PTH como predictor de hipocalcemia postiroidectomía total / PTH as a predictor of hypocalcemia after total thyroidectomy

Resumen Objetivo: Evaluar la asociación entre el valor de PTH medido a las 6 h posoperatorias de los pacientes sometidos a una tiroidectomía total, y la presentación de hipocalcemia en las primeras 24 h posoperatorias. Materiales y Método: Estudio analítico retrospectivo que utiliza una base de datos de 173 pacientes operados de tiroidectomía total entre enero de 2016 a diciembre de 2018 en el Hospital Militar de Santiago (HMS). Se revisaron datos demográficos y perioperatorios. Se utilizó curva ROC para evaluar la asociación entre PTH e hipocalcemia en nuestros pacientes. Resultados: 106 pacientes que cumplen criterios de inclusión. Promedio de PTH 30,5 (1,4-169), 58% presentó hipocalcemia, solo 17 pacientes fueron sintomáticos. PTH promedio en pacientes sintomáticos fue de 7,8 pg/ml. Curva ROC con área bajo la curva de 0,83 (0,75-0,92). Considerando valores útiles para la práctica clínica, una PTH menor a 6,3 (valor más bajo en nuestro laboratorio), tiene sensibilidad de 97%. El valor 18 de PTH (límite inferior del rango de normalidad del laboratorio) se obtiene 88,89% de sensibilidad con 66,07% de especificidad. Y con un valor de 47 pg/ml, se obtiene con un 91% de especificidad para predecir pacientes que no tendrían hipocalcemia. Conclusión: Con un valor de PTH disminuido bajo su valor normal, se puede decir que el riesgo de tener hipocalcemia es sobre el 80%, por lo que se debería iniciar tratamiento profiláctico y desistir del alta. En cambio, para definir un valor superior sobre el cual dar de alta precoz con seguridad, faltan más estudios.

Aim: To evaluate the association between PTH (parathormone) value measured at 6 hours postoperatively of patients submitted to total thyroidectomy, and the presentation of hypocalcemia in the first 24 hours. Materials and Method: Retrospective study of 173 patients with total thyroidectomy between January 2016 to December 2018 in HMS. Demographic and perioperative data were reviewed. The ROC curve was used to evaluate the association between PTH and hypocalcemia in our patients. Results: 106 patients meet inclusion criteria. Average of PTH 30.5 (1.4-169), 58% presented hypocalcemia, 17 patients were symptomatic. ROC curve with area under the curve of 0.83 (0.75-0.92) was obtained considering useful values for clinical practice, a PTH less than 6.3 (lowest value in our laboratory), has 97% sensitivity to predict hypocalcemia. If we use the value 18 we obtain 88.89% sensitivity with 66.07% specificity. And with a value of 47, it is obtained with 91% specificity to predict patients who would not have hypocalcemia Conclusion: With a PTH value decreased below its normal value, it can be said that the risk of having hypocalcemia is over 80%, so that prophylactic treatment should be initiated. To define a value on which to register early with security, more study is needed.

Patient-Centered Preference Assessment to Improve Satisfaction With Care Among Patients With Localized Prostate Cancer: A Randomized Controlled Trial.

PURPOSE: To study the effectiveness of the Patient Preferences for Prostate Cancer Care (PreProCare) intervention in improving the primary outcome of satisfaction with care and secondary outcomes of satisfaction with decision, decision regret, and treatment choice among patients with localized prostate cancer. METHODS: In this multicenter randomized controlled study, we randomly assigned patients with localized prostate cancer to the PreProCare intervention or usual care. Outcomes were satisfaction with care, satisfaction with decision, decision regret, and treatment choice. Assessments were performed at baseline and at 3, 6, 12, and 24 months, and were analyzed using repeated measures. We compared treatment choice across intervention groups by prostate cancer risk categories. RESULTS: Between January 2014 and March 2015, 743 patients with localized prostate cancer were recruited and randomly assigned to receive PreProCare (n = 372) or usual care (n = 371). For the general satisfaction subscale, improvement at 24 months from baseline was significantly different between groups (P < .001). For the intervention group, mean scores at 24 months improved by 0.44 (SE, 0.06; P < .001) from baseline. This improvement was 0.5 standard deviation, which was clinically significant. The proportion reporting satisfaction with decision and no regret increased over time and was higher for the intervention group, compared with the usual care group at 24 months (P < .05). Among low-risk patients, a higher proportion of the intervention group was receiving active surveillance, compared with the usual care group (P < .001). CONCLUSION: Our patient-centered PreProCare intervention improved satisfaction with care, satisfaction with decision, reduced regrets, and aligned treatment choice with risk category. The majority of our participants had a high income, with implications for generalizability. Additional studies can evaluate the effectiveness of PreProCare as a mechanism for improving clinical and patient-reported outcomes in different settings.

