Solitary fibrous tumor of the parapharyngeal space: report of 2 cases and a literature review.

The solitary fibrous tumor (SFT) is usually described as a lesion arising from the pleura. Rarely, it has been described in the parapharyngeal space (PS). This study aims to report two cases of SFT in the PS and to perform a literature review on this topic. Two patients undergoing surgical resection of a SFT in the PS, were reported. A literature review on SFT of the PS, was also performed. Two patients were analyzed. Both patients underwent surgical resection, followed by adjuvant radiotherapy, for SFT arising from the PS. The postoperative course was uneventful and both patients recovered well after the procedure. No recurrences were diagnosed during the followup. SFT of the PS is an infrequent entity. Surgical resection is the most used treatment, and adjuvant radiation should be considered in patients with recurrence risk factors or distant metastases.

Seguridad y factibilidad de la reconstrucción microquirúrgica en tumores de cabeza y cuello en pacientes mayores de 70 años / Safety and feasibility of free-flap reconstruction in head and neck tumors in patients aged 70 years or older

RESUMEN Antecedentes: debido al aumento en la expectativa de vida, se ha incrementado la incidencia de tumores de cabeza y cuello en pacientes añosos. Objetivo: evaluar los resultados de la reconstrucción con colgajos microquirúrgicos luego de la resección radical (RRMC) de tumores de cabeza y cuello en pacientes de 70 años o mayores. Material y métodos: se analizó una serie de pacientes sometidos a RRCM por tumores de cabeza y cuello en el período 2000-2020. Se dividió la muestra en dos grupos: G1: ≥ de 70 años y G2: < de 70 años. Se analizaron variables demográficas, quirúrgicas, posoperatorias y factores de riesgo de trombosis del colgajo en los pacientes ≥ de 70 años. Resultados: se incluyó un total de 178 pacientes, 61 en G1 y 117 en G2. Ambos grupos fueron homogéneos respecto del sexo, IMC (índice de masa corporal), alcoholismo, tabaquismo, tratamiento neoadyuvante e incidencia de HPV (virus del papiloma humano). Hubo mayor cantidad de pacientes con riesgo ASA ≥ III en G1 vs. G2; (p: 0,005). En G1, 33 (54%) correspondieron a estadio oncológico ≥ III vs. 99 (87%) en G2 (p: 0,001). Cuarenta y dos (69%) pacientes en G1 recibieron adyuvancia vs. 94 (83%) en G2 (p: 0,02) y no hubo diferencias en la morbimortalidad global y en fallas del colgajo. El sexo femenino fue el único factor de riesgo de trombosis del pedículo vascular (p: 0,05). Conclusión: la RRCM para tumores de cabeza y cuello es factible y segura en pacientes añosos, con una incidencia de morbimortalidad similar a la del resto de la población.

ABSTRACT Background: The higher life expectancy has increased the incidence of head and neck tumors in elder patients. Objective: the aim of this study was to evaluate the outcomes of free flap reconstructions after radical resection (FFRR) of head and neck tumors in patients aged 70 years or older. Material and methods: We analyzed a series of patients undergoing FFR due to head and neck tumors between 2000-2020. The patients were divided into two groups: G1: ≥ 70 years, and G2: < 70 years. The demographic, operative and postoperative variables and the risk factors for flap thrombosis in patients ≥ 70 years were analyzed. Results: A total of 178 patients were included, 61 in G1 and 117 in G2. Both groups were homogeneous regarding sex, BMI (body mass index), alcohol consumption, smoking habits, neoadjuvant treatment, and incidence of HPV (human papillomavirus). The incidence of ASA grade ≥ III was significantly higher in G1 vs. G2; (p: 0,005). In G1, 33 patients (54%) corresponded to cancer stage ≥ III vs. 99 (87%) in G2 (p: 0.001). Forty-two (69%) patients in G1 received adjuvant therapy vs. 94 (83%) in G2 (p = 0.02) and there were no differences in overall morbidity and mortality and in flap failure. Female sex was the only predictor of vascular flap thrombosis (p = 0.05). Conclusion: FFRR in head and neck tumors is feasible and safe in elderly patients, with morbidity and mortality rates similar to those of the general population.

Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria? / Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

Introducción: La causa más frecuente de hiperparatiroidismo primario (HPP) es el adenoma paratiroideo (único en el 80 a 85% de los casos y doble en un 4%, aproximadamente). El resto de los casos obedece a una hiperplasia de las glándulas paratiroides, o de forma más infrecuente, a un carcinoma paratiroideo. Nuestro objetivo es determinar la utilidad de la hormona paratiroidea intraoperatoria (PTHio) en pacientes con ecografía cervical y centellograma coincidentes preoperatorios, en el HPP por un adenoma simple. Métodos: Se realizó un estudio retrospectivo, unicéntrico, incluyendo a todos los pacientes sometidos a paratiroidectomía mini-invasiva (PMI) por HPP, por adenoma simple. Definimos estudios coincidentes cuando ambos localizaron el adenoma. La PTHio fue medida en tres ocasiones: en la inducción anestésica, inmediatamente antes y a los 15 minutos de la escisión de la glándula. El éxito se definió como la caída de al menos el 50% del valor máximo de la hormona paratiroidea (PTH) luego de remover la glándula. Se analizaron variables demográficas, intraoperatorias, postoperatorias y la utilidad de la PTHio. Resultados: Se realizaron un total de 499 paratiroidectomías, de estas, 218 presentaron un adenoma localizado en la ecografía y gammagrafía. La edad fue de 60,1 años y 85% eran mujeres. Luego de 15 minutos de la escisión del adenoma, la PTHio no descendió en nueve pacientes (4,2% OR 1,9 a 7,69%); todos ellos fueron a una exploración cervical bilateral. El valor agregado de la PTHio para la cura de la enfermedad fue de 3,6%. Hubo un 99% de curación de enfermedad. El tiempo operatorio fue de 66,4 minutos y el de espera de la PTHio fue de 31 minutos. La PTHio encareció el procedimiento al doble. Conclusiones: La ecografía y el centellograma preoperatorios coincidentes para la localización de un adenoma en HPP podrían evitar la medición de la PTHio durante las PMI. (AU)

Introduction: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. Methods: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. Results: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. Conclusions: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies. (AU)

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 min after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50% compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 min after its excision, IOPTH did not decrease in 9 patients (4.2%. OR 1.9%-7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 min and the waiting time for the third IOPTH result was 31 min. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

Comportamiento biológico de mallas para la reparación de paredes abdominales. Resultados preliminares en un modelo animal / Biological behavior of meshes used for abdominal wall surgery. Preliminary results in an animal model

Resumen La falla en la reparación de los defectos de la pared abdominal se relaciona con una alteración en la integración del material protésico. El objetivo de este trabajo fue evaluar el comportamiento biológico de mallas utilizadas en cirugía de paredes abdominales en un modelo animal. Luego de la confección de un defecto parietal se colocó una malla intraperitoneal, utilizando 4 grupos de 10 ratas; 1) Prolene (polipropileno microporo de alto peso), 2) Ultrapro (polipropileno + poliglecaprone, macroporo de bajo peso), 3) Proceed (polipropileno + polidoxanona + celulosa oxidada regenerada, macroporo de peso intermedio), y 4) Physiomesh (polipropileno + poliglecaprone, macroporo de bajo peso). Se realizó análisis macroscópico y microscópico a los 30 días y los resultados fueron evaluados por dos observadores independientes. Al examen macroscópico, la integración de la prótesis fue > 75% en todos los grupos. El análisis microscópico mostró mayor inflamación global y número de células gigantes multinucleadas en Prolene (p < 0.01) y menor cantidad de células inflamatorias en la interface músculo-malla en Physiomesh < Ultrapro (p < 0.05). La organización de las fibras de colágeno fue similar para todas las mallas, aunque hubo mayor depósito de colágeno en los espacios inter-filamento para las mallas macroporosas (p < 0.01). Concluimos que las mallas de polipropileno microporo y alto peso producen mayor reacción inflamatoria y de cuerpo extraño. Por lo tanto, las mallas compuestas tendrían una mejor biocompatibilidad y serían mejor toleradas por el huésped.

