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Risk-reducing operations are an important part of the management of hereditary predisposition to cancer. In selected cases, they can considerably reduce the morbidity and mortality associated with cancer in this population.The Brazilian Society of Surgical Oncology (BSSO) developed this guideline to establish national benchmarks for cancer risk-reducing operations.The guideline was prepared from May to December 2021 by a multidisciplinary team of experts to discuss the surgical management of cancer predisposition syndromes. Fourteen questions were defined and assigned to expert 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, classified the level of evidence, and voted on the recommendations.For all questions including risk-reduction bilateral salpingo-oophorectomy, hysterectomy, and mastectomy, major agreement was achieved by the participants, always using accessible alternatives.This and its accompanying article represent the first guideline in cancer risk reduction surgery developed by the BSSO, and it should serve as an important reference for the management of families with cancer predisposition.

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. 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. 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). Survival outcomes were similar between minimally invasive and open radical hysterectomy in this large retrospective multicenter cohort.

Lynch syndrome (LS), is the most common hereditary colorectal cancer syndrome. However, it is poorly characterized in Brazil. Therefore, we aimed to determine the spectrum of pathogenic variants in Mismatch Repair (MMR) genes and investigate the MLH1 promotor methylation role as a second hit in LS tumors. Tumor screening through microsatellite instability and immunohistochemistry for MMR proteins was performed in 323 cases who met clinical criteria. BRAF-V600E and MLH1 promoter methylation were analyzed for all MLH1-deficient tumors. Patients with MMR deficient tumor proceeded to germline genetic testing. MMR deficient tumors were detected in 41% of patients recruited. About half of patients carried a pathogenic germline variant. Two recurrent variants in MLH1 and three novel pathogenic variants were identified. Furthermore, pathogenic germline variants with concomitant somatic MLH1 hypermethylation were found in 6% of cases. Predictive genetic testing was offered to 387 relatives. Overall, 127 tumors were diagnosed in 100 LS patients, from 62 unrelated families. Our molecular data provide new information about the spectrum of MMR mutations, which contributes to a better characterization of LS in Brazil. Furthermore, we call attention to the possibility of failure in the diagnosis of germline MLH1 mutation carriers when somatic MLH1 hypermethylation is used to rule out LS.

The current study aimed to identify new breast and/or ovarian cancer predisposition genes. For that, whole‐exome sequencing (WES) was performed in the germline DNA of 52 non‐BRCA1/BRCA2/TP53 mutation carrier women at high‐risk for hereditary breast and ovarian cancer (HBOC). All variants were classified using information from population and disease specific databases, in silico prediction tools and the American College of Medical Genetics and Genomics (ACMG) criteria. Loss of heterozygosity (LOH) of tumor samples and segregation analyses were performed whenever possible. The variants identified were investigated in a second, independent cohort of 17 BC cases. Pathogenic/Likely Pathogenic variants were identified in known cancer genes such as CHEK2, MUTYH, PMS2, and RAD51C. Rare and potentially pathogenic variants were identified in DNA repair genes (FAN1, POLQ, and RAD54L) and other cancer‐related genes such as DROSHA and SLC34A2. Interestingly, the variant c.149T>G in the FAN1 gene was identified in two unrelated families, and exhibited LOH in the tumor tissue of one of them. In conclusion, this is the largest Brazilian WES study involving families at high‐risk for HBOC which has brought novel insights into the role of potentially new genetic risk factors for hereditary breast and ovarian cancer., The current study aimed to identify new breast and/or ovarian cancer predisposition genes. Rare and potentially pathogenic variants were identified in DNA repair genes (FAN1, POLQ, and RAD54L) and other cancer‐related genes such as DROSHA and SLC34A2. This is the largest Brazilian WES study involving families at high‐risk for hereditary breast and ovarian cancer which has brought novel insights into the role of potentially new genetic risk factors for hereditary breast and ovarian cancer.

