Tratamiento multidisciplinar del leimiosarcoma de vena cava inferior / Multidisciplinary treatment of leiomyosarcoma of inferior cava

Resumen Introducción Los leiomiosarcomas de la vena cava inferior son tumores raros, sólo hay 300 casos descritos en la literatura. Su incidencia es mayor en mujeres, suelen aparecer entre los 50-60 años, y presentan una progresión lenta y mal pronóstico. Los síntomas son inespecíficos haciendo que el diagnóstico se realice de forma tardía, éste se realiza mediante pruebas de imagen y biopsia guiada. Caso clínico Se presenta el caso de un varón de 73 años con diagnóstico de leiomiosarcoma de la vena cava inferior, como hallazgo incidental en TC de control, tratado mediante radioterapia neoadyuvante, cirugía y radioterapia intraoperatoria. Discusión El único tratamiento que ha descrito modificaciones en la supervivencia es la cirugía. El papel de la adyuvancia y neoadyuvancia en estos tumores es muy controvertido. La elección de la actitud terapéutica dependerá de la localización del tumor, tamaño, la relación con estructuras adyacentes y la presencia de circulación colateral.

Introduction Leiomyosarcomas of the inferior vena cava are rare tumors, with fewer than 300 cases reported. Its incidence is higher in females, usually appear in the sixth decade and they have a slow-growing and poor prognosis. Symptoms are generally non-specific. Diagnosis is made with imaging studies and guided biopsy. Clinical Case We report a case of a 73-year-old male patient with leimyosarcoma of the inferior vena cava treated by neoadjuvant radiotherapy, surgery and intraoperative radiotherapy. Discussion Surgery is the only treatment that can improve the survival. The role of the adjuvancy and neoadjuvancy is very controversial. Surgical management is determined by the location of the tumour, the relationship with adjacent structures and the presence of collateral veins.

Riscos e benefícios do rastreamento mamográfico no Brasil / Risks and benefits of breast cancer screening in Brazil

As evidências sobre a redução da mortalidade geral com o rastreamento mamográfico são inconclusivas e até hoje nenhum estudo publicado abrangeu todos os danos reconhecidamente associados ao rastreamento para a avaliação do balanço entre riscos e benefícios dessa intervenção. Adicionalmente, os benéficos e riscos do rastreamento variam entre os estados brasileiros, mas essas diferenças nunca foram estudadas. O objetivo do estudo foi estimar os riscos e benefícios do rastreamento mamográfico no Brasil, em termos de óbitos evitados e causados pelo mesmo. Foram construídas 196 tábuas de vida para estimativas de benefícios e 13.440 para estimativas de danos do rastreamento no Brasil e para as 27 Unidades da Federação, para 5 diferentes protocolos de rastreamento mamográfico, com base em dados nacionais de 2012 a 2015. O risco cumulativo de morte por câncer de mama em cada coorte e a redução absoluta na mortalidade com o rastreamento foram calculados. Foram também estimados os danos associados ao rastreamento, incluindo número de falso-positivos, excesso de biópsias, números de casos de sobrediagnóstico e so0bretratamento e mortes por: câncer de mama radioinduzido; por suicídio e cardiovascular associadas ao sobrediagnóstico; mortalidade cirúrgica; síndrome de Stewart-Treves e doença cardiovascular, câncer de pulmão, câncer de esôfago, tromboembolismo pulmonar e sarcoma de mama radioinduzidos pelo sobretratamento com radioterapia adjuvante. A análise de sensibilidade incluiu três cenários diferentes para cada protocolo de rastreamento, além de outras simulações adicionais. No cenário mais provável, a redução do risco absoluto de morte por câncer de mama com o rastreamento bienal de 50 a 69 anos no Brasil foi de 0,23% e, considerando os danos do rastreamento, o benefício líquido foi de 21,2 mortes evitadas por 10 mil convidadas para o rastreamento. O benefício absoluto do rastreamento e o benefício líquido do rastreamento na UF com pior resultado, chegam a ser três vezes e meia menores do que naquela com melhor resultado. O rastreamento anual de 40 a 49 anos provocou 1,2 óbitos por 10 mil convidadas para o rastreamento e, mesmo no cenário mais favorável para a eficácia, a diferença entre óbitos potencialmente evitados e causados foi de 1,48 por 10 mil convidadas, considerando os danos mais prováveis. Nessa faixa etária, a maior causa de óbitos foi a indução de câncer de mama radioinduzido pelas mamografias (70% do total), seguidas pelas doenças cardiovasculares associadas à radioterapia adjuvante (16%), as quais foram a principal causa na faixa de 50 a 69 anos (70% do total), seguidas pelo câncer de pulmão radioinduzido (13%). Os benefícios do rastreamento mamográfico são menores no Brasil ­ e especialmente nas regiões Norte e Nordeste - do que em países europeus. Para reduzir os danos do rastreamento mamográfico no Brasil, e assegurar que o balanço entre riscos e benefícios seja provavelmente favorável, as principais medidas que devem ser adotadas são incentivos para adesão às diretrizes oficiais de faixa etária e população-alvo; a instituição de decisão informada e compartilhada antes da solicitação de rastreamento; implementação de programas nacionais de qualidade em mamografia e de qualidade em radioterapia, além da cessação do tabagismo em pacientes que se submetem à radioterapia adjuvante

