The nutcracker syndrome is characterized by a group of clinical manifestations caused by compression of the Left Renal Vein. The main symptoms are: macro and micro hematuria, proteinuria, and flank pain. Diagnosis is usually made after excluding other causes, because there are no clinical criteria for diagnosis. Confirmation is by Doppler ultrasonography or computed tomography. Treatment can vary, depending on patient characteristics and the severity of the symptoms, while conservative treatment, open surgery, and endovascular surgery may be employed. Currently, open surgery is still the first-line treatment, but some less invasive approaches are gaining acceptance.  Certain reservations with regard to use of the terms “phenomenon” and “syndrome” should be noted. Although they are often treated as synonyms in the literature, “syndrome” should be reserved for cases in which the patient manifests symptoms, while “phenomenon” should be employed to refer to asymptomatic cases. , While the syndrome apparently affects a higher proportion of female patients, its exact prevalence remains unknown. This is not simply due to the condition’s rarity, but also to the wide variability of its symptomatic presentations. Reported cases involve patients with ages ranging from infancy to the seventh decade of life, with greater prevalence among young adults (20 to 30 years) and middle-aged adults. , Diagnosis is challenging and is generally made after exclusion of other more common causes, since there are no specific clinical diagnostic criteria.  For this review, the LILACS, MEDLINE, PubMed, and SciELO databases were used to identify publications from 2007 to 2017 in English, Spanish, and Portuguese. Search expressions were constructed using the terms Renal Nutcracker Syndrome, Stents, Hematuria, and Nephrectomy and combinations of them with the Boolean operator AND. A total of 84 articles published during the preestablished period and covering the subject were selected for the study, after exclusion of items that were in other languages or were published before 2007. After analytical reading of the article abstracts, 37 articles were considered directly related to diagnosis and treatment, and were then read in full for analysis of criteria   . ,, Presence of the clinical presentations described above, especially recurrent and isolated macroscopic hematuria, when present in young patients, should arouse a diagnostic suspicion.  A venous pressure gradient between the LRV and the inferior vena cava (IVC) ≥ 3 mmHg;  A five times increase in maximum flow velocity in the LRV as it passes the SMA, in relation to the renal hilum;  Computed tomography angiography or magnetic resonance angiography showing an angle between the aorta and the SMA of less than 45º.  The five times increase in flow velocity offers sensitivity of 80% and specificity close to 95% for nutcracker syndrome. , Computed tomography and magnetic resonance imaging (MRI) are additional methods, but in the past they were little used for diagnosis of nutcracker syndrome. ,, Nutcracker syndrome is a disease with variable severity and symptomatic presentation that reflect the degree of LRV compression, renocaval hypertension, and development of collateral circulation. ,,,,,,,, Conservative treatment is recommended for patients with discrete hematuria and mild symptoms. ,,,,, Adults should be monitored for at least 6 months before they are subjected to any procedures. This period is often sufficient for resolution of the condition in elderly patients with atypical and tolerable symptoms. ,,,,, The earliest descriptions of surgical interventions for nutcracker syndrome were published in the 1970s. Since then, a wide variety of techniques have been described. ,,,,,,,, Transposition of the LRV: this is the most common and effective surgery for treatment of anterior nutcracker syndrome and was first used for this purpose in 1982 by Stewart et al.. ,,, Left kidney autotransplantion: this is a highly invasive procedure consisting of nephrectomy and retransplantion of the kidney to the iliac fossa. ,,,,, Transposition of the SMA: this procedure comprises transposition of the SMA from its origin at the aorta and reimplantation at a point below the LRV, which is a more complex procedure when compared to venous transposition, but is a surgical option that requires little retroperitoneal exposure and reduces the risk of LRV thrombosis. , Nephropexy: a treatment method initially described in the 1980s.  Nephrectomy: this is the most radical of the surgical procedures and is recommended in cases in which hematuria persists after different therapeutic approaches, especially after transposition of the LRV.  Renocaval bypass: this technique employs the great saphenous vein to construct a bypass and does not require transposition of the LRV. , Transposition of the LGV: in this procedure the LGV is exposed via the transverse mesocolon, isolated, transected distally and reimplanted to the IVC below the inferior mesenteric vessels with interrupted sutures using 6.0 polypropylene thread. , Laparoscopic techniques have been increasing in popularity as minimally invasive surgery techniques improve.  A retroaortic LRV compressed between the spinal column and the abdominal aorta produces the same symptomology as the anterior variant of the syndrome. ,,,, Endovascular surgery is a form of intervention that is becoming ever more popular among specialists for treatment of vascular lesions, including nutcracker syndrome. ,, At least 150 successful cases of endovascular treatment have been reported in the medical literature.  Endovascular stent placement is an alternative treatment option. It is usually preferable to open surgery because of the long period of renal congestion, because of the greater likelihood of complications in these cases, and because of the need for extensive dissection in this type of operation. ,,,, The first report of using vascular endoprostheses to treat nutcracker syndrome dates from the 1990s. ,,,, The ideal stent should have enough radial strength to eliminate stenosis, good conformability to fit the epithelium of the vessel and little length shrinkage to enable adequate positioning. , Patients must take anticoagulant medication and antiplatelet drugs for 2 to 3 months, which is the time needed for complete endothelization of the stent. ,,, The principal complications of this intervention method include incorrect stent placement, device migration, partial displacement of the stent into the IVC, and migration to the renal hilum region of the LRV. , Even though the current literature suggests that the procedure is safe, caution is still needed, because the stent migration rate is 7.3% for all cases reported to date. The reasons for migration may be the effect of cardiac movements, activities too soon after surgery, incompatibility between the diameter of the LRV and the diameter of the stent, or incorrect positioning.  One type of stent that is mentioned little in the literature is the extravascular device. Compared to endovascular stents, it is a less invasive option, if the possibility of device migration is taken into account. Intravascular stents should be recommended with caution, especially when the patient is a child or adolescent, since the lumen of the LRV can increase in diameter and the device may no longer serve its purpose as physical development progresses. The extravascular device is an alternative option for maintaining the device in the correct position.  Once nutcracker syndrome has set in, one of its possible consequences is insufficient blood volume outflow from the LGV, causing a buildup of blood and dilatation of its walls, which can even lead to rupture.  Since its introduction in 1993, transcatheter embolization of the LGV has become the gold standard for treatment of pelvic congestion syndrome secondary to insufficiency of ovarian and pelvic veins. Several embolic agents have been described, including sclerosing foam, glue, vascular plugs, and coils. , The procedure is typically conducted via a femoral access, although jugular access can also be used.  According to the current literature, the decision on whether to treat one or both ovarian veins should be taken on the basis of the severity of symptoms, the degree of reflux through each ovarian vein, and the anatomy of pelvic varicosities. Clinical analysis and experience should be used to direct embolization therapy in conjunction with symptoms, anatomy, and functional studies.  