{"id":2246,"date":"2026-06-10T10:00:00","date_gmt":"2026-06-10T13:00:00","guid":{"rendered":"https:\/\/sevenresiduosaude.com.br\/blog\/?p=2246"},"modified":"2026-06-10T10:00:00","modified_gmt":"2026-06-10T13:00:00","slug":"pgrss-clinica-medicina-cir-oncologica-cca-extra-hepatica-klatskin-bismuth-corlette-whipple-pemigatinib","status":"publish","type":"post","link":"https:\/\/sevenresiduosaude.com.br\/blog\/pgrss-clinica-medicina-cir-oncologica-cca-extra-hepatica-klatskin-bismuth-corlette-whipple-pemigatinib\/","title":{"rendered":"PGRSS CCA extra: Klatskin, Whipple, pemig"},"content":{"rendered":"

A regula\u00e7\u00e3o brasileira de RSS \u00e9 frequentemente subaproveitada por gestores de cl\u00ednicas de cirurgia oncol\u00f3gica colangiocarcinoma extra-hep\u00e1tico que reduzem PGRSS a descarte de bisturi e gaze<\/strong>. Em 2026, h\u00e1 um cen\u00e1rio desafiador \u2014 cl\u00ednicas de cir oncol\u00f3gica CCA extra-hep\u00e1tico<\/strong> + Klatskin tumor pCCA hilar Bismuth-Corlette I-IV<\/strong> + dCCA distal cholangiocarcinoma + Whipple<\/strong> + GBC carcinoma ves\u00edcula<\/strong> + stenting biliar met\u00e1lico+pl\u00e1stico<\/strong> + pemigatinib Pemazyre + futibatinib Lytgobi FGFR2 fusion + ivosidenib Tibsovo IDH1 + durvalumab Imfinzi TOPAZ-1<\/strong> geram fluxos heterog\u00eaneos de RSS Grupo A1 (pCCA Klatskin + dCCA distal + GBC ves\u00edcula + adenoCa CBD comum + papilar Vater + adenoCa duodeno periampolar) + Grupo A4 (linfa hilar + porta hepatis + tronco cel\u00edaco + AMS + para-a\u00f3rtica + retroperitoneal) + Grupo C (Y-90 SIRT met\u00e1stase hep\u00e1tica + Iridium-192 brachy intraductal raro + I-131 raro) + Grupo E (perfuro bi\u00f3psia ERCP brush + EUS-FNA + bi\u00f3psia core) + Lista C5 (gemcitabina+cisplatina ABC-02 + nab-paclitaxel + FOLFOX + FOLFIRINOX + pemigatinib FIGHT-202 + futibatinib FOENIX-CCA2 + ivosidenib ClarIDHy + durvalumab Imfinzi TOPAZ-1 + pembrolizumab KEYNOTE-158 MSI-H + tucatinib HER2). A consequ\u00eancia \u00e9 a pr\u00e1tica de cl\u00ednicas que otimizam apenas para gaze cir\u00fargica<\/strong> + ignoram especificidades oncol\u00f3gicas + Klatskin Bismuth-Corlette + targeted FGFR2\/IDH1<\/strong> + subdimensionam Lista C5 imuno+targeted<\/strong> + perdem rastreabilidade tumor biliar<\/strong>. A realidade \u00e9 exatamente o oposto. PGRSS CCA extra opera em 5 fluxos oncol\u00f3gicos<\/strong> \u2014 A1 (pCCA Klatskin 50% + dCCA distal 30% + GBC 15% + outros 5%), A4 (linfadenectomia hilar + porta hepatis + tronco cel\u00edaco + AMS + para-a\u00f3rtica), C (Y-90 SIRT + Iridium-192 + I-131), E (ERCP brush + EUS-FNA + IDUS intraductal ultrasound), Lista C5 (gem+cis ABC-02 + pemigatinib FIGHT-202 + futibatinib FOENIX-CCA2 + ivosidenib ClarIDHy + durvalumab TOPAZ-1).<\/p>\n

Para o gestor que opera ou planeja cl\u00ednica de cir oncol\u00f3gica CCA extra, \u00e9 fundamental dimensionar PGRSS espec\u00edfico desde o in\u00edcio.<\/p>\n

