Perfect. Okay, guys, it's a complex topic, Ricardina and Andressa know it, and eventually you have these patients with endometriosis, right? You will sometimes hear Heitor here talking, okay, guys? Anyway, I'll try to talk a little about lymphadenectomy, but about sentinel lymph nodes, okay? For the Fellows 1, it's a bit of a complex subject, you'll have to study it later, but anyway, here. Let's start with the concepts then, right? You will hear us talk a lot about this, that there is stadiated lymphadenectomy, which are patients who have no suspected lymph nodes. You did the attack, did the resonance, and there is no increased lymph node, or with a change in signal, something like that, and there is the lymphadenectomy rebuking, or cytoreductor, which is the patient who has that lymph node clearly compromised, in the shape of a potato, as André Lopes says, which is the technical term, I'm kidding, and that you have to go there and remove that increased lymph node, and then it's the same principle, it's the same reasoning that we have for ovarian, which is to remove the macroscopic disease, okay? So it's important that you have these two sentences, these two concepts, which are totally different things, when we're talking about lymphadenectomy, in fact, in any neoplasm, in any chronic, okay? I'm going to the mouse. And I sent this to Susan now, Paul, but this one she didn't have time to do it, but let's think about a clinical case. The 61-year-old patient, obese, with an MC of 37, she did a curettage... Ah, Susan did it! Thank you, Susan! That came an adenocarcinoma endometrioide, degree 2, and in the resonance, there was an invasion of more than 50% of the myometer, without suspected lymph nodes. I want to know what you would do as a conduct. Option 1, sterectomy with bilateral salpingoforectomy, Option 2, sterectomy with bilateral salpingoforectomy and pelvic lymphadenectomy. The people in Brazil will be agonized when they hear this, agonized by not having the answer they want, but it's on purpose. Sterectomy with bilateral salpingoforectomy and pelvic lymphadenectomy, or option 4, very obese patient, let's move her to radiotherapy with chemotherapy. Please answer, I'm showing here and no one answered. I can't get it out of my face, it came out here now, let's see. If you load the box up there, it comes out in front of you, Gê. You can load the box from the top, and then close it when you want on the little red button. The mouse is gone, but it's okay. Well, from the top, you can load the box, and then close it when you want on the little red button. The mouse is gone, but it's okay. Well, there are answers there. So, most people think they have to do sterectomy with bilateral salpingoforectomy and pelvic lymphadenectomy, not paraortic. The minority also thinks they have to do paraortic. No one said they are satisfied only with sterectomy or move the patient to radiotherapy. Great. Do you want me to launch again? No, that's fine. Now, the next one, please, Luana. Now, guys, why do we do lymphadenectomy in patients... I heard, DS, it's great. But why do we do lymphadenectomy in patients who have no suspected lymph nodes? The goal is staging, so knowing how far this tumor has gone. It's therapeutic, so by removing the lymph nodes, I'm increasing the chance of this patient surviving, so being cured of cancer. Both things, I want to know how far the tumor has gone, but I want... I know, I think that when I remove the non-suspected lymph node, I'm increasing the chance of her being cured, or D, I don't know. Half think it's just staging, so it's just knowing how far the tumor has gone, but the other half thinks it also has a therapeutic role, so it would also increase the chance of this patient being cured. Okay, let's go then. I don't know if I can... I can't get it out of my face, funny, my mouse is not showing up, but okay. Let's go. So, what do we have to work with? You have to get used to it, that the classes we're going to show are always based on literature, not in our experience, it's what's in the publication, okay? So, what is important? That what, until a few years ago, there were only retrospective works, which said like this, we took all the patients who had lymphadenectomies, who didn't, in the past, and we saw that those who had lymphadenectomies lived longer. What's the problem? Retrospective work. There are a lot of things that may be involved, and not just lymphadenectomy. The main thing, the person who operated and had lymphadenectomy, is probably a better surgeon than the person who didn't have lymphadenectomy. And we know that the quality of surgery is something that has a lot of impact on the survival of these patients. So, just with retrospective work, we couldn't answer. But an interesting thing is that many surgeons just took one or the other ball there. Ah, I'm going to take these three lymph nodes here, which are a little bit increased, which is good, because then I don't need to take them all, which greatly increases the risk of surgery. They saw that it's no use, that just taking one or the other is almost the same as not doing anything. So, just doing the sample is not an acceptable alternative to do the lymph nodal evaluation, okay? And you will hear a lot in this talk that the staging of endometriosis is surgical. Because, precisely because of these works that showed, we need to know how far this lymph node went, and showed that there was someone surviving. And then, finally, a randomization came, it's important, we want, our expectation here, in this talk of yours, is that you have a sense of research, and levels of evidence, what is a good quality research that really changes conduct, what is a research that doesn't change much conduct, at most it generates hypotheses. And, supposedly, a randomized prospective study, it is to change conduct, it is to answer things to us. And there is this Aztec who is much talked about in congresses, he did, he staged, so he took a patient, supposedly