Introdução. Quem solicita biópsias de mama? Na maioria das vezes é o ginecologista. Em alguns locais a paciente é encaminhada ao mastologista antes de uma solicitação de biópsia e em outros locais um generalista da rede básica de saúde é quem faz essa solicitação. Para uma boa indicação é preciso conhecer diversos aspectos como: tipo de lesão, características da paciente e formas de realizar colheita tecidual e de guiar essa colheita.
Preceitos básicos. Usar o método menos invasivo e mais barato (em geral essas qualidades andam juntas) que atenda à necessidade do caso e que esteja disponível na comunidade. Preferir técnicas percutâneas (não cirúrgicas). Saber avaliar a concordância entre a suspeita imaginológica e o resultado anatomopatológico. Biopsiar apenas quem precisa de biópsia. Considero desnecessário explicar as afirmativas acima, pois todas elas são acima de tudo imperativos éticos. Vale mencionar que, caso uma forma de biópsia menos invasiva que atenda melhor à necessidade do caso não esteja disponível na comunidade, é boa norma informar à paciente para que ela decida se há conveniência em se deslocar para outro centro onde possa receber a forma de biópsia ideal.
Quando é necessário biopsiar: Lesões BI-RADS® 4 e 5, sempre. Lesões BI-RADS® 2, nunca. Lesões BI-RADS® 3, raramente. Um motivo para indicar biópsia no BI-RADS® 3 pode ser a impossibilidade de acompanhamento, como longas viagens para lugares sem assistência ou iminência de uma cirurgia mamária que possa dificultar o encontro da lesão posteriormente. Em pacientes de risco muito alto, ocasionalmente pode ser indicado biópsia de algumas lesões classificadas como BI-RADS® 3. Em lesões muito grandes no diagnóstico inicial (mais de 2 ou 2,5 cm), pode ser conveniente iniciar a abordagem com biópsia percutânea, pois em um acompanhamento semestral um eventual crescimento de um nódulo pode levá-lo a um tamanho que poderia piorar o prognóstico na eventualidade de uma condição maligna.
Tipos de pacientes. Situações particularizadas, como uma paciente com grande debilidade, podem exigir uma escolha não habitual. Portanto, as orientações abaixo não devem ser entendidas como absolutas.
Os tipos de biópsia e as formas de guiar a biópsia. As biópsias podem ser cirúrgicas ou percutâneas. As cirúrgicas estão praticamente abandonadas, mas quando for a opção, exigirá uma forma de localização pré-operatória, mesmo quando a lesão for palpável, pois há fatores durante a cirurgia que podem interferir com a identificação adequada da lesão. A localização pré-operatória pode ser feita através da colocação de um fio guia metálico ou injeção de uma substância identificável durante a cirurgia, seja um corante como carvão ou uma substância radioativa (nesse caso, além da localização da lesão, a substância radioativa por ser usada para identificar o linfonodo que drena a região de interesse na mama, chamado de linfonodo sentinela). Quando a injeção de substância radioativa tem apenas a intenção de marcar a lesão mamária, o procedimento é chamado de roll, e quando há intenção adicional de identificar o linfonodo sentinela o procedimento é chamado de snoll.
As biópsias percutâneas podem ser a biópsia de agulha fina (um procedimento aspirativo, que permite exame citopatológico), as biópsias que permitem análise tecidual, a biópsia de fragmentos (também chamada de core biopsy e trucut) e a biópsia vacuoassistida (também chamada de mamotomia).
As formas de guiar a biópsia são a palpação (praticamente abandonada), a ultrassonografia, a mamografia e a ressonância magnética. Quando a lesão é vista à ultrassonografia, a preferência recai sobre ela. Quando ela é vista à mamografia a orientação pode ser de duas maneiras: estereotáxica (que usa um recurso adicionado a o mamógrafo, e que permite localização pré-operatória e biópsias percutâneas) ou biplanar (que permite apenas biópsias cirúrgicas, mas não requer o recurso da estereotaxia, que é consideravelmente caro). A biópsia orientada por ressonância magnética é reservada para as lesões que só foram demostradas por esse método, mesmo após cuidadosa revisão à ultrassonografia e à mamografia. Esse é um tipo de biópsia caro e pouco disponível em nosso meio.
A complexidade. O leitor deve ter percebido que as formas de combinação entre tipo de biópsia e forma de dirigir a biópsia leva a um grande número de opções (23 tipos de biópsia, para ser exato), e isso leva a uma grande complexidade para escolher a forma ideal de biópsia. Complexidade de escolha, de codificação, de autorização nos convênios, de comunicação com o radiologista, etc… Do outro lado está a paciente, numa das piores fases da sua vida, angustiada, afobada, querendo resolver. Daí a responsabilidade do solicitante em conhecer bem esse tema, para minimizar a possibilidade de glosas, não autorizações e outras situações que podem elevar o sofrimento da paciente.
