Ricardo dos Reis

Does sentinel node mapping impact morbidity and quality of life in endometrial cancer?

To evaluate the prevalence of post-operative complications and quality of life (QoL) related to sentinel lymph node (SLN) biopsy vs systematic lymphadenectomy in endometrial cancer. A prospective cohort included women with early-stage endometrial carcinoma who underwent lymph node staging, grouped as follows: SLN group (sentinel lymph node only) and SLN+LND group (sentinel lymph node biopsy with addition of systematic lymphadenectomy). The patients had at least 12 months of follow-up, and QoL was assessed by European Organization for Research and Treatment of Cervical Cancer Quality of Life Questionnaire 30 (EORTC-QLQ-C30) and EORTC-QLQ-Cx24. Lymphedema was also assessed by clinical evaluation and perimetry. 152 patients were included: 113 (74.3%) in the SLN group and 39 (25.7%) in the SLN+LND group. Intra-operative surgical complications occurred in 2 (1.3%) cases, and all belonged to SLN+LND group. Patients undergoing SLN+LND had higher overall complication rates than those undergoing SLN alone (33.3% vs 14.2%; p=0.011), even after adjusting for confound factors (OR=3.45, 95% CI 1.40 to 8.47; p=0.007). The SLN+LND group had longer surgical time (p=0.001) and need for admission to the intensive care unit (p=0.001). Moreover, the incidence of lymphocele was found in eight cases in the SLN+LND group (0 vs 20.5%; p<0.001). There were no differences in lymphedema rate after clinical evaluation and perimetry. However, the lymphedema score was highest when lymphedema was reported by clinical examination at 6 months (30.1 vs 7.8; p<0.001) and at 12 months (36.3 vs 6.0; p<0.001). Regarding the overall assessment of QoL, there was no difference between groups at 12 months of follow-up. There was a higher overall rate of complications for the group undergoing systematic lymphadenectomy, as well as higher rates of lymphocele and lymphedema according to the symptom score. No difference was found in overall QoL between SLN and SLN+LND groups.

Analysis of Sentinel Lymph Node Adoption Compared to Systematic Lymphadenectomy in Staging Early Endometrial Cancer at a Tertiary Center: An Ambispective Study

ABSTRACTObjectiveThe purpose of this study was to assess the impact of changing endometrial carcinoma staging from systematic lymph node dissection to the sentinel lymph node approach.MethodsThis is an ambispective study including patients with endometrial carcinoma (EC) limited to the uterus (FIGO 2018 IA/IB). From December 2015 to October 2021, a group of patients underwent systematic staging with lymph node dissection (LND). From December 2021 to April 2024, another group of patients underwent surgical staging with the sentinel lymph node‐indocyanine green (SLN) algorithm and pathology ultrastaging analisys. The groups were matched (1 LND: 1 SLN) based on age, body mass index (BMI), tumor type, tumor size, and myometrial invasion. The primary endpoints were lymph node involvement, length of surgery, and complications. Complications were classified according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsTwo hundred fifty‐seven patients were surgically treated during the study period (156 in the LND cohort, 101 in the SLN cohort). Propensity score matching revealed two equivalent groups containing 84 patients each. The rate of positive lymph nodes was similar between the LND group (3.6%) and the SLN group (8.3%) (OR: 2.46, 95% CI: 0.61–9.84; p = 0.205). The length of surgery was significantly lower in the SLN group (152.2 ± 51.9 min) compared to the LND group (304 ± 77.8 min) (p &lt; 0.001). Intraoperative blood loss greater than 100 mL was significantly lower in the SLN group (9.5%) compared to the LND group (29.8%) (p &lt; 0.001). CTCAE grades requiring intervention (grades 3, 4, and 5) were higher in the LND group (14.3%) compared to the SLN group (4.8%) (p = 0.049).ConclusionThe transition from LND to SLN approach was similar compared to systematic lymphadenectomy, allowing the reduction of surgical length, blood loss and severity of complications without compromising surgical complications and lymph node positivity.

