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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.

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.

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.

ObjectiveThe objective of the ConCerv Trial was to prospectively evaluate the feasibility of conservative surgery in women with early-stage, low-risk cervical cancer.MethodsFrom April 2010 to March 2019, a prospective, single-arm, multicenter study evaluated conservative surgery in participants from 16 sites in nine countries. Eligibility criteria included: (1) FIGO 2009 stage IA2–IB1 cervical carcinoma; (2) squamous cell (any grade) or adenocarcinoma (grade 1 or 2 only) histology; (3) tumor size <2 cm; (4) no lymphovascular space invasion; (5) depth of invasion <10 mm; (6) negative imaging for metastatic disease; and (7) negative conization margins. Cervical conization was performed to determine eligibility, with one repeat cone permitted. Eligible women desiring fertility preservation underwent a second surgery with pelvic lymph node assessment, consisting of sentinel lymph node biopsy and/or full pelvic lymph node dissection. Those not desiring fertility preservation underwent simple hysterectomy with lymph node assessment. Women who had undergone an ‘inadvertent’ simple hysterectomy with an unexpected post-operative diagnosis of cancer were also eligible if they met the above inclusion criteria and underwent a second surgery with pelvic lymph node dissection only.Results100 evaluable patients were enrolled. Median age at surgery was 38 years (range 23–67). Stage was IA2 (33%) and IB1 (67%). Surgery included conization followed by lymph node assessment in 44 women, conization followed by simple hysterectomy with lymph node assessment in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Positive lymph nodes were noted in 5 patients (5%). Residual disease in the post-conization hysterectomy specimen was noted in 1/40 patients—that is, an immediate failure rate of 2.5%. Median follow-up was 36.3 months (range 0.0–68.3). Three patients developed recurrent disease within 2 years of surgery—that is, a cumulative incidence of 3.5% (95% CI 0.9% to 9.0%).DiscussionOur prospective data show that select patients with early-stage, low-risk cervical carcinoma may be offered conservative surgery.

ObjectiveUterine transposition has emerged as an alternative for fertility preservation in women with pelvic malignancies that require radiotherapy. The goal of this study was to evaluate the short-term outcomes of patients undergoing uterine transposition after trachelectomy for cervical cancer or before chemoradiation for vaginal cancer.MethodsWe retrospectively evaluated patients with early stage cervical cancer after radical trachelectomy or with vaginal cancer with indication for pelvic radiation who had uterine transposition performed as fertility sparing strategy.ResultsFour patients with cervical cancer and one patient with vaginal cancer were included. Median age was 32 years (range 28–38). All patients had squamous cell carcinomas. All patients with cervical cancer had radical trachelectomies with sentinel lymph node dissection (SLN). Two of these patients also had pelvic lymphadenectomies. Indications for adjuvant radiotherapy was due to Sedlis criteria in two patients and to lymph node metastasis in the other two patients. The patient with stage IIB vaginal cancer was recommended primary chemoradiation. All patients underwent uterine transposition before radiotherapy. The median uterine transposition surgical time was 90 min (range 80-205) and no early complications (30 days) occurred. Average time from uterine transposition to start of radiotherapy was 16 days (10–28). After radiation, the uterus along with the ovaries and tubes were repositioned and the residual cervix sutured to the vagina. One patient declined uterine reimplantation after radiation and underwent a hysterectomy. After a median follow-up of 25 months (range 1–30), all patients were without evidence of disease. All patients with preserved uterus have normal menses after treatment. One patient has attempted to conceive with IVF techniques without success.ConclusionsUterine transposition may be an option in selected patients with cervical and vaginal cancers who want to preserve fertility. However, further studies that address its oncological safety and obstetrical outcomes are encouraged.

