PSMA PET/CT in the Brazilian Unified Healthcare System reduces costs with futile salvage therapies in the management of cases of biochemical recurrence of prostate cancer.

Objective: To compare costs between treatment strategies employed prior to and after prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) via the Brazilian Unified Health Care System and their impact on the therapeutic management of biochemical recurrence of prostate cancer. Materials and Methods: The referring physicians were surveyed on their treatment intentions (strategies) at two different time points: prior to and after PSMA PET/CT. Cost comparison results are presented as median (IQR) for each of the two strategies. The shift in therapeutic management after PSMA PET/CT was also analyzed. Results: The study sample included 59 patients (mean age: 65.9 years). The PSMA PET/CT result was considered positive in 38 patients (64.4%) and was found to have an impact on the treatment strategy in for 36 patients (61.0%). Prior to PSMA PET/CT, salvage therapy (i.e., treatment with curative intent) was the intended treatment for most patients, and that was significantly less so after the examination (76.3% vs. 45.8%; p < 0.001). Conversely, a strategy involving systemic (i.e., palliative) therapy became more common after PSMA PET/CT (23.7% vs. 54.2%; p < 0.001). The after-PSMA PET/CT strategy presented higher overall costs than did the before-PSMA PET/CT strategy, in all scenarios evaluated. In all scenarios, nearly half of this cost difference was related to the cost of the PSMA PET/CT itself, the remainder being related to the new treatment choices that stemmed from knowledge of the PSMA PET/CT findings. Conclusion: For patients treated within the Brazilian Unified Health Care System, PSMA PET/CT presented higher costs in comparison with conventional imaging methods. Adding PSMA PET/CT to the workflow had an impact on therapeutic management, mainly representing a shift from futile curative treatments to systemic palliative ones. The amount of funds that could potentially be saved by not providing such futile treatments would suffice to evaluate roughly two patients with PSMA PET/CT scans for each futile treatment strategy avoided.

Objetivo: Comparar custos entre estratégias antes e após o exame de PET/CT-PSMA da perspectiva do Sistema Único de Saúde e seu impacto no manejo terapêutico para pacientes com recidiva bioquímica de câncer de próstata. Materiais e Métodos: Os médicos solicitantes informaram a intenção terapêutica em dois momentos: antes e após o exame. Os resultados de comparação de custo estão apresentados como medianas de custo (p25; p75). A mudança na intenção terapêutica também foi analisada. Resultados: O estudo envolveu 59 pacientes (idade média: 65,9 anos). A PET/CT-PSMA foi considerada positiva em 38 dos 59 pacientes (64.4%). O exame impactou a estratégia de tratamento para 36 pacientes (61%). Antes da obtenção das informações da PET/CT-PSMA, a terapia de resgate (i.e., com intenção curativa) era o tratamento sugerido para a maioria dos pacientes, e após o exame, reduziu significativamente (76,3% vs 45,8%; p < 0,001). Em contrapartida, a terapia sistêmica (i.e., paliativa) aumentou como intenção de tratamento após o exame (23,7% vs 54,2%; p < 0,001). A estratégia "após PET/CT-PSMA" apresentou maiores custos em relação à estratégia "antes da PET/CT-PSMA" nos cenários comparados. Cerca de metade da diferença de custos entre as duas estratégias foi relacionada aos custos do exame propriamente ditos, enquanto a outra metade foi relacionada às novas escolhas de tratamento a partir do exame. Conclusão: Oferecer a PET/CT-PSMA no Sistema Único de Saúde apresentou maiores custos em relação à estratégia com métodos de imagem convencionais e impactou o manejo terapêutico, pelo favorecimento de tratamentos sistêmicos paliativos no lugar de tratamentos curativos fúteis. A quantidade de recursos que poderiam ser poupados ao evitar tratamentos fúteis seria suficiente para avaliar aproximadamente dois pacientes com exames de PET/CT-PSMA para cada estratégia de tratamento fútil evitada.

Carcinoma escamoso variedad sarcomatoide de lengua. Reporte de caso / Sarcomatoid variant squamous cell carcinoma of the tongue. Case report

Introducción. El carcinoma de células escamosas es una patología relativamente frecuente en Paraguay, que debe ser diagnosticada y tratada a tiempo. La variedad sarcomatoide es un subtipo poco frecuente, pero mucho más agresivo que la presentación convencional, con altas tasas de recurrencia y metástasis linfática. La exposición previa a radiación es uno de los principales factores desencadenantes. Caso clínico. Paciente de 83 años con antecedente de radioterapia por carcinoma escamocelular del paladar blando, quien consultó por una masa en el borde lateral de la lengua que correspondió a un carcinoma escamocelular del subtipo sarcomatoide. Resultados. El paciente fue sometido a cirugía y quimioterapia, pero presentó recaída tumoral a los cuatro meses, sin aceptar una cirugía de rescate, optando por el tratamiento paliativo y falleciendo a los pocos meses. Conclusión. El examen exhaustivo de la cavidad oral en una primera consulta permite identificar lesiones en estadios tempranos y el tratamiento multidisciplinario temprano puede mejorar la supervivencia global. El pronóstico de estos pacientes en estadios avanzados es desalentador. Actualmente la cirugía microvascular es la mejor opción terapéutica, pero la hemiglosectomía sin reconstrucción sigue siendo una opción aceptable en nuestro medio, conociendo los altos costos de la primera y el requerimiento de un grupo mayor de especialistas, largos tiempos quirúrgicos y estancias hospitalarias.

