Usefulness of histological superstudy of sentinel lymph nodes detected with radioisotopes in colon cancer.

INTRODUCTION: Adjuvant chemotherapy (CT) significally reduces the rate of relapse in +pN (stage III) colon cancer (CC) and in some pN0 (stage II) with risk factors such as pT4, vascular invasion V1, perineural invasion Pn1, and complicated tumors. However, unexpectedly, 20%-30% of pN0 present a relapse in the follow-up, which may suggest that the lymph node involvement was not discovered in the conventional histological study (CS), and its finding with a superstudy (SS) could increase the number of patients who would benefit from neoadjuvant CT. It is not possible to perform this SS in every lymph node (LN) from the specimen, but it is possible in a small group of LN which are representative of the N status (definition of sentinel node SN). The aim of our work is to state the representativeness of the SN and to analyze de number of patients who are suprastaged after the SS of the SN. MATERIAL AND METHODS: Prospective study of a series of patients who have undergone curative surgery for CC, to whom we perform selective biopsy of sentinel node (SBDN). Identification of SN was carried out with in vivo injection of the radiotracer, with ex vivo isolation of SN. Once the specimen is out, we take pictures of the surgical bed to rule out the presence of aberrant drainage routes, out of the routine oncological resection area. We performed the histological CS (Hematoxilin-Eosin stain (H-E) in conventional sections) in the rest of the LN from the mesocolon. In the SN we performed the CS and a SS with H-E in serial sections, immunohistochemistry (IHC) and molecular study with OSNA® (One Step Nucleic Acid Amplification). Diagnostic validity study od SBSN was carried out, defining the false negative (FN) as the negativity of the SN while other LN are positive (N+), as well as a valuation of the suprastaging due to the SS of the SN. RESULTS: We performed lymphatic map in 72 patients, finding the SN in 62 of them (87.3%). The 9 identification failures happened in the first 17 cases. We have not found aberrant drainage routes. A total of 1.164 LN were studied in the 62 patients (18.8 LN/patient), from which 145 are SN (2,34 SN/patient), having found 103 positive LN with the CS and 112 positive with the SS of SN (9+ LN more in 8 patients than detected with the CS). Positivity after CS in the SN group is 17.24% (25/145), while it is 8.53% in the rest (87/1.019) (P < .001). With the CS, 50% of the patients (31/62) were pN+ (4 are N+ exclusively in the SN), and after the SS of the SN, only 1 of the 31 pN0 patients (3.2%) becomes pN1a, with a definitive 51.6% of N+ in the whole series (32 N+ in the 62 patients) (5 are N+ exclusively in the SN). Exclusively with the SS of the SN, FN rate ("-SN, +others", meaning patients who are N+ having -SN) is 54.8% (17/31). With the SS of the SN, 8 of the 62 patients (12.9%) increase their total number of +LN: apart from the patient who turns from pN0 to pN1a, suprastaging from IIA to IIIB (and therefore increasing the total number of pN+ to 32), 5 of the 17 FN in the CS turns into positive (2 change the pN subindex and one is suprastaged from IIIB to IIIC), decreasing FN to 37.5% (12/32 cases). Besides, 2 patients whose SN is already positive in the CS increase the number of +SN after the SS of the SN, therefore both changing their pN subindex and one of them suprastaging from IIIB to IIIC. In summary, 8 patients increase the total number of positive SN after the SS (8/62, 12.9%), 5 of them changing the pN subindex (5/62, 12.9%), even if only 3 of them get suprastaged (3/62, 4.8%), among them the one who turns from pN0 to pN1a. CONCLUSION: Technique is valid and reproducible, with a high detection rate even with a high learning curve. It globally increases the number of affected LN in 12.9% of patients, having prognostic implications in 4.8% (suprastaging rate). Only 3.2% of pN0 patients in the CS turn to be +pN after the SS of the SN, with its therapeutic implications (prescription of adjuvant CT), which could be relevant when extrapolated to a big number of patients. The high FN rate (37.5%) prevents us from accepting the representativeness of SN as the global N status, but it is not clinically relevant in CC, as its aim is not to avoid lymphadenectomy, which remains mandatory (opposite to breast cancer or melanoma in which SN detection decides upon whether to perform or not the lymphadenectomy), but to decide which patients would benefit from adjuvant CT.

Usefulness of histological superstudy of sentinel node detected with radioisotope in colon cancer. / Utilidad del superestudio anatomopatológico de ganglio centinela detectado con radioisótopos en el cáncer de colon.

