{"id":4241,"date":"2015-06-03T10:00:59","date_gmt":"2015-06-03T10:00:59","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/tratamento-de-tumor-neuroendocrino-gastrico\/"},"modified":"2022-06-10T11:55:33","modified_gmt":"2022-06-10T11:55:33","slug":"tratamento-de-tumor-neuroendocrino-gastrico","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/tratamento-de-tumor-neuroendocrino-gastrico\/","title":{"rendered":"Tratamento de tumor neuroend\u00f3crino g\u00e1strico"},"content":{"rendered":"<p><strong>INTRODU\u00c7\u00c3O<\/strong><\/p>\n<ul>\n<li>Os tumores neuroend\u00f3crinos s\u00e3o formados por hiperplasia das c\u00e9lulas enterocromoafins, respons\u00e1veis pela produ\u00e7\u00e3o de serotonina<\/li>\n<li>As c\u00e9lulas enterocromafins que situam-se na l\u00e2mina pr\u00f3pria (entre epit\u00e9lio e a muscular da mucosa)<\/li>\n<li>S\u00e3o classificadas como les\u00f5es de padr\u00e3o subepitelial e n\u00e3o submucoso<\/li>\n<li>Os padr\u00f5es histol\u00f3gicos s\u00e3o variados e confirmam-se pela imunohistoqu\u00edmica (positividade para marcadores como cromogranina A)<\/li>\n<li>Incid\u00eancia vem aumentando, talvez pelo maior disponibilidade de acesso a endoscopia e aos exames de imunohistoqu\u00edmica<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>CLASSIFICA\u00c7\u00c3O CL\u00cdNICA<\/strong><\/p>\n<p>Tipo 1: mais comum (70%)<\/p>\n<ul>\n<li>ocorre num contexto de gastrite atr\u00f3fica<\/li>\n<li>associado a hipergastrinemia<\/li>\n<li>geralmente m\u00faltiplos<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Tipo 2:&nbsp; s\u00e3o raros (5%)<\/p>\n<ul>\n<li>geralmente menores que 1,5 cm, multifocais no corpo<\/li>\n<li>Associado a s\u00edndrome neuroend\u00f3crina m\u00faltipla (NEM tipo 1) e s\u00edndrome de Zollinger Ellison<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Tipo 3:&nbsp; segundo mais comum (25%)<\/p>\n<ul>\n<li>espor\u00e1dico&nbsp; e&nbsp; isolado<\/li>\n<li>sem associa\u00e7\u00e3o com gastrite atr\u00f3fica e sem hipergastrinemia<\/li>\n<li>ocorrem em qualquer local do est\u00f4mago<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>O principal marcador para o diagn\u00f3stico dos tumores do tipo 1 \u00e9 o aumento da gastrina s\u00e9rica usualmente maior que 500 em pacientes que n\u00e3o est\u00e3o usando inibidores de bomba de pr\u00f3tons. (2)<\/p>\n<p>&nbsp;<\/p>\n<p><strong>CLASSIFICA\u00c7\u00c3O HISTOL\u00d3GICA<\/strong><\/p>\n<p>A &nbsp;classifica\u00e7\u00e3o histol\u00f3gica da OMS (2010) dos TNE g\u00e1stricos \u00e9 feita atrav\u00e9s:<\/p>\n<p>Contagem mit\u00f3tica em campos de grande aumento (10 cga) &nbsp; e &nbsp;\u00edndice de Ki67, sendo assim divididos em:<\/p>\n<ul>\n<li>Grau I &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;(G1 &#8211; bem diferenciado, cerca de 90%): &nbsp; &nbsp; &nbsp;Ki67 \u2264 2% &nbsp; &nbsp; &nbsp; e &nbsp; &nbsp; &lt; 2 mitoses\/10 cga<\/li>\n<\/ul>\n<ul>\n<li>Grau II &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(G2 &#8211; bem diferenciado): &nbsp; &nbsp; &nbsp; &nbsp; Ki67 de 3 a 20% &nbsp; &nbsp; &nbsp; &nbsp; e &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;2 a 20 mitoses\/10 cga<\/li>\n<\/ul>\n<ul>\n<li>Grau III &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(G3 &#8211; pouco diferenciado): &nbsp; &nbsp; &nbsp; &nbsp;Ki67 &gt; 20% &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;e &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &gt; 20&nbsp;&nbsp; mitoses\/10 cga<\/li>\n<\/ul>\n<p>O progn\u00f3stico deste tumores depende da jun\u00e7\u00e3o da classifica\u00e7\u00e3o cl\u00ednica com a histol\u00f3gica, sendo que cerca de 80% dos tumores do tipo 1 apresentam grau histol\u00f3gico&nbsp;I &nbsp;e &nbsp;cerca de 90% dos tumores do tipo 3 apresentam grau histol\u00f3gico II ou III. (2).