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Outcomes oncológicos da colocação de próteses metáli- cas auto-expansíveis como “ponte para cirurgia” versus cirurgia emergente na oclusão intestinal por cancro colorectal: Um estudo comparativo português
Get PDFPrémio Medtronic Investigação em Coloproctologia 2015, no XXV Congresso Nacional de Coloproctologia, que decorreu nos dias 26 e 27 de Novembro de 2015, no Porto.Introduction: The short-term results of colonic stenting followed
by elective surgery (bridge to surgery, BTS) for malignant large-
-bowel obstruction (MLBO) have been well described. However
long-term oncological outcomes are still debated and interna-
tional endoscopy societies have recently not recommended it
as a first-line approach.
Aims & Methods: A longitudinal observational cohort study was
performed based on clinical data review from patients treated
in our center between 2006 and 2012 (7 years). We analysed
disease-free survival (DFS), overall survival (OS) and recurrence
as primary end-points. We also reviewed demographic data,
disease staging and peri-operatory morbility and mortality.
Results: A total of 126 patients were included: 79 (62,7%)
were treated with a BTS strategy (group 1) and 47 (37,3%)
underwent an emergent surgery (group 2). The distribution by
sex, age (70,9+/-11,4 years) and TNM stage was similiar. The
median follow-up time was 49,2 +/- 3,6 months. There was no
significant difference in peri-operatory complications (p=0,23)
and adjuvant chemotherapy (p=0,53). The need for a definite
stoma was higher in group 2 (p<0,001). The recurrence did
not differ significantly between the two groups, although it was
superior in group 2 (34,5% vs. 42,5%,p=0,492). DFS (22,2 vs
19,7 months; p=0,652) and OS (43,2 vs. 31,9 months, p=0,096)
also did not differ signficantly between the two groups, being
slightly longer in group 1.
Conclusion: Results of our study on oncological outcomes, as
stated in most recent meta-analysis, as well as well-described
short-term outcomes, suggest that BTS could be a promising
alternative strategy for MLBO. Larger prospective studies and
randomized clinical trials are definetely needed in the future.Introdução: Os resultados a curto prazo da utilização de
próteses metálicas do cólon seguida de cirurgia eletiva
(ponte para cirurgia, PPC) na oclusão intestinal por cancro
colorectal são bem conhecidos. Os resultados oncológicos a
longo prazo permanecem alvo de discussão e levaram a que,
recentemente, as sociedades internacionais de endoscopia
não recomendassem esta estratégia como primeira linha.
Objetivo e Métodos: Realizámos um estudo longitudinal obser-
vacional de coorte com base nos dados clínicos dos doentes
tratados na nossa instituição entre 2006 e 2012 (7 anos).
Analisámos a sobrevida livre de doença (SLD), a sobrevida
global (SG) e a recidiva como end-points primários. Os dados
demográficos, o estádio da doença e a morbi-mortalidade
peri-operatórias foram também comparados.
Resultados: Incluímos 126 doentes, 79 (62,7%) foram tratados
seguindo uma estratégia PPC (grupo 1) e 47 (37,3%) foram
submetidos a cirurgia emergente (grupo 2). A distribuição por
sexo, idade (70,9+/-11,4 anos) e estádio TNM foi semelhante.
O tempo de
follow-up
médio foi de 49,2 +/- 3,6 meses. Não
houve diferenças estatisticamente significativas em relação
a complicações peri-operatórias (p=0,23) ou realização de
quimioterapia adjuvante (p=0,53). A incidência de estoma
definitivo foi superior no grupo 2(p<0,001). A recidiva não foi
significativamente diferente, apesar de ter sido superior no
grupo 2 (34,5%
vs
. 42,5%,p=0,492). A SLD (22,2
vs.
19,7
meses;p=0,652) e a SG (43,2 vs. 31,9 meses, p=0,096)
também não foram significativamnete diferentes, embora
tenham sido ligeiramente superiores no grupo 1.
Conclusões: Os resultados do nosso estudo vão ao encontro
das meta-análises mais recentes sugerindo que a estratégia
PPC poderá ser uma alternativa promissora à cirurgia emer-
gente. São necessários ensaios clínicos e estudos prospetivos
que o comprovem
Early tumour response as a survival predictor in previously- treated patients receiving triplet hepatic artery infusion and intravenous cetuximab for unresectable liver metastases from wild-type KRAS colorectal cancer.
