{"id":2326,"date":"2026-06-12T01:00:00","date_gmt":"2026-06-12T04:00:00","guid":{"rendered":"https:\/\/sevenresiduosaude.com.br\/blog\/?p=2326"},"modified":"2026-06-12T01:00:00","modified_gmt":"2026-06-12T04:00:00","slug":"pgrss-clinica-medicina-cir-oncologica-gastrica-avancada-her2-t-dxd-enhertu-pembrolizumab-keynote-859-checkmate-649-zolbetuximab","status":"publish","type":"post","link":"https:\/\/sevenresiduosaude.com.br\/blog\/pgrss-clinica-medicina-cir-oncologica-gastrica-avancada-her2-t-dxd-enhertu-pembrolizumab-keynote-859-checkmate-649-zolbetuximab\/","title":{"rendered":"PGRSS g\u00e1strica avan: HER2, T-DXd, zolbetux"},"content":{"rendered":"

A regula\u00e7\u00e3o brasileira de RSS \u00e9 frequentemente subaproveitada por gestores de cl\u00ednicas de cirurgia oncol\u00f3gica g\u00e1strica 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 g\u00e1strica avan\u00e7ada<\/strong> + CG carcinoma g\u00e1strico adenoCa Lauren intestinal 50%+difuso 40%+linitis pl\u00e1stica+Krukenberg+CDH1 HDGC+GIST KIT\/PDGFRA+linfoma MALT+EGJ Jun\u00e7\u00e3o Esofagog\u00e1strica Siewert I\/II\/III<\/strong> + gastrectomia subtotal Billroth I\/II+Roux-en-Y+total esofagojejunostomia+linfadenectomia D2 padr\u00e3o 25-30 LN<\/strong> + HER2 IHC 3+\/FISH+ trastuzumab Herceptin+T-DXd Enhertu DESTINY-Gastric01\/02\/04<\/strong> + PD-L1 CPS\u22655 pembrolizumab Keytruda KEYNOTE-859+nivolumab Opdivo CheckMate-649+atezolizumab Tecentriq IMpower<\/strong> + claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT+GLOW 1L CLDN18.2+<\/strong> + MSI-H pembrolizumab KEYNOTE-061+158+nivolumab+ipilimumab<\/strong> + FGFR2b bemarituzumab+darolutamide raros<\/strong> geram fluxos heterog\u00eaneos de RSS Grupo A1 (CG adenoCa intestinal+difuso+misto+CDH1 HDGC+linitis pl\u00e1stica+Krukenberg ov\u00e1rio+GIST+linfoma MALT+EGJ Siewert) + Grupo A4 (linfa D1+D2+D3+25-30 LN+cel\u00edaca+espl\u00eanica+hep\u00e1tica) + Grupo C (Y-90 SIRT raro+Iridium-192 raro+brachy raro) + Grupo E (perfuro bi\u00f3psia+ESD endoscopic submucosal dissection Olympus EndoCut+IT-knife+Hook-knife+Triangle-tip+Dual-knife+EUS-FNA+EUS-FNB endoscopic ultrasound) + Lista C5 (cisplatina+5-FU+capecitabina+oxaliplatina+SOX+CapeOx+FOLFOX+ECF MAGIC+FLOT preferencial perioperative+trastuzumab Herceptin Roche HER2 IHC 3+\/FISH+ TOGA OS 13,8m+T-DXd Enhertu trastuzumab deruxtecan AstraZeneca\/Daiichi Sankyo HER2 ADC DESTINY-Gastric01 ORR 51%+02\/04+pembrolizumab Keytruda Merck KEYNOTE-859 1L OS 12,9m+KEYNOTE-061+158+nivolumab Opdivo BMS CheckMate-649 1L OS 13,8m+ipilimumab Yervoy+atezolizumab Tecentriq+durvalumab Imfinzi+claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT 1L OS 18,2m+GLOW OS 14,4m CLDN18.2+ pos+bemarituzumab FGFR2b+dostarlimab Jemperli+nivolumab+ipilimumab CheckMate-358 Lista C5).<\/p>\n