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>DIAGN\u00d3STICO<\/strong><\/p>\n<ul>\n<li>Bi\u00f3psia do p\u00f3lipo para an\u00e1lise histol\u00f3gico e imunohistoqu\u00edmica<\/li>\n<li>Bi\u00f3psia do corpo g\u00e1strico para verificar a presen\u00e7a de atrofia<\/li>\n<li>Dosagem de gastrina s\u00e9rica<\/li>\n<li>Pesquisa de autoanticorpos para gastrite autoimune (anti-c\u00e9lula parietal e anti-fator intr\u00ednseco)<\/li>\n<li>Ecoendoscopia nas les\u00f5es com suspeita de invas\u00e3o da muscular pr\u00f3pria (&gt;10mm) para avaliar a possibilidade de ressec\u00e7\u00e3o endosc\u00f3pica<\/li>\n<\/ul>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/bi\u00f3psia-de-polipo1.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\" wp-image-1499 alignnone\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/biC3B3psia-de-polipo1.png\" alt=\"bi\u00f3psia de polipo\" width=\"245\" height=\"197\"><\/a><\/p>\n<p style=\"text-align: center;\"><em>Na suspeita de tumor neuroend\u00f3crino, antes de ser realizada a ressec\u00e7\u00e3o,&nbsp;o ideal \u00e9 a realiza\u00e7\u00e3o de uma simples bi\u00f3psia da les\u00e3o&nbsp;para diagn\u00f3stico especifico do tipo de tumor e seu grau histol\u00f3gico<\/em><\/p>\n<p><em>&nbsp;<\/em><\/p>\n<p><strong>TRATAMENTO<\/strong><\/p>\n<p><strong>Tumores de classifica\u00e7\u00e3o cl\u00ednica 1:<\/strong><\/p>\n<p>Tratamento endosc\u00f3pico se:<\/p>\n<p>&#8211;&nbsp; n\u00famero de les\u00f5es&nbsp;menor que 5<\/p>\n<p>&#8211; &nbsp;les\u00f5es menores que 1 cm<\/p>\n<p>&#8211;&nbsp; sem suspeita de invas\u00e3o da camada muscular pr\u00f3pria (ecoendoscopia &nbsp;obrigat\u00f3ria apenas em les\u00f5es maiores que 10mm)<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Tumores de classifica\u00e7\u00e3o cl\u00ednica 3:<\/strong><\/p>\n<ul>\n<li>An\u00e1lise individualizada de cada caso<\/li>\n<\/ul>\n<ul>\n<li>Pode-se considerar o tratamento endosc\u00f3pico em tumores menores que 10mm<\/li>\n<\/ul>\n<ul>\n<li>Desde que n\u00e3o possuam fatores de risco para met\u00e1stase<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><em>Fatores de risco para met\u00e1stase<\/em><\/p>\n<ul>\n<li>Classifica\u00e7\u00e3o histol\u00f3gica grau III (G3-pouco diferenciado \u2013 Ki67 &gt; 20% e IM &gt; 20)<\/li>\n<\/ul>\n<ul>\n<li>Invas\u00e3o da muscular pr\u00f3pria<\/li>\n<\/ul>\n<ul>\n<li>Invas\u00e3o angiolinf\u00e1tica<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Em estudo publicado na&nbsp;World Journal of&nbsp;Gastroenterology em 2013 <a href=\"http:\/\/www.wjgnet.com\/1007-9327\/full\/v19\/i46\/8703.htm\" target=\"_blank\" rel=\"noopener\">(3)<\/a>, foram avaliados 119 casos de tumores neuroend\u00f3crinos do tipo 3 que foram tratados e acompanhados por 46 meses. Destes 39 foram para cirurgia, 50 foram ressecados endoscopicamente e 15 foram observados clinicamente.