Definitive diagnosis of neuroendocrine tumors using fine-needle aspiration-puncture guided by endoscopic ultrasonography.

BACKGROUND: The detection and diagnosis of neuroendocrine tumors (NETs) is challenging. Endoscopic ultrasonography (EUS) has a significant role in the detection of NETs suspected from clinical manifestations or imaging techniques, as well as in their precise localization and cytological confirmation using EUS-Fine-needle aspiration-puncture (FNA). OBJECTIVE: To assess the usefulness and precision of EUS-FNAP in the differential diagnosis and confirmation of NETs, in a retrospective review of our experience. PATIENTS AND METHODS: in a total of 55 patients with suspected NETs who underwent radial or sectorial EUS, 42 tumors were detected in 40 cases. EUS-FNA using a 22G needle was performed for 16 cases with suspected functional (hormonal disorders: 6 cases) and non-functional NETs (10 cases). Ki 67 or immunocytochemistry (ICC) testing was performed for all.There was confirmation in 9 cases (5 female and 4 male) with a mean age of 51 years (range: 41-81 years).All tumors were located in the pancreas except for one in the mediastinum and one in the rectum, with a mean size of 19 mm (range: 10-40 mm). RESULTS: There were no complications attributable to FNA. Sensitivity was 100% and both precision and PPV were 89%, as a false positive result suggested a diagnosis with NET during cytology that surgery finally revealed to be a pancreatic pseudopapillary solid tumor. CONCLUSIONS: EUS-FNA with a 22G needle for NETs has high sensitivity and PPV at cytological confirmation with few complications.

Usefulness of endoscopic ultrasonography (EUS) for selecting carcinoid tumors as candidates to endoscopic resection.

INTRODUCTION: Carcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery. OBJECTIVE: Endpoints in this study included:--Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. --Assessing the effectiveness of local resection (complete carcinoid resection) and the safety (complications) of the technique involved. PATIENTS AND METHODS: OUr series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty-one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), excision was carried out with conventional polypectomy snare mucosectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following non-curative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resection: CR) and safety (complications). RESULTS: There were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%).EUS sensitivity was 94%. Complete resection was 90.5% (19/21). CONCLUSIONS: The endoscopic mucosal resection of selected carcinoid tumors is a safe, effective technique. EUS is the technique of choice to select patients eligible for endoscopic resection (carcinoids smaller than 20 mm in superficial layers, with an unscathed muscularis propria and negative extension study).

Utilidad de la ultrasonografía endoscópica (USE) para seleccionar tumores carcinoides como candidatos a una resección endoscópica / No disponible

Introduccion: los tumores carcinoides (TC) son los tumores neuroendocrinos (TNEs) más frecuentes. Los TC digestivos localizados en el tracto gastroduodenal y rectocolónico pueden ser evaluados por endoscopia y por ecoendoscopia o ultrasonografía endoscópica (USE), con el objetivo de efectuar una resección local como tratamiento curativo sin recurrir a la cirugía. Objetivo: los objetivos finales de este estudio fueron: —Analizar si es útil la USE en la selección de TC como candidatos a una extirpación endoscópica. —La evaluación de la eficacia de la resección local (resección completa del carcinoide) y la seguridad (complicaciones) de la técnica efectuada. Pacientes y metodos: la serie consta de 18 pacientes (12 varones y 6 mujeres) con 23 tumores. Se han seleccionado 16 pacientes (10 varones y 6 mujeres) con un rango de 40 a 81 años (media: 57 años), con tumores carcinoides digestivos biopsiados y tratados endoscópicamente, con estudio previo de extensión negativo. Se resecaron 21 tumores de 2 a 20 mm (tamaño medio: 8 mm), en 23 procedimientos. Después de endoscopia más biopsia y ecoendoscopia (USE), se llevó a cabo la extirpación mediante mucosectomía con asa de polipectomía convencional e inyección submucosa con suero salino y/o adrenalina en la mayoría de casos (15) y en seis con técnica de mucosectomía tras ligar la lesión con bandas elásticas. En dos casos con cirugía endoscópica transanal (TEM) (uno después de haber efectuado polipectomía no curativa). Se efectuaron en total 23 tratamientos localizados con el objetivo fundamental de evaluar la eficacia (resección completa: RC) y seguridad (complicaciones). Resultados: no hubo complicaciones muy importantes, excepto en la última mucosectomía gástrica por un carcinoide de 6 mm, en la que se produjo una miniperforación (1/23: 4,3%) que se resolvió con la colocación de 3 clips. La sensibilidad de la USE fue del 94%. La resección completa fue del 90,5% (19/21). Conclusiones: la resección mucosa endoscópica de tumores carcinoides seleccionados es una técnica segura y eficaz. La USE es la técnica de elección para seleccionar los pacientes candidatos a resección endoscópica (carcinoides menores de 20 mm situados en las primeras capas, con muscular propia indemne y con estudio de extensión negativo(AU)

