Angiolymphatic invasion as a prognostic fator in resected N0 pancreatic adenocarcinoma / Invasão angiolinfática como um fator prognóstico no adenocarcinoma pancreático ressecado N0

ABSTRACT Background: Pancreatic adenocarcinoma remains one of the worst digestive cancers. Surgical resection is the main target when treating a patient with curative intent. Aim: To assess angiolymphatic invasion as a prognostic factor in resected pN0 pancreatic cancer. Methods: Thirty-eight patients were submitted to pancreatoduodenectomy due to head pancreatic cancer. Tumor size, margins, lymph nodes, pTNM staging, angiolymphatic and perineural invasion were described in the pathologists' reports. Results: Most patients were female. Overall median survival was 13 months. Gemcitabine was the regimen of choice for chemotherapy in selected patients; however, it did not improve overall survival. pR0 resection had better survival compared with pR1. Within the pN0 group, survival was significantly better in patients without angiolymphatic invasion. Conclusion: Angiolymphatic invasion in N0 pancreatoduodenectomy can be demonstrated by the Hematoxylin-Eosin stain and may predict a poor prognosis factor for those patients.

RESUMO Racional: Adenocarcinoma pancreático continua sendo um dos piores cânceres do aparelho digestivo. A ressecção cirúrgica é o principal objetivo quando se trata de intenção curativa. Objetivo: Avaliar a invasão angiolinfática como um fator prognóstico no câncer da cabeça do pâncreas ressecado pN0. Método: Trinta e oito pacientes foram submetidos a duodenopancreatectomia por câncer da cabeça do pâncreas. Tamanho do tumor, margens, linfonodos, estadiamento pTNM, invasão angiolinfática e perineural foram descritos nos laudos anatomopatológicos. Resultados: A maioria foi de mulheres. A sobrevida mediana global foi de 13 meses. Gencitabina foi a droga de escolha para quimioterapia nos pacientes selecionados, entretanto não aumentou a sobrevida global. Pacientes com ressecção pR0 tiveram sobrevida global superior quando comparados com ressecção pR1. Dentro do grupo de pacientes com pN0, a sobrevida foi significativamente melhor no grupo de pacientes que não apresentavam invasão angiolinfática. Conclusão: A invasão angiolinfática da duodenopancreatectomia N0 pode ser demonstrada utilizando apenas a hematoxilina-eosina e pode predizer prognóstico ruim para estes pacientes.

Relevancia de la medicina nuclear en el diagnóstico y tratamiento del paraganglioma maligno / Relevance of nuclear medicine in the diagnosis and treatment of malignant paraganglioma

Introducción: Los paragangliomas son tumores del tejido cromafín caracterizados por la síntesis o secreción de catecolaminas, en los que el tratamiento depende de su extensión y características funcionales. Dentro de la evaluación diagnóstica anatómica y funcional de este padecimiento, los métodos de imagen de medicina nuclear sobresalen por su utilidad. Caso clínico: Paciente con paraganglioma a nivel de la bifurcación de la aorta en quien el diagnóstico se realizó por estudios de laboratorio, imagenología y medicina nuclear. Se llevó a cabo centelleografía con un análogo de norepinefrina, la metayodobencilguanidina marcada radiactivamente (131I-MIBG), que demostró funcional y específicamente la presencia de tejido adrenérgico neoplásico y su extensión extratumoral. Complementariamente se efectuó tomografía por emisión de positrones fusionada con tomografía computarizada, utilizando un análogo radiactivo de la glucosa que localizó la actividad extratumoral a nivel óseo. Los estudios de medicina nuclear permitieron concluir que se trataba de un paraganglioma maligno con metástasis óseas. El tratamiento incluyó resección quirúrgica del tumor y ablación del tejido tumoral residual y de los focos metastásicos con radioterapia interna mediante 131I-MIBG. El tratamiento radioterapéutico fue posible dada la capacidad del tumor y las metástasis de concentrar el análogo hormonal radiactivo. Conclusiones: Ante casos de paragangliomas, además de la localización del tumor y la evaluación de las alteraciones bioquímicas, es indispensable la evaluación funcional que brinda la medicina nuclear para la realización de un diagnóstico y tratamiento adecuados.

