Colgajo temporal en la reconstrucción de un defecto maxilar por exéresis de carcinoma ameloblástico / Temporalis muscle flap in the reconstruction of a maxillary defect caused by exeresis of ameloblastic carcinoma

RESUMEN Introducción: El carcinoma ameloblástico es una entidad rara que surge como una neoplasia primaria o a partir de un ameloblastoma preexistente. El colgajo de músculo temporal es una opción terapéutica frecuentemente empleada para la reconstrucción del defecto resultante luego de la exéresis quirúrgica. Objetivo: Presentar un caso clínico de restauración estética y funcional mediante reconstrucción con colgajo temporal de un defecto maxilar por exéresis de carcinoma ameloblástico, dada la infrecuente presentación de esta entidad. Caso clínico: Mujer de 49 años de edad, que refiere "una bola" en el paladar de 9 meses de evolución. Al examen físico facial presenta aumento de volumen en región infraorbitaria izquierda. Se realizó una tomografía axial computarizada en la que se constató la presencia de imagen hiperdensa en seno maxilar izquierdo con calcificación en su interior, produciendo lisis del hueso nasal y hueso cigomático infiltrando partes blandas. Se tomó muestra para biopsia que informó tumor de alto grado de malignidad correspondiente a carcinoma ameloblástico. En estudio radiográfico de tórax no se apreció presencia de metástasis pulmonar. Se realizó maxilarectomía de infra y mesoestructura, resección de la lesión con margen oncológico de seguridad y se reconstruyó el defecto palatino con colgajo pediculado del músculo temporal. Se indicó quimio y radioterapia como terapia adyuvante al tratamiento quirúrgico. Se mantuvo el chequeo posoperatorio mostrándose buena evolución clínica y una epitelización secundaria del músculo temporal en el área palatina con restauración de las funciones. Conclusiones: Se presentó un caso clínico de carcinoma ameloblástico, entidad patológica de escasa frecuencia. La cirugía constituyó el pilar de tratamiento utilizado. Una vez realizada la resección quirúrgica se reconstruyó el defecto palatino, utilizándose el colgajo del músculo temporal, opción útil para lograr el restablecimiento de las funciones estéticas y funcionales como la deglución y fonación(AU)

ABSTRACT Introduction: Ameloblastic carcinoma is a rare condition emerging as a primary neoplasm or from a preexisting ameloblastoma. Temporalis muscle flap is a therapeutic option frequently used for reconstruction of the defect resulting from surgical exeresis. Objective: Present a clinical case of esthetic and functional restoration by reconstruction with temporalis muscle flap of a maxillary defect caused by exeresis of an ameloblastic carcinoma. The case is presented because of the infrequent occurrence of this condition. Clinical case: A female 49-year-old patient reports "a lump" in her palate of nine months evolution. Physical examination finds an increase in volume in the left infraorbital region. Computed axial tomography was indicated, which revealed the presence of a hyperdense image in the left maxillary sinus with internal calcification causing lysis of the nasal bone and the zygomatic bone, and infiltrating soft tissue. A sample was taken for biopsy, which reported a tumor with a high degree of malignancy corresponding to ameloblastic carcinoma. Chest radiography did not show the presence of lung metastasis. Infra- and mesostructure maxillectomy was performed, the lesion was removed with a surgical safety margin, and the palatine defect was reconstructed with a pediculated temporalis muscle flap. Chemo- and radiotherapy were indicated as adjuvants to the surgical treatment. Postoperative follow-up found good clinical evolution and secondary epithelization of the temporalis muscle in the palatine area with restoration of functions. Conclusions: A clinical case was presented of ameloblastic carcinoma, a condition with a low frequency of occurrence. Surgery was the basic component of the treatment applied. Once surgical resection was performed, the palatine defect was reconstructed by means of a temporalis muscle flap, a useful option to achieve the restoration of esthetic and biological functions, such as swallowing and speech(AU)

Oncological outcomes in extended time intervals between preoperative chemoradiotherapy with capecitabine and surgery in operable rectal adenocarcinoma / Resultados oncológicos en intervalos extendidos de tiempo entre quimioradioterapia preoperatoria con capecitabina y cirugía en adenocarcinoma rectal operable