ObjectiveRevised staging of patients with locally advanced cervical cancer is based on clinical examination, imaging, and potential surgical findings. A known limitation of imaging techniques is an appreciable rate of understaging. In contrast, surgical staging may provide more accurate information on lymph node involvement. The aim of this prospective study was to evaluate the impact of pre-treatment surgical staging, including removal of bulky lymph nodes, on disease-free survival in patients with locally advanced cervical cancer.MethodsUterus-11 was a prospective international multicenter study including patients with locally advanced cervical cancer who were randomized 1:1 to surgical staging (experimental arm) or clinical staging (control arm) followed by primary platinum-based chemoradiation. Patients with histologically proven squamous cell carcinoma, adenocarcinoma, or adenosquamous cancer International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IIB–IVA underwent gynecologic examination and pre-treatment imaging including abdominal computed tomography (CT) and/or abdominal magnetic resonance imaging (MRI). Patients had chest imaging (any of the following: X-ray, CT, or PET-CT). The primary endpoint was disease-free survival and the secondary endpoint was overall survival. An ad hoc analysis was performed after trial completion for cancer-specific survival. Randomization was conducted from February 2009 to August 2013.ResultsA total of 255 patients (surgical arm, n=130; clinical arm, n=125) with locally advanced cervical cancer were randomized. Of these, 240 patients were eligible for analysis. The two groups were comparable with respect to patient characteristics. The surgical approach was transperitoneal laparoscopy in most patients (96.6%). Laparoscopic staging led to upstaging in 39 of 120 (33%) patients. After a median follow-up of 90 months (range 1–123) in both arms, there was no difference in disease-free survival between the groups (p=0.084). For patients with FIGO stage IIB, surgical staging is superior to clinical staging with respect to disease-free survival (HR 0.51, 95% CI 0.30 to 0.86, p=0.011). In the post-hoc analysis, surgical staging was associated with better cancer-specific survival (HR 0.61, 95% CI 0.40 to 0.93, p=0.020).ConclusionOur study did not show a difference in disease-free survival between surgical and clinical staging in patients with locally advanced cervical cancer. There was a significant benefit in disease-free survival for patients with FIGO stage IIB and, in a post-hoc analysis, a cancer-specific survival benefit in favor of laparoscopic staging. The high risk of distant metastases in both arms emphasizes the need for further evaluation.

BackgroundRadical trachelectomy is considered a viable option for fertility preservation in patients with low-risk, early-stage cervical cancer. Standard approaches include laparotomy or minimally invasive surgery when performing radical trachelectomy.Primary ObjectiveTo compare disease-free survival between patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive (laparoscopic or robotic) radical trachelectomy.Study HypothesisWe hypothesize that minimally invasive radical trachelectomy has similar oncologic outcomes to those of the open approach.Study DesignThis is a collaborative, multi-institutional, international, retrospective study. Patients who underwent a radical trachelectomy and lymphadenectomy between January 1, 2005 and December 31, 2017 will be included. Institutional review board approval will be required. Each institution will be provided access to a study-specific REDCap (Research Electronic Data Capture) database maintained by MD Anderson Cancer Center and will be responsible for entering patient data.Inclusion CriteriaPatients with squamous, adenocarcinoma, or adenosquamous cervical cancer FIGO (2009) stages IA2 and IB1 (≤2 cm) will be included. Surgery performed by the open approach or minimally invasive approach (laparoscopy or robotics). Tumor size ≤2 cm, by physical examination, ultrasound, MRI, CT, or positron emission tomography (at least one should confirm a tumor size ≤2 cm). Centers must contribute at least 15 cases of radical trachelectomy (open, minimally invasive, or both).Exclusion CriteriaPrior neoadjuvant chemotherapy or radiotherapy to the pelvis for cervical cancer at any time, prior lymphadenectomy, or pelvic retroperitoneal surgery, pregnant patients, aborted trachelectomy (intra-operative conversion to radical hysterectomy), or vaginal approach.Primary EndpointThe primary endpoint is disease-free survival measured as the time from surgery until recurrence or death due to disease. To evaluate the primary objective, we will compare disease-free survival among patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive radical trachelectomy.Sample SizeAn estimated 535 patients will be included; 256 open and 279 minimally invasive radical trachelectomy. Previous studies have shown that recurrence rates in the open group range from 3.8% to 7.6%. Assuming that the 4.5-year disease-free survival rate for patients who underwent open surgery is 95.0%, we have 80% power to detect a 0.44 HR using α level 0.10. This corresponds to an 89.0% disease-free survival rate at 4.5 years in the minimally invasive group.

