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Doctoral Thesis
DOI
10.11606/T.5.2012.tde-31072012-085512
Document
Author
Full name
José Humberto Simões Corrêa
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2012
Supervisor
Committee
Lopasso, Fabio Pinatel (President)
Maluf Filho, Fauze
Matos, Delcio
Nahas, Sergio Carlos
Ribeiro Júnior, Ulysses
Title in Portuguese
Ressecção abdominoperineal do reto após falha do tratamento radioquimioterápico do carcinoma anal
Keywords in Portuguese
Câncer anal
Carcinoma de células escamosas
Cirurgia de resgate
Neoplasias do ânus
Quimiorradioterapia
Ressecção abdominoperineal
Tratamento conservador
Abstract in Portuguese
INTRODUÇÃO: O tratamento padrão do Carcinoma Epidermoide do Ânus (CEDA) é a quimiorradioterapia ou radioterapia exclusiva. Os pacientes em que a terapêutica conservadora falha são tratados com Ressecção Abdominoperineal do Reto (RAP) de resgate. OBJETIVOS: Avaliar a sobrevivência com a RAP de resgate no CEDA, identificando os descritores favoráveis para sobrevivência maior e as características do agrupamento de variáveis relacionadas a descritores independentes de risco para mortalidade. MÉTODOS: Foram levantados dados através de 111 prontuários de portadores de CEDA, tratados inicialmente com quimiorradioterapia combinada ou radioterapia exclusiva e submetidos à RAP no período de outubro de 1982 a janeiro de 2011. RESULTADOS: A média de idade foi de 58 anos, 93 (83,8%) pacientes eram do sexo feminino e 80 (72,1%) da raça branca. O estadio cT3-4 compôs 66,7% e cN0 39,6% da casuística. A RAP foi indicada por persistência da doença (PD) em 61 (55%) pacientes e por recidiva (RD) em 50 (45%) pacientes. A ressecção cirúrgica sem resíduos tumorais (R0) foi realizada em 86 (77,5%) pacientes. O tempo médio de permanência hospitalar pós-operatório foi de 14 dias. A morbidade cirúrgica foi de 64,9%, sendo 78,3% dela devida às complicações da região perineal. Recidiva após RAP ocorreu em 68 (61,2%) pacientes, sendo 40 (58,8%) no primeiro ano do pós-operatório, a maioria locorregional (78%; 53/68). A mediana do seguimento foi de 16 meses (1,2-60 meses). Na análise multivariada, cirurgia R0 (p<0,001), invasão perineural vascular e/ou linfática negativa (p<0,0001) e linfonodo negativo na peça cirúrgica (p=0,03) foram estatisticamente associados à maior sobrevivência. CONCLUSÕES: A taxa de sobrevivência global estimada em cinco anos foi de 24,5%, com mediana de sobrevivência de 32 meses. O subgrupo de pacientes submetidos a cirurgias R0 em cujas peças cirúrgicas não foram encontrados invasão perineural vascular e/ou linfática nem linfonodos comprometidos apresentou taxa de sobrevivência estimada em três e cinco anos de 74,4% e 55,0%, respectivamente, com mediana de sobrevivência de 87 meses. Não houve diferença significativa entre pacientes que evoluíram com PD ou RD. Identificou-se a cirurgia R1-2, invasão perineural vascular e/ou linfática e linfonodo positivo na peça cirúrgica como fatores preditivos independentes de mortalidade
Title in English
Abdominoperineal resection of the rectum after failure of chemoradiation therapy for anal carcinoma
Keywords in English
Abdominoperineal resection
Anal cancer
Anal neoplasms
Chemoradiation
Conservative treatment
Salvage surgery
Squamous cell carcinoma
Abstract in English
INTRODUCTION: The standard treatment for epidermoid carcinoma of the anus (ECA) is the association of chemotherapy (QT) and radiotherapy or exclusive radiotherapy (RT). When conservative treatment fails, patients are submitted to abdominoperineal resection of the rectum (APR). OBJECTIVES: To assess survival with salvage APR in ECA, identifying the most favorable independent descriptors for longer survival and the characteristics of the group of independent variables for mortality risk. METHODS: Data were collected from the medical records of 111 patients with ECA, initially treated with QT/RT or exclusive RT and later submitted to APR, from October 1982 to January 2011. RESULTS: Their mean age was 58 years, 93 (83.8%) patients were female, and 80 (72.1%) were Caucasian. The cT3-4 stage represented 66.7% of the case series and cN0, 39.6%. The APR was indicated due to persistence of disease (PD) in 61 (55%) patients and recurrence of disease (RD) in 50 (45%) patients. Surgical resection without residual tumor (R0) was performed in 86 (77.5%) patients. The mean postoperative hospital length of stay was 14 days. Surgical morbidity was 64.9%, of which, 78.3% related to perineal infection. Recurrence after APR was observed in 68 (61.2%) patients, 40 (58,8%; 40/68) of whom in the first postoperative year, mostly locoregional (78%; 53/68). The median follow-up was 16 months (1.2 - 60 months). On multivariate analysis, R0 surgery (p<0.001), absence of perineural and/or lymphovascular invasion (p<0.0001) and negative lymph node status in the surgical specimen (p=0.03) were associated with increased survival. CONCLUSION: Estimated overall survival rate in 5 years was 24.5%, with median survival of 32 months. There was no significant difference in survival after APR in patients who had PD or RD after conservative treatment. The subgroup of patients who underwent R0 and whose surgical specimen showed absence perineural and/or lymphovascular invasion and negative lymph nodes had an estimated survival rate at 3 and 5 years of 74,4% and 55,0%, respectively, with a median survival of 87 months. The following were identified as independent predictors of mortality: R1-2 surgery; presence perineural and/or lymphovascular invasion; and positive lymph node in the surgical specimen
 
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Publishing Date
2012-07-31
 
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