Curva de aprendizaje para el diagnóstico ecográfico específico de masas anexiales / Learning curve for the specific ultrasound diagnosis of adnexal masses

OBJETIVO: Determinar el tiempo que requiere una curva de aprendizaje para diagnóstico ecográfico específico histopatológico en masas anexiales basándonos en cálculos estadísticos no influidos por la prevalencia según diferentes grados de experiencia. MÉTODOS: Estudio observacional, descriptivo, transversal. Se estudiaron imágenes de 108 masas anexiales. La prueba estándar de oro fue el reporte histopatológico definitivo. Se comparó el rendimiento diagnóstico de 4 examinadores con la siguiente experiencia en diagnóstico ecográfico de patología anexial: A > 20 años, B ≤ 20 hasta > 10 años, C ≤ 10 hasta > 5 años y D ≤ 5 años, analizando solo imágenes y sin datos clínicos de las pacientes, para emitir un diagnóstico específico a libre escritura. RESULTADOS: Prevalencia de masas malignas 17,2 % (15/87). Nivel de confianza en los examinadores se consideró según falta de respuesta diagnóstica: alto (<6 %) con experiencia de más de 10 años y moderado a bajo ≤ 10 años. Examinadores con más de 5 años siempre mostraron likelihood ratio positivo mayor a 10, exactitud diagnóstica mayor a 90 % y Odds ratio diagnóstica mayor a 46, no así para examinador con menor tiempo de experiencia, quién presentó resultados con mala utilidad clínica. El cambio de probabilidad de acierto específico pre-test a post-test mejoró consistentemente con los años de experiencia. CONCLUSIÓN: Se necesitarían más de 10 años de experiencia con especial dedicación a ecografía ginecológica avanzada para un rendimiento diagnóstico específico deseado junto con alta confianza en ecografía de masas anexiales.

OBJECTIVE: To determine the time required for a learning curve of histopathological specific ultrasound diagnosis in adnexal masses based on statistical calculations not influenced by prevalence according to different degrees of experience. METHODS: Observational, descriptive, cross-sectional study. Images of 108 adnexal masses were studied. The gold standard test was the definitive histopathological report. The diagnostic performance of 4 examiners with the following experience in ultrasound diagnosis of adnexal pathology: A > 20 years, B ≤ 20 to > 10 years, C ≤ 10 to > 5 years and D ≤ 5 years was compared, analyzing only images and blinded of clinical data of the patients, to issue a specific diagnosis with free writing. RESULTS: Prevalence of malignant masses 17.2% (15/87). The level of confidence in the examiners was considered according to the lack of diagnostic response: high (<6%) with experience of more than 10 years and moderate to low ≤ 10 years. The examiners with more than 5 years always showed likelihood ratio positive greater than 10, diagnostic accuracy greater than 90% and diagnostic Odds ratio greater than 46, not so for the examiner with less experience time who presented results with little clinical utility. The change in specific probability from pre-test to post-test improved consistently with years of experience. CONCLUSION: More than 10 years of experience with special dedication to advanced gynecological ultrasound are probably needed for a desired specific diagnostic performance coupled with high confidence in adnexal mass ultrasound.

Sistema IOTA ADNEX: ¿Confiable como predictor en pacientes con blastoma anexial? / ADNEX IOTA SYSTEM: Reliable as a predictor in patients with adnexal blastoma?

Objetivos: Evaluar el valor predictivo del sistema IOTA ADNEX®, en pacientes con diagnóstico de blastoma anexial. Objetivo secundario: Evaluar otras características sugestivas de malignidad no incluidas en el sistema IOTA ADNEX®. Materiales y métodos: Estudio observacional, retrospectivo, descriptivo. Se incluyeron 42 pacientes con diagnóstico ecográfico inicial de blastoma anexial que se atendieron y fueron operadas en nuestro servicio en el periodo 2013 - 2018, divididas en 2 grupos: Grupo A (21 pacientes con diagnóstico posterior de cáncer de ovario) y Grupo B (Pacientes con diagnóstico benigno postoperatorio). Se evaluó el valor predictivo del sistema IOTA ADNEX®, para dichas pacientes y se comparó los resultados del Grupo A vs Grupo B. Resultados: El aumento de Ca125, se encontró fuertemente asociado al cáncer de ovario. La diferencia entre Grupo A y B fue estadísticamente significativo p<0,0001. Encontramos una asociación entre el GRUPO A, con la predicción de cáncer de ovario, siendo esta diferencia estadísticamente significativa p<0,0001. Conclusión: De acuerdo a nuestros resultados el sistema ADNEX®, podría predecir tanto el riesgo de malignidad como de benignidad de un blastoma anexial de manera fidedigna. Dicho sistema presenta como ventaja el objetivar la interpretación de los estudios y su fácil implementación en todos los ámbitos. La adecuada caracterización e intervención pre quirúrgica permite la planificación del tratamiento mejorando el pronóstico de las pacientes (AU)