Abstract An adequate integration of the prosthetic materials used to repair abdominal wall defects is necessary for satisfactory outcomes. We aimed to evaluate, in an animal model, the biological behavior of meshes used for abdominal wall surgery. Four groups of 10 rats were separated. After laparotomy, intraperitoneal prostheses were placed: 1) Prolene (polypropylene microporous, heavy-weight), 2) Ultrapro (polypropylene + poliglecaprone, macroporous low-weight), 3) Proceed (polypropylene + polidoxanone + regenerated oxidized cellulose, microporous medium-weight), 4) Physiomesh (polypropylene + poliglecaprone, macroporous lowweight). Macroscopic and microscopic analyses were performed at 30 days. The results were evaluated by two independent observers and expressed in means with standard deviation. For statistical analysis p < 0.05 was considered significant. On macroscopic examination, mesh integration was greater than 75% in all cases. Microscopic analysis showed greater global inflammation and more multinucleated giant cells in Prolene (p < 0.01). Less inflammatory cells were observed at the muscle-mesh interface in Physiomesh vs. Ultrapro (p < 0.05). Collagen fibers disposition was similar in all meshes, although, microporous meshes had higher collagen deposit in the interfilamentous spaces (p < 0.01). In conclusion, in our animal model, microporous and heavy-weight polypropylene meshes produce greater inflammatory and foreign body reaction. Thus, composite meshes would have greater biocompatibility and better tolerance by the host.

[Biological behavior of meshes used for abdominal wall surgery. Preliminary results in an animal model]. / Comportamiento biológico de mallas para la reparación de paredes abdominales. Resultados preliminares en un modelo animal.

An adequate integration of the prosthetic materials used to repair abdominal wall defects is necessary for satisfactory outcomes. We aimed to evaluate, in an animal model, the biological behavior of meshes used for abdominal wall surgery. Four groups of 10 rats were separated. After laparotomy, intraperitoneal prostheses were placed: 1) Prolene® (polypropylene microporous, heavy-weight), 2) Ultrapro® (polypropylene + poliglecaprone, macroporous low-weight), 3) Proceed® (polypropylene + polidoxanone + regenerated oxidized cellulose, microporous medium-weight), 4) Physiomesh® (polypropylene + poliglecaprone, macroporous lowweight). Macroscopic and microscopic analyses were performed at 30 days. The results were evaluated by two independent observers and expressed in means with standard deviation. For statistical analysis p < 0.05 was considered significant. On macroscopic examination, mesh integration was greater than 75% in all cases. Microscopic analysis showed greater global inflammation and more multinucleated giant cells in Prolene® (p < 0.01). Less inflammatory cells were observed at the muscle-mesh interface in Physiomesh® vs. Ultrapro® (p < 0.05). Collagen fibers disposition was similar in all meshes, although, microporous meshes had higher collagen deposit in the interfilamentous spaces (p < 0.01). In conclusion, in our animal model, microporous and heavy-weight polypropylene meshes produce greater inflammatory and foreign body reaction. Thus, composite meshes would have greater biocompatibility and better tolerance by the host.

La falla en la reparación de los defectos de la pared abdominal se relaciona con una alteración en la integración del material protésico. El objetivo de este trabajo fue evaluar el comportamiento biológico de mallas utilizadas en cirugía de paredes abdominales en un modelo animal. Luego de la confección de un defecto parietal se colocó una malla intraperitoneal, utilizando 4 grupos de 10 ratas; 1) Prolene® (polipropileno microporo de alto peso), 2) Ultrapro® (polipropileno + poliglecaprone, macroporo de bajo peso), 3) Proceed® (polipropileno + polidoxanona + celulosa oxidada regenerada, macroporo de peso intermedio), y 4) Physiomesh® (polipropileno + poliglecaprone, macroporo de bajo peso). Se realizó análisis macroscópico y microscópico a los 30 días y los resultados fueron evaluados por dos observadores independientes. Al examen macroscópico, la integración de la prótesis fue > 75% en todos los grupos. El análisis microscópico mostró mayor inflamación global y número de células gigantes multinucleadas en Prolene® (p < 0.01) y menor cantidad de células inflamatorias en la interface músculo-malla en Physiomesh® < Ultrapro® (p < 0.05). La organización de las fibras de colágeno fue similar para todas las mallas, aunque hubo mayor depósito de colágeno en los espacios inter-filamento para las mallas macroporosas (p < 0.01). Concluimos que las mallas de polipropileno microporo y alto peso producen mayor reacción inflamatoria y de cuerpo extraño. Por lo tanto, las mallas compuestas tendrían una mejor biocompatibilidad y serían mejor toleradas por el huésped.