Objective: To assess whether extended time intervals (8-12, 13-20 and >20 weeks) between the end of neoadjuvant chemoradiotherapy and surgery affect overall survival, disease-free survival. Materials and methods: Retrospective study in 120 patients with rectal adenocarcinoma without evidence of metastasis (T1-4/N0-2/M0) at the time of diagnosis that underwent surgery with curative intent after neoadjuvant chemoradiotherapy with capecitabine and obtained R0 or R1 resection between January 2010 to December 2014 at the National Cancer Institute of Peru. Dates were evaluated by Kaplan-Meier method, log- rank test and Cox regression analysis. Results: Of the 120 patients, 70 were women (58%). The median age was 63(26-85) years. All received neoadjuvant chemoradiotherapy. No significant difference was found between the association of the median radial (0.6, 0.7 and 0.8 cm; p=0.826) and distal edge (3.0, 3.5 and 4.0 cm; p=0.606) with time interval groups and similarly the mean resected (18.8, 19.1 and 16.0; p=0.239) and infiltrated nodules (1.05, 1.29 and 0.41); p=0.585). The median follow-up time of overall survival and desease free survival was 40 and 37 months, respectively. No significant differences were observed in overall survival (79.0%, 74.6% and 71.1%; p=0.66) and disease-free survival (73.7%, 68.1% and 73.6%; p=0.922) according to the three groups studied at the 3-year of follow-up. Conclusions: We found that widening the time intervals between the end of neoadjuvant chemoradiotherapy and surgery at 24 weeks does not affect the overall survival, disease-free survival and pathological outcomes. It allows to extend the intervals of time for future studies that finally will define the best time interval for the surgery

Objetivo: Evaluar si los intervalos de tiempo extendidos (8-12, 13-20 y >20 semanas) entre el fin de la quimioradioterapia neoadyuvante y la cirugía afectan la sobrevida global, y la sobrevida libre de enfermedad. Material y métodos: Estudio retrospectivo de 120 pacientes con adenocarcinoma rectal sin evidencia de metástasis (T1-4/N0-2/M0) al momento del diagnóstico que se sometieron a cirugía con intención curativa luego de quimioradioterapia neoadyuvante con capecitabina y tuvieron resección R0 o R1 entre enero 2010 y diciembre 2014 en el Instituto Nacioanal de Enfermedades Neoplásicas de Perú. El análisis se hizo con el método de Kaplan-Meier, la prueba log-rank y la regresión de Cox. Resultados: De 120 pacientes, 70 fueron mujeres (58%). La mediana de la edad fue 63 años (26-85 años). Todos recibieron quimioradioterapia neoadyuvante. No hubo diferencia significativa entre la asociación de las medianas de los bordes radial (0,6, 0.7 y 0,8 cm; p=0,826) y distal (3,0, 3,5 y 4,0 cm; p=0,606) con los intervalos de tiempo de los grupos y similarmente con la media de los ganglios resecados (18,8, 19,1 y 16,0; p=0,239) e infiltrados (1,05, 1,29 y 0,41; p=0,585). No se observaron diferencias significativas en sobrevida global (79,0%, 74,6% y 71,1%; p=0,66) y sobrevida libre de enfermedad (73,7%, 68,1% y 73,6%; p=0,922), en los tres grupos estudiados a 3 años de seguimiento. Conclusiones: Encontramos que aumentar los intervalos de tiempo entre el fin de la quimioradioterapia neoadyuvante y la cirugía hasta 24 semanas no afecta la sobrevida global, sobrevida libre de enfermedad ni los desenlaces patológicos. Esto permitiría extender los intervalos de tiempo en estudios futuros para definir el mejor intervalo de tiempo para la cirugía

Osteoradionecrosis of the jaws: case series treated with adjuvant low-level laser therapy and antimicrobial photodynamic therapy

Abstract Background: Osteoradionecrosis of the jaw (ORNJ) is the most severe and complex sequel of head and neck radiotherapy (RT) because of the bone involved, it may cause pain, paresthesia, foul odor, fistulae with suppuration, need for extra oral communication and pathological fracture. We treated twenty lesions of ORNJ using low-level laser therapy (LLLT) and antimicrobial photodynamic therapy (aPDT). The objective of this study was to stimulate the affected area to homeostasis and to promote the healing of the oral mucosa. Methods: We performed aPDT on the exposed bone, while LLLT was performed around the bone exposure (red spectrum) and on the affected jaw (infrared spectrum). Monitoring and clinical intervention occurred weekly or biweekly for 2 years. Results: 100% of the sample presented clinical improvement, and 80% presented complete covering of the bone exposure by intact oral mucosa. Conclusion: LLLT and aPDT showed positive results as an adjuvant therapy to treat ORNJ.

