Recurrent aggressive angiomyxoma / Angiomixoma agressivo recidivante

INTRODUCTION: aggressive angiomyxoma is a highly aggressive, rare neoplasm of the mesenchymal tissue with a high recurrence rate. It represents an important differential diagnosis of pelvic tumors in women of reproductive age. This study aims to describe a case of aggressive angiomyxoma. CASE REPORT: woman, 37 years old, complained about a bulge on the right perianal region, and anal itching and burning, bleeding, tenesmus and incontinence. The proctologic examination confirmed the perianal bulge and extrinsic compression of the posterior wall of the rectum. Computed tomography (CT) of the pelvis showed a well-defined pelvic mass extending to the right rectal area. Exploratory laparotomy showed a mass of fibro elastic consistency adjacent to the pelvic organs and closely attached to the distal rectum, and performed a resection of the pelvic tumor afterward. Anatomopathological analysis revealed an aggressive angiomyxoma. Magnetic resonance imaging (MRI) of the pelvis showed signs of recurrence in the pelvic cavity on the right side of the rectum. A surgical procedure was performed to resect the lesion. After an asymptomatic period, the MRI showed solid growths located in the right ischiorectal fossa. A new surgical procedure identified only retention cysts in the pelvis and right ischiorectal fossa, only lysis of adhesions was performed. The patient is currently undergoing follow-up without disease recurrence. (AU)

INTRODUÇÃO: o angiomixoma agressivo é uma rara neoplasia do tecido mesenquimal de grande agressividade e alta taxa de recorrência. Representa um importante diagnóstico diferencial de tumorações pélvicas de mulheres em idade reprodutiva. Este estudo objetiva relatar um caso de angiomixoma agressivo. RELATO DE CASO: mulher, 37 anos, com queixa de abaulamento em região perianal direita, além de prurido e ardor anal, sangramento, tenesmo e incontinência anal. Exame proctológico confirmou o abaulamento perianal e compressão extrínseca da parede posterior do reto. Tomografia computadorizada (TC) de pelve evidenciou massa pélvica bem delimitada estendendo-se à região para-retal direita. Laparotomia exploradora demonstrou massa de consistência fibro-elástica adjacente aos órgãos pélvicos e intimamente aderida ao reto distal, sendo realizada ressecção do tumor pélvico. Anatomopatológico revelou angiomixoma agressivo. Ressonância nuclear magnética (RNM) de pelve demonstrou sinais de recidiva na escavação pélvica à direita do reto. Foi realizado procedimento cirúrgico para ressecção da lesão. Após período assintomática, RNM evidenciou processos expansivos sólidos localizados na fossa ísquio-retal direita. Novo procedimento cirúrgico identificou apenas cistos de retenção na pelve e fossa ísquio-retal direita sendo feita apenas lise de aderências. A paciente encontra-se em seguimento clínico sem recidiva da doença. (AU)

Actinomicosis pelviana: caso clínico / Pelvic actinomycosis: a case report

La actinomicosis pelviana es una enfermedad granulomatosa crónica muy infrecuente, causada por un bacilo Gram positivo, y que clínicamente suele confundirse con neoplasias pelvianas. Se presenta un caso clínico en que sospechó la infección en forma temprana, logrando resultados exitosos con tratamiento médico.

Pelvic actinomycosis is a chronic granulomatous disease quite uncommon; it is caused by positive Gram bacilli, and clinically it may appear as a pelvic neoplasia. We present a case report in which the infection was pursued actively, achieving excellent results with medical treatment.

Leiomiomatosis intravenosa de origen pelviano con extensión intracardiaca: Reporte de dos casos / Pelvic intravenous leiomyomatosis with intracardiac extension: Report of two cases

Background: symptoms predominate. Diagnosis is based on clinical findings and appropriate imaging. We report two females, aged 35 and 51 years. One of them presented with a pelvic mass and dyspnea, the other patient had severe cardiac failure on admission. Computed axial tomography scan allowed an accurate preoperative diagnosis on both patients. Successful one stage resection of the tumor was performed under cardiopulmonary bypass. Both patients are asymptomatic on follow up at 6 months and 25 years.

