Hola, muy buenos días a todos y todas. Es un gusto, un placer estar actualmente en este primer curso organizado por la Sociedad Internacional de Cáncer Ginecológico y el Colegio Mexicano de Ginecólogos Oncólogos. Como todos, les damos la bienvenida a todos. Y bueno, tenemos algunos datos que solo el orador activo haga clic en el botón de ver, el que está en la parte superior de la pantalla y seleccione vista del orador. Para ver todos los panelistas, seleccione vista de galería. Si existe alguna dificultad técnica, por favor, pueden ayudarse obteniendo ayuda. Si ustedes quieren oír el idioma en inglés, hagan clic en interpretación y luego elige el idioma que le gustaría escuchar. Como vemos, tenemos un programa de expertos, panelistas, profesores de diferentes partes de Latinoamérica. Y que en esta ocasión, el doctor Antonio Potadas será el coordinador del día de hoy. Su servidor, el doctor Víctor Manuel Vargas Hernández, hablará en esta ocasión, en este primer tema, de este primer curso internacional de cáncer de mama, de un tema importante que es la situación actual en cáncer de mama en América Latina. ¿Cuáles son los objetivos que he planteado? Es conocer los aspectos demográficos y epidemiológicos del cáncer de mama. ¿Qué dificultades existen en la implementación de programas de tamizaje poblacional? ¿Y las causas de desigualdad en los servicios públicos de salud? Los mensajes les quiero dar. El cáncer es una de las principales causas de muerte en América Latina y el Caribe. Los retos sobre el tamizaje para cáncer de mama son mejorar la organización y políticas de salud. La causa más frecuente y principal de muerte por cáncer está asociada al cáncer de mama. ¿Cuál es la carga mundial del cáncer? La carga mundial será que 28.4 millones de casos en 2040 aumenta del 47% a este año, con aumentos sobre todo en países emergentes de un 64% a un 95% si lo comparamos con países desarrollados que es de 32% a 56%. Y esto se debe a cambios demográficos y socioculturales con mayores factores de riesgo asociados a la globalización y al crecimiento económico. La incidencia general fue de dos a tres veces mayor en países desarrollados comparado con países emergentes para ambos sexos, mientras que la mortalidad varió dos veces para los hombres y menos para las mujeres. La tasa de mortalidad por cáncer de mama y de cáncer cérvico uterino son mayores en países emergentes si los comparamos con países desarrollados, 15 versus 12.8 por 100,000 y 12.4 versus 5.2 por 100,000 habitantes respectivamente. Estos esfuerzos para construir una infraestructura sostenible para la difusión de medidas de prevención del cáncer y la presentación de atención oncológica en los países emergentes es fundamental para el control mundial del cáncer. Y aquí, como vemos en esta gráfica que salió recientemente en este año, vemos que el cáncer de mama en la mujer es el principal cáncer que se presenta tanto en incidencia como tasa de mortalidad con más de 2.261.419 nuevos casos cada año y con una mortalidad de 684.966 millones. ¿Esto qué quiere decir? Que abarca el 6.9 de muertes y el 11.7 en frecuencia a nivel mundial. Bueno, todas las mujeres están en riesgo de desarrollar un cáncer de mama y es importante estar informadas y además de prevenirlas y, si es posible, reducir sus riesgos. El cáncer de mama forma parte de los órganos reproductivos de la mujer, por eso los ginecólogos tienen alta importancia en su manejo. El riesgo de desarrollar este cáncer aumenta con la edad, es decir, con el envejecimiento de la mujer. Cuando se detecta en etapas tempranas, el tratamiento es efectivo y curativo. Hablando de algunos aspectos de la epidemiología, la transición epidemiológica se ha producido de manera desigual y las enfermedades crónicas no transmisibles aumentan, incluyendo el cáncer, que representa la segunda causa más común de muerte después de las enfermedades cardiovasculares. Las tasas de incidencia actuales permanecen sin cambios y aumentarán 75% en el año 2025. If we talk specifically about the demography of Latin America and the Caribbean, it is made up of 41 countries, which vary in size and population. 8 of the 24 Caribbean countries had less than 100,000 inhabitants in 2009. Brazil is the largest country in terms of territory and population, with more than 210,147,000 people. Mexico is the second country with more than 129,000,000 inhabitants by 2020. The Federation of St. Kitts and Nevis is the smallest country with less than 50,000 inhabitants. As the population has increased from 2014 to 2024, depending on the regions, we see that this year in South America there will be more than 429 million, in Mexico more than 128 million, in Central America more than 51 million and in the Caribbean more than 27.8 million. Currently, 12.7 million new cases of cancer are reported worldwide. By 2030, the annual number of new cases of cancer in Latin America and the Caribbean will be 1.7 million with more than 1 million deaths. 13.7% occur in regions of extreme poverty. According to the new multidimensional poverty index, there are great variations, for example, 2% in Uruguay and 57% in Haiti. Life expectancy has increased 9 years from 65 to 74 years and with 6 years of difference in favor of women compared to men. Countries in Latin America and the Caribbean are classified by the World Bank as low or medium income countries and being indigenous increases the probability that a person lives in poverty with less education and access to medical care. Cancer affects more than 1 million annually. Globally, more than half of new cases and more than two-thirds of deaths from cancer occur in emerging countries. The mortality rate and incidence rate of cancer is 0.59, which is higher than in the European Union, where it is 0.43, and in the American Union, which is 0.35, indicating that these regions have greater support for cancer management compared to Latin America and the Caribbean. With greater inequality worldwide, practically unmovable since the 1970s, being 65% higher than in developed countries, 36% above the Far East and 18% above Sub-Saharan America. Brazil, Mexico and Colombia, the most populated countries in Latin America and the Caribbean, have poverty rates of 8.5%, 4% and 9.2%, respectively. We talked about the total number of new cases reported this year in women of all ages. We see that breast cancer occupies 28% with 210,100 cases, that is, the rectum with 9% with 67,725, uterine cancer with almost 60,008, thyroid cancer with 51,600 and lung cancer, which ceased to be the first cause. Let's say that the differences in wealth, education and health are correlated with greater exposure to infections and risk of developing cancers. Adequate funding is a global challenge. Only 6% is for cancer. This means that the mortality rate and incidence are responsible for 46.1% of new cancer cases. Health expenses are low in many countries in Latin America and the Caribbean. Historically, these expenses were directed to infectious and contagious diseases, leaving chronic, non-transmissible diseases such as cancer in a secondary position. In Mexico, 52% of the total health spending was for the private sector, which covers only 5% of the entire population. The cost of chemotherapy varies from one country to another. In emerging or medium-income countries, they charge higher prices than in high-income countries, and corruption within the system is common. Most chemotherapy is imported and is determined by who orders the drugs and who pays them. The consequences of the increase in the incidence and mortality rate for cancer increase the economic burden that affects health systems. The unequal allocation of resources, concentration of specialists, oncological centers in large cities, and the lack of investment in equipment and infrastructure lead to socioeconomic inequalities in cancer care. What are the challenges? There are several obstacles to oncological management, such as primary and secondary prevention, early detection, diagnosis, treatment, rehabilitation, follow-up, and palliative care. Mainly, the lack of national health plans that establish public policies to control cancer. Prevention, an early diagnosis, and treatment around the world would reduce new cases of cancer deaths. Better eating habits, obesity prevention, the elimination of tobacco and excessive alcohol consumption, vaccination against BPH and hepatitis, encouraging exercise and limiting sedentary lifestyle will reduce incidence and mortality rates. Modern diagnostic and chemotherapy methods that are widely available will increase the cure rate and reduce the mortality rate for cancer. In relation to health services, funds, insurance coverage, doctors, health workers, resources, and equipment are distributed unevenly, even within the same country. The lack of cancer records hinders credible vital cancer statistics. In relation to quality of care, there are no mechanisms or systems that allow us to assess or measure its impact. The priority keys are, first, to reinforce screening, early detection, strengthen the education of health professionals. Second, improve access to correct and timely treatment. Third, promote holistic care and treatment with standards of best practices, protocols, and clinical practice guides adapted to the region. Multidisciplinary support, introduce and support access to palliative care as a public health policy. The rural population travels to these large cities for comprehensive oncological management. Cultural differences are well documented. Lack of adequate transportation and accommodation prevent access to care and cancer treatment services. They delay diagnosis and treatment, affecting their prognosis when compared to patients who live in large cities. Organized and planned cancer services are needed in these countries. Decentralization reduces access inequalities, an important strategy to reduce its impact. Establishing a knowledge of the real impact of the incidence, mortality rate, and survival is a challenge. Strategies adapted to increase economic development are programs to improve cancer control. Early diagnosis and prevention are necessary. Evaluation, monitoring, and re-evaluation are required through epidemiological measures of the incidence population, mortality rate, and survival. In Latin America and the Caribbean, 2% of the world's investment is in research and development. For example, Brazil has more than 31,000 publications in the Science Intention Index, which represents 2.32%. Mexico alone, 0.64%. Argentina, 0.49%. Chile, 0.27%. These four countries contribute 90% of the total investment in research, about 2% of the national public health budget in research. What conclusions are we going to reach? The Human Development Index classifies countries according to a social indicator that includes life expectancy, education, and income. In turn, it is associated with the incidence and prevalence of certain types of cancer. Latin America and the Caribbean need to increase knowledge for the implementation and evaluation of preventive and early detection policies. Barriers are bureaucratic obstacles, lack of information, and adequate administration under the use of available public resources. Most of the cancer information is related to cervical cancer, and this is a general overview of the situation of cancer in Latin America and the Caribbean. I kindly thank you and invite you to continue with the next webinars on April 24, May 29, from 8 to 12 hours, Chicago time. I give the floor to Dr. Antonio Posadas, our coordinator and friend, to continue with the program. Thank you very much. Buenos días. Muchas gracias. A continuación, le damos las gracias a nuestro profesor titular, el Dr. Víctor Manuel Hernández, por su participación. Voy a compartir pantalla. Voy a presentar a nuestro siguiente panelista. A continuación, la Dra. Eva Rubalcaba Limón, es ginecólogo-oncóloga del Departamento de Cirugía de Mama en el FUCAM, la Fundación para Cáncer de Mama en México. Ella nos estará hablando acerca del diagnóstico por imagen en cáncer de mama. Agradecemos su participación y nuevamente les damos la bienvenida a todos nuestros participantes a este Congreso Internacional de Cáncer de Mama, auspiciado por la International Gynecologic Cancer Society y por el Colegio Mexicano de Oncólogos Ginecólogos. Bienvenidos sean todos ustedes. Dejo a continuación la pantalla a la Dra. Eva Rubalcaba Limón. Muchas gracias, doctora. Muchas gracias, Víctor. Buenos días. Eva, adelante. Si puedes compartir tu pantalla. Buenos días. Agradezco la invitación al comité organizador y les voy a hablar sobre diagnóstico por imagen en cáncer de mama. Sabemos que el cáncer de mama es una enfermedad muy heterogénea y tanto en manifestaciones clínicas y en este caso también en cuanto a los hallazgos radiológicos e histopathológicos. El proceso de detección, diagnóstico y tratamiento sabemos que debe de ser multidisciplinario. El objetivo de los estudios de imagen sabemos que en gran parte es el detección, pero también una parte importante es en cuanto a diagnóstico, el cual debe de ser preciso. También nos ayuda para biopsias guiadas en caso de lesiones no palpables y también para valorar la extensión local y a distancia de la enfermedad. Sin embargo, los estudios de imagen no únicamente responsabilidad de los médicos radiólogos, los cuales de preferencia deben de ser radiólogos oncólogos o con especialidad en mama, sino también están involucrados los técnicos con adquiramiento en los diferentes métodos y deben de estar involucrados en forma conjunta los oncólogos quirúrgicos y clínicos para que este sea un abordaje y manejo multidisciplinario. ¿Y a qué me refiero? Les voy a dar un ejemplo muy sencillo. Cuando nosotros solicitamos un estudio de imagen y únicamente por dar un ejemplo solicitamos una mastografía de ultrasonido en una mujer de 65 años y no colocamos en la solicitud antecedentes o datos clínicos, pues el radiólogo simplemente puede decir, bueno, ¿para qué una mujer de 65 años va a requerir un ultrasonido mamario si estamos ante una mamá muy grasa? Entonces puede que no realice el ultrasonido mamario. Sin embargo, si nosotros comunicamos al radiólogo que se trata de una mujer de 65 años que tuvo el antecedente de un cáncer de mama triple negativo, etapa 3, y que durante nuestra exploración del seguimiento encontramos un nódulo en la mama contralateral de centímetro y medio, apenas palpable, y por eso estamos solicitand ultrasound in that mother, then the context is very different. Hence, oncologists must be involved, both clinical and surgical, with the radiologist's body. In imaging studies, we know that there are morphological and functional studies, and those that are recognized at the international level for detection are practically mastectomy. And in very selected cases, especially in patients, in high-risk population women, it would be magnetic resonance for detection. And for diagnosis, tapification and follow-up, it would be ultrasonic mastectomy, magnetic resonance, and molecular studies such as PET-PEM. And there are new techniques that are already in use, such as tomosynthesis and contrasted mastectomy. And from now on, I tell you to be very careful, because there are studies that are being used, but they are not approved for detection of breast cancer. They are under investigation, and they are electrical impedance in the breast and thermo mammography. Effectively, they are not invasive, they do not use ionizing radiation, there is little pain, they do not damage the tissues, but they have not shown their usefulness in diagnosis or detection of breast cancer. They are still under investigation. So, the recommendation is that they are not used as a study of tamization. We know that all approved studies to study breast cancer, to address it, have a reporting system that you all know well, which is the V-RATS system, which goes from 0 to 6. Just to clarify, category 0 means that it is an incomplete study, additional studies have to be carried out, call it repeating the mastectomy projections, or make a complement with ultrasound, but this does not mean that 0 has nothing to do with the patient, it means that a qualification cannot be given, and additional studies have to be carried out. As for mastectomy, well, we know that its two main uses are tamization, this is for early detection of breast cancer, when the woman is asymptomatic, and diagnostic mastectomy, this is to evaluate the women who already have some sign or symptom that could suggest breast cancer. However, there is no study or group of studies that can guarantee the absence of breast cancer. It is important to have good quality studies. In this mastectomy that you can see, what draws attention is a nodule in the left breast, practically in the retrorheolar tissue, it is a practically nodular image, but if we do a digital study, it turns out that this image is not the suspicious one, the really suspicious image is found in the right breast, in the lower squares, where it is an image with speculated margins, practically considered as VRAT 5. Hence the importance of having good quality studies, because in the eyes of non-experts, this image of cancer can escape, and this woman will be able to go to the oncologist, and when this injury is palpable, we are practically already in front of an injury that will measure more than 3 centimeters. We must also take into account the composition of the breast, we know that breast densities are divided into A, B, C and D, according to the percentage of density that occupies the entirety of the breast. The higher the density, the greater the risk of details escaping, especially asymmetries and some distortions of the breast. It is very important that the higher the density, there is a need to carry out complementary studies, such as ultrasound or thrombosynthesis, which we will see later. The findings that we have to look for, or that we can find, are nodules, and we have to characterize them, if they are oval, round or irregular. We must also evaluate the margins, if they are darkened, defined, speculated. The density also has to be characterized. We have to evaluate if there are asymmetries, if they are global, focal, and also the presence of distortions. There are other findings that have to be evaluated, if there are spontaneous retractions at the level of weight, if there is thickening of the skin, and also the axillary glands can be evaluated, or if there are intramammaries, through this mastography study. The mammary ultrasound, all of you know it. It should be remembered that it is not a study for sweeping, it is a complementary study that is recommended in women, especially when they are under 35 years of age, or it can be used as a first study in pregnant women who are lactating, when there is the presence of inflammatory processes, such as mastitis or abscesses. When we find asymmetries or distortions in the mammography, it is also to characterize nodules, if they are cystic or solid tumors. It is also an auxiliary to do interventionism when there are no palpable lesions, and in the presence of dense mammas. The great disadvantage is that it is a dependent operator. If the person, the radiologist, or the specialist who has training in ultrasound, does not cover the entirety of the mamma, and does not make an ordered sweep, it can underestimate, or it can let mammary findings escape that may be a cancer. The advantage is that it does not emit ionizing radiation, and another recommendation is that the transducer has to be of a wide band, at least 10 hertz. Also here, the important thing is that it evaluates, we can have the advantage of evaluating nodules and characterize this nodule very well, especially the margins, the cogenicity, the composition, exactly the size of the nodule, and we have tools like elastography, this is to evaluate the hardness of that nodule. Other findings, we can also evaluate the tissue around these nodules, ductal changes can be evaluated, cutaneous changes, if there is edema of the skin or not, vascularity, if it is peripheral, central, and as I was saying, we have the option of elastography. Here we have another study, which is tomosynthesis, also called three-dimensional mastography. It is an extension of digital mastography, which has come to solve many, many studies, or calls, since it improves the detection of breast cancer up to 27%, and decreases the number of re-calls in breast cancer programs above 17%. What this study does is obtain multiple images from different angles, and what it does, what mastography does is, it makes a sum of all the findings, from one side to the other, either from top to bottom, from internal to external, and it does what we see in the projections or practically in the plate, it is a sum of densities. However, in tomosynthesis, we have the advantage that it makes different projections, and we can have the different slices, so to speak, of the breast, and we can choose which image is the one that interests us. In such a way that in dense breasts, this makes it much easier for us, because we no longer have the superimposition of tissues. This is an example, where the left image is a tomosynthesis study, where we can blur, where you can see the run, and on the left side, the right side, we choose the image that interests us, to be able to really evaluate the injury that draws our attention. Another study is magnetic resonance, which has already proven its usefulness a lot, especially in dense breasts. It is a functional study, it requires a medium of contrast with gadolinium, this evaluates the characteristics of rehabilitation, and you can make capture curves. For invasive breast cancer, it has a very high sensitivity, above 95%, for carcinoma ductal in situ, when this is of high degree, and when they are very extensive injuries, it can reach above 90%. Unfortunately, the specificity is very, very low, and this has led us to make incisions and biopsies, practically benign injuries, that were not really needed. So, that is why the role of resonance as a method of taming in the general population. The indications are in women with high risk of breast cancer, in those women where we have a positive ganglion, and in the breast there is no evidence of an injury by mastography or ultrasound. This is where we use magnetic resonance, when we are thinking of a hidden breast cancer, by these two methods. It also has great utility for the search for multicentricity. It can also be used to assess the response to non-adjuvant chemotherapy and in dense breasts. Here we have an example of a pre-contrast image, before the thin line, and this is after using the contrast medium. We can also find cutaneous retraction, or better assess the cutaneous thickening. The advantages of magnetic resonance is that it is still a very expensive study. There are few