Emilio Carlos Curcelli
PROGNÓSTICO EM OSTEOSSARCOMA:
análise clínica, epidemiológica, histopatológica e imuno-histoquímica
Tese apresentada à Faculdade de
Medicina de Botucatu - Unesp para
obtenção do título de doutor em
Bases Gerais da Cirurgia
Botucatu
2008
Emilio Carlos Curcelli
PROGNÓSTICO EM OSTEOSSARCOMA:
análise clínica, epidemiológica, histopatológica e imuno-histoquímica
Tese apresentada à Faculdade de
Medicina de Botucatu – Unesp para
obtenção do título de doutor em Bases
Gerais da Cirurgia.
Orientador: Prof. Dr. Sérgio Swain Müller
Co-orientadora: Profa. Dra Anete Kinumi Ueda
Botucatu
2008
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Dedicatória
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Curcelli EC. Prognóstico em osteossarcoma
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Abstract
hiz{yhj{G G jG ljUG wùG G aG çG óSG ùSG ùG G TóG {G ˀG kUG iaG mGGtGGiSG|GlGwbGYWW_UG hG G G G G G SG SG SG G G G G G G ]`G G G G G G G G G G GGGG| GoGGiGtGzSG zG G tG | G oSG |G OiSG zwSG i¡PG G G hGjGoGOqĀSGzwSGi¡PSGGX``WGGYWW[UGwGG G G G G G G G G G G G GGGGGG GG ¡GG oGGOX``XPUGkGGGGGGGGT GGSGGG\ZGGGGG G G O{G G hijPUG {G G G G G G G GGGG ¡G GrTtGG UGhGGGGGGGG G G G nG G G G G G G G G OnSG X`][SG X`]\PUG uG G G G G GGSGSGGGGGbGG G G pppG G G G UG {G G G G G SG G G G G G GCurcelli EC. Prognóstico em osteossarcoma
bGGGGGGGGGGGG GGGGGGGGGGGG G G G G UG jSG G G SG G G G G bG G G G G G G G G G G UG {G G G G G G \ZG G G G G G SGGG GGGUGG r aG bG bG G bG bG bG UG GG
Curcelli EC. Prognóstico em osteossarcoma
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Curcelli EC. Prognóstico em osteossarcoma
22
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24
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Curcelli EC. Prognóstico em osteossarcoma
26
YGyl}pzÉvGklGsp{lyh{|yhG hG G G íéG G G G G SG G ùGGGéSGGGðGGGGG G G G G G UG wG G G SGGGéGSGGGSGéG G G G çG G G G SG çG G GGGGGGðUG tGGUGOYWW[PGGóGGGĀGG GG¡GGíéGGGGGGG G G G G G G G G SG G éG G G éSG¡GGGGGGSGçGpGGppSGG`WLG G G G G G ùG G G TSG SG éG G UG wG G ¡SG G G G G íSG G G ûSG çG ppG G pppSG ¡G G éGïSGðGGĀGGGGæGGGG `WLSGGGGGGGçG GùGG ðG UG vG G G ðG G G G çG G ùGGùGUGG hGûGGtGGUGOYWW[PGTGGóGG ùSG G G { G G UG OX`_\PSG G G G G çaG G G G ¡G SG G SG G G G X\G SG èG ùG ùG G çSG íéG G G G G G G G G G G G ðG G ĀUG vG G G G G G G G G G UG lG SG G G G G GGGGóGGGíéGóUG hGGGGGíûGGSGG GGGíéGGçGGGùSGSGéG çG G ĀG G G íéG G G G SG SGRevisão da literatura
