of the total number of patients, 86 women underwent axillary lymph node dissection for metastatic sentinel lymph nodes (SNLs). One patient underwent axillary node dissection due to a suspicious SLN intraoperatively, thus, she was excluded from the study. Among these patients, 82/86 (95.3%) had one to two involved sentinel lymph nodes and met the criteria for the ACOSOG Z0011 trial with the omission of axillary lymph node dissection. Among the 82 eligible women, there were only 13 cases (15.9%) of lymphovascular invasion and 62 cases (75.6%) of tumors measuring up to 2 cm in diameter (T1).

CONCLUSION

 The ACOSOG Z0011 trial criteria can be applied to a select group of SLN-positive patients, reducing the costs and morbidities of breast cancer surgery.

Breast cancer mortality rates trends by race in São Paulo, Brazil

Background

Breast cancer is the main cause of female death by neoplasia in Brazil. Although half of the Brazilian population is black/brown (BB), socio-economic disparities translate in a vulnerable situation to those women. Access to health care is an important barrier to improve the health of BB women. This study aims to investigate trends in breast cancer mortality rates regarding race and age.

Methods

This is a population-based study of trends evaluation on breast cancer mortality in São Paulo state, Brazil, from 2000 to 2017. The absolute number of deaths and population figures (including race) by age-groups and years were available online from government data. Data on race were not available by ten-year age-groups, so the figures were projected according to the female age structure by year. Total rates by year and race were age-adjusted to the 'World Population (2000)'. For trend analysis, linear regression was used, with 5% level of significance.

Results

In the period were observed 60,940 breast cancer deaths, 76.7% in white and 17.5% in BB women. The absolute number of deaths in white and BB women was respectively 2,095 and 333 in 2000, and 3,076 and 999 in 2017. The total age-adjusted mortality rates per 100,000 women of white and BB in 2000 were respectively 16.4, 17.2 and 7.5. In 2017 rates were 14.6, 16.6 and 16.1. There was a trend towards reducing the mortality rates of white women (P = 0.002) and in their age-groups from 40 to 79 years (P < 0.03). There was a trend towards increasing the mortality rates of BB women (P < 0.001) and in all their age-groups (P < 0.02).

Conclusions

Although breast cancer figures of death and mortality rates in BB women have more than doubled in 18 years, rates reached almost the same figures of white women in the period. Changes in behaviour risk factors may explain this result. However, it is very likely that access to health care to these women has been improved, reducing the disparities in the health system.

Key messages

Breast cancer mortality rates in black/brown women have reached almost the same figures as white women from 2000 to 2017 in São Paulo, Brazil. Access to health care in black women may have improved in São Paulo, Brazil.

Excessive Pap smears due to opportunistic cervical cancer screening

The study aimed to analyze the Pap smears carried out for cervical cancer screening according to Ministry of Health guidelines. All smear tests carried out within the public health system in Campinas in 2003 were analyzed. All tests that did not conform to the guidelines were considered excessive. The guidelines recommend screening once every three years for all women aged 25 to 59 after they have received two negative smears. This study showed that the majority of women initiated screening prior to 25 years of age and the periodicity was predominantly annual, followed by biannual tests. In conclusion, 63.4% of tests were excessive. The screening coverage was 14.76%, but if all the tests had been performed as recommended, the final coverage over three years could have reached 65.4%. Thus it is possible to increase the coverage with the available resources since the screening works like an organized program.

Stromal cells play a role in cervical cancer progression mediated by MMP-2 protein

Metalloproteinases, especially metalloproteinase-2 (MMP-2), are known for their role in the degradation of the extracellular matrix. Nevertheless, a thorough understanding of MMP-2 expression in neoplastic lesions of the uterine cervix has yet to be accomplished. This study aimed to analyze the MMP-2 expression in cervical intraepithelial neoplasia III (CIN3) and in cervical squamous cell carcinoma, in tumor cells and adjacent stromal cells. MMP-2 expression was assessed by an immunohistochemical technique. MMP-2 expression was greater in the stromal cells of invasive carcinomas than in CIN3 (p < 0.0001). MMP-2 expression in stromal cells correlates with the clinical stage, gradually increasing as the tumor progresses (p = 0.04). This study corroborates that stromal cells play an important role in tumor invasion and progression, mediated by the progressive enhancement of MMP-2 expression from CIN3 to advanced invasive tumor. The intense MMP-2 expression most probably is associated with poor tumor prognosis.

p16INK4a Expression does not predict the outcome of cervical intraepithelial neoplasia grade 2

