RESUMO
BACKGROUND: Periampullary cancers are uncommon malignancies, often amenable to surgery. Several studies have suggested a role for adjuvant chemotherapy and chemoradiotherapy in improving survival of patients with periampullary cancers, with variable results. The aim of this meta-analysis was to determine the survival benefit of adjuvant therapy for periampullary cancers. METHODS: A systematic review was undertaken of literature published between 1 January 2000 and 31 December 2015 to elicit and analyse the pooled overall survival associated with the use of either adjuvant chemotherapy or chemoradiotherapy versus observation in the treatment of surgically resected periampullary cancer. Included articles were also screened for information regarding stage, prognostic factors and toxicity-related events. RESULTS: A total of 704 titles were screened, of which 93 full-text articles were retrieved. Fourteen full-text articles were included in the study, six of which were RCTs. A total of 1671 patients (904 in the control group and 767 who received adjuvant therapy) were included. The median 5-year overall survival rate was 37·5 per cent in the control group, compared with 40·0 per cent in the adjuvant group (hazard ratio 1·08, 95 per cent c.i. 0·91 to 1·28; P = 0·067). In 32·2 per cent of patients who had adjuvant therapy, one or more WHO grade 3 or 4 toxicity-related events were noted. Advanced T category was associated worse survival (regression coefficient -0·14, P = 0·040), whereas nodal status and grade of differentiation were not. CONCLUSION: This systematic review found no associated survival benefit for adjuvant chemotherapy or chemoradiotherapy in the treatment of periampullary cancer.
Assuntos
Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/cirurgia , Ampola Hepatopancreática/cirurgia , Neoplasias do Ducto Colédoco/tratamento farmacológico , Neoplasias do Ducto Colédoco/cirurgia , Neoplasias Duodenais/tratamento farmacológico , Neoplasias Duodenais/cirurgia , Adenocarcinoma/mortalidade , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Neoplasias do Ducto Colédoco/mortalidade , Neoplasias Duodenais/mortalidade , Humanos , Taxa de SobrevidaRESUMO
BACKGROUND: Intrahepatic recurrence of hepatocellular carcinoma (HCC) following resection is common. However, no current consensus guidelines exist to inform management decisions in these patients. Systematic review and meta-analysis of survival following different treatment modalities may allow improved treatment selection. This review aimed to identify the optimum treatment strategies for HCC recurrence. METHODS: A systematic review, up to September 2016, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of different treatment modalities was carried out using a random-effects model, with further assessment of additional prognostic factors for survival. RESULTS: Nineteen cohort studies (2764 patients) were included in final data analysis. The median 5-year survival rates after repeat hepatectomy (525 patients), ablation (658) and transarterial chemoembolization (TACE) (855) were 35·2, 48·3 and 15·5 per cent respectively. Pooled analysis of ten studies demonstrated no significant difference between overall survival after ablation versus repeat hepatectomy (hazard ratio 1·03, 95 per cent c.i. 0·68 to 1·55; P = 0·897). Pooled analysis of seven studies comparing TACE with repeat hepatectomy showed no statistically significant difference in survival (hazard ratio 1·61, 0·99 to 2·63; P = 0·056). CONCLUSION: Based on these limited data, there does not appear to be a significant difference in survival between patients undergoing repeat hepatectomy or ablation for recurrent HCC. The results also identify important negative prognostic factors (short disease-free interval, multiple hepatic metastases and large hepatic metastases), which may influence choice of treatment.
