Cancer risk-reducing surgery: Brazilian society of surgical oncology guideline part 1 (gynecology and breast).

BACKGROUND: 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. OBJECTIVES: The Brazilian Society of Surgical Oncology (BSSO) developed this guideline to establish national benchmarks for cancer risk-reducing operations. METHODS: 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. RESULTS: For all questions including risk-reduction bilateral salpingo-oophorectomy, hysterectomy, and mastectomy, major agreement was achieved by the participants, always using accessible alternatives. CONCLUSION: 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.

Cancer risk-reducing surgery: Brazilian Society of Surgical Oncology Guideline Part 2 (Gastrointestinal and thyroid).

BACKGROUND: 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. OBJECTIVES: The Brazilian Society of Surgical Oncology (BSSO) developed this guideline to establish national benchmarks for cancer risk-reducing operations. METHODS: The guideline was prepared from May to December 2021 by a multidisciplinary team of experts to discuss the surgical management of cancer predisposition syndromes. Eleven 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. RESULTS: For all questions including risk-reducing colectomy, gastrectomy, and thyroidectomy, a major agreement was achieved by the participants, always using accessible alternatives. CONCLUSION: 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.

Brazilian Society of Surgical Oncology consensus on fertility-sparing surgery for cervical cancer.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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 had <90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition). CONCLUSIONS: 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.

Guidelines of the Brazilian Society of Oncologic Surgery for pelvic exenteration in the treatment of cervical cancer.

BACKGROUND AND OBJECTIVES: The primary treatment for locally advanced cases of cervical cancer is chemoradiation followed by high-dose brachytherapy. When this treatment fails, pelvic exenteration (PE) is an option in some cases. This study aimed to develop recommendations for the best management of patients with cervical cancer undergoing salvage PE. METHODS: A questionnaire was administered to all members of the Brazilian Society of Surgical Oncology. Of them, 68 surgeons participated in the study and were divided into 10 working groups. A literature review of studies retrieved from the National Library of Medicine database was carried out on topics chosen by the participants. These topics were indications for curative and palliative PE, preoperative and intraoperative evaluation of tumor resectability, access routes and surgical techniques, PE classification, urinary, vaginal, intestinal, and pelvic floor reconstructions, and postoperative follow-up. To define the level of evidence and strength of each recommendation, an adapted version of the Infectious Diseases Society of America Health Service rating system was used. RESULTS: Most conducts and management strategies reviewed were strongly recommended by the participants. CONCLUSIONS: Guidelines outlining strategies for PE in the treatment of persistent or relapsed cervical cancer were developed and are based on the best evidence available in the literature.

Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources.

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.

Geographic clustering of leishmaniasis in northeastern Brazil.

To determine whether disease outcomes and clades of Leishmania braziliensis genotypes are associated, we studied geographic clustering of clades and most severe disease outcomes for leishmaniasis during 1999-2003 in Corte de Pedra in northeastern Brazil. Highly significant differences were observed in distribution of mucosal leishmaniasis versus disseminated leishmaniasis (DL) (p<0.0001). Concordance was observed between distribution of these disease forms and clades of L. braziliensis genotypes shown to be associated with these disease forms. We also detected spread of DL over this region and an inverse correlation between frequency of recent DL diagnoses and distance to a previous DL case. These findings indicate that leishmaniasis outcomes are distributed differently within transmission foci and show that DL is rapidly spreading in northeastern Brazil.

[Inadequacy of thromboprophylaxis in hospitalized medical patients]. / Inadequação de tromboprofilaxia venosa em pacientes clínicos hospitalizados.

