¿Cuándo el patólogo debe solicitar inmunomarcación con B-Catenina?: una revisión de la literatura a propósito de dos casos / When should the pathologist request immunostaining with B-catenin?: a review of the literature on two cases

For more than 20 years, immunohistochemistry has represented an auxiliary test of great relevance to support pathological work, however, it should be noted that the pillar of diagnosis continues and will continue to be the classic morphological description based on hematoxylin eosin and the trained eye of the specialist. In neoplastic pathologies, whether benign or malignant, it is becoming increasingly necessary to incorporate new tissue biomarkers that help objectify or confirm the diagnosis of each patient, in order to provide better treatment or a more precise diagnosis about the biological nature of their illness. In this line, there has been intense research in relation to the participation of the Wnt/ß-catenin pathway in the development of various types of tumors, including colon adenocarcinoma, some pancreatic neoplasms and even some tumors of mesenchymal origin, as will be seen. in this work. In this context and based on two clinical cases of special interest, we have prepared a brief review of the literature considering the biological aspects of ß-catenin, tumors where there is currently a true relative consensus that its immunolabeling offers a real contribution to the confirmation of the entity and finally a limited exposition regarding the future of this biomarker in the pathology discipline.

Desde hace más de 20 años la inmunohistoquímica ha representado una prueba auxiliar de gran relevancia para apoyar el trabajo anatomopatológico, no obstante, cabe señalar que, aún el pilar del diagnóstico sigue y seguirá siendo la descripción morfológica clásica basada en hematoxilina eosina y el ojo entrenado del especialista. En las patologías neoplásicas, ya sea benignas, como malignas, se hace cada vez más necesario la incorporación de nuevos biomarcadores tisulares que ayuden a objetivar o confirmar el diagnóstico de cada paciente, con objeto de entregar un mejor tratamiento o un diagnóstico más preciso de la naturaleza biológica de su enfermedad. En esta línea, ha habido intensa investigación en relación con la participación de la vía Wnt/ß-catenina en el desarrollo de varios tipos de cáncer, entre ellos el adenocarcinoma de colon, algunas neoplasias pancreáticas e incluso algunos tumores de origen mesenquimal como se verá en este trabajo. En este contexto y partir de dos casos clínicos de especial interés, hemos preparado una breve revisión de la literatura considerando los aspectos biológicos de la ß-catenina, los tumores donde en la actualidad existe verdadero consenso de que su inmunomarcación ofrece un aporte real a la confirmación de la entidad y finalmente una exposición acotada respecto al futuro de este biomarcador en la disciplina de la anatomía patológica.

Dermatomicosis superficiales: cuando el diagnóstico lo entrega la histología / Superficial dermatomycosis: when the diagnosis is provided by histology

Superficial dermatomycosis are prevalent pathologies in the medical field and their diagnosis is fundamentally clinical. Histopathology is not considered part of his study, however, the diagnosis is exceptionally obtained by biopsy, when dermatomycosis was not suspected. Unpublished retrospective work is carried out on patients who had the histopathological diagnosis of superficial dermatomycosis between the years 2000-2019 at the HCUCH, based on selection criteria, obtaining 19 patients, in which the following were analyzed: age, gender, clinical characteristics, location, presumptive diagnosis and mycological and histological examinations. He stressed, as was our hypothesis, that dermatomycosis was not clinically suspected, since the presumptive diagnoses were various dermatoses. The most suspected dermatosis was psoriasis, as a result that 57.8% of the dermatoses studied had erythematous scaly plaques on examination. Another relevant fact is that only 21% of the cases underwent a direct mycological prior to the biopsy, which was negative ('' false negative''). It is concluded, then, that superficial dermatomycosis should be considered clinical simulators of other dermatoses, so clinical suspicion and support of mycological examination and fungal culture is essential. (AU)

Enfermedad de Grover, una patología ampollar poco frecuente: a propósito de 2 casos / Grover's disease, a pathology blistering unusual: About 2 cases

