RESUMEN
Gastric cancer (GC) with peritoneal carcinomatosis (PC) has a particularly unfavorable prognosis. This limited survival raises doubts about which factors confer an extremely worse outcome and which patients could benefit from more aggressive treatments, in an attempt to improve survival and better control the disease. This study aimed to evaluate the survival outcomes of patients with PC due to GC and develop a prognostic score to predict 6-month mortality. We performed an analysis of clinical stage IV GC with PC. Scores were assigned to risk factors and calculated for each patient from nine variables. Among 326 IVB GC, 211 (64.7%) had PC and were included. After calculating the score, 136 (64.5%) GCs were classified as a low-risk group and 75 (35.5%) as a high-risk group. Median OS was 7.9 and 1.9 months for low- and high-risk patients (p < 0.001). In the high-risk group, 77.3% of the patients died in <6 mo (p < 0.001). Palliative surgery and chemotherapy were associated with better survival, and the prognostic groups maintained statistical significance even when the same type of treatment was performed. In conclusion, the scoring system developed with variables related to patient performance status and clinical data was able to distinguish GC with PC with a high risk of 6-month mortality. Accordingly, verifying and validating our findings in a large cohort of patients is necessary to confirm and guarantee the external validation of the results.
Asunto(s)
Neoplasias Peritoneales , Neoplasias Gástricas , Humanos , Neoplasias Gástricas/mortalidad , Neoplasias Peritoneales/mortalidad , Neoplasias Peritoneales/secundario , Masculino , Femenino , Persona de Mediana Edad , Anciano , Pronóstico , Factores de Riesgo , Adulto , Anciano de 80 o más Años , Medición de RiesgoRESUMEN
BACKGROUND: This study aims to assess and compare the extent to which preoperative chemotherapy prior to CRS improves survival in patients diagnosed with CRCPM. METHODS: We included 251 patients from 2012 to 2019 in our center. Inverse probability of treatment weighting (IPTW) analysis was used to minimize the selection bias. Survival analysis was performed to compare the survival outcomes. Multivariate Cox regression analysis was conducted to identify prognostic factors. RESULT: The baseline characteristics were well balanced using IPTW (standardized mean difference < 0.1). Preoperative chemotherapy cannot significantly improve overall survival (HR, 1.03; 95% CI 0.71-1.49; P = 0.88). In subgroup analysis, we found that intestinal obstruction after preoperative chemotherapy significantly reduced survival (HR, 2.25; 95% CI 1.01-5.03; P = 0.048), while in the upfront surgery group, intestinal obstruction had no impact on prognosis. CONCLUSION: For CRCPM patients treated with CRS, preoperative chemotherapy does not seem to prolong overall survival. Furthermore, the emergence of intestinal obstruction after chemotherapy may compromise the effectiveness of treatment, resulting in a worse prognosis. This finding has important clinical implications for treatment decisions.
Asunto(s)
Neoplasias Colorrectales , Hipertermia Inducida , Obstrucción Intestinal , Neoplasias Peritoneales , Humanos , Neoplasias Peritoneales/secundario , Procedimientos Quirúrgicos de Citorreducción/métodos , Neoplasias Colorrectales/tratamiento farmacológico , Neoplasias Colorrectales/cirugía , Neoplasias Colorrectales/patología , Hipertermia Inducida/métodos , Pronóstico , Obstrucción Intestinal/etiología , Obstrucción Intestinal/tratamiento farmacológico , Terapia Combinada , Tasa de Supervivencia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Estudios RetrospectivosRESUMEN
BACKGROUND: Peritoneal carcinomatosis in gastric cancer is considered a fatal disease, without expectation of definitive cure. As systemic chemotherapy is not sufficient to contain the disease, a multimodal approach associating intraperitoneal chemotherapy with surgery may represent an alternative for these cases. AIMS: The aim of this study was to investigate the role of intraperitoneal chemotherapy in stage IV gastric cancer patients with peritoneal metastasis. METHODS: This study is a single institutional single-arm prospective clinical trial phase II (NCT05541146). Patients with the following inclusion criteria undergo implantation of a peritoneal catheter for intraperitoneal chemotherapy: Stage IV gastric adenocarcinoma; age 18-75 years; Peritoneal carcinomatosis with peritoneal cancer index<12; Eastern Cooperative Oncology Group 0/1; good clinical status; and lab exams within normal limits. The study protocol consists of four cycles of intraperitoneal chemotherapy with paclitaxel associated with systemic chemotherapy. After treatment, patients with peritoneal response assessed by staging laparoscopy undergo conversion gastrectomy. RESULTS: The primary outcome is the rate of complete peritoneal response. Progression-free and overall survivals are other outcomes evaluated. The study started in July 2022, and patients will be screened for inclusion until 30 are enrolled. CONCLUSIONS: Therapies for advanced gastric cancer patients have been evaluated in clinical trials but without success in patients with peritoneal metastasis. The treatment proposed in this trial can be promising, with easy catheter implantation and ambulatory intraperitoneal chemotherapy regime. Verifying the efficacy and safety of paclitaxel with systemic chemotherapy is an important progress that this study intends to investigate.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica , Neoplasias Peritoneales , Neoplasias Gástricas , Adolescente , Adulto , Anciano , Humanos , Persona de Mediana Edad , Adulto Joven , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Ensayos Clínicos Fase II como Asunto , Paclitaxel/administración & dosificación , Paclitaxel/efectos adversos , Neoplasias Peritoneales/secundario , Neoplasias Peritoneales/terapia , Estudios Prospectivos , Neoplasias Gástricas/patología , Neoplasias Gástricas/terapiaRESUMEN
Peritoneal metastases (PM) occur when cancer cells spread inside the abdominal cavity and entail an advanced stage of colorectal cancer (CRC). Prognosis, which is poor, correlates highly with tumour burden, as measured by the peritoneal cancer index (PCI). Cytoreductive surgery (CRS) in specialized centres should be offered especially to patients with a low to moderate PCI when complete resection is expected. The presence of resectable metastatic disease in other organs is not a contraindication in well-selected patients. Although several retrospective and small prospective studies have suggested a survival benefit of adding hyperthermic intraperitoneal chemotherapy (HIPEC) to CRS, the recently published phase III studies PRODIGE-7 in CRC patients with PM, and COLOPEC and PROPHYLOCHIP in resected CRC with high-risk of PM, failed to show any survival advantage of this strategy using oxaliplatin in a 30-min perfusion. Final results from ongoing randomized phase III trials testing CRS plus HIPEC based on mitomycin C (MMC) are awaited with interest. In this article, a group of experts selected by the Spanish Group for the Treatment of Digestive Tumours (TTD) and the Spanish Group of Peritoneal Oncologic Surgery (GECOP), which is part of the Spanish Society of Surgical Oncology (SEOQ), reviewed the role of HIPEC plus CRS in CRC patients with PM. As a result, a series of recommendations to optimize the management of these patients is proposed.