Introduction. Squamous cell carcinoma is a relatively common pathology in Paraguay, which must be diagnosed and treated on time. The sarcomatoid variety is a rare subtype, but much more aggressive than the conventional presentation, with high rates of recurrence and lymphatic metastasis. Previous exposure to radiation is one of the main triggering factors. Clinical case. An 83-year-old patient with a history of radiotherapy for squamous cell carcinoma of the soft palate, who consulted for a mass on the lateral edge of the tongue that corresponded to a squamous cell carcinoma of the sarcomatoid subtype. Results. The patient underwent surgery and chemotherapy, but had tumor relapse after four months, without accepting salvage surgery, opting for palliative treatment and dying a few months later. Conclusion. Exhaustive examination of the oral cavity in a first consultation allows lesions to be identified in early stages and early multidisciplinary treatment can improve overall survival. The prognosis of these patients in advanced stages is discouraging. Currently, microvascular surgery is the best therapeutic option, but hemiglossectomy without reconstruction continues to be an acceptable option in our environment, knowing the high costs of the former and the requirement for a larger group of specialists, long surgical times and hospital stays.

Current practice in intermediate risk differentiated thyroid cancer - a review.

Although the overall prognosis for differentiated thyroid cancer (DTC) is excellent, a subset of patients will experience disease recurrence or may not respond to standard treatments. In recent years, DTC management has become more personalized in order to enhance treatment efficacy and avoid unnecessary interventions.In this context, major guidelines recommend post-surgery staging to assess the risk of disease persistence, recurrence, and mortality. Consequently, risk stratification becomes pivotal in determining the necessity of postoperative adjuvant therapy, which may include radioiodine therapy (RIT), the degree of TSH suppression, additional imaging studies, and the frequency of follow-up.However, the intermediate risk of recurrence is a highly heterogeneous category that encompasses various risk criteria, often combined, resulting in varying degrees of aggressiveness and a recurrence risk ranging from 5 to 20%. Furthermore, there is not enough long-term prognosis data for these patients. Unlike low- and high-risk DTC, the available literature is contradictory, and there is no consensus regarding adjuvant therapy.We aim to provide an overview of intermediate-risk differentiated thyroid cancer, focusing on criteria to consider when deciding on adjuvant therapy in the current context of personalized approach, including molecular analysis to enhance the accuracy of patient management.

PSMA PET/CT in the Brazilian Unified Healthcare System reduces costs with futile salvage therapies in the management of cases of biochemical recurrence of prostate cancer / PET/CT-PSMA no Sistema Único de Saúde reduz custos com terapias de resgate fúteis no manejo de pacientes com recidiva bioquímica de câncer de próstata

Abstract Objective: To compare costs between treatment strategies employed prior to and after prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) via the Brazilian Unified Health Care System and their impact on the therapeutic management of biochemical recurrence of prostate cancer. Materials and Methods: The referring physicians were surveyed on their treatment intentions (strategies) at two different time points: prior to and after PSMA PET/CT. Cost comparison results are presented as median (IQR) for each of the two strategies. The shift in therapeutic management after PSMA PET/CT was also analyzed. Results: The study sample included 59 patients (mean age: 65.9 years). The PSMA PET/CT result was considered positive in 38 patients (64.4%) and was found to have an impact on the treatment strategy in for 36 patients (61.0%). Prior to PSMA PET/CT, salvage therapy (i.e., treatment with curative intent) was the intended treatment for most patients, and that was significantly less so after the examination (76.3% vs. 45.8%; p < 0.001). Conversely, a strategy involving systemic (i.e., palliative) therapy became more common after PSMA PET/CT (23.7% vs. 54.2%; p < 0.001). The after-PSMA PET/CT strategy presented higher overall costs than did the before-PSMA PET/CT strategy, in all scenarios evaluated. In all scenarios, nearly half of this cost difference was related to the cost of the PSMA PET/CT itself, the remainder being related to the new treatment choices that stemmed from knowledge of the PSMA PET/CT findings. Conclusion: For patients treated within the Brazilian Unified Health Care System, PSMA PET/CT presented higher costs in comparison with conventional imaging methods. Adding PSMA PET/CT to the workflow had an impact on therapeutic management, mainly representing a shift from futile curative treatments to systemic palliative ones. The amount of funds that could potentially be saved by not providing such futile treatments would suffice to evaluate roughly two patients with PSMA PET/CT scans for each futile treatment strategy avoided.

