{"id":2318,"date":"2026-06-11T21:00:00","date_gmt":"2026-06-12T00:00:00","guid":{"rendered":"https:\/\/sevenresiduosaude.com.br\/blog\/?p=2318"},"modified":"2026-06-11T21:00:00","modified_gmt":"2026-06-12T00:00:00","slug":"pgrss-clinica-medicina-cir-oncologica-esofagica-avancada-keynote-590-checkmate-577-trastuzumab-deruxtecan","status":"publish","type":"post","link":"https:\/\/sevenresiduosaude.com.br\/blog\/pgrss-clinica-medicina-cir-oncologica-esofagica-avancada-keynote-590-checkmate-577-trastuzumab-deruxtecan\/","title":{"rendered":"PGRSS esofag avan: KEYNOTE-590, CheckMate-577"},"content":{"rendered":"

A regula\u00e7\u00e3o brasileira de RSS \u00e9 frequentemente subaproveitada por gestores de cl\u00ednicas de cirurgia oncol\u00f3gica esof\u00e1gica avan\u00e7ada 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 esof\u00e1gica avan\u00e7ada<\/strong> + CCE carcinoma escamoso es\u00f4fago 70-80% Brasil + adenoCa Barrett 20-30% + GIST esof\u00e1gico raro<\/strong> + Ivor-Lewis 2-campos+McKeown 3-campos+THLT Orringer transhiatal+MIE+RAMIE rob\u00f3tica<\/strong> + CROSS+FLOT neoadjuvante+pCR 25-40%<\/strong> + KEYNOTE-590 pembrolizumab+chemo 1L mUC OS extens\u00e3o<\/strong> + CheckMate-577 nivolumab adjuvante p\u00f3s-CROSS DFS extens\u00e3o<\/strong> + KEYNOTE-859 pembro+chemo 1L<\/strong> + trastuzumab deruxtecan Enhertu DESTINY-Gastric01\/02 HER2<\/strong> + dostarlimab MSI-H+claudin 18.2 zolbetuximab<\/strong> geram fluxos heterog\u00eaneos de RSS Grupo A1 (CCE+adenoCa Barrett+GIST+adenoescamoso+pequenas c\u00e9lulas raro) + Grupo A4 (linfa cervical bilateral+mediastinal alta-m\u00e9dia-baixa+abdominal cel\u00edaca+3-campos McKeown padr\u00e3o Jap\u00e3o) + Grupo C (Iridium-192 brachy intracavit\u00e1rio+I-131 raro+Y-90 SIRT) + Grupo E (perfuro bi\u00f3psia+ESD endoscopic+Olympus EndoCut+IT-knife+Hook-knife+Triangle-tip-knife+Dual-knife) + Lista C5 (CROSS carbo+pacli+RT 41,4 Gy\/23 fr+FLOT 5-FU+leuco+oxali+docetaxel+MAGIC ECF+nivolumab Opdivo CheckMate-577 adjuvante DFS+pembrolizumab Keytruda Merck KEYNOTE-590 1L+KEYNOTE-859+atezolizumab Tecentriq+durvalumab Imfinzi+ipilimumab Yervoy+T-DXd Enhertu trastuzumab deruxtecan AstraZeneca\/Daiichi Sankyo HER2 DESTINY-Gastric01\/02+dostarlimab Jemperli RUBY MSI-H+claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT+GLOW gastric Lista C5).<\/p>\n

Para o gestor que opera ou planeja cl\u00ednica de cir oncol\u00f3gica esof\u00e1gica avan\u00e7ada, \u00e9 fundamental dimensionar PGRSS espec\u00edfico desde o in\u00edcio.<\/p>\n

Os 5 fluxos oncol\u00f3gicos esof\u00e1gicos avan\u00e7ados<\/h2>\n

Em uma opera\u00e7\u00e3o de qualquer porte, o PGRSS esof\u00e1gica avan\u00e7ada 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 CCE+adenoCa Barrett<\/td>\n5-13 kg\/dia<\/td>\nDi\u00e1ria<\/td>\n70-80%\/20-30%+CID C15<\/td>\n<\/tr>\n
A4 Ivor-Lewis+McKeown<\/td>\n4-12 kg\/dia<\/td>\nDi\u00e1ria<\/td>\n25-40 LN+RAMIE<\/td>\n<\/tr>\n
C Iridium-192+Y-90<\/td>\n0,5-1,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nBrachy+CNEN<\/td>\n<\/tr>\n
E ESD+EUS-FNA<\/td>\n1-3 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nOlympus+R0 90+%<\/td>\n<\/tr>\n
Lista C5 KEYNOTE+CheckMate<\/td>\n1,5-4,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nKEYNOTE-590+T-DXd<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