BackgroundGrowing evidence suggest that sentinel lymph node (SLN) biopsy in endometrial cancer accurately detects lymph node metastasis. However, prospective randomized trials addressing the oncological outcomes of SLN biopsy in endometrial cancer without lymphadenectomy are lacking.Primary ObjectivesThe present study aims to confirm that SLN biopsy without systematic node dissection does not negatively impact oncological outcomes.Study HypothesisWe hypothesized that there is no survival benefit in adding systematic lymphadenectomy to sentinel node mapping for endometrial cancer staging. Additionally, we aim to evaluate morbidity and impact in quality of life (QoL) after forgoing systematic lymphadenectomy.Trial DesignThis is a collaborative, multicenter, open-label, non-inferiority, randomized trial. After total hysterectomy, bilateral salpingo-oophorectomy and SLN biopsy, patients will be randomized (1:1) into: (a) no further lymph node dissection or (b) systematic pelvic and para-aortic lymphadenectomy.Major Inclusion and Exclusion CriteriaInclusion criteria are patients with high-grade histologies (endometrioid G3, serous, clear cell, and carcinosarcoma), endometrioid G1 or G2 with imaging concerning for myometrial invasion of ≥50% or cervical invasion, clinically suitable to undergo systematic lymphadenectomy.Primary Endpoint(s)The primary objective is to compare 3-year disease-free survival and the secondary objectives are 5-year overall survival, morbidity, incidence of lower limb lymphedema, and QoL after SLN mapping ± systematic lymphadenectomy in high-intermediate and high-risk endometrial cancer.Sample size178 participants will be randomized in this study with an estimated date for completing accrual of December 2024 and presenting results in 2027.Trial Registration NumberNCT03366051.

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.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.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 had90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition).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 is the fourth most common cancer in women. Although cure rates are high for early stage disease, clinical outcomes for advanced, metastatic, or recurrent disease remain poor. To change this panorama, a deeper understanding of cervical cancer biology and novel study models are needed. Immortalized human cancer cell lines such as HeLa constitute crucial scientific tools, but there are few other cervical cancer cell lines available, limiting our understanding of a disease known for its molecular heterogeneity. This study aimed to establish novel cervical cancer cell lines derived from Brazilian patients. We successfully established one (HCB-514) out of 35 cervical tumors biopsied. We confirmed the phenotype of HCB-514 by verifying its' epithelial and tumor origin through cytokeratins, EpCAM and p16 staining. It was also HPV-16 positive. Whole-exome sequencing (WES) showed relevant somatic mutations in several genes including BRCA2, TGFBR1 and IRX2. A copy number variation (CNV) analysis by nanostring and WES revealed amplification of genes mainly related to kinases proteins involved in proliferation, migration and cell differentiation, such as EGFR, PIK3CA, and MAPK7. Overexpression of EGFR was confirmed by phospho RTK-array and validated by western blot analysis. Furthermore, the HCB-514 cell line was sensitive to cisplatin. In summary, this novel Brazilian cervical cancer cell line exhibits relevant key molecular features and constitutes a new biological model for pre-clinical studies., Barretos Cancer Hospital Research Support Department (NAP) for sample collection, Barretos Cancer Hospital Biobank for sample processing, Dr. Flávia de Paula and Gabriela Fernandes for technical support of STRs and BRCA2 Sanger validation, respectively, and Dr. Laura Musselwhite (Duke University) for revising the manuscript. This study was supported by grants from the FINEP (MCTI/FINEP/MS/SCTIE/DECIT-01/2013 - FPXII- BIOPLAT - Process number 01.13.0469.00) and Barretos Cancer Hospital. PhD scholarship from FINEP (Grant numbers 384088/2014-7 and 380434/2015-6) and Barretos Cancer Hospital to MNR.

