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Advisor(s)
Abstract(s)
A disseminação de um tumor abdominal ou pélvico unicamente para a cavidade peritoneal pode ocorrer quer na fase da apresentação primária do tumor quer na sua recorrência e é denominada de Carcinomatose Peritoneal (CP). Esta condição, apesar de não representar uma disseminação sistémica da doença, está associada a um prognóstico e sobrevida sombrios, sendo que sem tratamento condiciona uma sobrevida média de cerca de seis meses.
O tratamento oferecido para a CP sempre foi a quimioterapia sistémica (QS), que poucos benefícios apresenta, no que diz respeito à sobrevida, quando comparada com a ausência de tratamento. Outra terapêutica realizada comummente é a cirurgia paliativa, especialmente quando o doente apresenta obstrução intestinal, de modo a minorar as complicações decorrentes da invasão tumoral.
Hoje em dia com os novos quimioterápicos existentes e introduzidos no tratamento desta condição médica os resultados são ligeiramente melhores do que os relatados no passado, no entanto a resposta obtida com esta abordagem continua a não ser satisfatória, o que tem levado a uma crescente investigação de tratamentos inovadores e mais agressivos.
Desse modo surgiu a Quimioterapia Intraperitoneal Hipertérmica (HIPEC) que através da sua associação com a Cirurgia de Citorredução (CRS) representa um grande avanço no prognóstico e sobrevida dos doentes acometidos por tumores abdomino-pelvicos que evoluíram com o aparecimento de CP.
Com a administração de HIPEC são conseguidas concentrações muito superiores de quimioterápico na superfície peritoneal do que quando o tratamento é administrado de forma sistémica. Esta, administrada diretamente na cavidade peritoneal, visa a destruição de toda a doença microscópica existente.
A eliminação prévia de toda a doença macroscópica, não pode, no entanto, ser descurada, para que o fármaco possa penetrar de forma adequada nas células neoplásicas remanescentes e eliminar totalmente a doença. De facto a resseção completa dos implantes peritoneais através da CRS constitui o principal fator prognóstico destes doentes.
O elevado ceticismo quanto aos benefícios da aplicação destas técnicas desde cedo se prendeu com a alta morbilidade obtida em estudos efetuados no início da aplicação do tratamento. Por essa razão este é um dos principais objetos de estudo dos mais variados centros. No entanto os resultados continuam a não ser totalmente esclarecedores, devido à falta de uniformização de critérios. São originados pelos diversos estudos resultados muito díspares. Sendo, apesar disso, seguro afirmar que as taxas de morbi-mortalidade são ultimamente menos preponderantes do que as obtidas inicialmente. A principal vantagem destas técnicas diz respeito ao aumento da sobrevida em relação à abordagem clássica. Apesar de o benefício variar consoante a histologia do tumor e com diversos parâmetros respeitantes à sua evolução, é claro o quanto a sobrevida dos doentes beneficia com este tratamento.
Materiais e Métodos
Para a realização desta dissertação realizei o levantamento bibliográfico em bases de dados nacionais e internacionais, nomeadamente em bases de dados online como a Pubmed e a B-on. A escolha dos artigos foi feita tendo em conta a sua pertinência, validade e atualidade.