Para o gestor que opera ou planeja cl\u00ednica de cir oncol\u00f3gica g\u00e1strica avan\u00e7ada, \u00e9 fundamental dimensionar PGRSS espec\u00edfico desde o in\u00edcio.<\/p>\n

Os 5 fluxos oncol\u00f3gicos g\u00e1stricos avan\u00e7ados<\/h2>\n

Em uma opera\u00e7\u00e3o de qualquer porte, o PGRSS g\u00e1strica 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 CG Lauren+CDH1<\/td>\n5-13 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nIntest 50%+dif 40%<\/td>\n<\/tr>\n
A4 D2+25-30 LN+EGJ<\/td>\n4-12 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nBillroth+Roux-en-Y<\/td>\n<\/tr>\n
C Y-90+brachy raro<\/td>\n0,4-1,2 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nSIRT met\u00e1stase hep\u00e1tica<\/td>\n<\/tr>\n
E ESD+EUS-FNA<\/td>\n1-3 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nOlympus EndoCut+R0 90%<\/td>\n<\/tr>\n
Lista C5 T-DXd+zolbetux<\/td>\n1,5-4,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nDESTINY+SPOTLIGHT<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

A soma t\u00edpica \u00e9 11,9-33,7 kg\/dia<\/strong> em cl\u00ednica cir oncol\u00f3gica g\u00e1strica avan\u00e7ada m\u00e9dia porte.<\/p>\n

A1 CG adenoCa Lauren + CDH1 HDGC + biomarker HER2+PD-L1+claudin 18.2+MSI-H+FGFR2b: o est\u00e1gio cir\u00fargico+molecular<\/h2>\n

A primeira camada do PGRSS g\u00e1strica avan\u00e7ada \u00e9 A1. Padr\u00e3o setorial inclui (a) adenoCa Lauren intestinal 50%+difuso 40%+misto 10%<\/strong> com glandular bem-diferenciado intestinal+H. pylori erradica\u00e7\u00e3o prim\u00e1ria + difuso c\u00e9lulas anel sinete signet-ring+linitis pl\u00e1stica+Krukenberg ov\u00e1rio metastase+CDH1 muta\u00e7\u00e3o heredit\u00e1ria HDGC; (b) outros tipos<\/strong> com GIST 5% KIT 75-80%+PDGFRA+imatinib Glivec+linfoma MALT 5%+R-CHOP refrat\u00e1rio+adenoescamoso raro + carcinoma neuroend\u00f3crino + carcinoma indiferenciado; (c) biomarker comprehensive<\/strong> com HER2 IHC 3+\/FISH+ amplification 15-20% adenoCa+PD-L1 CPS\u22655 22C3 Dako+SP142 Ventana+claudin 18.2 express\u00e3o 38% IHC 75%+ membrane positivity+MSI-H 5-15%+EBV positive 9%+FGFR2b amplification 4-9%+TMB tumor mutational burden+comprehensive NGS FoundationOne CDx+Guardant360 ctDNA+TCGA molecular subtypes EBV+MSI+CIN+GS Genomically Stable; (d) EGJ Jun\u00e7\u00e3o Esofagog\u00e1strica Siewert I\/II\/III<\/strong> com Siewert I esof\u00e1gico distal + Siewert II cardia + Siewert III subcardia + abordagem cir\u00fargica diferente esofagogastrectomia vs gastrectomia total; (e) estadiamento TNM 8\u00aa edi\u00e7\u00e3o<\/strong> Tis+T1a\/b+T2 muscular+T3 subserosa+T4a serosa+T4b adjacente+N0-N3+M0\/M1+CID C16+grade Lauren+WHO 2019+TCGA molecular.<\/p>\n

