Colangiocarcinoma primario asociado a enfermedad de Caroli / Primary cholangiocarcinoma asociated with Caroli disease

A 68 years old male presented with right hypochondrium abdominal pain and jaundice with no other clinical finding. CAT Scan and Ultrasonography showed right lobe bile duct dilatation. Magnetic Resonance Cholangiopancreatography gave an outstanding vision of a restricted right lobe bile duct dilatation associated to choledocholithiasis. A right hepatectomy and bile duct exploration were performed. The histopathological study disclosed a Caroli disease associated to a primary cholangiocarcinoma. Caroli disease is a congenital disorder characterized by intrahepatic cystic bile duct dilatation with a high risk association with cholangiocarcinoma

Mutación del gen p53 en el cáncer de la vesícula biliar / P53 gene mutation in gallbladder cancer

Background: Gallbladder cancer frequency and mortality renders it one of the most important neoplastic diseases in Chile. P53 tumor suppressor gene has been studied in most types of cancer, but there is scarce information about it in gallbladder cancer. Aim: To study the frequency of P53 gene mutation in gallbladder cancer in the ninth region of Chile. Material and methods: In 25 pathological samples of gallbladder cancer, the direct amplification and sequencing of p53 gene exons 5,6,7,8-8 was possible. Results: Seventeen punctual mutations were observed in 13 cases (52 percent). There were 10 transitions, 5 transversions, one insertion (codon 194) and one deletion (codon 186). Eight cases had mutations in exon 5, six had mutations in exon 6, two had mutations in exon 7 and one had mutations in exons 8-9. In 14 of 25 cases, gene p53 protein was positive. When immunohistochemical expression of gene p53 protein was positive in more than 20 percent of cells, there was a high correlation between genetic alterations and immunohistochemical expression of the protein, with a specificity, sensitivity, positive and negative predictive values over 80 percent. Conclusions: P53 gene mutation is observed in a high proportion of gallbladder cancers at it can be accurately detected with conventional immunohistochemical techniques. The importance of this gene in the genesis of this carcinoma should be determined studying preneoplastic lesions and early carcinomas

Carcinoma incipiente de la vesícula biliar: estudio clínico patológico y pronóstico de 196 casos / Clinical and pathological features of early gallbladder carcinoma

Background: There is little information about the behavior of early gallbladder carcinoma. Aim: To report the clinical and pathological features of 196 patients with early gallbladder carcinoma. Material and methods: All patients with gallbladder cancer diagnosed between 1988 and 1997 were reviewed. In 703 of 829 patients, there was information about clinical features and follow up, and were included in this study. All gallbladders were subjected to a complete mapping. When neoplastic cells involved only the mucosa or muscular layer, the tumors were considered as early. Results: One hundred ninety six patients had an early carcinoma (161 women, aged 57.5 years and 35 male, aged 63.4 years). One hundred twenty eight tumors were located in the mucosa and 68 in the muscular layer. Patients with tumors involving the mucosa were younger than those with tumors involving the muscular layer. All tumors were adenocarcinomas, 66 per cent were well differentiated and 32 per cent moderately differentiated. Tumors were not visible macroscopically in 132 cases. Five and 10 years survival was 92 per cent. Subjects of less than 40 years old had a 100 per cent survival at 5 years. A hepatic and lymph node resection was done in 12 patients with tumors infiltrating the muscular layer but in only one, the tumor infiltrated the liver. No difference in survival was observed when a simple cholecystectomy or radical surgery was done. Conclusions: Nearly 25 per cent of gallbladder carcinomas can be classified as early and its diagnosis requires a directed study. Simple cholecystectomy is curative for this type of gallbladder cancer

Expresión de CD44 HCAM en el carcinoma subseroso de la vesícula biliar / CD44 HCAM expression in subserous gallbladder carcinoma

