RESUMO
Objective: To compare the long-term medical costs of active surveillance (AS), partial thyroidectomy (PT), and total thyroidectomy (TT) in patients with low-risk papillary thyroid microcarcinoma (PTMC) receiving care covered by the Brazilian Public Health System. Materials and methods: After reviewing AS cohorts and our own data, we created a model of AS, PT, and TT flow care for low-risk PTMC over 10, 20, and 30 years. The medical costs included those associated with diagnosis, surgery, and follow-up. We considered that 13.3% of the patients on AS would require surgery after a mean of 21.3 months, 4% undergoing TT would develop permanent hypoparathyroidism, and 43% undergoing PT would develop hypothyroidism. Results: The most economical alternative was AS. The costs of TT per patient were higher than those of AS by 182.8% over 10 years (866.89 versus 306.49 US dollars [USD], respectively), by 152.9% over 20 years (1,023.66 versus 404.73 USD, respectively), and by 134.7% over 30 years (1,180.42 versus 502.96 USD, respectively). The costs of PT per patient were higher than those of AS by 16.0% over 10 years (355.66 versus 306.49 USD, respectively), by 16.9% over 20 years (473.41 versus 404.73 USD, respectively), and by 17.5% over 30 years (591.17 versus 502.96 USD, respectively). Conclusion: The AS approach was less costly than immediate surgery throughout 30 years of follow-up. Hence, the implementation of AS in Brazil should not be hindered by cost considerations.
Assuntos
Carcinoma Papilar , Neoplasias da Glândula Tireoide , Tireoidectomia , Conduta Expectante , Humanos , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/economia , Brasil , Tireoidectomia/economia , Tireoidectomia/métodos , Conduta Expectante/economia , Carcinoma Papilar/cirurgia , Carcinoma Papilar/economia , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Custos de Cuidados de Saúde/estatística & dados numéricos , Fatores de TempoRESUMO
The incidence of thyroid cancer is increasing globally, but mortality rates have remained steady. Many patients with thyroid cancer have low-risk, nonmetastatic intrathyroidal tumors smaller than 2 cm. Active surveillance has shown benefits in these patients, but the adoption of this approach remains below standard in Latin America. The purpose of this article is to identify ways to improve the incorporation of active surveillance into clinical practice for patients with low-risk thyroid carcinoma in Latin America, taking into consideration cultural and geographic factors. Current recommendations include three steps involving patient participation. The first step, which consists of the initial clinical examination, has eight factors requiring special attention. Anxiety must be managed while considering individual, disease-related, cognitive, and environmental aspects. Terms like "overdiagnosis", "incidentaloma," and "overtreatment" must be explained to the patient. Implementing precise terminology contributes to adequate disease perception, substantially reducing stress and anxiety. Clarifying the nonprogressive nature of thyroid cancer helps dispel myths surrounding the disease. The second step includes advice about procedures and guidelines for patients who choose active surveillance. Flexible monitoring techniques should be implemented, with regular check-ins scheduled based on patient needs. Reasons for adjusting treatment must be clearly communicated to the patient, and changes in preference regarding active surveillance should be considered in advance. The third step includes assistance during follow-up. Patients must be educated about ultrasound results and receive surgical indications from specialized physicians. The effectiveness of active surveillance can be reinforced by explaining to the patients the dynamics of changes in nodule size using clear and concise visual aids.
Assuntos
Neoplasias da Glândula Tireoide , Humanos , Neoplasias da Glândula Tireoide/terapia , Neoplasias da Glândula Tireoide/patologia , América Latina , Conduta Expectante , Guias de Prática Clínica como Assunto , Participação do PacienteRESUMO
Thyroid nodules are a very common finding and have a malignancy rate of 7%-15%. Some malignant nodules have an indolent behavior and may not affect mortality if left untreated. Active surveillance (AS) is a strategy to prevent overtreatment in patients with papillary thyroid microcarcinomas (PTMCs). This review was conducted to evaluate the status of AS for low-risk PTMC in Latin America, including cultural and logistical challenges, disease progression data, and financial viability. We searched PubMed (MEDLINE), SciELO, LILACS, and Web of Science for articles published after 2014 and enrolling adult Latin American patients. Articles cited in the selected studies were also retrieved. We analyzed the AS protocols, technical or logistical challenges, patient adherence, reasons for AS interruption, surgical conversion rates, duration of AS, and disease progression during AS in our region. Three articles were included in the analysis, all of which considered AS a viable option and reported tumor progression and outcomes similar to those reported in other countries. Neck ultrasound and serum levels of thyroglobulin, thyroid-stimulating hormone (TSH), thyroxine (T4), and antithyroglobulin antibodies were included in the follow-up. No cases of new distant metastases were reported, and the outcomes were favorable when surgery was required. Anxiety was the main reason for AS interruption. We conclude that AS can be an acceptable approach and is safe and effective in Latin America, although more prospective studies are needed to consolidate this strategy in our region. Adequate infrastructure, follow-up, and patient education, as well as multidisciplinary healthcare teams trained in conducting AS must be ensured for successful results.
