Resecciones multiviscerales en el tratamiento quirúrgico de las recaídas locoregionales de cirugía de rectosigma. Factibilidad, complicaciones y resultados oncológicos / Multivisceral resections in the surgical treatment of locoregional relapses of rectosigma surgery. Feasibility, complications and oncologic results

Las inmunodeficiencias primarias (IDP) son enfermedades de baja prevalencia. Existen signos de alarma para su sospecha clínica. Los objetivos fueron describir características clínicas y signos de alarma de pacientes con IDP y comparar diferencias clínicas entre déficit selectivo de inmunoglobulina A (IgA) y otras IDP. Se estudiaron 89 pacientes, con mediana de edad, al momento del diagnóstico, de 6 años (4,08-11,67). 53 (59,5%) pacientes, varones. 54 (60,7%) pacientes, con déficit selectivo de IgA, y 35 (39,3%), con otras IDP. Las principales manifestaciones clínicas fueron rinofaringitis en 65 (73,03%) pacientes y atopia en 39 (43,82%) pacientes. Presentaron signos de alarma 24 (26,97%) pacientes, ninguno con déficit selectivo de IgA. En los pacientes con otras IDP, se observó mayor incidencia de infección respiratoria baja, sepsis, infecciones cutáneas, candidiasis mucocutánea, alteraciones dentales, malformaciones cardiovasculares, angioedema, internaciones y mortalidad. 10 (28,57%) pacientes recibieron gammaglobulina endovenosa; 15 (42,85%), antibiótico-profilaxis; y 2 (2,24%), antimicóticoprofilaxis. Palabras clave: infecciones respiratorias, hipersensibilidad, gammaglobulinas, síndromes de inmunodeficiencia, deficiencia de IgA. (AU)

Primary immunodeficiencies (PID) are low-prevalence diseases. There are warning signs that may raise clinical suspicion. The objectives of this study were to describe the clinical characteristics and warning signs of patients with PID and to compare the clinical differences between selective immunoglobulin A (IgA) deficiency and other PIDs. Eighty-nine patients were studied; their median age at the time of diagnosis was 6 years old (4.08-11.67). Fifty-three (59.5%) patients were male. Fifty-four (60.7%) patients had selective IgA deficiency, and 35 (39.3%) had other PIDs. The main clinical manifestations were rhinopharyngitis in 65 (73.03%) patients and atopy in 39 (43.82%). Twenty- four (26.97%) patients showed warning signs, and none had selective IgA deficiency. Patients with other PIDs had a higher incidence of lower respiratory tract infection, sepsis, skin infections, mucocutaneous candidiasis, dental alterations, cardiovascular malformations, angioedema, hospitalizations and death. Ten (28.57%) patients received intravenous gammaglobulin, 15 (42.85%) antibiotic prophylaxis, and 2 (2.24%) antifungal prophylaxis. (AU)

Contrast-enhanced ultrasound of hepatocellular carcinoma: correlation between enhancement pattern and cellular differentiation on histopathlogy.

The aim of this study was to evaluate and correlate the enhancement pattern of hepatocellular carcinoma (HCC) on contrast-enhanced ultrasound (CEUS) and tumour cellular differentiation on histopathology. Patients underwent hepatic CEUS, performed with SonoVue and contrast pulse sequencing. The correlation between enhancement time and enhancement level of the lesions in different vascular phases and tumour cellular differentiation was determined. The tumours were graded according to the Edmondson grading system. Then, diagnosis was obtained by histopathological examination following surgery or percutaneous ultrasound-guided biopsy. 189 patients with HCC were examined with CEUS and histopathological examination between 2003 and 2009: 159 had a solitary lesion (85 %), 24 had 2 lesions (12 %) and 6 had multiple lesions (3 %). The final histological grading of the tumours was as follows: 22, 114, 49, 4 grade I-IV, respectively. Significant differences were shown between the time that HCC become hypoenhancing or remained echogenic in late phase and tumour cellular differentiation (p = 0.006, p = 0.036). The timing of HCC becoming hypoenhancing was correlated with tumour cellular differentiation, with better differentiated HCCs washing out more slowly than poorly differentiated ones (p = 0.164, p = 0.113; p = 0.186, p = 0.070). The enhancement pattern of HCC by CEUS correlates with the cellular differentiation. In late phases, hyperechoic lesions are likely to be better differentiated, whereas hypoechoic lesion is more likely to be poorly differentiated.

