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4.
Colomb Med (Cali) ; 52(2): e4124776, 2021 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-34188328

RESUMO

Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.


Assuntos
Algoritmos , Colostomia , Consenso , Reto/lesões , Ferimentos Penetrantes/cirurgia , Colômbia , Colo/lesões , Tratamento Conservador , Exame Retal Digital , Humanos , Proctoscopia , Tomografia Computadorizada por Raios X/métodos , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapia
6.
Lancet Gastroenterol Hepatol ; 6(4): 327-334, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33714370

RESUMO

Anal squamous cell carcinoma is the most common type of anal cancer and is largely associated with anal human papillomavirus infection. The incidence of anal squamous cell carcinoma is increasing, and although still uncommon in the general population, a high incidence has been noted in specific population groups (eg, patients with HIV, men who have sex with men [MSM], recipients of solid organ transplants, women with genital neoplasia, and patients with systemic lupus erythematosus or inflammatory bowel disease). The higher incidence among individuals who are HIV-positive makes anal squamous cell carcinoma one of the most common non-AIDS-defining cancers among HIV-positive individuals. Anal cancer screening in high-risk groups aims to detect high-grade squamous intraepithelial lesions, which are considered anal precancerous lesions, and for which identification can provide an opportunity for prevention. A blind anal cytology is normally the first screening method, and for patients with abnormal results, this approach can be followed by an examination of the anal canal and perianal area under magnification, along with staining-a technique known as high-resolution anoscopy. Digital anorectal examination can enable early anal cancer detection. Several societies are in favour of screening for HIV-positive MSM and recipients of transplants. There are no current recommendations for screening of anal precancerous lesions via endoscopy, but in high-risk groups, a careful observation of the squamocolumnar junction should be attempted. Several treatments can be used to treat high-grade squamous intraepithelial lesions, including argon plasma coagulation or radiofrequency ablation, which are largely limited by high recurrence rates. Gastroenterologists need to be aware of anal squamous cell carcinoma and anal precancerous lesions, given that patients at high risk are frequently encountered in the gastroenterology department. We summarise simple procedures that can help in early anal squamous cell carcinoma detection.


Assuntos
Neoplasias do Ânus/prevenção & controle , Carcinoma de Células Escamosas/prevenção & controle , Lesões Pré-Cancerosas/prevenção & controle , Neoplasias do Ânus/diagnóstico , Neoplasias do Ânus/terapia , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/terapia , Humanos , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/terapia , Proctoscopia , Melhoria de Qualidade
7.
Tech Coloproctol ; 25(4): 461-466, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33569753

RESUMO

BACKGROUND: The development of high-resolution anoscopy (HRA) has advanced our ability to detect anal dysplasia. Historically, HRA is performed in a clinical setting and subsequent ablation is performed in the clinical setting or operating room. The aim of this study was to determine the most effective venue for the performance of HRA. METHODS: Following institutional review board (IRB) approval, the correlation between anal cytology and HRA performed in the clinic versus in the operating room was evaluated. Data were extracted from our IRB-approved prospective HRA database over the time period of 2013-2017. RESULTS: One hundred twenty-eight HRAs were compared (101 in the clinical setting, 27 in the operating room). There was a statistically significant difference in the correlation between anal cytology and HRA pathology for procedures performed in the clinical setting (55% [56/101]) versus those performed in the operating room (82% [22/27]) (p = 0.014). More biopsies were obtained in the operating room than in the clinic setting (3 vs. 1, p < 0.0001). The majority of patients who had HRA in a clinical setting with subsequent HRA in the operating room stated that they preferred to have their HRAs performed in the operating room due to discomfort from the HRA procedure. CONCLUSIONS: Detection rates for anal dysplasia on HRA, are significantly higher when performed in the operating room. To prevent discomfort in the clinical setting, patients with high-grade dysplasia on anal pap testing may benefit from proceeding directly to the operating room for concurrent HRA and ablation.


