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.

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.

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.

Surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision for low rectal cancer / Resultados cirúrgicos e oncológicos no curto prazo para a excisão abdominoperineal extra-levantador em pronação para câncer retal baixo

ABSTRACT Introduction: In recent years, a standardized surgical approach for low rectal cancer was proposed and adopted in many centres. The extralevator abdominoperineal excision introduce an extensive resection of the pelvic floor and demonstrated superiority if the procedure is done in the prone jack-knife position, especially regarding intraoperative perforation and circumferential resections margins. The aim of this study is to evaluate the surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision. Methods: All patients registered in our institution from January 2003 to January 2015 who underwent abdominoperineal resection or prone extralevator abdominoperineal excision for low rectal cancer after preoperative chemoradiation were retrospectively included from prospective maintained data base and were compared regarding surgical and oncological outcomes. Results: Eighty-nine patients underwent curative intent resections. Abdominoperineal resection was performed in 67 patients and prone extralevator abdominoperineal excision in 22 patients. There were no statistical significant differences between groups regarding pathological stage, median number of harvested lymph node, intraoperative perforation, circumferential resections margins involvement and recurrence rates. Surgical outcomes were statistically different between groups. Twenty-six patients (29%) developed perineal complications, 21% of the abdominoperineal resection patients and 55% of the prone extralevator abdominoperineal excision (p < 0.001). Most of these complications were due to delayed perineal wound healing (12.4%), and wound abscesses (4.5%). However, the readmission rate and median length of hospital stay was higher in the abdominoperineal resection group (p < 0.001). Conclusion: Prone extralevator abdominoperineal excision is comparable to standard abdominoperineal resection. It was associated to a decrease in length of hospital stay and readmission rate, although more perineal complications occurred. We cannot recommend it as a standard technique for all low rectal cancer. Notwithstanding, prone extralevator abdominoperineal excision can be considered a more radical approach when there is sphincter complex or levators muscles invasion.

RESUMO Introdução: Nos últimos anos, foi proposta e adotada em muitos centros uma abordagem cirúrgica padronizada para o câncer retal baixo (CRB). A excisão abdominoperineal extra-levantador (ELAPE) introduz uma ampla ressecção do assoalho pélvico, tendo demonstrado superioridade, se ELAPE for realizada na posição de canivete (carpado) em pronação, especialmente no que tange à perfuração intraoperatória (PIO) e às margens das ressecções circunferenciais (MRCs). O objetivo desse estudo é avaliar os resultados cirúrgicos e oncológicos no curto prazo da excisão abdominoperineal extra-levantador em pronação (pELAPE). Métodos: Todos os pacientes registrados em nossa instituição desde janeiro de 2003 até janeiro de 2015 e tratados com ressecção abdominoperineal (RAP) ou com pELAPE para CRB em seguida à quimiorradiação pré-operatória foram retrospectivamente incluídos a partir da base de dados prospectiva mantida, tendo sido comparados com relação aos resultados cirúrgicos e oncológicos. Resultados: Oitenta e nove pacientes foram tratados com ressecção com intenção curativa. Sessenta e sete pacientes foram tratados com RAP e 22 com pELAPE. Não foi observada diferença estatística significativa entre grupos com relação ao estágio patológico, número mediano de linfonodos coletados, PIO, envolvimento das MRCs e percentuais de recorrência. Os resultados cirúrgicos foram estatisticamente diferentes entre os grupos. Vinte e seis pacientes (29%) evoluíram para complicações perineais: 21% dos pacientes tratados com RAP e 55% dos tratados com pELAPE (p < 0,001). Quase todas essas complicações foram decorrentes do retardo na cicatrização da ferida perineal (12,4%) e de abscessos na ferida (4,5%). Mas o percentual de reinternação e a duração mediana do tempo de internação hospitalar (TIH) foram maiores no grupo tratado com RAP (p < 0,001). Conclusão: pELAPE é comparável à RAP de rotina. O procedimento foi associado à redução no TIH e no percentual de reinternação, embora tenha ocorrido maior número de complicações perineais. Não recomendamos pELAPE como técnica padrão para todos os casos de CRB. Apesar disso, pELAPE pode ser considerada uma abordagem mais radical, como nos casos em que esteja presente uma complexa invasão esfinctérica, ou dos músculos levantadores.