Surgical Consultation as Social Process: Implications for Shared Decision Making.

OBJECTIVE: This qualitative study examines surgical consultation as a social process and assesses its alignment with assumptions of the shared decision-making (SDM) model. SUMMARY OF BACKGROUND DATA: SDM stresses the importance of patient preferences and rigorous discussion of therapeutic risks/benefits based on these preferences. However, empirical studies have highlighted discrepancies between SDM and realities of surgical decision making. Qualitative research can inform understanding of the decision-making process and allow for granular assessment of the nature and causes of these discrepancies. METHODS: We observed consultations between 3 general surgeons and 45 patients considering undergoing 1 of 2 preference-sensitive elective operations: (1) hernia repair, or (2) cholecystectomy. These patients and surgeons also participated in semi-structured interviews. RESULTS: By the time of the consultation, patients and surgeons were predisposed toward certain decisions by preceding events occurring elsewhere. During the visit, surgeons had differential ability to arbitrate surgical intervention and construct the severity of patients' conditions. These upstream dynamics frequently displaced the centrality of the risk/benefit-based consent discussion. CONCLUSION: The influence of events preceding consultation suggests that decision-making models should account for broader spatiotemporal spans. Given surgeons' authority to define patients' conditions and control service provision, SDM may be premised on an overestimation of patients' power to alter the course of decision making once in a specialist's office. Considering the subordinate role of the risk/benefit discussion in many surgical decisions, it will be important to study if and how the social process of decision making is altered by SDM-oriented decision aids that foreground this discussion.

Second premolar agenesis as a subclinical phenotype of isolated cleft palate.

OBJECTIVE: To compare the prevalence of dental anomalies in patients with isolated cleft palate with or without hypodontia of the second premolar. SETTING AND SAMPLE POPULATION: A total of 653 patients with isolated cleft palate aged 8-12 years were divided into two groups: G1-subjects without hypodontia of second premolar (n = 546) and G2-subjects with hypodontia of at least one-second premolar (n = 107). The control group consisted of 107 non-cleft orthodontic patients. MATERIALS & METHODS: Panoramic and periapical radiographs and dental casts were used to analyze the presence of dental anomalies. Intergroup comparisons were performed using the chi-square test complemented by Proportion test and Bonferroni test. RESULTS: G2 presented higher prevalence of hypodontia of other permanent teeth compared to G1 and control. Ectopic eruption of the maxillary canine and tooth transposition were more frequent in patients with a cleft compared to patients without a cleft, without statistical differences. Deciduous molar infra-occlusion and second premolar disto-angulation were less prevalent in G1 and G2 compared to the control group. G2 showed a higher prevalence of complete cleft palate than G1. CONCLUSION: Patients with cleft palate and second premolar agenesis showed increased prevalence of tooth agenesis and palatally displaced canines.

Impact of Cost Sharing on Therapeutic Substitution: The Story of Statins in 2006.