Asunto(s)
Neoplasias Colorrectales , Hipertermia Inducida , Neoplasias Peritoneales , Humanos , Neoplasias Colorrectales/patología , Neoplasias Peritoneales/secundario , Estudios Retrospectivos , Estudios Prospectivos , Terapia Combinada , Hipertermia Inducida/métodos , Tasa de SupervivenciaRESUMEN
PURPOSE: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) treatment has classically presented a percentage of associated complications that have limited its expansion. The aim of this study is to describe the morbimortality results obtained from a referral center implemented with the support of a governmental health agency and directed by a surgical team experienced in CRS for Peritoneal Surface Malignancies (PSM). METHODS: Data from the Peritoneal Carcinomatosis Program of Catalonia (PCPC) prospective database, including patients who underwent CRS + HIPEC between September 2006 and January 2021, were analyzed. RESULTS: A total of 1151 consecutive patients underwent 1321 CRS + HIPEC procedures. Colonic origin of peritoneal metastasis was the most frequent (47.3%). Median PCI was 7 and most patients had CC0-1 (96.1%). Multivisceral resection was performed in 44% of all patients, 57% required digestive anastomosis. Median hospital stay was 11 days (range 6-144 days). High-grade complications occurred in 20% of all patient, most of them surgical complications. Anastomotic leak occurred in 0.6% of all cases. The overall in-stay and 30-day mortality rate was 0.4%. The low-rate of complications and the high rate of complete CRS were achieved from the beginning of the PCPC. Median overall survival was 54.7 months, with a 5-year survival rate of 47.5%. CONCLUSIONS: Implementation of a CRS + HIPEC referral program for the treatment of PSM with preferably an experienced surgical team enables acceptable rates of severe morbidity (20%) and mortality (< 1%).
Asunto(s)
Hipertermia Inducida , Intervención Coronaria Percutánea , Neoplasias Peritoneales , Humanos , Neoplasias Peritoneales/secundario , Quimioterapia Intraperitoneal Hipertérmica , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia Adyuvante , Hipertermia Inducida/métodos , Tasa de Supervivencia , Estudios Retrospectivos , Terapia Combinada , Procedimientos Quirúrgicos de Citorreducción/métodosRESUMEN
BACKGROUND: Complete surgical resection is the main determining factor in the survival of advanced gastric cancer patients, but is not indicated in metastatic disease. The peritoneum is a common site of metastasis and preoperative imaging techniques still fail to detect it. AIM: The aim of this study was to evaluate the role of staging laparoscopy in the staging of advanced gastric cancer patients in a Western tertiary cancer center. METHODS: A total of 130 patients with gastric adenocarcinoma who underwent staging laparoscopy from 2009 to 2020 were evaluated from a prospective database. Clinicopathological characteristics were analyzed to identify factors associated with the presence of peritoneal metastasis and were also evaluated the accuracy and strength of agreement between computed tomography and staging laparoscopy in detecting peritoneal metastasis and the change in treatment strategy after the procedure. RESULTS: The peritoneal metastasis was identified in 66 (50.76%) patients. The sensitivity, specificity, and accuracy of computed tomography in detecting peritoneal metastasis were 51.5, 87.5, and 69.2%, respectively. According to the Kappa coefficient, the concordance between staging laparoscopy and computed tomography was 38.8%. In multivariate analysis, ascites (p=0.001) and suspected peritoneal metastasis on computed tomography (p=0.007) were statistically correlated with peritoneal metastasis. In 40 (30.8%) patients, staging and treatment plans changed after staging laparoscopy (32 patients avoided unnecessary laparotomy, and 8 patients, who were previously considered stage IVb by computed tomography, were referred to surgical treatment). CONCLUSION: The staging laparoscopy demonstrated an important role in the diagnosis of peritoneal metastasis, even with current advances in imaging techniques.