national resonators, at least in Mexico, there are not many in many countries. In Latin America they are also scarce or poorly distributed, they are almost always in very large cities. And also, on the other hand, there are few specialists in mammary resonance radiologists. Another study that over the years has occupied a better place and is a better option for practically the same indications of magnetic resonance, which is contrasted mastography or functional mastography. The effectiveness is similar to magnetic resonance, it is more accessible, but at a better cost compared to magnetic resonance. And it is practically an alternative to magnetic resonance when there is a contraindication for it. To give an example, this is a study carried out in Taiwan with 148 patients, an average age of 52 years, where 75 benign and 73 malignant lesions were identified. Here the studies were evaluated by three different radiologists, digital mastography was compared to conventional and without contrast. It was evaluated at 2, 3, 4, 7 and 10 minutes. It must be taken into account that in functional mastography several cuts have to be made at different times. It is a very dynamic study. And it was found that the greatest diagnostic effectiveness is at 2, 3 and 4 minutes, compared to 7 and 10 minutes. Here we have an image on the right, where we have the basal study, where we find practically a global asymmetry. And after the medium of contrast, we find at least four nodules, which were later corroborated with ultrasound, which corresponded to malignant neoplasia. So this does help a lot to identify malignant lesions, especially when we are looking for multicentricity or when in basal studies of mastography it is not very clear. So this is a very good option. In the NCSN recommendations, contrasted mastography is already discussed and integrated, and in some other guidelines it is also given as a good option, especially due to the costs and the ease in which it can be carried out in the cabinets that have a digital mastographer. Functional studies such as tomography by emission of positrons, PETCT, are generally done by capturing radioisotopes. They generally use FDG. This is more to assess extension than diagnosis. It is an alternative in the detection of local-regional recurrence and metastatic distance, and to assess the response to therapy and follow-up. Here we have an example of the capture at the mammary level, at the axillary level, and even at the level of the supraclavicular ganglions. So it is not a first-time study. It has its indications, but it does have its role in assessing the extension of the disease. Now, already knowing the most frequent or most used studies that we can have at hand, we are going to touch on some points. Now, in terms of tanning of women with average risk, you all should already know what the indications are. We know that tanning with mastography, especially digital, has been shown to reduce mortality over the years. As time has passed, it has been corroborated and shown to decrease mortality. This goes from 7% to 23%, depending on the population, depending on the period of study, depending on the age at which these studies are carried out. However, for a good tanning program to work, there must be a coverage in the population that is at risk of developing breast cancer of more than 70%, so that there is a reduction in mortality between 20% and 30%. If this percentage is not covered, the tanning program will not work. Unfortunately, in populations like Mexico and some other countries in Latin America, this percentage has not been covered. Efforts are being made to improve these programs to increase coverage so that there is this repercussion or this benefit of reduction in mortality. Maybe we won't see it, but maybe in a few decades. The results of short-term tanning are to diagnose early stages of breast cancer and, in the long term, reduce mortality. The side effects, well, about diagnosis and many false positives. There are several meta-analyses where there has been a decrease in mortality compared to women who underwent mastectomy and compared to those who were not subjected to a tanning program. Depending on the design of the study, these are the results in terms of decrease in mortality. If they are clinical trials, studies, or the design of the study is more controlled, the decrease in mortality is less, but even so, there is benefit with tanning. Here you can see, with clinical trials, the decrease in mortality is 18 to 20%, and in case and control studies, with all the biases involved, the decrease is up to 54%. Now, according to the age groups, the decrease in mortality is less than 50%, from 15% to 50 to 59 years, up to 23%. And the group that has the most benefit in terms of decrease in mortality is 60 to 69 years. So, if you look, between 50 and 69 years are the women who have the most benefit in terms of decrease in mortality. And that's where the cuts come from, or the recommendation of at what age is when tanning should be started. Here you can see it. These are the women who have the greatest benefit in terms of decrease in mortality. Now, there are different guides, different recommendations throughout the world, and the trend in America is that studies are carried out annually. Some recommendations are proposed from the age of 40, for example, in SSN. In Mexico, also at the age of 40. Some are proposed at the age of 40, for example, in the American Cancer Society. It is proposed, but it is really recommended from the age of 45. Some recommend that it be bi-annual. In Mexico, it is recommended that it be bi-annual. And when to finish? Well, this is going to depend, this has changed a lot, I will touch on it later. The American College of Radiologists also from the age of 40. As I was telling you, the trend in America is that it starts at 40 and that it is annual. The trend in Europe is that it is bi-annual and that it starts at the age of 50. There is a lot of controversy about this. It will depend a lot on the risk factors and the conditions of the patient. But in general, it is from the age of 40, every year or every two years. And what is recommended is that it be two projections. Here it is practically the same, every year, every two years, the starting age, you can find a lot of bibliography about it. What is striking is how many women are needed, either to be invited to do a study or to find breast cancer. And this is going to be according to the age group, here are the numbers. Here it also depends on whether it is every year or every two years and hence the justification of doing it annually or biannually according to the age group. There are barriers to doing the sampling, this depends a lot on the resources of each country, whether the program works or not, it depends on the equipment, many times it is poorly distributed, there are few equipment, or the maintenance is inefficient, it also depends on the human resource and the coverage in each country. But it also depends on cultural aspects, it has been seen that women who are immigrants, who have little culture or who are in a medium with low income per capita, or simply there is not good communication with their doctor, whether it is a male doctor, or because he has a very specialized international education and is not so involved in primary care, there is not good communication with the woman and the woman somehow decreases the attention for her sampling. There are publications about this and it is a very interesting social issue. High-density mothers, we already mentioned it, women, the younger the woman, the higher the density, and there is a greater risk of detection failures. The recommended studies are tomosynthesis, it is not useful for microcalcifications, it is useful for high-density mothers and distortions, ultrasound you already know, magnetic resonance is the study par excellence for high-density mothers, but it is still a higher cost study and it is still not available in many countries. The disadvantage is that it also uses, it is necessary to use a contrast medium. Contrasted mastography is having a better role, it is less expensive than magnetic resonance and it can be done during the conventional mastography study. And the mammary molecular image has been seen that it can increase the detection of breast cancer in denser mothers, but it is more radiation and it is not available in many places. T-shirts, female women, this has changed a lot over the years, before the top was 70 years, then it went down to 74 years, but who are the elderly, who are the female? So we can have very active women at 90 years old, we can have women practically in bed at 60 years old, so we must not be guided only by age. So, something very important is that the mortality rate for breast cancer above 70 years is almost 50%, and what has been seen is that the decrease in mortality due to t-shirts is uncertain, since clinical trials with mastography practically did not integrate women over 70 years old, they put them aside. And what has been seen, what has changed, has revolutionized, is that women must continue with mastography according to the risk of breast cancer, according to the life expectancy with morbidity and the desire to continue with the studies. If you review the guidelines, you will see that there is insufficient data, if you have a life expectancy of more than 10 years, you must continue with the t-shirt, in some it is not recommended above 70 years, and it is practically according to the functional state and the life expectancy. If you already had a previous cancer, some guidelines recommend that you must continue your mastography annually, and in other guidelines they say that it is no longer beneficial to continue with regular mastography. And this goes hand in hand with the life expectancy, and we know that at an older age the life expectancy decreases. And these are some of the organizations that do evaluate or consider t-shirting in women over 70 years old. So the recommendation is to see which are the ones that do take these women into account and see if it is every two years, every three years, but the majority of the trend is not to take age into account, but to the functional state. As for the t-shirting of women with high risk of breast cancer, well, this has to be evaluated by a geneticist. They are almost always women who have a risk greater than 20%. These women must start their annual mastography from the age of 30. It has to be evaluated if they had thoracic radiotherapy before the age of 30. Almost always, in addition to the mastography, it must be accompanied by annual magnetic resonance from the age of 25 to 30. It has to be evaluated if they had, if they had family history of breast cancer. Black women and descendants of Jewish women who were born, they have to start the evaluation before the age of 30. So here there are many recommendations as to what age they should start. ESMO, in its recommendations for the year 2019, recommends that they should start with mastography and magnetic resonance annually, either with a comitant or alternate studies. That is, mastography and at 6 months resonance, and in an alternate way to do these studies. Because we have to remember that they are women with very dense breasts, for the same reason that they are young. They can be based on the guidelines of the NSSN, its latest version from last year, version 1. And it practically takes them by the hand in terms of age, in terms of risk. And here you can see what studies are recommended to be carried out. If only, if they can, according to age, physical exploration, or really start mastography in an annual way, more or less tomosynthesis, or if there is an increased risk, magnetic resonance can be started. Here we are already talking about contrasted mastography. And if she is a very high-risk woman, inclusive, measures can already be taken to reduce risk, either with medication or risk-reducing surgeries. And finally, to conclude, well, we have the studies for MAMA. We have those that are detection, which can be sweeping, risk population, average risk population, which is still mastography. The recommendation, in general, is at 40 years old. The age of term, well, this goes according to the conditions of the woman. And the tendency is to do it annually. In high-risk population women, the recommendation is mastography and magnetic resonance. The starting age is practically at 30 years and annually. Diagnostic studies, if necessary, carry out complementary studies, especially in women with high mammary density. Ultrasound, tomosynthesis, magnetic resonance. Remember that contrasted mastography is being used more and more. And it is an alternative to magnetic resonance. And to assess the extent of the disease, molecular studies such as PET-CT can be used. Thank you very much for the invitation and see you at the discussion table. Thank you very much. I think I was going to share my screen here. They don't accept me. There you go. Very good. We thank Dr. Rubalcaba for her excellent participation and her brilliant update on the concepts of imaging diagnosis and the update on the concepts and the indications for each of these methods in particular circumstances. Thank you very much. Next, in this first morning block, we are joined by Dr. Julio Lau, who is a gynecologist. He is with us from Guatemala. He is in the General Hospital San Juan de Dios in Guatemala. And he will give us a presentation on biopsy for the diagnosis of breast cancer. We welcome Dr. Julio Lau and the participants who are joining us. Thank you very much, doctor. We will leave it to share the screen. Hello, thank you very much. Thank you very much for the invitation. It is an honor to be here with many of my professors, teachers. And starting this new IGCS project, we are going to talk a little bit about sampling for breast diagnosis. Starting, we all know that a biopsy is the obtaining of tissue or cells to determine a diagnosis. And in mammary lesions, we have options. The options are to do it incisionally, excisionally, percutaneously, and by aspiration. So, we are going to go over these a little bit throughout the talk. When we have a patient who needs a biopsy for a breast lesion, we have to take several considerations. If the lesion is palpable, not palpable. If the lesion we have is solid or cystic or mixed. Or if we suspect that it is benign or malignant. And the location, if it is very close to the skin, close to the thoracic wall, or close to the armpit or some glass. These are characteristics of the lesion that we have to take into account, in addition to characteristics of the patient, such as age. We have to know if the patient has had previous resections or previous biopsies. The family history of cancer, both family and personal. The physical exam. And if this mass, the evolution it has. If it is recently appeared or if it already has some time. And all these characteristics of the patient, we have to link them to the radiological characteristics or by image that we find in the lesion. And that we can take, as explained by Dr. Rubalcaba, mammography, ultrasound and resonance to give a classification of bi-RATS. And based on the classification of bi-RATS that the radiologist gives us, we can decide whether it is necessary to perform a biopsy or it is just a routine control. And why is it important to determine the diagnosis of the lesions? One, to know if it is benign or malignant. And based on whether it is malignant or benign, we can determine the status if it is malignant and determine prognostic factors. And whether it is malignant or benign, we can determine or plan the treatment of this patient, which in the case of many benign lesions, will be observation or surveillance. And in malignant lesions, the treatment that is needed will be determined. All this to take a biopsy is a set of many things. Physical exam, clinical history, images to determine the pathology. What type of biopsy to do in each lesion, how to do it and what care should be taken. Let's talk a little bit. In the physical exam, we have to see where the lesion is, where it is located, in which part of the breast, what size it is, if it is palpable or not palpable, if it is mobile or not mobile, and if it is just one or there are other lesions. And we also have to have characteristics such as if there are lesions in the skin, if there is orange skin, if there is edema, erythema, and we also have to take into account the state of the lymphatic ganglions or the suspicion of a lesion in the lymphatic ganglion to take the biopsies. So when we have a patient with a lesion in the breast, we must do a triple evaluation, both physical exam, mammography. Usually we can combine mammography with ultrasound. We do an evaluation to see if this patient needs a biopsy. And based on this data, it is determined if they need a biopsy or probably do not need it. That is why it is important, as the doctor said, to have specialized radiologists in breast, because if someone is not specialized in breast, they can suggest a biopsy for a lesion that does not deserve it, or we can say that a lesion does not deserve a biopsy and it can be something bad. That is why it is important for someone to be an expert in this. So coordinating the radiological part, the clinical part, or the surgical part, we see that the ideal thing, when performing surgery procedures for a lesion, is to have a malignant benign ratio of 1 to 5. That means that by coordinating the radiological part with the surgical part, we are going to reduce the unnecessary surgeries due to benign pathology. Let's see the types of biopsy. There is the biopsy for aspiration with a fine needle. This is useful when performing, when we have lesions like cysts or axillary ganglions. It can be performed when we have a primary breast tumor, but it is usually not recommended because it has certain disadvantages. And the good thing about this is that we can do it with a needle, with a syringe that any of us can have in their office. It has a specificity of 97%, and a sensitivity of 72% to 94%. But it is a dependent operator, and it does not make a difference to us if it is an invasive or non-invasive lesion when we have the result. So we have the advantage that it is easy to perform it, that it is fast. The complications are minimal. The equipment that is needed is also minimal. There are no scars. The discomfort for the patient is very little. But we have the limitation that it can be a dependent operator. If the sample is poorly taken, we can have errors. If the sample was poorly fixed or poorly spread on the sheet, we can also have errors. So it does require training to perform it. And when we have a solid lesion, the amount of material obtained from the lesion is little. Here we can use a syringe. How to perform it? We can have a 10 or 20-liter syringe with a 18 or 22-liter needle. It basically consists of locating the nodule. If it is a palpable lesion, immobilize it with your fingers. Pulse it. Since we are inside, what is done is to suck with the syringe and make movements from top to bottom in the fan to obtain the sample. Then, before removing the needle, stop breathing to remove it and then spread it in the object holder. It can be done in solid lesions or in ganglions. Basically, visually, this is it. Immobilize the lesion and make the spread and take the sample. We can also do it with ultrasound, with ultrasound guide. This is useful in lesions that are small or also when we have cysts, it can be done with aspiration biopsies. Usually, cystic lesions will work if we have a complex cyst or if we have a cyst that deforms the mother and is already causing pain to the patient. The cytological analysis is generally not done unless we have blood content, we obtain blood content of the function. What we use the most in the diagnostic part of breast cancer is percutaneous biopsy or cutting-needle biopsy. Throughout history, percutaneous biopsy began to emerge in the early 90s by reports from Parker, who began to perform biopsies with a needle and compared them with open biopsies and found a correlation of 87% of the cases in general and 14G needles were used, the correlation could be 97%. Over the years or with the reports, it was found that doing percutaneous biopsies or Trucut biopsies decreased or was a savings for the cost of the patient's diagnosis of approximately $1,629. So the costs were decreasing. At first, it was not well accepted, mainly for the surgical part, because it was as if they were displacing us, but over time, it was seen that percutaneous biopsies had a good sensitivity and specificity. It is better if we do them guided by image, it improves our precision in the diagnosis and less complications are associated. And we see that in the trend over the years, this report of 2004-2016, we see that there was an increase of 51% of percutaneous biopsies guided by image, the surgical or open biopsies decreased by 64% and the biopsies carried out by radiologists increased, but the biopsies carried out by surgeons decreased. Maybe this is a weakness that we have had and that we could reinforce so that the surgical part learns the image part, at least ultrasound, to carry out those percutaneous biopsies. Currently, it is the standard in the diagnosis, so much so that the reason for surgical biopsies or open biopsies, because we do not have a diagnosis, it must be more or less 10% and the others must be percutaneous. What benefits does it have or what advantages does it have? Less morbidity, cosmetically it is better, the scar is minimal, costs are reduced, unnecessary surgeries are reduced due to venous pathologies and by having the diagnosis of something malignant, we know histological characteristics of the tumor, we can subclassify it, we have the advantage of doing extension studies before starting the treatment. We also have the advantage of submitting the case to multidisciplinary sessions to make decisions. And we can determine a better surgical medical treatment. We can also plan surgery in a better way. And one of the most important things is to inform the patient about his diagnosis, what treatment he will receive, the benefits, risks and adverse effects that he may have before starting this whole process. In quality indicators, it is determined that 95% of patients with breast cancer should have an exhalation statistic, both by image and if we suspect any malignancy, take a biopsy. And 90% or it should be more than 90% of patients going to a breast cancer treatment should have a histological diagnosis confirming the injury. How to approach or how to take biopsies? The approach can be freehand, which is what we do very easily in the office, with palpable injuries. Or guided by image, it can be guided by ultrasound, mammography, stereotaxia