Recombinant human TSH versus thyroid hormone withdrawal in adjuvant therapy with radioactive iodine of patients with papillary thyroid carcinoma and clinically apparent lymph node metastases not limited to the central compartment (cN1b)

ABSTRACT Objective To compare the short- and long-term outcomes of adjuvant therapy with radioactive iodine (RAI) preceded by the administration of recombinant human TSH (rhTSH) versus thyroid hormone withdrawal (THW) in patients with papillary thyroid carcinoma and clinically apparent lymph node metastases not limited to the central neck compartment (cN1b). Subjects and methods The sample consisted of 178 cN1b patients at intermediate risk who underwent total thyroidectomy with apparently complete tumor resection [including postoperative ultrasonography (US) without anomalies] and who received adjuvant therapy with RAI (30-100 mCi) preceded by the administration of rhTSH (n = 91) or THW (n = 87). Results One year after RAI, the rates of excellent response to therapy, i.e., nonstimulated thyroglobulin (Tg) ≤ 0.2 ng/mL with negative antithyroglobulin antibodies and negative neck US, and of structural disease were similar for the two preparations (84% and 4.5%, respectively, in both groups). During follow-up (median 66 months), the rate of structural or biochemical (nonstimulated Tg > 1 ng/mL, with increment) recurrence was also similar in the two groups (4.5%). In the last assessment, the percentage of patients without evidence of disease, i.e., nonstimulated Tg < 1 ng/mL and no evidence of structural disease, was similar for the two preparations [92.3% in the rhTSH group and 97.7% in the THW group (p = 0.17)]. Conclusion Preparation with rhTSH was equally effective (short- and long-term) as THW for adjuvant RAI therapy of cN1b patients at intermediate risk and with apparently complete tumor resection.

Intrahepatic, Perihilar and Distal Cholangiocarcinoma: Management and Outcomes

Abstract: Introduction and aims. Cholangiocarcinomas are a heterogeneous group of tumors that can be classified into three clinically distinct types of cancers, intrahepatic, perihilar and distal cholangiocarcinoma. The inconsistent use of nomenclature for these cancers has obscured a true knowledge of the epidemiology, natural history and response to therapy of these cancers. Our aims were to define demographic characteristics, management and outcomes of these three distinct cancer types. Materials and methods. A retrospective study of patients enrolled in an institutional cancer registry from 1992 to 2010. Median survival was compared between different treatment modalities over three time periods for the three types of cholangiocarcinoma at different stages of the disease using Kaplan Meyer analysis. Results. 242 patients were identified. All cases were reviewed and classified into intrahepatic (90 patients), distal (48 patients) or perihilar (104 patients) cholangiocarcinomas. These cancers differed in median age of onset, gender distribution, median survival and stage. 13.8% of patients presented with stage I, 5.8% with stage II, 9.6% with stage III, 28% with stage IV, with 41.8% having unknown stage. The overall median survival was 15.8 months, and was 23, 25, 14, and 4.5 months for stages I, II, III, and IV respectively. Surgery improved survival in both early and advanced stages. Multimodality therapies further improved outcomes, particularly for perihilar cholangiocarcinoma. Conclusion. Perihilar, distal and intrahepatic cholangiocarcinoma vary in their presentation, natural history and therapeutic approach to management. A consistently applied classification is essential for meaningful interpretation of studies of these cancers.

Adjuvant treatment delay in breast cancer patients / Atraso no tratamento adjuvante em pacientes com câncer de mama

Summary Background: to evaluate if time between surgery and the first adjuvant treatment (chemotherapy, radiotherapy or hormone therapy) in patients with breast cancer is a risk factor for lower overall survival (OS). Method: data from a five-year retrospective cohort study of all women diagnosed with invasive breast cancer at an academic oncology service were collected and analyzed. Results: three hundred forty-eight consecutive women were included. Time between surgery and the first adjuvant treatment was a risk factor for shorter overall survival (HR=1.3, 95CI 1.06-1.71, p=0.015), along with negative estrogen receptor, the presence of lymphovascular invasion and greater tumor size. A delay longer than 4 months between surgery and the first adjuvant treatment was also associated with shorter overall survival (cumulative survival of 80.9% for delays ≤ 4 months vs. 72.6% for delays > 4 months; p=0.041, log rank test). Conclusion: each month of delay between surgery and the first adjuvant treatment in women with invasive breast cancer increases the risk of death in 1.3-fold, and this effect is independent of all other well-established risk factors. Based on these results, we recommend further public strategies to decrease this interval.