Spontaneous regression of cervical intraepithelial neoplasia grade 2 (CIN2) lesions has been recognized since 1955, but predictors of this are poorly understood. Among the predictive markers studied, p16INK4a has been suggested to be of some value in monitoring the diagnosis of CIN2. In this clinical trial, 90 Brazilian women, diagnosed to CIN2 and high-risk human papillomavirus infection, were randomized into two groups of equal size: 45 women whose lesions were excised and 45 women subjected to prospective follow-up at 3-month intervals at least for 1 year (mean 6.8 months). p16INK4a expression was analyzed in paraffin-embedded sections using immunohistochemical staining. Among the 45 women in the follow-up group, 42% experienced spontaneous regression, 11% showed persistence, 22% progressed to CIN3, and 20% had partial regression to CIN1 or ASCUS (atypical squamous cell undetermined signifiance). p16INK4a expression was detected in 68.9% of the patients. In univariate survival (Cox) analysis, no significant difference in regression was obtained between p16INK4a-negative and -positive CIN2 lesions (adjusted HR = 1.1; 95% CI 0.6–2.0). In conclusion, p16INK4a expression could be useful in the diagnosis of CIN2. However, it failed to predict the outcome of CIN2. Because of its high spontaneous regression rate, follow-up could be considered as a management option of CIN2 in young and compliant women.

Evaluation of 100% rapid rescreening of negative cervical smears as a quality assurance measure

OBJECTIVE

The objective of this study was to compare the performance of 100% rapid rescreening, 10% random rescreening and the review of smears selected on the basis of clinical criteria, as a method of internal quality control of cervical smears classified as negative during routine screening.

METHODS

A total of 3149 smears were analysed, 173 of which were classified as positive and 2887 as negative, while 89 smears were considered unsatisfactory. The smears classified as negative were submitted to 100% rapid rescreening, 10% random rescreening, and rescreening based on clinical criteria. The rescreening stages were blinded and results were classified according to the Bethesda 2001 terminology. Six cytologists participated in this study, two of whom were responsible for routine screening while the other four alternated in carrying out rescreening so that no individual reviewed the same slide more than once.

RESULTS

The 100% rapid rescreening method identified 92 suspect smears, of which 42 were considered positive at final diagnosis. Of the 289 smears submitted to the 10% rescreening method, four were considered abnormal but only one was confirmed positive in the final diagnosis. Of the 690 smears rescreened on the basis of clinical criteria, 10 were considered abnormal and eight received a positive final diagnosis.

CONCLUSIONS

The 100% rapid rescreening method is more efficient at detecting false-negative results than 10% random rescreening or rescreening on the basis of clinical criteria, and is recommended as an internal quality control method.

Prediction of high-grade cervical disease with human papillomavirus detection in women with glandular and squamous cytologic abnormalities

The objective of this study was to assess whether human papillomavirus (HPV) detection with hybrid capture II (HC II) can help predict the presence and the nature, glandular or squamous, of histologic cervical lesions in women referred due to atypical glandular cells (AGC) or high-grade squamous intraepithelial lesion (HSIL). A total of 247 women were included. Referral Pap smears comprised AGC (51 cases), AGC plus HSIL (28 cases), adenocarcinoma in situ (10 cases), and HSIL (158 cases). All patients were tested for high-risk HPV with HC II and had a histologic assessment of their cervix. Histologic analysis showed 38 women with (15.3%) cervicitis, 194 with (75.5%) squamous lesions, and 15 with (9.2%) glandular neoplasia. The overall rate of high-risk HPV detection was 77%. Almost 70% of AGC-HPV-negative patients did not have a pathologically proven cervical neoplasia, whereas 76% of women with AGC-HPV-positive result were diagnosed with a squamous or glandular neoplasia. Most (95%) of the lesions in patients with AGC-HSIL were of squamous nature, and HPV detection did not contribute to their differentiation from glandular lesions. We conclude that in women with AGC, HPV positivity strongly correlated with the presence of glandular or squamous cervical lesion but did not help distinguishing women with squamous from those with glandular neoplasia.

Atypical glandular cells: criteria to discriminate benign from neoplastic lesions and squamous from glandular neoplasia

OBJECTIVE

To evaluate the presence of some criteria in cervical smears with atypical glandular cells and their correlation with histological patterns to identify pre-neoplastic and neoplastic lesions.

METHODS

Seventy-three women referred with an atypical glandular cell smear, who had undergone conization or hysterectomy, were included in this study. Referral Pap smears were reviewed using the set of 27 cyto-morphological criteria that was correlated with the histological diagnosis.

RESULTS

Histological results showed intraepithelial or invasive neoplasia in 35 (48%) cases and benign lesions in 38 (52%) cases. After logistic regression and decision tree analysis an increased nuclear/cytoplasmic ratio and the presence of dyskeratotic cells were strongly associated with intraepithelial or invasive neoplasia and the differential cyto-morphological criteria for glandular lesions were decreased cytoplasm, irregular nuclear membranes and the presence of nucleoli.

CONCLUSION

The analysis of individual cyto-morphological criteria can better predict intraepithelial or invasive neoplasia and differentiate glandular from squamous lesions.