Asunto(s)
Laparoscopía , Neoplasias Peritoneales , Neoplasias Gástricas , Humanos , Neoplasias Peritoneales/cirugía , Neoplasias Peritoneales/patología , Neoplasias Peritoneales/secundario , Neoplasias Gástricas/patología , Estadificación de Neoplasias , PeritoneoRESUMEN
BACKGROUND: Peritoneal metastases (PM) have a poor prognosis in gastric cancer (GC). Cytoreductive surgery (CRS) gives favorable outcomes, but the influence of hyperthermic intraperitoneal chemotherapy (HIPEC) remains contentious. We designed to distinguish results between CRS versus HIPEC-CRS in patients with peritoneal metastases from gastric cancer. MATERIALS AND METHODS: PubMed, Scopus, Embase and Cochrane library accessed to collect data and language is restricted to English. RevMan 5.4 was used to perform statistical analysis. The outcomes for categorical variables are mentioned in the risk ratio. RESULTS: Ten trials involving 1367 patients in which 707 were CRS-HIPEC, while 660 CRS. We got significant results in 3rd year survival (P < 0.05), while 1st and 5th years are not statistically significant P > 0.05. CONCLUSION: To compare with CRS, CRS-HIPEC has improved survival rate in deprived of further morbidity or mortality.
Asunto(s)
Hipertermia Inducida , Neoplasias Peritoneales , Neoplasias Gástricas , Humanos , Peritoneo , Neoplasias Gástricas/patología , Quimioterapia Intraperitoneal Hipertérmica , Neoplasias Peritoneales/secundario , Terapia Combinada , Procedimientos Quirúrgicos de Citorreducción/métodos , Hipertermia Inducida/métodos , Tasa de Supervivencia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéuticoRESUMEN
Resumen Introducción: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) Es una técnica que, vía laparoscopía, permite administrar quimioterapia en aerosol intraperitoneal, para el tratamiento de la carcinomatosis, ya sea para disminuir masa tumoral y aumentar la resecabilidad, o como paliación sintomática. Objetivo: Presentar los dos primeros casos de PIPAC en Chile, las consideraciones técnicas y revisión de la literatura. Pacientes y Método: Se describe la forma en que un programa PIPAC fue implementado en Clínica Las Condes. Se describe la técnica. Este procedimiento se realizó en dos pacientes, ambas portadoras de carcinomatosis con ascitis refractaria. Resultados: No hubo complicaciones. Alta a las 24 h. Ambas pacientes presentaron disminución de la ascitis, la que se ha mantenido a los seis meses de seguimiento. Discusión: PIPAC es una técnica emergente, que ha demostrado ser segura, con escasas complicaciones, cuya indicación incluye carcinomatosis por cáncer de colon y ovario y que se está extendiendo a páncreas, vía biliar y estómago. Su rol exacto está por definirse. Conclusiones: PIPAC es una técnica factible de realizar en nuestro país; sus resultados preliminares son alentadores y exentos de complicaciones.
Introduction: PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy is a technique that allows laparoscopic administration of aerosol chemotherapy in the peritoneum. This procedure is utilized for treatment of carcinomatosis, for debulk abdominal tumors, increasing resectability, or for palliation of abdominal symptoms. Aim: To present the first two cases of PIPAC performed in Chile, technical considerations and review of the literature. Patients and Method: The way this program was started at Clínica Las Condes is presented. The technique is described. This procedure was performed in two females, both with refractory ascites due to carcinomatosis. Results: The procedure was uneventfully and patients were discharged 24 hours later. Both patients showed important reduction of ascites, maintained at 6 months of followup. Discussion: PIPAC is a safe emerging technique, with low complication rate. It is indicated in carcinomatosis of colonic and ovarían origin and in selected cases of pancreatic, bile duct and gastric carcinomatosis. More prospective, randomized studies should be done to stablish its exact role. Conclusions: PIPAC is a feasible technique to perform in our country. Preliminary results are encouraging and no complications were observed.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Neoplasias Peritoneales/tratamiento farmacológico , Neoplasias Peritoneales/secundario , Neoplasias Gástricas/patología , Nebulizadores y Vaporizadores , Biopsia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Doxorrubicina/administración & dosificación , Cisplatino/administración & dosificaciónRESUMEN
Resumen Introducción: El cáncer gástrico continúa representando la más alta mortalidad por cáncer en hombres en Chile. En una revisión sistemática, evidenciaron que en el 59% de los pacientes que se catalogaron como M0 mediante diferentes estudios como TC, resonancia magnética y PET, se detectaron metástasis a la laparoscopia de etapificación. El objetivo de este estudio es describir la técnica quirúrgica de esta laparoscopía incluida la citología peritoneal y una revisión de la literatura en cuanto a sus indicaciones y posibilidad de cambio de conducta. Materiales y Método: Se realizó la búsqueda de artículos vía MED - LINE/PubMed (U.S.A. National Library of Medicine), Cochrane Library, Elsevier, SciELO; no se aplicó análisis estadístico, se incluyeron 23 referencias relacionadas al tema y materias afines internacionales y nacionales. El procedimiento que describiremos será la laparoscopia diagnóstica y la citología de líquido peritoneal para estudio anatomopatológico. Discusión y Conclusiones: La laparoscopía de etapificación, logra un cambio de conducta en un 20% aproximadamente de los casos, pero hacen faltan más estudios de validación de esta en los centros que tratan dicha enfermedad en el país.