Resumo Objetivo: avaliar se o tempo da cirurgia até o primeiro tratamento adjuvante (quimioterapia, radioterapia ou hormonioterapia) em pacientes com câncer de mama é um fator de risco para pior sobrevivência global (SG). Métodos: estudo retrospectivo em que foram coletados dados dos prontuários de todas as mulheres com câncer de mama invasivo, diagnosticadas entre janeiro de 2005 e dezembro de 2010, atendidas consecutivamente em um serviço acadêmico de oncologia. Resultados: foram incluídas 348 mulheres, com mediana de tempo entre a cirurgia e o primeiro tratamento adjuvante de 2 meses. A sobrevivência global foi pior entre as mulheres com maior tempo entre a cirurgia e o primeiro tratamento adjuvante. Após análise multivariada, essa variável permaneceu como fator de risco independente para SG, juntamente com receptor de estrógeno negativo, presença de invasão angiolinfática e maior tamanho tumoral. Conclusão: o tempo entre a cirurgia e o primeiro tratamento adjuvante é um fator de risco independente para a sobrevivência global de mulheres com câncer de mama invasivo.

Adjuvant radiotherapy versus observation alone, after radical prostatectomy in high risk prostate cancer / Radioterapia adjuvante versus vigilância após prostatectomia radical em câncer de próstata de alto risco

SummaryObjectives:the authors compared biochemical and clinical outcomes of patients with resected high-risk prostate cancer, managed with adjuvant radiotherapy or observation alone.Methods:patients treated with radical prostatectomy (RP) between January 1995 and December 2005 at the authors’ department were evaluated. Patients with pT3, with or without positive surgical margins (PSM), were included for analysis. Demographic, clinical, pathologic and follow-up data were recorded. Comparison was made between adjuvant radiotherapy group (AR) and observation alone group (OA). Primary end-point was biochemical progression-free survival.Results:out of 739 patients treated with RP, 49 presented with pT3 with or without PSM. 39 received adjuvant radiotherapy and 10 were observed. Median follow- up was 6.2 years for AR and 7.3 years for OA. Biochemical progression occurred in 12.8%, in AR, and 70%, in OA (p=0.0008). Five-year biochemical progression-free survival was 87.1% in AR and 30% in OA (HR 0.12, 95% CI 0.03- 0.48 – p<0.0001). Rescue androgen deprivation therapy was needed in 2.6%, in AR, and 30%, in OA (p=0.023).Conclusions:adjuvant radiotherapy after radical prostatectomy in high-risk prostate cancer provided better biochemical outcomes. Whether this translates into better clinical progression, it is still unknown.

ResumoObjetivo:comparar resultados clínicos e bioquímicos de pacientes com câncer de próstata de alto risco submetidos à prostatectomia radical, tratados com radioterapia adjuvante (RA) ou vigilância.Métodos:foram avaliados os pacientes tratados com prostatectomia radical, entre janeiro de 1995 e dezembro de 2005. Pacientes que apresentaram pT3, com ou sem margens cirúrgicas positivas, foram incluídos para análise. Foram registrados dados demográficos, clínicos, patológicos e de seguimento. Foram comparados os resultados entre o grupo que recebeu RA e o grupo em vigilância. O desfecho principal avaliado foi a sobrevida livre de progressão bioquímica.Resultados:entre os 739 pacientes tratados com prostatectomia radical, 49 apresentaram tumores pT3, com ou sem margens cirúrgicas positivas. Trinta e nove receberam RA e 10 foram submetidos à vigilância. O seguimento médio foi de 6,2 anos para a RA e de 7,3 anos para a vigilância. Houve progressão bioquímica em 12,8% dos pacientes no grupo RA e em 70%, no grupo da vigilância (p=0,0008). A sobrevida livre de progressão bioquímica em 5 anos foi de 87,1% na RA e 30% na vigilância (HR 0,12, IC95% 0,03-0,48 - p<0,0001). Terapia hormonal de resgate foi necessária em 2,6% dos pacientes na RA e em 30% na vigilância (p=0,023).Conclusões:a radioterapia adjuvante após prostatectomia radical em pacientes com câncer de próstata de alto risco ofereceu melhores resultados bioquímicos. Ainda não está claro se isso se traduz em uma evolução clínica melhor.

Persistent and recurrent disease in patients with papillary thyroid carcinoma with clinically apparent (cN1), but not extensive, lymph node involvement and without other factors for poor prognosis

Objective Lymph node metastases (LNM) are frequent in patients with papillary thyroid cancer (PTC). The risk of persistent disease (PD) and tumor recurrence (TR) is increased when factors for poor prognosis other than LNM exist, when LNM are numerous, large, detected by preoperative ultrasonography (US), or exhibit extranodal extension. This study evaluated the risk of PD and TR in patients with LNM not exhibiting these characteristics.Subjects and methods Eighty-six patients with 5 or fewer LNM detected during intraoperative inspection, but not by preoperative US, who had no other factors for poor prognosis [tumors > 4 cm, extensive extrathyroid invasion, vascular invasion, aggressive histological subtype, distant metastases, incomplete tumor resection], were studied. All patients underwent total thyroidectomy followed by radioiodine ablation. PD was defined as metastases on initial post-therapy whole-body scans (RxWBS) or detected by imaging methods up to 12 months after ablation. TR was defined as structural disease diagnosed more than one year after ablation in patients without PD.Results PD was diagnosed in 3/86 patients (3.5%). TR was observed in 2/83 patients (2.5%) after 62 months of follow-up. There was no case of death due to the disease. A correlation was observed between pre-ablation Tg and PD or TR [1/48 (2%) with Tg ≤ 2 ng/mL versus 2/22 (9%) with Tg > 2 ≤ 10 ng/mL versus 2/7 (28.5%) with Tg ≥ 10 ng/ml)]. It is noteworthy that 38 patients had up to 3 positive LN and pre-ablation Tg ≤ 2 ng/ml, and none of them had PD or TR.Conclusions The frequency of PD and TR was low in patients with PTC with 5 or fewer LNM and without other factors for poor prognosis. Low postoperative stimulated Tg was predictive of the absence of PD and TR in these patients.

