Ganglio centinela positivo en estadios iniciales de cáncer de mama. 2018. Resumen de recomendaciones / Positive sentinel lymph node in early stages of breast cancer. 2018. Summary of recommendations

Sabemos que el estado de la axila sigue siendo un factor pronóstico determinante y fundamental en la elección del tratamiento adyuvante de nuestras pacientes. Varios ensayos clínicos han hecho esfuerzos para intentar demostrar que la biopsia del ganglio centinela es tan efectiva como la linfadenectomía en cuanto a la estadificación. Estos mismos estudios evidenciaron que, en la gran mayoría de los casos ­del 40% al 60%­, ese ganglio centinela es el único metastásico. Por lo tanto, luego se quiso demostrar la efectividad de esa biopsia de ganglio centinela, no solo en cuanto a la eficacia de la estadificación, sino en cuanto al control local, incluso en pacientes con hasta uno o dos ganglios comprometidos pero que recibieron el tratamiento local adecuado, esto es, la exéresis adecuada, el tratamiento radiante completo y el tratamiento adyuvante que correspondiera en esos casos

Biopsias percutáneas en pacientes jóvenes menores de 35 años: correlación anátomo-radiológica / Percutaneous biopsies in young patients under 35 years of age: radiological-anatomical correlation

Introducción El cáncer de mama es el más frecuente en mujeres, aunque es de baja incidencia en pacientes jóvenes. Objetivos Analizar retrospectivamente las biopsias realizadas en pacientes menores de 35 años, en el Grupo Médico Rostagno en el período comprendido entre enero de 2010 y enero de 2015, clasificarlas según edad, presentación clínica e imagenológica y realizar una correlación anátomo-radiológica. Material y método Se estudiaron 381 biopsias realizadas a pacientes de hasta 35 años en el período comprendido entre enero de 2010 y enero de 2015. Resultados La mayoría de las biopsias ­247(66%)­ se realizaron en pacientes mayores de 30 años. Únicamente 28 (8%) fueron clínicamente palpables. Sobre el total, 328 (89%) correspondieron a lesiones nodulares diagnosticadas por ecografía, según categoría bi-rads; 187 (50%) se clasificaron bi-rads 4. Por otra parte, 301 (81%) fueron core biopsia bajo guía ecográfica. Únicamente 20 (5%) fueron malignas, y el carcinoma más frecuente fue el Carcinoma Ductal Infiltrante (55%). Conclusiones Las pacientes jóvenes presentan, en su mayoría, lesiones nodulares, con una baja incidencia de lesiones malignas. La lesión maligna más frecuente fue el Carcinoma Ductal Infiltrante tipo nos de alto grado histológico

Introduction Breast cancer is the most frequent in women, although it is of low incidence in young patients. Objectives To analyze retrospectively biopsies performed in patients under 35 years of age, classify them according to age, clinical and imaging presentation and perform an anatomo-radiological correlation. Materials and method We studied 381 biopsies performed on patients up to 35 years of age in the period between January 2010 and January 2015. Results The majority of biopsies 247 (66%) were performed in patients older than 30 years, only 28 (8%) were clinically palpable. 328 (89%) corresponded to nodular lesions, diagnosed by ultrasound, according to bi-rads category 187 (50%) were classified bi-rads 4. 301 (81%) were Core biopsy under ultrasound guidance. Only 20 (5%) were malignant, and the most frequent carcinoma was Infiltrating Ductal Carcinoma (55%). Conclusions Young patients have mostly nodular lesions, with a low incidence of malignant lesions. The most frequent malignant lesion was nos type Infiltrating Ductal Carcinoma of high histological grade

Volumetric Mammogram Assessment: A Helpful Tool in the Treatment of Breast Asymmetries.