BACKGROUND: Cost sharing is widely used to encourage therapeutic substitution. This study aimed to examine the impact of increases in patient cost-sharing differentials for brand name and generic drugs on statin utilization on entry into the Medicare Part D coverage gap. METHOD AND RESULTS: Using 5% Medicare Chronic Condition Warehouse files from 2006, this quasi-experimental study examined patients with hyperlipidemia who filled prescriptions for atorvastatin or rosuvastatin between January and March 2006. Propensity score matching and difference-in-difference regressions were used to compare changes in statin utilization for the study group (patients who were not eligible for low-income subsidies [non-LIS] and had generic-only gap coverage) to those of a control group (LIS patients who faced the same cost sharing before and during the Part D coverage gap). In the final sample, 801 patients in the study group were matched to 801 patients in the control group. We found that, compared to the control group, the study group had a larger decline in any monthly brand-name statin use (-0.24 30-day fills, P<0.001). This was only partially offset by increased monthly generic statin use (+0.06 30-day fill, P<0.001), with an overall drop in any monthly statin use (-0.18 30-day fills, P<0.001). Overall adherence with statins declined (OR 0.81, P<0.001), and statin discontinuation increased (OR 1.62, P<0.001) in the study group as compared to the control group. CONCLUSIONS: Increases in cost-sharing differentials for brand name and generic drugs on coverage gap entry were associated with discontinuation of statins in Medicare Part D patients with hyperlipidemia.

Effect of oral administration of a continuous 18 day regimen of meloxicam on ovulation: experience of a randomized controlled trial.

BACKGROUND: Cyclooxygenase-2 (COX-2) is expressed in all female reproductive organs. Therefore, inhibitors of COX-2 may affect reproductive function. We evaluated the effect of extended administration of meloxicam on ovulation and the menstrual cycle. Our hypothesis was that meloxicam administered from menstrual cycle day 5- 22 could interfere with follicular rupture, without disrupting the menstrual cycle, and could be a potential non-hormonal contraceptive method. METHODS: The study was conducted in 56 healthy sterilized women. Before the onset of treatment and after the end of treatment, participants were observed during a control cycle to ensure that they had progesterone (P4) serum levels (>12 nmol/l) consistent with ovulation. Participants were treated for 18 days, during three consecutive cycles. They were randomized to 15 or 30 mg/day. The menstrual cycle was monitored with serial ultrasound and hormone assays in blood. RESULTS: Fifty-six volunteers completed the study. In 55% of cycles treated with 15 mg/day and in 78% of cycles treated with 30 mg/day (p<0.001) we observed dysfunctional ovulation defined as follicular rupture not preceded 24-48 h earlier by an LH peak or preceded by a blunted LH peak (<21 IU/l) or not followed by an elevated serum P4 level >12 nmol/l. Ovulation was observed in 44.6% and in 21.7% of women in the lower dose group and the higher dose group, respectively. There were no differences between the two doses in other parameters measured. There were no serious adverse events and adverse events were not different between doses or between control and treated cycles. CONCLUSIONS: Although administration of meloxicam on menstrual cycle days 5- 22 resulted in a dose-dependent inhibition of ovulation, more than 20% of subjects had normal ovulation with the highest dose. IMPLICATIONS: Previous studies have shown that oral meloxicam can delay follicle rupture. This study investigated daily oral meloxicam as a non-hormonal contraceptive. Since ovulation occurs in over 20% of cycles even with a high dose of 30 mg daily, it is not likely that the approach would be a highly effective contraceptive strategy.

Validity of utility measures for women with urge, stress, and mixed urinary incontinence.

OBJECTIVE: We sought to evaluate the construct validity of 3 health status classification system instruments-Health Utilities Index Mark 3 (HUI-3), EuroQol (EQ-5D), and Short Form 6D (SF-6D)-and a visual analog scale (VAS) for measuring utility scores in women with urge, stress, and mixed urinary incontinence. STUDY DESIGN: Utility scores were measured in 202 women with urinary incontinence. Pelvic floor symptom severity and quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. Construct, discriminant, and concurrent validity were evaluated. RESULTS: Significant correlations were noted between utility scores and the Pelvic Floor Distress Inventory (r = -0.22 to -0.42, P < .05) and the Pelvic Floor Impact Questionnaire (r = -0.32 to -0.50, P < .05). Mean utility scores were significantly lower for women with urge or mixed incontinence compared to stress incontinence for the EQ-5D (0.71 ± 0.23, 0.73 ± 0.26, and 0.81 ± 0.16, respectively, P = .02) and the SF-6D (0.76 ± 0.12, 0.74 ± 0.12, and 0.81 ± 0.11, respectively, P = .02) but not the HUI-3 or the VAS. There was a clinically important difference in utility scores (>0.03) between women with urge or mixed incontinence as compared to stress incontinence for the HUI-3, EQ-5D, and SF-6D but not the VAS. Utility preference scores were significantly lower for women with combined urinary and fecal incontinence (0.69-0.73) than urinary incontinence alone (0.77-0.84, P < .01). CONCLUSION: The HUI-3, EQ-5D, and SF-6D, but not the VAS, provide valid measurements for utility scores in women with stress, urge, and mixed urinary incontinence.