Introduction: Gastric cancer continues to represent the highest mortality from cancer in men in Chile. In a systematic review, they showed that 59% of the patients who were classified as M0 by different studies such as CT, magnetic resonance imaging and PET, metastases were detected at staging laparoscopy. The objective of this study is to describe the surgical technique of staging laparoscopy including peritoneal cytology and a review of the literature regarding its indications and the possibility of behavior change. Materials and Method: Articles were searched via MEDLINE/PubMed (U.S.A. National Library of Medicine), Cochrane Library, Elsevier, SciELO, no statistical analysis was applied, 23 references related to the topic and related international and national subjects were included. The procedure to be described will be diagnostic laparoscopy and peritoneal fluid cytology for pathological study. Discussion and Conclusions: Staging laparoscopy achieve a change in behavior in approximately 20% of the cases, but more validation studies are needed in the centers that treat this disease in the country.
Asunto(s)
Humanos , Neoplasias Peritoneales/secundario , Neoplasias Gástricas/diagnóstico , Laparoscopía/métodos , Estadificación de Neoplasias , Neoplasias Peritoneales/diagnóstico , Neoplasias Gástricas/cirugía , Neoplasias Gástricas/mortalidadRESUMEN
BACKGROUND: To demonstrate whether extensive intraoperative peritoneal lavage (EIPL) could yield better results in overall survival and less recurrence, regardless of peritoneal cytology, compared to standard peritoneal lavage (SPL). METHODS: A prospective randomised multicenter study including 94 patients (47 per arm) to detect a 20% difference in 3-year overall survival in patients with locally advanced tumours without peritoneal carcinomatosis. Three samples of peritoneal fluid were obtained (at the beginning, the end of procedure and after the assigned peritoneal lavage). Clinicopathological and surgical data were analysed by group. Postoperative complications, location of recurrence and surgical approach were evaluated. Overall survival was calculated by the Kaplan-Meier method and the uni/multivariate analysis for prognostic factors was carried out using Cox regression analysis. RESULTS: A total of 86 patients were analysed (4 excluded per group). No statistical differences were observed in clinicopathological or surgical data between groups, considering both groups well-balanced for analysis. Overall survival at 3 years was 64.3% for SPL vs. 62.3% for EIPL (p 0.421). Only three patients had at least one positive peritoneal cytology (1:2). There were no differences regarding postoperative complications (SPL: 37.2% vs. EIPL: 32.5%, p 0.65) or between location of recurrence and number of recurrences. The number of recurrences did not differ between surgical approaches, but locoregional and peritoneal recurrences were fewer with the laparoscopic approach (p 0.048). CONCLUSIONS: The regular use of extensive peritoneal lavage in patients with locally advanced gastric cancer, regardless of peritoneal cytology, has not been effective as prophylaxis of peritoneal recurrence or better survival.
Asunto(s)
Cuidados Intraoperatorios/mortalidad , Recurrencia Local de Neoplasia/mortalidad , Lavado Peritoneal/métodos , Neoplasias Peritoneales/mortalidad , Neoplasias Gástricas/mortalidad , Anciano , Análisis de Varianza , Quimioterapia Adyuvante , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Invasividad Neoplásica , Recurrencia Local de Neoplasia/tratamiento farmacológico , Recurrencia Local de Neoplasia/prevención & control , Recurrencia Local de Neoplasia/secundario , Lavado Peritoneal/mortalidad , Neoplasias Peritoneales/tratamiento farmacológico , Neoplasias Peritoneales/prevención & control , Neoplasias Peritoneales/secundario , Estudios Prospectivos , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugíaRESUMEN
PURPOSE: The application of nanosecond pulsed electric fields (nsPEFs) could be an effective therapeutic strategy for peritoneal metastasis (PM) from colorectal cancer (CRC). The aim of this study was to evaluate in vitro the sensitivity of CT-26 CRC cells to nsPEFs in combination with chemotherapeutic agents, and to observe the subsequent in vivo histologic response. METHODS: In vitro cellular assays were performed to assess the effects of exposure to 1, 10, 100, 500 and 1000 10 ns pulses in a cuvette or bi-electrode system at 10 and 200 Hz. nsPEF treatment was applied alone or in combination with oxaliplatin and mitomycin. Cell death was detected by flow cytometry, and permeabilization and intracellular calcium levels by fluorescent confocal microscopy after treatment. A mouse model of PM was used to investigate the effects of in vivo exposure to pulses delivered using a bi-electrode system; morphological changes in mitochondria were assessed by electron microscopy. Fibrosis was measured by multiphoton microscopy, while the histological response (HR; hematoxylin-eosin-safran stain), proliferation (KI67, DAPI), and expression of immunological factors (CD3, CD4, CD8) were evaluated by classic histology. RESULTS: 10 ns PEFs exerted a dose-dependent effect on CT-26 cells in vitro and in vivo, by inducing cell death and altering mitochondrial morphology after plasma membrane permeabilization. In vivo results indicated a specific CD8+ T cell immune response, together with a strong HR according to the Peritoneal Regression Grading Score (PRGS). CONCLUSIONS: The effects of nsPEFs on CT-26 were confirmed in a mouse model of CRC with PM.