Grover's disease (GD) or transient acantholytic dermatosis, is a papulovesicular pruritic disease of unknown etiology. It´s most important histopathological finding is the presence of focal acantholysis. The incidence has not been firmly established. Case report: We report two cases of papulovesicular rashes, the first one in a 79 year old man with good response to second line treatment and the second one, in a 30 year old woman. Both with different suspected triggering factors. Comment: GD predominates in white men with an average age of presentation of 61. Clinically, it presents as erythematous papules, crusted-papule and is usually pruritic. The etiopathology is still unknown, but it is associated with triggers such as: ultraviolet radiation (UVR), ionizing radiation, heat, sweat, friction and chemotherapy. Acantholysis is the classic histological finding. Management includes general measures, topical corticosteroids, calcineurin inhibitors, tretinoin, calcipotriene and antihistamines. In refractory cases, second-line treatment is used: oral isotretinoin, systemic corticosteroids and phototherapy. Paradoxically, phototherapy can also trigger GD. Conclusions: Due to the low prevalence of GD in Chile, 2 new cases are provided to the literature. In both cases, the diagnostic presumption was based on an exhaustive clinical history, confirmed by histopathological findings. (AU)

Retención de cápsula endoscópica en enfermedad de Crohn ¿cómo manejarla? / Retained capsule endoscopy in Crohn´s disease: how to manage it?

Capsule endoscopy is a technique that allows the study of the small intestine, through a device that is swallowed by the patient, capturing images as it travels through the digestive tract. Capsule retention is the most serious complication. We report the case of a 69 year-old male presenting with iron deficiency anemia, with normal upper endoscopy and colonoscopy; but obscure gastrointestinal bleeding was diagnosed and therefore a study with capsule endoscopy was requested. The patient evolves with retained capsule in the small intestine with ulcerated stenosis as shown by imaging. This finding was confirmed by enteroscopy with biopsy, without being able to extract the capsule. Medical management with corticosteroids was indicated for intestinal obstruction secondary to inflammatory stenosis in the context of Crohn's disease: The capsule was expelled after 21 days of ingestion, with a positive outcome

La cápsula endoscópica es una técnica que permite el estudio del intestino delgado, mediante un dispositivo que es deglutido por el paciente y captura imágenes en su recorrido por el tubo digestivo. La complicación más grave es la retención de la cápsula. Se reporta el caso de un paciente de sexo masculino, de 69 años con anemia ferropénica, con endoscopia alta y colonoscopia normal; planteándose sangrado gastrointestinal de origen oscuro por lo que se solicita estudio con cápsula endoscópica. El paciente evoluciona con retención de la cápsula en intestino delgado, visualizándose en las imágenes la presencia de estenosis ulcerada, hallazgo que se confirma mediante enteroscopia con toma de biopsias, sin lograr extraer la cápsula. Se indica manejo médico con corticoides por obstrucción intestinal secundario a estenosis inflamatoria en contexto de enfermedad de Crohn, expulsando espontáneamente la cápsula al día 21 de su ingestión, sin complicaciones.

Percretismo placentario: manejo con oclusión de arterias ilíacas internas, embolización de arterias uterinas y oclusión de arterias ilíacas comunes / Placenta previa percreta: handling with occlusion of internal iliac artery, uterine artery embolization and occlusion of common iliac arteries

Presentamos el caso de una embarazada con placenta ístmica, percreta, previa central, con extensas anastomosis vasculares y flujo de alta velocidad. En la resolución mediante cesárea-histerectomía, para prevenir la hemorragia intraoperatoria, se utilizó una intervención radiológica en secuencia de oclusión temporal de las ilíacas internas, embolización de las arterias uterinas, reposicionamiento e insuflación de balones en ilíacas comunes. Se logró mantener estabilidad hemodinámica y el control del sangrado; estando ocluida la circulación uterina hubo pérdidas moderadas en la parte final de la operación. Se discuten la característica poco común de la implantación y percretismo ístmico, y el beneficio del uso combinado de la oclusión vascular con la cirugía expedita para minimizar el riesgo materno.

We present a patient with placenta previa percreta and oclusive. It had extensive vascular anastomosis with high velocity flow, in which resolution by cesarean-hysterectomy was done for bleeding control and followed by temporal occlusion of iliac arteries, embolization of uterine arteries, reposition and insuflation of balloons in common iliac arteries. The patient was stable and moderated bleeding happened to the end of intervention when the uterine arterial circulation was occluded. We discuss the uncommon of isthmic implantation and percretism and the benefits of both vascular occlusion and expedite surgery for to minimize maternal compromise or damage.