A soma t\u00edpica \u00e9 12-34 kg\/dia<\/strong> em cl\u00ednica cir oncol\u00f3gica esof\u00e1gica avan\u00e7ada m\u00e9dia porte.<\/p>\n

A1 CCE escamoso + adenoCa Barrett + biomarker HER2+PD-L1+claudin 18.2: o est\u00e1gio cir\u00fargico+molecular<\/h2>\n

A primeira camada do PGRSS esof\u00e1gica avan\u00e7ada \u00e9 A1. Padr\u00e3o setorial inclui (a) CCE carcinoma escamoso 70-80% Brasil<\/strong> com \u00e1lcool+tabaco+achalasia+Plummer-Vinson+corrosivo+nutricional vit A\/B\/C+alimento quente >65\u00b0C; (b) adenoCa Barrett 20-30% Brasil<\/strong> com DRGE cr\u00f4nica+Barrett’s IM intestinal metaplasia+dysplasia LGD\/HGD+Barrx Medtronic ERC eradica\u00e7\u00e3o RFA+EMR endoscopic mucosal resection; (c) subs\u00edtio anat\u00f4mico<\/strong> cervical 5%+tor\u00e1cico superior 15%+m\u00e9dio 50%+inferior 30%+EGJ Jun\u00e7\u00e3o Esofagog\u00e1strica Siewert I\/II\/III; (d) biomarker comprehensive<\/strong> com HER2 IHC 3+\/FISH+ amplification 20% adenoCa+PD-L1 CPS\u226510 22C3 Dako+SP142 Ventana+MSI-H 5%+claudin 18.2 express\u00e3o 50% adenoCa+EGFR amplification+TMB tumor mutational burden+comprehensive NGS FoundationOne CDx+Guardant360 ctDNA; (e) estadiamento TNM 8\u00aa edi\u00e7\u00e3o<\/strong> Tis+T1a M1-M3+T1b SM1-SM3+T2 muscular+T3 advent\u00edcia+T4a pleura+peric\u00e1rdio+diafragma+T4b traqueia+aorta+v\u00e9rtebra+CID C15.<\/p>\n

Cl\u00ednica com A1 esof\u00e1gica avan\u00e7ada madura garante margem R0<\/strong> + previne recidiva mediastinal<\/strong> + otimiza biomarker HER2+PD-L1+claudin 18.2 comprehensive<\/strong>. Como discutimos no post sobre esof\u00e1gica<\/a>, A1 esof\u00e1gica \u00e9 base.<\/p>\n

A4 Ivor-Lewis + McKeown + THLT + MIE + RAMIE rob\u00f3tica + 3-campos: o est\u00e1gio cir\u00fargico<\/h2>\n

A segunda camada \u00e9 t\u00e9cnica. Padr\u00e3o setorial inclui (a) Ivor-Lewis 2-campos<\/strong> com laparotomia abdominal + toracotomia direita + anastomose intrator\u00e1cica + linfadenectomia 2-campos abdominal+mediastinal; (b) McKeown 3-campos<\/strong> com laparotomia+toracotomia direita+cervicotomia esquerda+anastomose cervical+linfadenectomia 3-campos cervical+mediastinal+abdominal padr\u00e3o ouro Jap\u00e3o+25-40 LN dissecados; (c) THLT transhiatal Orringer+MIE Minimally Invasive+RAMIE Robot-Assisted MIE<\/strong> com videolaparoscopia + videotoracoscopia + rob\u00f3tica Da Vinci Xi + RAMIE+RAMIE-3-campos + redu\u00e7\u00e3o LOS Length of Stay; (d) reconstru\u00e7\u00e3o<\/strong> com gastric pull-up tubo g\u00e1strico isoperist\u00e1ltico+c\u00f3lon esquerdo+direito interposi\u00e7\u00e3o+jejuno Roux-en-Y+pyloroplasty Heineke-Mikulicz+J-tube jejunostomy alimenta\u00e7\u00e3o; (e) complica\u00e7\u00e3o cir\u00fargica<\/strong> f\u00edstula anastom\u00f3tica 5-15%+hemorragia 5-10%+chyloperitoneum+pneumonia p\u00f3s-op+SDRA+arritmia+DVT\/TEP+LOS 10-21 dias+30d mortality 3-8% high-volume centers.<\/p>\n

