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.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis.

PURPOSE: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. MATERIALS AND METHODS: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. RESULTS: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). CONCLUSIONS: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Prostate Cancer Screening in Brazil: a single center experience in the public health system.

PURPOSE: Incidence and mortality of prostate cancer (PCa) are still increasing in developing countries. Limited access to the health system or more aggressive disease are potential reasons for this. Ethnic and social differences in developed countries seem to make inappropriate to extrapolate data from other centers. We aim to report the epidemiological profile of a PSA-screened population from a cancer center in Brazil. MATERIALS AND METHODS: We retrospectively selected 9.692 men enrolled in a PCa prevention program, comprising total PSA level and digital rectal examination at the first appointment, associated with complementary tests when necessary. Men aged over 40 years-old were included after shared decision-making process. Prostate biopsy (TRUS) was performed when clinically suspected for PCa. After the diagnosis, patients underwent appropriate treatment. RESULTS: TRUS was performed in 5.5% of men and PCa incidence was 2.6%. Overall ratio between number of patients who needed to be screened in order to diagnose one cancer was 38.9 patients, with 2.1 biopsies performed to diagnose a cancer. Positive predictive value (PPV) of TRUS biopsy in this strategy was 47.2%, varying from 38.5% (<50 years-old) to 60% (>80 years-old). We evidenced 70 patients (27.9%) classified as low risk tumors, 74 (29.5%) as intermediate risk, and 107 (42.6%) as high-risk disease. CONCLUSIONS: PSA-screening remains controversial in literature. In front of a huge miscegenated people and considering the big proportion of high-risk PCa, even in young men diagnosed with the disease, it is imperative to inform patients and health providers about these data particularities in Brazil.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes.

INTRODUCTION: Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population. MATERIALS AND METHODS: We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-oneout, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC. RESULTS: We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample. CONCLUSIONS: In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

Completely endophytic renal tumor: A laparoscopic approach.

Kidney cancer is the third most common urologic malignancy and a 2% annual increase in the incidence has occurred over the past two decades, largely because of the increased utilization of imaging. The majority of these tumors are small, so the indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Complex kidney lesions, such as those completely endophytic, are still a challenge even for experienced surgeons. Our objective is to demonstrate the operative technique for laparoscopic partial nephrectomy with the aid of intra-operative ultrasound in a man with a totally endophytic renal lesion. Case: A 52 years old man, asymptomatic, with incidental renal mass of 2.9 cm, completely endophytic (R.E.N.A.L score 9p) submitted to partial laparoscopic nephrectomy. Surgical time was 2 hours, with 20 minutes of ischemia. Pathological anatomy confirmed tumor of clear cells T1a, free margins.

Long-term results of the implantation of the AMS 800 artificial sphincter for post-prostatectomy incontinence: a single-center experience.

OBJECTIVES: Report the long-term outcomes of the AMS 800 artificial sphincer (AS) for the treatment post-prostatectomy incontinence (PPI) in a single center in Brazil. MATERIALS AND METHODS: Clinical data from patients who underwent the procedure were retrieved from the medical records of individuals with more than 1 year of follow-up from May 2001 to January 2016. Continence status (number of pads that was used), complications (erosion or extrusion, urethral atrophy, and infection), malfunctions, and need for secondary implantation were evaluated. The relationship between complications and prior or subsequent radiation therapy (RT) was also examined. RESULTS: From May 2001 to January 2016, 121 consecutive patients underwent AS implantation for PPI at an oncological referral center in Brazil. At the last visit, the AS remained implanted in 106 patients (87.6%), who reported adequate continence status (maximum of 1 pad/day). Eight-two subjects (67.8%) claimed not to be using pads on a regular basis at the final visit (completely dry). Revision occurred in 24 patients (19.8%).Radiation therapy (RT) for prostate cancer following radical prostatectomy was used in 47 patients before or after AS placement. Twelve patients with a history of RT had urethral erosion compared with 3 men without RT (p=0.004). CONCLUSION: Considering our outcomes, we conclude that AS implantation yields satisfactory results for the treatment of PPI and should remain the standard procedure for these patients. Radiation therapy is a risk factor for complication.

American Confederation of Urology (CAU) experience in minimally invasive partial nephrectomy.

