Implementation of the use of SPECT-portable for evaluation of surgical margins in breast cancer with indication of ROLL: First results.

OBJECTIVES: Main objective: To compare the effectiveness for checking surgical margins between SPECT-portable and mammography of the piece (RxM). SECONDARY OBJECTIVE: To standardize a pre-operative protocol using SPECT-portable and to evaluate the time required in the use of this technique. MATERIAL AND METHODS: Prospective longitudinal study with 36 patients (39 lesions) diagnosed with breast cancer (CM) with criteria for SNOLL/ROLL. A pre-surgical study of the tumor lesion was performed, after the eco-guided administration of 99mTc-nanocolloids of albumin/99mTc-macroaggregates of albumin, in the tumor lesion. Hybrid images (optical + SPECT) and 3D navigation images with gamma probe are obtained using freehandSPECT. In the operating room, 4-5 images are obtained with freehandSPECT, (I) on skin for tumor location, (II) after exposure of surgical bed for resection guide, (III) of the surgical bed after exeresis, (IV and V) the anterior-posterior and lateral surface of the surgical specimen. The three criteria to decide to extend the margins are: (a) residual activity (cps) at the edges of the surgical bed resection; (b) visual analysis of the uptake in the specimen; (c) a minimum distance of 10 mm from the edges of the specimen to the center of greatest uptake, plus the radius of the lesion. We study the concordance of: the depth measurement between ultrasound and freehandSPECT; the surgical margins between freehandSPECT vs. mammography of the specimen (RxM), considering anatomical pathology (AP) as the gold standard technique as reference; surgical time used with freehandSPECT and RxM. RESULTS: Intraoperative localization was performed in all cases. False negative (FN: no detection margin affected) with freehandSPECT: 9 margins; with RxM: 8. True positive (TP: detection margin affected) with freehandSPECT: 5 margins, with RxM: 6. True negative (TN: consider free margin when healthy) with freehandSPECT: 213 margins; with RxM: 196. Negative predictive value (NPV: probability of negative margin on unaffected part) with freehandSPECT: 95.9%, with RxM: 96.07%. Specificity with freehandSPECT: 96.8%, with RxM: 97%. The concordance of surgical bed margins between freehandSPECT and RxM: 94.5%. Between freehandSPECT and AP: 93.1%. Between RxM and PA: 93.5%, being all statistically significant (p-value <0.000), so we can affirm that both techniques are related or dependent on the reference technique, the PA. Degree of correlation between SPECT-portable and low PA (Kappa index: 0.34, 95% CI [0.22-0.47], and between RxM and moderate PA (Kappa index: 0.42, 95% CI [0.29-0.56], p-value <0.001. Comparison of the successes and failures of both techniques (SPECT-portable and RxM) and PA: Distribution χ2: 0.023 with degree of freedom 1, with value <0.05, so we can affirm that both techniques are similar, since there are no significant statistical differences. Median total OR time: 60.25 min (30-145). Mean freehandSPECT OR time: 5 scans = 10 min. CONCLUSIONS: There are no statistically significant differences in the probability to rule out affective margins that require a second surgery between both techniques (SPECT-portable and RxM) so, the technique performed with SPECT-Portable is a useful and effective procedure, which requires specific training with an optimized and multidisciplinary protocol. The time spent with SPECT-portable is feasible for daily practice.

Hipertensión maligna y feocromocitoma: reporte de un caso / Malignant hypertension and pheochromocytoma: a case report

La hipertensión arterial maligna se define por cifras extremadamente altas de presión arterial asociadas a daño orgánico. Constituye una causa de emergencia hipertensiva donde coexisten cifras elevadas de presión arterial, con hemorragia y exudados bilaterales retinianas (retinopatía hipertensiva grado III), con o sin papiledema (retinopatía hipertensiva grado IV), asociada usualmente a lesión renal o cardíaca. En un 1% de los casos es secundaria a causas endocrinológicas, entre ellas, la más frecuente: el feocromocitoma, que clásicamente se ha caracterizado por la tríada cefalea, sudoración y palpitaciones. Sin embargo, no existe un hallazgo clínico único que tenga un valor significativo en su diagnóstico. A continuación, presentamos el caso de una paciente de 23 años con emergencia hipertensiva y masa suprarrenal asociado a retinopatía hipertensiva grado IV. (AU)