Background: HCAM or CD44 is a multifunctional cell adhesion molecule, related to cell-cell, cell-extracellular matrix interactions and involved in tumor invasion. Aim: To study the importance of CD44 expression in subserous gallbladder carcinoma. Material and methods: One hundred five samples (93 female) of subserous gallbladder carcinoma and 33 non tumoral gallbladder were studied. CD44 was stained using the streptavidine-biotin technique, using human anti CD44 antibodies. Eighty subjects with carcinoma were followed for a period up to 105 months. Results: Mean age of patients was 62,6 years old, all tumors were adenocarcinoma, all were silent and 13 percent were well differentiated. CD44 was expressed in all controls and in 91 percent, the expression was normal. In 57 percent of cancer samples, CD44 expression was abnormal, in 50 percent it was less expressed and in 24 percent, it was not expressed. No differences in CD44 expression was observed between mucosa from control samples and mucosa adjacent to the tumor or superficial or deep tumoral areas. Global five years survival was 40 percent. No significant differences in survival were observed in those tumors with a lower of absent CD44 expression. Six patients with a higher expression died before 18 months of follow up. Conclusions: Nearly 50 percent of subserous gallbladder carcinomas show an abnormal CD44 expression

¿Es el cáncer de la vesícula biliar una enfermedad de mal pronóstico en Chile? / Is galbladder cancer a tumor with bad prognosis?

Gallbladder cancer is frequent in Chile, but it is not uniformly mortal. The diagnosis is usually made after a cholecystectomy. indicated for a symptomatic cholelithiasis. Global survival of gallbladder cancer can be as high as 40 percent at five years. In 69 percent of women of less than 30 years old, the tumor is detected in early stages. In these cases, cholecystectomy is the curative procedure, with a 90 percent survival at five years. According to our experience, cholecystectomies should be performed between 40 and 50 years of age in men and between 30 and 40 years in women. The prognostic factors that should be considered are symptoms associated to lithiasis, age, parity, obesity, size of stones and the size of the gallbladder. If the tumor is detected in early stages, the survival is good. The natural history of the disease would change significantly if all women with symptomatic stones were operated

Estudio bacteriológico de la bilis vesicular en un área de alto riesgo de cáncer vesicular / Microbiological study of gallbladder bile in a high risk zone for gallbladder cancer

Background: Gallbladder cancer is frequent in Chile and there is sparse information about the association between this type of cancer and the presence of bacteria in the gallbladder bile. Aim: To determine the presence of aerobic bacteria in gallbladder bile in patients with and without gallbladder cancer. Material and methods: A microbiological analysis of bile and pathological study was performed in 608 gallbladders, obtained during to cholecystectomies performed to 513 women and 95 men aged 44 years old as a mean. Results: Pathological study showed a chronic cholecystitis in 468 cases (77 percent), an acute cholecystitis in 140 (33 percent), cancer in 24 (3.9 percent) and dysplasia in 5 cases (0.8 percent). A positive culture was obtained in 22.5 percent of women and 28.5 percent of males. Twenty seven percent of women over 30 years old had positive cultures compared with 10 percent of younger women (p <0.001). Thirty two percent of acute cholecystitis had positive cultures, compared with 24 percent of chronic cholecystitis (p=0.03). E Coli was isolated in 51 percent of positive cases, streptococci-enterococci in 24 percent, enterobacter sp in 9 percent, klebsiella and proteus in lower proportions. Salmonella sp was isolated in 4 cases, being all women with chronic cholecystitis. Thirteen of 29 cases with cancer or dysplasia had positive cultures (45 percent), compared with 25 percent of patients with inflammatory gallbladder diseases (p=0.02). streptococci-enterococci were isolated in 7 cases and enterobacter sp in three. Conclusions: The presence of salmonella sp in gallbladder bile was not frequent in the studied patients. Its role in the pathogenesis of gallbladder cancer must be reassessed

Hallazgos en reintervenciones quirúrgicas por cáncer de la vesícula biliar en pacientes con y sin quimio-radiación preoperatoria / Pathological findings in surgical reinterventions for gallbladder cancer in patients with and without preoperative chemo and radiotherapy