Sentinel lymph node mapping versus sentinel lymph node mapping with systematic lymphadenectomy in endometrial cancer: an open-label, non-inferiority, randomized trial (ALICE trial)

Growing 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. The present study aims to confirm that SLN biopsy without systematic node dissection does not negatively impact oncological outcomes. We 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. This 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. Inclusion 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. 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. 178 participants will be randomized in this study with an estimated date for completing accrual of December 2024 and presenting results in 2027. NCT03366051.

A Systematic Review of MicroRNAs Involved in Cervical Cancer Progression

To obtain a better understanding on the role of microRNAs in the progression of cervical cancer, a systematic review was performed to analyze cervical cancer microRNA studies. We provide an overview of the studies investigating microRNA expression in relation to cervical cancer (CC) progression, highlighting their common outcomes and target gene interactions according to the regulatory pathways. To achieve this, we systematically searched through PubMed MEDLINE, EMBASE, and Google Scholar for all articles between April 2010 and April 2020, in accordance with the PICO acronym (participants, interventions, comparisons, outcomes). From 27 published reports, totaling 1721 cases and 1361 noncancerous control tissue samples, 26 differentially expressed microRNAs (DEmiRNAs) were identified in different International Federation of Gynecology and Obstetrics (FIGO) stages of cervical cancer development. It was identified that some of the dysregulated microRNAs were associated with specific stages of cervical cancer development. The results indicated that DEmiRNAs in different stages of cervical cancer were functionally involved in several key hallmarks of cancer, such as evading growth suppressors, enabling replicative immortality, activation of invasion and metastasis, resisting cell death, and sustained proliferative signaling. These dysregulated microRNAs could play an important role in cervical cancer’s development. Some of the stage-specific microRNAs can also be used as biomarkers for cancer classification and monitoring the progression of cervical cancer.

Outcomes of open radical hysterectomy following implementation of an enhanced recovery after surgery program

Open surgery has become the standard approach for radical hysterectomy in early stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2018 IA1 with lymphovascular space invasion-IIA1). Our primary objective was to compare the length of stay in patients undergoing open radical hysterectomy before and after implementation of an enhanced recovery after surgery (ERAS) program. This was a single center, retrospective, before-and-after intervention study including patients who underwent open radical hysterectomy for cervical cancer from January 2009 to December 2020. Two groups were identified based on the time of ERAS implementation: pre-ERAS group included patients who were operated on between January 2009 and October 2014; post-ERAS group included patients who underwent surgery between November 2014 and December 2020. A total of 81 patients were included, of whom 29 patients were in the pre-ERAS group and 52 patients in the post-ERAS group. Both groups had similar clinical characteristics with no differences in terms of median age (42 years (interquartile range (IQR) 35-53) in pre-ERAS group vs 41 years (IQR 35-49) in post-ERAS group; p=0.47) and body mass index (26.1 kg/m Patients undergoing open radical hysterectomy on an ERAS pathway have a shorter length of hospital stay without increasing overall complications or readmissions rates.

Combined Oral Contraceptive Use and the Risk of Cervical Cancer: Literature Review

AbstractCervical cancer (CC) is caused by persistent infection of human papillomavirus of high oncogenic risk (hr-HPV); however, several cofactors are important in its carcinogenesis, such as smoking, multiparity, and prolonged use of oral hormonal contraceptives (COCs). Worldwide, 16% of women use COCs, whereas in Brazil this rate is of ∼ 30%. The safety and adverse effects of COCs are widely discussed in the literature, including the increase in carcinogenic risk. Due to the existence of several drugs, combinations, and dosages of COCs, it is hard to have uniform information in epidemiological studies. Our objective was to perform a narrative review on the role of COCs use in the carcinogenesis of cervical cancer. Several populational studies have suggested an increase in the incidence of cervical cancer for those who have used COCs for &gt; 5 years, but other available studies reach controversial and contradictory results regarding the action of COCs in the development of CC.

