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1.
Anticancer Res ; 39(11): 6217-6222, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31704850

RESUMO

BACKGROUND/AIM: Elderly cancer patients are more prevalent and require special attention. This study focused on the outcome of elderly (≥65 years) rectal cancer patients treated with tri-modality therapy. PATIENTS AND METHODS: A total of 105 patients receiving neoadjuvant radio-chemotherapy and resection for locally advanced rectal cancers were retrospectively evaluated. Nine characteristics were analyzed for loco-regional control (LRC), metastases-free survival (MFS) and overall survival (OS) including tumor location, gender, age, performance status, radiotherapy technique, primary tumor/lymph node categories, downstaging and histological grading. RESULTS: The 5-year rates of LRC, MFS and OS were 91%, 78% and 87%, respectively. Radio-chemotherapy was not completed in 12 patients (11%) due to toxicity; 18 patients (17%) experienced grade 3 toxicities. A total of 29 patients (28%) had surgical complications. On multivariate analyses, MFS was significantly associated with downstaging (p=0.003) and OS with lower histological grade (p=0.013). CONCLUSION: Tri-modality therapy resulted in promising outcomes and was tolerated reasonably well by elderly patients. Prognostic factors were identified that may help personalize future treatment.


Assuntos
Neoplasias Retais/terapia , Fatores Etários , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Bevacizumab/administração & dosagem , Capecitabina/administração & dosagem , Quimiorradioterapia Adjuvante/efeitos adversos , Terapia Combinada/efeitos adversos , Terapia Combinada/métodos , Intervalo Livre de Doença , Feminino , Fluoruracila/administração & dosagem , Humanos , Avaliação de Estado de Karnofsky , Masculino , Gradação de Tumores , Estadiamento de Neoplasias , Oxaliplatina/administração & dosagem , Complicações Pós-Operatórias , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Estudos Retrospectivos , Fatores Sexuais , Resultado do Tratamento
2.
Anticancer Res ; 39(10): 5797-5801, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31570484

RESUMO

Grade IV glioblastoma multiforme is a deadly disease, with a median survival of around 14 to 16 months. Maximal resection followed by adjuvant radiochemotherapy has been the mainstay of treatment since many years, although survival is only extended by a few months. In recent years, an increasing number of data from in vitro and in vivo research with cannabinoids, particularly with the non-intoxicating cannabidiol (CBD), point to their potential role as tumour-inhibiting agents. Herein, a total of nine consecutive patients with brain tumours are described as case series; all patients received CBD in a daily dose of 400 mg concomitantly to the standard therapeutic procedure of maximal resection followed by radiochemotherapy. By the time of the submission of this article, all but one patient are still alive with a mean survival time of 22.3 months (range=7-47 months). This is longer than what would have been expected.


Assuntos
Neoplasias Encefálicas/tratamento farmacológico , Neoplasias Encefálicas/terapia , Canabidiol/uso terapêutico , Glioblastoma/tratamento farmacológico , Glioblastoma/terapia , Adolescente , Adulto , Neoplasias Encefálicas/mortalidade , Quimiorradioterapia Adjuvante/métodos , Pré-Escolar , Terapia Combinada/métodos , Feminino , Glioblastoma/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida
3.
Khirurgiia (Mosk) ; (8. Vyp. 2): 6-15, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31502588

RESUMO

AIM: To optimize the indications for laparoscopic surgery in patients with locally advanced and prognostically unfavorable rectal cancer after neoadjuvant chemoradiotherapy. MATERIAL AND METHODS: 226 patients with locally advanced rectal cancer underwent combination therapy in A.F. Tsyba Medical Radiological Research Centre in 2003-2016. The patients were divided into two subgroups, depending on the surgical approach. The main group included 55 patients who underwent laparoscopic resections, and the control group included 171 patients - for conventional approach. RESULTS: In the subgroup of patients who underwent laparoscopic resections 42 (76.3%) organ preservation surgery were performed more often in comparison with the control subgroup 74 (43,2%) (p<0.0001). There were no significant differences in the incidence of intraoperative complications in both subgroups. The incidence of postoperative complications was lower in the laparoscopic approach group in comparison with the control group 12 (21.8%) patients and 62 (36.3%), respectively (p=0.0493). Data for local recurrence and dissemination of the process after surgery was not received. CONCLUSION: According to the main clinical and morphological features, laparoscopic resections may be an alternative, and in many cases even superior approach in comparison with the conventional surgery.