Asunto(s)
Antibióticos Antineoplásicos/uso terapéutico , Muerte Celular , Terapia por Estimulación Eléctrica/métodos , Mitomicina/uso terapéutico , Oxaliplatino/uso terapéutico , Neoplasias Peritoneales/patología , Neoplasias Peritoneales/terapia , Linfocitos T Citotóxicos , Animales , Neoplasias Colorrectales/patología , Terapia Combinada , Modelos Animales de Enfermedad , Inmunocompetencia , Ratones , Neoplasias Peritoneales/secundario , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: Current gastric cancer staging systems overlook the anatomic extent of metastatic lymph nodes (AEMLNs). This study aimed to analyze the prognostic impact of AEMLNs on gastric cancer (GC). METHODS: GC patients with metastatic lymph nodes (MLNs) undergoing curative surgery were retrospectively reviewed and assigned to perigastric (MLNs in station 1-6, PG) and extraperigastric group (7-12, with or without MLNs in PG area, EPG). Overall survival (OS), disease-free survival (DFS) and recurrence patterns were compared before and after 1:1 propensity score matching (PSM). RESULTS: 662 patients were enrolled, 341 (51.5%) and 321 (48.5%) of whom were in the PG and EPG, respectively. After PSM (n = 195), EPG showed poorer 5-year OS (43.4% vs 54.5%, p = 0.014) and DFS (65.0% vs 73.4%, p = 0.068) than PG. EPG had higher incidence of peritoneal recurrence (PR) than PG (19.4% vs 7.4%, p = 0.002). Multivariate analysis identified AEMLNs as prognostic factor for OS [HR = 1.409, 95% confidence interval (CI) 1.062-1.868), DFS (HR = 1.600, 95% CI 1.059-2.416) and PR (HR = 3.708, 95% CI 1.685-8.160). CONCLUSIONS: The anatomic extent of metastatic lymph nodes has an independent prognostic role for GC. Including this element may improve the accuracy of current staging systems.
Asunto(s)
Ganglios Linfáticos/patología , Metástasis Linfática/patología , Recurrencia Local de Neoplasia/patología , Neoplasias Gástricas/mortalidad , Neoplasias Gástricas/patología , Análisis de Varianza , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Neoplasias Peritoneales/secundario , Pronóstico , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Neoplasias Gástricas/cirugíaRESUMEN
Introdução: O melanoma cutâneo é um tumor com grande capacidade de metastização. Um dos quadros possíveis, mas bastante raro, é quando a metástase se aloja em peritônio (carcinomatose peritoneal). Relato do caso: Paciente feminina, 61 anos, encaminhada por massa inguinal esquerda suspeita e lesão hipercrômica de 2 cm, com área de regressão em membro inferior esquerdo. A paciente foi submetida à linfadenectomia inguinal esquerda e ressecção da lesão de pele, que evidenciou melanoma maligno cutâneo extensivo superficial invasor, de espessura de Breslow 1,2 mm, e nível de Clark II, bem como metástase linfonodal. O tratamento adjuvante incluiu radioterapia e quimioterapia. Durante follow-up, oito meses depois, ultrassonografia e tomografia computadorizada de abdome evidenciaram imagem nodular sólida hipoecoica, heterogênea e bosselada, mal definida e mal delimitada em projeção para-aórtica à esquerda, com 12,7x6,7x4,8 cm. Em laparotomia exploradora, encontrou-se massa volumosa retroperitoneal em flanco esquerdo, com envolvimento do ângulo de Treitz e presença de carcinomatose peritoneal. O laudo anatomopatológico evidenciou neoplasia maligna pouco diferenciada epitelioide infiltrativa, compatível com história clínica de melanoma. A paciente evoluiu a óbito após consulta com oncologia clínica. Conclusão:Existem poucos casos de metástase peritoneal de melanoma relatados na literatura. Contudo, deve-se levar em consideração sua possibilidade de ocorrência e as opções terapêuticas disponíveis, além de também compreender seu impacto no prognóstico do paciente. Apesar de rara, a carcinomatose peritoneal deve ser considerada quando pacientes com histórico pessoal de melanoma apresentarem queixas abdominais inespecíficas, como a paciente do caso relatado.
Introduction: Cutaneous melanoma is a tumor with great capacity for metastasis. One of the possible but quite rare scenarios is when the metastasis is lodged in the peritoneum (peritoneal carcinomatosis). Case report:61-year-old female patient, referred by a suspected left inguinal mass and 2 cm hyperchromic lesion, with regression area in the left lower limb. The patient underwent left inguinal lymphadenectomy and resection of the skin lesion, which revealed invasive extensive superficial cutaneous malignant melanoma, Breslow depth 1.2 mm and Clark II level, as well as lymph node metastasis. Adjuvant treatment included radiotherapy and chemotherapy. During follow-up, 8 months later, abdominal ultrasound and computed tomography showed hypoechoic, heterogeneous, and beveled solid nodular image, poorly defined and delimited in left para-aortic projection, with 12.7x6.7x4.8 cm. In exploratory laparotomy, a large retroperitoneal mass was found on the left flank, involving the Treitz angle, and revealed the presence of peritoneal carcinomatosis. The anatomopathological report showed a poorly differentiated malignant infiltrative epithelioid neoplasm, compatible with the clinical history of melanoma. The patient died after consultation with clinical oncology. Conclusion: There are few cases of peritoneal metastasis of melanoma reported in the literature. However, its possibility of occurrence and the therapeutic options available must be taken into account, in addition to understanding its impact on the patient's prognosis. Although rare, peritoneal carcinomatosis should be considered when patients with a personal history of melanoma have non-specific abdominal complaints, such as the patient in the case reported.