Combined metallothioneins and p53 proteins expression as a prognostic marker in patients with Dukes stage B and C colorectal cancer.

Our study aimed to evaluate metallothionein and p53 expression in colorectal cancer and to correlate their combined expression with selected clinical and pathologic variables of the disease, to define their prognostic significance. Colorectal cancer specimens from 99 patients were retrospectively analyzed by immunohistochemistry for metallothionein and p53 expression. Survival curves were generated according to the Kaplan-Meier method, and univariate survival distributions were compared with the use of the log-rank test. Multivariate models were computed using Cox proportional hazards regression. This research was approved by the institutional review boards of all centers. Tumors showing concomitant high metallothionein expression and negative p53 (metallothionein(H)/p53(-)) were significantly inversely related to depth of invasion, frequency of nodal metastasis, and Dukes stage (P < .01). In univariate analysis, patients with metallothionein(H)/p53(-) phenotype showed a better overall survival (hazard ratio [HR], 2.83; P < .05) and disease-free survival (HR, 2.03; P < .05). In multivariate analysis, considering staging, metallothionein, and metallothionein + p53 variables, in 83 patients with Dukes stages B and C, metallothionein(H)/p53(-) combination was the sole factor showing an independent prognostic value for overall survival (HR, 3.88; P < .1) and disease-free survival (HR, 2.56; P < .1). In conclusion, the combined analysis of metallothionein and p53 may enhance the prognostic power of each individual marker by predicting the progression of the disease and contributing to a better identification of patients at low risk for mortality, especially for those with Dukes stage B and C colorectal cancer.

An endocannabinoid tone limits excitotoxicity in vitro and in a model of multiple sclerosis.

The aim of this study was to evaluate how endocannabinoids interact with excitotoxic processes both in vitro, using primary neural cell cultures, and in vivo, in the TMEV-IDD model of multiple sclerosis. First, we observed that neuronal cells respond to excitotoxic challenges by the production of endocannabinoid molecules which in turn exerted neuroprotective effects against excitotoxicity. The inhibitor of endocannabinoid uptake, UCM707, protected specifically against AMPA-induced excitotoxicity, by activating CB(1) and CB(2) cannabinoid receptors, as well as the nuclear factor, PPARgamma. This neuroprotective effect was reverted by blocking the glial glutamate transporter, GLT-1. Mice subjected to the model of multiple sclerosis showed a decrease in the expression of GLT-1. UCM707 reversed this loss of GLT-1 and induced a therapeutic effect. Our data indicate that the enhancement of the endocannabinoid tone leads to neuroprotection against AMPA-induced excitotoxicity and provides therapeutic effects in this model of multiple sclerosis.

A cannabinoid agonist interferes with the progression of a chronic model of multiple sclerosis by downregulating adhesion molecules.

Adhesion molecules are critical players in the regulation of transmigration of blood leukocytes across the blood-brain barrier in multiple sclerosis (MS). Cannabinoids (CBs) are potential therapeutic agents in the treatment of MS, but the mechanisms involved are only partially known. Using a viral model of MS we observed that the cannabinoid agonist WIN55,212-2 administered at the time of virus infection suppresses intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) in brain endothelium, together with a reduction in perivascular CD4+ T lymphocytes infiltrates and microglial responses. WIN55,212-2 also interferes with later progression of the disease by reducing symptomatology and neuroinflammation. In vitro data from brain endothelial cell cultures, provide the first evidence of a role of peroxisome proliferator-activated receptors gamma (PPARgamma) in WIN55,212-2-induced downregulation of VCAM-1. This study highlights that inhibition of brain adhesion molecules by WIN55,212-2 might underline its therapeutic effects in MS models by targeting PPAR-gamma receptors.

