ABSTRACT
El tratamiento de la asimetría facial en pacientes con microftalmos o cavidades anoftálmicas adquiridas suele requerir cirugías reconstructivas agresivas. En los últimos años se han publicado trabajos sobre el uso de rellenos para optimizar la simetría del tejido orbitario, como técnicas mínimamente invasivas.Por este motivo, hemos realizado una revisión sistemática de la literatura publicada hasta el momento sobre la administración orbitaria de rellenos para el tratamiento de la pérdida de volumen. Se identificaron 14 artículos que cumplían con los criterios de selección; en los que se analizó el material utilizado, la técnica de inyección, el estudio anatómico de los pacientes antes del procedimiento y la presencia de complicaciones asociadas. Los materiales utilizados como relleno son: la grasa autóloga, la hidroxiapatita cálcica, el colágeno, el ácido hialurónico o el gel de poliacrilamida. Se aplicaron técnicas estándar de inyección peribulbar y retrobulbar, con escasas complicaciones asociadas, siendo la má grave el desarrollo de cuadros vaso-vagales. El seguimiento de los pacientes suele limitarse en la mayoría de los estudios a 12 meses, con variaciones significativas en la exoftalmometría posprocedimiento. En conclusión, la utilización de rellenos parece una práctica segura y con buenos resultados, aunque se precisan estudios con tiempo de seguimiento más prolongado que los publicados hasta el momento. (AU)
The treatment of facial asymmetry in patients with microphthalmos or acquired anophthalmic cavities usually requires aggressive reconstructive surgeries. In recent years, studies have been published on the use of fillers to optimize orbital tissue symmetry, as minimally invasive techniques.For this reason, we performed a systematic review of the literature published to date on the use of fillers for the treatment of volume loss in acquired anophthalmic or microphthalmic cavities. Fourteen articles were reviewed in which the material used, the injection technique, the anatomical study of the patients before the procedure and the presence of associated complications were analyzed.Various materials have been used as fillers, including autologous fat, calcium hydroxyapatite, collagen, hyaluronic acid, or polyacrylamide gel. Standard peribulbar and retrobulbar injection techniques were applied, with few associated complications, the most serious being the development of vasovagal symptoms. Patient follow-up is usually limited in most studies to 12 months.In Conclusion, the use of fillers seems to be a safe practice, with good results and few complications, although studies with longer follow-up times than those published to date would be required. (AU)
Subject(s)
Humans , Microphthalmos/drug therapy , Intravitreal Injections , Eye Enucleation , Eye Evisceration , Hyaluronic Acid/administration & dosageABSTRACT
The treatment of facial asymmetry in patients with microphthalmos or acquired anophthalmic sockets usually requires aggressive reconstructive surgeries. In recent years, studies have been published on the use of fillers to optimize orbital tissue symmetry, as minimally invasive techniques. For this reason, we performed a systematic review of the literature published to date on the use of fillers for the treatment of volume loss in acquired anophthalmic or microphthalmic cavities. Fourteen articles were reviewed in which the material used, the injection technique, the anatomical study of the patients before the procedure and the presence of associated complications were analyzed. Various materials have been used as fillers, including autologous fat, calcium hydroxyapatite, collagen, hyaluronic acid, or polyacrylamide gel. Standard peribulbar and retrobulbar injection techniques were applied, with few associated complications, the most serious being the development of vasovagal symptoms. Patient follow-up is usually limited in most studies to 12 months. In Conclusion, the use of fillers seems to be a safe practice, with good results and few complications, although studies with longer follow-up times than those published to date would be required.