Uterine transposition was first reported[1][1] in 2017 as a possible fertility sparing surgery for patients with non-gynecologic cancer who require pelvic radiotherapy. In 2018, it was reported in a patient with cervical cancer.[2][2] The main concept is that the uterus with the adnexas can be

Global cancer centres operate across different sizes, scales, and ecosystems. Understanding the essential aspects of the creation, organisation, accreditation, and activities within these settings is crucial for developing an affordable, equitable, and quality cancer care, research, and education system. Robust guidelines are scarce for cancer units, cancer centres, and comprehensive cancer centres in low-income and middle-income countries. However, some robust examples of the delivery of complex cancer care in centres in emerging economies are available. Although it is impossible to create an optimal system to fit the unique needs of all countries for the delivery of cancer care, we summarise what has been published about the development and management of cancer centres in low-income and middle-income countries so far and highlight the need for clinical and political leadership.

Study Objective To demonstrate the importance of planning all the steps of laparoscopic myomectomy, including incision, techniques to reduce blood loss, and suturing. Design Step-by-step video demonstration of the technique, with narration in the background. The video was approved by the local institutional review board. Setting Live surgery at Hospital PIO XII, Institute for Research into Cancer of the Digestive System and American Institute of Telesurgery, Barretos. Interventions We describe a case of a 33-year-old woman with no pregnancy and diagnosed with endometriosis and chronic pelvic pain associated with a 5-cm posterior transmural myoma. We performed a laparoscopic myomectomy, with temporary clipping of the uterine arteries associated with the treatment of endometriosis lesions. Specimen extraction was performed inside a bag [1] . The patient was discharged the next day with no complications. Ten months after the procedure, the patient reported that there was no pain, and that her menses were normal. Conclusion The laparoscopic approach remains the gold standard for myomectomy [2] . Planning the steps before execution is fundamentally important to ensure the security of the procedure. A seromuscularis baseball suture associated with figure-of-8 knotting with an H3H2 sequence at the internal layers seems to be an adequate technique for myometrium closure [3] . Choosing the correct angle for the incision, clipping the uterine artery, and developing the suture in 2 layers results in less bleeding, reduced operating time, decrease in hospital length of stay, and fewer complications.

BACKGROUND: Minimally invasive radical trachelectomy has emerged as an alternative to open radical hysterectomy for patients with early-stage cervical cancer desiring future fertility. Recent data suggest worse oncologic outcomes after minimally invasive radical hysterectomy than after open radical hysterectomy in stage I cervical cancer. OBJECTIVE: We aimed to compare 4.5-year disease-free survival after open vs minimally invasive radical trachelectomy. STUDY DESIGN: This was a collaborative, international retrospective study (International Radical Trachelectomy Assessment Study) of patients treated during 2005–2017 at 18 centers in 12 countries. Eligible patients had squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma; had a preoperative tumor size of ≤2 cm; and underwent open or minimally invasive (robotic or laparoscopic) radical trachelectomy with nodal assessment (pelvic lymphadenectomy and/or sentinel lymph node biopsy). The exclusion criteria included neoadjuvant chemotherapy or preoperative pelvic radiotherapy, previous lymphadenectomy or pelvic retroperitoneal surgery, pregnancy, stage IA1 disease with lymphovascular space invasion, aborted trachelectomy (conversion to radical hysterectomy), or vaginal approach. Surgical approach, indication, and adjuvant therapy regimen were at the discretion of the treating institution. A total of 715 patients were entered into the study database. However, 69 patients were excluded, leaving 646 in the analysis. Endpoints were the 4.5-year disease-free survival rate (primary), 4.5-year overall survival rate (secondary), and recurrence rate (secondary). Kaplan-Meier methods were used to estimate disease-free survival and overall survival. A post hoc weighted analysis was performed, comparing the recurrence rates between surgical approaches, with open surgery being considered as standard and minimally invasive surgery as experimental. RESULTS: Of 646 patients, 358 underwent open surgery, and 288 underwent minimally invasive surgery. The median (range) patient age was 32 (20–42) years for open surgery vs 31 (18–45) years for minimally invasive surgery (P=.11). Median (range) pathologic tumor size was 15 (0–31) mm for open surgery and 12 (0.8–40) mm for minimally invasive surgery (P=.33). The rates of pelvic nodal involvement were 5.3% (19 of 358 patients) for open surgery and 4.9% (14 of 288 patients) for minimally invasive surgery (P=.81). Median (range) follow-up time was 5.5 (0.20–16.70) years for open surgery and 3.1 years (0.02–11.10) years for minimally invasive surgery (P