BACKGROUND: The risk of venous thromboembolism (VTE) is high in hospitalized patients, however it can be reduced by adequate prophylaxis. OBJECTIVE: To evaluate the adequacy of VTE prophylaxis in hospitalized medical patients. METHODS: A cross-sectional study was performed in hospitalized patients with acute medical illnesses in 4 hospitals of Salvador. RESULTS: We evaluated 226 consecutive patients: 15.5% in medical ICU, 79% > 40 years of age and 48% male. The majority (97%) had a least 1 risk factor (RF) for VTE, 79% had reduced mobility and 62% were diagnosed as having a RF at admission. Of the 208 prophylaxis candidates, 54% received some form of prophylaxis: unfractionated heparin (UFH) in 44%, low molecular weight heparin (LMWH) in 56% and mechanical methods in 2 patients. The utilization rate was similar in private and public hospitals. (51% vs. 49%), but LMWH was more common in private hospitals, without a residence program (97%), and UFH in the public ones (86%). LMWH was more frequently used than UFH in patients > 40 years of age, more often in Caucasian than in Black patients, and less frequently in those with contraindications for heparin. Of the 112 patients receiving prophylaxis, 63% received adequate dosages: LMWH in 95.2% and UFH in 20.4%. VTE prophylaxis was adequate in only 33.6% (70/208) of the patients. CONCLUSION: Risk Factors for VTE were frequent in medical patients. There was considerable variability of the VTE prophylaxis prescribed in private and public hospitals. LMWH was used more appropriately than UFH. However, only a minority of patients candidates for prophylaxis, received adequate dosages.

Terapia renal substitutiva em pacientes do interior da Bahia: avaliação da distância entre o município de moradia e a unidade de hemodiálise mais próxima / Renal replacement therapy in the state of Bahia: evaluation of the distance between the patient’s hometown and the nearest hemodialysis unit

Introdução: Este estudo avalia a distância entre o município de moradia de pacientes em terapia renal substitutiva (TRS) na Bahia e a unidade de hemodiálise (HD) mais próxima, estimando o tempo de viagem gasto para manutenção de três sessões semanais de HD. Metodologia: Foram incluídos todos os pacientes provenientes do interior da Bahia que iniciaram HD no Hospital Geral Roberto Santos entre março/2004 e janeiro/2006 e permaneceram em HD de manutenção após alta hospitalar. O cálculo da distância entre os municípios foi realizado através do “Sistema ABCR de Coordenadas Geodésicas e Percursos entre os Municípios Brasileiros” (www.abcr.org.br). O tempo de viagem foi baseado numa velocidade média de 50km/h. Resultados: Foram avaliados 45 pacientes. A idade média foi 44,7±15,6 anos, sendo 55,6% do sexo feminino. A distância média entre o município de residência e o município da unidade de HD mais próxima foi 101,4±76,3km e a estimativa de tempo gasto para percorrer a distância de ida e volta entre os municípios foi de aproximadamente 4 horas. Considerando as unidades de HD para as quais os pacientes foram efetivamente referidos, a distância média entre os municípios foi 175,9±171,2km, com estimativa de tempo gasto para percorrer a distância de ida e volta de aproximadamente 7 horas. Discussão e Conclusão: A grande maioria dos pacientes estudados necessitou sair de seus municípios de residência e percorrer longas distâncias para ter acesso à HD, o que demanda gasto excessivo de tempo e implicações socioeconômicas. Estes resultados demonstram a importância da descentralização da TRS na Bahia.

Introduction: This study aims to evaluate the distance between the patient’s hometown and the nearest hemodialysis (HD) unity in Bahia, and estimate the amount of time spent on commuting three times per week. Methods: We included all patients from the inland of Bahia who initiated HD at Hospital Geral Roberto Santos between March, 2004 and January, 2006 and were discharged on maintenance HD. The distance between towns was calculated using the "ABCR System of Geodesic Coordinates and Routes Between Brazilian Cities" (www.abcr.org.br). Commute time was estimated based on a mean speedof 50 km/h. Results: We evaluated 45 patients. Mean age was 44.7±15.6 years; 55.5% were female. The mean distance between the patients’ hometown and the nearest HD unit was 101.4±76.3 Km. The estimated amount of time spent on commute was 4 hours. When we considered the HD units that patients were actually referred to after discharge, the mean distance between towns was 175.9±171.2 Km, and commute time increased to approximately 7 hours. Discussion and Conclusion: The vast majority of patients studied needed to leave their hometown and travel long distances to undergo HD, which resulted in excessive waste of time. These results demonstrate the need for public policies that stimulate the decentralization of renal replacement therapy in Bahia.