Responsabilidad sanitaria en odontólogos: Casuística de casos evaluados en el Servicio Médico Legal de Chile / Professional liability claims against dentists

Background: The frequency and features of malpractice lawsuits against dentists in Chile are not well known. Aim: To determine the magnitude and frequency of professional liability claims against dentists. Material and Methods: A retrospective analysis of the Medical Liability Unit of the Legal Medical Service of Chile database. This public organization deals with most professional liability claims in Chile. Results: Between 2007 and 2012, 3,990 expert opinions about liability of health care professionals were requested. Odontology was the fifth specialty most commonly sued and dentists, the second most frequently sued professionals. Sixty nine percent of cases originated in private clinics, which is coincident with a higher frequency of dentists working in private practice. Most petitioners were adult women and most claims originated from surgical interventions and infections. In 35% of claims against dentists, a violation of Lex Artis was confirmed, compared with 9% of all expert opinions that generated in the unit. Conclusions: Claims against dentists are more common than previously thought and these professionals should adopt preventive measures to avoid them.

Surgical treatment of clinically early-stage endometrial carcinoma without systematic lymphadenectomy / Tratamento cirúrgico do câncer de endométrio em estágio clínico precoce sem linfadenectomia radical.

Objective: the main aim of this study was to describe the authors’ experience with the surgical treatment of endometrial cancer without systematic lymphadenectomy. Methods: a retrospective cohort study was carried out on a subset of patients suffering of clinically early-stage endometrial carcinoma who underwent hysterectomy and salpingo-oophorectomy without systematic (radical) lymph nodes dissection at our centers from June, 2002, to November, 2011. Descriptive statistics were explored as medians (interquartile range) or frequencies (percentages), as appropriated, and the Kaplan–Meier method was applied for survival estimation. Results: eighty-three patients who underwent surgical treatment with no lymph node dissection (n = 20; 24.1%) or with only a sampling procedure (n=63; 75.98%) were selected for analysis. Among these patients, 27 (32.53%) underwent surgery alone and 56 (67.46%) received some adjuvant treatment. Postoperative complications occurred in five patients (6.02%). Over a median follow-up of 27.4 months (Q25 = 13.7 – Q75 = 46.5), 15 (18.07%) patients suffered from relapses and 11 deaths occurred as result of disease recurrence. Cumulative 1, 2 and 3-year disease- free survivals were 97.32, 91.18 and 78.02%, respectively. Conclusion: on a case-by-case basis, the surgical treatment of clinically early-stage endometrial carcinoma without systematic lymphadenectomy did not seem to decrease survival outcomes and presented low rates of surgical morbidity in our experience, but was also related to a high rate use of adjuvant therapy. .

Objetivo: descrever a experiência dos autores com o tratamento cirúrgico do câncer de endométrio em estádio precoce sem linfadenectomia radical. Métodos: realizou-se estudo de coorte retrospectivo envolvendo um subgrupo de pacientes com câncer de endométrio em estágio clínico precoce tratadas com histerectomia e salpingo-ooforectomia sem linfadenectomia radical, em dois centros pernambucanos, de junho de 2002 a novembro de 2011. As variáveis foram descritas como mediana (intervalo interquartílico) ou frequências (percentuais), utilizando- se o método de Kaplan-Meier para a estimativa das taxas de sobrevivência. Resultados: oitenta e três pacientes submetidas a tratamento cirúrgico sem dissecção linfonodal (n = 20, 24,1%) ou com dissecção apenas por amostragem (n = 63; 75,98%) foram selecionadas para análise. Entre essas pacientes, 27 (32,53%) foram tratadas somente com cirurgia e 56 (67,46%) receberam tratamento adjuvante. Cinco pacientes apresentaram complicações pós-operatórias (6,02%). Durante o acompanhamento mediano de 27,4 meses (Q25 = 13,7 - Q75 = 46,5), 15 (18,07%) pacientes apresentaram recorrência, dentre as quais 11 faleceram em decorrência da recidiva neoplásica. Observou-se sobrevivência cumulativa proporcional livre de doença em um, dois e três anos de 97,32, 91,18 e 78,02%, respectivamente. Conclusão: em um contexto de indicação caso-a-caso, o tratamento cirúrgico do câncer de endométrio em estádio precoce sem linfadenectomia radical parece não ter prejudicado a sobrevivência e apresentou baixas taxas de morbidade cirúrgica em nossa experiência, mas também foi acompanhado de elevada utilização de terapia adjuvante. .

