Características de la neoplasia quística mucinosa del páncreas en pacientes atendidos en un Hospital Nacional del Perú / Characteristics of pancreatic mucinous cystic neoplasm in patients treated at a National Hospital in Peru

RESUMEN Con el objetivo de analizar las características clínico, patológicas y quirúrgicas de la Neoplasia Quística Mucinosa de páncreas (NQM), se realizó un análisis de los pacientes del servicio de Cirugía de Páncreas, Bazo y Retroperitoneo del Hospital Nacional Guillermo Almenara Irigoyen en Lima, Perú desde enero del 2009 hasta octubre del 2018. La presencia del estroma ovárico se usó como criterio diagnóstico de NQM. De diez pacientes con edad promedio de 47,8 años, nueve fueron mujeres, las lesiones estuvieron localizadas en el páncreas distal, el tamaño tumoral promedio fue de 88,6 mm. En todos los pacientes se realizó una pancreatectomía distal siendo tres laparoscópicas, no hubo reoperaciones ni fallecidos, dos pacientes tuvieron carcinoma invasor asociado. En conclusión, la presentación de NQM es mayor en mujeres de edad media siendo la localización en el páncreas distal y el porcentaje de malignidad bajo. La cirugía laparoscópica es una alternativa de manejo.

ABSTRACT In order to analyze the clinical, pathological, and surgical characteristics of pancreatic mucinous cystic neoplasm (MCN), an analysis of the patients from the Pancreas, Spleen, and Retroperitoneal Surgery Service of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, was performed from January 2009 to October 2018. The presence of ovarian stroma was used as a diagnostic criterion for MCN. From ten patients with an average age of 47.8 years, nine were women; the lesions were located in the distal pancreas, and the average tumor size was 88.6 mm. All patients underwent a distal pancreatectomy, three of which were laparoscopic; there were no reoperations or deaths; two patients had associated invasive carcinoma. In conclusion, the frequency of MCN is higher in middle-aged women, being the location in the distal pancreas and the percentage of malignancy is low. Laparoscopic surgery is a disease management option.

[Characteristics of pancreatic mucinous cystic neoplasm in patients treated at a National Hospital in Peru]. / Características de la neoplasia quística mucinosa del páncreas en pacientes atendidos en un Hospital Nacional del Perú.

In order to analyze the clinical, pathological, and surgical characteristics of pancreatic mucinous cystic neoplasm (MCN), an analysis of the patients from the Pancreas, Spleen, and Retroperitoneal Surgery Service of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, was performed from January 2009 to October 2018. The presence of ovarian stroma was used as a diagnostic criterion for MCN. From ten patients with an average age of 47.8 years, nine were women; the lesions were located in the distal pancreas, and the average tumor size was 88.6 mm. All patients underwent a distal pancreatectomy, three of which were laparoscopic; there were no reoperations or deaths; two patients had associated invasive carcinoma. In conclusion, the frequency of MCN is higher in middle-aged women, being the location in the distal pancreas and the percentage of malignancy is low. Laparoscopic surgery is a disease management option.

Con el objetivo de analizar las características clínico, patológicas y quirúrgicas de la Neoplasia Quística Mucinosa de páncreas (NQM), se realizó un análisis de los pacientes del servicio de Cirugía de Páncreas, Bazo y Retroperitoneo del Hospital Nacional Guillermo Almenara Irigoyen en Lima, Perú desde enero del 2009 hasta octubre del 2018. La presencia del estroma ovárico se usó como criterio diagnóstico de NQM. De diez pacientes con edad promedio de 47,8 años, nueve fueron mujeres, las lesiones estuvieron localizadas en el páncreas distal, el tamaño tumoral promedio fue de 88,6 mm. En todos los pacientes se realizó una pancreatectomía distal siendo tres laparoscópicas, no hubo reoperaciones ni fallecidos, dos pacientes tuvieron carcinoma invasor asociado. En conclusión, la presentación de NQM es mayor en mujeres de edad media siendo la localización en el páncreas distal y el porcentaje de malignidad bajo. La cirugía laparoscópica es una alternativa de manejo.

