Daniela Medeiros Milhomem Cardoso

Metastatic cancer to the stomach

BackgroundMetastases in the stomach are rare. The increased use of esophagogastroduodenoscopy (EGD), associated with better treatment results for malignancies, requires them to be acknowledged. The aim of this study was to describe a series of cases of metastasis to the stomach, their primary sites, clinical and endoscopic features, treatment, and results.MethodsTwenty cases were diagnosed between December 1999 and January 2004. Their analysis included symptomatology, macroscopic presentation, time from diagnosis of the primary tumor to the detection of the gastric metastasis, treatment approach, and survival.ResultsThe primary sites were the esophagus, skin, lung, cervix, breast, sigmoid colon, and testis. The symptom most frequently requiring EGD was upper gastrointestinal bleeding. Ten patients showed concomitant metastases to other organs. The mean time between diagnosis of the primary tumor and diagnosis of gastric metastasis was 16 months (range, 0 to 56 months). Only seven patients were given some form of treatment after diagnosis of the gastric metastasis. The median survival was 4.75 months. Overall survival during the first year was 20% and survival was nil at 2 years.ConclusionsGastric metastasis marks advanced disease and the prognosis is poor. New advances in diagnosis and treatment are required for better results.

Initial experience in Brazil with endoscopic submucosal dissection for early gastric cancer using insulation-tipped knife: a safety and feasibility study

BackgroundEndoscopic resection is an adequate treatment for subgroups of patients with early gastric cancer. Endoscopic submucosal dissection (ESD) represents a recent advance and leads to good results when adequately indicated. There is great experience with this technique in Japan and it is gaining acceptance among Western endoscopists. We present the first gastric ESD series performed in Brazil.MethodsPatients with well-differentiated adenocarcinomas macroscopically classified as early cancer, less than 30 mm with no ulcer or scar, were included. ESD was performed with an insulated-tip knife and electrosurgical unit with endocut mode. Clinicopathological aspects and morbidity were evaluated. The study was approved by the local ethics committee and informed consent was obtained from all participant subjects.ResultsFrom October 2005 to July 2007, 160 patients received surgical treatment for gastric cancer; 44 patients (27.5%) had early gastric cancer. In this latter group, 15 procedures (ESD) were performed in 12 patients. The mean size of the lesions was 16.8 mm. Almost half of the lesions were located in the proximal third of the stomach and the mean elapsed time for the procedure was 140 min. In 80% of the cases resection was en bloc and 80% of the resections were considered curative. We had three perforations, which were managed clinically, and no bleeding.ConclusionWhen adequately indicated, ESD is a safe and feasible technique.

Frequência e fatores preditivos relacionados a metástase linfática em câncer gástrico precoce

BACKGROUND The standard treatment of gastric cancer still has high morbidity and mortality in western populations. Groups of patients with negligible risk of lymph node metastasis may benefit from less invasive treatments. Data regarding the frequency and predictive factors related to lymphatic metastasis in early gastric cancer are rare. AIM To perform the analysis of frequency and predictive factors related to lymphatic metastasis in patients with early gastric cancer treated in a tertiary center in Brazil. METHODS Nine hundred and twenty three patients underwent gastrectomy for gastric adenocarcinoma at the hospital. Of these, 126 had early tumors and were included in the analysis. Clinical and pathological related findings and lymphatic metastasis were evaluated. RESULTS Lymph node metastases were observed in 7.8% of patients with mucosal tumors and 22.6% of submucosal tumors. The presence of ulceration, Lauren histologic type, tumors larger than 50 mm, submucosal invasion, and presence of lymphatic or vascular invasion were significant factors in univariate analysis. The presence of ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion were factors independently related to lymphatic metastasis in multivariate analysis. CONCLUSION Ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion are independent risk factors related to lymphatic metastasis in early gastric cancer.

