Brazilian Society of Surgical Oncology: Guidelines for the management of anal canal cancer.

BACKGROUND: Anal canal squamous cell carcinoma (SCC) is a relatively uncommon neoplasia, and it is mostly a local-regional cancer, of low metastatic potential (only 15%), resulting in cure in most cases treated with definitive chemoradiation. On the other hand, its incidence has been steadily increasing over the last decades, which makes it an important public health problem. In an effort to provide surgeons and oncologists who treat patients with anal cancer with the most updated information based on the best scientific evidence, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guideline for the management of anal canal SCC, focused on the main topics related to daily clinical practice. OBJECTIVES: The SBCO developed the present guidelines to provide recommendations on the main topics related to the management of anal canal squamous cell carcinoma (SCC) based on current scientific evidence. METHODS: Between October 2022 and January 2023, 14 experts met to develop the guidelines for the management of anal canal cancer. A total of 30 relevant topics were distributed among the participants. The methodological quality of a final list with 121 sources was evaluated, all the evidence was examined and revised, and the management guidelines were formulated by the 14-expert committee. To reach a final consensus, all the topics were reviewed in a meeting that was attended by all the experts. RESULTS: The proposed guidelines contained 30 topics considered to be highly relevant in the management of anal canal cancer, covering subjects related to screening recommendations, preventive measures, tests required for diagnosing and staging, treatment strategies, response assessment after chemoradiotherapy, surgical technique-related aspects, and follow-up recommendations. In addition, screening and response assessment algorithms, and a checklist were proposed to summarize the important information and offer an updated tool to assist surgeons and oncologists who treat anal canal cancer and in providing the best care to their patients. CONCLUSION: These guidelines summarize recommendations based on the most current scientific evidence on relevant aspects of anal canal cancer management and are a practical guide to help surgeons and oncologists who treat anal canal cancer make the best therapeutic decisions.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES: The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS: Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS: The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION: These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Quality of life in a randomized trial comparing two neoadjuvant regimens for locally advanced rectal cancer-INCAGI004.

BACKGROUND: Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC), but the emergence of different drug regimens may result in different response rates. Good clinical response translates into greater sphincter preservation, but quality of life (QOL) may be impaired after treatment due to chemoradiotherapy and surgical side effects. OBJECTIVE: To prospectively evaluate the impact of clinical response and surgical resection on QOL in a randomized trial comparing two different neoCRT regimens. METHODS: Stage II and III rectal cancer patients were randomized to receive neoCRT with either capecitabine (group 1) or 5-Fu and leucovorin (group 2) concomitant to long-course radiotherapy. Clinical downstaging was accessed using MRI 6-8 weeks after treatment. EORTCs QLQ-C30 and CR38 were applied before treatment (T0), after neoCRT (T1), after rectal resection (T2), early after adjuvant chemotherapy (T3), and 1 year after the end of treatment or stoma closure (T4). The Wexner scale was used for fecal incontinence evaluation at T4. A C30SummaryScore (Geisinger and cols.) was calculated to compare QOL results. RESULTS: Thirty-two patients were assigned to group 1 and 31 to group 2. Clinical downstaging occurred in 70.0% of group 1 and 53.3% of group 2 (p = 0.288), and sphincter preservation was 83.3% in group 1 and 80.0% in group 2 (p = 0.111). No significant difference in QOL was detected when comparing the two treatment groups after neoCRT using QLQ-C30. However, the CR38 module detected differences in micturition problems (15.3 points), gastrointestinal problems (15.3 points), defecation problems (11.8 points), and sexual satisfaction (13.3 points) favoring the capecitabine group. C30SummaryScore detected significant improvement comparing T0 to T1 and deterioration comparing T1 to T2 (p = 0.025). The mean Wexner scale score was 9.2, and a high score correlated with symptoms of diarrhea and defecation problems at T4. CONCLUSIONS: QOL was equivalent between groups after neoCRT except for micturition problems, gastrointestinal problems, defecation problems, and sexual satisfaction favoring the capecitabine arm after. The overall QOL using the C30SummaryScore was improved after neoCRT, but decreased following rectal resection, returning to basal levels at late evaluation. Fecal incontinence was high after sphincter preservation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03428529.

