Malignant Uterine Neoplasms Attended at a Brazilian Regional Hospital: 16-years Profile and Time Elapsed for Diagnosis and Treatment.

OBJECTIVE: The present study aims to evaluate the profile of endometrial carcinomas and uterine sarcomas attended in a Brazilian cancer center in the period from 2001 to 2016 and to analyze the impact of time elapsed from symptoms to diagnoses or treatment in cancer stage and survival. METHODS: This observational study with 1,190 cases evaluated the year of diagnosis, age-group, cancer stage and histological type. A subgroup of 185 women with endometrioid histology attended in the period from 2012 to 2017 was selected to assess information about initial symptoms, diagnostic methods, overall survival, and to evaluate the influence of the time elapsed from symptoms to diagnosis and treatment on staging and survival. The statistics used were descriptive, trend test, and the Kaplan-Meier method, with p-values < 0.05 for significance. RESULTS: A total of 1,068 (89.7%) carcinomas (77.2% endometrioid and 22.8% non-endometrioid) and 122 (10.3%) sarcomas were analyzed, with an increasing trend in the period (p < 0.05). Histologies of non-endometrioid carcinomas, G3 endometrioid, and carcinosarcomas constituted 30% of the cases. Non-endometrioid carcinomas and sarcomas were more frequently diagnosed in patients over 70 years of age and those on stage IV (p < 0.05). The endometrioid subgroup with 185 women reported 92% of abnormal uterine bleeding and 43% diagnosis after curettage. The average time elapsed between symptoms to diagnosis was 244 days, and between symptoms to treatment was 376 days, all without association with staging (p = 0.976) and survival (p = 0.160). Only 12% of the patients started treatment up to 60 days after diagnosis. CONCLUSION: The number of uterine carcinoma and sarcoma cases increased over the period of 2001 to 2016. Aggressive histology comprised 30% of the patients and, for endometrioid carcinomas, the time elapsed between symptoms and diagnosis or treatment was long, although without association with staging or survival.

OBJETIVO: O presente estudo avaliou o perfil dos carcinomas endometriais e sarcomas uterinos atendidos em um centro brasileiro de câncer no período de 2001 a 2016, e avaliou o impacto do tempo decorrido entre os sintomas até o diagnóstico ou tratamento no estadiamento e sobrevida pelo câncer. MéTODOS: Estudo observacional com 1.190 casos que analisou o ano do diagnóstico, faixa etária, estágio e tipo histológico do câncer. Um subgrupo de 185 mulheres com histologia endometrioide e atendidas no período de 2012 a 2017 foi selecionado para avaliar informações sobre sintomas iniciais, métodos de diagnóstico, sobrevida global e para analisar a relação entre o tempo decorrido a partir dos sintomas até o diagnóstico e tratamento no estadiamento e sobrevida. Foram realizadas análises estatísticas descritiva, de tendência linear e de sobrevida pelo método de Kaplan-Meier, com valores de p < 0,05 para significância. RESULTADOS: Os casos estudados de acordo com a histologia foram 1.068 (89,7%) carcinomas (77,2% endometrioides e 22,8% não endometrioides) e 122 (10,3%) sarcomas, com tendência crescente no período (p < 0,05). Histologias de carcinomas não endometrioides, G3 endometrioides e carcinossarcomas consistiram em 30% dos casos. Carcinomas não endometrioides e sarcomas foram mais frequentemente diagnosticados em pacientes acima de 70 anos de idade e em estágio IV (p < 0,05). O subgrupo com 185 mulheres com carcinoma endometrioide apresentou 92% de sangramento uterino anormal e 43% de diagnóstico após curetagem. O tempo médio decorrido entre os sintomas e o diagnóstico foi de 244 dias e entre os sintomas e o tratamento, 376 dias, todos sem associação com estadiamento (p = 0,976) e sobrevida (p = 0,160). Apenas 12% das pacientes iniciaram o tratamento em até 60 dias após o diagnóstico. CONCLUSãO: O número de casos de carcinomas e sarcomas uterinos aumentaram no período de 2001 a 2016. A histologia agressiva compreendeu 30% dos pacientes e, no caso dos carcinomas endometrioides, o tempo decorrido entre os sintomas e o diagnóstico ou tratamento foi longo, embora sem associação com estadiamento ou sobrevida.

Diagnosis, treatment and survival of uterine sarcoma: A retrospective cohort study of 122 cases.