Introducción: El melanoma cutáneo es un tumor con gran capacidad de metástasis. Una de las situaciones posibles, pero bastante rara, es cuando la metástasis se aloja en el peritoneo. Relato del caso: paciente femenina de 61 años, remitida por sospecha de masa inguinal izquierda y lesión hipercrómica de 2 cm, con área de regresión, en miembro inferior izquierdo. La paciente fue sometida a linfadenectomía inguinal izquierda y resección de la lesión cutánea, que demonstró melanoma maligno cutáneo superficial extenso invasivo, Breslow 1,2 mm y nivel de Clark II, así como metástasis ganglionares. El tratamiento adyuvante incluyó radioterapia y quimioterapia. Durante el seguimiento, 8 meses después, la ecografía y la tomografía computarizada de abdomen mostraron una imagen nodular sólida hipoecoica, heterogénea y biselada, mal definida y delimitada en proyección para-aórtica izquierda, con 12,7x6,7x4,8 cm. En la laparotomía exploradora se encontró una gran masa retroperitoneal en el flanco izquierdo, involucrando el ángulo de Treitz y presencia de carcinomatosis peritoneal. El informe anatomopatológico mostró una neoplasia epitelioide infiltrativa maligna mal diferenciada, compatible con la historia clínica de melanoma. El paciente falleció tras consulta con oncología clínica. Conclusión: Hay pocos casos de metástasis peritoneal de melanoma reportados en la literatura. Sin embargo, se debe tener en cuenta su posibilidad de ocurrencia y las opciones terapéuticas disponibles, además de comprender su impacto en el pronóstico del paciente. Aunque es poco común, la carcinomatosis peritoneal debe considerarse cuando los pacientes con antecedentes personales de melanoma tienen molestias abdominales inespecíficas, como la paciente del caso.
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Neoplasias Peritoneales/secundario , Neoplasias Cutáneas/diagnóstico , Melanoma/diagnóstico , Neoplasias Peritoneales/diagnóstico , Neoplasias Peritoneales/terapia , Metástasis de la NeoplasiaRESUMEN
PURPOSE: Timing of metastasis is a controversial prognostic factor for patients with metastatic colorectal cancer (mCRC), as well as the performance of the common prognostic variables within patients with synchronous (SMs) or metachronous metastases (MMs). The aim of the current study is to evaluate outcome by the timing of metastases and to explore different tumor characteristics associated with SMs and MMs. METHODS: Data were collected from the clinical records of patients with mCRC, which were referred to the Department of Oncology of the Ospedale Civile di Sanremo from 2006 to 2011. A comparison of the characteristics of tumors of patients, overall and by the timing of metastases, and a Cox regression analysis have been performed to select the most relevant prognostic factors. Finally, the characteristics of the variables associated with the outcome were analyzed through a logistic regression. RESULTS: Two hundreds fifteen patients with SMs and two hundreds ten with MMs were included. Patients with SMs reported a poor prognosis (18.5 versus 62.8 months; p value < 0.001). Among patients with SMs there was a significant difference in overall survival between patients with a CEA-positive or negative disease, while no difference was present among patients with MMs. After multivariate analysis, only within the SMs group the occurrence of liver metastases was related to a CEA-positive disease. CONCLUSIONS: Within the cohort of SMs high CEA levels, occurrence of liver metastases and right-sided colon tumors were associated with a very poor prognosis, whereas no relationship was detectable in the group of patients with MMs.
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Antígeno Carcinoembrionario/sangre , Neoplasias del Colon/patología , Neoplasias Hepáticas/secundario , Neoplasias del Recto/patología , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/sangre , Neoplasias del Colon/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Hepáticas/sangre , Neoplasias Hepáticas/mortalidad , Neoplasias Pulmonares/sangre , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Neoplasias Peritoneales/sangre , Neoplasias Peritoneales/secundario , Neoplasias del Recto/sangre , Neoplasias del Recto/mortalidad , Análisis de RegresiónRESUMEN
BACKGROUND: The attitude toward cytoreductive surgery with HIPEC in peritoneal carcinomatosis from colorectal cancer is unclear. The aim of this study is to report the perioperative outcomes after cytoreductive surgery with HIPEC in patients ≥ 75 years. METHODS: This retrospective multicenter study collected the data the Spanish Group of Peritoneal Cancer Surgery. Thirty-six patients with peritoneal carcinomatosis from colorectal cancer met the selection criteria for the study. Morbidity, mortality, disease-free and overall survival were analyzed. RESULTS: Morbidity (grade III-IV) was 17% and 2 patients died of complications related to the procedure (5.4%). Median disease-free survival (DFS) was 16 months. DFS at 1 and 3 years was 81% and 42%, respectively. Overall survival at 1 and 3 years was 96% and 75%. In the univariate analysis, preoperative comorbidities (p = 0.01), liver metastases (p = 0.02), blood transfusion (p = 0.001) and postoperative complications (p = 0.001); and in the multivariate analysis, perioperative blood transfusion (OR 2.56, 95% CI 1.95-6.24, p = 0.03) and postoperative complications (OR 3.25, 95% CI 2.35-7.56, p = 0.02) were associated with a lower overall survival. CONCLUSIONS: Age is not an absolute contraindication to perform cytoreduction surgery with HIPEC in highly selected elderly patients with colorectal peritoneal carcinomatosis.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia del Cáncer por Perfusión Regional/mortalidad , Neoplasias Colorrectales/mortalidad , Procedimientos Quirúrgicos de Citorreducción/mortalidad , Hipertermia Inducida/mortalidad , Neoplasias Peritoneales/mortalidad , Anciano , Anciano de 80 o más Años , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/terapia , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Neoplasias Peritoneales/secundario , Neoplasias Peritoneales/terapia , Pronóstico , Estudios Retrospectivos , España , Tasa de SupervivenciaRESUMEN
