Cirugia En Tumores Mediastinales

CIRUGIA PARA TUMOR DE MEDIASTINO. DR LOPEZ SACHINAS FRANCISCO MARZO 2008

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],DeVita. Principles and Practice of Oncology, 7th. Ed.

ONCOTIPS ,[object Object],[object Object],[object Object]

Epidemiología ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],RHPNM 2003

MEDIASTINO ,[object Object],[object Object],[object Object],[object Object],[object Object]

ANATOMÍA DEL MEDIASTINO ANGULO DE LOUIS T4 T4 FRASSER

16% Posterior 59% Anterior 29% Medio Chest, 2005.128 ;4: pp 2893-2909

DISTRIBUCION Chest 2005;128:2893-2909 Chest 2003;123: 97-104 Lancet Oncol 2004 ;5: 107-118 De Vita, Cancer Principles and Practice, 2005 Adultos Niños Anterior 54-59 % 43% Medio 20-29 % 18% Posterior 16-26% 40-46%

FRECUENCIA Chest 2005;128:2893-2909 Chest 2003;123: 97-104 Lancet Oncol 2004 ;5: 107-118 De Vita, Cancer Principles and Practice, 2005 Adultos Niños Timo 31 % 28 % Neurogénico 15 % 47 % Linfomas 26 % 9 % Germinales 15 % 9 % Vascular 1 % 6 % Varios 13 % 2 %

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Surg Oncol 2003;83:24-30 Lancet Oncol 2005;5:107-118 Clin Ped Emerg Med 2005;6:156-164 4T

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Surg Oncol 2003;83:24-30 Lancet Oncol 2005;5:107-118 Clin Ped Emerg Med 2005;6:156-164 BLAB

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Surg Oncol 2003;83:24-30 Lancet Oncol 2005;5:107-118 Clin Ped Emerg Med 2005;6:156-164 NOBA

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet Oncol 2004;5:107-118 Ann Thorac Surg 2003;75:1086-1890 A M P

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 44: 229-237, 1987

MASA MEDIASTINAL BIOPSIA , MT, IRM MEDICINA NUCLEAR P E T TRATAMIENTO. Cx Qt Rt INVASIVAS ¿ MEDIASTINOSCOPIA MEDIASTINOSTOMIA VAST TORACOSCOPIA TORACOTOMIA. Localizacion Histologia Abeloff clinical oncology 3er. Ed 2007 cap 76 1.-MG 2.-MG(-), No Gg, no invasión 3.-Gg y SVCS, invasion capsular… Rx tórax AP y Lat 50% TOMOGRAFIA No biopsia Vascular Neumonectomia Sangrado..

Tele Torax Esencial para diagnóstico TC Estandar de oro en la evaluación no invasiva Vascular Vs quisticas. Establece el compartimento involucrado. Define invasión a estructuras adyacentes. Biopsia RMN Post y sup mediastino, pared torácica, diafragma Tumor adyacente a columna y cuerpo vertebral. Define masas intracardiacas Vista coronal y sagital Fibrosis Vs residual... Abeloff clinical oncology 07 3ed.cap 76

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;74:1720-1723

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;74:1720-1723 Lung cancer 2004 45 2 :555-561 Ann Thorac Surg 2006;82:2004-2009

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;74:1720-1723 Ann Thorac Surg 2006;82:2004-2009

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Menos del 2% Lung Cancer 2004;45:s55-s61 Ann Thorac Surg 2002;73:250-252

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Morbilidad 2% Mortalidad <0.5% Chest 2005;128:3784-3789 Ann Vasc Surg 2006;20:731-735

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Morbilidad 0% Conversion: 10% Mortalidad 0.5% Sur Endosc 2004 18:843-846

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;73:250-256 Curr Opin Pulm Med 2001;7:226-233

[object Object],MEDIASTINOSCOPIA CERVICAL EXTENDIDA Ginsberg 1987 Disección entre la arteria innominada y la carótida El endoscopio por delante del arco aórtico

[object Object],Muzzafer et al. 2002 ,[object Object],[object Object],[object Object],Ann Thorac Surg 2002;73:250-256

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lung Cancer2004;45:s55-s61 Ann Thorac Surg 2002;74:1720-1723