Assuntos
Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/terapia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/terapia , Carcinoma Hepatocelular/patologia , Ablação por Cateter , Quimioembolização Terapêutica , Hepatectomia , Humanos , Neoplasias Hepáticas/patologia , Recidiva Local de Neoplasia/patologia , PrognósticoRESUMO
The objective of this systematic review is to identify key components of enhanced recovery protocols (ERP) that lead to improved length of hospital stay (LOS) following esophagectomy. Relevant electronic databases were searched for studies comparing clinical outcome from esophagectomy followed by a conventional pathway versus ERP. Relevant outcome measures were compared and metaregression was performed to identify the key ERP components associated with reduced in LOS. Thirteen publications were included, ERP was associated with no changes in in-hospital mortality, total complications, anastomotic leak, or pulmonary complications compared with a conventional pathway, however LOS was reduced in the ERP group. Metaregression identified that immediate extubation was associated with reduced LOS (OR = -0.51, 95%CI -0.77 to -0.25; P < 0.01). Several postoperative factors were associated with a significant reduction in length of hospital stay, and in order of most important were (i) gastrograffin swallow ≤5 days (OR = -4.27, 95%CI -4.50 to -4.03); (ii) mobilization on postoperative day ≤1 (OR = -2.49, 95%CI -2.63 to -2.34); (iii) removal of urinary catheter ≤2 days (OR = -0.99, 95%CI -1.15 to -0.84); (iv) oral intake with at least sips of fluid ≤1 day (OR = -0.96, 95%CI -1.24 to -0.68); (v) enteral diet with feeding jejunostomy or gastrostomy ≤ 1 day (OR = -0.57, 95%CI -0.80 to -0.35) and (vi) epidural removal ≤ 4 days (OR = -0.17, 95%CI -0.27 to -0.07). Several core ERP components and principles appear to be associated with LOS reduction. These elements should form a part of the core ERP for the specialty, while surgical teams incorporate other elements through an iterative process.
Assuntos
Esofagectomia , Tempo de Internação , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/etiologia , Extubação , Analgesia Epidural , Meios de Contraste/administração & dosagem , Diatrizoato de Meglumina/administração & dosagem , Ingestão de Líquidos , Deambulação Precoce , Nutrição Enteral , Esofagectomia/efeitos adversos , Mortalidade Hospitalar , Humanos , Fatores de Tempo , Cateterismo UrinárioRESUMO
BACKGROUND: The aim was to evaluate the applicability of laparoscopic surgery in the treatment of primary rectal cancer in a training unit. METHODS: A cohort analysis was undertaken of consecutive patients undergoing elective surgery for primary rectal cancer over a 7-year interval. Data on patient and operative details, and short-term clinicopathological outcomes were collected prospectively and analysed on an intention-to-treat basis. RESULTS: A total of 306 patients (213 men, 69·6 per cent) of median (i.q.r.) age 67 (58-73) years with a median body mass index of 26·6 (23·9-29·9) kg/m(2) underwent surgery. Median tumour height was 8 (6-11) cm from the anal verge, and 46 patients (15·0 per cent) received neoadjuvant radiotherapy. Seven patients (2·3 per cent) were considered unsuitable for laparoscopic surgery and underwent open resection; 299 patients (97·7 per cent) were suitable for laparoscopic surgery, but eight were randomized to open surgery as part of an ongoing trial. Some 291 patients (95·1 per cent) underwent a laparoscopic procedure, with conversion required in 29 (10·0 per cent). Surgery was partially or completely performed by trainees in 72·4 per cent of National Health Service patients (184 of 254), whereas private patients underwent surgery primarily by consultants. Median postoperative length of stay for all patients was 6 days and the positive circumferential resection margin rate was 4·9 per cent (15 of 306). CONCLUSION: Supervised trainees can perform routine laparoscopic rectal cancer resection.
Assuntos
Conversão para Cirurgia Aberta/estatística & dados numéricos , Laparoscopia/educação , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Neoplasias Retais/cirurgia , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Proctocolectomia Restauradora/estatística & dados numéricos , Neoplasias Retais/patologia , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality. METHODS: MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data. RESULTS: Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy. CONCLUSION: Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).