Assuntos
Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Conduta Expectante , Humanos , América Latina/epidemiologia , Neoplasias da Glândula Tireoide/sangue , Câncer Papilífero da Tireoide/sangue , Progressão da Doença , Carcinoma PapilarRESUMO
BACKGROUND: The management of vestibular schwannomas (VS) encompasses a choice between conservative "wait-and-scan" (WAS) approach, stereotactic radiosurgery (SRS) or open microsurgical resection. Currently, there is no consensus on the optimal management approach for small to medium sized VS. This study aims to compared outcomes related to hearing in patients with small and medium sized VS who underwent initial treatment with WAS versus SRS. METHODS: A systematic review of the available literature was conducted using PubMed/MEDLINE, Embase, and Cochrane up December 08, 2023. Meta-analysis was performed using a random-effect model to calculate mean difference (MD) and relative risk (RR). A leave-one-out analysis was conducted. The risk of bias was assessed via the Risk of Bias in Non-randomized Studies-Interventions (ROBINS-I) and Cochrane Risk of Bias assessment tool (RoB-2). Ultimately, the certainty of evidence was evaluated using the GRADE assessment. The primary outcomes were serviceable hearing, and pure-tone average (PTA). The secondary outcome was the Penn Acoustic Neuroma Quality of Life Scale (PANQOL) total score. RESULTS: Nine studies were eligible for inclusion, comprising a total of 1,275 patients. Among these, 674 (52.86%) underwent WAS, while 601 patients (47.14%) received SRS. Follow-up duration ranged from two to eight years. The meta-analysis indicated that WAS had a better outcome for serviceable hearing (0.47; 95% CI: 0.32 - 0.68; p < 0.001), as well as for postoperative functional measures including PTA score (MD 13.48; 95% CI 3.83 - 23.13; p < 0.01), and PANQOL total score (MD 3.83; 95% CI 0.42 - 7.25; p = 0.03). The overall certainty of evidence ranged from "very low" to "moderate". CONCLUSIONS: Treating small to medium sized VS with WAS increases the likelihood of preserving serviceable hearing and optimized PANQOL overall postoperative score compared to SRS. Nevertheless, the limited availability of literature and the methodological weakness observed in existing studies outline the need for higher-quality studies.
Assuntos
Neuroma Acústico , Qualidade de Vida , Radiocirurgia , Humanos , Audição/fisiologia , Perda Auditiva/epidemiologia , Perda Auditiva/etiologia , Perda Auditiva/fisiopatologia , Perda Auditiva/prevenção & controle , Neuroma Acústico/complicações , Neuroma Acústico/fisiopatologia , Neuroma Acústico/radioterapia , Neuroma Acústico/cirurgia , Radiocirurgia/métodos , Resultado do Tratamento , Conduta Expectante/métodosRESUMO
BACKGROUND: Ventilator-associated tracheobronchitis is a common condition among invasively ventilated patients in intensive care units, for which the best treatment strategy is currently unknown. We designed the VATICAN (Ventilator-Associated Tracheobronchitis Initiative to Conduct Antibiotic Evaluation) trial to assess whether a watchful waiting antibiotic treatment strategy is noninferior to routine antibiotic treatment for ventilator-associated tracheobronchitis regarding days free of mechanical ventilation. METHODS: VATICAN is a randomized, controlled, open-label, multicenter noninferiority trial. Patients with suspected ventilator-associated tracheobronchitis without evidence of ventilator-associated pneumonia or hemodynamic instability due to probable infection will be assigned to either a watchful waiting strategy, without antimicrobial administration for ventilator-associated tracheobronchitis and prescription of antimicrobials only in cases of ventilator-associated pneumonia, sepsis or septic shock, or another infectious diagnosis, or to a routine antimicrobial treatment strategy for seven days. The primary outcome will be mechanical ventilation-free days at 28 days, and a key secondary outcome will be ventilator-associated pneumonia-free survival. Through an intention-to-treat framework with a per-protocol sensitivity analysis, the primary outcome analysis will address noninferiority with a 20% margin, which translates to a 1.5 difference in ventilator-free days. Other analyses will follow a superiority analysis framework. CONCLUSION: The VATICAN trial will follow all national and international ethical standards. We aim to publish the trial in a high-visibility general journal and present it at critical care and infectious disease conferences for dissemination. These results will likely be immediately applicable to the bedside upon trial completion and will provide information with a low risk of bias for guideline development.