Tumor-Infiltrating Lymphocytes in Patients with Melanoma: Which Is Its Prognostic Value?

Oncological impact of tumor-infiltrating lymphocytes (TILs) in melanoma remains controversial. We aimed to determine the significance of TILs on melanoma-specific survival (MSS), recurrence-free survival (RFS), and sentinel lymph node status (SLN). A retrospective analysis of patients undergoing melanoma resection during the period 2009-2019 was performed. Using the Melanoma Institute Australia grading system for TILs, the cohort was divided into two groups: group 1 (G1), patients with TILs grades 1, 2, or 3 and Group 2 (G2), patients with TILs grade 0. From a total of 386 melanoma resections, 151 (39%) were included in G1 and 39 (10%) in G2. Among the 151 patients who underwent SLN biopsy, the positivity rate according to the TILs grades 0, 1, 2, and 3 was 32%, 18%, 14%, and 0%, respectively, p = 0.02. With an average follow-up of 48 months, the 5-year MSS (G1: 86% vs G2: 75%, p = 0.002) and the 5-year RFS (G1: 81% vs G2: 60%, p = 0.004) were significantly higher in G1 than G2. Tumor-infiltrating lymphocytes in melanoma are associated with the SLN status and with a better MSS and RFS.

Preoperative matching studies in the diagnosis of parathyroid adenoma for primary hyperparathyroidism: Can we avoid intraoperative PTH monitoring? / Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria?

INTRODUCTION: We aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma. METHODS: All patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed. RESULTS: A total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive. CONCLUSIONS: Preoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.

[Long-term survival after small doses of radioiodine therapy for brain metastases of thyroid cancer]. / Supervivencia prolongada luego de pequeñas dosis de terapia con radioyodo en metástasis cerebral de cáncer de tiroides.

Differentiated thyroid cancer is generally accompanied by a long term survival. However, in some cases distant metastases can develop and among them, brain localizations are of poor prognosis. The aim of this presentation is to communicate the clinical case of a 65 year-old woman who consulted for diplopia in vertical gaze which had appeared one month earlier. MRI showed a big mass at the level of the occipital condyle. Diagnosis of primary brain tumor was made so she was operated twice with incomplete tumor resection. The pathological study was confirmatory of a metastatic lesion of thyroid carcinoma. A total thyroidectomy with resection of a papillary cancer of the follicular variant was performed. Then, she was successfully treated with small repetitive radioiodine amounts for a total accumulated dose of 325 mCi 131I, with a long-term survival.

El cáncer diferenciado de tiroides generalmente se acompaña de una supervivencia a largo plazo. Sin embargo, en algunos casos pueden desarrollarse metástasis a distancia y, entre ellas, las localizaciones cerebrales son de mal pronóstico. El objetivo de esta presentación es comunicar el caso clínico de una mujer de 65 años que consultó por diplopía en la mirada vertical que había aparecido un mes antes. La resonancia magnética mostró una gran masa a nivel del cóndilo occipital. Se realizó el diagnóstico de tumor cerebral primario, por lo que fue operada dos veces con resección tumoral incompleta. El estudio histopatológico confirmó una lesión metastásica de carcinoma de tiroides. Se realizó una tiroidectomía total con resección de un cáncer papilar de la variante folicular. Luego, fue tratada con éxito con pequeñas cantidades repetitivas de yodo radiactivo para una dosis total acumulada de 325 mCi 131I, con una supervivencia a largo plazo.

Supervivencia prolongada luego de pequeñas dosis de terapia con radioyodo en metástasis cerebral de cáncer de tiroides / Long-term survival after small doses of radioiodine therapy for brain metastases of thyroid cancer

Resumen El cáncer diferenciado de tiroides generalmente se acompaña de una supervivencia a largo plazo. Sin embargo, en algunos casos pueden desarrollarse metástasis a distancia y, entre ellas, las localizaciones cerebrales son de mal pronóstico. El objetivo de esta presentación es comunicar el caso clínico de una mujer de 65 años que consultó por diplopía en la mirada vertical que había aparecido un mes antes. La resonancia magnética mostró una gran masa a nivel del cóndilo occipital. Se realizó el diagnóstico de tumor cerebral primario, por lo que fue operada dos veces con resección tumoral incompleta. El estudio histopatológico confirmó una lesión metastásica de carcinoma de tiroides. Se realizó una tiroidectomía total con resección de un cáncer papilar de la variante folicular. Luego, fue tratada con éxito con pequeñas cantidades repetitivas de yodo radiactivo para una dosis total acumulada de 325 mCi 131I, con una supervivencia a largo plazo.