Primary colorectal diffuse large B-cell lymphoma: A report of eighteen cases in a tertiary care center.

Primary colorectal diffuse large B-cell lymphoma (DLBCL) is very rare colon malignancy. It is important to know the main demographic and clinical characteristics of these patients. We conducted a retrospective analysis of 18 patients diagnosed with primary colorectal DLBCL during a 17-year period at the National Cancer Institute of Brazil (INCA) between 2000 and 2018. Demographic characteristics, tumor localization, HIV status, lactate dehydrogenase (LDH) levels, treatment modality and follow-up status were obtained from medical records. Survival was estimated from the date of diagnosis until death. There were 11 male and seven female patients in our cohort, the median age at diagnosis was 59.5 years and four patients were HIV positive. Tumor was mainly localized in the right colon. Patients were treated with chemotherapy (CT) and/or surgical resection. Eleven patients died during a median follow-up of 59 months and the median survival time was 10 months. Six or more cycles of CT (HR=0.19; CI 95% 0.054-0.660, p = 0.009), LDH levels below 350 U/L (HR=0.229; CI 95% 0.060-0.876, p = 0.031) and surgical resection (HR=0.23; CI 95% 0.065-0.828, p = 0.030) were associated with reduced risk of death in univariate analysis. Patient's age and DLBCL right colon localization should be considered at diagnosis to distinguish between DLBCL and other diseases for differential diagnosis. Six cycles of CT, LDH levels below 350 U/L and surgical resection were associated with better survival. Our results are consistent with previous publications and address the importance of correct colorectal DLBCL diagnosis and treatment.

Involvement of signaling molecules in the prediction of response to imatinib treatment in metastatic GIST patients.

Imatinib therapy has undoubtedly contributed to the treatment of metastatic gastrointestinal stromal (GIST) tumors that were previously untreatable. However, disease progression during treatment with tyrosine kinase inhibitors remains an issue in clinical practice not fully explained by KIT and PDGFRA mutation status. We investigated the role of three important signaling molecules (insulin-like growth factor 1 receptor [IGF1R], protein kinase C-θ [PKCθ], and Raf kinase inhibitor protein [RKIP]) that have been implicated in GIST pathogenesis as potential biomarkers for prediction of response to imatinib treatment. We retrospectively reviewed 76 patients with metastatic GIST submitted to imatinib treatment between 2002 and 2007, and analyzed 63 of them. Insulin-like growth factor 1, total PKCθ, phosphorylated PKCθ, and RKIP immunohistochemical expression were correlated with objective response to imatinib treatment and progression-free and overall survival. Median follow-up was 31.2 mo (95% confidence interval, 26.3-36.1 mo). There was a statistically significant association between IGF1R expression and type of response to imatinib treatment (P = 0.05)-that is, higher IGF1R expression was related to lower objective response. However, IGF1R higher expression did not affect progression-free and overall survival. Insulin-like growth factor 1, but not PKCθ and RKIP, emerges as a potential biomarker for prediction of response to imatinib treatment in metastatic GISTs. Validation studies are warranted.

Induction Chemotherapy and Chemoradiotherapy Combined to ASA vs. Placebo for High-Risk Rectal Cancer: Results of a Randomized Trial.

INDUCTION: chemotherapy (IC) followed by chemoradiation (CRT) is an attractive approach in high-risk locally advanced rectal cancer. Additionally, ASA has shown potential to improve outcomes alongside CRT in rectal cancer. The ICAR trial aimed to evaluate the safety and efficacy of IC followed by CRT with or without ASA on MRI tumor response. METHODS: Single-center, double-blind, randomized phase II trial to evaluate induction treatment with CAPOX, followed by capecitabine-based chemoradiotherapy with ASA (arm 1) or placebo (arm 2) in high-risk stage II-III rectal adenocarcinoma staged by MRI. The primary endpoint was MRI tumor regression grade (mrTRG). Secondary endpoints were pathological response, surgical outcomes, postoperative complications, treatment tolerance, DFS, and OS. RESULTS: Between January 2018 and August 2019, 27 patients were eligible, 25 (92.5%) completed IC, and 23 patients were randomly assigned (12 to ASA group; 11 to placebo group). In the ASA arm, 3 pts (25%) presented distant disease progression at restaging. Seven patients (30.4%) had cCR after neoadjuvant treatment. All 13 patients submitted to surgery after neoadjuvant treatment underwent R0 resections except for 1 patient with positive CRM, and 12 patients (92.3%) had sphincter preservation. After a median follow-up of 34.9 months, the 2-year DFS was 83.1% and 3-year OS was 81.5%. CONCLUSION: There was good compliance in both treatment arms and encouraging cCR rate. ASA during CRT was safe but failed to improve on MRI tumor response. The study was closed due to the absence of benefits.