Effectiveness and safety of monoclonal antibodies for metastatic colorectal cancer treatment: systematic review and meta-analysis.

BACKGROUND: The effectiveness of chemotherapy (CT) for select cases of metastatic colorectal cancer (MCRC) has been well established in the literature, however, it provides limited benefits and in many cases constitutes a treatment with high toxicity. The use of specific molecular biological treatments with monoclonal antibodies (MA) has been shown to be relevant, particularly for its potential for increasing the response rate of the host to the tumour, as these have molecular targets present in the cancerous cells and their microenvironment thereby blocking their development. The combination of MA and CT can bring a significant increase in the rate of resectability of metastases, the progression-free survival (PFS), and the global survival (GS) in MCRC patients. OBJECTIVE: To assess the effectiveness and safety of MA in the treatment of MCRC. METHODS: A systematic review was carried out with a meta-analysis of randomised clinical trials comparing the use of cetuximab, bevacizumab, and panitumumab in the treatment of MCRC. RESULTS: Sixteen randomised clinical trials were selected. The quality of the evidence on the question was considered moderate and data from eight randomised clinical trials were included in this meta-analysis. The GS and PFS were greater in the groups which received the MA associated with CT, however, the differences were not statistically significant between the groups (mean of 17.7 months versus 17.1 months; mean difference of 1.09 (CI: 0.10-2.07); p = 0.84; and 7.4 versus 6.9 months. mean difference of 0.76 (CI: 0.08-1.44); p = 0.14 respectively). The meta-analysis was not done for any of the secondary outcomes. CONCLUSION: The addition of MA to CT for patients with metastatic colorectal cancer does not prolong GS and PFS.

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.

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 / Operação minimamente invasiva transanal para excisão total do mesorreto (ETM) através de acesso transanal (TaETM) com uso da robótica e de operações endoscópicas transanais (TEO) combinadas: passo a passo do procedimento

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. .

RACIONAL: No tratamento do câncer colorretal, a partir de 1982 Heald propôs padronização da excisão total do mesorreto, com redução importante no índice de recidivas. Apesar disso, o tratamento das lesões do reto inferior ainda permanecem um desafio. OBJETIVO: Descrever a associação da abordagem robótica por via abdominal - TATA (Transanal Abdominal Transanal Resection), com o acesso transanal utilizando o Transanal Endoscopic Operations - TEO no tratamento do câncer de reto inferior. MÉTODO: A TATA realiza o tempo abdominal por robótica e o TEO o tempo perineal, desenvolvendo a excisão total do mesorreto (ETM) por via transanal (TaETM). RESULTADO: A técnica TaETM foi aplicada em mulher com adenocarcinoma de reto a 5 cm da margem anal que tinha sido submetida à radioquimioterapia. O procedimento foi realizado com um tempo cirúrgico satisfatório bem como resultado oncológico favorável (ressecção mesorretal grau 3). Paciente obteve alta no segundo dia pós-operatório com seguimento ambulatorial satisfatório. CONCLUSÃO: Trata-se de um procedimento minimamente invasivo bastante promissor no arsenal terapêutico do câncer de reto, principalmente em situações de maior dificuldade técnica como pelve estreita, obesidade e lesões do reto distal. .

Clinical and epidemiological profile of cases of deaths from stomach cancer in the National Cancer Institute, Brazil.