Although rare, nutcracker syndrome is present in medical practice. It is therefore necessary to learn about it to be in a position to correctly diagnose and manage patients. Clinical findings and a high degree of diagnostic suspicion are decisive factors for establishing the ideal conduct, especially in patients who have not undergone imaging exams previously. There is a wide range of surgical options and only profound theoretical and practical mastery of these techniques enables the correct choice to be made for the various different types of patients with the syndrome. It is therefore evident that there is a need to improve underlying theoretical knowledge of nutcracker syndrome, which is the objective of this review.  nutcracker syndrome), entidade clínica rara, consiste na compressão da veia renal esquerda (VRE) pela artéria mesentérica superior (AMS) em sua passagem entre esta e a aorta abdominal (SQN anterior) ,,,, A síndrome de quebra-nozes (SQN)  e adultos de meia-idade , O diagnóstico é desafiador, geralmente feito após a exclusão de outras causas mais comuns, haja vista a ausência de critérios clínicos específicos de diagnóstico Renal Nutcracker Syndrome, Stents, Hematuria e Nephrectomy, bem como a combinação entre elas através do operador booleano AND. Selecionaram-se 84 artigos datados do período pré-estabelecido e que abordavam a temática deste estudo, excluindo-se aqueles que se apresentavam em outro idioma ou de épocas anteriores. Após leitura analítica com base nos resumos dos artigos, consideraram-se 37 trabalhos relacionados diretamente com diagnóstico e tratamento, que foram lidos na íntegra para análise dos critérios  ≥ 3 mmHg;  Aumento de cinco vezes na velocidade máxima do fluxo na VRE na passagem pela AMS em relação ao hilo renal;  Angiotomografia ou angiorresonância com ângulo entre a aorta e a AMS inferior a 45º  O aumento de cinco vezes na velocidade de fluxo corresponde a uma sensibilidade de 80% e uma especificidade próxima de 95% para SQN , A tomografia computadorizada e a ressonância magnética são métodos adicionais, porém pouco utilizados no passado, para o diagnóstico de SQN ,, A SQN é uma doença de gravidade e apresentação sintomática variável que reflete o grau de compressão da VRE, de hipertensão renocaval e de desenvolvimento colateral de circulação ,,,,,,,, É recomendado aos pacientes com hematúria discreta e pouco sintomáticos ,,,,, Em adultos, o acompanhamento deve ser de, ao menos, 6 meses antes da realização de qualquer procedimento. Frequentemente, esse período é suficiente para a resolução do quadro em pacientes idosos com sintomas atípicos e toleráveis ,,,,, As primeiras descrições de intervenções cirúrgicas para a SQN ocorreram na década de 1970. Desde então, uma ampla variedade de técnicas têm sido registradas ,,,,,,,, Transposição da VRE: é a cirurgia mais comum e efetiva para o tratamento de SQN anterior, aplicada primeiramente em 1982 por Stewart et al. ,,, Autotransplante do rim esquerdo: procedimento altamente invasivo que envolve nefrectomia e transplante renal para a fossa ilíaca ,,,,, Transposição da AMS: a transposição da AMS de sua origem aórtica para ser reimplantada em um ponto inferior à VRE, procedimento mais complexo de ser realizado se comparado à transposição venosa, é uma alternativa cirúrgica que possui pouca exposição retroperitoneal e reduz o risco de trombose da VRE , Nefropexia: modalidade terapêutica descrita inicialmente na década de 1980  Nefrectomia: é o mais radical dos procedimentos cirúrgicos, recomendado em casos de persistência da hematúria após diferentes formas de abordagens terapêuticas, especialmente após a transposição da VRE  Derivação renocaval: técnica que utiliza a veia safena magna como derivação sem a necessidade de transposição da VRE , Transposição da VGE: procedimento no qual a VGE é exposta via mesocolotransverso, isolada, transeccionada distalmente e reimplantada na VCI abaixo dos vasos mesentéricos inferiores com sutura interrompida com fio 6.0 de polipropileno , As técnicas laparoscópicas têm ganhado destaque com o avanço da tecnologia em cirurgia minimamente invasiva bypass renocaval em paciente com nutcracker. Entretanto, o PTFE não é recomendado como opção primária para esse procedimento devido ao risco precoce de trombose e infecção  A VRE retroaórtica, comprimida entre a coluna vertebral e a aorta abdominal, produz a mesma sintomatologia que a variante anterior da síndrome ,,,, A cirurgia endovascular tem sido uma forma de intervenção cada vez mais popular entre os especialistas para o tratamento de lesões vasculares, incluindo a SQN ,, No mínimo, 150 casos bem-sucedidos de tratamento endovascular já foram relatados na literatura médica  A colocação de stent endovascular é uma opção alternativa de tratamento. É usualmente preferível à cirurgia aberta devido ao longo período de congestão renal, por conta da maior possibilidade de complicações nesses casos, e à necessidade de extensa dissecção presentes nesse tipo de operação ,,,, O primeiro relato de uso de endopróteses vasculares para o tratamento da SQN data da década de 1990 ,,,, O stent ideal deve ter alta força radial para abolir a estenose, boa conformabilidade para se adaptar ao epitélio do vaso e pouco encolhimento no comprimento para permitir um posicionamento adequado , Faz-se necessário que os pacientes utilizem medicamento anticoagulante e antiagregante plaquetário durante 2 a 3 meses, período necessário para que ocorra a endotelização completa do stent ,,, As principais complicações desse meio de intervenção incluem colocação incorreta do stent, migração do dispositivo, deslocamento parcial do stent para a VCI e migração para a região do hilo renal da VRE , Mesmo que a literatura atual sugira que esse procedimento seja seguro, é necessário cautela, pois a taxa de migração do stent é de 7,3% em todos os casos já relatados. A razão da migração pode ser o efeito do movimento cardíaco, atividades muito precoces após a cirurgia, incompatibilidade entre o diâmetro da VRE e o diâmetro do stent, ou posicionamento incorreto  Uma forma de stent pouco presente na literatura é o extravascular. Comparado ao stent endovascular, é uma modalidade menos invasiva, se for levada em consideração a possibilidade de migração do dispositivo. Especialmente quando os pacientes são crianças e adolescentes, o stent intravascular deve ser recomendado com cautela, pois a luz da VRE pode aumentar de diâmetro e o aparelho não servir mais durante o desenvolvimento físico. A modalidade extravascular é uma forma alternativa de manter o dispositivo no seu devido lugar coils) para o pulmão  Uma vez que a SQN se instala, uma de suas possíveis consequências é a drenagem insuficiente do volume sanguíneo da VGE, ocorrendo acúmulo de sangue e dilatação de suas paredes, podendo resultar em seu rompimento plugs vasculares e molas  Desde sua introdução em 1993, a embolização transcateter da VGE se tornou o padrão-ouro no tratamento de síndrome da congestão pélvica secundária à insuficiência de veias ovarianas e pélvicas. Diversos agentes “embolizadores” foram descritos, como espuma esclerosante, cola, , O procedimento é tipicamente feito via acesso femoral, embora o acesso jugular também possa ser utilizado  A partir da literatura atual, a decisão quanto a tratar uma ou ambas as veias ovarianas deve depender da gravidade dos sintomas, do grau de refluxo em cada veia ovariana e da anatomia das varicosidades pélvicas. A análise clínica e a experiência devem ser utilizadas para guiar a emboloterapia em conjunto com sintomas, anatomia e estudos funcionais  Apesar de rara, a SQN está presente na prática médica. Faz-se necessário, portanto, o seu conhecimento para a realização de correto diagnóstico e manejo do paciente. Os achados clínicos e a alta suspeição diagnóstica são fatores decisivos para o estabelecimento da conduta, especialmente em pacientes que não realizaram exames de imagem previamente. As opções cirúrgicas são amplas e apenas o domínio aprofundado teórico-prático dessas técnicas permite a escolha correta diante dos diferentes tipos de pacientes portadores da síndrome. Sendo assim, torna-se evidente a necessidade de fortalecer os conhecimentos teóricos embasados em SQN, tal como realizado nesta revisão.