ObjectiveResponse evaluation after primary chemoradiation (RCTX) in patients with cervical cancer remains difficult. Routine hysterectomy after primary RCTX is associated with considerable surgical morbidity without impact on survival. The purpose of the present study was to evaluate value of routine curettage after RCTX to detect persistent tumor.MethodsBetween 2006 and 2012, patients (n = 217) with cervical cancer in International Federation of Gynecology and Obstetrics stages IB1 N1 (14%), IB2 (9%), IIA (5%), IIB (46%), IIIA (4%), IIIB (15%), IVA (6%), and IVB (1%), respectively, underwent primary RCTX. After RCTX, curettage was recommended to all patients to evaluate response.ResultsIn 136 (63%) of patients with cervical cancer, 1 or 2 consecutive curettages were performed at least 6 weeks after primary RCTX without any complications. In 21 (15%) patients, at least 1 curettage was positive for cervical cancer. In 7 patients, secondary hysterectomy was performed after 1 positive finding and persistent tumor was found in all of them. In the remaining 14 patients, there were 2 positive curettages in 5, 1 undetermined result followed by 1 positive in 3, and 1 positive followed by 1 negative in 6 patients, respectively. In the latter group, no tumor was detected in the uterus, whereas in all other patients with 2 curettages except one, residual carcinoma was detected. Five (24%) of 21 patients with positive histology are free of disease during follow-up. Decision for or against secondary hysterectomy was correct due to histological finding of curettage in 99%.ConclusionsRoutine curettage is a useful tool to guide decision for secondary hysterectomy with high accuracy after primary RCTX and avoids overtreatment.

Introduction: For the past few years, Nipple-Sparing Mastectomy (NSM) has been a tendency, and robotic breast surgery has become a reality. Until August, 2019, three robotic adenomastectmy procedures were carried out in Hospital Erasto Gaertner. The objective of this article is to demonstrate our results and publicize the knowledge in robotic surgery. Methods: Surgical Technique. The Da Vinci Surgical System Si® (Intuitive Surgical, Sunnyvale, CA) was used to perform the NSM surgeries. The 3 cm long incision was initiated in the axillary region, and the subcutaneous cellular tissue was resected to an area of 5 cm in diameter, to the portal. One mg/ml of adrenaline diluted in physiological serum 0.9% was infiltered in the subdermal breast tissue. Tunneling is executed with Metzenbaum scissors in the subdermal region. The device is coupled (GelPOINT Advanced Access Platformtm), and gas pressure of 8 mmHg is activated. The ProGrasp Forceps, the monopolar curved scissors and the 30º video camera are allocated in the robotic arms. The upper quadrants are superficially dissected, and then the lower quadrants, the retro-mammillary region and, finally, the breast muscle tissue. The expander is allocated between the chests with the open technique. Result: The duration of the mammary gland extirpation was 5 hours in the first unilateral adenomastectomy surgery, and 1 hour and 45 minutes in the last for the same type of surgery. In total, the first surgery took 6 hours and 20 minutes, which reduced to 3 hours in the last. In two surgeries we observed skin burns caused by electrocautery. These were solved in weeks, however, without the need for surgical intervention. We did not observe complications such as seroma, hematoma, loss of prosthesis, major pain, infection or subcutaneous emphysema due to carbon dioxide. Discussion: Complication rates are low, as shown by Lai et al. (2019), who analyzed a case series and showed transient nipple ischemia (10.3%) as the highest rate of complication; however, without nipple necrosis or loss of prosthesis. In the cases operated in Hospital Erasto Gaertner, the aesthetic results were very well evaluated both by the patients and the plastic surgery and mastology staff. Minor complications were solved in weeks, which maintained an excellent final outcome. The learning curve of the robotic technique was extremely fast, with considerable reduction in surgical time. Conclusion: We believe that innovative robotic surgery can contribute with the advancement of breast surgery around the world.

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.

