Cateterización bilateral de los senos petrosos inferiores: utilidad en el síndrome de cushing / Bilateral catheterization of inferior petrosal sinous: utility in cushing’ syndrome

Objetivo: Presentar la experiencia de los autores en el cateterismo bilateral y simultáneo de los senos petrosos inferiores (SPI) en pacientes con síndrome de Cushing dependientes de la hormona adrenocorticotropa (ACTH ). Material y método: Un estudio retrospectivo desde enero de 2003 hasta septiembre de 2009 con nueve pacientes (dos hombres y siete mujeres) diagnosticados con síndrome de Cushing y ACTH dependientes. Se cateterizaron simultáneamente los senos petrosos inferiores, estudiando la ACTH basal y tras un estímulo con la CRH, a fin de medir los gradientes intrahipofisarios y en sangre periférica. La sospecha diagnóstica se realizó por concentraciones inapropiadas y persistentemente elevadas de cortisol plasmático y del cortisol libre urinario; así como por ausencia de supresión con la dexametasona. En todos, salvo uno, las pruebas de imagen fueron negativas. Resultados: La cateterización fue exitosa y sin complicaciones. Hubo un diagnóstico definitivo en todos los casos. Conclusión: En los pacientes seleccionados, la cateterización de los SPI fue un procedimiento eficiente en el diagnóstico diferencial del síndrome de Cushing y en la localización intrahipofisaria de la secreción de ACTH.

Objective: The aim of this study is to present our experience on bilateral and simultaneous inferior petrous sinus catheterization, on those patients with ACTH -dependent Cushing’s sydrome. We describe the procedure and our results. Material and Method: A retrospective study was held between January 2003 and September 2009, including nine patients (2 men, 7 women) presenting ACTH -dependentCushing’s syndrome. Simultaneous inferior petrosal sinus catheterization was performed in all of them, sampling basal ACTH and after CRH stimulation. ACTH levels gradient in different pituitary locations and peripheral blood levels was recorded. Diagnosis was suggested when inappropriate and maintained hypercortisolemia. High urinary free cortisol levels and no response to dexamethasone suppressionwere detected. Eight out of nine patients had a prior negative imaging test result. Results: Inferior petrosal sinus bilateral catheterization was successfully performed in all cases, with no evidence of further complications. The results showed definitive diagnosis in all cases. In four patients ACTH levels gradient was lateralized to the left, leading to a specific surgical approach. One patient presented pituitary ACTH -secreting adenoma. Two other patients showed ectopic ACTH production, one showedsuprarenal adenoma secreting ACTH and other one showed response to pituitary stimulation without side lateralisation, presenting a histological diagnosis of pituitary hyperplasia. Conclusion: Petrosal sinus catheterization is shown to be an efficient procedure to manage Cushing’s syndrome differential diagnosis and to obtain specific anatomical information.

Right gastric artery embolization prior to treatment with yttrium-90 microspheres.

PURPOSE: Intra-arterial infusion of yttrium-90 microspheres is a form of radiation treatment for unresectable hepatic neoplasms. Misdeposition of particles in the gastroduodenal area such as the right gastric artery (RGA) may occur with serious consequences. We present a series of patients who underwent a detailed vascular study followed by RGA embolization. Special emphasis is placed on anatomic variations and technical considerations. METHODS: In a 1 year period, 27 patients were treated. Initial vascular evaluation was performed, with careful attention to anatomic variants or extrahepatic arterial supply, especially to the gastroduodenal area. Embolization of such arteries was planned if needed. RGA embolization was performed antegradely from the hepatic artery or retrogradely via the left gastric artery (LGA). Postprocedural follow-up included clinical interview and gastroscopy if necessary. RESULTS: RGA embolization was performed in 9 patients presenting with primary (n = 3) or metastatic liver tumors (n = 6). Six patients underwent antegrade RGA embolization and 3 had embolization done retrogradely via the LGA. Retrograde access was chosen for anatomic reasons. None of the patients complained of gastroduodenal symptoms. CONCLUSION: RGA embolization can help minimize the gastroduodenal deposition of radioactive particles. RGA embolization should routinely be carried out. The procedure can be performed, with similar technical success, by both anterograde and retrograde approaches.