Background The complications inherent to conization include vaginal bleeding, cervical stenosis, amenorrhea, dysmenorrhea, and deep dyspareunia. Cervical stenosis is the most important complication due to the clinical repercussions. Studies show rates of cervical stenosis ranging from 1.3 to 19% after the Loop Electrosurgical Excision Procedure (LEEP). Objective Our primary outcome was to compare the role of a new endocervical device to prevent cervical stenosis after LEEP in patients with high-grade squamous intraepithelial lesions (HSILs). Methods A randomized clinical trial was performed including phases II and III for evaluation of a new device for cervical stenosis prevention. In Phase II, we included 25 patients who underwent LEEP and placement of the device to assess its toxicity and efficacy. In phase III, we compared two groups (with and without the use of an anti-stenosis device) to evaluate its efficacy and safety. Results From August 2015 to June 2018, 265 participants were randomized (Phase II: 25, Phase III: 120 with DUDA and 120 without DUDA). The toxicity during phase II was observed in only one patient (4%) with pain grade > 7. There were 7 cases of toxicity during Phase III, 2 in the DUDA group (1.8%), and 5 in the No DUDA group (4.5%). The complications rate was numerically higher in the No DUDA group (2.5x higher) than the DUDA group, but this difference did not reach statistical significance (p = 0.52). The rate of cervical stenosis in DUDA group was (4–7,3%), and in No DUDA group was (4.3–5.8%) (p = 0.5). We did not find a significant difference when comparing the evolution at 3, 6, and 12 months in terms of cervical patency and visualization of the squamocolumnar junction (SCJ) during colposcopy. The DUDA group exhibited 15% to 19% nonvisualization of the SCJ, whereas that rate ranged from 10 to 12% in the No DUDA group. Conclusions The rate of cervical stenosis was not different comparing the use of a new device, specifically produced to prevent cervical stenosis, compared to no use after LEEP procedure. This clinical trial opens up space for a discussion of the utility of using cervical stenosis devices after LEEP. Perhaps in another type of conization it can be evaluated to avoid cervical stenosis.

To compare outcomes of radical hysterectomy (RH) across age groups based on surgical approach: minimally invasive surgery (MIS) vs laparotomy (LP).Cross-sectional retrospective review (Canadian Task Force classification II-2).Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M.D. Anderson Cancer Center.Patients with early-stage cervical cancer who underwent RH at a tertiary cancer center between 1990 and 2013.Patients were stratified by age group (50, 50-59, and ≥60 years) and by surgical approach (minimally invasive surgery [MIS] vs laparotomy [LP]).Patients with early-stage cervical cancer who underwent RH were retrospectively reviewed to obtain demographic data, surgical data, and clinical outcomes. We used the Fisher exact, Wilcoxon rank-sum, and Cochran-Mantel-Haenszel tests to compare categorical and continuous variables stratified by surgical approach and age group. A total of 548 patients were evaluated, including 427 (77.9%) who underwent LP (age50, 84.3%; 50-59, 11.2%; ≥60, 4.5%) and 121 (22.1%) who underwent MIS (age50, 71.9%; 50-59, 17.3%; ≥60, 10.8%). In the MIS group, 71 patients (58.7%) underwent laparoscopy and 50 (41.3%) underwent robotic surgery. Patients in the MIS group were significantly older and heavier than those in the LP group. The operative time was significantly longer in the MIS group. There was no between-group difference in intraoperative complications in any of the 3 age groups. LP patients had more infectious complications (respiratory, systemic, and wound) than MIS patients in the50-year age group (53.3% vs 21.8%). The difference between the LP and MIS groups with respect to the postoperative noninfectious complication rate was greatest in the ≥60-year age group (p = .0324).The between-group difference in postoperative noninfectious complication rate in the oldest age group was twice that in either of the other 2 age groups (p = .0324), even though the MIS patients were older, heavier, and had a longer operative time compared with the LP patients.