Cl\u00ednica com A1 g\u00e1strica avan\u00e7ada madura garante margem R0<\/strong> + previne recidiva peritoneal<\/strong> + otimiza biomarker HER2+PD-L1+CLDN18.2+MSI+FGFR2b comprehensive<\/strong>. Como discutimos no post sobre g\u00e1strica<\/a>, A1 g\u00e1strica \u00e9 base.<\/p>\n

A4 gastrectomia subtotal+total + D2 padr\u00e3o Jap\u00e3o + EGJ Siewert + RAMIE rob\u00f3tica: o est\u00e1gio cir\u00fargico<\/h2>\n

A segunda camada \u00e9 t\u00e9cnica. Padr\u00e3o setorial inclui (a) gastrectomia subtotal distal<\/strong> com 4\/5 est\u00f4mago distal + 1cm proximal margem + reconstru\u00e7\u00e3o Billroth I gastroduodenostomia + Billroth II gastrojejunostomia + Roux-en-Y; (b) gastrectomia total<\/strong> com remo\u00e7\u00e3o completa est\u00f4mago + es\u00f4fago distal + duodeno proximal + reconstru\u00e7\u00e3o Roux-en-Y esofagojejunostomia + jejunoplastia interposi\u00e7\u00e3o + pouch cria\u00e7\u00e3o; (c) linfadenectomia D2 padr\u00e3o Jap\u00e3o<\/strong> com D1 perig\u00e1strica n\u00edvel 1-6 + D2 cel\u00edaca n\u00edvel 7+8a+9+11p+12a + ocidente D2 sem esplenectomia rotina + Jap\u00e3o D2 esplenectomia condicional adenoCa proximal + 25-30 LN dissecados; (d) abordagem cir\u00fargica<\/strong> com aberto via incis\u00e3o xifoumbilical + laparoscopia 5 trocartes + rob\u00f3tica Da Vinci Xi + RAMIE Robot-Assisted gastrectomia + intracorp\u00f3rea anastomose; (e) HIPEC peritoneal<\/strong> com HIPEC Hyperthermic Intraperitoneal Chemotherapy mitomicina C+oxaliplatina+cisplatina + 41-43\u00b0C 30-90 min + indica\u00e7\u00e3o carcinomatose peritoneal limitada PCI<13 + GASTRICHIP+CYTO-CHIP+PHOENIX-GC.<\/p>\n

Cl\u00ednica com A4 gastrectomia D2 madura escala R0 90+%<\/strong> + escala 25-30 LN dissecados padr\u00e3o ouro Jap\u00e3o<\/strong> + previne f\u00edstula 3-10%<\/strong>. Conex\u00e3o com g\u00e1strica<\/a>.<\/p>\n

T-DXd Enhertu DESTINY-Gastric + KEYNOTE-859 + CheckMate-649 + zolbetuximab Vyloy SPOTLIGHT+GLOW: o est\u00e1gio sist\u00eamico+ADC+imuno+claudin 18.2<\/h2>\n