No full textBACKGROUND: Surgery for colorectal liver metastases results in an overall survival of about 40% at 5 years. Progression-free survival is increased with the addition of oxaliplatin and fluorouracil chemotherapy. The addition of cetuximab to these chemotherapy regimens results in an overall survival advantage in patients with advanced disease who have the KRAS exon 2 wild-type tumour genotype. We aimed to assess the benefit of addition of cetuximab to standard chemotherapy in patients with resectable colorectal liver metastasis.
METHODS:
Patients with KRAS exon 2 wild-type resectable or suboptimally resectable colorectal liver metastases were randomised in a 1:1 ratio to receive chemotherapy with or without cetuximab before and after liver resection. Randomisation was done using minimisation with factors of surgical centre, poor prognostic tumour (one or more of: ≥ 4 metastases, N2 disease, or poor differentiation of primary tumour), and previous adjuvant treatment with oxaliplatin. Chemotherapy consisted of oxaliplatin 85 mg/m(2) intravenously over 2 h and fluorouracil bolus 400 mg/m(2) intravenously over 5 min, followed by a 46 h infusion of fluorouracil 2400 mg/m(2) repeated every 2 weeks (regimen one) or oxaliplatin 130 mg/m(2) intravenously over 2 h and oral capecitabine 1000 mg/m(2) twice daily on days 1-14 repeated every 3 weeks (regimen two). Patients who had received adjuvant oxaliplatin could receive irinotecan 180 mg/m(2) intravenously over 30 min with fluorouracil instead of oxaliplatin (regimen three). Cetuximab was given as an intravenous dose of 500 mg/m(2) every 2 weeks with regimen one and three or a loading dose of 400 mg/m(2) followed by a weekly infusion of 250 mg/m(2) with regimen two. The primary endpoint was progression-free survival. This is an interim analysis, up to Nov 1, 2012, when the trial was closed, having met protocol-defined futility criteria. This trial is registered, ISRCTN22944367.
FINDINGS:
128 KRAS exon 2 wild-type patients were randomised to chemotherapy alone and 129 to chemotherapy with cetuximab between Feb 26, 2007, and Nov 1, 2012. 117 patients in the chemotherapy alone group and 119 in the chemotherapy plus cetuximab group were included in the primary analysis. The median follow-up was 21.1 months (95% CI 12.6-33.8) in the chemotherapy alone group and 19.8 months (12.2-28.7) in the chemotherapy plus cetuximab group. With an overall median follow-up of 20.7 months (95% CI 17.9-25.6) and 123 (58%) of 212 required events observed, progression-free survival was significantly shorter in the chemotherapy plus cetuximab group than in the chemotherapy alone group (14.1 months [95% CI 11.8-15.9] vs 20.5 months [95% CI 16.8-26.7], hazard ratio 1.48, 95% CI 1.04-2.12, p=0.030). The most common grade 3 or 4 adverse events were low neutrophil count (15 [11%] preoperatively in the chemotherapy alone group vs six [4%] in the chemotherapy plus cetuximab group; four [4%] vs eight [8%] postoperatively), embolic events (six [4%] vs eight [6%] preoperatively; two [2%] vs three [3%] postoperatively), peripheral neuropathy (six [4%] vs one [1%] preoperatively; two [2%] vs four [4%] postoperatively), nausea or vomiting (four [3%] vs six [4%] preoperatively; four [4%] vs two [2%] postoperatively), and skin rash (two [1%] vs 21 [15%] preoperatively; 0 vs eight [8%] postoperatively). There were three deaths in the chemotherapy plus cetuximab group (one interstitial lung disease and pulmonary embolism, one bronchopneumonia, and one pulmonary embolism) and one in the chemotherapy alone group (heart failure) that might have been treatment related.