Tratamiento quirúrgico de los tumores pelvianos avanzados que implican resección sacra / Surgical treatment of the advanced pelvianos tumors that imply sacred resection

Antecedentes: La invasión ósea del sacro fue tradicionalemente considerada como criterio de irresecabilidad (pelvis congelada). Objetivo: Analizar la técnica y los resultados a mediano plazo de la Resecciones Sacras (RS) en Tumores Pelvianos Avanzados (TPA) realizadas en el Instituto Alexander Fleming. Diseño: Estudio retrospectivo. Población: 21 pacientes portadores de TPA que requirieron RS a diversos niveles. Método: Se analizaron retrospectivamente las Historias Clínicas de los 21 pacientes. El seguimiento se realizó mediante visitas periódicas en consultorio externo, o telefónicamente en los perdidos. La supervivencia se analizó con el método actuarial de Kaplan Meier. Resultados: La altura de RS fue: S1 9,5%, S2 38%, S3 28,6%, S4 14,4% y S5 9,5%. La mortalidad de la serie fue del 81%. Transtornos esfinterianos 24%; infección y dehiscencia de herida posterior 57%; infección de la herida anterior 9,5% y fístula posoperatoria 9,5%. El seguimiento promedio fue de 21 meses, la supervivencia libre de enfermedad fue de 17 meses, la supervivencia global acutuarial a 5 años fue de 37,6 y excluyendo los 2 cordomas operados del 20,2%. Conclusiones: Técnica factible realizada por grupos entrenados. Procedimiento e internación prolongados. Es necesario estricta selección de los pacientes para evitar morbimortalidad innecesaria. La invasión sacra No debe ser considerada una contraindicación para el intento de resección.

Ganglio centinela en el cáncer de colon: técnica y análisis preliminar, 20 primeros casos / Sentinel node in colorectal carcinoma: technics and preliminary analysis, first 20 cases

El cáncer de colon es el tumor gastrointestinal más frecuente en EE.UU. y probablemente en nuestro medio. Lograr una correcta estadificación modifica la conducta terapéutica. En los últimos años el concepto de ganglio centinela descripto por Morton para el melanoma fue logrando aceptación en distintas patologías (mama, vulva, etc.). En nuestro análisis preliminar hemos logrado identificar el ganglio centinela en todos los pacientes. El hallazgo del mismo es una técnica simple y económica. En estudios posteriores se incluirá la técnica con inmunohistoquímica y cortes seriados con el fin de intentar demostrar la utilidad de éste método para hallar micrometástasis

Ganglio centinela en el cáncer de colon: técnica y análisis preliminar, 20 primeros casos / Sentinel node in colorectal carcinoma: technics and preliminary analysis, first 20 cases

El cáncer de colon es el tumor gastrointestinal más frecuente en EE.UU. y probablemente en nuestro medio. Lograr una correcta estadificación modifica la conducta terapéutica. En los últimos años el concepto de ganglio centinela descripto por Morton para el melanoma fue logrando aceptación en distintas patologías (mama, vulva, etc.). En nuestro análisis preliminar hemos logrado identificar el ganglio centinela en todos los pacientes. El hallazgo del mismo es una técnica simple y económica. En estudios posteriores se incluirá la técnica con inmunohistoquímica y cortes seriados con el fin de intentar demostrar la utilidad de éste método para hallar micrometástasis (AU)

Prognostic factors in ambulatory patients with inoperable locoregionally recurrent rectal cancer following curative surgery.