Objectives To compare two methods of hemostasis after loop electrosurgical excision procedure (LEEP), with and without vaginal pack. Methods A randomized clinical trial was performed at Barretos Cancer Hospital (BCH) from October 2014 to June 2015 with 100 patients that underwent LEEP of the cervix, randomized to insert a vaginal pack (VP) or to not insert it (WVP) after the procedure. The primary outcome was postoperative gynecologic intervention due to vaginal bleeding after procedure. The secondary was number of days with vaginal bleeding. Only the participants were blinded to group assignment. Categorical variables were compared using a chi-square test or the Fisher exact test and used 5% of significance level. Results Hormonal status, previous pregnancies and histological results were well distributed between the groups. Postoperative abnormal vaginal bleeding requiring intervention had no statistical difference between VP and WVP patients group (p=0.3074) as other complications as well (table 1). Median of related days of vaginal bleeding after the procedure were 7.4 days (SD 8.75) in VP group and 7.34days (SD 8.52) in WVP group, with no statistical difference (p=0.912). Conclusions Insert a vaginal pack or not, after LEEP, do not affect the number of postoperative gynecologic intervention due to vaginal bleeding or the amount of postoperative bleeding days. Previous pregnancies, hormonal status, cytology or LEEP specimen characteristics did not affect the disclosure. We also could not find any risk factor associated to abnormal bleeding. Based on that, the use of vaginal pack can be omitted with no further complications.

Objectives Phyllodes tumor of the vulva is a rare condition, potentially arising from extra-mammary glands or mammary-like tissue, with less than 20 cases described in the literature. Patients from 17yo to 69yo usually present a painless tumor, with no other symptoms. Surgical complete removal is the current mainstain therapy. Objetive To describe the diagnostic and therapeutic management of a Phyllodes tumor of the vulva occuring in a 15 year old female. Methods The patient presented a pedunculated vulvar mass on the left labia majora, with 8 cm in the largest diameter. CT scans suggested a localized non invasive tumor. A margin free local resection was performed. Pathology report was conclusive for a Phyllodes tumor, with positive estrogen and progesterone receptors, cytokeratin AE1/AE3, and alpha smooth-muscle actin. Ki-67 index was 1%. Two years later, she recurred in the contralateral labia majora, with two pedunculated lesions (2 cm and 1.5 cm). A surgical resection was proposed, with perioperative frozen-section analysis of the margins. Results Final pathology reports revealed a new diagnosis of Phyllodes tumor of the vulva, with free margins. There was a partial surgical site dehiscence, successfully managed conservatively. The patient is free of disease 8 months after last surgical resection. Conclusions In this case report, an extremelly rare condition was diagnosed in a very young patient, with a contralateral recurrence, unusual for this type of tumor. Management was succesfull, with free margins local resections.

Objectives To compare disease-free survival (DFS) between patients who underwent open (ORT) versus minimally invasive (MIS) radical trachelectomy (RT) [laparoscopic (LRT) or robotic (RRT)]. Methods Eligibility criteria included 1) RT and pelvic lymphadenectomy with/without sentinel lymph node mapping, 2) 1/2005 to 12/2017 3) squamous, adenocarcinoma, or adenosquamous histology, 4) stage IA2-IB1, 5) tumors ≤2 cm, 6) 15 or more cases per center. Results A total of 698 patients [open (n=388) vs. MIS (310)] were included. The median follow-up time was 40.9 months (range, 1–179.1) [MIS 38.6 (range, Conclusions Surgical approach in radical trachelectomy for low-risk cervical cancer was not associated with differences in recurrence rates or survival. MIS had worse perioperative outcomes.