Objective To present the first robotic-assisted uterus retrieval from a living donor for uterine transplantation in Brazil. Design Stepwise demonstration of the technique with narrated video footage. Setting A uterine transplantation was performed in a 33-year-old patient with Mayer-Rokitansky-Kuster-Hauser syndrome. The donor was a 50-year-old woman who underwent a robotic-assisted uterus retrieval. The procedure was held at Barretos Câncer Hospital, Barretos – Sao Paulo, Brazil. Interventions After approval from the National and local Institutional Review Board, the protocol was submitted to clinicaltrials.gov (NCT04249791), and the first case was performed. The screening of the patients was done. The uterus was retrieved through a Pfannenstiel incision to avoid complications to the uterine vessels. Uterus was transplanted in the recipient by end-to-end anastomosis of the internal iliac arteries and end-to-side anastomosis of the external iliac vein with a gonadal vein from the infundibulopelvic ligament. Surgical intraoperative parameters were measured. The docking time was 4 minutes. Robotic donor surgery took 400 minutes, bench surgery 62 minutes, and laparotomic recipient surgery was completed in 240 minutes. There were no intraoperative complications. The donor patient was discharged from the hospital in 48 hours and the recipient patient in 5 days. Conclusions This is the first case in Brazil of uterine transplantation with a living donor to the best of our knowledge. Traditionally, patients who undergo uterine transplantation by minimally invasive surgery are managed by laparoscopy. This video demonstrates a feasible robotic approach to uterine transplantation with superior imaging affording a three-dimensional vision, and stabilization of instruments allowing wrist-like movements.

Background: Surgical staging is associated with a significant rate of upstaging compared to clinical/radiological staging in patients with locally advanced cervical cancer. Objective: To analyze the stage-specific percentage of pelvic and para-aortic lymph node metastases and the upstaging ratio in a prospective randomized trial (Uterus-11). Methods: FIGO stage IIB-IVA cervical cancer patients were randomized to surgical staging (arm A) or to clinical staging and primary chemoradiation (arm B). Arm B patients underwent CT-guided biopsy of suspicious para-aortic lymph nodes. Confirmed para-aortic metastasis patients received extended-field radiation therapy. Results: A total of 234 patients were enrolled, including 120 (arm A) and 114 (arm B) treated per protocol. The groups were well balanced. Pelvic and para-aortic lymph node metastases were identified after surgical staging in 51 and 24% of patients, respectively (p < 0.001). Pelvic and para-aortic lymph node metastases were confirmed in 45 and 20% of IIB patients and in 71 and 37% of IIIB patients, respectively. Upstaging occurred in 39/120 (33%) in arm A and in 9/114 (8%) in arm B (p < 0.001). Conclusion: The histological results in both groups led to a considerable rate of upstaging. Oncological data from the Uterus-11 study may reveal whether modified therapy translates into a survival benefit.

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.

Objective To evaluate the difference between early and delayed removal of indwelling urinary catheter after radical hysterectomy (RH) or radical trachelectomy (RT). Methods An ambispective study was conducted in early-stage cervical cancer patients who underwent RH or RT. Delayed indwelling urinary catheter removal occurred on a postoperative day (POD) 7 in the retrospective group (January 2012-November 2013), and early removal occurred on POD 1 in the prospective group (May 2014-June 2017). The postvoid residual (PVR) test was performed after indwelling catheter removal in both groups. Results Our sample included 47 patients in the delayed group and 48 in the early one. There was no difference in age, body mass index, tumor size, histology, stage, surgical approach, and intraoperative and postoperative complications. Indwelling urinary catheter reinsertion was needed in 16 (34%) patients in the delayed group and 12 (25%) in the early group (P = .37), with no statistical difference between the median PVR volumes -82.5 and 45 mL (P = .06), respectively. Seven (14.9%) patients in the delayed group presented with 30-day urinary tract infection vs two (4.2%) in the early group (P = .09). Conclusions Early indwelling urinary catheter removal, in regard to the rate of catheter reinsertion and PVR volume, does not differ from delayed removal.