Subject(s)
Eye Diseases , Microphthalmos , Humans , Eye Enucleation , Orbit , Eye Evisceration , InjectionsABSTRACT
Paraneoplastic syndromes (PNSs) are remote effects of the primary tumor on tissues and organs, not related to direct invasion or metastasis. Ophthalmological involvement has been reported in 0.01-0.1% cases of PNSs. It may present as retinopathy, optic neuritis, myasthenia-like syndromes, or orbital myositis (OM), among others. An 89-year-old male with bilateral ocular pain and chemosis, was given an initial diagnosis of bilateral acute conjunctivitis. After 5 days, the patient presented worsening of the pain and bilateral complete ophthalmoplegia. Cranial CT scan showed diffuse bilateral thickening of the four rectus muscles. Inflammatory markers, thyroid hormones, and thyroid antibodies were normal. An abdominal ultrasound test was performed, observing a mass in the right kidney. After confirmation of the lesion with a CT scan, the radiological characteristics of the lesion were highly suggestive of renal cell carcinoma. Treatment with intravenous corticosteroids was ensued with complete resolution of all ophthalmological symptoms. Paraneoplastic orbital panmyositis was first described in 1994. Since then it has been reported scarcely, remaining an extremely rare entity. To our knowledge, this is the first report of its association with renal cell carcinoma. In the absence of inflammatory or dysthyroid blood markers, bilateral orbital panmyositis warrants further investigation for a possible underlying oncological pathology.
ABSTRACT
PURPOSE: There are still many challenges for modelling a thrombus migration process in aneurysms. The main novelty of the present research lies in the modelling of aneurysm clot migration process in a realistic cerebral aneurysm, and the analysis of forces suffered by clots inside an aneurysm, through transient FSI simulations. METHODS: The blood flow has been modelled using a Womersley velocity profile, and following the Carreau viscosity model. Hyperelastic Ogden model has been used for clot and isotropic linear elastic model for the artery walls. The FSI coupled model was implemented in ANSYS® software. The hemodynamic forces suffered by the clot have been quantified using eight different clot sizes and positions inside a real aneurysm. RESULTS: The obtained results have shown that it is almost impossible for clots adjacent to aneurysm walls, to leave the aneurysm. Nevertheless, in clots positioned in the centre of the aneurysm, there is a real risk of clot migration. The risk of migration of a typical post-coiling intervention clot in an aneurysm, in contact with the wall and occupying a significant percentage of its volume is very low in the case studied, even in the presence of abnormally intense events, associated with sneezes or impacts. CONCLUSIONS: The proposed methodology allows evaluating the clot migration risk, vital for evaluating the progress after endovascular interventions, it is a step forward in the personalized medicine, patient follow-up, and helping the medical team deciding the optimal treatment.
Subject(s)
Intracranial Aneurysm , Thrombosis , Humans , Hemodynamics , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/therapy , Thrombosis/diagnostic imaging , Thrombosis/etiologyABSTRACT
Introducción Los síndromes de pupila estrecha, incluido el síndrome de iris flácido intraoperatorio (IFIS), aumentan el riesgo de complicaciones durante la cirugía de cataratas si no se realiza una correcta planificación quirúrgica. La tamsulosina se asocia a un incremento muy significativo del riesgo de IFIS, debido a la inactivación prolongada de los receptores alfa-1 adrenérgicos en la fibra muscular lisa del iris. Material y métodos Estudio prospectivo observacional unicéntrico, llevado a cabo en el Hospital de lEsperança - Parc de Salut Mar.ResultadosSe incluyeron 622 ojos de 502 pacientes, de los cuales 337 (62%) eran mujeres. La media de edad de la muestra era de 74,8 años. Se observaron 61 casos de IFIS (11%), de los cuales 13 recibían tratamiento con tamsulosina y uno con doxazosina. Se observaron 23 casos de IFIS en pacientes mujeres. La ratio mujer:hombre fue de aproximadamente 1:3. Se observaron 19 casos (3%) de IFIS severo, de los cuales 6 recibían tratamiento con alfa-antagonistas, sin correlación estadísticamente significativa.La media del tiempo quirúrgico fue de 13,80min (desviación estándar [DE]: 4,01min) en pacientes sin IFIS y de 16,93min (DE: 4,32min) en pacientes con IFIS. La relación entre la duración del procedimiento quirúrgico en minutos y la presencia de IFIS fue estadísticamente significativa, aplicando un test t-Student «a dos colas» o bilateral con un p valor de 0,01. Conclusión Independientemente del grado de severidad, el diagnóstico de IFIS alarga el tiempo quirúrgico en cirugía de cataratas. Esto supone otra evidencia más que apoya la utilización de tratamientos antagonistas adrenérgicos menos alfa-1 selectivos que la tamsulosina o la realización de la cirugía de cataratas antes de iniciar dichos tratamientos. (AU)