BACKGROUND: Standard treatment of early cervical cancer involves a radical hysterectomy and retroperitoneal lymph node dissection. The existing evidence on the incidence of adverse events following minimally invasive versus open radical hysterectomy for early cervical cancer is either non-randomized or retrospective. OBJECTIVE: To compare the incidence of adverse events following minimally invasive versus open radical hysterectomy for early cervical cancer. STUDY DESIGN: The Laparoscopic Approach to Carcinoma of the Cervix (LACC) trial was a multinational, randomized non-inferiority trial conducted between 2008 and 2017, in which surgeons from 33 tertiary gynecological cancer centers in 24 countries randomized 631 women International Federation of Gynecology and Obstetrics 2009 stage IA1 with lymph-vascular invasion to IB1 cervical cancer to either minimally invasive versus open radical hysterectomy. Patients were randomly assigned to undergo minimally invasive (n = 319) or open radical hysterectomy (n = 312). The LACC trial was suspended for enrolment in September 2017 due to an increased risk of recurrence and death in the minimally invasive surgery group. Here we report on a secondary outcome measure, the incidence of intra and postoperative adverse events within 6 months after surgery. RESULTS: Of 631 patients randomized, 536 (85%) (mean age, 46.0 years) met inclusion criteria for this analysis; 279 (52%) underwent minimally invasive radical hysterectomy, and 257 (48%) underwent open radical hysterectomy. Of those, 300 (56%), 91 (16.9%), 69 (12.8%) experienced at least one grade 2+, grade 3+, or a serious adverse event. The incidence of intraoperative grade 2+ adverse events was 12% (34/279 patients) in the minimally invasive versus 10% (26/257) in the open group (difference; 2.1% (95% CI: −3.3%, 7.4%); p=0.45). The overall incidence of postoperative grade 2+ adverse events was 54% (152/279 patients) in the minimally invasive versus 48% (124/257) in the open group (difference; 6.2% (95% CI: −2.2%, 14.7%); p=0.14). CONCLUSIONS: For early cervical cancer, the use of minimally invasive compared with open radical hysterectomy resulted in a similar overall incidence of intraoperative or postoperative adverse events.

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.

Study Objective The aim of this study was to evaluate the results of the sentinel lymph node (SLN) biopsy performed by doctors in training. Design Prospective single-armed interventional study. Setting All sequential patients treated in a referral cancer center, from 2016 to 2020. IRB approved. Patients or Participants 126 patients, over 18y.o., with a prior diagnosis of initial endometrial (EC) or cervical (CC) cancer. Interventions Patients were submitted to SLN biopsy performed by surgical oncology residents or gynecologic oncology fellows, under direct supervision of a qualified preceptor. SLN was detected with blue dye with or without scintigraphy. Measurements and Main Results Patients underwent surgery by laparotomy - 22 surgeries (17.46%), by laparoscopy - 86 (81.13%) and by robotic - 18 (16.98%). SLN detection rate was 84.1% (n=106), bilateral in 53% (n=67) and mostly in younger patients (59.7% under 60y.o., p=0.022). There was a higher failure rate (non or unilateral detection) among older than 60y.o. (p=0.0075, CI:0.1656-0.7928, OR:0.3664). Among non-smokers, there was a greater bilateral detection of LNS (60.3%), and, among smokers, more cases of detection failure (59.4%). In 3 cases, the SLN was not identified, and there were positive pelvic nodes in the lymphadenectomy. There were no cases with positive nodes at lymphadenectomy with a negative SLN (false-negative). Mean surgical time was 217min and mean blood loss 116cc. Four patients had grade 3 complications, and none died. Conclusion We have demonstrated that residents and fellows can safely perform SLN biopsy for initial CC and EC under the direct supervision of a trained surgeon. Detection rates were aligned to the literature, and there were no false negatives. Lymph node positivity, age over 60y.o. and smoking were associated with a higher SLN non-detection rate.

This review concerns the uterine transposition technique for preserving fertility in patients who require pelvic radiotherapy. Uterine transposition was developed from adapting well-established surgical techniques with the goal of keeping the uterus and adnexa outside the radiotherapy field in order to preserve their function. The uterine transposition technique is presented step by step, with discussion of the literature that served as the basis for the technique's development. Its most recent modifications, resulting from the authors' experience, are also presented. Technical details relating to possible complications and their implications are also discussed. The uterine transposition technique is evolving. Although its basics are defined, the need for improvement remains. The results of the technique are pending and require further study.

Surgical management in epithelial ovarian cancer (EOC) has a significant impact in overall survival and progression-free survival. The Brazilian Society of Surgical Oncology (BSSO) supported a taskforce of experts to reach a consensus: experienced and specialised trained surgeons, in cancer centres, provide the best EOC surgery. Laparoscopic and/or radiological staging prognosticates the possibility of complete cytoreduction (CC0) and helps to reduce unnecessary laparotomies. Surgical techniques were reviewed. Multidisciplinary input is essential for treatment planning. Quality assurance criteria are proposed and require national consensus. Genetic testing is mandatory. This consensus states the final recommendations from BSSO for management of EOC. TWEETABLE ABSTRACT Brazilian Society of Surgical Oncology consensus for surgery in epithelial ovarian cancer patients.