Pulmonary sequestration is a congenital anomaly defined as a nonfunctioning mass of lung parenchyma. Presence of an independent pleural envelope classifies it as intralobar, accounting for approximately 75% of the cases, while absence classifies cases as extralobar, accounting for the remaining 25%. Diagnosis is made through radiography and confirmed by computed tomography, magnetic resonance, or angiography. The traditional treatment is open surgical repair, but endovascular techniques have been used, with good results. We report the case of a 29-year-old-woman presenting with recurrent pneumonia for 5 years. A CT scan of the chest revealed poor vascular formation in the lower region of the right lung. The pulmonary sequestration was treated by embolization of the anomalous branch.  The most common malformations include cystic adenomatoid malformation, pulmonary sequestration, congenital lobar emphysema, bronchogenic cysts, and pulmonary arteriovenous malformations. - Pulmonary sequestration is thus a rare congenital anomaly. It consists of a non-functional mass of pulmonary parenchyma that does not communicate with the normal tracheobronchial tree and which receives its blood supply from an anomalous systemic artery, generally from the descending aorta, although other sources of arterial supply are possible. Drainage may be via systemic veins or pulmonary veins. --, The malformation can be classified as one of two distinct forms, intralobar or extralobar, on the basis of whether it has its own pleural envelope. -,- In extralobar pulmonary sequestration, the sequestrated region is surrounded by its own pleural envelope, accounting for the remaining 25% of cases of this type of pulmonary malformation. , This type of malformation may initially be identified on chest X-ray as a homogeneous opaque mass. Diagnosis is confirmed using chest CT, magnetic resonance imaging, or arteriography, the last of which is the best diagnostic method. -, The classic treatment for pulmonary sequestration is surgical resection of the sequestrated lobe or segment by thoracotomy or videothoracoscopy.  This article describes a case of pulmonary sequestration and presents an endovascular method for treatment of the comorbidity.  The patient was a 29-year-old female telemarketing operative, born and resident in São Paulo, Brazil, who was referred to a pulmonologist with a diagnosis of recurrent pneumonia. She reported symptoms of dyspnea in response to moderate effort, both during non-acute periods and during crises. Her previous medical history included episodes of recurrent pneumonia associated, initially, with dyspnea, coughing, chest pain, and fever from 5 years of age onwards. She had often presented at walk-in clinics, which treated her with antibiotics, achieving temporary resolution.  She stated that more recent crises had consisted of dyspnea only, with no fever, hemoptysis, chest pain, or coughing. She also stated that she did not smoke or drink. She was sedentary and her diet was regular. She denied any type of family history of pulmonary pathologies. Examinations requested as part of investigation included tomography with contrast and angiotomography   and 2 . Under local anesthesia with sedation, the patient was placed in dorsal decubitus. The right femoral artery was punctured, followed by catheterization of the anomalous artery branch   . A micr The patient recovered well and was discharged at the end of the day after the operation. She is in outpatients follow-up with a pulmonologist and has been asymptomatic for 1 year, with no further pneumonia crises. , The first description of an anomalous pulmonary artery deriving from the aorta was written by Hubber, in 1777. In 1861, Rokitansky and Rektorzik described cases that appear to have been extralobar pulmonary sequestration, but the term “sequestration” was only proposed by Pryce in 1946 and, since then, the finding has been recognized as a clinical entity.  Two types of presentation of pulmonary sequestration are described in the literature: extralobar, in which there is total anatomic separation from the adjacent normal pulmonary parenchyma, and intralobar, in which the anomalous pulmonary segment is contiguous with the adjacent normal lung. ,, Pulmonary sequestration can be difficult to diagnose, since the symptoms it causes, such as dyspnea, respiratory infections, hemoptysis or, less frequently, chest pain, can be present in more common clinical conditions, including typical pneumonias or tuberculosis. The pathology may be identified in the prenatal period, during the second trimester, by examinations such as Doppler ultrasonography. , In children and adults, other imaging exams can be used, such as helical computed angiotomography of the chest, aortography and, if doubt remains, arteriography. It is worth pointing out that, although uncommon, the high blood flow from a vessel of the aorta may lead to an erroneous diagnosis of primary heart valve disease. The principal conditions to be ruled out during differential diagnosis include congenital or acquired pulmonary cyst, tumors of the posterior mediastinum, Bochdalek hiatus hernia, and congenital cyst of the diaphragm. -,-, The most common treatment for symptomatic cases of sequestration is surgical resection of the pulmonary parenchyma involved, whether lobe (lobectomy) or segment (segmentectomy).  An alternative treatment that has been described little in the literature, but which is increasingly popular in medical practice, is embolization of the anomalous vessel supplying the sequestrated pulmonary region, causing progressive infarction of the anomalous pulmonary tissue. Although this approach is still in development, it is a treatment option with promising characteristics in comparison with the surgical procedure described as ideal by the majority of authors. Surgery is an invasive process with a long recovery period and higher risk of infections, whereas embolization is minimally invasive, has a short recovery time, involves a lower risk of complications, and, as such, is less morbid. Certain effects, such as localized pain, nausea, and coughing may occur, but they are minimal when compared with the effects caused by surgery. In the case described here, we observed good results from this new procedure for patients with pulmonary sequestration.  - As malformações pulmonares, embora classificadas em patologias distintas, formam um conjunto de anomalias que possuem manifestações clínicas muito semelhantes e que se originam a partir de falhas no desenvolvimento embrionário. Entre as malformações mais comuns, podemos citar a malformação adenomatoide cística, o sequestro pulmonar, o enfisema lobar congênito, os cistos broncogênicos e as malformações arteriovenosas pulmonares - O sequestro pulmonar é, portanto, uma anomalia congênita rara. Trata-se de uma massa de parênquima pulmonar não funcionante, sem comunicação com a árvore traqueobrônquica normal e que possui o suprimento sanguíneo advindo de uma artéria sistêmica anômala, sendo realizado, geralmente, pela artéria aorta descendente, embora possa haver outras fontes de suprimento arterial. Já sua drenagem pode ser realizada tanto por veias sistêmicas quanto por veias pulmonares --, Essa malformação pode ser classificada em duas formas distintas, dependendo da existência de um envoltório pleural próprio, denominadas intra e extralobar -,- Já o sequestro pulmonar extralobar ocorre quando a região sequestrada está revestida por um envoltório pleural próprio, representando 25% dos casos desse tipo de malformação pulmonar , Esse tipo de malformação pode ser inicialmente identificado na radiografia de tórax como uma massa de opacidade homogênea. A confirmação diagnóstica é realizada com tomografia de tórax, ressonância nuclear magnética ou arteriografia, sendo este último o melhor método diagnóstico -, O tratamento clássico do sequestro pulmonar é a ressecção cirúrgica do lobo ou do segmento sequestrado por toracotomia ou videotoracoscopia  O presente trabalho relata um caso de sequestro pulmonar e apresenta o método endovascular como forma de tratamento para tal comorbidade.  Paciente do sexo feminino, 29 anos, operadora de telemarketing, natural e procedente de São Paulo, foi encaminhada ao pneumologista com diagnóstico de pneumonia de repetição. Referiu sintomatologia de dispneia por esforços moderados tanto no período intercrítico quanto durante as crises. Na história médica pregressa, a paciente relatou episódios de pneumonia de repetição associada, inicialmente, a dispneia, tosse, dor torácica e febre desde os 5 anos de idade. A paciente procurou diversas vezes o pronto-atendimento, e a conduta clínica foi antibioticoterapia com resolução temporária dos eventos.  A paciente referiu que as crises tardias apresentaram apenas dispneia, negando febre, hemoptise, dor torácica e tosse. Negou tabagismo e etilismo. Apresentou-se sedentária e com alimentação regular. Como antecedentes familiares, negou qualquer patologia pulmonar. Foram solicitados exames complementares para ajudar a elucidar o caso, incluindo tomografia contrastada e angiotomografia   e 2 . A©, procedente de Raynham, Estados Unidos da América, para embolização do ramo  ou segmento (segmentectomia)  Outro tratamento pouco descrito na literatura, mas que vem ganhando espaço na prática médica é a embolização do vaso anômalo, provedor da área pulmonar sequestrada, que ocasiona infarto progressivo do tecido pulmonar anômalo. Apesar de ser uma abordagem ainda em desenvolvimento, essa terapêutica possui características promissoras em relação ao procedimento cirúrgico, retratado como ideal pela maioria dos autores. Enquanto a cirurgia é um processo invasivo com maior período de recuperação e maior risco de infecções, a embolização é minimamente invasiva, propicia um curto período de recuperação e envolve menor risco de complicações, sendo assim menos mórbida. Alguns efeitos como dores locais, náuseas e tosse podem aparecer, mas são mínimos quando comparados aos efeitos causados por uma cirurgia. Através do caso relatado, notamos os bons resultados desse novo procedimento em pacientes que apresentam sequestro pulmonar.