BACKGROUND: The optimal treatment for locoregionally recurrent rectal cancer after curative surgery has not yet been defined. The definition of prognostic factors could lead to the selection of an aggressive therapeutic approach in patients with favourable prognosis alone. PATIENTS AND METHODS: The records of thirty-nine ambulatory pts, 15 female and 24 male, with diagnosis of locoregionally recurrent rectal cancer (LRRC) after curative surgery and treated with radiotherapy were retrospectively analyzed. The following factors were analyzed for their ability to predict the clinical response and outcome for LRRC: age, sex, initial tumor grading, primary surgical approach, initial primary tumor stage according to Dukes' classification, disease free survival (time to primary surgery and detection of a LRRC), pelvic-perineal structure affected by recurrence, total radiation dose, chemotherapy with fluorouracil, symptomatic response to the therapy, locoregional symptomatic re-recurrence, systemic progression disease. RESULTS: In the univariate analysis, predictive factors for survival, were graded (G1-2 vs G3 p = 0.04), Dukes' stage at first diagnosis (A-B vs C p = 0.01), and site of pelvic-perineal recurrence (Pelvic mass alone yes vs no p = 0.01; Nerve and/or Osseous involvement yes vs no p < 0.001). Following therapy for LRRC, a better survival was observed in pts with a complete symptomatic response (complete remission vs partial remission vs no change p < 0.001), without a further locoregional symptomatic re-recurrence (re-recurrence, yes vs no p = 0.001) and/or appearance of metastatic disease (yes vs no p < 0.001).

Vaciamientos ganglionares superselectivos en el melanoma cutáneo / Superselective node dissections in cutaneous melanoma

Objetivo: analizar la experiencia con la biopsia del Ganglio Centinela (G.C.) y sus implicancias terapéuticas en el melanoma. Metodología, Material y Método: entre diciembre 94 y abril 98, a 64 pacientes (pac) portadores de melanoma estadíos I y II se les realizó biopsia del G.C. Treinta y ocho eran varones y sus edades oscilaron entre 17 y 72 años (x 45). El espesor del tumor primario fue Breslow 0,5 a 1,49 mm 27 pac. 1,50 a 2,99 mm 21 pac, 3 a 3,99 mm 10 pac, y >4mm 3 pac; sin datos 3 pac. Su localización fue dorso 20, miembro superior 15, miembro inferior 13, tronco 13 y cabeza y cuello 3. Entre 2 y 4 hs previas a la biopsia del G.C. se realizó linfografía isotópica (LI) y marcación de piel sobre ganglio. Se utilizó inyección intradérmica de Azul Patente para su tinción. Resultados: la LI predijo la localización del ganglio en 61/64 pac (95,3 por ciento), con drenaje unilateral en 53 pac y bilateral en 11. El G.C. fue único en 50 pac y doble en 14 pac. No se lo pudo hallar en 2 pac (3 por ciento). La biopsia diferida mostró metástasis en 8 pac (12,5 por ciento). En ningún paciente con Breslow < 3 mm se halló otro ganglio comprometido además del G.C. en la pieza del vaciamiento subsiguiente. No hubo complicaciones. Con un seguimiento medio de 18 meses (1-41 m) sólo un paciente con biopsia del G.C. negativa desarrolló enfermedad en la axila y a distancia simultáneamente. Conclusiones: los vaciamientos ganglionares podrían no ser necesarios en pacientes con biopsia del G.C.+ y tumores primarios < 3 mm de espesor. Estas linfadenectomías superselectivas reducirían morbilidad y costos

Vaciamientos ganglionares superselectivos en el melanoma cutáneo / Superselective node dissections in cutaneous melanoma

