The idea is to talk a little about surgery in cancer of the endometrium. There are many topics to be discussed in this scenario. The idea is to go over it, but depending on your request, we can go a little deeper. These are the two institutions that I work in, in the private and public sector. These are the numbers of endometrial cancer in our country, in Brazil. I don't know how the endometrial cancer data are in Mozambique, I have no idea. If you could share with me, I would be very satisfied. But it is a disease that has a great predilection for obesity. We see the predominance of this disease in regions where obesity is more frequent, even in regions where the ethnic aspects are very different. In the southern region of Brazil, there is a higher incidence of the disease. These are populations of Italian and German origin, completely different from the northern regions of our country, which are predominantly of Portuguese and indigenous influence, and black too. What we find similar in these populations is basically obesity and an increase in life expectancy. In the United States, this is a big problem. Mila is there, so I see it up close. This problem represents the highest incidence of gynecological cancer in their country. And what do we expect? The expectation is not only an increase in the number of cases, but also an increase in the number of deaths related to this disease. We will talk a little about this path of surgery in endometrial cancer. In Brazil, there is already an expectation of a significant increase in the number of cases. And we have two important tools to investigate these patients. The vast majority of patients with endometrial cancer show bleeding in postmenopausal, or irregular bleeding. The clinical treatment in patients with perimenopausal or postmenopausal bleeding is reflected. These are the tools we use to assess the extent of the disease. So, if I don't have the resonance to make a good evaluation in relation to the other, but I know you have the ultrasonography, the well-done ultrasound, which is part of the practice of the gynecologist, to assess the extent of the disease within the uterus, the uterine body, the uterine muscle. This assessment can be done by ultrasound. But we have the standard method for assessing the infiltration of the uterus to the magnetic resonance. Tomography is very interesting for assessing the extent of the disease at a distance, both for the gums and for the liver and chest. The best test for assessing the disease at a distance is PET-CT. It is a tomography that has the fusion of the image with a scan that can identify a radioactive element that is linked to glucose. This is called PET-CT. PET is the tomography with the emission of positron. This tomography allows us to identify places of high metabolism of the disease and that consume glucose. But even with the best tests, we believe that the best understanding of the extent of the disease is given by surgery. And what surgery do we do to diagnose cancer? We have surgery related to the uterus, and we have surgery related to the understanding of the extent of the disease. We go from steroscopies to pelvic disinfection. Steroscopy is a method that I think is very useful and relatively cheap. It can perform simple endometrial and biopsy tests, allowing the patient to be released from the hospital quickly, avoiding hospital internships, or even ambulatory biopsies. However, when you suspect endometrial cancer, a very reasonable method to make the diagnosis are ambulatory biopsies with Novak's pureta. It is a tube with a window at the maxillofacial extremity, where you can do the endometrial biopsy when you suspect clinical endometriosis, and the ultrasonography reveals an endometrial thickness greater than 5 mm, but preferably greater than 1 cm. Why is this important? Because it is no longer possible to do the intraoperative diagnosis of endometrial cancer. We must always try to do this diagnosis before treatment. Because for each type of endometrial cancer, we have a different surgical proposal. So it is not enough to say that this is an endometrial cancer. If you presented me with a case like this, I would say that this is wrong. It is important that you define properly what type of endometrial cancer it is. For this, we do a good analysis by hematopoietic insulin in histopathology, but we also do a stoichiometric and molecular test. It is a work that we did in early 2017, together with Dr. Catherine Schmeller, which evaluated the depth of the lesions and the type of lesions, corresponding to the rates of lymph node metastases. We found data similar to literature that shows that the more serious this endometrial injury is, the worse the degree of differentiation, the higher the rates of lymph node metastases. In the same way, the more advanced the disease is in the uterine body, the higher the rates of lymph node metastases. For this, it is important that you do a good evaluation, a good classification, which has been known for more than 10 years, with a classification proposed by the multidisciplinary society of European oncology, which classified endometrial tumors as low-risk, intermediate-risk, intermediate-high, high-risk, advanced metastatic. Why is that? Because based on the risk classification, this is how we will propose the treatment for this patient. In pre-cancerous lesions, called endometrial hyperplasia with atypias, it is possible to preserve fertility. It is not mandatory to remove the uterus from a young woman who has a complex hyperplasia with atypias. There is the possibility of doing a steroscopy or a cleavage, to offer hormonal treatment with medrox progesterone, DIL with levonorgestrel. It is important that you also share with us what you have of progesterone available in Mozambique and follow up every 3 or 6 months with new dilatation and cleavage. I will tell you a little story about endometrial cancer, so that you can understand where we are currently. We talk about local and regional control and always talk about lymphatic dissemination. Until the end of the last century, we had the staging of this disease as a clinical staging, where the size of the uterus was measured, the uterus was removed, radiotherapy was done and then the uterus was removed. Then came this work, the work of Frisman, which evaluated about 