Introduction: carcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery. Objective: endpoints in this study included: —Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. —Assessing the effectiveness of local resection (complete carcinoid resection) and the safety (complications) of the technique involved. Patients and methods: our series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty- one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), excision was carried out with conventional polypectomy snare mucosectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following noncurative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resection: CR) and safety (complications). Results: there were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%). EUS sensitivity was 94%. Complete resection was 90.5% (19/21). Conclusions: the endoscopic mucosal resection of selected carcinoid tumors is a safe, effective technique. EUS is the technique of choice to select patients eligible for endoscopic resection (carcinoids smaller than 20 mm in superficial layers, with an unscathed muscularis propria and negative extension study)(AU)

[Interventionist endoscopic ultrasonography. A retrospective analysis of 60 procedures]. / Ultrasonografía endoscópica intervencionista. Análisis retrospectivo de 60 procedimientos.

INTRODUCTION AND OBJECTIVE: interventionist endoscopic ultrasonography is increasingly used because of its growing indications. We present here our retrospective and initial experience (60 procedures) with endoscopic ultrasonography (EUS) both for diagnosis (EUS-FNA) and therapy (EUS-guided tumorectomy and mucosectomy). PATIENTS AND METHOD: in a group with 27 cases including 10 submucosal tumors (SMTs), 2 adenopathies, and 15 potential pancreatic tumors (8 pancreatic cancers), a sectorial EUS-FNA at 7.5 MHz was performed for diagnosis prior to therapy (mainly surgical). A pancreatic pseudocyst was drained. In 21 cases with 27 SMTs (10 patients with 13 carcinoids) a tumorectomy was carried out using the standard loop or assisted polypectomy technique with submucosal injection, and in a few cases (two) using elastic band ligation following a radial EUS at 7.5, 12, or 20 MHz. In 6 cases of superficial gastroesophageal cancer or gastric dysplasia an endoscopic mucosal resection (classic EMR) was performed after EUS or MPs at 7.5 and 20 MHz. Fifty-five patients with 60 lesions, 29 femaes and 26 males with a mean age of 60 years (30-88 years) were retrospectively analyzed. RESULTS: diagnostic precision (P), sensitivity (S), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) for EUS-FNA was 85, 83, 100, 100, and 43%, respectively, when comparing results with specimen histology. P was higher for adenopathies (100%) and pancreatic tumors (87%) than for SMTs (80%). No complications arose, except for one episode of upper gastrointestinal bleeding (UGIB) (3.7%) that was endoscopically and satisfactorily treated in a gastric SMT. In the group with 21 patients (10 carcinoids with 13 tumors) 27 SMTs were endoscopically treated by tumorectomy with no perforation and only 2 UGIBs (7.4%), one of them self-limited, recorded. Endoscopic resection was complete in 92% of cases. No complications occurred with classic EMR, and all patients are still alive with no evidence of relapse, either local or metastatic. In this group the rate of complete resections was 100%. CONCLUSIONS: EUS-FNA is a safe technique with high diagnostic accuracy. EUS-guided tumorectomy and mucosectomy are also safe and effective techniques in the endoscopic management of these tumors.

Ultrasonografía endoscópica intervencionista. Análisis retrospectivo de 60 procedimientos / Interventionist endoscopic ultrasonography. A retrospective analysis of 60 procedures