Abstract Differentiated thyroid cancer is generally accompanied by a long term survival. However,in some cases distant metastases can develop and among them, brain localizations are of poor prognosis. The aim of this presentation is to communicate the clinical case of a 65 year-old woman who consulted for diplopia in vertical gaze which had appeared one month earlier. MRI showed a big mass at the level of the occipital condyle. Diagnosis of primary brain tumor was made so she was operated twice with incomplete tumor resection. The pathological study was confirmatory of a metastatic lesion of thyroid carcinoma. A total thyroidectomy with resection of a papillary cancer of the follicular variant was performed. Then, she was successfully treated with small repetitive radioiodine amounts for a total accumulated dose of 325 mCi 131I, with a long-term survival.

Factores de riesgo de hipocalcemia severa postiroidectomía total / Risk factors for severe hypocalcemia after total thyroidectomy

Antecedentes: la hipocalcemia es la complicación más frecuente luego de una tiroidectomía total y puede manifestarse de manera bioquímica, o con síntomas leves o severos. Objetivos: analizar factores de riesgo asociados al desarrollo de hipocalcemia severa postiroidectomía total. Material y métodos: se incluyeron pacientes en los que se realizó tiroidectomía total primaria, analizando factores de riesgo asociados al desarrollo de hipocalcemia severa (signos y síntomas que requirieron internación y tratamiento con calcio intravenoso o persistencia de signosintomatología luego de 48 horas de haber recibido tratamiento inicial vía oral). Se analizaron variables demográficas, clínico-quirúrgicas e histopatológicas. Resultados: se realizaron un total de 1665 tiroidectomías entre 2007 y 2018 y, de estas, 918 fueron tiroidectomías totales primarias. Un total de 203 (22%) pacientes desarrollaron hipocalcemia. De ellos, 183 (20%) presentaron hipocalcemia leve y 20 (2%) hipocalcemia severa. En el análisis univariado, la edad, la intervención por cirujano especialista en cabeza y cuello, el peso de la glándula tiroides mayor de 30 gramos, la resección paratiroidea y la patología maligna se vieron asociados al desarrollo de hipocalcemia severa. En el análisis multivariado, los últimos tres fueron factores de riesgo asociados a esta complicación, con significancia estadística. Conclusiones: en nuestra serie, los factores de riesgo asociados al desarrollo de hipocalcemia severa postiroidectomía total fueron la resección, advertida o inadvertida de las glándulas paratiroides, el peso de la glándula tiroides mayor de 30 gramos y la patología maligna. Por lo tanto, en estos pacientes debemos prestar especial atención al desarrollo de dicha complicación en el posoperatorio.

Background: Hypocalcemia is the most common complication after a total thyroidectomy. It may occur as biochemical hypocalcemia, or with mild or severe symptoms. Objectives: The aim of this study was to analyze the risk factors associated with the development of severe hypocalcemia after total thyroidectomy. Material and methods: Patients undergoing primary total thyroidectomy were included. The risk factors for the development of severe hypocalcemia (signs and symptoms requiring hospitalization and treatment with intravenous calcium or persistence of signs and symptoms after 48 hours of initial oral treatment) were analyzed. The evaluation included analysis of the demographic, clinical, surgical and histopathological variables. Results: Of 1665 thyroid resections performed between 2007 and 2018, 918 corresponded to primary total thyroidectomies; 203 (22%) of these patients developed hypocalcemia. Mild hypocalcemia occurred in 183 (20%) cases and sever hypocalcemia in 20 (2%) patients, The univariate analysis showed that a procedure performed by head and neck surgeons, thyroid gland weight > 30 g, resection of the parathyroid glands and thyroid cancer were associated with the development of severe hypocalcemia. On multivariate analysis, the last three variables were risk factors significantly associated with this complication. Conclusions: In our series, noticed or inadvertent resection of the parathyroid glands with subsequent reimplantation, high weight of the thyroid gland and malignancy were identified as risk factors for the development of severe hypocalcemia after total thyroidectomy. Therefore, we should pay special attention to the development of such complication in the postoperative period.

