Challenges in modeling the Agility multileaf collimator in treatment planning systems and current needs for improvement.

BACKGROUND: The Agility multileaf collimator (MLC) mounted in Elekta linear accelerators features some unique design characteristics, such as large leaf thickness, eccentric curvature at the leaf tip, and defocused leaf sides ('tilting'). These characteristics offer several advantages but modeling them in treatment planning systems (TPSs) is challenging. PURPOSE: The goals of this study were to investigate the challenges faced when modeling the Agility in two commercial TPSs (Monaco and RayStation) and to explore how the implemented MLC models could be improved in the future. METHODS: Four linear accelerators equipped with the Agility, located at different centers, were used for the study. Three centers use the RayStation TPS and the other one uses Monaco. For comparison purposes, data from four Varian linear accelerators with the Millennium 120 MLC were also included. Average doses measured with asynchronous sweeping gap tests were used to characterize and compare the characteristics of the Millennium and the Agility MLCs and to assess the MLC model in the TPSs. The FOURL test included in the ExpressQA package, provided by Elekta, was also used to evaluate the tongue-and-groove with radiochromic films. Finally, raytracing was used to investigate the impact of the MLC geometry and to understand the results obtained for each MLC. RESULTS: The geometry of the Agility produces dosimetric effects associated with the rounded leaf end up to a distance 20 mm away from the leaf tip end measured at the isocenter plane. This affects the tongue-and-groove shadowing, which progressively increases along the distance to the tip end. The RayStation and Monaco TPSs did not account for this effect, which made trade-offs in the MLC parameters necessary and greatly varied the final MLC parameters used by different centers. Raytracing showed that these challenging leaf tip effects were directly related to the MLC geometry and that the characteristics mainly responsible for the large leaf tip effects of the Agility were its tilting design and its small source-to-collimator distance. CONCLUSIONS: The MLC models implemented in RayStation and Monaco could not accurately reproduce the leaf tip effects for the Agility. Therefore, trade-offs are needed and the optimal MLC parameters are dependent on the specific characteristics of treatment plans. Refining the MLC models for the Agility to better approximate the measured leaf tip and tongue-and-groove effects would extend the validity of the MLC model, reduce the variability in the MLC parameters used by the community, and facilitate the standardization of the MLC configuration process.

Chronic toxicity and long-term outcome in intraoperative electron radiotherapy as boost followed by whole-breast irradiation.

PURPOSE: The administration of a dose boost to the tumor bed after breast-conserving surgery has proven to reduce local recurrence. Intra-operative electron radiotherapy (IOERT) offers an alternative method to deliver a boost with several advantages, such as direct visualization of the tumor bed, less inter- and intrafraction motion and a reduction in the number of medical appointments. The objective of our study is to assess chronic toxicity and long-term outcome for our patients after IOERT boost. MATERIAL AND METHODS: Forty-six patients treated at our institution between July 2013 and June 2020 with IOERT boost during Breast-Conserving Surgery and consecutive whole breast irradiation were prospectively analyzed. A 10-12 Gy boost was prescribed to 42 patients and 4 patients received a 20 Gy boost. An analysis for overall survival, local relapse and distant progression was performed. Acute and chronic toxicity was assessed by CTCAE 4.0. RESULTS: The median age was 64.5 years (40-90). The median follow-up was 62 months (4-86). We had no local recurrences but 2 patients (4.3%) presented a distant recurrence. Mean pathological tumor size was 16 mm (6-52). 84.8% (39) of the patients had invasive ductal carcinoma. 52.2% (24) presented histological grade II. 52.2% (24) were Luminal A like, 21.7% (10) Luminal B like, 13% (6) HER2 positive, 13% (6) triple negative. No Grade 3-4 chronic toxicity was observed. Grade 1-2 fibrosis was evidenced in 13% (6) of the patients, 4.3% (2) patients presented fat necrosis, 6.5% (3) presented seroma, 4.3% (2) had localized pain, 2.2% (1) presented localized hematoma and 2.2% (1) presented localized edema. CONCLUSIONS: IOERT boost in breast cancer treatment during BCS is a safe option with low chronic toxicity. The recurrence rates are comparable to published data and emphasize that IOERT as boost is an effective treatment.