Assuntos
Neoplasias Colorretais/cirurgia , Laparoscopia/métodos , Protocolos Clínicos , Neoplasias Colorretais/mortalidade , Estudos de Viabilidade , Humanos , Laparoscopia/mortalidade , Metanálise em Rede , Segurança do PacienteRESUMO
BACKGROUND: Muscle depletion is characterized by reduced muscle mass (myopenia), and increased infiltration by intermuscular and intramuscular fat (myosteatosis). This study examined the role of particular body composition profiles as prognostic markers for patients with colorectal cancer undergoing curative resection. METHODS: Patients with colorectal cancer undergoing elective surgical resection between 2006 and 2011 were included. Lumbar skeletal muscle index (LSMI), visceral adipose tissue (VAT) surface area and mean muscle attenuation (MA) were calculated by analysis of CT images. Reduced LSMI (myopenia), increased VAT (visceral obesity) and low MA (myosteatosis) were identified using predefined sex-specific skeletal muscle index values. Univariable and multivariable Cox regression models were used to determine the role of different body composition profiles on outcomes. RESULTS: Some 805 patients were identified, with a median follow-up of 47 (i.q.r. 24·9-65·6) months. Multivariable analysis identified myopenia as an independent prognostic factor for disease-free survival (hazard ratio (HR) 1·53, 95 per cent c.i. 1·06 to 2·39; P = 0·041) and overall survival (HR 1·70, 1·25 to 2·31; P < 0·001). The presence of myosteatosis was associated with prolonged primary hospital stay (P = 0·034), and myopenic obesity was related to higher 30-day morbidity (P = 0·019) and mortality (P < 0·001) rates. CONCLUSION: Myopenia may have an independent prognostic effect on cancer survival for patients with colorectal cancer. Muscle depletion may represent a modifiable risk factor in patients with colorectal cancer and needs to be targeted as a relevant endpoint of health recommendations.
Assuntos
Composição Corporal , Colectomia , Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos Eletivos , Obesidade Abdominal/complicações , Reto/cirurgia , Sarcopenia/complicações , Idoso , Neoplasias Colorretais/complicações , Neoplasias Colorretais/mortalidade , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Gordura Intra-Abdominal , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Músculo Esquelético , Obesidade Abdominal/diagnóstico , Obesidade Abdominal/epidemiologia , Complicações Pós-Operatórias/etiologia , Prevalência , Prognóstico , Sarcopenia/diagnóstico , Sarcopenia/epidemiologia , Análise de Sobrevida , Resultado do TratamentoRESUMO
Atypical teratoid rhabdoid tumour (ATRT) is a malignant tumour of the central nervous system with a dismal prognosis. There is no consensus on optimal treatment and different multimodal strategies are currently being used in an attempt to improve outcomes. To evaluate the impact of high-dose chemotherapy followed by autologous stem-cell rescue (HD48 SCR), radiotherapy (RT) at first line, intrathecal chemotherapy (IT) and extent of surgical resection upon recurrence-free survival (RFS) and overall survival (OS). An online database search identified prospective and retrospective studies focused on the treatment of children and adolescents with newly diagnosed ATRT. Clinical, therapeutic and outcome data were extracted and an individual pooled data analysis was conducted. Out of 389 publications, 12 manuscripts were included in our review. Data from 332 patients were analysed. Median age at diagnosis was 37 months (range 1-231). HD-SCR, RT and IT had been administered to 28.6% (58/203), 49.6% (118/238) and 21% (65/310) of the patients, respectively. Gross total resection (GTR) had been achieved in 46.5% (152/327) of the cases. In the multivariate analysis, hazard ratios (95% Confidence Interval) for HD-SCR were: RFS-HR = 0.570 (0.357-0.910) p = 0.019, and OS-HR = 0.388 (0.214-0.704) p = 0.002; and for RT: RFS-HR = 0.551 (0.351-0.866) p = 0.01, and OS-HR = 0.393 (0.216-0.712) p = 0.002. IT and GTR were not significantly associated with improved RFS or OS in the multivariate analysis. In our pooled data review, HD-SCR and RT at first line were associated with improved outcomes in children and adolescents with newly diagnosed ATRT.
Assuntos
Neoplasias do Sistema Nervoso Central/terapia , Tumor Rabdoide/terapia , Adolescente , Antineoplásicos/uso terapêutico , Criança , Terapia Combinada , Bases de Dados Factuais/estatística & dados numéricos , Transplante de Células-Tronco Hematopoéticas , Humanos , Radioterapia , Resultado do TratamentoRESUMO
AIM: Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old. METHOD: A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence. RESULTS: Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations. CONCLUSION: ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.