Self-estimation of surgical skills and competencies based on the learning curve theory in medical residents and fellows.

OBJECTIVE: The aim was to explore how in-training junior physicians perceive their surgical performance compared with the one externally rated by their senior surgeon trainers, using a general learning curve model. METHODS: Between April and June 2018, a prospective study was conducted at a community hospital associated with a school of medicine. To assess how in-training physicians estimated their surgical performance, 48 surgical residents and fellows were invited to choose one among six options using a scale ranging from "novice" to "automatic expert." In addition, five senior surgeons who supervised the residents/fellows were asked to give their own opinions on each surveyed physician's expertise level, according to the same categories. Concordance analysis was done to compare residents' and fellows' self-perceived skills and their actual performance as estimated by senior surgeons. RESULTS: Self-assessments tended to overestimate residents' and fellows' position on the learning curve; particularly for "proficient" over "competent," and for "automatic expert" over "expert" categories (p = 0.025). The average degree of agreement among senior physicians was 50.0%. Comparison between residents' and fellows' perceived skills and their performances as estimated by senior surgeons showed a weak concordance (kappa = 0.494, 95% confidence interval 0.359-0.631, p < 0.0001). CONCLUSIONS: Nearly 51% of the residents/fellows included in some surgical specialty training program overestimated his/her actual performance as evaluated by classical learning curve categories. Underestimation of self-assessed performance was also observed in 17% of respondents. A better feedback from expert observers to in-training surgeons could result in a more accurate self-perception of their real surgical skills and competencies.

OBJETIVO: Evaluar cómo los médicos en formación (juniors) perciben su propio desempeño quirúrgico en comparación con la calificación otorgada por sus instructores (seniors) según un modelo de curva de aprendizaje. MÉTODOS: Entre abril y junio de 2018 se realizó un estudio prospectivo en un hospital comunitario. Para evaluar cómo los médicos juniors estimaban su propio desempeño, 48 residentes/becarios de especialidades quirúrgicas eligieron una entre seis opciones excluyentes en una escala entre «novicio¼ y «experto automático¼. Además, cinco cirujanos que supervisaban a los residentes/becarios dieron sus propias opiniones sobre el nivel de desempeño de cada médico encuestado, usando las mismas categorías. Se realizó un análisis de concordancia para comparar las habilidades autopercibidas y el desempeño real según lo estimado por los cirujanos seniors. RESULTADOS: Cuarenta y siete juniors y 50 seniors completaron la encuesta. El 51% sobrestimó y el 17% subestimó su ubicación en la curva de aprendizaje con respecto a los observadores externos (p = 0.025). El grado promedio de acuerdo entre seniors fue del 50%. La comparación entre la autopercepción de los juniors con respecto a sus observadores seniors mostró una concordancia pobre (kappa = 0.494; intervalo de confianza del 95% [IC 95%]: 0.359-0.631; p < 0.0001; sesgo promedio de Bland-Altman: 0.40; IC 95%: 0.11-0.70). CONCLUSIONES: La mitad de los residentes/fellows sobrestimó, y uno de cada seis subestimó, su verdadera ubicación en la curva de aprendizaje en comparación a la opinión de los seniors. Un mejor conocimiento de la existencia de este sesgo de estimación del propio desempeño podría redundar en una mejor confiabilidad del juicio médico.

[Primary orbital squamous cell carcinoma]. / Carcinoma escamoso primario de órbita.

Primary orbital squamous cell carcinoma is a rare entity. There is little published literature. We report a case of primary squamous cell carcinoma of the orbital soft tissues. Surgical resection offered the best treatment for the patient. Complete resection of the lesion was achieved. The patient received adjuvant radiotherapy due to the proximity of the lesion to the surgical margins. Surgical treatment is feasible and should be considered as part of the surgeon's arsenal. However, therapeutic decisions must be made on a case-by-case basis.

Carcinoma escamoso primario de órbita / Primary orbital squamous cell carcinoma

El carcinoma escamoso primario de órbita es una entidad poco frecuente. Hay escasa literatura publicada al respecto. Presentamos un caso de carcinoma escamoso primario de los tejidos blandos de la órbita. La resección quirúrgica ofrecía el mejor tratamiento para esta paciente. Se realizó un abordaje cráneo-facial y se logró la resección completa de la lesión. La paciente recibió radioterapia adyuvante debido a la proximidad de la lesión a los márgenes quirúrgicos. El tratamiento quirúrgico es factible y debe ser considerado como parte del arsenal del cirujano. Sin embargo, las decisiones terapéuticas deben tomarse teniendo en cuenta las particularidades de cada caso.