INTRODUCTION: Adjuvant chemotherapy (CT) significally reduces the rate of relapse in +pN (stage III) colon cancer and in some pN0 (stage II) with risk factors such as pT4, vascular invasion V1, perineural invasion Pn1, and complicated tumors. However, unexpectedly, 20-30% of pN0 present a relapse in the follow-up, which may suggest that the lymph node involvement was not discovered in the conventional histological study (CS), and its finding with a superstudy (SS) could increase the number of patients who would benefit from neoadjuvant CT. It is not possible to perform this SS in every lymph node (LN) from the specimen, but it is possible in a small group of LN which are representative of the N status (definition of sentinel node SN). The aim of our work is to state the representativeness of the SN and to analyze de number of patients who are suprastaged after the SS of the SN. MATERIAL AND METHODS: Prospective study of a series of patients who have undergone curative surgery for colon cancer, to whom we perform selective biopsy of sentinel node. Identification of SN was carried out with in vivo injection of the radiotracer, with ex vivo isolation of SN. Once the specimen is out, we take pictures of the surgical bed to rule out the presence of aberrant drainage routes, out of the routine oncological resection area. We performed the histological CS (hematoxilin-eosin stain in conventional sections) in the rest of the LN from the mesocolon. In the SN we performed the CS and a SS with hematoxilin-eosin in serial sections, immunohistochemistry (IHC) and molecular study with One Step Nucleic Acid Amplification (OSNA®). Diagnostic validity study od selective biopsy of sentinel node was carried out, defining the false negative (FN) as the negativity of the SN while other LN are positive (N+), as well as a valuation of the suprastaging due to the SS of the SN. RESULTS: We performed lymphatic map in 72 patients, finding the SN in 62 of them (87.3%). The 9 identification failures happened in the first 17 cases. We have not found aberrant drainage routes. A total of 1.164 LN were studied in the 62 patients (18.8 LN/ patient), from which 145 are SN (2,34 SN/ patient), having found 103 positive LN with the CS and 112 positive with the SS of SN (9 +LN more in 8 patients than detected with the CS). Positivity after CS in the SN group is 17.24% (25/145), while it is 8.53% in the rest (87/1.019) (p<.001). With the CS, 50% of the patients (31/62) were pN+ (4 are N+ exclusively in the SN), and after the SS of the SN, only 1 of the 31 pN0 patients (3.2%) becomes pN1a, with a definitive 51.6% of N+ in the whole series (32 N+ in the 62 patients) (5 are N+ exclusively in the SN). Exclusively with the SS of the SN, FN rate ("-SN, +others", meaning patients who are N+ having -SN) is 54.8% (17/31). With the SS of the SN, 8 of the 62 patients (12.9%) increase their total number of +LN: apart from the patient who turns from pN0 to pN1a, suprastaging from IIA to IIIB (and therefore increasing the total number of pN+ to 32), 5 of the 17 FN in the CS turns into positive (2 change the pN subindex and one is suprastaged from IIIB to IIIC), decreasing FN to 37.5% (12/32 cases). Besides, 2 patients whose SN is already positive in the CS increase the number of +SN after the SS of the SN, therefore both changing their pN subindex and one of them suprastaging from IIIB to IIIC. In summary, 8 patients increase the total number of positive SN after the SS (8/62, 12.9%), 5 of them changing the pN subindex (5/62, 12.9%), even if only 3 of them get suprastaged (3/62, 4.8%), among them the one who turns from pN0 to pN1a. CONCLUSION: Technique is valid and reproducible, with a high detection rate even with a high learning curve. It globally increases the number of affected LN in 12.9% of patients, having prognostic implications in 4.8% (suprastaging rate). Only 3.2% of pN0 patients in the CS turn to be +pN after the SS of the SN, with its therapeutic implications (prescription of adjuvant CT), which could be relevant when extrapolated to a big number of patients. The high FN rate (37.5%) prevents us from accepting the representativeness of SN as the global N status, but it is not clinically relevant in colon cancer, as its aim is not to avoid lymphadenectomy, which remains mandatory (opposite to breast cancer or melanoma in which SN detection decides upon whether to perform or not the lymphadenectomy), but to decide which patients would benefit from adjuvant CT.

Una enfermedad granulomatosa “sarcoidosis-like”. A propósito de un caso clínico / A sarcoidosis-like granulomatosis disease. Based on a clinical case

La asociación de sarcoidosis e inmunodeficiencia variable común (IVC) se ha considerado como una enfermedad con entidad propia denominada síndrome “sarcoidosis-like”, cuya verdadera incidencia y su mecanismo responsable se desconocen.La clave podría encontrarse en aspectos inmunológicos que ambos procesos comparten. Presentamos el caso de unapaciente con diagnóstico de síndrome de Larsen1, en la que documentamos la concurrencia de una IVC y una sarcoidosis. Su evolución clínica y radiológica fue satisfactoria, tras iniciar tratamiento sustitutivo con inmunoglobulinas y corticoides

The association of sarcoidosis and common variable immunodeficiency (CVI) has been considered as a disease with its own entity called “sarcoidosis-like”syndrome. Its real incidence and responsible mechanism are unknown. The key could be found in immunological features shared by both conditions. We present the case of a female patient diagnosed oh Larsen1syndrome in which we document the concurrence of CVI and sarcoidosis. Its clinical and radiological course wassatisfactory after immunoglobulin and corticosteroid replacement treatment was begun (AU)

