Ameloblastoma mandibular maligno con metástasis hepática y pulmonar: caso clínico / Malignant mandibular ameloblastoma with hepatic and lung metastases: a case report

Ameloblastoma is a benign rare tumor, originated in the odontogenic epithelium, is locally invasive and with high tendency to local recurrence, a variety less common is the malignant or metastasizing ameloblastoma, where more frequent sites of deployment are the lung and cervical lymph nodes, being much less frequent sites the liver and skull among others. The surgical treatment is mainly the aggressive surgery of the primary tumor and metastases. We present a case of a patient with malignant mandibular ameloblastoma with metastases in liver and lung, which was subjected to a subtotal mandibulectomy, local radiotherapy and lung and liver metastasectomy in a second time, with late recurrence of the lesion.

El ameloblastoma es un tumor poco frecuente, benigno, originado en el epitelio odontogénico, es localmente invasivo y con alta tendencia a la recurrencia local, una variedad mucho menos frecuente es el ameloblastoma maligno o que causa metástasis, donde los sitios más frecuentes de implantación son el pulmón y los linfonodos cervicales, siendo sitios mucho menos frecuentes hígado y cráneo, entre otros. El tratamiento es principalmente quirúrgico con cirugía agresiva del tumor primario y posteriormente de las metástasis. Se presenta el caso de un paciente portador de ameloblastoma mandibular maligno, con metástasis hepáticas y pulmonares, que fue sometido a una mandibulectomía subtotal y radioterapia local. Posteriormente, resección de metástasis pulmonares y hepáticas en un segundo tiempo, con recidiva de las lesiones.

Enfermedad fúngica invasora en pacientes hemato-oncológicos y receptores de trasplante de precursores hematopoyéticos bajo la perspectiva de los criterios diagnósticos EORTC/MSG / Invasive fungal disease in hemato-oncological and hematopoietic stem cell transplantation patients from Hospital Clinico Universidad Católica, Santiago-Chile using revised EORTC/MSG diagnostic criteria

Introduction: Invasive fungal disease (IFD) is a severe complication occurring mostly in haemato-oncological (H-O) patients and hematopoietic stem cell transplant (HSCT) receptors. Our aim was to describe the IFD occurring in our H-O and HSCT patients according to the EORTC/MSG revised criteria. Patients and Methods: IFD surveillance was performed in adult patients of the Hospital Clínico Universidad Católica, Santiago, Chile, from January 2004 to January 2008. Results: A total of 41 IFD episodes were identified in 39 patients; mean age was 46.6 ± 9.9 years, and 87.8 percent and 12.2 percent occurred in H-O and HCTS patients respectively. 15/41(36.6 percent) episodes were proven, 36.6 percent probable and 11/41 (26.8 percent) possible. In 26 (63.4 percent) episodes aspergillosis was diagnosed (20 pulmonary, 3 sinus, 1 laryngeal and 1 case with pulmonary and cerebral involvement). In 7 patients (17.1 percent) candidiasis was diagnosed, 5 with a proven bloodstream infection and 2 with possible hepatosplenic candidiasis; mucormyeosis was diagnosed in 4 (9.8 percent) Fusarium infection was demonstrated in 2 patients (4.9 percent), and Mucor and Aspergillus pulmonary coinfection and Alternaría sp rhino-sinusitis in one patient each. The frequency of IFD among febrile neutropenic patients was 26.2 percent and 6.4 percent in H-O and HSCT receptors respectively. The overall mortality was 36 percent. Conclusions: Aspergillosis is the most common IFD infection among H-O patients and HSCT receptors in our center. Candidiasis followed although only in H-O patients most probably because of routine use of antifungal prophylaxis in HSCT recipients. Continuous surveillance is required to develop local guidelines and to evaluate antifungal strategies in different clinical scenarios.