Late perforation of a thoracic aortic dacron graft by a metallic stent-graft component.

PURPOSE: To describe a case involving perforation of a previously placed aortic Dacron graft by the uncovered proximal stent of a thoracic stent-graft. CASE REPORT: A 76-year-old man with a surgically treated type A dissection presented with residual type B dissection. Thoracic stent-grafting of the entry site was performed successfully. After 2 years, the patient was admitted for evaluation of a non-pulsating parasternal mass. Computed tomography showed a large, hypodense liquid-like mass affecting the mediastinum up to the subcutaneous tissue. A false aneurysm at the proximal end of the stent-graft was observed arising from an aortic perforation by the uncovered stent. One week later, the mass had almost completely resolved, and the patient has been scheduled for close surveillance. CONCLUSION: This case illustrated the importance of thoroughly examining the long-term durability and compatibility of prosthetic materials.

Transrectal US-guided seminal vesiculography and ejaculatory duct recanalization and balloon dilation for treatment of chronic pelvic pain.

Ejaculatory duct obstruction (EDO) is an uncommon but correctable cause of infertility and male chronic pelvic pain. The condition is thought to be underdiagnosed, but the increased application of noninvasive imaging tools, specifically transrectal ultrasonography (US), has lead to greater recognition of EDO. Moreover, the development of minimally invasive therapies now offers comprehensive evaluation and treatment options with low morbidity for select patient groups. This report describes the technique of transrectal US-guided seminal vesiculography, percutaneous recanalization, and ejaculatory duct balloon dilation for EDO as a treatment for male chronic pelvic pain.

Complications of embolization.

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Reservorio intraarterial hepático para quimioterapia. Colocación percutánea en la arteria subclavia izquierda / Intra-arterial hepatic reservoir for chemotherapy. Percutaneous placement in left subclavian artery

Objetivos: Describir la técnica empleada y valorar los resultados, en la implantación percutánea de un catéter en la arteria hepática a través de la subclavia izquierda, para administración de quimioterapia regional. Material y métodos: Entre abril de 1999 y junio de 2002, a 33 pacientes (17 varones y 16 mujeres) de 52,9 años de media y con evidencia de lesión hepática (32 metástasis hepáticas, un hepatocarcinoma fibrolamelar), se les implantaron 36 catéteres intraarteriales. El acceso en todos los casos fue la arteria subclavia izquierda con guía ecográfica. Se estudió la vascularización hepática y se emplazó el catéter distal en arteria hepática. Asimismo, se embolizaron ramas extrahepáticas de la arteria hepática, para evitar fuga del quimioterápico. La cánula se conectó al reservorio (Port-a-cath Titaniumvenous system. Daltec MN. USA) implantado, subcutáneo, próximo al punto de punción. Resultados: El éxito técnico se consiguió en todos los casos (catéter en arteria hepática común en 31 casos, tres en la arteria hepática derecha, uno en la arteria hepática izquierda procedente de la gástrica izquierda y uno en la arteria hepática derecha procedente de la mesentérica superior). La permanencia de los reservorios osciló entre 22 y 740 días (media, 222,4 días). Se registraron complicaciones en 13 casos (36,1%): cinco migraciones de cánula, cuatro vainas de fibrina, tres obstrucciones del vaso cateterizado, una contaminación y una fuga en la conexión. Se solucionaron de modo percutáneo o con retirada del dispositivo. Conclusión: La implantación percutánea de un catéter intraarterial hepático y reservorio, a través de la subclavia izquierda con ayuda ecográfica, es técnicamente factible, y con una tasa de complicaciones aceptable además de solucionables percutáneamente