Objetivo: analizar la experiencia con la biopsia del Ganglio Centinela (G.C.) y sus implicancias terapéuticas en el melanoma. Metodología, Material y Método: entre diciembre 94 y abril 98, a 64 pacientes (pac) portadores de melanoma estadíos I y II se les realizó biopsia del G.C. Treinta y ocho eran varones y sus edades oscilaron entre 17 y 72 años (x 45). El espesor del tumor primario fue Breslow 0,5 a 1,49 mm 27 pac. 1,50 a 2,99 mm 21 pac, 3 a 3,99 mm 10 pac, y >4mm 3 pac; sin datos 3 pac. Su localización fue dorso 20, miembro superior 15, miembro inferior 13, tronco 13 y cabeza y cuello 3. Entre 2 y 4 hs previas a la biopsia del G.C. se realizó linfografía isotópica (LI) y marcación de piel sobre ganglio. Se utilizó inyección intradérmica de Azul Patente para su tinción. Resultados: la LI predijo la localización del ganglio en 61/64 pac (95,3 por ciento), con drenaje unilateral en 53 pac y bilateral en 11. El G.C. fue único en 50 pac y doble en 14 pac. No se lo pudo hallar en 2 pac (3 por ciento). La biopsia diferida mostró metástasis en 8 pac (12,5 por ciento). En ningún paciente con Breslow < 3 mm se halló otro ganglio comprometido además del G.C. en la pieza del vaciamiento subsiguiente. No hubo complicaciones. Con un seguimiento medio de 18 meses (1-41 m) sólo un paciente con biopsia del G.C. negativa desarrolló enfermedad en la axila y a distancia simultáneamente. Conclusiones: los vaciamientos ganglionares podrían no ser necesarios en pacientes con biopsia del G.C.+ y tumores primarios < 3 mm de espesor. Estas linfadenectomías superselectivas reducirían morbilidad y costos (AU)

Transudative vs exudative pleural effusions: differentiation using Gd-DTPA-enhanced MRI.

The aim of this study was to investigate the capability of Gd-DTPA-enhanced MRI to differentiate between exudative and transudative pleural effusions. An MRI examination was performed on 22 patients with different types of pleural effusion (10 transudative and 12 exudative effusions). T1-weighted SE images were obtained before and 20 min after administration of Gd-DTPA (0.1 mmol/kg). The degree of enhancement of pleural effusions was evaluated both by visual assessment and by quantitative analysis of images. None of 10 transudative effusions showed significative enhancement, whereas 10 of 12 exudative effusions showed enhancement (sensitivity 83 %, specificity 100 %, positive predictive value 100 %). The postcontrast signal intensity ratios (SIRs) of exudates were significantly higher than corresponding precontrast ratios (P = 0. 0109) and the postcontrast SIRs of exudates were significantly higher than those of transudates (P = 0.0300). Exudative pleural effusions show a significant enhancement following administration of Gd-DTPA. We presume that this may be caused by increased pleural permeability and more rapid passage of a large amount of Gd-DTPA from the blood into the pleural fluid in case of exudative effusions. In our limited group of patients, signal enhancement proved the presence of an exudative effusion. Absence of signal enhancement suggests a transudate, but does not exclude an exudate.

Detection of right ventricular ischaemia during coronary surgery by means of a right precordial lead.

This study was designed to determine the intra-operative incidence of right-sided ventricular ischaemia and any association with left ventricular ischaemia. In 60 patients, undergoing coronary artery bypass grafting surgery, a right-sided precordial lead V5R was used. ST segment deviation of more than 1 mm in V5R was considered significant for myocardial ischaemia. Right ventricular ischaemia occurred in 14 patients (23.3%) but was not associated with left ventricular inferior wall ischaemia. In 4 patients (6.6%) presenting with right ventricular ischaemia, ischaemia of the left inferior wall also developed but in all cases was transient and disappeared by the end of surgery. No myocardial infarction was detected in the post-operative period. The present study showed that the use of a right-sided lead may improve intra-operative electrocardiographic monitoring, by revealing ischaemia in those patients in whom ECG abnormalities were not detected by conventional leads. The transient right ventricular ischaemia recorded in this study was probably related to a reduced hypothermic protection of the right ventricle during aortic cross clamping.

Staging of hilar cholangiocarcinoma with ultrasound.