Risk factors for esophageal cancer in a low-incidence area of Brazil

CONTEXT AND OBJECTIVES Esophageal cancer is the eighth commonest type of cancer worldwide, occupying sixth place in terms of mortality. Smoking and alcohol use are known risk factors for this type of cancer. The aim here was to evaluate the risk factors for esophageal cancer in a low-incidence area. DESIGN AND SETTING Case-control study in Goiânia, with 99 cases of esophageal cancer and 223 controls. METHODS The variables were sociodemographic, dietary, occupational and lifestyle data. The sample was analyzed using the chi-square test, Mann-Whitney test and Mantel-Haenszel approach for multivariate analysis. Odds ratios (OR) were calculated with 5% significance and 95% confidence intervals. RESULTS The risk of esophageal cancer was higher in patients ≥ 55 years (OR = 1.95; P < 0.001). Patients from rural areas were at greater risk of esophageal cancer (OR = 4.9; P < 0.001). Smoking was a risk factor among the cases (OR = 3.8; P < 0.001), as was exposure to woodstoves (OR = 4.42; P < 0.001). The practice of oral sex was not a risk factor (OR = 0.45; P = 0.04). Consumption of apples, pears, vegetables, cruciferous vegetables and fruit juices were protective against esophageal cancer. CONCLUSION In a region in which the incidence of esophageal cancer is low, the most significant risk factors were exposure to woodstoves, smoking and living in rural areas.

CLINICAL TRIAL : A RANDOMIZED STUDY COMPARING THE DURABILITY OF SILICONE AND LATEX PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBES

Background:  The use of percutaneous endoscopic gastrostomy (PEG) for nutrition support is increasing worldwide, but few studies have evaluated the durability of and complications related to the different materials used to manufacture gastrostomy tubes. Latex PEG tubes are widely used in our clinical setting, but no studies have compared their durability with silicone PEG tubes. The aim of the present study was to compare the durability of latex tubes with the durability of silicone tubes.

Aspectos ultra-sonográficos da trombose da veia porta

Portal vein thrombosis may be associated with many alterations, such as the presence of tumors (for example, hepatocellular carcinoma, metastatic liver disease and carcinoma of the pancreas) as well as pancreatitis, hepatitis, septicemia, trauma, splenectomy, portacaval shunts, hypercoagulable conditions (for example, pregnancy), in neonates (for example, omphalitis and umbilical vein catheterization) and in acute dehydration. The authors discuss herein the sonographic features of portal vein thrombosis as well as some aspects of clinical relevance.

Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants

BACKGROUND When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.

ADENOMA DETECTION RATE EVALUATION AND QUALITY OF COLONOSCOPY IN THE CENTER-WEST REGION OF BRAZIL

BACKGROUND Colorectal cancer is the third commonest cancer in men and the second in women worldwide. Peculiarities of its evolution allow secondary prevention measures through colonoscopy, with high diagnostic and therapeutic capacity. In this context, the quality indicators of the procedure become important, among them the adenoma detection rate (ADR). OBJECTIVE To relate the ADR in a medium risk population subjected to colonoscopy with sociodemographic, technical and histopathological indicators. METHODS This was a descriptive, observational and retrospective study whose data were collected from medical records of colonoscopy exams with the indication of colorectal cancer screening or prevention in the period from August to October 2016. RESULTS A total of 436 exams were included for analysis. Female sex represented 66.3% with 289 patients versus 33.7% for men. Patients aged between 50 and 59 years were 223 (51.1%) and those between 60 and 75 years were 213 (48.9%). In 99 exams (22.7%) chromoscopy was used, and 420 patients (96.3%) were adequately prepared. There were 118 patients with adenomas, resulting in an overall ADR of 27.1%. The ADR for men was 30.6% and 25.3% for women. Patients between 60 and 75 years old had a significantly higher ADR (31.9%, compared to 22.4% of the younger ones). Examinations in which chromoscopy was used also presented higher ADR. CONCLUSION The ADR values found for the population of the studied region were compatible with internationally established goals. Continuous evaluation of the ADR may yield interventions aimed at improving quality standards for colonoscopy and promote better prevention of colorectal cancer.

