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.

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.

Analysis of the Perroca Scale in Palliative Care Unit. / Análise da Escala de Perroca em Unidade de Cuidados Paliativos.

Objective To analyze the complexity of nursing care with use of the Perroca scale in a Palliative Care Unit. Method Retrospective descriptive study of quantitative analysis. Results Between 2008 and 2016, the total of 2,486 patients were hospitalized, and their median length of hospital stay was 12 days. Of these patients, 1,568 had at least one Perroca scale evaluation. Nine hundred and ten patients (58%) were classified as minimal or intermediate care. Of these, 602 (66%) were discharged. As semi-intensive and intensive care were classified 658 (42%) patients, of whom 64% died and only 36% were discharged. Conclusion The Perroca scale is a tool to identify patients with greater need for care and the possible prognosis for hospitalized patients.

Moistening the new vaginal misoprostol tablets: does it increase the efficacy of cervical priming before manual vacuum aspiration in first-trimester miscarriage? A randomised clinical trial.

OBJECTIVES: The primary objective of our study was to ascertain whether moistening the Brazilian formulation of vaginal misoprostol tablets increases cervical dilation before manual vacuum aspiration (MVA), compared with use of dry misoprostol, in first-trimester miscarriage. The secondary objective was to ascertain whether there was any correlation between vaginal pH and the degree of cervical dilation using a moistened or dry misoprostol tablet. METHODS: In a single-centre, double-blind, randomised trial, 46 patients with first-trimester miscarriage were randomly allocated to treatment with dry or moistened (with 200 µl distilled water) 2 × 200 µg misoprostol tablets. RESULTS: The median (range) cervical dilation in the wet and dry groups was 8 mm (6-12 mm) and 7 mm (5-10 mm), respectively (p = .06). The median time between misoprostol insertion and carrying out the procedure did not differ between the dry (406 min, range 180-550 min) and wet (448 min, range 180-526 min) groups (p = .1). No correlation was found between vaginal pH and cervical dilation using continuous data (p = .57; r= 0.08; 95% confidence interval -0.02, 0.3) or dichotomous data (pH ≤5/>5; cervical dilation ≥8 mm or <8 mm; p = .8). CONCLUSION: No difference was observed in cervical dilation between moistened and non-moistened misoprostol use prior to MVA.

Use of a gamma probe to identify and guide resection of recurrent parathyroid carcinoma: report of a case.

Parathyroid carcinoma (PC) accounts for less than 0.005% of all cancers and less than 5% of causes of hyperparathyroidism. This tumor is difficult to identify during surgery, which is detrimental to the oncologic results. Surgery is still the main treatment for the primary tumor and to control parathyroid hormone levels after recurrence. We report a case of recurrent parathyroid carcinoma in a 30-year-old man, identified and managed with the use of a gamma probe during surgery. To our knowledge, this is only the second report of a gamma probe being used to guide resection of a recurrent PC. We discuss the diagnosis and treatment, analyzing the current evidence-based literature.

Intestinal lymphangitis carcinomatosa related to ovarian cancer: Case report and review of the literature.

We present a 57-year-old woman with ovarian cancer that presented to the Emergency Room with a proximal small bowel obstruction. Exploratory laparotomy evidenced a thickened 10 cm extension of the proximal jejunum without bowel peristalsis, with stenotic enteric lumen, with a lesion apparently originating from its submucosal and muscular layers. The patient underwent an exploratory laparotomy with total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, small bowel resection and peritoneal biopsies. Final pathology and immunohistochemistry confirmed the intra-operative suspicion of lymphatic intestinal spread of malignant cells originating from a high grade serous carcinoma of ovarian origin. To the best of our knowledge, this is the first report in the literature of intestinal carcinomatous lymphangitis related to ovarian cancer, and the first report of involvement of the proximal portion of the jejunum.

Carcinoid tumors and morbid obesity.

Carcinoid is a rare gastrointestinal tumor, with an incidence varying from 1 to 2.5 per 100,000 in the general population. In this article, we report an elevated incidence of carcinoid tumor in an obese population, showing the importance of performing an endoscopic procedure before bariatric surgery.

Palliative care in Brasil: present and future.