Background Small pupil syndromes, including intraoperative-floppy iris syndrome (IFIS), increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris. Material and methods Single-center prospective observational study, carried out at the Hospital de lEsperança Parc de Salut Mar.ResultsSix hundred and twenty-two eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. Sixty-one cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. Twenty-three cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. Nineteen cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation.The mean surgical time was 13.80min (standard deviation SD: 4.01min) in patients without IFIS and 16.93min (SD: 4.32min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a two-tailed or bilateral t-Student test with a p value of 0.01. Conclusion Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than tamsulosin or the performance of cataract surgery before starting these treatments. (AU)
Subject(s)
Humans , Male , Female , Adolescent , Young Adult , Adult , Middle Aged , Aged , Aged, 80 and over , Intraoperative Complications , Iris Diseases/etiology , Phacoemulsification/adverse effects , Severity of Illness Index , Prospective Studies , SyndromeABSTRACT
BACKGROUND: Small pupil syndromes, including IFIS, increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris. MATERIAL AND METHODS: Single-center prospective observational study, carried out at the Hospital de l'Esperança - Parc de Salut Mar. RESULTS: 622 eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. 61 cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. 23 cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. 19 cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation. The mean surgical time was 13.80â¯min (Standard Deviation - SD: 4.01â¯min) in patients without IFIS and 16.93â¯min (SD: 4.32â¯min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a 'two-tailed' or bilateral t-Student test with a p value of 0.01. CONCLUSION: Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than Tamsulosin or the performance of cataract surgery before starting these treatments.
Subject(s)
Cataract Extraction , Cataract , Iris Diseases , Phacoemulsification , Humans , Female , Male , Aged , Tamsulosin , Phacoemulsification/adverse effects , Sulfonamides/adverse effects , Cataract Extraction/adverse effects , Iris Diseases/chemically induced , Iris Diseases/diagnosis , Intraoperative Complications/chemically induced , Cataract/chemically induced , Cataract/complicationsABSTRACT
BACKGROUND: Macular hemorrhages are a severe complication of other retinal pathologies, such as age-related macular degeneration (AMD) or macroaneurysms. Their therapeutic approach is not standardized, and can vary from observation to surgical treatment. MATERIAL AND METHODS: Retrospective analysis of 22 cases of macular hemorrhage, treated with vitrectomy associated to subretinal rTPA and intravitreal anti-VEGF over a period of 5 years. RESULTS: 22 eyes of 22 patients were included, of which 12 (52%) were women. The mean age at diagnosis was 84.4 years. 13 patients were pseudophakic (54.1%) and 19 (86.36%) had previous ophthalmological comorbidities. The etiology of the macular hemorrhage was AMD in 19 patients (86.36%). The mean of best VA corrected at diagnosis was 24.55 (Early Treatment Diabetic Retinopathy Study score -ETDRS), with a statistically significant improvement to 36.78 3 months after surgery (p = 0.011). With an average of 23.5 months of follow-up, no differences in prognosis associated with the etiology or size of the hemorrhage were observed. CONCLUSION: The treatment of macular hemorrhages by vitrectomy, subretinal rTPA and antiVEGF improves the visual prognosis of affected patients.