Assuntos
Protectomia/métodos , Neoplasias Retais/cirurgia , Quimiorradioterapia Adjuvante , Humanos , Laparoscopia , Terapia Neoadjuvante , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/patologia , Neoplasias Retais/radioterapia , Resultado do Tratamento
4.
Gynecol Oncol ; 155(1): 13-20, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31395371

RESUMO

OBJECTIVE: While women with stage III endometrial cancer are often treated with chemotherapy and external beam radiation, the optimal sequence of these modalities is unknown. We examined the association between the sequence of chemotherapy (CT) and external beam radiation therapy (RT) on survival for women with stage IIIC endometrial carcinoma. METHODS: The National Cancer Database was used to identify women with stage IIIC endometrial carcinoma treated with adjuvant CT and RT from 2004 to 2015. Patients were stratified based on the sequence of therapy: RT before CT, CT before RT, or concurrent therapy. The association between treatment sequence and mortality was examined through a weighted propensity score analysis. RESULTS: A total of 6981 patients were identified, including 5116 (73.3%) who received CT before RT, 696 (10.0%) who received RT before CT, and 1169 (16.7%) who received concurrent therapy. The use of CT-RT increased from 39.9% in 2004 to 75.5% in 2015, while use of RT-CT decreased from 34.0% to 4.4% and concurrent therapy decreased from 26.1% to 20.2% over the same period (P < 0.001). Compared to CT-RT, there was no difference in risk of mortality with RT before CT (HR = 1.01; 95% CI, 0.86-1.19) while concurrent therapy was associated with a 47% increased risk of mortality (HR = 1.47; 95% CI, 1.31-1.66). In a sensitivity analysis combining the groups that received RT first (RT before CT or concurrent RT-CT), mortality was 25% higher (HR = 1.25; 95% CI, 1.13-1.39) compared to a strategy of CT followed by RT. CONCLUSION: Among women with stage IIIC endometrial carcinoma treated with combination chemotherapy and external beam radiation, a strategy employing chemotherapy first is associated with improved survival compared to concurrent therapy.


Assuntos
Neoplasias do Endométrio/tratamento farmacológico , Neoplasias do Endométrio/radioterapia , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias
5.
Medicine (Baltimore) ; 98(34): e16653, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441840

RESUMO

Brain metastases deriving from esophageal cancer are very rare with scarce data available concerning these patients' outcome. We, therefore, evaluated outcome after surgical resection followed by radiotherapy of brain metastasis from esophageal cancer.A retrospective analysis was conducted on consecutive patients undergoing resection of brain metastasis from esophageal cancer in 2 neuro-oncological centers between 2008 and 2018. Clinical and demographic data were retrieved from electronic patient charts. Post-treatment survival was calculated using Kaplan-Meier estimates.Twenty-five patients were identified. Treatment for primary disease comprised neo-adjuvant radio-chemotherapy followed by surgery (64.0%), surgery and adjuvant radio-chemotherapy (8.0%), radio-chemotherapy only (24.0%), and 1 patient receiving esophageal stenting only. Median time interval since initial diagnosis was 16 (range 0-110) months. All but 1 brain lesion were neurologically symptomatic and median Karnofsky performance score improved postoperatively from 70 to 80. After resection of brain metastases patients received whole-brain (n = 13 (52.0%)) or local fractionated (n = 9 (36.0%)) radiotherapy. In 2 patients adjuvant treatment was impeded by clinical deterioration; 1 patient refused radiotherapy. By the time of analysis 22 patients had died. Median survival after brain metastasis was 6 (95% CI 0.5-11.6) months.Survival after resection of metastasis from esophageal cancer is poor compared to other tumor entities. Nevertheless, resection of symptomatic brain metastases may improve clinical status in the context of a palliative concept.


Assuntos
Neoplasias Encefálicas/secundário , Neoplasias Encefálicas/terapia , Neoplasias Esofágicas/patologia , Idoso , Quimiorradioterapia Adjuvante , Terapia Combinada , Feminino , Humanos , Estimativa de Kaplan-Meier , Avaliação de Estado de Karnofsky , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
6.
Cancer Radiother ; 23(6-7): 716-719, 2019 Oct.
Artigo em Francês | MEDLINE | ID: mdl-31421997

RESUMO

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.