Assuntos
Antibacterianos , Bronquite , Pneumonia Associada à Ventilação Mecânica , Respiração Artificial , Traqueíte , Conduta Expectante , Humanos , Antibacterianos/uso terapêutico , Antibacterianos/administração & dosagem , Bronquite/tratamento farmacológico , Bronquite/microbiologia , Unidades de Terapia Intensiva , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/microbiologia , Respiração Artificial/efeitos adversos , Traqueíte/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
BACKGROUND: Neoadjuvant radiation and oxaliplatin-based systemic therapy (total neoadjuvant therapy-TNT) have been shown to increase response and organ-preservation rates in localized rectal cancer. However, trials have been heterogeneous regarding treatment protocols and few have used a watch-and-wait (WW) approach for complete responders. This trial evaluates if conventional long-term chemoradiation followed by consolidation of FOLFIRINOX increases complete response rates and the number of patients managed by WW. METHODS: This was a pragmatic randomized phase II trial conducted in 2 Cancer Centers in Brazil that included patients with T3+ or N+ rectal adenocarcinoma. After completing a long-course 54 Gy chemoradiation with capecitabine patients were randomized 1:1 to 4 cycles of mFOLFIRINOX (Oxaliplatin 85, irinotecan 150, 5-FU 2400)-TNT-arm-or to the control arm, that did not include further neoadjuvant treatment. All patients were re-staged with dedicated pelvic magnetic resonance imaging and sigmoidoscopy 12 weeks after the end of radiation. Patients with a clinical complete response were followed using a WW protocol. The primary endpoint was complete response: clinical complete response (cCR) or pathological response (pCR). RESULTS: Between April 2021 and June 2023, 55 patients were randomized to TNT and 53 to the control arm. Tumors were 74% stage 3, median distance from the anal verge was 6 cm, 63% had an at-risk circumferential margin, and 33% an involved sphincter. The rates of cCR + pCR were (31%) for TNT versus (17%) for controls (odds ratio 2.19, CI 95% 0.8-6.22 P = .091) and rates of WW were 16% and 9% (P = ns). Median follow-up was 8.1 months and recurrence rates were 16% versus 21% for TNT and controls (P = ns). CONCLUSIONS: TNT with consolidation FOLFIRINOX is feasible and has high response rates, consistent with the current literature for TNT. This trial was supported by a grant from the Brazilian Government (PROADI-SUS - NUP 25000.164382/2020-81).
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica , Fluoruracila , Irinotecano , Leucovorina , Terapia Neoadjuvante , Estadiamento de Neoplasias , Oxaliplatina , Neoplasias Retais , Humanos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Retais/terapia , Neoplasias Retais/patologia , Terapia Neoadjuvante/métodos , Oxaliplatina/uso terapêutico , Oxaliplatina/administração & dosagem , Pessoa de Meia-Idade , Masculino , Fluoruracila/administração & dosagem , Fluoruracila/uso terapêutico , Feminino , Idoso , Brasil , Irinotecano/uso terapêutico , Irinotecano/administração & dosagem , Leucovorina/uso terapêutico , Leucovorina/administração & dosagem , Adulto , Quimiorradioterapia/métodos , Adenocarcinoma/terapia , Adenocarcinoma/patologia , Conduta Expectante/estatística & dados numéricos , Resultado do Tratamento , Quimiorradioterapia Adjuvante/métodos , Quimiorradioterapia Adjuvante/estatística & dados numéricos , Capecitabina/administração & dosagem , Capecitabina/uso terapêutico , SeguimentosRESUMO
PURPOSE: Cervical lymph nodes (LN) represent the most common site of recurrence in differentiated thyroid cancer (DTC), frequently requiring repeated interventions that contribute to increase morbidity to a usually indolent disease. Data on active surveillance (AS) of nodal metastasis are limited. Therefore, we performed a systematic review and meta-analysis to evaluate AS in nodal metastasis of DTC patients. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched up to July 2023 for studies including DTC patients with metastatic LN who were followed up with AS. The primary outcome was disease progression, according to the study's definition. Additional outcomes were LN enlargement ≥3 mm, occurrence of new cervical metastasis, and conversion from AS to surgical treatment. RESULTS: The search identified 375 studies and seven were included, comprising 486 patients with metastatic nodal DTC. Most were female (69.5%) and had papillary thyroid cancer (99.8%). The mean AS follow-up ranged from 28-86 months. Following each study's definition of progression, the pooled incidence was 28% [95% confidence interval (CI), 20-37%]. The pooled incidence of LN growth ≥ 3 mm was 21% [95% CI, 17-25%] and the emergence of new LN sites was 19% [95% CI, 14-25%]. Combining growth of 3 mm and the emergence of new LN criteria, we found an incidence of 26% [95% CI, 20-33%]. The incidence of neck dissection during AS was 18% [95% CI, 12-26%]. CONCLUSIONS: AS seems to be a suitable strategy for selected DTC patients with small nodal disease, avoiding or postponing surgical reintervention. PROSPERO REGISTRATION: CRD42023438293.
