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TREATMENT OF NEOPLASTIC DISEASES OF THE SACRUM
GEORGE H. RAQUE, Jr., MD* TODD W. VITAl, MD, AND CHRISTOPHER B. SHIELDS, MD, FRCS (C)
Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
*Correspondence to: George H. Raque, Jr., MD, Department of Neurological Surgery, University of Louisville, 210 E. Gray St., Suite l.102, Louisville, Kentucky 40202. FAX (502) 629-5512.

Sacral neoplasms constitute a wide range of pathological entities including primary and metastatic as well as benign and malignant conditions. Often these lesions are large at the time of initial diagnosis and surgical cure may be difficult. Nonetheless, surgery may be indicated for a wide range of reasons including tissue diagnosis, palliation of pain, preservation of neurological function, or attempts for curative resection. There are numerous surgical approaches to lesions of this area which require a complete understanding of the neural, pelvic, and bony anatomy. For this reason we utilize a multidisciplinary team approach when treating these lesions. This allows for the combination of expertise from areas such as general surgery, orthopedic surgery, and neurosurgery that optimizes the treatment of these patients. In this article we review the basic techniques of diagnosis and treatment of these lesions. This overview includes the relative anatomy, symptoms, diagnosis, imaging, operative indications, surgical approaches, and potential complications.

PHASE II STUDY OF RITUXIMAB IN COMBINATION WITH CHOP CHEMOTHERAPY IN PATIENTS WITH PREVIOUSLY UNTREATED, AGGRESSIVE NON-HODGKIN’S LYMPHOMA
By J.M. Vose, B.K. link, M.l. Grossbard, M. Czuczman, A. Grillo-lopez, P. Gilman, A. lowe, l.A. Kunkel, and R.I. Fisher
From the University of Nebraska Medical Center, Omaha, NE; University of Iowa Hospital and Clinics and General Clinical Research Center, Iowa City, IA; Massachusetts General Hospital, Boston, MA; Roswell Park Cancer Institute, Buffalo, NY; IDEC Phannaceuticals, San Diego, and Genentech Incorporated. South San Francisco. CA; and Loyola University School of Medicine, Maywood, IL.
Address reprint requests to Julie M. Vose, MD. 987680 Nebraska Medical Center, Omaha, NE 68198-7680; email jmvose@unmc.edu.

Purpose: To determine the safety and efficacy of the combination of the chimeric anti-CD20 antibody Rituxan (rituximab, IDEC-C2B8; Genentech Inc, South San Francisco, CA) and cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in patients with aggressive non-Hodgkin’s lymphoma (NHL).

Patients and Methods: Thirty-three patients with previously untreated advanced aggressive B-cell NHL received six infusions of Rituxan (375 mg/m2 per dose) on day 1 of each cycle in combination with six doses of CHOP chemotherapy given on day 3 of edch cycle.

Results: The ORR by investigator assessment confirmed by the sponsor was 94% (31 of 33 patients). Twenty patients experienced a complete response (CR) (610;0), 11 patients had a partial response (PR) (33%), and two patients were classified as having progressive disease. In the 18 patients with an International Prognostic Index (IPI) score 2: 2, the combination of Rituxan plus CHOP achieved an ORR of 89% and CR of 56%. The median duration of response and time to progression had not been reached after a median observation time of 26 months. Twenty-nine of 31 responding patients remained in remission during this follow-up period, including 1 S of 16 patients with an IPI score 2: 2. The most frequent adverse events attributed to Rituxan were fever and chills, primarily during the first infusion. Rituxan did not seem to compromise the ability of patients to tolerate CHOP; all patients completed the entire six courses of the combination. The bcl-2 translocation of blood or bone marrow was positive at baseline in 13 patients; 11 patients had follow-up specimens obtained (eight CR, three PR), and all had a negative bcl-2 status after therapy. Only one patient has reconverted to bcl-2 positivity, and all patients remain inclinical remission.

Conclusion: This is the first report to demonstrate the safety and efficacy of the Rituxan chimeric anti-CD20 antibody in combination with standard-dose CHOP in the treatment of aggressive B-celllymphoma. The clinical responses are at least comparable to those achieved with CHOP alone with no significant added toxicity. The presence or absence of the bcl-2 translocation did not affect the ability of patients to achieve a CR with this regimen. The ability to achieve sustained remissions in patients with an IPI score 2 warrants further investigation with a randomized study.