stage 1 of endometriosis, and staged, for stereoectomy, with sopingoforectomy, and randomized, sorry. Half of the people did only stereoectomy and sopingoforectomy, and half did a pelvic endometriosis, okay? And he showed that it made no difference, that it's all the same, it's the same for both patients, for both groups. And he said, wow, so are we doing this endometriosis for nothing? Those works that showed that increased survival, was everything wrong? What's the problem? There were two randomizations, besides evaluating the role of endometriosis, in this work they also randomized to do radiotherapy or not. And there were a lot of protocol breaks, most of the patients were very low risk, and in the end it was like this, I don't know if the patients had an equal outcome, because it was lymphadenectomy, or if it was because of radiotherapy, as there were two interventions, it was not possible to respond, and besides that, it was a selection of very low-risk patients. And then, in short, it was useless. Poor authors, but no one changed conduct because of this work, okay? And what do we have to remember? That lymphadenectomy has risks. It has risks both in the intraoperative, you know, but also post-operative. That's what we've talked about the most. In this work, it showed 6% of nerve injury, 3% of lymphocele infected, with the need for intervention, 7% of patients with lymphedema, so you get that swollen leg, with difficulty. And then, that previous work was the doctor who asked, are you with a swollen leg? Let me see. And then there is this work in which the patient responded, they sent a questionnaire to the patient, and she answered, if she swollen leg, if she swollen when she exercised, if she swollen when it was hot, and look how this number has increased, 41% of patients reported some degree of post-surgical edema. Showing how we doctors don't always ask, in fact, in a detailed way to patients their complaints. So we have that other difficulty, which is the endometrial cancer patient is an obese patient, which has a much greater surgical difficulty. Here, just to show that even these obese patients, we can do it minimally invasive, and with Trendelenburg, that it is possible to do the surgery, I'm seeing it on my cell phone too, I'm seeing that it's delayed. But anyway, even obese patients it is possible to do it minimally invasive, I know that you will start to have material later on, and it is not a reality today, but it is a reality of the future, if you fight for improvements, right? Funny, there's a strong delay here. It's because I'm seeing it on my cell phone and on my computer. Now it's gone. Let me scroll through all this. And then the question, so do we really need to do the conodal evaluation in endometrial cancer patients? Since the vast majority of patients have the diagnosis already in stage 1, the initial one, the answer is yes. So, when we do the conodal evaluation, we find out if this patient has a neoplasia outside the uterus, and we treat this patient differently. Here the data from the American Data Bank, which is a lot of patients, and those who did, in fact, the lymphadenectomy, had a survival rate, and that at the cost of what? Look down here, what are each of these curves? The type of treatment that these patients did later. So, the patients who didn't do anything, which is the last curve down there, after the diagnosis of a conodal metastasis, lived much, much worse than the patients who did chemotherapy and radiotherapy. So, ok, we have to do it, because when we find out, we indicate an additional treatment. But what are we going to do? This has already been tried to do through these risk factors. Today it says low risk, intermediate risk, high intermediate risk, high risk, which is very confusing and difficult to reproduce, most people don't obey. Then there was a low, high risk question, low risk, doesn't do anything, there is myometrial invasion, over 50%, already does paraortic, which then started to overoperate many patients. Then they tried to do it with the evaluation of pre-operative exams, and saw that pre-operative exams fail too, and they also tried with intraoperative evaluation, which is with the exam, the congelation that we talk about here, which is extemporaneous, you talk about it there, and it also has some discrepancy. And the solution, as Dersia has already mentioned, is sentinel lymphoma, ok? So, sentinel lymphoma, as we do, we increase, decrease the surgical time, and decrease the morbidity. I'll talk 8 more minutes, ok, Susan? So, it won't be a problem for your next meeting. Yes. But what is most interesting in sentinel lymphoma is that even if you take only one lymphoma, you do more metastatic diagnosis. That's the coolest thing. What decreases morbidity is kind of obvious, right? That we are doing a minor surgery, but in fact we are doing more diagnosis. And what are the costs? And that's why you need a pathologist engaged and updated with each area of ​​his performance. Gustavo, for example, is very focused on gynecology. I know that this is not yet a reality in Mozambique, but when they increase the pathologists, it is possible that they specialize in each type of pathology, in each sub-area, at least, to increase the quality. It's like us, I always say this about pathologists, I don't know if Gustavo is there, but put me to treat a rheumatological disease. I'm not going to treat it well. No one can specialize in all areas of the body, in all diseases. This goes to our pathologist. The pathologist who is specialized in an area, he can offer a cure for better results. But what is the other staging that we do in Sentinel? We take the lymph node and make several additional cuts, several. And besides that, it does a chemical immunosuppression. How is the normal evaluation of a lymph node? It usually cuts in half, some services even make some additional cuts, but when we send that paraortic pelvic, which sometimes has 50 lymph nodes, you can't make millions of