Indicadores de calidad en cáncer de mama / Quality indicators in breast cancer surgery

Introduction: although clear guidelines for breast cancer management have been developed and widespread, there are many variations between centers and even among breast cancer surgeons, with impact in clinical outcomes. Use of quality indicators to assess surgical care allows comparison with standards and with other centers and monitoring changes post intervention. Objective: to apply quality indicators to breast cancer surgery and evaluate usefulness. Material and Methods: selected indicators obtained from EUSOMA 2008 workshop were applied to 213 consecutive surgical treatment breast cancer patients from Hospital Militar de Santiago de Chile between 2006 and 2011, comparing results with previously defined standards. Results: benign/malignant index in surgical biopsies: 1: 2.27 (minimum standard: 1/2; Optimum: 1/4), patients with complete pathologic report percentage: 99,2 percent (minimum: 95 percent, optimum: 98 percent), breast conserving surgery percentage: 80.20 percent (minimum: 70 percent, optimum: 80 percent), patients with sufficient axillary sampling percentage: 92.4 percent (minimum: 95 percent, optimum: 98 percent), correct axillary dissection indication percentage: 100 percent (minimum: 95 percent, optimum: 98 percent) and patients who underwent single surgery percentage: 90.40 percent (minimum: 80 percent, optimum: 90 percent), most of them ranged between established standards. Conclusion: the use of quality indicators allows breast cancer surgery result evaluation, enabling comparison between centers and established standards, giving objective and reproducible information, helpful to plan process optimization. These or similar indicators are useful in all breast cancer treatment steps and for breast cancer unit accreditation processes. Our indicator values that are under the standard reveal that some specific local indicators are required.

Introducción: aunque existen guías clínicas ampliamente difundidas para el manejo del cáncer de mama, las variaciones entre centros impactan en los resultados. El uso de indicadores de calidad, permite compararse con estándares, con otros centros y evaluar los cambios posteriores a una intervención. Objetivos: aplicar indicadores de calidad al tratamiento quirúrgico del cáncer de mama evaluando su utilidad. Material y Métodos: se aplicó indicadores de calidad a 213 pacientes consecutivos sometidos a cirugía por cáncer de mama en el Hospital Militar de Santiago entre mayo/2006 y abril/2011, comparando los resultados con estándares. Resultados: se calculó: índice benignidad/malignidad en biopsias quirúrgicas: 1:2,27 (mínimo 1:2; óptimo 1:4), porcentaje pacientes con informe patológico completo 99,2 por ciento (mínimo: 95 por ciento, óptimo: 98 por ciento), porcentaje cirugía conservadora 68,42 por ciento (mínimo: 70 por ciento, óptimo: 80 por ciento), porcentaje pacientes con muestreo axilar suficiente 92,40 por ciento (mínimo: 95 por ciento, óptimo: 98 por ciento), porcentaje pacientes con indicación adecuada de disección axilar 100 por ciento y porcentaje pacientes que requirió una sola cirugía 90,40 por ciento (mínimo: 80 por ciento, óptimo: 90 por ciento). La mayoría cumplió los estándares establecidos. Conclusión: la utilización de indicadores de calidad permite evaluar resultados a través del tiempo, compararse con otros centros, y con los estándares establecidos. Proporciona información objetiva y reproducible que permite evidenciar los puntos críticos en los procesos y focalizarse en ellos. El uso de indicadores de calidad puede ampliarse a todas las etapas del tratamiento del cáncer de mama y servir para unificar criterios en acreditación. El análisis de los valores que resultaron bajo el estándar reveló la necesidad de proponer nuevos indicadores útiles a nivel local.