Extragastrointestinal stromal tumors (EGIST): a series of case reports.

BACKGROUND/AIM: Gastrointestinal stromal tumors (EGIST) are mesenchymal tumors which may originate in sites outside the gastrointestinal tract with clinico-pathological and molecular profiles similar to GISTs. Here is a series of case reports from The National Cancer Institute (INCA) about this rare type of tumor. METHODOLOGY: We retrospectively analyzed 142 patients with a diagnosis of GIST who were treated at INCA between 1997 and 2009, among which 9 were confirmed as having EGIST. RESULTS: We identified 9 patients with a diagnosis of EGIST, 7 of which (77.8%) were female patients with an average age of 56.8 (36-81) years. All patients were symptomatic, with abdominal pain present in 55% of cases. The tumors were located in the pancreas (n=2), in the retroperitoneum (n=3), and in the mesocolon, in the mesentery of the small intestine, in the spleen and in the pelvis (all n=1), respectively. The average tumor size was 18(8.5-27)cm. Immunohistochemistry revealed CD 117 positive in 100% of cases and CD34 positive in 62.5%. Five patients were treated surgically, three of which were submitted to R0 resection. Among those patients, all recurred after 31, 23 and 17 months respectively, and the most frequent sites were the liver and the peritoneum. Out of these three recurrences, two were "rescued" surgically (66%). Five patients were given imatinib (three patients considered unresectable, one submitted to R2 resection and another patient with recurrent disease not amenable to surgery) two patients did not receive any treatment due to compromised clinical conditions. The average overall survival was 26.4 (04-114) months. CONCLUSION: The occurrence of EGIST is extremely rare and little is known about their actual origin. They manifest through bulky masses, which compromise the prognosis. Aggressive surgical intervention is the most effective treatment associated with the use of imatinib, and a strict followup is necessary due to high recurrence rates.

The Evolving Field of Neoadjuvant Therapy in Locally-advanced Rectal Cancer: Evidence and Prospects.

The standard treatment of locally advanced rectal cancer comprises neoadjuvant chemoradiation followed by total mesorectal excision. This strategy provides low local recurrence rate, however distant recurrence is still an issue and may impact on survival rates. Novel approaches in the neoadjuvant setting have been tested to improve early and late outcomes, as well as to reduce treatment-related toxicity and morbidity. In this review, we discuss the current literature of neoadjuvant treatment in locally advanced rectal cancer, including total neoadjuvant methods, protocols for radiation delivery, chemotherapy regimen and efforts to add novel targeted therapies, selective withdrawal of surgery or radiotherapy, and future perspectives. Moreover, we highlight relevant issues that have emerged with these new treatment possibilities.

Colorectal GISTs: from presentation to survival. An analysis of 13 cases.

This papers is a retrospective analysis of all cases of colorectal GIST treated at our institution. Considering the increased interest in this pathology, in 2008, we recently established a unit supported by Novartis in our department to research and treat GIST. Since then, there was a dramatic increase in the referral of this type of tumor to our center. Before initiating our research group, we had the permission of the ethics committee and the medical directors to study and publish the analysis of our cases. Now, we have a cohort of 98 patients treated during the last 10 years and from that, we selected all cases of Colorectal GIST's. They numbered 13 cases. We performed an analysis of these cases from the presentation to the results of treatment.

Do We Have to Treat All T3 Rectal Cancer the Same Way?

Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation.

What is the prognostic significance of metastatic lymph nodes in GIST?