600 women with endometrial cancer, in the pre-initial stage, where women who only had a stereotomy with a salpingo-phorectomy versus those women who also had a lymph nodal dissection were compared. And what was found? That the lymph nodes were correlated, that is, the lymph nodes were correlated to the worst prognosis. From this study, which is called GEOG33, these patients are staged surgically. So we started taking lymph nodes from all women, since 1988 until 2004. Professor Andrés Mariani, from Mayo Clinic, United States, said, look, I really like doing endometriomy, however, some women, it is possible that we do not need to do endometriomy. So who are these women? Women with tumors less than 50% of myometrial infiltration, tumors less than 2 cm, well or moderately differentiated. So we consider this as low-risk tumors. It was the first classification that emerged as a low-risk tumor of lymph nodal metastasis, in 2004. Soon after, in 2005, Professor Andrés Mariani said that if it is to do endometriomy, so that group that I will not do endometriomy, but if it is to do endometriomy, we must do the endometriomy well done, taking a large number of lymph nodes, so about 30 lymph nodes dried up with pelvic and parietal endometriomy. In 2007, in a review by an American group, they began to classify and show that the survival of these women when they did not do endometriomy, was worse than when endometriomy was omitted. So for you to see in the graph here, this was a time when the classification was still A1B1C, this no longer exists, but always not doing endometriomy in the most serious tumors was bad. In the same way that Professor Andrés Mariani showed that in a group endometriomy could not be performed, he already said that in another group, the group of more serious tumors, it is mandatory to perform endometriomy. Let's build our thinking. Meanwhile, in the initial stages, and then in the more advanced stages, this is even worse, very similar to the study we published. So the more advanced the disease is in the endometrial body, the higher the rate of lymph node metastases. But just remember that these patients are obese, elderly, delicate, fragile, where the implementation of endometriomy systematically, that is, removing more than 33 tumors, which is what Professor Andrés Mariani showed, has unacceptable complications rates. If you operate all the patients you receive with endometrial cancer, and perform endometriomy for both skin and eye, I can tell you in advance, because we have already done this, that you will have about 18% complications related to surgical access and the procedure. It is very high. So Professor Abul Rustum, who today, in about 4 hours, will give a very interesting and available class. If you want, share the link with you. A very interesting class on lymphocytic lymph nodes. He presented this proposal as a standardization of the most important lymph node research that had to be removed, thus being able to achieve the implementation of lymphadenectomy. So this is the proposal for the reduction of the morbidity of lymphadenectomy, offering only 1, 2 or 3 lymph nodes, and that these lymph nodes are representative of the whole, that is, changing the staging of this patient from stage 1 to stage 3. Metastasis of the anus is stage 3. And then comes in 2008, the study of Dr. Benedetti Panitti, which describes that if you do lymphadenectomy in everyone, all women with endometriosis, you will not have a difference in survival, and you will have a difference in morbidity, so the good understanding of the risk factors and the classification of risk that this woman encounters is fundamental for you to define her treatment. It is not all endometrial cancer that is to remove the lymph node. So they showed that there was no impact on lymphadenectomy. So doing this lymphadenectomy, which we do on the occasion of laparoscopy, raising the aorta, raising the cava, doing this type of lymphadenectomy, more and more we do less, fortunately, it brings significant morbidity. I'll show you a little bit of anatomy, the cava, the renal vein, the aorta, the right gonadal vein. So this lymphadenectomy. So today, since 2009, that is, more than 10 years, it has already been pronounced that the staging has changed. So we will now have stage 1, when the tumor is smaller than 50%, it will be called 50% of the myometric, called 1A, larger than 50% of the myometric, called stage 1B. Stage 2, when the cervical stroma dies. Stage 3, when there is a disease in the anexes or lymph nodes, pelvic or parietal. Stage 4, when there is a metastatic infiltration, extra-abdominal infiltration or infiltration of the bladder. This study was a study that was conclusive in an English study, which showed that, in a randomized way, with a large number of participants, about 1,400 women, randomized in doing lymphadenectomy or not doing lymphadenectomy in the initial tumors, there was no difference. On the other hand, a good part of these patients had insufficient lymph nodal samples. Another criticism of this study is that patients who were randomized to not do lymphadenectomy, took some damage. So it is a study that was very important, but had its criticisms. Regarding the access route, if we cut everyone's belly, we will have complications. So, for you to see the patient who was subjected to laparoscopic surgery, a patient with a very high risk of complications, and the surgery being done with low morbidity. Doing this laparoscopic tumor is good, it is cheaper, and it is safe from an oncological point of view. So it is possible to do this treatment. This was based on evidence, in several studies, comparing laparotomy with laparoscopy. But patients who do not need to remove the ganglions, because the uterus is small, we have the experience, already reasoned, to remove the uterus through the vagina. The uterus and the ovaries through the vagina. With good conventional material, good permanent material, it is possible to do total stereotomy, with lateral salpingoforectomy, through the vagina, with a low rate of complication. When we compare the vaginal route with robotic surgery, the vaginal route is much better than robotic surgery. Just so you can think about how you can insert yourself in this environment. In 2010, a Japanese group showed that in low-risk patients, there is no