Obesity has reached pandemic proportions in recent years. Not only adults suffer from the disease, but increasingly children and young people. One of the main causes of overweight and obesity is excessive food intake, in particular heavily processed carbohydrates. Obesity alters multiple organs, including the salivary glands, bringing functional alterations with it. Among researchers, the relation between obesity and tooth decay, periodontal disease and xerostomia is being debated. More and more scientific reports are drawing attention to the changes in the microflora of the oral cavity during obesity. All changes are closely related to the morphological and functional alterations of the salivary glands. This article review presents the current points of view regarding the impact of obesity on the health of the salivary glands, and how changes their functions influence other structures in the oral cavity. To date, the results observed differ in the possible effect of obesity on the morphology and function of the salivary glands, although its relation to several oral pathologies has been reported, such as tooth caries periodontitis and xerostomia, The aim of this article is to present an up-to-date review of the impact obesity has on the health of the salivary glands as well as on other tissues in the oral cavity that are closely related to salivary function. and antioxidants can play a key role in the development of pathologies in the salivary glands ,In models of obesity induced in animals by monosodium glutamate (MSG), a significant increase in the content of substances reactive to thiobarbituric acid and a significant reduction in the activity of superoxide dismutase and catalase have been observed, which suggest an imbalance in the pro-oxidant and antioxidant systems and the onset of oxidative stress, Additionally, oxidative stress has been linked to obesity and cancer, which combined with angiogenesis, chronic inflammation, and the interaction of proinflammatory cytokines, as well as hormones and adipokines  may be involved in altering the cellular metabolism, contributing to tumor development and progression et al. , which is linked to dental caries, reinforcing even more the negative effect of obesity on oral health. Based on the above, the proinflammatory cytokines derived from adipocytes and macrophages that have accumulated in the adipose tissue can negatively affect the function of the salivary glands due to low-grade chronic inflammation in the gland ,et al. and waist circumference presented a lower prevalence of caries (p <0.05) . .On the other hand, the inverse relation between caries and obesity/overweight Salivary function is reduced in patients with obesity and overweight, which could affect the course of dental caries. There are many studies carried out in which a relationship between obesity and dental caries is established, other authors indicate that being pathologies that coexist over time and share etiological factors, this relationship could not be established, due to the multifactorial nature of dental caries. The decrease in flow and salivary quality in obese patients is clear, which undoubtedly will cause some effect in the process of remineralization, an important factor in the progression of dental caries. The need for more studies, both experimental and prospective, could help explain this association.,Healthy human microbiota is largely composed of microorganisms Porphyromonas gingivalisTannerella forsythia in subgingival biofilm has been described in obese subjects et al. . Possible causes of how obesity affects the periodontal tissues may be due to the secretion of proinflammatory cytokines from the fatty tissue -et al. , evaluating the needs for periodontal treatment, demonstrated a positive correlation between the exacerbation of the symptoms that indicate a significant progression of periodontal disease and the increase in body weight measured by the BMI. Although in experimental studies of periodontitis induced in animals, it was noted that there were no significant differences in the loss of alveolar process bone between obese and normal animalsThere is sufficient evidence to the association between obesity and periodontal disease is establish a significant positive association between the two et al. p <0.05). The Visible Plaque Index (VPI) was similar between the two groups (p >0.05). Bleeding on probing was greater in obese patients than in children with normal weight (p <0.05), which may indicate that obese children are more predisposed to periodontal disease. Similar results were found by Scorzetti et al. .For their part, Zuza Obesity and its important inflammatory component undoubtedly contribute to increasing the severity and sequelae of periodontal disease. As previously described, there are many studies that describe the positive association between overweight/obesity and periodontal disease, mainly due to the constant action of chemical mediators secreted from the fatty tissue in the oral cavity, which creates a general pro-inflammatory environment and contributes to an increase in periodontal disease. This is added to the decreased salivary secretion, which plays an important anti-bacterial and anti-inflammatory role locally.This review describes the main underlying mechanisms around the influence of obesity on the morphology and function of the salivary glands, and how these alterations impair the functioning of other components of the oral cavity, being associated with pathologies of high prevalence such as caries and periodontal disease. Given the increase in the prevalence of the population with overweight/obesity all over the world, these are important aspects to consider.The background presented should induce cooperation between physicians and dentists to increase awareness about health and improve the conditions of the oral cavity in patients with obesity and overweight.More research is needed in this area, given how few morphological, ultrastructural and functional studies there are regarding the obesity-related changes that occur in the structures of the oral cavity, particularly in the salivary glands. These morphofunctional studies together with studies focusing on other aspects would make it possible to design new pharmacological therapies that would help mitigate the effects caused by obesity on the oral cavity.  --La obesidad es una enfermedad crónica reconocida como una epidemia global extendida tanto en países desarrollados como en vías de desarrollo -,,La creciente prevalencia de la obesidad representa una amenaza importante para la salud pública, debido principalmente a comorbilidades tales como la diabetes tipo 2, las enfermedades cardiovasculares y ciertos tipos de cáncer ,-Una de las principales estructuras afectadas por la obesidad y sus comorbilidades son las glándulas salivales, quienes son las responsables de la secreción de una serie de enzimas, factores de crecimiento necesarios para el equilibrio biológico de la cavidad oral, así como para la protección de ésta. Hasta ahora los resultados observados difieren en el posible efecto de la obesidad ante la morfología y función de las glándulas salivales, aunque ha sido reportada su relación con diversas patologías orales, tales como caries, periodontitis y xerostomía El objetivo de este artículo es presentar una revisión actualizada del impacto que tiene la obesidad en la salud de las glándulas salivales, así como en otros tejidos de la cavidad oral que están estrechamente relacionados con la función salival.et al. reportaron una disminución en el peso de las glándulas salivales en ratas con obesidad inducida por daño hipotalámico, resultados interpretados como una alteración que induciría disminución en la actividad de los nervios simpáticos et al. Estudios de obesidad realizados en modelos animales, han evidenciado ciertas alteraciones en diversos órganos, entre ellos las glándulas salivales. Inoue et al.Si bien no hay suficientes estudios que relacionen obesidad con alteraciones de las glándulas salivales, otras patologías asociadas a obesidad, muestran alteraciones a nivel de las mismas. Lilliu ,et al.  Recientemente se ha visto que un desequilibrio entre los niveles de especies reactivas de oxígeno (ROS) y antioxidantes pueden jugar un rol clave en el desarrollo de patologías en las glándulas salivales ,En modelos de obesidad inducida por glutamato monosódico (GMS) se ha observado un aumento significativo del contenido de sustancias reactivas al ácido tiobarbitúrico y una disminución significativa en la actividad de la superóxido dismutasa y la catalasa, lo cual indica el desequilibrio de los sistemas prooxidantes y antioxidantes y el desarrollo de estrés oxidativo Adicionalmente, el estrés oxidativo se encuentra relacionando obesidad y cáncer, las que junto a la angiogénesis, inflamación crónica, y la interacción de citocinas proinflamatorias, además de hormonas y adipoquinas  estarían implicados en la alteración en el metabolismo celular, participando en el desarrollo y progresión tumoral et al. vs 2.0 mL/min, p <0.001), asociándose con caries, fortaleciéndose aún más el efecto negativo de la obesidad sobre la salud oral. En base a esto, las citoquinas proinflamatorias derivadas de adipocitos y macrófagos que se han acumulado en el tejido adiposo pueden afectar negativamente a la función de las glándulas salivales debido a la inflamación crónica de bajo grado en la glándula ,et al.Con respecto al flujo salival, Modéer Con respecto a las características de la saliva, las personas obesas presentan cambios en la concentración de ácido siálico, fósforo y actividad de la peroxidasa, así como un menor flujo de saliva estimulada, esto se encuentra íntimamente relacionado con caries y enfermedad periodontal, indicando que hay suficiente evidencia para afirmar que la saliva de sujetos obesos y no-obesos es diferente Al analizar concentraciones totales de distintos componentes salivales, se encontró que las concentraciones de proteína total, amilasa, urea, fosfato, triglicéridos y calcio, fueron similares entre saliva estimulada y no estimulada en niños con peso normal, sobrepeso y obesos. Sin embargo, las concentraciones de urea, fosfato y calcio difirieron significativamente entre la saliva estimulada y no estimulada, de los grupos de peso normal y obesos, con los valores más bajos para la saliva estimulada Las glándulas salivales y la saliva desempeñan un papel importante en el mantenimiento de la salud bucal, ayudando a desarrollar y mantener la salud de los tejidos blandos y duros. Cuando se reduce el flujo de saliva, pueden desarrollarse problemas de salud bucal, como caries e infecciones orales.--et al. et al.. Posibles causas de cómo afecta la obesidad a los tejidos periodontales, estaría dado por la secreción de citoquinas proinflamatorias, desde el tejido adiposo -et al. 2 aumentó en más del cuatro veces el riesgo de periodontitis. Otros estudios japoneses que analizaron el estado periodontal mediante el índice CPITN , evaluando las necesidades de tratamiento periodontal, demostraron una correlación positiva entre la exacerbación de los síntomas que indican una progresión significativa de la enfermedad periodontal y el aumento del peso corporal medido por IMC. Aunque en estudios experimentales de periodontitis inducida en animales, se vio que no hubo diferencias significativas en la pérdida de hueso proceso alveolar entre los animales obesos y normales Con respecto a la asociación entre obesidad y enfermedad periodontal, existe suficiente evidencia para establecer una asociación positiva significativa entre ambas et al., en comparación con sujetos de peso normal (p <0.05). El índice de placa visible (Visible Plaque Index VPI) fue similar entre ambos grupos (p >0.05). El sangrado al sondeo fue mayor en pacientes obesos que en niños con peso normal (p <0.05), lo que estaría indicando que los niños obesos parecen ser más susceptibles a la enfermedad periodontal. Resultados similares a los encontrados por Scorzetti et al.et al. (p <0.05). Por su parte Zuza La obesidad y su importante componente inflamatorio contribuyen, sin duda, a aumentar la gravedad y las secuelas de la enfermedad periodontal. Como se describió anteriormente, hay muchos estudios que describen la asociación positiva entre el sobrepeso / obesidad y la enfermedad periodontal, principalmente debido a la acción constante de los mediadores químicos secretados por el tejido graso en la cavidad oral, lo que crea un ambiente proinflamatorio general y contribuye A un aumento de la enfermedad periodontal. Esto se agrega a la disminución de la secreción salival, que desempeña un importante papel antibacteriano y antiinflamatorio a nivel local.Esta revisión describe los principales mecanismos subyacentes en torno a la influencia de la obesidad en la morfología y la función de las glándulas salivales, y cómo estas alteraciones afectan el funcionamiento de otros componentes de la cavidad oral, y están asociadas a patologías de alta prevalencia, como caries y enfermedad periodontal. Dado el aumento en la prevalencia de la población con sobrepeso / obesidad en todo el mundo, estos son aspectos importantes a considerar.El fondo presentado debería inducir la cooperación entre médicos y dentistas para aumentar la conciencia sobre la salud y mejorar las condiciones de la cavidad oral en pacientes con obesidad y sobrepeso.Se necesita más investigación en esta área, dado que existen pocos estudios morfológicos, ultraestructurales y funcionales con respecto a los cambios relacionados con la obesidad que ocurren en las estructuras de la cavidad oral, particularmente en las glándulas salivales. Estos estudios morfofuncionales junto con estudios que se centran en otros aspectos permitirían diseñar nuevas terapias farmacológicas que ayudarían a mitigar los efectos causados por la obesidad en la cavidad oral.