Malignant arterial hypertension is defined by extremely high levels of pressure associated with organ damage. It is a cause of hypertensive emergency and is defined by the coexistence of high blood pressure and bilateral retinal haemorrhage or exudates (grade III hypertensive retinopathy), with or without papilloedema (grade IV hypertensive retinopathy) currently associated with organ damage such as renal or cardiac failure. Around 1% of malignant arterial hypertension is secondary to endocrinological causes, including the most common: pheochromocytoma, which is classically characterized by the triad: headache, sweating and palpitations. However, there is no single clinical finding that is of significant value in its diagnosis. We now present the case of a 23-year-old patient with a hypertensive emergency, an adrenal mass associated with grade IV hypertensive retinopathy. (AU)

[Malignant hypertension and pheochromocytoma: a case report]. / Hipertensión maligna y feocromocitoma: reporte de un caso.

Malignant arterial hypertension is defined by extremely high levels of pressure associated with organ damage. It is a cause of hypertensive emergency and is defined by the coexistence of high blood pressure and bilateral retinal haemorrhage or exudates (grade III hypertensive retinopathy), with or without papilloedema (grade IV hypertensive retinopathy) currently associated with organ damage such as renal or cardiac failure. Around 1% of malignant arterial hypertension is secondary to endocrinological causes, including the most common: pheochromocytoma, which is classically characterized by the triad: headache, sweating and palpitations. However, there is no single clinical finding that is of significant value in its diagnosis. We now present the case of a 23-year-old patient with a hypertensive emergency, an adrenal mass associated with grade IV hypertensive retinopathy.

Efficacy and safety of bortezomib in refractory lupus nephritis: a single-center experience.

BACKGROUND AND OBJECTIVES: Resistant lupus nephritis (LN) has been associated with the persistence of long-lived plasma cells. Preliminary studies identified bortezomib as a potential treatment option for patients with refractory LN. The aim of this study was to analyze the efficacy and safety of bortezomib in the treatment of severe refractory LN. METHODS: This retrospective study included 12 female patients diagnosed for the first time with class IV or IV/V LN with acute or rapidly progressive kidney injury (n = 11) and/or severe nephrotic syndrome (n = 1) who showed resistance to induction therapy with cyclophosphamide, steroids, mycophenolate, and rituximab, and were treated with either intravenous or subcutaneous bortezomib plus intravenous dexamethasone. RESULTS: All patients with acute or rapidly progressive kidney injury showed a significant reduction in both biochemical and immunological activity after a mean of 6 (minimum 5, maximum 7) weekly cycles of bortezomib regimen, with a significant increase in C3 levels and a significant decrease of anti-ds DNA antibody titers, Systemic Lupus Erythematosus Disease Activity Index score, serum creatinine, and proteinuria. One patient (8.3%) achieved a complete response, and 10 patients (83.4%) achieved a partial response. During follow-up, all these patients maintained partial responses under treatment with mycophenolate and low-dose glucocorticoids. The patient with refractory nephrotic syndrome showed a partial response but relapsed 11 months after the end of bortezomib treatment and was resistant to treatment. A significant decrease in serum IgG levels after initiation of bortezomib treatment was observed in all patients, five of them (41.6%) showed hypogammaglobulinemia (<500 mg/dl), but no patient suffered from opportunistic infections; in only two patients (16.6%) hypogammaglobulinemia persisted at the end of follow-up. Two patients (16.6%) suffered from sensory neuropathy, which led to bortezomib treatment discontinuation. CONCLUSIONS: Bortezomib may be an effective option for refractory LN, but close monitoring must be performed for possible adverse events such as peripheral neuropathy and hypogammaglobulinemia.

Antibodies to M-type phospholipase A2 receptor (PLA2R) in membranous lupus nephritis.