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Paraaortic lymph node dissection (PA lnd) is an important staging technique, with significant implications. Beyond the poor prognostic impact of involved paraaortic nodes, this knowledge alters further primary tumor management. Although not considered in FIGO staging system of cervix carcinoma, demonstration of paraaortic node involvement usually triggers the extension of pelvic chemoradiation fields up to the renal pedicle. In endometrial carcinoma, positive nodes upstage the disease to stage IIIC2, and extended-field radiation therapy and chemotherapy are considered. In ovarian carcinomas, this situation corresponds to a FIGO IIIC disease and implies chemotherapy.

One of the more important prognostic factors in gynecological malignancies is the lymph node status. A combination of risk factors, the organ anatomy and drainage, the histology, and the stage are the key factors related to lymph node metastasis that may range from 1.5% up to 70%.

Epithelioid sarcoma is a distinct sarcoma type with specific morphology and immunophenotype. An epithelioid sarcoma of the vulva is an extremely rare and aggressive tumor and most commonly occurs on the labia majora in women of reproductive age. Only few cases have been reported, especially with the presence of focal myxoid changes. Early diagnosis is difficult because of its benign appearance as a painless subcutaneous nodule. Optimal treatment is not well established due to its rarity. We report a successfully approached case of vulvar epithelioid sarcoma that occurred in a 34-year-old female patient, treated with wide local excision, and review of the current medical literature.

Objective To translate and perform the cultural adaptation of the tool Functional Assessment of Chronic Illness Therapy – Cervical Dysplasia (FACIT-CD) to the Portuguese language. Methods A descriptive cross-sectional study, with translation and cultural adaptation of the assessment tool performed according to international guidelines and the Functional Assessment of Chronic Illness Therapy (FACIT) protocol group. It involved eight experts, six from Brazil, one from Portugal and one from the United States. After translation and back-translation of the tool, the semantic analysis process was carried out. We randomly included 20 women aged between 18 and 70 years with altered cervical cytology exam, seen at the Department of Prevention and Gynecologic Oncology - Hospital de Câncer de Barretos. Results The sample consisted of women with low education level. In the first pre-test, ten women participated and half of them considered the questions CD1, CD2 and CD3 as difficult, because they did not understand the meaning of the term “pelvic area”. The question CD5, “I worry about spreading the infection”, was also considered difficult to understand by five women. After the reconsideration of the expert committee and FACIT group, the second pre-test was performed. At this stage, we concluded that the previously raised understanding problems had been solved. Conclusion The translated version of FACIT-CD in universal Portuguese language is equivalent to the original version in English and was easily understood by patients with cervical intraepithelial neoplasia. RESUMO Objetivo Traduzir e adaptar o instrumento Functional Assessment of Chronic Illness Therapy – Cervical Dysplasia (FACIT-CD), para a língua portuguesa. Métodos Estudo descritivo, transversal, com metodologia de tradução e adaptação cultural de instrumento de avaliação, realizado por meio de diretrizes internacionais e seguindo o protocolo do grupo Functional Assessment of Chronic Illness Therapy (FACIT). Envolveu oito especialistas, sendo seis nativos do Brasil, um de Portugal e um dos Estados Unidos. Ao término do processo de tradução e retrotradução, deu-se início ao processo de análise semântica. Foram incluídas aleatoriamente 20 mulheres entre 18 e 70 anos com exame de citologia cervical alterado, atendidas no Departamento de Prevenção e Ginecologia Oncológica do Hospital de Câncer de Barretos. Resultados A amostra foi composta por mulheres com baixa escolaridade. No primeiro pré-teste participaram dez mulheres, sendo que a metade considerou as questões CD1, CD2 e CD3 difíceis por não compreenderem o significado do termo “região pélvica”. A questão CD5, “Estou preocupada em disseminar a infecção”, também foi considerada de difícil entendimento por cinco mulheres. Após as reconsiderações do comitê de especialistas e do grupo FACIT, foi realizado o segundo pré-teste. Nesta fase, pode-se concluir que os problemas de entendimento anteriores foram resolvidos. Conclusão A versão traduzida do FACIT-CD é equivalente à versão original em inglês e em língua portuguesa universal, sendo facilmente compreendida pelas pacientes com neoplasia intraepitelial cervical.