The present study aimed to assess the diagnosis, treatment and follow-up of uterine sarcoma cases. A retrospective cohort study with 122 women recruited between 2001 and 2016 was performed. The data regarding epidemiology, clinical presentation, treatment and follow-up were analyzed based on the following histological types: Carcinosarcoma, leiomyosarcoma, endometrial stromal sarcoma (ESS) and adenosarcoma. Statistical analysis included descriptive statistics, logistic regression and survival curves. The diagnosis of uterine sarcoma exhibited an increasing trend of +1.2 new cases every 2 years (P=0.044) and comprised 10% of all uterine cancer diagnoses. There were 47% carcinosarcomas, 22% leiomyosarcomas, 16% ESS and 14% adenosarcomas. The majority of the women was ≥60 years old (62%). Among the subjects, 77% were postmenopausal, 61% had a body mass index up to 29.9 kg/m2 and 71% presented with a comorbidity. Regression analysis exhibited an association between post menopause and the histological type associated with lower overall survival (OS), namely leiomyosarcoma or carcinosarcoma (odds ratio, 5.45, P<0.001). Stage I malignancy was present in 44% and Stage IV in 22%. The treatment included primary surgery in 78% of the cases, whereas 79% received adjuvant therapy. Only 55 cases achieved disease control and 20 relapsed (36%) with a 5-year OS rate of 33%. The OS was lower for carcinosarcoma and leiomyosarcoma (20%; P=0.003). In summary, the present study indicated that the number of uterine sarcoma cases had increased between 2001 and 2016. The majority of the women were >60 years old and diagnosed in advanced stages. The postmenopausal status was associated with histological types of poor prognosis. The OS was low and worse for patients with carcinosarcoma and leiomyosarcoma.

[Laparoscopy for diagnosis and treatment of adnexal masses]. / Laparoscopia na abordagem inicial de tumores anexiais.

PURPOSE: To assess clinical factors, histopathologic diagnoses, operative time and differences in complication rates between women undergoing laparoscopy or laparotomy to diagnose and treat an adnexal mass and their association with laparoscopy failure. METHODS: In this prospective study, 210 women were invited to participate and 133 of them were included. Eighty-eight women underwent laparotomy and 45 underwent laparoscopy. Fourteen of the 45 laparoscopies were converted to laparotomy intraoperatively. We assessed whether age, body mass index (BMI), previous abdominal surgeries, CA-125, Index of Risk of Malignancy (IRM), tumor diameter, histological diagnosis, operative time and surgical complication rates differed between the laparoscopy group and the group converted to laparotomy and whether those factors were associated with conversion of laparoscopy to laparotomy. We also assessed surgical logs to evaluate the reasons, as stated by the surgeons, to convert a laparoscopy to laparotomy. RESULTS: In this research, 30% of the women had malignant tumors. CA-125, IRM, tumor diameter and operative times were higher for the laparotomy group than the laparoscopy group. Complication rates were similar for both groups and also for the successful laparoscopy and unsuccessful laparoscopy groups. The surgical complication rate in women with benign tumors was lower for the laparoscopy group than for the laparotomy group. The factors associated with conversion to laparotomy were tumor diameter and malignancy. During laparoscopy, adhesions a large tumor diameter were the principal causes of conversion. CONCLUSION: This study suggests that laparoscopy for the diagnosis and treatment of adnexal masses is safe and does not increase complication rates even in patients who need conversion to laparotomy. However, when doubt about the safety of the procedure and about the presence of malignancy persists, consultation with an expert gynecology-oncologist with experience in advanced laparoscopy is recommended. A large tumor diameter was associated with the necessity of conversion to laparotomy.

Laparoscopia na abordagem inicial de tumores anexiais / Laparoscopy for diagnosis and treatment of adnexal masses