Adenoma de células basales de parótida: caso clínico y revisión de la literatura / Basal cell adenoma of the parotid gland: case report and literature review

To report a case of basal cell adenoma in an adult patient. Introduction: The basal cell adenoma is a rare tumor, it represents the 1-2percent of the major salivary gland tumors. It has a low malignancy rate and a good prognosis, but it has high recurrency. It is tipically presented during the fifth decade of life, and its usually as a firm and movable mass of slow growth. Case Report: A 58-year-old man with a left parotid tumor of 4 months of evolution, with no other symptoms. A total parotidectomy is performed without any incidents, or sequels. The deferred biopsy showed a basal cell adenoma. Discussion: The histopathological analysis is essential for the differential diagnosis with malignant tumors. As there are case reports that shows malignancy of the basal cell adenoma the surgical excision has become the treatment of choice, along with a patient follow-up...

Melanoma acral: a propósito de un caso / Acral melanoma: report of a case

Acral melanoma is an uncommon cutaneous malignant tumour, which may arise on the foot. A 73 years old female patient presented with an ulcerated lesion on the sole of the left foot for one year, associated to an older pigmented lesion. The biopsy of both lesions, showed “in situ cutaneous melanoma” in the pigmented lesion and “infiltrating cutaneous melanoma” in the ulcerated lesion. In this case report is discussed the epidemiology of acral melanoma around the world, showing the importance in early recognition and proper management...

Vasa previa y corioamnionitis: imágenes de un riesgo continuo / Vasa previa and chorioamnionitis

We are presenting a case of vasa previa diagnosed at 22 week’s gestation and then she started with threatened premature labor on week 27th.In spite of attempted tocolysis, labor continued to painless fully dilatation, spontaneous rupture of membranes, umbilical cord prolapse and unexpectedvaginal delivery of a 760 g baby in good conditions. Gross placental examination was in agreement with ultrasound findings and microscopic study demonstrated chorioamnionitis and funisitis associated to vasa previa and prematurity. We consider series of facts that happened in this case as a continuous risk condition from the morbidity to the epilog like “near miss perinatal case”. We discuss the importance of chance in the resultand we think that the preventive intervention was in the medical management and not in the attention system.

Se presenta un caso clínico de vasa previa diagnosticada con ultrasonido a las 22 semanas que evolucionó con amenaza de parto prematuro en semana 27. Pese a la frenación inicial se produjodilatación completa en forma silenciosa, rotura de membranas, procidencia de cordón y parto vaginal sorpresivo de un prematuro de 760 gramos que tuvoevolución favorable. El examen macroscópico placentario fue concordante con las imágenes observadas con ultrasonido y el estudio histológico confirmó corioamnionitis y funisitis asociadas a la vasa previa y la prematurez. La interpretación de la secuencia de eventos es de un riesgo continuo desde su inicio como morbilidad y su epílogo de probable mortalidad perinatal (“near miss”).Se discute la importancia del azar en la evolución y se concluye que una intervención preventiva estuvo en el ámbito del manejo médico y no en el sistema de atención.

Quiste suprarrenal primario / Primary adrenal cyst

Adrenal cyst is the commonest type of benign lesions of adrenal gland, althought is a very rare entity. Tipically, they are presented with abdominal pain or palpable mass, but nowdays they are detected most frecuently an imaging studies like incidentaloma. Adrenal Cyst have a broad differential diagnoses, rendering definitive diagnosis and subsequent management difficult. Are categorized into four subtypes: endothelial, pseudocyst, epithelial, and parasitic. This management paradigm may be summarized as: ruling out functional status of the cyst, evaluating chances of incidental malignancy by imaging, avoiding potential complications of surveillance (hemorrhage, infection), particularly in large cysts. A case of a patient with a left non-functioning adrenal cyst is reported, with abdominal pain. The diagnostic and therapeutic options are discussed and the literature is reviewed.