The surgical approach to breast asymmetry depends on several factors, including the surgeon's experience, the anatomy of the patient, and several methods that may help to choose a technique and define the size of the implant or the amount of breast tissue to be excised. The aim of this study is to assist in evaluation of breast volumes with the Quantra™ software application, intended for use with Hologic™ digital mammography systems. Twenty-eight women were studied with full-field digital mammography (FFDM) with the Quantra™ software application, for use with Hologic™ digital mammography systems preoperatively. The case diagnoses were as follows: breast hypertrophy, ptosis, hypoplasia, and reconstruction, and the surgeries included breast reduction, mastopexy, mastopexy and breast reduction, mastoplasty and breast augmentation, breast augmentation, and immediate or delayed breast reconstruction. Patients were evaluated from 6 to 18 months after surgery. Volumetric mammogram studies help to decide the amount of tissue to be excised, the size of the implants, and the combination of both. The results of this study were evaluated by surgeons and patients and found to be highly satisfactory. The use of full-field digital mammography with adequate software should be considered as another tool to assist in making decisions regarding the correction of breast asymmetries. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Direct to Implant Reconstruction in Nipple Sparing Mastectomy: Patient Selection by Preoperative Digital Mammogram.

BACKGROUND: Digital mammography clearly distinguishes gland tissue density from the overlying nonglandular breast tissue coverage, which corresponds to the existing tissue between the skin and the superficial layer of the fascia superficialis surrounding the gland (i.e., dermis and subcutaneous fat). Preoperative digital imaging can determine the thickness of this breast tissue coverage, thus facilitating planning and reducing the rate of necrotic complications after direct to implant (DTI) reconstruction in nipple sparing mastectomy (NSM). METHODS: Thirty NSMs in 22 patients with type 3 tissue coverage (subcutaneous tissue thickness of 2 cm or more) were selected for DTI reconstruction after NSM to evaluate immediate skin flap/nipple areola complex ischemic complications and patient satisfaction. RESULTS: We experienced no wound healing problems or ischemic complications immediately after surgery in our population. Only 1 seroma was observed as a short-term complication. Quality of life and patients' satisfaction level were optimal at 3 and 6 months follow-up, respectively. The aesthetic results have been evaluated as good/excellent in all cases. CONCLUSIONS: DTI immediate reconstruction with silicone implants following NSM appears to be a safe option in selected cases with enough tissue coverage, also providing a high level of patient satisfaction. The possibility of selecting cases for this procedure according to the preoperative digital mammogram showing more than 2 cm of superficial tissues thickness may help reducing the risk of immediate ischemic complications.

Preoperative digital mammography imaging in conservative mastectomy and immediate reconstruction.

BACKGROUND: Digital mammography clearly distinguishes gland tissue density from the overlying non-glandular breast tissue coverage, which corresponds to the existing tissue between the skin and the Cooper's ligaments surrounding the gland (i.e., dermis and subcutaneous fat). Preoperative digital imaging can determine the thickness of this breast tissue coverage, thus facilitating planning of the most adequate surgical techniques and reconstructive procedures for each case. METHODS: This study aimed to describe the results of a retrospective study of 352 digital mammograms in 176 patients with different breast volumes who underwent preoperative conservative mastectomies. The breast tissue coverage thickness and its relationship with the breast volume were evaluated. RESULTS: The breast tissue coverage thickness ranged from 0.233 to 4.423 cm, with a mean value of 1.952 cm. A comparison of tissue coverage and breast volume revealed a non-direct relationship between these factors. CONCLUSIONS: Preoperative planning should not depend only on breast volume. Flap evaluations based on preoperative imaging measurements might be helpful when planning a conservative mastectomy. Accordingly, we propose a breast tissue coverage classification (BTCC).

Endovascular treatment of iatrogenic aortic injury after spinal surgery.

A 59-year-old female presented to our institution with paraparesis caused by medullar compression secondary to multiple myeloma. Spinal cord decompression and transpedicular spine fixation were performed. A month later, the patient complained of sudden pain in her middle back. A CT scan revealed screw impingement on the aortic wall at T8 level. A thoracic stent-graft was deployed before removing the fixation. The patient had an uneventful postoperative course, without complications during the four-year follow-up. In this case report, stent-graft placement proved to be safe and effective in avoiding bleeding during screw removal.