Does Enzymatic Debridement Allow Us To Perform Conservative Treatment On Clinically Deep Hand Burns? A Retrospective Review.

The hands are one of the main locations of burns. In deep second-degree and third-degree burns, the gold standard of treatment is surgical debridement and subsequent coverage, which can result in suboptimal aesthetic and functional results. The aim of our study is to assess whether treatment by initial enzymatic debridement (NexoBrid®) of deep second-degree and third-degree burns prevents the need for surgery. We carried out a retrospective study of 53 hands with deep burns treated in our centre from May 2015 to December 2016. Two experts evaluated the initial photographs of the burns and classified them as surgical or nonsurgical (interobserver kappa index = 0.83). These assessments were compared with the actual need for surgery on each hand. Sixteen of the 32 (50%) hands that the experts considered surgical spontaneously epithelialized. Four of the 17 hands (23.5%) that were not considered surgical required a split-thickness skin graft for healing. Enzymatic debridement helps to preserve viable tissue, which reduces the number and extension of surgical interventions, thus favouring better results.

Les mains sont une des principales localisations de brûlures. Dans les brûlures du 2e degré profond et du 3e degré, le traitement de référence est l'excision chirurgicale suivie d'un geste de couverture, et donne des résultats fonctionnels ou esthétiques pas toujours parfaits. Le but de notre étude est d'évaluer si le débridement enzymatique (NexoBrid®) des brûlures du 2e degré profond et du 3e degré permet d'éviter les gestes chirurgicaux. Nous avons mené une étude rétrospective sur 53 mains présentant des brûlures profondes traitées dans notre centre entre mai 2004 et décembre 2016. Deux experts ont évalué les photographies initiales et classé les brûlures en « chirurgicales ¼ ou « non chirurgicales ¼ (coefficient Kappa inter-opérateur = 0,83). Ces évaluations ont été comparées à la nécessité réelle de prise en charge chirurgicale pour chacune des mains. 16 des 32 mains (50%) que les experts avaient jugées « chirurgicales ¼ ont cicatrisé spontanément. 4 des 17 mains (23,5%) qui ont été considérée comme « non chirurgicales ¼ ont nécessité une greffe de peau mince pour obtenir la cicatrisation. Le débridement enzymatique permet de conserver les tissus viables, ce qui diminue le nombre et l'importance des gestes chirurgicaux, et donc favorise l'obtention de meilleurs résultats.

Surgical treatment of pulmonary aspergilloma in pediatric patients: report of 3 cases. / Tratamiento quirúrgico del aspergiloma pulmonar en pacientes pediátricos. A propósito de tres casos.

OBJECTIVE: To describe our experience in the surgical management of pulmonary aspergilloma (PA) and review surgery's role in PA treatment in pediatric patients. MATERIAL AND METHODS: A descriptive study of patients diagnosed with PA undergoing surgical resection from 2017 to 2019 was carried out. A review of pediatric studies mentioning "aspergilloma", "surgical", and "treatment" was performed. RESULTS: During the study period, 3 patients with single PA aged 18 months old, 3 years old, and 13 years old underwent surgery. All of them had leukemia and little or no response to aspergilloma medical treatment. In all patients, the procedure was initiated using the thoracoscopic route, but conversion into thoracotomy was required in two cases. In all three cases, pulmonary segmentectomy was carried out with complete PA removal, without severe intraoperative or postoperative complications. No pulmonary recurrence was observed after 30-, 34-, and 16-month follow-up, respectively. CONCLUSIONS: PA surgical resection is a feasible alternative in pediatric patients with a poor antifungal treatment response or related complications.

OBJETIVOS: El objetivo de este trabajo es describir la experiencia de nuestro centro en el manejo quirúrgico del aspergiloma pulmonar (AP) y la realización de una revisión sobre el papel de la cirugía en el tratamiento del AP en el niño. MATERIAL Y METODOS: Estudio descriptivo de los pacientes diagnosticados e intervenidos mediante resección del AP desde el 2017 hasta el 2019. Se realizó una revisión con los términos "aspergilloma", "surgical", "treatment", descartando los estudios no referidos a pacientes pediátricos. RESULTADOS: Durante el periodo de estudio se intervinieron 3 pacientes con AP único, de 18 meses, 3 y 13 años de edad respectivamente, los 3 afectos de leucemia y con poca o nula respuesta al tratamiento médico habitual del aspergiloma. En todos los pacientes se inició la intervención por vía toracoscópica, siendo necesaria la conversión a toracotomía en 2 casos. En los tres casos se realizó segmentectomía pulmonar con exéresis completa del AP, sin complicaciones intraoperatorias ni postoperatorias graves. No se observaron recidivas pulmonares tras un seguimiento de 30, 34 y 16 meses respectivamente. CONCLUSIONES: La resección quirúrgica del AP, se presenta como una alternativa factible en pacientes pediátricos con pobre respuesta a tratamiento antifúngico o con complicaciones derivadas de este.