27
¡G G G éG G G G G SG ĂSG G G O~G G USG YWWWbG rG G USG YWW[PUG vG G G ĂG SG G G G ùSG G G G G SG éG G G UG G YUXGpG G kG G G oG OX``XPSG ]WLG G G G G G G G G çG G G YXG UG uG G G mG MG tG OX``ZPSG _\LG G G G G G SG G ]WLG G ¡G G G UG }G G UG OYWW^PSGG G ïG G G G XZSZGUGGwGOYWW\PGG^WS^LGGGG¡GGX_GSG X]S`LGGGGG¡GGGXYS[LGGGX_GUG|T iGGUGOX`^^PSGGGðGGGGGïG GSGG^]S\LGGGGGGGGY\GUGG
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Curcelli EC. Prognóstico em osteossarcoma
28
oGOX`_]PGGGGGG GGGG GðGGùSGGi¡GGUGOX`__PGGGG G G G G G ùUG wG tG G UG OYWW[PSG GG GGGðGGGGSGSGGG G\\GUGG wGt GGUGOX``YPSGi¡GGUGOX`__PGGz¡GG UG OYWWWPSG G G G G G ùSG G G GGGGSGðGíéGGGðGGG G¡GGGSGGèGæGGGG éGGUG wG nG G UG OYWWZPSGG G G G G G G GGSGGGGGGG G G G UG lSG vG G UG OYWW[PSG G G ][G G G SG G G G G ĂG SG óGGGGçGéGïGGGGGGG GGïGðUG
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Revisão da literatura
29
GGGGGGGGjóGt SGGXS]aGXUGrGGUG OX`_`PGGíéGGXS]aGXGGGtGGUGOYWW[PSGGXSX\aGXUG zGGUGOX`^\PSG{ GGUGOX`_\PSGwGGUGOX``XPGG nGGUGOX``ZPGGGGGGGGUG jGGt GGUGOX``YPSGz¡GGUGOYWWWPSGtGGUGOYWW[PG GiGGUGOYWW]PSGGGGGéGGGùGGG GGUG G YUZGss¡íéGGG G vGG¡TSGGĂSGGûG çG G G ðG G çG G G óUG vG G G éGGGSGGGĂGGðSGóSGĀGGóG O|TiG G USG X`^^bG zSG X`_YbG oSG X``XbG tG G USG YWW[PUGoçGïGGGíéGG¡íéGGùG G G G UG wG kG G UG OX``[PSG wG G UG OX``^PSG{GGUGOX```PSGy GGUGOYWWWPSGmGGUGOYWWXPGGiG GUGOYWW]PSGéGçGíéGGóGGGGGG GGGGGGGGUG zG { G G UG OX`_\PSG GG G G ðG G G ĀG ïG G G ùG çSG G G nG G UG OX`_^PSGG G G ¡G G ĀG G ðG G ùUG qçG nG MG sG OX``XPGG G GG GG ûG G ðG G G G G SG G G G ¡G G sG G UG OX``XPSGGGGGGçG¡GGóGG ùGGçUG wG nG G UG OX``YPSG G G ¡G G ðG GðGGGðGGðG¡GGGGG¡íéG
G
Curcelli EC. Prognóstico em osteossarcoma
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GSGSGGùGGGGz¡GGUGOYWWWPSGGGG¡íéG GGGïGGGùGUG
hG¡íéGGGGïGGĂSGGG G G ùG Oi¡G G UG X`__bG t G G USG X``YbG tG G USG YWW[bGzGGUSGYWW\PUGkGGGGoGGUGOX``_PSGGGGG ðGGGGGĀSGSGGGGSG éG G G G éSG G G G íéG óG G ïG GçUG wGG zG G UG OX``^PSG G G ùG G G GG G¡GGGGïGĂðGGGG G G íéG ĀG G G G G G G SG GGGæGUG wGtGGUGOYWW\PSGGGG¡GGG ðGGùUG G YU[GkéG G hG éG G G ïG G G G ùG O{ G G USG X`_\bG wG G USG X``XbG kG G USG X``[bG z¡G G USG YWWWbG iG G USG YWW]bG wG G USG YWW]PUG wG zG OX`^_PG G GGSGGGùUGG
iG G UG OX``]PG G G G G éG GGXY_GUGkGGGGGG G X\WG ZSG G _LG G çSG G G G G GSGGGGGGGG[WLUG rG G UG OYWW[PG G G G G G éG SG G G G G G G èG ïSG G GéGGùUGjóGGGéGGïGGG ùG G G G G G G G G íéG G GGGUG