Assuntos
Neoplasias do Ânus , Salas Cirúrgicas , Canal Anal/cirurgia , Neoplasias do Ânus/cirurgia , Humanos , Proctoscopia , Estudos Prospectivos
8.
Zhonghua Fu Chan Ke Za Zhi ; 56(1): 34-42, 2021 Jan 25.
Artigo em Chinês | MEDLINE | ID: mdl-33486926

RESUMO

Objective: To evaluate the value of high-resolution anoscopy (HRA) in the diagnosis of anal precancerous lesions. Methods: A retrospective cohort study was performed, which included 142 patients who underwent HRA in vulvar and anal clinic at Obstetrics and Gynecology Hospital of Fudan University from January 2014 to December 2019. With the perianal and anal canal biopsy pathology as the "gold standard", the diagnostic value of HRA and specific findings for anal precancerous lesions were evaluated and the clinical characteristics of patients with anal precancerous lesions were analyzed. Results: (1) Agreement between HRA and anal pathology were 76.6% (95/124, perianal) and 70.0% (84/120, anal canal), in which there was no significant difference (χ2=1.365, P=0.243). The strength of agreement with weighted Kappa statistic were 0.604 (perianal) and 0.455 (anal canal) respectively. HRA diagnosis were more overestimated [16.9% (21/124) in perianal and 25.0% (30/120) in anal canal] than underestimated [6.5% (8/124) in perianal and 5.0% (6/120) in anal canal]. The sensitivity and specificity of HRA in the diagnosis of anal precancerous lesions were all more than 60.0% (perianal lesions: 97.8% and 74.7%; anal canal lesions: 90.9% and 66.7%), and Youden's index were >0.5 (perianal lesions: 0.725; anal canal lesions: 0.576). The positive predictive value of HRA in anal canal lesions (50.8%) was lower than that in perianal lesions (68.8%). (2) The thin acetowhite epithelium was the most common finding in anal precancerous lesions, and its performance in anal canal lesions (the sensitivity, the specificity and the Youden's index were 78.8%, 62.4% and 0.412, respectively) were better than those in perianal lesions (the sensitivity, the specificity and the Youden's index were 28.9%, 96.9% and 0.258, respectively). The dense acetowhite epithelium and vascular patterns were only seen in anal canal lesions. Lugol's iodine was little useful for perianal lesions (the incidence of iodine negative was 0),but quite useful to evaluate the canal lesions (the positive predictive value was 83.3% and the negative predictive value was 82.3%). (3) The average age of patients with low-grade anal precancerous lesion was (37±10) years old, and high-grade anal precancerous lesion was (42±11) years old, and there was significant difference between them (P=0.034). Age curve showed that the peak age was 30-40 years old. Vulvar intraepithelial lesion was the risk factor of anal precancerous lesions (χ2=4.284, P<0.05). Conclusions: HRA patterns are reliable in the diagnosis of anal precancerous lesions, which is important for guiding biopsy. However, it is easy to be overestimated, especially for anal canal lesions. The acetowhite epithelium is the most common finding in anal precancerous lesions, but vascular patterns are only seen in anal canal lesions.


Assuntos
Canal Anal/diagnóstico por imagem , Neoplasias do Ânus/patologia , Lesões Pré-Cancerosas/patologia , Proctoscopia/métodos , Adulto , Neoplasias do Ânus/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/diagnóstico por imagem , Gravidez , Estudos Retrospectivos
10.
Asian J Endosc Surg ; 14(3): 653-657, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33258292

RESUMO

INTRODUCTION: Reestablishing continuity after the Hartmann procedure, the Hartmann reversal has been recognized as a complex procedure with a high morbidity rate. Laparoscopic reversal of the Hartmann procedure (LHR) is technically challenging, although good short-term results have been reported. We formulated this technique in 2013 and have been gradually devising and standardizing it. MATERIAL AND SURGICAL TECHNIQUE: Ten patients who had undergone the Hartmann procedure from January 2013 to December 2019 and subsequently LHR were retrospectively examined. During the procedure, a circular incision was made at the original site of the colostomy to safely reach the abdominal cavity, and pneumoperitoneum was performed using the glove technique. Next, pelvic adhesions and the descending colon were dissected. If the rectal stump was difficult to identify, an intraoperative endoscope was used. Finally, either a Gambee or stapled anastomosis without tension was performed. The median surgical time was 265 minutes (range, 160-435 minutes), and the median blood loss was 100 mL (range, 10-700 mL). The median postoperative hospital stay was 11 days (range, 8-14 days). In one case, laparotomy was performed because of severe intra-abdominal adhesion. DISCUSSION: No major complication was observed during or after surgery. Therefore, LHR can be performed safely. Standardizing this procedure could render it minimally invasive, although a high level of evidence is needed.