ABSTRACT: AIM: To assess the predictive value of the IOTA ADNEX® system, in patients diagnosed with adnexal blastoma. Secondary aim: To evaluate other characteristics suggestive of malignancy not included in the IOTA ADNEX® system. Materials and methods: Observational, retrospective, descriptive study. We included 42 patients with initial ultrasound diagnosis of adnexal blastoma, who were treated and operated in our service 2013-2018 period, divided into 2 groups: Group A (21 patients with subsequent diagnosis of ovarían cancer) and Group B (Patients with benign postoperative diagnosis). The predictive value of the IOTA ADNEX® system was evaluated for these patients and the results of Group A vs Group B were compared. Results: Ca125 was found to be strongly associated with ovarian cancer. The difference between Group A and B was statistically significant p <0.0001. We found an association between GROUP A, with the prediction of ovarian cancer, this difference being statistically significant p <0.0001. Conclusion: According to our results, the ADNEX® system could predict both the risk of malignancy and benignity of an adnexal blastoma reliably. This system has the advantage of objectifying the interpretation of the studies and their easy implementation in all areas. Proper characterization and presurgical intervention allows treatment planning to improve the prognosis of patients (AU)

GIRADS: método de clasificación de masas anexiales, revisión sistemática y metanálisis. 10 años de experiencia / GIRADS: adnexal masses classification method, systematic review and metanalysis. 10 years of experience

OBJETIVO: evaluar la experiencia en la utilización del método GIRADS para clasificar masas anexiales a diez años de su primera publicación. MÉTODO: Se realizó búsqueda de estudios que utilizan el sistema GIRADS: Medline (Pubmed), Google Scholar y Web of Science, desde enero de 2009 hasta diciembre de 2019. Se calculó la sensibilidad y especificidad agrupada, Likelihood ratio (LR) (+) y LR (-) y Odds ratio de diagnóstico (DOR). La calidad de los estudios se evaluó con QUADAS-2. RESULTADOS: Se identificaron 15 estudios y se incluyeron 13 de ellos con 4473 masas, 878 de ellas malignas. La prevalencia media de malignidad ovárica fue del 23 % y la agrupada de 19.6%. El riesgo de sesgo fue alto en cuatro estudios para el dominio "selección de pacientes" y fue bajo en todos en todos los estudios para los dominios "prueba índice" y "prueba de referencia". La sensibilidad, especificidad, LR (+) y LR (-) agrupadas y el DOR del sistema GIRADS para clasificar las masas anexiales fueron: 96.8% (intervalo de confianza [IC] 95% = 94% - 98%), 91.2 % (IC 95 % = 85% - 94%), 11.0 (IC 95% = 6.9 -13.4) y 0.035 (IC 95% = 0.02- 0.09), y 209 (IC 95% = 99-444), respectivamente. La heterogeneidad fue alta para la sensibilidad y especificidad. De acuerdo a la metaregresión, la heterogeneidad entre los estudios se explica por la prevalencia de malignidad, múltiples observadores y la ausencia de diagnóstico histopatológico para todos los casos incluidos en un determinado estudio. CONCLUSIÓN: el sistema GIRADS tiene un buen rendimiento diagnóstico para clasificar masas anexiales.