INTRODUCTION: Stomach cancer is the third most common cause of death worldwide, mainly affecting people with low socioeconomic status. In Brazil, we expect 20,390 new cases of stomach cancer in 2014, in both sexes, and according to the proportional distribution of the ten most prevalent types of cancer (except non-melanoma skin cancer) expected for 2014, this type of cancer was estimated to be the fourth most common in men and sixth in women. AIM: To investigate and analyse the clinical and epidemiological profile of deaths caused by stomach adenocarcinoma in patients enrolled in the National Cancer Institute, Brazil. METHODS: Cross-sectional study, with samples which consisted of data from the medical records of deaths from stomach cancer, enrolled in the period from 1 February 2009 to 31 March 2012 and who had died as of 30 April 2012. STATISTICAL ANALYSIS USED: The Epi Info ®, version 7. RESULTS: We included 264 cases, mostly male. The mean age was 61.7 years. They were smokers, drinkers, white, and married, with elementary education and an income of one minimum salary. They had advanced stage disease (E IV), with symptoms characteristic of this phase, and the majority died within six months. CONCLUSION: The findings are similar to other studies. The advanced stage of the disease at the time of admission of the patients reflects the difficulty for users of the Unified Health System to access early diagnosis, demonstrating the need for efforts to identify groups and risk factors for the development of gastric cancer. Training of health professionals will facilitate planning and implementation of programmes for the prevention and control of disease, considering socioeconomic conditions, as seen in the sample, which is common among most users.

The introduction of navigation in liver surgery in Brazil.

The authors thoroughly report the development, the technical aspects and the performance of the first navigated liver resections, by laparotomy and laparoscopy, in Brazil, done at the National Cancer Institute, Ministry of Health, using a surgical navigator.

Brazilian consensus in gastric cancer: guidelines for gastric cancer in Brazil.

BACKGROUND: In Brazil, gastric cancer is the fourth most common malignancy among men and sixth among women. The cause is multivariate and the risks are well known. It has prognosis and treatment defined by the location and staging of the tumor and number of lymph nodes resected and involved. AIM: The Brazilian Consensus on Gastric Cancer promoted by ABCG was designed with the intention to issue guidelines that can guide medical professionals to care for patients with this disease. METHODS: Were summarized and answered 43 questions reflecting consensus or not on diagnosis and treatment that may be used as guidance for its multidisciplinary approach. The method involved three steps. Initially, 56 digestive surgeons and related medical specialties met to formulate the questions that were sent to participants for answers on scientific evidence and personal experience. Summaries were presented, discussed and voted in plenary in two other meetings. They covered 53 questions involving: diagnosis and staging (six questions); surgical treatment (35 questions); chemotherapy and radiotherapy (seven questions) and anatomopathology, immunohistochemistry and perspective (five questions). It was considered consensus agreement on more than 70% of the votes in each item. RESULTS: All the answers were presented and voted upon, and in 42 there was consensus. CONCLUSION: It could be developed consensus on most issues that come with the care of patients with gastric cancer and they can be transformed in guidelines.

Colon and rectum neuroendocrine tumors: experience of the National Cancer Institute in Brazil.

BACKGROUND: Neuroendocrine tumors (NETs) are rare, comprising nearly 0.49% of all malignancies. The majority occurs in the gastrointestinal tract. AIM: To analyze the demographic factors, clinicopathologic features, treatment employed, prognostic factors and the oncologic results related to colorectal NETs. METHODS: Between the period from 1996 to 2010 174 patients were treated. From these, 34 were localized in the colon and rectum. Demographic factors, stage, therapeutics and its results were analyzed. All patients were followed for more than three years with image exams, urinary 5-hydroxyindolacetic acid (5-HIIA), serum chromogranin A and prostatic acid phosphatase. RESULTS: The median age was 54,4 years (22-76), the majority was female (64,7%). Out of the 12 patients with colon NETs, one (8.3%) patient was classified as Stage IA; one (8.3%) as Stage IB; three (25%) as Stage IIIB and seven (58.4%) as Stage IV. Out of the 22 patients with rectum NETs, six (27.3%) were classified as Stage IA; four (18.2%) as IB; three (13.6 %) as IIIA; one (4.5%) as IIIB and eight (36.4%) as IV. Of rectal NETs, nine (41%) were treated with endoscopic resection, six (27.2%) underwent conventional surgical treatment and six (27.2%) were treated with chemotherapy. Eleven patients with colon NETs (91.6%) were surgically treated, seven of them with palliative surgery, one (8.4%) was treated with endoscopic resection and no patient was submitted to chemotherapy. After an average follow-up of 55 months, 19 (55%) patients were alive. Analyzing the overall survival was obtained an average overall survival of 29 months in Stage IA, 62 months in IB, 12 months in IIIA, 31 months in IIIB and 39 months in IV. CONCLUSION: The treatment of colon and rectal NETs is complex, because it depends of the individuality of each patient. With adequate management, the prognosis can be favorable with long survival, but it is related to the tumor differentiation degree, efficacy of the chosen treatment and to the patient adhesion to the follow-up after treatment.

