Conservative Treatment of Stage IA1 Cervical Carcinoma Without Lymphovascular Space Invasion: A 20-year Retrospective Study in Brazil.

PURPOSE: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. METHODS: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. RESULTS: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. CONCLUSION: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

OBJETIVO: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. MéTODOS:: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. RESULTADOS: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. CONCLUSãO:: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

Preservação da fertilidade em pacientes com câncer ginecológico / Fertility preservation in gynecologic cancer patients

CONTEXTO CLÍNICO O câncer ginecológico afeta diretamente a fertilidade, pois o tratamento consiste na remoção cirúrgica do sistema reprodutor e/ou na sua exposição a agentes gonadotóxicos. Entretanto, pacientes em estádios iniciais e que estejam dentro de critérios estabelecidos podem ser tratadas com cirurgias conservadoras da fertilidade, com resultados oncológicos equivalentes aos dos tratamentos tradicionais. As técnicas de preservação da fertilidade, como criopreservação de oócitos, embriões e tecido ovariano, também podem ser oferecidas em algumas situações. A American Society of Clinical Oncology (ASCO) publicou recomendações sobre a preservação de fertilidade, com o objetivo de aumentar a conscientização sobre o tema, e, juntamente com a American Society for Reproductive Medicine (ASRM), recomenda que pacientes em idade fértil com câncer passem por aconselhamento reprodutivo. Essas pacientes apresentam menores taxas de arrependimento, mesmo quando optam por desistir do tratamento conservador. O interesse na preservação da fertilidade aumentou nas últimas décadas, tanto pelo fato de as mulheres postergarem a gestação como pelo aumento da incidência de câncer em jovens. A taxa de incidência de todos os cânceres aumentou 29% entre 1973 e 2015 em adolescentes e adultos jovens de ambos os sexos. O câncer de colo uterino, em mulheres de 20-29 anos, aumentou anualmente em uma média de 10,3% entre 2000 e 2009. A omissão em orientar pacientes com câncer sobre as possibilidades de preservação da fertilidade pode gerar questionamentos futuros; em alguns países. isso já se configura má prática médica.

Conservative Treatment of Stage IA1 Cervical Carcinoma Without Lymphovascular Space Invasion: A 20-year Retrospective Study in Brazil / Tratamento conservador do câncer do colo do útero IA1 sem invasão linfovascular: estudo retrospectivo no Brasil

Abstract Purpose: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. Methods: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. Results: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. Conclusion: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

Resumo Objetivo: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. Métodos: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. Resultados: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. Conclusão: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

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.

Cervical cancer screening abnormalities in immunosuppressed renal transplant women: case-control study in Southern Brazil.

PURPOSE: To evaluate the prevalence of cervical pre-malignancies in the cervical cytology of female renal transplant recipients (RTR) and compare to immunocompetent patients. METHODS: A prospective case-control study of 165 RTR (cases) and 372 immunocompetent women (controls) was carried out from May 2015 to August 2016. The participants completed a questionnaire with demographic characteristics, habits, reproductive history, and information about the renal transplant. Cervical cytology samples were collected at their visit for cervical cancer screening. Relevant medical history was obtained from medical records and previous cervical cytology results were retrieved: from the time of kidney transplantation to the beginning of this study for RTR and all collected throughout life for controls. RESULTS: The mean age was similar between groups (42.6 ± 11.4 vs. 41.8.2 ± 11.1 years, p = 0.447). Considering cervical cytology collected since the kidney transplant, RTR had three times higher rates of abnormal cervical cytology test (24.8% of RTR vs. 6.3% for controls), and the abnormalities were more frequent (p < 0.001) for low squamous intraepithelial lesion (LSIL) (n = 23, 13.9%) and high squamous intraepithelial lesion (HSIL) (n = 9, 5.5%). Cervical cytology collected during the study had normal results in 152 RTR (92.1%) vs. 326 controls (93.9%) (p > 0.05). When the altered results were broken down, a higher frequency of LSIL could be seen in RTR (3.6% vs 0.0%, p = 0.008). CONCLUSION: RTR had significantly higher rates of cervical cytology abnormalities comparing to the control group and most of it was composed of LSIL.

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.

Paget's disease of the vulva: A review of 89 cases.

The purpose of this study was to retrospectively review the clinical characteristics and outcomes of a series of women with Paget's disease of the vulva. A retrospective review was performed of 89 women with Paget's disease of the vulva evaluated at a single institution between 1966 and 2010. Medical records were reviewed for demographic information, clinical data, pathologic findings, treatment modalities and outcomes. We found that the primary treatment was surgery for 74 (83.1%) patients, with positive margins noted in 70.1% of cases. Five patients (5.6%) underwent topical treatment with imiquimod and/or 5-fluorouracil, one patient (1.1%) underwent laser ablation and treatment was unknown in 9 patients (10.1%). The majority of patients had multiple recurrences, with 18% having four or more recurrences. There were no significant differences in recurrence rates between patients who underwent surgery and those who did not. Furthermore, there was no association between positive margins following primary surgery and recurrence. Forty-one patients (46.1%) were diagnosed with 53 synchronous or metachronous cancers. Seven patients (7.9%) were found to have invasive vulvar cancer with 1 mm or more depth of invasion, but none of the patients died of Paget's disease or associated vulvar/vaginal cancer. Our findings suggest that the majority of patients with Paget's disease of the vulva develop multiple recurrences regardless of treatment modality or margin status. Alternatives to surgery are needed to better care for women with this disease.