Assuntos
Carcinoma/terapia , Quimiorradioterapia Adjuvante/métodos , Neoplasias Esofágicas/terapia , Terapia Neoadjuvante , Humanos , Cuidados Pré-Operatórios/métodos , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada/métodos
7.
Gynecol Oncol ; 154(3): 583-589, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31307665

RESUMO

OBJECTIVE: To evaluate the health-related quality of life (HRQOL) in locally advanced cervical cancer (LACC) patients treated with neoadjuvant concurrent chemoradiation (CCRT) or radiation (RT) alone followed by radical surgery (RS). METHODS: In a single-center retrospective study from a prospective database, 275 FIGO Stage IB2-IIIB patients who underwent CCRT/RT + RS were included. HRQOL was prospectively assessed by EORTC QLQ-C30 and EORTC QLQ-CX24 prior to any treatment (baseline) and 6 months after surgery, respectively. RESULTS: A statistically significant and clinically relevant improvement in physical functioning (P < 0.001) and role functioning (P = 0.002, P = 0.031) was observed in patients receiving either CCRT+RS or RT + RS at follow-up. In addition, quality of life (QoL), physical functioning, and social functioning were better in the RT + RS group than the CCRT+RS group after treatment (P = 0.028, P = 0.010, P = 0.014). Symptom scores of fatigue decreased in both groups over time (P < 0.001, P = 0.004) while insomnia decreased only in the RT + RS group (P = 0.042). Worsened menopausal symptoms were documented in both groups at follow-up (P = 0.001, P = 0.047), while lymphedema was deteriorated only in patients receiving CCRT + RS (P < 0.001). Sexuality scores did not differ between groups or over time with the exception of sexual worry, which was deteriorated in patients receiving RT + RS (P = 0.042). CONCLUSIONS: QLQ-C30 functioning and tumor-related symptoms scores improved while lymphedema and menopausal symptoms worsened 6 months after neoadjuvant CCRT or RT alone followed by RS in LACC patients. Patients treated with RT + RS had a generally better HRQOL compared with those receiving CCRT+RS, though further validation with prospective randomized clinical trials is warranted.


Assuntos
Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Quimiorradioterapia , Quimiorradioterapia Adjuvante , Bases de Dados Factuais , Feminino , Humanos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Qualidade de Vida , Radioterapia Adjuvante , Estudos Retrospectivos , Neoplasias do Colo do Útero/fisiopatologia , Neoplasias do Colo do Útero/cirurgia
8.
J Surg Oncol ; 120(4): 698-706, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31273803

RESUMO

BACKGROUND: This study aimed to create a nomogram for postoperative prediction of the risk of recurrence in laryngeal squamous cell carcinoma patients who received laryngectomy alone and to assess indications for postoperative adjuvant treatments (POAT). METHODS: A retrospective analysis of 1571 newly diagnosed laryngeal carcinoma patients was conducted. Those patients were divided into two groups-the development cohort (n = 1102) and the validation cohort (n = 469). Patients were classified into three subgroups according to their individual points calculated from the nomogram. The efficiency of POAT was examined among various subgroups. RESULTS: Five variables, including pT classification, pN classification, surgical margin, tumor differentiation, and primary location, were included in the nomogram. The C-index was 0.753 in development cohort and 0.744 in validation cohort. Patients were classified into three subgroups with incremental risks of recurrence. In the high-risk group, patients receiving POAT showed significantly better recurrence-free survival (RFS) than did those receiving surgery alone, while POAT was not significantly associated with RFS in either the low- or moderate-risk groups. CONCLUSIONS: The risk of tumor recurrence in patients with laryngeal carcinoma was quantified by our newly constructed nomogram. Patients categorized as high-risk were found to benefit from POAT in RFS.