A terceira camada \u00e9 sist\u00eamico+targeted+claudin 18.2. Padr\u00e3o setorial inclui (a) HER2-positivo IHC 3+\/FISH+ TOGA padr\u00e3o 1L<\/strong> trastuzumab Herceptin Roche 6 mg\/kg IV q3w + cisplatina+capecitabina\/5-FU OS 13,8m vs 11,1m chemo HR 0,74; (b) T-DXd trastuzumab deruxtecan Enhertu AstraZeneca\/Daiichi Sankyo HER2 ADC<\/strong> DESTINY-Gastric01 6,4 mg\/kg q3w 2L+ HER2 IHC 3+\/2+ FISH+ ORR 51% vs 14% chemo + DESTINY-Gastric02 western + DESTINY-Gastric04 DGU vs ramucirumab+paclitaxel + ILD pneumonite intersticial monitor; (c) KEYNOTE-859 pembrolizumab Keytruda Merck+chemo 1L<\/strong> PD-L1 CPS\u22655+all-comer + cisplatina+capecitabina\/FOLFOX + OS 12,9m vs 11,5m HR 0,78 + KEYNOTE-061+158 2L+ MSI-H 1L+ + KEYNOTE-590 esof\u00e1gica overlap; (d) CheckMate-649 nivolumab Opdivo BMS+chemo 1L<\/strong> PD-L1 CPS\u22655+all-comer + FOLFOX + OS 13,8m vs 11,6m HR 0,78 + CheckMate-577 esof\u00e1gica adjuvante overlap + nivolumab+ipilimumab CheckMate-032+649 + atezolizumab Tecentriq IMpower; (e) claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT 1L<\/strong> CLDN18.2+ pos \u226575% IHC + EOX epirrubicina+oxaliplatina+capecitabina + OS 18,2m vs 15,5m HR 0,75 + GLOW mFOLFOX OS 14,4m vs 12,2m HR 0,77 + bemarituzumab FGFR2b 4-9% Five Prime FORTITUDE+nivolumab+pembrolizumab+atezolizumab+durvalumab+ipilimumab+dostarlimab Lista C5.<\/p>\n

Cl\u00ednica com T-DXd+KEYNOTE-859+CheckMate-649+zolbetuximab madura escala T-DXd ORR 51% HER2 DESTINY-Gastric01<\/strong> + escala KEYNOTE-859+CheckMate-649 OS 12,9m+13,8m 1L PD-L1 CPS\u22655<\/strong> + escala SPOTLIGHT zolbetuximab OS 18,2m claudin 18.2+<\/strong>. Conex\u00e3o com Lista C5<\/a>.<\/p>\n

Tr\u00eas perfis de PGRSS por capacidade g\u00e1strica avan\u00e7ada<\/h2>\n

Cl\u00ednica g\u00e1str 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 g\u00e1str avan A1 + A4 + FLOT.<\/strong> 3 fluxos. Custo mensal R$ 24.000-58.000<\/strong>, captura cirurgia + perioperative.<\/p>\n

Cl\u00ednica g\u00e1str 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 g\u00e1strica avan\u00e7ada + T-DXd ORR 51% HER2 + KEYNOTE-859 OS 12,9m + CheckMate-649 OS 13,8m + SPOTLIGHT zolbetuximab OS 18,2m.<\/p>\n

Os tr\u00eas erros que aparecem em cir oncol\u00f3gica g\u00e1strica avan\u00e7ada<\/h2>\n

O primeiro \u00e9 a subdimensionamento Lista C5 ADC+imuno+claudin 18.2 g\u00e1strica<\/strong>. Sem segrega\u00e7\u00e3o cisplatina+5-FU+capecitabina+oxaliplatina+FLOT+trastuzumab+T-DXd+pembrolizumab+nivolumab+atezolizumab+durvalumab+ipilimumab+zolbetuximab+bemarituzumab+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 adenoCa Lauren intestinal vs difuso vs CDH1 HDGC<\/strong>. Confunde rastreabilidade tipo histol\u00f3gico+TCGA molecular subtypes EBV+MSI+CIN+GS + impossibilita biomarker comprehensive HER2+PD-L1+CLDN18.2+MSI+FGFR2b + risco indica\u00e7\u00e3o inadequada (T-DXd HER2 vs SPOTLIGHT CLDN18.2 vs KEYNOTE-859 PD-L1 vs MSI-H imuno).<\/p>\n

O terceiro \u00e9 a falta de protocolo claudin 18.2 IHC \u226575% membrane positivity testing universal<\/strong>. Sem IHC HER2+PD-L1 22C3+SP142+claudin 18.2 \u226575% membrane+MSI-H+EBV+FGFR2b+comprehensive NGS FoundationOne CDx+Guardant360 = perda elegibilidade SPOTLIGHT zolbetuximab + zero precision medicine.<\/p>\n

