RESUMO
BACKGROUND: Organ-preserving strategies have been considered for patients with distal rectal cancer and complete or near-complete response to neoadjuvant chemoradiation to avoid the functional consequences of radical surgery. Transanal endoscopic microsurgery and no immediate surgery (watch and wait) have been considered in selected patients. OBJECTIVE: The aim of this study is to compare anorectal function following these 2 organ-preserving strategies (transanal endoscopic microsurgery and watch and wait) for rectal cancer with complete or near-complete response to neoadjuvant chemoradiation. DESIGN: This study is based on the comparison of prospectively collected data. SETTINGS: This study was conducted at a single center. PATIENTS: Consecutive patients with distal rectal cancer undergoing neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were prospectively studied. Patients with complete clinical response were managed by watch and wait. Patients with near-complete response (≤3 cm, ycT1-2N0) were managed by transanal endoscopic microsurgery. MAIN OUTCOME MEASURES: Functional outcomes were determined by anorectal manometry and Fecal Incontinence Index and Quality of Life assessment. RESULTS: Two groups of patients were included in the study. Twenty-nine patients with near-complete response undergoing transanal endoscopic microsurgery and 53 with complete response after watch and wait were assessed. Baseline features were similar between groups. Patients undergoing transanal endoscopic microsurgery had worse resting/squeeze pressures (p = 0.004) and rectal capacity (p = 0.002). In addition, their incontinence scores (2.3 vs. 6.5; p < 0.001) and quality-of-life questionnaire responses (in all domains; p ≤ 0.01) were significantly worse in comparison with patients undergoing watch and wait. LIMITATIONS: This study was limited by the small sample size and the absence of baseline anorectal function information. CONCLUSIONS: Nonoperative management of patients with complete clinical response following chemoradiation results in better anorectal function in comparison with patients with near-complete response managed by transanal endoscopic microsurgery. In the absence of clinically detectable residual cancer, this latter approach may result in significant worsening of anorectal function.
Assuntos
Adenocarcinoma/terapia , Canal Anal/fisiopatologia , Antimetabólitos Antineoplásicos/uso terapêutico , Quimiorradioterapia , Fluoruracila/uso terapêutico , Neoplasias Retais/terapia , Reto/fisiopatologia , Microcirurgia Endoscópica Transanal , Conduta Expectante , Adenocarcinoma/patologia , Idoso , Canal Anal/cirurgia , Incontinência Fecal/epidemiologia , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Indução de Remissão , Resultado do Tratamento , Carga TumoralRESUMO
BACKGROUND: The main tenets of local excision of rectal cancer following neoadjuvant chemoradiation (CRT) are that the mucosal scar represents the main focus of residual disease and a solid conglomerate around this rather than being scattered (fragmented) through the bowel wall. METHODS: Retrospective review of a prospective cohort of patients with residual rectal ycT1-2N0 adenocarcinoma with small residual tumors (≤3 cm) following CRT who underwent transanal endoscopic microsurgery (TEM) with 1-cm margins around the residual mucosal abnormality was performed. Distribution and morphology (solid vs. fragmented) of tumor spread were studied and correlated to postoperative oncological outcomes. RESULTS: Thirty patients were included. Twenty percent (n = 6) were ypT1, 60% (n = 18) were ypT2, and 20% (n = 6) were ypT3 tumors. Fragmentation was present in 37%. The mean distance between foci of residual scattered tumor was 3.6 ± 2.0 mm. Lateral spread under normal mucosa was present in 19 specimens (53%; mean extension 4.8 ± 2.4 mm). With a median follow up of 32 months, none of these findings impacted upon development of recurrence. CONCLUSIONS: Both occult lateral spread and fragmented tumor patterns are common findings after CRT. Despite the potential of occult spread to mislead surgeon choice of resection margin, its presence did not influence oncological outcome in this series.
