The use of 5-aminolevulinic acid fluorescence guidance in resection of pediatric brain tumors.

INTRODUCTION: Whereas in the adult population 5-Aminolevulinic acid (5-ALA) fluorescence guidance has been widely accepted for improving the extent of tumor resection, the application in children remains an off-label use. Even though most pediatric study protocols require a complete resection for improving outcome parameters, only few pediatric patients have been operated with fluorescence guidance, and it remains questionable, whether and which pediatric tumors show useful fluorescence. We present casuistic reports of application of 5-ALA in children collected from three different neurosurgical departments. PATIENTS AND METHODS: In children with suspected malignant intracerebral tumor or recurrence, individual informed consent was obtained in each case from the parents. 5-ALA was administered according to the adult protocol, with 20 mg/kg, 2 h before induction of anesthesia. We retrospectively analyzed 18 patients (13 male, 5 female; age 3-18 years), using the intraoperative neurosurgical protocol, the postoperative MRI results, and the follow-up clinical examinations. RESULTS: The use of 5-ALA fluorescence guidance proved to be safe in our group of pediatric patients. Fluorescence guidance was most useful for recurrent glioblastoma resection. Medulloblastoma tissue displayed fluorescence only inconsistently, and most pilocytic astrocytoma remained without staining. Ganglioglioma showed partial staining in the central tumor areas, without allowing the use for circumferent resection. CONCLUSION: The off-label use of 5-ALA fluorescence guidance in pediatric patients appears to be most useful in recurrent high-grade gliomas. Fluorescence accumulation in other pediatric brain tumor entities is not predictable and should be evaluated in future clinical studies before being integrated into the current treatment protocols.

[Giant sacral schwannoma with pelvic extension. Therapeutic strategy. Apropos of a case]. / Schwannome sacré géant avec extension pelvienne. Stratégie thérapeutique. A propos d'un cas.

A 48-year-old woman was admitted for acute urinary retention. Clinical pelvic examination disclosed a voluminous retro-rectal mass. Plain X-rays, pelvic echography, computerized tomography and MRI were all consistent demonstrating the presence of a 15cm-diameter lesion in the pelvic space with sacral erosion at S3-S4 and extension in the sacral canal up to S2. After a preoperative embolization, the tumor was removed in a two-stage procedure. First, an anterior transabdominal approach dissected the superior and lateral aspects of the tumor. To make easier the intra-abdominal dissection and to avoid any rectosigmoid necrosis, hysterectomy and rectosigmoid section with an end-colostomy were performed. Lastly, a piecemeal removal of the whole tumor was achieved using a posterior approach. At 6 months postoperatively, she recovered a satisfactory urinary control and the colo-rectal anastomosis was then successfully performed. Clinically only a slight hypesthesia of the left perineum was present. In the recent literature, 21 cases were described with similar clinical presentation and similar technical problems to achieve a complete treatment. In the discussion, details of the surgical anterior and posterior approaches are given. Before deciding the most appropriate surgical approach for such a mass, a biopsy is useful to determine whether total removal is relevant. A preoperative embolization can help to reduce the duration of the procedure and the loss of blood.

[Thoracic spondylotic myelopathies. Apropos of 4 new cases]. / Myélopathies dorsarthrosiques. A propos de 4 nouvelles observations.

Four cases of thoracic spondylotic myelopathy are reported, one man and three women, respectively 61, 66, 67 and 76 years old. Clinical presentation was numbness and weakness in the lower limbs in two cases, weakness alone in one and numbness alone in the last one. Diagnosis was settled by both myelography and CT-myelogram in three cases, by both MRI and CT-scan in the other one. The involved thoracic levels were both T9-T10 and T10-T11 for two cases and T11-T12 for the other one. The stenosis was due to hypertrophic ossification of the ligamentum flavum in three cases and to osteophytic changes in one. A laminectomy was performed for each patient and three patients had a significant recovery and the fourth a mild one. Thoracic myelopathy is an uncommon disease which requires a meticulous study of myelogram and now MRI to be recognized and to be cured by laminectomy. As for cervical myelopathy, it results from mechanical and ischemic factors which can lead to a definitive myelomalacia.

[Amebiasis. Has its clinical expression changed?]. / Amibiasis. Ha variado su expresión clínica?

