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GANGLIO CENTINELA EN CIRUGIA DIGESTIVA
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¿El estudio de ganglio centinela es útil en el manejo del cáncer digestivo?

¿El estudio de ganglio centinela es útil en el manejo del cáncer digestivo?
Reunion semanal de los residentes de cirugia general del HNERM

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GANGLIO CENTINELA EN CIRUGIA DIGESTIVA Presentation Transcript

  • 1. PAPEL DEL GANGLIO CENTINELA EN CÁNCER DIGESTIVO WALTER ROBLES VALVERDE MR3 CIRUGÍA GENERAL EsSALUD HOSPITAL NACIONAL EDGARDO REBAGLIATI MARTINS DEPARTAMENTO DE CIRUGIA GENERAL Y DIGESTIVA DR IVAN VOJVODIC JEFE
  • 2. INTRODUCCIÓN
    • Sentinel Node (SN)… 1er ganglio linfático que recibe el drenaje de un tumor primario… metástasis inicial.
    • Diseminación linfática: es la ruta de metástasis en mayoría de tumores epiteliales lo que determina la Resección tumoral + linfadenectomía
    • Metástasis nodal:
      • Factor pronóstico.
      • Estadiaje.
      • Indicación de tp adjuvante….
    Historical Review of Lymphatic Mapping in Gastrointestinal Malignancies. Annals of Surgical Oncology. 2004.
  • 3. INTRODUCCIÓN
    • El papel de mapeo del SN está establecido en melanoma y cáncer de mama
    • Papel en tumores GI está en debate.
      • Aplicación clínica del SN en cirugía GI está en relaciòn a cirugìas menos invasivas en casos de SN(-).
    Historical Review of Lymphatic Mapping in Gastrointestinal Malignancies. Annals of Surgical Oncology. 2004.
  • 4. HISTORIA
    • 1950: Weinberg reporta visualización directa de drenaje linfático con el uso de colorantes en cáncer gástrico.
    • 1952: Morl: drenaje linfático axilar
    • 1960: Gould, 1ra descripción del ganglio centinela.
    • 1977: Cabanas usó lymphangiograms en pacientes con ca pene.
    • 1992: Morton, radioactive gold colloid para manejo de estadíos temprano de melanoma
    • Desde entonces se utiliza la biopsia de SN en el manejo de diversos cáncer, con la esperanza de eliminar extensas linfadenectomías innecesarias, que aumentan la morbilidad.
    • Actualmente se acepta el mapeo de SN en el manejo multidisciplinario del cáncer de mama y melanoma cutáneo. .
    Historical Review of Lymphatic Mapping in Gastrointestinal Malignancies. Annals of Surgical Oncology. 2004.
  • 5. ESTÓMAGO
    • Ventaja: disección linfática limitada y la preservación de nervios autonómicos mejoraría resultados funcional post qx ca gástrico.
    • Obstáculo: extensa red linfática del estómago, pueden obviarse metástasis que pasan a la 2da estación (17% casos)
    Solitary lymph node metastasis in gastric cancer. Li C. J Gastrointest Surg 2008;12:550–4
  • 6. ESTÓMAGO: TÉCNICA
    • Marcadores:
      • Colorantes: patent blue
      • Radioactivos .
    • Técnicas de administración:
      • Inyección endoscópica preop de colorante o marcador radioactivo, seguido de mapeo intraoperatorio.
      • Inyección endoscópica intraoperatoria.
      • Inyección subserosa de colorante intraoperatoriamente.
    The accuracy of sentinel node mapping according to T stage in patients with gastric cancer) Rabin. Gastric cancer 2010.
  • 7. ESTÓMAGO: TÉCNICA Sentinel node navigation in early Stage gaStric cancer – updated data and current status Kitagawa. Scandinavian Journal of Surgery 95: 256–259, 2006
  • 8.
    • Background: The clinical impact of sentinel lymph node biopsy (SLNB) in gastric cancer is controversial. We performed a prospective trial to compare different methods: radiocolloid method (RM), dye method (DM), and both methods simultaneously (dual method, or DUM) for reliability and therapeutic consequences.
    • Methods: RM and DM were applied in 35 gastric cancer patients. After endoscopic peritumoral injection of 99m Tc-colloid and Patent Blue V, the positions of all blue sentinel lymph nodes (SLNs) were recorded, and the SLNs microscopically examined by hematoxylin and eosin, step sections, and immunohistochemistry.
    • Results: RM, DM, and DUM identified the SLNs in 34 (97%) of 35 patients. The sensitivity for the prediction of positive lymph node status for RM was 22 (92%) of 24, for DM 16 (66%) of 24, and for DUM 22 (92%) of 24. In 7 of 17 (RM), 5 of 15 (DM), and 7 of 17 (DUM) patients classified as N0 by routine hematoxylin and eosin staining, micrometastases or isolated tumor cells were found in the SLN (upstaging) after focused examination. If only a limited lymph node dissection of the SLN basins would have been performed in patients, residual lymph node metastases were left in 9 of 24 (RM), in 7 of 34 (DM), and in 5 of 24 (DUM) of patients with node-positive disease.