Platinum-based primary or adjuvant chemoradiation is the treatment of choice for patients with cervical cancer. However, despite national guidelines and international recommendations, many aspects in diagnosis, therapy, and follow-up of patients with cervical cancer are not based on valid data.To evaluate the current patterns of care for patients with cervical cancer in Germany, a questionnaire with 25 items was sent to 281 radiooncologic departments and out-patient health care centers.The response rate was 51%. While 87% of institutions treat 0-25 patients/year, 12 % treat between 26 and 50 and only 1% treat more than 50 patients/year. In 2011, the stage distribution of 1,706 treated cervical cancers were IB1, IB2, IIA, IIB, IIIA/IIIB, and IV in 11, 12, 11, 22, 28, and 16%, respectively. CT (90%) and MRI (86%) are mainly used as staging procedures in contrast to PET-CT with 14%. Interestingly, 27% of institutions advocate surgical staging prior to chemoradiation. In the majority of departments 3D-based (70%) and intensity-modulated radiotherapy (76%) are used for percutaneous radiation, less frequently volumetric arc techniques (26%). Nearly all colleagues (99.3%) apply conventional fractioning of 1.8-2 Gy for external-beam radiotherapy, in 19% combined with a simultaneous integrated boost. Cisplatinum mono is used as a radiosensitizer with 40 mg/m(2) weekly by 90% of radiooncologists. For boost application in the primary treatment, HDR (high-dose rate) brachytherapy is the dominant technique (84%). In patients after radical hysterectomy pT1B1/1B2, node negative and resection in sound margins adjuvant chemoradiation is applied due to the occurrence of 1-4 other risk factors in 16-97%. There is a broad spectrum of recommended primary treatment strategies in stages IIB and IVA.Results of the survey underline the leading role but also differences in the use of chemoradiation in the treatment of cervical cancer patients in Germany.

Background Diffusion Weighted (DW) Magnetic Resonance Imaging (MRI) has been studed in several cancers including cervical cancer. This study was designed to investigate the association of DW-MRI parameters with baseline clinical features and clinical outcomes (local regional control (LRC), disease free survival (DFS) and disease specific survival (DSS)) in cervical cancer patients treated with definitive chemoradiation. Methods This was a retrospective study approved by an institutional review board that included 66 women with cervical cancer treated with definitive chemoradiation who underwent pre-treatment MRI at our institution between 2012 and 2013. A region of interest (ROI) was manually drawn by one of three radiologists with experience in pelvic imaging on a single axial CT slice encompassing the widest diameter of the cervical tumor while excluding areas of necrosis. The following apparent diffusion coefficient (ADC) values (×10−3 mm2/s) were extracted for each ROI: Minimum - ADCmin, Maximum - ADCmax, Mean - ADCmean, and Standard Deviation of the ADC - ADCdev. Receiver operating characteristic (ROC) curves were built to choose the most accurate cut off value for each ADC value. Correlation between imaging metrics and baseline clinical features were evaluated using the Mann Whitney test. Confirmatory multi-variate Cox modeling was used to test associations with LRC (adjusted by gross tumor volume – GTV), DFS and DSS (both adjusted by FIGO stage). Kaplan Meyer curves were built for DFS and DSS. A p-value

Background and Objectives Some authors states that the removal of lymph node would only contribute towards assessing the lymph node status and regional disease control, without any benefit for the patients' survival. The aim of this paper was to assess the influence of the number of surgically dissected pelvic lymph nodes (PLN) on disease-free survival. Methods Retrospective cohort study on 42 women presenting squamous cell carcinoma (SCC) of the uterine cervix, with metastases in PLN treated by radical surgery. The Cox model was used to identify risk factors for recurrence. The model variables were adjusted for treatment-related factors (year of treatment, surgical margins and postoperative radiotherapy). The cutoff value for classifying the lymphadenectomy as comprehensive (15 PLN or more) or non-comprehensive (