BACKGROUND: Approximately 70% of cancer-related deaths occur in low- and middle-income countries. In addition to social and racial inequalities, treatment options in these countries are usually limited because of the lack of trained staff and equipment, limited patient access to health services, and a small number of clinical guidelines. OBJECTIVES: The Brazilian Society of Surgical Oncology developed this guideline to address these barriers and guide physicians treating patients with endometrial cancer (EC) in regions with limited resources and few specialized centers. METHODS: The guideline was prepared from 10 January to 25 October 20192019 by a multidisciplinary team of 56 experts to discuss the main obstacles faced by EC patients in Brazil. Thirteen questions considered critical to the surgical treatment of these patients were defined. The questions were assigned to groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments for presentations in meetings, classified the level of evidence, and voted on the recommendations. RESULTS: For all questions including staging, fertility spearing treatment, genetic testing, sentinel lymph node use, surgical treatment, and other clinical relevant questions, major agreement was achieved by the participants, always using accessible alternatives. CONCLUSIONS: It is possible to provide adequate treatment for most EC patients in resource-limited areas, but the first option should be referral to specialized centers with more resources.
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Países en Desarrollo , Neoplasias Endometriales/cirugía , Accesibilidad a los Servicios de Salud , Brasil , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , Continuidad de la Atención al Paciente , Diagnóstico por Imagen , Neoplasias Endometriales/patología , Femenino , Preservación de la Fertilidad , Humanos , Histerectomía , Escisión del Ganglio Linfático , Recurrencia Local de Neoplasia/terapia , Estadificación de Neoplasias , Neoplasias Peritoneales/secundario , Neoplasias Peritoneales/terapia , Examen Físico , Derivación y Consulta , Biopsia del Ganglio Linfático Centinela , Sociedades MédicasRESUMEN
BACKGROUND: In the last 20 years, intraperitoneal chemotherapy (IPC) has been explored as a modality for the management of peritoneal metastases of gynecologic, gastrointestinal, and primary peritoneal tumors. Direct delivery of chemotherapeutic agents to the peritoneal cavity space has proved superior to systemic chemotherapy when evaluating characteristics such as drug concentration reached in the peritoneal space, penetration into peritoneal metastases, and chemotherapy-related toxicity. Traditionally, IPC is delivered by peritoneal lavage with a liquid solution. This form of delivery has limitations, including inhomogeneous intraperitoneal distribution and limited ability to penetrate tissues and metastatic nodules. An alternative mode of delivery is so-called pressurized intraperitoneal aerosol chemotherapy (PIPAC). Within this context, the present study sought to identify the pattern of spatial distribution of therapeutic solutions aerosolized into the peritoneal space using a single-port PIPAC device and ascertain whether the aerosolized method is superior to the traditional (liquid) mode of IPC delivery. METHODS: Analysis of the rate of intra-abdominal staining with aerosolized 2% silver nitrate in five porcine models. RESULTS: Assessment of differences in stain impregnation between the upper, middle, and lower abdomen did not reveal significant differences (p = 0.42). The median sum scores were 1 for the upper abdomen and 3 for the middle and lower abdomen. CONCLUSIONS: Aerosolization does not reach all regions of the abdomen homogeneously. However, adequate exposure of the upper abdomen, mid-abdomen, and lower abdomen to chemotherapeutic agents can be achieved with PIPAC.
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Antineoplásicos/administración & dosificación , Quimioterapia/instrumentación , Neoplasias Peritoneales , Cavidad Abdominal/patología , Aerosoles/administración & dosificación , Aerosoles/farmacología , Animales , Antineoplásicos/farmacología , Quimioterapia/métodos , Diseño de Equipo , Inyecciones Intraperitoneales/instrumentación , Inyecciones Intraperitoneales/métodos , Neoplasias Peritoneales/tratamiento farmacológico , Neoplasias Peritoneales/secundario , Peritoneo/efectos de los fármacos , PorcinosRESUMEN
INTRODUCTION: Goblet cell carcinoma (GCC) is an appendicular neoplasia representing less than 5% of all appendicular tumors, found in 0.3-0.9% of the appendectomies, 35-58% of all appendicular neoplasms, and less than 14% of malign appendix tumors. The most frequent clinical presentation is abdominal pain associated with a picture of acute appendicitis. MATERIALS AND METHODS: We present 3 clinical cases of appendix GCC, 2 subjected to cytoreductory surgery plus intraperitoneal hyperthermic chemotherapy and a third, who is currently receiving neoadjuvant treatment with a good response to chemotherapy and who will be offered the same treatment as the first two patients. Given the unpredictable behavior of these tumors, the use of molecular markers could help us to predict their behavior and prognosis. In this context, the TP73 gene would make an interesting putative marker. ∆Np73 has been described as overexpressed in a great variety of tumor types including colon cancer and this up-regulation is associated with a poor prognosis. To evidence its role in this malignancy, we evaluate here the status of ∆Np73 in the primary tumor and normal counterpart tissues, in the metastatic implants and in healthy areas of the peritoneum from the appendicular GCC patients. In addition, we checked the expression levels of this p73 variant in the tumor and normal tissue of 26 patients with colon cancer. RESULTS: Remarkably, 2 patients showed significant ∆Np73 down-regulation in both the primary tumor and the implants. Case 1 presented a fourfold decrease of levels in the primary tumor and 20-fold decrease in the implants. Case 2 showed a seven- and fourfold down-regulation in the primary tumor and implants, respectively. However, Case 3 showed an up-regulation of 53- and threefold in the primary tumor and implants, respectively. CONCLUSION: Goblet cell carcinoma of the appendix is very rate. It tends to seed throughout the peritoneum, making aggressive surgical cytoreduction and chemotherapy viable treatment options. Investigation into the molecular basis of these tumors may improve the diagnosis, prognosis and therapeutic decisions regarding these patients. ∆Np73 seems a good candidate for further analysis in longer series.