INTERPRETATION:
Addition of cetuximab to chemotherapy and surgery for operable colorectal liver metastases in KRAS exon 2 wild-type patients results in shorter progression-free survival. Translational investigations to explore the molecular basis for this unexpected interaction are needed but at present the use of cetuximab in this setting cannot be recommended
Endothelial dysfunction evaluated by peripheral arterial tonometry is related with peak TnI values in patients with ST elevation myocardial infarction treated with primary angioplasty
No full textPURPOSE:
The role of endothelial-dependent function in patients with acute ST elevation myocardial infarction (STEMI) is not clear. Endothelial dysfunction may contribute to the pathophysiological processes occurring after STEMI and influence the extension of myocardial necrosis. Endothelial-dependent dysfunction evaluated by peripheral arterial tonometry (PAT) has already showed to be correlated with microvascular coronary endothelial dysfunction. Our purpose was to evaluate the impact of endothelial dysfunction on peak Troponin I (TnI) values, as a surrogate for the extension of myocardial infarction, in patients with STEMI treated with primary angioplasty (P-PCI).
METHODS:
58 patients with STEMI treated with P-PCI (mean age 59.0 ± 14.0 years, 46 males) were included. Endothelial function was assessed by reactive hyperaemia index (RHI) determined by PAT. Patients were divided in two groups according to the previously reported RHI threshold for high risk (1.67). The extension of myocardial necrosis was evaluated by peak TnI levels.
RESULTS:
RHI median value was 1.78 (IQR0.74);25 patients had endothelial dysfunction (RHI b 1.67). The two groups had no significant differences in age, gender, main risk factors and pain-to-balloon time. Patients with an RHI b 1.67 had significant larger infarcts: TnI 73.5 ng/mL (IQR 114.42 ng/mL) versus TnI 33.2 ng/mL (IQR 65.2 ng/mL); p = 0.028. On multivariate analysis, the presence of an RHI b 1.67 kept significant impact on TnI peak values (p=0.02).
CONCLUSIONS:
The presence of endothelial-dependent dysfunction, assessed by PAT, is related with higher peak TnI values in STEMI patients treated with P-PCI. These results strength the possibility that endothelial-dependent dysfunction may be a marker of poor prognosis and eventually a therapeutic target in patients with STEMI.info:eu-repo/semantics/publishedVersio
Cytomorphological features of blastic plasmacytoid dendritic cell neoplasm on FNA and cerebrospinal fluid cytology: a review of 6 cases.
No full textBACKGROUND:
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematopoietic tumor that was once believed to be derived from natural killer cells and is now recognized as originating from precursors of plasmacytoid dendritic cells. It generally involves the skin and has an aggressive clinical course. Due to its highly malignant behavior, a fast and accurate diagnosis of this condition is of the utmost importance.
METHODS:
Six cytology specimens from 5 patients diagnosed with BPDCN were reviewed as well as their clinical records. Findings were compared with 3 previously published cases.
RESULTS:
Two exfoliative cytology specimens (cerebrospinal fluid) and 4 fine-needle aspiration specimens (3 lymph node specimens and 1 cutaneous specimen) were reviewed. The cytomorphological aspects were similar in all cases. The smears were hypercellular with a monotonous population of intermediate-sized cells, dispersed singly or arranged in loose aggregates. The cells had round to oval nuclei, with fine chromatin and prominent nucleoli; the cytoplasm was generally scant, without visible granules. Intracytoplasmic microvacuoles were found in the majority of cases. Four cases were also characterized by flow cytometry, which revealed expression of CD 123, CD56 and/or CD4. Fine-needle aspiration was used in 1 case for primary diagnosis. Histological confirmation was available in all cases.
CONCLUSIONS:
BPDCN is a highly malignant neoplasm with a poor outcome. Cytology, in association with flow cytometry immunophenotyping and clinical history, is a reliable method with which to establish the diagnosis.info:eu-repo/semantics/publishedVersio
Off-Label Use of Ultrasound Contrast Agents for Intravenous Applications in Children: Analysis of the Existing Literature
No full textOBJECTIVES:
The purpose of this study was to collect and analyze the published data related to intravenous (IV) use of ultrasound (US) contrast agents in children.
METHODS:
We searched the literature to collect all of the published studies reporting the IV administration of a second-generation US contrast agent in children.