BACKGROUND/AIMS: So many variables have been identified as prognostic factors influencing survival after curative resection in gastrointestinal stromal tumors (GIST), but the role of lymph node metastasis remains uncertain. METHODOLOGY: Twenty-nine patients with c-Kit positive gastric GIST who underwent surgical resection at the Brazilian National Cancer Institute between 1983 and 2004 were reviewed retrospectively. The prognostic significance of lymph node metastasis was investigated. The endpoints were overall survival and disease free survival. RESULTS: The median follow-up was 35 months. The 5-years estimate survival rate was 53%. Three patients presented lymph node metastasis and developed recurrence disease. Univariate analysis for overall survival identified the size >13.5cm (p = 0.01) and recurrence (p = 0.03) as prognostic factors. Size > 13.5cm and recurrence were independent factors (p = 0.01 and p = 0.03, respectively) in the multivariate analysis. Univariate analysis for disease free survival identified the size > 13.5cm (p = 0.04) and the grade (p = 0.04) as prognostic factors but, only the size > 13.5cm was an independent factor in the multivariate analysis. Lymph node metastasis had no prognostic significance for overall and disease free survival (p = 0.65 and p = 0.57, respectively). CONCLUSIONS: GIST lymph node metastasis was not related to poor survival in this study, but more studies are needed to identify the real incidence and the proper role of the GIST metastatic nodal disease.

[Analysis of the age-period-cohort effect on mortality from colorectal cancer in Rio de Janeiro State, Brazil, from 1980 to 2014]. / Análise do efeito idade-período-coorte na mortalidade por câncer colorretal no Estado do Rio de Janeiro, Brasil, no período 1980 a 2014.

The aim of this study was to estimate the contribution of the effect of age, period, and birth cohort on mortality from colorectal cancer. The study analyzed data on deaths from this cancer in individuals over 35 years of age in Rio de Janeiro State, Brazil, obtained from the Mortality Information System (SIM) from 1980 to 2014. Mortality rates were calculated by gender and age bracket. The effect of age, period, and birth cohort was estimated by the method that uses estimable functions: deviations, curves, and drift in the Epi library of the R software. Standardized mortality rates from colorectal cancer were 27.37/100,000 men and 21.83/100,000 women in 2014. The data showed an increase in mortality from this cancer from 1980 to 2014, and mortality rates were higher in men than in women after the 1990s. Age effect was observed with an increase in the rates and aging. Generational analysis showed lower risk of death in older versus younger cohorts, possibly related to the adoption of the Western lifestyle. This scenario underscores the need for screening strategies aimed at early diagnosis and treatment of precursor lesions.

O objetivo deste trabalho foi estimar a contribuição do efeito da idade, do período e da coorte de nascimento na mortalidade por câncer colorretal. Foram analisados dados de óbitos pela neoplasia entre indivíduos com mais de 35 anos de idade do Estado do Rio de Janeiro, Brasil, extraídos do Sistema de Informações sobre Mortalidade (SIM) entre 1980 e 2014. As taxas de mortalidade foram calculadas por gênero e faixa etária. O efeito da idade, período e coorte de nascimento foi estimado pelo método que utiliza funções estimáveis: desvios, curvaturas e drift, na biblioteca Epi do software R. As taxas de mortalidade por câncer colorretal padronizadas foram 27,37/100 mil homens e 21,83/100 mil mulheres em 2014. Verificou-se aumento da mortalidade pela neoplasia entre 1980 e 2014, sendo as taxas de mortalidade entre homens superiores às das mulheres após a década de 1990. O efeito idade foi observado com o aumento das taxas e o envelhecimento. A análise das gerações mostrou o menor risco de óbito nas coortes mais antigas comparadas às mais recentes coortes, o que pode estar ligado à adoção do estilo de vida ocidental. Tal cenário aponta a relevância da implantação de estratégias de rastreamento visando ao diagnóstico e ao tratamento precoce de lesões precursoras da doença.