BACKGROUND: Antibodies to M-type phospholipase A2 receptor (a-PLA2R) have been identified in most patients with idiopathic membranous nephropathy, but the prevalence in membranous lupus nephritis (MLN) is still unclear. The objective of this study was to assess the prevalence of a-PLA2R antibodies in a large cohort of patients with lupus nephritis. METHODS: a-PLA2R antibodies were measured by ELISA in serum from patients with systemic lupus erythematosus ( n = 190), of whom 37 had a biopsy-proven MLN. Positive samples were confirmed by commercial ELISA kit, Western blot and immunohistochemistry in renal tissue. RESULTS: A total of 10 from 190 patients (5.3%) with systemic lupus erythematosus had circulating a-PLA2R measured by in-house ELISA assay. The antibodies were detected in 7 patients with MLN (18.9%) and 3 patients with non-renal lupus disease (3.2%). PLA2R staining was detected in the kidney biopsy of 5 of the 7 (71.4%) patients with MLN. a-PLA2R levels were associated with active disease but not proteinuria levels. Presence of a-PLA2R antibodies at baseline was associated with worse remission rates and longer time to remission compared to those patients serologically negative. CONCLUSIONS: a-PLA2R antibodies can be detected with low prevalence in MLN patients, but their detection is associated with a worse renal prognosis.

Utilidad del diagnóstico por la imagen en el mielolipoma extraadrenal / Utility of diagnostic imaging in the diagnosis of extra adrenal myelolipoma

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Histoplasmosis en un trasplantado renal / Histoplasmosis in a renal transplant patient

Presentamos el caso de un paciente trasplantado renal nacido en España quedesarrolló una histoplasmosis diseminada aproximadamente un año y medio despuésdel trasplante, sin haber vivido ni viajado previamente a áreas endémicas dehistoplasmosis. Según la búsqueda por pubmed se trata del primer caso de estapatología en pacientes trasplantados renales sin antecedentes epidemiológicos deexposición descrito en España. El estudio de anticuerpos anti-histoplasma por fijaciónde complemento del donante y el receptor no permitió aclarar con seguridadel mecanismo de contagio

The case of a Spanish kidney transplant patient who developed disseminatedhistoplasmosis approximately one year and a half after transplantation without havingpreviously visited or travelled to endemic areas of histoplasmosis is presented.To our knowledge this is the first case of this disease in a kidney transplantpatient in Spain without epidemiologic antecedent. The study of anti-histoplasmantibodies by complement fixation of the donor and recipient did not safely clarifythe mechanism of contagion

Nefropatía IgA con proliferación extracapilar y ANCA positivos / IgA nephropathy with crescentic glomerulonephritis and anca positive

Presentamos un caso de nefropatía IgA diagnosticado por biopsia renal que presentaa los 2 años de seguimiento un empeoramiento de la función renal asociadohistológicamente a un brote extracapilar. Las determinaciones inmunológicas practicadasen aquel momento revelaron la presencia de anticuerpos anti-citoplasma delneutrófilo (ANCA) positivos a títulos altos (P-ANCA anti-MPO IgA y P-ANCA anti-MPO IgG). La paciente inició tratamiento sustitutivo con hemodiálisis y un año mástarde recibió un trasplante de riñón de donante cadáver con buen resultado. A losdos años del mismo, se mantiene con un sedimento de orina normal, una proteinurianegativa y una función renal normal bajo tratamiento inmunosupresor pero sedetectan de forma mantenida P-ANCA IgG e IgA positivos por inmunofluorescenciaindirecta (IFI) y títulos altos de IgG e IgA anti-MPO por ELISA. Creemos que la determinaciónde P-ANCA anti-MPO IgG, y en menor medida de P-ANCA anti-MPOIgA, en los casos de nefropatía IgA que presentan un empeoramiento rápido de lafunción renal puede indicar la existencia de un brote extracapilar de la enfermedadde base o de una vasculitis de pequeño vaso asociada, y confiere un mal pronósticorenal. El mantenimiento de P-ANCA positivos con títulos altos de IgG anti-MPOdurante todo el seguimiento sugiere que la determinación secuencial que ANCA IgGen esta entidad no es útil en la monitorización de la actividad clínica