A regula\u00e7\u00e3o de PGRSS g\u00e1strica 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 Est\u00f4mago<\/a> \u00e9 refer\u00eancia t\u00e9cnica nacional.<\/p>\n

Solicite cota\u00e7\u00e3o PGRSS g\u00e1strica avan\u00e7ada 5 fluxos oncol\u00f3gicos<\/a><\/strong> \u2014 cap\u00edtulo dedicado a A1 adenoCa Lauren intestinal 50%+difuso 40%+misto 10%+CDH1 HDGC Hereditary+linitis pl\u00e1stica+Krukenberg ov\u00e1rio+GIST 5% KIT+PDGFRA+linfoma MALT 5%+EGJ Jun\u00e7\u00e3o Esofagog\u00e1strica Siewert I\/II\/III+HER2 IHC 3+\/FISH+ 15-20%+PD-L1 CPS\u22655 22C3 Dako+SP142+claudin 18.2 \u226575% membrane 38%+MSI-H 5-15%+EBV+ 9%+FGFR2b 4-9%+TCGA molecular subtypes EBV+MSI+CIN+GS+FoundationOne CDx+Guardant360+CID C16+TNM 8\u00aa, A4 gastrectomia subtotal Billroth I+II+Roux-en-Y+gastrectomia total esofagojejunostomia+jejunoplastia+pouch+linfadenectomia D2 padr\u00e3o Jap\u00e3o D1 1-6+D2 7+8a+9+11p+12a cel\u00edaco+espl\u00eanico+hep\u00e1tico+25-30 LN+laparoscopia 5 trocartes+rob\u00f3tica Da Vinci Xi+RAMIE+intracorp\u00f3rea+HIPEC mitomicina+oxaliplatina+cisplatina 41-43\u00b0C+GASTRICHIP+CYTO-CHIP+PHOENIX-GC PCI<13, C Y-90 SIR-Spheres SIRT met\u00e1stase hep\u00e1tica+Iridium-192 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+EUS-FNA+EUS-FNB endoscopic ultrasound, Lista C5 cisplatina+5-FU+capecitabina+oxaliplatina+SOX+CapeOx+FOLFOX+ECF MAGIC+FLOT 5-FU+leuco+oxali+docetaxel preferencial perioperative+trastuzumab Herceptin Roche TOGA HER2 OS 13,8m+T-DXd Enhertu trastuzumab deruxtecan AstraZeneca\/Daiichi Sankyo HER2 ADC DESTINY-Gastric01 ORR 51%+02 western+04 DGU+pembrolizumab Keytruda Merck KEYNOTE-859 1L OS 12,9m+KEYNOTE-061+158+nivolumab Opdivo BMS CheckMate-649 1L OS 13,8m+ipilimumab Yervoy+atezolizumab Tecentriq+durvalumab Imfinzi+claudin 18.2 zolbetuximab Vyloy Astellas SPOTLIGHT 1L OS 18,2m EOX epirrubicina+oxaliplatina+capecitabina+GLOW mFOLFOX OS 14,4m CLDN18.2+ \u226575% membrane+bemarituzumab FGFR2b 4-9% Five Prime FORTITUDE+dostarlimab Jemperli MMR-d+nivolumab+ipilimumab CheckMate-358.<\/p>\n","protected":false},"excerpt":{"rendered":"

PGRSS g\u00e1strica avan: HER2 + T-DXd + KEYNOTE + claudin 18.2. Veja.<\/p>\n","protected":false},"author":3,"featured_media":2325,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[2712,3164,3156,3165],"class_list":["post-2326","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance-legislacao","tag-cirurgia-oncologica","tag-gastrica-avancada","tag-t-dxd","tag-zolbetuximab"],"_links":{"self":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2326","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=2326"}],"version-history":[{"count":1,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2326\/revisions"}],"predecessor-version":[{"id":4385,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2326\/revisions\/4385"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media\/2325"}],"wp:attachment":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media?parent=2326"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/categories?post=2326"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/tags?post=2326"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}