Assuntos
Carcinoma de Células Escamosas/secundário , Tomada de Decisões , Neoplasias Laríngeas/patologia , Recidiva Local de Neoplasia/patologia , Nomogramas , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia Adjuvante , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Laríngeas/cirurgia , Neoplasias Laríngeas/terapia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/terapia , Período Pós-Operatório , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
9.
N Engl J Med ; 380(24): 2317-2326, 2019 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-31189035

RESUMO

BACKGROUND: Stage III or IVA endometrial cancer carries a significant risk of systemic and locoregional recurrence. METHODS: In this randomized phase 3 trial, we tested whether 6 months of platinum-based chemotherapy plus radiation therapy (chemoradiotherapy) is associated with longer relapse-free survival (primary end point) than six cycles of combination chemotherapy alone in patients with stage III or IVA endometrial carcinoma. Secondary end points included overall survival, acute and chronic toxic effects, and quality of life. RESULTS: Of the 813 patients enrolled, 736 were eligible and were included in the analysis of relapse-free survival; of those patients, 707 received the randomly assigned intervention (346 received chemoradiotherapy and 361 received chemotherapy only). The median follow-up period was 47 months. At 60 months, the Kaplan-Meier estimate of the percentage of patients alive and relapse-free was 59% (95% confidence interval [CI], 53 to 65) in the chemoradiotherapy group and 58% (95% CI, 53 to 64) in the chemotherapy-only group (hazard ratio, 0.90; 90% CI, 0.74 to 1.10). Chemoradiotherapy was associated with a lower 5-year incidence of vaginal recurrence (2% vs. 7%; hazard ratio, 0.36; 95% CI, 0.16 to 0.82) and pelvic and paraaortic lymph-node recurrence (11% vs. 20%; hazard ratio, 0.43; 95% CI, 0.28 to 0.66) than chemotherapy alone, but distant recurrence was more common in association with chemoradiotherapy (27% vs. 21%; hazard ratio, 1.36; 95% CI, 1.00 to 1.86). Grade 3, 4, or 5 adverse events were reported in 202 patients (58%) in the chemoradiotherapy group and 227 patients (63%) in the chemotherapy-only group. CONCLUSIONS: Chemotherapy plus radiation was not associated with longer relapse-free survival than chemotherapy alone in patients with stage III or IVA endometrial carcinoma. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00942357.).


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia Adjuvante , Neoplasias do Endométrio/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante , Intervalo Livre de Doença , Neoplasias do Endométrio/mortalidade , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Neoplasia Residual , Prognóstico , Qualidade de Vida , Recidiva , Estatísticas não Paramétricas , Resultado do Tratamento
10.
Gynecol Oncol ; 154(2): 328-332, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31221496

RESUMO

OBJECTIVE: To evaluate clinicopathologic factors and adjuvant treatment effects on recurrence free (RFS) and overall survival (OS) in early stage uterine clear cell carcinoma (UCCC). METHODS: Our retrospective review included central pathology confirmed stage I or II UCCC treated and/or followed between 2000 and 2016. Cases with pure or mixed histology with >50% UCCC were included. Data were analyzed using Kaplan-Meier method and Cox proportional hazards regressions. RESULTS: 112 women were identified. Median age was 65.5 years (range 34-94). Most patients had mixed UCCC (61%), while 39% had pure UCCC. The majority of patients had stage IA UCCC (66%) versus stage IB (15%) or stage II (18%) disease. Adjuvant treatment included chemotherapy + radiation (26%), brachytherapy (27%), whole pelvic radiation (15%), chemotherapy alone (8%), and observation (24%). Thirty-eight (34%) women had recurrent disease. Median RFS was 4.32 years (95% CI 2.77-5.78). On multivariate analysis, age ≥70 (HR 2.48, 95% 1.28-4.81) and positive LVSI (HR 2.19, 95% CI 1.15-4.18) were associated with shorter RFS. Median OS was 9.8 years (95% CI 7.46-15.93). On multivariate analyses, age ≥70 (HR 3.57, 95% CI 1.64-7.74) and positive LVSI (HR 2.46, 95% CI 1.12-5.37) were associated with shorter OS. In this retrospective descriptive uncontrolled patient series, adjuvant treatment type did not impact RFS or OS. CONCLUSIONS: OS approaches 10 years for early stage UCCC patients. Women ≥70 years have worse PFS and OS regardless of treatment modality, encouraging consideration of quality of life implications when electing for adjuvant therapy.