El objetivo de este trabajo fue estimar la contribución del efecto de la edad, del período y de la cohorte de nacimiento en la mortalidad por cáncer colorrectal. Se analizaron datos de óbitos por la neoplasia entre individuos con más de 35 años de edad del estado de Río de Janeiro, Brasil, extraídos del Sistema de Informaciones sobre Mortalidad (SIM) entre 1980 y 2014. Las tasas de mortalidad fueron calculadas por género y franja de edad. El efecto de la edad, período y cohorte de nacimiento fue estimada por el método que utiliza funciones estimables: desvíos, curvaturas y drift, en la biblioteca Epi del software R. Las tasas de mortalidad por cáncer colorrectal estandarizadas fueron 27,37/100 mil hombres y 21,83/100 mil mujeres en 2014. Se verificó un aumento de la mortalidad por la neoplasia entre 1980 y 2014, siendo las tasas de mortalidad entre hombres superiores a las de las mujeres tras la década de 1990. El efecto edad se observó con el aumento de las tasas y el envejecimiento. El análisis de las generaciones mostró un menor riesgo de óbito en las cohortes más antiguas, comparadas con las cohortes más recientes, lo que puede estar vinculado a la adopción del estilo de vida occidental. Tal escenario apunta la relevancia de la implantación de estrategias de monitoreo con el objetivo del diagnóstico y el tratamiento precoz de lesiones precursoras de la enfermedad.

Factors affecting local regrowth after watch and wait for patients with a clinical complete response following chemoradiotherapy in rectal cancer (InterCoRe consortium): an individual participant data meta-analysis.

BACKGROUND: In patients with rectal cancer who achieve clinical complete response after neoadjuvant chemoradiotherapy, watch and wait is a novel management strategy with potential to avoid major surgery. Study-level meta-analyses have reported wide variation in the proportion of patients with local regrowth. We did an individual participant data meta-analysis to investigate factors affecting occurrence of local regrowth. METHODS: We updated search results of a recent systematic review by searching MEDLINE and Embase from Jan 1, 2016, to May 5, 2017, and used expert knowledge to identify published studies reporting on local regrowth in patients with rectal cancer managed by watch and wait after clinical complete response to neoadjuvant chemoradiotherapy. We restricted studies to those that defined clinical complete response using criteria equivalent to São Paulo benchmarks (ie, absence of residual ulceration, stenosis, or mass within the rectum on clinical and endoscopic examination). The primary outcome was 2-year cumulative incidence of local regrowth, estimated with a two-stage random-effects individual participant data meta-analysis. We assessed the effects of clinical and treatment factors using Cox frailty models, expressed as hazard ratios (HRs). From these models, we derived percentage differences in mean θ as an approximation of the effect of measured covariates on between-centre heterogeneity. This study is registered with PROSPERO, number CRD42017070934. FINDINGS: We obtained individual participant data from 11 studies, including 602 patients enrolled between March 11, 1990, and Feb 13, 2017, with a median follow-up of 37·6 months (IQR 25·0-58·7). Ten of the 11 datasets were judged to be at low risk of bias. 2-year cumulative incidence of local regrowth was 21·4% (random-effects 95% CI 15·3-27·6), with high levels of between-study heterogeneity (I2=61%). We noted wide between-centre variation in patient, tumour, and treatment characteristics. We found some evidence that increasing cT stage was associated with increased risk of local regrowth (random-effects HR per cT stage 1·40, 95% CI 1·00-1·94; ptrend=0·048). In a subgroup of 459 patients managed after 2008 (when pretreatment staging by MRI became standard), 2-year cumulative incidence of local regrowth was 19% (95% CI 13-28) for stage cT1 and cT2 tumours, 31% (26-37) for cT3, and 37% (21-60) for cT4 (random-effects HR per cT stage 1·50, random-effects 95% CI 1·03-2·17; ptrend=0·0330). We estimated that measured factors contributed 4·8-45·3% of observed between-centre heterogeneity. INTERPRETATION: In patients with rectal cancer and clinical complete response after chemoradiotherapy managed by watch and wait, we found some evidence that increasing cT stage predicts for local regrowth. These data will inform clinician-patient decision making in this setting. Research is needed to determine other predictors of a sustained clinical complete response. FUNDING: None.

Transanal minimally invasive surgery for total mesorectal excision (ETM) through transanal approach (TaETM) with robotic and Transanal Endoscopic Operations (TEO) combined access: step by step surgery.