or resonance. The easiest thing in a consultancy is to do it guided by ultrasound, accompanied by a radiologist. If there is any training, they can do it in the gynecologist or the surgeon. And the most complex are mammography, stereotaxia and resonance. What advantages does it have to do it guided by image? It improves the accuracy and precision of the place of the sample we have. And it also reduces complications such as pulsing the pectorals or the ribs, because we know where the shot will be directed. Less probability of neophotorax or vascular injuries. What are the indications of performing biopsies guided by image, guided by ultrasound when we have cystic lesions, especially if they are symptomatic. Or by image we cannot determine if it is something solid or something cystic. And we can take samples of these lesions guided by ultrasound. When we have complex lesions or solid masses, which are classified as VRATs 4 or 5, we can also perform biopsies guided by ultrasound. Here we have an example of a lesion that is small, that is solid, that has vascularity, and that was biopsied by ultrasound. This is another example of a lesion that is of uncircumscribed margins, which is small, not palpable, but it is solid and has both peripheral vascularity and lesion. Another indication is when we have a solid lesion within a cystic lesion. It is better to do it guided by image of this solid part. Or even though we have lesions that are very circumscribed, but that have certain solid areas or that have a lot of vascularity in the internal part, biopsies are recommended. Another indication of performing biopsies is when we have microcalcifications. Many times we can see microcalcifications, most of the time in mammography, but we can also see them by ultrasound and we can perform biopsies. Another indication of performing biopsies is when the initial biopsy could not determine the diagnosis, but we suspect a lot that this lesion may be malignant, when the pathologist tells us that the sample is not enough and we need to get more samples, or when we take a biopsy by initial aspiration and the diagnosis, we have atypical cells, but we do not have a definitive diagnosis. Also the ganglions, it is necessary to perform biopsies when we suspect, and there is classification of the shape and size of the ganglions, when it is suggested to do biopsies, which is very similar to the bi-RATS classification. When it is contraindicated to perform a biopsy by ultrasound, when we do not have a visible lesion, when there is an allergy to drugs, the use of drugs, for example aspirin and anticoagulants, is not a contraindication because this type of biopsies, the risk of bleeding is low. Then there are biopsies guided by stereotaxia, here we do need a lot, this is done by the radiologist. It is indicated when we have microcalcifications or non-visible nodules by another method, when we have asymmetries or distortions, or we need to repeat the biopsies. And it is contraindicated when we cannot visualize the lesion by this method. This is the part by stereotaxia, we can do it, it is done in a patient lying down, or there is another way to do it sitting down, which can be used by the stereotaxia equipment, or sometimes thomosynthesis can also be used. Usually needles are used here, a little thicker. The technique is to do asepsia, do the biopsy with a guide, use the trigger, it is recommended to place a clip and use Formol. This is with an ultrasound biopsy, usually we locate the lesion, and here we can see that it was in the right place. We always recommend after doing a biopsy, whether it is a benign or malignant lesion, big or small, leave a clip or marker inside the lesion. If it is a benign lesion, anyone who sees it later will know that this lesion already had a biopsy. And if it is a malignant lesion, this is how the marker is seen by mammography, and this is how the markers are seen by ultrasound. This patient will receive nevus joint chemotherapy, or if this patient goes to surgery for a very small lesion, and the pathologist helps them locate where the lesion is, because many times they are millimeters or a piece that is larger. When we are at risk of having a lesion, for example, nodules, ganglions that are very close to the vessels, or a lesion that is very close to the wall, we can use needles or the advanced technique, which are different shooters, which already advanced a part of the needle, and we do not have the risk that it will advance further to injure another part that we do not want. How many cylinders to obtain? Depending on the caliber of the needle, if we have a 14 needle, we have an accuracy in the diagnosis of 99%, with two cylinders, and if we have a 16-needle needle, with three to five cylinders, the quality is good. If needles are made by stereotaxia or vacuum, it is recommended to have a 11 needle instead of 14, and there are no differences between needles 8 to 11. And depending on the caliber of the needle, it will be the amount of sample we obtain, if it is a cutting needle, and if we use mammoth, the amount will be greater. These are the differences in specificity and sensitivity. We also have incisional biopsies. These are already performed with less frequency, but they have indication when we have a lesion, especially in the skin, or some recurrence, and when it is not possible to perform a Tukut biopsy, and we need more tissue. Basically, this is the way to perform them, take a cut, or we can use these sponges used by dermatologists to obtain these biopsies if the lesion is in the skin. And why? Because probably in Latin America, in many parts, these lesions are not seen, but here in my country, we still have this type of lesion in the breast, where it is very easy to obtain an incisional biopsy. Or this type of recurrence or lesion in the nipple, where it is necessary to perform incisional biopsies. Incisional biopsy, this is to dry the lesion with healthy tissue margins. If we have the indication, if we have a biopsy that is suspicious of malignancy and it was not possible to determine it by other techniques, it is a valid lesion. And if the patient requests an incisional biopsy, because he had bad experiences with percutaneous lesions, of course, you have to take into account that an incisional biopsy does not replace an oncological surgery or the oncological care that is needed. You have to take into account if they are palpable or not palpable lesions. The lesion can be, if it is a non-palpable lesion, there are two ways to mark it, with a marker or in a rod. This will be deepened in the next talk. Or if we do it percutaneously, what we already talked about, guide it by image. If we do a lesion, if we are going to perform an incisional biopsy, it is advisable to place a marker to determine the site where the lesion is and do the resection of this lesion, especially if it is a non-palpable lesion. And this is an example of a non-palpable lesion, of a 3-millimeter breast cancer that was resected by placing a marker. If we perform microcalcifications biopsies, incisional biopsies, it is always recommended to do the radiological control of the back during surgery to be sure that these microcalcifications were completely dried up. This is the role part, which is to inject a radioactive medium. The disadvantage is that this technology is needed to perform this type of lesion. Here we have the lesion. Here we have when it dried up, that there is no radioactive part of this lesion. Always mark the margins. This can be marked with threads, or it can also be done with paint so that the pathologist knows how it is oriented and tell us if there is any near margin, which one we have to enlarge and which one not. Transoperatory study also helps us with this, both by image and that the pathologist observes the lesion and that it has healthy tissue margins around it. If there is a positive margin, we can enlarge it. In conclusion, we have several options to perform breast biopsies. All have advantages and disadvantages. Generally, if we have a lesion that is suspected of malignancy, we prefer true cut biopsies. That is the choice. But if it is not possible to perform them, we have other options such as incisional, excisional and PA. Thank you very much. Thank you very much, Dr. Lau. We thank you for your presentation. I will introduce our next participant. To conclude this first block of the morning, we will have a break later. Dr. Amelia Rodriguez-Trejo will join us. She is a gynecologist-oncologist. She is with us from the State Cancer Center of Nayarit, here in Mexico. She will give a conference on breast cancer management. Welcome, Dr. Rodriguez. Thank you very much. Thank you. Good morning for the invitation. Good morning, everyone. The topic I was invited to present is breast cancer management. As a definition, we know that a palpable injury is an injury that due to its size, depth, or simply due to its similarity to the mammary tissue, can only be detected by imaging methods, such as mammography, ultrasound, and resonance, depending on the patient's study. The fact that a mammary injury is classified as not palpable and is seen only by imaging studies does not necessarily mean that it is a small injury. On many occasions, we could find fairly large injuries associated with a cancer in situ, for example. As for non-palpable mammary injuries, as previously mentioned, the main objective of mammography is to detect injuries in early stages, in non-palpable stages, when there is still no ganglion infection, and this subsequently helps us reduce or improve the probability of survival of these patients. In the United States, with the increase in the TAMI programs, the percentage of injuries that occur in early stages has increased, and it is considered that specifically cancer in situ is detected by mammography at 25%. As Dr. Vargas previously mentioned, in Mexico we have serious problems with our TAMI programs organized by mammography, and although the objective of the Health Secretary's program is to have coverage of at least 20% of the population, we know that this coverage is low, because in Mexico, and probably in many Latin American countries, we have deficiencies in terms of infrastructure, mainly the number of mammographs that are installed for this purpose. So, in our oncological centers, and even in the National Institute of Cancer, unfortunately, 80% of the patients we treat are in advanced stages, and only less than 5% are treated as cancer in situ, and 10.8% as early-stage cancer, or as a non-palpable injury. As for mammary injuries, when they are not palpable, they can present as microcalcifications, as very small nodules, which due to their depth cannot be palpable, as a symmetrical density, or as an alteration in the architecture, and can correspond to a very wide variety of histological injuries that range from a non-proliferative benign injury to proliferative injuries with atypia, cancer in situ, or invasive cancer. Within the mammary injuries, they are generally diagnosed as a non-palpable injury, specifically as microcalcifications, most of the time, and those that should interest us, especially due to their subsequent risk of cancer, are the proliferative injuries that atypia presents, such as atypical ductal hyperplasia, low-degree cancers, pulmonary hyperplasia, and epithelial type of flat cells. For many years now, in different studies, it has been proven that all these injuries that present proliferation and are associated with atypia have an increased risk of cancer, and in general, the accumulated risk of cancer at 20 years is from 20% to 21%, and this is in the long term, but nevertheless, these are injuries that we must keep in mind, because if they are associated with other risk factors, they have an important risk of cancer. And, well, regarding the management of these injuries, we ask ourselves if it is necessary that these injuries, after an initial diagnosis, either by percutaneous biopsy or some type of biopsy done by imaging, when we are reported with a proliferative injury with atypical ductal hyperplasia, if it is necessary that all these injuries should be taken to a later extensive examination, well, if it is necessary, the probability of finding a major injury is 22% to 65%, and in the case of these injuries, the main justification is that the real difference between an atypical ductal hyperplasia and an in situ cancer varies mainly in the complete analysis of the injury, since this difference that pathologists can report to us is quantitative. So, if we need to do extensive examinations, after an initial diagnosis of atypical ductal hyperplasia, and the surgery will not be indicated, after a biopsy, when the margins reported it negative. We only have to do a re-examination when we are reported with a present injury in the margins or when there are doubts about a complete injury. Atypical ductal hyperplasia, we know that it is not considered a real cancer injury, its probability of major injury is only 5%, and in this case, if there is an adequate clinical-radiological correlation, it is not necessary to do an extensive examination of this injury. For flat-cell epithelial atypia, there is no consensus, there is currently no clear need for us to have to perform a subsequent surgery, since the probability of major injury is quite low, of approximately 2%. As for the handling of in situ ductal cancer, we know that in the vast majority of cases, this cancer is found as a mastographic finding, as a non-palpable injury. And well, we mentioned it previously, in our environment, the probability or the frequency with which we detect this cancer is less than 5%, and 90% of these we are going to detect with mastography. So, the less studies of taming we do, the less likely we are to find the cancer itself. In general, it is diagnosed by the presence of microcalcifications, and these will represent 50% of all the biopsies we do for microcalcifications. In 10 to 50% of these biopsies that we carry out with microcalcifications, we will find cancer, and of these, 70% will be cancer itself. As previously mentioned, there are different types of biopsy, and sometimes, when it is not possible to carry out a percutaneous biopsy, guided by image or by a team carried out by a radio diagnostic, it is necessary for these patients to be taken to an allied biopsy with ARPON. Many times, it is necessary to place two ARPONs to corroborate the complete decision of the injury. It is very important to comment that for the proper management of an injury, already diagnosed oncologically, we have the diagnosis in two times. First, with a previously corroborated biopsy, and then to make the decision to carry out the best oncological treatment for the patient. As for the decision of the injury, the technical aspects are very important, and for this I refer to this article published by Dr. Eva Rubalcaba Limón, where they perfectly describe what is the most correct technical aspect to locate this injury. Any injury that is carried out with conservative surgery has to have strict radiological control of the piece to corroborate the complete decision of the injury. All the pieces have to have well-defined surgical margins, they must be six margins, preferably referred with ink, if not, then with wax to guide the pathologist, place a radiopathic mark on the surgical site to guide the radiologist in case he has to give a radiotherapy treatment. And as it was defined in the consensus published in 2016 by the American Society of Oncological Surgery, the margin that is currently considered adequate for an in-situ injury of more than 2 mm must be this so that it is considered adequate, and the restriction will only be indicated in patients with positive margins. We know that the local surgical treatment is the elective treatment, and patients with in-situ cancer can be properly treated with conservative surgery, as far as possible, it is the elective treatment. Some patients will not be candidates for this treatment, they will have to be taken to mastectomy with reconstruction. Currently, it is known that oncoplastic surgery is a safe method, and in very specific cases, when an infarction is suspected, it could be performed even with a pre-in-situ cancer diagnosis. In the past, it was known that mastectomy, for many years, total mastectomy was the standard treatment for total in-situ cancer, and this was based on the 1982 publication, where in a pathological analysis of 53 pieces of mastectomy performed at that time, it was found that in-situ cancer in 30% is a multifocal disease, that in 40% of these pieces there was residual tumor after local extinction, and that 50% of the patients who received a local treatment would do it as an invasive cancer. They also observed that if the patient was taken to mastectomy, in 1% to 2% of the cases, they would only have local residues. So, for many years, mastectomy was the treatment that was carried out, but well, to date, and rather, it was never carried out, and it will no longer be necessary. There are random studies between mastectomy and radiotherapy in cancer. Well, at the same time, conservative surgery was already being carried out against total invasive mastectomy in cancer, and transferring these results. Later, in the 1980s, the study of SBPV 17 was carried out, where this study strongly demonstrated a general rate of recurrence decrease from 31% to 15.7% when radiotherapy was used in this group of patients. It decreased recurrence as an invasive cancer from 16% to 7.0%, and as an in-situ cancer from 14% to 8%. This study, as a pathological characteristic, found that all histological types benefited from being treated with conservative surgery and radiotherapy, and the only adverse, bad prognosis factor that was found was the presence of comedonecrosis in the surgical piece. Another study carried out at the same time in the European Union by the European Group also demonstrated an absolute reduction in a 10-year follow-up of 47% for this group of patients. And well, in this study, as important clinical parameters, it found benefit in all evaluated groups, except in patients under 40 years of age, when there were dubious margins of less than one millimeter, when they had an intermediate or high degree, and a solid and uniform growth pattern, and also if the patient was detected as a palpable disease. So, to date, we know that there is a constant benefit of treating the patient with in-situ cancer, with conservative surgery, adding radiotherapy for all in-situ cancer groups. And this was corroborated more recently in this meta-analysis of 4 updated studies that included 3,729 patients, where they show that there is a benefit for all in-situ cancer patient groups, including patients with small, low-risk groups, with negative margins, since in this group, specifically, it found a risk reduction of 18% to 10 years of follow-up. So, for many years, well, we also had, or we used, the Banoch prognosis index, which is an index that evaluates, as we already know, three risk factors for in-situ cancer. And, well, this was published in 1996 in this retrospective study of 353 low-risk patients, which were aliatorized to excision, against radiotherapy excision, and well, in the low-risk group, which were left only with a surgical excision, the recurrence rate they found was only 2% to 7 years, at the same time, another study that evaluated this low-risk group with margins of more than 10 millimeters, found a recurrence rate of 4%. Although this group showed a low recurrence rate in low-risk patients with in-situ cancer, the study of a CBPV17 did not identify any group of patients that did not benefit from radiotherapy. More recently, therefore, the RTOG group carried out a prospective study precisely in low-risk in-situ cancer groups, to compare surgery against radiotherapy surgery. In this prospective analysis, they found that for in-situ injuries, small, less than 25 millimeters, low-grade, with margins greater than 3 millimeters, the local recurrence rate was 0.9% for the radiotherapy group against 6.7% for the observation group. Therefore, it is concluded that currently, specifically in in-situ cancer, all patients benefit from surgery plus radiotherapy, even in low-risk patients. As for hormone therapy for adjuvant treatment, such as in-situ breast cancer, well, we already know all the studies of NSABP24, which randomized the group of patients with surgery plus radiotherapy and placebo versus surgery plus radiotherapy plus tamoxifen. And in 1,804 patients, in this group of patients, there was a decrease in the recurrence rate as breast cancer in general and as exolateral breast cancer in 4.2% to 2.1%, although there were no differences in HIV. Subsequently, the NSABP25 study was carried out, which randomizes patients with in-situ cancer treated with surgery plus radiotherapy with anastrozole versus tamoxifen. And although in this group it was shown that there was an improvement in favor of anastrozole, especially in patients under 60 years of age. However, the IBIDS-2 did not show that there were significant and important statistics in favor of anastrozole versus tamoxifen. Well, there are other studies that have also evaluated other inhibitors of aromatase and well, they were also evaluated. So, currently, treating patients with breast cancer with hormone therapy after the initial surgical treatment will depend on the patient's age and their secondary risk factors, such as age, osteoporosis, or some contraindications for a certain treatment. As for in-situ breast cancer, which presents microinvasion, well, this is a little-seen entity, it constitutes only 1% of all breast cancers, and in-situ cancers only 5 to 10% of the cases. It was first defined in the fifth edition of the JCC in 1997, and well, it is still defined in the eighth edition. It is defined as a focus of invasion of the membrane of less than 1 mm, and in terms of this type of injury, well, we do not know much about it, since there is no proper consensus, there is a consensus currently published in relation to the management of in-situ breast cancer, but, in general, this type of injury is associated with major injuries, such as cancers greater than 3.2 cm in height, which present necrosis. In the studies of immunochemistry, the presence of CAI-67 is positive. In several retrospective studies, it has been shown that it is a cancer that has a worse prognosis than in-situ breast cancer, but it behaves in a similar way to in-situ breast cancer with comedal pattern. There is no consensus for the treatment, but, in general, the treatment is transferred to the surgical treatment that is used for what is in-situ ductal carcinoma. The difference with this is that it can have a probability of up to 20% of positive cancers, so, in patients with