Estudio clínico, radiológico y derivación en tumores musculoesqueléticos / Diagnosis and referral of musculoskeletal tumors

Musculoskeletal tumors are uncommon. However, the true burden of all bone and soft tissue tumors of extremities is underestimated. Usually, the diagnosis of sarcomas is missed or delayed. Therefore, an adequate clinical and radiological assessment, along with the awareness and application of simple guidelines for referral to a specialized center, are of utmost importance. These are critical steps for an appropriate diagnosis and treatment of sarcomas, improving their prognosis.

Puesta al día en hemangiomas de la infancia / Update in infantile haemangioma

Los hemangiomas de la infancia (HI) son los tumores de partes blandas más frecuentes de la infancia. Se presentan en un 5 por ciento- 10 por ciento de la población pediátrica. El comportamiento de estos tumores es especial, ya que, a diferencia de otras neoplasias benignas, los HI tienden a regresar e involucionar espontáneamente en un 90 por ciento. Algunos pacientes con HI pueden sufrir complicaciones tales como ulceración y hemorragia. Estas complicaciones han llevado a la búsqueda de alternativas terapéuticas, donde, por mucho tiempo fueron los esteroides la primera opción de tratamiento. Esto hasta el año 2008, cuando se descubre accidentalmente el propranolol administrado por vía oral, como alternativa terapéutica para los HI severos, convirtiéndose hasta el día de hoy, en el gold standard de tratamiento. Dado la diversidad en su presentación, y las diferentes alternativas de manejo existentes, es que esta revisión pretende abordar la patogenia, clínica y enfrentamiento de estos tumores de la infancia.

Hemangiomas of infancy (HI) are the most common soft tissue tumors of childhood. They occur in up to percent-10 percent of the pediatric population and they have a special behaviour because, unlike other benign neoplasms, HI tend to regress spontaneously in up to 90 percent of the cases. Complications such as ulceration and hemorrhage can occur. These complications have led to search for new therapeutic options. Steroids were the first choice of treatment for a long time, until 2008, when oral propranolol was accidentally discovered as a potential treatment for large HI4. Today, propranolol is the gold standard for treatment. Given their variable clinical presentation and different therapeutic options available nowadays, this paper to review the pathogenesis, clinical presentation and approach of these tumors of infancy.

Recurrence of atypical fibroxanthoma. Diagnosis and treatment

Introduction: The soft tissue sarcomas (SPM) accounts for only 1% of malignant tumors of the adult population. The SPM is the most frequent malignant fibrous histiocytoma (MFH) that exhibits behavior characterized by the tendency to invasion of adjacent tissue and metastatic spread early. One of its variants is the atypical fibroxanthoma (FA). Objective: To describe a case of probable recurrence of AF underwent surgical treatment and presentation of a literature review. Case report: Patient female, 63 years, presenting with a mass in the face about four inches and a history of prior resection of the lesion in the same topography. The patient underwent surgical resection with a diagnosis of AF. Conclusion: The FA is a rare tumor histological diagnosis difficult. The correct histological diagnosis and patient follow-up are essential...

Lipoma in Floor of Mouth.

Lipomas are adipose mesenchymal neoplasms, they are relatively uncommon in the oral cavity, representing about 0.5% to 5% of all benign oral tumors1. The clinical presentation is typically as an asymptomatic yellowish mass. The overlying epithelium is intact, and superficial blood vessels are usually evident over the tumour. We report a case with an unusual and atypical presentation of the lipomas in the floor of mouth, which is quite a rare site in the literature even in the oral cavity lipomas.