Assuntos
Colo/cirurgia , Cuidados Pós-Operatórios/métodos , Recuperação de Função Fisiológica , Reto/cirurgia , Fatores Etários , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Humanos , Tempo de Internação , Readmissão do Paciente , Reoperação , Fatores de TempoRESUMO
AIM: Chronic kidney disease (CKD) is increasing in prevalence and is associated with cardiovascular events and mortality in asymptomatic and vascular surgery populations. This study aimed to determine the role of CKD in stratifying peri- and postoperative risk for colorectal cancer (CRC) patients with nonmetastatic disease undergoing elective curative resection. METHOD: Patients diagnosed with nonmetastatic colorectal adenocarcinoma and undergoing surgical resection between 2006 and 2011 were identified from a prospectively collated database. Further information on survival and cause of death was gathered from a regional cancer registry. Estimated glomerular filtration rates were calculated using the Modification of Diet in Renal Disease (MDRD) equation. Kaplan-Meier survival curves were constructed for disease-free and overall survival. Multivariate Cox regression models were used to determine the role of CKD after stratification by several clinicopathological factors. RESULTS: Seven-hundred and eight colorectal resections were studied [median follow up: 45 (interquartile range, 21-65) months). Overall postoperative complications were similar, but patients with CKD were more likely to develop cardiovascular morbidity (P < 0.001) and 30-day mortality [4.8% (six of 124) in the CKD group vs 2.1% (12/580) in the non-CKD group]. Kaplan-Meier analysis revealed poorer overall survival for localized (Stage I-II; P = 0.019) and Stage III (P = 0.001) CRC in the CKD population. Multivariate Cox regression analysis identified CKD as an independent prognostic factor for noncancer death [hazard ratio (HR) = 1.82 (95% CI: 1.07-3.10); P = 0.027] but not for overall survival [HR = 1.21 (95% CI: 0.90-1.47); P = 0.116]. CONCLUSION: Patients with CKD may be more likely to develop cardiovascular complications following CRC resection and have an increased risk of a noncancer death. Future research should explore the interaction of CKD in competing mortality risks following CRC surgery.
Assuntos
Adenocarcinoma/cirurgia , Colectomia , Neoplasias Colorretais/cirurgia , Insuficiência Renal Crônica/complicações , Adenocarcinoma/complicações , Adenocarcinoma/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/complicações , Neoplasias Colorretais/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Enteropatias/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Artérias/cirurgia , Nádegas/irrigação sanguínea , Cóccix/cirurgia , Colectomia/efeitos adversos , Humanos , Enteropatias/etiologia , Masculino , Pessoa de Meia-Idade , Períneo/cirurgiaRESUMO
PURPOSE: To evaluate the safety and efficacy of timolol 0.5%/travoprost 0.004% combination (duotrav) as observed in primary open-angle glaucoma (POAG), ocular hypertension (OHT) and normal tension glaucoma (NTG) in real-life conditions. MATERIALS AND METHODS: Patients with uncontrolled intraocular pressure (IOP) on other medication and no contraindication to ß-blockers were switched to duotrav in 56 eyes of 28 patients. The drop in IOP was the primary outcome measured. RESULTS: Switch to duotrav provided an additional IOP reduction after 3-month follow-up that was statistically significant for those on latanoprost (P=0.02857), bimatoprost (P =0.04978) and travoprost (P =0.0078). Patients on latanotrost had an additional 25.9% drop 3 months after switching to duotrav while those on bimatoprost and travatan had 18.04% and 17.59% drop, respectively, after the switch. It was effective in lowering the IOP to clinically significant levels of ≤ 18.5 mmHg in POAG, NTG and OHT (12.5-17.9% drop), but not in chronic angle closure glaucoma. CONCLUSION: Duotrav was well-tolerated and produced significant additional IOP reduction when switched from other anti-glaucoma drugs in patients with uncontrolled glaucoma. It also achieved IOP of ≤ 18.5 mmHg in glaucoma patients.