RATIONAL: In the treatment of colorectal cancer, from 1982 Heald proposed standardization of the total mesorectal excision, with a significant reduction in the recurrence rate. But the treatment of lower rectal lesions is still a challenge. AIM: To describe the association of robotic low anterior resection- TATA (Transanal Abdominal Transanal Resection), with transanal access using Transanal Endoscopic Operations - TEO in the treatment of lower rectal cancer. METHOD: The TATA performs robotic abdominal approach and the TEO performs the perineal approach, developing total mesorectal excision (TME) transanally (TaETM). RESULT: The TaETM technique was applied in a woman with rectal adenocarcinoma 5 cm from the anal verge that had been submitted to chemoradiation. The procedure was performed with satisfatory operative time and favorable oncological outcome (grade 3 mesorectal excision). CONCLUSION: This is a promising minimally invasive procedure in the armamentarium of rectal cancer treatment, specially in challenging scenarios such as narrow pelvis, obesity and very low rectal tumors.

Robotic transanal ressection for rectal tumor: a description of the technique / Ressecção transanal robótica para tumor retal: uma descrição da técnica

ABSTRACT Introduction: Robotic transanal surgery (RTS) is the analog of TAMIS and represents a new focus for the advancement of transanal platforms robotic transanal surgery is sometimes referred to as robotic TAMIS. Though limited to only a few centers world-wide, experience with robotic transanal surgery has been encouraging. Most research with robotic transanal surgery has concentrated on local excision of rectal neoplasia, although more complex procedures such as transanal proctectomy are possible using the robotic approach. This article reports the surgical technique of R-TAMIS performed in the Brazilian National Cancer Institute (INCA, Rio de Janeiro). Methods: 71-year-old, female with cardiologic disease (heart failure), with a 1.5 cm rectal neoplasm at 4 cm from the anal verge in the right anterolateral position. Biopsy revealed neuroendocrine tumor. A compete colonoscopy revealed no evidence of synchronous lesions. Work-up included 3D endorectal ultrasonography and magnetic resonance imaging, which demonstrated the lesion to be uT1uN0. The patient was counseled about surgical options − local excision versus low anterior resection. Due to the cardiologic condition, the patient was elected to proceed with local excision with robotic transanal surgery. Conclusion: Robotic TAMIS is a safe and effective operative procedure for high selected cases of rectal neoplasm. It enhances surgeon ergonomics and facilitates tumor removal and suture in the transanal approach.

RESUMO Introdução: A cirurgia transanal robótica (RTS,Robotic Transanal Surgery) é análoga da TAMIS (cirurgia minimamente invasiva transanal) e representa um novo foco para o avanço das plataformas transanais. A cirurgia transanal robótica é algumas vezes chamada de TAMIS robótica. Embora limitada a apenas alguns centros em todo o mundo, a experiência com a cirurgia transanal robótica tem sido encorajadora. A maioria das pesquisas com cirurgia transanal robótica tem se concentrado na excisão local da neoplasia retal, embora procedimentos mais complexos, como a proctectomia transanal, sejam possíveis utilizando a abordagem robótica. Este artigo relata a técnica cirúrgica de R-TAMIS realizada no Instituto Nacional do Câncer (INCA, Rio de Janeiro). Métodos: paciente de 71 anos, sexo feminino, com doença cardiológica (insuficiência cardíaca), com neoplasia retal de 1,5 cm a 4 cm da borda anal em posição anterolateral direita. A biópsia revelou tumor neuroendócrino. Uma colonoscopia completa não revelou evidências de lesões sincrônicas. A investigação incluiu ultrassonografia endorretal em 3D e ressonância magnética, que demonstrou que a lesão era uT1uN0. A paciente foi aconselhada sobre as opções cirúrgicas - excisão localversus ressecção anterior baixa. Devido à condição cardiológica, optou-se por proceder à excisão local com cirurgia transanal robótica. Conclusão: A TAMIS robótica é um procedimento cirúrgico seguro e eficaz para casos altamente selecionados de neoplasia retal. Ela melhora a ergonomia do cirurgião e facilita a remoção do tumor e a sutura na abordagem transanal.

