OBJECTIVE: To evaluate the genetic tests is fundamental for the adequate treatment of non-small cell lung cancer (NSCLC) with tyrosine kinase inhibitors (TKI). Given that access to this evaluation is still limited for those who depend on the Brazilian Public Health System, it seems important to provide regulatory agencies with epidemiological and prognostic information to guide future health policies and guidelines in Brazil. This work aims to characterize EGFR and KRAS mutations in NSCLC and associating them with patients demographic and tumor clinical-pathologic features.
METHODS: From 2004 to 2017, 237 metastatic NSCLC patients treated at Erasto Gäertner Cancer Hospital were included in this study. Electronic medical records were retrospectively reviewed and the mutational status EGFR and KRAS were defined.
RESULTS: We detected EGFR mutation in 20 samples (15.7%), and KRAS mutation in 26 samples (21.5%). The majority of EGFR mutations was detected within the exon 19 (n=9, 45.0%), and for KRAS G12V (n=8, 30.8%) and G12C (n=8, 30.8%) were the hotspots. The median overall survival was 11 months. We did not detect any statistical differences in survival rates between mutated and wild-type tumors neither for EGFR (p=0.898) nor for KRAS (p=0.458). Only two patients had access to TKI and were considered outliers with the best survival rates.
CONCLUSION: We described important information about NSCLC biological behavior in a population treated in a reference public cancer center in South Brazil. Studies like this highlight the magnitude that TKI treatment could have in the overall survival of patients with NSCLC after being introduced into the SUS. Future studies that address the economic impact of this issue are also needed. Here we also make a comparison of our results with other regions of Brazil that have different genetic backgrounds to evaluate the impact of targeted therapies.
Keywords: Lung Neoplasms, Genes, erbB-1, Kirsten murine sarcoma virus, Public Health, Brazil.
In the last decade, important advances have been made in the treatment of metastatic prostate cancer, resulting in a better understanding of the biology underlying the disease, and in the approval of several therapeutic agents such as immunotherapy, new generation antiandrogens, cytotoxic chemotherapies, and radiopharmaceuticals. All these recent advances have been incorporated in clinical guidelines and a critical analysis of the data available should be important to help the decision-making process. In addition, the incorporation of well established therapies in early disease stages have demonstrated a robust overall survival gain for patients with castration-sensitive metastatic prostate cancer. However, no predictive biomarkers of response are available and the selection of the best therapeutic option is still challenging depending on clinical and pathological factors. Many questions related to the optimal sequencing of agents, or comparison of its efficacy remain unanswered.
Keywords: Prostate; Review/drug therapy; Receptors; Androgen; Androgen Antagonists; Advanced Treatment; Prostate-Specific Antigen
Metastatic castration-resistant prostate cancer (mCRPC) is an extremely severe disease that relentlessly evolves to death. Over the past few years, we have seen significant improvements in the different types of treatments available, which have positively impacted several clinical outcomes, including higher survival rates and better quality of life. Since Radium-223 approval by FDA in 2013, nuclear medicine has been incorporated to the therapeutic arsenal. Progress in this field have motivated a pursuit for new targeted therapies using radioactive isotopes. Recent reports addressing the first cases treated with this technique are impressive due to the high response rates obtained in refractory patients. Here we report the case of a patient with mCRPC who had been previously treated with several lines of anti-androgen therapy and cytotoxic chemotherapy, recently treated with PSMA labeled with the alpha-emitting radioisotope Actinium-225 (225Ac).
Keywords: Prostatic Neoplasms; Castration-Resistant; Nuclear Medicine; Alpha Particles
Giant-cell tumor is a relatively rare neoplasia, benign but locally aggressive, that causes significant bone destruction with predilection for epiphyseal and metaphyseal regions of long bones and the spine. Definitive treatment is surgical, with complete tumoral resection followed by autograft, homograft, arthrodesis, unconventional endoprostheses or methylmethacrylate. In most cases, surgery is accompanied by high morbidity and variable recurrence rates, depending on the site, size and type of surgical intervention.Denosumab, a RANKL inhibitor, acts by decreasing tumoral osteoclastic activity and is approved by the Food and Drug Administration for treatment of GCT when surgery is not possible or when it is associated with high morbidity. This report of cases is based on the review of medical records from the Ambulatory Service for Adolescents and Young Adults (AYA), aiming to show the experience of the Service with the use of denosumab for neoadjuvant purposes.