Ovarian transposition as a minimally invasive fertility preservation technique: ten years of experience in a pediatric center. / La transposición ovárica como técnica de preservación de la fertilidad en edad pediátrica: 10 años de experiencia en un centro de tercer nivel.

INTRODUCTION: Ovarian transposition is a surgical procedure allowing gonadal mobilization from a radiation spotlight to a safer, radiation therapy-free place in patients receiving abdominal or pelvic radiation therapy. And these patients can be managed using minimally invasive surgery. Although some authors have reported good results in fertility preservation with this technique, there are no long-term studies in the pediatric population. We present our results with this procedure in our oncological patients from the last decade. MATERIAL AND METHODS: Retrospective review of medical reports of patients who underwent laparoscopic ovarian transposition in our pediatric oncological surgery unit from 2008 to 2018. The technique varied depending on age, irradiation zone, and concomitant oncological resections. RESULTS: A total of 21 ovarian transpositions were successfully performed in 13 patients. Eight were bilateral, four were left and only one was right. An ovarian cortex cryopreservation was simultaneously carried out in all patients. Eleven procedures were completed laparoscopically, and the suspensory ovarian ligament was divided in sixteen cases. The Fallopian tube was divided in one case, and a simple ovarian transposition was conducted in five cases. Mean hospital stay was 2.4 days, and no complications in the immediate postoperative period were noted. CONCLUSION: Ovarian transposition is a feasible, safe technique. These patients require an extended follow-up to assess ovarian function after oncological treatment.

INTRODUCCION: La transposición ovárica es una técnica quirúrgica que permite alejar los ovarios de la zona de irradiación en pacientes que van a recibir radioterapia abdominal o pélvica. Se han descrito buenas tasas de conservación de función. Sin embargo, no existen estudios en pacientes pediátricos. Presentamos nuestra serie de pacientes intervenidas en nuestro centro. MATERIAL Y METODOS: Estudio retrospectivo de pacientes a las que se le realizó transposición ovárica en nuestra unidad de cirugía oncológica pediátrica entre los años 2008 y 2018. La técnica empleada dependió de la edad, la zona de la irradiación y de la asociación o no con la cirugía del tumor primario. RESULTADOS: Durante el periodo de estudio se realizaron un total de 21 transposiciones ováricas en 13 pacientes (8 bilaterales, 4 izquierdas y 1 derecha). En todos los casos se realizó criopreservación de corteza ovárica dentro del programa de preservación de fertilidad. Once de las 13 intervenciones fueron por laparoscopia, seccionándose el ligamento tubo-ovárico en 16 unidades y en 5 se realizó transposición ovárica simple. La estancia hospitalaria media fue de 2,4 días sin registrarse ninguna complicación en el postoperatorio. Actualmente 9 pacientes continúan seguimiento en sus unidades de oncología pediátrica de referencia, sin haberse notificado ninguna complicación. CONCLUSION: La transposición ovárica es una técnica segura y reproducible. Estas pacientes requieren un seguimiento prolongado para conocer el estado de los ovarios tras el tratamiento oncológico.

[Minimally invasive surgery of neural tumors in childhood]. / Cirugía mínimamente invasiva en tumores de estirpe neural en la infancia.

