99mTc-MIBI scintimammography as a complement of the mammography in patients with suspected breast cancer. A multicentre experience.

The aim of this work has been to evaluate the clinical usefulness of 99mTc-MIBI scintimammography, used as a complement to mammography, in the study of patients with suspected breast cancer. We performed prone breast scintigraphy in 253 patients (268 lesions) with suspected breast cancer. The size and degree of the suspected breast cancer was evaluated by mammography. Diagnosis was established by biopsy. Malignancy was diagnosed in 155 lesions and benign diseases in 113. The results of the scintimammography were a sensitivity of 91%, a specificity of 71%, PPV=81% and NPV=85%. In lesions smaller than 1 cm, sensitivity and specificity were 57% and 100%; in lesions with a diameter of between 1 and 2 cm, these figures were 90% and 72% respectively, and in lesions of more than 2 cm the sensitivity was 99% and the specificity 50%. On mammography, 155 lesions were considered as having a high suspicion of malignancy, whilst 72 were indeterminate and 41 had a low probability. In lesions with a low or indeterminate suspicion of malignancy on mammography, the sensitivity and NPV of the scintimammography were 97% and 98%. Scintimammography is a useful technique in the study of lesions where breast cancer is suspected. Scintimammography results are closely related to tumour size and the degree of mammographic suspicion. Scintimammography can be useful where mammography identifies lesions with a low or indeterminate suspicion of malignancy.

[A Spanish multicenter scintigraphic study of the breast using Tc 99m MIBI. Report of results]. / Estudio multicéntrico español gammagrafía de mama con MIBI-99mTc. Presentación de resultados.

UNLABELLED: The aim of this work has been to study, with a homogenous method, a wide sample of patients with breast cancer suspicion, in order to evaluate the real clinical usefulness of the scintimammography with MIBI-99mTc. METHODS AND MATERIAL: We have studied by way of prone scintimammography 388 patients (418 lesions) with breast cancer suspicion. In the mammography the size and degree of breast cancer suspicion was evaluated. Diagnosis was established by biopsy. RESULTS: 247 lesions were diagnosed as breast cancer and 171 as benign diseases. She results of the scintimammography were sensitivity 90%, specificity 70%, PPV 81% and NPV 83%. In palpable lesions sensitivity and specificity were 94% and 61%, and in non-palpable lesions 75% and 81% respectively. In 264 lesions mammographic breast cancer suspicion was establish. 13 of the 14 FN results were obtained in lesions with a high malignancy suspicion. In lesions with a low or indeterminate suspicion, sensitivity and NPV of the scintimammography were 97% and 98%. CONCLUSIONS: Scintimammography has a high sensitivity but a relatively low specificity in the study of lesions with breast cancer suspicion. Scintimammography could be a good complement of the mammography in lesions with a low or indeterminate suspicion of malignancy.

[Pain and jaundice secondary to hemobilia resolved by ERCP and endoscopic sphincterectomy]. / Dolor e ictericia secundario a hemobilia resuelto mediante CPRE y esfinterectomía endoscópica.

We report the case of a patient with hemobilia resulting from a liver biopsy where the performance of the endoscopic sphincterectomy solved the jaundice and the pain of the patient. ERCP has been used previously in the diagnosis of biliary and pancreatic tumors that manifested themselves as an hemobilia. The therapeutic utilization of endoscopic sphincterotomy had been described rarely in this type of bleedings. We recommend endoscopic retrograde cholangiopancreatography and sphincterotomy in the cases of hemobilia with severe abdominal pain resulting from the accumulation of clots inside the biliary tract.

[The endoscopic Nd-YAG laser treatment of the "watermelon stomach"]. / Tratamiento endoscópico con láser Nd-YAG del "estómago en sandía".

The watermelon stomach is a vascular malformation at the gastric antrum which is responsible for chronic bleeding. We report here nine patients (5 females and 4 males) referred to our Department from December 1990 to May 1995 with ferropenic anemia resulting from chronic gastrointestinal bleeding and with the diagnosis of watermelon stomach. The mean age at presentation was 52 years (range, 29-80). Seven patients required periodic blood transfusions and the remaining patients therapy with iron compound. All patients were treated with photocoagulation of antral lesions with Nd-YAG laser applied endoscopically. In all patients an almost complete disappearance of endoscopic lesions was achieved and during the 19-month follow-up period (range, 2-54) no patient required blood transfusions or iron therapy. No secondary complications from therapy were noted.

[Adult patients with clinically suspected or known biliopancreatic pathology in whom ERCP is not indicated: the 10 most frequent situations]. / Pacientes adultos con sospecha clínica o patología biliopancreática conocida en los que la CPRE no está indicada: las 10 situaciones más frecuentes.