OBJETIVO: Avaliar o uso da laparoscopia como método diagnóstico e terapêutico na abordagem inicial de tumores anexiais em população de risco para malignidade, bem como fatores clínicos associados à falha do método e conversão para laparotomia, e comparar taxas de complicação com pacientes cuja abordagem inicial se deu por laparotomia. MÉTODOS: Estudo prospectivo com 210 mulheres com exames de imagem prévios constando tumor anexial, das quais 133 foram incluídas. Destas, 45 foram submetidas à laparoscopia e 88, à laparotomia. Catorze das 45 cirurgias iniciadas por laparoscopia foram convertidas a laparotomia no intraoperatório. Foi avaliado se idade, índice de massa corporal (IMC), número de cirurgias abdominais prévias, CA-125, índice de risco de malignidade (IRM), diâmetro do tumor, duração da cirurgia e número de complicações cirúrgicas diferiram entre os grupos laparoscopia, laparoscopia com conversão à laparotomia e laparotomia. Foi também avaliado o motivo reportado pelos cirurgiões como falha da laparoscopia e a razão da conversão para laparotomia. RESULTADOS: A taxa de tumores malignos neste estudo foi de 30%. Houve diferença nos valores de CA-125, IRM e diâmetro do tumor entre os grupos laparoscopia e laparotomia. A duração da cirurgia foi maior no grupo de laparoscopias convertidas à laparotomia, porém as taxas de complicação cirúrgica foram semelhantes entre os grupos e, quando isolados os tumores benignos, as taxas de complicação cirúrgica da laparoscopia se mostraram inferiores à laparotomia. Dentre os fatores em estudo, apenas o tamanho do tumor esteve relacionado à conversão para laparotomia. CONCLUSÃO: Este estudo sugere que a abordagem inicial de pacientes com tumores ...

PURPOSE: To assess clinical factors, histopathologic diagnoses, operative time and differences in complication rates between women undergoing laparoscopy or laparotomy to diagnose and treat an adnexal mass and their association with laparoscopy failure. METHODS: In this prospective study, 210 women were invited to participate and 133 of them were included. Eighty-eight women underwent laparotomy and 45 underwent laparoscopy. Fourteen of the 45 laparoscopies were converted to laparotomy intraoperatively. We assessed whether age, body mass index (BMI), previous abdominal surgeries, CA-125, Index of Risk of Malignancy (IRM), tumor diameter, histological diagnosis, operative time and surgical complication rates differed between the laparoscopy group and the group converted to laparotomy and whether those factors were associated with conversion of laparoscopy to laparotomy. We also assessed surgical logs to evaluate the reasons, as stated by the surgeons, to convert a laparoscopy to laparotomy. RESULTS: In this research, 30% of the women had malignant tumors. CA-125, IRM, tumor diameter and operative times were higher for the laparotomy group than the laparoscopy group. Complication rates were similar for both groups and also for the successful laparoscopy and unsuccessful laparoscopy groups. The surgical complication rate in women with benign tumors was lower for the laparoscopy group than for the laparotomy group. The factors associated with conversion to laparotomy were tumor diameter and malignancy. During laparoscopy, adhesions a large tumor diameter were the principal causes of conversion. CONCLUSION: This study suggests that laparoscopy for the diagnosis and treatment of adnexal masses is safe and does not increase complication rates even in patients who need conversion to laparotomy. However, when doubt about the safety of the procedure and about the presence of malignancy persists, consultation with an expert gynecology-oncologist ...

Analysis of the contribution of immunologically-detectable HER2, steroid receptors and of the "triple-negative" tumor status to disease-free and overall survival of women with epithelial ovarian cancer.

We assessed associations between steroid receptors including: estrogen-alpha, estrogen-beta, androgen receptor, progesterone receptor, the HER2 status and triple-negative epithelial ovarian cancer (ERα-/PR-/HER2-; TNEOC) status and survival in women with epithelial ovarian cancer. The study included 152 women with primary epithelial ovarian cancer. The status of steroid receptor and HER2 was determined by immunohistochemistry. Disease-free and overall survival were calculated and compared with steroid receptor and HER2 status as well as clinicopathological features using the Cox Proportional Hazards model. A mean follow-up period of 43.6 months (interquartile range=41.4 months) was achieved where 44% of patients had serous tumor, followed by mucinous (23%), endometrioid (9%), mixed (9%), undifferentiated (8.5%) and clear cell tumors (5.3%). ER-alpha staining was associated with grade II-III tumors. Progesterone receptor staining was positively associated with a Body Mass Index≥25. Androgen receptor positivity was higher in serous tumors. In stand-alone analysis of receptor contribution to survival, estrogen-alpha positivity was associated with greater disease-free survival. However, there was no significant association between steroid receptor expression, HER2 status, or TNEOC status, and overall survival. Although estrogen-alpha, androgen receptor, progesterone receptor and the HER2 status were associated with key clinical features of the women and pathological characteristics of the tumors, these associations were not implicated in survival. Interestingly, women with TNEOC seem to fare the same way as their counterparts with non-TNEOC.

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.

[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.