ANGELITA HABR GAMA
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Gastroenterologia, Faculdade de Medicina - Docente
10 resultados
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Agora exibindo 1 - 10 de 10
- Rectal Cancer and Organ-Preservation: Safety First, Then the King(2023) FERNANDEZ, Laura M.; JULIAO, Guilherme P. Sao; RENEHAN, Andrew G.; BEETS, Geerard L.; PAPOILA, Ana L.; VAILATI, Bruna B.; KRANENBARG, Elma Meershoek-Klein; ROODVOETS, Annet G. H.; FIGUEIREDO, Nuno L.; VELDE, Cornelis J. H. van de; HABR-GAMA, Angelita; PEREZ, Rodrigo O.
- Local Regrowth and the Risk of Distant Metastases Among Patients Undergoing Watch-and-Wait for Rectal Cancer: What Is the Best Control Group? Multicenter Retrospective Study(2024) JULIAO, Guilherme Pagin Sao; FERNANDEZ, Laura M.; VAILATI, Bruna Borba; HABR-GAMA, Angelita; AZEVEDO, Jose M.; SANTIAGO, Ines A.; PARES, Oriol; PARVAIZ, Amjad; VENDRELY, Veronique; RULLIER, Anne; RULLIER, Eric; DENOST, Quentin; PEREZ, Rodrigo OlivaBACKGROUND:A proportion of rectal cancer patients who achieve a clinical complete response may develop local regrowth. Although salvage appears to provide appropriate local control, the risk of distant metastases is less known.OBJECTIVE:To compare the risk of distant metastases between patients who achieve a clinical complete response (watch-and-wait strategy) and subsequent local regrowth and patients managed by surgery after chemoradiation.DESIGN:Retrospective multicenter cohort study.SETTINGS:This study used data of patients from 3 institutions who were treated between 1993 and 2019.PATIENTS:Patients with initial clinical complete response (after neoadjuvant therapy) followed by local regrowth and patients with near-complete pathological response (<= 10%) after straightforward surgery after chemoradiation were included.MAIN OUTCOME MEASURES:Univariate and multivariate analyses were performed to identify risk factors for distant metastases. Kaplan-Meier curves were created (log-rank test) to compare survival outcomes. Analyses were performed using time zero as last day of radiation therapy or as date of salvage resection in the local regrowth group.RESULTS:Twenty-one of 79 patients with local regrowth developed distant metastases, whereas only 10 of 74 after upfront total mesorectal excision following neoadjuvant chemoradiation therapy (p = 0.04). Local regrowth and final pathology (ypT3-4) were the only independent risk factors associated with distant metastases. When using date of salvage resection as time zero, distant metastases-free survival rates were significantly inferior for patients with local regrowth (70% vs 86%; p = 0.01).LIMITATIONS:Small number of patients, many neoadjuvant therapies, and selection bias.CONCLUSIONS:Patients undergoing watch-and-wait strategy who develop local regrowth are at higher risk for development of distant metastases compared to patients with near-complete pathological response managed by upfront surgery after chemoradiation. See Video Abstract
- Conditional Survival in Patients With Rectal Cancer and Complete Clinical Response Managed by Watch and Wait After Chemoradiation Recurrence Risk Over Time(2020) JULIAO, Guilherme P. Sao; KARAGKOUNIS, Georgios; FERNANDEZ, Laura M.; HABR-GAMA, Angelita; VAILATI, Bruna B.; DATTANI, Mit; KALADY, Matthew F.; PEREZ, Rodrigo O.Objective: Analyze conditional recurrence-free survival (cRFS) for rectal cancer patients with complete clinical response (cCR) after neoadjuvant chemoradiation (nCRT) managed nonoperatively after each year without recurrence. Summary Background Data: Select patients with cCR after nCRT have been managed nonoperatively. Risk factors for local recurrence, the need for prolonged follow-up, and the risk of recurrence over time are not well defined. Methods: Retrospective review of patients with rectal cancer cT2-4N0-2M0 treated with nCRT. Mean follow-up was 64 months. Patients who achieved cCR were managed nonoperatively. cRFS was used to investigate the evolution of recurrence-odds, as patients remain recurrence-free after completion of nCRT. Three-year cRFS was estimated at ""x"" years after completion of nCRT based on the formula cRFS(3) = RFS(x+3)/RFS(x). Results: One hundred ninety-seven patients with cCR after nCRT were included. Overall survival and recurrence-free survival (RFS) at 5 years were 81.9% (95% CI 74.0%-87.6%) and 60.4% (95% CI 52.5%-67.4%) respectively. Using cRFS estimates, the probability of remaining disease-free for an additional 3 years if the patient survived without disease at 1, 3, and 5 years, was 77.4% (95% CI 68.8%-83.8%), 91.0% (95% CI 81.9%-95.7%), and 94.3% (95% CI 82.9%-98.2%), respectively. In contrast, actuarial RFS rates for similar intervals were 79.1% (95% CI 72.5%-84.2%), 64.2% (95% CI 56.5%-70.8%), and 60.4% (95% CI 52.5%-67.4%). After 2 years disease-free, 3 year cRFS became similar for T2 and T3 cancers. In contrast, patients undergoing extended nCRT became less likely to develop recurrences only after initial 2 years of successful organ-preservation. Conclusions: Conditional survival suggests that patients have significantly lower risks (<= 10%) of developing recurrences after 2 years of achieving cCR following nCRT.