Delayed postoperative radiation therapy in local control of squamous cell carcinoma of the tongue and floor of the mouth / Retardo da radioterapia pós-operatória no controle local do carcinoma epidermoide de língua e soalho de boca

Objective To evaluate the effect of time between surgery and postoperative radiation therapy on local recurrence of squamous cell carcinoma of the tongue and floor of the mouth. Methods A total of 154 patients treated between 1996 and 2007 were selected considering local recurrence rate and time of the adjuvant radiotherapy. Results Local recurrence was diagnosed in 54 (35%) patients. Radiation therapy reduced the rate of local recurrences, although with no statistical significance. The time between surgery and initiation of postoperative radiotherapy did not significantly influence the risk of local recurrence in patients referred to adjuvant treatment (p=0.49). Conclusion In the presence of risk factors for local recurrence, a short delay in starting the adjuvant radiation therapy does not contraindicate its performance. .

Objetivo Avaliar o efeito do tempo entre o tratamento cirúrgico e a radioterapia pós-operatória nas recidivas locais do carcinoma epidermoide de língua e soalho da boca. Métodos Foram selecionados 154 pacientes tratados entre 1996 e 2007, considerando a frequência das recidivas locais e o tempo para início da radioterapia adjuvante. Resultados As recidivas locais foram diagnosticadas em 54 (35%) pacientes. A radioterapia reduziu a frequência de recidivas locais, embora sem significância estatística. O tempo entre a cirurgia e o início da radioterapia pós-operatória não influenciaram, de forma significante, no risco de recidivas locais entre o pacientes que tinham indicação de tratamento adjuvante (p=0,49). Conclusão Na presença de fatores de risco para recidiva local, um pequeno atraso no início da radioterapia adjuvante não contra-indica sua realização. .

Tailored treatment including radical prostatectomy and radiation therapy + androgen deprivation therapy versus exclusive radical prostatectomy in high-risk prostate cancer patients: results from a prospective study

Purpose To evaluate outcomes of patients with high risk prostate cancer (PCa) who underwent radical prostatectomy (RP) in a context of a multidisciplinary approach including adjuvant radiation (RT) + androgen deprivation therapy (ADT). Matherials and Methods 244 consecutive patients with high risk localized PCa underwent RP and bilateral extended pelvic lymph node dissection at our institution. Adjuvant RT + 24 months ADT was carried out in subjects with pathological stage ≥ T3N0 and/or positive surgical margins or in patients with local relapse. Results After a median follow-up was 54.17 months (range 5.4-117.16), 13 (5.3%) subjects had biochemical progression, 21 (8.6%) had clinical progression, 7 (2.9%) died due to prostate cancer and 15 (6.1%) died due to other causes. 136 (55.7%) patients did not receive any adjuvant treatment while 108 (44.3%) received respectively adjuvant or salvage RT+ADT. Multivariate Cox proportional hazard analysis showed that pre-operative PSA value at diagnosis is a significant predictive factor for BCR (HR: 1.04, p < 0.05) and that Gleason Score 8-10 (HR: 2.4; p<0.05) and PSMs (HR: 2.01; p < 0.01) were significant predictors for clinical progression. Radical prostatectomy group was associated with BPFS, CPFS, CSS and OS at 5-years of 97%, 90%, 95% and 86% respectively, while adjuvant radiation + androgen deprivation therapy group was associated with a BPFS, CPFS and CSS at 5-years of 91%, 83%, 95% and 88%, without any statistical difference. Conclusions Multimodality tailored treatment based on RP and adjuvant therapy with RT+ADT achieve similar results in terms of OS after 5-years of follow-up. .

Radioterapia intraoperatória como protocolo de tratamento do câncer de mama inicial / Intraoperative radiotherapy as a protocol for the treatment of initial breast cancer

OBJETIVO: Avaliar a experiência inicial de implementação e aplicação de radioterapia única e intraoperatória com feixe de elétrons em pacientes selecionadas com diagnóstico de câncer de mama em estágio inicial. Avaliar também a recorrência local e os eventos adversos (complicações locais). MÉTODOS: Foram avaliadas 50 pacientes com câncer de mama, pós-menopausadas, com tumores de <2,5cm e linfonodos axilares clinicamente não palpáveis, que se submeteram a uma ressecção segmentar e biópsia de linfonodo sentinela e técnica de radioterapia intraoperatória. Essas pacientes foram seguidas por um período médio de 52,1 meses. RESULTADOS: A idade média dos pacientes foi de 65,5 anos de idade. O diâmetro médio do tumor foi de 1,41cm 82% tinham tumores com receptor hormonal positivo e HER-2 negativo. A dose de radiação empregada foi de 21 Gy em todas as pacientes, com um tempo médio de irradiação intraoperatória de 8,97 minutos. O seguimento médio dessas pacientes foi de 52,1 meses. Foram evidenciados três casos com recorrência local durante esse período, sendo que nenhuma dessas pacientes tinha metástases à distância no momento do diagnóstico da recidiva. O diagnóstico patológico dessas três pacientes foi idêntico ao do tumor primário. Nesta casuística, não se registrou infecção pós-operatória ou formação de seroma. No entanto, em 35 pacientes (70%), foi observada uma fibrose local como sequela de pós-operatório. Esta, quando presente, diminuiu gradualmente e desapareceu completamente em um período médio de 18 meses. CONCLUSÃO: A radioterapia parcial é uma técnica viável e promissora, mas que deve ser indicada em casos selecionados, pelo menos até que tenhamos um maior tempo de seguimento que proporcione maior segurança para indicá-la em nossa rotina, como fazemos com a radioterapia convencional.