Estrategias de detección precoz de melanoma cutáneo / Strategies for early detection of cutaneous melanoma

La incidencia y mortalidad del melanoma cutáneo en Chile ha presentado un aumento sostenido en las últimas décadas. El conocimiento de que la exposición excesiva a la irradiación ultravioleta es un importante factor de riesgo modificable para desarrollar melanoma cutáneo, ha permitido disminuir, en algunos países, la incidencia del melanoma cutáneo con campañas de educación y políticas que disminuyan la exposición solar. Una vez producida la enfermedad, el principal factor determinante de su pronóstico es la precocidad del diagnóstico. Las estrategias de detección precoz constituyen la intervención de mayor relevancia para la población. Estas estrategias pueden ser dirigidas a la población general o a poblaciones específicas de alto riesgo de melanoma como, por ejemplo, miembros de familias con melanoma hereditario. El conocimiento y la correcta aplicación de estas técnicas diagnósticas tiene un efecto significativo sobre la sobrevida y la morbilidad asociada al tratamiento del melanoma cutáneo. El objetivo del presente trabajo es entregar una breve síntesis de las estrategias de detección precoz que han demostrado ser de utilidad en la prevención primaria y secundaria de melanoma maligno.

The incidence and mortality of malignant melanoma in Chile has increased over the last decades. Current knowledge regarding ultraviolet radiation exposure as a modifiable risk factor to develop melanoma, has enabled a decrease in the incidence of melanoma in some countries that have applied population based education strategies against sun exposure. Once melanoma has developed, early diagnosis is the main factor determining its prognosis, strategies focused on early detection are the most important intervention over the population. These strategies can be directed towards the general population or focused over specific populations sharing high risk of malignant melanoma: for example, family members with familial melanomas.The knowledge and correct usage of these diagnostic methods has a significant effect on mortality and morbidity related to the treatment of cutaneous melanoma. Our objective is to give a brief synthesis of early detection strategies that have demonstrated to be useful in primary and secondary prevention of melanoma.

Effect of PM(10) and O(3) on infant mortality among residents in the Mexico City Metropolitan Area: a case-crossover analysis, 1997-2005.

INTRODUCTION: Consistent evidence has shown a positive association between air pollution and daily mortality among adults. Less is known about its effect on infant mortality and the modification of this association by socioeconomic status (SES). OBJECTIVE: To assess the association of particulate matter with an aerodynamic diameter of ≤10µm (PM(10)) and ozone (O(3)) on infant mortality and its modification by SES. METHODS: We evaluated the relationship of 24 h mean PM(10) and 1h daily maximum O(3) levels with 12 079 all-cause deaths (3903 respiratory deaths) among 1- to 11-month-old infants residing in the Mexico City Metropolitan Area between January 1997 and December 2005 using a case-crossover approach. The data were analysed using conditional logistic regression models, controlling for weather conditions and day of the week. RESULTS: Single-effect models showed, for all-cause mortality, increases of 5.5% (95% CI 1% to 10%) at lag1 and 6.6% (2% to 11.4%) at lag2; cumulative exposure models (0-2 days) showed an increase of 6.3% (0.01% to 32.7%). Respiratory mortality increased marginally at 5.3% (-0.02% to 13.2%) with a 1-day lag and 10% (2.1% to 18%) with a 2-day lag per increase of 38.7 µg/m(3) (IQR) in PM(10) levels. When data were stratified by SES (low, medium, and high), only infants with low and medium SES presented a significant increase in risk of all-cause mortality and respiratory mortality in relation to PM(10). O(3) was only significantly related to respiratory mortality in low SES. CONCLUSION: Our results suggest that in the Mexico City Metropolitan Area, infants with lower SES (low to medium) are at higher risk of mortality when exposed to ambient PM(10) and O(3).

[Occult breast cancer: Report of two cases]. / Cancer de mama oculto: dos casos clínicos analizados según el concepto actual.