<\/p>\n<p>Dos 39 pacientes operados, 33 seguiram o acompanhamento sendo que 29 n\u00e3o tiveram recidiva, 4 tiveram recidivas sendo dois casos evolu\u00edram para \u00f3bito e outros dois foram reoperados.<\/p>\n<p>Dos 15 pacientes que foram observados, 14 seguiram o acompanhamento, destes 11 n\u00e3o tiveram evolu\u00e7\u00e3o da doen\u00e7a e 3 tiveram evolu\u00e7\u00e3o sendo que um destes foi a \u00f3bito.<\/p>\n<p>Dos 50 pacientes tratados endoscopicamente, 40 tiveram ressec\u00e7\u00e3o completa do tumor, destes 36 fizeram o acompanhamento e nenhum teve recidiva da doen\u00e7a. &nbsp;Os 10 pacientes que tiveram a ressec\u00e7\u00e3o incompleta da les\u00e3o, &nbsp;7 tiveram comprometimento vertical ou lateral da margem sendo apenas observados posteriormente com endoscopia. &nbsp;J\u00e1 3 pacientes tiveram&nbsp; invas\u00e3o angiolinf\u00e1tica, sendo todos os tr\u00eas encaminhados para complementa\u00e7\u00e3o cir\u00fargica. Todos os 10 pacientes que tiveram ressec\u00e7\u00e3o incompleta, inclusive o que tiveram que ser submetidos a complementa\u00e7\u00e3o cir\u00fargica n\u00e3o tiveram recidiva da doen\u00e7a.<\/p>\n<p>&nbsp;<\/p>\n<p>Este estudo mostra a efetividade do tratamento endosc\u00f3pico mesmo nos tumores do tipo 3, desde que sigam as indica\u00e7\u00f5es e contra-indica\u00e7\u00f5es do procedimento e principalmente se os tumores forem ressecados completamente.<\/p>\n<p>Por isto as t\u00e9cnicas ideais para a ressec\u00e7\u00e3o de tumores neuroend\u00f3crinos, s\u00e3o aquelas que tem o potencial de fazer ressec\u00e7\u00e3o profundas (mucosa e submucosa) tendo em vista que o tumor cresce na l\u00e2mina pr\u00f3pria e o comprometimento da submucosa nestes casos \u00e9 esperado.<\/p>\n<p>T\u00e9cnicas de polipectomia simples ou mucosectomia tem altos \u00edndices de ressec\u00e7\u00e3o incompleta, principalmente de comprometimendo vertical da margem pois geralmente n\u00e3o conseguem ressecar completamente a submucosa. (4)<\/p>\n<p>&nbsp;<\/p>\n<p><strong>T\u00e9cnicas de ressec\u00e7\u00e3o endosc\u00f3pica profunda (mucosa + submucosa):<\/strong><\/p>\n<ul>\n<li>Ligadura el\u00e1stica + Polipectomia &nbsp;(<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/resseccao-de-tumor-neuroendocrino-duodenal\/\" target=\"_blank\" rel=\"noopener\">assista v\u00eddeo da t\u00e9cnica<\/a>)<\/li>\n<\/ul>\n<ul>\n<li>Ressec\u00e7\u00e3o com al\u00e7a monofilamentar &nbsp;(<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/reseccao-de-tumor-de-celulas-granulares\/\" target=\"_blank\" rel=\"noopener\">assista v\u00eddeo da t\u00e9cnica<\/a>)<\/li>\n<\/ul>\n<ul>\n<li>Dissec\u00e7\u00e3o endosc\u00f3pica da submucosa (ESD)<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>TRATAMENTO EM CASOS ESPECIAIS<\/strong><\/p>\n<ul>\n<li>Tumores neuroend\u00f3crinos que apresentam fator de risco para met\u00e1stase, est\u00e1 indicada a gastrectomia com linfadenectomia.<\/li>\n<\/ul>\n<ul>\n<li>Pacientes com TNE tipo 1, que n\u00e3o responderam ou tiveram recorr\u00eancia ap\u00f3s tratamento endosc\u00f3pico, pode-se tentar terapia para supress\u00e3o da gastrina s\u00e9rica &nbsp;com an\u00e1lagos da somastotastina (ex: octeotride) &nbsp;ou&nbsp; antrectomia<\/li>\n<\/ul>\n<ul>\n<li>Nos casos de met\u00e1stases, h\u00e1 op\u00e7\u00f5es como t\u00e9cnicas de radiologia intervencionista, radioterapia para dissemina\u00e7\u00e3o \u00f3ssea sintom\u00e1tica e quimioterapia em doen\u00e7a metast\u00e1tica irressec\u00e1vel.