PURPOSE: To describe the perioperative and oncology outcomes in a series of laparoscopic or robotic partial nephrectomies (PN) for renal tumors treated in diverse institutions of Hispanic America from the beginning of their minimally invasive (MI) PN experience through December 2014. METHODS: Seventeen institutions participated in the CAU generated a MI PN database. We estimated proportions, medians, 95 % confidence intervals, Kaplan-Meier curves, multivariate logistic and Cox regression analyses. Clavien-Dindo classification was used. RESULTS: We evaluated 1501 laparoscopic (98 %) or robotic (2 %) PNs. Median age: 58 years. Median surgical time, warm ischemia and intraoperative bleeding were 150, 20 min and 200 cc. 81 % of the lesions were malignant, with clear cell histology being 65 % of the total. Median maximum tumor diameter is 2.7 cm, positive margin is 8.2 %, and median hospitalization is 3 days. One or more postoperative complication was recorded in 19.8 % of the patients: Clavien 1: 5.6 %; Clavien 2: 8.4 %; Clavien 3A: 1.5 %; Clavien 3B: 3.2 %; Clavien 4A: 1 %; Clavien 4B: 0.1 %; Clavien 5: 0 %. Bleeding was the main cause of a reoperation (5.5 %), conversion to radical nephrectomy (3 %) or open partial nephrectomy (6 %). Transfusion rate is 10 %. In multivariate analysis, RENAL nephrometry score was the only variable associated with complications (OR 1.1; 95 % CI 1.02-1.2; p = 0.02). Nineteen patients presented disease progression or died of disease in a median follow-up of 1.37 years. The 5-year progression or kidney cancer mortality-free rate was 94 % (95 % CI 90, 97). Positive margins (HR 4.98; 95 % CI 1.3-19; p = 0.02) and females (HR 5.6; 95 % CI 1.7-19; p = 0.005) were associated with disease progression or kidney cancer mortality after adjusting for maximum tumor diameter. CONCLUSION: Laparoscopic PN in these centers of Hispanic America seem to have acceptable perioperative complications and short-term oncologic outcomes.

Predictive role of Trimprob associated with multiparametric MRI in the diagnosis of prostate cancer.

OBJECTIVES: To evaluate the predictive value of TRIMprob test to detect prostate cancer (PCa) in patients referred to prostate biopsy (PB). MATERIAL AND METHODS: Patients with PSA <10ng/mL and rectal exam without findings suggestive of prostate cancer were selected for TRIMprob evaluation. Exam was performed by a single operator through transperineal approach. Patients admitted for the study were submitted to TRIMprob and multiparametric magnetic resonance (mpMRI) and posteriorly to PB. RESULTS: In total, 77 patients were included. TRIMprob showed evidences of PCa in 25 (32.5%) and was negative in 52 patients (67.5%). The rate of detection of prostate cancer at biopsy was higher in patients with positive TRIMprob (16/25; 64.0%) than in patients with negative TRIMprob (11/52; 21.1%; p<0.001). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TRIMprob were respectively 61.5%, 82.0%, 64.0%, 80.3% and 74.0%. ROC curve showed the following areas under the curve values for TRIMprob, mpMRI and combination of TRIMprob + mpMRI: 0.706; 0.662 and 0.741 respectively. At combined analysis, when both TRIMprob and mpMRI were negative for prostate cancer, accuracy was 96.3% or only 1 in 27 PB was positive (3.7%). CONCLUSIONS: Trimprob had similar predictive value for PCa in patients submitted to PB as mpMRI. Combined TRIMprob and mpMRI showed higher accuracy than when performed singly.

Tumor histologic grade is the most important prognostic factor in patients with penile cancer and clinically negative lymph nodes not submitted to regional lymphadenectomy.

INTRODUCTION: The presence and extension of inguinal lymph node metastasis are the main prognostic factors in patients with penile cancer. Physical exam and image exams are not adequate to evaluate inguinal lymph nodes and many patients are submitted to non-therapeutic lymphadenectomies. However, it is known that not all patients with clinically or histologically negative inguinal lymph nodes evolve favorably. CASUISTIC AND METHODS: the authors evaluated the clinical and pathologic characteristics of 163 patients with penile carcinoma and clinically negative inguinal lymph nodes followed for three or more years and their impact on global survival (GS) and cancer-specific survival (CSS) in the 10-year follow-up. Primary pathologic tumor stage (p=0.025) and the presence of high grade of tumor differentiation (p=0.018) were predictive of CSS. The presence of high grade tumor was an independent specific prognostic factor of death risk (RR 14.08; p=0.019). CONCLUSION: high histologic grade was an independent predictive factor of specific death risk in patients with penile carcinoma and clinically negative lymph nodes followed for three or more years.