in-situ ductal cancer that is suspected or corroborated by microinvasion, it is necessary to perform this sentinel ganglion to determine if they should be subjected to Satsila. And, well, although in this study it was found that of 257 patients, 12% had positive ganglions, only 5 were macrometastasis, and also, well, in a follow-up to 11 years, only rectal cancer was found. So, it has not been shown that performing sentinel ganglion or Satsila dissection improves the survival or prognosis of these patients, since, in general, their prognosis is excellent. In summary, in-situ ductal cancer can be treated according to the clinical characteristics of the patient's injury with conservative surgery or mastectomy, and, well, we have to necessarily add RT, only in very specific cases radiotherapy could not be added. Another non-palpable injury that we find, and that is what we should frequently find, is early stage breast cancer, usually stage 1 clinical, and for this type of injury, the surgical options include mastectomy or conservative surgery. We know that conservative surgery, with many, is the treatment of the injury, as long as we have an adequate selection of the patient, in relation to the location of the injury, the size, the anesthesia of the mastectomy, and, mainly, that the patient wants to preserve his or her breast. Conservative surgery offers women the excellent option of preserving the breast without compromising their survival, as has already been demonstrated by studies from many years ago, such as NACBP 04, which currently already exists in publications of follow-ups of more than 20 years, where it has been demonstrated the safety of performing conservative surgery with radiotherapy in these patients, where it is shown that survival is practically similar. This is the other study, also published with 20 years of follow-up, these patients who were authorized to conservative surgery against mastectomy, and, well, it also shows that the survival rates are similar in both treatment groups, and that the recurrence rates do not change. Another point that has been without consensus for some years is the surgical margins that we need. In the studies that had previously been carried out, there was no adequate consensus on what should be the adequate margin for an invasive cancer, and, well, in 2014 this consensus was published, carried out by the Society of Oncological Surgery and the Society of Radiotherapy and Radiologists, where they demonstrated that the margins are an important factor of recurrence, that when there were positive margins in a surgical piece, the double risk of recurrence increased. Therefore, the current consensus is that, simply because there is no ink in the surgical margins, the patient has an adequate margin, and that by expanding more margins, the survival did not increase nor did the recurrence of these injuries decrease. And, well, this is applicable for all types of cysts, and for patients, even minors, or those that have extensive intra-ductal components. So, in short, in terms of breast cancer treatment in stage 1, conservative surgery is adequate, and that as long as the patient manages to have adequate margins, and that there is no contraindication for him to receive radiotherapy. Thank you very much. Thank you very much to all the participants of this block. We are going to have a break, and we will return at 9 a.m. Mexico time, 10 a.m. in the United States, at the headquarters of the organizers. Muchas gracias a todos los profesores por su participación. Muy amables. Muy buenos dias a todos, nuevamente regresamos de este receso, estamos en nuestro curso internacional de cáncer de mama, organizado por la Sociedad Internacional de Cáncer Ginecológico y el Colegio Mexicano de Ginecólogos Oncólogos. Esta es nuestra segunda parte de este primer sábado, recordar que el Congreso, el curso consta de tres sábados, este primer sábado que es el 27 de marzo, segundo sábado será el 24 de abril y el tercer sábado 29 de mayo. Es importante también recordarles que para sus constancias deben estar conectados los tres sábados. Pues bueno, vamos a continuar con este segundo bloque de esta mañana. Me voy a permitir presentar a nuestro siguiente panelista, es la doctora Milagros Pérez Quintanillas, ginecóloga oncóloga y es adscrita al Servicio de Tumores Mamarios del Instituto Nacional de Cancerología y del Hospital ABC en México. Le damos la cordial bienvenida a la doctora, ella nos tocará el tema de oncofertilidad y cáncer de mama. Adelante doctora Pérez, muchas gracias, bienvenida, la dejo en la pantalla. Hola, muchas gracias por la invitación. Primero a todo el comité organizador y a la IGCS por permitir presentar este tema que nos apasiona, yo creo que a la mayoría de los ginecólogos porque cubrimos dos áreas muy importantes, lo que es todo lo de ginecología y la parte oncológica. Voy a tratar de ser muy puntual, y siéntense con toda la confianza de preguntar al final, porque es un tema que es mucho para debatir. Primero esta es la agenda que vamos a hablar, primero tenemos la introducción, que es la definición de oncofertilidad, que es lo de las mujeres jóvenes menos de 40 años, que es la reserva ovárica o función ovárica, cómo vamos a evaluar esta función ovárica, cuáles son los métodos de preservación ovárica que tenemos, y posteriormente vamos a ver situaciones especiales, cuándo se puede dar un embarazo posterior a un cáncer de mama, y ahorita que hablando de mujeres jóvenes pues tenemos que hablar de las mutaciones PRCA. Se dice que aproximadamente se diagnostican entre 10 a 15% cáncer de mama en mujeres menos de 40 años, las cifras mundiales son aproximadamente de 5 a 7%, sin embargo en México tenemos una tasa hasta del 15% de mujeres menores de 40 años. Y de aquí surge el término de oncofertilidad, ¿qué quiere decir esto? Oncofertilidad es el abordaje oncológico con la preservación de la fertilidad. ¿Cuáles son los retos que tenemos en esto? Primero que nada, sabemos que las terapias oncológicas tienen un beneficio estimado, pero ¿a costa de qué? ¿El riesgo de la falla ovárica que me vaya a producir? ¿El impacto de la terapia endocrina de 5 a 10 años? ¿Cuándo voy a suspender o voy a valorar que esta mujer se pueda embarazar? ¿La seguridad? ¿Es seguro hacer una preservación de la fertilidad? ¿Es seguro un futuro embarazo? ¿Qué impacto tiene que yo guarde óvulos en mujeres que puedan tener una mutación PRCA? ¿Qué opciones tengo? ¿Cómo voy a hacer la predicción de la reserva ovárica? ¿Cuáles son las tasas de éxitos que voy a tener? Y si puedo usar los agonistas de la genera H. Tenemos que las mujeres menores de 40 años, 13% van a estar asociadas con un origen hereditario. De estas, el 90% va a ser por la mutación PRCA 1 o 2. El retraso de la maternidad, se dice que en la actualidad las mujeres están retrasando su maternidad. 5 de las mujeres menores de 40 años, 5 de 10 van a tener vida sexual activa. Menos del 50 de estas están utilizando un método de anticoncepción. Y uno de los retos que tenemos en la mujer joven es que los diagnósticos van a estar en etapas clínicas más avanzadas. Y esto va a ser que sean estirpete, peor pronóstico, generalmente triples negativo, ojer 2 positivo, y los retrasos del tratamiento. Se hizo una encuesta por el programa Joven y Fuerte, que voy a mencionarlo de último, donde encontraron que 30 a 50% de las mujeres tenían un deseo de un embarazo. Y que solo el 3 al 7% van a lograr un embarazo posterior al tratamiento. Pero esto no cambia en relación a las estadísticas mundiales. Se reporta únicamente 5% de embarazo en mujeres menores de 40 años, posterior a un cáncer de mama. La preservación de la fertilidad y cáncer de mama tiene 3 retos. Uno, el tratamiento oncológico, lo citotóxico, que nos van a provocar fallas ováricas prematuras. La terapia endócrina. Todos conocemos que el tamoxifeno es teratogénico. ¿Cuánto tiempo voy a usar la terapia? Y otro de los retos es la reserva ovárica. Las mujeres se comienzan a disminuir la reserva ovárica a partir de los 35 años. Para poder abordar esto, vamos a hablar, vamos a repasar un poco de fisiología de la ovogénesis. Todos sabemos que se va produciendo una trecea de los ovocitos desde las 20 semanas de gestación, que tenemos de 6 a 7 millones. Después que nacen aproximadamente un millón, las niñas nacen con un millón de ovocitos. Pero en la puberta ellas solo tienen 3,000 a 500,000. Cuando llegamos a los 40 años, a los 35, 40 años, probablemente solo van a haber 4,000 ovocitos. De estos, 400 van a ser ovulados en vida reproductiva. Entonces aquí tenemos que valorar bien la respuesta de la conadotropina e hipofisiarias, la FSH y la LH, y que va a permitirnos el desarrollo y la secreción de las hormonas esteroideas. ¿Qué es función ovárica? ¿Qué es lo que va a definirlo? ¿Qué falla ovárica? Realmente la función ovárica es el número absoluto de ovocitos. Nos van a definir el lapso reproductivo de una mujer. Esta imagen es súper gráfica. Podemos observar cómo a los 30 años el número de ovocitos se ha reducido a la mitad. Y vamos a definir ahorita en la siguiente cómo voy a evaluar una reserva ovárica y qué es una falla ovárica como tal. Los dos principales elementos para evaluar la reserva ovárica es la hormona antimuleriana. Esta fue descrita desde 1996 y esta se secreta en las células de la granulosa y nos va a evaluar los folículos preantrales y antrales. Y el contenido de los folículos antrales, que este lo vamos a realizar por medio de un ultrasonido transpaginal, necesitamos tener de 4 a 6 folículos antrales de 2 a 10 milímetros. Esto es muy importante saberlo porque muchas veces pedimos un perfil hormonal y realmente lo que nos va a medir la reserva ovárica va a ser la hormona antimuleriana. Lo que sí debemos de saber es que una hormona foliculoestimulante elevada es un dato clínico de menopausia. ¿Cuál es el impacto del tratamiento del cáncer de mama en la función reproductiva? Estos citotóxicos lo que van a hacer es una falla ovárica porque van a tener una afección directa a las células somáticas de la granulosa y las células antrales. Y además producen una apotopsia y una disminución del flujo sanguíneo que está bien reportado. Esto nos va a producir agotamiento prematuro de la reserva del folículo primordial. Existen muchos agentes alquilantes, hablando exclusivamente del cáncer de mama, la principal de alto riesgo de producir una falla ovárica es la ciclofofamida. Se dice que la mayoría de las mujeres entre 30 y 39 años, un 70% van a tener una menorrea si no se realiza alguna acción para la preservación ovárica y hasta el 80% mayores de 40 años. Cuando usamos adremicina o antraciclinas, este disminuye. El principal o el de mayor alto riesgo de agentes es la ciclofofamida con adremicina. El 35% va a entrar en una menorrea. Algo importante que debemos de saber es que una menorrea no es sinónimo de falla ovárica. Sin embargo, es un factor a tomar en cuenta para la evaluación. En 2019, el Dr. Lambert, quien es uno de los pioneros de la ONCOFEM. Una disculpa por la falla técnica. Vamos a pasar con nuestro siguiente panelista en lo que la doctora arregla su pantalla, su presentación. Voy a presentar al Dr. Santiago Escaso, profesor adjunto de ginecología obstetricia. El doctor nos acompaña desde Uruguay, desde la Universidad de la República Oriental de Uruguay. El doctor nos estará hablando acerca del manejo quirúrgico radical en cáncer de mama. Adelante doctor, bienvenido. Continuamos con su presentación y retiro mi pantalla. Muchas gracias. Hola, buen día, buenas tardes para todos. A ver si ahí comparte la pantalla. Well, first of all, I would like to thank the organizing committee, the Mexican School of Oncology and Gynecology for this opportunity to be with you. For me, it is a true honor and pleasure to participate in this day. I would like to thank the IGGS and, on behalf of Latin America, René Pareja for the momentum that the region is giving internationally. The topic that was asked of me to present is about radical surgical management in breast cancer. And I'm going to talk a little about the evolution to understand where we stand today. Regarding the background of this topic, there has been fantastic progress in the last cycle regarding breast cancer treatment. We have seen an unparalleled gain in terms of free interval of disease and global survival, as well as the reduction of morbidity in our procedures. We have gone from a range of radical and ultra-radical surgery to conservative techniques and oncoplasty concepts for the crazy regional management of the disease. We have evolved conceptually from a single treatment for all patients to an individualized treatment, a personalized medicine. The development of radiotherapy techniques, the adjustments of the chemistry and hormone therapy schemes, the development of Dr. Bastarget, have contributed to a radical and important decrease in the crazy regional recurrences and diseases. And today, it would practically not be justified to see women treated for breast cancer. Simply as a screenshot to see what has happened in the last century, and these are some of the points that we will touch on in this presentation. There is a history, there is an evolution, there is a revolution in terms of breast cancer management. The starting point to which I am going to refer, obviously, is Professor Halsted. At the end of the 1800s, more specifically in 1890, he published his surgical technique, which he called radical mastectomy. In 1994, he already has a follow-up of those patients, in which he publishes for the first time that there is a group of patients that can be cured of this disease. And there is an important crazy regional control of the disease. In 1907, he makes a more exhaustive follow-up of this case. And well, from then on, radical surgery became standard for breast cancer treatment in the United States. It should be remembered that at that time, the Halstedian theory, that is, the tumor had a centrifugal dissemination, compromised the seat organ, and then it was disseminated through the main lymphatic veins. It is important, and I recommend it to those who like the history of medicine. There is a report by the then director of the John Hopkins Department of Surgery, which talks about the legacy that Halsted left us in the history of surgery, and fundamentally in the history of the United States. Because one thinks of Halsted and directly relates it to breast surgery, but it was an impact that had in various areas. For example, I did not know, maybe many of you already knew, it was through him that we began to use rubber gloves, latex gloves, in surgery. It is a somewhat romantic story, because it was through seeing a dermatitis that his nurse had, in which he spoke directly with Goodyear, and they began to design the latex or rubber gloves that we use to this day. But it also had an important impact in biliary surgery, in hernia surgery, in digestive anastomosis, and what most impacted, which was together with three others in the directorate of the John Hopkins, Professor Osler, Professor Walsh, Professor Kelly, who designed what is until today the program of residencies and training of the United States, which was later disseminated worldwide. We have to keep in mind what that surgery was like. The surgery was a radical surgery that dried the skin, dried the mammary gland, in blockage with both pectoral muscles, a wide axillary cell-lymphatic dissection, with sacrifice, routinely, of the long thoracic nerve and the thoracodorsal vehicle. But this mutilating surgery achieved for the first time in history a control of the disease, which until then was a simply symptomatic treatment, and published at the age of three a local recurrence rate of 6%, a local-regional recurrence rate of 22%, and a survival rate of 40% at the age of 5, which was double compared to untreated patients. As I said before, the radical mastectomy of Halter was the standard surgical treatment for breast cancer in the United States, and more than 90% of women until the 1970s were treated with this type of surgery. Obviously, a mutilating surgery, a surgery that left sequels, lymphedema was the rule, chronic pain was the rule, it was a surgical bed that was often closed by second, by granulation. We also have to put ourselves in the context of that historical moment of surgery. But already in the region and in the world, several surgeons, several anatomists, began to visualize a less radical technique. These are two referent professors in the region, Professor Lorenzo Omero, from my country, Professor Fino Chieto, from Argentina, with anatomical studies and lymphatic drainage, who were looking for strategies to do axillary emptying without the need for the resection of the pectoral muscles. We also have to put in context the development of radiotherapy. Marie Curie, at the end of the 1800s, beginning of the 1900s, begins to speak, that is where the discovery of radio is made, the discovery of ionizing failures, but Professor Keynes is attributed to him in London, who was the pioneer in the management of radiotherapy with radio pins at the local and auxiliary level for the treatment of this disease. It is only in 1948 that there is an important change in the paradigm of surgery, which is the professor, Professor Pate is attributed to him, in which he confirms, he does a study of 13 years of follow-up, that radical mastectomy versus a modified radical mastectomy or less radical, which was with the preservation of the minor pectoral, we achieved the same oncological results, with much less morbidity and better cosmesis. This is a scheme for the youngest, showing the disinsertion of the minor pectoral muscle, of the apoxis coracoes, and the power left us clean for a complete axillary dissection of the three levels. These images I am going to thank Professor Roberto Cartaño, President of the Argentine Association of Mastectomy, in which they are photographs of a modified radical mastectomy of Pate. Pate himself already said that this surgery, although it achieved good regional local control, many of these patients were going to relapse at the distance level, because the concept was already beginning to appear that breast cancer was a systemic disease from the beginning, and that with the scalpel we were not going to be able to control the disease. At that time, Professor MacWhirter also appears, who is the one who designs the fields of radiotherapy, and the radiotherapy schemes that were used from then on, which are the tangential fields, so much heard today. We arrived in 1970, Professor Meiren describes, and names them like this, as modified radical mastectomy, in which the resection is carried out in block, breast, major pectoral aponeurosis, minor pectoral aponeurosis, but the preservation of both pectoral muscles, with the corresponding axillary emptying. At the time it was said that with this technique it was not possible to do an apical axillary emptying, but he could show it with studies and infosentellographics, that it could be technically reviewed, and that the neurovascular preservation of the minor pectoral was important, which was often damaged in the technique of axillary lymphoanectomy. At the same time, even in favor of the modified radical mastectomy, he questioned the need to have a systematic resection of the apical ganglions, what we know today as level 3 of Berg, stating that they should only be removed in case of evident commitment. This image seems very graphic to me, it is a woman with both surgical techniques, a radical mastectomy of Halsted on the right, a modified radical mastectomy of Madden on the left, and a recurrence at the level of the scar of the first surgery. In this eagerness to decrease the morbidity and the surgical sequels with the same oncological result, Miller and Kenney in the United States, but associated with Kai Johansson in Denmark, they do a 10-year follow-up of a total or simple mastectomy, plus radiotherapy with the fields of McWharter, and they showed the same oncological result in terms of local, contralateral recurrences, and at a distance of 10 years of follow-up with respect to the radical mastectomy of Halsted until then. So, no differences in 10 years. An iconic point is the 70s, is this publication by Professor Gianni Bonadonna. Gianni Bonadonna was an Italian oncologist who graduated from the Memorial in New York and who returns to Italy and participates as Technical Director of the Instituto Nazionale del Tumor in Milan, together with Umberto Veronese, and it is the first work that uses chemotherapy with a scheme of cyclophosphamide, metrotexate and 5-fluoracid for surgical breast cancer, showing a very important impact that until that time had been stable for 30 years with oncological results, a significant impact on local recurrences, decreasing from 22% to 5% in a follow-up at 27 years, a randomized study with approximately 200 patients in each arm, and the greatest impact was seen in the group of patients with very positive axilla, more than 3 grams. At that same time, two people appeared who made a radical change in the paradigm of how we have been addressing breast cancer so far. One of them is Professor Bernard Fischer in the NSABP collaborative group. This is protocol 04, in which he compared radical mastectomy versus simple mastectomy, more or less radiotherapy, in the group of patients with negative ganglions or in the group of patients with positive ganglions. It is from this protocol that the United States gives the role of radical mastectomy of Halsted and becomes the standard of care, total mastectomy with axillary emptying. In the following years, Fischer's own team and the group of Veronese from Milan, already at a time in which, as well presented today, mammography began to have a more important disclosure. In the 1970s, we could reach early diagnoses of breast cancer. Then they raised the treatment of conservative treatment that we know today. At the time, Veronese called it quadrantectomy, plus radiotherapy, plus axillary emptying, versus the radical mastectomy of Halsted, and Fischer called it lumpectomy, versus total mastectomy, in which they showed, they did a follow-up for 20 years of these patients, and they showed that there were no significant differences in terms of mestatosis at a distance, nor in contralateral breast cancer. At that time, from 1970 onwards, a series of randomized controlled studies evolved the concept of radical breast surgery, a radical mastectomy, more or less a total mastectomy with radiotherapy, a total mastectomy to a lumpectomy, or lumpectomy with radiotherapy, and so on, scaling surgical radicality, always maintaining the same oncological result. What happened at the axillary level? It begins to be seen, Berg describes the three levels, it is a surgical anatomical classification with respect to the