Surgical treatment of pressure ulcers: a two-year experience / Tratamento cirúrgico de úlceras por pressão: experiência de dois anos

BACKGROUND: Pressure ulcers are defined as lesions of ischemic etiology in the skin or soft tissue. These lesions are secondary to increased external pressure and usually occur over bony prominences. Classification of various stages of pressure ulcers is important for the development of therapeutic strategies. The fundamental surgical treatments are debridement and excision of underlying bursa and involved bone tissue, followed by tissue coverage. This study reports our experience in repairing pressure ulcers and analyzes patient characteristics, outcomes, and complications. METHODS: A total of 33 pressure ulcers were treated in 17 patients, the most prevalent of which was sacral ulcer. The development of pressure ulcers in hospitals accounted for 82 percent of the cases. Treatment options included debridement, primary synthesis, random skin flaps, rhomboid skin flap, myocutaneous flaps of the gluteus maximus in V-Y, classic fasciocutaneous flaps of fascia lata, fasciocutaneous flap of fascia lata in V-Y, and posterior fasciocutaneous flaps of the thigh in V-Y. RESULTS: Complications occurred in 39 percent of cases. Preoperative anemia was associated with complications. CONCLUSIONS: Pressure ulcers can be avoided in most cases, given sufficient knowledge of their pathogenesis and correct management of patients at risk. Multi-professional and family participation is essential for the treatment of patients with pressure ulcers since complications, recurrence, and the incidence of new ulcers are common. Complication risk factors such as anemia should be avoided in order to provide a better prognosis and proper closure of the ulcer.

INTRODUÇÃO: Úlceras por pressão são definidas como lesões cutâneas ou de partes moles de etiologia isquêmica, secundárias ao aumento da pressão externa, predominando sobre proeminência óssea. A classificação em estágios é importante na elaboração de estratégias terapêuticas. Os princípios fundamentais no tratamento cirúrgico são: debridamento e exérese de bursa subjacente e tecido ósseo envolvido, seguida de cobertura tecidual. Este estudo teve por objetivo relatar a experiência em reparação de úlceras por pressão, analisando características dos pacientes, resultados e complicações. MÉTODO: Em 17 pacientes, foram tratadas 33 úlceras por pressão, sendo a localização sacral a mais prevalente. O desenvolvimento de úlceras por pressão no ambiente hospitalar correspondeu a 82 por cento dos casos. As opções de tratamento foram: debridamento, síntese primária, retalhos cutâneos ao acaso, retalho cutâneo romboide, retalhos miocutâneos de glúteo máximo em V-Y, retalhos fasciocutâneos de fascia lata clássicos, retalho fasciocutâneo de fascia lata em V-Y, e retalhos fasciocutâneos posteriors da coxa em V-Y. RESULTADOS: Complicações ocorreram em 39 por cento dos casos. A anemia pré-operatória foi associada a complicações. CONCLUSÕES: O conhecimento da patogênese da úlcera por pressão e o correto manejo do paciente de risco podem evitá-la na maioria dos casos. É indispensável a participação multiprofissional e dos familiares para o tratamento do paciente portador de úlcera por pressão, pois complicações, recidivas e incidência de novas úlceras são comuns. Fatores de risco para complicações, como anemia, devem ser evitados, para obtenção de melhor prognóstico e fechamento adequado da úlcera.

Sinoviosarcoma de tornozelo: quarta recidiva / Ankle's synoviosarcoma: fourth relapse

Esse relato apresenta o caso de uma paciente com quarta recidiva de sinoviosarcoma, um sarcoma de partes moles que possui estreita relação com bainhas tendinosas, bursas e cápsulas articulares. A paciente apresentou uma quarta recidiva, sendo necessária a realização da amputação de perna, visto que as cirurgias conservadoras já não aliviam o sofrimento da paciente. O principal objetivo deste relato de caso é apresentar um caso clássico de neoplasia rara, expondo a doença e fazer uma breve revisão da literatura e mostrar sua importância, visto que corresponde a apenas 5% das neoplasias de partes moles.

This report presents the case of a female patient with fourth synoviosarcoma recurrence, a sarcoma of soft parts that have close relationship with tendom sheaths, bursas and articular capsule.The patient present her fourth recurrence, in wich the perfomance of amputation was required, since the conservative surgeriesno longer relieved the patient suffering. The main objective of this case report is to present a classic case of a rare cancer, exposing the disease, and to make a brief review of the literature to show its importance, since it corresponds to only five percent of the cancers of soft parts.