Primary orbital squamous cell carcinoma is a rare entity. There is little published literature. We report a case of primary squamous cell carcinoma of the orbital soft tissues. Surgical resection offered the best treatment for the patient. Complete resection of the lesion was achieved. The patient received adjuvant radiotherapy due to the proximity of the lesion to the surgical margins. Surgical treatment is feasible and should be considered as part of the surgeon´s arsenal. However, therapeutic decisions must be made on a case-by-case basis.

[Giant adrenal myelolipoma. Right laparoscopic adrenalectomy]. / Mielolipoma adrenal gigante. Adrenalectomía derecha laparoscópica.

Adrenal myelolipoma is a rare, benign, non-functioning tumor. It is composed by fat and hematopoietic tissues. We present the case of a 33-year-old woman with diagnosis of a 14 cm diameter non-functioning right adrenal incidentaloma, with imaging features suggestive of myelolipoma. Based on the benign nature of the tumor, laparoscopic resection was performed. Histopathology showed a myelolipoma, weighting 444 grams. The patient evolved with an uneventful postoperative period. Laparoscopic adrenalectomy for a giant myelolipoma was feasible and successful.

Mielolipoma adrenal gigante: Adrenalectomía derecha laparoscópica / Giant adrenal myelolipoma. Right laparoscopic adrenalectomy

El mielolipoma es un tumor adrenal poco frecuente. Se trata de un tumor benigno no funcionante compuesto por tejido adiposo y hematopoyético. Presentamos el caso de una paciente de 33 años de edad con diagnóstico de incidentaloma adrenal de 14 cm de diámetro no funcionante. Los estudios imagenológicos presentaban características sugestivas de mielolipoma. Debido a la naturaleza benigna del tumor se decidió el abordaje laparoscópico. La anatomía patológica informó un mielolipoma de 444 gramos. La paciente evolucionó favorablemente en el postoperatorio. El abordaje laparoscópico para la resección del mielolipoma gigante fue factible y exitoso.

Adrenal myelolipoma is a rare, benign, non-functioning tumor. It is composed by fat and hematopoietic tissues. We present the case of a 33-year-old woman with diagnosis of a 14 cm diameter non-functioning right adrenal incidentaloma, with imaging features suggestive of myelolipoma. Based on the benign nature of the tumor, laparoscopic resection was performed. Histopathology showed a myelolipoma, weighting 444 grams. The patient evolved with an uneventful postoperative period. Laparoscopic adrenalectomy for a giant myelolipoma was feasible and successful.

[Melanoma behavior according to age]. / Comportamiento del melanoma según la edad.

In recent years the incidence of melanoma in elderly patients has increased with an unfavorable oncologic outcome due not only to immune deterioration but also to greater aggressiveness of the tumor. The aim of this study was to evaluate the behavior of cutaneous melanoma in relation to age. A consecutive series of cases with melanoma operated in a reference center in the period 2001-2013 was included. The sample was divided into two groups according to the age. Group 1 (G1): under 65 years and Group 2 (G2): over 65 years. Histopathological variables and oncologic outcomes were compared between the two groups. Three hundred and eighty eight patients were operated. They belonged to G1 241 (62%) and to G2 147 (38%). Both groups were homogeneous with respect to the histological type of melanoma. Group 2 had thicker melanomas (Breslow > 4 mm 19% vs. 7%, p < 0.005) and higher rates of ulceration (37% vs. 20%, p: 0.007) and distant metastases (stage IV 11% vs. 3%, p 0.01). There was no difference between groups regarding nodal involvement. With a mean follow up of 45 (6-98) months throughout the series, recurrence of disease was higher in group 2 (26% vs. 17%, p: 0.03), but the specific mortality showed no significant difference (9.5% vs. 5.3%, p: 0.12). In conclusion, cutaneous melanoma in patients over 65 years is more aggressive with higher rates of local recurrence and distant metastases.