Assuntos
Adenocarcinoma de Células Claras/terapia , Neoplasias Uterinas/terapia , Adenocarcinoma de Células Claras/mortalidade , Adenocarcinoma de Células Claras/patologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Braquiterapia , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Feminino , Humanos , Estimativa de Kaplan-Meier , Estudos Longitudinais , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Radioterapia Adjuvante , Estudos Retrospectivos , Neoplasias Uterinas/mortalidade , Neoplasias Uterinas/patologia , Conduta Expectante
11.
Phys Med ; 62: 111-119, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31153390

RESUMO

OBJECTIVES: The aim of this study was to investigate and validate the performance of individual and ensemble machine learning models (EMLMs) based on magnetic resonance imaging (MRI) to predict neo-adjuvant chemoradiation therapy (nCRT) response in rectal cancer patients. We also aimed to study the effect of Laplacian of Gaussian (LOG) filter on EMLMs predictive performance. METHODS: 98 rectal cancer patients were divided into a training (n = 53) and a validation set (n = 45). All patients underwent MRI a week before nCRT. Several features from intensity, shape and texture feature sets were extracted from MR images. SVM, Bayesian network, neural network and KNN classifiers were used individually and together for response prediction. Predictive performance was evaluated using the area under the receiver operator characteristic (ROC) curve (AUC). RESULTS: Patients' nCRT responses included 17 patients with Grade 0, 28 with Grade 1, 34 with Grade 2, and 19 with Grade 3 according to AJCC/CAP pathologic grading. In without preprocessing MR Image the best result was for Bayesian network classifier with AUC and accuracy of 75.2% and 80.9% respectively, which was confirmed in the validation set with an AUC and accuracy of 74% and 79% respectively. In EMLMs the best result was for 4 (SVM.NN.BN.KNN) classifier EMLM with AUC and accuracy of 97.8% and 92.8% in testing and 95% and 90% in validation set respectively. CONCLUSIONS: In conclusion, we observed that machine learning methods can used to predict nCRT response in patients with rectal cancer. Preprocessing LOG filters and EL models can improve the prediction process.


Assuntos
Quimiorradioterapia Adjuvante , Aprendizado de Máquina , Imagem por Ressonância Magnética , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/terapia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
12.
Dis Colon Rectum ; 62(7): 802-808, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31188180

RESUMO

BACKGROUND: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed by organ-preserving strategies and acceptable long-term outcomes. Controversy still exists regarding optimal timing for the assessment of tumor response after neoadjuvant chemoradiation. OBJECTIVE: The purpose of this study was to estimate the time interval for achieving complete clinical response using strict endoscopic and clinical criteria after a single neoadjuvant chemoradiation regimen. DESIGN: This was a retrospective review of consecutive patients managed by 54-Gy and consolidation 5-fluorouracil-based chemotherapy. Assessment of response was performed at 10 weeks after radiation. Patients with suspected complete clinical response were offered watch-and-wait strategy and reassessment every 6 to 8 weeks until achievement of strict criteria of complete clinical response or overt residual cancer. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Patients with complete clinical response who underwent a successful watch-and-wait strategy until last follow-up were eligible. Dates of radiation completion and achievement of strict endoscopic and clinical criteria (mucosal whitening, teleangiectasia, and no ulceration or irregularity) were recorded. Patients with incomplete response or with initial complete clinical response followed by local recurrence or regrowth were excluded. MAIN OUTCOMES MEASURES: The distribution of time intervals between completion of radiation and achievement of strict complete clinical response was measured. Patients who achieved early complete clinical response (≤16 wk) were compared with late complete clinical response (>16 wk). RESULTS: A total of 49 patients achieved complete clinical response and were successfully managed nonoperatively. A median interval of 18.7 weeks was observed for achieving strict complete clinical response. Only 38% of patients achieved complete clinical response between 10 and 16 weeks from radiation completion. Patients with earlier cT status (cT2/T3a) achieved a complete clinical response significantly earlier when compared with those patients with more advanced disease (T3b-d/4; 19 vs 26 wk; p = 0.03). LIMITATIONS: This was a retrospective study with a small sample size. CONCLUSIONS: Assessment at 10 to 16 weeks may detect a minority of patients who achieve complete clinical response without additional recurrence after neoadjuvant chemoradiation. Patients suspected for a complete clinical response should be considered for reassessment beyond 16 weeks before definitive management when considered for a watch and wait strategy. See Video Abstract at http://links.lww.com/DCR/A901.