GoalTo assess the impact of chemoradiation on pelvic floor (PF) muscle function after the treatment of cervical cancer (CC).MethodsWe performed a prospective cohort study of women between the ages of 20 and 70 years old who had a diagnosis of CC. Patients were treated with chemoradiation at the Barretos Cancer Hospital (BCH), between August 2016 and July 2017. We performed three evaluations at different time points after chemoradiation treatment to compare changes in muscle function. Pelvic floor muscle function was assessed through perineometry (PNM) and surface electromyography (EMG) at the following time points: Pretreatment Moment 1 (M1): evaluated before chemoradiation; Moment 2 (M2): at the first follow-up medical visit (usually 3 to 4 months after treatment); and Moment 3 (M3): at the second follow-up medical visit (usually after 6 to 9 months after treatment). Mean vaginal squeeze pressure levels were determined by PNM and muscle electromyographic activity by EMG and the results were evaluated by Generalized Linear Model comparisons.ResultsForty-nine patients were evaluated at M1; 35 at M2; and 32 at M3, so that 32 patients had all three muscle evaluations performed. There was a statistically significant increase in the frequency of women with urgency urinary incontinence at the M2 evaluation time (41.9%), compared to pretreatment M1 (18.6%), pConclusionThese results show that chemoradiation causes reduction of muscle function of the pelvic floor, especially in the late phase after the end of treatment. Both the high BMI and urgent urinary incontinence symptoms were related to decreased muscle strength.

Objective To describe a series of cases of ovarian Sertoli-Leydig cell tumors (SLCTs). Methods Retrospective review of 12 cases of SLCT treated at the Hospital do Câncer de Barretos, Barretos, state of São Paulo, Brazil, between October 2009 and August 2017. Results The median age of the patients was 31 years old (15-71 years old). A total of 9 patients (75.0%) presented symptoms: 8 (66.7%) presented with abdominal pain, 5 (41.7%) presented with abdominal enlargement, 2 (16.7%) presentedwith virilizing signs, 2 (16.7%) presented with abnormal uterine bleeding, 1 (8.3%) presented with dyspareunia, and 1 (8.3%) presented with weight loss. The median preoperative lactate dehydrogenase (LDH) was 504.5 U/L (138-569 U/L), alpha-fetoprotein (AFP) was 2.0 ng/ml (1.1-11.3 ng/ml), human chorionic gonadotropin (β-hCG) was 0.6 mUI/ml (0.0-2.3 mUI/ml), carcinoembryonic antigen (CEA) was 0.9 ng/ml (0.7-3.4 ng/ml), and cancer antigen 125 (CA-125) was 26.0 U/ml (19.1-147.0 U/ml). All of the tumors were unilateral and surgically treated. Lymphadenectomy was performed in 3 (25.0%) patients, but none of the three patients submitted to lymphadenectomy presented lymph node involvement. In the anatomopathological exam, 1 (8.3%) tumor was well-differentiated, 8 (66.7%) were moderately differentiated, and 3 (25.0%) were poorly differentiated. A total of 5 (55.6%) tumors were solid-cystic, 2 (22.2%) were purely cystic, 1 (11.1%) was cystic with vegetations, and 1 (11.1%) was purely solid, but for 3 patients this information was not available. The median lesion size was 14.2 cm (3.2-23.5 cm). All of the tumors were at stage IA of the 2014 classification of the International Federation ofGynecology andObstetrics (FIGO). A total of 2 (16.7%) patients received adjuvant treatment; 1 of themunderwent 3 cycles of paclitaxel and carboplatin every 21days, and the other underwent 4 cycles of ifosfamide, cisplatin and etoposide every 21 days. None of all of the patients had recurrence, and one death related to complications after surgical staging occurred. Conclusion Abdominal pain was the most frequent presentation. There was no ultrasonographic pattern. All of the SLCTs were at stage IA, and most of them were moderately differentiated. Relapses did not occur, but one death related to the surgical staging occurred. Resumo Objetivo Descrever uma série de casos de tumores de células de Sertoli-Leydig (TCSLs) ovarianos. Métodos Revisão retrospectiva de 12 casos de TCSL tratados no Hospital de Câncer de Barretos entre outubro de 2009 e agosto de 2017. Resultados A mediana de idade foi 31 anos (15-71 anos). Um total de 9 pacientes (75,0%) apresentaram sintomas: 8 (66,7%) apresentaram dor abdominal, 5 (41,7%) apresentaram aumento abdominal, 2 (16,7%) apresentaram virilização, 2 (16,7%) apresentaram sangramento uterino anormal, 1 (8,3%) apresentou dispareunia, e 1 (8,3%) apresentou emagrecimento. A mediana de desidrogenase láctica (DHL) foi 504,5 U/L (138-569 U/L), alfafetoproteína (AFP) foi 2,0 ng/ml (1,1-11,3 ng/ml), gonadotrofina coriônica humana (β-hCG) foi 0,6 mUI/ml (0,0-2,3 mUI/ml), antígeno carcinoembrionário (CEA) foi 0,9 ng/ml (0,7-3,4) ng/ml, e antígeno cancerígeno 125 (CA-125) foi 26,0 U/ml (19,1-147,0 U/ml), todos pré-operatórios. Todos os tumores foram unilaterais e tratados cirurgicamente. Realizou-se linfadenectomia em 3 (25,0%) pacientes, por em, nenhuma das tr^es apresentou acometimento linfonodal. No exame anatomopatológico, 1 tumor (8,3%) era bem diferenciado, 8 (66,7%) eram moderadamente diferenciados, e 3 (25,0%) eram pouco diferenciados. Um total de 5 (55,6%) tumores eram sólido-císticos, 2 (22,2%) eram puramente císticos, 1 (11,1%) era cístico com vegetações, e 1 (11,1%) era puramente sólido, mas para 3 pacientes estas informações não estavam disponíveis. A mediana da dimensão da lesão foi 14,2 cm (3,2-23,5 cm). Todos os tumores eram estádio IA de acordo com a classificação de 2014 da Federação Internacional de Ginecologia e Obstetrícia (FIGO, na sigla em inglês). Duas (16,7%) pacientes receberam adjuvância; uma realizou 3 ciclos de paclitaxel e carboplatina a cada 21 dias, e a outra 4 ciclos de ifosfamida, cisplatina e etoposide a cada 21 dias. Dentre todas as pacientes, nenhuma apresentou recidiva e houve um óbito relacionado a complicações após estadiamento cirúrgico. Conclusão Dor abdominal foi a apresentação mais frequente. Todos os TCSLs eram estádio IA e a maioria era moderadamente diferenciada. Não ocorreram recidivas, mas ocorreu um óbito relacionado ao estadiamento cirúrgico.