lower pectoral, on the outside, behind, and above the lower pectoral. Kreil, for his part, begins to say that it is not necessary the axillary systematic emptying in all patients, that there are subgroups of patients in which mastectomy can be done, and in deferred, in the case of being positive ganglios, or clinically positive ganglios, it will be an axillary emptying. And the concept, a third fundamental pillar in this evolution that we have had, of radical mastectomy, total mastectomy, is the gangliosentinella biopsy. In 1993, the first article of gangliosentinella in breast cancer appears, this is due to the context, we had an increase in early diagnosis, smaller tumors, 75% of axillary emptying had negative axilla, the therapeutic role of axillary emptying was in doubt, and the associated comorbidity that is determined. There are two people who were the world leaders, one is Armando Giuliano, who publishes his first series in 1994, 174 patients, in which gangliosentinella was done, with blue at that time, more axillary emptying, later, and they show how the technique is necessary a learning curve in this technique, with a high sensitivity to it, a low level of false negatives, and that these false negatives even go down more as the technique is learned. He begins to talk about the technical issues of this procedure. But the drive, one of the most important drivers was Professor David Trach, from Vermont, United States. This is a pivotal study, in 1998, of 443 patients, and the analysis of the diagnostic technique of gangliosentinella, talking about the sensitivity, the negative predictive value, the positive predictive value, and concludes that the biopsy of gangliosentinella can predict the presence or absence of metastasis in patients with breast cancer, but that it is still a challenging technique, and that it must be experienced surgically, and correctly select the patients. I want to make a point because in 2000, we are in 1998, another iconic work appears, that of Peru and Surly, that change the concept of breast cancer as a unique disease to a molecular classification that 20 years later we continue to use in clinical practice, and is a fundamental part in the guide of our therapeutic decisions. I close parentheses and we continue with the history of gangliosentinella. Professor Crack publishes the NSVP-32 protocol, a study that took 8 years of gangliosentinella versus axial emptying in patients with clinically negative axial emptying. In the follow-up of 8 years, there is no significant difference, which concludes that in global survival, in free disease survival, in regional control, there are no significant differences between gangliosentinella negative and the appropriate, safe surgery in patients with clinically negative axial emptying and it can be avoided axial emptying, being this a point of inflection in our treatment of breast cancer. As in the approach of breast surgery, in axial emptying, the same, a revolution of studies of gangliosentinella in the 2000s, sentinella versus axial emptying, positive gangliosentinella versus axial emptying, the need for axial emptying in patients with mycometastasis, axial emptying versus axial radiotherapy, have been molding the treatment that we carry out today. In negative gangliosentinella, Crack, in positive gangliosentinella, Armando Giuliani, with this protocol, in 2011, published after 6 years of follow-up, and in 2017, published after 10 years of follow-up, in patients with gangliosentinella 1 or 2 positive, T1 or T2, in which a conservative treatment is done in the breast, plus complementary radiotherapy, axial emptying is not necessary. This has been the evolution, this is a diapositive of Professor Monica Morrow, in the 90s, gangliosentinella for patients with clinically negative gangliosentinella, in the 2000s, Giuliano, gangliosentinella, plus radiotherapy for patients with positive gangliosentinella, in the 2010s, we were in gangliosentinella post neoadjuvantia, and now, in the 2020s, we are really seeing the role of gangliosentinella, even in patients that we can omit gangliosentinella. I bring you simply a presentation of the ultrasound study. Humberto Beronesi himself, from there, from his beginnings, this was one of his last works, and the Enzyme Study, in which the selected group of patients could avoid the need for ganglion stagnation, as long as we have an axial ecography, as the colleagues have said before, that do not show pathological aneopathy. This is the San Gallen of this year, which ended last week, international consensus, in which a meeting of experts opinions on different topics regarding gangliosentinella, above what age could avoid the need for gangliosentinella in patients with clinically negative gangliosentinella, and well, notice that a high percentage, above 70-80%, in patients over 70 years, could avoid the need for gangliosentinella. So the concept today, in the management of breast cancer, depends on several factors, from the load of the disease, as the colleagues commented today, the reality in our country is very different, and within each country, the reality of the private sector is also different, we still have women with locally advanced breast cancer, but luckily the rule is that there is no need for gangliosentinella, so we can make decisions, see what availability of therapies, targets and drugs we have, for an integrated approach of patients with breast cancer. In 2010, a new line is opened, called the new mastectomies, and in the standard of care, it is the conservative treatment, in 15-20% of the initial stages, the tumorectomy cannot be carried out, either by a volume-mammary-volume-tumor relationship, in the case of recurrence, in the case of positive images, then the mastectomy in those cases is still necessary, but we have evolved in this concept of mastectomy, plastic concepts appear, and the era of oncoplasty appears. I'm not going to dwell on this much because there is a presentation on this topic, but both oncoplasty is for mastectomy as for conservative treatment, and here is Professor Benigno Aseo from La Coruña, explaining the general principles of oncoplasty. This publication is interesting, it is also a bit of history, how we have changed a mastectomy, a mutilating surgery, to a conservative oncoplastic surgery of the I.O. group, and how we have evolved and the revolution we have had in breast cancer, same patient, and a totally different oncological aesthetic result. These new mastectomies include the SkinSpark Mastectomy, the Skin Preservative Mastectomy, and the Orel-Apezón Complex Preservative Mastectomy. These techniques require an oiled surgical technique, and, well, more recent publications tell us about the importance of taking care of the impact of the residual mammary tissue that can be left in these surgeries, which are places of seats of local recurrences. To finish, I wanted to present a clinical case. These are the guides of the American College of Mammary Surgeons, in which, these are from 2017, the last one that is published, in which, although the standard treatment is the conservative treatment, in its group of patients, in which, as I said before, they will require the performance of a mastectomy. So we have to have the technique oiled. This is a 39-year-old lady, who we operated on in December, who consulted for a mammary tumor, 2 cm clinically, with a mammary prosthesis, as you can see in the digital mammography on the right, in which she had an area of ​​extensive microcalcifications, the puncture in an octane-filtering carcinoma, the luminal type, clinically a N0. We have, as a rule, systematic axillary echography, she had a suspicious ganglion, she had a puncture with a fine needle, which was negative. Given the volume-tumor-mammary relation, she applied for a mastectomy with sentinel ganglion. This is to show a little of the surgical technique. Right breast, marking of the injury. The performance of the collars. The identification, in the first step, of the sentinel ganglion, with intraoperative study, since the patient was going to have a mastectomy, because if we do not have the Z011 protocol open in the service. The mastectomy with the prosthesis, with the major pectoral ponobrosis, with the minor pectoral ponobrosis. The blockage. In the intraoperative, we are informed that the sentinel ganglion, there were two positive sentinel ganglions, so according to our protocols, we had to go to axillary emptying of levels 1 and 2. In this image, I do not know if it looks good, for the youngest, the anatomical description, this is the minor pectoral, major pectoral, the major serratum, the long thoracic nerve, the sub-scapular nerve, the sub-scapular peak, and the preservation of the intercostal nerve. Always keep anatomy in mind. And this is also from the last consultation in St. Gallen, a data that I found important, that within the standard surgical technique, which many times the intercostal nerve we saw sacrificed in the context of the blockage of the axillary component, today it is proposed that within the standard technique we must try to preserve, 84% were the answers, the intercostal nerve. Finally, for reasons of time, I can not show you, but I leave you this presentation, here you have the QR that you can take out later, which will take you to a video about a meticulous technique of radical mastectomy, with axillary emptying of the three levels, which is a procedure that is not usually necessary to do, but in this case it was breast cancer, residual post chemotherapy neoadjuvant. Well, thank you very much for your attention, again, thank you very much for the invitation, and I stay at the orders for the final discussion. Thank you very much, Dr. Santiago Escaso, excellent participation, and we are ready to continue with the program, we return with Dr. Milagros Pérez, who has already corrected the technical details, we are going to give up the microphone again to continue with the presentation of fertilization and breast cancer with Dr. Pérez. Doctor, go ahead, your microphone, doctor, if you can activate it. Yes, hello, I apologize for the technical problems, but we are already here. Yes, I think I had finished on the toxicity produced by the cytotoxics, and then the next point to take into account is endocrine therapy, right? One of the main points of endocrine therapy is that we are going to give it for 5 years, and in young women, premenopausal, because we all know the trials of ATOMS, where a benefit is shown up to 10 years, but then when are we going to stop so that this patient can get pregnant? Something important that we must know is that tamoxifeno will not affect us, nor will aromatase inhibitor affect us as such, the permanent cessation of ovarian fusion can produce amenorrhea, but a permanent cessation of ovarian fusion, right? Something important that we must know is that these patients must use an anticonception method, because they are drugs that are totally theratogenic. A trial is currently underway, which is the POSITIV, with which they seek to know, this is the leader of the study, Dr. Lambertini, and they seek to see the effectiveness of inhibiting endocrine therapy to achieve a spontaneous pregnancy. What they intend to do is give 18 to 30 months, women with endocrine therapy, wait 3 months without endocrine therapy, and spontaneously let the patient get pregnant and at the end of the pregnancy, continue endocrine therapy for 5 to 10 years. We are waiting for the results. What are the factors to take into account when we are going to select a treatment? First of all, we cannot forget everything oncological, the disease, in which clinical stage, the biology of the tumor, and whether they are carriers or not of mutations. When evaluating the patient's age, I already mentioned at the beginning that those over 35 years old, the ovarian reserve is expected to be lower. We have to evaluate if this patient has sexual life. Reproductive factors are essential to know what method of fertility preservation we are going to do, if it has a partner or not, if that patient really has reproductive desire. At the National Institute of Cancerology, I was surprised, I don't have the statistics, but more and more women who do not have a reproductive desire, and that must be respected too, if they have previous pregnancies, and something important that very few times we address is contraception. Many of our patients are using some oral contraceptive method or implants. Another factor to take into account is the social and cultural status of these women. A fertility treatment is not cheap. We must evaluate that aspect and what is going to happen to the two or three years with those embryos or those eggs that are stored, if we get to do it, and the psychological aspects of the patient. What are the techniques of fertility preservation at present? We have ovarian protection, which we are going to see right now with the H gene agonists. We are going to see a little of the evidence that exists, or the opheropexia that is being investigated, and the assisted reproduction techniques that we have, the cryopreservation of oocytes, or the cryopreservation of embryos, which are the ones that have been used for more than 30 years, and in the last 10-15 years have been used in oncology and are very safe. We have to take into account the new reproduction techniques that we have, such as ovarian tissue preservation, or transplantation of ovarian tissue, either subcutaneous or subcutaneous, or pelvis, and we must know that this is still being investigated. We are going to address a little more of these. The H gene agonists already in the fertility control guide in 2018 it is already that we can assess its use. Something very important is to know what is the main protection mechanism, which is the ability to inhibit the follicles entering a stage of growth by inhibiting the secretion of the stimulating hormone of follicles. Something important that you should know here is that patient follow-up with an H gene agonist, such as Gocereline or Euprolide, will not produce an elevation of FSH. What it will produce is estrogen, and we will realize that this patient is blocked when we have estrogen levels less than 10. There are 5 to 7 meta-analyses that support and support ovarian protection with H gene agonists. One of the main ones is the POEMS study, which shows that patients who used an H gene agonist achieved a 23.1% pregnancy rate in relation to the control group, which was with chemotherapy alone, which was 12.2%. Another important point that these studies evaluated and are evaluated in Dr. Lambertini's meta-analysis is the survival of free disease and global, and it is the same as the group of patients who used an H gene agonist versus chemotherapy alone. These are the recommendations of the ASCO guide, that you can offer an H gene agonist to patients with the hope of reducing the probability of ovarian failure induced by chemotherapy, but we are not 100% sure that this patient will not have an ovarian failure, so it should not be used by superimposing or not offering patients fertility preservation methods, already known as ovulation or embryonic cryopreservation. We are going to use this in patients who are not candidates for this. It is said that of all the patients in the meta-analysis, 873 patients included with the use of H gene inhibitors, 12.1% of the patients had an ovarian failure despite using the agonist. So it is not an absolute protection. Regarding the cryopreservation of ovaries and embryos, I am not going to delve into the technique as such, however, we must know that up to 75% of patients can achieve a pregnancy, have their failures as a whole reproduction method, and these are very dependent on the use or not of chemotherapy. Something that concerns us oncologically and that concerns the patient is that if the ovarian stimulation is surely oncological. Since 2006-2007, Dr. Obtai, biologist of reproduction, proposed the use of letrozole 2-3 days of the menstrual cycle to make a safe ovarian stimulation. With this, we are going to obtain ovarian and embryonic oocytes rates, just like a standard stimulation, but with lower estradiol levels, so we can offer the patient the preservation of ovarian and embryonic oocytes, and that this should mainly be done prior to a treatment with cytotoxics as soon as the oncological diagnosis is made, and that it is very safe. Here we can see in the COSLES study that they used agonists of H gene with gonadotropin and letrozole, and that the maturation of oocytes was very similar in relation to the patients who had a standard stimulation. What is the success rate of live births? I had already mentioned it, this goes from 20% to 75%, which will affect other criteria, not necessarily oncological, from the age and morbidity of the patient. The cryopreservation of ovarian tissue, I mentioned it previously, is experimental, it is generally being used and is an option for pre-puberty women, and what it consists of is more than anything to remove fragments of the ovarian cortex and transplant it either to pelvis, subcutaneous tissue, or to abdominal and thoracic. I put this picture that catches my attention because many times we say, or the patient and the doctor, the oncologist, both surgical and medical, says that I am going to delay the oncological treatment to offer some fertility preservation. And we really need only two weeks after the menstrual cycle so that the patient can do one of these treatments. In general, the cryopreservation of ovaries, whether they are mature or immature, we are going to offer it in women who do not have a partner. And in women under 30 years of age, in women over 35 years of age, embryo cryopreservation is preferred. And for the embryo, we require sperm. This is preferably for women who have a partner or who are candidates for a sperm donation. Regarding ovarian cryopreservation and transplant, this requires a surgical treatment and is still experimental. In summary, we are going to divide women, biologists of reproduction, when doing their fertility analysis, divide it into women under 35 years of age and over 35 years of age, as we mentioned at the beginning of the ovarian cryopreservation. However, in most publications, in fertility publications, they divide women under 40 and over 40. If we have a woman under 40, we evaluate her adrenal follicle and her antimolar hormone and conclude that this patient has a normal ovarian cryopreservation and will receive chemotherapy. The first option we should offer her is a controlled ovarian stimulation, either for ovarian cryopreservation or embryonic. If this woman is not going to chemotherapy and is going to receive tamoxifen from 5 to 10 years, fertility preservation should be evaluated with her with an agonist of H gene and talk very seriously about some anticonception method. Between women of 40 to 45 years of age, it is still controversial. We have to give the right to this patient. First, we have to do an analysis of her ovarian reserve before offering a preservation method. But what happens now? What do we live now in cancerology? We already have ovarian preservation, we already have embryos. How long am I going to wait to get pregnant with this patient? Is it safe for my patient? Literature indicates that we should wait two years, usually in early clinical stages. There are several trials. Mainly, there is POSITIV, which I mentioned previously. These are mainly in Europe. What they are looking for is to show that the pregnancy is safe. There are already multiple publications where they show that women who had breast cancer and later looked for a pregnancy did not have a higher risk of local recurrence or at a distance. Something that was found is a higher risk of premature pregnancies. What happens in the group of women with BRCA mutation? We have indicated risk-reducing surgeries with salpingoferectomy. The guides indicate that from the age of 35 a salpingoferectomy should be evaluated if this woman already had satisfactory parity. The publications are that we must take into account the hereditary risk. It has been observed that women with BRCA1 mutation have a lower ovarian reserve in relation to young women without mutation. This can lead to an early menopause. Ideally, in these patients, it is the cryopreservation of embryos so that we can do pre-implantation tests and always take into account the delay of the genetic result because in our country, as I suppose in most of Latin America, we do not get genetic results so soon. So many times we are not going to realize if this patient has a mutation or not. This must be taken into account. I want to share a little bit of what is done in Mexico. The program of young and strong women led by Dr. Cynthia Villarreal is a program that has been active since November 2014 in centers of reference in Mexico, the National Institute of Cancerology in Monterrey. It has five allied clinics. Approximately 500 women have benefited from it. Of these, 34 have had ovulation preservation, 10 of embryos, and there is a pregnant patient. It was not for ovulation and embryonic preservation. It was spontaneous, a 32-year-old patient who had tamoxifen. I hope that at the end of the program and the message I want to leave is that it is not just to achieve a pregnancy or just to preserve fertility, but it is the integral treatment that must be given to these women, both psychological as well as contraception support, which is also very vital, which sometimes we do not address. What do the guides say? From the NSCAN, ESMOR, the Spanish Society of Oncology, SANGALE, ASCO, is that all premenopausal women must be informed of the potential impact that chemotherapy will have on their fertility and the therapeutic options they have, fertility options they may have. I am saying that oncological treatments have a high global survival rate at present, but our patient must know that they may have a loss of ovarian function, that fertility preservation is not only for one person, it is a multidisciplinary management and that we have preservation options that we cannot overlook, such as degeneration agonists, that controlled ovarian stimulation is very safe and that post-pregnancy breast cancer does not have an impact on the recurrence of the disease. Thank you very much. I will leave you my email in case you have any questions. Thank you very much, Dr. Pérez. Brilliant participation. Very kind. I will introduce our next panelist. Next, we will have Dr. Robin Shaw-Dulin. She is a gynecologist and oncologist from the medical staff of the ABC hospital and the National Cancer Institute in Mexico, in the area of breast tumors. She will give us a talk on breast cancer surgery. Dr. Shaw, we thank you for your participation. I will leave you the screen. Very kind. Thank