Predictores de metástasis de ganglio centinela en melanoma cutáneo / Predictors for sentinel lymph node metastasis of cutaneous melanoma

Antecedentes: se han descripto múltiples factores de riesgo para el compromiso del ganglio centinela en melanoma cutáneo, pero existe discrepancia en cuanto a la importancia de cada uno de ellos. El objetivo de este estudio fue identificar factores predictores de metástasis del ganglio centinela en pacientes con melanoma cutáneo. Material y métodos: se incluyeron los mapeos linfáticos realizados en pacientes con melanoma cutáneo entre 2001 y 2013. Se evaluaron variables demográficas y características del tumor primario. Se realizaron análisis univariado y multivariado en busca de factores predictivos del compromiso del ganglio centinela. Resultados: en el período citado se efectuaron 117 mapeos linfáticos; 25 pacientes (21,3%) presentaron ganglio centinela positivo. La edad y la localización de la lesión primaria no se asociaron con riesgo de metástasis linfática. Los melanomas con espesor de 1 a 4 mm se asociaron con mayor compromiso ganglionar que aquellos con espesor menor de 1 mm, y aquellos con espesor mayor de 4 mm tuvieron aún mayor tasa de ganglio centinela positivo. La presencia de ulceración y el tipo histológico nodular tuvieron mayor compromiso del ganglio centinela. La regresión tumoral y el número de mitosis no se relacionaron con la positividad del ganglio centinela. En el análisis multivariado solo el índice de Bres-low mayor de 4 mm y el tipo histológico nodular presentaron significación estadística. Conclusiones: la ulceración, el índice de Breslow y el tipo histológico nodular se asocian a mayor compromiso del ganglio centinela. El índice de Breslow y el tipo histológico nodular serían predictores independientes de compromiso ganglionar en melanoma cutáneo.

Background: multiple risk factors have been described in order to predict sentinel lymph node (SLN) compromise in patents with cutaneous melanoma. However, there is no agreement as to the impor-tance of each of those factors. The aim of this study was to identify risk factors of SLN metastasis. Methods: consecutive SLN biopsies in patents with cutaneous melanoma in the period 2001-2013 were included. Demographic factors and primary tumor characteristics were evaluated and univariate and multivariate analyses were performed. Results: of 117 SLN biopsies, 25 patents (21.3%) had a positive SLN. Age and tumor locaton were not associated with risk of lymphatic metastasis. Patents with Breslow thickness 1-4 mm were associated with more nodal involvement than those with thickness < 1mm and those with > 4mm had even higher rate of positive SLN. Ulceraton and nodular histology showed higher SLN compromise. Tumor regres-sion and number of mitoses were not associated with positive SLN. In the multivariate analysis Breslow thickness > 4mm and nodular histologic type showed statstical significance. Conclusions: ulceraton, Breslow thickness and nodular histologic type are associated with the SLN status. Furthermore, Breslow thickness and nodular histologic type could be independent predictor factors of SLN involvement.

Carcinoma basocelular gigante: comunicación de dos lesiones en un paciente / Giant basal cell carcinoma: two lesions in the same patient report

Los carcinomas basocelulares gigantes (CBCG) son muy pocos frecuentes. Se los puede definir como aquellos mayores de 5 cm de diámetro. La mayoría de estos pacientes no refiere antecedentes de exposición crónica al sol ni presentan otros factores de riesgo conocidos. Existe en cambio una relación estrecha con situaciones de negligencia y tratamientos inadecuados. Se los encuentra frecuentemente en el tronco. Las lesiones mayores de 10 cm de diámetro tienen un alto riesgo de generar metástasis y en consecuencia producir la muerte. Presentamos una paciente de 92 años con dos masas tumorales en área malar y mejilla derecha que fue trtada quirúrgicamente, con buena evolución hasta los dos años de siguimiento posterior.

Giant basal cell carcinoma (GBCC) is an uncommon cutaneous tumor defined as a neoplasm largerthan 5 cm in diameter. Most of the affected patients neither present a chronic sun exposure historynor any significant risk factor.Negligence and inadequate treatments may undoubtedly contribute to this type of tumor.GBCC occurs must commonly on the trunk. Lesions greater than 10 cm in diameter have a highrate of metastasis.We report a 92-year-old woman with two such tumors located on the right zygomatic area andthe homolateral cheek. Surgical treatment was performed. After a follow up of two years no signsof dissemination or local recurrence have been detected.