Cancer is a burden in the world, especially for the least developed countries. The Population Registries of Cancer are fundamental in order to know the territorial profiles of cancer, and to evaluate the impact of their control programs. To estimate the incidence and mortality from cancer in the Metropolitan Area of Bucaramanga in the period 2008-2012. A descriptive population study of cancer incidence and mortality in the Metropolitan Area of Bucaramanga was conducted. Primary invasive cancer cases from the 2008-2012 period was obtained from the RPC-AMB base. Population and death data were provided by the National Administrative Department of Statistics . Crude rates of global and specific incidence and mortality were estimated by sex, and standardized incidence and mortality rates.  During the five-year period, 8,775 incidents of cancer were recorded (excluding non-melanoma skin cancer). The global standardized incidence rates per 100,000 person-years were 151.7 in men and 157.2 in women. The main locations were prostate, stomach and colorectal, in men; breast, thyroid and colorectal in women. The standardized mortality rate per 100,000 person-years was 94.8 in men and 78.0 in women. The incidence and mortality rates in most locations are lower than the national ones and those in the previous quinquennium in the Metropolitan Area of Bucaramanga. Thyroid cancer, colorectal cancer, and leukemia show a tendency to increase, which demands further investigation.  The burden of cancer is increasing in less developed countries, from which about 57% of the new cases come up as well as 65% of the deaths caused by this disease. It is estimated that 48% of prevalent cases of cancer at five years of diagnosis occur in the regions with less economic development ,,The incidence of cancer is increasing. It is expected that by 2025, there will be more than 20 million new cases, and a greater burden in low and middle income countries To generate impact on the reduction of the problems generated by this disease, the World Health Organization (WHO) promotes the creation of effective programs that improve early detection, timely diagnosis, and a specific and effective treatment It also leads cancer control programs with the promotion of national cancer control policies, plans and programs. One of the strategies has been the promotion, establishment and strengthening of the monitoring and evaluation of this disease through registries, as well as research aimed at the burden of the disease, as well as increasing the availability of resources for its care ,Population Cancer Registries  are essential information systems for cancer control programs; these allow determining frequencies, incidences, mortality and trends, which are the result of activities aimed at collecting, analyzing and continuously disseminating information on cancer cases that occur in a specific population, with guarantee of the quality of the data  ,In Colombia there are four RPC with international recognition. One of these is the Population Registry of Cancer of the Metropolitan Area of Bucaramanga (RPC-AMB), which has managed to consolidate a continuous work during 18 years of operation With the leadership of the Ministry for Health and Social Protection, the National Cancer Information System was set up and the National Cancer Observatory for Colombia was created, led by the National Cancer Institute of Colombia , in order to know the territorial profile and evaluate the impact of cancer control programs This study describes the total and specific incidence and mortality rates by sex, corresponding to the Metropolitan Area of Bucaramanga during the period 2008-2012.A descriptive population study was proposed, with the incident cases of invasive cancer registered in the databases of the RPC-AMB in the quinquennium 2008-2012.2. Each municipality is independent in its political organization, but they are completely related from an economic and social perspective Metropolitan Area of Bucaramanga is a geographical area made up of four municipalities in the province of Santander: Bucaramanga , Floridablanca, Girón and Piedecuesta. It is located in the Andean region and it has an area of 1,479 kmAccording to population projections of DANE, AMB had 1,074,000 inhabitants at the middle of the 2008-2012 period ; 94.3% were urban residents, 51.9% were women, 24.5% were aged under 15 years, and 20.4% were older than 50 years AMB is an important reference center for the care of cancer patients in the northeastern part of the country, with state  and private institutions  that provide various oncological services for diagnosis and treatment.. The economic resources are assigned in the research calls of the university, and it receives annual co-financing from the INC.RPC-AMB has carried out permanent activities since April 2000, as a result of the commitment assumed by La Universidad Autónoma de Bucaramanga)RPC-AMB makes active collection of incident cases through periodic visits to information sources: pathology and hematology laboratories, hospital discharges, imaging centers, screening centers, volunteer programs, oncology centers, medical specialists, autopsies and certificates of deaths that are obtained in the Provincial Health Secretariat. A recordable case is any malignancy of any location including benign neoplasms of the Central Nervous System (CNS) and carcinomas in situ that have been diagnosed after January 1 of the year 2000 in residents of AMB, both in urban and rural areas, regardless of the diagnostic method used, so that cases identified by death certificate are also included. It excludes non-melanoma skin cancer .The cases obtained by hospital discharge and death certificates follow a process of verification of the diagnosis, through the search of the clinical history. When no additional information is obtained from the case obtained by the death certificate, it is recorded as a case identified only by its death certificate (death certificate only - DCO).,The coding of cancer cases is carried out under the supervision of the RPC Director, by personnel trained in the International Classification of Diseases for Oncology (ICD-O) - 3rd edition, 1st revision, published by the World Health Organization (WHO) ) in 2013, and the IARC criteria for multiple primary tumors ,RPC-AMB complies with confidentiality standards following the parameters of the IARC and the research commitment ethics. Only the staff of RPC-AMB accesses the information of each case, which allows exhaustive work in the control of the duplicity of the information The source of information on deaths was DANE, the official entity that collects, organizes and codifies the basic causes of mortality using the tenth revision of the International Classification of Diseases (ICD 10) ,The CanReg5 program ©, version 5.00.42, software created by the International Agency for Research on Cancer (IARC), in collaboration with the International Association of Cancer Registries (IACR), available for free all members of the IACR For the estimation of the incidence rates, the population of the AMB of the study period, projected by DANE, was used as the denominator. Crude and standardized rates were calculated by direct method using the global standard population proposed by Segi and corrected by Doll p <0.0001).During the 2008-2012 quinquennium, there were 8,775 incident cases of cancer in AMB (excluding non-melanoma skin cancer); (57.2%) occurred in women, (84.2%) were verified by microscopy , (7.6%) were detected only by death certificate, and (7.2%) by clinical history . The perp <0.0001). The location of the most frequent malignant tumors in women were breast (26.1%), colorectal (9.1%), thyroid (9.1%), cervix (8.3%) and stomach (6.9%). In men, the most frequent cancers were: prostate (26.1%), stomach (11.4%), colorectal (9.4%), trachea bronchi and lung (6.7%), lymphoma and myeloma (6.2%) (The average age at diagnosis was 57.3 years in women and 61.8 years in men (a (6.2%) . Rates are expressed per 100,000 persons-years. The cancer incidence rate standardized by age was 151.7 in men, and 157.2 in women. The standardized rates of the five most frequent cancers in men were prostate (40.9), stomach (17.1), colorectal (14.3), lung (10.3) and lymphoma (9.1). In women, they were breast (41.2), thyroid (14.5), colorectal (13.7), cervix (13.0) and stomach (10.2).In women, the five tumor sites with a percentage of microscopic diagnosis greater than 95.2% were: thyroid, lymphoma, leukemia, kidney and breast. In men, they were skin