Assuntos
Metástase Linfática , Neoplasias da Glândula Tireoide , Feminino , Humanos , Masculino , Progressão da Doença , Linfonodos/patologia , Linfonodos/cirurgia , Metástase Linfática/terapia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Conduta ExpectanteRESUMO
Objective: After initial treatment, up to 30% of patients with papillary thyroid cancer (PTC) have incomplete response, mainly cervical lymph node (LN) disease. Previous studies have suggested that active surveillance (AS) is a possible option for these patients. Our aim was to report the results of AS in patients with PTC and cervical LN disease. Materials and methods: In this retrospective observational study, we included adult patients treated and followed for PTC, who presented with cervical LN disease and were managed with AS. Growth was defined as an increase ≥ 3mm in either diameter. Results: We included 32 patients: 27 (84.4%) women, age of 39 ± 14 years, all initially treated with total thyroidectomy, and 22 (69%) with therapeutic neck dissection. Cervical LN disease was diagnosed 1 year (0.3-12.6) after initial management, with a diameter of 9.0 mm (6.0-19.0). After a median AS of 4.3 years (0.6-14.1), 4 (12.5%) patients had LNgrowth: 2 (50%) of whom were surgically removed, 1 (25%) was effectively treated with radiotherapy, and 1 (25%) had a scheduled surgery. Tg increase was the only predictive factor of LN growth evaluated as both the delta Tg (p < 0.0366) and percentage of Tg change (p < 0.0140). None of the included patients died, had local complications due to LN growth or salvage therapy, or developed distant metastases during follow-up. Conclusion: In selected patients with PTC and suspicious cervical LNs diagnosed after initial treatment, AS is a feasible and safe strategy as it allows effective identification and treatment of the minority of patients who progress.
Assuntos
Linfonodos , Metástase Linfática , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Tireoidectomia , Conduta Expectante , Humanos , Feminino , Masculino , Adulto , Estudos Retrospectivos , Tireoidectomia/métodos , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Pessoa de Meia-Idade , Câncer Papilífero da Tireoide/cirurgia , Câncer Papilífero da Tireoide/patologia , Linfonodos/patologia , Estudos de Viabilidade , Pescoço/cirurgia , Carcinoma Papilar/cirurgia , Carcinoma Papilar/patologia , Esvaziamento Cervical/métodos , Adulto JovemRESUMO
Bladder cancer (BC) is the tenth most common cause of cancer worldwide and is the thirteenth leading cause of cancer mortality. The non-muscle invasive (NMI) variant represents 75% of cases and has a mortality rate of less than 1%; however, it has a high recurrence rate. The gold standard of management is transurethral resection in the case of new lesions. However, this is associated with significant morbidity and costs, so the reduction of these procedures would contribute to reducing complications, morbidity, and the burden to the health system associated with therapy. In this clinical scenario, strategies such as active surveillance have emerged that propose to manage low-risk BC with follow-up; however, due to the low evidence available, this is a strategy that is underutilized by clinicians. On the other hand, in the era of biomarkers, it is increasingly known how to use them as a tool in BC. Therefore, the aim of this review is to provide to clinical practitioners the evidence available to date on AS and the potential role of biomarkers in this therapeutic strategy in patients with low-grade/risk NMIBC. This is the first review linking use of biomarkers and active surveillance, including 29 articles.
Assuntos
Biomarcadores Tumorais , Neoplasias não Músculo Invasivas da Bexiga , Humanos , Neoplasias não Músculo Invasivas da Bexiga/diagnóstico , Conduta Expectante/métodosRESUMO
La anomalía de Ebstein es una cardiopatía congénita rara y poco frecuente caracterizada por el adosamiento de los velos valvulares tricuspídeos; en la etapa prenatal se estima que su incidencia corresponde a un 3% de todas las cardiopatías diagnosticadas. Se presenta el caso de un feto con diagnóstico de anomalía de Ebstein a quien se le realizó un diagnóstico prenatal adecuado, lo que permitió planificar el nacimiento neonatal con un equipo multidisciplinario integral. Debido a la rareza del diagnóstico prenatal de esta entidad, se describe el caso clínico y los hallazgos imagenológicos representativos.