Os 5 fluxos oncol\u00f3gicos CCA extra<\/h2>\n

Em uma opera\u00e7\u00e3o de qualquer porte, o PGRSS CCA extra tem 5 fluxos.<\/p>\n\n\n\n\n\n\n\n\n\n
Fluxo<\/th>\nVolume<\/th>\nFrequ\u00eancia<\/th>\nParticularidade<\/th>\n<\/tr>\n<\/thead>\n
A1 pCCA+dCCA+GBC<\/td>\n5-13 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nKlatskin Bismuth I-IV<\/td>\n<\/tr>\n
A4 hilar+porta hepatis<\/td>\n4-11 kg\/dia<\/td>\nDi\u00e1ria<\/td>\n15-25 LN+cel\u00edaco+AMS<\/td>\n<\/tr>\n
C Y-90+Ir-192+I-131<\/td>\n0,5-1,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nSIRT+brachy+CNEN<\/td>\n<\/tr>\n
E ERCP brush+EUS-FNA<\/td>\n0,5-1,5 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nIDUS+SpyGlass<\/td>\n<\/tr>\n
Lista C5 gem+pemig+ivos<\/td>\n1,5-4,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nTOPAZ-1+FIGHT-202<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

A soma t\u00edpica \u00e9 11,5-31,5 kg\/dia<\/strong> em cl\u00ednica cir oncol\u00f3gica CCA extra m\u00e9dia porte.<\/p>\n

A1 Klatskin pCCA Bismuth-Corlette + dCCA + GBC: o est\u00e1gio cir\u00fargico<\/h2>\n

A primeira camada do PGRSS CCA extra \u00e9 A1. Padr\u00e3o setorial inclui (a) Klatskin pCCA perihilar 50%<\/strong> com Bismuth-Corlette I conflu\u00eancia preservada + II envolve conflu\u00eancia + IIIa estende ducto direito + IIIb estende ducto esquerdo + IV estende bilateral + Blumgart staging T1\/T2\/T3 estendido; (b) dCCA distal 30%<\/strong> com col\u00e9doco + ampola Vater + Whipple DPC + adenoCa biliar versus pancre\u00e1tico; (c) GBC carcinoma ves\u00edcula 15%<\/strong> com colecistectomia radical + leito IVb+V + linfa hepatoduodenal + CBD ressection eventual + Mirizzi syndrome; (d) adenoCa CBD comum + papilar Vater + duodeno periampolar 5%<\/strong> com IPMN-B intraductal papilar mucinoso biliar + cisto coledociano Todani I-V; (e) estadiamento TNM 8\u00aa edi\u00e7\u00e3o<\/strong> espec\u00edfico pCCA + dCCA + GBC + biomarker CA 19-9 + CEA + estadiamento IDUS intraductal ultrasound + ERCP+MRCP+colangiografia.<\/p>\n

Cl\u00ednica com A1 CCA extra madura garante margem R0<\/strong> + previne recidiva regional<\/strong> + otimiza Bismuth-Corlette I-IV stratifica\u00e7\u00e3o<\/strong>. Como discutimos no post sobre vias biliares<\/a>, A1 \u00e9 base.<\/p>\n

A4 hepatectomia + Whipple + linfadenectomia + stenting biliar: o est\u00e1gio cir\u00fargico<\/h2>\n

A segunda camada \u00e9 t\u00e9cnica. Padr\u00e3o setorial inclui (a) hepatectomia para Klatskin<\/strong> com Bismuth I trissegmentectomia esquerda + II direita estendida + IIIa hepatectomia direita estendida + IIIb esquerda estendida + IV TX hep\u00e1tico Mayo Clinic protocol + ALPPS + PVE; (b) DPC Whipple para dCCA<\/strong> com cabe\u00e7a p\u00e2ncreas + duodeno + 1\u00aa al\u00e7a jejunal + ves\u00edcula+CBD + est\u00f4mago distal antrectomia + reconstru\u00e7\u00e3o Whipple ou PPPD Traverso-Longmire; (c) linfadenectomia padr\u00e3o<\/strong> com hilar 12 + porta hepatis 8 + 13 + tronco cel\u00edaco 9 + AMS 14 + para-a\u00f3rtica 16 seletiva + retroperitoneal + 15-25 LN dissecados padr\u00e3o; (d) stenting biliar paliativo<\/strong> com SEMS Self-Expandable Metal Stent Wallflex Boston Scientific + Niti-S Taewoong + Evolution Cook + pl\u00e1stico Amsterdam 7-10Fr + percutaneous transhepatic PTBD; (e) drenagem percut\u00e2nea PTC Percutaneous Transhepatic Cholangiography<\/strong> com agulha Chiba 22G + dilatador Cook + cateter pigtail + bilomas evacua\u00e7\u00e3o + colangite Charcot+Reynolds.<\/p>\n