A biópsia para cada tipo de lesão
Segue abaixo a escolha ideal para cada caso:
Nódulo: é a lesão mais comum. Melhor opção: biópsia de fragmentos orientada por ultrassonografia. Independente do tamanho do nódulo. A noção de que nódulos de tamanho pequeno seriam melhor biopsiados por biópsia vacuoassistida não se sustentou (a biópsia vacuoassistida é mais invasiva e não mostrou ser melhor; aliás, pode até ser pior, por provocar mais distorção tecidual, potencialmente aumentando o risco de não identificação da lesão durante o procedimento). Ocasionalmente nos deparamos com um nódulo cujas características à ultrassonografia não permitem diferenciar entre um nódulo sólido e um cisto com conteúdo espesso. Sendo esse o caso, é uma boa opção iniciar a abordagem com uma biópsia de agulha fina, pois caso o nódulo mostre ser cístico, a situação será resolvida com um mínimo de invasividade.
Microcalcificações: Segundo tipo de lesão mais comum. Melhor opção: biópsia vacuoassistida orientada por estereotaxia. Tem a desvantagem de ser menos disponível. Alternativa: biópsia de fragmentos orientada por estereotaxia, que tem a desvantagem de ter uma chance um pouco maior de erro de alvo e de subestimativa, mas é aceitável. Outra alternativa: biópsia cirúrgica sob localização pré-operatória (normalmente conhecida por agulhamento, que pode ser feito pela técnica biplanar e não exige estereotaxia). Em casos mais raros; as microcalcificações podem ter uma lesão correspondente visível à ultrassonografia. Nesses casos, preferir biópsia de fragmentos orientada por ultrassonografia, muito vantajosa pela menor invasividade e menor custo.
Distorções de arquitetura: Em geral preferir exérese cirúrgica. Algumas lesões pequenas podem ser abordadas com biópsia vacuoassistida ou, se tiverem uma correlação ultrassonográfica razoavelmente segura, pode ser tentado uma biópsia de fragmentos orientada por ultrassonografia. Quando não são vistas à ultrassonografia, que é a maior parte das vezes, a orientação tem que ser mamográfica, estereotáxica quando for realizada uma abordagem percutânea e biplanar quando for realizada uma abordagem cirúrgica.
Assimetrias: Se forem demonstradas à ultrassonografia, a opção ideal é a biópsia de fragmentos orientada por ultrassonografia. Na maioria das vezes, porém, as assimetrias só são vistas à mamografia e assim exigirão biópsia orientada por mamografia, seja orientação biplanar para realizar cirurgia sob agulhamento ou orientação estereotáxica para biópsia percutânea, simples ou vacuoassistida.
Lesões vistas apenas à ressonância magnética: Sempre que se encontra uma lesão suspeita à ressonância magnética, a primeira providência é voltar à ultrassonografia e até mesmo à mamografia para tentar procurar essa lesão de uma forma dirigida. Caso a lesão permaneça exclusiva da ressonância magnética, a biópsia terá que ser feita sob orientação desse método. Também nesse caso pode ser realizado um agulhamento com biópsia cirúrgica ou uma biópsia percutânea. Nesse caso, por causa do fato de que a orientação por ressonância magnética é um pouco menos precisa, é necessário usar a biópsia vacuoassistida, para remover mais material e garantir a amostragem. Além de pouco disponíveis, os procedimentos orientados por ressonância magnética requerem material (agulhas e fios) especial não ferromagnético, geralmente feitos de titânio.
Suspeita de carcinoma inflamatório: Na maioria das vezes é possível fazer uma biópsia de fragmentos orientada por ultrassonografia. No passado se falava de biópsias em cunha incluindo uma porção de derme para comprovar invasão linfática, mas hoje isso e desnecessário. O importante é confirmar a presença de carcinoma e o componente inflamatório é uma característica clínica.
Linfonodopatia axilar: Em geral a preferência é pela biópsia de agulha fina orientada por ultrassonografia, principalmente em função da dificuldade técnica relacionada à forma côncava da axila e às estruturas vasculares e neurais da axila. A biópsia de agulha fina é a que oferece maior controle ao operador, e para confirmação de envolvimento neoplásico em portadoras de câncer de mama tem acurácia excelente. Caso se suspeite de envolvimento linfonodal por neoplasias como linfomas ou melanomas, a melhor opção é a biópsia de fragmentos orientada por ultrassonografia.
Doença de Paget: Caso não haja lesão à ultrassonografia ou mamografia, a melhor opção é realizar uma biópsia em cunha da porção afetada da aréola.
Comentários finais
Dado a complexidade relatada acima, considere sempre discutir o caso com o imaginologista para otimizar a escolha do método de biópsia. Procura sempre ser claro no pedido, sobre qual lesão deve ser biopsiada e qual o tipo de biópsia escolhido. Procure preencher o pedido com clareza para evitar confusão na autorização da operadora (a complexidade também sobrecarrega a parte burocrática da biópsia e devemos evitar sofrimento adicional nesse momento já vulnerável para a paciente).
Autor: Hélio Sebastião Amâncio de Camargo Júnior
2.579 comentários
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