melanoma, leukemia, lymphoma, bladder and thyroid. The type of cancer with the highest percentage of diagnosis by death certificate was: liver (31.9% in women and 35.6% in men), pancreas (31.1% in women and 33.3% in men) and lung (23.5% in women and 21.9% in men).The behavior of the age-specific incidence of the two most frequent types of cancer in women is different. Breast cancer rises sharply since the end of the third decade of life, reaching its peak at around 70 years of age; in contrast, the incidence of thyroid cancer begins in the middle of the second decade of life, and reaches its peak at around 55 years of age, with a magnitude 60% lower than that of breast cancer at this age . In men,During the 2008-2012 quinquennium, of 24,860 deaths registered in AMB, 4,998 (20.1%) corresponded to malignant neoplasms; 50.2% occurred in women. For the general population, the mortality rate standardized by cancer was 84.6 per 100,000 persons-years. The most frequent cancers were: stomach (13.9%), lung (11.4%), colorectal (9.0%), breast (7.1%), prostate (6.0%), leukemia (5.3%), liver (5.1%), lymphoma (5%), cervix (3.8%) and pancreas (3.5%).Women had a standardized mortality rate by age of 78.0 per 100,000 women-year. The cancers that caused the greatest number of deaths were breast (13.3%), stomach (11.8%), colorectal (9.4%), lung (8.7%), cervix (7.1%), liver (4.8%), leukemia and lymphomas. (4.7% each). In men, the mortality rate standardized by age was 94.8 per 100,000 men-year, cancers of stomach (15.9%), lung (14.1%) and prostate (12.4%), colorectal (8.0%), liver (5.4%), leukemia (6.0%) and lymphoma (5.4%)  . This study presents the results of cancer incidence and mortality in the quinquennium 2008-2012, thus providing continuity with the data for the 2003-2007 quinquennium In the interpretation of data, it is important to bear in mind that the classification of the cases used in the current study was based on the first revision of the ICD-O-3, which includes changes in the codes related to the behavior of some tumor lesions and morphological codes of hematolymphoid and central nervous system neoplasms, which were not taken into account in the analysis of the previous quinquennium.When compared with the 2003-2007 quinquennium, the average age at diagnosis moment was similar for both sexes. The total number of new cases (excluding non-melanoma skin cancer) increased 6.7%, as well as the percentage representation of women, which went from 54.3% to 57.2%. However, the overall incidence rate in men and women decreased, especially in men, because the male/female ratio (m/f) was 1.0, showing a behavior contrary to that reported by the Population Registry of Cali Cancer  for the same period (ratio m/f of 1.1) The standardized rates of incidence in the 2008-2012 period in AMB were lower than those reported by RPCC in the same period Breast cancer was the most frequent in women from AMB, with percentage representation and standardized incidence rate similar to those of the previous quinquennium  According to the estimates of the National Health Observatory  in Colombia for the year 2012, breast cancer, followed by cervical cancer, continued to have the highest incidence in women, with magnitudes higher than those of AMB ; while cancer of the colon, rectum and anus , thyroid cancer  and stomach cancer  had lower rates. Particularly, the latter showed a marked downward trend in the country during the 2010-2014 period In men, the order of the five cancers with the highest incidence remains the same from one quinquennium to another; all but colorectal cancer showed a decrease in the standardized incidence rate compared to the quinquennium 2003-2007 In relation to mortality, the profile of AMB is similar to the quinquennium 2003-2007, although with lower rates in most locations; especially stomach cancer, which decreased particularly in men, from 20.1 to 15.2 per 100,000 men- year. In contrast, the death rate for colorectal cancer increased in men, as did the mortality rate from leukemia, which increased in men and women, with mortality in the period 2008-2012 being 2.4 times higher than in the previous quinquennium The outlook in AMB contrasts with that of the country, which according to ONS calculations had higher standardized mortality rates and a tendency to increase in several locations. However, mortality from leukemia showed an opposite behavior compared to the national estimate for 2012, with AMB reaching a 46.5% higher rate in men and 70.5% higher in women in the 2008-2012 quinquennium. Unlike the behavior of the country, whose mortality from cancer of the colon, rectum and anus increased in men and women during the quinquennium 2010-2014, in AMB this behavior was only observed in men The behavior of the country reflects the double burden of cancer faced by the Central and South America regions, which manifests in high rates of cancer related to infection  and an increase in cancers related to lifestyle , the latter ones possibly have to do with aspects of economic development, such as the increase in the age of first pregnancy, lower parity, smoking and alcohol consumption, diets poor in fruits and vegetables , obesity and physical inactivity Although in several locations of tumors, AMB has lower incidences compared to the total population of the country, here the double burden is also appreciated. In addition, the magnitude of colorectal cancer and its tendency to increase in both sexes is noteworthy, as well as the high frequency of stomach cancer and the increased incidence of thyroid cancer in women. Also, although the risk of dying from cancer is lower in AMB than in the rest of the country for almost all locations, and it was lower than in the previous quinquennium, the increase in mortality from colon cancer and rectum in men, and from leukemia for both sexes is significant.This profile raises more attention to the prevention of colon and rectum cancer in AMB, where the magnitude of the incidence is similar for both sexes, unlike what happens in much of the world. This type of cancer shares with breast cancer several prevention measures, such as the maintenance of body weight, increased physical activity and decreased consumption of alcohol, red and processed meats, and tobacco ,It should be noted that the prevalence of overweight or obesity in the province of Santander is 50.1%, higher in men, although abdominal obesity is higher in women (46.6% versus 40.11%), the consumption of fruits and vegetables is very low (94.9% did not reach the recommended daily consumption) Improving and promoting equity at all preventive levels in relation to stomach cancer is also a priority for AMB, especially when marked socio-economic inequalities have been documented in the survival of patients, despite the existence of the "universal" system of social security in health With regard to thyroid cancer, this presents an increase on incidence rates similar to the data reported for several regions of the world and the country. In some countries such as the United States, the increase in incidence rates was recorded three decades ago due to a greater use of diagnostic methods such as ultrasound, which allowed them to find very small nodules that would probably go unnoticed for a long time; that is, the relative increase in incidence could be influenced by the diagnosis.Finally, the behavior of hematolymphoid neoplasms, especially in leukemia, with mortality rates that have doubled the rates of the previous quinquennium in our region, raises concerns about the factors that have impacted this marked increase in mortality rates. It is important to explore modifiable factors, especially those that have been associated with barriers in the health care of patients with cancer, such as administrative, economic and cultural factors, with delays in the opportunity for diagnosis and treatment This study presents the magnitude of cancer in the Metropolitan Area of Bucaramanga during the quinquennium 2008-2012, comparatively with the quinquennium 2003-2007. Positive behaviors are revealed for several cancers, which show a decrease in the incidence of one quinquennium to another, or magnitudes lower than those of the country; however, the magnitude and tendency to increase in colorectal cancer for both sexes is to significant, as well as the high frequency of stomach cancer, and the increased incidence of thyroid cancer in women. Likewise, mortality from colon and rectal cancer in men, and from leukemia for both sexes has increased, which requires further investigation