Factores de sobrevida en 152 pacientes con tumores estromales gastrointestinales / Survival factors in 152 patients with gastrointestinal stromal tumors

INTRODUCCIÓN: El tumor estromal gastrointestinal (GIST), es la designación para un tipo específico de tumor mesenquimal del tracto digestivo que proviene de las células intersticiales de Cajal (ICC) o de sus precursores multipotenciales, es de presentación infrecuente y por ello, su mejor conocimiento deberá incidir en un adecuado manejo diagnóstico y terapéutico. OBJETIVOS: Valorar las características clínicas e identificar los factores que influencian la sobrevida de los pacientes con diagnóstico de tumor estromal gastrointestinal. MATERIAL Y MÉTODOS: El presente estudio es de diseño cuantitativo, no experimental, descriptivo, retrospectivo y transversal. Ha sido realizado en 152 pacientes con diagnóstico de tumor estromal gastrointestinal que fueron atendidos en el Instituto Nacional de Enfermedades Neoplásicas (INEN), Lima-Perú, desde Enero del año 1999 hasta Diciembre del año 2009. Para el diagnóstico definitivo se consignó el resultado de la pieza quirúrgica y la histología se complementó con test de inmuno histoquímica. Para valorar la distribución normal de la población se usaron las pruebas de Shapiro-Wolk, Anderson-Darling, Lilliefors, respecto a la estadística inferencial se usó tablas de supervivencia y para valorar la significancia en el análisis univariado (p<0.05 significativa), se usaronlas pruebas de Wilcoxon, Tarone-ware y Log-rank, además para evaluar la diferencia entre grupos en las tablas de contingencia se utilizó el chi cuadrado y el test de Fisher. El análisis multivariado se realizó utilizando el modelo de riesgo proporcional de Cox.RESULTADOS: El grupo de 152 pacientes comprendió 78 mujeres (51%) y 74 varones (49%) con rango etáreo de 16 a 92 años, con una edad promedio de 54 años. La frecuencia de presentación se incrementó a partir de la cuarta década de vida y alcanzó su mayor expresión entre los 50 y 70 años. La presentación inicial fue de enfermedad localizada para 79 pacientes (52%) y con metástasis primaria...

INTRODUCTION: The gastrointestinal stromal tumor (GIST) is the designation for a specific type of mesenchymal tumor of the digestive tract that is origin in the interstitial cells of Cajal (ICC) or its precursor multipotentials, its presentation is rare and therefore its best knowledge must affect a proper diagnosis and treatment. OBJECTIVES: To evaluate the clinical characteristics and to identify factors influencing survival of patients with gastrointestinal stromal tumor. MATERIAL AND METHODS: This study design is quantitative, non experimental, descriptive, retrospective and transversal. The study has been performed in 152 patients with gastrointestinal stromal tumor who were treated at the National Institute of Neoplastic Diseases (INEN), Lima, Peru, from January 1999 through December 2009. For the final diagnosis was registered the outcome of the surgical and histology was complemented by immunohistochemical test. To assess the normal distribution of the population was used the Shapiro-Wolk, Anderson-Darling, Lilliefors, regarding the use of inferential statistical tables for survival and to assess its significance in the univariate analysis (p<0.05 significance), was used the Wilcoxon test, Tarone-Ware Log-rank and also to evaluate the difference between groups in contingency tables used the chi square and FisherÆs test. Multivariate analysis was performed using the proportional hazards model of Cox. RESULTS: The group of 152 patients included 78 women (51%) and 74 men (49%) with age range from 16 to 92 years, with an average age of 54. The frequency presentation was increased from the fourth decade of life and reaches its highest expression between 50 and 70. The initial presentation was with localized disease to 79 patients (52%) and primary metastases in 73 patients (48%), with an average time of disease 14 months. The prevalence of GIST tumor in the differents organs was as follows: stomach with 77 patients (50.65%), jejunum with 21 patients...

[Case reports. Endoscopic resection of rectal carcinoid tumors: classical and submucosal resection with band-snare method]. / Resección Endoscópica de Tumor Carcinoide RectaL: Extracción Clásica y con Elevación Submucosa y Banda.

Rectal isolated carcinoid tumor can de treated endoscopically and locally. There is concern about margin involvement due to the fact that there is inward migration of these lessions from the mucosa into deeper layers (submucosa), because of the internal origin in Kutchinsky cells, which are located between mucosa and submucosa (deep in the mucosa). We review and present 6 cases of rectal carcinoid tumors treated endoscopically with polypectomy, polypectomy plus sub mucosal elevation and band -snare-elevation resection. We review current techniques, benefits of elevation, and results from the Endoscopy Unit at the INEN or National Cancer Center (Instituto Nacional de Enfermedades Neoplásicas) in Lima-Perú.