Síndrome de la vena cava superior en el posoperatorio inmediato de trasplante cardíaco: tratamiento endovascular / Endovascular Treatment of Superior Vena Cava Syndrome in the Immediate Postoperative Period of Heart Transplantation

El trasplante cardíaco está indicado en pacientes con insuficiencia cardíaca terminal sin opción de tratamiento médico, intervencionista o quirúrgico y puede realizarse utilizando fundamentalmente tres variantes técnicas. El beneficio de la técnica bicava en términos de parámetros hemodinámicos y clínicos la ha convertido en la más utilizada, aunque es técnicamente más demandante y puede tener algunas consecuencias, como estenosis en las anastomosis de las venas cavas. En esta presentación se describe el caso de un paciente sometido a trasplante cardíaco ortotópico con técnica bicava que en el primer día del posoperatorio desarrolló el síndrome de la vena cava superior. Durante el segundo día posoperatorio y ante sintomatología progresiva, a pesar de haberse administrado anticoagulación, se decidió realizar una flebografía diagnóstica y al mismo tiempo tratamiento endovascular. En ese procedimiento se recanalizó la vena cava superior y se implantaron tres stents autoexpandibles, con lo que se logró permeabilidad de la anastomosis entre las venas cavas donante y receptora, la vena cava superior y la subclavia derecha. La evolución fue favorable con alivio inmediato de la sintomatología. El paciente fue dado de alta sin complicaciones.

Heart transplantation is indicated in patients with end-stage heart failure who have no options with medical, interventional or surgical treatment. Among the three techniques available, the bicaval technique is the one most frequently used due to its hemodynamic and clinical benefits. However, it is technically more demanding and may have some consequences, as vena caval anastomotic stenosis. We describe the case of a patient who developed superior vena cava syndrome at postoperative day one of orthotopic heart transplantation with bicaval technique. At the second day symptoms progressed and, despite having initiated anticoagulation therapy, the patient underwent a diagnostic phlebography followed by endovascular treatment. After dilatation of the superior vena cava three self-expandable stents were implanted producing patent anastomosis between the donor and receptor venae cavae, the superior vena cava and the right subclavian vena. The patient had favorable outcomes with immediate symptoms relief and was discharged without complications.

Aneurisma de la aorta abdominal: Tratamiento endovascular con una endoprótesis fenestrada / Abdominal aortic aneurysm: Endovascular treatment with fenestrated endoprothesis

El tratamiento endovascular de los aneurismas de aorta abdominal es una alternativa a la cirugía abierta para pacientes de alto riesgo. Consiste en la exclusión del saco aneurismático mediante la interposición de una endoprótesis colocada por vía femoral. El tratamiento endovascular no puede ser utilizado en todos los pacientes. Una limitación frecuente la constituye el nacimiento de una arteria visceral desde el saco aneurismático. Para contrarrestar esta limitación recientemente se han desarrollado endoprótesis fenestradas que presentan orificios que se corresponden con el nacimiento de las arterias involucradas en el aneurisma evitando su oclusión, permitiendo de esta manera el tratamiento endovascular. En esta comunicación se presenta un caso de tratamiento endovascular de un aneurisma de aorta abdominal mediante la colocación de una endoprótesis fenestrada en un paciente cuya arteria renal izquierda nacía directamente del saco aneurismático.

Endovascular treatment of the abdominal aortic aneurysm is consider an alternative to open surgery for high risk patients. Its goal is to exclude the aneurysm from the circulation by using an endoprothesis introduced from a femoral approach. Patients must be strictly selected to avoid possible complications. The most frequent limitation is related to anatomic contraindications such as visceral arteries involved in the aneurysm. Fenestrated endograft have been recently developed to allow endovascular treatment when anatomic features contraindicate classic endovascular procedures. Fenestrated endograft have holes that match with the origin of the visceral arteries maintaining its potency. In this paper we report the endovascular treatment of an abdominal aortic aneurysm by using a fenestrated endoprothesis in a patient whose left renal artery is originated from the aneurysm.

Endovascular treatment of extracranial internal carotid aneurysms using endografts.

Aneurysms of the extracranial internal carotid artery (EICA) are infrequent. They are difficult to treat with conventional surgery because of their distal extension into the skull base. We report three cases of EICA aneurysms in two symptomatic patients successfully treated with polytetrafluoroethylene self-expanding endografts using an endovascular approach. The aneurysms were located distal to the carotid bifurcation and extended to the subpetrous portion of the internal carotid artery.