    • Conclusions: Use of RM was superior. DUM did not further increase the sensitivity. A limited lymph node dissection—i.e., lymphatic basin in patients with SLN-positive disease—is associated with a high risk of residual metastases. Patients with negative SLNs may be selected for a limited surgical procedure if they meet certain criteria.
    ESTÓMAGO: TÉCNICA Efficacy of Different Technical Procedures for Sentinel Lymph Node Biopsy in Gastric Cancer Staging. Annals of surgical oncology Vol 14, num 7. 2004. 2028-2035
    • Conclusions: Use of RM was superior. DUM did not further increase the sensitivity. A limited lymph node dissection—i.e., lymphatic basin in patients with SLN-positive disease—is associated with a high risk of residual metastases. Patients with negative SLNs may be selected for a limited surgical procedure if they meet certain criteria.
  • 9. ESTOMAGO
    • En Japón: manejo standard para T1N0-stage en ca gástrico: gastrectomía + linfadenectomía (riesgo de micrometástasis).
    • Sin embargo, la biopsia SN puede cambiar el manejo de estos pacientes.
    • Datos actuales: micrometásis son más limitadas dentro del contexto del SN en pacientes con T1N0.
    • SN (+) son un buen objetivo para linfadenectomía selectiva en pacientes con ca gástrico T1N0
    • Uso de la laparoscopía
    Sentinel node navigation in early Stage gaStric cancer – updated data and current status Kitagawa. Scandinavian Journal of Surgery 95: 256–259, 2006
  • 10. ESTÓMAGO: T1 N0 M0 Sentinel node navigation in early Stage gaStric cancer – updated data and current status Kitagawa. Scandinavian Journal of Surgery 95: 256–259, 2006
  • 11. ESTÓMAGO: T1 N0 M0 Sentinel node navigation in early Stage gaStric cancer – updated data and current status Kitagawa. Scandinavian Journal of Surgery 95: 256–259, 2006 La ausencia de Ganglio Centinela permite una cirugìa menos radical
  • 12.
    • Treatment strategy for early gastric cancer.
    • J.Wang. Surgical Oncology (2011)
    ESTÓMAGO: T1 N0 M0 Nótese las 7 posibilidades de tratamiento quirúrgico planteadas para el Early Cancer. NO MAS D2 STANDAR T1 < 4cm. Tasa de detección: 95% Tasa de Falsos Neg. 4%
  • 13. ESTÓMAGO: T1Y T2 N0 M0 Sentinel lymph node biopsy in gastric cancer: Possible applications and limits the journal of cancer surgery. Cozzaglio. Oct 2010
  • 14. ESTÓMAGO The Accuracy of Sentinel Node mapping according to T stage in patients with gastric cancer Igor Rabin. Gastric Cancer. 2010. 76%
  • 15. ESTÓMAGO The Accuracy of Sentinel Node mapping according to T stage in patients with gastric cancer Igor Rabin. Gastric Cancer. 2010.
  • 16. ESTÓMAGO The Accuracy of Sentinel Node mapping according to T stage in patients with gastric cancer Igor Rabin. Gastric Cancer. 2010. A MAYOR T MAYOR NUMERO DE FALSOS NEGATIVOS (DISMINUYE LA SENSIBILIDAD) SU UTILIDAD ES MAYOR EN LOS T1
  • 17. GANGLIO CENTINELA EN CANCER GASTRICO CONCLUSION
    • Podria ser de utilidad en tumores en estadios tempranos (t1) y con un tamaño menor a 40 mm.
    • No es útil en estadios avanzados (t3 y t4)
  • 18. COLORECTAL
    • 1er reporte de SLNM en cáncer colorectal: 1997 at the Society of Surgical Oncology's 50th Annual Cancer Symposium in Chicago.
      • Viabilidad técnica: 98%, exactitud 95%.
    • Joosten et al. 1999…. Vaibilidad 70%, Falsos negativos: 60%.
      • Diferencia en técnica de inyección y tiempo de examen patológico..
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 19. COLORECTAL
    • Utilidad: upstage de aquellos tumores cuyas metástasis no pueden ser detectadas por métodos convencionales… Estadiaje es dependiente de ganglios resecados.
    • Nuevas técnicas patológicas…. Identifican micrometástasis…. Costoso e impractico ultraestadiar todos los ganglios de un especimen..
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 20. COLORECTAL
    • Fácil identificación de SN en ca colon (simple distribución)…
      • Inesperada distribución paracólica distante al tumor 1ro puede alterar la extensión de la resección.
      • Drenaje linfático aberrante más allá de los márgenes de resección. (8%)
    • En ca rectal, scintigrafía preoperatorio.
      • 10% de ca rectal bajo muestan SN en áreas laterales…. ETM es procedimiento qx stardard… existe riesgo de distribución aberrante del SN más allá de la extensión del ETM. .
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 21. COLORECTAL
    • Abstract
    • Background :By systematically reviewing the literature on sentinel lymph node mapping of colon cancers, this study aimed to evaluate this technique as it applies to colon cancers.