Subject(s)
Retinal Hemorrhage , Tissue Plasminogen Activator , Vascular Endothelial Growth Factors , Vitrectomy , Female , Humans , Intravitreal Injections , Macular Degeneration/complications , Macular Degeneration/drug therapy , Male , Retinal Hemorrhage/drug therapy , Retinal Hemorrhage/etiology , Retinal Hemorrhage/surgery , Retrospective Studies , Tissue Plasminogen Activator/therapeutic use , Vascular Endothelial Growth Factors/therapeutic use , Visual AcuityABSTRACT
Introducción: Las hemorragias maculares suponen una complicación severa de otras patologías retinianas, como la degeneración macular asociada a la edad (DMAE) o los macroaneurismas. El abordaje terapéutico de las mismas no se encuentra estandarizado, pudiendo variar desde la observación hasta el tratamiento quirúrgico.Material y métodosAnálisis retrospectivo de 22 casos de hemorragia macular, tratados mediante vitrectomías asociada a rTPA subretiniano y antiVEGF intravítreo durante un período de cinco años.ResultadosSe incluyeron 22 ojos de 22 pacientes, de los que 12 (52%) eran mujeres. La edad media al diagnóstico fue de 84,4 años. Del total de pacientes, 13 eran pseudofáquicos (54,1%) y 19 (86,36%) presentaban comorbilidades oftalmológicas previas. La etiología de las hemorragias maculares fue DMAE en 19 pacientes (86,36%). La media de mejor agudeza visual (AV) corregida al diagnóstico fue de 24,55 (puntuación Early Treatment Diabetic Retinopathy Study - ETDRS), con una mejoría estadísticamente significativa a 36,78 a los tres meses de la cirugía (p=0,011). Con un promedio de 23,5 meses de seguimiento, no se observaron diferencias en el pronóstico asociadas a etiología o tamaño de la hemorragia.ConclusiónEl tratamiento de las hemorragias maculares mediante vitrectomía, rTPA subretiniano y antiVEGF mejora el pronóstico visual de los pacientes afectos. (AU)
Background: Macular hemorrhages are a severe complication of other retinal pathologies, such as age-related macular degeneration (AMD) or macroaneurysms. Their therapeutic approach is not standardized, and can vary from observation to surgical treatment.Material and methodsRetrospective analysis of 22 cases of macular hemorrhage, treated with vitrectomy associated to subretinal rTPA and intravitreal anti-VEGF over a period of 5 years.Results22 eyes of 22 patients were included, of which 12 (52%) were women. The mean age at diagnosis was 84.4 years. 13 patients were pseudophakic (54.1%) and 19 (86.36%) had previous ophthalmological comorbidities. The etiology of the macular hemorrhage was AMD in 19 patients (86.36%). The mean of best VA corrected at diagnosis was 24.55 (Early Treatment Diabetic Retinopathy Study score -ETDRS), with a statistically significant improvement to 36.78 3 months after surgery (p = 0.011). With an average of 23.5 months of follow-up, no differences in prognosis associated with the etiology or size of the hemorrhage were observed.ConclusionThe treatment of macular hemorrhages by vitrectomy, subretinal rTPA and antiVEGF improves the visual prognosis of affected patients. (AU)
Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Macular Degeneration/complications , Macular Degeneration/drug therapy , Retinal Hemorrhage/etiology , Retinal Hemorrhage/therapy , Tissue Plasminogen Activator/therapeutic use , Vascular Endothelial Growth Factors/therapeutic use , Vitrectomy , Retrospective Studies , Intravitreal Injections , Visual Acuity , PrognosisABSTRACT
BACKGROUND: To assess the benefit of macular spectral-domain optical coherence tomography (SD-OCT) as a part of the routinary preoperative study of patients undergoing cataract surgery. METHODS: A prospective single-center study study was performed. Consecutive patients with normal biomicroscopic funduscopy, moderate cataract and no history of ophthalmological pathologies were enrolled. All patients underwent macular SD-OCT. The obtained images were analysed by a general ophthalmologist and two retina specialists. Incidence of macular pathology and its relation to age and comorbidities were assessed. RESULTS: Eight-hundred and thirty-six eyes of 419 patients were enrolled in this study. All images were analysed telematically by a general ophthalmologist. Forty-nine eyes were excluded due to insufficient quality of the obtained images. Abnormal images were observed in 156 eyes (18.6%), including age-related macular degeneration in 68 (8.2%), epiretinal membrane (ERM) in 67 (8.0%), cystoid macular edema in 3 eyes (0.4%), among others. Diagnostics with severe impact on patient visual prognosis were observed in 16 eyes (3.82%) from 12 patients. The relationship between incidence of macular pathologies and age or comorbidities was not statistically significant. To assess accuracy of the first observer, images were subsequently analysed by two retinologists. The kappa index of concordance was 0.80 and 0.85. CONCLUSIONS: Implementing a systematic macular SD-OCT as a preoperative test prior to cataract surgery would improve quality of postoperative visual prognosis information. A general ophthalmologist would be suitable to screen for pathology through macular OCT images.