and the strengthening of preventive measures. ,El cáncer constituye una enorme carga en el mundo, ocasionando cerca de 14.1 millones de casos nuevos y 8.2 millones de muertes en el 2012. La carga por cáncer es cada vez mayor en los países menos desarrollados, de donde provienen alrededor del 57% de los casos nuevos y el 65% de las muertes ocasionadas por esta enfermedad. Se estima que el 48% de los casos prevalentes de cáncer a cinco años del diagnóstico se presentaron en las regiones con menor desarrollo económico ,,La incidencia del cáncer está aumentando. Se espera que para el año 2025 se presenten más de 20 millones de casos nuevos, y una mayor carga en los países de bajos y medianos ingresos Para impactar en la reducción de la problemática generada por esta enfermedad, la OMS promueve la creación de programas efectivos que logren mejorar la detección precoz, el diagnóstico oportuno y un tratamiento específico y efectivo Asimismo, lidera programas de control del cáncer con la promoción de políticas, planes y programas nacionales de control del cáncer. Una de las estrategias ha sido la promoción, el establecimiento y fortalecimiento del monitoreo y la evaluación de esta enfermedad por medio de registros, así como de investigaciones dirigidos a la carga de la enfermedad y mayor disponibilidad de recursos para su atención ,Los Registros Poblacionales de Cáncer (RPCs) son sistemas de información imprescindibles para los programas del control de cáncer; estos permiten determinar frecuencias, incidencias, mortalidad y tendencias, como resultado de actividades encaminadas a recoger, analizar y difundir de manera continua, información de los casos de cáncer que ocurren en una población específica, con garantía de la calidad de los datos  ,En Colombia existen cuatro RPCs con reconocimiento internacional. Uno de estos, es el Registro Poblacional de Cáncer del Área Metropolitana de Bucaramanga (RPC-AMB) que ha logrado consolidar un trabajo continuo durante 18 años de funcionamiento Con el liderazgo del Ministerio de Salud y de la Protección social se organiza el Sistema Nacional de Información en Cáncer y se crea el Observatorio Nacional de Cáncer para Colombia liderado por el Instituto Nacional de Cancerología de Colombia (INC) con el fin de conocer el perfil territorial y la evaluación del impacto de los programas de control de cáncer En este estudio se describen las tasas de incidencia y mortalidad totales y específicas por sexo, correspondientes al Área Metropolitana de Bucaramanga en el periodo 2008-2012.Se planteó un estudio poblacional descriptivo, con los casos incidentes de cáncer invasivos registrados en las bases de datos del RPC-AMB en el quinquenio 2008-2012. 2. Cada municipio es independiente en su organización política, pero están completamente relacionados desde la perspectiva económica y social El AMB es una zona geográfica conformada por cuatro municipios del departamento de Santander: Bucaramanga , Floridablanca, Girón y Piedecuesta. Está ubicada en la región andina y cuenta con una extensión de 1,479 KmSegún proyecciones de población del Departamento Administrativo Nacional de Estadística (DANE), a mitad del periodo 2008-2012 el AMB contaba con 1,074,000 , 94.3% eran residentes urbanos, 51.9% eran mujeres, 24.5% menores de 15 años y 20.4% mayores de 50 años El AMB es un importante centro de referencia para la atención de pacientes con cáncer en la zona nororiental del país, cuenta con instituciones públicas  y privadas  que proveen diversos servicios oncológicos para el diagnóstico y tratamiento.El RPC-AMB ha realizado actividades permanentes desde abril del 2000, fruto del compromiso asumido por la UNAB. Los recursos económicos son asignados en las convocatorias de investigación de la Universidad y recibe cofinanciación anual del Instituto Nacional de Cancerología.El RPC-AMB hace recolección activa de los casos incidentes mediante visitas periódicas a las fuentes de información: laboratorios de patología y hematología, egresos hospitalarios, centros de imagenología, centros de tamizaje, voluntariados, centros de oncología, médicos especialistas, autopsias y certificados de defunción que son obtenidos en la Secretaría de Salud Departamental.in situ que hayan sido diagnosticadas después del 1ro de enero del año 2000 en residentes del AMB, tanto de zona urbana como rural, independiente del método diagnóstico utilizado, de tal forma que también se incluyen los casos identificados por certificado de defunción. Se excluye el cáncer de piel no melanoma (basocelular y escamocelular).Un caso registrable es toda neoplasia maligna de cualquier localización incluyendo las neoplasias benignas del Sistema Nervioso Central (SNC) y los carcinomas Los casos obtenidos por egreso hospitalario y certificados de defunción siguen un proceso de verificación del diagnóstico, mediante la búsqueda de la historia clínica. Cuando no se obtiene información adicional del caso obtenido por el certificado de defunción, se registra como caso identificado únicamente por certificado de defunción (DCO por su sigla en inglés). ,La codificación de los casos de cáncer es realizada con supervisión de la Directora del RPC, por personal entrenado en la Clasificación Internacional de Enfermedades para Oncología (CIE-O) - 3ª edición, 1ª revisión, publicado por la Organización Mundial de la Salud (OMS) en el 2013, y en los criterios de la IARC para los tumores primarios múltiples ,El RPC-AMB cumple con normas de confidencialidad siguiendo parámetros de la IARC y los compromisos de ética de la investigación. Sólo el personal del RPC-AMB accede a la información de cada caso que permite un trabajo exhaustivo en el control de la duplicidad de la información La fuente de información de defunciones fue el DANE, entidad oficial que recoge, organiza y codifica la causa básica de mortalidad utilizando la décima revisión de la Clasificación Internacional de Enfermedades (CIE 10) ,El programa CanReg5 ®, versión 5.00.42, software creado por la International Agency for Research on Cancer (IARC) en colaboración con la International Association of Cancer Registries (IACR), disponible gratuitamente para todos los miembros de la IACR Para la estimación de las tasas de incidencia se utilizó como denominador la población del AMB del período de estudio, proyectada por el DANE. Se calcularon tasas crudas y estandarizadas por método directo empleando la población estándar mundial propuesta por Segi y corregida por Doll p <0.0001), en contraste, el porcentaje de casos identificados por certificado de defunción fue mayor en hombres que en mujeres (9.1 y 6.5 p <0.0001). Durante el quinquenio 2008-2012 se registraron 8,775 casos incidentes de cáncer en el AMB (excluyendo cáncer de piel no melanoma), (57.2%) se presentaron en mujeres, (84.2%) fueron verificados por microscopía , (7.6%) fueron detectados únicamente por certificado de defunción y (7.2%) por historia clínica . El porcp <0.0001). La localización de los tumores malignos más frecuentes en las mujeres fueron mama (26.1%), colorrectal (9.1%), tiroides (9.1%), cuello de útero (8.3%) y estómago (6.9%). En los hombres, los tipos de cáncer más frecuentes fueron: próstata (26.1%), estómago (11.4%), colorrectal (9.4%), tráquea bronquios y pulmón (6.7%), linfomas y mielomas (6.2%)  .Las tasas se expresan por 100,000 personas-año. La tasa de incidencia de cáncer estandarizada por edad fue de 151.7 en hombres, y 157.2 en mujeres. Las tasas estandarizadas de los cinco tipos de cáncer más frecuentes en hombres fueron próstata (40.9), estómago (17.1), colorrectal (14.3), pulmón (10.3) y linfoma (9.1). En mujeres fueron mama (41.2), tiroides (14.5), colorrectal (13.7), cuello de útero (13.0) y estómago (10.2).En mujeres las cinco localizaciones de tumores con porcentaje de diagnóstico microscópico mayor al 95.2% fueron: tiroides, linfomas, leucemias, riñón y mama. En hombres fueron melanoma de la piel, leucemia, linfoma, vejiga y tiroides. El tipo de cáncer con mayor porcentaje de diagnóstico por certificado de defunción fue: hígado (31.9% en mujeres y 35.6% en hombres), páncreas (31.1% en mujeres y 33.3% en hombres) y pulmón (23.5% en mujeres y 21.9% en hombres).El comportamiento de la incidencia específica por edad de los dos tipos de cáncer más frecuentes en las mujeres fue diferente. El cáncer de mama asciende de manera acentuada desde el final de la tercera década de vida, alcanzando su pico máximo alrededor de los 70 años, mientras que la incidencia del cáncer de tiroides inicia a mediados de la segunda década de vida y alcanza su