Hemangiopericytoma/Solitary Fibrous Tumor of the Parietal Bone: A Case Report.

Hemangiopericytoma/solitary fibrous tumor (HPC/STF) is a rare tumor arising from Zimmerman's pericytes and it is characterized by an aggressive malignancy, with a high tendency for local and distant recurrence. The authors report the case of a middle-aged woman with HPC/SFT of the right parietal bone, which is an extremely rare primary location of involvement. The patient presented with a painful deformity of insidious growth at the right parietal region. Assessment with cranial computed tomography scan and magnetic resonance imaging revealed an expansive lesion at the right parietal bone, with exocranial extension and 27 mm of maximal diameter. Craniotomy with gross tumor removal, duraplasty, and cranioplasty was performed, and the diagnosis of HPC/SFT, WHO grade III, was established by pathological and immunohistochemical analysis. The patient was then evaluated for adjuvant radiation therapy and received a dose of 60 Gy (2 Gy/fraction) with 3D conformal radiotherapy to the surgical bed. The adjuvant treatment was uneventful and, after 8 months of follow-up, there was no suspected local or distant recurrence. The rarity of this diagnosis, its aggressive behavior, and the lack of published data posed several challenges for the treatment management.

Neoadjuvant radiotherapy in the approach of locally advanced breast cancer.

BACKGROUND: Approximately 4% of European patients are diagnosed with locally advanced breast cancer (LABC), a clinical condition commonly associated with poorer prognosis. Systemic therapy is the recommended initial treatment and when inoperability criteria prevails, radiotherapy (RT) should be used for tumour downstaging. This study intends to evaluate the impact of neoadjuvant radiotherapy (NART) in the treatment of inoperable LABC. METHODS: A retrospective study of female patients, submitted to the NART between January 2014 and December 2018 at our institution. The evaluation of pathological response (pR) was made based on Pinder criteria. Primary endpoint: pR. Secondary endpoints: overall survival (OS) and progression-free survival (PFS). OS and PFS were calculated using the Kaplan-Meier method. Differences between groups were compared using Student's t-test, ANOVA (Analysis of variance) and χ2 test. The statistical analyses were performed using Stata (V.13). RESULTS: A total of 76 patients were included, 18% with breast complete response. The 5 years OS was 54% and PFS was 61%. Subgroup analysis showed that pR >90% is correlated with a better OS (p=0.004). Basal-like intrinsic subtype is correlated with worse OS and PFS (p<0.05). No relation was found between response and age, intrinsic subtype, treatment performed and clinical T stage. CONCLUSION: Our study confirms that NART is an effective downsizing treatment in inoperable LABC, allowing for a surgical resection regardless of the systemic treatment performed. Response to NART is independent of the intrinsic subtype and pR >90% is correlated with a better OS. Prospective studies to explore predictive response biomarkers are necessary in order to improve patient selection and optimisation of the treatment.

An unusual case of diffuse pigmented villonodular synovitis of the shoulder: A multidisciplinary approach with arthroscopic synovectomy and adjuvant radiotherapy.

Pigmented villonodular synovitis (PVNS) is a rare proliferative disorder of the synovial membrane. This condition is usually monoarticular, can be locally destructive, and involves muscles, tendons, bursae, bones, and skin. The most commonly affected joints are the knee and hip, followed by the ankle and shoulder. Patients often present with pain, swelling, and joint effusion; however, the duration of symptoms varies. Total synovectomy is the preferred treatment for PVNS. Subtotal synovectomy is a factor of recurrence, and in diffuse PVNS, total excision is very difficult to achieve. Radiotherapy may have an adjunctive role, particularly in incomplete resection or as a treatment of salvation in recurrent cases. This treatment modality has low toxicity levels and enables satisfactory joint function. This is a case report of a rare case of diffuse PVNS of the shoulder that was treated with partial arthroscopic synovectomy and adjuvant radiotherapy. A 74-year-old male patient presented with gradual onset pain, hemarthrosis, and functional impairment of the right shoulder without previous trauma history. Magnetic resonance imaging of the shoulder demonstrated a diffuse synovial thickening that was compatible with PVNS and rotator cuff destruction. The lesion was partially excised by arthroscopy. The patient underwent adjuvant radiation therapy with a total dose of 40 Gy/20 fractions/4 weeks. At the final follow-up, i.e., 1 month after treatment, the patient had increased shoulder mobility and no pain, with a mild change in cutaneous pigmentation. Radiation therapy is safe and effective in treating and preventing recurrence of diffuse PVNS, particularly after incomplete synovectomy.