Cl\u00ednica com A4 Ivor-Lewis+McKeown+RAMIE madura escala R0 90+%<\/strong> + escala 3-campos 25-40 LN padr\u00e3o Jap\u00e3o<\/strong> + previne f\u00edstula 5-15%<\/strong>. Conex\u00e3o com esof\u00e1gica<\/a>.<\/p>\n

CROSS + KEYNOTE-590 + CheckMate-577 + T-DXd Enhertu + claudin 18.2 zolbetuximab: o est\u00e1gio sist\u00eamico+ADC+imuno<\/h2>\n

A terceira camada \u00e9 sist\u00eamico+targeted+imuno. Padr\u00e3o setorial inclui (a) CROSS protocolo neoadjuvante<\/strong> com carboplatina AUC 2 + paclitaxel 50 mg\/m\u00b2 semanal \u00d7 5 + RT concomitante 41,4 Gy\/23 fr 5 semanas + cirurgia 6-8 semanas p\u00f3s + pCR 25-40%; (b) alternativa quimio<\/strong> com FLOT 5-FU+leucovorin+oxaliplatina+docetaxel preferencial adenoCa + MAGIC ECF epirrubicina+CDDP+5-FU + DCF docetaxel+CDDP+5-FU + FOLFOX; (c) KEYNOTE-590 pembrolizumab Keytruda Merck+chemo 1L mUC<\/strong> PD-L1 CPS\u226510 + cisplatina+5-FU + OS 13,5m vs 9,4m chemo HR 0,73 + ORR 45% vs 29% + KEYNOTE-859 pembro+chemo gastric\/GEJ; (d) CheckMate-577 nivolumab Opdivo BMS adjuvante p\u00f3s-CROSS<\/strong> com nivolumab 240mg q2w + 480mg q4w por 1 ano + DFS 22m vs 11m placebo HR 0,69 + adjuvante padr\u00e3o p\u00f3s-neoadjuvante chemoradiation residual disease; (e) T-DXd trastuzumab deruxtecan Enhertu AstraZeneca\/Daiichi Sankyo HER2 ADC<\/strong> DESTINY-Gastric01 6,4 mg\/kg q3w 2L+ HER2+ + DESTINY-Gastric02+04 + ILD pneumonite intersticial monitor + claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT+GLOW 1L gastric\/GEJ adenoCa CLDN18.2+ + atezolizumab Tecentriq+durvalumab Imfinzi+ipilimumab+dostarlimab Jemperli MSI-H Lista C5.<\/p>\n

Cl\u00ednica com CROSS+KEYNOTE-590+CheckMate-577+T-DXd madura escala CROSS pCR 25-40%<\/strong> + escala KEYNOTE-590 OS 13,5m PD-L1 CPS\u226510<\/strong> + escala CheckMate-577 DFS 22m adjuvante<\/strong> + escala T-DXd ORR 51% HER2 DESTINY-Gastric01<\/strong>. Conex\u00e3o com Lista C5<\/a>.<\/p>\n

Tr\u00eas perfis de PGRSS por capacidade esof\u00e1gica avan\u00e7ada<\/h2>\n

Cl\u00ednica esof\u00e1g avan s\u00f3 A1.<\/strong> 1 fluxo. Custo mensal R$ 9.500-28.000<\/strong> mas perda de A4+ESD+sist\u00eamico.<\/p>\n

Cl\u00ednica esof\u00e1g avan A1 + A4 + CROSS.<\/strong> 3 fluxos. Custo mensal R$ 24.000-58.000<\/strong>, captura cirurgia + neoadjuvante.<\/p>\n

Cl\u00ednica esof\u00e1g avan 5 fluxos completos.<\/strong> A1+A4+C+E+sist\u00eamico + integra\u00e7\u00e3o com servi\u00e7os hospitalares<\/a>. Custo mensal R$ 42.000-98.000<\/strong>, efic\u00e1cia 95%, ROI 800-2.500% via captura completa esof\u00e1gica avan\u00e7ada + KEYNOTE-590 OS 13,5m + CheckMate-577 DFS 22m + T-DXd HER2 + zolbetuximab claudin 18.2.<\/p>\n

Os tr\u00eas erros que aparecem em cir oncol\u00f3gica esof\u00e1gica avan\u00e7ada<\/h2>\n

O primeiro \u00e9 a subdimensionamento Lista C5 imuno+ADC esof\u00e1gica<\/strong>. Sem segrega\u00e7\u00e3o carbo+pacli+5-FU+oxaliplatina+docetaxel+pembrolizumab+nivolumab+atezolizumab+durvalumab+ipilimumab+T-DXd+zolbetuximab+dostarlimab + Lista C5 = n\u00e3o-conformidade ANVISA RDC 222 + risco contamina\u00e7\u00e3o cruzada profissional + impacto financeiro.<\/p>\n