Pathologic and imunohistochemical characterization of tumoral inflammatory cell infiltrate in invasive penile squamous cell carcinomas: Fox-P3 expression is an independent predictor of recurrence.

Penile carcinomas (PeCa) are relatively rare, but devastating neoplasms, more frequent among people of underprivileged socioeconomic status. There is mounting evidence that immune cells may trigger various mechanisms that enhance tumor growth and metastasis, but no data on the peritumoral inflammation is available for PeCa. The objectives of the present study are to evaluate the immunohistomorphology of tumoral inflammation in PeCa, and to correlate it with clinicopathological parameters, which could contribute to the prognostic evaluation. One hundred and twenty-two patients with the diagnosis of usual-type squamous cell penile carcinoma were included. Paraffin-embedded tissue was submitted to immunohistochemical evaluation of p16 protein, CD3, CD4, CD8, CD20, CD68, CD138, granzyme B, and Fox-P3. The Fisher's exact test was employed for comparison between histological variables and parameters, and the Kaplan-Meier method for the analysis of survival. Improved 5-year overall survival was significantly associated to age ≤60 years, stage I + II, tumor size T1 + T2, lymph node status N0, and absent perineural invasion. In a multivariate analysis age ≥60 years, presence of lymph node metastasis, urethral invasion, and high histologic grade retained a significantly more unfavorable outcome. Improved 5-year failure free survival was associated to stage of the disease I + II, lymph node status N0, absence of perineural, vascular, and urethral invasion, and Fox-P3 expression. In a multivariate analysis, presence of lymph node metastasis, perineural and vascular invasion, and of Fox-P3-positive lymphocytes together with low inflammatory infiltrate retained a significantly more unfavorable outcome. These results support the prognostic value of determining the levels of Fox-P3-positive lymphocytes by immunohistochemistry in PeCa, as this parameter adds value to the traditional clinicopathological features.

Pattern of invasion is the most important prognostic factor in patients with penile cancer submitted to lymph node dissection and pathological absence of lymph node metastasis.

OBJECTIVES: To identify prognostic factors in a cohort of patients with penile carcinoma with pathological absence of lymph node metastasis (pN0), as penile carcinoma is a rare neoplasm in European countries, in which the presence of lymph node metastasis is the most important prognostic factor but few studies have examined patients with penile carcinoma with histologically negative nodes (pN0). PATIENTS AND METHODS: Of patients with penile carcinoma, 101 met the inclusion criteria; 47 (46.5%) underwent bilateral inguinal lymph node dissection (LND) and 54 (53.5%) underwent bilateral inguinopelvic LND. Variables that had a prognostic impact on survival rates in univariate analysis were selected for multivariate survival analysis. RESULTS: The cohorts cancer-specific survival (CSS) and overall survival (OS) rates were 88.1% and 52.5%, respectively. Histological grade and pattern of invasion were the only features to significantly impact survival rates in the univariate analysis. The CSS and OS rates in patients with 'pushing' vs 'infiltrating' patterns of invasion were 98.0% vs 78.4% (P = 0.003) and 70.0% vs 35.3% (P = 0.005), respectively. Pattern of invasion was the only independent predictor of survival. Patients with infiltrating invasion had a higher probability of death from cancer (hazard ratio [HR] 11.5, P = 0.019) and overall death (HR 2.3, P = 0.007) compared with those with a pushing invasion pattern. CONCLUSIONS: The presence of an infiltrating pattern of invasion is the most important predictor of survival in patients with penile carcinoma. We encourage other centres to confirm our findings that the pattern of invasion is an important prognostic factor in patients with penile carcinoma and pN0 disease.

Prognostic factors in patients with penile carcinoma and inguinal lymph node metastasis.

OBJECTIVES: To identify prognostic factors in patients with penile carcinoma and confirmed lymph node metastasis. METHODS: Patients were selected from a historical series of patients with penile carcinoma. An experienced pathologist reviewed all cases. Information regarding the total number of lymph nodes excised, the number of positive lymph nodes and the presence of extranodal extension were used. Lymph node ratio was categorized as <0.15 and >0.15. RESULTS: The 5-year recurrence-free survival and disease-specific survival rates were 55.3% and 64.1%, respectively. Lymphovascular invasion, lymph node ratio and pN status influenced survival rates in univariate analysis. Lymphovascular invasion and lymph node ratio remained as independent predictors of disease-specific survival and recurrence-free survival in the multivariate analysis. A risk stratification of death and tumor recurrence was observed when patients were grouped into three categories: absence of risk factors; the presence of one risk factor; and the presence of two or more risk factors. CONCLUSIONS: The presence of one or more of the following parameters is correlated with a significantly higher risk of death and tumor recurrence in patients with penile carcinoma and inguinal lymph node metastasis: extranodal extension, lymph node ratio >0.15 and lymphovascular invasion.

