Análisis de los factores relacionados con la sobreestadificación y la positividad del ganglio centinela en las pacientes con diagnóstico inicial de carcinoma ductal in situ / Analysis of factors related to upstaging and sentinel node positivity in the initial diagnosis of ductal carcinoma in situ

Objetivo. Determinar el porcentaje de pacientes con diagnóstico inicial de carcinoma ductal in situ (CDIS) que presentó infiltración tras la excisión quirúrgica e identificar los factores relacionados tanto con la sobreestadificación como con la positividad del ganglio centinela (GC) en el estudio definitivo. Material y métodos. Análisis retrospectivo de 135 pacientes diagnosticadas mediante biopsia core de CDIS a las que se les realizó biopsia selectiva del GC de forma consecutiva de 2003 a 2011. La técnica fue mixta en el período inicial y posteriormente mediante administración intraperilesional de radiocoloides. En 2009 se introdujo una gammacámara portátil y se inició el estudio intraoperatorio molecular mediante amplificación de ácido nucleico de un solo paso. Resultados. Se produjo sobreestadificación en 45 de las 135 pacientes (33,3%), de las que 30 (22,2%) presentaron CDIS con microinfiltración y 15 (11,1%) carcinoma infiltrante. Los CDIS con microinfiltración mostraron mayor tamaño, mayor porcentaje de alto grado, de HER2 positivo y de Ki-67 alto que los CDIS (p < 0,001, p < 0,001, p = 0,002 y p = 0,031, respectivamente). Los porcentajes de positividad del GC fueron del 3,6% en el CDIS, del 6,9% en el CDIS con microinfiltración y del 20% en los carcinomas infiltrantes, correspondiendo a 8 pacientes, de las cuales 6 presentaron HER2 positivo y Ki-67 alto. Conclusiones. El porcentaje global de infraestimación fue alto, principalmente debido a la presencia de microinfiltración. Tanto esta como la afectación metastásica del GC mostró relación con el HER2 positivo y el Ki-67 alto, por tanto, disponer de estos datos en la biopsia percutánea podría ser relevante para establecer la indicación de realización de biopsia selectiva del GC en el CDIS

Objective. To determine the percentage of patients with ductal carcinoma in situ (DCIS) with infiltration after surgical excision and to identify the factors related to both upstaging and sentinel node (SN) positivity in the final study. Material and methods. A retrospective analysis was performed in 135 patients diagnosed with DCIS by core biopsy who subsequently underwent sentinel lymph node biopsy from 2003 to 2011. In the first period of the study, the technique was mixed and subsequently consisted of intra-perilesional radiocolloid administration. In 2009, a portable gamma camera was introduced and we began to use intraoperative one-step nucleic acid amplification. Results. Upstaging occurred in 45 of the 135 patients (33.3%), of which 30 (22.2%) had DCIS with microinfiltration and 15 (11.1%) had invasive carcinoma. Compared with DCIS, DCIS with microinfiltration were larger and showed a higher percentage of high grade, HER2 positivity and high Ki-67 (P < .001, P < .001, P = .002 and P = .031, respectively). SN positivity rates were 3.6% in DCIS, 6.9% in DCIS with microinfiltration, and 20% in invasive carcinomas, corresponding to 8 patients, of whom 6 showed HER2-positivity and high Ki-67. Conclusions. Overall underestimation was high, mainly due to the presence of microinfiltration. Both microinfiltration and metastatic SN involvement were associated with HER2-positivity and high Ki-67. Therefore, the availability of this information in core needle biopsy could be relevant in establishing the indication for sentinel lymph node biopsy in DCIS

[Hepatopulmonary syndrome: relationship with liver dysfunction and systemic hemodynamic disorder]. / Síndrome hepatopulmonar: relación con el grado de disfunción hepática y el trastorno hemodinámico de la cirrosis hepática.

BACKGROUND AND OBJECTIVE: The hepatopulmonary syndrome (HPS) causes an increased alveolar to arterial gradient of oxygen and in advanced phases hypoxemia, as the result of pulmonary vasodilation. In liver cirrhosis, it has been demonstrated the existence of splachnic vasodilation and also in other vascular beds. Our main objectives were to know the hemodynamic status, the renal function and the condition of some humoral systems in patient diagnosed of HPS. PATIENTS AND METHOD: We studied consecutively 32 cirrhotic patients Divided in two groups, a group of 18 cirrhotic patients with normal gaseous exchange (NGE), and another group of 14 cirrhotic patients diagnosed of HPS by contrast-enhanced transthoracic echocardiography and/or lung and brain scintigraphy with 99Tc albumin macroaggregates. They were all in rest in bed, upon alcohol and tobacco abstinence and on a diet of 50 mEq of sodium. Cardiovascular drugs were all withheld during 4 days in order to reach steady state. RESULTS: Patients of the HPS group were characterized by a more advanced index of Child-Pugh and presence of clubbing and vascular spiders. They presented a greater degree of hypoxemia in a sitting position, greater hypocapnia and smaller transference factor values (TLCO). They also showed a hyperkinetic circulatory condition characterized by smaller arterial blood pressure, greater cardiac index, smaller vascular resistances and greater femoral flows, with smaller clearance of creatinine, elimination of urinary sodium, urinary volume/24 h and an increased plasmatic volume, accompanied with a greater activation of the renin-angiotensin-aldosterone axis and a greater urinary elimination of nitrites and nitrates. CONCLUSIONS: The pulmonary vasodilation that explains the HPS is a constitutive part of the systemic vasodilation occurring in liver cirrhosis, and it is related to the degree of liver dysfunction as measured by the classification of Child-Pugh. The greater activation of the renin-aldosterone system and the rise of the plasmatic volume express a highest grade of arterial underfilling caused by an increment in the nitric oxide production.