Endoscopic retrograde cholangiopancreatography is an invasive endoscopic technique widely used in the diagnosis and eventual therapeutic procedures of many biliopancreatic conditions. While endoscopic retrograde cholangiopancreatography indications are well known, it is not the same in those patients with clinically suspected or known biliopancreatic entities in whom endoscopic retrograde cholangio-pancreatography is not indicated because it will not add valuable information with the potential of changing the previous diagnosis or therapy. Ten very common clinical situations in which this technique is not indicated are presented; among them idiopathic abdominal pain, some pancreatic carcinomas, chronic pancreatitis and pancreatic pseudocyst, and some patients awaiting conventional or laparoscopic cholecystectomy. We acknowledge that some aspects of this paper are controversial.

[The palliative treatment of esophageal tumors with the laser (Nd-YAG). The results of an initial experience]. / Tratamiento paliativo de tumores de esófago con láser (Nd-YAG). Resultados de experiencia inicial.

Palliative treatment of esophagus tumors leads to a remarkable improvement of dysphagia allowing oral feeding, prolonging the survival period and improving patient's quality of life. We have treated 30 patients with such tumors, who had previously been discarded for surgical therapy, with Nd-YAG laser through endoscopy. The procedure could be ended, so the dysphagia improved remarkably, in 23 patients (77.7%). Survival mean length was 7,3 months (range: 2,5-22 months) in eleven patients who already died when this study was finished, and 6,5 months (range: 2,5-10 months) in the remaining 12 patients. Five patients required the implant of a esophageal prosthesis as result of a proneness of the tumor to produce stenosis again. Follow-up visits were done regularly every 1 to 1.5 months. In summary best results were obtained on medial and distal thirds of the esophagus, where dilatation previous to laser therapy is easier, obtaining an important improvement of dysphagia. If the tumor has a localization in the upper part of the esophagus or if it has its origin in the stomach and later on it invades cardias, both cases pose more difficulties to the treatment with laser, which determines the results, so another alternative technique to feed the patient may be used.

[False pancreatic pseudocyst during endoscopic retrograde cholangiopancreatography (ERCP) in a gastrectomized patient]. / Falso pseudoquiste pancreático durante la colangiopancreatografía retrógrada endoscópica (CPRE) en un paciente gastrectomizado.

Endoscopic retrograde cholangiopancreatography (ERCP) is a very useful procedure for the diagnosis of biliopancreatic disorders. As a mixed endoscopic and radiologic procedure, its diagnostic yield depends heavily on the quality and skillful interpretation of radiological images. Diagnostic pitfalls must be kept in mind and avoided. We report on the case of a gastrectomized patient (Billroth II), in whom the observation during ERCP of two contrast-filled cavities, suggested the diagnosis of pancreatic pseudocysts. Other imaging procedures fully ruled out this diagnosis. The cause of this diagnostic pitfall was the accumulation of contrast in the blind end of the afferent loop. Additionally, we comment on other false cystic images in the ERCP.

[Treatment of colonic cancer with laser (Nd-YAG). Our initial experience]. / Tratamiento del cáncer de colon con láser (Nd-YAG). Nuestra experiencia inicial.

Laser-therapy represents an acceptable alternative in the palliative treatment of colon cancer. We have treated 25 patients with this pathology, 10 with obstructive tumor, which impeded the insertion of the endoscope, and 15 non-obstructive tumors. Higher technical difficulties on the former, together with a worse clinical situation, due to the fact that the tumor was more invasive, produce a more discrete result and with a higher risk of complications (one patient had a perforation and other an obstructive stenosis after two months of treatment) in comparison with the group of patients with non-obstructive tumors. However the treatment improved their quality of life with the recovery of their intestinal function. Among patients with non-obstructive tumors of the colonic light, prolonged survival (mean 6.8 months) was reached by 73.3% of patients belonging to this group; disappearing after treatment even the endoscopic view of the tumor in 33.3% of the patients.

A single technique for polypropylene mesh hernioplasty of inguinal and femoral hernias.

The main factor in the repair of groin hernias is the reinforcement of posterior wall defects of the inguinal canal, including the femoral ring, because the normal insertion of the transversalis fascia and transversus abdominis muscle is on Cooper's ligament and not Poupart's ligament. In approximately one-half of primary femoral hernia repairs in men, a coincidental ipsilateral inguinal hernia existed. Recurrence after inguinal herniorrhaphy is usually femoral. Forty-three patients with direct, large indirect or femoral hernias (primary or recurrent) had a Marlex mesh hernioplasty to treat the inguinal and femoral region simultaneously.

[Endoscopic retrograde cholangiopancreatography in Mirizzi's syndrome]. / La colangiopancreatografía retrógrada endoscópica en el síndrome de Mirizzi.

Mirizzi's syndrome is characterized by compression and or stenosis of the common duct as a consequence of impaction of a stone in the gallbladder neck, the cystic duct and eventually by a cholecystobiliary fistula. Preoperative diagnosis is important to avoid iatrogenic injury of the biliary tree. We present two cases with Mirizzi's syndrome confirmed at operation in whom ERCP was done prior to the operation. In one of them the examination was diagnostic, while in the other, cystic duct compression and absence of the gallbladder image were the non-specific findings.