Background: The usefulness of surgery in the treatment of gallbladder cancer has not been clearly established. The benefits of chemo and radiotherapy are similarly dubious. Aim: To report the pathological findings in patients subjected to surgical reinterventions for gallbladder cancer. Patients and methods: We report 54 patients with gallbladder cancer that were subjected to a second surgical intervention for resection of liver segments IVb and V and lymph nodes corresponding to the liver hilar, portal, peripancreatic, celiac artery and periaortic territories. Thirteen of these patients were subjected to preoperative chemo-radiotherapy (4500 Gy and 5-fluouracil 500 mg/m2). Results: Lymph node metastases were found in 25 and 38 percent, and liver metastases in 25 and 28 percent of patients with or without chemo-radiotherapy respectively. The most frequent pathological findings attributed to radiation in the liver were fatty infiltration in 75 percent of cases, vascular transformation in 83 percent of cases and minimal periportal lymphocyte infiltration in 40 percent of cases. Lymph nodes were atrophic in 67 percent of cases and had foci of cortical necrosis in 46 percent of cases. Three cases had regional lymph node and liver metastases. Most tumor cells were viable. Conclusions: No differences in the number of lymph node or liver metastases were observed between patients with and without chemo-radiotherapy. No effect of the treatment on residual tumor was observed either

Elementos morfológicos pronósticos en el cáncer de la vesícula biliar / Morphological prognostic factors in gallbladder cancer

Background: The exact survival rates and prognostic factors of gallbladder cancer are still incompletely known. Aim: To report the actuarial survival of patients with gallbladder cancer. Material and methods: Six hundred thirty seven women, aged 59 years old as a mean and 108 men, aged 64 years old as a mean, with gallbladder cancer are reported. Patients were followed for up to 150 months. Results: Two hundred twenty four patients had an early and 521 had an advanced carcinoma. Overall survival was 38 percent at ten years. Sex or ethnic origin did not influence survival. Early tumors had a 92 percent survival at 10 years whereas the survival of advanced tumors was 16 percent at 5 years. Subserous tumors had a 5 years survival of 32 percent whereas serous tumors had a 5 years survival of 11 percent. Well-differentiated advanced tumors had a significantly better survival than moderately or poorly differentiated tumors. Vascular or lymphatic infiltration was also associated to a lower survival. All patients with advanced tumors and vascular infiltration died before 5 years. Conclusions: Tumor infiltration and differentiation degree were the most important prognostic independent factors in gallbladder cancer

Manometría endoscópica biliar y del esfínter de Oddi / Endoscopic biliary and Oddi's sphincter manometry

Se reportan hallazgos de motilidad del esfínter de Oddi obtenidos en 5 pacientes sometidos a manometría biliar y del esfínter de Oddi. Se trata de 4 mujeres y 1 hombre que fueron referidos a CPRE por sintomatología de la esfera biliopancreática y cuya colangiografía posterior fue normal. Se realizó una duodenoscopía convencional con un equipo Olimpus JFT-20, canulación de la papila de Vater con una sonda BMC-I-93100 Cook la que fue perfundida en forma constante mediante un sistema de infusión neumohidráulico capilar. Una vez en colédoco se efectuó retiro de la sonda con técnica de retirada estacionaria a 2 mm cada 5 segundos. Así se valoró la presión de reposo, longitud y morfología del esfínter y las presiones intraduodenal e intracoledociana. Posteriormente se efectuó una nueva canulación papilar y se localizó la sonda de registro en medio del esfínter. De esta forma se analizó la amplitud y frecuencia de contracciones por minuto. Se constataron las siguientes presiones: intraduodenal=2,4 mmHg, intracoledociana=7,4 mmHg, del esfínter en reposo=14,5 mmHg. Longitud esfinteriana=4,2 mm. Amplitud=100,2 mmHg, duración=4,5 s y 3,3 contracciones por minuto

Cáncer de vesícula biliar: algunas consideraciones / Gallbladder cancer: some considerations