Introducción: La enfermedad fúngica invasora (EFI) es una complicación grave en pacientes hemato-oncológicos (H-O) y receptores de trasplante de precursores hematopoyéticos (TPH). Objetivo: Describir las EFI diagnosticadas en pacientes adultos H-O y receptores de TPH de nuestro centro, bajo los criterios diagnósticos revisados de EORTC/MSG. Pacientes y Métodos: Estudio de vigilancia de EFI en pacientes adultos del Hospital Clínico de la Pontificia Universidad Católica de Chile entre enero 2004 y enero 2008. Resultados: Se identificaron 41 episodios de EFI, correspondientes a 39 pacientes: 46,6 ± 9,9 años, 87,8 por ciento H-Oy 12,2 por ciento TPH. Se documentaron 15/41 (36,6 por ciento) EFI demostrada, 36,6 por ciento probable y 11/41 (26,8 por ciento) posible. En 26/41 (63,4 por cientoo) se diagnosticó aspergilosis (20 pulmonar, 3 rinosinusal, 1 laríngeo y un caso cerebral-pulmonar). En 7/41 (17,1 por ciento) se diagnosticó candidiasis, 5 candidemias y 2 candidiasis hepato-esplénica posibles; 4/41 (9,8 por cientoo) correspondió a mucormicosis demostrada (2 rinosinusal, 1 oral y 1 pulmonar); en 2/41 (4,9 por cientoo) fusariosis; 1/41(2,4 por ciento)) coinfección pulmonar por mucoral y Aspergillus sp y 1 caso de rinosinusitis por Alternaría sp. La frecuencia de EFI entre pacientes H-O con neutropenia febril fue 26,2 por ciento) y 6,4 por ciento) en los receptores de TPH. La mortalidad global fue de 36 por ciento). Conclusiones: Aspergilosis es la EFI más frecuente en H-O y receptores de TPH de nuestro centro. Candidiasis es la segunda EFI en frecuencia; sin embargo, no se documentó entre los pacientes receptores de TPH, lo que puede relacionarse al uso de antifúngicos profilácticos en este grupo. Es necesaria la vigilancia continua para desarrollar guías clínicas locales y evaluar estrategias de uso de antifúngicos en distintos escenarios clínicos.

Etiología de episodios de neutropenia febril en pacientes adultos con cáncer hematológico y de órganos sólidos en el Hospital Clínico Universidad Católica, Santiago-Chile / Etiology of febrile neutropenia episodes among cancer patients from Hospital Clinico Universidad Catolica, Santiago-Chile

Introduction: The surveillance of febrile neutropenia (FN) episodes in every center allows adapt the antibiotic therapy guidelines to local epidemiology. Aim: To characterize clinical features and compare the FN etiology between hematological cáncer (HC) and solid organ cancer (SOC) in our center. Patients and Methods: Surveillance study in adult patients with FN admitted to Hospital Clinico Universidad Católica, in Santiago, Chile, from January 2004 to August 2007. Results: 154 FN episodes corresponding to 87 patients were included. Mean age: 47 ± 6 years-old; 71 percent had HC and 29 percent SOC. A clinical and/or microbiologically documented infection was recognized in 76 percent. Gastrointestinal 31.5 percent, upper respiratory 30.3 percent and lower respiratory 16.9 percent were the more frequent clinical focus. In 30.5 percent blood culture resulted positive: gram negative rods 51 percent, gram positive cocci 41 percent and yeasts 8 percent; being Escherichia coli 22 percent, S. coagulase negative (SCoN) 20 percent and Klebsiella pneumoniae 12 percent most frequent bacteria; 22.2 percent Enterobacteriaceae were ESBL producers and 55.6 percent 5CoN were methicillin resistant. In 18.3 percent of FN episodes the etiology was not established. Highest mortality was observed in episodes with microbiologically documented infection (14.5 percent vs 1.3 percent, p < 0.005). A clinical observed focus and positive blood cultures were more frequently obtamed among HC than SOC associated episodes: 37.3 percent vs 13.6 percent; (p < 0.01) and 67.2 percent vs 50 percent; (p = 0.045), respectively. Conclusions: The etiological profile of FN in our center and the necessity to continue the surveillance was described. Future studies are needed regarding risk factors of invasive infection that have worst prognosis.