The dissemination of an abdominal or pelvic tumor only to the peritoneal cavity can occur either at the time of presentation or in its recurrence, that is called Peritoneal Carcinomatosis (CP). This condition, even though it doesn’t represent a systemic dissemination of the disease, is associated with a shadowed prognostic and survival, moreover without treatment it conditions a median survival of about six months Historically, and even today in many centers, the treatment offered for CP was systemic chemotherapy (QS), that presented few benefits concerning the overall survival. Another therapy commonly used was palliative surgery, especially when the patient presented bowel obstruction. Nowadays with the emergence of new chemotherapeutics the results are slightly better, however the response obtained with this treatment is still not satisfying leading to growing numbers of investigations about innovating and more aggressive treatments. This was the path that lead to the arising of the Hyperthermic Intraperitoneal Chemotherapy (HIPEC) that when associated with the Cytoreductive Surgery (CRS) represents a major improvement in the outcome and survival of the patients affected by abdomino-pelvic tumors that evolved with the appearance of CP. With the administration of HIPEC, higher concentrations of chemotherapeutic agent can be achieved in the peritoneal surface when compared with the ones obtained when the same agent is given systemically. The HIPEC aim is the destruction of all the microscopic disease. The previous elimination of all the macroscopic disease cannot, however, be neglected, so that the medicine can properly penetrate in the reminiscent neoplastic cells to completely eliminate the disease. In fact the completeness of resection is the main prognostic factor to determine the progression of the disease. There has always been a high skepticism concerning the benefits of this techniques and this is mainly related with the high morbidity obtained in studies made early on. Therefor morbidity is one of the main parameters studied by various centers. Regardless the results are still confusing, due to the lack of criteria standardization. The studies tend to generate very disparate results. Even though, it is safe to allege that the morbi-mortality rates obtained in more recent studies are less preponderant than the ones initially reported. The main advantage of this techniques concerns the increase of the survival rates when compared with the classical approach. Notwithstanding the variation with the different tumor histology’s and the various parameters related with its evolution, it is clear how much the patient’s survival really benefits with this treatment. Materials and Methods In order to accomplish this thesis I’ve made a bibliographic research in national and international databases, namely online databases like Pubmed and B-on. The choice of articles was made taking into account its relevance, validity and topicality.
The dissemination of an abdominal or pelvic tumor only to the peritoneal cavity can occur either at the time of presentation or in its recurrence, that is called Peritoneal Carcinomatosis (CP). This condition, even though it doesn’t represent a systemic dissemination of the disease, is associated with a shadowed prognostic and survival, moreover without treatment it conditions a median survival of about six months Historically, and even today in many centers, the treatment offered for CP was systemic chemotherapy (QS), that presented few benefits concerning the overall survival. Another therapy commonly used was palliative surgery, especially when the patient presented bowel obstruction. Nowadays with the emergence of new chemotherapeutics the results are slightly better, however the response obtained with this treatment is still not satisfying leading to growing numbers of investigations about innovating and more aggressive treatments. This was the path that lead to the arising of the Hyperthermic Intraperitoneal Chemotherapy (HIPEC) that when associated with the Cytoreductive Surgery (CRS) represents a major improvement in the outcome and survival of the patients affected by abdomino-pelvic tumors that evolved with the appearance of CP. With the administration of HIPEC, higher concentrations of chemotherapeutic agent can be achieved in the peritoneal surface when compared with the ones obtained when the same agent is given systemically. The HIPEC aim is the destruction of all the microscopic disease. The previous elimination of all the macroscopic disease cannot, however, be neglected, so that the medicine can properly penetrate in the reminiscent neoplastic cells to completely eliminate the disease. In fact the completeness of resection is the main prognostic factor to determine the progression of the disease. There has always been a high skepticism concerning the benefits of this techniques and this is mainly related with the high morbidity obtained in studies made early on. Therefor morbidity is one of the main parameters studied by various centers. Regardless the results are still confusing, due to the lack of criteria standardization. The studies tend to generate very disparate results. Even though, it is safe to allege that the morbi-mortality rates obtained in more recent studies are less preponderant than the ones initially reported. The main advantage of this techniques concerns the increase of the survival rates when compared with the classical approach. Notwithstanding the variation with the different tumor histology’s and the various parameters related with its evolution, it is clear how much the patient’s survival really benefits with this treatment. Materials and Methods In order to accomplish this thesis I’ve made a bibliographic research in national and international databases, namely online databases like Pubmed and B-on. The choice of articles was made taking into account its relevance, validity and topicality.
Description
Keywords
Carcinomatose Peritoneal Cirurgia de Citorredução Quimioterapia Intraperitoneal Hipertérmica Quimioterapia Sistémica