Oh, I hit the... Okay. So, guys, this is a quick lesson about the initial colorectal cancer treatment. So, stage 1 and stage 2 to 1. We'll talk a little bit more about that later. So, these are tumors up to 4 cm, so up to a B2, actually 2 to 1. And it invades the vagina, but it's less than 4 cm. I like to start with clinical cases that we record more. I want to know, if possible, about Celso, what he would do. So, a 58-year-old patient, totally asymptomatic, did a pap test that showed a high-degree trepidylal injury, but that cannot be removed by invasion. Celso, what would you do? A one-minute answer. Cold cone. Cold cone. Cold cone already? And no colposcopy? Oh, I see. No, I don't want feedback. The only information you have is really from an altered pap test. I would do colposcopy and... depending on the injury, I would do a liposuction or I would do a fusion. Okay, let's go. So, remember that colposcopy, you biopsy what you see as altered. In some situations, you may be talking about the protocols of seeing and treating. So, we don't expect any results, and depending on what you see, you choose to do the treatment, which in this case is conization. But usually, in an ideal situation, and I think that in the central hospital of Maputo you can do it that way, is to do a biopsy guided by colposcopy, not to go for a conization. Okay? Right? Do you agree? Yes. And Celso, do you agree? I agree. Yes, yes. Okay. Well, this same patient, then, in colposcopy, they thought it was a high-degree injury, but in the lip biopsy, there was an invasive carcinoma epidermoid. So, what would you do? I believe that the injury is a colposcopic injury. I would like to consider it a first-degree injury, and I would like to consider it a candidate patient for surgery. Which stage is it? Is it an A1, an A2, a B1, a B2? First, the pathological anatomy. The pathological anatomy? Yes. I understood what you said. It's the answer that most people answer. So, she already has an invasive carcinoma epidermoid, I'm going to take this patient for a sterectomy. That's what was considered, right? I understand, right? Come on, guys, interact. Celso, do you agree? Yes. I agree. Okay. I understood, right? Come on, guys, interact. Yes. That's what you think. However, then, observe. I can't say that this patient has a macroscopic injury, because the injury that was seen in the colposcopy, they think it was just a high-degree injury. So, in this patient, I have to do a stadiating conization. Right? So, let's remember Figo's new stadiating. 1 to 1, the injury is less than 3 millimeters. 1 to 2, the injury is more than 3 millimeters and less than 5 millimeters. When we're talking about millimeters, the only way we can say that is in a pathological anatomy piece, which, in this case, is the conization. So, not always, when we have a cancer diagnosis, colocterin cancer invasive, we go straight to the sterectomy. You have to take the first treatment step, the first treatment reasoning in oncology, know the correct stadiating. In the case of uterine colo, when there is a microscopic injury, the only way is to do the decisional biopsy of this injury, which, in this case, is with the conization. Did you understand? Do you agree? I understood. So, remembering that the change in Figo's stadiating, so you have to be careful with old books, the lateral extension is no longer used, only the 3 and 5 millimeters of stroma invasion, and 1B is now divided into three. 1B1 up to 2 centimeters, 1B2 between 2 and 4, and 1B3 above 4 centimeters. 1B3 we no longer consider initial, consider already a locally advanced, which is a very large tumor. And 2 was finally made official in 2A1, 2A2. For 2A1, which is when he takes that beginning of the vagina, and with less than 4 centimeters still considered an initial tumor. These are the other changes. So, let's go to the treatment. So, in the initial tumors, so, as we said, stadium 1 to 1B2, so tumors with less than 4 centimeters, or 2A1, the treatment ... Oh, I already put it here. What is the treatment, guys? Anyone can answer. Preferably the second. Is it the only alternative? No. Which is the second? I'll tell you so we don't delay. It's radiotherapy, okay? So, the initial tumors, so stadium up to 1B2 and 2A1, we can choose surgery or radiotherapy. So, radiotherapy is an alternative, in the same way that it is an alternative in advanced tumors. And do you think that the chance of cure of this patient, when we do surgery, is the same chance of cure when we do radiotherapy? I will also advance. So, we have this work, this is a work from 1997, from an Italian called Landone, sorry, I didn't put the reference, but I'll send it to you. So, it's a randomized, he took patients with the initial tumor, and randomized, a part went to radical stereotomy, with pelvic lymphadenectomy, and the other part went to exclusive radiotherapy. And what do we see here in the survival curves? The same. So, even in the initial stages, we have these two alternatives, which is radiotherapy or surgery. When do we decide one or the other? Do you want to ask something? No. So, the toxins are, in oncological terms, the same. We