OBJECTIVE: To report on preliminary outcomes of single-dose intraoperative radiotherapy for early-stage breast cancer based on local recurrence rates and complications. METHODS: Fifty postmenopausal women with <2.5cm breast tumors and clinically normal axillary lymph nodes were submitted to quadrantectomy, sentinel lymph node biopsy and intraoperative radiotherapy and studied. Mean follow-up time was 52.1 months. RESULTS: Mean patient age was 65.5 years; mean tumor diameter was 1.41cm 82% of nodules were hormonal receptor positive and HER-2 negative. All patients received a 21 Gy radiation dose for a mean time of 8.97 minutes. Distant metastases were not observed. Local recurrence was documented in three cases, with identical histological diagnosis as the primary tumors. Thirty-five (70%) patients had local fibrosis, with gradual improvement and complete resolution over 18 months. Postoperative infection and seroma formation were not observed. CONCLUSION: Partial radiotherapy is a potentially feasible and promising technique. Careful patient selection is recommended before a longer follow-up period has elapsed to confirm intraoperative radiotherapy safety and efficacy.

Braquiterapia endobronquial de alta tasa de dosis en pacientes con obstrucción de la vía aérea central: experiencia en el Instituto Nacional del Cáncer y revisión de la literatura / High dose rate endobronchial brachytherapy in patients with central airway obstruction

Introduction: The main indication of modern high dose rate end bronchial brachyherapy (HDR EBBT) is the palliation of symptoms related to the growth of the endobronchial lung cancer. Methods: EBBT was performed to 27 patients who suffered symptomatic tumoral endobronchial or tracheal pathology, due to primary bronchial disease or secondary metastasis cancer, evaluating the rate of clinical benefit. The tumors were located at tracheal, carinal or proximal bronchial level. Fibrobronchoscopy was performed to all the patients to measure the degree of airway obstruction and to install brachytherapy endobronchial catheters. Between 1 to 4 fractions of 7 to 7.5 Gy were administered. Dyspnea, cough and hemoptysis were subjectively registered before and after treatment, according to an international validated scale. Results: After treatment, all symptoms considerably decreased, disappearing all of the severe categories. Hemoptysis and dyspnea resolved in a 100 percent and 40 percent of patients, respectively; and cough disappeared or was reduced to a minimum grade in 90 percent of cases.

Introducción: La indicación principal de la braquiterapia endobronquial moderna (BTEB) de alta tasa de dosis (HDR), es la paliación de síntomas por crecimiento endobronquial de cánceres pulmonares. Métodos: Se realizó BTEB HDR a 27 pacientes sintomáticos de patología tumoral endobronquial o traqueal, debido a patologías primarias bronquiales o secundarias metastásicas. Los tumores se ubicaban en tráquea, carina o a nivel bronquialproximal. Para observar mejorías en la sintomatología clínica, a todos se les realizó una fibrobroncoscopía (FBC) para medir el grado de obstrucción bronquial e instalar catéteres endobronquiales de braquiterapia. Se administraron entre 1 y 4 fracciones de 7 a 7,5 Gy. Se registró subjetivamente la disnea, tos y hemoptisis antes y después del tratamiento, de acuerdo a una escala internacionalmente validada. Resultados: Tras el tratamiento todos los síntomas disminuyeron considerablemente, desapareciendo toda sintomatología severa. La hemoptisis y disnea desaparecieron en el 100 por ciento y 40 por ciento de los pacientes respectivamente, y la tos desapareció o disminuyó a grado leve en el 90 por ciento de los pacientes.

Neoadjuvant chemoradiation therapy for soft tissue sarcomas of the extremities

INTRODUCTION AND OBJECTIVE: Neoadjuvant and adjuvant therapies for soft tissue sarcomas of the extremities are still controversial. The aim of this study was to analyze the results of a protocol of neoadjuvant chemoradiation therapy for extremity sarcomas. METHODS: A retrospective analysis was carried out in a consecutive series of 49 adult patients with advanced extremity soft tissue sarcomas that could not be resected with adequate margins during the primary resection. All patients were treated with a protocol of preoperative radiation therapy at a total dose of 30 Gy, concomitant with doxorubicin (60 mg/m²) chemotherapy. The main endpoints assessed were local recurrence-free survival, metastasis-free survival and overall survival. The median follow-up time was 32.1 months. RESULTS: The five-year local recurrence-free survival, metastasis-free survival and overall survival rates were 81.5 percent, 46.7 percent and 58.3 percent, respectively. For high-grade tumors, the five-year metastasis-free and overall survival rates were only 36.3 percent and 41.2 percent, respectively. Severe wound complications were observed in 41.8 percent of the patients who underwent surgery. These complications precluded adjuvant chemotherapy in 73.7 percent (14/19) of the patients eligible to receive it. CONCLUSIONS: In this study, neoadjuvant chemoradiation therapy was associated with a good local control rate, but the distant relapse-free rate and overall survival rate were still poor. The high rate of wound complications modified the planning of adjuvant treatment in most patients.