additional cuts with 50 lymph nodes. This will generate 500 blades, and there is no time or money to do this. Not even in services, not even in the United States, this is possible. So you send a lymph node that has a higher risk of having metastases and the pathologist is thrilled to make several cuts, and when available, which I also know is not possible sometimes, a chemical immunosuppression to do the diagnosis. And that's why we're increasing the diagnosis. We send the right lymph node and the pathologist does a much more dedicated job. A question that sometimes arises, it's not there yet, but it will be soon, but now that there is PET-CT, do I really need to remove the lymph node? If the PET is negative, can't I trust that this patient has no positive lymph node? And the answer is no. PET's accuracy is lower than the accuracy of the sentinel's lymph node. So a negative PET does not exclude the need to do lymphadenectomy. And look what's interesting about the sentinel. Even low-risk patients, patients with a well-differentiated tumor, with superficial myometrial leakage, we are doing more metastatic and phonodal diagnosis, thanks to the sentinel's lymph node, and in a much higher number than we imagined before. So this low-risk issue is being questioned a little by the sentinel, because we are seeing that the number of metastatic and phonodal is higher than the historical series showed, precisely because the sentinel makes us do a lot more diagnosis. I'll just go through it quickly here, but I'll just show you that there are many works, we got this information that it is a safe way to do lymph nodal stagnation, because these works showed a high accuracy. How did they do it? They did the sentinel, then they did the systematic, and they saw that the false negative rate, that is, the sentinel being negative, in fact, not having any lymph node, was compatible. So a false negative is acceptable. We come to this conclusion through these works. How to do it? We inject it in the uterus collar, so even in endometrial cancer, we inject it in the uterus collar. Usually, today, we inject at 3 and 9 o'clock. Usually, most people do a superficial and a deep injection, some centers are doing only superficial, but the most common is this one, it does a superficial, which is 1 to 3 millimeters of blue, in this case we are doing the patent blue, there is the inducealine green, but even here in Brazil there are few implants that have it, but with the patent blue it is possible to do it, you have it available there, ok? I'll move on here. And then comes the question, but people, but the tumor is in the endometrium, why are you injecting it in the neck, right? And even more so, most endometrial tumors are in the bottom of the uterus. And this doubt comes from the fact that we have two forms of lymphatic drainage, of the uterus, the main one is the parametrial, which is where the injection of the neck would take, but it also has the drainage of the fungus, so by the ovarians, right? And there is this meta-analysis that showed that when you do it on the neck, the chance of you detecting it in the endometrium is much greater, but there is also this very interesting work of MD Anderson, an institution that Mila and Ellen are in, what did they do? They took only the tumors that we are most afraid of letting pass, the very high risk, so deep endometrial invasion or unfavorable histology, and they did lymphadenectomy, the Sentinel, and did lymphadenectomy, pelvic, parahortic, in all patients, all. And what did they see? A high sensitivity, a very high negative predictive value, 98%, and there were, in fact, two positive false cases, but it was in the pelvic, it was not in the parahortic region. Which gives us a lot of peace of mind to keep the injection in the neck. And then the concern, okay, but what about the oncological safety, the survival of these patients? Are the patients doing only Sentinel? Do they live the same as those who do systemic lymphadenectomy? I have one more minute, guys. And the answer, for retrospective studies, is yes, it seems so. This series that... The patients who did only Sentinel, a very large number, those who did systematic, lived the same, okay? And the main societies agree with this technique. Let me put... I put the wrong class, wait a minute. I'll put it forward here, look. Should I stop doing lymphadenectomy in all patients? So, remembering that it is only acceptable when the detection is bilateral, so I have to find the neurons on both sides. The detection rate with blue, it is not so high, so you will not find the Sentinel in 100% of patients. It is mandatory to do a thorough evaluation of these lymph nodes, so the pathologist has to be aware of the Sentinel protocol, and there is the learning curve. So I don't want you, from tomorrow, to do lymphadenectomy on anyone else. Look, the literature says that the learning curve is long, there are up to 30 cases for you to stop doing lymphadenectomy and start doing the Sentinel, okay? So, the conclusion is that the Sentinel lymph node research has high sensitivity, with detection rates of lymph nodal metastases greater than conventional lymphadenectomy, but with some limitations, which is the long learning curve that you have to reach, and in patients that you have not been able to detect bilaterally, you will have to do lymphadenectomy, at least on one side, and that the pathologist has to do the 3-stage. That's it. So, we could do Sentinel, and then separate the Sentinel lymph node and then do a systemic one to win this curve. Great! This is very good, and even for you to know, you are being very false negative. But that's it, for you to get to the curve, you do the Sentinel and do the systematic one later. That's right. I think we're running out of time so as not to disturb Susan's meeting later. We could... Let me stop sharing. Take a class, Jorge. Thank you. Thank you.

lymphadenectomy

endometriosis

staging

therapeutic

sentinel lymph nodes

metastases