Tumores neuroendócrinos do cólon e reto: experiência do Instituto Nacional do Câncer no Brasil / Colon and rectum neuroendocrine tumors: experience of the National Cancer Institute in Brazil

RACIONAL: Os tumores neuroendócrinos (TNEs) são raros e compreendem apenas 0,49% de todas as neoplasias malignas. A maioria acomete o trato gastrointestinal. OBJETIVO: Analisar os fatores demográficos, características clinicopatológicas, tratamento empregado, fatores prognósticos e resultados oncológicos relacionados aos TNEs colorretais. MÉTODOS: No período compreendido entre 1996 e 2010 foram tratados 174 pacientes. Destes, 34 localizavam-se no cólon e reto. Foram analisados fatores demográficos, estadiamento, os procedimentos terapêuticos aplicados e seus resultados. No seguimento todos os pacientes foram acompanhados acima de três anos com exames de imagem, dosagem de 5-HIIA urinário, cromogranina-A sérica e fosfatase ácida prostática. RESULTADOS: A média de idade no diagnóstico foi de 54,5 anos (22-76), com predominância do sexo feminino (64,7%). Dos 12 com TNEs de cólon, um (8,3%) foi classificado como estádio IA; um (8,3%) em IB; três (25%) em IIIB e sete (58,4%) em IV. Dos 22 pacientes com TNEs de reto, seis (27,3%) foram classificados como estádio IA; quatro (18,2%) em IB; três (13,6%) em IIIA; um (4,5%) em IIIB e oito (36,4%) em IV. Dos TNEs de reto, nove (41%) foram tratados com ressecção endoscópica, seis (27,2%) com procedimento cirúrgico e seis (27,2%) somente com quimioterapia. Onze pacientes com TNEs de cólon (91,6%), foram tratados cirurgicamente, sendo sete paliativamente, um (8,4%) com ressecção endoscópica e nenhum foi submetido à quimioterapia no primeiro momento. Após seguimento médio de 55 meses, 19 (55%) pacientes estavam vivos. Analisando a sobrevida global obteve-se média de 29 meses no estádio IA, 62 meses no IB, 12 meses no IIIA, 31 meses no IIIB e 39 meses no IV. CONCLUSÃO: O tratamento dos TNEs de cólon e reto é complexo, pois depende de variáveis que são individuais a cada paciente. Com adequado manuseio, o prognóstico pode ser favorável e a sobrevida longa, mas ela está relacionada ao grau de diferenciação tumoral, tamanho, localização do tumor, estadiamento no momento do diagnóstico, eficácia da terapêutica adotada e à aderência do paciente ao seguimento após o tratamento.

BACKGROUND: Neuroendocrine tumors (NETs) are rare, comprising nearly 0.49% of all malignancies. The majority occurs in the gastrointestinal tract. AIM: To analyze the demographic factors, clinicopathologic features, treatment employed, prognostic factors and the oncologic results related to colorectal NETs. METHODS: Between the period from 1996 to 2010 174 patients were treated. From these, 34 were localized in the colon and rectum. Demographic factors, stage, therapeutics and its results were analyzed. All patients were followed for more than three years with image exams, urinary 5-hydroxyindolacetic acid (5-HIIA), serum chromogranin A and prostatic acid phosphatase. RESULTS: The median age was 54,4 years (22-76), the majority was female (64,7%). Out of the 12 patients with colon NETs, one (8.3%) patient was classified as Stage IA; one (8.3%) as Stage IB; three (25%) as Stage IIIB and seven (58.4%) as Stage IV. Out of the 22 patients with rectum NETs, six (27.3%) were classified as Stage IA; four (18.2%) as IB; three (13.6 %) as IIIA; one (4.5%) as IIIB and eight (36.4%) as IV. Of rectal NETs, nine (41%) were treated with endoscopic resection, six (27.2%) underwent conventional surgical treatment and six (27.2%) were treated with chemotherapy. Eleven patients with colon NETs (91.6%) were surgically treated, seven of them with palliative surgery, one (8.4%) was treated with endoscopic resection and no patient was submitted to chemotherapy. After an average follow-up of 55 months, 19 (55%) patients were alive. Analyzing the overall survival was obtained an average overall survival of 29 months in Stage IA, 62 months in IB, 12 months in IIIA, 31 months in IIIB and 39 months in IV. CONCLUSION: The treatment of colon and rectal NETs is complex, because it depends of the individuality of each patient. With adequate management, the prognosis can be favorable with long survival, but it is related to the tumor differentiation degree, efficacy of the chosen treatment and to the patient adhesion to the follow-up after treatment.