Instilação de formalina endoluminal como opção terapêutica da retite actínica hemorrágica / Endoluminal formalin instillation as a therapeutic option of radiation-induced hemorrhagic proctitis

A retite actínica hemorrágica é um quadro grave que pode ocorrer em qualquer paciente submetido à radioterapia pélvica, por vezes, sendo necessária terapia transfusional e internação hospitalar. A abordagem terapêutica ainda é bastante controversa. Tanto para o tratamento inicial como para casos refratários, uma das opções é a aplicação de formalina. Este método é barato, facilmente disponível, de simples execução e eficaz no controle da hemorragia. Os autores relatam dois casos de retite actínica hemorrágica de pacientes tratados com instilação de formalina endoluminal, e sua eficácia terapêutica e complicações são discutidas.

The radiation-induced hemorrhagic proctitis is a serious condition that can occur in any patient undergoing pelvic radiotherapy, sometimes being required hospitalization and transfusion therapy. The therapeutic approach is still very controversial. Both for the initial treatment and for refractory cases, one option is formalin application. This method is cheap, easily available, simple to perform, and effective in controlling bleeding. The authors report two cases of radiation-induced hemorrhagic proctitis treated with endoluminal instillation of formalin, and they discuss its therapeutic efficacy and complications.

Hemipelvectomias: tratamento, avaliação funcional e prognóstica dos tumores pélvicos / Hemipelvectomies: treatment, functional outcome and prognostic of the pelvic tumors

OBJETIVO: Demonstrar a experiência de uma única instituição em hemipelvectomias internas sem reconstrução. Avaliar as cirurgias pélvicas preservadoras e as amputações interílio-abdominais e seu prognóstico. MÉTODOS: 21 pacientes com tumores primitivos pélvicos submetidos à hemipelvectomia com ou sem preservação de membro. Sete foram tratados com hemipelvectomias externas (amputação) e 14 com internas, entre junho de 2004 e julho de 2009. A classificação cirúrgica utilizada foi a de Enneking para tumores pélvicos. O método de avaliação funcional foi o escore de ISOLS/MSTS. RESULTADOS: A sobrevida dos pacientes em dois anos foi de 63,9 por cento. A média de sobrevida do grupo todo foi de 43 meses. A avaliação funcional demonstrou que as hemipelvectomias preservadoras com ressecção do osso inominado obtiveram 12,5 por cento, 62,5 por cento e 25 por cento de resultados ruins, bons e excelentes, respectivamente. Nos casos em que o osso inominado foi preservado, os resultados foram 16,7 por cento e 83,3 por cento bons e excelentes, respectivamente. CONCLUSÕES: A hemipelvectomia é procedimento pouco usual e causador de importante limitação funcional e comorbidades. A alternativa de ressecar a hemipelve sem reconstrução tem demonstrado resultados tão bons quanto a não-reconstrução. Os elevados custos médicos, além das possíveis complicações com uso de enxerto e próteses justificam a técnica empregada neste artigo. Nível de Evidência IV, Estudo de caso-controle.

OBJECTIVE: To describe the experience of one single institution in internal hemipelvectomies without reconstruction and external hemipelvectomies. METHODS: Twenty-one patients with primary tumors of the pelvic region underwent total hemipelvectomy, at Barretos Cancer Hospital, São Paulo, Brazil, between 2004 and July 2009. Of these, seven were treated with external hemipelvectomy (classic) and 14 with internal hemipelvectomy. Evaluation was done based on Enneking's surgical classification for internal hemipelvectomy. RESULTS: Overal survival in two years was 63,9 percent. Median survival of 43 months. Functional outcomes demonstrated that procedures with inominate bone ressection reached 12,5 percent, 62,5 percent and 25 percent of bad, good and excellent results, respectively. When inominate bone was preserved the results were 16,7 percent and 83,3 percent good and excellent, respectively. No endoprosthesis or bone graft reconstructions were done. CONCLUSIONS: Hemipelvectomy is an unusual procedure that is rarely performed because it is infrequently indicated and because of its high morbidity rate. In some reports, the morbidity rate has reached 77 percent of the cases. We did not perform any type of reconstruction or arthrodesis based on complications and the experience of good results with this method. Our results are similar to the main reports and are still subject of discussion by the oncologic surgeons. Level of evidence IV, Case-control study.