treat the same, we give the same chance of cure to this patient. What changes are the toxicities. So, now you started to have radiotherapy, I don't know if you've had time to attend patients with some toxicity of radiotherapy. Of surgery, you already know. So, we have a lot of morbidity in the intra and postoperative stage. So, bleeding, decency, blah, blah, blah. But also changes, dysfunctions, related to the nervous injury that sometimes we do, commit, in surgery. I'll talk about that later. So, the patient can have some, the most common are vesical dysfunctions, so urinary dysfunction. So, the patient has some degree of neurogenic bladder, making it difficult to completely empty the bladder, with vesico-ureteral reflux, eventually evolving even to renal insufficiency. Or with lesion, with ureteral stenosis, with need for approach, catheterization, So, these are the surgical morbidities that you are already used to. We also have to remember that there is sexual morbidity. So, sometimes we can injure the nerve and this patient has anorgasmia. And sometimes even intestinal dysfunction morbidity, the patient has constipation. Everything related to the nervous injury of the lower hypogastric plexus, the spleen, the pelvic plexus in general. In radiotherapy, Ricardina, Adécio, Ciro, have seen a lot here in Brazil. We are going to have a lot of late toxicity morbidity. So, of actinic alterations, which we say is the term when it is caused by radiotherapy. So, inflammation of the mucosa, both of the vagina, of the bladder and of the rectum. So, vaginal mucositis, cystitis actinica, retitis, enteritis, colitis actinica. Some very serious. So, the patient may have an important hematoma, hematoxia, intestinal perforation. All of this will depend on the type of device, if it is a 3D, and the planning, the technician, the physician of the radiotherapy to be able to calculate the right dose in the tumor and minimize the lateral dose. So, we have, we who do surgery, we always have that idea. Initial colorectal cancer, always surgery. But radiotherapy is an option. So, when do we decide, knowing these toxicities, these morbidities? Most of the patients we prefer surgery, but if you have a patient with some complication, some surgical contraindication, like a serious cardiopathy, some serious comorbidity, a very old patient, we can opt for radiotherapy for these patients. So, remembering that radiotherapy in colo-diutera is divided into teletherapy and brachytherapy. So, I know you don't have brachytherapy. This is something we have to consider. In the beginning, many times you get the control of the disease only with teletherapy, which is external radiotherapy, but the planning, what is known in colo-diutera is that brachytherapy is a fundamental part of this treatment. You can put a dose of radiotherapy directly in the tumor. And brachytherapy, we have some ways to do it, there is the ovoid, but in general we use this applicator and it has to go through the internal hole and then it applies the radiotherapy directly here in the uterus. It's something I've already thought about, it's something we have to consider in the patients you treat with radiotherapy, if not having brachytherapy, if we can consider this patient treated or if it would have to do something else. So it's an important thing for you to think about. Celso, I know you've been in some radical stereotomies, so you know the difference. Basically, in simple, the correct one is the extrafacial, so intrafacial is not acceptable for colo-diutera cancer, even if it's 1 to 1. So we go back to the colon in a radical way, where you take out the parameter, which is another class for us to talk about the surgical techniques. So today we divide the parameter into lateral, anterior and posterior parameters, and we will have the stereotomy classifications based on that. So here is a drawing, the patient's foot is here, the head is here, being pulled to the left side, here the patient's right side. So here the urethra is being pulled too, and here we have the lateral parameter, the posterior parameter and the anterior parameter. And here the vascular spaces, which when we develop and open during surgery, we can isolate, identify the parameters and the nerves and do our surgery. So, as you know, it's a complex surgery, and in terms of morbidity, the main risk of this surgery, morbidity in the long run, is that we inject these nerves. The lower hypogastric nerve, the splenic muscles, the vesicle branch of the pelvic plexus. When we inject these structures, this patient, as I mentioned, will have these dysfunctions. These nerves we see here in the drawing, the hypogastric, in general, we inject it when we are developing the posterior parameter and doing the urethra tunneling. The splenic, when we are cutting the lateral parameter, and the vesicle branch, when we are cutting the anterior parameter. And in surgical techniques, we always have to consider the position of these nerves so that we can do this surgery with less morbidity. This is when we did radical stereotomy surgery per video. You know, but just showing a little of the video, of the complexity. I