The preoperative assessment of the extent of biliary and vascular involvement by hilar cholangiocarcinoma is clinically important because resectability may be limited by tumor extension along the bile ducts into the hepatic parenchyma or to the adjacent hilar vessels. Thirty-five patients with hilar cholangiocarcinoma were studied with ultrasound, and the results were compared with operative findings and other diagnostic modalities. The level of intrahepatic biliary obstruction was determined in 100% of patients with ductal ectasia, and a tumor mass was shown in 37.1%. Imaging and Doppler ultrasound proved accurate in detecting the neoplastic involvement of the portal vein. Both correctly diagnosed portal occlusion and wall infiltration in 4 of 4 and 15 of 18 (83%) patients, respectively, without any false-positives. On the contrary, imaging ultrasound had poor sensitivity in detecting infiltration of the hepatic artery (43%) and metastases in regional lymph nodes (37%), liver (66%), and peritoneum (33%). In conclusion, ultrasound may be valuable in the preoperative staging of hilar cholangiocarcinoma, specially in predicting ductal and portal involvement.

CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery.

OBJECTIVE: Postthoracotomy atrophy of chest wall muscles results from nerve injury during surgery. After encountering patients with different patterns of chest wall muscular atrophy postthoracotomy, we performed this study to determine the relationship between type of thoracotomy and atrophic muscles as seen on CT scans. MATERIALS AND METHODS: CT scans of 58 patients who had previously undergone unilateral thoracotomy were reviewed. Forty patients had a posterolateral thoracotomy, and 18 had an anterolateral thoracotomy. In two cases, the incision extended posteriorly. Atrophy seen on CT scans was defined as a marked decrease in size or thickness of a muscle compared with the muscle on the other side. RESULTS: Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle was detected on CT scans in 40 patients. No atrophy was found in 16 patients. The remaining two displayed atrophy only in the serratus anterior muscle. Atrophy of the latissimus dorsi muscle and of the inferior portion of the serratus anterior muscle developed in all patients who had a posterolateral thoracotomy. Atrophy developed in only two of the 18 patients who had an anterolateral thoracotomy, and in these two, the incision had been extended posteriorly. CONCLUSION: A direct correlation was found between type of thoracotomy and site of atrophy of the chest wall muscles seen on CT scans. This finding may account for different CT appearances of the thoracic wall in patients who have had thoracic surgery.

Case report: bowel infarction with splenic air embolism: computed tomography findings.

Computed tomography (CT) is used increasingly as an early radiological examination in patients with suspected bowel infarction because it provides information about the intestinal wall, mesenteric circulation and peritoneal cavity [1, 2]. Other disorders that present with similar symptoms such as intraabdominal abscess, pancreatitis and ulcerative colitis can be excluded [3]. CT can demonstrate small amounts of air within the bowel wall, in the spleno-mesenteric-portal venous system and in the peritoneal cavity, making it possible to differentiate portal venous gas from pneumobilia. The authors describe a patient in whom a specific diagnosis of bowel infarction was made on the characteristic CT findings. Furthermore, air embolism was observed in the splenic parenchyma. This finding has not been previously reported in bowel infarction or in any other abdominal disorder.

[Role of computerized tomography in the evaluation of extraductal extension of hilar cholangiocarcinoma]. / Ruolo della tomografia computerizzata nella valutazione dell'estensione extra-duttale del colangiocarcinoma ilare.

This study was aimed at assessing the role of CT in the investigation of extraductal spread of hilar cholangiocarcinoma. October 1990 to November 1993, twenty-one patients with hilar cholangiocarcinoma were examined. The diagnosis was made on the basis of the following CT findings: intrahepatic bile ducts dilatation, nonunion of the right and the left bile ducts, normal size of extrahepatic bile ducts and the tumor depicted "per se". As for extraductal spread, we considered parenchymal invasion, involvement of vascular structures and parenchymal, lymph node and peritoneal metastases. In all cases CT demonstrated intrahepatic bile duct dilatation and nonunion at the confluence. CT demonstrated a hypodense mass in 10/21 cases and an isodense mass in 11/21 cases. Portal vein involvement was detected in 7/10 cases and hepatic artery involvement was correctly suspected in 1/8 cases; CT demonstrated parenchymal and lymph node metastases in 1/6 and 2/7 cases. In conclusion, CT proved to be a valuable technique, like PTC and US, to assess tumor resectability.