Resección endoscópica de tumor carcinoide rectal: extracción clásica y con elevación submucosa y banda / Endoscopic resection of rectal carcinoid tumors: clasical and submucosal resection with band-snare method

El tumor carcinoide rectal aislado, puede ser resecado localmente. Existe preocupación sobre compromiso de los márgenes al ser estas lesiones mucosas pero con crecimiento hacia la sub-mucosa, al originarse en las células enterocromafines de Kutchinsky que limitan con esta última. Presentamos una serie de 6 casos de tumor carcinoide rectal tratados endoscópicamente con polipectomía, polipectomía con elevación y aplicación de banda elástica. Se revisa la tecnología actual, los beneficios de la elevación y los resultados de la técnica en el área de endoscopia del servicio de gastroenterología del Instituto Nacional de Enfermedades Neoplásicas (INEN).

concern about margin involvement due to the fact that there is inward migration of these lessions from the mucosa into deeper layers (submucosa), because of the internal origin in Kutchinsky cells, which are located between mucosa and submucosa (deep in the mucosa). We review and present 6 cases of rectal carcinoid tumors treated endoscopically with polypectomy, polypectomy plus sub mucosal elevation and band ûsnare-elevation resection. We review current techniques, benefits of elevation, and results from the Endoscopy Unit at the INEN or National Cancer Center (Instituto Nacional de Enfermedades Neoplásicas) in Lima-Perú.

[Survival factors in 152 patients with gastrointestinal stromal tumors]. / Factores de sobrevida en 152 pacientes con tumores estromales gastrointestinales.

INTRODUCTION: The gastrointestinal stromal tumor (GIST) is the designation for a specific type of mesenchymal tumor of the digestive tract that is origin in the interstitial cells of Cajal (ICC) or its precursor multipotentials, its presentation is rare and therefore its best knowledge must affect a proper diagnosis and treatment. OBJECTIVES: To evaluate the clinical characteristics and to identify factors influencing survival of patients with gastrointestinal stromal tumor. MATERIAL AND METHODS: This study design is quantitative, non experimental, descriptive, retrospective and transversal. The study has been performed in 152 patients with gastrointestinal stromal tumor who were treated at the National Institute of Neoplastic Diseases (INEN), Lima, Peru, from January 1999 through December 2009. For the final diagnosis was registered the outcome of the surgical and histology was complemented by immunohistochemical test. To assess the normal distribution of the population was used the Shapiro-Wolk, Anderson-Darling, Lilliefors, regarding the use of inferential statistical tables for survival and to assess its significance in the univariate analysis (p <0.05 significance), was used the Wilcoxon test, Tarone-Ware Log-rank and also to evaluate the difference between groups in contingency tables used the chi square and Fisher's test. Multivariate analysis was performed using the proportional hazards model of Cox. RESULTS: The group of 152 patients included 78 women (51%) and 74 men (49%) with age range from 16 to 92 years, with an average age of 54. The frequency presentation was increased from the fourth decade of life and reaches its highest expression between 50 and 70. The initial presentation was with localized disease to 79 patients (52%) and primary metastases in 73 patients (48%), with an average time of disease 14 months. The prevalence of GIST tumor in the different organs was as follows: stomach with 77 patients (50.65%), jejunum with 21 patients (13.82%), retroperitoneum with 17 patients (11.18%), duodenum 11 patients (7.24%), colon 11 patients (7.24%), ileum 8 patients (5.26%),pancreas, 3 patients (1.97%), rectum, 3 patients (1.97%) and esophagus with 1 patient (0.66%). The most common symptoms of GIST tumors in general were gastrointestinal bleeding, abdominal tumor and abdominal pain. There are organ-specific symptoms such as jaundice in pancreas, dysphagia in esophagus and obstruction in the ileum. The tumor size greater than 10 centimeters was found in 92 patients (60.51%), 39 patients had size between 5 and 10 centimeters (25.65%) and 20 patients had lesions smaller than 5 centimeters (13.15%). Immunohistochemistry tests performed in 75 patients show that for all locations, the expression of KIT (CD117) is 94.8%, followed by CD34 to 70.35%; on the other hand, actin (61.68%) and S-100 (57.56%) have a smaller range of expression. Retroperitoneal GIST tumors had an expression of CD117 of 92.86% and CD34 of 60%, and GIST tumors of the pancreas had an expression of CD117 of 100% and CD34 of 100%. We evaluated 27 patients with low mitotic index, of which 10 had primary metastases (37%), in turn, of 25 patients with high mitotic index, 8 had primary metastases (32%). Of the 152 patients, 93 had complete resection of the disease, 28 had partial resection, 24 were unresectable and 07 did not undergo surgery, the more aggressive behavior was observed in ileum, 03 patients were unresectable, 02 patients had partial resection and only 02 could be completely resected, the rest of the series in general, for each location, the GIST tumors completely resected outscored the unresectable and partially resected. Of 93 patients that had completely resected, recurrence was found in 32 of these patients (34.4%), recurrence was local in 8 patients, metastases in 18 patients and local recurrence + metastases in 6 patients, with an average time of recurrence 22 months. The overall cumulative survival at 5 years was 81.35%. The survival of patients under and over 50 expressed a p = 0.08, cumulative survival rates by tumor size expressed p = 0.56, cumulative survival rates for stomach and intestinal location shows a p = 0.056. The 5-year survival of completely resected patients was 87.70%. Overall survival of patients with and without metastasis expressed p = 0.001, the cumulative survival function completely resected patients, the resected and partially resected, expresses with p <0.0001. Multivariate analysis showed that the most significant factor for disease progression was the primary metastases with p = 0.007, and that survival was directly related to complete resection of the disease which is expressed with p <0.0001. CONCLUSIONS: The most important prognostic factor of survival for gastrointestinal stromal tumors (GIST) is the complete resection of the disease. The factor that is associated with progression of the disease is the presence of metastases. In our series of 152 patients, tumor locations tend to relate better survival in gastric GIST that in intestinal GIST. Similarly, we found a tendency to express a lower survival in patients younger than 50 years. Differentiated tumor size in three size categories expressed no more related to survival. The low mitotic index associated with metastasis, not reflected a good prognosis of disease.