Introducción: La vigilancia de la etiología de los episodios de neutropenia febril (NF) en cada centro permite adaptar guías de antibioterapia a la epidemiología local. Objetivo: Caracterizar y comparar la etiología de la NF en pacientes con cáncer hematológico (CH) y de órganos sólidos (COS). Pacientes y Métodos: Estudio de vigilancia de NF de pacientes adultos en el Hospital Clínico Universidad Católica, en Santiago, Chile, entre enero 2004 y agosto 2007. Resultados: 154 episodios de NF correspondientes a 87 pacientes: 47 ± 6 años; 71 por ciento CH y 29 por ciento COS. Se documentó infección clínica y/o microbiológicamente en 76 por cientoo. Más frecuente fueron: foco gastrointestinal 31,5 por ciento, respiratorio alto 30,3 por cientoo y respiratorio bajo 16,9 por cientoo. En 30,5 por cientoo hubo hemocultivos positivos: bacilos gramne-gativos en 51 por ciento, cocáceas grampositivas en 41 por ciento, levaduras en 8 por cientoo; predominando: Escherichia coli 22 por cientoo, Staphylococcus coagulasa negativa (SCoN) 20 por cientoo y Klebsiella pneumoniae 12 por ciento; 22,2 por cientoo de las entero-bacterias eran productoras de (3-lactamasa de espectro expandido y 55,6 por cientoo >SCoN meticilina resistentes. En 18,3 por cientoo de los episodios no se identificó causa de fiebre. Hubo mayor mortalidad en episodios con documentación microbiológica (14,5 por ciento vs 1,3 por ciento, p < 0,005). En los pacientes con CH fue más frecuente obtener hemocultivos positivos (37,3 por cientoo vs 13,6 por ciento; p < 0,01) e identificar foco clínico (67,2 por ciento vs 50 por ciento; p = 0,045). Conclusiones: Se establece el perfil etiológico de las NF en nuestro centro y la necesidad de mantener vigilancia. En futuros estudios será necesario evaluar factores de riesgo de pacientes con infecciones invasores que tendrían peor pronóstico.

Detección de micrometástasis por RT-PCR de citokeratina 20 y su correlación con la sobrevida global en pacientes portadores de cáncer colorrectal / Cytokeratin 20 as a marker of tumor progression or dissemination in patients with colorectal cancer

Background: Colorectal cancer relapses or metastasizes in 30 percent of cases. Cytokeratin 20 is present in 95 percent of colorectal tumors and their metastases and could be used as a marker to detect tumor cells. Aim: To assess the usefulness and prognostic value of peripheral blood and bone marrow cytokeratin 20 determinations in patients with colorectal cancer. Material and methods: Blood and bone marrow samples were obtained from 56 patients with colorectal cancer aged 26 to 77 years (31 females) before surgical procedure. They were followed for a mean of 22 months (range 2.9 to 72 months) after surgery. Blood and bone marrow from 45 patients without cancer and 35 healthy subjects were used as negative controls. Messenger RNA expression of cytokeratin 20 was studied by real time and nested polymerase chain reaction. Results: Cytokeratin 20 was detected in 6 percent of controls and 41 percent of patients. There was no relation between cytokeratin 20 expression and age, gender, overall survival, tumor relapse, progression, localization or stage. Conclusions: Cytokeratin 20 determination is not useful as a marker of tumor progression or dissemination in patients with colorectal cancer.