Revisão da literatura
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zGGUGOYWWZPGGGGðGGðGGG G G ðG ïG G G G G G G GGGGX\WSGGùUG {GGGðGGGGíéGG G G SG G G SG G G G GGùUGuéGçSGGSGGGGèG GGGGGGGéGSGGGçGG G G ùSG G G ïG G íéG éG éG UG kG G SG G G G G SG éG ïG óG ¡G GéGGóGçGGçUGG G YU\GjjíéG G zGGíéGGSGTGGGG ûGGGóSGùGGGùG UG xG æG ¡íéG G SG G G G G GGGGïGOz¡SGX``ZPUG vGGGGéGGSGGGG G `WLG G G OmG MG tSG X``ZbG kG G UG YWW^PUG lG G SG ùG G ùSG G ¡éG G íéG ùG G G íéG ùG SG G G TïUG jSG G ĀG çG G íéG G ïG G G G G G G ¡G GG GOz¡SGX`_YPUG vG G ùG G G G éaG çSG çSG çSG çSG G G ïGGTùGGGOz¡SGX``ZPUGGG uG G çSG G ¡G G ïG G G ùG G ùUG uG çSG G G G G G GG
Curcelli EC. Prognóstico em osteossarcoma
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G G G éG ùUG vG G çG ïG GGïGGGGG¡GùSGG GGGOy GGUSGYWWYPUGG lGGGGèGçGGGG G G G G G G ĂSG G ðG ïG çSG GGíéGGðGGïGùGUGGGzG y G G UG OYWWYPSG G G çG G G G \WLG G SG G G çG G G çG GGG\WLSGGGGY\LUGGG
wG OYWW\PG G _XSZLG G G G G G èGçSGXXS]LSGçGGZSZLSGçUG
}G G UG OYWW^PG G ]`G SG G SG ]^G O`^SXLPG G SG G \^G G G çG O_\LPSG G G G G çG G SG çSG G \S`LG G XS[LSG UG
|TiG G UG OX`^^PSG G ^^LG G G G èGçSGXZLSGçGG`LSGçUG
vG G çG ïG ¡G G G íGGGSGGGGUGÏGG çGGóGGGGùUGÏGGGGG XLGG\LGGGGGOoSGX``XbGmGMGtSGX``ZbG y G G USG YWWYPUG G hSG G óSG G ðG G GùSGGGGGY\LGGGOy GG USGYWWYPUG
uG SG TG G G ðG G G G ïG G SG G ïG ïG SG G G G ïSGGGXLGG[LSGGíéGGGGGOmGMG tSG X``ZSG rG MG iSG YWWYSG }G G USG YWW^PUG G ÏG óG G GïGSGGGæGGGGGlG GGUGhGíéGùGGïGçSGGGSGïG
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G G OmG MG tSG X``ZPUG iG G UG OX`_`PG G zG G UG OX`^`PGGGGGGïGGðGGùG GGGUGlSGGh GGUGOX`_`PSGG ùGïGGGGGUGG vGGTùGGGGG G XLG G G G G G G G G ùG OoSG X``XbGmGMGtSGX``ZbG~GGUSGYWWYbGkGGUSGYWW^PUG wGwGGUGOX``^PSG{GGUGOX```PSGy GGUG OYWWWPSG iG G UG OYWW]PSG G éG G G G G SG G G G G èG ùSG éG ïG ĀG G G G ùUG z
G
tGG UG OYWW[PSG éG çG ðG G íG G GóSGGGGùUGG z¡G OX`_YPG G SG G G G SG G íéG G G G SG G G G G ùG éG éG çG SG æG ¡SG ïG óG G G G bG G éG G G éG TG ĀSG SGGùUG lSGGGGíGGùGG íéG G íéG ùG G UG wG { G G UG OX`_\PSG G èG çG G çSG G ùG çUGkGGSGnGGUGOX`_^PGGíéG óG G çG G G G G G èG ùG éG G óG G ïG çUG i¡G G UG OX``_PGG G G íéG óG G G çSG Gz¡GGUGOYWWWPGGGGGGGGYWLGG èGGðGGùUGwGiGGUGOX``_PSGG GçGéGGóGGGçUG vGGïGéGGGSGGG GGGGóSGGGGGGUGG
Curcelli EC. Prognóstico em osteossarcoma