Quimiorradioterapia adyuvante en el cáncer gástrico resecado con intención curativa: análisis de supervivencia y toxicidad de pacientes tratados entre 1995 y 2003 en el Instituto Nacional del Cáncer, Chile / Results of adjuvant chemoradiation after curative surgery for gastric cancer: a retrospective study

Background: Survival rates after curative surgery for gastric cancer are disappointing. Therefore adjuvant therapeutic strategies are required. Aim: To analyze survival and side effects of treatment among gastric cancer patients treated with adjuvant chemo radiotherapy after curative resection of gastric adenocarcinoma. Material and methods: Retrospective review of medical records of 74 patients aged 20 to 74 years, treated with complete resection of gastric adenocarcinoma followed by adjuvant chemo radiation. Survival analysis was based on the records and information from the National Mortality Registry. Results: Five years survival fluctuated from 50 percent among patients in stage IB to 25 percent among those is stage IV. Significant acute toxicity was observed in 23 patients (31 percent). No patients died due to acute toxicity. Eleven patients (16.4 percent) developed significant late toxicity, with two possible deaths related to treatment. Conclusions: Postoperative chemo radiotherapy is feasible in our experience. Continues infusion of 5-fluoruracil is recommended to reduce toxicity.

Quelóide: fatores de influência prognóstica / Keloids: prognostic factors

Introdução: Quelóides são um dos maiores problemas relacionados ao processo de cicatrização. O tratamento pode ser difícil e envolver uma variedade de possibilidades terapêuticas, com resultados muitas vezes frustrantes. Considerando-se estas informações, este trabalho objetivaestudar variáveis que poderiam estar correlacionadas à recidiva dos quelóides tratados. Método: Foram analisados, retrospectivamente, 48 quelóides tratados em um período de cincoanos, que mantiveram seguimento mínimo de 18 meses após término do tratamento. Os resultados obtidos com várias modalidades terapêuticas foram correlacionados com outras variáveis. Foram considerados para análise a regressão completa e o tratamento sem resposta favorável. Resultados: Das 48 lesões analisadas (45% do sexo masculino e 55% do feminino),a idade média foi de 24 anos (8-69 anos), a melhora completa, considerando-se os diversostratamentos adotados no serviço, foi alcançada em 64,5% dos quelóides. O tamanho da lesão mostrou-se significativo (t-Student; p< 0,04 e ANOVA; p= 0,042) em recidiva para lesões > 40 mm e cura para as menores que 20 mm. A terapêutica nas lesões > 20 mm com exérese associadaà betaterapia foi significativamente superior à associação com corticóide injetável (quiquadrado; p < 0,04). Conclusão: A exérese associada à betaterapia é significativamente superiorà associação com corticóide injetável nas lesões maiores que 20 mm. Quanto à resposta terapêutica, o tamanho da lesão foi o principal fator prognóstico.

Introduction: Keloids are a challenging problem related to the wound healing process. The treatment can be difficult and includes a variety of therapeutical possibilities that sometimes show frustrating outcomes. Considering that information, the present study aimed to analyze the features that could be correlated to the recurrence of treated keloids. Methods: Forty eight lesions were analyzed retrospectively in a period of five years, with a follow-up of at least 18 months. The therapeutical response was correlated with other keloids variables. It was considered for analysis the complete regression and the treatment without favorable response. Results: Considering 48 analyzed keloids (45% male and 55% female). The average age was24 year-old (8-69 year-old). The complete regression obtained with diverse treatments was 64.5%. The keloid size was statistically significant (t-Student; p< 0.04 e ANOVA; p= 0.042) for recurrence in lesions > 40 mm and for cure in lesions < 20 mm. Keloids bigger than 20 mm reachedstatistically significant favorable outcomes with excision and superficial radiation than those treated with excision and steroid injections (chi-square; p < 0.04). Conclusions: The excision associated to the betatherapy is significantly better than the excision with steroid injections in lesions bigger than 20 mm. The size of the keloid was the main prognostic factor for cure.