PURPOUSE: The aim of the paper is to describe the experience in our center with the use of minimally invasive surgery (MIS) of neural tumors in childhood. METHODS: Descriptive and retrospective study of patients diagnosed with neural neoplasia (neuroblastoma and neuroganglioma) on whom MIS technique surgery has been performed between October 2012 and December 2017. The inclusion criteria were patients with a neural tumor diagnosis who, at the time of the intervention, did not have imaging-defined risk factors (IDRFs). Patients with a different diagnosis than neural tumor or with IDRFs were excluded from the study. RESULTS: The study comprises 19 cases (6 female and 13 male) with a median age of 47 months. According to the International Neuroblastoma Risk Group Staging System (INRGSS) classification, nine cases were in L1 stage, six in L2, two in M and two in MS. Laparoscopy was used in 14 patients (12 adrenal and 2 abdominal tumors) and thoracoscopy was used in the other 5. In 4 of the 19 cases (21%), conversion to open surgery was needed due to fibrosis in 2 cases and vascular structures entrapment in another 2 (3 in laparoscopy and 1 in thoracoscopy). There were no surgical complications, achieving complete resection in all cases. Three cases showed postsurgical adverse effects grade I and II, according to Clavien-Dindo classification. After a median of 27 months of follow up, two patients showed disease progression without local recurrence. CONCLUSIONS: In conclusion, MIS are useful techniques in the surgical exeresis of non-disseminated neural tumors without IDRFs.

OBJETIVOS: El objetivo de este trabajo es describir la experiencia de nuestro centro en el tratamiento de tumores de estirpe neural mediante técnicas de Cirugía Mínimamente Invasiva (CMI). MATERIAL Y METODOS: Estudio retrospectivo y descriptivo de pacientes intervenidos en nuestro hospital mediante técnicas de CMI y diagnóstico de tumor de estirpe neural, entre octubre de 2012 y diciembre de 2017. Los criterios de inclusión fueron pacientes con diagnóstico de tumor neural que en el momento de la intervención no presentaban factores de riesgo por imagen (IDRFs). Se excluyeron aquellos pacientes con diagnóstico distinto al de tumor neural y con IDRFs en el momento de la cirugía. RESULTADOS: Se incluyen 19 casos (6 niñas y 13 niños) con una mediana de edad de 47 meses. Según la clasificación International Neuroblastoma Risk Group Staging System (INRGSS) fueron diagnosticados 9 casos en estadio L1, 6 en estadio L2, 2 en M y 2 en estadio MS. Por laparoscopia se intervinieron 14 pacientes (12 tumores suprarrenales y 2 abdominales extradrenales) y 5 por toracoscopia. No existieron complicaciones intraoperatorias, consiguiéndose la exéresis completa en todos los casos. Tres casos presentaron efectos adversos postoperatorios, de grados I y II según la clasificación de Clavien-Dindo. En 4 de 19 pacientes fue necesaria la conversión a cirugía abierta (3 por laparoscopia y 1 por toracoscopia) debido a adherencias a estructuras vasculares o fibrosis. Tras una mediana de seguimiento de 27 meses, 2 pacientes presentaron progresión de su enfermedad sin recidiva local. CONCLUSIONES: En conclusión, la CMI es una herramienta útil para la exéresis de tumores de estirpe neural sin IDRFs.

ADVANCED SURVEILLANCE OF ENVIROMENTAL RADIATION IN AUTOMATIC NETWORKS.

The objective of this study is the verification of the operation of a radiation monitoring network conformed by several sensors. The malfunction of a surveillance network has security and economic consequences, which derive from its maintenance and could be avoided with an early detection. The proposed method is based on a kind of multivariate distance, and the verification for the methodology has been tested at CIEMAT's local radiological early warning network.

[Prophylactic thyroidectomy in RET proto-oncogen mutation]. / Tiroidectomía profiláctica en mutación del protooncogén RET.

OBJECTIVE: Analysis of prophylactic thyroidectomy cases carried out in our Center in patients with RET gene mutations. MATERIAL AND METHODS: Retrospective study of 25 patients with RET proto-oncogene mutations subjected to prophylactic thyroidectomy between January 2000 and January 2016. Epidemiologic variables, surgical technique, histological results and follow-up were studied. RESULTS: Our sample consists of 25 patients, 15 males and 10 females. The range of age was from 7 months to 12 years old, with a median of 5 years old. We obtained 21 cases with NEM2A, from which 19 (76%) presented 634 mutation and 2 (8%) presented 611 mutation. Four cases were NEM2B, all with 918 mutation. Microscopical findings showed microcarcinoma, in situ carcinoma or medullary thyroid carcinoma in 16 patients (64%). Eight of them showed hyperplasia (32%) and 1 presented fibrosis (4%). The presence of elevated calcitonin was correlated with histologic alterations in 7 cases (43.7%), without significant differences (χ2 0.3; p 0.6). From 16 patients with carcinoma (13 NEM2A and 3 NEM2B), 10 were 5 years old or less at the moment of the surgery. A total thyroidectomy was performed in all patients. There were no intra or post-surgical complications. During the follow-up of the patients, levels of calcitonin, calcium, parathormone, catecholamines and metanephrines were normal, except from one case. CONCLUSIONS: The study of RET proto-oncogene allows the identification of patients susceptible of performing a prophylactic thyroidectomy, which have to be carried out early, in an experienced centers.