Keywords: Denosumab; RANK Ligand; Giant Cell Tumors.
Applications for 68Ga-PSMA PET-CT continue to expand beyond prostate cancer. The objective of this case report is to illustrate a rare phenomenon known as tumor-totumor metastasis in which precise histological diagnosis is an essential prerequisite for correct clinical management of patients. A 89-year-old man with prostate cancer underwent 68Ga-PSMA PET-CT study for rescreening after increasing prostate specific antigen (PSA), revealing abnormal uptake of the radioindicator in the prostate and bilateral lung nodules. A biopsy was performed on one of the left lung nodules and the results of the pathology examination revealed that the lesion consisted of metastatic prostatic adenocarcinoma within a primary lung adenocarcinoma.
Keywords: 68Ga-PSMA; Tumor-to-tumor metastasis; Prostate cancer; Lung cancer.
We present a case of a 69 year-old, non-obese, post-menopausal woman diagnosed with synchronous endometrial adenocarcinoma and renal cell carcinoma. Immunolocalization and expression of the EGFR, HER-2, HER-3, HER-4 and p53 proteins by immunohistochemistry (IHC) was performed to investigate synchronous expression of these proteins. The endometrial adenocarcinoma was a well-differentiated tumor, with discernable glandular structure with moderate mitotic index. IHC revealed weak HER-2, HER-3 and HER-4 staining of cell membranes in well-differentiated areas, and intense HER-2 and p53 staining in papillary areas. The renal cell carcinoma showed clear cell type, solid tumor, Fuhrman nuclear grade 2, presence of necrosis and hemorrhage. IHC revealed intense HER-2 and HER-4 staining of cell membranes, weak EGFR staining, and negative expression for HER3 and p53 protein. In summary, overexpression of HER-2 and HER-4 may correlate with histological grade of the tumor and patient prognosis.
Keywords: Endometrial carcinoma; Renal clear cell carcinoma; EGFR family; p53
The paclitaxel-cisplatin is a non-infusional alternative for induction chemotherapy (IC) for LASCCHN based on phase-II trials. Here, we describe our institutional experience with this combination in Southern Brazil.
METHODS: Thirty-three consecutive patients with unresectable LASCCHN were selected between April/2012 and June/2014. They received weekly paclitaxel 80mg/m2 on days 1, 8, 15 and cisplatin 75mg/m2 on day 1 for three cycles followed by chemoradiotherapy (CRT) with cisplatin at standard dose. Overall response, toxicity, progression free survival (PFS) and overall survival (OS) were evaluated.
RESULTS: The median follow-up was 25.5 months. Median age was 58.6 years and 96% had PS 1. Most patients presented with bulky disease at stages IVA and IVB (60.6% and 21.2%, respectively). Concerning primary site of tumor, 33.3% were oropharingeal tumors, 27.3% larynx tumors and 33.3% oral cavity tumors. The majority of patients had both smoking and alcohol abuse records. Twenty-eight patients (84.8%) at the time of diagnosis had a BMI <25. Twenty-seven patients (81.8%) completed the planned treatment and three patients (9%) underwent exclusive radiotherapy after IC. All patients were evaluated for response; 75.7% presented complete response and 21.2% presented partial response. Severe toxicity (grades 3-5) for asthenia, neutropenia, anemia and thrombocytopenia were observed in 6.1%, 9.1%, 6.1% and 3% of patients, respectively. One treatment-related death was associated with febrile neutropenia. The 2- and 3-year PFS rates were 63.3% and 68.4%, respectively; 2- and 3-year OS rates were 62.3.5% and 50.6%.
