Analysis of Conservative Surgical Treatment and Prognosis of Microinvasive Squamous Cell Carcinoma of the Cervix Stage IA1: Results of Follow-Up to 20 Years.

OBJECTIVE: The aim of this study was to evaluate the prognosis and recurrence of microinvasive squamous cervical (MIC) cancer stage IA1 in women treated conservatively or by hysterectomy, and followed-up to 20 years. METHODS: It was studied in a cohort of 139 women with MIC, 41 definitively managed by conization and 98 by hysterectomy from January 1994 to December 2003 and followed-up until 2013. The definitive treatment, age, conization technique (loop electrosurgical excision procedure or cold knife conization), cone margin, residual disease in hysterectomy specimen, and the association with recurrence (intraepithelial cervical neoplasia grade 3/intraepithelial vaginal neoplasia grade 3 or worse, and microinvasive or worse) were analyzed. RESULTS: There were 2.5 times more conservative treatment in younger women than older (>40 years), and high proportion of residual disease in hysterectomy specimens (67% of intraepithelial cervical neoplasia grade 3 or worse), more common if positive cone margin (74% vs 35%, P < 0.002). There were 2.3% (3/133) recurrences detected as microinvasive or worse, and 6% (8/133) recurrences detected as intraepithelial cervical neoplasia grade 3/intraepithelial vaginal neoplasia grade 3 or worse: 7.3% (3/41) in the conization group and 5.4% (5/92) in the hysterectomy group (P = 0.701). Almost all recurrences (88%, 7/8) were diagnosed until 36 months after treatment, and they were not associated with conization technique. There were no differences in risk of recurrence and overall disease-free survival time related to type of treatment. CONCLUSIONS: This study demonstrates the good prognosis of MIC, regardless the treatment. When fertility is not a concern, hysterectomy should be considered as definitive treatment to avoid the risk of residual disease. Regular follow-up for a long period should be maintained.

Performance of the Risk of Malignancy Index for Discriminating Malignant Tumors in Women With Adnexal Masses.

OBJECTIVES: We examined the performance of 4 risk of malignancy index (RMI) variants in a medium-resource gynecologic cancer center. METHODS: A total of 158 women referred for adnexal masses were evaluated before surgery by the 4 RMI variants. Physicians with varied experience in ultrasound assessment of adnexal masses performed ultrasound examinations. We compared the performance of the 4 RMI variants using receiver operating characteristic curve analyses followed by calculation of sensitivity, specificity, and positive and negative likelihood ratios using the pathologic diagnosis of the masses as the reference standard. RESULTS: Among the 158 women with adnexal masses included in this study, 51 (32%) had malignant tumors; 26 (51%) of them were stage I. All RMI variants performed similarly (accuracy range, 74%-83%), regardless of menopausal status. Considering all women included, the positive likelihood ratios of the 4 RMI variants ranged from 3.52 to 4.41. In subset analyses, all RMI variants had decreased sensitivity for stage I malignant tumors and for those of nonepithelial histologic types. CONCLUSIONS: The 4 RMI variants performed acceptably in a medium-resource setting where ultrasound examiners were physicians with varied experience. This finding indicates a good tradeoff between performance and feasibility, since ultrasound RMI protocols are of low complexity.

Prevalence of Preeclampsia in Brazil: An Integrative Review.

OBJECTIVE: To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. METHODS: We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. RESULTS: We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. CONCLUSION: The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

OBJETIVO: Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. MéTODOS: Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. RESULTADOS: Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. CONCLUSãO: A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome.

OBJECTIVE: This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy. METHODS: A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed. RESULTS: Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7-92.3% for up to 24 mm cone height and 100% from 25 mm. CONCLUSION: Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.

Prevalence of Preeclampsia in Brazil: An Integrative Review / Prevalência de pré-eclâmpsia no Brasil: Uma revisão integrativa

Abstract Objective To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. Methods We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. Results We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. Conclusion The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

Resumo Objetivo Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. Métodos Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. Resultados Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. Conclusão A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

[Inclusion of symptoms in the discrimination between benign and malignant adnexal masses]. / Inclusão dos sintomas na discriminação entre tumores anexiais benignos e malignos.

PURPOSE: To assess the association between clinical symptoms and the diagnosis of malignancy in women with adnexal tumors who underwent surgery. METHODS: Cross-sectional study, in which 105 women with adnexal tumors and indication for laparotomy/laparoscopy were included. All women were treated at a teaching hospital in the state of São Paulo between November 2009 and March 2011. All patients underwent a structured interview about the occurrence of 18 symptoms associated with ovarian cancer. The interview included the severity, frequency, and duration of these symptoms in the 12 months prior to the first medical consultation. The CA125 levels and the ultrasound classification of the tumors were also evaluated. We calculated for each symptom the prevalence ratio with 95% confidence intervals. The golden-standard was the result of the pathological examination of the surgical specimens. RESULTS: Of the 105 women included, 75 (71.4%) had benign tumors and 30 (28.6%) had malignant ones. In women with malignant tumors, the most frequent symptoms were: abdominal bloating (70%), increased abdominal size (67%), pelvic pain (60%), menstrual irregularity (60%), swelling (53%), abdominal pain (50%), backache (50%), and early repletion (50%). Women with benign tumors showed essentially pelvic pain (61%), menstrual irregularities (61%), and abdominal swelling (47%). Symptoms significantly associated with malignancy were: bloating (PR=2.0; 95%CI 1.01 - 3.94), increased abdominal size (PR=2.16; 95%CI 1.12 - 4.16), backache (RP=1.97; 95%CI 1.09 - 3.55), swelling (PR=2.25; 95%CI 1.25 - 4.07), early repletion (RP=2.06; 95%CI 1.14 - 3.70), abdominal mass (PR=1.83; 95%CI 1.01 - 3.30), eating difficulties (PR=1.98; 95%CI 1.10 - 3.56), and postmenopausal bleeding (PR=2.91; 95%CI 1.55 - 5.44). The presence of pelvic pain, constipation, dyspareunia, fatigue, abdominal pain, nausea or vomiting, menstrual irregularity, weight loss, diarrhea, and bleeding after intercourse was similar in both groups. CONCLUSIONS: In women with adnexal tumors including indication of surgical treatment, the preoperative evaluation of symptoms may help predicting malignancy.