Malignant Mesothelioma Presenting as a Giant Chest, Abdominal and Pelvic Wall Mass

Malignant mesothelioma (MM) is a relatively rare carcinoma of the mesothelial cells, and it is usually located in the pleural or peritoneal cavity. Here we report on a unique case of MM that developed in the chest, abdominal and pelvic walls in a 77-year-old female patient. CT and MRI revealed mesothelioma that manifested as a giant mass in the right flank and bilateral pelvic walls. The diagnosis was confirmed by the pathology and immunohistochemistry. Though rare, accurate investigation of the radiological features of a body wall MM may help make an exact diagnosis.

Sarcoma de Ewing en paciente masculino / Ewing's sarcoma in a male patient

El sarcoma de Ewing es un tumor óseo maligno de células redondas pequeñas. Es el segundo tumor óseo maligno más frecuente en la infancia, y se puede presentar en cualquier momento durante la niñez y comienzos de la edad adulta. El tumor puede originarse en cualquier parte del cuerpo, generalmente en los huesos largos de las extremidades, la pelvis o el tórax, al igual que en el cráneo o en los huesos planos del tronco. Se trata de un paciente masculino, mestizo, de 38 años de edad, que acude a consulta externa en el hospital de Nickerie, Suriname, por presentar aumento de volumen en la región lateral derecha del abdomen. Refiere que ha presentado pérdida de peso, decaimiento marcado y anorexia. Estos síntomas se iniciaron 3 meses antes, y se han incrementado paulatina y progresivamente. Tiene también dificultad para deambular y dolor en la pierna derecha

The Ewing's sarcoma is a malignant bone tumor of round cells. The second malignant bone tumor more frequent in childhood and may to appear in any moment during this life stage and at onset of adulthood. Tumor may to originate in any place of body, generally in limbs long bones, pelvis or thorax as well as in skull or in trunk flat bones. This case is a black male patient aged 38 seen in external consultation in the hospital of Nickerie, Surinam presenting with a volume increase in the right lateral region of abdomen. He refers a weight loss, a marked weakness and anorexia. These symptoms appeared three months before increasing in a gradual and progressively way. He has difficulty to walk and pain in the right leg

Eficiencia diagnóstica del ca-125 como predictor preoperatorio de malignidad en tumores pélvicos / Diagnostic efficacy of the ca-125 as preoperatory predictor of malignancy in pelvic tumours

El objetivo de esta investigación fue evaluar la eficacia diagnóstica del CA-125 como predictor de malignidad en tumores pélvicos. Se seleccionaron en forma prospectiva las pacientes que se ingresaron con diagnóstico de tumoración pélvica que tenían evaluación ecográfica y determinación de las concentraciones de CA-125 antes de la cirugía. La histología de la tumoración pélvica fue el punto final del estudio y se dividió en dos grupos: lesiones benignas. El promedio de edad de las pacientes fue de 42,1 ± 12,9 años. Se encontraron 13 neoplasias malignas en las 110 pacientes evaluadas, de estas tumoraciones, 10 eran tumoraciones malignas de ovario. La sensibilidad del CA-125 fue de 61%, la especificidad de 70%, el valor predictivo positivo y negativo fue de 46% y 93%, respectivamente. El incremento del valor de corte a 65 Ul/mL no mejoró la precisión. Las pacientes con neoplasias malignas presentaron un valor promedio de CA-125 de 1557 ± 346 Ul/mL y las pacientes con neoplasias benignas de 110 ± 73 Ul/mL (p<0,05). Se concluye que el CA-125 tiene una moderada eficacia diagnóstica como predictor preoperatorio de malignidad en tumores pélvicos

The obejtive of the research was to evaluate the diagnóstic efficacy of CA-125 as predictor of pre-surgical malignacy in pelvic tumors. Patients were selective prospectively and who were admitted with diagnosis of pelvic tumors who had ultrasound evaluation and CA-125 concentration were assessed before surgery. Histology of pelvic tumors was the final point of research and was divided in two groups: bening and malignacy. Mean age of patients was 42.1 ± 12.9 years old. There were found 13 malignancies in 110 patients, from these tumors, 10 were malignancies of ovaries. CA-125 sensitivity was 61%. specificity 70%, positive and negative predictive value was 46% and 93%, respectively. Increasing the cur off value to 65 Ul/mL did not improve accuracy. Patients with malignancy presented a mean CA-125 concentration of 1557 ± 346 Ul/mL and patients with bening tumor of 110 ± 73 Ul/mL(p<0,05). It is concluded that CA-125 has a moderate diagnostic efficacy as predictor of malignancy in pelvic tumors