CONCLUSIONS: Our results corroborate previous observations that IC (paclitaxel-cisplatin) is a well-tolerated and highly active regimen for the treatment of patients with LASSHNC, being associated with acceptable toxicity, good locoregional control and survival rates. This may be a good treatment option for patients in developing countries.
Keywords: Head and Neck Cancer; Induction Chemotherapy; Chemoradiation Therapy; Squamous Cell Carcinoma.
The diagnosis of cervical mass is a challenge due to the wide variety of benign and malignant etiologies. Extrapulmonary small cell carcinomas (EPSCC) are rare entities, and those tumours arising as a primary cervical, especially in the thyroid gland, are exceedingly rare. As others small cell neuroendocrine carcinomas, the disease has an aggressive behavior. This case report is about a 40-years-old female patient admitted to the Hospital Felício Rocho, with airway compression caused by a cervical mass originated in the thyroid gland. The data were extracted from the medical records and information provided by the attendants. We describe here the multidisciplinary approach used to treat the patient as well as her outcome. We also review the clinical and molecular aspects of this rare entity.
Keywords: Carcinoma; Neuroendocrine tumors; Thyroid gland; Molecular biology; Diagnosis; Differential.
Cancer is the second leading cause of death in Brazil. This study aimed to review the nutrition role in prevention and post-treatment of cancer as a health promoter. Regarding prevention, when analyzing lifestyle (obesity and physical activity), there was a positive correlation between body mass index and body fat with incidence in several types of cancer; physical activity shown an inverse correlation. Ethanol consumption, frying, red meat and processed meats eaten carefully or even avoided. Differently, the consumption of fruits and vegetables should be stimulated. Bioactive compounds are shown with well elucidated actions, and also as a healthy eating habit. In relation to survivors, the healthy lifestyle is capable of ensuring a better quality of life for this population, as well as preventing them from new diseases. This review highlights the importance of adequate lifestyle and eating habits, stimulates public health policy and more scientific research in this field.
Keywords: Primary prevention; Cancer survivors; Nutritional requirements; Healthy lifestyle.
A 64-year-old female patient with uncompensated fever and secretive cough, an active smoker with a history of tuberculosis treated irregularly, developed non-small cell lung cancer such as squamous cell carcinoma in the pulmonary cavernoma.
Keywords: Carcinoma; Tuberculosis; Cavitation.
INTRODUCTION: Clinical trials (CT) represent an important alternative treatment for oncologic patients. Also, CTs represent an essential step to development of improved therapeutic strategies. However, little is known on Brazilian perception regarding CT. The aim of this survey was to describe the overall perception of CT in Brazilian participants of oncology patient advocacy group.
DESIGN AND SETTING: Cross-sectional survey conducted online through patient advocacy group website.
METHODS: From April 2012 to October 2014, 254 respondents answered an internet-based survey related to knowledge on CT from an independent nonprofit oncology patient advocacy group.
RESULTS: Overall, about 85% of respondents stated they would participate in an oncology trial. Of all respondents, 99.9% believe that CTs can contribute positively to advancement of cancer treatment by increasing the scientific knowledge, improving the treatment, finding a cure, providing a new treatment option, or improving the quality of life. Also, 96% affirmed they have already had some information on CT, being internet the most used form of communication (69%), followed by physicians orientation (8%), magazines and newspaper (8%), and hospital handout material (7%). In addition, only 18 respondents reported previously participation in CTs (6.9%), and approximately 10% answered they knew someone that participated in a CT (e.g. friend or other).
CONCLUSIONS: This survey demonstrated that respondents associate CT as an option in cancer treatment; however, only a small number of respondents have participated in a CT previously. The data indicate the lack of available information as the current major barrier to CT participation in Brazil.
Keywords: Clinical trial; Patient advocacy; Awareness; Physician-Patient relations; Health surveys.
INTRODUCTION: To evaluate the safety and e?cacy of hepatic transarterial embolization (TAE) or transarterial chemoembolization (TACE) in patients with irresectable liver metastases from neuroendocrine tumors (NETs) treated at two Brazilian cancer centers.