OBJECTIVE: to evaluate the experience of using GIRADS method to classify adnexal masses ten years after its publication. METHOD: A search was carried out for studies reporting on the use of the GIRADS system in the Medline (Pubmed), Google Scholar and Web of Science databases, from January 2009 to December 2019. Pooled sensitivity and specificity, Likelihood ratio (LR) (+) and LR (-) and Diagnostic Odds ratio (DOR) were calculated. The quality of the studies was assessed by QUADAS-2. RESULTS: 15 studies were identified, and 13 of them were included with 4473 masses, of which 878 were malignant. The mean prevalence of ovarian malignancy was 23% and the prevalence pooled. of 19.6%. The risk of bias was high in four studies for the domain 'patient selection' and low for all studies for the domains 'index test' and 'reference test'. The sensitivity, specificity, pooled LR (+) and LR (-) and the DOR of the GIRADS system to classify adnexal masses were 96.8% (95% confidence interval [CI] = 94% -98%), 91.2 % (95% CI = 85% -94%), 11.0 (95% CI = 6.9-13.4) and 0.035 (95% CI = 0.02-0.09), and 209 (95% CI = 99-444), respectively. Heterogeneity was high for both sensitivity and specificity. According to meta-regression, this heterogeneity was explained by the prevalence of malignancy, the use of multiple observers, and the absence of histopathological diagnosis for all cases included in a given study. CONCLUSION: the GIRADS system has a good diagnostic performance to classify adnexal masses.

Laparoscopia na abordagem inicial de tumores anexiais / Laparoscopy for diagnosis and treatment of adnexal masses

OBJETIVO: Avaliar o uso da laparoscopia como método diagnóstico e terapêutico na abordagem inicial de tumores anexiais em população de risco para malignidade, bem como fatores clínicos associados à falha do método e conversão para laparotomia, e comparar taxas de complicação com pacientes cuja abordagem inicial se deu por laparotomia. MÉTODOS: Estudo prospectivo com 210 mulheres com exames de imagem prévios constando tumor anexial, das quais 133 foram incluídas. Destas, 45 foram submetidas à laparoscopia e 88, à laparotomia. Catorze das 45 cirurgias iniciadas por laparoscopia foram convertidas a laparotomia no intraoperatório. Foi avaliado se idade, índice de massa corporal (IMC), número de cirurgias abdominais prévias, CA-125, índice de risco de malignidade (IRM), diâmetro do tumor, duração da cirurgia e número de complicações cirúrgicas diferiram entre os grupos laparoscopia, laparoscopia com conversão à laparotomia e laparotomia. Foi também avaliado o motivo reportado pelos cirurgiões como falha da laparoscopia e a razão da conversão para laparotomia. RESULTADOS: A taxa de tumores malignos neste estudo foi de 30%. Houve diferença nos valores de CA-125, IRM e diâmetro do tumor entre os grupos laparoscopia e laparotomia. A duração da cirurgia foi maior no grupo de laparoscopias convertidas à laparotomia, porém as taxas de complicação cirúrgica foram semelhantes entre os grupos e, quando isolados os tumores benignos, as taxas de complicação cirúrgica da laparoscopia se mostraram inferiores à laparotomia. Dentre os fatores em estudo, apenas o tamanho do tumor esteve relacionado à conversão para laparotomia. CONCLUSÃO: Este estudo sugere que a abordagem inicial de pacientes com tumores ...

PURPOSE: To assess clinical factors, histopathologic diagnoses, operative time and differences in complication rates between women undergoing laparoscopy or laparotomy to diagnose and treat an adnexal mass and their association with laparoscopy failure. METHODS: In this prospective study, 210 women were invited to participate and 133 of them were included. Eighty-eight women underwent laparotomy and 45 underwent laparoscopy. Fourteen of the 45 laparoscopies were converted to laparotomy intraoperatively. We assessed whether age, body mass index (BMI), previous abdominal surgeries, CA-125, Index of Risk of Malignancy (IRM), tumor diameter, histological diagnosis, operative time and surgical complication rates differed between the laparoscopy group and the group converted to laparotomy and whether those factors were associated with conversion of laparoscopy to laparotomy. We also assessed surgical logs to evaluate the reasons, as stated by the surgeons, to convert a laparoscopy to laparotomy. RESULTS: In this research, 30% of the women had malignant tumors. CA-125, IRM, tumor diameter and operative times were higher for the laparotomy group than the laparoscopy group. Complication rates were similar for both groups and also for the successful laparoscopy and unsuccessful laparoscopy groups. The surgical complication rate in women with benign tumors was lower for the laparoscopy group than for the laparotomy group. The factors associated with conversion to laparotomy were tumor diameter and malignancy. During laparoscopy, adhesions a large tumor diameter were the principal causes of conversion. CONCLUSION: This study suggests that laparoscopy for the diagnosis and treatment of adnexal masses is safe and does not increase complication rates even in patients who need conversion to laparotomy. However, when doubt about the safety of the procedure and about the presence of malignancy persists, consultation with an expert gynecology-oncologist ...

Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue type of the ocular adnexa: Retrospective single institution review of 95 patients.

Context: There are few reports on the management of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT), which are based on the experience of a single institution, as opposed to large multicenter randomized trials. Aim: The aim of this study was to report on the clinical experience of a single institution. Materials and Methods: A retrospective review was undertaken of records of 95 patients with MALT lymphoma of the ocular adnexa. Histologic diagnosis of MALT lymphoma was made according to established criteria, and clinical staging was carried out to determine treatment modalities. All patients were treated by external beam irradiation (30.6–45.0 Gy) after biopsy. Additional chemotherapy was performed in accordance with the clinical stage of the disease. All the patients were treated by the same hemato-oncologist and radio-oncologist. Results: Almost all patients showed complete response, except for four patients who showed partial response. In two of 95 patients, contralateral eye showed recurrence, and they were salvaged by additional radiotherapy. The 3-year overall survival and event-free survival rates were 100 and 97%, respectively, by Kaplan–Meier survival analysis. Moreover, there were no serious radiation-associated complications. Conclusions: Radiotherapy alone can be an important treatment modality for the local control and survival in patients with localized MALT lymphoma of ocular adnexa. Systemic chemotherapy should be considered in patients with advanced stage disease.

Laparoscopic surgery versus laparotomy in common gynecological problems

Endoscopic surgery is rapidly advancing to be the surgery of the future. Laparoscopy is currently the most frequently performed gynecological procedure. Laparoscopic surgery is now firmly established as the operation of choice or "Gold standard" for treatment of most gynecological problems needing surgery. Laparoscopy is now fully accepted as the treatment of choice for conditions like ectopic pregnancies, pain due to adhesions, non-cancerous ovarian cysts, endometriosis, and infertility. Was to evaluate and compare the results of treating the adnexal pathology by using either operative laparoscopy or laparotomy. All studied patients were subjected to full routine clinical and gynecological examination including relevant investigations, and were allocated to two groups; Group [1] patients who had operative laparoscopy and Group [2] the laparotomy patients. In each group, 4 gynecological procedures were carried out: Ectopic Pregnancy, Ovarian cystectomy, Endometriosis with adhesiolysis, and Tubal sterilization. A total of 154 patients were included in the study. Comparing the operative laparoscopy group to the laparotomy group, there was a significant difference in all postoperative parameters including the operative time,% of Hb reduction, duration of hospital stay in days, operative cost, analgesia required in the 1[st] 24 hrs, and recovery after surgery. The patients treated with operative laparoscopy showed early resumption of oral intake [hrs], faster resumption of movement and domestic work [days], and earlier return to work [days]. Operative laparoscopy has become an effective and precise diagnostic and treatment procedure in gynecology

Tumores anexiales en niñas y adolescentes: experiencia del Hospital Clínico de la Universidad de Católica de Chile, 1991-2003 / Adnexal mass in girls and teenagers: experience of Hospital Clínico de la Universidad de Católica de Chile, 1991-2003

Se analiza retrospectivamente la experiencia de los últimos 13 años en el manejo de la patología anexial quirúrgica en niñas y adolescentes menores de 19 años. Se revisa la forma de presentación clínica y los hallazgos anatopatológicos de 106 pacientes. Del total de lesiones anexiales, un 62 por ciento correspondieron a lesiones neoplásicas benignas y malignas, la mayoría de ellas originadas en el ovario. El riesgo de malignidad para las lesiones neoplásicas fue de un 26,7 por ciento. La neoplasia ovárica benigna más frecuente fue el teratoma maduro (31,1 por ciento). Las neoplasias malignas más frecuentes fueron las originadas en el estroma gonadal específico y en el tejido germinal (en conjunto 37,5 por ciento del total de neoplasias malignas). La forma de presentación clínica más frecuente fue el dolor abdominal habitualmente como manifestación de complicación de una neoplasia benigna. La vía de abordaje más frecuente fue por laparotomía y se privilegió la cirugía conservadora para preservar el potencial reproductivo.