Rare intra-tumoral colonization of Fusobacterium nucleatum in endometrial cancer

The presence of Fusobacterium nucleatum has been associated with gynecological disorders, namely endometriosis and pregnancy complications; however, its role in endometrial cancer remains unexplored. This study aimed to assess the presence of intra-tumoral F nucleatum in endometrial carcinoma tissues and its association with patients' clinicopathological and molecular features. A total of 260 patients were included, and a droplet digital polymerase chain reaction assay was employed to detect F nucleatum in formalin-fixed paraffin-embedded tumor tissues. F nucleatum was detected in only 3 cases (1.2%), and none exhibited high bacterial levels, even within the 79 microsatellite instability-high molecular subgroup. These findings suggest that intra-tumoral F nucleatum does not play an oncogenic role in endometrial cancer.

Patient-reported outcomes and experiences following robotic, laparoscopic, and open surgery for endometrial cancer

Endometrial cancer is the most common gynecologic malignancy in developed countries, and minimally invasive surgery is increasingly used. However, comparisons among surgical approaches regarding patient-centered outcomes remain scarce. In this study, we aimed to compare patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) between minimally invasive (robotic and laparoscopic) and open surgeries for endometrial cancer staging, and to assess functional, physical, and emotional domains. This cross-sectional study was conducted at Barretos Cancer Hospital (Brazil) with retrospective clinical data and prospective collection of PROMs and PREMs. A total of 182 women with histologically confirmed endometrial cancer underwent robotic (n = 29), laparoscopic (n = 91), or open surgery (n = 62) between January 2020 and December 2023. Statistical analyses were descriptive and univariate to explore associations between surgical approach and outcomes. Overall, PROMs were highest in the robotic group (72.2 ± 6.6), followed by laparoscopic (70.8 ± 6.4) and open (70.2 ± 7.4). PREMs showed a similar pattern-robotic (98.8 ± 4.1), open (97.5 ± 3.9), and laparoscopic (97.0 ± 6.1). Robotic surgery achieved higher satisfaction (99.7 ± 7.2), sexual function (78.1 ± 23.9), and quality of life (86.6 ± 12.6). Laparoscopy favored mobility (88.6 ± 18.8) and daily activities (89.4 ± 21.7), while open surgery had higher emotional wellbeing (80.8 ± 21.6) but more gastrointestinal symptoms. Robotic surgery yielded better satisfaction, quality of life, and sexual function; laparoscopy improved mobility and daily activities; and open surgery enhanced emotional wellbeing. PROMs and PREMs proved feasible for evaluating patient-centered outcomes and revealed meaningful differences supporting personalized surgical decisions.

Is infracolic omentectomy necessary for presumed early-stage Borderline Ovarian Tumors (BOTs)? A retrospective cohort study and meta-analysis

While omentectomy is included in the guidelines for the surgical management of Borderline Ovarian Tumors (BOTs), it is unclear whether removal of a normal-appearing omentum confers a therapeutic advantage. The retrospective cohort study of patients with BOTs evalua0 ted the role of routine omentectomy and was followed by a meta-analysis to enhance the robustness of the findings. Data were obtained from patients treated at three Brazilian reference centers between January 2009 and October 2023. Progression-Free Survival (PFS), risk of death, and recurrence were compared between patients who underwent omentectomy and those who did not. A total of 218 patients with BOTs were assessed: omentectomy was performed in 161 (73.8 %) and not performed in 57 (26.1 %). OS at 60 months was 95.5 % in the omentectomy group and 94.6 % in the non-omentectomy group (HR = 0.97 [95 % CI 0.20‒4.68]; p = 0.96). PFS was 97.2 % and 89.3 %, respectively (HR = 0.42; 95 % CI 0.10‒1.76; p = 0.23). Twelve studies comprising 2996 women with BOT, were included in the systematic review to evaluate the outcomes with and without omentectomy. Relative Risk (RR) of recurrence was 0.94 (95 % CI 0.67‒1.31; p = 0.7) for the non-omentectomy group compared with the omentectomy group. No statistically significant difference was observed, with an RR of 1.98 (95 % CI 0.24‒16.43; p = 0.53) for risk of death and an HR of 1.02 (95 % CI 0.25‒4.15; p = 0.98) for PFS. The retrospective cohort study and meta-analysis showed a low incidence of metastatic disease in the omentum. No effect of omentectomy on OS, PFS, and recurrence in patients with BOT.