Introducción y objetivo: la ultrasonografía endoscópica intervencionista cada día se realiza con más frecuencia debido a que goza de mayores indicaciones. Presentamos nuestra experiencia retrospectiva e inicial (60 procedimientos) en ultrasonografía endoscópica (USE) intervencionista diagnóstica (USE-PAAF) y terapéutica (tumorectomía y mucosectomía guiada por USE). Pacientes y método: en un grupo de 27 casos, con 10 tumores submucosos (TSM), 2 adenopatías y 15 posibles tumores de páncreas (8 cánceres de páncreas), se practicó USE-PAAF sectorial con 7,5 MHz con fines diagnósticos previa a la actuación terapéutica (fundamentalmente quirúrgica). Un caso de seudoquiste pancreático fue drenado. En 21 casos con 27 TSM (10 enfermos con 13 carcinoides) se practicó tumorectomía mediante la técnica convencional de polipectomía con asa o asistida con inyección submucosa, y en pocos casos (dos) ligando la lesión con bandas elásticas, previa USE radial con 7,5, 12, o 20 MHz. En 6 casos de cáncer superficial gastroesofágico o displasia gástrica se ha practicado resección mucosa endoscópica (RME clásica) previa USE o MS de 7,5 y 20 MHz. Se analizaron retrospectivamente 55 pacientes con 60 lesiones, 29 mujeres y 26 varones, con una edad media de 60 años (30-88 años). Resultados: la precisión diagnóstica (P), sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y valor predictivo negativo (VPN) de la USE-PAAF fue del 85, 83, 100, 100, y 43%, respectivamente, al comparar los resultados con la histología de la pieza. La P fue mayor para las adenopatías (100%) y tumores pancreáticos (87%) que para los TSM (80%). No hubo complicaciones excepto una hemorragia digestiva alta (HDA) (3.7%) que se trató endoscópicamente y satisfactoriamente en un TSM gástrico. En el grupo de 21 enfermos (10 carcinoides con 13 tumores) se trataron endoscópicamente mediante tumorectomía 27 TSM sin que se registrara ninguna perforación, y tan sólo 2 HDA (7,4%) una de ellas autolimitada. La resección endoscópica fue completa en el 92% de los casos. Con la técnica de la RME clásica no hubo complicaciones, y todos los pacientes están vivos y sin evidencia de recidiva local o metastásica. En este grupo el porcentaje de resección completa fue del 100%. Conclusiones: la USE-PAAF es una técnica segura con una buena precisión diagnóstica. La tumorectomía y la mucosectomía asistidas por USE son también técnicas seguras y eficaces en el tratamiento endoscópico de dichos tumores

Introduction and objective: interventionist endoscopic ultrasonography is increasingly used because of its growing indications. We present here our retrospective and initial experience (60 procedures) with endoscopic ultrasonography (EUS) both for diagnosis (EUS-FNA) and therapy (EUS-guided tumorectomy and mucosectomy). Patients and method: in a group with 27 cases including 10 submucosal tumors (SMTs), 2 adenopathies, and 15 potential pancreatic tumors (8 pancreatic cancers), a sectorial EUS-FNA at 7.5 MHz was performed for diagnosis prior to therapy (mainly surgical). A pancreatic pseudocyst was drained. In 21 cases with 27 SMTs (10 patients with 13 carcinoids) a tumorectomy was carried out using the standard loop or assisted polypectomy technique with submucosal injection, and in a few cases (two) using elastic band ligation following a radial EUS at 7.5, 12, or 20 MHz. In 6 cases of superficial gastroesophageal cancer or gastric dysplasia an endoscopic mucosal resection (classic EMR) was performed after EUS or MPs at 7.5 and 20 MHz. Fifty-five patients with 60 lesions, 29 femaes and 26 males with a mean age of 60 years (30- 88 years) were retrospectively analyzed. Results: diagnostic pecision (P), sensitivity (S), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) for EUS-FNA was 85, 83, 100, 100, and 43%, respectively, when comparing results with specimen histology. P was higher for adenopathies (100%) and pancreatic tumors (87%) than for SMTs (80%). No complications arose, except for one episode of upper gastrointestinal bleeding (UGIB) (3.7%) that was endoscopically and satisfactorily treated in a gastric SMT. In the group with 21 patients (10 carcinoids with 13 tumors) 27 SMTs were endoscopically treated by tumorectomy with no perforation and only 2 UGIBs (7.4%), one of them self-limited, recorded. Endoscopic resection was complete in 92% of cases. No complications occurred with classic EMR, and all patients are still alive with no evidence of relapse, either local or metastatic. In this group the rate of complete resections was 100%. Conclusions: EUS-FNA is a safe technique with high diagnostic accuracy. EUS-guided tumorectomy and mucosectomy are also safe and effective techniques in the endoscopic management of these tumors

EUS-guided mucosectomy for gastrointestinal cancer.