Prevalence of human papillomavirus infection in pregnant versus non-pregnant women in Brazil.

PURPOSE: To investigate the prevalence of human papillomavirus (HPV) in cervical samples of pregnant and non-pregnant women in South-Brazil. METHODS: A prospective study of 91 pregnant and 92 non-pregnant women with no previous history of cervical dysplasia or cancer was carried out. Cervical samples for HPV testing and cytology were collected in each trimester of pregnancy and in the puerperium for pregnant women and at matched intervals for the non-pregnant women. All samples were analyzed through PCR with consensus primers GP5+/GP6+. Genotyping was performed using specific primers. To control for confounding factors, the analysis of multivariate logistic regression was applied. The measure of odds ratio (OR) and the 95 % confidence interval (95 % CI) were used. The level of statistical significance was set at 5 % (P ≤ 0.05). RESULTS: HPV DNA was detected in 23/91 (25.3 %) cervical samples from the pregnant women and in 12/92 (13 %) cervical samples from non-pregnant women (P = 0.035). There was a significant association among cervical HPV infection and young age, number of lifetime sexual partners, and the presence of abnormal cervical cytology. HPV16 and HPV18 were the viral types more frequently detected. Out of the 23 HPV-positive pregnant women, 17 (73.9 %) had normal cervical cytology. CONCLUSION: Our results suggest a higher prevalence of HPV infection in pregnant vs. non-pregnant women. This finding may be related to the relative immunosuppression observed in pregnant women, outlining the importance of the appropriate monitoring of the viral infection in this specific population.

Efeitos da obesidade materna sobre o prognóstico gestacional e perinatal: [revisão] / Effects of maternal obesity on gestational and perinatal outcomes: [review]

A literatura obstétrica atual sugere a existência de impacto da obesidade sobre os desfechos maternos e perinatais à medida que inúmeros relatos demonstram implicações críticas aos períodos anteparto, intraparto e pós-parto. Apesar dessas publicações, a extensão desse impacto permanece controversa. Dada a crescente prevalência de obesidade entre mulheres em idade fértil e considerando-se o fato de que o peso materno acima do ideal é um dos poucos fatores de risco potencialmente modificáveis e, provavelmente, relacionados a um desfecho gestacional desfavorável, estratégias que incluam a prevenção da obesidade gestacional fornecidas ainda no período periconcepcional se tornam atualmente importantes ações de saúde pública. No presente estudo, os autores realizam uma atualização sobre o assunto, focalizando na interface dos efeitos da obesidade materna sobre o prognóstico gestacional e perinatal.

Clinical and histomolecular endometrial tumor characterization of patients at-risk for Lynch syndrome in South of Brazil.

Lynch syndrome is an autosomal dominant cancer predisposition syndrome caused by germline mutations in one of the mismatch repair (MMR) genes: MLH1, MSH2, MSH6 and PMS2. Clinically, Lynch syndrome is characterized by early onset (45 years) of colorectal cancer (CRC), as well as extra-colonic cancer. Male and female carriers of Lynch syndrome-associated mutations have different lifetime risks for CRC and in women endometrial cancer (EC) may be the most common tumor. Whenever Amsterdam criteria are not fulfilled, the currently recommended laboratory screening strategies involve microsatellite instability testing and immunohistochemistry staining of the tumor for the major MMR proteins. The aim of this study was to estimate the frequency of MMR deficiencies in women diagnosed with EC who are at-risk for Lynch syndrome. Thirty women diagnosed with EC under the age of 50 years and/or women with EC and a first degree relative diagnosed with a Lynch syndrome-associated tumor were included. To assess MMR deficiencies four methods were used: multiplex PCR, Single Strand Conformation Polymorphism, Immunohistochemistry and Methylation Specific-Multiplex Ligation-dependent Probe Amplification. Twelve (40%) patients with EC fulfilling one of the inclusion criteria had results indicative of MMR deficiency. The identification of 5 women with clear evidence of MMR deficiency and absence of either Amsterdam or Bethesda criteria among 10 diagnosed with EC under the age of 50 years reinforces previous suggestions by some authors that these women should be considered at risk and always screened for Lynch syndrome after informed consent.

Tamoxifen use and endometrial lesions: hysteroscopic, histological, and immunohistochemical findings in postmenopausal women with breast cancer.