Study Objective Sentinel lymph node (SLN) mapping has been proven to accurately stage endometrial cancer (EC). However, there is a lack of studies comparing the incidence of complications between different lymph node approaches in EC. The objective of the study was to define the complication rates of SLN biopsy in EC patients. Design A retrospective cohort study Setting A tertiary referral hospital Patients All patients who were surgically treated for EC form April 2013 to March 2018 Interventions Authors evaluated intraoperative complications and 30-day complications using the Memorial Sloan Lettering Cancer Center's Surgical Secondary Events Grading System, separating the patients into 4 groups: group I, hysterectomy (HT); group II, hysterectomy plus sentinel lymph node biopsy (HT+SLN); group III, hysterectomy plus pelvic lymphadenectomy, with or without para-aortic dissection (HT+LND); and group IV, hysterectomy plus lymphadenectomy and sentinel lymph node biopsy (HT+SLN+LND). Measurements and Main Results Authors identified a total of 250 cases. As compared with the HT group, the HT+SLN group did not show any increased risk of complications in terms of intraoperative complications (0 vs 1; p = 1.0) and 30-day complications (8 vs 7; p = .782), but surgical time was approximately 20 minutes longer (p = .016). Performing LND was associated with a greater risk of 30-day complications (hazard ratio [HR]: 3.11; 95% confidence interval [CI]: 1.62–5.98), intraoperative complications (HR: 14.25; 95% CI: 1.85–19.63), and lower-limb lymphedema (HR: 8.14; 95% CI: 1.01–65.27). Conclusion SLN mapping does not increase morbidity in the surgical treatment of EC patients, and compared with comprehensive lymphadenectomy, it has a lower risk of complications. Our findings support the use of the SLN algorithm in EC patients