Assuntos
Antimetabólitos Antineoplásicos/uso terapêutico , Quimiorradioterapia Adjuvante , Fluoruracila/uso terapêutico , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/terapia , Conduta Expectante , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Metástase Neoplásica , Estadiamento de Neoplasias , Tratamentos com Preservação do Órgão , Neoplasias Retais/patologia , Reto , Estudos Retrospectivos , Fatores de Tempo
13.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 507-513, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238630

RESUMO

Neoadjuvant chemoradiotherapy plus total mesorectal excision (TME) is the standard care for locally advanced middle-low rectal cancer. Some patients could benefit from neoadjuvant chemoradiotherapy to achieve clinical complete response (cCR). Therefore, in recent years, for patients with cCR after neoadjuvant therapy, the "watch and wait" strategy has been widely recommended by their doctors to let them enter "waiting period" without surgery, so that the quality of life is improved. However, the "watch and wait" strategy also has many practical problems that have not been resolved. Firstly, the diagnostic criteria for cCR and pathologic complete response (pCR) are not uniform and different significantly. Secondly, some cCR patients have found tumor regrowth and subsequently underwent salvage surgery during the "watch and wait" period. Thirdly, there is no clinical consensus on the adjuvant therapy for patients during the "watch and wait" period. Fourthly, the role of surgery in patients with cCR is controversial. Finally, we need to accumulate more clinical evidence to confirm whether the "watch and wait" strategy can be selected immediately after achieving cCR for rectal cancer. At the same time, we should find novel molecular markers that can predict the efficacy of chemoradiotherapy. Only rational choice of "watch and wait" strategy will allow more patients with rectal cancer to benefit from chemoradiotherapy.


Assuntos
Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Protectomia/métodos , Neoplasias Retais/terapia , Terapia Combinada , Humanos , Mesentério/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Qualidade de Vida , Neoplasias Retais/patologia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
14.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 514-520, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238631

RESUMO

Therapeutic goal for locally advance rectal cancer (LARC) patients includes long-term survival and function preservation of pelvic organs. During the recent two decades, treatment strategy for LARC is gradually shifing to minimally invasive surgery, even avoiding a major surgery. "Watch and wait (W&W)" strategy is effective in dramatically decreasing surgical trauma and significantly improving preservation of defecation, urination and sexual function. Total neoadjuvant therapy (TNT) shifts all or part of adjuvant chemotherapy to the neoadjuvant phase and has showed obvious advantage in tumor shrinkage and complete clinical response (cCR) achievement. This article will summarize the transition of treatment strategy of LARC towards W&W from standard treatment. After more than ten years of development, both NCCN and ESMO guidelines recommend stratified neoadjuvant treatment considerations based on distinct risk classifications and especially suggest TNT for LARC patients with advanced diseases, which affirms the value of TNT in tumor shrinkage. Although accumulating data show that pelvic control and organ preservation using W&W strategy after cCR is equal or non-inferior to standard surgery, impact on long-term survival still needs prospective randomized controlled study; no consensus has been achieved for the detail of the W&W strategy. Thus W&W strategy is suggested to applied in hospitals specialized in the treatment of rectal cancer within the framework of multiple disciplinary treatment. In view of special medical conditions of our country, we still need to accumulate more experience and data of W&W strategy for rectal cancer patients with appeals for sphincter preservation and actively participate in international researches.


Assuntos
Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Neoplasias Retais/terapia , Conduta Expectante/normas , Humanos , Recidiva Local de Neoplasia , Protectomia , Estudos Prospectivos , Neoplasias Retais/patologia , Conduta Expectante/métodos , Conduta Expectante/tendências
15.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 521-526, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238632

RESUMO

Neoadjuvant chemoradiation has been accepted as a standard of care for local advanced middle to low rectal cancer. Patients with clinical complete response (cCR) or near cCR following neoadjuvant chemoradiation may benefit from watch and wait strategy or organ-preserving surgery with good short- and long-term outcome and quality of life (QOL). Yet the criteria of cCR varies and cCR is not consistent with pCR. Therefore, the obstacle to the strategy lies on whether its failure can be salvaged and the complexity of follow-up. Available studies demonstrated that local recurrence or regrowth can be salvaged by surgery without compromising the survival. So, the key is appropriate follow-up schedule and timely salvage. The strategy has not drawn much attention until recently, and relevant studies go slowly because of low data availability, patient awareness, and peer acceptance. We still believe that more and more patients might benefit from this strategy, along with the increasing attention of QOL from the patients. That may be obtained through screening of the right patients and optimizing treatment modality, evaluation methods, and protocol of follow-up.