Resumo Objetivo: Comparar custos entre estratégias antes e após o exame de PET/CT-PSMA da perspectiva do Sistema Único de Saúde e seu impacto no manejo terapêutico para pacientes com recidiva bioquímica de câncer de próstata. Materiais e Métodos: Os médicos solicitantes informaram a intenção terapêutica em dois momentos: antes e após o exame. Os resultados de comparação de custo estão apresentados como medianas de custo (p25; p75). A mudança na intenção terapêutica também foi analisada. Resultados: O estudo envolveu 59 pacientes (idade média: 65,9 anos). A PET/CT-PSMA foi considerada positiva em 38 dos 59 pacientes (64.4%). O exame impactou a estratégia de tratamento para 36 pacientes (61%). Antes da obtenção das informações da PET/CT-PSMA, a terapia de resgate (i.e., com intenção curativa) era o tratamento sugerido para a maioria dos pacientes, e após o exame, reduziu significativamente (76,3% vs 45,8%; p < 0,001). Em contrapartida, a terapia sistêmica (i.e., paliativa) aumentou como intenção de tratamento após o exame (23,7% vs 54,2%; p < 0,001). A estratégia "após PET/CT-PSMA" apresentou maiores custos em relação à estratégia "antes da PET/CT-PSMA" nos cenários comparados. Cerca de metade da diferença de custos entre as duas estratégias foi relacionada aos custos do exame propriamente ditos, enquanto a outra metade foi relacionada às novas escolhas de tratamento a partir do exame. Conclusão: Oferecer a PET/CT-PSMA no Sistema Único de Saúde apresentou maiores custos em relação à estratégia com métodos de imagem convencionais e impactou o manejo terapêutico, pelo favorecimento de tratamentos sistêmicos paliativos no lugar de tratamentos curativos fúteis. A quantidade de recursos que poderiam ser poupados ao evitar tratamentos fúteis seria suficiente para avaliar aproximadamente dois pacientes com exames de PET/CT-PSMA para cada estratégia de tratamento fútil evitada.

EPIDEMIOLOGICAL PROFILE AND EVOLUTION OF ANKLE MUSCULOSKELETAL TUMORS.

Objective: Characterizing ankle tumors, presenting the epidemiological profile of these lesions. Methods: Retrospective observational case series study to evaluate the results of clinical and/or surgical treatments of patients with ankle tumors whose first visit occurred from 1990 to 2020. The dependent variables were: benign bone tumor, malignant bone tumor, benign soft tissue tumor, malignant soft tissue tumor, and infection. The independent variables were: sex, age; presence of symptoms (pain/local volume increase/fracture), duration of symptoms until treatment, diagnosis, treatment, and recurrence. Results: In total, 70 patients were included-58.5% were women, with a mean age at the time of diagnosis of 21.66 years. Among all cases, 76% were bone tumor, 14% were soft tissue tumor, and 10% were infection. The mean age at the time of diagnosis was 21.7 ± 2.29 years. The overall prevalence of pain was 77.1%. In total, 55.6% patients had a general local volume increase 13.4% had fractures. The mean time from symptoms to treatment was 17.4 ± 4.61 months and the mean diagnosis time was 10.13 ± 0.86 months. Of all cases, 73.44% underwent surgical treatment and 22.64% had recurrence. Conclusion: In this series, ankle tumors corresponded mainly to bone tumors. Benign tumors were the most prevalent type of tumor and the highest occurrence was among young people. Level of Evidence IV, Case Series.

Objetivos: Caracterizar tumores da região do tornozelo apresentando o perfil epidemiológico destas lesões. Métodos: Estudo observacional retrospectivo de série de casos para avaliação dos resultados de neoplasias do tornozelo submetidos a tratamento clínico e/ou cirúrgico em que o primeiro atendimento tenha ocorrido entre 1990 e 2020. As variáveis dependentes foram: tumor ósseo benigno, tumor ósseo maligno, tumor de partes moles benigno, tumor de partes moles maligno e infecção. As variáveis independentes foram: sexo, idade, presença de sintomas (dor/aumento de volume local/fratura), tempo de sintomas até o atendimento, diagnóstico, tratamento e recidiva. Resultados: Foram analisados 70 pacientes, sendo 58,5% do sexo feminino, com média de idade no momento do diagnóstico de 21,66 (21,7 ± 2,29) anos. As neoplasias ósseas correspondem a 76% dos casos, seguidas de tumor de partes moles com 14% e de infecção com 10%. A prevalência geral de dor foi de 77,1%. O aumento geral de volume local ocorreu em 55,6% pacientes e presença de fraturas em 13,4%. A média de tempo de sintomas até o atendimento foi de 17,4 ± 4,61 meses e a média de tempo para o diagnóstico foi de 10,13 ± 0,86 meses. O tratamento cirúrgico ocorreu em 73,44% dos casos e a recidiva em 22,64%. Conclusão: Os tumores ao nível do tornozelo nesta série correspondem majoritariamente a tumores ósseos, com prevalência do benigno e maior ocorrência em jovens. Nível de Evidência IV, Série de Casos.