Assuntos
Adenocarcinoma/patologia , Quimiorradioterapia/efeitos adversos , Microcirurgia/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Terapia Neoadjuvante/efeitos adversos , Neoplasia Residual/patologia , Neoplasias Retais/patologia , Adenocarcinoma/terapia , Canal Anal/cirurgia , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Neoplasia Residual/terapia , Prognóstico , Estudos Prospectivos , Neoplasias Retais/terapia , Estudos RetrospectivosRESUMO
The treatment of rectal cancer has evolved significantly over the last 100 years. Standardization of total mesorectal excision and the development of techniques for sphincter preservation have resulted in significant improvements in the management of this disease. Still, local disease control and functional outcomes of sphincter preserving procedures remain a relevant issue. In this historical paper, the oncological and functional outcomes of patients with rectal cancer treated between 1960 and 1971 by a pioneer woman surgeon using a sphincter preserving approach and a technique resembling total mesorectal excision performed at that time are reported. The results reflect one of the earliest steps of partial intersphincteric resection and total mesorectal excision with good oncological outcomes (2% local recurrence) and acceptable functional outcomes in a highly selected group of patients. (AU)
O tratamento do câncer de reto tem evoluído significativamente ao longo dos últimos 100 anos. A padronização da excisão total do mesorreto e o desenvolvimento de técnicas com preservação do esfíncter resultaram em melhorias significativas no tratamento da doença. Ainda assim, o controle local da doença e os resultados funcionais dos procedimentos de preservação do esfíncter continuam a ser uma questão relevante. Nesse documento histórico, são relatados os resultados oncológicos e funcionais de pacientes com câncer retal, tratados entre 1960 e 1971, utilizando-se uma abordagem com preservação do esfíncter e uma técnica parecida com a excisão total do mesorreto realizada por uma cirurgiã pioneira naquela época. Os resultados refletem um dos primeiros passos de ressecção parcial interesfinctérica e a excisão total do mesorreto com bons resultados oncológicos (2% de recidiva local), e os resultados funcionais aceitáveis em um grupo altamente selecionado de pacientes. (AU)
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Canal Anal , Neoplasias Retais/cirurgia , Protectomia , Recidiva , Resultado do Tratamento , Incontinência FecalRESUMO
Antecedentes: La malformación arteriovenosa (MAV) en cabeza y cuello sintomática en el adulto es un enfermedad infrecuentey potencialmente fatal.Objetivo: Describir el manejo quirúrgico y resultado de dos casos de pacientes tratados por MAV avanzada del adulto en la mejilla.Lugar de aplicación: Hospital universitario de tercer nivel.Diseño: Retrospectivo observacional.Población: Dos pacientes adultos varones con MAV sintomática en la mejilla.Método: Revisión de historias clínicas e informes patológicos.Resultados: Ambos pacientes se presentaron con grandes masas y habían sido tratados previamente con embolizaciones sin éxito.Ambos eran estadio Schobinger III. Se realizó una resección amplia y reconstrucción con colgajos libres: anterolateral de muslo en un caso, y de peroné y anterolateral de muslo en el otro. Evolucionaron sin complicaciones con aceptable resultado estético. Se encuentran libres de enfermedad a 50 y 30 meses de seguimiento.Conclusiones: El tratamiento quirúrgico requiere un equipo multidisciplinario con experiencia para una extensa resección, agresiva reposición de sangre y fluidos, y una reconstrucción compleja con colgajos libres.
Background: Sympthomatic adult arteriovenous malformation (AVM) in the head and neck is an unfrequent and potential lifethreatening disorder.Objetive: To describe surgical management and outcome of two cases of surgically treated advanced cheek AVM.Setting: Third level universitary hospital.Design: Retrospective observational.Population: Two adult male patients with symptomatic AVM of the cheek.Method: Review of clinical records and pathological reports.Results: Both patients presented with great masses and had been previously treated with unsuccessful embolizations. They wereSchobinger III stage. It was undertaken wide surgical resection and reconstruction with free flaps: antero lateral thigh flap in onecase and fibular and anterolateral thigh flap in the other. Evolution was uneventful with acceptable cosmetic result. They are lesionfree at 50 and 30 months of follow-up.Conclusions: Surgical treatment requires an experience and multidisciplinary team for extensive resection, aggressive blood andfluid reposition, and complex reconstruction with free flaps.