Invaginación intestinal en el adulto / Intussusception in adults

La invaginación intestinal es una causa poco frecuente de dolor abdominal en adultos. Ocurre en menos del 1% de obstrucción intestinal de delgado. En adultos la mayoría de los casos son el resultado de una lesión intestinal; la invaginación idiopática es extremadamente rara. Presentamos un caso de obstrucción intestinal diagnosticado mediante tomografía computadorizada de invaginación de intestino delgado secundaria a un tumor. Se discute la etiología, diagnóstico y tratamiento de la invaginación intestinal del adulto (AU)

Intussusception is a rare cause of abdominal pain in adults. It occurs in less than 1% of all cases of adult small bowel obstruction. In adult population, most cases are the result of some type of intestinal lesion; idiopathic intussusceptions are an extremely rare occurrence in adults. This report describes one case of intestinal obstruction caused by an intussusception diagnosed by computed tomography(CT) scan. This report discusses the etiology, diagnosis, and treatment of adult intususcepción (AU)

Fibrosarcoma congénito de pared torácica / Congenital fibrosarcoma of the thracic wall

No disponible

[Silent celiac disease: exploring the iceberg in the school-aged population]. / Enfermedad celíaca silente: explorando el iceberg en población escolar.

BACKGROUND: Epidemiological studies have shown a high prevalence of silent celiac disease (CD) among unselected pediatric populations and a low ratio of diagnosed to undiagnosed CD. OBJECTIVES: To quantify the prevalence of silent CD, to assess the clinical features of subclinical CD and to determine the total prevalence of CD (silent plus symptomatic cases). METHODS: We determined total serum IgA, IgA antiendomysial antibodies (EMA) and IgG antigliadin antibodies (IgG AGA), if IgA deficiency was found, in schoolchildren aged 10-12 years from health district IX in Madrid. RESULTS: A total of 3,378 schoolchildren (47.8 % of the eligible population) were studied. Fifteen were EMA-positive and one child with IgA deficiency was IgG AGA-positive. CD was confirmed by intestinal biopsy in 12 children, representing a prevalence of undiagnosed CD of 1/281. Of these 12 children, 7 showed clinical features of CD. The most frequent symptom was iron-deficiency, followed by recurrent aphthous stomatitis and mild malnutrition. Before the start of this study, CD had been diagnosed in seven children from the same population, which would increase the total prevalence of the disease to 1/220 with an estimated ratio of diagnosed to undiagnosed CD of 1 to 3.5. CONCLUSIONS: We confirm the high prevalence of silent celiac disease among the school-aged population. This ratio is one of the highest published and could be due to a high diagnostic suspicion for CD among pediatricians in our health district. Greater awareness of the minor symptoms of CD would reduce the number of patients with undiagnosed CD.

Enfermedad celíaca silente: explorando el iceberg en población escolar / Silent cardiac disease: exploring the iceberg in the school-aged population

Fundamento: Los estudios epidemiológicos realizados sobre población infantil no seleccionada han demostrado una elevada prevalencia de enfermedad celíaca silente y una baja relación de enfermedad celíaca conocida frente a no diagnosticada. Objetivos: Realizar un cribado de enfermedad celíaca silente en población escolar, caracterizar clínicamente a estos pacientes y valorar su prevalencia global (casos silentes más sintomáticos). Métodos: Se determinaron anticuerpos antiendomisio (EMA), inmunoglobulina A (IgA) sérica y anticuerpos antigliadina IgG (AGA IgG), si existía déficit de IgA, a los escolares de 10 a 12 años del área IX de Madrid. Resultados Se han estudiado 3.378 niños (47,8% de la muestra). Quince fueron EMA positivos y uno déficit de IgA tuvo AGA IgG positivos. La enfermedad celíaca se confirmó mediante biopsia intestinal en 12 niños, lo que representa una prevalencia de enfermedad celíaca silente de 1/281. Siete de los 12 niños mostraban hallazgos clínicos, entre los que los más frecuentes fueron ferropenia, aftas orales recurrentes y malnutrición leve. Previamente a este estudio de detección habían sido diagnosticados 7 enfermos celíacos en la misma población, con lo que la prevalencia global calculada ascendería a 1/220 y la relación entre enfermedad celíaca conocida y no diagnosticada sería de 1/3,5. Conclusiones: Se confirma una elevada prevalencia de enfermedad celíaca silente en nuestro medio. La relación entre enfermedad celíaca conocida y silente es una de las mayores de la bibliografía y podría relacionarse con un importante nivel de alerta frente a esta enfermedad por parte de los pediatras de nuestra área de salud. Un mejor conocimiento de los síntomas menores de la enfermedad celíaca disminuirá el número de casos de enfermedad celíaca no diagnosticada (AU)