[Abdominal aortic aneurysm. Endovascular treatment with fenestrated endoprothesis]. / Aneurisma de la aorta abdominal. Tratamiento endovascular con una endoprótesis fenestrada.

Endovascular treatment of the abdominal aortic aneurysm is consider an alternative to open surgery for high risk patients. Its goal is to exclude the aneurysm from the circulation by using an endoprothesis introduced from a femoral approach. Patients must be strictly selected to avoid possible complications. The most frequent limitation is related to anatomic contraindications such as visceral arteries involved in the aneurysm. Fenestrated endograft have been recently developed to allow endovascular treatment when anatomic features contraindicate classic endovascular procedures. Fenestrated endograft have holes that match with the origin of the visceral arteries maintaining its potency. In this paper we report the endovascular treatment of an abdominal aortic aneurysm by using a fenestrated endoprothesis in a patient whose left renal artery is originated from the aneurysm.

Bilateral hypogastric artery occlusion in endovascular repair of abdominal aortic aneurysms and its clinical significance.

PURPOSE: Endovascular treatment of aortoiliac aneurysms near or involving the hypogastric artery (HGA) requires HGA occlusion before endografting to avoid retrograde filling of the aneurysm. The purpose of this study is to evaluate clinical outcomes of bilateral HGA occlusion and determine if benefits gained by endovascular aneurysm repair (EVAR) outweigh the morbidity associated with the procedure. MATERIALS AND METHODS: Between 1999 and 2004, 128 patients with abdominal aortic aneurysm (AAA) were treated with bifurcated endograft placement. Bilateral coverage or embolization of HGAs was performed in 14 patients (10.9%). Embolization was achieved by deployment of coils and coverage was accomplished by extending the endoprosthesis into the external iliac artery. Clinical follow-up and computed tomographic angiography were performed at 1, 3, 6, 9, and 12 months and annually thereafter to detect potential aneurysm growth and endoleaks. RESULTS: During follow-up (range, 1-72 months), buttock claudication was noted in four patients (28.6%), including unilateral claudication in two and bilateral claudication in two. One patient experienced claudication longer than 12 months, which resolved within 18 months. De novo erectile dysfunction was seen in one patient, and pelvic ischemia was not found in any patient. There was no evidence of endoleak, aneurysm enlargement, or death associated with HGA occlusion. CONCLUSIONS: In our series, complications of bilateral HGA occlusion before EVAR were moderate and resolved over time. The benefits gained from EVAR outweigh the clinical problems caused by bilateral HGA occlusion, as there are no technical complications added to the EVAR procedure.

Reparación endovascular de aneurismas de aorta abdominal (parte I). Epidemiología indicaciones y limitaciones / Endovascular repair of abdominal aortic aneurysms (Part I). Epidemiology, indications, and limitations

Los aneurismas de la aorta abdominal son una patología frecuente, con alta afinidad hacia la ruptura y muerte. La reparación endovascular es una alternativa al reparo convencional en pacientes de alto riesgo, y el desarrollo tecnológico y el perfeccionamiento de las endoprótesis va a permitir su aplicación en pacientes de buen riesgo para reparo convencional con cirugía abierta. En este artículo se dan las pautas básicas que deben conocer los especialistas en enfermedades cardiovasculares acerca de la epidemiología, indicaciones y limitaciones del reparo endoluminal de los aneurismas de la aorta abdominal.

[Occlusion of a pulmonary arteriovenous fistula with an amplatzer vascular plug]. / Oclusión de una fístula arteriovenosa pulmonar con el tapón vascular Amplatzer.

Pulmonary arteriovenous malformations are rare anomalies that carry a considerable risk of serious complications such as cerebral thromboembolism or abscess and pulmonary hemorrhage. The first-line treatment of such malformations is detachable coil or balloon embolotherapy. However, coils and balloons may migrate and cause paradoxical embolism especially in malformations with large arteriovenous shunts. We report a case in which we used a new vascular occlusion device (amplatzer vascular plug), to occlude a pulmonary arteriovenous fistula in a patient with Rendu-Osler-Weber syndrome.