Cl\u00ednica com A4 hepatectomia+Whipple madura escala R0 50-70%<\/strong> + previne f\u00edstula biliar<\/strong> + otimiza estadiamento intra-operat\u00f3rio<\/strong>. Conex\u00e3o com hep\u00e1tica HCC<\/a>.<\/p>\n

Gem+cis ABC-02 + pemigatinib FIGHT-202 + futibatinib FOENIX + ivosidenib ClarIDHy + durvalumab TOPAZ-1: o est\u00e1gio sist\u00eamico+targeted<\/h2>\n

A terceira camada \u00e9 sist\u00eamico+targeted+imuno. Padr\u00e3o setorial inclui (a) gem+cis ABC-02 1L sist\u00eamico padr\u00e3o ouro<\/strong> gemcitabina 1.000 mg\/m\u00b2 + cisplatina 25 mg\/m\u00b2 q3w \u00d7 8 ciclos + OS 11,7m vs 8,1m gem mono; (b) TOPAZ-1 quimio+imuno 1L<\/strong> durvalumab Imfinzi AstraZeneca anti-PD-L1 1.500mg q3w + gem+cis \u00d7 8 ciclos seguido durva manuten\u00e7\u00e3o q4w + OS 12,8m vs 11,5m placebo HR 0,80 + KEYNOTE-966 pembrolizumab Keytruda+gem+cis OS 12,7m HR 0,83; (c) pemigatinib Pemazyre Incyte FGFR2 fusion 2L<\/strong> FIGHT-202 13,5mg PO 14d on\/7d off + ORR 35,5% + PFS 6,9m + futibatinib Lytgobi Taiho FGFR2 fusion 2L FOENIX-CCA2 20mg PO QD + ORR 41,7% + PFS 9,0m; (d) ivosidenib Tibsovo Servier IDH1-R132 mutated 2L<\/strong> ClarIDHy 500mg PO QD + PFS 2,7m vs 1,4m placebo HR 0,37; (e) outras mol\u00e9culas<\/strong> trastuzumab+tucatinib HER2 SGNTUC-019 + larotrectinib Vitrakvi+entrectinib Rozlytrek NTRK + selpercatinib Retevmo RET + dabrafenib+trametinib BRAF-V600E + KRAS-G12C sotorasib + repotrectinib Augtyro ROS1+NTRK Lista C5.<\/p>\n

Cl\u00ednica com sist\u00eamico+targeted+imuno madura escala TOPAZ-1 OS 12,8m 1L<\/strong> + escala pemigatinib FIGHT-202 PFS 6,9m FGFR2<\/strong> + escala ivosidenib ClarIDHy IDH1<\/strong>. Conex\u00e3o com Lista C5<\/a>.<\/p>\n

Tr\u00eas perfis de PGRSS por capacidade CCA extra<\/h2>\n

Cl\u00ednica CCA extra s\u00f3 A1.<\/strong> 1 fluxo. Custo mensal R$ 9.000-26.000<\/strong> mas perda de A4+C+E+sist\u00eamico.<\/p>\n

Cl\u00ednica CCA extra A1 + A4 + gem+cis.<\/strong> 3 fluxos. Custo mensal R$ 22.000-54.000<\/strong>, captura cirurgia + sist\u00eamico padr\u00e3o.<\/p>\n

Cl\u00ednica CCA extra 5 fluxos completos.<\/strong> A1+A4+C+E+targeted\/imuno + integra\u00e7\u00e3o com servi\u00e7os hospitalares<\/a>. Custo mensal R$ 40.000-95.000<\/strong>, efic\u00e1cia 95%, ROI 800-2.500% via captura completa CCA + TOPAZ-1 OS 12,8m + targeted FGFR2\/IDH1.<\/p>\n

Os tr\u00eas erros que aparecem em cir oncol\u00f3gica CCA extra<\/h2>\n

O primeiro \u00e9 a subdimensionamento targeted FGFR2\/IDH1 Lista C5<\/strong>. Sem segrega\u00e7\u00e3o pemigatinib+futibatinib+ivosidenib+durvalumab + Lista C5 = n\u00e3o-conformidade ANVISA RDC 222 + risco contamina\u00e7\u00e3o cruzada profissional + impacto financeiro.<\/p>\n