D2 lymphadenectomy with para-aortic sampling improves lymph node staging for gastric cancer

RACIONAL: O papel da linfadenectomia no estadiamento de câncer gastrico e de grande importância quando lidando com câncer gastrico. OBJETIVO: Verificar se a linfadenectomia com estacoes linfonodais separadas aumenta o numero da disseccao de linfonodos e estabelecer comparacao entre o TNM 2002 e o JGCA 1998, avaliando o status dos linfonodos (N). METODOS: Foi realizada analise retrospectiva de pacientes que foram submetidos a gastrectomia curativa e disseccoes do tipo D2 para adenocarcinomas, entre 2004 e 2006. Entre janeiro de 2004 e junho de 2005 (grupo 1), a linfadenectomia foi realizada em flape unico com gastrectomia e somente o sistema TNM foi utilizado. Apos junho de 2005 (grupo 2), o cirurgiao realizou a disseccao de estacoes linfonodais, permitindo o uso dos sistemas TNM e JGCA. Os aspectos estudados e analisados foram idade, classificacao de Borrmann, grau histologico, invasao venosa ou linfatica, profundidade da invasao, citologia peritoneal e tipo de gastrectomia. Foram analisados o numero de linfonodos dissecados, o numero de linfonodos positivos e o entendimento entre os sistemas de estadiamento. O teste do Chi-quadrado e teste-t foram utilizados para realizar a analise estatistica. RESULTADOS: Foram realizadas 145 gastrectomias, sendo 76 no grupo 1 e 69 no grupo 2. A idade media referente ao grupo 1 foi de 61 anos e de 59 no grupo 2 (P=0,12). Em ambos os grupos 80% dos tumores eram avancados. Invasao venosa e linfatica e citologia peritonial positiva foram mais frequentes no grupo 1, 65.6% vs 35.3% (P=0,001) e 13.9% vs 3.1% (P=0,03), respectivamente. A classificacao de Borrmann, grau histologico, classificacao de Lauren e tipo de gastrectomia nao foram diferentes entre os grupos. No grupo 1, a media de linfonodos foi de 32.7 e no grupo 2 de 37.35 (P=0,09). O indice de linfonodos positivos nos grupos 1 e 2 foi de 72.2% e 53%, respectivamente (P=0,02). A analise de migracao do status de linfonodos (N) foi realizada no grupo 2 (69 pacientes) em concordância com o TNM e JGCA em 50 pacientes (72.5%). Ao utilizar o sistema JGCA, ocorreram modificacoes em 19 pacientes (27.5%), com aumento de estadiamento em 13 (18.8%) e diminuicao em 6 (8.7%). CONCLUSAO: Neste estudo, foi verificada tendencia ao aumento do numero de linfonodos quando o cirugiao realizou, ele mesmo, a disseccao das estacoes linfonodais. O sistema JGCA modificou o estadiamento linfonodal quando comparado ao sistema TNM em 30% de todos os casos.

Percutaneous endoscopic gastrostomy in advanced head and neck cancer

RACIONAL: A gastrostomia endoscopica percutânea executada conforme a tecnica proposta por Gauderer et al., em 1980, tem sido frequentemente utilizada em pacientes com tumores de cabeca e pescoco. Diversos autores relatam que ela, conhecida como tecnica de “puxar”, esta associada a risco de implante de tumor na parede abdominal assim como risco bastante elevado de infeccao na ferida operatoria. Algumas variantes tecnicas proporcionam melhores resultados, contudo existem duvidas acerca da sua viabilidade tecnica na pratica diaria. OBJETIVO: Verificar a exequibilidade, seguranca e morbidade da gastrostomia endoscopica percutânea realizada por tecnica padronizada e bem definida em pacientes com tumores avancados ou irressecaveis da cabeca e pescoco. METODO: E descrita serie consecutiva de pacientes com tumores avancados ou irressecaveis de cabeca e pescoco, incapazes de receber dieta por via oral, submetidos a gastrostomia endoscopica percutânea no setor de endoscopia digestiva de um hospital oncologico de referencia terciaria. As sondas foram implantadas pela tecnica de puncao compreendida de duas etapas principais. A primeira, consistiu na aplicacao de dois pontos transfixantes com o proposito de fixar a parede anterior do estomago a parede abdominal. A segunda, introducao do tubo de gastrostomia por puncao percutânea. RESULTADOS: Foram realizadas 129 gastrostomias endoscopicas percutâneas e incluiu 60 pacientes. Todos foram liberados para receber dieta no mesmo dia. Morbidade operatoria ocorreu em seis pacientes (10%) e mortalidade relacionada ao procedimento foi verificada em um paciente (1,6%). CONCLUSAO: A gastrostomia endoscopica percutânea e exequivel e segura, alem de estar associada a baixa morbidade e aceitavel mortalidade.