Subject(s)
Cataract Extraction , Cataract , Epiretinal Membrane , Cataract/diagnosis , Epiretinal Membrane/diagnosis , Humans , Prospective Studies , Tomography, Optical Coherence/methodsABSTRACT
BACKGROUND AND OBJECTIVE: The attainment of a methodology to simulate the hemodynamic in patient-specific cerebral vessels with aneurysms is still a challenge. The novelty of this work is focused on the effect of coil embolization in a realistic cerebral aneurysm, according to the vessel wall thickness and aneurysm thickness, through transient FSI simulations. METHODS: The quality of the mesh for simulations was checked with a specific mesh convergence study; and the numerical methodology was validated using numerical research data of the literature. The model was implemented in ANSYS® software. The total deformation and equivalent stress evolution in the studied cases, before and after coil embolization, were compared. More than 20 different models were employed due to different arterial wall thickness and aneurysm wall thickness combinations. RESULTS: The obtained results have showed that deformation and stress values are highly influenced with the sac thickness. The thinner sac aneurysm thickness is, the greater deformation and stress are. The results after coil embolization process have highlighted that considering typical values of arterial wall thickness and aneurysm thickness 0.3 mm and 0.15 mm respectively, a deformation reduction around 50% and a stress reduction around 70% can be achieved. CONCLUSIONS: The proposed methodology is a step forward in the personalized medicine, quantifying the aneurysm rupture risk reduction, and helping the medical team in the preoperative planning, or to deciding the optimal treatment.
Subject(s)
Intracranial Aneurysm , Models, Cardiovascular , Arteries , Hemodynamics , Humans , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/therapyABSTRACT
No disponible
No disponible
Subject(s)
Middle Aged , Male , Humans , Ofloxacin/adverse effects , Ofloxacin/therapeutic use , Achilles Tendon/injuries , Achilles Tendon/pathology , Fluoroquinolones/therapeutic use , Colchicine/therapeutic use , Adrenal Cortex Hormones/therapeutic use , Tendons/pathology , Heel/pathology , Heel , Quinolones/adverse effects , Quinolones/therapeutic useABSTRACT
Objetivo: Examinar las diferencias en las formas de afrontamiento de la seropositividad a VIH entre personas toxicómanas y no toxicómanas afectadas, y explorar la relación entre las formas de afrontamiento de la seropositividad y la afectividad. DISEÑO.- Transversal, comparación de dos grupos. Método: 105 sujetos seropositivos a VIH (50 toxicómanos y 55 no-toxicómanos) son evaluados a través de un cuestionario que agrupa escalas de afrontamiento de la seropositividad, variables del estado de ánimo (depresión, ansiedad y afectividad) y el apoyo social objetivo y subjetivo. Resultados: No se encuentran diferencias en la forma de afrontar la seropositividad entre los grupos, ni tampoco respecto a la afectividad. Un análisis correlacional muestra que las formas de afrontamiento activas, tanto cognitivas como conductuales, están asociadas (p<0,05) a una mayor afectividad positiva (r=0,45) y a una menor ansiedad (r=-0,24), mientras las formas evitantes están asociadas a una mayor depresión (r=0,31), afectividad negativa (r=0,31), ansiedad rasgo (r=0,33), y ansiedad estado (r=0,21). Conclusión: Los resultados del estudio guardan concordancia con los encontrados en la literatura, que muestran una relación positiva entre las formas activas y la afectividad, así como una asociación negativa de ésta con las formas evitantes (AU)