Assuntos
Colo/cirurgia , Colostomia , Laparoscopia , Reto/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Laparoscopia/métodos , Laparoscopia/normas , Proctoscopia , Padrões de Referência , Estudos Retrospectivos , Aderências Teciduais/etiologia , Aderências Teciduais/cirurgia
12.
Gastroenterol Hepatol ; 44(6): 418-423, 2021.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-33303284

RESUMO

OBJECTIVE: To assess the effectiveness and safety of cap-assisted endoscopic resection and the usefulness of endoscopic ultrasonography (EUS) for managing small rectal subepithelial tumors (SETs). PATIENTS AND METHODS: Patients with small rectal SETs≤10mm in diameter were enrolled in this study at our hospital from October 2014 to December 2017. First, EUS was performed to evaluate the lesions. Then, cap-assisted endoscopic resection was performed by suctioning the SET into a transparent cap, ligating with a metal snare and then resecting the tumor. The wound was closed using endoclips if necessary. RESULTS: Forty patients were enrolled in the study. EUS showed lesions originating from muscularis mucosa or submucosa with an average diameter of 5.4×3.1mm. The en bloc resection rate was 85.0% obtained by cap-assisted endoscopic resection, with a mean total procedure time of 17.6min. No immediate perforation happened. Immediate bleeding occurred in five patients; all cases were managed successfully by endoscopy. No delayed bleeding was observed. Pathology examination showed that 70.0% of the lesions were neuroendocrine tumors (G1). One case of recurrence was seen in follow-up; it was managed successfully by endoscopic submucosal dissection. There was no tumor recurrence in a median follow-up period of 41 months in the remaining 39 patients. CONCLUSIONS: Most small rectal SETs arising from the muscularis mucosa or submucosa are neuroendocrine tumors and require proper treatment. Cap-assisted endoscopic resection is simple, effective and safe for resecting such lesions, and EUS is useful for case screening.


Assuntos
Proctoscopia , Neoplasias Retais/cirurgia , Adulto , Ressecção Endoscópica de Mucosa/métodos , Endossonografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/cirurgia , Duração da Cirurgia , Hemorragia Pós-Operatória , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/patologia , Sucção , Resultado do Tratamento , Carga Tumoral , Adulto Jovem
13.
Eur J Surg Oncol ; 47(2): 304-310, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32873453

RESUMO

PURPOSE: To describe the regional burden of AIN and rate of progression to cancer in patients managed in specialist and non-specialist clinic settings. METHODS: Patients with a histopathological diagnosis of AIN between 1994 and 2018 were retrospectively identified. Clinicopathological characteristics including high-risk status (chronic immunosuppressant use or HIV positive), number and type of biopsy (punch/excision) and histopathological findings were recorded. The relationship between clinicopathological characteristics and progression to cancer was assessed using logistic regression. RESULTS: Of 250 patients identified, 207 were eligible for inclusion: 144 from the specialist and 63 from the non-specialist clinic. Patients in the specialist clinic were younger (<40 years 31% vs 19%, p = 0.007), more likely to be male (34% vs 16%, p = 0.008) and HIV positive (15% vs 2%, p = 0.012). Patients in the non-specialist clinic were less likely to have AIN3 on initial pathology (68% vs 79%, p = 0.074) and were more often followed up for less than 36 months (46% vs 28%, p = 0.134). The rate of progression to cancer was 17% in the whole cohort (20% vs 10%, p = 0.061). On multivariate analysis, increasing age (OR 3.02, 95%CI 1.58-5.78, p < 0.001), high risk status (OR 3.53, 95% CI 1.43-8.74, p = 0.006) and increasing number of excisions (OR 4.88, 95%CI 2.15-11.07, p < 0.001) were related to progression to cancer. CONCLUSION: The specialist clinic provides a structured approach to the follow up of high-risk status patients with AIN. Frequent monitoring with specialist assessments including high resolution anoscopy in a higher volume clinic are required due to the increased risk of progression to anal cancer.