We present a case of IgA nephropathy diagnosed by renal biopsy that presentsafter 2 years of folow-up an impairment of the renal function associate histoligicallyto a crescentic glomerulonephritis. The immunologic determinations showedof high titers of antineutrophil cytoplamic antibodies (ANCA) (P-ANCA IgG anti-MPO and P-ANCA IgA anti-MPO). The patient began treatment with haemodyalisisand one year later she received a cadaveric kidney transplantation with goodresult. Two years later she had normal urine sediment, negative proteinuria, normalrenal function but high titers of IgG and IgA PANCA anti-MPO. In summary,we believe that the determination ANCA in acute renal failure due to IgA nephropathy can indicate the existence of a IgA crescentic glomerulonephritis superimposedor an associated small vessel vasculitis and it confers a worse prognosis.The positive maintenance of IgG P-ANCA anti-MPO IgG anti-MPO titers duringthe course suggests that the sequential determination of ANCA in this entityis not useful to the monitoring of the clinical activity

[Histoplasmosis in a renal transplant patient]. / Histoplasmosis en un trasplantado renal.

The case of a Spanish kidney transplant patient who developed disseminated histoplasmosis approximately one year and a half after transplantation without having previously visited or travelled to endemic areas of histoplasmosis is presented. To our knowledge this is the first case of this disease in a kidney transplant patient in Spain without epidemiologic antecedent. The study of anti-histoplasm antibodies by complement fixation of the donor and recipient did not safely clarify the mechanism of contagion.

[IgA nephropathy with crescentic glomerulonephritis and ANCA positive]. / Nefropatía IgA con proliferación extracapilar y ANCA positivos.

We present a case of IgA nephropathy diagnosed by renal biopsy that presents after 2 years of folow-up an impairment of the renal function associate histoligically to a crescentic glomerulonephritis. The immunologic determinations showed of high titers of antineutrophil cytoplamic antibodies (ANCA) (P-ANCA IgG antiMPO and P-ANCA IgA anti-MPO). The patient began treatment with haemodyalisis and one year later she received a cadaveric kidney transplantation with good result. Two years later she had normal urine sediment, negative proteinuria, normal renal function but high titers of IgG and IgA PANCA anti-MPO. In summary, we believe that the determination ANCA in acute renal failure due to IgA nephropathy can indicate the existence of a IgA crescentic glomerulonephritis superimposed or an associated small vessel vasculitis and it confers a worse prognosis. The positive maintenance of IgG P-ANCA anti-MPO IgG anti-MPO titers during the course suggests that the sequential determination of ANCA in this entity is not useful to the monitoring of the clinical activity.

Renal transplantation with limit donors: to what should the good results obtained be attributed?

BACKGROUND: With the aim of offsetting the reduction in donors of kidneys for transplantation, we extended the acceptance criteria, considering donors over 60 years old. METHODS: The results obtained in 84 transplants carried out with this type of donor (group A) was compared with those of a control group of 125 transplants carried out with kidneys from donors under 60 years old (group B). The protocol for selection of donors was appropriate creatinine clearance, minimum proteinuria, and normal renal scan. The histological study was not included because it was not considered appropriate to assess the extent of the possible glomerulosclerosis, as this has a focal, segmented distribution. There were no significant differences between the recipients except for age (57.8 years old in group A vs. 39.2 years in group B). RESULTS: After the transplantation, there were significant differences in the duration of hospitalization (26.8 days vs. 21.8 days, P<0.009), annual plasma creatinemia (177, 225, 233, 235, and 205 micromol/L vs. 136, 150, 121, 111, and 133 micromol/L, P<0.0002/0.0004), graft survival (87%, 85%, 81%, 81%, and 81% vs. 89%, 88%, 86%, 86%, and 85%, P<0.03), and patient survival (92%, 89%, 85%, 85%, and 85% vs. 99%, 99%, 97%, 96%, and 95%, P<0.0004). Death of the patient was the only significantly more frequent cause of graft loss among group A patients (7 vs. 1 death, P<0.004). No kidney was "never working" and none were lost because of chronic rejection. CONCLUSIONS: It was concluded that elderly donors should be considered as suitable for transplantation irrespective of their chronological age, provided that they fulfill the acceptance criteria. The quality of life achieved was comparable in both groups. Despite the lower renal function in group A, this remained constant during the follow-up period.