Occult breast cancer is expressed as a metastatic axillary lymph node without clinical or imaging evidence of a primary tumor in the breast. The old concept involved non palpable tumors. Its incidence is low, representing only 0.3 to 1% of all breast cancer cases. The search for the primary tumors is performed with mammography, whose sensitivity is low, ranging from 0 to 56%. Several studies have shown a higher sensitivity of magnetic resonance imaging, ranging from 85 to 100%, to detect occult lesions. The treatment of isolated axillary metastases of breast cancer is controversial. An axillary dissection is recommended. If there is a suspicious image, a radiosurgical or stereotaxic biopsy should be done. However, in patients without radiological lesions in the breast, the tendency is not to perform a radical mastectomy as previously recommended, since the primary tumor will not be found in the surgical specimen in two thirds of cases. A superior and external quadrantectomy or exclusive radiotherapy should suffice. An expecting behavior is not recommended as a therapeutic alternative. Treatment should be complemented with hormonal therapy or chemotherapy. The literature suggests that prognosis is better than stage II, with a ten years survival ranging from 50 to 71%. We report two patients with a well defined occult breast cancer and based on them, a review of the subject is attempted. Considering its prognosis, physicians should be aware of this uncommon and difficult to diagnose disease.

Cancer de mama oculto: dos casos clínicos analizados según el concepto actual / Occult breast cancer: Report of two cases

Occult breast cancer is expressed as a metastatic axillary lymph node without clinical or imaging evidence of a primary tumor in the breast. The old concept involved non palpable tumors. Its incidence is low, representing only 0.3 to 1 percent of all breast cancer cases. The search for the primary tumors is performed with mammography, whose sensitivity is low, ranging from 0 to 56 percent. Several studies have shown a higher sensitivity of magnetic resonance imaging, ranging from 85 to 100 percent, to detect occult lesions. The treatment of isolated axillary metastases of breast cancer is controversial. An axillary dissection is recommended. If there is a suspicious image, a radiosurgical or stereotaxic biopsy should be done. However, in patients without radiological lesions in the breast, the tendency is not to perform a radical mastectomy as previously recommended, since the primary tumor will not be found in the surgical specimen in two thirds of cases. A superior and external quadrantectomy or exclusive radiotherapy should suffice. An expecting behavior is not recommended as a therapeutic alternative. Treatment should be complemented with hormonal therapy or chemotherapy. The literature suggests that prognosis is better than stage II, with a ten years survival ranging from 50 to 71 percent. We report two patients with a well defined occult breast cancer and based on them, a review of the subject is attempted. Considering its prognosis, physicians should be aware of this uncommon and difficult to diagnose disease.

Acceso venoso prolongado en el paciente oncológico / Prolonged venous access in the oncologic patient

En el manejo actual del paciente oncológico que requiere de tratamiento sistémico prolongado, es fundamental disponer de un acceso venoso adecuado. En el transcurso del tiempo se han desarrollado y utilizado distintos procedimientos para cumplir este objetivo hasta llegar a los catéteres centrales con reservorio subcutáneo, que son los más utilizados en este momento y con los que se dispone de un acceso venoso eficiente y con el menor disconfort para los pacientes. El acceso venoso es una necesidad importante en el cuidado y manejo del paciente oncológico. El desarrollo y uso de drogas antineoplásicas sistémicas en un mayor número de patologías neoplásicas ha significado que muchos pacientes requieran el empleo de un acceso venoso central prolongado. Esto evita venopunciones repetidas y traumáticas que con el tiempo se hacen cada vez más dificultosas, agregando a esto el compromiso venotóxico que los agentes antineoplásicos producen en la integridad venosa. A través del tiempo, se han utilizado distintos procedimientos para cumplir esta necesidad

Valor de la tomografía de emisión de positrones con F18-fluordeoxiglucosa (PET-FDG) en pacientes con cáncer de mama / Use of positron emisión tomography (pet) with F18-fluorodeoxyglucose in patients with breast cancer