Pattern of rectal cancer recurrence following potentially curative surgical treatment

Survival in rectal cancer has been related mainly to clinical and pathological staging. Recurrence is the most challenging issue when surgical treatment of rectal cancer is concerned. This study aims to establish a recurrence pattern for rectal adenocarcinoma submitted to surgical treatment between June 2003 and July 2021. After applying the exclusion criteria to 305 patients, 166 patients were analyzed. Global recurrence was found in 18.7% of them, while 7.8% have had local recurrence. Recurrences were diagnosed from 5 to 92 months after the surgical procedure, with a median of 32.5 months. Follow-up varied from 6 to 115 months. Recurrence, in literature, is usually between 3 and 35% in 5 years and shows a 5-year survival rate of only 5%. In around 50% of cases, recurrence is local, confined to the pelvis. This study was consonant with the literature in most aspects evaluated, although a high rate of local recurrence remains a challenge in seeking better surgical outcomes. (AU)

Selective Neck Dissection for Node-Positive Oral Cavity Squamous Cell Carcinoma: A Retrospective Cohort Study

Abstract Introduction Selective neck dissection inclinically node-negative neckisconsidered the standard of care for oral squamous cell carcinomas (SCCs). Controversy still prevailsinnode-positive disease regarding the extent of neck dissection. In our part of the world, comprehensive neck dissection is mostly considered to be the minimal optimal treatment for palpable neck disease. Objective To compare regional control and disease-specific survival between clinically node-positive and node-negative patients undergoing selective neck dissection for oral SCC. Methods This was a retrospective cohort study conducted in the department of ENT, Head and Neck surgery at a tertiary care hospital. All patients with biopsy-proven oral and lip SCC, with or without nodal disease, who underwent selective neck dissection between April 2006 and July 2015 were included in the study. Results During the study period, 111 patients with oral SCC underwent selective neck dissection, of whom 71 (62%) were clinically node-negative and 40 (38%) patients had clinically positive nodes in the neck. The mean follow-up was 16.62 months (standard deviation [SD]: 17.03). The overall regional control rates were 95 versus 96% for clinical negative versus positive nodes, respectively (p = 0.589). The disease-specific survival was 84.5% in the node negative group versus 82.5% in the node-positive group (p = 0.703). Conclusion Selective neck dissection in node-positive neck oral SCC has similar regional control rates when compared with node-negative neck SCC. The difference in disease-specific survival between the two groups is also not significant.

Selective Neck Dissection for Node-Positive Oral Cavity Squamous Cell Carcinoma: A Retrospective Cohort Study.

Introduction Selective neck dissection in clinically node-negative neck is considered the standard of care for oral squamous cell carcinomas (SCCs). Controversy still prevails in node-positive disease regarding the extent of neck dissection. In our part of the world, comprehensive neck dissection is mostly considered to be the minimal optimal treatment for palpable neck disease. Objective To compare regional control and disease-specific survival between clinically node-positive and node-negative patients undergoing selective neck dissection for oral SCC. Methods This was a retrospective cohort study conducted in the department of ENT, Head and Neck surgery at a tertiary care hospital. All patients with biopsy-proven oral and lip SCC, with or without nodal disease, who underwent selective neck dissection between April 2006 and July 2015 were included in the study. Results During the study period, 111 patients with oral SCC underwent selective neck dissection, of whom 71 (62%) were clinically node-negative and 40 (38%) patients had clinically positive nodes in the neck. The mean follow-up was 16.62 months (standard deviation [SD]: 17.03). The overall regional control rates were 95 versus 96% for clinical negative versus positive nodes, respectively ( p = 0.589). The disease-specific survival was 84.5% in the node negative group versus 82.5% in the node-positive group ( p = 0.703). Conclusion Selective neck dissection in node-positive neck oral SCC has similar regional control rates when compared with node-negative neck SCC. The difference in disease-specific survival between the two groups is also not significant.

Second Adjuvant Radioiodine Therapy after Reoperation for Locoregionally Persistent or Recurrent Papillary Thyroid Carcinoma.

Introduction Differentiated thyroid carcinoma (DTC) has increased incidence. Intermediate- and high-risk patients have lymph node relapse rate ranging from 10 to 50%, and receive multiple reinterventions, increasing the morbidity of the disease. Currently, there are no established guidelines for the use of second radioactive iodine (RAI) therapy after the reintervention for local recurrence. Materials and Methods This is a retrospective review of the medical records of 1,299 patients treated from January 2016 to July 2019 with DTC. We included 48 patients who received total thyroidectomy, RAI remnant ablation, surgery to remove the locally recurrent/persistent papillary thyroid carcinoma (PTC), and received a second RAI therapy. Results There were no significant differences between thyroglobulin (Tg) levels before reoperation (Tg0), Tg levels postoperatively (Tg1), and Tg levels after 6 months of second adjuvant RAI therapy (Tg2). However, we evidenced a 69.79% drop in first Tg levels (Tg0: 24.7 vs. Tg1: 7.56, p =0.851) and 44.4% decrease in second Tg levels (Tg1: 7.56 vs. Tg2: 4.20, p =0.544). Also, 77.1% of the patients did not have another documented recurrence. The median relapse-free time was 10.9 months (range: 1.3-58.2 months). Conclusion The results of the study cannot assess that a second RAI treatment after reoperation for locoregionally persistent or recurrent disease have a significant impact on treatment outcomes in intermediate- or high-risk patients with PTC. However, the 77.1% of patients have not presented a second documented recurrence and the median values of Tg and TgAb levels showed a substantial decrease after surgery and second RAI treatment.