AUTOLOGOUS TRANSPLANTATION FOR DIFFUSE AGGRESSIVE NON-HODGKIN'S LYMPHOMA IN PATIENTS NEVER ACHIEVING REMISSION: A REPORT FROM THE AUTOLOGOUS BLOOD AND MARROW TRANSPLANT REGISTRY
By Julie M. Vose, Mei-Jie Zhong, Philip A. Rowlings, Hillord M. lazoNs, Brian J. Bolwell, Cesor 0. Freytes, Santiago Pavlovsky, Armand Keating, Burhan Vanes, Koen van Besien, James 0. Armilage, Mary M. Horowilz, and Others of the Autologous Blood and Marrow T ronsplant Registry Lymphoma Working Committee
From the Lymphoma Working Committee of the Autologous Blood and Marrow Transplant Registry, Health Policy Institute, Medical College of Wisconsin, Milwaukee, WI; University of Nebraska Medical Center, Omaha, NE; Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, The cleveland Clinic Foundation, Cleveland, and Miami Valley Hospital, Dayton. OH; University of Texas Health Science Center at San Antonio, San Antonio, TX; Fandaleu Hospital, Buenos Aires, Argentina; Princess Margaret Hospital, Toronto, Ontario, Canada; and University of Illinois, Chicago, IL.
Address reprint requests to Julie M. Vose, MD, Department of Internal Medicine, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198-7680; email: jmvose@unmc.edu.

Purpose: To evaluate the results of high-dose chemotherapy and autologous hematopoietic stem-cell transplantation (autotransplants) in patients with diffuse aggressive non-Hodgkin’s lymphoma (NHL) who never achieve a complete remission with conventional chemotherapy.

Patients and Methods: Detailed records from the Autologous Blood and Marrow Transplant Registry (ABMTR) on 184 patients with diffuse aggressive NHL who never achieved a complete remission with conventional chemotherapy and subsequently received an autotransplant were evaluated. Transplants were performed between 1989 and 1995 and were reported to the ABMTR by 48 centers in North and South America.

Results: seventy-nine (440;0) of 184 patients achieved a complete remission or a complete remission with residual imaging abnormalities of unknown significance after autotransplantation. Thirty-four ( 19%) of 184 hod a partial remission and ss (310;0) of 184 had no response or progressive disease. Eleven patients (6%) were not ossessoble for response because of early death. The probabilities of progression-free and overoll survival at 5 years after transplantation were 31% (95% confidence interval [CI], 24% to 38%) and 37% (95% CI, 30% to 45%), respectively. In multivariate analysis, chemotherapy resistance, Karnofsky performance status score less than 80 at transplantation, age ~ 55 years at transplantation, receiving three or more prior chemotherapy regimens, and not receiving pre- or posttransplant involved-fjeld irradiation therapy were adverse prognostic factors for overall survival.

Conclusion: High-dose chemotherapy and autologous hematopoietic stem-cell transplontotion should be considered for patients with diffuse aggressive NHL who never achieve a complete remission but who are still chemotherapy-sensitive and are otherwise transplant candidates.

MOST INFECTIOUS COMPLICATIONS IN PARENTERALLY FED TRAUMA PATIENTS ARE NOT DUE TO ELEVATED BLOOD GLUCOSE LEVELS
Kenneth A. Kudsk, MD; Anne Laulederkind, RN, BSN; and M. Keith Hanna, MD From the University of Tennessee, MemPhis, Tennessee
Correspondence and reprint requests: Kenneth A. Kudsk, MD, 956 Court Avenue, Suite E228, Memphis, TN 38163. Electronic mail may be sent to kkudsk@Utmem.edu.

Objectives: To determine the relationship between hyperglycemia and infectious complications in nutritional studies of trauma patients. Methods: Retrospective review of serum glucose values in two published randomized, prospective studies of patients receiving either enteral or parenteral feeding (trial 1) or isonitrogenous, isocaloric enteral diets (trial 2). Trial 2 also included patients prospectively followed who received little or no enteral feeding.

Results: Patients randomized to enteral or parenteral feeding in trial 1 exhibited no significant differences in the highest recorded serum glucose (SG) until the fourth or fifth day after protocol entry. SG tended to be higher in infected than noninfected patients in the first 4 hospital days, but SG was far below values considered to increase the risk for infection (SG > 220 mg/dL). In trial 2, glucose levels tended to be slightly higher in infected than in noninfected patients within the first 5 days reaching statistical significance by day 5. Unfed control patients had similar sa values but significantly more major infectious complications.

Results: Five patients had postoperative complications, 2 were treated with a total laryngectomy. The remaining 25 patients kept the normal airway, swallowing, and speech. None of the patients in the neck dissection group had neck metastasis. Two patients had recurrences, 1 with local recurrence was treated with a total laryngectomy and is alive without disease; the other patient had neck recurrence, was treated with radical neck dissection plus radiotherapy, and is dead of the disease. One patient had a second tumor in oropharynx treated with palliative radiotherapy and is dead of the disease. Three years disease-free survival was 75% for T2 and 79% for T3.