Nuclear alterations of cells and atypical metaplastic cells in cervical smears are predictive criteria of high-grade cervical intraepithelial neoplasia

Diagnoses based on the screening of cervical smears show low interobserver reproducibility and are frequently discordant with the final histological diagnosis. The aim of this study was to identify which of the cytomorphologic criteria used in the screening of cervical smears were most predictive of the histopathological grades of cervical intraepithelial neoplasia. The abnormal cervical smears of 206 women were reviewed blindly according to 22 pre-established cytomorphological criteria. Colposcopic evaluation was carried out in all cases. The marked presence of several nuclear criteria frequently found together in the same smear was associated with high grade intraepithelial neoplasia regardless of the presence of any other criteria. On the other hand, when the nuclear criteria were less evident, the cluster of criteria related to metaplastic cells was predictive of a diagnosis of high-grade intraepithelial neoplasia. Focusing on selected cytological criteria can aggregate predictive value to cervical smear diagnoses.

Aided visual inspection with acetic acid (VIA) and HPV detection as optional screening tools for cervical cancer and its precursor lesions

PURPOSE OF INVESTIGATION

To assess the contribution of visual inspection with acetic acid (VIA) and Hybrid Capture II (HCII) as adjunct methods to the Pap test in detecting cervical neoplasia.

SUBJECTS AND METHODS

This was a cross-sectional study with 809 women who consecutively attended gynecological consultations at Campinas University, Brazil, from January 2002 to July 2003. Pap test, HCII, VIA, and colposcopy were offered to all patients. Performance of tests (alone or in combination) in detecting histologically confirmed lesions was evaluated.

RESULTS

Of the 40 patients with CIN, 69% had CIN1, 26% CIN2 or CIN3 and one patient had invasive carcinoma. VIA had the best performance in detecting CIN, yielding 72% sensitivity and 91% specificity. Considering only CIN2 or worse as significant lesions, HCII had the best sensitivity (73%), while the Pap test was the most specific (93%). Combining the three exams, 92% of the CIN1 or worse were detected. When CIN1 was excluded from the analysis, Pap smear plus HCII delivered 82% sensitivity and 79% specificity. However, this combination yielded a very low (5%) PPV.

CONCLUSION

VIA and HCII contributed to the screening of cervical neoplasia in a group of Brazilian women, but the cost-effectiveness of conjoint screening modalities is still debatable.

Comparison of Immunoexpression of 2 Antibodies for Estrogen Receptors (1D5 and 6F11) in Breast Carcinomas Using Different Antigen Retrieval and Detection Methods

The importance of in situ immunodetection of hormone receptors for therapy planning and prognostic evaluation in patients with breast carcinoma is well established. Sensitive detection methods are of utmost importance, especially in poorly fixed tissues, which are not uncommon in routine pathologic practice. The purpose of the present study is to compare immunoexpression of estrogen receptors in 20 cases of invasive ductal carcinoma using two antibodies, 1D5 and 6F11, and to verify the effect of different antigen retrieval solutions and detection systems. Immunoperoxidase was performed on paraffin sections using 1D5 and 6F11 as primary antibodies. Heat-induced antigen retrieval was performed using citrate buffer (pH 6.0) or Tris-EDTA buffer (pH 8.9). Detection was achieved using the following systems: EnVision, EnVision Plus, and labeled streptavidin-biotin peroxidase complex. Reaction was semiquantified from 0 to 4. There were no differences between the two markers, 1D5 and 6F11, except when 6F11 was used with EnVision and citrate buffer, in which case weaker reactivity was observed. Only in this combination (6F11/EnVision) was EDTA buffer significantly better than citrate. Labeled streptavidin-biotin peroxidase complex presented the best results, followed by EnVision Plus.

Prognostic value of P53 codon 72 polymorphism in invasive cervical cancer in Brazil

OBJECTIVE

The prognostic value of p53 codon72 polymorphism was analyzed in Brazilian women with cervical cancer.

METHODS

The present study consists of 148 women diagnosed and treated for invasive cervical carcinoma (FIGO stages Ib-IIIb) between 1992 and 2002. Demonstration of p53 polymorphism was performed in DNA extracted from paraffin-embedded sections using the polymerase chain reaction (PCR).

RESULTS

Among the 148 women, arg/arg was found in 99 (67%) and, arg/pro in 49 (33%). The overall survival (OS) curves (univariate) were different between arg/arg and arg/pro patients (P = 0.01). There was slightly increased risk of death for arg/arg patients (crude HR 2.2 CI 95% 1.2-4.0), which was not confounded by FIGO stages (adjusted HR 2.4 CI 95% 1.3-4.3). For disease-free survival (DFS), two situations were considered: (1) 124 women who received any treatment, and (2) 118 who received FIGO-recommended treatment. In the first group, 59% of arg/arg patients presented recurrence as compared to 32% in the arg/pro group (P = 0.02), whereas in the second group, 61% of the arg/arg and 34% arg/pro showed recurrence (P = 0.04). The risk of recurrence adjusted by FIGO stage for the 124 patients was 2.4 (CI 95% 1.0-3.7) and for the 118 it was 1.9 (CI 95% 1.0-3.4). These adjusted models showed no confounding and no interaction.