In Mexico, like in other countries, there is an special interest for amebiasis because it represents a Public health problem; there are about 5 million people that in some time of their lives had tissue invasion by this parasite. 1-2% of mexicanas have intestinal amebiasis and probably there are 850,000 to 1,700,000 carriers of entamoeba cysts. 6% of the general population have circulating antiameba antibodies. In 1988 we studied the amebic hepatic abscess seen in the hospitals of the Instituto Mexicano del Seguro Social in the Valley of Mexico. During that year there were 396 patients with such illness (0.19% of hospital admissions) with a 1.01% mortality. Comparing this data with reports of 1969 there was a reduction in the number of patients and deaths. Also amebiasis has decreased in autopsy studies. However, we have not found recent variations in the clinical behavior of amebiasis. Advances in diagnostic methods and more liberal use of metronidazole have reduced the number of severely ill patients.

Lesion hepatica secundaria al uso de alfametildopa: informe de tres casos y revision de la literatura. / Secondary hepatic injury to the use of alphamethyldopa: report of 3 cases and literature review

En la literatura se tiene conocimiento de multiples casos de hepatopatia secundaria a la ingestion de alfametildopa, la lesion varia entre elevacion transitoria de aminotransferasas hasta hepatitis fulminante y muerte del enfermo. Al revisar la literatura al alcance se obtuvo informacion de 198 pacientes con esta complicacion. Se presentan los casos de tres pacientes con lesion hepatica en quienes la unica causa de la misma fue la ingestion de alfametildopa. Aun no se conoce exactamente cual es el mecanismo patogenico del farmaco, pero por la evolucion de los pacientes y la revision de la literatura se proponen los dos siguientes: 1. Alteraciones inmunologicas en el huesped. 2. Probable produccion de factores inmunogenos por la incorporacion del farmaco o sus metabolitos a la membrana celular del hepatocito

Sindrome de Zollinger y Ellison. / Zollinger and Ellison syndrome

El sindrome de Zollinger-Ellison es una enfermedad que en las personas que la padecen se manifiesta por presencia de ulcera peptica incurable, acompanada ademas, de hipersecrecion e hiperacidez gastrica.Es causada por la presencia de un tumor que se origina en el sistema neuroendocrino difuso, especificamente a partir de las celulas no beta de los islotes pancreaticos, que produce gastrina, hormona que normalmente se encuentra en el antro gastrico en una proporcion de casi 90 por ciento, y de la que hasta la fecha se han identificado cuatro componentes. La presente revision analiza algunos conceptos primordiales en relacion con la gastrina necesarios a nuestro juicio, para entender el problema. Enseguida aborda los aspectos clinicos, bioquimicos, radiograficos, histologicos y ultraestructurales indispensables para establecer el diagnostico preciso y por onde, el tratamiento adecuado

Cambios morfologicos en el higado del paciente sometido a nutricion parenteral. / Morphological changes in the liver of patient subjected to parenteral nutrition

La nutricion parenteral (N.P.) no es un procedimiento inocuo, cursa con complicaciones metabolicas, septicas y en la colocacion del cateter. El proposito de este trabajo fue de valorar las alteraciones funcionales y anatomicas que ocasiona este tratamiento en el higado. Se estudiaron 20 pacientes en forma prospectiva, a quienes se les instituyo N.P. con la tecnica habitual de nuestro servicio. Se les realizo pruebas de funcionamiento hepatico (P.F.H.), una vez por semana, biopsia hepatica al inicio y al finalizar el tratamiento. Las biopsias hepaticas fueron estudiadas en microscopia de luz, histoquimica y microscopia electronica. Las P.F.H.demonstraron elevacion moderada de T.G.O., T.G.P. y fosfatasa alcalina, posterior a la N.P. En microscopia de luz y pruebas de histoquimica se observaron: cambios em la distribucion del glucogeno, presencia de esteatosis, inversion de la red canalicular en la ATPasa. En microscopia electronica: Gran cantidad de figuras de mielina, dilatacion canalicular, esteatosis intracelular y mitocondrias normales. Las alteraciones hepaticas que se observaron: esteatosis, colestasis y vacuolacion nuclear son procesos reversibles, que en general no repercuten en la evolucion de los pacientes con nutricion parenteral