The current study aimed to evaluate the accuracy of diffusion‑weighted imaging and morphological aspects at 3 Tesla (T) and 1.5T MRI for diagnosing metastatic lymph nodes (LN) in cervical cancer. A retrospective study was conducted at the Barretos Cancer Hospital. A total of 45 patients with cervical cancer who underwent MRI examination and pelvic and/or para‑aortic lymphadenectomy as part of surgical procedure were included. Data regarding LN images included size (short‑axis diameters), morphology (usual, rounded or amorphous), appearance (homogeneous or heterogeneous), limits (regular, irregular or imprecise), presence or absence of necrosis, diffusion (normal or greater restriction than expected for normal tissue) and aspect (suspected, undetermined or normal). These findings were compared with histopathological results. According to histology results, among the 45 patients, 14 (31.1%) LNs were tested positive for metastasis and 31 (68.9%) LNs were tested negative. A total of 41 metastatic positive LNs were detected from a total of 976 resected nodes. Twelve patients from the 45 (26.7%) had LN classified as metastatic by histology and suspected by MRI, 26 (57.8%) as negative in both evaluations, 2 (4.4%) as positive by histology and negative by MRI and five (11.1%) as negative by histology and positive by MRI. Based on these results, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were 85.7, 83.9, 70.6, 92.9 and 84.4%, respectively. The Cohen's κ test exposed a general outcome of 0.657 (P0.05), demonstrating that the two variables (histology and MRI) have substantial concordance. The κ test results between histological and MRI data for paraaortic and pelvic LNs were found to be 1 and 0.657, respectively. Finally, short axis10 mm, T2 hypointensity, rounded morphology and greater restriction than expected for normal tissues are the four most common MRI findings associated with metastatic LN. The concordance between MRI and histology was substantial, indicating that this method using MRI for diagnosing suspected LN metastasis is reliable. The results of the current study revealed that the most important aspects to be evaluated in MRI include: Short axis10 mm, T2 hypointensity, rounded morphology and greater restriction than expected for normal tissues. If these four characteristics are present in MRI, histological evaluation is likely to reveal positive lymph node metastasis.

Study Objective To illustrate a technique of robotic vesicovaginal fistula repair in a patient with a prior history of pelvic radiation therapy and multiple abdominal surgeries. Design Stepwise demonstration of the technique with narrated video footage. Setting Barretos Cancer Hospital, Brazil. Patient A 59-year-old woman presenting with vesicovaginal fistula, who had a past history of rectosigmoidectomy followed by pelvic radiotherapy for Stage III colon cancer 23 years before, and robotic hysterectomy, bilateral salpingo-oophorectomy, omentectomy with bilateral pelvic and para-aortic lymphadenectomy for stage II Mixed Cell Endometrial carcinoma, which needed surgical reintervention because of a pelvic hematoma and complete vaginal cuff dehiscence. Interventions Robotic vesicovaginal fistula repair. Measurements and Main Results We performed a robotic approach to vesicovaginal fistula with several key strategies to perform the fistula repair and maintain the integrity of the abdominopelvic structures: 1-Careful bowel adhesiolysis involving multiple segments of the intestine to the abdominal and pelvic peritoneum. 2-Cystotomy using a vaginal probe guidance. 3-Fistulectomy by monopolar scissors, after ureteral orifices visualization. 4-Dissection of the retropubic space of Retzius, taking off bladder tension. 5-Transverse sutures to coapt the raw surfaces on the vaginal side and the bladder in two layers with minimal tension. 6-Transurethral instillation of methylene blue into the bladder. Conclusions Traditionally, patients with vesicovaginal fistula after pelvic radiation therapy and multiple abdominal surgeries are managed by laparotomy. This video demonstrates a feasible robotic approach to vesicovaginal fistula repair, with superior imaging affording a three-dimensional vision and stabilization of instruments allowing wrist-like movements.