Assuntos
Anti-Hipertensivos/uso terapêutico , Cloprostenol/análogos & derivados , Glaucoma de Ângulo Aberto/tratamento farmacológico , Pressão Intraocular/efeitos dos fármacos , Soluções Oftálmicas/uso terapêutico , Timolol/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Cloprostenol/uso terapêutico , Combinação de Medicamentos , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Hipertensão Ocular/tratamento farmacológico , Tonometria Ocular , Travoprost , Resultado do TratamentoRESUMO
Chemotherapy dosing is traditionally based on body surface area calculations; however, these calculations ignore separate tissue compartments, such as the lean body mass (LBM), which is considered a big pool of drug distribution. In our era, colorectal cancer patients undergo a plethora of computed tomography scans as part of their diagnosis, staging and monitoring, which could easily be used for body composition analysis and LBM calculation, allowing for personalised chemotherapy dosing. This systematic review aims to evaluate the effect of muscle mass on dose-limiting toxicity (DLT), among different chemotherapy regimens used in colorectal cancer patients. This review was carried out according to the PRISMA guidelines. MEDLINE and EMBASE databases were searched from 1946 to August 2019. The primary search terms were 'sarcopenia', 'myopenia', 'chemotherapy toxicity', 'chemotherapy dosing', 'dose limiting toxicity', 'colorectal cancer', 'primary colorectal cancer' and 'metastatic colorectal cancer'. Outcomes of interest were - DLT and chemotoxicity related to body composition, and chemotherapy dosing on LBM. In total, 363 studies were identified, with 10 studies fulfilling the selection criteria. Seven studies were retrospective and three were prospective. Most studies used the same body composition analysis software but the chemotherapy regimens used varied. Due to marked study heterogeneity, quantitative data synthesis was not possible. Two studies described a toxicity cut-off value for 5-fluorouracil and one for oxaliplatin based on LBM. The rest of the studies showed an association between different body composition metrics and DLTs. Prospective studies are required with a larger colorectal cancer cohort, longitudinal monitoring of body composition changes during treatment, similar body composition analysis techniques, agreed cut-off values and standardised chemotherapy regimens. Incorporation of body composition analysis in the clinical setting will allow early identification of sarcopenic patients, personalised dosing based on their LBM and early optimisation of these patients undergoing chemotherapy.
Assuntos
Composição Corporal , Neoplasias do Colo , Superfície Corporal , Humanos , Músculos , Estudos Prospectivos , Estudos RetrospectivosRESUMO
BACKGROUND: There is strong evidence suggesting that excessive fat distribution, for example, in the bowel mesentery or a reduction in lean body mass (sarcopenia) can influence short-, mid-, and long-term outcomes from patients undergoing various types of surgery. Body composition (BC) analysis aims to measure and quantify this into a parameter that can be used to assess patients being treated for abdominal wall hernia (AWH). This study aims to review the evidence linking quantification of BC with short- and long-term abdominal wall hernia repair outcomes. METHODS: A systematic review was performed according to the PRISMA guidelines. The literature search was performed on all studies that included BC analysis in patients undergoing treatment for AWH using Medline, Google Scholar and Cochrane databases by two independent reviewers. Outcomes of interest included short-term recovery, recurrence outcomes, and long-term data. RESULTS: 201 studies were identified, of which 4 met the inclusion criteria. None of the studies were randomized controlled trials and all were cohort studies. There was considerable variability in the landmark axial levels and skeletal muscle(s) chosen for analysis, alongside the methods of measuring the cross-sectional area and the parameters used to define sarcopenia. Only two studies identified an increased risk of postoperative complications associated with the presence of sarcopenia. This included an increased risk of hernia recurrence, postoperative ileus and prolonged hospitalisation. CONCLUSION: There is some evidence to suggest that BC techniques could be used to help predict surgical outcomes and allow early optimisation in AWH patients. However, the lack of consistency in chosen methodology, combined with the outdated definitions of sarcopenia, makes drawing any conclusions difficult. Whether body composition modification can be used to improve outcomes remains to be determined.