Assuntos
Quimiorradioterapia Adjuvante/métodos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias Retais/terapia , Conduta Expectante/métodos , Humanos , Qualidade de Vida , Neoplasias Retais/patologia , Conduta Expectante/normas
16.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 527-533, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238633

RESUMO

Neoadjuvant chemoradiotherapy is the current standard of care for locally advanced rectal cancer. However, this modality is facing more and more challenges. The research progress on this issue around the world can be summarized into three aspects. The first is to increase the intensity of treatment to obtain better tumor regression, such as adding a second drug during the neoadjuvant chemoradiotherapy, prolonging the interval and receiving sufficient chemotherapy before surgery. Current research data are not sufficient to support strategies for adding drugs or receiving sufficient chemotherapy before surgery, but it may be worth looking forward to adding irinotecan during neoadjuvant chemoradiotherapy, and an appropriate extension of the interval before surgery may also be a good option. Secondly, we can reduce the intensity of treatment to improve the quality of life of patients with a non-inferior clinical outcome, such as non-surgical approach, local excision rather than total mesorectal excision and removal of preoperative radiotherapy. The data of the International Watch & Wait Database (IWWD) suggest that patients with a Watch & Wait strategy have similar long-term survival outcomes as those who have undergone surgery and have pathologic complete response, meanwhile the data are still inadequate to support using local excision instead of total mesorectal excision, or removal of preoperative radiotherapy strategies. Finally, to achieve a precise individual treatment, some potential biomarkers are investigated via genomics, metabolomics and radiomics. But so far, there is no recognized biomarker for clinical treatment in the field of neoadjuvant therapy for rectal cancer. This article summarizes the clinical research progress of locally advanced rectal cancer in recent years from the above three aspects.


Assuntos
Quimiorradioterapia Adjuvante/normas , Terapia Neoadjuvante/normas , Neoplasias Retais/terapia , Quimiorradioterapia Adjuvante/métodos , Terapia Combinada , Humanos , Mesentério/cirurgia , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Protectomia/métodos , Qualidade de Vida , Radioterapia Adjuvante , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Resultado do Tratamento , Conduta Expectante/métodos , Conduta Expectante/normas
17.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 550-559, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238634

RESUMO

Objective: To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher's exact test for categorical variables. Results: Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR. Conclusions: Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.


Assuntos
Quimiorradioterapia Adjuvante/métodos , Terapia Neoadjuvante , Neoplasias Retais/terapia , Conduta Expectante/métodos , Atitude do Pessoal de Saúde , Estudos Transversais , Pesquisas sobre Serviços de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Recidiva Local de Neoplasia , Inquéritos e Questionários
18.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 560-565, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238635

RESUMO

Objective: To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. Results: There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. Conclusion: For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.


Assuntos
Quimiorradioterapia Adjuvante , Terapia Neoadjuvante , Recidiva Local de Neoplasia/terapia , Neoplasias Retais/cirurgia , Microcirurgia Endoscópica Transanal , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Estudos Retrospectivos , Resultado do Tratamento
19.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 566-572, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238636