Evaluación de un modelo computacional para la indicación de quimioterapia en cáncer de mama / Evaluation of a computer program in use of adjuvant chemotherapy in early breast cancer

El cáncer de mama es la segunda causa de muerte por cáncer en mujeres en Chile. El tratamiento adyuvante con quimioterapia ha demostrado disminuir la recurrencia y muerte por la enfermedad. La recomendación de usar adyuvancia en un paciente individual es compleja y depende de la evaluación del riesgo de recaída, muerte y condición del enfermo. Adjuvant! es un modelo computacional útil en la predicción de la sobrevida y beneficio de la terapia adyuvante en pacientes con cáncer de mama. El modelo Adjuvant! se estudió en nuestra población de pacientes para conocer el beneficio estimado de la quimioterapia y la relación con su prescripción. Se aplicó Adjuvant! a 125 pacientes con cáncer de mama precoz (T1N0M0) tratadas con cirugía conservadora y radioterapia, 20 (16%) recibieron quimioterapia adyuvante. Según el modelo, el beneficio absoluto en sobrevida global a 10 años con quimioterapia en este grupo es de 1.3% (0,1-11,1%) y la reducción absoluta en el riesgo de recurrencia de 6.45% (0.4-20%). Un 25% de pacientes obtendría un beneficio en sobrevida global mayor del 2% y un 58,4% (73/125) mayor al 1%. De las pacientes de nuestra serie que recibieron quimioterapia un 50% (10/20) recibirían un beneficio esperado en sobrevida global menor al 2%. La mediana de beneficio del tratamiento combinado quimioterapia / hormonoterapia en la sobrevida global es de 1,8% (2-11,1) y en la sobrevida libre de enfermedad de 10.5% (1-25,6%). En estudios clásicos, al consultar a pacientes ya tratadas, más del 50% usarían nuevamente quimioterapia por un beneficio absoluto menor al 1%.

Breast cancer is the second cause of female death in Chile. Adjuvant chemotherapy has reduced breast cancer recurrence and death. The decision to use adjuvant chemotherapy for a specific patient is complex and must consider the general condition of the patient and its risks of recurrence and death. The computer model called Adjuvant! was designed for breast cancer to predict survival and determine the benefit of adjuvant chemotherapy. The Adjuvant! model was calculated for our population of breast cancer patients to determine the predicted benefit of chemotherapy and compare it with the actual indication. The Adjuvant model was applied to 125 patients with early breast cancer, (T1N0M0), treated with breast conserving surgery and post operative radiotherapy. Adjuvant chemotherapy was use in 20 patients (16%). According to the predictive model the absolute 10-year survival benefit with chemotherapy is 1.3% (0.1-11.1%) and the absolute recurrence risk reduction is 6.45% (0.4-20%). For 25% of the patients chemotherapy would result in an overall survival benefit larger than 2% and for 58.4% (73/125) larger than 1%. In our series 50% (10/20) received chemotherapy with a predicted overall survival benefit less than 2%. The median benefit with the combination of chemotherapy and hormonal therapy in overall survival was 1.8% (0.2-11.1) and in disease free survival was 10.5% (1-25.6%). Reports from the literature indicate that more that 50% of patients treated with chemotherapy would agree to receive it again for a benefit less than 1%.

Tratamiento endovascular del síndrome de vena cava superior / Endovascular treatment of superior vena cava syndrome

Background: Superior vena cava syndrome (SVCS) is caused by the obstruction of venous drainage from the upper portion of the body. Common clinical findings are headache and cervical, facial and upper limb edema. Occasionally, clouding of consciousness appears. Aim: to report our experience with endovascular treatment of SVCS. Material and methods: Retrospective review of all patients with SVCS subjected to endovascular treatment between 1999 and 2005. Results: Eight patients were treated, all of them with malignancies. Six had a benign obstruction due to the presence of a chemotherapy catheter located in the superior vena cava, one had obstruction secondary to radiation therapy and one a tumor compression of the superior vena cava. Two patients underwent thrombolytic therapy. Angioplasty and stenting was performed in all patients. The chemotherapy catheter was removed to all patients and installed again in one. One patient had a hemothorax secondary to a simultaneous needle lung biopsy under video thoracoscopy. No patient died in relation to the procedure. Congestive signs and symptoms subsided in all patients within 24 hours after the procedure. During follow up, only one patient had symptoms related to vena cava obstruction and three died due to their malignant tumor. Conclusions: Endovascular treatment of SVCS has a low rate of complications and provides immediate and mid-term symptom relief.