Ebsteins anomaly is a rare and infrequent congenital heart disease characterized by the attachment of the tricuspid valve leaflets; in the prenatal stage it is estimated that its incidence corresponds to 3% of all diagnosed heart diseases. We present the case of a fetus diagnosed with Ebsteins anomaly who underwent an adequate prenatal diagnosis, which made it possible to plan the neonatal birth with a comprehensive multidisciplinary team. Due to the rarity of the prenatal diagnosis of this entity, the clinical case and the representative imaging findings are described.
Assuntos
Humanos , Masculino , Feminino , Gravidez , Recém-Nascido , Adolescente , Ecocardiografia , Anomalia de Ebstein/diagnóstico por imagem , Resultado da Gravidez , Ultrassonografia Pré-Natal , Conduta ExpectanteRESUMO
BACKGROUND: The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC. METHODS: The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657. RESULTS: The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four. CONCLUSION: Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.
Assuntos
Técnicas de Ablação , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Tireoidectomia , Conduta Expectante , Humanos , Terapia a Laser , Qualidade de Vida , Ablação por Radiofrequência/métodos , Câncer Papilífero da Tireoide/cirurgia , Câncer Papilífero da Tireoide/mortalidade , Câncer Papilífero da Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/mortalidade , Tireoidectomia/métodos , Resultado do TratamentoRESUMO
Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.
Assuntos
Neoplasias Retais , Conduta Expectante , Humanos , Consenso , Recidiva Local de Neoplasia/tratamento farmacológico , Neoplasias Retais/patologia , Terapia Neoadjuvante/métodos , Quimiorradioterapia/métodos , Resposta Patológica Completa , Resultado do TratamentoRESUMO
Active Surveillance is a non-invasive strategy designed to identify a minority of patients with low-risk papillary thyroid carcinoma who might experience clinical progression and benefit from additional definitive treatments. Global experience suggests that these tumors typically show minimal changes in size during active surveillance, often demonstrating very slow growth or even size reduction. Moreover, the rate of lymph node metastases is low and can be effectively managed through rescue surgery, without impacting cancer-related mortality. However, despite 30 years of experience demonstrating the safety and feasibility of active surveillance for appropriately selected patients, this approach seems to have limited adoption in specific contexts. This limitation can be attributed to various barriers, including disparities in access to accurate information about the indolent nature of this disease and the prevalence of a maximalist mindset among certain patients and medical settings. This review aims to revisit the experience from the last three decades, provide current insights into the clinical outcomes of active surveillance trials, and propose a systematic approach for its implementation. Furthermore, it intends to emphasize the importance of precise patient selection and provides new perspectives in the field.
Assuntos
Carcinoma Papilar , Neoplasias da Glândula Tireoide , Humanos , Tireoidectomia , Conduta Expectante , Carcinoma Papilar/patologia , Neoplasias da Glândula Tireoide/epidemiologiaRESUMO
A recorrência de metástases linfonodais é frequente nos pacientes com carcinoma diferenciado de tireoide, levando a procedimentos cirúrgicos repetidos, que parecem trazer um maior potencial de efeitos adversos do que benefícios ao tratamento da neoplasia. A vigilância ativa de linfonodos positivos pode ser uma ferramenta terapêutica confiável em pacientes selecionados conforme resultados de trabalhos recentes. O conhecimento dos fatores que possam predizer o crescimento desses linfonodos e, porventura, a necessidade futura, ou não, de intervenção, poderá ajudar a individualizar o seguimento de longo prazo desses pacientes. Neste estudo foram avaliados, retrospectivamente, os fatores preditores de progressão em linfonodos metastáticos cervicais nos pacientes acompanhados no Instituto Nacional do Câncer, que apresentaram recorrência de doença confirmada através de punção aspirativa e/ou dosagem de tireoglobulina no aspirado da punção aspirativa e que foram submetidos à vigilância ativa. Os critérios de inclusão foram metástases cervicais de ≤ 2 cm e pelo menos 6 meses de vigilância ativa. Foram excluídos os pacientes menores de 18 anos, que apresentaram presença de histologia agressiva, doença de rápida progressão, carcinoma medular, carcinoma com invasão local, linfonodos maiores que 2 cm no maior diâmetro, radioterapia cervical prévia, terapia sistêmica com inibidores de tirosina cinase, confirmação de segundo tumor primário e os pacientes submetidos à radioablação ou alcoolização do linfonodo em questão. O desfecho primário foi progressão de doença (aumento de 3 mm em qualquer diâmetro ou novos sítios de metástase cervical). Trinta e seis pacientes completaram os critérios de elegibilidade para nosso estudo. Vinte e quatro apresentaram doença estável e doze apresentaram progressão da doença. Dezenove pacientes seguem em vigilância ativa na data da apresentação deste trabalho, completando um tempo de sobrevivência livre de progressão de 3 anos em â da amostra, enquanto que nos outros â o tempo foi maior que 5 anos (67, 68 meses), o que sugere que a vigilância ativa é uma opção terapêutica segura em linfonodos positivos menores que 2 cm. O único fator prognóstico associado à progressão de doença que teve significância estatística (P<0,02) foi o volume do maior linfonodo do histopatológico inicial.