OBJECTIVE: To estimate the human resources and services needed to meet the demand of the Brazilian population who would benefit from palliative care, based on the population growth projection for 2040. METHODS: Population and mortality estimates and projections were obtained from the Brazilian Institute of Geography and Statistics. Service needs were estimated based on literature data. RESULTS: The expected increase in the Brazilian population for 2000-2040 is 31.5%. The minimum estimate of patients with palliative care needs was 662,065 in 2000 and 1,166,279 in 2040. The staff required for each hundred thousand inhabitants would increase from 1,734 to 2,282, the number of doctors needed would increase from 4,470 to 6,274, and the number of nurses from 8,586 to 11,294, for the same period. CONCLUSION: The definition of a national strategy predicting the increasing palliative care needs of the population is necessary. The expansion of the support network for chronic and non-transmissible diseases is necessary, but the training of existing human resources at all levels of attention to perform palliative actions can be a feasible alternative to minimize the suffering of the population.

Palliative care in Brasil: present and future

SUMMARY OBJECTIVE: To estimate the human resources and services needed to meet the demand of the Brazilian population who would benefit from palliative care, based on the population growth projection for 2040. METHODS: Population and mortality estimates and projections were obtained from the Brazilian Institute of Geography and Statistics. Service needs were estimated based on literature data. RESULTS: The expected increase in the Brazilian population for 2000-2040 is 31.5%. The minimum estimate of patients with palliative care needs was 662,065 in 2000 and 1,166,279 in 2040. The staff required for each hundred thousand inhabitants would increase from 1,734 to 2,282, the number of doctors needed would increase from 4,470 to 6,274, and the number of nurses from 8,586 to 11,294, for the same period. CONCLUSION: The definition of a national strategy predicting the increasing palliative care needs of the population is necessary. The expansion of the support network for chronic and non-transmissible diseases is necessary, but the training of existing human resources at all levels of attention to perform palliative actions can be a feasible alternative to minimize the suffering of the population.

RESUMO OBJETIVO: Estimar as necessidades de recursos humanos e serviços necessários para o atendimento de pacientes que se beneficiariam de cuidados paliativos a partir da projeção de crescimento da população brasileira até 2040. MÉTODO: As estimativas e projeções populacionais e de mortalidade foram obtidas nos dados do Instituto Brasileiro de Geografia e Estatística e do Sistema Único de Saúde. As estimativas de estrutura de serviços e recursos humanos foram realizadas a partir de dados da literatura. RESULTADOS: A expectativa de aumento da população brasileira entre 2000 e 2040 é de 31,5%. A estimativa mínima de pacientes com necessidades de cuidados paliativos foi de 662.065 em 2000 e é de 1.166.279 em 2040. O número de equipes necessárias para cada 100 mil habitantes passaria de 1.734 para 2.282 no mesmo período; o número de médicos foi de 4.770 para 6.274 e o número de enfermeiros necessários para atender as demandas dessa população foi de 8.586 para 11.294 nesse espaço de tempo. CONCLUSÃO: A definição de uma estratégia nacional prevendo a necessidade de cuidados crescentes da população se torna necessária. A expansão da rede de assistência a doenças crônicas e não transmissíveis se mostra necessária, porém a capacitação de recursos humanos já existentes em todos os níveis de atenção para desempenhar ações paliativas pode ser uma alternativa factível para minimizar o sofrimento da população.

Análise da Escala de Perroca em Unidade de Cuidados Paliativos / Análisis de la Escala de Perroca en Unidad de Cuidados Paliativos / Analysis of the Perroca Scale in Palliative Care Unit

RESUMO Objetivo Analisar a complexidade do cuidado de enfermagem com o uso da escala de Perroca em uma Unidade de Cuidados Paliativos. Método Estudo retrospectivo descritivo com análise quantitativa. Resultados Entre 2008 e 2016, foram internados 2.486 pacientes, a mediana de tempo de internação foi de 12 dias. Desses pacientes, 1.568 tiveram pelo menos uma avaliação pela escala de Perroca, classificados em cuidados mínimos ou intermediários (910, 58%), obtendo alta (602, 66%). Como cuidados semi-intensivos e intensivos, foram 658 (42%) pacientes, dentre os quais 64% morreram e apenas 36% receberam alta hospitalar. Conclusão A escala Perroca é uma ferramenta para identificar os pacientes com maior necessidade de cuidados e de possível prognóstico para os pacientes internados.