Salvage Nipple-sparing Mastectomy for Patients with Breast Cancer Recurrence: A Case Series of Brazilian Patients / Mastectomia preservadora de mamilo para pacientes com recidiva de câncer de mama: Uma série de casos de pacientes brasileiras

Abstract Objective Few studies analyzed the safety of salvage nipple-sparing mastectomy (NSM) for local relapse treatment. We evaluated the outcomes of patients with indications for mastectomy who chose to undergo NSM for ipsilateral breast tumor recurrence (IBTR). Methods Between January 2001 and December 2018, we evaluated 24 women who underwent NSM for local relapse after conservative surgery. Results Thepatientswere followedupfor amean time of132months since thefirst surgery. After the NSM, 5 (20.8%) patients were diagnosed with local recurrence and only 1 (4.2%) patient died. The patients presented 4.8% (2) of partial and 2.4% (1) of total nipple necrosis. Conclusion In this long-term follow-up since the first surgery, we observed low rates of complication and good survival, although associated with high local recurrence in patients diagnosed with IBTR undergoing NSM as salvage surgery.We demonstrated that NSMmay be considered after IBTR for patients who did not want to undergo total mastectomy.

Resumo Objetivo Há poucos estudos sobre a segurança de se realizar adenomastectomia (nipple-sparing mastectomy, NSM, em inglês) para tratamento de recidiva local. O objetivo deste estudo foi avaliar os resultados de pacientes com indicação para mastectomia que optaram por se submeter a NSM para o tratamento de recorrência local. Métodos Foram analisadas 24 pacientes submetidas a NSM para tratamento de recidiva local após tratamento conservador entre janeiro de 2001 e dezembro de 2018. Resultados As pacientes foramacompanhadas por um períodomédio de 132meses a partir da primeira cirurgia. Após a NSM, 5 (20,8%) pacientes foram diagnosticadas com recorrência local, e apenas 1 paciente foi a óbito. As pacientes apresentaram 4,8% de necrose parcial e 2,4% de necrose total do mamilo. Conclusão Em um longo período de acompanhamento desde a primeira cirurgia, foram observadas baixas taxas de complicação pós-operatória e boa sobrevida, porém, associadas comuma alta taxa de recorrência local em pacientes submetidas a NSM para tratamento de recidiva local após cirurgia conservadora. Neste estudo, demonstrou-se que a NSM pode ser considerada uma opção cirúrgica para pacientes que não querem se submeter a mastectomia total.

Prognostic factors in locally advanced cervical cancer with pelvic lymph node metastasis.

OBJECTIVE: To evaluate the prognostic impact of clinical and pathological variables and patterns of recurrence in patients with locally advanced cervical cancer with pelvic lymph node involvement (stage IIIC1 according to the 2018 FIGO Staging System). METHODS: We retrospectively analyzed 62 patients with locally advanced cervical cancer treated with curative intent with radiotherapy associated with chemotherapy in AC Camargo Cancer Center from January 2007 to December 2018. RESULTS: Lymph node involvement was assessed by CT, MRI and positron emission tomography (PET)/CT in 28 (45.2%), 20 (32.3%) and 14 (22.6%) patients, respectively. The median tumor size was 5.0 cm and 72.6% of cases were squamous cell carcinomas. The median number of positive pelvic lymph nodes was three, and the median size of lymph nodes was 24 mm. Twenty-two (35.5%) patients had recurrence and 50% had only one site of recurrence. The sites of recurrence were pelvic, para-aortic and distant in 12 (19.4%), 6 (9.7%) and 16 (25.8%) patients, respectively. The 3 year overall and disease-free survival were 70.8% and 64.6%, respectively. Patients with adenocarcinoma had worse disease-free survival (HR 2.38; 95% CI 1.01 to 5.60; p=0.047) and overall survival (HR 2.99; 95% CI 1.14 to 7.75; p=0.025) compared with squamous cell carcinoma. In multivariate analysis, metastatic pelvic lymph node size of >2.5 cm (HR 4.38; 95% CI 1.65 to 11.6; p=0.003) and incomplete response to radiotherapy (HR 5.14; 95% CI 1.60 to 16.4; p=0.006) maintained the negative impact for overall survival. CONCLUSIONS: We found that pelvic lymph node size and incomplete response to radiotherapy negatively impact overall survival in patients with advanced cervical cancer with pelvic lymph node involvement. This finding may help to stratify risk in this group of patients.

The impact of worst pattern of invasion on the extension of surgical margins in oral squamous cell carcinoma.

BACKGROUND: To evaluate margins for oral carcinoma according to types of invasion front. METHODS: Retrospective cohort of 772 patients with worst pattern of invasion (WPOI) graded 1-5. Local recurrence was the outcome of interest. RESULTS: Local recurrences occurred in 164 patients (21.2%) and was affected by WPOI type 4/5, margin distance, perineural invasion, and adjuvant radiotherapy. In patients with WPOI types 1/2/3, a cutoff of 1.7 mm was considered ideal margin extent and in patients with WPOI types 4/5, the cutoff was 7.8 mm. Patients below these thresholds had a significantly higher incidence of local recurrence. CONCLUSIONS: Different WPOI determine the ideal extent of surgical margins as 1.7 mm for patients with types 1-3, and 7.8 mm in patients with types 4/5.