Objetives: To describe the technique used and to assed about the results obtained in the percutaneous implantation of a catheter in hepatic artery (HA) through left subclavian artery to administer regional chemotherapy. Material and methods: Between April 1999 and June 2002, 33 patients (17 men and 16 women) with a mean age of 52.9 years and with evidence of hepatic lesion (32 hepatic metastases, 1 fibrolamellar hepatocarcinoma (HCC), 36 intra-arterial catheters were implanted. Access in every case was the left subclavian artery with ultrasonographic guide. Hepatic vascularization was studied and distal catheter was located in the HA. Furthermore, extrahepatic branches of the HA were embolized to avoid chemotherapeutic escape. The cannula was connected to the subcutaneous implanted reservoir (Port-a-cath Titaniumvenous system. Daltec. M.N. USA) close to the puncture point. Results: Technical success was achieved in every case (catheter in common HA 31 cases, 3 in right HA, 1 in left HA from left gastric artery and 1 in right HA from upper mesenteric artery). The permanence of the reservoirs ranged from 22 to 740 days (mean 222.4 days). Complications were recorded in 13 cases (36.1%): 5 canula migrations, 4 fibrin sheath, 3 obstruction of catheterized vessel, 12 contamination and 1 escape from the connection. They were solved percutaneously or by withdrawal of the device. Conclusion: Percutaneous implantation of an intra-arterial hepatic catheter and reservoir through the left subclavian artery with ultrasonographic guidance is technically feasible and has an acceptable rate of complications besides being percutaneously solutionable

Embolización portal prequirúrgica / Presurgical portal embolization

En pacientes con tumores hepáticos, el tratamiento más eficaz es la cirugía. Sin embargo, no todos pueden ser tratados de esta manera. Uno de los motivos que contraindican el tratamiento quirúrgico es que el parénquima hepático que queda tras la resección de la zona tumoral sea insuficiente para asegurar la función hepática del paciente. Es conocido que el hepatocito, tras determinados estímulos, tiene la posibilidad de desdiferenciarse y clonarse. La embolización portal prequirúrgica (EPP) del volumen hepático que se va a resecar puede generar, tras este estímulo y respuesta (que será diferente en hígados fibróticos y no fibróticos), un crecimiento hepático que alcanzará niveles adecuados en 3-4 semanas. Por tanto, la EPP puede incrementar el número de candidatos a recibir tratamiento quirúrgico y, del mismo modo, puede disminuir la aparición de posibles complicaciones postoperatorias. En este artículo se presentan lo criterios de inclusión y exclusión que, de forma comúnmente aceptada, se utilizan para realizar una EPP. No hay acuerdo, sin embargo, sobre la técnica más adecuada para acceder al sistema portal, por ejemplo, la vía contralateral (con punción de los segmentos portales que no van a ser resecados) tiene considerables ventajas técnicas, pero pone en riesgo de trombosis a las ramas portales del tejido hepático sano. Son muchos los materiales embolizantes que se han usado en EPP, algunos autores recomiendan el empleo de «pegamentos», pues son relativamente sencillos de utilizar, de bajo coste y altamente eficaces pero, por otra parte, generan una importante inflamación periportal que puede dificultar la resección quirúrgica. Si se emplean partículas, éstas deben ser de un tamaño que oscile entre las 100 y las 300 micras. En conclusión, aunque todavía hay muchos aspectos de la EPP que requieren ser investigados, la técnica debería de estar disponible en todos los centros en los que se realice cirugía hepática, pues los beneficios clínicos derivados de ésta son muy satisfactorios