Deep Vein Thrombosis as Initial Manifestation of Whipple Disease.

INTRODUCTION: Wipple disease (WD) is a rare chronic disease caused by the bacillus Tropheryma whipplei. Constitutive, rheumatologic, gastrointestinal, cardiac, cerebral, lymphatic, cutaneous, and ophthalmological signs are possible systemic symptoms. However, thrombotic manifestations are rarely described as "stroke-like syndrome" or arterial thrombosis. Diagnosis is based on clinical manifestations and pathological examination. Laboratory findings may include anemia, leukocytosis, and thrombocytosis. OBJECTIVE: We report a case of venous thrombosis as initial manifestation of WD. CASE REPORT: We describe the case of a 53-year-old male with iliofemoral vein thrombosis followed by intermittent diarrhea, loss of appetite, abdominal distension, and bloating. A mild malnutrition state with a weight loss of 13 kg, pallor (+/4 +), presence of lower-limb edema (+/4 +), and hypertympanic distended abdomen occurred. Laboratory tests on admission revealed anemia, positive inflammatory activity tests, and normal coagulation. Endoscopic examination showed villous edema with white dotted infiltrates in the second duodenal portion and intestinal lymphangiectasia in the terminal ileum. Pathological examination revealed numerous macrophages with positive periodic acid-Schiff inclusions. Venous Doppler ultrasound showed extensive deep thrombosis on the left lower limb and recanalization of the femoral vein in the right lower limb. The patient was treated with ceftriaxone and enoxaparin sodium, which led to an improvement of gastrointestinal and thrombosis symptoms. COMMENTS: Hypercoagulability, endothelial damage, vasculitis, and blood stasis are present in T. whipplei infection, which are associated with the activation of inflammatory mechanisms as well as procoagulant and thromboembolic events. WD should be part of the differential diagnosis of diseases that cause venous thrombosis of unknown origin.

Polyglandular Syndrome Type III and Severe Peripheral Neuropathy: An Unusual Association.

INTRODUCTION: Polyglandular syndrome is characterized by the association of autoimmune, organ-specific, endocrine and non-endocrine diseases. OBJECTIVE: To present a case of polyglandular syndrome type III (b) accompanied by pernicious anemia and autoimmune thyroiditis. METHOD: Report the clinical case of a young patient that developed progressive and disabling peripheral neuropathy framework, triggered by vitamin B12 deficiency. DISCUSSION: It was proven that atrophic gastritis with positive intrinsic anti-factor was responsible for the framework of pernicious anemia, which in turn dangerously reduced the serum levels of vitamin B12, leading to myelopathy. There was a progressive neurological improvement after parenteral cyanocobalamin replacement, keeping the patient at ambulatory, under maintenance therapy. CONCLUSION: The importance of suspecting on polyglandular syndrome in the presence of autoimmune frameworks is important, especially those involving diabetes, thyroiditis, atrophic gastritis, pernicious anemia, vitiligo, among others.

INTRODUÇÃO: A Síndrome Poliglandular é caracterizada pela associação de doenças autoimune órgão-específicas, endócrinas e não endócrinas. OBJETIVO: Apresentar um caso de Síndrome Poliglandular do tipo III (b) acompanhada de anemia perniciosa e tireoidite auto-imune. MÉTODO: Relata-se o caso clínico de uma paciente jovem que desenvolveu quadro de neuropatia periférica progressiva e incapacitante, desencadeada pela deficiência de vitamina B12. DISCUSSÃO: Ficou comprovado que a gastrite atrófica com anticorpo anti-fator intrínseco positivo foi responsável pelo quadro de anemia perniciosa, que por sua vez reduziu perigosamente os níveis séricos da vitamina B12. Houve melhora progressiva do quadro neurológico após reposição parenteral da cianocobalamina, mantendo-se a paciente, em seguimento ambulatorial, sob terapia de manutenção. CONCLUSÃO: Ressalta-se a importância de se suspeitar da síndrome poliglandular na vigência de quadros auto-imunes, especialmente aqueles envolvendo diabetes, tireoidites, gastrite atrófica, anemia perniciosa, vitiligo, entre outros.