Assuntos
Humanos , Malformações Arteriovenosas , Cabeça , Pescoço , Bochecha , Cirurgia Geral , TerapêuticaRESUMO
Antecedentes: La malformación arteriovenosa (MAV) en cabeza y cuello sintomática en el adulto es un enfermedad infrecuente y potencialmente fatal. Objetivo: Describir el manejo quirúrgico y resultado de dos casos de pacientes tratados por MAV avanzada del adulto en la mejilla. Lugar de aplicación: Hospital universitario de tercer nivel. Diseño: Retrospectivo observacional. Población: Dos pacientes adultos varones con MAV sintomática en la mejilla. Método: Revisión de historias clínicas e informes patológicos. Resultados: Ambos pacientes se presentaron con grandes masas y habían sido tratados previamente con embolizaciones sin éxito. Ambos eran estadio Schobinger III. Se realizó una resección amplia y reconstrucción con colgajos libres: anterolateral de muslo en un caso, y de peroné y anterolateral de muslo en el otro. Evolucionaron sin complicaciones con aceptable resultado estético. Se encuentran libres de enfermedad a 50 y 30 meses de seguimiento. Conclusiones: El tratamiento quirúrgico requiere un equipo multidisciplinario con experiencia para una extensa resección, agresiva reposición de sangre y fluidos, y una reconstrucción compleja con colgajos libres.(AU)
Background: Sympthomatic adult arteriovenous malformation (AVM) in the head and neck is an unfrequent and potential life threatening disorder. Objetive: To describe surgical management and outcome of two cases of surgically treated advanced cheek AVM. Setting: Third level universitary hospital. Design: Retrospective observational. Population: Two adult male patients with symptomatic AVM of the cheek. Method: Review of clinical records and pathological reports. Results: Both patients presented with great masses and had been previously treated with unsuccessful embolizations. They were Schobinger III stage. It was undertaken wide surgical resection and reconstruction with free flaps: antero lateral thigh flap in one case and fibular and anterolateral thigh flap in the other. Evolution was uneventful with acceptable cosmetic result. They are lesion free at 50 and 30 months of follow-up. Conclusions: Surgical treatment requires an experience and multidisciplinary team for extensive resection, aggressive blood and fluid reposition, and complex reconstruction with free flaps.(AU)
RESUMO
Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal excision (APE), described more than 100 years ago, remains as an important procedure for the treatment of selected advanced distal tumors with direct invasion of the anal sphincter or preoperative fecal incontinence. Historically, oncological outcomes of patients undergoing APE have been worse when compared to sphincter preserving operations. More recently, it has been suggested that patients undergoing APE for distal rectal cancer are more likely to have positive circumferential resection margins and intraoperative perforation, known surrogate markers for local recurrence. Recently, an alternative approach known as "Extralevator Abdominoperineal Excision" has been described in an effort to improve rates of circumferential margin positivity possibly resulting in better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard abdominal perineal excision techniques. (AU)
Um dos pilares mais importantes no tratamento do câncer de reto ainda é a ressecção cirúrgica. A amputação de reto, ou excisão abdomino-perineal do reto (APE), descrita há mais de 100 anos, continua sendo um procedimento importante para o tratamento de tumores retais distais que invadem o aparelho esfincteriano ou em casos de incontinência pré-operatória. Entretanto, os resultados oncológicos dos pacientes submetidos à APE são piores quando comparados com os pacientes submetidos a procedimentos com preservação esfincteriana. Recentemente, foi sugerido que os pacientes submetidos à APE por câncer de reto distal apresentam mais frequentemente margem radial positiva, assim como perfuração intraoperatória do tumor, fatos reconhecidamente associados à recidiva local. Uma nova técnica cirúrgica conhecida como "Amputação de reto extraelevador ou cilíndrica" tem sido descrita em um esforço para reduzir as taxas de margem radial positivas, sugerindo melhores resultados oncológicos quando comparada com o procedimento convencional. O objetivo deste trabalho é descrever a técnica deste procedimento e comparar seus resultados com os obtidos com a técnica convencional de acordo com a evidência disponível. (AU)
Assuntos
Canal Anal/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Recidiva , Margens de ExcisãoRESUMO
BACKGROUND: Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection. OBJECTIVE: The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery. DESIGN: This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy. SETTINGS: This study was a single-institution experience. PATIENTS: Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound- or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (≤3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery. INTERVENTIONS: Transanal endoscopic microsurgery was performed. MAIN OUTCOME MEASURES: The primary outcome measured was local recurrence. RESULTS: Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure. LIMITATIONS: This study was limited by the small sample size and limited follow-up. CONCLUSIONS: A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.