- A new paradigm for rectal cancer: Organ preservation: Introducing the International Watch & Wait Database (IWWD)(2015) BEETS, G. L.; FIGUEIREDO, N. L.; HABR-GAMA, A.; VELDE, C. J. H. van de
- Salvage Surgery Following Organ Preservation With Local Regrowth After Watch and Wait: Picture Still Unclear Reply(2021) FERNANDEZ, Laura M.; FIGUEIREDO, Nuno L.; HABR-GAMA, Angelita; JULIAO, Guilherme P. Sao; VIEIRA, Pedro; VAILATI, Bruna B.; NASIR, Irfan; PARES, Oriol; SANTIAGO, Ines; CASTILLO-MARTIN, Mireia; CARVALHO, Carlos; PARVAIZ, Amjad; PEREZ, Rodrigo O.
- Salvage Surgery With Organ Preservation for Patients With Local Regrowth After Watch and Wait: Is It Still Possible?(2020) FERNANDEZ, Laura M.; FIGUEIREDO, Nuno L.; HABR-GAMA, Angelita; JULIAO, Guilherme P. Sao; VIEIRA, Pedro; VAILATI, Bruna B.; NASIR, Irfan; PARES, Oriol; SANTIAGO, Ines; CASTILLO-MARTIN, Mireia; CARVALHO, Carlos; PARVAIZ, Amjad; PEREZ, Rodrigo OlivaBACKGROUND: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed nonoperatively. Thirty percent of these patients may develop a local regrowth, and salvage resection with radical surgery is usually recommended. However, selected patients could be offered additional organ preservation by local excision. We hypothesized that patients with baseline T2 who underwent neoadjuvant therapy (for the specific purpose of achieving a complete clinical response) were more likely to harbor recurrent disease at an earlier stage and amenable to organ preservation strategies (local excision) when compared with T3/T4 (undergoing neoadjuvant chemoradiation for oncologic reasons). OBJECTIVE: The purpose of this study was to compare patients with local regrowth requiring salvage resection according to their baseline stage. DESIGN: This was a retrospective review of consecutive patients with nonmetastatic distal rectal cancer undergoing neoadjuvant chemoradiation. SETTINGS: The study included 2 independent tertiary centers with institutional watch-and-wait organ preservation programs. PATIENTS: Consecutive patients with distal rectal cancer (cT2-4N1-2M0) managed by watch and wait and local regrowth from 2 institutions were included. MAIN OUTCOMES MEASURES: Final pathologic features and surgical and oncologic outcomes were compared according to baseline staging. RESULTS: A total of 73 of 257 patients experienced local regrowth. cT2 presented similar to ypT, ypN, R0, and abdominal perineal resection rates (p> 0.05) at the time of salvage when compared with cT3 to cT4. Patients with cT2 at baseline were more likely to undergo an organ preservation procedure for salvage (56.2% vs 26.5%;p= 0.03). Overall and disease-free survival after salvage were similar between groups irrespective of the type of surgery for the regrowth. LIMITATIONS: Retrospective study, small sample size, and possible inaccurate baseline staging. CONCLUSIONS: Although patients with baseline cT2 rectal cancer had similar pathologic stage at the time of recurrence, these patients were more likely to continue an organ preservation pathway after local regrowth through transanal local excision when compared with cT3 to cT4. Despite differences in the use of radical salvage resection, there were no differences in oncologic outcomes.