show this to the patients, because sometimes they say, taking a little piece of paper around the uterus seems to be a simple thing. The problem is the things that go through the parameter. Here I made a pass, otherwise we'll be late. The problem is the things that go through the parameter and the situation, and we can't injure and this patient doesn't have these risks. And that's why, because of these complications and morbidity of parametrectomy, one of the tendencies in uterine colorectal cancer is to question whether parametrectomy is always necessary. This is an article by Dr. Catherine Schmiller, in which she made a very important review. Look at the number of patients, more than 1,000 patients, in which it was evaluated retrospectively which patients actually had the risk of parametric invasion. And what did they see? Small tumors, less than 2 centimeters, with a superficial stromal invasion, that tumor that is not very infiltrating, less than 1 centimeter, or less than 50% of the thickness of the uterus, with negative lymph nodes, the chance of parametric commitment is less than 1%. In fact, most of the articles she reviewed were zero. Some of them took this number to less than 1%. And so, taking into account the morbidity, it has been considered whether we really need to do this surgery. These reviews led to some paradigm changes in treatment. From 1 to 2, tumors with less than 5 millimeters, we generally did parametrectomy on all patients. So, radical sterectomy. But the NCCN, which is the guideline that Americans use, has already authorized, in 1 to 2 stages, tumors with less than 5 millimeters. In patients who want to preserve, we do parametrectomy, that is, without ultrafacial. But always, always with a lymph node evaluation. I will say this. In 1 to 1, there is a need to do parametrectomy. And the guidelines of ESGO, of the European Society, also authorize in 1 to 2 diseases, that is, with less than 5 millimeters, to omit parametrectomy. So, conization or simple sterectomy, with parametric resection without indication, but always with a lymph node evaluation. So, just to remind you, Dr. Kathleen has already presented this, but I will show the results of her study, which is the CONSERVE, which evaluated precisely these low-risk patients if we needed to do parametrectomy. Let's go to the results. So, what did they see? That 5% of the patients had a positive lymph node. This is a considerable number, which justifies us always doing a lymph node evaluation in these patients. So you can't omit, even in these low-risk patients, a lymph node evaluation. And the low recidivism rate, when parametrectomy was not done, with the exception of those unfunny sterectomies that we all take, unfortunately. For the patient who has a NIC-3, and the person has already gone to a sterectomy and then came a cancer, or a patient who went for any benign indication and came a cancer. The chance of these patients recidivizing is very high, 12%. Therefore, it is important to always remember not to skip steps. If you have a NIC-3, do the conization before any consideration of removing this other one from these patients. Here are the obstetrical results in relation to the patients who only did the conization. And what she concluded is that omitting is feasible, but it is an initial study with only 100 patients, and more studies must be done before we consider this. But considering that we are taking risk-benefit in some situations, the difficulty of training in radical sterectomy, the fact that not all doctors are able to perform this surgery, and in specific situations, such as in some places in Mozambique, I'm not saying it's right, but it can be considered, in these small tumors, to do a sterectomy. Omitting the parametrectomy, doing an extrafacial sterectomy, always with a lymph nodal evaluation. The standard is still radical sterectomy, this has to be very clear, but it is important for you to see these tendencies of change of conduct, for you to follow up, and in selected cases, in complex situations where radical surgery is not feasible, consider this, instead of simply not treating the patient. So, the treatment, when it is surgical, remembering that radiotherapy is an alternative, so when it is surgical, and 1 to 1, without lymph nodal evaluation, which is conization or simple sterectomy, 1 to 1 with lymph invasion, or 1 to 2. We are authorized, both by the NCCN and by ESBO, to do the omitting of parametrectomy with simple sterectomy. It can still be done radically, it is a traditional situation, and what many people do is not wrong, especially if it is a surgery enabled with a low complication rate, but always with a lymph nodal evaluation. This can be sentinella or systematic lymphadenectomy. 1 to 1, radical sterectomy with lymph nodal evaluation, and in the future, and in highly selected cases, as we just mentioned, and in complex and individualized situations, omitting parametrectomy. And 1 to 2, radical sterectomy with systematic lymphadenectomy, in all cases. Okay. Thank you. I spent three minutes.

initial treatment

colorectal cancer

stages

treatment options

clinical cases

colposcopy