Ginseng, green tea or fibrate: valid options for nonalcoholic steatohepatitis prevention?

OBJECTIVES: Panax ginseng, Camellia sinensis and bezafibrate were compared for their lipid-lowering, antioxidant and anti-inflammatory properties as potential agents to prevent nonalcoholic fatty liver disease and its progression to nonalcoholic steatohepatitis. METHODS: Fifty Wistar rats were randomized into five groups: G1 (feed with standard diet); G2 (feed with high-fat diet with 58% of energy from fat); G3 (high-fat diet + standardized Panax ginseng extract at 100 mg/kg/day); G4 (high-fat diet + standardized Camellia sinensis extract at 100 mg/kg/day); and G5 (high-fat diet + bezafibrate at 100 mg/kg/day), given by gavage. The animals were sacrificed eight weeks later and blood was collected for glucose, insulin, cholesterol, triglycerides, AST, ALT, alkaline phosphatase and gamma-glutamyl transferase determinations. The score system for nonalcoholic fatty liver disease was used to analyse the liver samples. RESULTS AND CONCLUSIONS: High-fat diet resulted in a significant increase in animal body weight, biochemical changes and enzymatic elevations. Steatosis, inflammation and hepatocellular ballooning scores were significant high in this group. The biochemical and histological variables were statistically similar in the bezafibrate group and control group. Treatment with Panax ginseng extract prevented obesity and histological features of nonalcoholic steatohepatitis (steatosis and inflammation) compared to high-fat diet. Camellia sinensis showed a less effective biochemical response, with small reduction in steatosis and inflammation but lower ballooning scores.

GINSENG, GREEN TEA OR FIBRATE: valid options for nonalcoholic steatohepatitis prevention? / Ginseng, chá verde ou fibrato: opções válidas para prevenção da esteatohepatite não alcoólica?

Objectives Panax ginseng, Camellia sinensis and bezafibrate were compared for their lipid-lowering, antioxidant and anti-inflammatory properties as potential agents to prevent nonalcoholic fatty liver disease and its progression to nonalcoholic steatohepatitis. Methods Fifty Wistar rats were randomized into five groups: G1 (feed with standard diet); G2 (feed with high-fat diet with 58% of energy from fat); G3 (high-fat diet + standardized Panax ginseng extract at 100 mg/kg/day); G4 (high-fat diet + standardized Camellia sinensis extract at 100 mg/kg/day); and G5 (high-fat diet + bezafibrate at 100 mg/kg/day), given by gavage. The animals were sacrificed eight weeks later and blood was collected for glucose, insulin, cholesterol, triglycerides, AST, ALT, alkaline phosphatase and gamma-glutamyl transferase determinations. The score system for nonalcoholic fatty liver disease was used to analyse the liver samples. Results and conclusions High-fat diet resulted in a significant increase in animal body weight, biochemical changes and enzymatic elevations. Steatosis, inflammation and hepatocellular ballooning scores were significant high in this group. The biochemical and histological variables were statistically similar in the bezafibrate group and control group. Treatment with Panax ginseng extract prevented obesity and histological features of nonalcoholic steatohepatitis (steatosis and inflammation) compared to high-fat diet. Camellia sinensis showed a less effective biochemical response, with small reduction in steatosis and inflammation but lower ballooning scores. .