Mesotelioma pleural maligno: experiência multidisciplinar em hospital público terciário / Malignant pleural mesothelioma: multidisciplinary experience in a public tertiary hospital

OBJETIVOS: Avaliar a experiência com o diagnóstico e a terapêutica do mesotelioma pleural maligno (MPM) acumulada durante 5 anos em um hospital público terciário. MÉTODOS: Avaliação retrospectiva dos prontuários dos pacientes com diagnóstico de MPM entre janeiro de 2000 e fevereiro de 2005. RESULTADOS: Foram analisados 17 pacientes, 14 homens e 3 mulheres, com idade média de 54,1 (13-75) anos. Os espécimes de biópsia para exame histopatológico foram obtidos por meio de pleuroscopia em 9 pacientes (53 por cento), agulha de Cope em 5 (29,5 por cento) e biópsia pleural aberta em 3 (17,5 por cento). Os tipos histológicos foram: epitelial em 14 pacientes (82 por cento), sarcomatóide em 1 (6 por cento) e bifásico em 2 (12 por cento). As terapêuticas instituídas foram: multimodal (pleuropneumonectomia com radioterapia e quimioterapia adjuvante) em 6 pacientes (35 por cento), quimioterapia e radioterapia em 6 (35 por cento), radioterapia exclusiva em 3 (17,5 por cento) e quimioterapia exclusiva em 2 (12 por cento). A sobrevida média foi de 11 (1-26) meses. CONCLUSÕES: Na presente experiência foi empregada a abordagem multidisciplinar integrada, e contou-se com uma estrutura hospitalar de alta complexidade para o diagnóstico e tratamento do MPM, como preconizado na literatura. Apesar disso, a sobrevida média observada foi de apenas 11 meses, refletindo a agressividade da doença.

OBJECTIVE: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. METHODS: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. RESULTS: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53 percent), Cope needle in 5 (29.5 percent), and open pleural biopsy in 3 (17.5 percent). The following histological types were identified: epithelial, in 14 patients (82 percent); sarcomatoid, in 1 (6 percent); and biphasic, in 2 (12 percent). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35 percent); chemotherapy and radiotherapy in 6 (35 percent); radiotherapy alone in 3 (17.5 percent); and chemotherapy alone in 2 (12 percent). The mean survival was 11 months (range, 1-26 months). CONCLUSIONS: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

Resultados a largo plazo del tratamiento con quimioterapia y radioterapia en linfoma no Hodgking localizado, de grados intermedio y alto / Long term results for intermediate and high grade localized non Hodgkin lymphoma, treated with chemotherapy and radiotherapy

Background: Treatment of intermediate and high grade non-Hodgkin lymphoma (NHL) includes chemotherapy with or without radiotherapy, depending on the clinical stage. The standard treatment for advanced NHL is 8 cycles of combined chemotherapy, cyclophosphamide, adriamicin, vincristine and prednisone (CHOP). Patients presenting with localized disease are treated with fewer chemotherapy cycles and involved field radiotherapy, with good results. Aim: To evaluate the treatment results including overall survival (OS) and event-free survival (EFS) in localized aggressive NHL patients treated at the Pontificia Universidad Católica de Chile, Clinical Hospital. Patients and Methods: Retrospective analysis of all patients with Ann Arbor stages I and II referred to the hematology and radiotherapy clinic between 1998 and 2003. OS and EFS analysis was made according to the Kaplan and Meier method. Log-rank and Cox methods were used for univariate and multivariate analyses, respectively. Chemotherapy and radiotherapy toxicities were scored according to World Health Organization (WHO) and Radiation Therapy Oncology Group (RTOG) scales, respectively. Results: 39 patients (20 men), aged between 20 to 85 years, were the source for this study. The average follow-up was 51 months (range 6-115). The 5 years OS and EFS were 72,4 percent and 63,3 percent, respectively. On univariate analysis, age over 60 was the only variable that affected negatively OS and EFS. Acute toxicity caused by chemotherapy and radiotherapy was uncommon. Conclusions: Age over 60 was the only independent variable associated with poor prognosis. The number of chemotherapy cycles and the drug combination did not influence the results. These results support the usefullness of a shortened chemotherapy regimen plus involved field radiotherapy.

Cáncer incidental de cérvix (CIC) / Incidental cervical cancer (ICC)

Ocasionalmentes luego de una histerectomía simple, aparece un cáncer de cuello uterino (CCU) como hallazgo incidental (CIC) a la Anatomía Patológica (AP). Esta entidad, es de alto riesgo de recidiva locorregional, por lo que requiere de un tratamiento complementario. Propósito: analizar retrospectivamente los resultados de Radioterapia (RTX) complementaria en mujeres con diagnóstico de CIC referidas al Hospital Las Higueras (HH) y Centro Onco-Radiológico Regional (CORR) y compararlos con similares a comunicados en la literatura. Se analizan 29 pacientes con diagnóstico de CIC, referidos a HH y CORR entre agosto 1988 y junio 2000, tratados complementariamente con radioterapia externa y/o intracavitaria. La sobrevida actuarial a 5 años fue de 86%. El control locorregional actuarial de la totalidad de la muestra fue de 86%. En 5/29 pacientes fallecidas, todas de CCU. De las 5 fallas a tratamiento, 4 con falla locorregional. Una, con histología carcinoma indiferenciado de células pequeñas, con control locorregional y falla distante a los 175 meses. La RTX complementaria es altamente efectiva en el tratamiento de CIC.

Twenty nine patients with proven invasive cervical cancer found after simple hysterectomy were treated with complementary external and/or intracavitary Radiotherapy, 5 year actuarial survival rate of 86%. Local and regional control was achieved in 25/29, 83%. One patient presented with a complication grade 2, no treatment related deaths.