Lymphoparietal index in esophageal cancer is stronger than tnm staging in long-term survival prognosis in a latin-american country / índice linfoparietal no câncer esofágico é mais forte do que tnm no prognóstico de sobrevivência em longo prazo em um país latinoamericano

ABSTRACT Background: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. Aim: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). Method: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. Results: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). Conclusion: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

RESUMO Racional: A identificação de fatores prognósticos do câncer de esôfago permitiu prever a evolução dos pacientes. Objetivo: Avaliar diferentes fatores prognósticos da sobrevida em longo prazo do câncer de esôfago e avaliar um novo fator prognóstico da sobrevida em longo prazo chamado índice linfoparietal (N+/T). Método: Estudo prospectivo do Hospital Clínico da Universidade do Chile, entre janeiro de 2004 e dezembro de 2013. Incluiu todas as operações de câncer de esôfago com intenção curativa e anastomose cervical. Os critérios de exclusão incluíram: câncer em estágio 4, ressecções R1, procedimentos paliativos e operações de emergência. Resultados: Cinquenta e oito pacientes foram incluídos, 62,1% eram homens, a idade média foi de 63,3 anos. Um total de 48,3% eram escamosos, 88% eram cânceres avançados, a colheita média de linfonodos foi de 17,1. A morbidade cirúrgica pós-operatória foi de 75%, com 17,2% de reoperações e 3,4% de mortalidade. A sobrevida global média foi de 41,3 meses, a sobrevida em três anos foi de 31%. A análise multivariada dos fatores prognósticos mostrou que variáveis significativas foram elevação pelo mediastinal anterior (p=0,01, OR: 6,7 [1,43-31,6]), fístula anastomótica (p=0,03, OR: 0,21 [0,05-0,87]), classificação N (p=0,02, OR: 3,8 [1,16-12,73]), estágio TNM (p=0,04, OR: 2,8 [1,01-9,26]) e índice linfoparietal (p=0,04, RR: 3,9 [1,01-15,17]. As curvas ROC do índice linfoparietal, classificação N e estádio TNM apresentam áreas abaixo da curva de 0,71, 0,63 e 0,64, respectivamente, com diferença estatística significativa (p=0,01). Conclusão: Os fatores prognósticos independentes de sobrevida em longo prazo no câncer de esôfago são a elevação mediastinal anterior, fístula anastomótica, classificação N, estágio TNM e índice linfoparietal. No câncer de esôfago, o novo índice linfoparietal é mais forte que o estágio TNM no prognóstico de sobrevida em longo prazo.

Introduction of the new lymphoparietal index for gastric cancer patients / Introdução de novo índice linfoparietal para pacientes de câncer gástrico

ABSTRACT Background: The identification of prognostic factors of gastric cancer (GC) has allowed to predict the evolution of patients. Aim: Assess the reliability of the lymphoparietal index in the prediction of long-term survival in GC treated with curative intent. Method: Prospective study of the Universidad de Chile Clinical Hospital, between May 2004 and May 2012. Included all gastric cancer surgeries with curative intent. Exclusion criteria were: gastrectomies due to benign lesions, stage 4 cancers, R1 resections, palliative procedures, complete esophagogastrectomies and emergency surgeries. Results: A total of 284 patients were included; of the sample 65.4% were male,mean age of 64.5 years,75% were advanced cancers, 72.5% required a total gastrectomy, 30 lymph nodes harvest. Surgical morbidity and mortality were 17.2% and 1.7%. 5-year survival was 56.9%. The N+/T index could predict long-term survival in all de subgrups (p<0.0001), although had a reliable prediction in early GC (p=0.005), advanced GC (p<0.0001), signet ring cell GC (p<0.0001), proximal GC (p<0.0001) and distal GC (p<0.0001). The ROC curves N+/T index, LNR and T classification presented areas below the curve of 0.789, 0.786 and 0,790 respectively, without a significant statistical difference (p=0.96). Conclusion: The N+/T index is a reliable quotient in the prognostic evaluation of gastric adenocarcinoma patients who have been resected with curative intent.