Surgery is the most efficacious treatment for hepatic tumors; however, not all patients with hepatic tumors can be treated surgically. One condition in which surgery is contraindicated is when the amount of liver parenchyma remaining after resection of the affected zone is considered to be insufficient to ensure hepatic function. The hepatocyte is known to be able to dedifferentiate and clone itself after certain stimuli. Presurgical portal embolization (PPE) of the hepatic volume to be resected can generate hepatic growth after this stimulus and response (which will be different in fibrotic and nonfibrotic livers), achieving adequate levels within 3-4 weeks. Therefore, PPE can increase the number of candidates for surgical treatment and decrease the number of possible postsurgical complications. This article describes the commonly accepted inclusion and exclusion criteria used for PPE. There is no consensus, however, regarding the most appropriate technique for accessing the portal system. For example, the contralateral approach (with puncture of the portal segments that are not to be resected) has considerable technical advantages, but places the portal branches of healthy liver tissue at risk for thrombosis. Many different materials have been used for embolization in PPE. Some authors recommend the use of "glues", as these are relatively easy to use, low cost, and highly efficacious; however, they also generate significant periportal inflammation that can make surgical resection more difficult. If particles are used, they should measure between 100-300 micras. In conclusion, although many aspects of PPE still need to be investigated, this technique should be made available in all centers performing hepatic surgery, as it can result in significant clinical benefits

Early lung cancer detection using spiral computed tomography and positron emission tomography.

RATIONALE: Lung cancer screening using computed tomography (CT) is effective in detecting lung cancer in early stages. Concerns regarding false-positive rates and unnecessary invasive procedures have been raised. OBJECTIVE: To study the efficiency of a lung cancer protocol using spiral CT and F-18-fluorodeoxyglucose positron emission tomography (FDG-PET). METHODS: High-risk individuals underwent screening with annual spiral CTs. Follow-up CTs were done for noncalcified nodules of 5 mm or greater, and FDG-PET was done for nodules 10 mm or larger or smaller (> 7 mm), growing nodules. RESULTS: A total of 911 individuals completed a baseline CT study and 424 had at least one annual follow-up study. Of the former, 14% had noncalcified nodules of 5 mm or larger, and 3.6% had nodules of 10 mm or larger. Eleven non-small cell lung cancers (NSCLC) and one small cell lung cancer (SCLC) were diagnosed in the baseline study (prevalence rate, 1.32%), and two NSCLCs in the annual study (incidence rate, 0.47%). All NSCLCs (92% of prevalence cancers) were diagnosed in stage I (12 stage IA, 1 stage IB). FDG-PET was helpful for the correct diagnosis in 19 of 25 indeterminate nodules. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for the diagnosis of malignancy were 69, 91, 90, and 71%, respectively. However, the sensitivity and negative predictive value of the screening algorithm, which included a 3-month follow-up CT for nodules with a negative FDG-PET, was 100%. CONCLUSION: A protocol for early lung cancer detection using spiral CT and FDG-PET is useful and may minimize unnecessary invasive procedures for benign lesions.

Treatment of ureteroarterial fistulae with covered vascular endoprostheses and ureteral occlusion.

BACKGROUND: Ureteroarterial fistulae (UAFs) are a rare entity, often difficult to identify, and associated with a high mortality rate. This fact has been attributed to a delay in diagnosis and treatment. Five conditions that can predispose to the development of this uncommon entity have been described: prior pelvic surgery, prolonged ureteral stenting, radiation therapy, previous vascular surgery and vascular pathology. METHODS: We present 4 patients with UAFs and at least three of the above-mentioned conditions. Ureteral ischemia and subsequent necrosis promote the formation of these fistulae. The constant pulsation of the iliac artery is transmitted to an already compromised ureter containing a stiff intraluminal foreign body, resulting in pressure necrosis, most likely where the ureter crosses the iliac artery. RESULTS AND CONCLUSION: Cases were managed percutaneously with a combination of the deployment of a covered prosthesis and, when needed, with mechanical occlusion of the ureter. Hematuria stopped in all the patients with no evidence of immediate rebleeding. One patient presented a new episode of vaginal bleeding 13 months after endograft placement and ureteral embolization. Arteriography showed the presence of a hypogastric artery pseudoaneurysm that was occluded using coils. No new bleeding has occurred in this patient 12 months after the second embolization. At present all 4 patients are alive with follow-up periods of 5, 9, 11 and 25 months since the first procedure.