In Chile, gallbladder cancer is the tumor with the highest mortality rates among women. Cholelithiasis is the most common associated factor and the reduction in cholecystectomy rates could be an important factor in the incidence of gallbladder cancer. Unfortunately, the disease is diagnosed late and the study of the surgical piece is the main form of early recognition. The degree of gallbladder wall infiltration by the tumor is the simplest and best staging method that has prognostic value. Gallbladder fat must be considered as a separate tissue, since its biological behavior differs from that of the subserosa. The treatment of these tumors is based in their dissemination modality that is mainly local and regional. Surgical resection and radiotherapy are potentially effective. However the detection of high risk patients that should be subjected to cholecystectomy should be the better therapeutic alternative

Análisis de factores pronósticos en el cáncer de la vesícula biliar con infiltración de la subserosa / Prognostic factor analysis in gallblader cancer with subserosal infiltration

La incidencia del cáncer de la vesícula biliar (CVB) en el país está en aumento y es la mayor del mundo. El diagnóstico preoperatorio es tardío y de mal pronóstico. El diagnóstico precoz se basa en el hallazgo histológico de una lesión tumoral pequeña. El nivel de invasión de la pared es el principal factor pronóstico, el cual determina la terapia. El objetivo de este trabajo es evaluar los factores pronósticos en el CVB con infiltración hasta la subserosa (CVBSS). Se estudiaron 60 pacientes portadores de CVBSS, mediante protocolo prospectivo desde enero de 1987 hasta junio de 1995. Conforme al protocolo se efectuó laparotomía exploradora, realizando resección en cuña del lecho vesicular y linfadenectomía del pedículo hepático. 35 pacientes fueron sometidos a cirugía, siendo rechazada por 25. La población global presentó una sobrevida a 60 meses de 27 por ciento. La sobrevida según sexo, edad y compromiso de linfonodos no presentó diferencia ES. Según histología, la sobrevida fue superior para el tipo bien diferenciado en relación al moderado y al mal diferenciado; sin embargo, no alcanzó diferencia ES (p= 0,08). La sobrevida según macroscopia fue inferior para el tipo inaparente en relación a los solevantados (18 por ciento versus 42 por ciento a 60 meses, p= 0,04). El grupo sometido a cirugía presentó una sobrevida mayor (33 por ciento versus 20 por ciento a 60 meses), sin embargo, no alcanzó diferencia ES (p= 0,18)

Consideraciones sobre el manejo de los cánceres más frecuentes en Chile / Considerations about the management of the more frequent cancers in Chile

Debido a la importancia que la patología oncológica ha cobrado en nuestro país, se hace necesario el análisis de la forma más racional en que debemos manejar estos pacientes. De los tumores más comunes en Chile destacan el de vesícula biliar, de mama, colorrectal, bronquial y gástrico. Cada uno de ellos posee diferente pronóstico y significación dentro de la población chilena. El costo del manejo de pacientes oncológicos ha presentado un aumento progresivo derivado en gran parte de la gran variedad de recursos tecnológicos y nuevas modalidades terapéuticas existentes. Desafortunadamente, no siempre el empleo masivo de dicha tecnología ha derivado en una mejoría de la pesquisa precoz, sobrevida o calidad de vida. Considerando lo anterior se hace necesario el análisis objetivo del manejo de cada uno de los anteriores tumores bajo el concepto de costo efectividad. Este tipo de análisis debería traducirse en la aplicación de pautas de manejo basadas de la evaluación científica de datos, lo que significará no sólo optimizar el gasto en el manejo de estos pacientes, sino también en los resultados en cuanto a sobrevida, asociados a una mayor satisfacción del paciente y calidad de vida

Formas de invasión tumoral en el cáncer de la vesícula biliar: importancia del diagnóstico de la infiltración tumoral vascular sanguínea / Diagnosis of vascular invasion using victoria blue stain in gallbladder carcinoma