O segundo \u00e9 a mistura A1 pCCA + dCCA + GBC<\/strong>. Confunde rastreabilidade tumor + impossibilita Bismuth-Corlette+TNM + risco indica\u00e7\u00e3o cir\u00fargica inadequada (Whipple vs hepatectomia vs colecistectomia radical).<\/p>\n

O terceiro \u00e9 a falta de protocolo NGS molecular profiling pr\u00e9-targeted<\/strong>. Sem FoundationOne CDx+Guardant360 ctDNA+sequenciamento FGFR2 fusion+IDH1+HER2+NTRK+BRAF+KRAS = perda elegibilidade targeted + zero stratifica\u00e7\u00e3o precision medicine.<\/p>\n

A regula\u00e7\u00e3o de PGRSS CCA extra no Brasil est\u00e1 em fase de moderniza\u00e7\u00e3o t\u00e9cnica acelerada com cir oncol\u00f3gica preservadora como prioridade. As institui\u00e7\u00f5es que estruturam fluxos completos desde o in\u00edcio \u2014 alinhadas com PGRSS cl\u00ednicas especializadas<\/a> \u2014 atravessam o crescimento sem solavanco. Para gestores que precisam alinhar com gest\u00e3o paralela industrial, o portal Seven Res\u00edduos sobre servi\u00e7os completos<\/a> traz a perspectiva integrada. A INCA C\u00e2ncer Vias Biliares<\/a> \u00e9 refer\u00eancia t\u00e9cnica nacional.<\/p>\n

Solicite cota\u00e7\u00e3o PGRSS CCA extra 5 fluxos oncol\u00f3gicos<\/a><\/strong> \u2014 cap\u00edtulo dedicado a A1 Klatskin pCCA 50% Bismuth-Corlette I-IV+Blumgart+dCCA distal 30% Vater+GBC ves\u00edcula 15% Mirizzi+adenoCa CBD+papilar Vater+IPMN-B+Todani I-V+CA 19-9+CEA+IDUS+ERCP+MRCP+CID C24, A4 hepatectomia Klatskin Bismuth I-IV+ALPPS+PVE+TX hep\u00e1tico Mayo+DPC Whipple dCCA+PPPD Traverso-Longmire+linfadenectomia hilar 12+porta hepatis 8+13+cel\u00edaco 9+AMS 14+para-a\u00f3rtica 16+15-25 LN+stenting SEMS Wallflex Boston+Niti-S Taewoong+Evolution Cook+PTBD percutaneous+colangite Charcot+Reynolds, C Y-90 SIR-Spheres+TheraSphere+Iridium-192 intraductal+I-131+CNEN-NN-3.05, E ERCP brush+EUS-FNA+IDUS+SpyGlass cholangioscopy direct visualization, Lista C5 gem+cis ABC-02 OS 11,7m+TOPAZ-1 durvalumab Imfinzi AstraZeneca OS 12,8m+KEYNOTE-966 pembrolizumab Keytruda+pemigatinib Pemazyre Incyte FIGHT-202 ORR 35,5%+futibatinib Lytgobi Taiho FOENIX-CCA2 ORR 41,7%+ivosidenib Tibsovo Servier ClarIDHy+trastuzumab+tucatinib HER2 SGNTUC-019+larotrectinib+entrectinib NTRK+selpercatinib RET+dabrafenib+trametinib BRAF+sotorasib KRAS+repotrectinib Augtyro ROS1.<\/p>\n","protected":false},"excerpt":{"rendered":"

PGRSS CCA extra-hep\u00e1tico: Klatskin + Whipple + pemigatinib + ivosidenib. Veja.<\/p>\n","protected":false},"author":3,"featured_media":2245,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[2948,2712,3080,3081],"class_list":["post-2246","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance-legislacao","tag-cca","tag-cirurgia-oncologica","tag-klatskin","tag-pemigatinib"],"_links":{"self":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2246","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/comments?post=2246"}],"version-history":[{"count":1,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2246\/revisions"}],"predecessor-version":[{"id":4346,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2246\/revisions\/4346"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media\/2245"}],"wp:attachment":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media?parent=2246"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/categories?post=2246"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/tags?post=2246"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}