[Long-term results of endoscopic sphincterotomy in the treatment of residual/recurrent choledocholithiasis]. / Resultados a largo plazo de la esfinterotomía endoscópica en el tratamiento de la coledocolitiasis residual/recidivante.

Endoscopic sphincterotomy is widely accepted as the technique of choice in the treatment of residual or recidivant choledocholithiasis since the results obtained with this technique are favorable when compared to biliary surgery in most series. However, the experience of long term follow up of patients with choledocholithiasis in whom this technique would have been applied as the only treatment is still scarce up to date. We have studied 40 patients (mean age 65.6 +/- 11.1 years) with residual or recidivant choledocholithiasis who had undergone endoscopic treatment successfully before the 30th of June 1985, who could be contacted by a mailed questionnaire or by phone by August 1990. The follow up time 70.7 +/- 19.4 months (mean +/- typical deviation). Out of them, 36 (90%) had been asymptomatic up to the contact date (30 cases) or up to death due to causes not related to biliary pathology (6 patients). Out of the 4 remaining patients, 2 presented mild dyspepsia and another patient has probably developed recidivant choledocholithiasis (according to I.V. cholangiography). The fourth patient presented a severe episode of cholangitis and acute pancreatitis, related to a new episode of choledocholithiasis and died 5 and a half years after the endoscopic sphincterectomy. This represents a 2.5% mortality. These long term results of endoscopic sphincterotomy in patients with residual or recidivant choledocholithiasis are an other point in favour of using this technique as the single treatment of choice in patients above 60 years old.

[Treatment of residual choledochal calculi in patients with Kehr's T drainage: role and results of endoscopic sphincterotomy]. / Tratamiento de los cálculos coledocianos residuales en pacientes portadores de drenaje en T de Kehr: papel y resultados de la esfinterotomía endoscópica.

The results of sphincterotomy in the treatment of residual gallstones after cholecystectomy in a series of 62 patients, bearers of a T tube are reported. The mean time after surgery was 26.4 +/- 19.2 days. The procedure was technically successful in 59/62 (95.1%). Stones were passed spontaneously or were retrieved in 55/62 patients (88.7%). In four patients gallstones persisted in spite of sphincterotomy. All were operated with favorable results. Complications were observed in 4 patients (6.4%), without mortality. Sphincterotomy is a safe and relatively efficient technique in the treatment of cholecystectomized patients with residual gallstones and a T tube drainage.

[The value of endoscopic biopsy in the diagnosis of carcinoma of Vater's ampulla]. / Valor de la biopsia endoscópica en el diagnóstico del carcinoma de la ampolla de Vater.

In a series of 23 ampullary carcinomas, confirmed by the pathological examination of the duodenopancreatectomy specimens, 17 were biopsied during the previous ERCP examination. Biopsies were diagnostic of carcinoma in 12 (70.5%). Among 11 exophytic tumours biopsy was positive in 8 (72.7%) while in 6 tumours growing inside the papilla biopsies were positive in 4 (66.6%) (NS). It is concluded that endoscopic biopsy may be diagnostic in two-thirds of ampullary carcinomas.

[Mucinous cystadenocarcinoma of the pancreas presenting as acute distal duodenal obstruction]. / Obstrucción aguda de duodeno distal como forma de presentación de un cistadenocarcinoma mucinoso de cuerpo de páncreas.

A 75 year old patient underwent laparotomy for an acute obstruction of the third portion of the duodenum. Obstruction was due to a mucinous cystadenocarcinoma of the pancreas with metastases of the liver and regional lymphnodes. A gastrojejunostomy was performed. A review of the literature discloses only another example of this rare presentation.

[Is endoscopic retrograde cholangiopancreatography useful in the diagnosis of cholangiocarcinoma?]. / Es útil la colangiopancreatografía retrógrada endoscópica en el diagnóstico del colangiocarcinoma?

We have been interested in demonstrating the usefulness of the reverse endoscopic cholangiopancreatography, a technique already accepted in extrahepatic biliary pathology and the cholangiocarcinoma diagnosis. First of all we reviewed those cases diagnosed as cholangiocarcinoma using the REC and we found that only in 14 (60.9%) of a total of 23 cases the diagnosis was confirmed by surgery, resulting in a false positive ratio of 39.1%. In the second analysis of 22 patients who underwent surgery and whose surgical diagnosis was cholangiocarcinoma, we confirmed a correct presurgery diagnosis by REC in 14 (63.6%) with a false negative ratio of 36.3% which could be reduced to 26.3% after excluding the technically incorrect explorations or those in which only the pancreatic ductus was visualized. We conclude that cholangiocarcinoma diagnosis by REC has a high false positive or negative ratio, thus, treatment, specially non surgical, of a possibly malignant stenosis or obstruction of the bile duct can not only be based on choleangiopatic findings.