Objective To develop a prognostic model for women who underwent surgical treatment for cervical intraepithelial neoplasia. Design Cohort study. Patient inclusion and follow-up occurred retrospectively and prospectively. Setting Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil. Population Women (n = 242) diagnosed with cervical intraepithelial neoplasia who were submitted to conization. Methods Immediately prior to surgical treatment, a cervical cytology sample was collected from each individual included in the study by endocervical brushing and stored in a preservative solution with methanol. A human papilloma virus-DNA test was conducted using an aliquot of the endocervical brushings. The surgical specimens were subjected to immunohistochemical analysis of p16 (immunohistochemical analysis 4a) protein expression. Main outcome measures Two-year disease-free survival rates calculated for each study variable. Identified variables in the multivariate Cox model were used for elaboration of prognostic scores. Results Variables associated with outcome included age (p = 0.033), tobacco use (p

Study Objective To demonstrate a laparoscopic vaginal-assisted nerve-sparing radical trachelectomy. Design An edited educational video, including a step-by-step description of the procedure. Setting Radical trachelectomy is the main surgical indication for selected cases of initial cervical cancer with a fertility-sparing approach. Although transvaginal access is the most traditional route, this technique has not gained widespread acceptance because of the complexity of the ureteral dissection and the limited amount of resected parametrial tissue. This video describes a laparoscopic technique including an adequate parametrial resection with autonomic preservation (C1 level) and a standard laparoscopic ureteric dissection under direct visualization. All parametrial dissections were performed by laparoscopy using a nerve-sparing technique. The uterine vessels were well dissected and transected at their origin. The colpotomy was performed by laparoscopy with a 1-cm vaginal margin using a monopolar energy hook. To achieve an adequate endocervical margin and to avoid thermal injury to the endocervix, the cervical section was performed transvaginally with a cold knife. The specimen was then retrieved, and a segment of the remaining cervix was removed for frozen section analysis. If the margin was free of tumor, the cervical-vaginal anastomosis was performed transvaginally. An endocervical device was placed to avoid postoperative cervical stenosis. Interventions Laparoscopic vaginal-assisted nerve-sparing radical trachelectomy. Conclusion This video demonstrates a reproducible laparoscopic technique for radical trachelectomy with a nerve-sparing technique. The vaginal route was used at the moment of sectioning the cervix/isthmus to permit adequate margin evaluation.

Cervical cancer remains the most frequent gynecological tumor in Brazil and other developing countries. Minimally invasive techniques, especially laparoscopy, have been increasingly employed in such tumors. This article aims to describe the main applications of laparoscopy in the treatment and staging of cervical cancer. In the early stages, it is possible to provide a fertility-preserving surgery in the form of radical trachelectomy and, in a study protocol, the function-preserving surgery, avoiding parametrectomy and the associated morbidity. A fully laparoscopic radical hysterectomy is fairly standard in the literature and has the tendency to become the standard of care in early cases, for patients who want to bear no more children. In advanced stages, minimally invasive surgery can offer ovarian transposition, with intent to prevent actinic castration, without upsetting the time for the start of radiotherapy and chemotherapy. Staging laparoscopic surgery, including pelvic and para-aortic lymphadenectomy, has been the subject of studies, since it has the potential to modify the extension of radiotherapy depending on the extent of lymph node spread. O câncer de colo uterino permanece o tumor ginecológico mais incidente no Brasil e em diversos países em desenvolvimento. As técnicas minimamente invasivas, principalmente a videolaparoscopia, têm sido progressivamente mais empregadas nestes tumores. Este artigo tem o objetivo de descrever as principais aplicações da videolaparoscopia no tratamento e no estadiamento do câncer de colo. Para os estádios iniciais, é possível oferecer a cirurgia preservadora de fertilidade, na forma de traquelectomia radical e, em protocolo de estudo, na cirurgia conservadora de função, evitando-se a parametrectomia e a morbidade associada. A histerectomia radical totalmente videolaparoscópica está adequadamente padronizada na literatura e tem a tendência de se tornar o padrão de tratamento nos casos iniciais, para pacientes com prole definida. Nos estádios avançados, a cirurgia minimamente invasiva pode oferecer a transposição ovariana, com intenção de evitar a castração actínica, sem prejudicar o tempo para o início do tratamento radioterápico e quimioterápico. A cirurgia laparoscópica estadiadora, incluindo linfadenectomia pélvica e paraórtica, tem sido alvo de estudos, uma vez que tem o potencial de modificar a extensão do tratamento radioterápico, na dependência da extensão da disseminação linfonodal.