Reconsidering adjuvant radiotherapy in intermediate-risk cervical cancer: findings from the CIRCOL study group

To evaluate survival outcomes associated with intermediate-risk factors in patients who underwent radical hysterectomy for cervical cancer, with a focus on the role of adjuvant radiotherapy. A multicenter retrospective cohort database comprising 1280 patients who underwent radical hysterectomy for cervical cancer was analyzed. For inclusion, patients had tumors ≤4 cm (International Federation of Gynecology and Obstetrics 2018 stages Ia2-Ib2) and were treated surgically between January 2000 and December 2017. Patients with lymph node metastasis, positive surgical margins, or parametrial involvement were excluded. Intermediate-risk factors were defined as tumor size >2 cm to ≤4 cm, stromal invasion ≥10 mm, and presence of lymphovascular space invasion. A total of 759 patients met inclusion criteria, of whom 158 (20.8%) received external beam radiotherapy. Patients who received external beam radiotherapy were older, more often underwent open surgery, and exhibited a higher incidence of adverse pathological features, including larger tumors, deeper stromal invasion, and lymphovascular space invasion. In multivariate analysis, tumor size >2 cm (HR 5.25, 95% CI 1.86 to 14.8) and stromal invasion ≥10 mm (HR 2.68, 95% CI 1.14 to 6.30) were independently associated with increased recurrence risk. No variables were independently associated with cancer-specific mortality. The presence of ≥2 intermediate-risk factors significantly increased the risk of recurrence (HR 3.48, 95% CI 2.05 to 5.91) and cancer-related death (HR 2.47, 95% CI 1.04 to 2.89), regardless of radiotherapy use. Tumor size and depth of stromal invasion were associated with increased recurrence risks. Adjuvant radiotherapy was not associated with improved survival outcomes in patients with intermediate-risk features.

Surgery in Ovarian Cancer—Brazilian Society of Surgical Oncology Consensus

ABSTRACTSurgical management in epithelial ovarian cancer (EOC) has a significant impact on overall survival (OS) and progression‐free survival (PFS). The Brazilian Society of Surgical Oncology (BSSO) supported an expert‐led task force for consensus: the best EOC surgery is provided by experienced and specialized trained surgeons in cancer centers. Laparoscopic or radiological staging can predict the possibility of complete cytoreduction (CC0) and help to reduce unnecessary laparotomies. Carcinomatosis and nodal extension should be evaluated at imaging. Multidisciplinary input is essential for determining the need for the selection of patients for surgery and adjuvant chemotherapy in patients with EOC. The BSSO proposes quality assurance criteria and the need for national consensus. Genetic counseling was deemed mandatory for all patients with EOC. This consensus states the final recommendations from BSSO for the management of EOC.

Comparison of Two-Position and Four-Position Cervical Injection Techniques for Sentinel Lymph Node Mapping in Endometrial Cancer Using Methylene Blue

This clinical trial evaluates lymph node mapping in newly diagnosed endometrial cancer patients undergoing surgery. The standard technique uses a 2-point methylene blue cervical injection. The study aims to determine if increasing injection points improves mapping success.

Sentinel Node Mapping in High Risk Endometrial Cancer

This study will evaluate the role of systematic lymphadenectomy after sentinel node (SLN) mapping in high risk endometrial cancer (high grade histologies or deep myometrial invasion). The participants will be randomized in a non-inferiority controlled trial in 2 groups: SLN mapping or SLN mapping followed by systematic lymphadenectomy.