Tratamiento de las fracturas proximales del fémur provocadas por metástasis de carcinomas / Treatment of proximal femur fracture caused by metastatics of carcinomas

Fueron evaluados 25 pacientes que acudieron a la Unidad de Tumores Óseos y Partes Blandas (UTO-PB) del Hospital "Manuel Núñez Tovar" entre enero de 2002 a enero de 2008, con fracturas de la región proximal del fémur, provocadas por lesiones metastásicas de carcinomas, predomino en el estudio el sexo masculino, las edades de los pacientes estuvieron por encima de los 40 años, con mayor numero en la década de los 50, el cáncer mas importante en el hombre fue el de próstata y en la mujer el de cuello uterino. En todos los procedimientos se seleccionó pacientes con expectativa de vida superior a 4 semanas y se persiguió como objetivo fundamental mejorar calidad de vida, aliviar dolor y reincorporar al paciente a su estilo de vida previo a sufrir la fractura. Se realizó artroplastia para lesiones cervicales y osteosíntesis con clavos intramedulares y sistemas de placas con tornillos deslizantes para la región subtrocantérica e intertrocantérica, obteniéndose mejores resultados funcionales con las artroplastias y menor índice de complicaciones con respecto al uso de clavos intramedulares y a los DCS, DHS.

We evaluated 25 patients who came to the Unit of Bone and soft tissue tumors (UTOPB) Hospital "Manuel Núñez Tovar" between january 2002 and january 2008, with fractures of the proximal femur, lessions caused by metastic carcinoma, predominance in the study males, ages of the patients were above age 40, with the highest number in the 50s, the most important cancer in men was prostate cancer and women in the cervical. All procedures were selected patients with life expectancy greater than 4 weeks and was pursued as a key objective to improve quality of life, alleviate pain and return patients to their lifestyle prior to suffering the fracture. Arthroplasty was performed for cervical lesions and osteosynthesis with intramedullary nails and screws systems with sliding plates for the region subtrocanterica and intertrocanterica, obtained better functional results with arthroplasties and lower complication rate with respect to the use of intramedullary nails and DCS, DHS.

Neoadjuvant chemoradiation therapy for soft tissue sarcomas of the extremities

INTRODUCTION AND OBJECTIVE: Neoadjuvant and adjuvant therapies for soft tissue sarcomas of the extremities are still controversial. The aim of this study was to analyze the results of a protocol of neoadjuvant chemoradiation therapy for extremity sarcomas. METHODS: A retrospective analysis was carried out in a consecutive series of 49 adult patients with advanced extremity soft tissue sarcomas that could not be resected with adequate margins during the primary resection. All patients were treated with a protocol of preoperative radiation therapy at a total dose of 30 Gy, concomitant with doxorubicin (60 mg/m²) chemotherapy. The main endpoints assessed were local recurrence-free survival, metastasis-free survival and overall survival. The median follow-up time was 32.1 months. RESULTS: The five-year local recurrence-free survival, metastasis-free survival and overall survival rates were 81.5 percent, 46.7 percent and 58.3 percent, respectively. For high-grade tumors, the five-year metastasis-free and overall survival rates were only 36.3 percent and 41.2 percent, respectively. Severe wound complications were observed in 41.8 percent of the patients who underwent surgery. These complications precluded adjuvant chemotherapy in 73.7 percent (14/19) of the patients eligible to receive it. CONCLUSIONS: In this study, neoadjuvant chemoradiation therapy was associated with a good local control rate, but the distant relapse-free rate and overall survival rate were still poor. The high rate of wound complications modified the planning of adjuvant treatment in most patients.

