Brazilian Society of Surgical Oncology consensus on fertility-sparing surgery for cervical cancer.

OBJECTIVE: Several controversies remain on conservative management of cervical cancer. Our aim was to develop a consensus recommendation on important and novel topics of fertility-sparing treatment of cervical cancer. METHODS: The consensus was sponsored by the Brazilian Society of Surgical Oncology (BSSO) from March 2020 to September 2020 and included a multidisciplinary team of 55 specialists. A total of 21 questions were addressed and they were assigned to specialists' groups that reviewed the literature and drafted preliminary recommendations. Further, the coordinators evaluated the recommendations that were classified by the level of evidence, and finally, they were voted by all participants. RESULTS: The questions included controversial topics on tumor assessment, surgical treatment, and surveillance in conservative management of cervical cancer. The two topics with lower agreement rates were the role of minimally invasive approach in radical trachelectomy and parametrial preservation. Additionally, only three recommendations had <90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition). CONCLUSIONS: As very few clinical trials have been developed in surgery for cervical cancer, most recommendations were supported by low levels of evidence. We addressed important and novel topics in conservative management of cervical cancer and our study may contribute to literature.

Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study.

PURPOSE: To analyze the survival outcomes of patients in a Brazilian cohort who underwent minimally invasive surgery (MIS) compared with open surgery for early stage cervical cancer. METHODS: A multicenter database was constructed, registering 1280 cervical cancer patients who had undergone radical hysterectomy from 2000 to 2019. For the final analysis, we included cases with a tumor ≤ 4 cm (stages Ia2 to Ib2, FIGO 2018) that underwent surgery from January 2007 to December 2017. Propensity score matching was also performed. RESULTS: A total of 776 cases were ultimately analyzed, 526 of which were included in the propensity score matching analysis (open, n = 263; MIS, n = 263). There were 52 recurrences (9.9%), 28 (10.6%) with MIS and 24 (9.1%) with open surgery (p = 0.55); and 34 deaths were recorded, 13 (4.9%) and 21 (8.0%), respectively (p = 0.15). We noted a 3-year disease-free survival (DFS) rate of 88.2% and 90.3% for those who received MIS and open surgery, respectively (HR 1.32; 95% CI: 0.76-2.29; p = 0.31) and a 5-year overall survival (OS) rate of 91.8% and 91.1%, respectively (HR 0.80; 95% CI: 0.40-1.61; p = 0.53). There was no difference in 3-year DFS rates between open surgery and MIS for tumors ≤ 2 cm (95.7% vs. 90.8%; p = 0.16) or > 2 cm (83.9% vs. 85.4%; p = 0.77). Also, the 5-year OS between open surgery and MIS did not differ for tumors ≤ 2 cm (93.1% vs. 93.6%; p = 0.82) or > 2 cm (88.9% vs. 89.8%; p = 0.35). CONCLUSIONS: Survival outcomes were similar between minimally invasive and open radical hysterectomy in this large retrospective multicenter cohort.

Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources.

BACKGROUND: Approximately 70% of cancer-related deaths occur in low- and middle-income countries. In addition to social and racial inequalities, treatment options in these countries are usually limited because of the lack of trained staff and equipment, limited patient access to health services, and a small number of clinical guidelines. OBJECTIVES: The Brazilian Society of Surgical Oncology developed this guideline to address these barriers and guide physicians treating patients with endometrial cancer (EC) in regions with limited resources and few specialized centers. METHODS: The guideline was prepared from 10 January to 25 October 20192019 by a multidisciplinary team of 56 experts to discuss the main obstacles faced by EC patients in Brazil. Thirteen questions considered critical to the surgical treatment of these patients were defined. The questions were assigned to groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments for presentations in meetings, classified the level of evidence, and voted on the recommendations. RESULTS: For all questions including staging, fertility spearing treatment, genetic testing, sentinel lymph node use, surgical treatment, and other clinical relevant questions, major agreement was achieved by the participants, always using accessible alternatives. CONCLUSIONS: It is possible to provide adequate treatment for most EC patients in resource-limited areas, but the first option should be referral to specialized centers with more resources.

Analysis of patients diagnosed with primary cutaneous melanoma in the last six years in Hospital Erasto Gaertner: epidemiologic profile.

