Mastopatia fibrótica : revisão clínica, de imagem e patológica de 31 casos

Abstract

Introdução: a mastopatia diabética ou mastopatia fibrótica é uma lesão benigna, pouco freqüente, normalmente associada a diabetes mellitus tipo 1 de longa duração e que clínica e radiologicamente pode simular um carcinoma. Objetivos: investigar os casos dos pacientes com diagnóstico histológico de mastopatia diabética/mastopatia fibrótica/mastopatia linfocítica com diabetes mellitus tipo 1 e tipo 2, outras doenças auto-imunes e não diabéticas. Métodos: foram analisados 31 pacientes da Unidade de Mastologia do Hospital de Base do DF e da clínica privada pessoal, a partir dos laudos histológicos das mesmas, no período de 1994 a 2007. Resultados: todos os pacientes eram do sexo feminino. A média de idade foi de 46,6 anos. O motivo mais freqüente de consulta foi de tumor em 22 pacientes (71%). Onze pacientes (35,5%) tinham mais de 12 meses de evolução e seis (19,3%) foram achados de exame. Seis pacientes (19,3%) tinham lesões não palpáveis; 15 pacientes (48,4%) tinham lesão entre 10 e 30 mm; e duas (6,4%) tinham lesão superior a 50 mm. Dez pacientes (32,2%) com ausência de patologias. Nove pacientes (29%) eram diabéticas, sendo que seis delas (19,3%) eram portadoras de diabetes tipo 2 e três (9,7%) eram portadoras de diabetes tipo 1. Três (9,7%) eram intolerantes à glicose. Sete pacientes (22,6%) tinham mastopatia fibrótica e câncer. Dessas, seis (19,3%) apresentavam câncer de mama e uma (3,2%) de tireóide. Das seis pacientes (19,3%) que tinham câncer de mama, quatro (12,9%) apresentavam alterações do metabolismo da glicose e duas (6,4%), somente câncer de mama. Duas (6,4%) eram hipotiroideas. Onze pacientes (35,5%) tiveram hipótese diagnóstica de câncer e sete (22,6%) de nódulo a esclarecer. Somente uma paciente (3,2%) teve o diagnóstico inicial correto de mastopatia diabética feito pelo mastologista com base na história clínica de diabetes mellitus de longa duração e achados clinícos. Em 20 pacientes (64,5%) houve algum grau de suspeição de malignidade. A mamografia foi compatível com mamas densas em seis pacientes (19,3%); com lesão benigna em oito (25,8%); com lesão suspeita em sete (22,6%); e em uma (3,2%) foram observadas microcalcificações suspeitas. Em 13 pacientes (41,9%) os exames de ultra-som (US) foram compatíveis com lesão benigna e em nove (29%) com lesão suspeita. Dez pacientes (32,2%) fizeram ressonância magnética (RM) com contraste, sendo três (9,7%) para diagnóstico e sete (22,6%) para seguimento de recorrência. Em sete pacientes (22,6%) o material da punção aspirativa por agulha fina (PAAF) foi insuficiente. Doze pacientes (38,7%) foram submetidas à biópsia por agulha de grosso calibre. Trinta pacientes (96,8%) foram submetidas à biópsia cirúrgica. A média do tempo de diagnóstico da mastopatia foi de 56,3 meses. Das 12 pacientes (38,7%) que tinham distúrbio do metabolismo da glicose, cinco (41,7%) tiveram o diagnóstico de diabetes mellitus após a biópsia, e nas demais a média do tempo do diagnóstico foi de 165,6 meses. Oito pacientes (25,8%) apresentaram recidiva. Foram avaliados a presença e o tipo do infiltrado lobular linfocítico, fibroblastos epitelióides, linfócitos intra-epiteliais e feito estudo imunohistoquímico para CD-20CY, CD-45RO, CD-68 e actina. Em 27 pacientes (87,1%) foi possível fazer revisão de lâminas para avaliar o infiltrado lobular linfocítico, fibroblastos epitelióides e linfócitos intra-epiteliais. Infiltrado lobular linfocítico: em 17 pacientes (63%) o resultado foi +; em sete (25,9%) foi ++; e em três (11,1%) foi +++. Fibroblastos epitelióides: em 13 pacientes (48,1%) o resultado foi +; em 11 (40,7%) foi ++; e em três (11,1%) foi +++. Linfócitos intra-epiteliais: em 13 pacientes (48,1%) estavam presentes. Em 26 pacientes (83,9%) foi feito estudo imunohistoquímico para CD-20CY e actina. CD-20CY: em 20 pacientes (76,9%) o resultado foi +; em cinco (19,2%) foi ++; e em uma (3,8%) foi +++. Actina: em duas pacientes (7,6%) o resultado foi +; em 19 (73,1%) foi ++; em cinco (19,2%) foi +++. Em 28 pacientes (90,3%) foi feito estudo para CD-45RO e em 22 (71%) para CD-68. CD-45RO: em 19 pacientes (67,9%) o resultado foi ++; e em nove (32,1%) foi +++. CD-68: em 16 pacientes (72,7%) o resultado foi +; em cinco (22,7%) foi ++; e em uma (4,5%) foi +++. Conclusões: a mastopatia fibrótica pode ocorrer tanto em pacientes diabéticas e com outras doenças auto-imunes quanto em pessoas com ausência de patologias. Encontramos oito recorrências (25,8%) e regressão da lesão em uma paciente (3,2%). Somente existe associação entre a dimensão da lesão e o motivo da consulta (p=0,0066) e há uma predominância dos linfócitos T sobre os B (p < 0,001). _____________________________________________________________________________________ ABSTRACT