Los quistes suprarrenales son las lesiones quísticas más frecuentes de la glándula suprarrenal, a pesar de que constituyen una rara entidad. Típicamente se presentan por un cuadro de dolor abdominal o masa palpable, pero en la actualidad se detectan cada vez con más frecuencia en estudios radiológicos como incidentalomas. Los quistes suprarrenales cuentan con amplios diagnósticos diferenciales, lo que hace un difícil diagnóstico definitivo y una dificultad en el manejo posterior. Estos quistes se clasifican en cuatro subtipos: endoteliales, pseudoquiste, epiteliales y parasitarios. El manejo de un quiste suprarrenal se puede resumir en tres pilares fundamentales: descartar el estado funcional del quiste, evaluación de eventual malignidad por imágenes, y evitar las posibles complicaciones (hemorragia, infección), sobre todo en los quistes de gran tamaño. Se presenta el caso de una paciente con quiste suprarrenal izquierdo no funcionante asociado a dolor abdominal. Se realiza revisión de la literatura y se plantean los distintos diagnósticos y alternativas terapéuticas.

Pioderma gangrenoso en paciente con colitis ulcerosa tratada con infliximab / Pyoderma gangrenosum in a patient with ulcerative colitits treated with infliximab

El pioderma gangrenoso (PG) es una dermatitis neutrofílica, que en algunos casos puede ser severa y de difícil manejo. Presentamos el caso de una paciente con múltiples lesiones de PG asociadas a colitis ulcerosa, en la cual, por severidad del cuadro, se optó por adicionar infliximab al tratamiento habitual. La respuesta clínica fue excelente y rápida tras la primera dosis de infliximab, pese a que recibió solo dos de las tres dosis recomendadas habitualmente. La mejoría cutánea y digestiva se ha mantenido un año después de este tratamiento. Infliximab ha demostrado ser, en este y otros reportes, una herramienta muy útil, especialmente en casos de compromiso severo como en nuestra paciente. Se requiere mas evidencia aún para comprobar en cuáles pacientes podría ser beneficioso. Se presenta este caso por su severidad y la rápida y sostenida respuesta obtenida con infliximab.

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis and in some cases can be severe and difficult to manage. We report the case of a patient with multiple lesions of PG associated with ulcerative colitis. Due to the severity of the clinical presentation treatment with infliximab was added to standard therapy. Clinical response was excellent and fast after the first dose of infliximab, although ha received only two of the three doses usually recomended. Skin and digestive improvement has been maintained 1 year after treatment. Infliximab has proven, in this and other reports, as a very useful tool in the treatment of PG, especially in cases of severe involvement as in our patient. More evidence is required to prove in which patients with PG infliximab could beneficial. We present this clinical case because of its severity and the rapid and susteined response obtained with infliximab.

Carcinoma de células de Merkel: a propósito de dos casos / Merkel cell carcinoma: report of two cases

El carcinoma de células de Merkel es un raro carcinoma neuroendocrino primario de la piel que generalmente se presenta como un nódulo redondeado, violáceo, solitario o como una placa indurada en áreas fotoexpuestas de pacientes añosos. El diagnóstico histopatológico puede ser difícil debido a su semejanza con el carcinoma metastásico de células pequeñas de pulmón, linfomas y otros tumores cutáneos. Para la distinción de tumores primarios pobremente diferenciados o metástasis se requiere de análisis inmunohistoquímico. La citoqueratina 20 constituye un marcador sensible y específico para este tumor y es útil para distinguirlo de otras neoplasias, malignas o benignas. Presentamos dos casos vistos en nuestro Servicio con este diagnóstico y una breve revisión de la literatura.

Merkel cell carcinoma is a rare primary neuroendocrine carcinoma of the skin that usually appears as a solitary, violaceous, dome-shaped nodule or indurated plaque in a sun exposed area of elderly patients. Histopathologic diagnosis may be difficult because of histologic and immunohistochemical similarities with metastatic small cell lung carcinomas, lymphomas, and other cutaneous neoplasms. Distinction from poorly differentiated oat cell primary tumors or metastasis requires immunohistochemical analysis. Cytokeratin 20 is a sensitive and specific marker for Merkel cell carcinoma and is helpful in distinguishing this tumor among other malignant and benign neoplasms. We report two cases with this diagnosis seen at our department and a brief report of the literature.