Assuntos
Adenocarcinoma , Canal Anal/cirurgia , Microcirurgia , Complicações Pós-Operatórias/epidemiologia , Proctoscopia , Neoplasias Retais , Adenocarcinoma/epidemiologia , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Brasil/epidemiologia , Quimiorradioterapia/métodos , Feminino , Fluoruracila/uso terapêutico , Humanos , Masculino , Microcirurgia/efeitos adversos , Microcirurgia/métodos , Microcirurgia/estatística & dados numéricos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Gradação de Tumores , Invasividade Neoplásica , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Neoplasia Residual , Avaliação de Resultados em Cuidados de Saúde , Proctoscopia/efeitos adversos , Proctoscopia/métodos , Proctoscopia/estatística & dados numéricos , Neoplasias Retais/epidemiologia , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Reto/patologia , Reto/cirurgia , Estudos Retrospectivos , Medição de Risco , Análise de SobrevidaRESUMO
La resección quirúrgica sigue siendo la piedra angular de la terapia curativa en el cáncer de recto. La amputación abdominoperineal implica la remoción en bloque del recto, mesorrecto, aparato esfinteriano y el ano; con la creación de una colostomía definitiva. Esta cirugía es la propuesta para pacientes sin posibilidad de conservación esfinteriana. Este grupo representa aproximadamente el 80% de los pacientes con lesiones a menos de 5 cm del margen anal y aquellos con una continencia preoperatoria deficiente. Recientemente una modificación de la técnica denominada ôAmputación abdominoperineal extraelevadorö destinada a la ampliación del margen circunferencial sugiere mejores resultados oncológicos que la técnica clásica. El siguiente trabajo tiene por objetivo caracterizar y describir a la amputación abdominoperineal cilíndrica en comparación a la técnica clásica. (AU)
Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal resection involves the en bloc removal of the rectum, mesorectum, sphincters and anus with confection of a definitive colostomy. This surgery is indicated in patients without the possibility of sphincter preservation. This group represents approximately 80% of patients with lesions <5 cm from the anal verge and those with preoperative incontinence. Recently ôExtralevator Abdominoperineal Excisionö has been described to improve rates of circumferential margin positivity suggesting better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard techniques. (AU)
Assuntos
Humanos , Neoplasias Retais/diagnóstico , Neoplasias Retais/cirurgia , Reto/cirurgia , Cirurgia Colorretal/métodos , Cirurgia Colorretal/normas , Reto/lesões , Colostomia/métodos , Colostomia/normas , Espectroscopia de Ressonância Magnética , Resultado do Tratamento , Complicações Pós-Operatórias , Posicionamento do Paciente/métodosRESUMO
La resección quirúrgica sigue siendo la piedra angular de la terapia curativa en el cáncer de recto. La amputación abdominoperineal implica la remoción en bloque del recto, mesorrecto, aparato esfinteriano y el ano; con la creación de una colostomía definitiva. Esta cirugía es la propuesta para pacientes sin posibilidad de conservación esfinteriana. Este grupo representa aproximadamente el 80% de los pacientes con lesiones a menos de 5 cm del margen anal y aquellos con una continencia preoperatoria deficiente. Recientemente una modificación de la técnica denominada Amputación abdominoperineal extraelevador destinada a la ampliación del margen circunferencial sugiere mejores resultados oncológicos que la técnica clásica. El siguiente trabajo tiene por objetivo caracterizar y describir a la amputación abdominoperineal cilíndrica en comparación a la técnica clásica.
Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal resection involves the en bloc removal of the rectum, mesorectum, sphincters and anus with confection of a definitive colostomy. This surgery is indicated in patients without the possibility of sphincter preservation. This group represents approximately 80% of patients with lesions <5 cm from the anal verge and those with preoperative incontinence. Recently Extralevator Abdominoperineal Excision has been described to improve rates of circumferential margin positivity suggesting better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard techniques.