Assuntos
Canal Anal/patologia , Neoplasias do Ânus/terapia , Carcinoma in Situ/terapia , Gerenciamento Clínico , Estadiamento de Neoplasias , Adulto , Neoplasias do Ânus/diagnóstico , Carcinoma in Situ/diagnóstico , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Proctoscopia/métodos , Estudos Retrospectivos
14.
Dis Colon Rectum ; 64(1): 53-59, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32639283

RESUMO

BACKGROUND: Endoscopic assessment is crucial in diagnosing clinical complete response after neoadjuvant therapy in rectal cancer. OBJECTIVE: The purpose of this research was to evaluate the benefits of adding narrow-band imaging endoscopy to conventional chromoendoscopy in predicting pathologic complete response in the surgical specimen. DESIGN: This was a prospective nonrandomized study. SETTINGS: This was an ad hoc study of a prospective phase II trial at a single comprehensive cancer center that evaluated oncologic outcomes of a neoadjuvant therapy for rectal cancer. PATIENTS: Patients with high-risk stage II to III low rectal cancer who received neoadjuvant modified folinic acid, fluorouracil, and oxaliplatin plus bevacizumab followed by chemoradiotherapy and surgery were included. INTERVENTION: Tumor response after neoadjuvant therapy was evaluated using conventional white light endoscopy plus chromoendoscopy then followed by using narrow-band imaging based on a predefined diagnostic protocol. MAIN OUTCOME MEASURES: Diagnostic accuracy for predicting pathologic complete response and inter-rater agreement between an expert and trainee endoscopists were compared between the assessments using conventional white light endoscopy plus chromoendoscopy and the assessment adding narrow-band imaging. RESULTS: In total, 61 patients were eligible for the study, and 19 had pathologic complete response (31.1%). Although the addition of narrow-band imaging correctly converted the diagnosis in 3 patients, overall diagnostic improvement in predicting pathologic complete response was limited (conventional chromoendoscopy vs adding narrow-band imaging: accuracy, 70.5% vs 75.4%; sensitivity, 63.2% vs 73.7%; specificity, 73.8% vs 76.2%; positive predictive value, 52.2% vs 58.3%; and negative predictive value, 81.6% vs 86.5%). A κ value for the inter-rater agreement improved from 0.599 to 0.756 by adding narrow-band imaging. LIMITATIONS: This was a single-center study with a relatively small sample size. CONCLUSIONS: Despite the limited improvement in diagnostic accuracy, adding narrow-band imaging to chromoendoscopy improved inter-rater agreement between the expert and nonexpert endoscopists. Narrow-band imaging is a reliable and promising modality for universal standardization of the diagnosis of clinical complete response. See Video Abstract at http://links.lww.com/DCR/B275. ADICIÓN DE IMÁGENES DE BANDA ESTRECHA A LA CROMOENDOSCOPÍA PARA LA EVALUACIÓN DE LA RESPUESTA TUMORAL A LA TERAPIA NEOADYUVANTE EN EL CÁNCER DE RECTO: La evaluación endoscópica es fundamental para valorar la respuesta clínica completa después de la terapia neoadyuvante en el cáncer de recto.Evaluar los beneficios de agregar endoscopia de imagen de banda estrecha a la cromoendoscopía convencional para predecir la respuesta patológica completa en la muestra quirúrgica.Estudio prospectivo no aleatorizado.Un estudio ad hoc de un ensayo prospectivo de fase II en un solo centro integral de cáncer que evaluó los resultados oncológicos de una terapia neoadyuvante para el cáncer rectal.Pacientes con cáncer rectal bajo de alto riesgo en estadio II-III que recibieron ácido folínico neoadyuvante modificado, fluorouracilo y oxaliplatino más bevacizumab seguido de quimiorradioterapia y cirugía.La respuesta tumoral después de la terapia neoadyuvante se evaluó mediante endoscopia de luz blanca convencional más cromoendoscopía, seguido de imágenes de banda estrecha basadas en un protocolo de diagnóstico predefinido.La precisión diagnóstica para predecir la respuesta patológica completa y el acuerdo entre evaluadores entre un experto y un endoscopista en entrenamiento se compararon entre las evaluaciones utilizando endoscopia de luz blanca convencional más cromoendoscopía y la evaluación agregando imágenes de banda estrecha.En total, 61 pacientes fueron elegibles para el estudio, y 19 tuvieron una respuesta patológica completa (31.1%). Aunque la adición de imágenes de banda estrecha convirtió correctamente el diagnóstico en 3 pacientes, la mejora diagnóstica general en la predicción de la respuesta patológica completa fue limitada (cromoendoscopía convencional versus adición de imágenes de banda estrecha: precisión, 70.5% versus 75.4%; sensibilidad, 63.2% versus 73.7%; especificidad, 73.8% versus 76.2%; valor predictivo positivo, 52.2% versus 58.3%; y valor predictivo negativo, 81.6% versus 86.5%). Un valor de kappa para el acuerdo entre evaluadores mejoró de 0.599 a 0.756 al agregar imágenes de banda estrecha.Un estudio de centro único con un tamaño de muestra relativamente pequeño.A pesar de la mejora limitada en la precisión diagnóstica, agregar imágenes de banda estrecha a la cromoendoscopía mejoró el acuerdo entre evaluadores entre los endoscopistas expertos y no expertos. La imagenología de banda estrecha es una modalidad confiable y prometedora para la estandarización universal del diagnóstico de respuesta clínica completa. Consulte Video Resumen en http://links.lww.com/DCR/B275.