pico alrededor de los 55 años con una magnitud 60% inferior a la del cáncer de mama en esta edad . En los Durante el quinquenio 2008-2012, de las 24,860 muertes registradas en el AMB, 4,998 (20.1%) correspondieron a neoplasias malignas, 50.2% ocurrieron en mujeres. En la población general la tasa de mortalidad estandarizada por cáncer fue de 84.6 por 100,000 personas-año. Los tipos de cáncer con mayor frecuencia fueron: estómago (13.9%), pulmón (11.4%), colorrectal (9.0%), mama (7.1%), próstata (6.0%), leucemia (5.3%), hígado (5.1%), linfoma (5.0%), cuello de útero (3.8%) y páncreas (3.5%). Las mujeres tuvieron una tasa de mortalidad estandarizada por edad de 78.0 por 100,000 mujeres-año. Los cánceres que mayor número de muertes ocasionaron fueron mama (13.3%), estómago (11.8%), colorrectal (9.4%), pulmón (8.7%), cuello de útero (7.1%), hígado (4.8%), leucemias y linfomas (4.7% cada uno). En hombres, la tasa de mortalidad estandarizada por edad fue de 94.8 por 100,000 hombres-año, los cánceres de estómago (15.9%), pulmón (14.1%) y próstata (12.4%), colorrectal (8.0%), hígado (5.4%), leucemia (6.0%) y linfoma (5.4%) . Este estudio presenta los resultados de la incidencia y la mortalidad por cáncer en el quinquenio 2008-2012, brindando así continuidad con los datos del quinquenio 2003-2007 En la interpretación de los datos es importante tener en cuenta que la clasificación de los casos empleada en el actual estudio se basó en la primera revisión del CIE-O-3, la cual incluye cambios en los códigos relacionados con el comportamiento de algunas lesiones tumorales y códigos morfológicos de neoplasias hematolinfoides y del sistema nervioso central; los cuales no se tuvieron en cuenta en el análisis del quinquenio anterior.Al comparar con el quinquenio 2003-2007, la edad promedio al momento del diagnóstico en los casos de ambos sexos fue similar. El número total de casos nuevos (excluyendo cáncer de piel no melanoma) aumentó 6.7%, así como la representación porcentual de las mujeres, que pasó de 54.3% a 57.2%. No obstante, la tasa de incidencia global en hombres y mujeres disminuyó, especialmente en hombres, por cuanto la relación hombre/mujer (h/m) fue de 1.0, mostrando un comportamiento contrario a lo reportado por el Registro Poblacional de Cáncer de Cali (RPCC) para el mismo periodo (razón h/m de 1.1) Las tasas estandarizadas de incidencia en el quinquenio 2008-2012 en el AMB fueron inferiores a las reportadas por el RPCC en el mismo periodo El cáncer de mama fue el más frecuente en mujeres del AMB, con representación porcentual y tasa de incidencia estandarizada similares a las del quinquenio anterior  De acuerdo con las estimaciones del Observatorio Nacional de Salud (ONS) en Colombia para el año 2012, el cáncer de mama seguido del cáncer de cuello uterino continúan siendo los de mayor incidencia en mujeres, con magnitudes superiores a las del AMB , mientras que el cáncer de colon, recto y ano , de tiroides (11.2 por 100.000 mujeres-año) y de estómago  cuentan con tasas inferiores. Particularmente este último mostró una marcada tendencia a la disminución en el país durante el periodo 2010-2014 En hombres, el orden de los cinco cánceres con mayor incidencia se mantuvo de un quinquenio a otro; todos a excepción del cáncer colorrectal mostraron una disminución en la tasa de incidencia estandarizada en comparación con el quinquenio 2003-2007 En relación con la mortalidad, el perfil del AMB es similar al quinquenio 2003-2007, aunque con tasas más bajas en la mayoría de localizaciones, especialmente por cáncer de estómago que disminuyó particularmente en hombres, pasando de . En contraste, la tasa de mortalidad por cáncer de colorrectal aumentó en hombres así como la tasa de mortalidad por leucemia, que aumentó en hombres y en mujeres, siendo la mortalidad en el periodo 2008-2012 de 2.4 veces mayor a la del quinquenio anterior El panorama en el AMB contrasta con el del país, que según cálculos del ONS contó con tasas estandarizadas de mortalidad más altas y con tendencia al aumento en varias localizaciones. Sin embargo, en la mortalidad por leucemia se observó un comportamiento contrario en comparación con el estimado nacional a 2012, alcanzando el AMB una tasa 46.5% superior en los hombres y 70.5% superior en las mujeres en el quinquenio 2008-2012. A diferencia del comportamiento del país, cuya mortalidad por cáncer de colon, recto y ano aumentó en hombres como en mujeres durante el quinquenio 2010-2014, en el AMB este comportamiento solo se observó en hombres El comportamiento del país refleja la doble carga por cáncer que enfrenta la región de Centro y Sur América, que se manifiesta en altas tasas de cáncer relacionadas con infección  y un incremento en cánceres relacionados con el estilo de vida , estos últimos posiblemente tienen que ver con aspectos del desarrollo económico, tales como el aumento en la edad del primer embarazo, menor paridad, consumo de tabaco y alcohol, y dietas pobres en frutas y vegetales, obesidad e inactividad física Aunque en varias localizaciones de tumores, el AMB cuenta con incidencias más bajas en comparación con la población total del país, en este también se aprecia la doble carga; y es de resaltar la magnitud y la tendencia al aumento del cáncer de colorrectal en ambos sexos, así como la alta frecuencia del cáncer de estómago y el aumento de la incidencia por cáncer de tiroides en mujeres. Asimismo, aunque el riesgo de morir por cáncer es más bajo en el AMB que en la población nacional en casi todas las localizaciones, y fue inferior al del AMB en el quinquenio anterior, es de resaltar el aumento en la mortalidad por cáncer de colon y recto en hombres y por leucemias en ambos sexos. Este perfil plantea una mayor atención a la prevención del cáncer de colon y recto en el AMB, en donde la magnitud de la incidencia es similar en ambos sexos, a diferencia de lo que ocurre en gran parte del mundo. Este tipo de cáncer comparte con el de mama varias medidas de prevención, tales como el mantenimiento del peso corporal, aumento de la actividad física y disminución del consumo de alcohol, carnes rojas, procesadas y tabaco ,Cabe destacar que la prevalencia de sobrepeso u obesidad en el departamento de Santander es del 50.1%, superior en los hombres, aunque la obesidad abdominal es más alta en mujeres (46.6% versus 40.11%), el consumo de frutas y verduras es muy bajo  Mejorar y propender por la equidad en todos los niveles preventivos en relación con el cáncer de estómago también supone una prioridad para el AMB, máxime cuando se han documentado marcadas desigualdades socioeconómicas en la supervivencia de los pacientes, a pesar de la existencia del sistema “universal” de seguridad social en salud Con relación al cáncer de tiroides, este presenta un aumento en las tasas de incidencia similar a los datos reportados por varias regiones del mundo y del país. En algunos países como Estados Unidos el aumento de las tasas de incidencia se registró hace tres décadas debido al mayor uso de métodos diagnósticos como ecografías, logrando encontrar nódulos muy pequeños que probablemente pasarían desapercibidos por largo tiempo, es decir, el aumento relativo de la incidencia podría estar influenciado por el diagnóstico. Finalmente, el comportamiento de las neoplasias hematolinfoides especialmente en las Leucemias con tasas de mortalidad que han duplicado las tasas del quinquenio anterior en nuestra región genera inquietudes sobre cuáles son los factores que han impactado en este aumento marcado en sus tasas de mortalidad. Es importante explorar factores modificables especialmente aquellos que se han asociado con las barreras en la atención de salud de pacientes con cáncer como son factores administrativos, económicos y culturales con demoras en la oportunidad de diagnóstico y tratamiento En este estudio se presenta la magnitud del cáncer en el Área Metropolitana de Bucaramanga durante el quinquenio 2008-2012 comparativamente con el quinquenio 2003-2007. Se revelan comportamientos positivos en varios cánceres, que muestran una disminución en la incidencia de un quinquenio a otro o magnitudes inferiores a las del país; sin embargo, resalta la magnitud y la tendencia al aumento del cáncer colorrectal en ambos sexos, así como la alta frecuencia del cáncer de estómago y el aumento de la incidencia por cáncer de tiroides en las mujeres. Asimismo, la mortalidad por cáncer de colon y recto en los hombres y por leucemias en ambos sexos aumenta, lo cual requiere indagaciones posteriores y el fortalecimiento de las medidas preventivas.