Buschke-Lowenstein tumor in a patient with HIV and Psoriasis / Tumor de Buschke-Lowenstein em um paciente com HIV e psoríase

Abstract The Buschke-Lowenstein tumor, known as the giant condyloma acuminatum, is a rare lesion of the anorectal and PerianaL region; it is sexually transmitted and associated with human papilloma virus, types 6 and 11. Histologically, it is a benign tumor, but it can reach big proportions and may behave aggressively. The purpose of this study is to report the case of a patient diagnosed with HIV and psoriasis 14 years ago, associated with Buschke-Lowenstein tumor and other diffuse condylomatous lesions in the body.

Resumo O tumor de Buschke-Lowenstein, também conhecido como condiloma acuminado gigante, é uma lesão rara da região anorretal e perianal, sexualmente transmitida, associada ao papiloma vírus humano, Tipos 6 e 11. Histologicamente, trata-se de um tumor benigno, mas clinicamente atinge grandes proporções e pode se comportar de forma agressiva. O objetivo deste estudo é relatar o caso de um paciente com diagnóstico de HIV e psoríase há 14 anos, associado ao tumor de Buschke-Lowenstein e outras lesões condilomatosas difusas no corpo.

The role of staging laparoscopy in treatment of locally advanced gastric cancer.

PURPOSE: The aim of this study was to evaluate the role of videolaparoscopy (VLP) in gastric cancer staging, particularly for the detection of peritoneal cancer, to verify its impact in changing the therapeutic conduct, as well as defining the characteristics of the group that can benefit from VLP as staging method. PATIENTS AND METHODS: A prospective cohort study was conducted from May 2011 to March 2013. Thirty-two patients with gastric adenocarcinoma underwent conventional staging together with VLP staging. RESULTS: VLP identified peritoneal disease in 22.6% of patients. Sensitivity was 86%, and specificity was 100%. In the group with non-Borrmann IV, <8 cm tumors, and without evidence of lymphadenomegaly, VLP identified peritoneal implants in 23.1% of cases. CONCLUSIONS: VLP is a safe procedure capable of improving the accuracy of gastric cancer staging. There is no justification for failing to perform laparoscopy in patients with <8 cm, non-Borrmann type IV tumors and without evidence of lymphadenomegaly on preoperative examinations.

Laparoscopic versus robotic approach in rectal cancer / Abordagem laparoscópica ou robótica no câncer retal

Abstract The treatment of rectal cancer is complex and responsible for sequelae due to the various therapeutic modalities, especially the surgical resection. The advent of minimally invasive surgery provided a faster postoperative recovery and a lower complication rate when compared to conventional surgery. The implementation of laparoscopic approach in rectal cancer was responsible for these better results, but the limitations of this method added to the development of robotics, raised the question of which minimally invasive method would be more advantageous in the approach of rectal cancer. The present review will address the most recent data regarding the comparison between the laparoscopic and robotic approach in rectal cancer.

Resumo O tratamento do câncer de reto é complexo e responsável por sequelas causadas pelas diversas modalidades terapêuticas, principalmente a ressecção cirúrgica. O advento da cirurgia minimamente invasiva está associado a uma recuperação pós-operatória mais rápida e uma menor taxa de intercorrências do que as observadas na cirurgia convencional. A implementação da abordagem laparoscópica no câncer de reto foi responsável por esses melhores resultados, mas as limitações do método, bem como o desenvolvimento da cirurgia robótica, levantaram a questão de qual método minimamente invasivo seria mais vantajoso na abordagem desse tipo de câncer. A presente revisão apresenta os dados mais recentes na comparação entre a abordagem laparoscópica e robótica no câncer retal.

Multiple approaches to sexually transmitted infections: from diagnosis to treatment

ABSTRACT Sexually transmitted infections are mainly caused by viruses and bacteria. They are transmitted trough sexual intercourse, without a condom, with an infected individual. The anus, vagina, and mouth may become involved. This study aimed to present six clinical cases with the diagnosis of sexually transmitted infections, but in which different treatment approaches were required. This demonstrates the dynamic and unique character of the disease in each individual. That is, the behavior of sexually transmitted infections will vary not only according to its causative microorganism (virus or bacteria), but also according to the characteristics of the combination of etiologic agent and host.