BACKGROUND: Paragangliomas are neoplasms of the chromaffin tissue characterized by the synthesis and/or secretion of catecholamines. Their treatment depends on the extension and functional characteristics of the tumor. In this pathology, the anatomic and functional diagnostic evaluations provided by nuclear medicine imaging studies have significant usefulness. CLINICAL CASE: A 34-year-old male was diagnosed with a paraganglioma at the level of the aortic bifurcation by means of laboratory tests, imaging studies and nuclear medicine studies. Nuclear medicine was carried out with a scintigraphy with a norepinephrine analog, radioactive meta-iodo-benzyl-guanidine (131I-MIBG), which demonstrates functionally and specifically the presence of neoplastic adrenergic tissue and extratumoral extension. In addition, a positron emission tomography coupled with computed tomography with a radioactive analog of glucose locates the extratumoral activity at bone level. Nuclear medicine studies allow the diagnosis of a malignant paraganglioma with presence of bone metastasis. The therapy includes surgical removal of the tumor and ablation of residual malignant tissue and metastatic lesions by radiotherapy with 131I-MIBG. Radiotherapeutic treatment was possible due to the capacity of the tumor to uptake and to concentrate the radioactive hormonal analog. CONCLUSIONS: In cases of paraganglioma, in addition to the localization of the tumor and the evaluation of biochemical alterations, it is indispensable to obtain anatomic and functional evaluation provided by nuclear medicine studies in order to achieve appropriate diagnoses and treatment.

Papel de la cirugía de sustitución vascular en la infiltración arterial metastásica / Role of vascular replacement surgery in the metastatic arterial infiltration

Se presenta el caso de una mujer de 40 años de edad, tratada por vías convencionales a causa de un carcinoma epidermoide infiltrante del canal anal, con patrón basaloide. La evolución ulterior permitió reconocer la aparición subsecuente de metástasis ganglionares en la región inguinocrural derecha 6 meses después. La ecografía Doppler del territorio iliofemoral indicó desplazamiento y compresión arterial femoral común con infiltración de la pared del vaso, que se trató efectivamente con excisión radical de la metástasis y reconstrucción vascular femoral con injerto venoso de safena. Se obtuvieron buenos resultados funcionales(AU)

The case of a 40-year-old female conventionally treated due to an infiltrating epidermoid carcinoma of the anal canal with basaloid pattern was presented. The further evolution allowed to recognize the subsequent appearance of ganglionic metastases in the right inguinocrural region 6 months later. Doppler echography of the iliofemoral territory indicated displacement and common arterial femoral compression with infiltration of the vessel wall that was effectively treated by radical excision of the metastasis and femoral vascular reconstruction with venous graft of the saphena . Good functional results were obtained(AU)

Malignant fibrous histiocytoma: Vascular invasion and metastasis to heart

A 52 years old male fisherman presented in April 2000, with a history of pain in the left calf while standing and walking with swelling of the ipsilateral foot for the last three months. Clinically he was an overweight, middle aged man. His pulse, blood pressure and respiratory rate were normal. There were no significant findings on the examination of chest and abdomen. Local examination revealed pitting edema along with increased circumference of the left leg and lower thigh. The superficial veins were prominent on the left side. Inguinal lymph nodes were not enlarged. On dorsiflexion of the left foot, pain was experienced in the left calf. His routine investigations were within normal limits. However, Doppler ultrasound reported thrombosis of the left femoral vein. The clot extended from the sub sartorial canal to the upper part of femoral triangle. He was diagnosed as a case of deep vein thrombosis and treated with anticoagulants, stockinnette and analgesics. There was symptomatic improvement in the calf pain and the edema decreased. Three months later he started complaining of vague pain in the anteromedial aspect of the left thigh. On examination an ill-defined, diffuse, firm lump could be felt in the femoral triangle. MRI of the area exhibited a soft tissue mass of 10 x 6 cm size arising from the deep soft tissues of the femoral triangle, 16 surrounding the femoral vessels and infiltrating into the adjoining muscles. Biopsy showed grade IV malignant pleomorphic fibrous histiocytoma. During surgery [wide margin resection planned] femoral vein was solidified and filled with the tumor mass which was extending above the inguinal ligament. The femoral artery was also surrounded by the tumor mass which resulted in iatrogenic injury during dissection, that was immediately repaired. Only debulking was done due to inoperability of the tumour. During the next six weeks, the patient developed a fungating mass in the left femoral triangle culminating in fatal arterial bleeding