Subject(s)
Adult , Female , Male , Humans , Acquired Immunodeficiency Syndrome/psychology , Mood Disorders/psychology , Opioid-Related Disorders/psychology , Acquired Immunodeficiency Syndrome/drug therapy , Acquired Immunodeficiency Syndrome/diagnosis , Depression/psychology , Anxiety/psychology , Social Support , Cross-Sectional Studies , Attitude to Health , Opioid-Related Disorders/complications , Substance Abuse, Intravenous/complications , Substance Abuse, Intravenous/psychologyABSTRACT
Objetivo: Examinar las diferencias en las formas de afrontamiento de la seropositividad a VIH entre personas toxicómanas y no toxicómanas afectadas, y explorar la relación entre las formas de afrontamiento de la seropositividad y la afectividad. Diseño: Transversal, comparación de dos grupos. Método: 105 sujetos seropositivos a VIH (50 toxicómanos y 55 no-toxicómanos) son evaluados a través de un cuestionario que agrupa escalas de afrontamiento de la seropositividad, variables del estado de ánimo (depresión, ansiedad y afectividad) y el soporte social objetivo y subjetivo. Resultados: No se encuentran diferencias en la forma de afrontar la seropositividad entre los grupos, ni tampoco respecto a la afectividad. Un análisis correlacional muestra que las formas de afrontamiento activas, tanto cognitivas como conductuales, están asociadas (p<0,05) a una mayor afectividad positiva (r=0,45) y a una menor ansiedad (r=-0,24), mientras las formas evitantes están asociadas a una mayor depresión (r-0,3'1). afectividad negativa (r=0,31), ansiedad rasgo (r=0,33), y ansiedad estado (r=0,21). Conclusión: Los resultados del estofo son concordantes con los encontrados en la literatura, que muestran una relación positiva entre las formas activas y la afectividad, así como una asociación negativa de ésta con las formas evitantes (AU)
Subject(s)
Adult , Female , Male , Humans , Acquired Immunodeficiency Syndrome/psychology , HIV Infections/psychology , HIV Seropositivity/psychology , Surveys and Questionnaires , Psychosocial Deprivation , Social Support , Mood Disorders/complications , Mood Disorders/psychology , Substance-Related Disorders/psychology , Substance-Related Disorders/complications , Anxiety/psychology , Depression/psychology , Affective Symptoms/psychology , Cross-Sectional Studies , Epidemiology, Descriptive , Epidemiology, DescriptiveSubject(s)
Antiviral Agents/therapeutic use , HIV Infections/drug therapy , Zidovudine/therapeutic use , Acquired Immunodeficiency Syndrome/drug therapy , Acquired Immunodeficiency Syndrome/immunology , Antiviral Agents/administration & dosage , CD4-Positive T-Lymphocytes/immunology , HIV Infections/immunology , Humans , Zidovudine/administration & dosageSubject(s)
AIDS-Related Opportunistic Infections/prevention & control , Clonal Anergy , Isoniazid/therapeutic use , Tuberculosis/prevention & control , AIDS-Related Opportunistic Infections/epidemiology , AIDS-Related Opportunistic Infections/immunology , Humans , Longitudinal Studies , Prevalence , Spain/epidemiology , Tuberculosis/epidemiology , Tuberculosis/immunologySubject(s)
Aging , Hypertension , Aged , Humans , Hypertension/drug therapy , Hypertension/etiology , Hypertension/physiopathology , Kidney/physiopathologyABSTRACT
A case report of pulmonary carcinosarcoma and a review of the literature is presented. This is the only case where diagnosis has been obtained by thin needle percutaneous biopsy.