The recurrence of lymph node metastases is common in patients with differentiated thyroid carcinoma, leading to repeated surgical procedures, which seem to bring a greater potential for adverse effects than benefits to the treatment of the neoplasm. Active surveillance of positive lymph nodes may be a reliable therapeutic tool in selected patients according to results of recent studies. Knowledge of the factors that can predict the growth of these lymph nodes, and perhaps, a future need, or not, for intervention, can help to individualize the long-term follow-up of these patients. In this study, the predictors of progression in cervical metastatic lymph nodes were retrospectively evaluated in patients at the National Cancer Institute, who presented recurrence of the disease detected through needle aspiration and/or thyroglobulin measurement in the needle aspiration aspirate and who underwent to active surveillance. Inclusion criteria were neck metastases of ≤ 2 cm and at least 6 months of active surveillance. Patients under 18 years of age were excluded if they presented aggressive histology, rapidly progressing disease, medullary carcinoma, carcinoma with local invasion, lymph nodes larger than 2 cm in largest diameter, previous cervical radiotherapy, systemic therapy with tyrosine kinase inhibitors, confirmation of a second primary tumor and patients submitted to radioablation or alcoholization of the lymph node in question. The primary stage was disease progression (3 mm increase in any diameter or new sites of neck metastasis). Thirty patients met the eligibility criteria for our study. Twenty-four had stable disease and twelve had disease progression. Nineteen patients remain under active surveillance at the date of presentation of this work, completing a progression-free survival time of 3 years in â of the sample, while in the other â the time was greater than 5 years (67, 68 months), which suggests that active surveillance is a safe therapeutic option in positive lymph nodes smaller than 2 cm. The only prognostic factor associated with disease progression that had statistical significance (P<0.02) was the volume of the largest lymph node in the initial histopathology.
Assuntos
Neoplasias da Glândula Tireoide , Intervalo Livre de Progressão , Metástase Neoplásica , Progressão da Doença , Conduta ExpectanteRESUMO
Introducción: En Uruguay el cáncer de próstata ocupa el primer lugar en incidencia y el tercer lugar en mortalidad en el hombre. La mayoría de estos cánceres se diagnostican en estadios precoces. Hoy en día, para pacientes con adenocarcinoma de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, la vigilancia activa es una opción adecuada. Objetivos: Describir una población de pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, en vigilancia activa en COMERI. Material y métodos: Estudio descriptivo, observacional, retrospectivo. Se incluyeron pacientes con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, tratados entre 2010 y 2018 en COMERI. Se recopilaron datos en el sistema de registro clínico electrónico. Resultados: Se incluyeron 33 pacientes, la mediana de edad al diagnóstico fue de 74 años. Todos los pacientes fueron sometidos a controles clínicos y determinación de PSA cada 3 meses. El tacto rectal se realizó en forma anual. El tiempo mediano de vigilancia activa fue de 33 meses. Durante el seguimiento, se observaron pocas variaciones en los valores de PSA. El 21% de los pacientes fue sometido a una nueva biopsia durante el seguimiento activo, y en todos los casos, el Gleason se mantuvo incambiado. Ningún paciente abandonó la modalidad de vigilancia activa. Conclusión: En nuestro entorno, la vigilancia activa se considera una opción terapéutica válida para pacientes altamente seleccionados con cáncer de próstata de muy bajo riesgo, bajo riesgo o riesgo intermedio favorable, y es bien aceptada por ellos.