OBJETIVO: Analizar los casos de tiroidectomía profiláctica realizados en nuestro centro en pacientes con mutaciones del gen RET. MATERIAL Y METODOS: Estudio retrospectivo de 25 pacientes con mutación del protooncogén RET a los que se les realizó tiroidectomía profiláctica entre enero del 2000 y enero de 2016. Se estudiaron variables epidemiológicas, técnica quirúrgica, resultados anatomopatológicos y seguimiento. RESULTADOS: Nuestra serie consta de 25 pacientes, 15 varones y 10 mujeres. La mediana de la edad fue de 5 años con un rango de 7 meses a 12 años. Obtuvimos 21 casos con MEN2A de los que 19 (76%) presentaban la mutación 634 y 2 (8%) la mutación 611. Cuatro casos fueron MEN2B, todos con la mutación 918. Los hallazgos microscópicos revelaron microcarcimona, carcinoma in situ o carcinoma medular de tiroides en 16 casos (64%). 8 presentaron hiperplasia (32%) y 1 (4%) fibrosis. La presencia de calcitonina elevada se correlacionó con alteraciones anatomopatológicas en 7 casos (43,7%), pero no mostró diferencias significativas (χ² 0,3; p 0,6). De los 16 pacientes con carcinoma, (13 MEN2A, 3 MEN2B), 10 de ellos (62,5%) tenían 5 años o menos en el momento de la intervención. En todos los casos se realizó tiroidectomía total. No existieron complicaciones intra ni postoperatorias. Durante el seguimiento, los valores de calcitonina, calcio, paratohormona, catecolaminas y metanefrinas se han mantenido normales, excepto en 1 paciente. CONCLUSIONES: El estudio del protooncogén RET permite identificar pacientes susceptibles de realizar tiroidectomía profiláctica, la cual debe ser realizada de forma precoz, y en centros con experiencia.

The Influence of Radon (Gas and Progeny) and Weather Conditions on Ambient Dose Equivalent Rate.

The purpose of this study is to identify the influence of radon (gas and progeny) on the ambient dose equivalent rate measured at the reference station ESMERALDA, where continuous measurements of the ambient dose equivalent rate (every 10 min) combined with activity concentration measurements of radon gas and radon progeny as well as meteorological parameters have been collected. This study has been performed using a correlation study based on a principal components analysis and the Spearman's rank correlation coefficient.

Spanish consensus for the management of patients with anaplastic cell thyroid carcinoma.

Anaplastic thyroid cancer (ATC) is the most aggressive solid tumor and almost uniformly lethal in humans. The Boards of the Thyroid Cancer Group of the Spanish Society of Endocrinology and Nutrition and the Grupo Español de Enfermedades Huérfanas e Infrecuentes of the Spanish Society of Oncology requested that an independent task force draft a more comprehensive consensus statement regarding ATC. All relevant literature was reviewed, including serial PubMed searches together with additional articles. This is the first, comprehensive Spanish consensus statement for ATC and includes the characteristics, diagnosis, initial evaluation, treatment goals, recommendations and modalities for locoregional and advanced disease, palliative care options, surveillance, and long-term monitoring. Newer systemic therapies are being investigated, but more effective combinations are needed to improve patient outcomes. Though more aggressive radiotherapy has reduced locoregional recurrences, median overall survival has not improved in more than 50 years.

Consensus on the management of advanced radioactive iodine-refractory differentiated thyroid cancer on behalf of the Spanish Society of Endocrinology Thyroid Cancer Working Group (GTSEEN) and Spanish Rare Cancer Working Group (GETHI).