Inclusão dos sintomas na discriminação entre tumores anexiais benignos e malignos / Inclusion of symptoms in the discrimination between benign and malignant adnexal masses

OBJETIVO: Avaliar a associação entre sintomas clínicos e malignidade em mulheres com tumores anexiais, submetidas à cirurgia. MÉTODOS: Estudo de corte transversal com coleta prospectiva, no qual foram incluídas 105 mulheres, atendidas em um hospital de ensino do Estado de São Paulo de novembro de 2009 a março de 2011, devido ao tumor anexial e à indicação de laparotomia/laparoscopia. Todas foram submetidas a uma entrevista estruturada sobre a ocorrência de 18 sintomas associados ao câncer de ovário. A entrevista incluiu gravidade, frequência e duração dos sintomas nos 12 meses prévios à primeira consulta. Também foram avaliados os níveis de CA125 e a classificação ultrassonográfica. Foi calculada para cada sintoma a razão de prevalência com intervalo de confiança de 95%. O padrão-ouro foi o resultado do exame anatomopatológico das peças cirúrgicas. RESULTADOS: Das 105 mulheres incluídas, 75 (71,4%) apresentaram tumores benignos e 30 (28,6%), malignos. Em mulheres com tumores malignos, os sintomas foram mais frequentes, dentre eles: inchaço abdominal (70%), aumento do volume abdominal (67%), dor pélvica (60%), irregularidade menstrual (60%), empachamento (53%), dor abdominal (50%), dor nas costas (50%) e saciedade precoce (50%). As mulheres com tumores benignos apresentaram essencialmente dor pélvica (61%), irregularidade menstrual (61%) e inchaço abdominal (47%). Os sintomas significativamente associados com malignidade foram: sensação de inchaço abdominal (RP=2,0; IC95% 1,01 - 3,94), aumento objetivo do volume abdominal (RP=2,16; IC95% 1,12 - 4,16), dor nas costas (RP=1,97; IC95% 1,09 - 3,55), empachamento (RP=2,25; IC95% 1,25 - 4,07), saciedade precoce (RP=2,06; IC95% 1,14 - 3,70), massa abdominal (RP=1,83; IC95% 1,01 - 3,30), dificuldade para deglutir (RP=1,98; IC95% 1,10 - 3,56) e sangramento pós-menopausa (RP=2,91; IC95% 1,55 - 5,44). A presença de dor pélvica, constipação, dispareunia, fadiga, dor abdominal, náusea e/ou vômito, irregularidade menstrual, perda de peso, diarreia e sinusorragia foram semelhantes nos dois grupos. CONCLUSÕES: Em mulheres com tumores anexiais com indicação cirúrgica, a avaliação pré-operatória dos sintomas pode auxiliar na predição da malignidade.

PURPOSE: To assess the association between clinical symptoms and the diagnosis of malignancy in women with adnexal tumors who underwent surgery. METHODS: Cross-sectional study, in which 105 women with adnexal tumors and indication for laparotomy/laparoscopy were included. All women were treated at a teaching hospital in the state of São Paulo between November 2009 and March 2011. All patients underwent a structured interview about the occurrence of 18 symptoms associated with ovarian cancer. The interview included the severity, frequency, and duration of these symptoms in the 12 months prior to the first medical consultation. The CA125 levels and the ultrasound classification of the tumors were also evaluated. We calculated for each symptom the prevalence ratio with 95% confidence intervals. The golden-standard was the result of the pathological examination of the surgical specimens. RESULTS: Of the 105 women included, 75 (71.4%) had benign tumors and 30 (28.6%) had malignant ones. In women with malignant tumors, the most frequent symptoms were: abdominal bloating (70%), increased abdominal size (67%), pelvic pain (60%), menstrual irregularity (60%), swelling (53%), abdominal pain (50%), backache (50%), and early repletion (50%). Women with benign tumors showed essentially pelvic pain (61%), menstrual irregularities (61%), and abdominal swelling (47%). Symptoms significantly associated with malignancy were: bloating (PR=2.0; 95%CI 1.01 - 3.94), increased abdominal size (PR=2.16; 95%CI 1.12 - 4.16), backache (RP=1.97; 95%CI 1.09 - 3.55), swelling (PR=2.25; 95%CI 1.25 - 4.07), early repletion (RP=2.06; 95%CI 1.14 - 3.70), abdominal mass (PR=1.83; 95%CI 1.01 - 3.30), eating difficulties (PR=1.98; 95%CI 1.10 - 3.56), and postmenopausal bleeding (PR=2.91; 95%CI 1.55 - 5.44). The presence of pelvic pain, constipation, dyspareunia, fatigue, abdominal pain, nausea or vomiting, menstrual irregularity, weight loss, diarrhea, and bleeding after intercourse was similar in both groups. CONCLUSIONS: In women with adnexal tumors including indication of surgical treatment, the preoperative evaluation of symptoms may help predicting malignancy.