METHODS: Retrospective multicenter analysis of patients (pts) with histological diagnosis of neuroendocrine tumor of any origin with unresectable and measurable hepatic metastases who underwent at least one procedure of TAE or TACE.
ENDPOINTS: Hepatic progression free survival (HPFS), overall survival (OS), tumor response and toxicity assessment.
RESULTS: Thirty-six pts were evaluated. Primary tumors were as follow: midgut 20 pts, pancreas 7 pts, others 9 pts. Most of patients had grade (G) 1-2 tumors (93.3%). In patients with functioning NETs, clinically signi?cant symptomatic control was 41.7%. Concerning type of embolization (TAE vs TACE), there were no signi?cant di?erences in the proportion of patients achieving reduction of at least 50% of 5HIAA (45.5% vs 50%) and radiological disease control rate (91.3% vs 92.3%), respectively. In a median follow up of 40.8 months (m), median HPFS was 38.9m, and mean OS was 98m (median not reached). No signi?cant di?erences were found in HPFS or OS by type of embolization procedure. Pancreatic primary tumor and G3 tumor by WHO classi?cation were associated with signi?cantly shorter HPFS. Tumor G3 was also associated with shorter OS. Adverse events of any grade were: abdominal pain (13.8%), fever (5.5%), and 2 pts developed biloma.
CONCLUSION: Our study is the ?rst in our region reporting results of TAE/TACE in patients with irresectable liver metastases from NETs. We observed that pts with pancreatic or G3 NET derive less bene?t from these procedures. In pts with G1-2 NETs, both techniques oer similar results.
Keywords: Therapeutic; Chemoembolization, Therapeutic; Neuroendocrine tumors; Neoplasm metastasis.
OBJECTIVES: Tumor sidedness and RAS/BRAF status have changed the treatment landscape of metastatic colorectal cancer (mCRC). This study was performed to understand the ?rst line choices of Brazilian oncologists for patients with mCRC, especially in the emergent context of tumor sidedness and RAS/BRAFV600E status.
METHODS: This was a cross-sectional electronic survey composed of six questions sent to Brazilian medical oncologists through social media. The survey instrument collected demographic data of participants and assessed current practices in terms of ?rst-line treatment choices for ?t patients with mCRC. Participants with at least 50% of their clinical practice dedicated to patients with GI malignancies were deemed GI specialists.
RESULTS: The survey was completed by 239 medical oncologists from across the country. Most oncologists were male (59%) and were in oncology practice for less than 10 years (62.2%). Only 20.9% of the participants were specialists in GI tumors. For left-sided, wild-type (wt) RAS/wt-BRAFV600E mCRC, most oncologists (82%) chose ?rst line chemotherapy (CT) + anti-EGFR therapy, with 53.6% of them preferring FOLFIRI as the CT backbone. Meanwhile, for right-sided, wt-RAS/wt-BRAFV600E mCRC, the majority (70.7%) would offer CT + bevacizumab (53.9% with FOLFOX). For mutated-RAS mCRC, most oncologists decided for FOLFOX + bevacizumab (51.9%). Subgroup analyses revealed statistically signi?cant differences for therapeutic choices in ?rst line for left-sided wt-RAS/wt-BRAFV600E mCRC: female oncologists prefer FOLFOX as CT backbone (p=0.004) and in right-sided wt-RAS/wt-BRAFV600E mCRC, GI cancer specialists more often use FOLFOXIRI and bevacizumab (18 vs 7.9%; p=0.001).
CONCLUSION: Our survey indicates that tumor sidedness in?uences the choice of both CT backbone and monoclonal antibody in unresectable wt-RAS mCRC. In addition, oncologists' gender and percentage of time dedicated to treat GI cancers also impacted on therapeutic choices for mCRC in Brazil.
Keywords: Colorectal neoplasms; Surveys and questionnaires; Antineoplastic agentes.
INTRODUÇÃO: O tratamento do melanoma avançado foi revolucionado na última década. A adoção de novos tratamentos é necessária para oferecer uma sobrevivência signi?cativamente maior.
Objetivo: Avaliar como os pacientes estão sendo tratados para o melanoma avançado no Sistema Público de Saúde no Brasil.