RESUMEN Objetivo Analizar la complejidad del cuidado de enfermería con el uso de la escala de Perroca en una Unidad de Cuidados Paliativos. Método Estudio retrospectivo descriptivo con análisis cuantitativo. Resultados Entre 2008 y 2016, fueron ingresados 2.486 pacientes, la mediana de tiempo de estancia hospitalaria fue de 12 días. De esos pacientes, 1.568 tuvieron por lo menos una evaluación por la escala de Perroca, clasificados en cuidados mínimos o intermedios (910, 58%), obteniendo el alta (602, 66%). Como cuidados semintensivos e intensivos, fueron 658 (42%) pacientes, entre los que el 64% fallecieron y solo el 36% recibieron el alta hospitalaria. Conclusión La escala de Perroca es una herramienta para identificar a los pacientes con mayor necesidad de cuidados y de posible pronóstico para los pacientes ingresados.

ABSTRACT Objective To analyze the complexity of nursing care with use of the Perroca scale in a Palliative Care Unit. Method Retrospective descriptive study of quantitative analysis. Results Between 2008 and 2016, the total of 2,486 patients were hospitalized, and their median length of hospital stay was 12 days. Of these patients, 1,568 had at least one Perroca scale evaluation. Nine hundred and ten patients (58%) were classified as minimal or intermediate care. Of these, 602 (66%) were discharged. As semi-intensive and intensive care were classified 658 (42%) patients, of whom 64% died and only 36% were discharged. Conclusion The Perroca scale is a tool to identify patients with greater need for care and the possible prognosis for hospitalized patients.

Primitive neuroectodermal tumor of the liver: a case report.

Primary liver sarcomas represent a rare group of neoplasias, with angiosarcoma being the most common histological type. Primitive neuroectodermal tumor (PNET) represents a high malignant neoplasia that usually affects the central nervous system and soft tissues. An 18-year-old male patient was admitted with clinical complains of pain in the right upper abdominal quadrant. The clinical evaluation revealed a solid mass in the right hepatic lobe. On the gross examination of the resected liver specimen, the right lobe of the liver was replaced by a yellow-red solid mass measuring 21 cm in its largest dimension. On the histopathology, a tumor composed of small round blue cells with little cytoplasm and round nuclei was identified. The lesion revealed positive immunoexpression for vimentin and CD99 and negative immunostaining for desmin, CD45, cytokeratin, and neuroblastoma protein, suggesting, then, the diagnosis of PNET. Although it is an unusual tumor, it should be considered in the differential diagnosis of liver masses, especially in young patients.

Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection.

BACKGROUND: Historically, tertiary syphilis infection has been the most common cause of thoracic aortic aneurysm, resulting in 5% to 10% of cardiovascular deaths until the era of antibiotics. METHODS: A 49-year-old Caucasian man presented to our institution with progressive dysphagia, weight loss, incomplete bladder emptying, alcohol and tobacco consumption, systemic arterial hypertension, Argyll Robertson pupil, leg paresthesias, and mediastinal widening. He was admitted to investigate clinical alterations. Thoracic computed tomography revealed an aortic aneurysm complicated with chronic aortic dissection from the ascending aorta to the iliac vessels with 2 communicating lumens. Cerebrospinal fluid examination tested positive for neurosyphilis in a venereal disease research laboratory test (titre 1/32). RESULTS: Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection was diagnosed. CONCLUSIONS: This is a unique presentation of a syphilitic infection. Syphilitic aortitis, the hallmark of cardiovascular syphilis, has become rare and is hardly considered by today's clinicians in their differential diagnosis.

Angiosarcoma arising in an ovarian fibroma: a case report.

Primary ovarian angiosarcoma is a very rare gynaecological sarcoma, with poor prognosis. These tumors are though to arise from carcinosarcomas, teratomas, or the ovarian vasculature and occur at any age. There are only a few cases reported in the international literature, most commonly associated to surface epithelial-stromal or germ cell tumours. Herein, the authors report the clinicopathologic features of an angiosarcoma arising in an ovarian fibroma. A 65-year-old patient was admitted with a palpable mass in the hypogastrium. Grossly, the removed ovary was completely replaced by a solid tumor mass. On histological analysis, the lesion revealed the typical histological features of angiosarcoma with sinusoidal patterns and anaplastic cells, admixed with spindle-shaped cells arranged in fascicles or in a storiform pattern, compatible with a fibroma. The vascular component was strongly immunopositive for CD31 and CD34. The patient was submitted to chemotherapy, and she was alive for two months after surgical proceedings.