O segundo \u00e9 a mistura A1 CCE escamoso + adenoCa Barrett<\/strong>. Confunde rastreabilidade tumor + impossibilita biomarker HER2 (apenas adeno)+claudin 18.2 (apenas adeno)+PD-L1+MSI-H + risco indica\u00e7\u00e3o inadequada (KEYNOTE-590 PD-L1 CPS\u226510 vs T-DXd HER2 vs zolbetuximab CLDN18.2).<\/p>\n

O terceiro \u00e9 a falta de protocolo MDT tumor board pr\u00e9-CROSS<\/strong>. Sem CT+RM+EUS endoscopic ultrasound+PET-CT staging+biomarker comprehensive NGS+MDT multidisciplinar GI cir+onco+RT+endoscopia+patologia = perda planejamento personalizado + risco indica\u00e7\u00e3o inadequada (CROSS adenoCa+CCE vs FLOT adeno vs cirurgia direta).<\/p>\n

A regula\u00e7\u00e3o de PGRSS esof\u00e1gica avan\u00e7ada 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 Es\u00f4fago<\/a> \u00e9 refer\u00eancia t\u00e9cnica nacional.<\/p>\n

Solicite cota\u00e7\u00e3o PGRSS esof\u00e1gica avan\u00e7ada 5 fluxos oncol\u00f3gicos<\/a><\/strong> \u2014 cap\u00edtulo dedicado a A1 CCE escamoso 70-80% Brasil \u00e1lcool+tabaco+achalasia+Plummer-Vinson+adenoCa Barrett 20-30% DRGE+IM+LGD\/HGD+ERC Barrx+EMR+EGJ Siewert I\/II\/III+HER2 IHC 3+\/FISH+ 20% adenoCa+PD-L1 CPS\u226510 22C3 Dako+SP142+MSI-H 5%+claudin 18.2 50% adenoCa+EGFR+TMB+FoundationOne CDx+Guardant360+CID C15+TNM 8\u00aa, A4 Ivor-Lewis 2-campos+McKeown 3-campos cervical+mediast+abd padr\u00e3o Jap\u00e3o+THLT Orringer+MIE+RAMIE Robot-Assisted Da Vinci Xi+RAMIE-3-campos+gastric pull-up+c\u00f3lon+jejuno+pyloroplasty+J-tube jejunostomy+25-40 LN+f\u00edstula 5-15%, C Iridium-192 brachy intracavit\u00e1rio+I-131 raro+Y-90 SIRT raro+CNEN-NN-3.05, E ESD Olympus EndoCut Q+Erbe VIO 300D+IT-knife+Hook-knife+Triangle-tip+Dual-knife J+EMR cap-fitted+R0 90+% T1a, Lista C5 CROSS carbo AUC 2+paclitaxel 50mg\/m\u00b2\u00d75+RT 41,4Gy\/23fr pCR 25-40%+FLOT preferencial adeno+MAGIC ECF+pembrolizumab Keytruda Merck KEYNOTE-590 1L OS 13,5m PD-L1 CPS\u226510+KEYNOTE-859+nivolumab Opdivo BMS CheckMate-577 adjuvante DFS 22m+CheckMate-649+atezolizumab Tecentriq+durvalumab Imfinzi PACIFIC+ipilimumab Yervoy+T-DXd Enhertu trastuzumab deruxtecan AstraZeneca\/Daiichi Sankyo HER2 DESTINY-Gastric01 ORR 51%+02\/04+claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT+GLOW 1L gastric\/GEJ CLDN18.2+ pos+dostarlimab Jemperli RUBY MMR-d+ILD monitor.<\/p>\n","protected":false},"excerpt":{"rendered":"

PGRSS esof\u00e1gica avan: KEYNOTE-590 + CheckMate-577 + T-DXd. Veja.<\/p>\n","protected":false},"author":3,"featured_media":2317,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[2712,3154,3155,3156],"class_list":["post-2318","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance-legislacao","tag-cirurgia-oncologica","tag-esofagica-avancada","tag-keynote-590","tag-t-dxd"],"_links":{"self":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2318","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=2318"}],"version-history":[{"count":1,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2318\/revisions"}],"predecessor-version":[{"id":4381,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2318\/revisions\/4381"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media\/2317"}],"wp:attachment":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media?parent=2318"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/categories?post=2318"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/tags?post=2318"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}