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.

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer.

BACKGROUND AND OBJECTIVES: The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS: A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS: Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS: Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

High Frequency of Malignant Transformation of Ovarian Mature Teratoma into Squamous Cell Carcinoma in Young Patients in Northeast Brazil.

The malignant behavior of an ovarian teratoma is related to immaturity, or rarely to the malignant transformation of a somatic component in a mature teratoma (MT). The aim of this work was to review 189 consecutive ovarian teratomas diagnosed between 2006 and 2010 at a public referral center for cancer in Brazil, focusing on cases of MT with malignant transformation. MTs with transformation to squamous cell carcinoma (SCC) were further analyzed by immunohistochemistry for p16 staining. The median age of all patients was 36 yr (mean age, 39.6 yr; SD±4.9). Mature and immature teratomas represented 95.7% (181/189) and 4.2% of the cohort, respectively. Immature teratoma occurred mainly in adolescents under 18 yr. Malignant transformation of the somatic component in MT was observed in 10 of 181 patients (5.5%). SCC was the most common subtype (4/10), followed by differentiated thyroid carcinoma in struma ovarii(3/10), adenosquamous carcinoma (1/10), mucinous intestinal-type adenocarcinoma (1/10), and a well-differentiated neuroendocrine tumor/carcinoid (1/10). Two of 4 SCC cases were strong and diffusely positive for p16, and 2 were negative. In 5 further patients, MT was synchronously observed with other benign and malignant ovarian neoplasms in the ipsilateral ovary (3 mucinous cystadenomas and 1 Brenner tumor) and 1 cystadenocarcinoma in the contralateral ovary. MTs with malignant transformation were larger than those without transformation (P<0.001), but did not demonstrate any association with age. Indeed, our patients with SCC in MT were much younger [median and mean age, 37 and 38 yr (SD±4.9), respectively] than those described previously. As p16 is considered a surrogate marker for HPV infection, the malignant transformation of MT into SSC in young patients raises the possibility of HPV infection as a risk factor in some of these cases. However, molecular studies are needed to clarify the possible role of HPV in the malignant transformation of MT to SCC.

Study of biomolecular and clinical prognostic factors in patients with cancer of the vulva undergoing surgical treatment.

INTRODUCTION: Cancers of the vulva account for 3% to 5% of all cancers of the female genital. This study was conducted to evaluate clinical, pathological, and molecular prognostic factors in patients with cancer of the vulva. METHODS: Patients with squamous cell carcinoma of the vulva who had undergone surgical treatment at the Department of Pelvic Surgery and Gynecology Service, Aristides Maltez Hospital, between June 1993 and June 2011 were selected. Clinical, epidemiological, pathological, and molecular characteristics related to the prognosis of these patients were evaluated in relation to the prognosis. In the molecular evaluation, we studied the expression of p53 and matrix metalloproteinase 2 by immunohistochemistry. RESULTS: Seventy-five patients were eligible for the study. In multivariable analysis, factors related to survival were as follows: tumor size larger than 4 cm (P = 0.014), an invasion depth greater than 2 mm (P = 0.023) and matrix metalloproteinase 2 expression in more than 50% of the tumor cells (P = 0.046). With the use of the relative risks of the factors identified in the multivariable analysis, a point count was developed for a prognostic classification (the score classifies patients into 3 categories). CONCLUSIONS: A tumor size larger than 4 cm, an invasion depth greater than 2 mm, and metalloproteinase 2 expression in more than 50% of the tumor cells seem to be related to lower overall survival rate in patients with cancer of the vulva undergoing surgical treatment. A classification of the patient's prognosis can be performed using a point count based on these relative risks.

Laparoscopic surgical staging of locally advanced cervix cancer (IB2 to IVA): initial experience.

INTRODUCTION AND OBJECTIVES: Cervical cancer incidence worldwide is about 500,000 new cases per year with most of them being detected at a locally advanced stage. Many studies have shown the need to look for extra-pelvic disease when planning appropriate therapy. We performed surgical staging by laparoscopy in 43 cases of cervical cancer at stages IB2 to IVa and evaluated our initial results. MATERIALS AND METHODS: Between February 2008 and May 2010, we selected 43 patients with histologically confirmed cervical cancer at stages IB2 to IVA with a Karnosfsky index>70. We classified the tumors according to the FIGO (International Federation of Gynecology and Obstetrics) stage and performed tomographic evaluations of the abdomen to select patients without signs of peritoneal or para-aortic tumor spread. We performed a laparoscopic evaluation of the peritoneal cavity and para-aortic lymph nodes by an extra-peritoneal route. We did not use tweezers or disposable energy seals. RESULTS: The mean surgical time was 130.8min. The mean blood loss was 111.5ml. There was no conversion to laparotomy for any case. We describe a case with peritoneal implants that was classified as IVB. We removed an average of 16.4 lymph nodes; nine cases had para-aortic lymph node metastases. CONCLUSION: Laparoscopic surgical staging diagnosed 23.3% of cases with peritoneal spread of the tumor or extra-pelvic lymph node metastases. In this study, we could better define the lymph node status through laparoscopic surgical staging and could therefore recommend more suitable adjuvant therapy for patients with locally advanced cervical cancer.

Tumor endometrioide borderline de ovário em adolescente: relato de caso / Borderline ovarian endometrioid tumor in adolescent: case report and review of the literature

Os tumores endometrioides malignos ovarianos são neoplasias epiteliais raras em pacientes jovens. Enquanto os carcinomas endometrioides ovarianos acometem mulheres na quinta e na sexta décadas de vida, os tumores borderline acometem mulheres em uma faixa etária mais ampla (de 22 a 77 anos). Descreveremos a seguir um caso raro de tumor endometrioide borderline ocorrendo em paciente de 16 anos. Desde que tumores do saco vitelino (TSV) e de Sertoli-Leydig (TCSL) podem mimetizar morfologicamente tumor endometrioide, o uso da imuno-histoquímica, além dos aspectos morfológicos, foi fundamental para estabelecer o diagnóstico diferencial entre essas condições.

Malignant endometrioid ovarian tumors are rare epithelial neoplasias among young patients. Whereas endometrioid ovarian carcinomas are more common among women in their fifth and sixth decades of life, borderline endometrioid tumors affect 22 to 77 year-old women. The present study reports a rare case of borderline endometrioid tumor in a 16 year-old patient. Since yolk sac and Sertoli-Leydig cell tumor may morphologically mimic endometrioid tumor, both the use of immunohistochemistry and morphological aspects were essential to establish the differential diagnosis.

Gangrena de Fournier pós-hemorroidectomia / Fournier's gangrene post-hemorrhoidectomy

A fascite necrotizante do períneo e regiäo escrotal é uma entidade rara, caracterizada por extensa necrose da pele e tecido celular subcutâneo, tendo sido descrita em 1883 por Jean Alfred Fournier. A hemorroidectomia, apesar de ser procedimento operatório que ocorre em regiäo contaminada por resíduos fecais, muito raramente evolui para complicaçöes sépticas graves e necrotizantes. Neste trabalho apresentamos um caso de gangrena de Fournier que ocorreu em um doente alcoólatra e desnutrido, submetido a hemorroidectomia Miligan-Morgan em unidade ambulatorial. O desbridamento cirúrgico associado à colostomia derivativa, à antibioticoterapia ampla e à oxigeniterapia hiperbárica foram fatores determinantes para o sucesso terapêutico. Neste artigo discutimos as principais causas ou fatores envolvidos na gênese do processo infeccioso necrotizante pós-hemorroidectomia, realçando a necessidade de diagnóstico e terapêutica precoces