Introduction: diabetic mastopathy or fibrous mastopathy is a benign lesion, infrequent, normally associated to long term type 1 diabetes mellitus. It may simulate a carcinoma on radiological and clinical examination. Objectives: to study the cases of patients with type 1 and 2 diabetes mellitus, other auto-immune diseases and non-diabetic individuals presenting with histological findings of diabetic mastopathy, lymphocytic mastopathy or fibrous mastopathy. Methods: the cases of 31 patients from the Mastology Unit at the Hospital de Base do DF and a private clinic were analyzed based on their histological findings, between 1994 and 2007. Results: all patients were female. The average age was 46.6 years. The most frequent reason for the appointment was tumor, in 22 patients (71%). Eleven patients (35.5%) had more than 12 months of tumor evolution and in six (19.3%) the lesion was found on examination. Six patients (19.3%) had non-palpable lesions; 15 (48.4%) had lesions ranging in size from 10 to 30 mm; and two (6.4%) had lesions larger than 50 mm. Ten patients (32.2%) didn’t show any other pathology. Nine patients (29%) were diabetics and among those, six (19.3%) had type 2 diabetes, three (9.7%) had type 1 diabetes. Three (9.7%) were glucose intolerant. Seven patients (22.6%) had cancer and fibrous mastopathy. Among those, six (19.3%) had mammarian cancer and one (3.2%) had thyroid cancer. Among these six patients with mammarian cancer, four (12.9%) showed glucose metabolism alterations. Two patients (6.4%) showed hypothyroidism. Eleven patients (35.5%) had a suspected cancer diagnosis and seven (22.6%) were diagnosed with nodule to be analyzed. Only one patient (3.2%) had a correct initial diagnosis of diabetic mastopathy, which was made based on the clinical history of long term diabetes mellitus and clinical findings. Twenty patients (64.5%) were suspected of having malignant tumors. The mammography was compatible with dense breasts in 6 patients (19.3%); for eight patients (25.8%) it was compatible with benign lesion; it showed a suspected lesion in seven of the patients (22.6%), and in one patient (3.2%) were observed suspicious microcalcifications. The ultrasound (US) exam was compatible with benign lesion in 13 patients (32.2%), and in nine patients (29%) it showed a suspicious lesion. Magnetic resonance imaging (MRI) was performed with contrast in 10 patients (32.2%), in seven of these patients (22.6%) it was for evaluation of relapse and in three (9.7%) it was performed for diagnosis purpose. In seven patients (22.6%), the sample collected by fine needle aspiration punction (FNAP) was insufficient. Twelve patients (38.7%) were submitted to core needle biopsy. Thirty patients (96.8%) underwent surgical biopsy. The average time for diagnosis of mastopathy was 56.3 months. Among 12 of the patients (38.7%) having glucose metabolism disorder, five (41.7%) were diagnosed after biopsy as having diabetes mellitus. For the rest of them the average time for diagnosis was 165.6 months. Eight patients (25.85) relapsed. The presence and the type of lobular lymphocytic infiltration, epithelioid fibroblasts and intraepithelial lymphocytes were evaluated and an Immunohistochemical analysis for CD-20CY, CD-45RO, CD-68 and Actin was performed. It was possible to re-examine the slides from 27 patients (87.1%) to evaluate the lobular lymphocytic infiltrated, epithelioid fibroblasts and intraepithelial lymphocytes. The lobular lymphocytic infiltrated: in 17 patients (63%) the result was +; in 7(25.9%) it was ++; and in three patients (11.1%) it was +++. Epithelioid fibroblasts: in 13 patients (48.1%) the result was +; in 11 (40.7%) it was ++; and in three patients (11.1%) it was +++. Intraepithelial lymphocytes: they were present in 13 patients (48.1%). An Immunohistochemical study was carried out in 26 patients (83.9%) for CD-20CY and actin. CD-20CY: in 20 patients (76.9%) the result was +; in five (19.2%) it was ++; and in one (3.8%) it was +++. Actin: in two patients (7.6%) the result was +; in 19 (73.1%) it was ++; and in five patients (19.2%) it was +++. A study for CD-45RO was carried out in 28 patients (90.3%), and in 22 patients (71%) for CD-68. CD-45RO: in 19 patients (67.9%) the result was ++; and in nine patients (32.1%) it was +++. CD-68: in 16 patients (72.7%) the result was +; in five (22.7%) it was ++; and in one patient (4.5%) it was +++. Conclusions: fibrous mastopathy may occur in diabetic patients and in patients with other auto-immune diseases as well as in individuals showing no other pathologies. In our findings, eight patients (25.8%) relapsed, and one (3.2%) showed regression of the lesion. There is only association between the dimension of the lesion and the reason for the appointment (p=0.0066), and there is also a prevalence of T-lymphocyte over B (p<0.001).