CONCLUSIONS

Despite the prognostic significance of p53 polymorphism in univariate survival analysis, there was no or only marginal evidence on the independent prognostic value of p53arg/arg in multivariate analysis. The more ominous prognosis of the homozygous (arg/arg) patients was explained by the primary treatment, independent on the FIGO stage.

P53 expression as a predictor of recurrence in cervical squamous cell carcinoma

P53 protein function is frequently down-regulated in cervical cancer by complexing with human papillomavirus (HPV) E6 protein, leading to degradation of p53, genomic instability, and mutations. Results are controversial, however, on the prognostic value of p53 protein expression in cervical cancer. In this study, a cohort of 220 Brazilian women with FIGO stage IB-III cervical squamous cell carcinoma (SCC), followed for 5 years, was analyzed for p53 protein expression using immunohistochemistry. The disease-free survival (DFS) and relapse rate were analyzed using univariate (Kaplan-Meier) and multivariable (Cox's proportional hazards model) survival analyses. P53 protein expression was detected in 35% of the patients, including 21% in stage I, 28% in stage II and 51% in stage III of disease. Of 220 women, only 116 completed one of the treatment options standardized by FIGO within 120 days. There was a higher risk of relapse in stage II and III disease, that was not modified by p53 positivity; HR 3.0 (1.3-6.5) to stage II and HR 4.0 (1.9-8.5) to stage III. The multivariate analysis evidenced that p53 expression is not an independent factor exceeding the power of FIGO stage as the single most important determinant of the hazards for disease relapse.

c-Myc protein expression is not an independent prognostic predictor in cervical squamous cell carcinoma

The c-myc protein is known to regulate the cell cycle, and its down-regulation can lead to cell death by apoptosis. The role of c-myc protein as an independent prognostic determinant in cervical cancer is controversial. In the present study, a cohort of 220 Brazilian women (mean age 53.4 years) with FIGO stage I, II and III (21, 28 and 51%, respectively) cervical squamous cell carcinomas was analyzed for c-myc protein expression using immunohistochemistry. The disease-free survival and relapse-rate were analyzed using univariate (Kaplan-Meier) survival analysis for 116 women who completed the standard FIGO treatment and were followed up for 5 years. Positive c-myc staining was detected in 40% of carcinomas, 29% being grade 1, 9% grade 2, and 2% grade 3. The distribution of positive c-myc according to FIGO stage was 19% (17 women) in stage I, 33% (29) in stage II, and 48% (43) in stage III of disease. During the 60-month follow-up, disease-free survival in univariate (Kaplan-Meier) survival analysis (116 women) was lower for women with c-myc-positive tumors, i.e., 60.5, 47.5 and 36.6% at 12, 36, and 60 months, respectively (not significant). The present data suggest that immunohistochemical demonstration of c-myc does not possess any prognostic value independent of FIGO stage, and as such is unlikely to be a useful prognostic marker in cervical squamous cell carcinoma.

[Knowledge, attitudes, and practices related to the Pap smear among women with cervical cancer]

Despite screening programs, Brazil has a high cervical cancer mortality rate. The objective of this cross-sectional study was to analyze knowledge, attitudes, and practices related to the Pap smear and to understand why women fail to submit to this screening test. A structured questionnaire was used to interview 138 women: 90 with high grade intraepithelial neoplasia and 48 with invasive cervical cancer. Inadequate practices were more frequent among women with invasive cancer. In terms of difficulties in obtaining medical care, more than 80% of women reported lack of motivation, 60% reported that physicians failed to conduct a complete physical examination, and some 50% reported that physicians' schedules were busy. Having a Pap smear usually depended on a physician's request and the woman being symptomatic. Women over than 56 years old showed more frequent inadequate knowledge, attitudes and practices. However, those with more schooling were more knowledgeable of the Pap smear procedure. Age and less schooling could be barriers against women participating in screening programs, but socioeconomic problems must also be considered for improving practices related to the Pap smear.

Evolution of cystic and adnexal tumors identified by echography

The authors present their experience in detecting volume and echostructure alterations of the ovary in 14,525 women examined echographically and clinically. They analyzed 499 adnexal tumors and observed after clinical follow-up and echography that 60.6% of the cystic-septa tumors had involuted spontaneously. Percentage of spontaneous resolution was higher in small-diameter tumors, avoiding unnecessary surgery.