Intestinal obstruction due to small intestinal metastasis from primary Merkel cell carcinoma of the gluteal region.

Merkel cell carcinoma (MCC) is a rare neoplasm of unknown multifactorial origin first described in 1972. It occurs most often in older Caucasian males and is typically associated with sun-exposed areas of skin. However, cases have also been reported in other areas, such as the trunk and the gluteal region. Metastatic disease will occur in up to one-third of cases at onset or during the course of the disease, including metastases to the abdominal organs. We present the case of a 53-year-old male with a history of primary MCC of the right buttock and local resection surgery. Eighteen months later, he presented with a small bowel obstruction and had an emergency segmental bowel resection. Pathology examination with immunohistochemistry concluded that findings were consistent with metastatic MCC.

Perineural Invasion as Worsening Criterion for Salivary Gland Mucoepidermoid Carcinoma.

Mucoepidermoid carcinomas (MECs) are a form of salivary gland malignancy. They are classified according to histological grade and perineural invasion (PNI). In another cancer subtypes, positive-PNI suggests increased poor prognosis; however, the role of isolated positive-PNI salivary gland MEC can still be better investigated as a risk factor. This study investigated whether isolated PNI is independently associated with poor outcomes. Retrospective study, cohort case-series, single-center hospital from 2009 to 2019. Patient demographics, primary tumor, intervention, and survival data are included. Univariate, multivariate, and Kaplan-Meier survival curve analyses were used for comparison.The study group consisted of 32 patients (15 PNI-positive tumors, and 17 PNI-negative tumors), all admitted for surgery. Univariate analysis showed differences in grade (p = 0.038), positive margins (p = 0.034), soft tissue invasion (p < 0.001), pathological stage (p = 0.014), recurrence (p = 0.015), distant metastasis (p = 0.015) and MEC related death (p = 0.015). The risk in PNI-positive patients to develop soft tissue invasion and positive surgical margins was OR = 8.57 and OR = 4.88, respectively. Multivariate analysis found age differences (p = 0.038), with OR = 1.08. The Disease Specific Survival (DSS) was worst in the PNI-positive group (log-rank p-value = 0.0011), where the probability of dying occurred in the 12-24 months period (log-rank p-value = 0.002). PNI-positive salivary gland MEC is an independent prognostic factor, with poor DSS, increased locoregional recurrence, close correlation with a more aggressive pattern of the disease, and should be reviewed as a high grade histological criteria. Our findings may imply changes in the clinical approach with a more aggressive attitude in the overall treatment.

Epidemiological profile and evolution of ankle musculoskeletal tumors / Perfil epidemiológico e evolução nos tumores musculoesqueléticos ao nível do tornozelo

ABSTRACT Objective: Characterizing ankle tumors, presenting the epidemiological profile of these lesions. Methods: Retrospective observational case series study to evaluate the results of clinical and/or surgical treatments of patients with ankle tumors whose first visit occurred from 1990 to 2020. The dependent variables were: benign bone tumor, malignant bone tumor, benign soft tissue tumor, malignant soft tissue tumor, and infection. The independent variables were: sex, age; presence of symptoms (pain/local volume increase/fracture), duration of symptoms until treatment, diagnosis, treatment, and recurrence. Results: In total, 70 patients were included-58.5% were women, with a mean age at the time of diagnosis of 21.66 years. Among all cases, 76% were bone tumor, 14% were soft tissue tumor, and 10% were infection. The mean age at the time of diagnosis was 21.7 ± 2.29 years. The overall prevalence of pain was 77.1%. In total, 55.6% patients had a general local volume increase 13.4% had fractures. The mean time from symptoms to treatment was 17.4 ± 4.61 months and the mean diagnosis time was 10.13 ± 0.86 months. Of all cases, 73.44% underwent surgical treatment and 22.64% had recurrence. Conclusion: In this series, ankle tumors corresponded mainly to bone tumors. Benign tumors were the most prevalent type of tumor and the highest occurrence was among young people. Level of Evidence IV, Case Series.

RESUMO Objetivos: Caracterizar tumores da região do tornozelo apresentando o perfil epidemiológico destas lesões. Métodos: Estudo observacional retrospectivo de série de casos para avaliação dos resultados de neoplasias do tornozelo submetidos a tratamento clínico e/ou cirúrgico em que o primeiro atendimento tenha ocorrido entre 1990 e 2020. As variáveis dependentes foram: tumor ósseo benigno, tumor ósseo maligno, tumor de partes moles benigno, tumor de partes moles maligno e infecção. As variáveis independentes foram: sexo, idade, presença de sintomas (dor/aumento de volume local/fratura), tempo de sintomas até o atendimento, diagnóstico, tratamento e recidiva. Resultados: Foram analisados 70 pacientes, sendo 58,5% do sexo feminino, com média de idade no momento do diagnóstico de 21,66 (21,7 ± 2,29) anos. As neoplasias ósseas correspondem a 76% dos casos, seguidas de tumor de partes moles com 14% e de infecção com 10%. A prevalência geral de dor foi de 77,1%. O aumento geral de volume local ocorreu em 55,6% pacientes e presença de fraturas em 13,4%. A média de tempo de sintomas até o atendimento foi de 17,4 ± 4,61 meses e a média de tempo para o diagnóstico foi de 10,13 ± 0,86 meses. O tratamento cirúrgico ocorreu em 73,44% dos casos e a recidiva em 22,64%. Conclusão: Os tumores ao nível do tornozelo nesta série correspondem majoritariamente a tumores ósseos, com prevalência do benigno e maior ocorrência em jovens. Nível de Evidência IV, Série de Casos.