RESUMO

Objective: To evaluate the effect of preservation of left colic artery (LCA) on postoperative anastomotic leakage in patients with rectal cancer after neoadjuvant therapy. Methods: A retrospective cohort study was conducted to collect data of rectal cancer patients at Department of Gastrointestinal Surgery of Fujian Cancer Hospital from September 2014 to August 2017. Inclusion criteria: (1) age of 18 to 79 years; (2) rectal adenocarcinoma confirmed by postoperative pathology; (3) patients without preoperative serious cardiovascular and cerebrovascular disease receiving preoperative neoadjuvant radiotherapy or chemoradiotherapy; (4) laparoscopic-assisted anterior rectal resection and distal ileostomy were performed simultaneously; (5) complete clinical data. Exclusion criteria: patients with extensive abdominal metastasis, or distant organ metastasis during operation, and combined organ resection. According to whether LCA was retained during operation, the patients were divided into two groups, then the intraoperative and postoperative clinical outcomes were compared. Moreover, univariate analysis and multivariate logistic regression were used to analyze risk factors of postoperative anastomotic leakage. Results: A total of 125 patients were included in this study, including 56 patients in the retained LCA group and 69 patients in the non-retained LCA group. Differences in baseline data, such as gender, age, diabetes mellitus, body mass index, hemoglobin, distance between tumor and anal margin, maximum diameter of tumor, preoperative neoadjuvant therapy, and ypTNM stage, between retained LCA group and non-retained LCA group were not statistically significant (all P>0.05), indicating that two groups were comparable. Meanwhile there were no significant differences in operation time, intraoperative blood loss, total number of lymph node harvested, number of harvested lymph node at the root of inferior mesenteric artery, circumferential margin, anastomotic bleeding, or postoperative hospital stay between two groups (all P>0.05). Thirteen patients in the non-retained LCA group (18.8%) developed postoperative anastomotic leakage, including 7 cases of grade A, 5 cases of grade B and 1 case of grade C, while in the retained LCA group, only 5.4% (3/56) of patients developed postoperative anastomotic leakage, including 1 case of grade A and 2 cases of grade B without case of grade C, whose difference was statistically significant (U=1674.500, P=0.028). Univariate analysis showed that preoperative hemoglobin <120 g/L and non-retained LCA were associated with postoperative anastomotic leakage (both P<0.05). Multivariate analysis cofirmed that preoperative hemoglobin < 120 g/L (OR=3.508, 95% CI: 1.158 to 10.628, P=0.017) and non-retained LCA (OR=4.065, 95%CI: 1.074 to 15.388, P=0.031) were independent risk factors for postoperative anastomotic leakage. Median follow-up time was 31 months (16 to 51 months), and no long-term complication was found. Local recurrence and distant metastasis were found in 1 case (1.8%) and 7 case (12.5%) in the retained LCA group, while those were found in 2 cases (2.9%) and 5 cases (7.2%) respectively, in the non-retained LCA group, whose differences were not statistically significant (P=1.000, P=0.321 respectively). Conclusion: Preservation of left colic artery not only can ensure radical lymph node dissection efficacy under the condition of similar operation time and blood loss, but also can effectively reduce the incidence of postoperative anastomotic leakage for rectal cancer patients after neoadjuvant therapy.


Assuntos
Adenocarcinoma/cirurgia , Fístula Anastomótica/etiologia , Artéria Mesentérica Inferior/cirurgia , Protectomia/efeitos adversos , Neoplasias Retais/cirurgia , Reto/irrigação sanguínea , Quimiorradioterapia Adjuvante/efeitos adversos , Humanos , Terapia Neoadjuvante/efeitos adversos , Protectomia/métodos , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos
20.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(6): 594-596, 2019 Jun 25.
Artigo em Chinês | MEDLINE | ID: mdl-31238639

RESUMO

Colorectal cancer is one of the most common malignant tumors worldwide. Surgical resection is the most important and decisive method in the treatment of rectal cancer. Total mesorectal excision (TME) has greatly reduced the local recurrence rate of middle and low rectal cancer. However, local recurrence and distant metastasis remain the leading cause of death in patients with rectal cancer. 5-fluorouracil (5-FU)-based neoadjuvant chemoradiotherapy has been widely accepted in locally advanced rectal cancer and was recommended by various clinical practice guidelines as the standard treatment option. Tumors often achieve satisfactory reduced stage after neoadjuvant radiotherapy, and some patients even achieve pathological complete regression, which brings much controversies to the choice of adjuvant chemotherapy. This article intends to introduce evidence-based evidences for adjuvant chemotherapy for rectal cancer, impact of current neoadjuvant models on choice of adjuvant chemotherapy strategies, controversies and considerations for adjuvant chemotherapy in the context of neoadjuvant radiotherapy.


Assuntos
Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Protectomia/métodos , Neoplasias Retais/terapia , Intervalo Livre de Doença , Humanos , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Retais/patologia
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