Objetivos Panax ginseng, Camellia sinensis e bezafibrato foram comparados por suas propriedades hipolipemiantes, antioxidantes e anti-inflamatórias, como potenciais agentes capazes de prevenir a doença hepática gordurosa não alcoólica e sua progressão para esteato-hepatite não alcoólica. Métodos Cinqüenta ratos Wistar foram distribuídos aleatoriamente em cinco grupos: G1 (alimentados com dieta padrão); G2 (alimentados com dieta hipercalórica com 58% de energia a partir de gordura); G3 (dieta rica em gordura + extrato padronizado Panax ginseng em 100 mg / kg / dia); G4 (dieta rica em gordura + extrato de Camellia sinensis padronizado a 100 mg / kg / dia); e G5 (dieta rica em gordura + bezafibrato, a 100 mg / kg / dia), administrado via oral. Os animais foram sacrificados após oito semanas e o sangue foi coletado para determinação da glicose, insulina, colesterol, triglicérides, AST, ALT, fosfatase alcalina e gama-glutamil transferase. O sistema NAS de pontuação para doença hepática gordurosa não alcoólica foi utilizado para analisar as amostras de fígado. Resultados e conclusões A dieta hipercalórica resultou em um aumento significativo no peso corporal dos animais, associado a alterações bioquímicas e elevações enzimáticas. Os escores de esteatose, inflamação e balonização hepatocelular foram significativamente mais elevados neste grupo. As variáveis bioquímicas e histológicas foram estatisticamente semelhantes entre os grupos bezafibrato e controle. O uso do extrato do Panax ginseng esteve associado a um menor ganho de peso dos animais, em média, bem como a menores índices nos escores de esteato-hepatite (esteatose e inflamação) em comparação com o grupo apenas alimentado com dieta hipercalórica. No grupo ...

Diffuse Caroli's disease with atypical presentation: a case report.

This paper describes a case of Caroli's disease in a female patient aged 32, who complained of nonspecific abdominal pain without cholesthasis or cholangitis. Liver resonance shows segment saccular dilations closely connected to intrahepatic biliary ducts, that differ from the Caroli's syndrome, which is more common and consists of multiple intrahepatic cystic dilatations, associated to congenital hepatic fibrosis. This patient has a congenital anomaly with an uncommon oligosymptomatic form of Caroli's disease that should be included in the differential diagnosis of patients with recurrent abdominal pain.

Imunoexpressão hepática de marcadores inflamatórios e de resistência insulínica na esteato-hepatite não alcóolica / Immunohistochemistry pattern of hepatic inflammatory and insulin resistance markers in experimental model of nonalcoholic steatohepatitis

Introduction: The pathophysiology of nonalcoholic steatohepatitis (NAS) includes, basically, insulin resistance, inflammation and oxidative stress. Thus, a study of immunostaining for liver insulin, adiponectin, tumor necrosis factor alpha (TNF-α), and inducible nitric oxide synthase (iNOS) receptors was conducted. Objective: To expand the knowledge about the pathophysiological and molecular mechanisms underlying the experimental model of steatohepatitis in rats fed a high-fat diet. Method: Twenty Wistar rats were divided into two groups: G1 (control, fed a standard diet), and G2 (fed a high-fat diet containing 58% of energy derived from fat, 18% from protein and 24% from carbohydrate). After eight weeks the animals were sacrificed. Blood glucose, insulin, total cholesterol, high-density lipoprotein (HDL), the very low-density lipoproteins (VLDL), triglycerides, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were determined. The liver tissue was submitted to histopathological analysis, using a NAS score. In immunohistochemistry, we studied the expression of the insulin receptor, adiponectin, TNF-α and iNOS by tissue microarray method. Results and conclusion: There was marked cytoplasmic immunostaining for TNF-α and iNOS mediators in the group on a fat diet. Regarding insulin and adiponectin molecular markers, a reduction of cytoplasmic immunoreactivity of these antigens was observed in the group on a fat diet, reflecting, respectively, the state of hepatocellular inflammation (steatohepatitis) and insulin resistance in this experimental model of fat liver disease...