Assuntos
Parede Abdominal/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Herniorrafia/métodos , Sarcopenia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , PrognósticoRESUMO
The aim of this retrospective cohort study was to review urological complication rates arising from familial adenomatous polyposis associated desmoid tumours and their management. All patients over a 35-year period were identified from a prospectively maintained polyposis registry database and had an intra-abdominal desmoid tumour. Those without ureteric complications (n = 118, group A) were compared to those that developed ureteric obstruction (n = 40, group B) for demographics, treatment interventions and survival outcomes. 158 (56% female) patients were identified. Median age at diagnosis was 31 years and desmoids typically occurred 3.6 years after colectomy for familial adenomatous polyposis. Ureteric obstruction secondary to tumour growth occurred in 25% of cases. There was no significant difference in gender distribution or overall age at desmoid diagnosis between the two groups. In group B, the median age at desmoid diagnosis was significantly younger in women compared to men (25 and 43 years, respectively) (p = 0.01). Thirty-eight percent of patients already had ureteric obstruction at desmoid diagnosis, the remainder occurred after 48.6 months, but 20 years in two cases. Seventy-three percent (29/40) had ureteric stenting, a long-term requirement for most. Permanent renal injury occurred in six cases but survival between the two groups was not significantly different. Ureteric obstruction occurs frequently in patients with familial adenomatous polyposis and an intra-abdominal desmoid tumour. Those most at risk are the young following colectomy. Clinicians should actively survey the renal tract at regular intervals after a diagnosis of an intra-abdominal desmoid tumour as complications can arise insidiously, at any stage.
Assuntos
Neoplasias Abdominais/complicações , Polipose Adenomatosa do Colo/patologia , Fibromatose Agressiva/complicações , Obstrução Ureteral/etiologia , Neoplasias Abdominais/etiologia , Polipose Adenomatosa do Colo/cirurgia , Proteína da Polipose Adenomatosa do Colo/genética , Adulto , Estudos de Coortes , Colectomia , Feminino , Fibromatose Agressiva/etiologia , Humanos , Masculino , Mutação , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento , Obstrução Ureteral/diagnóstico por imagem , Obstrução Ureteral/terapiaRESUMO
BACKGROUND: Anti-tumour necrosis factor (TNF)s form a major part of therapy in Crohn's disease and have a primary nonresponse rate of 10%-30% and a secondary loss of response rate of 5% per year. Myopenia is prevalent in Crohn's disease and is measured using body composition analysis tools. AIM: To test the hypothesis that body composition can predict outcomes of anti-TNF primary nonresponse and secondary loss of response. METHODS: Between January 2007 and June 2012, 106 anti-TNF naïve patients underwent anti-TNF therapy for Crohn's disease with body composition parameters analysed using CT scans to estimate body fat-free mass. The outcome measures were primary nonresponse and secondary loss of response. COX-regression analysis was used with 3 year follow-up data. RESULTS: A total of 106 patients were included for analysis with 26 (24.5%) primary nonresponders and 29 (27.4%) with secondary loss of response to anti-TNF therapy. Sex-specific cut-offs for muscle and fat were ascertained by stratification analysis. On univariate analysis, primary nonresponse was associated with low albumin (OR 0.94; 0.88-0.99, P = .04) and presence of myopenia (OR 4.69; 1.83-12.01, P = .001) when taking into account patient's medical therapy, severity of disease and body composition. On multivariate analysis, presence of myopenia was associated with primary nonresponse (OR 2.93; 1.28-6.71, P = .01). Immunomodulator therapy was associated with decreased secondary loss of response (OR 0.48; 0.23-0.98, P = .04). BMI was poorly correlated with lean body mass (r2 = 0.15, P = .54). CONCLUSIONS: In this cohort study, body composition profiles did not correlate well with BMI. Myopenia was associated with primary nonresponse with potential implications for dosing and serves as an explanation for pharmacokinetic failure.
Assuntos
Composição Corporal , Doença de Crohn/tratamento farmacológico , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Estudos de Coortes , Doença de Crohn/diagnóstico por imagem , Feminino , Humanos , Imunoterapia , Masculino , Pessoa de Meia-Idade , Prevalência , Tomografia Computadorizada por Raios XRESUMO
Colorectal cancer (CRC) exhibits differences in incidence, pathogenesis, molecular pathways and outcome depending on the location of the tumor. This review focuses on the latest developments in epidemiological and scientific studies, which have enhanced our understanding on the underlying genetic and immunological differences between the proximal (right-sided) colon and the distal (left-sided) colorectum. The different ways in which environmental risk factors influence the pathogenesis of CRC depending on its location and the variations in surgical and oncological outcomes are also discussed in this review. In the current era of personalized medicine, we aim to reiterate the importance of tumor location in management of CRC and the implication on future clinical and scientific research.