INTRODUCTION: the only way of improving prognosis and survival in gastrointestinal cancer is early diagnosis, with intramucosal localization as confirmed by endoscopic ultrasonography (EUS) or 20-MHz miniprobes (MPs) (T1) being most appropriate. Endoscopic mucosal resection (EMR) has proven effective in the treatment of this sort of lesions. PATIENTS AND METHOD: in a group (18 cases) with 15 cases of superficial gastrointestinal cancer and 3 cases of severe gastric dysplasia, 9 cases (3 esophageal, 4 gastric, 2 rectal) underwent a classic EMR following EUS or a 7.5- and 20-MHz miniprobe exploration. RESULTS: ultrasonographic studies showed a T1 in all but one esophageal case (Tis), and in both gastric dysplasias, with no changed layer structure being demonstrated in the latter (T0). No complications arose with classic EMR, and all 9 patients are alive and free from local or metastatic recurrence, except for one esophageal case, which recurred distally to the esophageal lesion (metachronous). CONCLUSIONS: echoendoscopically-assisted EMR is a safe, effective technique in the endoscopic management of superficial gastrointestinal (esophageal, gastric, colorectal) cancer. Recurrence most likely depends upon cancer multiplicity.

Mucosectomía guiada por USE en el cáncer digestivo / EUS-guided mucosectomy for gastrointestinal cancer

Introducción: la única forma de mejorar el pronóstico y la supervivenciadel cáncer digestivo es su diagnóstico precoz, siendosu estadio ideal la localización intramucosa, confirmada por ultrasonografíaendoscópica (USE) o minisondas (MS) de 20 MHz (T1).La resección mucosa endoscópica (RME) se ha demostrado eficazen el tratamiento de este tipo de lesiones.Pacientes y método: en un grupo (18 casos) de 15 casos decáncer superficial digestivo y 3 displasias severas gástricas, se hanpracticado en 9 casos (3 de esófago, 4 de estómago, y 2 de recto)RME clásica, previa USE o MS de 7,5 y 20 MHz.Resultados: los estudios ultrasonográficos demostraron entodos los casos que se trataba de un T1 menos en un caso, esofágico(Tis), y en los dos casos de displasias gástricas, en los cualesno se pudo demostrar alteración de la estructura de capas (T0).Con la técnica de RME clásica no hubo complicaciones, y los9 están vivos, sin recidiva local o metastásica, excepto un caso,esofágico, que recidivó distalmente a la lesión esofágica (metacrónico).Conclusiones: la RME asistida por ecoendoscopia es una técnicasegura y eficaz en el tratamiento endoscópico del cáncer superficialdigestivo (esofágico, gástrico y colorrectal). La recidivaprobablemente está en función de la multiplicidad del cáncer

Introduction: the only way of improving prognosis and survivalin gastrointestinal cancer is early diagnosis, with intramucosallocalization as confirmed by endoscopic ultrasonography (EUS)or 20-MHz miniprobes (MPs) (T1) being most appropriate. Endoscopicmucosal resection (EMR) has proven effective in the treatmentof this sort of lesions.Patients and method: in a group (18 cases) with 15 cases ofsuperficial gastrointestinal cancer and 3 cases of severe gastricdysplasia, 9 cases (3 esophageal, 4 gastric, 2 rectal) underwent aclassic EMR following EUS or a 7.5- and 20-MHz miniprobe exploration.Results: ultrasonographic studies showed a T1 in all but oneesophageal case (Tis), and in both gastric dysplasias, with nochanged layer structure being demonstrated in the latter (T0).No complications arose with classic EMR, and all 9 patientsare alive and free from local or metastatic recurrence, except forone esophageal case, which recurred distally to the esophageal lesion(metachronous).Conclusions: echoendoscopically-assisted EMR is a safe, effectivetechnique in the endoscopic management of superficialgastrointestinal (esophageal, gastric, colorectal) cancer. Recurrencemost likely depends upon cancer multiplicity

Endoscopic staging of low-grade gastric MALT lymphoma.

INTRODUCTION: Endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. PATIENTS AND METHOD: 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. RESULTS: Echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed.