you. Good morning. Perfect. Good morning. It is a pleasure to be here with you. This is a very controversial topic. I think that most of us who do breast surgery always have the expectation of being able to help our patients through the therapeutic tools that we have at our disposal. And it is sometimes difficult to understand that sometimes doing less is more. So, in what specific cases, taking the words of Dr. Julia White we will always offer it to patients with metastatic breast cancer sometimes, or really never. So, for this we have to understand that approximately 5 to 10% of patients worldwide are diagnosed with metastatic breast cancer. And in countries like ours, this rate is up to 10% to 20%. So, metastatic breast cancer is considered incurable, and we know that it has a poor prognosis. In the 1970s, survival at 5 years was approximately 10%. However, in recent decades, with the advent of much more functional therapeutic elements, survival at 5 years can go up to 40% depending on the immunophenotype. We know that systemic treatment, of course, is the cornerstone of management in these patients. And we also know that surgery has a clear space when our patients have symptoms associated with their intact primary. So, these are patients who have bleeding, who have an infection of a voluminous tumor, who have pain or who are progressing. In these patients, the benefit is clear. However, it is in patients who have an excellent response to their systemic treatment and who achieve better survival, where the fact of offering or not offering primary control is really controversial. So, we have retrospective analysis that have shown a possible impact on survival, and some studies have been used that have data that are really conflicting so far. Now, what would be the pros and cons of offering surgery to a patient with metastatic breast cancer? Those arguments in favor mention that in multiple retrospective studies there is an increase in survival. There is also the hypothesis that surgery can eliminate the primary tumor as a source of stem cells, and in this way reduce the probability of new disease sites at a distance. Primary surgery can stop the secretion of growth factors such as the beta tumor growth factor, which can send signals that favor the implantation and growth of metastatic sites. It also reduces the possibility, of course, of uncontrolled local-regional disease, the eventual formation of a scab, for example. And it has the potential to improve quality of life, precisely through the control of local symptoms. Those who are against offering local surgical management mention that, in reality, survival has dramatically improved with modern systemic treatment, and that it is not necessary to add local control. There is also a lot of criticism that there are selection biases in retrospective analysis. In general, tumors in patients who are taken to surgery are smaller, have a lower load of systemic disease, have a higher percentage of patients with luminal cancer, and are generally younger patients. They also criticize the fact that there is a higher cost and therapeutic toxicity when adding surgery without a real benefit, and potentially the delay in administering systemic treatment. So, well, retrospective studies are multiple. What I think is most relevant is to present this meta-analysis, which is the most recent, published in 2018, where 19 retrospective studies were included, a total of 67,000 patients. And here it was seen that primary resection was associated independently with a better global survival, and a reduction of 35% was observed in the mortality risk of patients who were taken to surgery. However, they themselves in the discussion commented that the evidence is questionable, that they are retrospective at the end of the day, that they have biases, that the patients had limited metastases, they practically did not have a visceral disease, they were younger patients, they had a better functional state, and they were also selected according to their response to systemic treatment. Of course, that patient who does not respond to systemic treatment does not go to surgery. So, what do prospective studies tell us? Here today I am going to comment about four studies that are published so far, controlled randomizations, and from an observational prospective study that I find very interesting. We are still waiting for the publication in 2022 of a Japanese study that hopes to recruit or randomize 507 patients. So, that will give us even more information. But let's start with the study that was published last year, well, that was presented last year at ASCO by Dr. Sima Khan, which is E2108, a randomized phase 3 trial of the value of early local therapy for the intact primary tumor in patients with metastatic breast cancer. What they do is identify patients with breast cancer in stage 4 clinical with intact primary, they offer systemic treatment based on the characteristics of each patient and the immunogenotype of the disease, and those who did not progress after 4 to 8 months of treatment were randomized either to receive prolonged systemic treatment or to receive optimal surgical treatment, and this according to guides. If they could do conservative surgeries, they did conservative surgeries, if they deserved mastectomy for tumor volume or multifocality, mastectomy was offered, when necessary, radical axillary dissection was done and even the guides were applied to offer adjuvant radiotherapy after surgery, and the follow-up was 5 years. The primary objective was global survival and the secondary objectives were time, local-regional progression, quality of life, which they measured through an instrument at month 6, month 12, and month 18, and the presence of circulating tumor cells. So, this study recruited patients from 2011 to 2015, a total of 368 patients was included, finally randomizing to 256 of these, 131 of the patients in the systemic treatment arm and 125 in the local treatment arm. The average age of the patients was 57, in the vast majority, 2 thirds were postmenopausal, and the majority of the patients included were patients with locally advanced diseases. The average tumor size, for example, was 13 centimeters and 50% of the patients had cutaneous infection or N2 or N3. So, we can infer that a large part of these patients had very large tumor loads. So, well, once the patients were allotterated to receive local surgical treatment, 14 of these were not operated for different reasons and 109 patients were taken to surgery, where it is striking that only 87 patients achieved negative surgical margins. So, this is undoubtedly very questionable, and 74 of the patients later received radiotherapy according to specific indications. We can see here in this curve, after the follow-up period, that, in reality, there was no improvement in global survival, there was no improvement in free-of-progress survival, and when an analysis of the subgroup was done, according to the monophenotype, there was no improvement in global survival, in patients with GER2 overexpression, in patients with luminal tumors, and there was even a worse survival for those patients who had triple negative lymphoma. So, Dr. Khan concludes that local treatment should not be offered to the intact primary with the expectation of achieving a survival benefit. What is worth emphasizing is that a reduction in local recurrence or local progression was observed, however, there was no correlation with an increase in quality of life. That is, of those patients who were taken to surgery, only 10% had a local progression or recurrence, and those patients who did not receive surgery, a quarter of these patients had local progression. What are the criticisms? We have been commenting on them. The total number of patients who were randomized to the surgical arm was not operated on, there were no free margins in a large portion of the patients, there was a high percentage of patients with T4B, there was no analysis of the subgroup according to the metastatic site, and a great criticism is that the instrument of quality of life measurement was applied in 6, 12, and 18 months, with follow-up of up to 3 years. If we take into account that 25% of patients without surgery progressed locally, we can infer that probably after 3 years, their quality of life is significantly worse than those who did receive surgery. The next study that I want to bring to light today is the study of TATA Memorial. They proposed surgical resection after a complete or partial response to 6 treatment cycles with chemotherapy in combination with antracyclines. They recruited patients from 2005 to 2013 and finally had 415 patients with a partial or complete clinical response, of which they randomized to 350. The average age of the patients was 48 years old, half were postmenopausal, 2% had metastasis of the only site, and two-thirds were luminal patients. It is striking that 30% of the population over-expressed GERDOS. The primary goal was global survival at 2 years. They did not find an improvement in global survival, but they did find an improvement in free-of-progress local survival, as in the study of Dr. Khan. This was quite significant. What is striking and what can be criticized from this study is that only 8% of the patients who over-expressed GERDOS received white treatment. This could change a lot the statistics if they had received the appropriate systemic treatments. The next study is the MG07 study of the Turkish Federation. Unlike the previous studies, they randomized patients to local surgical treatment prior to systemic treatment. They selected patients with operable breast cancer. 312 patients were recruited, of which 278 were randomized. The average age was 51 years old. 78% were patients with luminal disease. Almost half of the patients were patients with bone metastasis. 29% were patients with bone metastasis. 90% of the patients received systemic treatment with chemotherapy based on anticyclines. The primary goal was global survival at 3 years. When they reported initial survival at 3 years, they observed an increase of survival at 9 months in the group that received local treatment. This is 46 versus 37 months. They found a survival at 5 years of 41% in patients who had been operated versus 24% in patients who had not been operated. Specifically, in patients with bone metastasis, they observed an improvement in survival at 5 years, 51 versus 29%. The survival was 14 months more in patients who were still operated. A sub-analysis in this study showed that the survival in patients who were under 55 years old, who had positive hormonal receptors, who did not overexpress and who had bone metastasis on a single site, were the patients who benefited more from local control. In addition, as in previous studies, there was an increase in local progression in patients who were not operated, 1 versus 11%. They also conclude that patients who have multiple metastasis, for example in the lung, liver, should not be operated because they even have a worse survival at 3 years. The Austrian Breast and Colorectal Cancer Study Group published their study, which is the ABS-CG28 Positive. They had a target of inclusion of 254 patients, recruiting patients between 2011 and 2015. They also, like the previous study, alienated the initial surgical resuscitation followed by systemic treatment versus only systemic treatment. This study closed prematurely because it had insufficient recruitment with a total of 92 patients. The average age was 62, 87% were postmenopausal, 63% positive receptors, 40% with bone infection as the only site of metastasis and 64% received hormone therapy as systemic treatment. The primary goal was a global survival at 3 years. They observed an average of 37.5 months. They did not observe a global survival improvement at 3 years and did not show an improvement in average survival. They also showed a tendency to a lower incidence of local progression, like all previous studies with a less significant one. This next study is the study of Dr. Terry King which I find very interesting. They selected patients with a partial, complete or stable response to a first line of treatment and then channeled them to discussion to decide if they wanted to receive surgery or not together with their medical team. 85% of the patients were classified as responders. This is 94 out of 112 patients. The average age was 51 years. The average tumor size was 3.2 cm. They were smaller tumors. They were luminal patients at 63%, triple positive patients at 21%, and triple negative patients at 8%. After an average of 54 months, they observed that the best survival rate was marked by the response they had to systemic treatment. Those patients who responded to their first line systemic treatments had a survival rate of 3 years at 78% versus those who did not, who had a survival rate of 3 years at 24%. Of those patients who responded to their initial systemic treatments, 41% chose surgery. There was no impact on the survival rate at 3 years. The survival rate in one group and the other was 77% versus 76%. However, what is very interesting here is that the subgroup HER2 positive had a survival rate of 3 years at 75% in the group that received surgery versus 75% in those who did not receive surgery. What is also emphasized is that the patients who chose surgery had more voluminous tumors. Therefore, the local symptomatology was more evident. They were more likely to have a single site of metastatic disease. There is a regional study consisting of clinical trials. Practically all of them mention that there is an improvement in local control. There is a crossover of approximately 10% of the studies in those arms that were not randomized to surgery. Finally, this percentage of patients develops local situations that deserve intervention. Of course. As long as there are local symptoms or progression, surgery in the metastatic breast cancer scenario is an option. Through the study of the Turkish Federation, we know that we can consider those patients who have single site metastatic osteoarthritis, those young patients, and those patients with indolent diseases. Dr. Terry King's study also makes us question whether in those patients who are HER-positive and have spectacular responses, they can also potentially benefit from surgical treatment. In the end, metastatic breast cancer surgery is focused on palliation and symptom control. In reality, there is no consistent data that can make us think that there is an improvement in global survival. But it does reduce the subsequent local progression. Finally, up to 20% of our patients will develop at some point local symptoms that will lead us to surgery. The local-regional treatment must be reserved for those patients who are symptomatic or who are progressing. Of course, the clinical trial in those patients who have the possibility of having quite long remission times, and those patients who are candidates for systemic treatment with novelties such as CDK46 inhibitors, mTOR, Pertuzumab, or the TDM1 molecule. We will evaluate case by case after 6 to 8 months of systemic treatment according to clinical trial and patient preference. It is suggested to choose patients with a good performance status, who have oligometastasis, non-visceral metastasis, single site metastasis, young patients, and patients with LUMINAL or HER2 with intense response. The NCCN, of course, leaves us with the door open and they ensure that the available data does not support the general use of local treatment, but that it can be a reasonable alternative for patients who respond to local systemic treatment. And remember that these decisions must always be taken in the scenario of a multidisciplinary team and also take joint decisions with our patients by presenting all these elements. Thank you very much. Thank you very much, Dr. Shaw. Excellent participation. I would now like to introduce Dr. Patricia Villarreal-Colin. Dr. Silvia Patricia Villarreal-Colin is a gynecologist-oncologist and is enrolled in the Department of Tumors and Mammaries of the National Institute of Cancerology in Mexico City. She will be talking to us about primary oncoplastic surgery in breast cancer. At the end of this talk, we will finish this morning's block and Dr. Guillermo Herber will be coordinating 20 minutes of questions and answers with all the panelists. If you want to join us, you can send your questions in the chat and the doctor will be coordinating them. We leave Dr. Villarreal-Colin with her presentation. Thank you very much. How are you? Good morning, good afternoon. It is a privilege to be with you in our first international talk on breast cancer. I thank you for the invitation to be with you. The topic I would like to discuss with you is something about primary oncoplastic surgery in breast cancer, which is increasingly flourishing, fortunately, for the benefit of our patients. Breast cancer treatment is a multidisciplinary treatment where surgery, chemotherapy, radiotherapy, immunotherapy, and white therapy are very much at hand, depending on each patient in particular. Surgery is and will continue to be an angular part of breast cancer treatment, especially in early cancers. Achieving a balance between controlling the disease and offering the patient a satisfactory quality of life is sometimes something difficult to achieve. We know, as has already been mentioned in previous talks, that surgery is an important part of breast cancer. The role of mastectomy versus conservative surgery has also been established. We have several publications with follow-ups of more than 20 years. We do not find a difference in terms of global survival comparing patients subjected to local therapy with conservative surgery plus radiotherapy versus patients subjected to mastectomy. When more recurrences were found, these were generally associated with poor surgical technique, inadequate selection of cases, or the intrinsic aggressiveness of tumors. Recently, a few days ago, this new article was published, in which, comparing a database of more than 100,000 patients, in which women undergoing conservative surgery and malaria therapy were compared, versus patients undergoing mastectomy, it was found that, in fact, not only is there no difference in global survival in patients undergoing malaria conservation, but rather, global survival was better for patients with this type of procedure versus mastectomy. Next slide. When it was separated by clinical stage, it was found that this difference remained. Next slide, please. Y vemos como aquí en la etapa uno se sigue observando esta mejoría en la supervivencia en las pacientes sometidas a cirugía conservadora. Y, nuevamente, en la etapa dos, esta diferencia parece ser mucho mayor. Y, según las gráficas, pareciera que esta curva se va abriendo a lo largo del tiempo. Próximo. Next. Entonces, ¿qué mujeres deben de llevarse a cirugía conservadora? Pues, en primer lugar, la paciente debe de tener el deseo de preservar la mamá. Idealmente, debería ser una enfermedad unifocal, de preferencia tumores pequeños menores de 3 centímetros. Algo importantísimo es que debe de haber una ausencia de microcalcificaciones difusas y, por supuesto, que la paciente quiera y pueda recibir tratamiento con radioterapia, es decir, que tenga la accesibilidad para este tipo de manejo. Next. Existen, por supuesto, contraindicaciones absolutas, como son el primer y segundo trimestre del embarazo, debido a que el tiempo que va a transcurrir entre la cirugía y el inicio de radioterapia puede ser prolongado y, tal vez, el beneficio de este tratamiento no sea el óptimo. También, una contraindicación absoluta es la presencia de multicentricidad o de microcalcificaciones difusas, como se ejemplificó en esta imagen de mastografía, el extenso componente intraductal y el antecedente de radioterapia previa, que tal vez dificulte volver a dar tratamiento nuevamente a esa mamá. Next. Dentro de las contraindicaciones relativas, pues estas tal vez podríamos ya incluso casi tacharlas, que son una mala relación mama-tumor, los tumores centrales y los de enfermedades de la colágena por el advenimiento de este grupo de cirugías que son las cirugías oncoplásticas. Next. Y, bueno, estos procedimientos, pues, no están exentos de riesgos. ¿Cuáles son los riesgos de la cirugía conservadora? Pues, en primer lugar, la posibilidad de una recurrencia local, que generalmente esta sucedida a la aparición de una nueva lesión cercana al sitio de la cirugía previa, la aparición de segundos primarios y psilaterales, es decir, tumores que tienen una histología diferente al tumor inicial y que generalmente aparece en un cuadrante diferente al sitio donde ya se trató. También la dificultad para el seguimiento de estas mujeres, ya sea por el mismo procedimiento quirúrgico o por el hecho de haber recibido redotraque donde la mama puede tornarse sumamente densa y hacer más difícil la interpretación por imagen de esa mama en seguimiento. Y, por supuesto, algo sumamente importante es el riesgo de deformidad, la cual puede ser inmediato o puede ser tardía. Tener, obviamente, estos resultados cosméticos, pues, no es lo ideal. Estoy segura que todos los que hemos tratado pacientes con cáncer de mariposa The type 2, where we see an insufficient amount of skin or subcutaneous tissue or the combination of both. The type 3, where there is an important retraction of the tissue. And the type 4, which is the highest degree of deformity, generally associated with the use of adjuvant radiotherapy. Y bueno, es justamente por este gran número de pacientes que tienen un resultado cosmético no satisfactorio o que presentan alguna enformidad después de la cirugía conservadora de mamá, por lo que surge este nuevo concepto que se llama cirugión coplástica. Hay muchas definiciones sobre este término, sin embargo, una de las que más me parecen a mí, es que la describe como la más avanzada expresión de la cirugía conservadora de mamá, donde el objetivo es conservar el parenchyma mamario con un excelente resultado cosmético, pero siempre teniendo en cuenta respetar los principios oncológicos de la radicalidad. Se describe como una tercera vía de tratamiento, teniendo obviamente por un lado la mastectomía y por otro lado la cirugía conservadora tradicional. Se describe en una tasa de resultados cosméticos deficientes tan alta como 30-40% de los casos. Entonces, ¿qué implica una cirugía oncoplástica? Pues bueno, esto implica la remoción de un volumen ideal del parenchio mamario suficiente para reducir el riesgo de recurrencias locales. Con este tipo de procedimientos, podemos dar márgenes más amplios. Por ejemplo, en casos de carcinoma in situ, donde se describen que los márgenes deben ser mayores, o pacientes, por ejemplo, con tumores lobulares, donde tal vez el margen a la palpación