Assuntos
Adenocarcinoma/diagnóstico por imagem , Quimiorradioterapia Adjuvante , Imagem de Banda Estreita , Terapia Neoadjuvante , Proctoscopia/métodos , Neoplasias Retais/diagnóstico por imagem , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Protectomia , Estudos Prospectivos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Sensibilidade e Especificidade , Resultado do Tratamento
16.
J Am Coll Surg ; 231(6): 681-692, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33121903

RESUMO

BACKGROUND: Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT. STUDY DESIGN: We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy. RESULTS: From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence. CONCLUSIONS: WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.


Assuntos
Terapia Neoadjuvante/métodos , Neoplasias Retais/terapia , Conduta Expectante , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/cirurgia , Proctoscopia , Neoplasias Retais/diagnóstico , Neoplasias Retais/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
17.
Dig Liver Dis ; 52(11): 1359-1364, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32919905

RESUMO

For patients at high risk of anal cancer, annual screening strategies using invasive evaluation methods are stressful. According to a normal examination at baseline using simple and non invasive tests, the aim of the work was to quantify neoplastic events. PATIENTS AND METHOD: Data from patients with a normal evaluation at the first visit were retrospectively extracted from a prospective database. The individual follow-up period was at least two years and three evaluations. Patients with abnormal cytology were assessed using high-resolution anoscopy and targeted biopsies. RESULTS: A total of 182 subjects (F/M: 10/90, aged 48.1(10.6) years, HIV: 81%) were followed for 41(11) months. Anal cytology remained normal in 94 patients (52%), but high-grade anal neoplasms occurred in 28 patients (15%). Patients with a negative HPV16 status at baseline had cumulative probabilities of high-grade AIN of 0.4%(0.1%-1.9%), 2.6%(1.2%-5.9%) and 7.5%(4.5%-12.2%) after 1 year, 2 years and 3 years of follow-up, respectively. These probabilities were lower than those of patients with a positive HPV16 at baseline and those with a previous history of AIN. CONCLUSION: In patients with normal cytology and negative HPV16 at baseline, a three-year interval screening may be a less cumbersome alternative to traditional annual screening.


Assuntos
Neoplasias do Ânus/epidemiologia , Carcinoma in Situ/diagnóstico , Infecções por HIV/complicações , Programas de Rastreamento/estatística & dados numéricos , Infecções por Papillomavirus/complicações , Adulto , Canal Anal/patologia , Neoplasias do Ânus/complicações , Neoplasias do Ânus/patologia , Neoplasias do Ânus/virologia , Biópsia , Carcinoma in Situ/patologia , Citodiagnóstico , Feminino , França , Humanos , Estudos Longitudinais , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Infecções por Papillomavirus/diagnóstico , Lesões Pré-Cancerosas/diagnóstico , Proctoscopia , Estudos Retrospectivos
18.
Dis Colon Rectum ; 63(10): 1363-1371, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32969879