RESUMO As infecções sexualmente transmissíveis são causadas, principalmente, por vírus e bactérias. Por meio do contato sexual, sem preservativo, com um indivíduo que esteja infectado. O ânus, a vagina e a boca podem se tornar órgãos acometidos. O objetivo deste trabalho é apresentar 06 casos clínicos com o diagnóstico de infecções sexualmente transmissíveis, mas que para serem tratados foram necessárias diferentes abordagens. Isso demonstra o caráter dinâmico e singular da doença em cada indivíduo. Ou seja, o comportamento das infecções sexualmente transmissíveis vai variar não somente conforme o seu microrganismo causador (vírus × bactéria), mas também de acordo com o conjunto (agente etiológico + hospedeiro).

Colorectal robotic surgery: INCA's experience / Cirurgia robótica colorretal: experiência do INCA

ABSTRACT Introduction: Minimally invasive surgery has revolutionized surgical management in the treatment of colorectal neoplasms, reducing morbidity and mortality, hospitalization, inactivity time and minimizing cost, as well as providing adequate oncological results when compared to the conventional approach. Robotic surgery, with Da Vinci Platform, emerges as a step ahead for its potentials. The objective of this article is to report the single institutional experience with the use of Da Vinci Platform in robotic colorectal surgeries performed at a reference center in oncological surgery in Brazil. Materials and methods: A retrospective cohort study was conducted based on the prospective database of patients from the institution submitted to robotic surgery for treatment of colorectal cancer from July 2012 to September 2017. Clinical and surgical variables were analyzed as predictors of morbidity and mortality. Results: A total of 117 patients underwent robotic surgery. The complications related to surgery occurred in 33 patients (28%), the most frequent being anastomotic fistula and surgical wound infection, which corresponded to 11% and 3%, respectively. Conversion rate was 1.7%. Median length of stay was 5 days. The only variable associated with increase of complications and death risk was BMI >30, with p-value of 0.038 and 0.027, respectively. Conclusion: Robotic surgery is safe and feasible for approaching colorectal cancer surgeries, presenting satisfactory results regarding length of hospital stay and rate of operative complications, as well as presenting a low rate of conversion. Obesity has been shown to be a risk factor for surgical complication in robotic colorectal surgery.

RESUMO Introdução: A cirurgia minimamente invasiva revolucionou o tratamento cirúrgico no manejo das neoplasias colorretais, reduzindo a morbidade e mortalidade, a hospitalização, o tempo de inatividade e minimizando os custos, além de fornecer resultados oncológicos adequados quando comparada à abordagem convencional. A cirurgia robótica, com a Plataforma Da Vinci, surge como um passo à frente por seus potenciais. O objetivo deste artigo é relatar a experiência institucional única com o uso da Plataforma Da Vinci em cirurgias robóticas colorretais realizadas em um centro de referência em cirurgia oncológica no Brasil. Materiais e métodos: Foi realizado um estudo de coorte retrospectivo, baseado na base de dados prospectiva de pacientes da instituição que foram submetidos à cirurgia robótica para tratamento de câncer colorretal, de julho de 2012 a setembro de 2017. As variáveis clínicas e cirúrgicas foram analisadas como preditores de morbidade e mortalidade. Resultados: Um total de 117 pacientes foram submetidos à cirurgia robótica. As complicações relacionadas à cirurgia ocorreram em 33 pacientes (28%), sendo as mais frequentes fístula anastomótica e infecção da ferida cirúrgica, correspondendo a 11% e 3%, respectivamente. A taxa de conversão foi de 1,7%. O tempo mediano de permanência foi de 5 dias. A única variável associada ao aumento de complicações e risco de óbito foi o IMC >30, com p-valor de 0,038 e 0,027, respectivamente. Conclusão: A cirurgia robótica é segura e viável para a abordagem de cirurgias de câncer colorretal, apresentando resultados satisfatórios quanto ao tempo de internação hospitalar e taxa de complicações operatórias, além de apresentar baixo índice de conversão. A obesidade tem se mostrado um fator de risco para complicações cirúrgicas na cirurgia colorretal robótica.