Brazilian Society of Surgical Oncology recommendations on Merkel cell carcinoma surgical treatment.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare neuroendocrine skin cancer with poor 5-year survival rates. Surgery and radiation are the current first-line treatments for local and nodal disease. OBJECTIVES: The Brazilian Society of Surgical Oncology developed this document aiming to guide the surgical oncology role in multimodal MCC management. METHODS: The consensus was established in three rounds of online discussion, achieving consensus on specific topics including diagnosis, staging, treatment, and follow-up. RESULTS: Patients suspected of having MCC should undergo immunohistochemical examination and preferably undergo pathology review by a dermatopathologist. Initial staging should be performed with dermatologic and nodal physical examination, combined with complementary imaging. Whole-body imaging, preferably with positron emission tomography (PET) or computed tomography (CT) scans, are recommended. Due to the need for multidisciplinary approaches, we recommend that all cases should be discussed in tumor boards and referred to other specialties as soon as possible, reducing potential treatment delays. We recommend that all patients with clinical stage I or II may undergo local excision associated with sentinel lymph node biopsy. The decision on margin size should consider time to recovery, patient's comorbidities, and risk factors. Patients with positive sentinel lymph nodes or the presence of risk factors should undergo postoperative radiation therapy at the primary site. Exclusive radiation is a viable option for patients with low performance. Patients with positive sentinel lymph node biopsy should undergo nodal radiation therapy or lymphadenectomy. In patients with nodal clinical disease, in addition to primary tumor treatment, nodal radiation therapy and/or lymphadenectomy are recommended. Patients with advanced disease should preferably be enrolled in clinical trials and discussed in multidisciplinary meetings. The role of surgery and radiation therapy in the metastatic/advanced setting should be discussed individually and always in tumor boards. CONCLUSION: This document aims to standardize a protocol for initial assessment and treatment for Merkel cell carcinoma, optimizing oncologic outcomes in middle-income countries such as Brazil.

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.

[Transhiatal versus transthoracic esophagectomy: experience of the Brazilian National Cancer Institute]. / Esofagectomia trans-hiatal versus transtorácica: experiência do Instituto Nacional do Câncer (INCA).

OBJECTIVE: Analyses of morbidity, mortality and overall survival after transhiatal (TH) or transthoracic (TT) esophagectomy. METHODS: Retrospective non randomized study of 68 patients with esophagus neoplasia operated in the Brazilian National Cancer Institute between 1997 and 2005. We divided in two groups: Group 1--TH (33 patients); and Group 2--TT (35 patients). RESULTS: The mean age was 40.7 years old (25-74 years old), being 73.5% male. Middle third tumors predominated in Group 2 (48.6% vs. 21.2%, p = 0,02). The mean of dissected lymph nodes was biggest in Group 2 (21.6 vs. 17.8 lymph nodes, p = 0.04), however without difference in number of metastatic lymph nodes (4.1 vs. 3.9 linfonodos, p = 0.85). The mean of operative time was higher in Group 2 (410 vs. 270 minutes, p = 0.001). Also the mean of length of stay was higher in Group 2 (19 vs. 14 days, p = 0.001). The operative morbidity was 50%, without statistical difference between the groups (42.4% vs. 57.1%, p = 0,23). Esophageal leakage occurred in 13.2% of cases, also without statistical difference (9.1% vs. 17.1%, p = 0.23). The mortality was 5.8% (04 patients), without statistical difference (1.4% vs. 4.4%, p = 0,83). CONCLUSION: In our study, the morbidity and mortality showed no statistical difference in relation to the access performed, although higher operative time and length of stay were observed in TT access. The 3 and 5-years overall survival also were biggest in TT access, probably due to the biggest frequency of patients on initial stages between the submitted to the TT access.

Esofagectomia trans-hiatal versus transtorácica: experiência do Instituto Nacional do Câncer (INCA) / Transhiatal versus transthoracic esophagectomy: experience of the Brazilian National Cancer Institute

OBJETIVO: Analisar comparativamente a morbimortalidade e sobrevida após esofagectomia trans-hiatal (TH) ou transtorácica (TT). METODOS: Estudo retrospectivo não randomizado de 68 pacientes com neoplasia de esôfago operados no INCA entre 1997 e 2005, divididos em dois grupos: 1 - TH (33 pacientes); e 2 - TT (35 pacientes). RESULTADOS: A idade média foi 40,7 anos (25 - 74 anos), sendo 73,5 por cento homens. Tumores do 1/3 médio predominaram no Grupo 2 (48,6 por cento versus 21,2 por cento, p = 0,02). A média de linfonodos dissecados foi maior no Grupo 2 (21,6 versus 17,8 linfonodos, p = 0,04), porém sem diferença no número de linfonodos metastáticos (4,1 versus 3,9 linfonodos, p = 0,85). O tempo cirúrgico médio foi maior no Grupo 2 (410 versus 270 minutos, p = 0,001). O tempo médio de internação também foi maior no Grupo 2 (19 versus 14 dias, p = 0,001). A morbidade operatória foi 50 por cento, sem diferença significativa (42,4 por cento versus 57,1 por cento, p = 0,23). Fístula esofágica ocorreu em 13,2 por cento, sem diferença significativa (9,1 por cento versus 17,1 por cento, p = 0,23). A mortalidade foi 5,8 por cento (04 pacientes), sem diferença significativa (1,4 por cento versus 4,4 por cento, p = 0,83). CONCLUSÃO: Neste estudo, a morbimortalidade não apresentou diferença em relação à via de acesso para a esofagectomia, apesar do maior tempo cirúrgico e de permanência hospitalar na via TT. A sobrevida global em 3 e 5 anos também foi maior na TT, possivelmente devido a maior freqüência de estágios iniciais em pacientes submetidos à transtorácica.

OBJECTIVE: Analyses of morbidity, mortality and overall survival after transhiatal (TH) or transthoracic (TT) esophagectomy. METHODS: Retrospective non randomized study of 68 patients with esophagus neoplasia operated in the Brazilian National Cancer Institute between 1997 and 2005. We divided in two groups: Group 1 - TH (33 patients); and Group 2 - TT (35 patients). RESULTS: The mean age was 40,7 years old (25 - 74 years old), being 73,5 percent male. Middle third tumors predominated in Group 2 (48,6 percent vs. 21,2 percent, p = 0,02). The mean of dissected lymph nodes was biggest in Group 2 (21,6 vs. 17,8 lymph nodes, p = 0,04), however without difference in number of metastatic lymph nodes (4,1 vs. 3,9 linfonodos, p = 0,85). The mean of operative time was higher in Group 2 (410 vs. 270 minutes, p = 0,001). Also the mean of length of stay was higher in Group 2 (19 vs. 14 days, p = 0,001). The operative morbidity was 50 percent, without statistical difference between the groups (42,4 percent vs. 57,1 percent, p = 0,23). Esophageal leakage occurred in 13,2 percent of cases, also without statistical difference (9,1 percent vs. 17,1 percent, p = 0,23). The mortality was 5,8 percent (04 patients), without statistical difference (1,4 percent vs. 4,4 percent, p = 0,83). CONCLUSION: In our study, the morbidity and mortality showed no statistical difference in relation to the access performed, although higher operative time and length of stay were observed in TT access. The 3 and 5-years overall survival also were biggest in TT access, probably due to the biggest frequency of patients on initial stages between the submitted to the TT access.