RESUMO

BACKGROUND: Local recurrence is a significant risk after anal squamous cell carcinoma. OBJECTIVES: This study aimed to examine the occurrence of high-grade squamous intraepithelial lesions and local recurrence after anal cancer at surveillance with high-resolution anoscopy. DESIGN: This is a retrospective observational study. SETTING: This study was conducted at an anogenital neoplasia referral center. PATIENTS: There were 76 anal/perianal cancers from 1998 to 2018. Sixty-three patients were eligible and 3 were excluded, for a total of 60 patients; 35 of 60 (58%) patients were male. INTERVENTION: High-resolution anoscopy after chemoradiation or excision only for anal squamous cell carcinoma was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were local recurrence and high-grade squamous intraepithelial lesion detection rates. RESULTS: Sixty patients, 27% HIV positive, underwent surveillance over a median 42 (range 7-240) months of follow-up. Seven had had a prior local recurrence at study entry so were analyzed separately. Thirty of 53 underwent chemoradiation (57%) and 23 of 53 underwent excision alone (43%); 33 had perianal cancer and 20 had anal cancer. Ten of 30 of the chemoradiation group had had stage 1 (33%) disease in comparison with 22 of 23 of the excision only group (96%, p < 0.001). OUTCOMES: High-grade squamous intraepithelial lesions were detected in 4 of 30 (13%) patients after chemoradiation and in 17 of 23 (74%) patients after excision only (p < 0.001). Twenty of 21 (95%) high-grade lesions were treated with ablation. Six of 7 (86%) patients with prior local recurrence had high-grade squamous intraepithelial lesions over a median of 21 months follow-up. One local recurrence (T1N0M0) occurred during surveillance after primary chemoradiation (0.56/1000 person-months), none occurred after excision only, and 2 of 7 with prior local recurrence developed further local recurrence (6.86/1000 person-months). All 3 local recurrences occurred after treatment of high-grade squamous intraepithelial lesions. There were no metastases, abdominoperineal excisions, or deaths from anal squamous cell carcinoma. LIMITATIONS: Retrospective data were used for this study. CONCLUSIONS: High-grade squamous intraepithelial lesions after anal squamous cell carcinoma are more common after excision only than after chemoradiation. Local recurrence is low in this high-resolution anoscopy surveillance group in which high-grade squamous intraepithelial disease was ablated. Excision of small perianal cancers appears safe; however, a subset of patients is at excess risk. See Video Abstract at http://links.lww.com/DCR/B285. VIGILANCIA POR ANOSCOPÍA DE ALTA RESOLUCIÓN EN CASOS DE CARCINOMA ANAL A CÉLULAS ESCAMOSAS: LA DETECCIÓN Y TRATAMIENTO DE UNA LESIÓN INTRAEPITELIAL ESCAMOSA DE ALTO GRADO (HSIL) PUEDE INFLUIR EN LA RECURRENCIA LOCAL: La recurrencia local tiene un riesgo significativo después del carcinoma anal a células escamosas.Evaluar la aparición de lesiones intraepiteliales escamosas de alto grado (HSIL) y su recurrencia local durante la vigilancia con anoscopía de alta resolución en casos de cancer anal.Estudio observacional retrospectivo.Centro de referencia de neoplasia anogenital.Se diagnosticaron 76 cánceres anales / perianales entre 1998 y 2018. Un total de 63 pacientes fueron elegidos, 3 excluidos (n = 60), 35/60 (58%) fueron varones.Anoscopía de alta resolución después de la quimio-radioterapia, o solo excisión en casos de carcinoma anal a células escamosas.Recurrencia local primaria y tasas de detección de lesión intraepitelial escamosa de alto grado.Sesenta pacientes, 27% VIH positivos, fueron sometidos a vigilancia durante una mediana de 42 (rango 7-240) meses de seguimiento. Siete habían tenido una recurrencia local antes de ser incluidos en el estudio, por lo que se analizaron por separado. Treinta de 53 se sometieron a quimio-radioterapia (57%) y 23/53 solo a excisión (43%). 33 eran lesiones perianales, 20 de canal anal. 10/30 del grupo de quimio-radioterpia se encontraban en Fase 1 (33%) comparados con 22/23 del grupo de excisión (96%, p <0.001).Se detectaron lesiones intraepiteliales escamosas de alto grado en 4/30 (13%) después de la quimio-radioterapia, y en 17/23 (74%) solo después de la excisión (p < 0.001). 20/21 (95%) lesiones de alto grado fueron tratadas con ablación. Seis de siete (86%) con recurrencia local previa tenían lesiones intraepiteliales escamosas de alto grado durante una mediana de seguimiento de 21 meses. Se produjo una recurrencia local (T1N0M0) durante la vigilancia después de la quimio-radioterapia primaria (0.56/1000 persona-meses), ninguna después de la excisión sola y 2/7 con recurrencia local previa desarrollaron una recurrencia local adicional (6.86/1000 persona-meses). Las 3 recidivas locales ocurrieron después del tratamiento de las lesiones intraepiteliales escamosas de alto grado. No hubieron metástasis, excisiones abdominoperineales o muertes por carcinoma anal a células escamosas.Datos retrospectivos.Las lesiones intraepiteliales escamosas de alto grado en casos de carcinoma escamocelular anal son más comunes después de la excisión sola que después de la quimio-radioterapia. La recurrencia local es baja en este grupo de vigilancia de anoscopía de alta resolución en el que se retiró la enfermedad intraepitelial escamosa de alto grado. La excisión de pequeños cánceres perianales parece segura; sin embargo, un subconjunto de pacientes tiene un riesgo excesivo. Consulte Video Resumen en http://links.lww.com/DCR/B285. (Traducción-Dr. Xavier Delgadillo).