Salvage abdominoperineal resection for anal cancer following chemoradiation: a proposed scoring system for predicting postoperative survival.

BACKGROUND AND OBJECTIVES: Anal carcinoma is treated primarily by chemoradiation. Failure of this treatment requires salvage surgery. The aims of this retrospective study were to assess the survival probability after rescue surgery and design a pathological risk score (PRS) to predict postoperative outcome. METHODS: From 1982 to 2011, the clinical and pathological data of 111 patients treated with chemoradiation or radiation alone and abdominoperineal resection were reviewed. The Kaplan-Meier method was used to assess overall survival and parametric modeling was applied to determine prognostic factors and design a PRS. RESULTS: The 2- and 5-year overall survival rates were 60% and 24.5%, respectively. The multivariate analysis showed that nodal disease (P < 0.03), resection margin (P < 0.001), and perineural and/or lymphovascular invasion (P < 0.0001) were significantly associated with survival. Patients who presented negative values for these three variables were estimated to show a 5-year survival rate of 55% compared with 0.03% for patients who presented positive values. CONCLUSIONS: Positive surgical margin, the presence of perineural and/or lymphovascular invasion and positive nodal involvement were identified as significant independent predictors of mortality. The PRS was shown to be highly predictive of postoperative outcome.

Tumores estromais do trato gastrointestinal: avaliação prognóstica e sobrevida em relação às margens cirúrgicas ressecadas / Gastrointestinal stromal tumors: prognosis and survival according to surgically resected margins

Introdução: o tratamento cirúrgico do GIST para fins curativos baseia-se na ressecção completa do tumor com margens livres, sem ruptura tumoral com linfadenectomia de amostragem. Objetivo: análise e comparação do impacto na sobrevida dos pacientes tratados por cirurgia que tiveram margens livres (R0) e margens microscopicamente comprometidas (R1). Material e métodos: análise retrospectiva de todos os casos de GIST tratados no INCA (Instituto Nacional do Câncer) no período de 1997 a 2010, com ênfase na margem cirúrgica definida como R1, doença residual microscópica e R0 sem comprometimento de margens. Resultados: estudamos 190 pacientes e encontramos comprometimento microscópico das margens em 4 casos vs. 129 com margens livres. A sobrevida global média dos casos R0 foi de 48 meses, enquanto a do grupo R1 foi de 46 meses. Não encontramos diferença estatisticamente significativa. Conclusão: este estudo sugere que a margem cirúrgica microscopicamente comprometida não é um fator prognóstico adverso.

Introduction: surgical treatment of GIST for curative purposes is based on complete tumor resection with free margins, without rupturing the tumor, with lymph node sampling. Objective: analysis and comparison of the impact on survival of patients treated by surgery who had clear margins (RO) and margins microscopically involved (R1). Methods: retrospective analysis of all cases of GIST treated at INCA for the period 1997 to 2010 with emphasis on surgical margin defined as R1, and R0 microscopic residual disease without compromising margins. Results: we studied 190 patients and found microscopic involvement of margins in cases vs 4. 129 with free margins. The median overall survival of cases R0 was 48 months while the R1 group was 46 months. We found no significant difference. Conclusion: this study suggests that surgical margins microscopically committed is not as adverse prognostic factor.