Performance of adjuvant treatment correlates with survival in reoperated glioblastomas / Uso de tratamento adjuvante é relacionado ao aumento da sobrevida em pacientes com glioblastoma submetidos à reoperação

ABSTRACT Objective To analyze cases of recurrent glioblastoma subjected to reoperation at a Brazilian public healthcare service. Methods A total of 39 patients subjected to reoperation for recurrent glioblastoma at the Department of Neurosurgery, São Paulo Hospital, Federal University of São Paulo, from January 2000 to December 2013 were retrospectively analyzed. Results The median overall survival was 20 months (95% confidence interval – CI = 14.9–25.2), and the median survival after reoperation was 9.1 months (95%CI: 2.8–15.4). The performance of adjuvant treatment after the first operation was the single factor associated with overall survival on multivariate analysis (relative risk – RR = 0.3; 95%CI = 0.2–0.7); p = 0.005). Conclusion The length of survival of patients subjected to reoperation for glioblastoma at a Brazilian public healthcare service was similar to the length reported in the literature. Reoperation should be considered as a therapeutic option for selected patients.

RESUMO Objetivo Analisar o papel da reoperação em pacientes com glioblastoma recidivado em um serviço público no Brasil. Métodos Foram analisados retrospectivamente 39 pacientes submetidos à reoperação por recorrência de glioblastoma no Departamento de Neurocirurgia da Universidade Federal de São Paulo, no período de janeiro de 2000 até dezembro de 2013. Resultados A sobrevida global mediana foi de 20 meses (IC 95% = 14.9–25.2), e a sobrevida mediana após a reoperação foi de 9.1 meses (IC 95% = 2.8–15.4). A realização de tratamento adjuvante após a primeira cirurgia foi o único fator associado com a sobrevida global numa análise multivariada (RR = 0.3; IC 95% = 0.2–0.7; p = 0.005). Conclusão A sobrevida dos pacientes submetidos à reoperação em um serviço público no Brasil é semelhante à reportada pela literatura. A reoperação deve ser considerada como uma opção terapêutica em pacientes selecionados.

Mixed adenoneuroendocrine carcinoma of the gastric stump following Billroth II gastrectomy: case report and review of the literature / Adenocarcinoma neuroendócrino misto do coto gástrico após gastrectomia à Billroth II: relato de caso e revisão de literatura

CONTEXT: Gastric stump cancer after gastric resection is a well-known disease. It may be a newly developed cancer after resection due to benign disease, or recurrent or residual disease after oncological surgery. The predominant histological type is usually adenocarcinoma. This study aimed to report on a rare occurrence of a mixed adenoneuroendocrine carcinoma (MANEC) on the gastric stump. CASE REPORT: The case of an 83-year-old female who presented a locally aggressive gastric stump MANEC, 35 years after Billroth II gastrectomy to treat a peptic ulcer, is reported. The patient underwent resection and adjuvant therapy. She has been followed up for one year without signs of recurrence. CONCLUSION: MANEC is a rare type of gastrointestinal neoplasm. The classification, histopathology, clinical features, treatment issues and prognosis are discussed along with a brief review of the literature.

CONTEXTO: O câncer de coto gástrico após gastrectomia é uma condição extensamente documentada. Pode se tratar de doença desenvolvida após a ressecção por doença benigna, ou ainda doença recorrente ou residual após cirurgia oncológica. Geralmente, o tipo histológico predominante é o adenocarcinoma. Este estudo tem como propósito relatar a rara ocorrência de um adenocarcinoma neuroendócrino misto (MANEC) no coto gástrico. RELATO DE CASO: É relatado o caso de uma mulher de 83 anos que apresentou um MANEC localmente agressivo 35 anos após uma gastrectomia à Billroth II devido a úlcera péptica. Foi submetida a ressecção e terapia adjuvante e foi seguida por 12 meses sem sinais de recorrência. CONCLUSÃO: Os MANECs constituem raro tipo de neoplasia gastrointestinal. Sua classificação, histopatologia, aspectos clínicos, tratamento e prognóstico são discutidos junto com uma breve revisão de literatura.