Conclusions: Patients developing infections had slightly higher sa levels than noninfected patients early in admission, but these SG values were far below levels considered a risk for infective complications. Significant hyperglycemia does not explain differences in infectious complications in critically ill trauma patients randomized to various routes and types of nutrition.

ENTERAL VERSUS PARENTERAL NUTRITION: A PRAGMATIC STUDY
Nicholas P. Woodcock, FRCS, Dietmar Zeigler, FRCS, M. Diane Palmer, BSc, RGN, Paul Buckley, FRCA, Charles J. Mitchell, FRCP, and John MacFie, MD, FRCS
From the Combined Gastroenterology Unit, Scarborough Hospital, Scarborough, UK
Correspondence to: John MacFie, MD, FRCS, Consultant Surgeon, Scarborough Hospital, Woodlands Drive, Scarborough YOl2 6QL, UK. E-mail: johnmacfie@aol.com

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in tenns of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician’s assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, p < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the ade uacy of gastrointestinal function should be fed by the parenteral route.

ACUTE EFFECTS OF DIFFERENT NUTRITIONAL SUPPLEMENTS ON SYMPTOMS AND FUNCTIONAL CAPACITY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE ^1,2
Marja AP Vermeeren, Emiel F Wouters, Lotte H Nelissen, Annika van Lief, Zandrie Hofman, and Annemie M Schols
¹ From the Departments of Pulmonology and Dietetics. University Hospital Maastricht, Maastricht, Netherlands, and Numico Research, Wageningen, Netherlands.
² Address correspondence to MAP Vermeeren, Department of Pulmonology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, Netherlands. E-mail: mverm@bze5.azm.nl.

Background: Use of nutritional supplements in depleted patients with chronic obstructive pulmonary disease (COPD) requires optimization between positive effects on outcome and potential acute adverse effects on metabolism and exercise performance.
Objective: The aim of this study was to investigate the acute effects of nutritional supplements on metabolism and exercise capacity in stable COPD patients.
Design: In part 1, the effects of 3 different energy loads (placebo, 1046 kJ, and 2092 kJ) with a normal distribution of macronutrients were investigated in 14 COPD patients. In part 2, the effects of a fat-rich compared with a carbohydrate-rich supplement (both 1046 kJ) were studied in 11 COPD patients. The study was performed in a randomized, double-blind, crossover fashion. Metabolic and ventilatory variables were measured postprandially and during a submaximal cycle endurance exercise test.
Results: Overall, no immediate negative effects of the supplements were found in part I. A slight but significant postprandial increase in respiratory quotient was found after the 1046-kJ and 2092-kJ supplements compared with placebo. There was no significant difference in metabolism or exercise capacity after a fat-rich or carbohydrate-rich supplement. Surprisingly, the change in shortness of breath (postprandial compared with preprandial) was significantly g~ater after the fat-rich supplement.
Conclusions: An energy load up to 2092 kJ had no adverse immediate effect in COPD patients compared with placebo. The subjects who consumed the fat-rich supplement experienced more shortness of breath t~an did the sub .ects who con umed the carbohydrate-rich supplement.

LAPAROSCOPY AS THE PRIMARY MODALITY FOR THE TREATMENT OF WOMEN WITH ENDOMETRIAL CARCINOMA
Garnal H. Eltabbakh, MD; Mousa I. Shamonki, MD; Joanne M. Moody, RN; Lynda lee Garafano, RN
Division of Gynecologic Dncology, University of Vermont College of Medicine, Burlington, Vermont.
Address for reprints: Gamal H. Eltabbakh, MD, Divisiori of Gynecologic Oncology, University of VermonVFletcher Allen Health Care, MCHV Campus, Shepardson 330 South, 111 Colchester Avenue, Burlington, vr 05401; Fax: (802) 847-2360; E-mail: gamal.eltabbakh@vtmednet.org

Background: The current study was conducted to assess the feasibility of laparoscopy in the treatment of women with early stage endometrial carcinoma and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy.
Methods: A prospective study was conducted over 2 years in which all women with early stage endometrial carcinoma who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures through laparotomy in the previous 2 years were used as the control group. Both groups were compared with regard to their characteristics, surgical outcome. and cost and were interviewed regarding their quality of life.
Results: Eighty-six of 90 women with endometrial carcinoma underwent LAVH. The procedure was converted to laparotomy in 5 patients (5.8%). Laparoscopic surgery thus was successful in 90% of the women. There were no significant differences noted between those women who underwent LA VH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LA VH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received, less pain medication, had a shorter hospital stay. an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients.
Conclusions: The majority of women with early stage endometrial carcinoma can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher financial cost.