RESULTS:
We analyzed 9 case series and 5 case reports, as well as 5 individual cases, of pediatric contrast-enhanced US use reported in a study group that also included adults. We found that 502 children underwent contrast-enhanced US examinations (mean age, 9.7 years; range, 1 day-18 years). Most patients (89%) were injected with the sulfur hexafluoride contrast agent SonoVue (Bracco SpA, Milan, Italy). The mean dose used was 1.5 mL (range, 0.1-9.6 mL). Only 10 patients (2%) had adverse reactions related to the contrast agent administration: 1 life-threatening anaphylactic shock and 9 mild transitory adverse effects. We additionally found 38 papers in which the study groups included at least 1 child; thus, we obtained a total of 540 reported cases of off-label use of IV US contrast agents in children. The most frequent target organ was the liver, and most indications were related to space-occupying lesion characterization and abdominal evaluations after blunt trauma. Some studies also evaluated the diagnostic performance of contrast-enhanced US in different clinical scenarios and found very good accuracy. Concordance between contrast-enhanced US imaging and the respective reference-standard imaging methods ranged between 83% and 100% in different studies.
CONCLUSIONS:
Our results support the idea that the IV use of US contrast agents in children is safe, feasible, diagnostically robust, and effective.info:eu-repo/semantics/publishedVersio
Intracardiac leiomyomatosis presenting as an intraoperative consultation.
No full textIntravenous leiomyomatosis (IVL) is an extremely rare variant of leiomyoma in which nodular masses of tumor grow within venous channels. Rarely, the tumor can reach the vena cava and right heart. We present a case of a 45-year-old woman, admitted with rapidly evolving exertional dyspnea. Cardiac ultrasonography revealed a "mass in the right chambers". She was submitted to right atriotomy plus tumorectomy, with intraoperative consultation requested. Grossly, the tumor was polypoid, firm, with a smooth surface. The frozen section showed a lesion composed of tortuous vessels and some areas with a fibrillar eosinophil extracellular matrix and others with spindle cells, without significant atypia, mitosis or necrosis. The diagnosis was deferred for definitive paraffin sections. In the definitive H&E and immunohistochemical stains, the case was diagnosed as an IVL and confirmed in the hysterectomy specimen. This is the first case report describing an intraoperative consultation of an intracardiac leiomyomatosis. Clinical information and pathologist awareness to this entity are essential for the correct diagnosis in frozen section.info:eu-repo/semantics/publishedVersio
Campaign “Caring of who takes care of us” or the profile of the respiratory health of Portuguese firefighters: evaluation of the respiratory impact in first responders (FR).
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Relação entre a histeresis da córnea e a espessura da lâmina crivosa no glaucoma primário de ângulo aberto e glaucoma pseudoesfoliativo
No full textObjectivos: Este estudo visa analisar a relação entre a histeresia da córnea (HC) e a espessura da lâmina crivosa (LC) em doentes com glaucoma primário de ângulo aberto (GPAA) e glaucoma pseudoesfoliativo (GPS), comparando também os resultados entre os grupos.
Material/Métodos: Estudo transversal que inclui doentes com diagnóstico de GPS e GPAA. Registaram-se os dados demográficos, as espessuras da LC e da camada de fibras nervosas peri-papila (CFNPP) segmentar e global, a pressão intra-ocular (PIO), o mean defect (MD) da perimetria estática compturizada (Octopus*), a HC e o factor de resistência corneano, de todos os doentes incluídos no estudo. Para a análise dos dados recorreu-se aos testes de Mann-Whitney e Spearman (SPSS*). A significância estatística foi estabelecida para p<0,05.
Resultados: Foram incluídos 29 olhos (18 doentes) com GPS e 28 olhos (19 doentes) com GPAA. Verificou-se a correlação entre a espessura da LC e a HC no grupo GPAA (spearman
r= -0,370, p=0,048). A mediana da HC revelou-se significativamente inferior no GPAA (p=0,006)
e a mediana da espessura da LC nos doentes com GPS, relativamente aos doentes com
GPAA. Ambos poderão constituir importantes factores de prognóstico do GPAA e GPS. No entanto, são necessários mais estudos de forma a avaliar as consequências clínicase terapêuticas dos resultados apresentados.info:eu-repo/semantics/publishedVersio