Tumor estromal gastrointestinal: análise de 146 casos do centro de referência do Instituto Nacional do Câncer - INCA / Gastrointestinal stromal tumor: analysis of 146 cases of the center of reference of the National Cancer Institute - INCA

OBJETIVO: Avaliar os resultados do tratamento de GIST no INCA. MÉTODOS: Análise retrospectiva de todos os casos de GIST tratados no INCA no período de 1997 a 2009. RESULTADOS: Analisamos 146 pacientes, com média de idade de 44,5 anos e predomínio do sexo feminino. O principal sintoma foi dor abdominal. Tivemos ocorrência de segundo primário em 22 por cento dos casos e na imuno-histoquímica, 92 por cento foram positivos para CD117. A localização mais frequente foi estômago e predominou o grupo de alto risco. A cirurgia foi R0 (extenso) em 70 por cento e os principais sítios de metástases foram fígado e peritônio. A sobrevida global foi, respectivamente, em dois e cinco anos de 86 por cento e 59 por cento. Houve significante diferença entre a sobrevida global (p=0,29) do grupo de alto risco versus os demais. CONCLUSÃO: Os nossos pacientes apresentam-se principalmente sob forma de doença de alto risco com repercussão óbvia na sobrevida. O uso de Imatinib melhorou a sobrevida dos pacientes com doença metastática e recidivada. Devemos estudar seu uso no cenário de adjuvância e neoadjuvancia visando melhorar os índices do grupo de alto risco. A criação de centros referenciais é uma necessidade para o estudo de doenças pouco frequentes.

OBJECTIVE: To evaluate the treatment of GIST in INCA. METHODS: We conducted a retrospective analysis of all cases of GIST treated at INCA in the period from 1997 to 2009. RESULTS: We analyzed 146 patients with a mean age of 44.5 years and female predominance. The main symptom was abdominal pain. We observed the occurrence of a second primary tumor in 22 percent of cases and 92 percent of the immunohistochemistry exams were positive for CD117. The most frequent location was in the stomach and the high-risk group was predominant. Surgery was considered R0 (extensive) in 70 percent of the cases and the main sites of metastases were liver and peritoneum. Overall survival in two and five years was, respectively, 86 percent and 59 percent. There was a significant difference between overall survival (p = 0.29) of the high-risk group versus the other. CONCLUSION: Our patients presented mainly in the form of high-risk disease, with obvious impact on survival. The use of imatinib improved survival of patients with recurrent and metastatic disease. We should study its use in the setting of adjuvant and neoadjuvant therapy to improve results of the high risk group. The creation of reference centers is a need for the study of rare diseases.

Gastrointestinal stromal tumor: analysis of 146 cases of the center of reference of the National Cancer Institute--INCA.

OBJECTIVE: To evaluate the treatment of GIST in INCA. METHODS: We conducted a retrospective analysis of all cases of GIST treated at INCA in the period from 1997 to 2009. RESULTS: We analyzed 146 patients with a mean age of 44.5 years and female predominance. The main symptom was abdominal pain. We observed the occurrence of a second primary tumor in 22% of cases and 92% of the immunohistochemistry exams were positive for CD117. The most frequent location was in the stomach and the high-risk group was predominant. Surgery was considered R0 (extensive) in 70% of the cases and the main sites of metastases were liver and peritoneum. Overall survival in two and five years was, respectively, 86% and 59%. There was a significant difference between overall survival (p = 0.29) of the high-risk group versus the other. CONCLUSION: Our patients presented mainly in the form of high-risk disease, with obvious impact on survival. The use of imatinib improved survival of patients with recurrent and metastatic disease. We should study its use in the setting of adjuvant and neoadjuvant therapy to improve results of the high risk group. The creation of reference centers is a need for the study of rare diseases.

Complicaçäo inusitada na colocaçäo de sonda de Dobb-Hoff: relato de caso / Unusual complications in Dobb-Holf catheter insertion: a case report

Relata-se um caso clínico em que houve uma complicaçäo rara na colocaçäo de sonda de Dobb-Hoff, com a formaçäo de um nó espontâneo