puede ser difícil de evaluar. También nos evita la deformidad mamaria, especialmente en tumores localizados en cuadrantes de riesgo, que más adelante se los comentaré cuáles son estos, y aumenta las indicaciones de conservación mamaria, y esto obviamente reduce la necesidad de hacer más tectomías en un gran número de pacientes. Este grupo de procedimientos fueron descritos desde los años 80 en el Instituto Gustavo Rossi por el Dr. Petit. Sin embargo, el término fue acuñado hasta 1998 por el Dr. Aldrich. Y para el año 2003, el Dr. Krishna Clough fue el que en realidad retomó este grupo de procedimientos y le dio mayor difusión con la publicación que presentó en este año. ¿Cuáles son entonces los objetivos de la cirugía oncoplástica? Pues, muy importantemente mejorar la calidad en el tratamiento quirúrgico, y esto basado en tres principios, como son un mejor control local oncológico de la enfermedad, ofreciendo la oportunidad de dar márgenes más amplios, una mayor preservación de la glándula mamaria, al tratar pacientes que a lo mejor podrían estar condicionadas para una mastectomía si no se aplicaran este tipo de procedimientos, y por supuesto mejorar el resultado cosmético en los pacientes con conservación mamaria. También nos puede ayudar a mejorar la planeación de los campos de radioterapia. Esto, por ejemplo, de ejemplo típico sería una paciente con macromastia donde tal vez la conformación y el volumen mamario sería difícil de incluir en los campos de radioterapia, entonces hacer una mamoplastia de reducción en estos casos realmente ayuda a mejorar el tratamiento con radioterapia. También nos ayuda a evitar la duplicidad asistencial, ya que el mismo quirúrgico, ya sea ginecólogo, oncólogo, cirujano-oncólogo, con la capacidad de hacer estos procedimientos, hace el procedimiento de resección oncológica y de reconstrucción. Y esto, por supuesto, implica una disminución en los costos de atención para todas nuestras pacientes, lo cual es importante en países como el nuestro donde tal vez los recursos pueden ser limitados. Hay muchas clasificaciones de este tipo de procedimientos. Una de ellas las describen como las técnicas de desplazamiento glándular o las de reemplazamiento glándular. Dentro de los desplazamientos, pues tenemos la remoción o remodelación glándular con patrones como el rumblog, el badwin, la rotación de colgajo, el patrón lateral y las típicas mamoplastias de reducción que pueden ser la típica de té invertida, la de rama única vertical o las técnicas de grisote. Y dentro de las técnicas de reemplazamiento, pues los colgajos ya sean colgajos laterales, laterales tóraco-dorsal, el tóraco pigrástico o de músculo dorsal ancho. Sin embargo, creo que la clasificación que propone el doctor Krishna Glove es mucho más descriptiva sobre las formas de tratar a los pacientes. Él describe dos tipos de cirugías oncoplásticas o dos niveles de cirugías oncoplásticas dependiendo de la cantidad de tejido de resecar y de la dificultad quirúrgica que implica cada uno de estos procedimientos. Dentro del nivel 1, pues tenemos que la resección tumoral es generalmente menor del 20% del volumen mamario. Generalmente no se requiere una resección amplia de la piel y casi siempre va acompañada de una centralización del complejo de la presón. En cambio, en el nivel 2, estas son cirugías mucho más complejas, implican la remoción de volumen mamarios que van de un 20 al 50%. Casi siempre van acompañadas con alguna técnica de mamoplastía de reproducción y estas implican resecciones de piel y remodelamiento de la mama importante. ¿Cuáles son las indicaciones oncológicas de los procedimientos oncoplásticos? Pues justamente esto, la necesidad de secciones extensas del volumen mamario, 20-40%. Hay estudios comparativos donde mencionan que el volumen o el peso promedio de una cirugía conservadora generalmente va de 40 gramos versus 220 gramos en una cirugía oncoplástica. El volumen promedio también es mucho mayor para los procedimientos oncoplásticos. Otra de las indicaciones oncológicas es la necesidad de márgenes libres. Ya está bien documentado que con mayor margen quirúrgico, la probabilidad de tumor residual se disminuye. Pacientes con tumores voluminosos mayores de T2 también son pacientes elegibles para una cirugía oncoplástica. ¿Cuál es un ejemplo de esto? Por ejemplo, pacientes con tumores musinosos que sabemos que responden poco a quimioterapia, que responden poco a hormonoterapia, que no responden a radiación. Entonces, tal vez esto es una paciente candidata ideal para hacer una cirugía oncoplástica y evitar una mastectomía. Pacientes con extenso componente intraductal o histologial o bolillar. La anterior, por favor. Pacientes que no son elegibles para mastectomía con reconstrucción porque tengan alguna contraindicación o que por cuestiones económicas no puedan ser susceptibles a algún procedimiento reconstructivo. Y, por supuesto, y antes que nada, que la paciente desea conservar su mama. Dentro, la que sigue de las indicaciones cosméticas, pues es que tengamos una paciente con una relación mama-tumor desfavorable. La localización central del tumor, esto era antiguamente una indicación absoluta de mastectomía. Ahora, afortunadamente, con estas técnicas podemos conservar la mama. Pacientes con localización tumoral en sitios de riesgo, que estos riesgos son sobre todo de deformidad cuando está dentro de los cuadrantes superinternos y los mediales. Cuando hay una simetría mamaria-optosis significativa. En pacientes con una necesidad de reducción mamaria, hablábamos del ejemplo de una paciente con macromase, que más adelante les mostraré una imagen. Cuando de antemano anticipamos un resultado cosmético desfavorable, si hacemos una cirugía conservadora tradicional. La que sigue. ¿Cuáles son las contraindicaciones relativas? Pues tumores extensos de localización medial. Sabemos que es el sitio de la mama donde existe menor volumen glandular. Mamas con pequeño volumen y que no presentan tosis. Pacientes que han recibido previamente radioterapia. Pacientes con grandes resecciones de piel fuera del área de mamoflastía. Pacientes también que tengan tabaquismo o diabetes no controlada. Y algo también importantísimo es una contraindicación relativa a aquellas mujeres que ven este tipo de procedimientos como un procedimiento cosmético y no como un procedimiento oncológico. Entonces, si esta paciente tiene unas expectativas exageradas en relación a cómo va a ser su resultado cosmético, pues tal vez no es la mejor candidata. La que sigue. Existen muchos patrones oncoplásticos. Dependiendo de la localización o del cuadrante de la mama que se va a tratar, dependiendo del volumen mamario, existen ciertos patrones sugeridos. La que sigue. Aquí les muestro para el cuadrante superior externo, dependiendo del volumen mamario, y también obviamente dependiendo del volumen tumoral, existen varios patrones sugeridos. La que sigue. Esto es para cuadrante superior interno. La que sigue. Cuadrante inferior interno. Próxima. El inferior externo. La que sigue. Y, finalmente, la porción central que, si se fijan, pues tenemos varias opciones de tratamiento. La que sigue. ¿Cuáles son los puntos importantes a considerar cuando vamos a ofrecer un procedimiento oncoplástico? Pues, bueno, tenemos que tener en cuenta cuál es el tamaño del tumor, la localización del tumor, el volumen mamario, la densidad de la mamateria también es algo importante a considerar. Si existe la evidencia de multicentricidad o multifocalidad, la distancia que existe entre el tumor y el complejo aéreo, son para saber si se debe o no se debe resecar, el grado de etosis mamaria, si existe simetría o asimetría mamaria, y el antecedente de cirugías previas, incluyendo cirugías plásticas. La que sigue. Una vez que vamos a considerar una paciente para un procedimiento oncoplástico, pues tenemos que tener en cuenta estas tres mediciones importantísimas para lograr un resultado cosmético satisfactorio. Uno de ellos es la distancia que existe entre la horquilla externa o el borde infraclavicular hacia el pezón, que debe de ir de 19 a 21 centímetros. Otra distancia importante es la distancia que existe entre la línea media y el pezón, que normalmente debe ir entre 9 y 11 centímetros. Y otra distancia que es sumamente importante, que a veces se pasa por alto, es la distancia que existe entre el pezón y el surcomamario, la cual no debe ser de más de 8 centímetros. Dejar mayor dimensión en este polo inferior pues va a hacer que el polo inferior se sobreexponga y va a tener un resultado cosmético inadecuado. La que sigue. Aquí les explico con una paciente en quirófano cómo estamos haciendo el marcaje del nuevo patrónico plástico. Vemos aquí la proyección en una línea dibujada del surcomamario, la nueva localización del complejo Aruela Pezón. La que sigue. Algo también sumamente importante es que debemos de tener una evidencia fotográfica de los casos clínicos y fotografías de la paciente de frente, oblicuas, laterales, con los brazos a los lados, con los brazos en alto. Tener una iluminación adecuada. Idealmente tener un fondo liso azul de preferencia y sobre todo pues obviamente respetar la privacidad del paciente. Documentar las imágenes preoperatorias, posoperatorias inmediatas y posoperatorias tardías. Y si existe algún dato de interés en la imagen clínica, por ejemplo en este caso la presencia de una lesión en la proyección del pezón en el surcomamario y que fue el motivo de por qué elegir este patrónico plástico en particular. La que sigue. ¿Cuáles son los pasos de los procedimientos oncoplásticos? Pues bueno, veíamos que en primer lugar, la que sigue, es la planeación del abordaje, teniendo en cuenta todos los aspectos que ya habíamos comentado. La que sigue. Una vez que ya estamos en quirófano, pues hacer la resección tumoral con todos los principios oncoplásticos, dar un margen quirúrgico tridimensional libre. La que sigue. La movilización del complejo aerolapezón que casi siempre va de la mano de todos estos tipos de procedimientos. La remodelación mamaria, que implica movilización del tejido glandular para dar una mejor conformación a la mama. El manejo de la axila que requiera la paciente. Cada caso en particular se debe de individualizar. Y finalmente, y en un gran porcentaje de los casos, la asimetrización de la mama contralateral. La que sigue. Y bueno, dentro de la planeación del abordaje, si tenemos una paciente con una cicatriz de una resección tumoral previa, que eso es frecuente que lo veamos en nuestra consulta, tenemos que incluir dentro del patrón elegido esa cicatriz porque hay que resecarla. Sabemos que si esta paciente la llevamos solamente a una ampliación de los márgenes, seguramente tendremos un defecto tipo uno en cuanto a las deformidades de la mamá, porque vamos a disminuir todavía más este polo con poco tejido glandular, y el resultado cosmético pues no va a ser el adecuado. Seguramente se lateralizará el complejo de la pezón, se retraerá, y pues no son parte de los objetivos de este tipo de procedimientos. Entonces debemos de incluir un patrón en el que podamos resecar esa cicatriz quirúrgica. La que sigue. La que sigue. También tenemos que tener en cuenta entonces la localización del tumor. Esta paciente con un tumor en el radio L6 cercano al surco mamaro. La que sigue. Sabemos que si hacemos una resección convencional solamente de esta zona, nos va a causar una deformidad que llamamos en pico del oro. La que sigue, por favor. Que es justamente amputar todo este polo inferior y nos dejará este resultado cosmético totalmente inaceptable. La que sigue. Es por eso que para esta paciente en particular su mejor opción terapéutica será hacer una mamoplastía de reducción con un patrón vertical de doble rama con la preservación del polo superior para poder resecar todo este polo inferior. La que sigue. Y dejar un resultado cosmético adecuado. La que sigue. Y bueno, estando en quirófano, lo primero que tenemos que hacer es marcar todas las líneas de interés que son justamente la nueva localización del pezón. Aquí estamos proyectando el surco mamaro para poder dibujar hacia la parte anterior cuál será la nueva localización del complejo de la pezón. Esta distancia recordemos que debe ser entre 19 y 21 centímetros. Medimos la distancia que tendrá en la mama que vamos a tratar oncológicamente y esa misma medida la tenemos que proyectar hacia la mama contralateral. En la mayoría de los casos se requerirá hacer un procedimiento de simetrización. Yo personalmente prefiero siempre hacer el mismo patrón oncoplástico en la mama sana porque el resultado cosmético pues será mejor. La que sigue. Después de esto tenemos que hacer el marcaje quirúrgico de todo el patrón oncoplástico, hacer la deshipitalización de la zona que vamos a movilizar. Esta zona en particular, como aquí está dibujado el tumor, pues no tenemos que deshipitalizarlo porque esto se resecará en un bloque. La que sigue. Tenemos que hacer la resección tumoral bajo todos los principios oncológicos. Es importante dar un margen tridimensional adecuado. Lo mínimo que se sugiere es hacer un margen a la palpación de un centímetro. Obviamente en este tipo de patrones a veces es más fácil dar márgenes más amplios. La que sigue. Algo importantísimo es hacer la referencia de los márgenes que puede ser como en este caso lo hacemos nosotros con material de sutura con sedas o se puede hacer con tinta o se puede hacer con grapas. Entonces es importantísimo esto para el patólogo y para nosotros saber si existe algún margen quirúrgico cercano comprometido, saber exactamente cuál es el que tenemos que resecar. Les pongo aquí el estudio transoperatorio muy señalado porque esto es algo importantísimo en este tipo de procedimientos debido a que normalmente hacemos grandes movilizaciones del tejido glandular, que el momento quirúrgico inicial es el mejor momento para hacer la ampliación de márgenes si es que es necesario. Hacer una ampliación de márgenes en una paciente posoperada de este tipo de procedimientos a veces se torna difícil. Entonces el momento transoperatorio es el momento ideal para hacer el estudio transoperatorio que nos diga el patólogo si existen todos los márgenes libres y si existirá alguno cercano comprometido pues hacer la reexcisión. La que sigue. La hemostasia meticulosa es importantísima para evitar la formación de hematomas que vayan a comprometer el resultado cosmético de la paciente al prevenir infecciones. La que sigue. Y nuevamente, algo sumamente importante en este tipo de procedimientos es la colocación de grapas o clips quirúrgicos en los márgenes tumorales. ¿Por qué? Porque en la gran mayoría de los casos el lecho tumoral no va a coincidir con el sitio de la cicatriz. Entonces para el radioterapeuta es importante saber a dónde específicamente tiene que dirigir el bus en caso necesario de que la paciente lo amerite. Entonces siempre debemos de colocar estos clips en los cuatro puntos cardinales y en el lecho quirúrgico. La que sigue. Después de esto, generalmente se va a requerir la movilización del complejo a la persona, la remodelación del tejido glandular para lograr el mejor resultado cosmético como se los muestro en estas imágenes. La que sigue. El manejo de la axila, pues es algo que tenemos bien claro que tenemos que hacer durante el procedimiento quirúrgico para que la persona no se mueva. Entonces es algo que tenemos bien claro que tenemos que hacer durante el procedimiento quirúrgico primario. Este puede hacerse dependiendo de lo que requiera la paciente, ya sea anglocentinela, ya sea disección radical de axila. ¿Con cuál técnica? Pues la que tengamos disponible radio coloide, azul patente, verde hidroxilina, lo que tengamos disponible. Normalmente yo el abordaje de la axila siempre la hago dentro del mismo patrón noncoplástico. Casi siempre se puede para evitar una incisión adicional. La que sigue. Y bueno, finalmente, en un gran porcentaje de los casos se requiere algún procedimiento de simetrización que les comentaba yo que particularmente eso quiero hacerlo con el mismo patrón noncoplástico que hicimos en la mamá con cáncer. La que sigue. ¿Cuáles son las desventajas de estos procedimientos? Pues obviamente que implica una dificultad importante para la reexcisión, como se los comentaba, al mover importantemente el tejido glandular. Pues a veces será difícil saber dónde quedó cada margen, que aunque lo dejamos marcado con grafas, pues a menos que quien haga la reexcisión sea el oncólogo que la operó inicialmente, tal vez será muy difícil hacer una adecuada ampliación de márgenes. De ahí la importancia de hacer el estudio transoperatorio durante la cirugía inicial. Por supuesto que implica un mayor tiempo quirúrgico porque pues tenemos que hacer toda la movilización y la remodelación de la mamá y generalmente pues requerirá la simetrización contralateral y debido a eso pues también existe una mayor pérdida en mátrica. La cual obviamente con una técnica quirúrgica adecuada pues será mínima. La que sigue. ¿Cuáles son las complicaciones? Pues la presencia de necrosis glandular, necrosis grasa, obviamente infección, nematomas, eromas y por supuesto la posibilidad de deformidad. La que sigue. Y les muestro rápidamente algunos patrones oncoplásticos con casos clínicos míos. La que sigue. Vamos de los patrones más sencillos que es el Romblo, una paciente con un tumor periodular que fácilmente puede ser abordada con este patrón. Hacemos una simetrización contralateral. La que sigue. El patrón lateral. Este caso a mí me gusta mucho presentarlo porque fue de mis primeras pacientes hace ya prácticamente 10 años que empezamos con la cirugía oncoplástica en el Instituto de Cancerología y esta paciente la rescatamos de una mastectomía. Estaba ya programada para mastectomía. Tenía un antecedente de una tumorectomía, por eso la simetría tan importante. Y bueno, si pueden observar aquí el resultado cosmético, pues fue bastante satisfactorio. Ella ya tiene casi 10 años libre de enfermedad y su resultado cosmético es este. La que sigue. Este es otro patrón que también es bastante sencillo. El patrón horizontal en alas de murciélago. La que sigue. El patrón de grisote, que implica la remoción de la porción central de la rama. En este caso, lo que hicimos fue un patrón vertical de doble rama con la preservación de la isla de piel del polo inferior para hacer la reconstrucción de lo que podría ser su nueva viola. Estos fueron los primeros casos. La que sigue. Otro patrón grisote donde vemos una franca afección del complejo de alpesón de la mama derecha. Este paciente nuevamente se preservó esta pequeña isla de piel para hacer la forma de la nueva arola que posteriormente se podría tatuar. La que sigue. Este es uno de los casos también que me gusta presentar porque es una paciente con unas mamas muy voluminosas con macromacia donde dar tratamiento con radioterapia esta mama tan voluminosa se tornaría difícil para la radioterapéutica por los campos de radioterapia que son difíciles de conformar. Esta paciente lo que hicimos fue una mamoplastia de reducción. Si se fijan, tiene dos arpones porque tenía dos lesiones. Redujimos el volumen mamal e hicimos una simetrización contralateral y el resultado cosmético fue impresionante. La paciente tiene actualmente siete años libre de enfermedad y con un resultado cosmético espectacular. La que sigue. Este es otro caso de una mamoplastia vertical pero ahora con periculo superior. La que sigue. Y a medida que fuimos avanzando en las técnicas lo que yo empecé a hacer fue hacer precisamente un patrón con cercaría a la resección del pezón. Hacer la reconstrucción del complejo de la pezón con esta misma isla de pie haciendo tanto la reconstrucción de la arola como del pezón en el mismo tiempo quirúrgico. Este paciente fue llevado también a ganglia sentinela a través del mismo abordaje. La que sigue. Este es otro paciente también con una reconstrucción del complejo de la pezón un patrón vertical de doble rama y simetrización contralateral. La que sigue. Nuevamente una paciente con franca flexión del complejo de la pezón mamas muy voluminosas, asimetría importante y en ella también hicimos un patrón vertical de doble rama con patrón de grisote con reconstrucción del complejo de la pezón con su misma isla de piel del polo inferior y la disección vertical de axila. La que sigue. Y bueno, quisiera concluir diciendo que la cirugía oncoplástica es un procedimiento oncológicamente seguro donde podemos mejorar los resultados cosméticos de la cirugía conservadora de mama. También tenemos una menor tasa de márgenes comprometidos sobre todo si implementamos y tenemos cuidado de mandar a un estudio transoperatorio y que esto definitivamente puede evitar mastectomías innecesarias. La que sigue. Creo que todos los quirúrgicos que manejamos cáncer de mama debemos de tener pues bien establecidos cuáles son los principios anatómicos y las técnicas básicas de cirugía oncoplástica para mejorar nuestros resultados cosméticos en beneficio de las pacientes. Sabemos que requiere una curva de entrenamiento y aprendizaje pero que son procedimientos que una vez que se dominan son muy sencillos de hacer y que realmente son muy satisfactorios ver cómo la paciente tiene una mejor actitude hacia su tratamiento y hacia su enfermedad. La que sigue. Y bueno, con esto quiero agradecer a todos su atención y pues quedo atenta para sus comentarios. Muchas gracias doctora. Muy amable, excelente presentación. Pues a continuación estamos sobre el tiempo, nos quedan algunos minutos. El doctor Guillermo Herbert coordinará la parte de las preguntas y respuestas y será nuestra culminación de este bloque, de este primer sábado, de los tres sábados que consta el Congreso Internacional de Cáncer de Mama organizado por la Sociedad Internacional de Cáncer Ginecológico y el Colegio Mexicano de Oncólogos Ginecólogos. Doctor Guillermo Herbert. Muchas gracias doctor Toño. Una felicitación a todos los profesores, a IGCES por este logro, al Colegio Mexicano. Y bien en brevedad del tiempo, quedan muy pocos minutos. Y si tenemos algunas preguntas para la doctora Eva. Comentan que, ¿a qué pacientes considera y cada cuánto hacer la resonancia magnética si los considera de alto riesgo? No tengo video. Muy buenos. Si se considera de alto riesgo, nada más que no tengo, me bloquearon el video. Lo escuchamos perfecto. Sí, bueno, espero que me escuchen. Se recomienda a partir de los 30 años de edad, esto tendrá que ser evaluado por el genetista, ya que hay diferentes factores de riesgo. Y se recomienda cada año. Esto puede realizarse en forma alterna con la mastografía, puede realizarse en forma conjunta con la mastografía, o sea, mastografía junto con resonancia, o puede hacerse mastografía a los seis meses resonancia, a los seis meses mastografía y así sucesivamente. Hay que recordar que esto generalmente son mujeres jóvenes que tienen mamás de muy alta densidad, entonces no