Assuntos
Humanos , Cirurgia Colorretal/métodos , Cirurgia Colorretal/normas , Neoplasias Retais/cirurgia , Neoplasias Retais/diagnóstico , Reto/cirurgia , Colostomia/métodos , Colostomia/normas , Complicações Pós-Operatórias , Espectroscopia de Ressonância Magnética , Posicionamento do Paciente/métodos , Reto/lesões , Resultado do TratamentoRESUMO
PURPOSE: To estimate the metabolic activity of rectal cancers at 6 and 12 weeks after completion of chemoradiation therapy (CRT) by 2-[fluorine-18] fluoro-2-deoxy-d-glucose-labeled positron emission tomography/computed tomography ([(18)FDG]PET/CT) imaging and correlate with response to CRT. METHODS AND MATERIALS: Patients with cT2-4N0-2M0 distal rectal adenocarcinoma treated with long-course neoadjuvant CRT (54 Gy, 5-fluouracil-based) were prospectively studied (ClinicalTrials.org identifier NCT00254683). All patients underwent 3 PET/CT studies (at baseline and 6 and 12 weeks from CRT completion). Clinical assessment was at 12 weeks. Maximal standard uptake value (SUVmax) of the primary tumor was measured and recorded at each PET/CT study after 1 h (early) and 3 h (late) from (18)FDG injection. Patients with an increase in early SUVmax between 6 and 12 weeks were considered "bad" responders and the others as "good" responders. RESULTS: Ninety-one patients were included; 46 patients (51%) were "bad" responders, whereas 45 (49%) patients were "good" responders. "Bad" responders were less likely to develop complete clinical response (6.5% vs. 37.8%, respectively; P=.001), less likely to develop significant histological tumor regression (complete or near-complete pathological response; 16% vs. 45%, respectively; P=.008) and exhibited greater final tumor dimension (4.3 cm vs. 3.3 cm; P=.03). Decrease between early (1 h) and late (3 h) SUVmax at 6-week PET/CT was a significant predictor of "good" response (accuracy of 67%). CONCLUSIONS: Patients who developed an increase in SUVmax after 6 weeks were less likely to develop significant tumor downstaging. Early-late SUVmax variation at 6-week PET/CT may help identify these patients and allow tailored selection of CRT-surgery intervals for individual patients.
Assuntos
Adenocarcinoma/metabolismo , Adenocarcinoma/terapia , Quimiorradioterapia Adjuvante/métodos , Terapia Neoadjuvante/métodos , Neoplasias Retais/metabolismo , Neoplasias Retais/terapia , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Algoritmos , Feminino , Fluordesoxiglucose F18/farmacocinética , Humanos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Tomografia por Emissão de Pósitrons , Estudos Prospectivos , Compostos Radiofarmacêuticos/farmacocinética , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Análise de Regressão , Indução de Remissão/métodos , Análise de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Carga TumoralRESUMO
BACKGROUND: Neoadjuvant chemoradiation (CRT) therapy may result in significant tumor regression in patients with rectal cancer. Patients who develop complete tumor regression have been managed by treatment strategies that are alternatives to standard total mesorectal excision. Therefore, assessment of tumor response with positron emission tomography/computed tomography (PET/CT) after neoadjuvant treatment may offer relevant information for the selection of patients to receive alternative treatment strategies. METHODS: Patients with clinical T2 (cT2) through cT4NxM0 rectal adenocarcinoma were included prospectively. Neoadjuvant therapy consisted of 54 grays of radiation and 5-fluorouracil-based chemotherapy. Baseline PET/CT studies were obtained before CRT followed by PET/CT studies at 6 weeks and 12 weeks after the completion of CRT. Clinical assessment was performed at 12 weeks after CRT completion. PET/CT results were compared with clinical and pathologic data. RESULTS: In total, 99 patients were included in the study. Twenty-three patients were complete responders (16 had a complete clinical response, and 7 had a complete pathologic response). The PET/CT response evaluation at 12 weeks indicated that 18 patients had a complete response, and 81 patients had an incomplete response. There were 5 false-negative and 10 false-positive PET/CT results. PET/CT for the detection of residual cancer had 93% sensitivity, 53% specificity, a 73% negative predictive value, an 87% positive predictive value, and 85% accuracy. Clinical assessment alone resulted in an accuracy of 91%. PET/CT information may have detected misdiagnoses made by clinical assessment alone, improving overall accuracy to 96%. CONCLUSIONS: Assessment of tumor response at 12 weeks after CRT completion with PET/CT imaging may provide a useful additional tool with good overall accuracy for the selection of patients who may avoid unnecessary radical resection after achieving a complete clinical response. Cancer 2012;3501-3511. © 2011 American Cancer Society.
Assuntos
Imagem Multimodal , Tomografia por Emissão de Pósitrons , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/terapia , Tomografia Computadorizada por Raios X , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia/métodos , Quimioterapia Adjuvante , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Neoplasias Retais/mortalidade , Resultado do TratamentoRESUMO
Luego de la quimioradioterapia neoadyuvante un porcentaje de adenocarcinomas de recto bajo localmente avanzados presentarán remisión total de la lesión, a esto se lo conoce como Respuesta Clínica Completa; en estos casos la cirugía puede ser innecesaria. Nuestro grupo desde principios de los noventa ha incluído estos pacientes en un protocolo estricto de seguimiento que ha demostrado ser igual de seguro que el tratamiento convencional, sin las morbilidades de la cirugía radical. El presente reporte tiene por objeto definir lo que consideramos una Respuesta Clínica Completa, analizar sus implicancias y presentar nuestra experiencia en el manejo de este acontecimmiento.