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vG G G ïG G G G G G G G óG O|G MG rSG YWWYbG kG G USG YWW^PSG ¡TG G TG G óG G G G G G G GGíéUGhGGĂGóGGïGG G G G G G G G G UG vG GïGGíéGĀGGSGGGGSG GGGGGGGG^WLGG`XLGOvGGUGX``[PUG vGGGïGGèGçSGG çG G G G óG ùSG G íéG G çG G GUGhGóGïGGGGSGGGðGGĀUG yG G G YLG G G G G OrG G USG X`_`bG z¡SG X``ZbG h G MG j¡SG YWWYbG kG G USG YWW^PSG G ïG G ĂGGGGïGGGGGGG GGGGGGGGGUGG
vG G G G G G G ðG G ùG G G G G G G OrG G USG X`_`bG oSG X``XbG mG MG tSG X``ZbG z¡SG X``ZbG h G MG j¡SG YWWYbG |G MG rSG YWWYPUG vG G G G G G óSG G SG GGGùGGGGGO~GGUSG X`_[PUG vG çG éG G G G G G G G G ïTG G G íG G wSG íéG G G ûG OtG G USG X`_`PUG {ðG G ùG G G G G G G éG G G ùG OrG G USG X`_`bG mG G USG YWWYPUG zG mG G UG OYWWYPSG G ðGGGçGæGGGGZS[LGG \S\LG G G G SG G íûG G G íGGwGGGWS^GGWS`LGGUGkGGUGOYWW^PG GXS^LGGðGGGçSGGG GGíUGG
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G YU]GlG G vGGGGéGGGGG ðSG G íéG G G G ïG G G G G G G G íéG G G G G OlSGX``ZPUG vGGGGïGGGGlGGGG X`_WGGtG{Gz GOlSGX`_ZPGGGhG qG jG G jG zG G lG yG yG OoG G UG X`_`bGkGGUSGYWWYPUG lG G G ðG óG G G aGnSGGGíéGùbG{SGGGGúbGGtSGGG íG G ðG G çUG wG ðG óG G G G G pSG ppG G pppSG G G hSG G G GGiSGUGkG G G oG G UG OX`_`PSG G G G éG G G G G ĀTïSG SG ZWLG SGGùSGGGçGpbG]WLSGGçGppGGXWLSGG çG pppUG vG G ĂSG G çG pSG éG G G O]]LPSGGSGGçGppSGéGGGO`WLPUGG wG G G G G çG pppG OíG çPSGGùSGGGùGGSGGGSG G G G G G ðG G G OiG G USG X``_SG YWWWbG ~G G USG YWWWbG w÷TnG G USG YWWZbG tG G USG YWW[bGyGGUSGYWW[bGtGGUSGYWW\bGt{GGUSGYWW]bGwGG USGYWW]PUGxGGGGGçSGGûGéGG GGĂGGOsGGUSGX`_]PUG
tG G UG OX``YPG G G G G G G GðGGGG\WLGGGGGGZWLGGíGG
G
Curcelli EC. Prognóstico em osteossarcoma
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G G G çG G G ùUG t G G UG OX``ZPG G SG G ]YG G G G G çGGùSGGXXLGGGGGUGqçG G G ¡G GG iG G UG OX``^PSG ùG G ïG G ZWG SG\\LGGGTGGGíGùGGUG tçGùGGGGGGG GùGéGGGGGGùGOz¡SGX`_YbG oSGX``XbGmGMGnSGYWWXbGkGwGGUSGYWW\PUGGrGGUG OX```PGGGGWS\LGGçGùGG{GGUGOX`_\PGG G çG G SG G YSZG LG G SG G ïG G GG_S\GUG hG çG ùG éG G G G G G G çSG G G G G æG éG çUG hG ðG ïG G G XS[LG G ]S\LG OzG G UG YWW[bG rG G USG YWW]bPUG zéG G G G G ðG G G çG G OlG MG rSG X`^\PUG ~G MG lG OX``WPG G G G G G G G æG G çG pppiG G ùUG G wG s G G UG OYWWZPSG G çG ùGéGGGGùGUG jG G G ïG óG G G G G G G ùG UG vG G G G G G pSG G SG ðG G ùG G G GGGGGpppSGçSGGùUG uGSGGGGGGGGGGppSG éGïGóG¡GGùSGGGGGíéGGGG GGGùUG