Validation of the Effectiveness and Safety of Temozolomide during and after Radiotherapy for Newly Diagnosed Glioblastomas: 10-year Experience of a Single Institution

This study was performed to validate the effectiveness and safety of concurrent chemoradiotherapy and adjuvant therapy with temozolomide for newly diagnosed glioblastoma multiforme as a standard treatment protocol. Between 2004 and 2011, patients newly diagnosed with glioblastoma who were treated with temozolomide during concurrent chemoradiotherapy and adjuvant chemotherapy were included from a single institution and analyzed retrospectively. The primary endpoint was overall survival, and the secondary endpoints were progression-free survival, response, and safety. A total of 71 patients were enrolled in this study. The response rate was 41% (29/71), and the tumor control rate was 80% (57/71). In the 67 patients who completed the concurrent chemoradiotherapy with temozolomide, the median overall survival was 19 months and the 1- and 2-yr overall survival rates were 78.3% and 41.7%, respectively. The median progression free survival was 9 months, and the 1- and 2-yr progression free survival rates were 33.8% and 14.3%, respectively. The mean duration of survival after progression of disease in salvage treatment group was 11.9 (1.3-53.2) months. Concurrent chemoradiotherapy with temozolomide resulted in grade 3 or 4 hematologic toxic effects in 2.8% of the patients. The current protocol of temozolomide during and after radiation therapy is both effective and safe and is still appropriate as the standard protocol for treatment of glioblastoma. An active salvage treatment might be required for a better prognosis.

Respuesta patológica completa en pacientes sometidos a neoadyuvancia en cáncer de recto / Pathologic complete response in patients with neoadjuvant chemoradiotherapy for rectal cancer

Background: the standard treatment of locally advanced rectal cancer (RC) of the middle and lower third of the rectum is neoadjuvant chemoradiotherapy (XRQT) follow by oncologic resection. After this treatment in 15-25 percent of the cases, the pathologist reports complete pathological response (pCR). Aim: to describe demographic, clinical and survival data of patients with pCR undergoing chemoradiotherapy and radical resection for RC. Material and Methods: historic cohort study. In a prospectively maintained database between 2000 and 2010, we identified patients with RC, who underwent neoadjuvant chemoradiotherapy according to protocol, followed by radical resection. The preoperative staging was obtained by clinical examination, endoscopy, rectal ultrasound, CT scan of chest, abdomen and pelvis and pelvic MRI. Demographic data, tumor location, time between the end of XRTQ and surgery, postoperative staging (according AJCC) and survival, were collected. Results: 119 patients received preoperative XRTQ, 65 percent male, with a mean age of 58 years. The most frequent tumor site was the lower third (63 percent). Surgery was performed 8 weeks after the end of XRTQ. Of 119 patients with XRTQ, 15.1 percent had a pCR. Overall survival was 75 percent, and cancer-specific survival was 80.4 percent at 5 years in patients without pCR. For patients with pCR, the 5 year survival estimates for overall and cancer specific survival was 100 percent. We did not identify factors associated with pCR. Conclusions: in this study, pCR was comparable to other larger series reported elsewhere. No factors associated with pCR were identified.

Introducción: el cáncer de recto (CR) de tercio medio e inferior localmente avanzado se trata con radio-quimioterapia (XRTQ) preoperatoria. Luego XRQT y resección quirúrgica, 15-25 por ciento presentan respuesta patológica completa (RPC) de la lesión. Objetivo: comparar características demográficas, clínicas y sobrevi da de pacientes con RPC y respuesta parcial sometidos XRTQ preoperatoria y resección radical. Materiales y Métodos: estudio cohorte concurrente. En la base de datos de pacientes con CR mantenida prospectivamente, entre 2000-2010, se identificaron pacientes con CR tercio medio e inferior, sometidos XRTQ preoperatoria según protocolo, seguidos de resección radical. Etapificación preoperatoria según: examen clínico, endoscopia, endosonografía rectal, TAC tórax abdomen pelvis y resonancia nuclear magnética de pelvis. Se registraron datos demográficos, localización tumoral, lapso entre término de XRTQ y cirugía, etapificación post operatoria (AJCC), seguimiento y sobrevida. Resultados: 119 pacientes recibieron XRTQ preoperatoria por CR, 65 por ciento hombres. Edad promedio: 58 años. Localización tumoral más frecuente: tercio inferior (63 por ciento). Cirugía se realizó 8 semanas después del término de XRTQ. Etapificación post operatoria: Etapa I 26,1 por ciento, II 34,5 por ciento, III 16,8 por ciento, IV 5 por ciento y RPC 15,1 por ciento. Sobrevida global 75 por ciento, sobrevida específica por cáncer 80,4 por ciento a 5 años. Sobrevida pacientes con RPC fue 100 por ciento a 5 años. No se identificaron factores asociados a RPC. Conclusiones: en este estudio no se logró reconocer factores asociados a RPC. Con las limitaciones que impone el número de pacientes y el seguimiento, se reproducen hallazgos vistos en series más extensas.