Tumor limítrofe del ovario: revisión de un viejo conocido con nuevas propuestas terapéuticas / Ovarian borderline tumor: Review of an old acquaintance with new therapeutic proposals

Resumen ANTECEDENTES: Las pacientes con un tumor limítrofe del ovario pueden tratarse conservadoramente en etapas tempranas y con ello conseguir una supervivencia considerable. Las etapas avanzadas tienen un periodo libre de enfermedad prolongado, algunas con crecimiento de implantes peritoneales y recaída posterior a 10 años del tratamiento. OBJETIVO: Conocer cuál es el pronóstico de las pacientes con un tumor limítrofe del ovario, y su tratamiento en México y otros países. MÉTODOLOGÍA: Revisión sistemática de ensayos clínicos recientes registrados en las bases de datos de PubMed, Embase y Cochrane de artículos publicados en inglés y en español entre los años 2006 y 2021. Además, una revisión analítica de la experiencia acumulada en 10 años en la atención de pacientes con tumor limítrofe del ovario atendidas en la Unidad Médica de Alta Especialidad de Oncología del Centro Médico Nacional siglo XXI del Instituto Mexicano del Seguro Social, en la Ciudad de México y otros centros médicos de la República Mexicana. RESULTADOS: Se encontraron 62 artículos relacionados con los términos de búsqueda; de éstos, se descartaron 11 porque no eran artículos originales solo de tumores limítrofes del ovario y 4 porque el texto completo estaba escrito en idiomas diferentes al inglés y español. Uno más se eliminó porque sus conclusiones diferían del objetivo planteado y su sustento se consideró endeble. Al final se analizaron 41 artículos. CONCLUSIONES: Las posibilidades de atención quirúrgica de pacientes con tumor limítrofe del ovario, con preservación de la fertilidad, son altas pues su recurrencia es baja. Los tumores microinvasores mucinosos, con permeación vascular y linfática, tendrán mayor posibilidad de recaída a largo plazo. En general, su pronóstico de supervivencia, en cada etapa, es alto. La linfadenectomía retroperitoneal no está indicada en etapas tempranas de la enfermedad.

Abstract BACKGROUND: Patients with borderline ovarian tumor can be treated conservatively in early stages and thereby achieve considerable survival. Advanced stages have a prolonged disease-free period, some with peritoneal implant growth and relapse after 10 years of treatment. OBJECTIVE: To know the prognosis of patients with borderline ovarian tumor and its treatment in Mexico and other countries. METHODOLOGY: Systematic review of recent clinical trials registered in PubMed, Embase and Cochrane databases of articles published in English and Spanish between 2006 and 2021. In addition, an analytical review of the experience accumulated in 10 years in the care of patients with borderline ovarian tumor attended at the Oncology High Specialty Medical Unit of the XXI Century National Medical Center of the Mexican Social Security Institute, in Mexico City and other medical centers in the Mexican Republic. RESULTS: We found 62 articles related to the search terms; of these, 11 were discarded because they were not original articles only on ovarian borderline tumors and 4 because the full text was written in languages other than English and Spanish. One more was eliminated because its conclusions differed from the stated objective and its support was considered weak. In the end, 41 articles were analyzed. CONCLUSIONS: The chances of surgical care of patients with ovarian borderline tumor, with fertility preservation, are high because its recurrence is low. Mucinous microinvasive tumors, with vascular and lymphatic permeation, will have a higher chance of long-term relapse. In general, their prognosis for survival, at each stage, is high. Retroperitoneal lymphadenectomy is not indicated in early stages of the disease.

Epidemiological features of meningiomas: a single Brazilian center's experience with 993 cases / Características epidemiológicas de meningiomas: experiência de um centro único brasileiro com 993 casos

ABSTRACT Background: Meningiomas are the most frequent primary central nervous system (CNS) tumors. Their geographical and ethnic characteristics need to be known, in order to enable rational treatment. Objective: To investigate clinical and epidemiological aspects in a series of patients with meningiomas. Methods: Retrospective analysis on the demographic profile, location and histopathology of 993 patients with meningiomas (768 operated and 225 not operated). Results: Meningiomas represented 43.8% of the primary CNS tumors; 6.8% were multiple tumors (14.7% with neurofibromatosis 2) and 0.6% were radiation-induced tumors. The mean ages were 53.0 and 63.9 years for operated and non-operated patients and the female/male ratios were 3.2:1 and 6.3:1. Diagnosis was made later among females. The peak incidences were in the 6th and 7th decades respectively for operated and non-operated patients. The incidence was low at early ages and higher among patients aged 70+ years. The meningiomas were intracranial in 96.5% and most were WHO grade I (88.9%) and transitional. In the spinal canal (3.5%), they occurred mainly in the dorsal region (all grade I; mostly transitional). The racial distribution was 1.0% in Asian-Brazilians, 87% in Caucasians and 12% in African-Brazilians. 83.4% and 51.6% of the patients were estimated to be recurrence-free at 10 and 20 years, and the mortality rate was 3%. Conclusions: Most of the demographic data were similar to what has been observed in other western centers. Differences were higher incidence of meningiomas, female and older predominance in non-operated patients, predominance in Caucasian, and higher association with neurofibromatosis 2.