Derrame pleural incomum: metástase pleuropulmonar de tumor neuroectodérmico primitivo / Uncommon pleural effusion: pleuropulmonary metastasis from primitive neuroectodermal tumor

O tumor neuroectodérmico primitivo é uma neoplasia com diferenciação neural de comportamento invasivo que origina metástases para diversos órgãos. Relatamos um caso de tumor neuroectodérmico primitivo primário em axila com metástases para pulmão, pleura, osso, músculo ilíaco e medula óssea. Enfatizamos o achado incomum da análise citológica do líquido pleural.

Primitive neuroectodermal tumor is an invasive neoplasm with neuronal differentiation, which frequently results in metastasis in various organs. We report the case of a patient with primitive neuroectodermal tumor whose primary site was the axilla. The patient presented with metastases in the lung, pleura, bone, iliac muscle and bone marrow. We highlight the uncommon finding in the pleural fluid cytology.

Influência da manipulação prévia no tratamento e na recidiva local dos sarcomas de tecidos moles / Influence of previous manipulation in the treatment and local relapse of soft tissue sarcomas

OBJETIVO: Avaliar os efeitos da manipulação prévia no tratamento ci rúrgico e na recidiva local dos sarcomas de tecidos moles. MÉTODO: Foram avaliados 30 pacientes submetidos a tratamento cirúrgico de um sarcoma de tecidos moles (STM), que foram divididos em dois grupos: pacientes que foram submetidos a uma biópsia ou ressecção inadvertida prévia do tumor e os encaminhados para tratamento sem qualquer procedimento prévio. Os grupos foram comparados de acordo com o tipo de cirurgia realizada, as complicações e a ocorrência de recidiva local. RESULTADOS: A manipulação prévia dos STM foi observada em 60 por cento da casuística, alterando a técnica operatória em 66,6 por cento dos casos. A freqüência de amputações foi semelhante nos dois grupos, mas três amputações foram realizadas por ressecção prévia inadequada. As complicações não foram significativamente diferentes nos grupos (p = 0,282), assim como a recidiva local (p = 0,461). CONCLUSÕES: A manipulação prévia dos STM influenciou no tratamento cirúrgico, mas não influenciou nas complicações pós-operatórias ou na recidiva local.

OBJECTIVE: Evaluate the influence of previous manipulation in the treatment and local relapse of soft tissue sarcomas. METHODS: We evaluated 30 patients submitted to soft-tissue sarcoma (STS) surgery. These patients were divided into two groups: patients with previous unplanned resection of the tumor, and patients referred to a specialized center without any previous surgical treatment. We compared the two groups by the type of surgical treatment, complications and local relapse. RESULTS: Previous manipulation of the STS was seen in 60 percent of the patients on the series, changing the surgical technique in 66.6 percent of the cases. The amputation rate was similar between both groups, but three patients were amputated as a result of inappropriate previous resection. Complications were not significantly different between the groups (p = 0.282), as well as for local relapse (p = 0.461). CONCLUSION: The previous manipulation of soft tissue sarcomas influenced the surgical treatment, but neither influenced post-operative complications nor local relapse.

Indicadores de prognóstico dos sarcomas de tecidos moles: revisão dos achados atuais / Prognostic indicators for soft tissue sarcomas: a review of the present aspects

Os sarcomas de tecidos moles (STMs) consistem em um grupo heterogêneo de neoplasma malignos que se oroginam a partir dp tecido conjuntivo extra-esquelético, com tendência a metastatizar em estágios precoces, principalmente, por via hematogênica, exibindo como sítios de predileção os pulmões e, menos frequentemente, o fígado e ossos. A presença de doença metastática representa um problema clínico importante, já que cerca de 30 - 50 por cento dos pacientes sucumbem à doença, dentro de um período de 5 anos após o diagnóstico da condição, em decorrência, principalmente, do desenvolvimento de recorrência à distância. Dentro deste contexto, destaca-se a importância do desenvolvimento de indicadores de prognósticos confiáveis para aconselhamento e seleção de pacientes para aplicação de terapia adjuvante e determinação de protocolos clínicos e metas para o tratamento. Dentre os diversos indicadores pesquisados, aqueles relaconados ao tratamento incluem o tipo de procedimento cirúrgico e a utilização de radio e quimioterapia antineoplásticas. Além disso, aspectos intrinsecamente correlacionados aos STMs, como tamanho de tumor, localização anatômica, subtipo e gradação histológica, bem como, análises citogenéticas e moleculares apresentam-se como importantes determinantes preditivos para estas neoplasias.