Thyroid cancer is the single most prevalent endocrine malignancy; differentiated thyroid cancer (DTC) accounts for more than 90 % of all malignancies and its incidence has been rising steadily. For more patients, surgical treatment, radioactive iodine (RAI) ablation, and thyroid-stimulating hormone (TSH) suppressive therapy achieve an overall survival (OS) rate of 97.7 % at 5 years. Nevertheless, locoregional recurrence occurs in up to 20 % and distant metastases in approximately 10 % at 10 years. Two-thirds of these patients will never be cured with radioactive iodine therapy and will become RAI-refractory, with a 3-year OS rate of less than 50 %. Over the last decade, substantial progress has been made in the management of RAI-refractory DTC. Given the controversy in some areas, the Spanish Task Force for Thyroid Cancer on behalf of Spanish Society of Endocrinology Thyroid Cancer Working Group (GTSEEN) and the Spanish Rare Cancer Working Group (GETHI) have created a national joint task force to reach a consensus addressing the most challenging aspects of management in these patients. In this way, multidisciplinary management should be mandatory and nuclear medicine targeted therapy, novel molecular targeted agents, and combinations are currently changing the natural history of RAI-refractory DTC.

Functional reconstruction of acutely burnt achilles tendon with composite anterolateral thigh flap with fascia lata: a case report.

Soft tissue defects in the postero-inferior aspect of the leg are still challenging, especially when they affect the Achilles tendon due to its important functional involvement in the normal movement of the ankle. Dorsiflexion and flexion may be affected if proper reconstruction is not achieved, thus limiting daily activities such as walking, climbing stairs or running. Several techniques, including local or regional flaps, combinations of tendon substitutes with free muscular or fasciocutaneous flaps, and free composite flaps with tendon have been described for the reconstruction of complex defects caused by burn sequelae, tumors, trauma, chronic ulcers, etc. The gold standard treatment for moderate to large defects is the anterolateral thigh (ALT) flap with vascularized fascia lata. The ALT flap is reliable because of a long vascular pedicle and a large donor area. Moreover, the fascia lata mimics the Achilles tendon perfectly when rolled on itself. The aim of this article is to present the application of this technique for the first time in a case of an acute burn. The timing of reconstruction with free flaps is critical in acute burns. In our case, it was performed on the 24th day post-burn and no microsurgical complications appeared. More than six months after surgery, the patient showed a normal gait, was able to lift his own weight against gravity and no complications were detected in the donor area.

Les pertes de substance des parties molles de la région postéro inférieure de jambe constituent un problème majeur, surtout quand elles intéressent le tendon d'Achille, à cause de son importante implication dans les mouvements normaux de la cheville. La dorsiflexion et la flexion peuvent être affectées si une réparation correcte n'est pas réalisée, car elle limite les activités journalières telles que la marche, la montée d'escaliers, ou la course. Plusieurs techniques incluant les lambeaux locaux et régionaux, l'association de substituts tendineux avec des lambeaux libres musculaires ou fascio cutanés, et les lambeaux libres composites avec tendon ont été décrits pour la reconstruction des pertes de substances complexes en rapport avec séquelles de brûlures, tumeurs, traumatismes, ulcères chroniques etc. Le traitement de référence pour des pertes de substances modérées ou importantes est constitué par le lambeau antero latéral de cuisse avec fascia lata vascularisé. Ce lambeau est sûr, du fait du long pédicule vasculaire et de l'importance de la surface de la zone donneuse. Cependant, le fascia lata imite parfaitement le tendon d'Achille, que s'il est roulé sur lui-même. Le but de cet article est de présenter une application de cette technique pour la première fois dans un cas de brûlures en urgence. Le moment de la reconstruction par lambeaux libres est discuté dans les brûlures. Dans notre observation, il a été réalisé au cours du 24 e jour après la brûlure et sans complications micro chirurgicales. Plus de six mois après la chirurgie, le patient affiche une démarche normale, il est capable de se lever tout seul et aucune complication n'est apparue au niveau de la zone donneuse.

[Laparoscopic adrenalectomy: advantages of the minimally invasive approach]. / Adrenalectomía por vía laparoscópica: ventajas del abordaje mínimamente invasivo.