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Adenocarcinoma/química , Neoplasias del Apéndice/química , Biomarcadores de Tumor/análisis , Células Caliciformes/química , Neoplasias Ováricas/química , Neoplasias Peritoneales/química , Proteína Tumoral p73/análisis , Adenocarcinoma/secundario , Adenocarcinoma/terapia , Neoplasias del Apéndice/patología , Neoplasias del Apéndice/terapia , Colon/química , Neoplasias del Colon/química , Procedimientos Quirúrgicos de Citorreducción , Regulación hacia Abajo , Femenino , Humanos , Hipertermia Inducida , Masculino , Persona de Mediana Edad , Neoplasias Ováricas/secundario , Neoplasias Peritoneales/secundario , Peritoneo/químicaRESUMEN
BACKGROUND: Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in peritoneal carcinomatosis treatment causes significant hemodynamic, metabolic, and hematological alterations. Studies on the anesthetic intraoperative management are heterogeneous and scarce. There is a great heterogeneity in the anesthetic management of CRS and HIPEC. The aim of this study is to analyze perioperative hemodynamic goal-directed management and to evaluate the complications arisen until the seventh postoperative day. METHODS: Prospective, observational study of all CRS and HIPEC patients from March 2014 to May 2017. Hemodynamic and clinical parameters were registered during surgery and the first 3 postoperative days. We correlated intraoperative data with the postoperative course until the seventh day. RESULTS: A total of 92 patients were included in the study (age 58.5 ± 10.9 years, 47% colorectal carcinoma, and 38% ovarian carcinoma). Peritoneal Carcinomatosis Index (PCI) (median and ranges) was 10 [0-39]. Cardiac Index (CI) 3.15 l/min-1/m-2 [1.79-5.60]) and Systolic Volume Variation (SVV) (10% [3%-17%]) remained within the values of normality in all surgery phases. A large difference was observed between the minimum and maximum ranges of fluid therapy administered (median 9.8 ml/kg/h [5.3-24.3]), showing a great interindividual variation in the fluids requirement. A direct relationship was observed between PCI and surgery duration, fluid therapy, and intraoperative transfusion percentage (p < 0.02). CONCLUSIONS: There is a great variability in the intraoperative fluid therapy needs of the patients. SVV monitoring makes it possible to adjust the fluid therapy needs in each surgery phase. The use of a hemodynamic goal-directed anesthetic protocol in CRS and HIPEC enables to individually adjust the fluid therapy, avoiding over-hydration and ensuring hemodynamic stability in all surgery phases.
Asunto(s)
Quimioterapia del Cáncer por Perfusión Regional/métodos , Neoplasias Colorrectales/terapia , Procedimientos Quirúrgicos de Citorreducción/métodos , Hipertermia Inducida/métodos , Neoplasias Ováricas/terapia , Neoplasias Peritoneales/terapia , Complicaciones Posoperatorias , Neoplasias Colorrectales/patología , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neoplasias Ováricas/patología , Neoplasias Peritoneales/secundario , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Neuroendocrine carcinoma (NEC) of the colon is a rare and very aggressive tumor with poor prognosis. The current case report presents a 53-year-old male with a 6 cm × 10 cm ascending colon carcinoma, causing large intestine obstruction, with simultaneous multiple hepatic metastases and peritoneal carcinomatosis. Surgical resection of the primary tumor was performed, because of the bowel obstruction, to ameliorate the symptoms before the onset of chemotherapy. Histopathology revealed that the tumor was a small-cell undifferentiated NEC. During the post0operative period, the patient presented pulmonary metastases, and on the 36th post-operative day, death occurred due to respiratory failure.
El carcinoma neuroendocrino del colon es un tumor raro y muy agresivo, con mal pronóstico. Se presenta el caso de un hombre de 53 años con un carcinoma de colon ascendente de 6 × 10 cm que causa obstrucción del intestino grueso, con metástasis hepáticas múltiples simultáneas y carcinomatosis peritoneal. Se realizó la resección quirúrgica del tumor primario, debido a la obstrucción intestinal, para mejorar los síntomas antes del inicio de la quimioterapia. La histopatología reveló que el tumor era un carcinoma neuroendocrino indiferenciado de células pequeñas. Durante el posoperatorio, el paciente presentó metástasis pulmonares y el día 36 posoperatorio se produjo la muerte por insuficiencia respiratoria.