Sarcoma de partes blandas / Soft tissues sarcoma

Los sarcomas de tejido blando son tumores malignos que pueden surgir en cualquiera de los tejidos mesodérmicos de las extremidades, tronco, retroperitoneo, cabeza o cuello. Las opciones disponibles para el tratamiento dependerán del compromiso de los tejidos adyacentes, en estos casos es muy importante una biopsia inicial ya que la selección del tratamiento esta determinada por la histología del tumor. El tratamiento más eficaz es la cirugía seguida de radioterapia postoperatoria. El pronóstico para sarcomas de tejido blando en adulto depende de: edad del paciente, tamaño del tumor, grado histológico y la etapa en que este se encuentre con este motivo presentamos un caso clínico y su manejo quirúrgico.

Intervalo libre de enfermedad (ILE) en tumores malignos de partes blandas / Disease-free interval (ILE) in malignant tumors of soft tissues

Se realiza un estudio retrospectivo del ILE en los SPB, atendidos en el INOR durante los años 1973 a 1982. Se halló en el 66,3 por ciento de nuestros enfermos durante el primer año y en el 56,4 por ciento a los cinco años, después de finalizado su tratamiento, una evolución satisfactoria con la terapéutica empleada al permanecer libre de la enfermedad. Observamos en el tratamiento quirúrgico radical, el factor básico en la terapéutica multidisciplinaria de los SPB y en su técnica depurada, el pilar necesario para minimizar las posibles recaídas, por lo que se elevó el número de curaciones, es decir el ILE

Sarcoma de partes blandas: estudio comparativo de dos decenios / Sarcoma of soft parts: a comparative study of two decades

Se revisan todos los pacientes con diagnostico histologico de sarcoma de partes blandas atendidos en el INOR, durante los anos 1963-1982, comparandose la incidencia, la distribucion por grupos etareos y el sexo, asi como la localizacion del tumor, la histologia, el tratamiento y la sobrevida. Se senala que las tasas de incidencia se mantuvieron sin variacion en el periodo asi como la atencion de pacientes en etapas tardias, pero que en el decenio 1973-1982, se logro un aumento de la sobrevida de los casos gracias al manejo multidisciplinario y a una metodologia adecuada de diagnostico y estadiamiento

Presentation and management of soft tissue sarcomas

Soft tissue sarcomas [STSs] are uncommon malignancies and may occur at any age, arise at any site and from any of the extraskeletal mesodermal tissues. From September 1st, 1991 to December 31st, 1995, 73 patients with STSs were presented. The age ranged from 2 to 77 years [mean age 37.4 years] with male to female ratio of 0.97:1. The cardinal presenting symptoms were painless mass [57.1%], painful mass [15.1%] and limb disability [7.6%]. Extremity sarcomas represented 50.7% and non-extremity sarcomas 49.3%. The commonest histopathological subtypes were fibrosarcoma [17.8%], rhabdomyosarcoma [16.4%] and malignant vascular tumors [12.3%]. The management of patients included biopsy and radiotherapy and/or chemotherapy [15.1%], marginal resection with postoperative adjuvant therapy [35.6%], wide local resection with or without adjuvant therapy [46.6%] and amputation [2.7%]. Follow up for a period ranged from 6 to 52 months [mean duration of 20.7 months] showed that local recurrence accounted for 35.5%, distant metastases [21.9%], tumor-related death [28.7%], loss at follow up [15.1%] and disease-free survival [56.2%]. The aim of this study is to review the clinicopathological features, management and early results of the cases as compared to that of the literature