Introdução: Os mecanismos fisiopatológicos da esteato-hepatite não alcoólica incluem basicamente resistência insulínica, processo inflamatório e estresse oxidativo. Desta forma, um estudo sobre o padrão de imunoexpressão hepática para receptores de insulina, adiponectina, fator de necrose tumoral alfa (TNF-α) e sintase indutível do óxido nítrico (iNOS) foi conduzido. Objetivo: Ampliar os conhecimentos sobre os mecanismos moleculares subjacentes, em modelo experimental de esteato-hepatite. Método: Vinte ratos Wistar com dois meses de idade, pesando de 250 a 300 mg foram subdivididos em dois grupos: G1 (controle normal, submetido à dieta padrão) e G2 (grupo-controle, submetido à dieta hiperlipídica contendo 58% de energia derivada de gorduras, 18% de proteínas e 24% de carboidratos). Após oito semanas, os animais foram sacrificados; o sangue, submetido à análise bioquímica; e o fígado, removido e fixado em formalina tamponada e emblocado em parafina para estudo histopatológico. Para estudo imuno-histoquímico, foi utilizada a técnica de microarranjo de tecido. As lâminas obtidas foram submetidas à incubação com os anticorpos contra adiponectina, receptor de insulina, TNF-α e iNOS. Resultados e conclusão: Observou-se marcada imunoexpressão citoplasmática para os mediadores TNF-α e iNOS no grupo submetido à dieta hiperlipídica. No que diz respeito aos marcadores moleculares insulina e adiponectina, observou-se uma redução da imunoexpressão citoplasmática desses anticorpos no grupo submetido à dieta hiperlipídica, traduzindo, respectivamente, o estado de inflamação hepatocelular (esteato-hepatite) e resistência insulínica, desenvolvidos nesse modelo experimental de doença hepática gordurosa...

[Neoadjuvant radiotherapy and hormonotherapy in locally advanced breast cancer: state of the art]. / Radioterapia e hormonoterapia a título neoadjuvante no carcinoma localmente avançado da mama: estado da arte.

INTRODUCTION: Breast cancer is a health problem of great magnitude. In recent years we have seen an increasing incidence and decreasing mortality from this disease due to implementation of campaigns for early diagnosis and the effectiveness of existing treatments. For more than a century that we know the evidence that growth and development of some tumours depends in part on hormonal stimuli, and the purpose of hormone therapy to prevent the hormonal stimulation of cell proliferation, decreasing the plasma levels of different hormones. Radiotherapy which uses a controlled ionizing radiation for therapeutic purposes, it is one of the fundamental modalities in the treatment of cancer. According to the international guidelines these modalities of treatment, radiotherapy and hormone therapy, can be used in the treatment of breast cancer both within the neoadjuvant, adjuvant or palliative treatment. OBJECTIVES: Obtain data to support or not the use of concomitant radiotherapy and neoadjuvant hormone therapy instead to neoadjuvante chemotherapy in post menopausal patients diagnosed with locally advanced breast cancer and positive hormone receptors. METHODS: Bibliographic search in MEDLINE databases, and evidence based review databases, using the MeSH terms: Radiotherapy, Hormonotherapy, Tamoxifen, Neoadjuvant, Endocrine Therapy, Breast of articles published at any time and in English, Portuguese, French and Spanish. It was also researched the Index of Portuguese Medical Journal and scientific societies dedicated to Oncology. RESULTS: We analyzed 32 studies (in vitro experiments, animal studies and clinical studies). There was the existence of antagonistic interaction between Radiotherapy and Tamoxifen in the in vitro studies, which has not been confirmed in the animal studies and clinical trial. Clinical studies suggest that a combination of radiotherapy and Tamoxifen increases the local control in the in situ carcinoma like in the invasive breast cancer. The available clinical studies do not demonstrate that the simultaneous application of Radiotherapy and tamoxifen is disadvantageous, as suggested in the in vitro studies. However, the tolerance of lung tissue to radiation may be slightly reduced if tamoxifen is given concurrently with radiotherapy, such as swelling of the breast and its duration can be increased. The cosmetic results were not harmed in the combined treatment, except for one study where there was an increased of hyperpigmentation. Finally, the combined treatment was an increase in cardiovascular events. CONCLUSIONS: In the literature there are few studies on these issues, most of which are adjuvant intention in women with breast cancer at an early stage, and the results are inconclusive. There is great uncertainty in the combination of the two modalities. There isn't a randomized study where differences in local control when hormonotherapy is initiated before, during or after radiation therapy were investigated.