[Pancreatic adenocarcinoma in young patient diagnosed by endoscopic ultrasonography]. / Adenocarcinoma de páncreas en paciente joven diagnosticado por ultrasonografía endoscópica.

The Pancreatic adenocarcinoma appears generally in patients with more than 60 years old. Their finding in young people is very rare. We report the case of a man of 29 years diagnosed and treated in the National Institute of Neoplastic Diseases (INEN), that presented symptoms as: dorsalgia, jaundice and weight loss. The tomografic image showed a mass located in the head of the pancreas with hepatic and ganglionar metastases. It was evaluated by means of endoscopic ultrasonography (USE) and performed a directed fine needle puncture aspiration (PAAF), that obtained a bad differentiated adenocarcinoma from the pancreas. An endoscopic biliary drainage by PCRE was realized later and treatment with chemotherapy started. We present the case by the unusual occurrence in the related age group and by the importance of the puncture guided by endoscopic ultrasonography in the diagnosis and handling of this pathology [corrected]

Adenocarcinoma de Páncreas en paciente joven diagnosticado por Ultrasonografía Endoscópica / Adenocarcinoma of the pancreas in young patients diagnosed by endoscopic ultrasonography

El adenocarcinoma de páncreas se presenta por lo general en pacientes mayores de 60 años. El hallazgo en gente joven es muy raro. Reportamos el caso de un varón de 29 años diagnosticado y tratado en el Instituto Nacional de Enfermedades Neoplásicas(INEN), quien presentó como síntomas principales: dorsalgia, ictericia y baja ponderal. La imagen tomográfica mostró una masa ubicada en la cabeza del páncreas asociada a metástasis hepática y ganglionar múltiples. Fue evaluado mediante ultrasonografía endoscópica (USE), realizándose una punción aspiración dirigida con aguja fina (PAAF), para la obtención de muestra correspondiendo a un adenocarcinoma poco diferenciado de páncreas. Se realizó un drenaje biliar endoscópico por PCRE y posteriormente tratamiento con quimioterapia. Se presenta el caso por lo infrecuente de su manifestación en el grupo etáreo señalado y por la importancia de la punción guiada por ultrasonografía endoscópica en el diagnóstico y manejo de dicha patología.

Diffuse hemangioma of the rectum is a rare benign vascular lesion. The case of a 30 year-oldmale with intermittent rectal bleeding with an evolution of 2 years and symptoms relatedto chronic ferropenic anemia is presented. The rectal endoscopy was interpreted as amalignant neoplastic epithelial lesion spread throughout the rectum. The biopsy indicatedthat it was a rectal hemangioma. A surgical resection was successfully performed. Thestudy of the surgical specimen concluded that it was a diffuse rectal hemangioma.