Introduction: In Uruguay, prostate cancer ranks first in incidence and third in mortality among men. The majority of these cancers are diagnosed at early stages. Nowadays, active surveillance is an appropriate option for patients with adenocarcinoma of very low risk, low risk, or favorable intermediate risk. Objectives: To describe a population of patients with prostate cancer of very low risk, low risk, or favorable intermediate risk under active surveillance at COMERI. Materials and Methods: Descriptive, observational, retrospective study. Patients with prostate cancer of very low risk, low risk, or favorable intermediate risk treated between 2010 and 2018 at COMERI were included. Data were collected from the electronic clinical registry system. Results: Thirty-three patients were included, with a median age at diagnosis of 74 years. All patients underwent clinical monitoring and PSA determination every 3 months. Digital rectal examination was performed annually. The median time of active surveillance was 33 months. During follow-up, there were few variations in PSA values. 21% of patients underwent a repeat biopsy during active surveillance, and in all cases, the Gleason score remained unchanged. No patient discontinued active surveillance. Conclusion: In our setting, active surveillance is considered a valid therapeutic option for highly selected patients with prostate cancer of very low risk, low risk, or favorable intermediate risk, and it is well accepted by them.
Introdução: No Uruguai, o câncer de próstata ocupa o primeiro lugar em incidência e o terceiro lugar em mortalidade entre os homens. A maioria desses cânceres é diagnosticada em estágios precoces. Atualmente, para pacientes com adenocarcinoma de risco muito baixo, baixo risco ou risco intermediário favorável, a vigilância ativa é uma opção adequada. Objetivos: Descrever uma população de pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável sob vigilância ativa em COMERI. Material e métodos: Estudo descritivo, observacional, retrospectivo. Foram incluídos pacientes com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, tratados entre 2010 e 2018 em COMERI. Os dados foram coletados no sistema de registro clínico eletrônico. Resultados: Foram incluídos 33 pacientes, com mediana de idade no diagnóstico de 74 anos. Todos os pacientes foram submetidos a controles clínicos e determinação de PSA a cada 3 meses. O toque retal foi realizado anualmente. O tempo médio de vigilância ativa foi de 33 meses. Durante o acompanhamento, houve poucas variações nos valores de PSA. 21% dos pacientes foram submetidos a uma nova biópsia durante a vigilância ativa, e em todos os casos, o Gleason permaneceu inalterado. Nenhum paciente abandonou a modalidade de vigilância ativa. Conclusão: Em nosso ambiente, a vigilância ativa é considerada uma opção terapêutica válida para pacientes altamente selecionados com câncer de próstata de risco muito baixo, baixo risco ou risco intermediário favorável, e é bem aceita por eles.
Assuntos
Humanos , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Próstata/terapia , Adenocarcinoma/terapia , Progressão da Doença , Conduta Expectante , Estudos Retrospectivos , Resultado do Tratamento , Seleção de Pacientes , OctogenáriosRESUMO
Numerous Antarctic species are recognized as reservoirs for various pathogens, and their migratory behavior allows them to reach the Brazilian coast, potentially contributing to the emergence and circulation of new infectious diseases. To address the potential zoonotic risks, we conducted surveillance of influenza A virus (IAV) and coronaviruses (CoVs) in the Antarctic Peninsula, specifically focusing on different bird and mammal species in the region. During the summer of 2021/2022, as part of the Brazilian Antarctic Expedition, we collected and examined a total of 315 fecal samples to target these respiratory viruses. Although we did not detect the viruses of interest during this particular expedition, previous research conducted by our team has shown the presence of the H11N2 subtype of influenza A virus in penguin fecal samples from the same region. Given the continuous emergence of new viral strains worldwide, it is crucial to maintain active surveillance in the area, contributing to strengthening integrated One Health surveillance efforts.
Assuntos
Infecções por Coronavirus , Vírus da Influenza A , Influenza Aviária , Spheniscidae , Animais , Regiões Antárticas , Conduta Expectante , Influenza Aviária/epidemiologia , Filogenia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/veterinária , MamíferosRESUMO
BACKGROUND: Prostate cancer exhibits a very diverse behaviour, with some patients dying from the disease and others never needing treatment. Active surveillance (AS) consists of periodic PSA assessment (prostate-specific antigen), DRE (digital rectal examination) and periodic prostate biopsies. According to the main guidelines, AS is the preferred strategy for low-risk patients, to avoid or delay definitive treatment. However, concerns remain regarding its applicability in certain patient subgroups, such as African American men, who were underrepresented in the main cohorts. Brazil has a very racially diverse population, with 56.1% self-reporting as brown or black. The aim of this study is to evaluate and validate the AS strategy in low-risk prostate cancer patients following an AS protocol in the Brazilian public health system. METHODS: This is a multicentre AS prospective cohort study that will include 200 patients from all regions of Brazil in the public health system. Patients with prostate adenocarcinoma and low-risk criteria, defined as clinical staging T1-T2a, Gleason score ≤ 6, and PSA < 10 ng/ml, will be enrolled. Archival prostate cancer tissue will be centrally reviewed. Patients enrolled in the study will follow the AS strategy, which involves PSA and physical examination every 6 months as well as multiparametric MRI (mpMRI) every two years and prostate biopsy at month 12 and then every two years. The primary objective is to evaluate the reclassification rate at 12 months, and secondary objectives include determining the treatment-free survival rate, metastasis-free survival, and specific and overall survival. Exploratory objectives include the evaluation of quality of life and anxiety, the impact of PTEN loss and the economic impact of AS on the Brazilian public health system. DISCUSSION: This is the first Brazilian prospective study of patients with low-risk prostate cancer under AS. To our knowledge, this is one of the largest AS study cohort with a majority of nonwhite patients. We believe that this study is an opportunity to better understand the outcomes of AS in populations underrepresented in studies. Based on these data, an AS national clinical guideline will be developed, which may have a beneficial impact on the quality of life of patients and on public health. TRIAL REGISTRATION: Clinicaltrials registration is NCT05343936.