Assuntos
Adenocarcinoma Mucinoso/patologia , Colo/patologia , Neoplasias Colorretais/patologia , Reto/patologia , Adenocarcinoma Mucinoso/metabolismo , Adenocarcinoma Mucinoso/mortalidade , Carcinoma/metabolismo , Carcinoma/mortalidade , Carcinoma/patologia , Colo/metabolismo , Neoplasias Colorretais/metabolismo , Neoplasias Colorretais/mortalidade , Humanos , Reto/metabolismoRESUMO
BACKGROUND: Strong evidence indicates that excessive adipose tissue distribution or reduced muscle influence short-, mid-, and long-term colorectal cancer outcomes. Computerized tomography-based body composition (CTBC) analysis quantifies this in a reproducible parameter. We reviewed the evidence linking computerized tomography (CT) based quantification of BC with short and long-term outcomes in colorectal cancer (CRC). METHODS: A systematic review was performed according to PRISMA guidelines. A literature search was performed by two independent reviewers on all studies that included CTBC analysis in patients undergoing treatment for CRC using Medline, EMBASE, Google Scholar, and Cochrane databases. Outcomes of interest included short-term recovery, oncological outcomes, and survival. RESULTS: Seventy-five studies were identified; sixteen met the inclusion criteria. None were randomized controlled trials and all were cohort studies of small sample size. Several types of CTBC image analysis software were identified, reporting subcutaneous, visceral and skeletal muscle tissues. Visceral obesity and reduced muscle mass were categorical parameters quantified by CTBC analysis. Due to marked study heterogeneity, quantitative data synthesis was not possible. High visceral adipose tissue and reduced skeletal muscle resulted in poorer short-term recovery (eleven studies), poorer oncological outcomes (six studies), and poorer survival (six studies). CONCLUSIONS: CTBC techniques may be linked to outcomes in colorectal cancer patients, however larger studies are required. CTBC based assessment may allow early identification of high-risk patients, allowing early optimisation of patients undergoing cancer treatments.
Assuntos
Adiposidade , Neoplasias Colorretais/terapia , Gordura Intra-Abdominal , Músculo Esquelético , Tomografia Computadorizada por Raios X , Neoplasias Colorretais/mortalidade , Humanos , Tempo de Internação , Duração da Cirurgia , Complicações Pós-Operatórias , Sarcopenia/complicações , Taxa de Sobrevida , Resultado do TratamentoAssuntos
Doença de Crohn , Fator de Necrose Tumoral alfa , Adalimumab , Humanos , Infliximab , Medicina de PrecisãoRESUMO
High-intensity focused ultrasound (HIFU) is a rapidly maturing technology with diverse clinical applications. In the field of oncology, the use of HIFU to non-invasively cause tissue necrosis in a defined target, a technique known as focused ultrasound surgery (FUS), has considerable potential for tumour ablation. In this article, we outline the development and underlying principles of HIFU, overview the limitations and commercially available equipment for FUS, then summarise some of the recent technological advances and experimental clinical trials that we predict will have a positive impact on extending the role of FUS in cancer therapy.
Assuntos
Medicina Baseada em Evidências/tendências , Ablação por Ultrassom Focalizado de Alta Intensidade/estatística & dados numéricos , Oncologia/tendências , Neoplasias/cirurgia , Ensaios Clínicos como Assunto , Humanos , Avaliação da Tecnologia Biomédica , Resultado do TratamentoRESUMO
Groin lump secondary to avulsion fracture of the adductor muscles of the middle thigh in the absence of any hernia is rare. The authors discuss a case of a young footballer who presented with a painful groin swelling. Surgical exploration revealed that the cause of the lump was an avulsion fracture of the adductor muscles.