MÉTODOS: Avaliamos a Autorização do Procedimento de Assistência Ambulatorial (APAC) relacionada a todos os pacientes tratados para o melanoma avançado, entre janeiro de 2015 e dezembro de 2017. Nós agrupamos o tratamento de acordo com a e?cácia relatada, como sendo: inadequada, minimamente e?caz, moderadamente e?caz. Avaliamos tratamentos administrados de acordo com a e?cácia, variedade na primeira linha de tratamentos e duração do tratamento no geral.
RESULTADOS: Foram analisadas 10.843 APACs relacionadas ao tratamento de 4.338 pacientes. Os pacientes eram 57% homens, 43% mulheres, 72% tinham mais de 50 anos de idade. A mediana do número de APACs preenchidos por paciente foi de 2 (variando de 1 a 15). A média dos diferentes tipos de tratamento prescritos para pacientes individuais foi de 1,22 (1 - 5). Identi?camos 19 diferentes protocolos de tratamento usados como primeira linha, dos quais 11 consistiam de drogas simples e 8 combinações de drogas. No período de dois anos, 3.097 (88%) e 281 (8%) pacientes iniciaram o tratamento com um regime minimamente e?caz ou moderadamente e?caz, respectivamente. Apenas 0,4% dos pacientes iniciaram o tratamento com uma terapia e?caz. A duração média de qualquer tratamento foi de seis meses.
CONCLUSÃO: Mais de 98% dos pacientes tratados, entre 2015 e 2017, receberam tratamentos minimamente efetivos para melanoma avançado no Sistema Público de Saúde no Brasil.
Keywords: Melanoma; Terapia de modalidade combinada; Sistemas de saúde; Sistema único de saúde; Metástase neoplásica.
While lung carcinoma is the most common of the malignant tumors, primary lung tumors metastatic to the breast are rare and the prognosis is poor. We report a case of a Brazilian, 65- year-old, black, female patient with no family history of breast or lung cancer. During physical gynecological examination, she presented with a palpable nodule in the outer quadrant of the right breast. Based on X-ray, CT, PET-CT and immunohistochemistry investigation, a diagnosis of primary tumor metastatic lung to breast was made. The patient was referred for setorectomy and bi-lobectomy, combined with chemotherapy. She was in remission from November 2012 until December 2018. Given the poor prognosis related to the disease, the evolution presented is surprising.
Keywords: Non-small-cell lung carcinoma; Neoplasm metastasis; Case report; Metastasis to breast.
NUT carcinoma (midline testicular carcinoma nuclear protein) is a relatively new, rare, aggressive and underdiagnosed entity. Its sites of involvement are medial structures of the head and neck and mediastinum, but other sites may be affected, and even in so-called common structures, the clinical course may impress. The objective of this systematic review was to describe the pathophysiological characteristics of NUT carcinoma and to analyze the types of treatments employed and their efficacy. Throughout the text, treatment - chemotherapy-related forms have been discussed that have led to the complete remission of tumors in some cases, such as the treatment regimen: alternating cycles of vincristine / doxorubicin / ifosfamide and cisplatin / doxorubicin / ifosfamide combined with focal radiotherapy (Scandinavian protocol for inoperable Ewings sarcoma). Other possible future therapies are discussed, in addition to the role of alpha- fetoprotein as a prognostic factor.
Keywords: Carcinoma; Drug Therapy; Medical Oncology.
In 2018, there were some important trials presented over multiple international meetings. The objective of this article is to summarize the most important and practice changing studies in gastrointestinal oncology this year. Some studies in gastroesophageal, pancreatic, colorectal and anal canal have been selected, including adjuvant therapy in pancreatic cancer, immunotherapy in metastatic gastroesophageal cancer, as well as strategies in regorafenib dose escalation and the role of hyperthermic intraperitoneal chemotherapy in metastatic colorectal.
Keywords: Gastrointestinal neoplasms; Stomach neoplasms; Esophageal neoplasms; Pancreatic neoplasms; Colorectal neoplasms; Anal canal.