Intimal dehiscence in the abdominal aorta following balloon fenestration for type B dissection.

PURPOSE: To report a case of intimal dehiscence associated with endovascular intervention in patients with aortic dissection. CASE REPORT: A 65-year-old man presented with a type B dissection extending to the level of the common iliac arteries. Two Talent stent-grafts were placed in the descending thoracic aorta to close the entry point, but 2 lumens remained. Three days later, abdominal pain prompted another imaging session, which demonstrated a large cylindrical filling defect in the abdominal aorta ("tube-in-tube") assumed to be a partially or completely dehisced intima. Fenestration marginally improved flow to the visceral vessels, and the patient improved clinically. However, 4 days later, recurrent ischemic symptoms prompted surgery; a complete dehiscence of the aortic intima starting at the descending aorta extended to the distal abdominal aorta. The aorta was resected, but the patient died from disseminated intravascular coagulation. CONCLUSIONS: Intimal flap dehiscence associated with an endovascular procedure in the management of aortic dissection is an uncommon complication. Early detection and prompt surgical intervention of such a complication could save the patient's life. Endovascular procedures are unlikely to resolve the hemodynamic problem caused by a dehisced, distally migrated, collapsed intima.

Bifurcated endoprosthesis for treatment of aortoiliac occlusive lesions.

PURPOSE: To report our initial experience with a bifurcated endoprosthesis in the management of aortoiliac occlusive disease. METHODS: From May 2001 to February 2004, 112 patients were referred to our institution for the management of aortoiliac disease. Among these, 5 (6%) patients (3 men; mean age 57.8 years) with severe ischemia owing to TASC C or D iliac occlusions were selected for endovascular treatment with a bifurcated stent-graft. An Excluder stent-graft was placed after preliminary recanalization (thrombolysis and/or balloon dilation) the day before. The patients were followed clinically and ultrasonographically every 3 months during the first year and semiannually thereafter. RESULTS: Technical success was achieved in all patients. Endovascular aortoiliac bifurcation reconstruction restored iliac artery flow immediately in all cases. There were no procedure-related complications. The mean ankle-brachial index (ABI) was significantly improved, from 0.66+/-0.04 before the procedure to 0.94+/-0.06 immediately after the procedure (p<0.01). The aortoiliac reconstructions remained patent during the mean 17-month follow-up (range 3-36), and the ABIs were stable. There was no mortality or amputation required in this series. CONCLUSIONS: Endovascular placement of a bifurcated stent-graft appears to be technically feasible, effective, and safe in the management of aortoiliac occlusive disease.

Obstrucción colorrectal maligna: tratamiento con endoprótesis metálicas autoexpandibles / Colorectal obstruction: treatment with expandible stent endoprosthesis

Objetivo: evaluar la utilidad de las endoprótesis metálicas autoexpandibles en el tratamiento de la obstrucción colorrectal secundaria a una neoplasia maligna. Material y métodos: se instalaron un total de doce endoprótesis en doce pacientes bajo fluorscopica, en dos casos asistido por endoscopía. Los pacientes presentaban signos clínicos y radiológicos de una obstrucción intestinal a nivel colorrectal. Las indicaciones de instalación fueron: tratamiento paliativo en 10 pacientes con evidencias de enfermedad tumoral a distancia (9) o pelvis congelada (1) y en 2 pacientes como método de descompresión prequirúrgica. Se utilizaron prótesis metálicas autoexpandibles (Wallstent 20 x 55 mm). Resultados: la colocación de la endoprótesis fue exitosa en 12 pacientes, que se recuperaron de su obstrucción colónica dentro de las 24 horas siguientes. Conclusión: la instalación de endoprótesis autoexpandibles en pacientes con obstrucción intestinal a nivel colorrectal es un método mínimamente invasivo, efectivo como tratamiento paliativo en aquellos pacientes de alto riesgo para una intervención quirúrgica. Por otra parte, éste procedimiento también permite la preparación preoperatoria del colon y así proceder en una sola etapa quirúrgica