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Quando indicar adenomastectomia em pacientes de risco congresso sgorj 09-04-2011 (2)

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Quando indicar adenomastectomia em pacientes de risco congresso sgorj 09-04-2011 (2)

  1. 1. Flávia Clímaco, PhD. Universidade Federal do Rio de Janeiro Hospital Federal de Ipanema - Ministério da Saúde
  2. 2. <ul><li>Não há estudos randomizados que avaliem o impacto na redução do risco. </li></ul><ul><li>90% de redução de risco -> 5 - 10% de tecido mamário. </li></ul><ul><li>Grau de satisfação até 60 - 94%. </li></ul><ul><li>Alterações de sensibilidade e necrose do CAP. </li></ul>Jatoi I & Anderson W. Surg Clin N Am 2008; 88: 845- 861 Gahm J et al . J Plast Reconstr Aesthet Surg 2010; 63: 332 -338
  3. 4. <ul><li>MODELO DE GAIL </li></ul><ul><li>Idade atual </li></ul><ul><li>Idade de menarca </li></ul><ul><li>Idade ao nascimento do primeiro filho </li></ul><ul><li>Número de biópsias de mama prévias </li></ul><ul><li>Presença de hiperplasia atípica </li></ul><ul><li>Número de parentes de 1 o grau afetados </li></ul><ul><ul><li>Avaliam risco absoluto (5 anos) e lifetime risk (90 anos) </li></ul></ul><ul><ul><li>Não avalia história paterna, CA de ovário, câncer bilateral, câncer de mama masculino; idade do diagnóstico no parente afetado… </li></ul></ul><ul><ul><li>Subestima o risco em pacientes com predisposição genética </li></ul></ul>www. nccn .org - guideline 2011
  4. 5. <ul><li>Risco alto  RR = 5 a 10 vezes (fatores de risco histológico ou HF sem mutação BRCA1/2 com lifetime risk > 20% ). </li></ul><ul><li>Risco muito alto  RR  10 vezes ( mutação BRCA 1/2, PTEN, p53 ou outro tipo , irradiação torácica ˂ 30 anos). </li></ul>Conferência Internacional de Consenso, 2007 Schwartz GF et al . The Breast Journatl 2009; 15(1): 4-16
  5. 6. Tecido normal HDA RR: 3.3-6.5x HLA RR: 3.3-6.5x Hiperplasia ductal RR: 1-2x CDIS RR: 8-10x CLIS RR: 8-10x INVASIVE DUCTAL CARCINOMA INVASIVE LOBULAR CARCINOMA Dupont WD & Page DL. N Engl J Med 1985; 353: 229-237
  6. 8. <ul><li>5-10% dos CA de mama são hereditários (40% c/ BRCA +). </li></ul><ul><li>BRCA 1/2 Lifetime risk = 56 a 84%. </li></ul><ul><li>Maior frequencia de lesões pré-malignas e carcinomas nas mastectomias profiláticas (35% de HA). </li></ul><ul><li>74% relatam redução do “medo” </li></ul>Frost MH et al . JAMA 2 000;284:319-324 Dowdy SC et al . Am J Obst Gyneco 2004; 191: 1113 -1123 Isern et a l. EJSO 2008; 34(10) : 1148-1154
  7. 9. <ul><li>2 parentes de 1º grau com CA de mama onde um recebeu o diagnóstico com idade ≤ 50 anos. </li></ul><ul><li>Combinação de 3 ou mais parentes de 1º grau com CA de mama independente da idade do diagnóstico. </li></ul><ul><li>Parente de 1º grau com CA de mama bilateral. </li></ul><ul><li>Combinação de 2 ou mais parentes de 1º ou 2º grau com câncer de ovário independente da idade do diagnóstico. </li></ul><ul><li>Parente de 1º ou 2º grau com CA de mama e ovário em qualquer idade. </li></ul><ul><li>História de CA de mama em parente do sexo masculino. </li></ul>Ann Intern Med. 2005;143:355-361
  8. 10. Hartmann LC et a l. N Engl J Med 1999; 340(2):77-84 <ul><li>MAYO CLINIC (1960-1993); n= 1065; follow-up = 14 anos </li></ul><ul><li>4 cânceres / 425 pacientes “risco moderado” </li></ul><ul><li>38 cânceres esperados (modelo de Gail) </li></ul><ul><li>90% redução de risco </li></ul><ul><li>Nenhuma morte por câncer </li></ul>
  9. 11. <ul><li>MAYO CLINIC (1960-1993); n=1065; follow-up = 14 anos </li></ul><ul><li>3 cânceres / 214 pacientes “alto risco” (1,4%) </li></ul><ul><li>Controle: 403 irmãs sem cirurgia profilática </li></ul><ul><li>156 cânceres / 403 irmãs (38,7%) </li></ul><ul><li>90-94% redução de risco </li></ul><ul><li>2 mortes no grupo operado; 90 mortes entre as irmãs </li></ul><ul><li>(81-94% de redução de morte) </li></ul>Hartmann LC et a l. N Engl J Med 1999; 340(2):77-84
  10. 12. n=139 76 MP  0 CA 63 seguimento  8 CA (1 morte) F ollow-up = 3 anos Meijers-Heijboer et al . N Engl J Med 2001; 345(3):159-164 Mastectomia profilática p=0.003
  11. 13. Mastectomia profilática <ul><li>The PROSE Study Group: n = 483 BRCA, follow-up = 6,4 anos </li></ul><ul><li>2 CA em 105 MP (1,9%) </li></ul><ul><li>184 CA em 378 controles (48,7%) </li></ul><ul><li>90% redução de risco sem ooforectomia profilática </li></ul><ul><li>95% redução de risco com ooforectomia profilática </li></ul>Rebbeck TR et al . J Clin Oncol 2004; 22(6): :1055-1062
  12. 14. Mastectomia profilática contralateral <ul><li>Pacientes c/ estádio I e II  risco de 17% em 20 anos. </li></ul><ul><li>Pacientes c/ história familiar forte  risco de 35% em 16 anos. </li></ul><ul><li>Pacientes c/ mutação BRCA1/2  39% em 15 anos. </li></ul><ul><li>Mais frequente quando indicada mastectomia (40% x 12%) </li></ul><ul><li>Sem evidência de benefício em sobrevida. </li></ul>Pierce LJ et al . J Clin Oncol 2006; 24:2437-2443 Metcalfe KA et al . J Clin Oncol 2008; 26: 1093-1097
  13. 15. Van Sprudel TC et al . Br J Cancer 2005; 93: 287-292 148 BRCA 1/2 com CDI estádios I – IIIA (6 anos) 79 mastectomia contralateral  1 CA 69 seguimento  6 CA (p< 0.001) 91% de redução de risco Sem alteração na SG Mastectomia profilática contralateral
  14. 17. [email_address]

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