Paranoia e agressividade: um caso clínico psicanalítico / Paranoia and aggression: a psychoanalytic case history

Um caso de psicose foi encaminhado ao Ambulatório de Saúde Mental do município de Macaé, cuja questão do paciente compreende atos violentos que permeiam sua fala. para além do delírio, os atos relatados pela ex-namorada confirmam cenas em que ações de extrema violência física e verbal foram empregadas pelo paciente. Ademais, esse paciente construiu um plano para matar seus algozes. Sendo assim, o objetivo deste artigo é propor a seguinte questão: estariam os paranoicos particularmente vulneráveis a cometer um ato agressivo que pudesse facilmente resultar em um crime? E ainda: na clínica, que lugar ocupa o psicanalista diante dessa hipótese?(AU)

A case of paranoid psychosis was sent to the Mental Health Clinic in the city of Macaé. The question which such a case has brought about has to do with the violence employed by the patient within his oral speech. Although his speech sounds rather delirious, his violent actions have been actually confirmed by his former girlfriend who has reported that some extreme phsysical and verbal violence has been employed by the patient. Besides all that, this patient has also built a plan to kill their tormentors. Taking all these facts into consideration, we might as well propose the following questions: Is the paranoid particularly vulnerable to commit an aggressive act that could easily result in a crime? And yet, in our practice, which place is taken by the analyst who bears this hypothesis?(AU)

Fortalecimento egóico observado em idosos submetidos à psicoterapia grupal em clínica escola / Ego empowerment in eldery patients who attend group counselling at a school clinical

O presente trabalho refere-se ao atendimento psicoterápico a um grupo de terceira idade. Teve como objetivo criar condições para que os participantes expusessem conflitos e ansiedades decorrentes da idade avançada. O grupo foi constituido por 7 pessoas (6 mulheres e 1 homem), com mais de 60 anos, que se reuniram durante um ano, uma vez por semana, com sessões de hora e meia, nas dependências da Clínica Psicológica da PUC-SP. Constatou-se que os participantes encontram meios de elaborar alterações, como mudanças orgânicas e falecimento ou afastamento de entes queridos, no desenvolvimento da possibilidade da escuta do outro. A vivência da impotência frente à explicação destes conteúdos manifesta-se por estados depressivos grupais: faltas, sono, conversas paralelas, falas compulsivas. O grupo psicoterapêutico para idosos propiciou o fortalecimento da auto-estima pelo intercâmbio de vivências, reflexão dos conteúdos individuais e coletivos e possibilidade de elaboração de projetos pessoais e revisão deles (AU)

Fortalecimento egóigo observado em idosos submetidos à psicoterapia grupal em clínica escola / Ego empowerment in elderly patients who attend group counselling at a school clinical

O presente trabalho refere-se ao atendimento psicoterápico a um grupo de terceira idade. Teve como objetivo criar condiçöes para que os participantes expusessem conflitos e ansiedades decorrentes da idade avançada. O grupo foi constituído por 7 pessoas (6 mulheres e 1 homem), com mais de 60 anos, que se reuniram durante um ano, uma vez por semana, com sessöes de hora e meia, nas dependências da Clínica Psicológica da PUC-SP. Constatou-se que os participantes encontram meios de elaborar alteraçöes, como mudanças orgânicas e falecimento ou afastamento de entes queridos, no desenvolvimento da possibilidade da escuta do outro. A vivência de impotência frente à explicitaçäo destes conteúdos manifesta-se por estados depressivos grupais: faltas, sono, conversas paralelas, falas compulsivas. O grupo psicoterapêutico para idosos propiciou o fortalecimento da auto-estima pelo intercâmbio de vivências, reflexäo dos conteúdos individuais e coletivos e possibilidade de elaboraçäo de projetos pessoais e revisäo deles