El PET es un técnica de imágenes que permite evaluar el hipermetabolismo glucídico tumoral con Flúor-18deoxiglucosa (FDG). Su utilidad en cáncer de mama ha sido ampliamente estudiada. El objetivo fue evaluar los resultados del PET-FDG en nuestro medio en pacientes con cáncer de mama. Método: SE analizaron 52 estudios en 44 pacientes con cáncer de mama (100 por ciento mujeres, edad: 52 ± 12 años). Se utilizó equipo PET dedicado y se realizaron imágenes de cuerpo entero. Se efectuó seguimiento clínico e histológico cuando estaba disponible. Resultados: A. Diagnóstico inicial y etapificación: En 2 pacientes, se encontraron focos hipermetabólicos en mamas, sin compromiso a distancia y fueron sometidas a cirugía con confirmación histológica. Tres pacientes fueron evaluadas sólo para etapificación. B. Reetapificación: De 23 pacientes, en 11 se demostró diseminación secundaria, por lo que fueron tratadas con quimioterapia u hormonoterapia, sin confirmación histológica de las lesiones. En 12 pacientes, el PET fue negativo y el seguimiento clínico no ha demostrado alteraciones hasta la fecha. C. Sospecha de recidiva: En 15 pacientes se realizó el PET por alteraciones en la mamografía, elevación de marcadores tumorales o alteraciones sospechosas en otros estudios. Se encontró recidiva local en 2 pacientes, metástasis en 6 y PET normal en 7. D. Evaluación de terapia: En 9 pacientes, se controló la respuesta a tratamiento, encontrando regresión parcial, progresión o respuesta mixta en 8 de ellas y un estudio negativo (respuesta completa). Conclusión: En esta serie inicial, se confirma que el PET FDG es una herramienta útil en el control del cáncer de mama, tanto en diagnóstico, etapificación, reetapificación, evaluación de recurrencia y control de terapia.

Radioterapia en la neomama reconstruida con tejido autológo: efecto en la estética, complicaciones y control local / Effects of radiotherapy on mammary reconstruction with autologous tissues

Introducción: Un subgrupo de pacientes sometidas por cáncer de mama a mastectomía y reconstrucción mamaria inmediata (RM) con colgajo miocutáneo de recto anterior del abdomen (TRAM Flap), necesitará de radioterapia externa para el control de su enfermedad. El efecto de la radiación sobre los colgajos usados para RMI esta poco dilucidado. Material y Método: Estudio retrospectivo entre abril 1994 y diciembre 2003. Se confeccionaron dos grupos. El grupo 1: Catorce (14) mujeres sometidas a mastectomía con conservación de piel y RMI con TRAM Flap pediculizado a las que se les realizó radioterapia fraccionada adyuvante. Grupo 2: Treinta mujeres (30) sometidas a mastectomía con conservación de piel y RMI con TRAM Flap pediculizado sin radioterapia adyuvante. Se compararon los resultados cosméticos, la morbilidad y el control local de la enfermedad entre ambos grupos. Resultados: El seguimiento mínimo fue de 6 meses post radioterapia y/o cirugía. En ambos grupos el resultado cosmético fue comparable. No hubo pérdida de colgajos ni reducción importante de volumen por contractura en el grupo irradiado. Dos pacientes del grupo 1 y dos pacientes en el Grupo 2 requirieron de biopsia por necrosis grasa sospechosa de recidiva tumoral. Ninguna de las 44 pacientes ha presentado recidiva locorregional. Una paciente del Grupo 2 falleció por diseminación a distancia y una se encuentra con enfermedad metastásica en tratamiento hormonal. Conclusión: Los efectos de la radioterapia sobre una neomama reconstruida con tejido autólogo son menores y sin significativa relevancia. La posibilidad de radioterapia post operatoria después de un TRAM Flap no debe ser obstáculo para la RMI.

Biopsia del ganglio centinela axilar en cáncer de mama: ¿estamos en condiciones de validar el método? / Axillary sentinel lymph node biopsy in breast cancer: are we in conditions for validate this method?