Prognostication of prostate cancer based on TOP2A protein and gene assessment: TOP2A in prostate cancer.

BACKGROUND: TOP2A encodes for topoisomerase IIα, a nuclear enzyme that controls DNA topological structure and cell cycle progression. This enzyme is a marker of cell proliferation in normal and neoplastic tissues; however, little information is available about its expression in prostate cancer (PCa). METHODS: Immunohistochemistry (IHC) was automated using mouse monoclonal antibody against TOP2A (clone SWT3D1; DAKO, Carpenteria, CA, USA) at dilution 1:800 and Flex Plus detection system in autostainer 48Ultra (DAKO). FISH was performed using TOP2A (17q21)/ CEP17 probe kit (Kreateck Biotechnology, San Diego, CA, USA). Biochemical and pathological data from 193 patients with PCa were retrieved for the analysis, whose significance was considered when p < 0.05. Also, fractal analysis was performed in a subset of 20 randomly selected cases. RESULTS: TOP2A protein expression correlated with higher Gleason scores and higher levels of preoperative PSA (p = 0.018 and p = 0.011). Patients with higher levels of TOP2A presented shorter biochemical recurrence-free survival (BRFS) (p = 0.001). In multivariate analysis, we found that TOP2A remained an independent prognostic factor of BRFS, with a relative risk of 1.98 (p = 0.001; 95% CI, 1.338-2.93); thus, cases that expressed high levels of this enzyme had a shorter BRFS compared with TOP2A-negative or TOP2A-low cases. No alterations in TOP2A gene status nor correlation between FISH and IHC results were observed. Concerning fractal analysis, patients who expressed higher levels of TOP2A have angiolymphatic invasion and presented higher Gleason scores (p = 0.033 and p = 0.025, respectively). Also, patients with higher expression of TOP2A presented shorter BRFS (p = 0.001). CONCLUSIONS: This is the first study to perform TOP2A protein and gene digital assessment and fractal analysis in association with BRFS in a large series of PCa. Also, we show that TOP2A gene copy number alterations are not observed in this type of tumor. So, higher protein expression of TOP2A is not related to gene amplification in PCa. Furthermore, TOP2A protein assessment has prognostic importance and, due to its relation with poor outcome, TOP2A IHC evaluation in the biopsy can represent an important tool for selecting the most suitable surgical and clinical approach for patients with PCa.

Does histologic type correlate to outcome after pelvic exenteration for cervical and vaginal cancer?

BACKGROUND: Adenocarcinoma (AC) of the cervix comprises 15-20 % of all cervical carcinomas, and data regarding the prognostic value of histologic type after pelvic exenteration (PE) are lacking. Our aim was to analyze the prognostic value of histologic type in overall survival (OS) and disease-specific survival (DSS) after PE and correlate it to clinical and pathologic variables. METHODS: We reviewed a series of 77 individuals who underwent PE for cervical or vaginal cancer from January 1980 to December 2010. RESULTS: Mean age was 54.5 years. Fifty-three patients (68.9 %) had cervical and 24 (31.1 %) vaginal cancer. Fifty-six (72.7 %) were squamous cell carcinoma (SCC) and 21 (27.3 %) ACs. We performed 42 (54.5 %) total, 18 anterior, 8 posterior, and 9 lateral extended PE. Median tumor size was 5 cm. Surgical margins were negative in 91.7 % of cases. Median operative time, length of hospital stay, and blood transfusion volume were, respectively, 420 (range 180-720) mins, 13.5 (range 4-79) days, and 900 (range 300-3900) ml. Median follow-up was 13.7 (range 1.09-114.3) months. SCC statistically correlated with presence of perineural invasion (p = 0.004). Five-year OS and DSS were, respectively, 24.4 and 37.1 %. SCC (p = 0.003) and grade 3 (p = 0.001) negatively affected OS in univariate analysis. SCC (p = 0.006), grade 3 (p = 0.003), perineural invasion (p = 0.03), lymph node metastasis (p = 0.02), and positive margins (p = 0.04) negatively affected DSS in univariate analysis. SCC and grade 3 retained the higher risk of death (OS and DSS) in multivariate analysis. CONCLUSIONS: AC histology in cervical and vaginal cancer is associated with better outcome after PE compared to SCC.