Estadificación por ecoendoscopia en el linfoma gástrico tipo MALT de bajo grado / Endoscopic staging of low-grade gastric malt lymphoma

Introducción: la ultrasonografía endoscópica (USE) ha demostrado ya su utilidad en la evaluación de las lesiones submucosas, en la estadificación del cáncer digestivo en general, y del linfoma gástrico tipo MALT en particular. El objetivo de este trabajo fue la estadificación por USE. Pacientes y método: veinticuatro enfermos (10 mujeres y 14 varones) con edad media de 56 años y con posible linfoma gástrico tipo MALT (25 casos) fueron estudiados con videoendoscopia, biopsias y ecoendoscopia con USE radial de 7,5 y 20 MHz, y con minisondas (MS) de 12 y 20 MHz. Se evaluaron definitivamente 19 pacientes (7 mujeres y 12 varones) con 20 MALT, ya que cinco enfermos se desestimaron por demostrarse a posteriori que presentaban un linfoma gástrico invasivo de alto grado (3c) o un plasmocitoma (2c). De los 19 pacientes todos eran T1 menos dos pacientes que eran T2, y otra presentaba un linfoma T1 gastroduodenal. Los hallazgos ecográficos de las MS fueron comparados con la USE (gold standard) y con la histología antes y después de la erradicación. Después, fueron seguidos cada 1, 3 y 6 meses mediante videoendoscopia y MS. Resultados: la ecoendoscopia identificó el estadio T correcto en el 90% de los casos. Las MS identificaron el estadio T en el 88% de los casos y la N en el 33% de los casos, con resultados discretamente inferiores a los obtenidos con la USE convencional (91 y 45%), por lo que se utilizaron en el seguimiento. Después de la erradicación, todos menos dos están en remisión completa y han sido seguidos cada 1, 3 y 6 meses con las MS sin observar anomalías ecográficas, excepto una paciente que hizo una recidiva

Introduction: endoscopic ultrasonography (EUS) has already proven useful in the assessment of submucosal lesions, and the staging of gastrointestinal cancer, particularly gastric MALT-type lymphoma. The goal of this paper was EUS staging. Patients and method: 24 patients (10 females, 14 males) with a median age of 56 years and possibly gastric MALT lymphoma (25 cases) were studied using videoendoscopy, biopsies, and echoendoscopy with 7.5- and 20-MHz radial EUS, and also with 12- and 20-MHz miniprobes (MPs). Nineteen patients were definitely evaluated (7 females, 12 males) as having 20 MALT-type lymphomas, as five patients were post-hoc disregarded when an invasive, high-grade gastric lymphoma (3c) or plasmocytoma (2c) was subsequently demonstrated. Of these 19 patients, all had T1 lesions except for two with T2 lesions; one patient had a gastroduodenal T1 lymphoma. Echographic findings with MPs were compared to EUS (gold standard) and histology both before and after eradication. Then, patients were followed up every 1-3-6 months using videoendoscopy and MPs. Results: echoendoscopy correctly identified T stages in 90% of cases. MPs identified T stages in 88% of cases, and N stages in 33% of cases, with results being slightly inferior to those obtained with conventional EUS (91 vs. 45%); they were consequently used for follow-up. After eradication, all but two patients are in complete remission and have been followed every 1-3-6 months using MPs without echographic abnormalities, except for a patient who relapsed

Leiomioma de epiplón menor localizado por ecoendoscopia / Leiomyoma of lesser omentum localized by means of endosonography

Hallazgo ecográfico casual de una tumoración de 4 cm, hipoecogénica y heterogénea en un varón de 67 años asintomático, con elevación de la gammaglutamiltranspeptidasa, que acudió para revisión médica. Ni la ecografía abdominal ni la TAC abdominal localizaron el origen de la tumoración. El interés de este caso estriba en constatar la aportación de la ecoendoscopia para el diagnóstico diferencial entre compresión extrínseca y lesión submucosa, como exploración de segunda intención (AU)

Thyroidal hemiagenesis.

Three cases of thyroidal hemiagenesis have been reported. The patients were euthyroid and presented with adenomatous goiters; one uninodular and the others multinodular in the contralateral lobe. In two cases the diagnosis was established by the thyroid stimulation test and confirmed at operation. In one case, this test was not performed and the hemiagenesia was discovered at routine surgical exploration of the scintigraphically absent lobe. From our cases and review of the literature we have concluded that the anomaly is usually discovered while searching for a contralateral pathologic abnormality, a thyroid stimulation test is essential for a preoperative suspicion, it occurs more frequently among women and in the left lobe, and ours are the first cases reported from Spain.