RESUMO Racional: A identificação de fatores prognósticos do câncer gástrico (GC) permitiu predizer a evolução dos pacientes. Objetivo: Avaliar a confiabilidade do índice linfoparietal na predição de sobrevida em longo prazo em pacientes tratados com intenção curativa. Método: Estudo prospectivo do Hospital das Clínicas da Universidade de Chile, entre maio de 2004 e maio de 2012. Todas as operações de câncer gástrico foram com intenção curativa. Os critérios de exclusão foram: gastrectomia por lesões benignas, cânceres estágio 4, ressecções R1, procedimentos paliativos, esofagogastrectomias completas e operações de emergência. Resultados: Foi incluído um total de 284 pacientes; da amostra 65,4% eram homens, com média de idade de 64,5 anos, 75% eram cânceres avançados, 72,5% necessitaram de gastrectomia total e 30 coletas de linfonodos. A morbimortalidade cirúrgica foi de 17,2% e 1,7%. Sobrevida em cinco anos foi de 56,9%. O índice N +/T pôde predizer a sobrevida em longo prazo em todos os subgrupos (p<0,0001), embora tivesse previsão confiável em GC precoce (p=0,005), GC avançado (p<0,0001), célula GC de anel de sinete (p< 0,0001), GC proximal (p<0,0001) e GC distal (p<0,0001). As curvas ROC N +/T, LNR e T apresentaram áreas abaixo da curva de 0,789, 0,786 e 0,790, respectivamente, sem diferença estatística significativa (p=0,96 ). Conclusão: O índice N +/T é um quociente confiável no prognóstico na avaliação de pacientes com adenocarcinoma gástrico que foram ressecados com intenção curativa.

Resultados del tratamiento quirúrgico en pacientes con cáncer gástrico de 80 o más años / Results of surgical treatment of gastric cancer in patients with 80 or more years of age

Introducción: La población chilena, al igual que la mundial, ha presentado un importante envejecimiento en los últimos 25 años. El cáncer gástrico ocupa la primera causa de mortalidad por tumores malignos en Chile. Objetivo: Determinar la mortalidad operatoria de la gastrectomía total o subtotal en pacientes con cáncer gástrico de 80 o más años y la sobrevida a 5 años. Material y método: Estudio retrospectivo y prospectivo de todos los pacientes sometidos a resección gástrica por cáncer gástrico entre 1988 y 2016, con 80 o más años. Se excluyeron los pacientes sometidos a técnicas quirúrgicas no resectivas. Se analizaron las siguientes variables: síntomas y signos, comorbilidades, características anatomopatológicas, mortalidad según el tipo de gastrectomía y sobrevida global a 5 años. Resultados: En el periodo de tiempo analizado hubo 70 pacientes con cáncer gástrico y edad igual o mayor de 80 años, que representan al 7,4% del total de pacientes con resección gástrica. Los síntomas más frecuentes fueron dolor, baja de peso y anemia crónica microcítica. Hubo un 66% de pacientes con comorbilidades. El cáncer se ubicó preferentemente en el tercio superior, siendo un adenocarcinoma en 66 pacientes. En 4 pacientes hubo 2 linfomas, un GIST maligno y un carcinoide maligno. El carcinoma incipiente correspondió al 12% de los adenocarcinomas. La mortalidad global de la gastrectomía fue del 17%, siendo el 5% para la subtotal y el 22% para la total. La sobrevida promedio a 5 años fue del 26%. Conclusiones: La gastrectomía subtotal o total en pacientes con cáncer gástrico sobre 80 años es factible de realizar en pacientes seleccionados, pero el riesgo de mortalidad operatoria es de 7 a 10 veces mayor que en pacientes bajo los 75 años.