interference in doing lymphadenectomy. But in high-risk patients, they have the benefit of doing lymphadenectomy, not only pelvic lymphadenectomy, but also paraortic lymphadenectomy. That is, if it is to do lymphadenectomy, we have to do pelvic lymphadenectomy and also paraortic. Several studies again show, I'm trying to put the studies in chronological order, several studies show good results with minimally invasive technique, and in 2011, 10 years ago, randomized studies appeared with the proposal of Professor Abu Rustum, which is to look for only one lymph node, as a representative lymph node of the lymph node situation of this patient. So, using a blue dye, patent blue, or even methylene blue, if you don't have patent blue, but I think you do, and when you have minimally invasive technique, it is possible to do this by looking for lymphatic drainage guided by a fluorescent dye called green endocyanin. In 2012, a study finally came out, a study that proves the ecological safety when patients are treated with minimally invasive technique. In 2012, there is an editorial saying that these minimally invasive techniques are useful in the treatment of endometriosis. A large number of women in the United States begin to be treated with minimally invasive surgery, where until 2005, 2006, before the robot, only 6% of patients were treated with minimally invasive surgery. Today, more than 90% of patients are treated with minimally invasive surgery, which is what we experience here in our environment. In advanced stages, conventional surgery is still the standard. This study shows that the lymph node is very interesting, and the rate of false negative metastases means that if I remove only two glands and leave a metastasis behind, it is very small. It is close to 3%. Only 3% of patients subjected to the search for the lymph node show recurrences of lymph nodes without having been investigated. Validating this method as an important method to reduce the morbidity of surgery. This is a study by MD Anderson, of the institution that Dr. Mila and Dr. Kathleen are part of, showing that this proposal may not only be for low-risk tumors, but also for high-risk patients. It is important to define patients with metastases versus patients without metastases. Patients with lymph node metastases need chemotherapy. Patients without lymph node metastases usually do not need chemotherapy. This distinction is extremely important. When you do not have any lymph nodal mass, the lymph node in it seems to be a very interesting strategy, especially in the low-resource location, which is where you find yourself and a good part of our country. Some recommendations from the Ethiopian group in the treatment of this disease. When the lymphadenectomy is indicated, it must be done in both the lapel and the paraortic region. This is a consensus resolution, but with a low level of evidence. This publication is from 2016 and it must change. The lymph node for the European group is experimental, for the American group it is standard. Lymphadenectomy involves complications. In low-risk patients, this level of evidence is much better. The level of evidence is 2. A force of recommendation. There is a consensus of 100% of the participants of this consensus. When you classify this patient as a low-risk tumor, remember that a low-risk patient is a tumor less than 50% of the myometrial infiltration, degree 1 and degree 2, it has no indication of doing lymphadenectomy. We can do the analysis of this tumor extension during surgery, which you call extemporaneous, which is the intraoperative congelation exam. It is possible, but it is important. I don't know if your pathologist is with us. Unfortunately, I don't think so. But there is a formal protocol on how to evaluate this infiltration, making multiple cuts at the time of surgery. So pay attention. If the colleague went there and in three minutes came back with the answer, this is an initial tumor, know that this examination was not done properly. This is a case where we diagnose micro metastases. This is a very important concept. This research of these metastases in these lymph nodes shows how you remove these lymph nodes. The evaluation is done on the microscope with hematoxylin and ozine, with cuts every 5 microns, and no metastases are identified. Wow, that's good. So there are no metastases? No. We take this material and submit the new evaluation, now with immunostochics, and try to identify with the cytokeratin, with this cytokeratin marker, if there are neoplasmic cells or not. This is the concept of micrometastases. And micrometastases are able to modify stagnation. Again, to get information from the clinic, to separate between women who need chemotherapy and those who do not need chemotherapy. And in advanced disease, then it changes the chat, we go to more radical surgery, with the reception sometimes with radical sterectomy, with bilateral salpingophorectomy, sometimes with extensive lymphadenectomy, paraortic pelvic, parameterectomies, and also eventually intestinal resections, peritoneal resections, and extensive lymphadenectomies. So the idea in the most advanced disease is to adopt extremely high radicality. Why? Because these women, unlike ovarian cancer, they do not have an exceptional response to chemotherapy. So this is important that you keep in mind. Another super important thing, it is not possible for you to accept that the patient was subjected to emergency sterectomy, with a compromised margin, and we will send her to chemotherapy. No. This patient has to return to the surgical center, do surgical amplification, to go without measurable disease, be subjected to chemotherapy treatment, and often with radiotherapy too. Sometimes with peritoneal resections. This is a case where we treated an elderly lady who had a punctual recurrence of endometrial cancer. I have already done this retaliation with you in Mozambique, where we resected the metastasis and covered the resected region with a perineal retaliation. That's what I had to tell you, a little bit about the surgical aspects in the treatment of endometrial cancer. Do you want to ask any questions? Let's see if we understand, I mean, if you understand, explain.

endometrial cancer

surgery

obesity

diagnosis

treatment

minimally invasive techniques

lymph node assessment