Background: The infiltration of venous blood vessels in gallbladder carcinoma and its importance as a Prognostic factor has not been well studied. Victoria blue stain has been used to identify vascular involvement in gastric and thyroidal carcinomas. Aim: To assess blood vessel infiltration using Victoria blue stain in gallbladder carcinomas. Material and methods: One hundred forty eight samples of gallbladder carcinoma, coming from 24 men and 123 women aged 60.4ñ12.2 years old, were studied. They were stained with Victoria blue stain to quantify blood vessel invasion. Results: Twenty nine percent of tumors had blood vessel infiltration, 61 percent had lymph vessel and 20 percent had perineural infiltration. Lymph vessel or perineural involvement was found in 81por ciento and 31 percent of those tumors with blood vessel infiltration, respectively. Perineural infiltration was associated with lymph or vascular involment in 93 and 40 percent of tumors, respectively. None of the early carcinomas had blood vessel infiltration, whereas 33 percent of advanced tumors had this type of infiltration (p< 0.001). No differences in vascular infiltration were observed according to the differentiation of the tumor Conclusions: Blood vessel infiltration was observed only in advanced gallbladder carcinomas and was tightly related to the degree of gallbladder wall infiltration. The presence of perineural infiltration was the best ma rker of 1ymph or blood vessel infiltration

Avances en el diagnóstico y tratamiento del cáncer de páncreas / Advances in the diagnosis and treatment of pancreatic carcinoma

Pancreatic carcinoma has a dismal prognosis. In the last years, great efforts have been made to improve diagnosis and preoperative staging of potentially curable carcinomas. Actually, the diagnosis of fairly small tumours is possible. Chemoradiation therapy protocols prior to pancreatectomy, aiming to improve survival, are currently being held. This therapy allows radiation to be distributed into well oxygenated cells before surgical devascularization. This procedure can be done with acceptable morbidity and mortality rates. In selected cases of irresectable carcinoma, surgical palliation allows a better quality of life. Pancreatoduodenal resection, along with other traditional oncological therapies, will continue to be the therapy of choice for patients with carcinoma of the head of the pancreas, without local or regional metastases. However, an intensive search for new therapeutic strategies, specially in the field of molecular biology, is being carried out

Carcinoma hepatocelular: aspectos clínicos, terapéuticos y pronósticos / Hepatocellular carcinoma: clinical, therapeutical and prognostic aspects

Alrededor del 90 por ciento de los carcinomas hepatocelulares se desarrollan sobre una cirrosis hepática, siendo más frecuente en hombres que en mujeres. El 20 por ciento son asintomáticas y el 65 por ciento de los casos consulta por descompensación de la hepatopatia. Nuestro centro aplica al tumor la clasificación de Okuda y cols, la de Child-Upgh para la capacidad funcional del hígado y el perfomance status para valorar las condiciones generales del paciente. En el estudio de esta patología se utilizan el laboratorio general midiendo pruebas hepáticas, albuminemia, marcadores tumoreales, receptores hormonales, alteraciones genéticas y estudio por imágenes como ecotomografía, cintigrafía, tomografía axial computarizada y angiografia selectiva. Existen alternativas de tratamiento médicas y quirúrgicas. Entre las terapias médicas se han planteado el alcohol etílico intratumoral, la mebolización arterial, la radioterapia instersticial y la se han planteado el alcohol etilico intratumoral, la embolización arterial, la radioterapia intersticial y la quimioterapia. Las alternativas quirúrgicas son las resecciones hepáticas como resección local, segmentectomía, lobectomía y los trasplantes hepáticos. La mortalidad operatoria es cercana al 24 por ciento y la sobrevida es muy variable dependiendo del diámetro tumoral, presencia de satelitosis, plioidía del tumor, histopatología y tipo de resección

Análisis de pHmetría intraesofágica en 40 pacientes con reflujo gastroesofágico / Intraesophagic Ph analysis in 40 patients with gastroesophagic reflux

Se analizan los cambios del pH intraesofágico mediante pHmetría ambulatoria de 24 horas en 40 sujetos con RGE, demostrado radiológica o endoscópicamente (evidencias de esofagitis de diversa cuantía). Se trata de 15 hombres y 25 mujeres con una media etaria de 46,7 años (mínima 14 y máxima 69 años). Con el paciente en ayunas y previa manometría esofágica, se introdujo vía nasal el electrodo de pH y se situó su extremo distal 5 cm por encima del borde superior del EEI. El electrodo de referencia se colocó en la cara anterior del tórax. El análisis del estudio fue efectuado mediante el sistema matemático de valoración propuesto por De Meester. El estudio se realizó con un pHmetro modelo Digitrapper Mark II Gold. El estudio permitió constatar un número total de reflujos de 118ñ34 min; el tiempo total de pH inferior a 4 fue de 110ñ151 minutos; el porcentaje total de tiempo de reflujo fue de 7,7ñ10,5 por ciento y el score final de 29,2ñ32,2 puntos. De los síntomas referidos por los pacientes durante el estudio en relación a episodios de reflujo el que logró mayor significancia fue pirosis