Ultrasonido y cáncer de ovario: caracterización subjetiva / Ultrasound and ovarian cancer: a subjective assessment

Se analizan 51 masas anexiales complejas en las que en base a una caracterización subjetiva del aspecto ecográfico, se realizó el diagnóstico presuntivo de anaplasia. La sensibilidad diagnóstica fue 90 por ciento y la especificidad 85 por ciento. Se concluye que frente a una masa anexial, la caracterización subjetiva mediante ultrasonografía transvaginal, por parte de un operador entrenado tiene un alto rendimiento en el diagnóstico de malignidad.

Tumores anexiales y embarazo / Adnexal tumors and pregnancy

Objetivo: Evaluar la frecuencia de tumores anexiales en el embarazo, la histología tumoral y los resultados perinatales. Pacientes y método: Análisis retrospectivo de 33 pacientes con diagnóstico de tumor anexial y embarazo atendidas en el Servicio de Obstetricia del Hospital San Juan de Dios entre febrero de 2001 a julio de 2004. Resultados: La asociación tumor anexial y embarazo fue 1 en 424 embarazos. El tipo histológico más frecuente fue el cistoadenoma seroso (19,2 por ciento no alteró el pronóstico perinatal. Conclusión: Recomendamos la resolución quirúrgica de las masas anexiales complejas durante el embarazo sobre las 12 semanas, período que da un margen de seguridad bastante amplio sin afectar la evolución del embarazo o los resultados perinatales.

Adnexal torsion following gonadotropin-releasing hormone analog therapy: a case report

Torção anexial pode ocorrer em crianças e adolescentes do sexo feminino. Frequentemente está associada com doenças ovarianas que resultam em crescimento da gônada. A torção anexial pode comprometer os ovários isoladamente, as tubas uterinas ou ambos e o sintoma principal é dor pélvica aguda. Descrevemos um caso de dor pélvica aguda em uma menina de 8 anos de idade, com diagnóstico prévio de puberdade precoce e que estava em tratamento com análogo de GnRH. O exame ultra-sonográfico demonstrava útero de tamanho normal com ovários aumentados bilateralmente e múltiplos cistos. Na laparotomia foi encontrado torção completa do anexo direito. O exame histológico demonstrou edema maciço de ovário associado com múltiplos cistos antrais e redução da reserva folicular.

Laparoscopic cystectomy of an ovarian mucinous cystadenoma in a 12-year-old girl: a possible role of operative laparoscopy for a huge benign adnexal mass.

The case of an obese 12-year-old girl with a huge and mobile pelvic cystic mass is presented. After ultrasonography and determination of tumor markers, a right huge benign adnexal mass was suspected. In order to avoid exploratory laparotomy because severe pain and a large operative scar were expected, an operative laparoscopy was performed. No intra-operative and post-operative complications were observed. With the uneventful recovery, only a one-day hospital stay was needed. Neither residual nor recurrent evidence was suspected after 2-, 6-, 12-, 18- and 24-months follow-up. With proper case selection, good pre-operative counseling and the operation performed under familiarity and good training in laparoscopy, laparoscopic management of a huge suspected benign adnexal mass is technically feasible. The benefits are reducing hospital stay, lowering morbidity, especially less pain and cosmetic acceptance of the operative scar.

Distribución de la patología anexial en mujer chilena: experiencia de la Universidad Católica de Chile / Distribution of adnexal pathology in chilean women: Universidad Católica de Chile experience

Se presenta la distribución de los hallazgos anátomo-patológicos anexiales en pacientes operadas por patología ginecológica durante el período comprendido entre los años 1991 y 2002. Se analiza su frecuencia según edad, localización anatómica y malignidad. El riesgo de cáncer en pacientes operadas con diagnóstico de tumor anexial es 9,5 por ciento. El hallazgo incidental de cáncer en pacientes operadas por patología ginecológica benigna es aproximadamente 1 en 3000 casos (0,3 por ciento).

Papillary cystadenocarcinoma arising in a paratubal mesothelial cyst of the mesosalpinx--a case report.