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;74:1720-1723

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2006;82:2004-9

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Chest 2000;117:1179.1183 Surg Endosc 2001;15:1167-1170

[object Object],[object Object],[object Object],VATS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Tiempo Dx 20-70min Tiempo Tx 25-180 min Conversion 5 ptes. Chest 117 4 april 2000

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Surg Endosc 2001;15:1167-1170 Surg Clin North Am 2000;80:1511-1533 CHEST june 2000 1787-1792

MEDIASTINOSCOPIA VS TORACOSCOPIA GOSSOT Similar efectividad. Mediastinoscopia menor tiempo hospitalaria MEDIASTINOSCOPIA VS TORACOSCOPIA vs VATS VAST 100% todos los casos. Mayor tiempo. 88% toracoscopia y mediastinoscopia ---24 hr hospitalización. Chest 117 6/june 2000 Chest 1996 110:1328-1331

[object Object],[object Object],[object Object],[object Object],Surg Clin North Am 2000;80:1511-1533

[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2002;74:1720-1723 Surg Clin North Am 2000;80:1511-1533

[object Object],Esternotoracotomia bilateral (Clamshell) J surg Oncol 1992;50:105 Surg Clin North Am 2000;80:1511-1533

[object Object],Toracotomia Ann Thorac Surg 2003;76:1650-4 Surg Clin North Am 2000;80:1511-1533

Clasificación de Masoaka Ann Thorac Surg 2004;77:1860-1869 I Encapsulado. Microscópicamente sin invasión extracapsular II a Macroscópicamente con invasión a tejido graso periférico o pleura mediastinal. II b Invasión microscópica a la capsula. III Invasión macroscópica a órganos vecinos ( pericardio, grandes vasos o pulmón). IVa Diseminación pleural o pericárdica IVb Metástasis linfáticas o hematógenas.

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2004;77:1860-1869

Ann Thorac Surg 2004;77:1860 -9 ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2006;81: 305-308

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2001;72:208-211

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Thorac Cardiovasc Surg 2002;112:1352-60

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2003;76:1041-5 Ann Thorac Surg 2004;77:1860-9

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ann Thorac Surg 2003;76:1041-5

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Chest 2005;27:755-761

[object Object],[object Object],[object Object],Resección extendida esta justificada, ya que la resección completa es el factor pronóstico mas importante Ann Thorac Surg 2004;77:1860-9

[object Object],[object Object],[object Object],Actualmente solo se justificada solo si resección completa (R0) Ann Thorac Surg 2004;77:1860-9 J Thorac Cardiovasc Surg 1996;118:711-6 Pericardio, N. frénico, estructuras vasculares Diafragma, pulmón

[object Object],[object Object],[object Object],[object Object],Chest 2005;27:755-761 J Thorac Cardiovasc Surg 2005;130:1413-21

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Clin Oncol 2002;20:1864-1873

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Curr Surg 2004;61:576-579 J Clin Oncol 2002;20:1864-1873

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Am Coll Surg;203:699-703 Eur J Cardiothorac Surg;2007.

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Am Coll Surg;203:699-703 Eur J Cardiothorac Surg;2007.

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Eur J Cardiothorac Surg 2002;22:712-716

ROBOTIC SURGICAL SYSTEM DA VINCI. . Evalua Torax y Mediastino 3ra dimensión. Movimientos gentiles y finos de disección MEJOR VISUALIZACION CONTROL Y PRESICION. Seguro y eficiente. Control vascular. Mejor comodidad. Solo diagnóstico .. No recomendable en timoma por siembra.¡? Ann Thorac Surg 2003;75, 571-3

ROBOTIC SURGICAL SYSTEM DA VINCI. Ann Thorac Surg 2004, 78 259-66 2001-2003 N=14 ptes. Edad 21-71 a. 9 timectomias 3 neurinomas 1 paratiroidectomia 1 linfangioma.. T qx: 166 minutos 0 morbilidad y mortalidad. Bodner

CIRUGIA CITOREDUCTORA Y QT HIPERTERMICA. Chest 2002; 122:2249-2252 3 PTES. SEG 18 MESES SEAT CDDP Y ADRIAMICINA PENETRANCIA MINIMA MORBILIDAD 47%

Cirugia En Tumores Mediastinales

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