Se presentan los resultados de 59 pacientes con cáncer de mama en etapa in situ, I y II con axila clínicamente negativa, en las cuales se efectuó el procedimiento biopsia de ganglio centinela axilar (GC) entre febrero del 2000 y julio de 2002. El objetivo de este estudio es analizar la experiencia recogida con este grupo de pacientes enfatizando las fallas del método y estableciendo sus posibles causas, comparándolas con otras casuísticas, como forma de validación de este método de etapificación axilar. En 59 pacientes se intentó la biopsia de ganglio centinela axilar con la técnica de colorante isosulfan azul inyectado directamente en el sitio de la tumorrectomía. En 4 pacientes se asoció linfocintigrafía con tecnecio 99-dextrán y uso de gammacámara intraoperatoria para el mapeo linfático y biopsia de ganglio (técnica mixta). En 7 de los 59 pacientes no se encontró ganglio teñido (11,9 por ciento). En los 57 casos de cáncer infiltrante se efectuó disección axilar estándar, sólo 14 tuvieron compromiso histológico por tumor (24,5 por ciento). En los 41 pacientes que el ganglio centinela fue histológicamente negativo en 2 se pesquisó compromiso tumoral en el resto de la axila (falso negativo). Se propone un protocolo para optimizar la técnica del mapeo linfático y biopsia de ganglio centinela axilar para reemplazar la disección axilar estándard en la etapificación del cáncer de mama.

Biopsia del ganglio centinela axilar en cancer de mama: ¿podemos reproducir la experiencia extranjera y validar el metodo?

Se presentan los resultados de 90 pacientes con cáncer de mama en etapa in situ, I y II con axila clínicamente negativa, en las cuales se efectuó el procedimiento biopsia de ganglio centinela axilar (GC) entre febrero del 2000 y marzo del 2003. El objetivo de este estudio prospectivo es comparar la tasa de detección del ganglio centinela con el colorante Isosulfan azul (Lymphazurin 1%) y medir la especificidad y sensibilidad de la técnica con la disección axilar estándar de los niveles I y II de Berg. En 90 pacientes se intentó la biopsia de ganglio centinela axilar con la técnica de colorante Isosulfan azul inyectado directamente en el sitio de la tumorectomía o en el plexo peri areolar de Sappey. En 12 de los 90 pacientes no se encontró ganglio teñido (13%). De los 90 casos, 85 correspondían a cáncer infiltrante y 5 CDIS extenso con microinvasión. En todos se efectuó disección axilar estándar, solo en 22 de los 85 cánceres infiltrantes se encontró compromiso histológico por tumor (36%). No se pesquiso compromiso axilar en ninguno de los 5 CDIS. En los 56 pacientes que el ganglio centinela fue histológicamente negativo en 3 había compromiso tumoral en el resto de la axila (falso negativo). Concluimos que esta técnica pude ser reproducida a nivel nacional con los beneficios que conlleva el no realizar disección axilar estándar a todas las pacientes con cáncer de mama operable.

Análisis histopatológico del ganglio centinela: técnica y resultados / Sentinel lymph histopathological analysis: technic and results

En la mayoría de los tumores sólidos el compromiso ganglionar neoplásico regional es el principal factor pronóstico en ausencia de enfermedad a distancia. La necesidad imperiosa de conocer esta situación ha motivado el vertiginoso desarrollo del mapeo linfático y biopsia del ganglio centinela. En esta presentación exponemos nuestra experiencia en los primeros 60 estudios histopatológicos de ganglio centinela (30 melanomas, 18 cánceres de mama, 10 cánceres cutáneos no melanoma y 2 carcinomas vulvares. Todos los ganglios centinela fueron fijados en formalina tamponada por 8 horas, procesando la totalidad del ganglio y realizando tinción clásica con hematoxilina-eosina. Ocasionalmente se usaron otras tinciones especiales complementarias (PAS, melanina, etc.). A todos los ganglios catalogados como negativos con H&E se les practicó tinción inmunohistoquímica (HQ) específica para la patología en estudio. De los 65 ganglios estudiados 11 fueron positivos para neoplasia con H&E (6/30 melanomas y 5/18 carcinomas mamarios). De los 54 ganglios negativos con H&E tratados con IHQ 3 demostraron presencia de células tumorales (2/24 melanomas y 1/13 carcinomas mamarios). Se concluye lo trascendente de un acucioso estudio histopatológico del ganglio centinela para obtener un certero diagnóstico del compromiso ganglionar regional de la enfermedad y desarrollar una terapia más eficaz