Pancreatoduodenectomía tardía más reconstrucción esofágica y manejo por etapas de trauma pancreatoduodenal grave por cáusticos / Later pancreatoduodenectomy, esophageal reconstruction and management of severe pancreatic-duodenal injuries due to caustic intake

Se presenta un caso clínico de una paciente que con fines suicidas ingiere 200 cc de ácido sulfúrico. Durante 464 días, tiempo durante el cual fue tratada, presenta diversas complicaciones gastrointestinales, pulmonares, metabólicas y sistémicas, motivo por el cual fue sometida a diversos tratamientos médico-quirúrgicos. Fue dada de alta en forma definitiva en julio de 1998

Cáncer de la vesícula biliar: expresión inmunohistoquímica de la proteína relacionada con receptor estrogénico (p29) y de la proteína inducida por estrógeno (pS2) / Cáncer of gallbladder: immunohistochemical expression of estrogen receptor related protein (p29) and estrogen induced protein (pS2)

The high frequency of gallblader cancer in women suggest a role for estrogens in its development. The aim of this study was to study the immunohistochemical expression in of p29 estrogen receptor associated protein and pS2 estrogen induced protein in 111 pathological samples of gallbladder carcinoma, coming from 88 women and 23 men, 30 metastases of gallbladder cancer, coming from 25 women and 5 men and in 25 non-tumoral gallbladders. In the latter, p29 protein was positive in 12 samples (48 percent) and pS2 in 15 cases (60 percent). p29 was positive in 40 percent and pS2 in 32 percent of tumors. p29 expressed with higher frequency in metastases than in primary tumors (57 and 31 percent respectively, p<0.02). Early tumors had a significantly lower expression of p29 than advanced tumors or than metastases. Both proteins expressed in 18 percent of samples (synchronic expression) whereas one of both proteins did so in 60 percent of cases (asynchronic expression). We conclude that most gallbladder cancer samples express proteins associated to estrogen receptor or induced by estrogens

Carcinoma hepatocelular: aspectos generales del diagnóstico y tratamiento / Hepatocellular carcinoma: general aspects of diagnosis and treatment

Hepatocellular carcinoma is the most frequent form of primary hepatic cancer and has a high dissemination capacity. About 90 percent of tumors develop over a pre-existing cirrhosis but they also may occur in a normal liver. It has a higher frequency among males and 80 percent of tumors have clinical manifestations. It is associated to hepatitis B and C virus infection, alcoholism, cirrhosis of any etiology, consumption of aflatoxin B1, oriental race and familial history. Patients are staged using classification proposed by Okuda, Child-Pugh snf the performance status test. Alpha feto protein is useful for diagnosis and follow-up. Abdominal ultrasound, hepatic scintiscan, angiography with lipiodol, CAT scan and nuclear magnetic resonance have a high diagnostic yield. Non surgical therapeutic alternatives include intratumoral alcoholization, chemoembolization and other such as tomoxifen and monoclonal antibodies. Surgical treatment is based on hepatic resection, whose magnitude depends on hepatic function. Hepatic transplantation is a new therapeutic alternative for aptients in whom resection is not feasible and have a single small tumor without metastases

Páncreas divisium como causa de pancreatitis crónica: caso clínico / Pancreas divisium as cause of chronic pancreatitis: clinical case

We report a 6 years old girl with pancreatitis, presenting as recurring bouts of abdominal pain and hyperamylasemia, secondary to a lack of communication between the main papilla and pancreatic duct (pancreas divisium). The diagnosis was made during an intraoperative pancreatography and treatment consisted in a sphincteroplasty of the secondary papilla