- cT2N0 Distal Rectal Cancer: Do Not Believe in Fairy Tales(2022) FERNANDEZ, Laura M.; FIGUEIREDO, Nuno; HABR-GAMA, Angelita; JULIAO, Guilherme P. Sao; VIEIRA, Pedro; VAILATI, Bruna B.; NASIR, Irfan; PARES, Oriol; SANTIAGO, Ines; CASTILLO-MARTIN, Mireia; CARVALHO, Carlos; PARVAIZ, Amjad; PEREZ, Rodrigo O.
- The Risk of Distant Metastases in Patients With Clinical Complete Response Managed by Watch and Wait After Neoadjuvant Therapy for Rectal Cancer: The Influence of Local Regrowth in the International Watch and Wait Database(2023) FERNANDEZ, Laura M.; JULIO, Guilherme P. Sao; RENEHAN, Andrew G.; BEETS, Geerard L.; PAPOILA, Ana L.; VAILATI, Bruna B.; BAHADOER, Renu R.; KRANENBARG, Elma Meershoek-Klein; ROODVOETS, Annet G. H.; FIGUEIREDO, Nuno L.; VELDE, Cornelis J. H. Van de; HABR-GAMA, Angelita; PEREZ, Rodrigo O.BACKGROUND: Nearly 30% of patients with rectal cancer develop local regrowth after initial clinical complete response managed by watch and wait. These patients might be at higher risk for distant metastases. OBJECTIVE: This study aimed to investigate risk factors for distant metastases using time-dependent analyses. DESIGN: Data from an international watch and wait database were retrospectively reviewed. Cox regression analysis was used to determine risk factors for worse distant metastases-free survival. Conditional survival modeling was used to investigate the impact of risk factors on the development of distant metastases. SETTING: Retrospective, multicenter database. PATIENTS: A total of 793 patients (47 institutions) with rectal cancer and clinical complete response to neoadjuvant treatment from the International Watch & Wait Database were included. MAIN OUTCOME MEASURES: Distant metastases-free survival. RESULTS: Of the 793 patients managed with watch and wait (median follow-up 55.2 mo), 85 patients (10.7%) had distant metastases. Fifty-one of 85 patients (60%) had local regrowth at any time. Local regrowth was an independent factor associated with worse distant metastases-free survival in the multivariable model. Using conditional estimates, patients with local regrowth without distant metastases for 5 years (from decision to watch and wait) remained at higher risk for development of distant metastases for 1 subsequent year compared to patients without local regrowth (5-year conditional distant metastases-free survival 94.9% vs 98.4%). LIMITATIONS: Lack of information on adjuvant chemotherapy, salvage surgery for local regrowth, and heterogeneity of individual surveillance/follow-up strategies used may have affected results. CONCLUSIONS: In patients with clinical complete response managed by watch and wait, development of local regrowth at any time is a risk factor for distant metastases. The risk of distant metastases remains higher for 5 years after development of local regrowth. See Video Abstract at http://links.lww.com/DCR/C53.