BACKGROUND: Melanoma is one of the conditions with greater increase in incidence worldwide in recent decades. It is a skin cancer with potential high lethality and predominates in Caucasian adults. Treatment of primary cutaneous melanoma is essentially surgical and search for sentinel lymph node can modify the aggressiveness of the treatment. OBJECTIVE: To analyze the epidemiological profile of patients diagnosed with primary cutaneous melanoma, histopathological features and compare with literature data. METHODS: This is a retrospective, observational, single-center, case series study of patients with primary cutaneous melanoma, who underwent surgery between January 2008 and December 2013. The parameters include: Age, sex, clinical stage, date of surgery, tumor location, histological subtype, condition of surgical margins, Breslow thickness, mitotic index, presence of ulceration and metastasis on admission. RESULTS: We included 321 melanoma patients who were treated at Hospital Erasto Gaertner. The population consisted of 58.9% females and 41.1% males with an average age of 52.8 ± 16.3 years. As for the clinical stage, 51.1% were in the initial stage, 24.3% in the clinical stage II (A, B and C), 21.2% in clinical stage III and 3.4% with distant metastases. The most frequent location of the primary melanoma was the trunk, and the histological subtype was superficial spreading pattern. Intermediate and thick melanomas were the most frequent. STUDY LIMITATIONS: This is a retrospective study and some information and data could be incomplete or absent. CONCLUSION: The diagnosis and treatment of melanoma in early stages provides less morbidity and improved survival of patients. Understanding the biological behavior of tumor and knowing the local epidemiology guide health strategies.

Analysis of patients diagnosed with primary cutaneous melanoma in the last six years in Hospital Erasto Gaertner: epidemiologic profile

Abstract: BACKGROUND: Melanoma is one of the conditions with greater increase in incidence worldwide in recent decades. It is a skin cancer with potential high lethality and predominates in Caucasian adults. Treatment of primary cutaneous melanoma is essentially surgical and search for sentinel lymph node can modify the aggressiveness of the treatment. OBJECTIVE: To analyze the epidemiological profile of patients diagnosed with primary cutaneous melanoma, histopathological features and compare with literature data. METHODS: This is a retrospective, observational, single-center, case series study of patients with primary cutaneous melanoma, who underwent surgery between January 2008 and December 2013. The parameters include: Age, sex, clinical stage, date of surgery, tumor location, histological subtype, condition of surgical margins, Breslow thickness, mitotic index, presence of ulceration and metastasis on admission. RESULTS: We included 321 melanoma patients who were treated at Hospital Erasto Gaertner. The population consisted of 58.9% females and 41.1% males with an average age of 52.8 ± 16.3 years. As for the clinical stage, 51.1% were in the initial stage, 24.3% in the clinical stage II (A, B and C), 21.2% in clinical stage III and 3.4% with distant metastases. The most frequent location of the primary melanoma was the trunk, and the histological subtype was superficial spreading pattern. Intermediate and thick melanomas were the most frequent. STUDY LIMITATIONS: This is a retrospective study and some information and data could be incomplete or absent. CONCLUSION: The diagnosis and treatment of melanoma in early stages provides less morbidity and improved survival of patients. Understanding the biological behavior of tumor and knowing the local epidemiology guide health strategies.

Potential Surgical and Oncologic Consequences Related to Skin Tattoos in the Treatment of Cervical Cancer.

STUDY OBJECTIVE: Skin tattoos on the feet, legs, and lower abdominal wall are progressively gaining popularity. Consequently, the number of tattooed women with cervical cancer has significantly increased in the last decade. However, pigments of tattoo ink can be transported to regional lymph nodes and potentially clog lymphatic pathways that might also be used by sentinel labeling substances. Therefore, here we report whether the presence of tattoo ink affected pelvic lymph nodes in women with early cervical cancer and discuss its potential oncologic and surgical consequences. DESIGN: Prospective observational study. SETTING: University Hospital in Hamburg, Germany (Canadian Task Force classification II2). PATIENTS: Women affected by cervical cancer. INTERVENTIONS: Between January 2014 and May 2016, 267 laparoscopic oncologic operations, including at least a pelvic sentinel or complete lymphadenectomy, were performed in the Department of Advanced Surgical and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany. Among these, 191 patients were affected by cervical cancer. MEASUREMENTS AND MAIN RESULTS: Data of patients in whom dyed lymph nodes without the use of patent blue as a sentinel marker or different from blue-colored pelvic lymph nodes in the case of sentinel procedure were identified and prospectively collected. RESULTS: In 9 patients, skin tattoos localized in the lower extremities caused discoloration of at least 1 pelvic lymph node. This effect was observed in 40% of women (9/23) with tattoos in this area of the body. Mean patient age was 34 years (range, 27-56). All women had cutaneous tattoos on their feet or legs, and in 1 woman an additional tattoo situated on the inferior abdominal wall was observed. The stage of cervical cancer was FIGO IB1 in all cases. One woman was at the 16th week of gestation at the time of cancer diagnosis. On average, 26 pelvic lymph nodes (range, 11-51) were harvested from both pelvic basin sides. None of the removed lymph nodes was tumor involved. Three patients (33%) developed postoperatively infected lymphoceles on the side of the tattooed lymph nodes, and 1 woman had multiple episodes of fever without a clear origin. CONCLUSION: In women affected by cervical cancer with skin tattoos located in the lower limbs, the pelvic lymph nodes can be partially or totally occupied by the ink. This must be taken into consideration, especially for women scheduled exclusively for sentinel node biopsy. Infectious complications related to nodal dissection, in particular infected lymphoceles, may be more frequent in this population.