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>CONCLUS\u00c3O<\/strong><\/p>\n<ul>\n<li>Os tumores neuroend\u00f3crinos g\u00e1stricos constituem um espectro de neoplasias com caracter\u00edsticas cl\u00ednico-patol\u00f3gicas, mecanismo patog\u00eanico e progn\u00f3stico diferentes do adenocarcinoma podendo ser mais indolentes ou se comportar como tal<\/li>\n<\/ul>\n<ul>\n<li>O conhecimento deste complexo tema com suas classifica\u00e7\u00f5es e apresenta\u00e7\u00f5es \u00e9 de fundamental import\u00e2ncia para a condu\u00e7\u00e3o adequada de tumores desta linhagem<\/li>\n<\/ul>\n<ul>\n<li>Antes de ser realizado o tratamento endosc\u00f3pico, deve ser feito o correto diagn\u00f3stico do tipo de tumor neuroend\u00f3crino em quest\u00e3o, com simples bi\u00f3psia da les\u00e3o, exames laboratoriais e de imagem para estadiamento<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><em><a title=\"Tumor Neuroend\u00f3crino G\u00e1strico\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/tumor-neuroendocrino-gastrico\/\" target=\"_blank\" rel=\"noopener\"><strong>VEJA AQUI ALGUNS CASOS CL\u00cdNICOS SOBRE TUMOR NEUROEND\u00d3CRINO G\u00c1STRICO<\/strong><\/a><\/em><\/p>\n<p>&nbsp;<\/p>\n<p><strong>REFER\u00caNCIAS<\/strong><\/p>\n<p>Link dos artigos originais:<\/p>\n<p><a href=\"http:\/\/www.cabdirect.org\/abstracts\/20113051318.html;jsessionid=356977D7AE7E0254A54C49B6C7AAFFF0\" target=\"_blank\" rel=\"noopener\">1-&nbsp;Pathology and Genetics of Tumours of the Digestive System. WHO Classification of Tumours 2010. p. 53-57<\/a><\/p>\n<p><a href=\"http:\/\/biomed.papers.upol.cz\/artkey\/bio-201403-0020_Neuroendocrine_neoplasms_of_the_stomach.php#.VU_Bco5VhBc\" target=\"_blank\" rel=\"noopener\">2 &#8211; Oldrich Louthan, Neuroendocrine neoplasms of the stomach. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2014 Sep; 158(3):455-460<\/a><\/p>\n<p><a href=\"http:\/\/www.wjgnet.com\/1007-9327\/full\/v19\/i46\/8703.htm\" target=\"_blank\" rel=\"noopener\">3- Kwon YH et al .Long-term follow up of endoscopic resection for type 3 gastric NET. <i>World J <\/i><i>Gastroenterol<\/i><i> 2013 <\/i><i>December<\/i><i> 14; 19(46): 8703-8708<\/i><\/a><\/p>\n<p><a href=\"http:\/\/czasopisma.viamedica.pl\/ep\/article\/view\/EP.2013.0028\" target=\"_blank\" rel=\"noopener\">4-&nbsp;Beata Kos-Kud\u0142a et al.,&nbsp; Diagnostic and therapeutic guidelines for gastro-entero-pancreatic neuroendocrine neoplasms&nbsp;&nbsp; Endokrynologia Polska 2013; 64 (6)<\/a><\/p>\n<p><a href=\"http:\/\/www.karger.com\/Article\/Abstract\/342988\" target=\"_blank\" rel=\"noopener\">5- David A. Crosby ,&nbsp; Gastric Neuroendocrine Tumours ,&nbsp; Dig Surg 2012;29:331\u2013348<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>INTRODU\u00c7\u00c3O Os tumores neuroend\u00f3crinos s\u00e3o formados por hiperplasia das c\u00e9lulas enterocromoafins, respons\u00e1veis pela produ\u00e7\u00e3o&hellip;<\/p>\n","protected":false},"author":1772,"featured_media":3562,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[282],"tipo":[153],"volume":[263],"class_list":["post-4241","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-282","tipo-endoscopia-digestiva-alta","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Tratamento de tumor 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