- Organ Preservation Among Patients With Clinically Node-Positive Rectal Cancer: Is It Really More Dangerous?(2019) HABR-GAMA, Angelita; JULIAO, Guilherme Pagin Sao; VAILATI, Bruna Borba; FERNANDEZ, Laura M.; ORTEGA, Cinthia D.; FIGUEIREDO, Nuno; GAMA-RODRIGUES, Joaquim; PEREZ, Rodrigo OlivaBACKGROUND: Select patients with complete clinical response to chemoradiation have been managed without radical surgery. The presence of radiologic evidence of nodal metastases at baseline could be a risk factor for local tumor regrowth, more advanced stage at the time of recurrence, and worse distant metastases-free survival. OBJECTIVE: The purpose of this study was to compare the outcomes of patients with baseline node-positive and node-negative cancer after neoadjuvant chemoradiation and complete clinical response managed nonoperatively. DESIGN: This was a retrospective review of consecutive patients with nonmetastatic distal rectal cancer undergoing neoadjuvant chemoradiation. PATIENTS: Consecutive patients with clinical and radiologic evidence of complete clinical response at 8 to 10 weeks were managed nonoperatively and enrolled in a strict follow-up program (watch and wait). Patients with incomplete clinical response or tumor regrowth after initial complete clinical response were referred to surgery. MAIN OUTCOMES MEASURES: Surgery-free and distant metastases-free survival were compared between patients according to nodal status at baseline. RESULTS: A total of 117 patients with node-positive and 218 with node-negative cancer at baseline were reviewed. Overall, 62 (53.0%; node positive) and 135 (61.9%; node negative) achieved a complete clinical response and were managed nonoperatively (p = 0.13). Patients with baseline node-positive cancer had similar rates of pathologic nodal metastases at the time of recurrence. Five-year surgery-free (39.7% vs 46.8%; p = 0.2) and distant metastases-free survival (77.5% vs 80.5%; p = 0.49) were similar between baseline node-positive and node-negative patients. LIMITATIONS: This was a retrospective study with a small sample size and possible inaccurate nodal staging. CONCLUSIONS: Patients with rectal cancer with node-positive cancer at baseline who develop a complete clinical response after neoadjuvant chemoradiation are not at increased risk for local tumor regrowth or development of more advanced disease at the time of recurrence. These patients seem to be safe candidates for organ-preserving strategies after achieving complete clinical response. See Video Abstract at http://links.lww.com/DCR/A902.
- Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study(2021) FERNANDEZ, Laura M.; JULIAO, Guilherme P. Sao; FIGUEIREDO, Nuno L.; BEETS, Geerard L.; VALK, Maxime J. M. van der; BAHADOER, Renu R.; HILLING, Denise E.; KRANENBARG, Elma Meershoek-Klein; ROODVOETS, Annet G. H.; RENEHAN, Andrew G.; VELDE, Cornelis J. H. van de; HABR-GAMA, Angelita; PEREZ, Rodrigo O.Background Watch and wait is a novel management strategy in patients with rectal cancer who have a clinical complete response after neoadjuvant chemoradiotherapy. Surveillance of these patients is generally intensive, because local regrowth (with the potential for salvage) occurs in 25% of patients, and distant metastases occur in 10% of patients. It is unclear for how long these patients should be followed up. To address this issue, we did conditional survival modelling using the International Watch & Wait Database (IWWD), which is a large-scale registry of patients with a clinical complete response after neoadjuvant chemotherapy who have been managed by a watch-and-wait strategy. Methods We did a retrospective, multicentre registry study using a dataset from the IWWD, which includes data from 47 clinics across 15 countries. We selected patients (aged >= 18 years) with rectal cancer who had a clinical complete response after neoadjuvant chemotherapy, and who were subsequently managed by a watch-and-wait strategy between Nov 25,1991, and Dec 31,2015. Patients who had not achieved a clinical complete response or who had undergone any surgical procedure were excluded. The criteria used for defining a clinical complete response and the specific surveillance strategies were at the discretion of each participating centre. We used conditional survival modelling to estimate the probability of patients remaining free of local regrowth or distant metastasis for an additional 2 years after sustaining a clinical complete response or being distant metastasis-free for 1,3, and 5 years from the date of the decision to commence watch and wait. The primary outcomes were conditional local regrowth-free survival at 3 years, and conditional distant metastasis-free survival at 5 years. Findings We identified 793 patients in the IWWD with clinical complete response who had been managed by a watch-and-wait strategy. Median follow-up was 55.2 months (IQR 36.0-75.6). The probability of remaining free from local regrowth for an additional 2 years if a patient had a sustained clinical complete response for 1 year was 88.1% (95% CI 85.8-90.9), for 3 years was 97.3% (95.2-98.6), and for 5 years was 98.6% (97.6-100.0). The probably of remaining free from distant metastasis for a further 2 years in patients who had a clinical complete response without distant metastasis for 1 year was 93.8% (92.3-95.9), for 3 years was 97.8% (96.6-99.3), and for 5 years was 96.6% (94.0-98.9). Interpretation These results suggest that the intensity of active surveillance in patients with rectal cancer managed by a watch-and-wait approach could be reduced if they achieve and maintain a clinical complete response within the first 3 years of starting this approach.