AIM: To describe our experience as a tertiary center on the use of laparoscopic adrenal surgery in children. MATERIAL AND METHODS: A descriptive, retrospective study of patients with pathologic adrenal masses undergoing laparoscopic adrenal surgery, between 2012 and 2015. Epidemiological variables, surgical technique, complications and follow-up were studied. RESULTS: Nine patients were studied with a median age of 62 months (5-184). In 3 patients (33.33%) there was a prenatal diagnosis. Three patients had symptoms: hypertension and renal failure, precocious puberty, and an infected lymph node secondary to metastasis. In the rest, findings were incidental. In five patients the lesion was located on the right side and in four, on the left. The operation was performed laparoscopically. There was one conversion to open surgery because of poor visualization of the surgical field and no major intra- or postoperative complications were noted. The average hospital stay was 4 days (2-5). Postoperative pain was controlled during the first 24 hours with first step painkillers. Diagnoses were histologically confirmed: two ganglioneuroma, three neuroblastoma, bronchogenic cyst, pulmonary sequestration and adenoma. Mean follow-up was 22 months (1-53). CONCLUSIONS: In our series this surgical approach is associated with low morbidity and mortality, early recovery, shorter hospital stay and satisfactory results. We therefore propose laparoscopic adrenalectomy as a good alternative for approaching the pathologic adrenal masses in the pediatric population.

OBJETIVO: Describir nuestra experiencia como centro terciario en el uso de la laparoscopia para la exéresis de lesiones adrenales en la edad pediátrica. MATERIAL Y METODOS: Estudio descriptivo y retrospectivo de pacientes con lesiones en la glándula suprarrenal intervenidos de suprarrenalectomía laparoscópica entre los años 2012 y 2015. Se estudiaron variables epidemiológicas, técnica quirúrgica, complicaciones y seguimiento. RESULTADOS: Se estudiaron 9 pacientes con una mediana de 62 meses (5-184). Tres pacientes (33,33%) tenían un diagnóstico prenatal y tres pacientes debutaron con síntomas: hipertensión e insuficiencia renal, pubertad precoz y otro con un adenoflemón secundario a metástasis. En el resto, el hallazgo fue incidental. En cinco pacientes la lesión se situó en el lado derecho y en cuatro en el izquierdo. La intervención se realizó por vía laparoscópica. En un paciente se convirtió a cirugía abierta por mala visualización en el campo quirúrgico. No se produjeron complicaciones perioperatorias ni necesidad de trasfusión. La media de la estancia hospitalaria fue de 4 días (2-5). El dolor postoperatorio fue controlado durante las primeras 24 horas y con analgésicos de primer escalón. Los diagnósticos confirmados por histología fueron: seis neuroblastomas, dos ganglioneuromas y un adenoma. La media de seguimiento fue de 22 meses (1-53). CONCLUSIONES: En nuestra serie esta vía de abordaje está asociada a una baja morbimortalidad con una recuperación precoz, corta estancia hospitalaria y resultados satisfactorios. Por tanto, proponemos la adrenalectomía laparoscópica como una buena alternativa para el abordaje de las lesiones suprarrenales en la población pediátrica.

Consensus on management of advanced medullary thyroid carcinoma on behalf of the Working Group of Thyroid Cancer of the Spanish Society of Endocrinology (SEEN) and the Spanish Task Force Group for Orphan and Infrequent Tumors (GETHI).

BACKGROUND: Of all thyroid cancers, <5 % are medullary (MTC). It is a well-characterized neuroendocrine tumor arising from calcitonin-secreting C cells, and RET gene plays a central role on its pathogeny. METHODS: The electronic search was conducted using MEDLINE (PubMed), EMBASE and Cochrane Central Register of Controlled Trials. Quality assessments of selected current articles, guidelines and reviews of MTC were performed. RESULTS: This consensus updates and summarizes biology, treatment and prognostic considerations of MTC. CONCLUSIONS: Multidisciplinary teams and specialized centers are recommended for the management of MTC patients. In the metastatic setting, those patients with large volume of disease are candidates to start systemic treatment mainly if they are symptomatic and the tumor has progressed in the last 12-14 months. Wait and see strategy should be offered to patients with: disseminated disease with only high levels of calcitonin and no macroscopic structural disease, low burden and absence of progression.