After neoadjuvant chemoradiation, some patients with locally advanced low rectal adenocarcinoma will present with total tumor regression, this situation is known as Complete Clinical Response (CCR). In this setting immediate radical surgery could be unnecessary. Since the early nineties, our group has included this patients in a striet follow-up protocol, wich has proven to be oncologically equally safe as conventional treatment, without the morbidities of radical surgery. The objective of this report is to define what we consider a CCR and to present our experience in the management of this clinical situation.
Assuntos
Humanos , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/radioterapia , Tratamento Farmacológico , Terapia Neoadjuvante , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/radioterapia , Antígeno Carcinoembrionário , Diagnóstico por Imagem , Seguimentos , Leucovorina/administração & dosagem , Neoplasias Retais/cirurgia , Resultado do TratamentoRESUMO
Introducción: La incidencia del Cáncer de ano se encuentra en aumento tanto en pacientes HIV positivos o inmunosuprimidos como en los inmunocompetentes. Éste se asocia a la infección por HPV, con un comportamiento similar al del desarrollo del cáncer de cuello uterino, a través de la producción de lesiones intra-epiteliales escamosas (SIL). Para su diagnóstico se utiliza la anoscopía de alta resolución. Su tratamiento es aún controversial. Objetivo: Presentamos nuestra experiencia en el tratamiento quirúrgico de lesiones intra-epiteliales anales de alto grado (AIN III) guiadas con anoscopía de alta resolución. Lugar de aplicación o marco de referencia: Hospital Universitario. Diseño: Estudio retrospectivo. Material y métodos: Realizamos una revisión de los pacientes diagnosticados y operados (escisión/cauterización de las lesiones visualizadas con anoscopia de alta resolución) con diagnóstico de lesiones anales intra-epiteliales de alto grado (AIN III) en el marco del Programa de Prevención, Diagnóstico, Terapéutica y Vacunación en Patología del Tracto Genital Inferior del Hospital de Clínicas de Buenos Aires "José de San Martín". Resultados: A las pacientes con antecedentes de infección por HPV en el tracto genital inferior, se las evaluó con anoscopía magnificada. Entre enero de 2005 y agosto de 2010, se estudiaron 305 pacientes (32 inmunosuprimidas). De éstas, 18 (5.9%) presentaron lesiones intra-epiteliales de alto grado (AIN III) confirmadas por histología. Las mismas fueron remitidas para tratamiento quirúrgico. Tres eran inmunosuprimidas, dos por HIV. La edad media fue de 34 años (19-63 años). El seguimiento medio fue de 15 meses, 4 a 39 meses. Se produjo una recurrencia a los 4 meses. Ningún paciente desarrolló incontinencia, estenosis, infección postoperatoria, o hemorragia significativa después del tratamiento quirúrgico... (TRUNCADO)
Introduction: Over the last decades, anal cancer incidence rose to an epidemic range in general population and in some risk groups like inmuno-supressed or HIV patients. Anal cancer develops from squamous intraepithelial lesion (SIL) in the anal transitional zone produced by HPV infection. High resolution anoscopy is used to diagnose these dysplastic changes. There is no consensus about the best treatment option for high grade anal intraepithelial neoplasia (AIN III). Objective: To report our experience in the treatment of high grade anal intraepithelial neoplasia targeted by high resolution anoscopy. Design: Retrospective study. Material and method: Patients diagnose and treated for AIN III in the "Prevention, Diagnosis, Treatment and Vaccination of the Inferior Genital Tract" Program of the Hospital de Clínicas de Buenos Aires "José de San Martín". Results: Patients with history of HPV disease in the genital tract were studied with high resolution anoscopy. 305 patients (32 inmunosupressed) were studied between January of 2005 and August of 2010. 18 (5.9%) had AIN III and were surgically treated. Mean age was 34 years (19-63). Mean follow-up was 15 months (4 to 39). We observed one recurrenee at 4 month. No complications were present. Conclusions: High resolution anoscopy targeted surgery AIN III is feasible and seams to eradicate these lesions in the inmunocompetent patient.