Angiomixoma agresivo en un hombre: reporte de un caso / Aggressive angiomyxoma in a man: a case report

El Angiomixoma agresivo es una neoplasia de diferenciación incierta descrita por primera vez por Steeper y Rosai (1983), que tiene predilección por la región pélvica y perineal de mujeres entre la 3ra y la 6ta década de la vida, afectando con menor frecuencia al sexo masculino, con casos descritos de localización escrotal. En Venezuela hasta la fecha, no hay casos informados de este tumor en pacientes masculinos. Presentamos un caso de localización pélvica, confirmado mediante estudios de inmuno-histoquímica en un varón de 27 años de edad con una recidiva luego de 3 años de la exéresis inicial.

Aggressive angiomyxoma is a neoplasm of uncerta in differentiation first described by Steeper and Rosai (1983), which has a predilection for the pelvic and perineal region of females between the 3rd and 6th decade of life, affecting males less frequently, with reported cases of scrotal location. In Venezuela, to date, no cases were reported in male patients. A case of pelvic location we presented, confirmed by immunohistochemistry studies in a male of 27 years-old with a relapse after three years of the initial excision.

Manejo de los tumores retrorrectales del adulto / Management of the retrorectal tumors of the adult

Antecedentes: Los tumores que asientan en el espacio virtual entre el mesorrecto y el sacrocoxis comprenden un grupo heterogéneo y poco frecuente cuya incidencia se estima en 1/40.000 ingresos. Se clasifican en congénitos, neurogénicos, óseos y misceláneas. Por ser asintomáticos u ocasionar síntomas inespecíficos su diagnóstico suele ser tardío y muchas veces cuando han alcanzado un gran tamaño o comprometido las estructuras vecinas. El diagnóstico y tratamiento, que requiere un equipo multidisciplinario, han evolucionado en los últimos años por el aporte de la resonancia magnética nuclear (RMN), las nuevas terapias quimiorradiantes y un abordaje quirúrgico más agresivo. Objetivo: Comunicar nuestra experiencia y sugerir la estrategia de manejo de estos tumores basada en esta serie y la de los centros internacionales de referencia. Pacientes y Métodos: Se revisaron retrospectivamente las historias clínicas de los pacientes con tumores retrorrectales operados entre 1991 y 2006 en la División Cirugía del Hospital Juan A. Fernández. Se excluyeron procesos inflamatorios, tumores rectales localmente avanzados y metastásicos. Se registraron sexo, edad, síntomas/signos, tiempo de evolución, estudios preoperatorios, tamaño tumoral, compromiso sacro y/o de órganos vecinos, tratamiento quirúrgico, morbimortalidad inmediata, estadía postoperatoria, secuelas, histopatología, recurrencia y supervivencia. Además se evaluó la utilidad de la tomografía axial computada (Te) y la RMN para establecer la estirpe tumoral, la posible malignidad, la invasión de estructuras vecinas y la vía de abordaje. Resultados: Hubo 7 pacientes (5 mujeres), edad promedio 37,5 (23-54) años. Congénitos: 2 (cordoma 1, hamartoma quístico 1), neurogénicos: 2 (neurofibroma plexiforme 1, schwanoma maligno 1), óseos: 1 (tumor de células gigantes del sacro) y misceláneas: 2 (liposarcoma 1, fibroma extrapleural maligno 1)...

Background: Tumors occupying the virtual space between the mesorectum and sacro-coccyx are heterogeneous and infrequent, with an estimated incidence of 1/40.000 hospitalizations. They are classified as congenital, neurogenic, osseous, and miscellaneous. Because they are asymptomatic or cause non-specific symptoms diagnosis is usually delayed, and very often done when have reached a great dimension or involved adjacent structures. Diagnosis and treatment, that required a multidisciplinary team, has evolved in recent years due to the role of magnetic resonance imaging (MRI), new chemo-radiation therapies and a more aggressive surgical approach. Objective: Report on our experience, and suggest the management strategy for these tumors based on this series and that of international referral centers. Patients and Methods: Clinical records of patients with retrorectal tumors operated on, between 1991 and 2006 in the Division of Surgery of the Hospital Juan A. Fernández were retrospectively reviewed. Inflammatory processes, locally advanced rectal tumors and metastatic lesions were excluded. Registe red data included gender, age, symptom/signs, time of evolution, preoperative studies, size of tumors, involvement of sacrum and/or adjacent viscera, surgical treatment, 30-day morbidity and mortality, postoperative hospital stay, secuela, histopathology, recurrence and survival. Besides, the usefulness of computed tomography (CT) and MRI to establish the histologic tumor type, possible malignancy, invasion of adjacent structures, and operative approach was assessed. Results: Seven patients (5 women), mean age 37.5 (23-54) years, were treated. Congenital: 2 (chordoma 1, tailgut cyst 1), neurogenic: 2 (plexiform neurotibroma 1, malignant schwannoma 1), osseous: 1 (gigant cell tumor of the sacrum) and miscellaneous: 2 (liposarcoma 1, extrapleural malignant fibroma 1)...