OBJECTIVE: To evaluate immunohistochemical, hysteroscopic, and histological findings in postmenopausal women taking tamoxifen for breast cancer. METHODS: Forty postmenopausal women taking 20 mg/day tamoxifen for breast cancer underwent hysteroscopy and endometrial biopsy from January 2000 to December 2003. Medical records and paraffin blocks were analyzed retrospectively, and Ki-67, estrogen receptors (ERs), and progesterone receptors were measured using an immunohistochemical technique. RESULTS: The mean +/- SD age of the women was 59 +/- 14 years at hysteroscopy (95% CI, 54.2-63.7) and 45.1 +/- 7 years at menopause (95% CI, 42.6-47.6). Mean +/- SD duration of tamoxifen therapy was 27.3 +/- 16.5 months (95% CI, 22.0-32.5). Hysteroscopies were performed because of abnormal sonographic findings in 60% of the women and postmenopausal bleeding in 40%. The most common hysteroscopic and histological findings were endometrial polyps (32.5%) and atrophic endometria (22.5%). Immunohistochemistry showed that 85% of the women were progesterone receptor positive, 75% were ER positive, and 50% were Ki-67 positive. Endometrial polyps and polyps associated with atrophic endometrium were ER positive (P = 0.019). Results that were ER negative were more frequent in atrophic endometria (P = 0.01). The longer the time since menopause, the lower the Ki-67 expression in the endometrium was (P = 0.03). Ki-67 expression was greater in the endometrium of younger postmenopausal women (P = 0.01). CONCLUSIONS: The expression of steroid receptors in the endometrium was high in our series. All cases of endometrial polyps were ER positive. Estrogen receptors may play a major role in the development of endometrial polyps in postmenopausal women taking tamoxifen. Although most histological findings were benign, 22.5% were atrophic.

Chlamydia trachomatis e gestação / Chlamydia trachomatis and pregnancy

A infecção pela Chlamydia trachomatis é uma das mais freqüentes e curáveis doenças bacterianas de transmissão sexual, constatação que traz consigo sérias conseqüências para a saúde reprodutiva da mulher. A prevalência da infecção do trato genital inferior pela C. trachomatis varia, conforme dados obtidos na literatura, entre 2 e 25 porcento, sendo mais prevalente em adultos jovens. A infecção é assintomática em 75 porcento das mulheres e em pelo menos 50 porcento dos homens, portanto, a infecção do trato genital inferior por esse agente permanece indetectável em sua grande maioria. Essa infecção situa-se entre as causas mais comuns de doença inflamatória pélvica (DIP), gravidez ectópica e infertilidade. Há aumento de evidências de que a infecção por C. trachomatis pode acarretar desfechos adversos na gestação, como abortamento, infecção intra-uterina, natimorto, prematuridade e ruptura prematura e membranas. Essa atualização focalizará a epidemiologia, características clínicas, fisiopatologia e seqüelas reprodutivas da infecção por esse agente, abordando de modo geral os métodos de triagem e o tratamento clínico preconizado.

Chlamydia trachomatis is the most common and curable bacterial disease sexually transmitted, in many countries, a fact that has serious consequences for the reproductive women's health. The prevalence of the lower tract infection with C. trachomatis varies from 2 percent to 25 percent and is higher among young people. The infection is asymptomatic in 75 percent of women and at least 50 percent of men, thus the lower genital tract infection remains largely undetected. It is a major cause of pelvic inflammatory disease (PID), which in turn is a major cause of infertility and ectopic pregnancy. It has been also demonstrated that the infection for C. trachomatis can cause adverse outcomes for the pregnancy, as abortion, intrauterine infection, stillborn, prematurity and premature rupture of membranes. This updating highlights the epidemiology, pathophysiology, clinical features and reproductive sequelae of the infection. Current screening and management methods are outlined.(au)

Terapia de reposiçäo hormonal em pacientes tratadas por câncer de endométrio / Hormonal replacement therapy in patients treated for endometrial cancer

O adenocarcinoma de endométrio, por ser uma neoplasia estrogênio-dependente, vinha sendo considerado uma contra-indicação absoluta para o uso da terapia de reposição hormonal(TRH). Os autores realizam revisão bibliográfica e analisam os principais estudos que questionam este assunto e que apontam para a possibilidade de uso de TRH em pacientes com câncer de endométrio em casos selecionados, baseados em indicadores prognósticos e na autorização da paciente, conhecedora dos riscos/benefícios da mesma

Câncer de endométrio: condutas diagnósticas e terapêuticas / Adenocarcinoma of endometrium: diagnostic and therapeutic procedures

As condutas adotadas no Serviço de Ginecologia da Santa Casa de Porto Alegre no procedimento diagnóstico e na orientaçäo terapêutica do câncer de endométrio säo descritas. É enfatizado o valor da histerescopia no diagnóstico preciso do câncer de endométrio e discutidas as opçöes de tratamento cirúrgico

Videoisteroscopia ginecológica: indicaçöes e possibilidades / Hysteroscopy: indications and possibilities

Em funçäo da grande evoluçäo que a histeroscopia apresentou nos últimos 10 anos, o texto se propöe a situar o médico na sua atual abordagem diagnóstica e terapêutica (ou cirúrgica)

Câncer de colo uterino: condutas diagnósticas e terapêuticas / Cervical cancer: diagnosis and therapeutics

A conduta no diagnóstico e no tratamento das neoplasias intraepiteliais cervicais e do câncer de colo uterino adotadas no Serviço de Ginecologia da Santa Casa é descrita. O manejo dos meios diagnósticos e das opçöes terapêuticas é avaliado