EXTENDED LEFT HEPATECTOMY (LEFT HEPATIC TRISEGMENTECTOMY) IN CHILDHOOD
By Richard D. Glick, Evan P. Nadler, Leslie H. Blumgart, and Michael P. La Quaglia New York, New York
From the Department of Surgery (Pediatric and Hepatobiliary Surgery), Memorial Sloan-Kettering Cancer Center, New York, NY. Address reprint requests to Michael P. La Quaglia, MD, Department of Surgery (Pediatric Surgery), Memorial Sloan-Kettering Cancer Center, 1275 York Ave. New York, NY 10021.

Background/Purpose: Extended left hepatectomy, also referred to as left hepatic trisegmentectomy, in which segments II, 111, IV, V, and VIII are excised, is rarely performed in children. Experience with 7 such resections is reported to describe the anatomy, technique, indications, and outcomes of the operation.
Methods: The medical records of all pediatric patients treated at our institution over the last 15 years who underwent extended left hepatectomy were reviewed. Demographic information as well as operative, pathological, and follow-up data were analyzed.
Results: Seven patients underwent extended left hepatectomy over this period. There were 5 boys and 2 girls ranging in age between 4 months and 9 years with a median age of 3.1 years. Follow-up ranged from 8 months to 5 years with a median of 3.5 years. Diagnoses included hepatoblastoma (HB, n = 3), focal nodular hyperplasia (FNH, n = 1), leiomyosarcoma (LMS, n = 1), hepatocellular carcinoma (HCC, n = 1), and metastatic neuroblastoma (NB, n = 1). All surgical margins were grossly negative. Median operative blood loss was 13 mU kg (range, 5 to 32 mU kg), and mean hospital stay was 9 days (range, 7 to 12 days). No major intra- or postoperative complications were encountered, and there was no perioperative mortality. The 3 HB patients, 1 FNH patient, 1 LMS patient, and 1 NB patient are without evidence of disease, whereas the 1 child with HCC died of recurrent and distant disease. The 6 surviving children have normal hepatic function.
Conclusion: Although technically challenging and rarely performed, extended resection of the left hepatic lobe is feasible in children and can yield curative results with minimal morbidity.

BACTEREMIA, CENTRAL CATHETERS, AND NEONATES: WHEN TO PULL THE LINE
Daniel K. Benjamin, Jr, MD*‡; William Miller, MD, PhD, MPH‡; Harmony Garges, MD*; Daniel K. Benjamin, PhD§; Ross E. McKinney, Jr, MD*; Michael Cotton, MD; Randall G. Fisher, MDII; and Kenneth A. Alexander, MD, PhD*
From the “Department of Pediatrics. Duke University Medical Center, Durham, North Carolina; tDepartment of Epidemiology, Schools of Medicine and Public Heath, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; §Department of Economics, Clemson University, Clemson, South Carolina; and IIChildren’s Hospital of the King’s Daughters, Norfolk, Virginia.
Reprint requests to (D.K.B.) Box 3499 Department of Pediatrics, Duke University Medical Center, Durham, NC 27710.

Objectives: Physicians who treat neonates who become bacteremic while dependent on central venous catheters face a serious and common dilemma. We sought 1) to evaluate the relationship between central venous catheter removal and outcome in bacteremic neonates, 2) to determine species of bacteria that are associated with an increased risk of infectious complications if the central catheter is not removed promptly, and 3) to provide evidence-based recommendations for central catheter management.

Method: A retrospective cohort study of all neonates who had central venous access and developed bacteremia between July 1,1995, and July 31,1999, was conducted in the Duke University neonatal intensive care unit.

Results: The outcome for patients in whom the central catheter was not removed within 24 hours of organism identification was significantly worse (odds ratio = 9.8) than it was for those whose catheters were removed promptly. For patients who were infected with Staphylococcus aureus or with nonenteric Gram-negative rods, delayed removal of the central catheter was associated with complicated bacteremia. Catheter sterilization was attempted in 27 neonates who were infected with enteric Gram-negative rods; only 10 of these infants retained their catheters without infection-related complications. Infants who had 4 consecutive blood cultures that were positive for coagulase-negative staphylococcus (CoNS) were at significantly increased risk for end-organ damage and death, compared with infants who had 3or fewer positive blood culture for CoNS (odds ratio = 29.58).

Conclusions: Bacteremic infants experienced fewer infection-related complications when the central catheter was removed promptly. One positive blood culture for S aureus or a Gram-negative rod warrants central line removal in a neonate. Clinicians who are faced with a neonate who has 1 positive culture for CoNS may attempt medical management without central catheter removal, but documentation of subsequent negative blood cultures is crucial. Once a neonate has 3 positive blood cultures for CoNS, the central catheter should be removed.