Apresentação unirio
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apresentação de tratamento multidisciplinar em oncologia
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Apresentação unirio
- 1. Tumores de Cabeça e Pescoço Visão Multidisciplinar Dr. Leonardo G. Rangel Cirurgião de Cabeça e Pescoço -HUPE-UERJ Doutorando em Cirurgia Coordenador de Residência ORL-CCP UERJ Chefe do Ambulatório de CCP UERJ - HUPE
- 3. "Experiência não é Igual a Competência"
- 12. O Problema
- 13. Diagnóstico de Câncer Comorbidades Prévias Angústias Dor Procedimentos Tratamentos Morte O Problema
- 15. “O bom médico trata a doença, o grande médico trata o paciente que tem a doença” Sir William Osler 1849-1919
- 17. Fatores do Paciente Idade Comorbidades Alterações Neurológicas Alterações Visuais Alterações Auditivas Estado Nutricional prévio Álcool, Tabagismo, Drogas Aceitação e Cooperação Independência
- 18. Fatores Tumorais Biologia Tumoral Sítio Tumoral Estadiamento Características Histopatológicas
- 24. Fatores Tumorais características Histopatológicas epithelial membrane antigen and are negative for muscle- specific actin and vimentin. They may or may not express cribriform growth patterns reminiscent of adenoid cystic carcinoma [250]. Basal cell adenocarcinomas show areas Fig. 3.11: Adenoid cystic carcinoma. a Cribriform growth pattern. Cells with dense angular nuclei and scant clear cytoplasm sur- round spaces producing a classic Swiss cheese pattern (H&E, 200×). b Perineural invasion (H&E, 200×) 61Pathology of Salivary Gland Disease Chapter 3
- 27. Biologia Tumoral Fatores Tumorais Fator de Necrose Tumoral - alfa Interleucina - 6 Interleucina - 1 Interferon - gama prod pelo tumor ou hospedeiro
- 28. Fatores Tumorais Biologia Tumoral • Angiogênise • Disseminação Linfática • Radioresistência • Quimioresistência • elevação da TMB antes ⬇peso • perda Massa Magra ≈ % gordura
- 30. Caquexia associada a 20% das mortes Caquexia ≠ Inanição não reverte com Calorias extras Anorexia 15-40% Apetite e Habilidade em comer principais fatores de Qualidade de Vida Disfagia≈Desnutrição≈Caquexia
- 31. Fatores Tumorais Estadiamento / Lesões Benignas
- 33. should be clearly identified, ligated, and divided to com- plete the isolation of the internal jugular vein. Other smaller branches can be cauterized, by means of bipolar cautery. The dissection of the carotid sheath has 2 danger points, one at each end—upper and lower—of the dissection. At these 2 points the traction exerted to facilitate the dissection of the fascial envelope produces a folding of the wall of the internal jugular vein that can be easily sectioned at the touch of the scalpel blade. The surgeon must be extremely cau- tious to avoid injuring the vein at these points. Lower in the neck, the terminal portion of the thoracic duct on the left side, and the right lymphatic duct—when present—also are within the boundaries of the dissection and must be preserved. Once the internal jugular vein is released from its covering fascia, the dissection continues medially over the carotid artery. The specimen is now com- pletely separated from the great vessels and remains at- tached only to the strap muscles Dissection of the strap muscles Although this is described as the last step of the operation (Figure 10), it may be performed in a different order according to the needs of the surgery and the location of the primary tumor. The midline constitutes the medial border of the dissection for unilateral opera- tions. Thus, a midline cut is made in the superficial layer is identified, ligated, and divided at both ends of the surgical field. The fascia is now dissected from the un- derlying strap muscles. The dissection starts at the upper part of the surgical field and continues in a lateral and inferior direction. The sternohyoid and omohyoid mus- cles are completely freed from their fascial covering. The superior thyroid artery can be identified coursing in an inferomedial direction toward the thyroid gland. Depending on the resection of the primary tumor, the Figure 10 The strap muscles are released from their fascial covering. (1) Strap muscles, (2) thyroid cartilage, (3) thyroid gland, (4) fascia of the strap muscles, (5) stylohyoid muscle, (6) digastric muscle, (7) anterior facial vein, and (8) submandibular gland optionally preserved. the neck. (1) Carotid artery, (2) internal jugular vein (3) hyoid bone, (4) suprasternal notch, and (5) thyroid gland Figure 12 The neck after a right functional neck dissection for supraglottic cancer of the larynx. (1) Internal jugular vein, (2) carotid artery, (3) sternocleidomastoid muscle, (4) submandibular F@lJRE 1. Transection of the strap muscles: Along the superior border of the thyroid cartilage, the stemohyoid, omohyoid and tlqrohyoid muscles are cut. The sternothyroid muscle is also transected. This is performed bilaterally. FIGURE 3. Disarticulation of the cricothyroid joint: A Freer ele- vator is placed carefully between the inferior thyroid comu and the cricoid cartilage so that the recurrent laryngeal nerve is not damaged. The nerve is not identified during the dissection. FIGURE 2. Transection of the constrictor muscles: The inferior pharyngeal constrictor muscles and the thyroid perichondrium are transected with a No. 15 blade along the posterolateral and superolateral borders of the thyroid cartilage. brane, and the periosteum of the inferior hyoid bone is incised. A Freer elevator is then used to dissect the preepi- glottic space from the inferior and posterior aspect of the hyoid bone. The larynx is now entered through a small transvallecular pharyngotomy, just wide enough to visu- alize the epiglottis. It is grasped with an Allis clamp and pulled externally. The surgeon now moves to the head of the bed, and further tumor cuts can be made under direct visualization (Fig 5). Using scissors, incisions are made so that the entire preepiglottic space is resected, but the cuts are made medial to the main trunk of the internal branch of the superior laryngeal nerve. Further tumor cuts are now made on the non-tumor bearing side. The scissors are advanced anterior to the previously released pyriform sinus. Precise cuts are made through the aryepiglottic fold and down to the level of the false cord. The false cord is transected just anterior to the arytenoids; the vocal process and true cords are transected just posterior to the ventricle. It is essential that the aryte- noid cartilage be preserved on the non-tumor bearing side of the larynx. In addition, it is important not to enter the cricoarytenoid joint inadvertently so that postoperative ankylosis may be avoided. Incisions are now made con- necting these prearytenoid cuts to the cricothyroidotomy. The cricothyroid and lateral cricoarytenoid muscles are transected along the superior border of the cricoid carti- lage. Complete visualization of the tumor bearing side is necessary. The surgeon takes both thyroid ala in her/his hands and cracks the cartilage down the middle. It is akin to opening a book. The resection along the tumor bearing DUANE SEWELL 29 Fatores do Tratamento Cirurgia
- 36. Cirurgia RXT QT Melhores Resultados Nutrição Pré-operatória ptns de fase Aguda Elevação de Hb≈RXT Radicais Livre de O2 Prevenção de Dist Eletrolítico Proteção Renal
- 37. "Good judgement comes from experience; and experience comes from bad judgement!" Ashok Shara