Tumores mucocele-like de mama / Mucocele-like breast tumors

Objetivo: Los tumores mucocele-like (TML) de mama son lesiones infrecuentes que se definen anatomo-patológicamente como quistes o conductos dilatados que contienen mucina. Nuestro objetivo es describir los hallazgos clínicos, mamográficos y ecográficos de los TML de mama. Material y métodos: Estudio retrospectivo. En los archivos de nuestro centro se encontraron cuatro casos de TML, todos ellos confirmados mediante biopsia escisional. Se revisó la presentación clínica (edad y palpación), así como los hallazgos mamográficos y ecográficos. Resultados: La edad media de las pacientes fue de 42 años (rango: 35-48). Uno de los casos resultó palpable, se trataba de un nódulo blando de baja sospecha. Los hallazgos mamográficos consistieron en dos casos en una agrupación de microcalcificaciones polimórficas sospechosas, mientras que en los otros dos las mamografías fueron normales. La ecografía mostró la presencia de quistes con ecos internos difusos en los dos casos con mamografías normales. Conclusiones: Los TML son lesiones mamarias que pueden manifestarse como un nódulo palpable de baja sospecha en la exploración física, como microcalcificaciones sospechosas en mamografía o como quistes con ecos internos difusos en ecografía

Objective: Mucocele-like breast tumors (MLT) are uncommon lesions histologically defined as cysts or dilated ducts that contain mucin. We describe the clinical, mammographic, and echographic findings for MLT. Material and methods: Retrospective study of the four cases of MLT found in our archives; all diagnoses were confirmed at histological study of excisional biopsies. We review the clinical presentation (age and palpation), as well as the mammographic and echographic findings. Results: Mean patient age was 42 years (range: 35-48 years). In one case MLT presented as a soft, low-suspicion, palpable lesion. At mammography, two cases showed a set of suspicious polymorphic micro-calcifications and the other two had normal findings. Echography showed cysts with diffuse internal echoes in the two cases with normal findings at mammography. Conclusions: Breast MLT can present as a low-suspicion palpable nodule at physical examination, as suspicious microcalcifications at mammography, or as cysts with diffuse internal at echography

Disminución de tamaño de un cáncer de mama tras biopsia con aguja gruesa / Reduction in breast tumor size after core needle biopsy

La biopsia de lesiones mamarias con aguja gruesa es una técnica diagnóstica muy difundida, que se acompaña de escasas complicaciones. Presentamos un caso de disminución del tamaño de un carcinoma ductal infiltrante tras la realización de una biopsia con aguja gruesa de calibre 14-G, que complicó la posterior localización con arpón metálico. Tras la escisión de la lesión, se comprobó una extensa necrosis del tumor, con zonas hemorrágicas. En la bibliografía revisada únicamente se han publicado dos casos similares, y ambos tras punciones con aguja fina (AU)

Detección y cuantificación de la calcificación de las arterias coronarias: perspectiva radiológica / Detection and quantification of coronary artery calcification: radiological perspective

La propia historia natural de la arteriosclerosis posibilita el desarrollo de estudios y proyectos dirigidos a identificar y clasificar los sujetos con alto riesgo de presentar enfermedad coronaria. Han sido diversas las técnicas radiológicas que han tratado de determinar la severidad de la afectación de las arterias coronarias, con un éxito relativo. En esta última década, los continuos avances en tomografía computarizada (TC) han posibilitado la detección y cuantificación de los depósitos de calcio en las arterias coronarias, con una sensibilidad y especificidad prácticamente superponibles a los datos obtenidos tras coronariografía. La cuantificación total del calcio coronario, indicador inequívoco de arteriosclerosis, permite estratificar el riesgo cardiovascular de los pacientes de manera no invasiva y con mayor fiabilidad que con los métodos habituales. Hoy día, las principales aplicaciones clínicas de la detección y cuantificación de la ateromatosis coronaria incluyen: dolor torácico de características atípicas; cribado del riesgo coronario en pacientes asintomáticos, y seguimiento de la progresión de la arteriosclerosis coronaria en los pacientes tratados (AU)