Assuntos
Antígeno Prostático Específico , Neoplasias da Próstata , Masculino , Humanos , Estudos Prospectivos , Brasil/epidemiologia , Conduta Expectante/métodos , Qualidade de Vida , Saúde Pública , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapiaRESUMO
To establish a set of variables that define a predictive profile of events of maxillofacial trauma resulting from interpersonal violence, we analyzed sociodemographic variables and clinical characteristics of injuries recorded in three tertiary care hospital centers in Chile. To assess the relation between categories, we applied a multiple correspondence analysis. We identified 567 cases. Two dimensions explained 53.4% of the model. The first dimension was composed of variables related to the severity of the injury: medical-legal prognosis (.574), type of trauma (.511), and the destination of the patient (.332); the second dimension was composed of variables related to the typology of interpersonal violence: type of violence (.398) and sex of the patient (.370). Two profiles were recognized: women, victims of domestic violence, with lesions affecting mainly soft tissues and not requiring hospitalization and men, victims of community violence, with lesions involving fractures associated with greater severity and requiring hospitalization. There are two key dimensions in the diagnosis of maxillofacial trauma resulting from interpersonal violence: severity of the injury and typology of the interpersonal violence. Exploring these predictive profiles can be a useful complement to the current screening tools of violence in clinical practice.
Assuntos
Violência Doméstica , Traumatismos Maxilofaciais , Masculino , Humanos , Feminino , Conduta Expectante , Serviço Hospitalar de Emergência , Traumatismos Maxilofaciais/epidemiologia , Estudos RetrospectivosRESUMO
Colorectal cancer is currently the third most frequently diagnosed type of cancer and the second cause of cancer death in the western world. Inflammatory bowel disease patients are 2-6 times more likely to develop CRC than the general population. Patients with CRC arising through Inflammatory Bowel Disease have an indication for surgery. However, in patients without Inflammatory Bowel Disease, the use of organ (rectum) preservation strategies after neoadjuvant treatment is on the rise, which means that patients are able to keep the organ without the need for complete excision, either by treatment with radiotherapy and chemotherapy, or in combination with endoscopic or surgical techniques that allow local excision without the need for resection of the entire organ. The patient management approach known as the Watch and Wait programme was first introduced in 2004 by a team from São Paulo, Brazil. This approach suggested that patients who had an excellent or complete clinical response after neoadjuvant treatment could defer surgery and instead undergo Watch and Wait. This organ preservation technique became popular because it allowed patients to avoid the complications associated with major surgery while achieving similar oncological outcomes to those who underwent both neoadjuvant therapy and radical surgery. Following completion of neoadjuvant treatment, a decision to defer surgery is made based on whether a clinical Complete Response can be achieved, which means there is no evidence of tumour in clinical and radiological examination. The International Watch and Wait Database has published long-term oncological outcomes for patients treated with this strategy, and more patients are showing interest in this treatment option. However, it is important to note that up to 1/3 of patients selected for Watch and Wait may eventually require surgery for local regrowth (also known as 'deferred definitive surgery') at any time during follow-up after an initial 'apparent' clinical Complete Response. Compliance with a strict surveillance protocol ensures early detection of regrowth, which is usually amenable to R0 surgery and provides excellent long-term local disease control. Nonetheless, it is crucial to assess the perioperative consequences of having surgery for regrowth later and whether there are any negative effects from deferring surgery. Currently, the Watch and Wait strategy is recommended in the NCCN guidelines for clinical complete responders and only in specialised multidisciplinary centres.There is no case in the literature that portrays the use of the Watch and Wait programme for patients with inflammatory bowel disease and rectal cancer.The authors intend to present a case that demonstrates the difficulties in the assessment of patients with inflammatory bowel disease, the risks of using radiotherapy in this patients and the challenges of surveillance for patients with colorectal cancer and inflammatory bowel disease.