Introduction: The longevity of Chilean population has increased greatly in the last 25 years, similar to world population. Gastric cancer in Chile is the first cause of death due to malignant tumors. Purpose: To determine operative mortality of subtotal or total gastrectomy in patients with gastric cancer older than 80 years, and the rate 5 year-survival. Material and method: This is an retrospective-prospective study of all patients with 80 years of age or more submitted to gastric resection due to gastric cancer between 1988 and 2016. Patients submitted to non-resective procedures were excluded. The following parameters were analized: symptoms and signs, comorbidities, pathologic features of the gastric cancer, operative mortality according to the gastrectomy and 5-year survival rate. Results: There were 70 patients with gastric cancer older than 80 years of age, which represented 7.4% of all patients with gastric cancer submitted to gastric resection in the same period of time. Most frequent symptoms were epigastric pain, loss of weight and chronic microcitic anemia. There were 66% of the patients with comorbidities. The tumor was located mainly in the upper third of the stomach, being an adenocarcinoma in 66 patients (94%). There were also 2 linfomas, one GIST and one patient with a malignant carcinoid. Early cancer was observed in 12% of the adenocarcinomas. Global operative mortality was 17% being 5% for subtotal and 22% for total gastrectomy. Mean 5-year survival rate was 26%. Conclusions: Subtotal or total gastrectomy in patients with gastric cancer with 80 years of age or more is possible to perform in selected patients, but the risk of operative mortality is 7 to 10 times greater than below 75 years of age.

Resección total del mesorrecto por vía transanal en cáncer de recto: análisis de resultados de una serie preliminar en un hospital universitario / Transanal total mesorectal excision in rectal cancer: analysis of a preliminary series in universitary hospital

Introducción: La resección total del mesorrecto por vía transanal es un abordaje híbrido que combina el uso de una plataforma transanal y laparoscopia convencional. Objetivos: Realizar el análisis de casos seleccionados con cáncer de recto medio e inferior en los cuales se utilizó un abordaje transanal combinado para su resolución y la descripción de la técnica quirúrgica. Materiales y métodos. Corresponde a una serie prospectiva de pacientes con diagnóstico de cáncer de recto de tercio medio e inferior con resección mesorrectal asistida por monopuerto endoanal entre octubre de 2012 y diciembre de 2015, en Hospital Clínico Universidad de Chile. Se utilizó estadística descriptiva para el análisis de los datos. Resultados: Fueron sometidos a cirugía por cáncer de recto medio e inferior un total de 29 pacientes utilizando monopuerto transanal. De estos, 22 fueron de sexo masculino y 7 de sexo femenino, con edad promedio de 55,5 años e IMC de 26,4. La distancia media al margen anal fue 4,8 cm. Todos recibieron neoadyuvancia. Se realizaron 17 Ta-TME (58,6%) y 12 Ta-TME con abordaje interesfintérico (41,4%). La anastomosis fue coloanal manual en 15 pacientes (51,7%) y grapada en 14 (48,3%). El abordaje laparoscópico se utilizó en 26 pacientes y el abierto en 3, registrando 4 conversiones (15,4%). El tiempo operatorio promedio fue de 282 min. La estadía hospitalaria media fue de 9 días. Conclusión: El monopuerto endoanal aparece como una herramienta útil en la disección total del mesorrecto por su seguridad y factibilidad. Creemos que es necesaria la realización de trabajos prospectivos aleatorizados, donde es relevante la comparación de resultados oncológicos y funcionales a largo plazo.

Introduction: Transanal total mesorectal excision is a hybrid approach that combines the use of a conventional laparoscopic and a transanal platform. Objectives: To conduct an analysis of selected cases with medium and lower rectal cancer, were a combined transanal approach was used and description of the surgical technique. Materials and methods: Prospective series of patients diagnosed with middle and lower third rectal cancer with mesorectal resection assisted by endoanal single port, between October 2012 and December 2015 at University of Chile Clinical Hospital. Descriptive statistics were used for data analysis. Results: A total of 29 patients underwent surgery for middle and lower rectal cancer using a transanal single port. Gender distribution was 22 male and 7 female patients, with a mean age of 55.5 years and a mean BMI of 26.4. The mean distance from the anal margin was 4.8 cm. All patients received neoadjuvant therapy. The surgeries performed were 17 Ta-TME (58.6%) and 12 Ta-TME with intersphincteric approach (41.4%). The colo-anal anastomosis was hand sewn in 15 patients (51.7%), and stapled in 14 (48.3%). The laparoscopic approach was used in 26 patients and the open approach in 3, with 4 conversions (15.4%). The mean operative time was 282 min. The mean hospital stay was 9 days. Conclusion: The endoanal single port appears as a useful tool in total mesorectal dissection for its safety and feasibility. We believe we need randomized prospective studies, where comparison of oncological and functional long-term results is relevant.