[Endoscopic sclerosis with pneumatic distension for pyriform sinus fistula treatment]. / Esclerosis endoscópica con distensión neumática para el tratamiento de las fístulas del seno piriforme.

Classic treatment for pyriform sinus fistula (PSF) has been surgical excision; however, less invasive therapeutic alternatives whose aim is the obliteration of the sinus have been described subsequently. The authors present a technical modification of endoscopic sclerosis with diathermy (ESD): continuous infusion of air flow through the flexible endoscope was used to distend the pyriform sinus and facilitate recognition of the fistula opening. The sinus obliteration was performed with a wire guide and diathermy. In the last 15 years, 9 patients were diagnosed of suffering from PSF in our institution. Initial treatment was antibiotics therapy associated in some cases to cervical abscess drainage. Fistulectomy was performed in 4 cases and ESD in 4. The ninth patient received both treatments, performing electrocauterization after a surgical recurrence. Three of the patients who underwent surgery relapsed; none treated by ESD did, or had any complications. In our experience, endoscopic sclerosis with pneumatic distension is a simple technique, reproducible, not invasive and very effective; hence we consider it might become a first line therapy for PSF.

Pannexin1 hemichannels are critical for HIV infection of human primary CD4+ T lymphocytes.

HIV is a major public health issue, and infection of CD4(+) T lymphocytes is one of its key features. Whereas several cellular proteins have been identified that facilitate viral infection and replication, the role of hemichannels in these processes has not been fully characterized. We now show that the HIV isolates, R5 and X4, induced a transient-early (5-30 min) and a later, persistent (48-120 h) opening of Panx1 hemichannels, which was dependent on the binding of HIV to CD4 and CCR5/CXCR4 receptors. Blocking Panx1 hemichannels by reducing their opening or protein expression inhibited HIV replication in CD4(+) T lymphocytes. Thus, our findings demonstrate that Panx1 hemichannels play an essential role in HIV infection.

Relationship between bacterial load, morbidity and cagA gene in patients infected by Helicobacter pylori.

One hundred and seventy-six biopsies of the gastric corpus and antrum from 97 patients were processed using classical and molecular methods in order to study the relationship between the factor cagA of Helicobacter pylori, bacterial load and morbidity. Bacterial load in patients with cagA was greater than in patients without it, both in the antrum and corpus (p<0.01). There was a statistically significant association between cagA and consumption of proton pump inhibitors (adjusted odds ratio 3.11). Haemorrhage of the upper digestive tract was more associated with bacterial load than with the cagA gene (adjusted odds ratio 2.34 and 1.12, respectively), but none of these associations yielded statistical significance.

[Ovarian cryopreservation in girls with cancer: new challenges]. / Criopreservación ovárica en niñas con cáncer: nuevos retos.

BACKGROUND: Ovarian cortex cryopreservation (OCC) for future autotransplant represents a treatment alternative for those paediatric cancer survivors affected of ovarian failure and fertility disorders. METHODS: Patients with high gonadotoxic risk are included in the Oncology Paediatric Fertility Preservation Programme: those receiving pelvic radiotherapy, bone marrow transplantation, high doses of cranial radiotherapy or alquilating agents, or those with bilateral ovarian pathology. Prior to the oncological treatment, the ovarian tissue is harvested laparoscopically. At the same time, other invasive procedures are done. Once malignancy is ruled out of the specimen and the presence of primordial follicles is confirmed, the multidisciplinary team of oncologist, paediatric surgeon and fertility specialist coordinate the processing and delivery of the ovarian cortex to the Comunidad Valenciana Tissue Bank. RESULTS: From July 2008 to May 2010 eight patients have been included in the programme, aged between 8-18 years old and with diagnosis of: Hodgkin's lymphoma (n= 2), Acute Myeloblastic and Lymphoblastic leukaemia (n= 2), pelvic Ewing's sarcoma, bilateral ovarian Teratoma and Meduloblastoma. Five patients underwent non gonadotoxic chemotherapy before OCC. Six additional procedures were done using the same anaesthetic event. Partial oophorectomy was performed in half the cases, total oophorectomy in the rest of them, and an ovarian pexia was once associated. All taken samples were found to be valid. CONCLUSIONS: OCC of selected patients was performed safely, with neither postoperative complications nor delay of the oncological treatment. Therefore, the first national experience in this procedure has been satisfactorily achieved.