podemos dejarlas con tanto tiempo sin vigilancia, pero es en forma anual. Y hay que recordar que la resonancia tiene que ser con medio de contraste y una alternativa es realizar la mastografía contrastada, pero en mujeres, sobre todo que tienen mutación de BRCA, el estudio indicado y el que está aceptado es la resonancia magnética. Okay. Y ya tenemos actualmente una banda de estudios importantes. ¿Y todavía podríamos considerar que existe el término de cáncer de mama oculto? Ya con la resonancia magnética, no. Si contamos con el estudio de resonancia, no. Porque además tenemos ya muy buenos paneles de inmunoestroquímica, entonces ya con la resonancia ya cada vez es mucho más raro encontrar este término. Okay. Y obviamente todos tenemos en la, en nuestra historia de trabajo, pacientes que por abajo de 40 años o incluso más jóvenes han tenido cáncer de mama. ¿Consideras que se debería de mover la, como se llama la edad de diagnóstico para tamizaje o tendría que seguir siendo la misma? Y bueno, tendríamos que detectar estos casos eventuales de alguna otra forma. En países como el nuestro, hasta el 15% del cáncer de mama se ha diagnosticado en menores de 40 años, pero no es el grueso de pacientes. Entonces todavía consideramos que no se debe de mover el tamizaje, porque además el tamizaje está aceptado con mastografía y la mastografía en menores de 40 años, exclusivamente con mastografía es muy difícil. Tendríamos que agregar tomosíntesis o algún estudio funcional y la radiación es sumamente alta. Entonces hasta el momento no, no mover, no se tendría que mover la edad. Entonces sería a partir de los 40 y aquellas que tienen alto riesgo, ser muy específicos y estar muy de cerca con ellas para, para utilizar otros métodos como resonancia o mastografía contrastada, pero en población con riesgo promedio todavía no. Y en el otro extremo de la vida, qué pacientes consideras o hasta qué edad dirías ya hasta aquí? O si es por edad o es por la funcionalidad de la paciente? Es por la funcionalidad de la paciente. Antes era por edad y después se movió a la expectativa de vida. La mayoría es si tiene una expectativa de vida mayor a 10 años, puede continuar con el tamizaje ya sea cada año o cada dos años, tomando en cuenta también sus factores de riesgo para cáncer de mama, pero en la actualidad y la tendencia es si la mujer puede, tiene un buen estado de salud, puede desplazarse, es una mujer activa y puede continuar con los estudios de tamizaje, inclusive anual debe de seguir con el tamizaje. Hay que recordar que un buen grupo, acuérdense que el cáncer de mama es bimodal, o sea tenemos una, la prevalencia del cáncer de mama es entre 40 y 50 años y viene otro pico arriba de los 60 años. Entonces a mayor edad hay mayor riesgo de cáncer de mama. Entonces no debemos de descuidar este grupo de pacientes que generalmente son cánceres de mama hormonodependientes. Si la paciente puede acudir a seguir haciendo su mastografía, debe de hacerlo. Obviamente si es una mujer que tiene comorbilidades, tiene secuelas de EBC, está postrada en cama, está en silla de ruedas, obviamente esa mujer no la vamos a llevar a que se haga sus estudios de mastografía. La paciente va a fallecer por complicaciones de otras enfermedades y no por cáncer de mama. Entonces tenemos que evaluar quienes sí y quienes no. Pero muchos de ustedes han visto pacientes, mujeres que tienen 90 a 95 años, trabajan, hacen que hacer en su casa, están a cargo de sus nietos, etc. Entonces esas mujeres hay que continuar con el tamizaje. Entonces acorde a su estado de salud, es en donde tenemos que evaluar si puede conseguir, si puede seguir con el tamizaje o no. Okay. Muchísimas gracias. Doctor Julio, pues también una brillante presentación. Y queríamos ver, obviamente en pacientes que tienen lesiones no palpables, lesiones que se sugiere la biopsia, ¿en qué paciente recomendarías omitir biopsia previo al tratamiento quirúrgico o es biopsia a todas las pacientes? Bueno, actualmente la recomendación es hacer biopsia a todas las pacientes o por lo menos todo lo que sospechamos que puede ser sospecha de malignidad, debe entrar ya con diagnóstico. Y la recomendación del estándar es que por lo menos el 90% de estos pacientes tengan una biopsia. El único motivo donde entraríamos sin biopsia o sin un diagnóstico oncológico es que ya hicimos varias biopsias y seguimos sospechando clínicamente que hay un cáncer y la biopsia no sale positiva, pues entramos a hacer algo a ver sin el diagnóstico oncológico. Pero después yo creo que todo cáncer tiene que tener un diagnóstico antes de una cirugía. Y en relación a la axila, ¿qué manejo prefieres en cuanto a biopsia? ¿Que sea con una biopsia TrueCut o con una biopsia con la aguja fina? Las dos opciones son muy buenas. La aguja fina pues igual nos va a dar si es maligno o no. Y TrueCut es bueno usar estos disparadores que no tienen el avance para no causar lesión. Acá preferimos hacerlo todo guiado con ultrasonido porque vimos que cuando lo hacemos a manos libres pues nuestro error o la probabilidad de resultados no adecuados en patología que nos dan un diagnóstico pues es más alta. Pero ambos son adecuados y nos dan la información. Y en el caso de una lesión mayor en el cual estamos viendo afección de la piel, ¿consideras que solo con el TrueCut de la lesión es suficiente o aportarías algo más hacia la piel? Depende de lo que tengamos. Si una TrueCut con un tumor pues nos va a dar el diagnóstico de malignidad. Pero si tenemos una cutánea en piel pues igual vamos a tener la información. Esta otra, esa pregunta iba por el T4D, un inflamatorio. Pues si tenemos la biopsia de piel vamos a tener esa característica de los embolos en la piel. Pero si no las tenemos y es clínicamente un inflamatorio pues no quiere decir que no se abra. Ok. Y para la doctora Amelia Rodríguez, ¿considera que te merece la pena en una paciente que se le hizo una resección por un tumor in situ para considerarla suficientemente tratada? Okay, le comento esta, pero creo que no se escucha. Disculpen, tenía el micrófono apagado. Comentaba que, bueno, las últimas recomendaciones del consenso publicado en 2016 de la Sociedad Americana de Cirugía Oncológica para Cáncer in situ las recomendaciones con más de dos milímetros es un margen suficiente para considerar adecuadamente tratada esta lesión. ¿Y para las lesiones invasoras? También recomienda que simplemente con que no exista presencia de tinta o lesión en los bordes quirúrgicos se considera un margen suficiente. Okay, y todos los que trabajamos con cirugías conservadoras, con nódulos, con patología maligna, tenemos que tener un patólogo experto y obviamente lo que recomendaría sería siempre tenerlo en el transoperatorio. Si estamos tratando con cirugía conservadora, sobre todo oncoplástica, como lo comentó la doctora Patricia, es muy importante para evitar la rescisión de esta paciente. Solamente en casos donde sea una lesión, un nódulo palpable, que nosotros macroscopicamente podamos ver el margen que estamos dando, pues no es necesario que tengamos al patólogo para el transoperatorio, pero de ideal, si se tiene la ventaja de tenerlo, pues sí, sí es necesario para asegurar los márgenes y evitar que esta paciente tenga que ser llevada a una rescisión posterior. Okay, ¿y qué casos de alguna paciente que tienes diagnosticada como cáncer in situ le recomendarías hacer una biosentinela? ¿A todas las in situ o tiene que tener alguna sospecha en particular? Bueno, la recomendación es cuando se sospecha que tiene un foco de microinvasión o focos de invasión, y esto pues generalmente va a estar dado por las características mastográficas, la extensión de la lesión se ha visto que lesiones grandes, generalmente mayores de 3 centímetros, lesiones que previamente fueron biopsiadas y nos están reportando alto grado o con componente de comedor necrosis, de comedor necrosis, sobre todo el tamaño, a mayor tamaño es mayor riesgo. Entonces, en este caso, si se tiene la sospecha, tiene que ser llevada a una biopsia de gangliosentinela para descartar invasión. Okay, muchas gracias. Doctora Mili, después de esa gran salvada de la falla de tecnología, obviamente la cirugía de oncofertilidad, o sea, el concepto de oncofertilidad es más nuevo porque estamos empezando a ver pacientes más jóvenes. ¿Con quién te quedarías y qué le dejarías a los médicos para que lo empiecen a hacer en sus pacientes? Primero que nada, tener en cuenta que no es solo de uno, que es un manejo totalmente multidisciplinario. O sea, desde el gineonco, el cirujano-oncólogo, el oncólogo médico que tenga el primer contacto con el paciente, y biología de la reproducción, que muchas veces perdemos ese enlace con el biólogo de la reproducción. Y que lo principal es darle la información a la paciente. Yo comenzaría en decir, en conocer bien cómo funciona el funcionamiento ovárico y pidiendo los estudios. Casi siempre pedimos un perfil hormonal y olvidamos cosas como la hormona antimugleriana, el ultrasonido transpaginal. Poder avanzar en esa parte para definir si tiene una reserva ovárica. Y desde el 16 se está implementando lo que es el agonista de género EH, pero aquí tenemos que tener mucho, mucho cuidado porque no todas nuestras pacientes van a bloquearse realmente y hasta el 12% van a tener falla ovárica aún con el agonista de género EH. Yo comenzaría más pidiendo, haciendo conciencia, menor de 40 años, no tienes hijos, tienes deseo, comencemos a ver la reserva ovárica. Y una vez que tú ves la reserva ovárica, recomiendas por ese tipo de fallas del género EH, mejor comenzar con una hiperestimulación y hacer captura de óvulos. Si obviamente la pareja, la paciente está casada y ya está pensando en hijos, hacer una... De embriones. Sí. De hecho, las guías y principalmente ASCO, en su guidelines del 18, ellos dicen de que lo primero que debe ir la paciente es a una preservación ya sea de óvulos o de embriones. Lo ideal en mujeres después de 35 años de embriones para el estudio genético, no solo pensando en BRCA, sino en otras mutaciones y si qué tan viables son, ¿sí? Y tomar en cuenta que eso es algo mucho más que ya le va a tocar mucho al biólogo, es la donación de esperma para pacientes mayores de 35 años, valorar una donación de esperma para preservación de embriones. Pero lo primero que debemos de tomar en cuenta es una preservación ya sea de ovocitos o de embriones. Y tomar en cuenta que no nos va a quitar mucho tiempo porque a veces tenemos ese mito. O sea, decir, no, bueno, es que va a retrasar todo el tratamiento. En instituciones públicas, el inicio de un tratamiento oncológico es entre 20 días a un mes. Y solo se requieren dos a tres semanas. Yo creo que dentro de la protocolización de tu paciente, en lo que empiezas a hacer estudios de extensión, perfectamente cabe hacer una preservación de ovocitos. Y el otro reto que tenemos son los estudios genéticos. Sí, que sería lo ideal, pero la verdad es que el estudio genético nos va a durar cuatro a seis semanas el resultado, ¿sí? Muchísimas gracias. Santiago, esta brillante evaluación de la historia y de la mastectomía. ¿Con qué te quedas y quiénes son las pacientes para hacerles actualmente una mastectomía radical? Bien. Bueno, son los criterios que recomienda la Sociedad Americana de Cirujanos Mastólogos. En aquellas pacientes en las cuales hice un tratamiento conservador y quedamos con margen negativo. En aquellas pacientes que tenemos esa discordancia, volumen tamaño, volumen tumoral, si bien la parte de oncoplastia hoy nos está poniendo cada vez más en duda y tironeando más a la paciente para un tratamiento conservador. En aquellas pacientes que luego de un tratamiento conservador tenemos una recurrencia. Y en aquellos pacientes con un carcinoma inflamatorio de mama. Esos serían como los criterios actuales para la mastectomía radical. No, no. Sí, sí, sí. ¿Y a alguien en especial le agregarías la ultra radical de Halsted? Bueno, todavía tenemos, como bien dijo Julio, las realidades de nuestros países. Y dentro de nuestros países las realidades también son muy distintas, sector público, sector privado. Todavía seguimos viendo casos como calculamos, veía Halsted en su momento, localmente avanzados, pieles ulceradas. En esos casos se hace una quimioterapia en el yuvante y en función de su respuesta. A veces hay que continuar con una mastectomía de Halsted. Hay una revisión interesante que hizo el Grupo Brasilero de OIAS donde publicaron en el 2016, hicieron un randomizado, mastectomía radical de Halsted. O sea, con resección en bloque y mastectomías conservadoras. Así que como que todavía en algunas pacientes existe la necesidad de hacer ese tratamiento radical. Por suerte son las menos. Sí, afortunadamente. Y bueno, Robyn, te dejamos un tema sumamente complicado, muy controvertido. Pero, ¿qué nos dejarías que, de qué pacientes sí una mastectomía o una cirugía después del tratamiento de yuvante o con un diagnóstico de metástasis? Pues yo creo que hay que empezar por seleccionar sin duda las pacientes que tengan síntomas locales. Entonces aquellas pacientes que tengan tumores fungantes, infectados, ulcerados, que estén sangrando, pues sin duda estas pacientes necesitan una cirugía para control local y mejorar calidad de vida. Creo que en el escenario de las pacientes que responden a tratamiento y que no tienen síntomas locales es el área de oportunidad que tenemos como clínicos y de forma multidisciplinaria que seleccionar a nuestras pacientes en conjunto con ellas mismas. Entonces, hoy por hoy no hay evidencia clara. Se sugiere que algunas pacientes ultraseleccionadas, aquellas jóvenes menores de 55 con tumores indolentes, por ejemplo, luminales, o pacientes con enfermedad HER2 positivo, pues para el cual tenemos trastuzumab, pertuzumab, catxila, que es TDM1, pacientes que tienen enfermedad oligometastásica o pacientes que tienen enfermedad ósea de sitio único. Estas pacientes son las mejores pacientes para ser llevadas a cirugía, pero por ende ya sabemos que son pacientes que tienen un mejor pronóstico, ¿no? Entonces, pues tendemos a ser más radicales con las pacientes que tienen mejores respuestas porque pensamos que les va a ir mejor. Creo que es una decisión que se tiene que tomar de forma multidisciplinaria, pero pues sin duda no hay siempre en estos casos. Entonces, perfectamente podemos discutirlo con las pacientes y en vista de una excelente respuesta, dejarlas en cirugía porque tampoco hay un beneficio comprobado. Okay. Creo que lo que más recomendaría sería que pues tengamos en mente que no la metasta si está condenada una paciente a que le vaya mal, que siempre tiene otra opción. Así es. ¿Quisieras agregar algo más? Gracias. Muchas gracias por todo. Y a la doctora Fati, ¿la mastectomía preservadora de piel y de complejo areopezón la llegas a considerar ya como radical o conservadora y requiere del uso de radioterapia? No, yo creo que finalmente sigue siendo una mastectomía, es un procedimiento radical, solamente con la posibilidad de hacer una reconstrucción inmediata que creo que si es posible hacer la preservación de la piel y del complejo areopezón, pues los resultados cosméticos van a verse muy favorecidos. Entonces sigue siendo un procedimiento radical, no es conservación de mama. Y creo que es una excelente opción que algunas pacientes requerirán. Claro. ¿Qué pacientes recomendarías en tu momento de cirugía un poco plástica, utilizar algún material, como se llama, de implantes o expansores? Pues yo creo que justamente estas pacientes que no son candidatas ni a una cirugía conservadora convencional ni a una cirugía oncoplástica, por ejemplo, las que tienen contraindicación absoluta que son pacientes con multicentricidad, con microclasificaciones, pues esas pacientes obviamente no las vamos a llevar a una preservación mamaria. Creo que son las mejores candidatas para hacer un procedimiento oncoplástico de reconstrucción en mastectomía. Ok. ¿Y más o menos qué porcentaje de pacientes actualmente consideras que ya pueden ser llevadas a una cirugía oncoplástica? Porque esto ha cambiado y cada vez hay menos ventajas. Sí, claro. Mientras más temprano encontremos la enfermedad, tal vez las necesidades de resecciones amplias de volumen mamario se disminuyen, pero pues nuestra realidad es que vemos todavía pacientes con cánceres localmente avanzados que a veces no responden bien al tratamiento con quimioterapia y que tenemos aún tumores residuales grandes. Esas son las mejores candidatas para una cirugía oncoplástica. ¿Qué porcentaje? Yo creo que cada vez va en aumento este número de procedimientos afortunadamente porque el resultado cosmético se ve favorecido y la preservación de la mamá también. Yo calculo que ahorita estaremos alrededor de un 40 o 50% de cirugías oncoplásticas en los procedimientos conservadores de mamá. Ok. ¿Y en pacientes que se decidió por tamaño tumoral, por alguna característica en especial, llevar los años a adyuvancia, con una respuesta patológica o clínica completa, ¿cambiarías tu diagnóstico inicial o tu tratamiento inicial a un oncoplástico? Yo creo que en algunos casos solamente. Por ejemplo, el caso que les mostré de la paciente con macromastia, esa paciente yo creo que independientemente del resultado residual que tuviera después de la adyuvancia, tal vez yo aún así seguiría ofreciendo una cirugía oncoplástica como la que le hicimos, que fue una mamoplastia de reducción justamente porque vamos a mejorar su contorno y su volumen mamario para también con esto mejorar su tratamiento con radioterapia. Hacer una mastectomía y reconstrucción en esas pacientes con mamás tan voluminosas realmente se convierte en un problema y la regla es que el resultado cosmético sea muy pobre y pues es una mala elección en este tipo de pacientes. Y obvio, tú siempre recomiendas que se tenga una capacitación extra en oncoplástica, ¿estás de acuerdo? Sí, definitivamente. Creo que todos los cirujanos que manejamos cáncer de mamá debemos de tener algún tipo de capacitación. Tal vez si no lo haces de forma rutinaria, los procedimientos en el nivel dos, hacer los procedimientos de nivel uno, que son un patrón oncoplástico de Romblo, a lo mejor un patrón lateral que son muy sencillos y realmente los resultados cosméticos van a mejorar en nuestros pacientes. Creo que debe de ser parte del entrenamiento de todos los residentes de oncología. Y siempre tener en cuenta que tienes que tener un backup de radioterapia y un equipo que te complente tu cirugía. Así es, todas deben de ir a radioterapia. Y lo que comentamos durante la ponencia es que el estudio transoperatorio es fundamental. Muchísimas gracias. Me salta en el orden al Dr. Víctor Vargas. Yo quiero que cierre este gran sábado. La verdad que le agradezco a todos. Una excelente presentación de todos. Se cierra con un gran día. Y Víctor, obviamente América Latina, muchas veces nos encanta hacernos las víctimas de que tenemos pocos recursos, pero con los que tenemos, ¿qué sugieres que hagamos? Yo creo que podemos hacer grandes cosas. Y América Latina tiene que cambiar. Lo que tiene que cambiar primero es su mentalidad. ¿Tú qué sugieres? Bueno, miren, como yo di una ponencia donde los recursos económicos, tanto para tener centros especializados, como sería el INCAN, en cualquier parte, en los 32 estados de la República Mexicana, sería lo ideal. Hablando de México. Hablando de América Latina, creo que es un poco más complejo aún. Y tener centros especializados para llevar a cabo técnicas que permitan a la mujer mantener su estética con un control oncológico bastante adecuado. Y tener todos los medicamentos al alcance, tanto biológicos como quimioterapéuticos, para dar los mejores tratamientos de hormonoterapia también. Esto va a ser complejo. Esto llevará muchos años. Tiene que existir políticas de salud que permitan a nuestros dirigentes políticos administrar más, invertir más en la investigación. Si ustedes vieron en mi plática, somos muy pocos los países en Latinoamérica que hacemos investigación. Hay una inversión precaria de presupuesto en la sede de investigación clínica en América Latina. Nosotros ocupamos el segundo lugar y en primer lugar Brasil, y de ahí van a seguir algunos otros países. Entonces invertir en la investigación, invertir en centros de salud, va a ser que las pacientes indígenas, autóctonas de regiones que están alejadas de las grandes ciudades, Guadalajara, Monterrey, la Ciudad de México, acudir para atenderse. Y en ese lapso de tiempo, su pronóstico va a cambiar porque de por sí, de tener una etapa probablemente curativa, lleguen a ser atendidas ya para tratamiento paliativo. Entonces nosotros los médicos, a través del Colegio Mexicano de Ginecólogos Oncólogos, que estamos varios socios en diferentes partes de la región, debemos insistir en que dar el mejor tratamiento a una mujer será un objetivo ético, médico y humanista por parte de cada uno de nosotros que veamos a una paciente con un tumor que puede o no ser cáncer de mama. En segundo lugar, agradezco infinitamente a la Sociedad Internacional de Cáncer Ginecológico esta fusión que tuvimos con el Colegio Mexicano de Oncólogos Ginecólogos de hacer posible llevar a América Latina y al mundo algunas ponencias de profesores latinoamericanos, incluyendo los nacionales. Y esperándolos este próximo mes, otro sábado y otro sábado más, creo que nos dará el grupo organizador de la Sociedad Internacional de Cáncer Ginecológico y vernos el 24 de abril y el día 29 de mayo. Yo le pediría a Susan que nos diera un record cuando menos, creo que andábamos por ahí de los 300, digamos, colegas que estuvieron conectados en este primer sábado. Y por supuesto, a todos ustedes. Y por supuesto, ahora sí que la equidad de género, si ustedes vieron, estuvo muy bien cimentada en profesoras y profesores, lo cual siempre es un agrado de tener la equidad de género, sobre todo que yo creo que con estas profesoras, aparte de ser sumamente brillantes en su área, son sumamente guapas. Les agradezco mucho su amable participación. Y a los ponentes de Uruguay y de Guatemala, en este caso, que ahora nos ha permitido tener más amigos a nivel latinoamericano e internacional, Santiago y el doctor Lua, no se me fue el nombre, pero es un gran amigo de Guatemala que por el momento no se me pasó el nombre. Estoy tan emocionado realmente desde que se hizo este proyecto que la verdad de las cosas, creo que se ha logrado el objetivo. Ahora sí, Susan o quien esté, pueden dar la parte internacional sobre este primer módulo sabatino. Thank you very much. We will see you next time. Bye-bye. Bye-bye, everyone. Thank you.

breast cancer management

non-palpable breast lesions

mammography

coverage and access to screenings

biopsy techniques

fine needle aspiration

percutaneous biopsy

incisional biopsy

excisional biopsy

ductal carcinoma in situ

diagnosis and radiological control

treatment options

surgery in metastatic breast cancer

role of surgery

survival benefit