Inadequação de tromboprofilaxia venosa em pacientes clínicos hospitalizados / Inadequacy of thromboprophylaxis in hospitalized medical patients

O risco de tromboembolismo venoso (TEV) é alto em pacientes internados, mas pode ser reduzido com a utilização adequada de profilaxia. OBJETIVO: Avaliar a utilização e adequação de profilaxia para TEV em pacientes clínicos internados. MÉTODOS: Estudo de coorte transversal em pacientes internados por doenças clínicas em quatro hospitais de Salvador. RESULTADOS: Foram avaliados 226 pacientes: 15,5 por cento em UTIs clínicas, 79 por cento tinham idade > 40 anos e 48 por cento eram homens. A maioria (97 por cento) apresentava pelo menos um fator de risco (FR) para TEV: mobilidade reduzida em 79 por cento e diagnóstico principal como FR em 62 por cento. Dos 208 candidatos a profilaxia, 54 por cento receberam alguma forma: heparina não fracionada (HNF) em 44 por cento, heparina de baixo peso molecular (HBPM) em 56 por cento e métodos mecânicos em dois pacientes. A taxa de utilização foi semelhante entre hospitais privados e públicos (51 por cento versus 49 por cento), mas HBPM predominou em privados (97 por cento) e sem residência médica e HNF em públicos (86 por cento). HBPM foi usada mais freqüentemente que HNF em pacientes > 40 anos, em brancos que em negros ou mulatos, e menos freqüentemente em pacientes com contra-indicações para heparina. Dos 112 pacientes com profilaxia, 63 por cento receberam dosagem adequada: HBPM em 95,2 por cento e HNF em 20,4 por cento. Profilaxia para TEV foi adequada em apenas 33,6 por cento (70/208) dos pacientes. CONCLUSÃO: FR para TEV são freqüentes em pacientes clínicos. Existe ampla variabilidade da profilaxia prescrita em hospitais públicos e privados. HBPM é utilizada mais adequadamente que HNF, entretanto, apenas a minoria dos pacientes clínicos hospitalizados e candidatos a profilaxia recebem dosagem adequada.

BACKGROUND: The risk of venous thromboembolism (VTE) is high in hospitalized patients, however it can be reduced by adequate prophylaxis. OBJECTIVE: To evaluate the adequacy of VTE prophylaxis in hospitalized medical patients. METHODS: A cross-sectional study was performed in hospitalized patients with acute medical illnesses in 4 hospitals of Salvador. RESULTS: We evaluated 226 consecutive patients: 15.5 percent in medical ICU, 79 percent > 40 years of age and 48 percent male. The majority (97 percent) had a least 1 risk factor (RF) for VTE, 79 percent had reduced mobility and 62 percent were diagnosed as having a RF at admission. Of the 208 prophylaxis candidates, 54 percent received some form of prophylaxis: unfractionated heparin (UFH) in 44 percent, low molecular weight heparin (LMWH) in 56 percent and mechanical methods in 2 patients. The utilization rate was similar in private and public hospitals. (51 percent vs. 49 percent), but LMWH was more common in private hospitals, without a residence program (97 percent), and UFH in the public ones (86 percent). LMWH was more frequently used than UFH in patients > 40 years of age, more often in Caucasian than in Black patients, and less frequently in those with contraindications for heparin. Of the 112 patients receiving prophylaxis, 63 percent received adequate dosages: LMWH in 95.2 percent and UFH in 20.4 percent. VTE prophylaxis was adequate in only 33.6 percent (70/208) of the patients. CONCLUSION: Risk Factors for VTE were frequent in medical patients. There was considerable variability of the VTE prophylaxis prescribed in private and public hospitals. LMWH was used more appropriately than UFH. However, only a minority of patients candidates for prophylaxis, received adequate dosages.