Foreign Body Granulomas Simulating Recurrent Tumors in Patients Following Colorectal Surgery for Carcinoma: a Report of Two Cases

We report here two cases of foreign body granulomas that arose from the pelvic wall and liver, respectively, and simulated recurrent colorectal carcinomas in patients with a history of surgery. On contrast-enhanced CT and MR images, a pelvic wall mass appeared as a well-enhancing mass that had invaded the distal ureter, resulting in the development of hydronephrosis. In addition, a liver mass had a hypointense rim that corresponded to the fibrous wall on a T2-weighted MR image, and showed persistent peripheral enhancement that corresponded to the granulation tissues and fibrous wall on dynamic MR images. These lesions also displayed very intense homogeneous FDG uptake on PET/CT.

Chondrolipoma in the Pelvic Cavity: a Case Report

A chondrolipoma is an extremely rare form of a benign mesenchymal tumor containing mature cartilage and fatty tissue. Chondrolipomas may be found in almost any part of the body, particularly in the connective tissue of the breast, head and neck area, as well as in the skeletal muscle. However, to the best of our knowledge, chondrolipomas located in the pelvic cavity have not been reported. In this case report, we describe a case of a chondrolipoma in the pelvis, and show that it has its own characteristic imaging findings, which included the composition of fatty tissue and calcification in most parts, as well as some focal areas of chondroid tissue based on the CT and MR findings.

Benign mesothelioma of peritoneum presenting as a pelvic mass

A large solitary multiloculated pelvic cyst in a 40-year-old woman with chronic pelvic pain was diagnosed to be a Multicystic Benign Mesothelioma [MBM] of peritoneum at laparotomy. Operative findings showed dense adhesions between uterus and bladder anteriorly, small intestines and pouch of Douglas posteriorly, a right ovarian cyst cm containing clear serous fluid and two nodular deposits were seen in the pouch of Douglas, small multiple deposits was found over the mesentery of small intestine and parietal peritoneum. Total abdominal hysterectomy with bilateral oophorectomy and infracolic omentectomy was done. During surgery, there was injury to the small intestine hence, resection of 10 inches of small intestine with re-anastomosis was carried out. Postoperative recovery was satisfactory. At 3 years follow-up, patient is symptom-free

Ultra-sonografia na condução de massas pélvicas / Ultrasonography in the management of pelvic masses

O uso da morfologia do ultra-som da escala de cinzas tem a finalidade de caracterizar uma massa pélvica. Uma massa com irregularidades deve sempre evocar a suspeita de malignidade. Uma massa que seja completamente lisa é quase cetamente benigna. As projeções papilares - consideradas sinal forte de malignidade - são mais comuns em tumores do borderline do que em cânceres invasivos, mas podem também ser vistas em tumores benignos, para o exemplo, nos adenofribromas, explicando muitos diagnósticos falso-positivos da ultra-sonografia. A morfologia ecográfica é superior a todas as outras avaliações possíveis para a discriminação entre massas pélvicas benignas e malignas. O atual uso freqüente e demasiadamente liberal da ultrasonografia resulta em dilema clínico. Muitas massa anexiais que provavelmente remanesceriam não detectadas antes da era do ultra-som são encontradas agora acidentalmente no exame de ultra-som transvaginal nas mulheres sem sintomas de tumor anexial. Não se sabe o histórico natural de massas pélvicas acidentalmente detectadas com morfologia benigna do ultra-som. Conseqüentemente, o melhor tratamento de tais tumores é também desconhecido.