RESUMO Antecedentes: Meningiomas são os tumores mais frequentes do sistema nervoso central (SNC). Suas características étnicas e geográficas precisam ser conhecidas para o seu tratamento racional. Objetivo: Investigar aspectos clínicos e epidemiológicos de uma série de pacientes com meningiomas. Métodos: Análise retrospectiva demográfica de 993 pacientes com meningiomas (768 operados e 225 tratados conservadoramente) Resultados: Meningiomas constituíram 43.8% dos tumores primários do SNC. 0.8% deles eram múltiplos (14,7% com neurofibromatose 2) e 0,6% eram radioinduzidos. A idade média e o índice mulheres/homens foram respectivamente 53,0 e 63,9 anos e 3.2:1 e 6.3:1 para pacientes operados e não operados. O diagnóstico foi mais tardio em mulheres. Ocorreram picos de incidências na 6ª e na 7ª décadas respectivamente para pacientes operados e não operados. A incidência foi menor na infância e maior após 70 anos. Meningiomas predominaram no crânio (96.5%), a maioria grau I da OMS, subtipo transicional. Do total, 3.5% ocorreram no canal raquídeo, principalmente na região torácica, todos grau I, a maioria transicional. Em relação à distribuição racial, 1.0% dos meningiomas ocorreu em amarelos, 87% em brancos e 12% em negros. As taxas de sobrevida sem recorrência foram 83.4% e 51.6% em 10 e 20 anos e a mortalidade operatória foi 3%. Conclusões: A maioria dos dados demográficos observados foi similar aos de outros centros ocidentais. As diferenças observadas foram maior incidência, predominância em mulheres e idosos nos pacientes não operados e em caucasianos, e maior associação com neurofibromatose 2.

Impacto del fenómeno de migración de estadio ganglionar en la supervivencia y la recurrencia de pacientes con cáncer papilar de tiroides sometidos a vaciamiento ganglionar profiláctico / Impact of the node-stage migration phenomenon on survival and recurrence of patients with papillary thyroid cancer who underwent prophylactic lymphnode dissection

Introducción. Dado que un ensayo clínico aleatorio es irrealizable, el rol del vaciamiento ganglionar profiláctico en pacientes con cáncer papilar de tiroides sin comprobación clínica de compromiso ganglionar metastásico (cN0) es controversial. El vaciamiento ganglionar profiláctico acarrea un proceso de reclasificación de pacientes, al hacer evidente la positividad ganglionar micrometastásica antes ignorada, lo que genera una aparente pero falsa mejoría en los desenlaces de los grupos de estadificación, mientras el pronóstico individual y total de la población no cambia, fenómeno conocido como migración de estadio o fenómeno de Will Rogers. Métodos. Se ejecutaron simulaciones de poblaciones con cáncer papilar de tiroides con compromiso ganglionar metastásico clínicamente evidente (cN+) y cN0, para determinar el impacto del fenómeno de migración de estadio en los pacientes sometidos a vaciamiento ganglionar profiláctico. Resultados. Con la simulación de las poblaciones y sus estadios ganglionares, se observa cómo la migración de estadio ganglionar genera una aparente mejoría en los desenlaces de recurrencia loco regional y supervivencia, sin cambiar los desenlaces de la población total ni individuales. Discusión. El fenómeno de migración de estadio es uno de los sesgos más importantes que limitan el uso de grupos históricos de control en ensayos de tratamiento experimental. De acuerdo con nuestros resultados, este fenómeno podría explicar los beneficios observados con el vaciamiento ganglionar profiláctico en algunos de los estudios agregativos publicados hasta el momento, hallazgos que no han sido documentados para el cáncer papilar de tiroides

Introduction. The role of prophylactic central lymph node dissection at the time of total thyroidectomy remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma. Moreover, a prospective randomized controlled trial of prophylactic central lymph node dissection in cN0 RCT is not readily feasible. Methods. In this study we simulated cN0 and clinically node-positive (cN+) populations, to evaluate impact of nodal stage migration in papillary thyroid carcinoma patients that undergo prophylactic central neck dissection. We use simulations of population and nodal stages .Results. Nodal stage migration phenomenon seems to have an improvement in locoregional recurrence and overall survival of cN0 and cN+ populations, without changes in overall population and individual outcomes.Discussion. Nodal stage migration is recognized as an important bias that precludes the use of historical controls groups in experimental treatment trials. In accordance to our findings, this phenomenon could explain the improvements observed in outcomes in patients that undergo prophylactic central neck dissection