Neoadjuvant cheooradiotherapy and surgery compaed with surgery alone in squamoous cell carcinoma of the esophagus / Radioterapia e quimioterapia neoadjuvantes e cirurgia comparado com a cirurgia no tratamento do carcinoma epidermoide do esofago

Context Despite progress in recent years in methods of diagnosis and surgical treatment of esophageal cancer, there is still controversy about the benefits from neoadjuvant chemoradiotherapy. Objective To analise the survival of patients submitted to esophagectomy for squamous cell carcinoma of the esophagus with or without neoadjuvant chemoradiotherapy. Method A retrospective, non-randomized study conducted using the medical charts of patients operated for squamous cell carcinoma of the esophagus at the School of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil between 1979 and 2006. The Kaplan-Meier analysis was used to calculate survival curves and the log-rank test to compare data in each group. The significance level was settled as 5%. Results A total of 123 patients were evaluated in this study, divided into three groups: I - 26 (21.2%) patients submitted to esophagectomy alone; II - 81 (65.8%) patients submitted to neoadjuvant radiotherapy plus esophagectomy and III - 16 (13%) patients submitted to neoadjuvant chemoradiotherapy plus esophagectomy. A statistically significant survival was recorded between the groups (log rank = 6.007; P = 0.05), survival being greatest in the group submitted to neoadjuvant chemoradiotherapy, followed by the group submitted to neoadjuvant radiotherapy compared to the group submitted to esophagectomy alone as the initial treatment of choice. Conclusion Radiotherapy and chemotherapy neoadjuvants in patients with squamous cell carcinoma of the esophagus offers benefits and increases survival. .

Contexto Apesar dos progressos realizados nos últimos anos em métodos de diagnóstico e tratamento cirúrgico do câncer de esôfago, ainda há controvérsias sobre os benefícios reais da quimioradioterapia neoadjuvante. Objetivo Avaliar o tempo de sobrevida em pacientes operados de carcinoma de células escamosas do esôfago com ou sem quimioradioterapia neoadjuvante. Método Estudo retrospectivo, não randomizado, realizado com os prontuários dos pacientes submetidos a esofagectomia por carcinoma de células escamosas do esôfago na Faculdade de Ciências Médicas da Universidade de Campinas (UNICAMP), Campinas, São Paulo, Brasil, entre 1979 e 2006. Na análise estatística, o estimador de Kaplan-Meier foi utilizado para calcular as curvas de sobrevivência e do teste log-rank para comparar a sobrevivência em cada grupo. O nível de significância foi estabelecido em 5%. Resultados O total de 123 pacientes foi avaliado neste estudo, dividido em três grupos: I - 26 (21,2%) pacientes submetidos a esofagectomia, II - 81 (65,8%) pacientes submetidos a radioterapia neoadjuvante seguido de esofagectomia e III - 16 (13%) submetidos a quimioradioterapia neoadjuvante seguido de esofagectomia. Diferença estatisticamente significativa na sobrevida foi registrado entre os grupos (log rank = 6,007, P = 0,05), tendo maior sobrevida o grupo submetido a quimioradioterapia neoadjuvante, seguida pelo grupo submetido a radioterapia neoadjuvante em comparação com o grupo submetido a esofagectomia apenas como o tratamento inicial de escolha. Conclusão A radioterapia e a quimioterapia neoadjuvantes em pacientes com carcinoma de células escamosas do esôfago oferecem benefícios e aumenta a sobrevida. .