Primary carcinoma arising from a paratubal cyst in the mesosalpinx in uncommon. Serous tumors of low malignant potential outnumber invasive carcinomas, which are often of endometrioid type. Only five cases of serous papillary cystadenocarcinoma with capsular invasion have been documented. We report a case of invasive papillary cystadenocarcinoma arising in a large paratubal cyst of the mesosalpinx, in an infertile woman. Possible hormonal basis, its link to serous borderline and malignant tumors of the peritoneum, and value of pre/intra operative cyst fluid cytology are discussed. Lack of definitive management protocols, prognostic indicators and possible consequences are briefly reviewed.

Pseudomixoma peritoneal secundario a cistoadenocarcinoma del apéndice cecal: caso clínico / Pseudomyxome peritonei secondary to a cystadenocarcinoma of the appendix: clinical case

We report a 40 years old female that presented with an ovarian tumor and ascitis. The exploratory laparotomy revealed a mucocele of the appendix that was informed as a cystadenoma of the appendix in the fast biopsy. The definitive pathological diagnosis, a cystadenocarcinoma of the appendix, motivated a second intervention, preforming a right hemicolectomy, left adnexectomy and omentumectomy. Three years later she presented with an abdominal mass and was subjected to a total hysterectomy and right adnexectomy. The pathological diagnosis was a mucinous cystadenocarcinoma with peritoneal involvement. The patient completed five years of follow up since the first intervention and is free of tumor. Pseudomixome peritoneai generally is a tumor of ovarian origin, followed by the appendix. Surgical treatment must include the excision of neighboring compromised organs. The follow up must be lengthy considering the possibility of late recurrences

Ultrasonic, cytologic and histopathologic findings in adnexal cysts of infertile females

14 patients enrolled in the infertility program of the International Fertility Center [IFC], Alexandria, Egypt were included in this study. Ultrasound guided fine needle aspiration [FNA] of adnexal cysts incidentally discovered during evaluation of these 14 patients was performed under general anesthesia, and the sterile aspirate was centrifuged and examined cytologically. Twelve patients had non surgical cysts [simple cysts, functional cysts, endometriotic chocolate cysts and acute nonspecific cophoritis]. One patient had pseudomucinous cystadenoma, ovary and another had a papillary serous cystic lesion, the biologic nature of which was not possibly determined cytologically. It was concluded that ultrasound-guided FNA of incidentally discovered adnexal cysts offers definitive diagnosis of these cysts. Prompt intervention of cysts with neoplastic change overrides the risk of dissemination of malignant cells from needle puncture

Teratoma quistico extragonadal: analisis estructural e histoquímico / Cystic extragonadal teratoma: structural and histochemical study

Se efectuó el estudio de un tumor quístico del ligamento uterosacro encontrado accidentalmente en el transcurso de una anexohistectomía. Esta localización es infrecuente de acuerdo con los datos obtenidos de la literatura consultada. La pieza tumoral fue fijada en formal neutro al 10% a pH 7,4 en "buffer"fosfato. Se realizaron cortes seriados del material incluindo en parafina y se emplearon técnicas de hematoxilina y eosina, PAS, PAS/sialidas, PAS/amilasa. alcian blue a pH 2,5 y 1,0, reacciones de bloqueo, azul de toluidina a pH 3,8, Weigert y matenamina/plata. El tumor demostró tratase de un teratoma quístico extragonadal, identificándose elementos estructurales e histoquímicos compatibles con tejido traqueal. Se identifivó un epitelio cilíndrico seudoestratificado ciliado con granulacione apicales PAS positivas, alcianofílicas, metacromáticas y peryodatorrectivas, com células caliciformes PAS positivas, metacromárticas, alcinofílicas y peryodatorreactivas. La membrana basal aparecía bien manifiesta y por debajo se observaba una franja de fibras elásticas muy desarrolladas y fácilmente idenfifcables con Weigert. Se encontraban ácinos serosos, mucosos y mixtos PAS positivos, alcianofílicos, metacromáticos y periodatorreactivos y placas de cartílago hialino bien desarrolladas con las mismas características tintoriales. Nuestros hallazgos sugieren que: 1) el tumor tiene un probable origen biblástico (endodermo y mesodermo); 2) se trata de un teratoma benigno maduro grado ), en el que todos los componentes tisulares aparecen bien diferenciados; 3) la presencia de glicosaminoglicanos y glicoproteínas detectados por métodos histoquímicos en células del epitelio superficial, calciformes y ácinos glandulares serían un factor indicativo de su actividad funcional