    • Methods Human studies on lymphatic mapping for colon cancers were reviewed. Multiple publications of the same studies, abstracts, and case reports were excluded. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated.
    • Results: Lymphatic mapping appears to be readily applicable to colon cancers, identifying lymph nodes most likely to harbor metastases. Identification of sentinel lymph nodes varied from 58% to 100% and carried a false-negative rate of approximately 10% in larger studies, but potentially rose 4% to 25% among patients representing a range from node-negative to node-positive (micrometastases) conditions. The prognostic implication of these micrometastases requires further evaluation. Lymphatic mapping in 6% to 29% of cases identified aberrant lymphatic drainage that altered the extent of the lymphadenectomy.
    • Conclusions Further follow-up evaluation to assess the prognostic significance of micrometastases for colon cancers is required before the staging benefits of sentinel node mapping can have therapeutic implications. Lymphatic mapping offers the possibility of improving staging by identifying patients with early disseminated disease who should be considered for adjuvant treatment or included in trials of adjuvant treatment to speed up the breakthrough of more effective adjuvant regimens. Large studies are needed to determine whether the sentinel node concept is as valid for colon cancers as studies so far have shown it is for malignant melanoma and breast cancer.
    Sentinel lymph node mapping in colon cancer Surgical endoscopy 2004
  • 22. COLON Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004
  • 23. COLON Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004 The investigators found a higher 5-year survival rate among patients with RT-PCR–negative nodes, as compared with those who had at least one RT-PCR– positive node (91% vs 50%; p = 0.02).
  • 24. COLON Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004
  • 25. COLON
    • Incidencia de skip metastases (false-negative SLN) reportados en los mapeos de SLN: 0–60%.... Utilidad de técnicas moleculares
    • Falsos negativos:
      • Disrupción quirúrgica del drenaje linfático
      • Inadecuada inyección de colorante.
      • Mayor cantidad son por obstrucción de las vías de drenaje linfático normales.
    Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004
  • 26. COLON: SLN mapping techniques Intraoperative lymphatic mapping (in vivo) Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004
  • 27. COLON: Intraoperative lymphatic mapping during laparoscopic resection Technique and clinical consequences of sentinel lymph node biopsy in colorectal cancer Surgical Oncology (2007) 16, S129–S132
  • 28. COLON: SLN mapping techniques Intraoperative lymphatic mapping (ex vivo) Sentinel lymph node mapping in colon cancer. Surgical endoscopy 2004
  • 29. COLON Sentinel lymph node biopsy in colorectal cancer. Surgical oncology 2008
  • 30. COLON Sentinel lymph node biopsy in colorectal cancer. Surgical oncology 2008
  • 31. COLON Sentinel lymph node biopsy in colorectal cancer. Surgical oncology 2008
  • 32. COLON Sentinel lymph node biopsy in colorectal cancer. Surgical oncology 2008
  • 33. ESÓFAGO
    • Considereciones específicas en el mapeo de SN en ca esófago.
      • Imposibilidad de métodos con colorantes.
      • SN múltilples y distribuidos ampliamente.
      • Uso de linfocintigrafía.
      • Uso de quimioradioterapia en cT1N0 esophageal cancer..
      • 3 campos ganglionares
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 34. ESOFAGO
    • SI SN mediastinal (-) y no hot spot en área cervical en la cintigrafía pre operatoria… disección ganglionar cervical no es necesaria.
    • SN (-) y no hot spot en área medistinal, no se necesita disección ganglionar extensa..
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 35. HÍGADO
    • HCC metástasis ganglionar es rara y un evento tardío…
    • Poco probable que SN ayude en HCC.
    • En colangiocarcinoma intrahepático, metástasis ganglionar tiene significado pronóstico… no hay estudios de mapeo de SN
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 36. PÁNCREAS
    • Ohta et al, demostró que usando colorante en cáncer de cabeza de páncreas, el grupo más afectado era el del área duodenopancreática posterior… y su patología era predictor de ganglios para aórticos.
    • Propusieron disección paraaórtica selectiva basados en esta información.
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 37. PÁNCREAS The pronostic value of micrometastases in pancreatic cancer Surgical Oncology (2008)
  • 38. PÁNCREAS The pronostic value of micrometastases in pancreatic cancer Surgical Oncology (2008)
  • 39. CONCLUSIÓN
    • SN navigational surgery tiene gran potencial de alterar manejo de cánceres tempranos .
    • Se requieren establecer procedimientos standard y evidencia futura en base a estudios multicéntricos prospectivos
    • Para ser considerado procedimiento mínimamente invasivo, SN navigational surgery debe ser combinado con cirugía endoscópica (laparoscopic or thoracoscopic) .
    • Aplicación clínica inicial ha sido el manejo del cáncer gástrico T1N0
    • Para evitar disección ganglionares innecesarias para los casos de SN (-) se requieren pruebas intraop rápida y sensibles para detectar micrometástasis …. Linfadenectomía selectiva.
    Current Status and future prospects of sentinel node navigation surgery for gastrointestinals cancers. Kitagawa. Annals of Surgical Oncology 2004.
  • 40.