Assuntos
Neoplasias do Ânus/patologia , Neoplasias do Ânus/terapia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Recidiva Local de Neoplasia/diagnóstico , Proctoscopia , Lesões Intraepiteliais Escamosas/diagnóstico , Adulto , Idoso , Feminino , Soropositividade para HIV , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos
20.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(5): 480-485, 2020 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-32842428

RESUMO

Objective: To identify the factors associated with successful transrectal specimen extraction after laparoscopic rectal cancer resection. Methods: A retrospective case-control study was conducted. Clinical data of rectal cancer patients who did or did not successfully undergo transrectal specimen extraction in Shanghai East Hospital between January 2017 and December 2017 were retrieved through the rectal cancer database of Shanghai East Hospital. Case inclusion criteria: (1) tumor size ≤7 cm by pelvic MRI; (2) body mass index (BMI)≤ 30 kg/m(2); (3) no history of neoadjuvant chemoradiotherapy; (4) no anal stenosis. Clinical data including age, gender, BMI, tumor obstruction, distance from tumor to anal verge, history of abdominal operation, maximal diameter of tumor and width of mesorectum in the anteroposterior dimension measured by pelvic MRI, etc. were collected. The χ(2) test was used to perform univariate analysis. Multivariate logistic regression was used to identify factors affecting transrectal specimen extraction. Results: A total of 208 patients were included in the analysis. Of 208 patients, 132 were men and 76 were women; mean age was (63±11) years old and median tumor size was 3.8 (IQR, 3.0 to 5.0) cm. Sixty-six (31.7%) patients completed transrectal specimen extraction successfully. Univariate analysis showed that patients who completed transrectal specimen extraction were more likely to have a lower BMI (χ(2)=7.420, P=0.006), be free from malignant obstruction (χ(2)=8.972, P=0.003), have a shorter distance from tumor to the anal verge (<5.0 cm) (χ(2)=14.960, P<0.001), a smaller tumor size (≤5.0 cm) (χ(2)=18.495, P<0.001) and a thinner mesorectum in the anteroposterior dimension (≤6.0 cm) (χ(2)=34.612, P<0.001) than those who failed to perform transrectal specimen extraction. Gender, age or history of abdominal operation were not associated with the successful extraction (all P>0.05). Multivariate analysis revealed that BMI ≤25.0 kg/m(2) (OR=2.32, 95% CI: 1.06 to 5.06, P=0.034), free from malignant obstruction (OR=3.01, 95% CI: 1.82 to 6.69, P<0.001), the distance from tumor to the anal verge <5.0 cm (OR=3.73, 95% CI: 1.22 to 11.43, P=0.021), tumor size ≤ 5.0 cm (OR=4.43, 95% CI: 1.39 to 14.09, P=0.012), and the anteroposterior width of mesorectum ≤ 6.0 cm (OR=4.30, 95% CI: 2.02 to 9.18, P<0.001) were independent protective factors for successful transrectal specimen extraction. Conclusion: Preoperative assessment of BMI, malignant obstruction, distance from tumor to the anal verge, tumor size and anteroposterior width of mesorectum is beneficial to choose appropriate patients with rectal cancer to undergo transrectal specimen extraction.


Assuntos
Cirurgia Endoscópica por Orifício Natural , Protectomia/métodos , Neoplasias Retais/cirurgia , Reto/cirurgia , Idoso , Estudos de Casos e Controles , China , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Proctoscopia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
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