Endometriosis pélvica-linfática simulando: cáncer de ovario avanzado / Pelvic-lymphatic endometriosis simulating: neoplasms of advanced ovary

La endometriosis es una enfermedad que afecta a la mujer en edad fértil. Consiste en tejido endometrial fuera del abdomen. Los estimados actuales indican que fluctúa entre el 2 y el 10 por ciento en la edad reproductiva. Alrededor de un 30 a 40 por ciento de las mujeres con endometriosis no son fértiles, siendo una de las causas de infertilidad femenina. La endometriosis ganglionar es un fenómeno infrecuente. Más raro aún es hallar Endometriosis Linfática - Ganglionar simulando un cáncer de ovario avanzado.

Ganglioneuroma of pelvis--an unique presentation in a young man.

Ganglioneuromas presented as a pelvic tumor around the pelvic organs is a rare entity. A case with unusual presentation is reported. Young man of 18 years old presented with a complaint of lower abdominal mass increasing in size for last 3 years. It was treated with partial resection for debulking purpose after the conformation during surgery with frozen section. Debulking surgery with preservation of organ functions is feasible in these slow growing tumors for better quality of life.

Laparoscopic resection of metastatic pelvic liposarcoma

We report a pelvic liposarcoma originating from the left spermatic cord that recurred following inadequate excision. In our case, the tumor was resected without performing orchiectomy previously. The patient was managed by laparoscopic resection, before undergoing radical orchiectomy in the left inguinal region. To our knowledge, no case of laparoscopic resection for the recurrent liposarcoma has been described. In addition, the present case serves to demonstrate that radical orchiectomy with wide excision is needed for paratesticular tumor.

Estudo retrospectivo de osteossarcoma primário dos ossos da pelve em cães em um período de 14 meses / Retrospective study of primary osteosarcoma in pelvis's bones of dogs during a period of fourteen months

O osteossarcoma (OSA) é um dos tumores malignos mais comum em cães. Geralmente acomete cães de raça grande e gigante, com idade média de sete anos. Esta neoplasia envolve, freqüentemente, a metáfise de ossos longos, sendo indicado à amputação radical do membro, acrescido de quimioterapia com cisplatina. A terapêutica desta neoplasia com localização na pelve toma-se difícil e normalmente não aceita pelos proprietários. O presente trabalho relata a incidência de osteossarcoma primário em ossos da pelve em cães, durante um período de 14 meses. Dos oito animais atendidos com esta neoplasia, observou-se maior freqüência nos cães da raça Rottweiler e Pastor Alemão. Dentre os ossos que compõem a pelve do animal se observou maior incidência de OSA acometendo o ílio (6 casos). Claudicação, impotência funcional de membro pélvico e dor foram os principais sinais clínicos observados. Em sete casos encontrou-se estágio avançado de comprometimento ósseo na imagem radiográfica, evidenciado, principalmente, pela lise da cortical óssea. Todos os animais foram submetidos à eutanásia por não apresentarem possibilidade de tratamento cirúrgico (hemipelvectomia) com margem de segurança. Também se levou em consideração para esta decisão à condição clínica dos pacientes, as chances de conferir melhora na qualidade de vida dos cães e a opção dos proprietários frente ao prognóstico.

The osteosarcoma (OSA) is one of the most common malignant tumors of dogs. Large and giant -breed dogs are affected and the mean age of these dogs is about 7 years. The tumor usually involves the metaphyses of long bones and the treatment is radical amputation and chemotherapy with cisplatin. The therapy of neoplasia located in pelvis is difficult and usually don't accept by owners. This report describes the incidence of primary osteosarcoma in pelvis of dogs, duting a period of fourteen months. Of the eight animals taken care with this neoplasia, a bigger frequency in the dogs of the race Rottweiler and German Pastor was observed. Amongst the bones that compose animal's pelvis was observed greater osteosarcoma incidence in ileum (6 cases). Lameness, functional impotence of pelvic member and pain had been the main observed clinical signals. In seven cases was found advanced involvement osseous, mainly, for lyses of the cortical. All the animals had been submitted to the euthanasia for not presenting possibility of surgical treatment with safety margin. Also one was taken in consideration for this decision to the clinical condition of the patients, the possibilities to confer improvement in the quality of life of the dogs and the option of the owners' front to the prognostic.