Tratamiento multidisciplinario de un sarcoma recurrente de la fosa isquiorrectal / A successful multidisciplinary approach to a recurrent ischiorectal fossa sarcoma

Los tumores de la fosa isquiorrectal son poco frecuentes, habitualmente descritos en reportes o series de casos. Estas lesiones son un reto terapéutico, requiriendo un estudio preoperatorio apropiado, además de discusión y manejo guiado por un comité multidisciplinario, que permiten lograr resultados óptimos tanto oncológicos como funcionales. Presentamos un caso de un hombre de 73 años con antecedentes de resección de un tumor glúteo izquierdo en otro centro 5 años antes. La biopsia fue compatible con un sarcoma epiteloideo (SE) de alto grado, con margen quirúrgico < 0,5 mm que requirió ampliación de los márgenes posteriormente. Además, se realizó radioterapia adyuvante. Al cuarto año de seguimiento el paciente desarrolla dolor e induración con retracción en relación a cicatriz quirúrgica, siendo objetivada una recidiva tumoral local. Luego de una discusión multidisciplinaria, se realizó una desfuncionalización con ileostomía en asa laparoscópica y resección tumoral con preservación del ano y del piso pélvico. El defecto fue cubierto por el equipo de cirugía plástica utilizando un colgajo perforante de la arteria glútea superior. La biopsia confirmó la recidiva tumoral y los márgenes quirúrgicos fueron negativos. El paciente es dado de alta a los 25 días postoperatorios por cuidados del colgajo, sin complicaciones. Al año de seguimiento el paciente no presenta recidiva tumoral, la ileostomía fue cerrada, y sus resultados funcionales en términos defecatorios y de la herida son buenos.

Ischiorectal fossa tumors are rare lesions, mostly described in case reports or case series. These lesions represent a diagnostic and therapeutic challenge. Hence, an appropriate preoperative study and multidisciplinary discussion are essential to achieve good oncologic and functional results. We report a case of a 73-year-old male operated on five years before in another health center due to the diagnosis of a left gluteal tumor. The lesion was excised, and biopsies confirmed a high-grade epithelioid sarcoma with a close margin, requiring a subsequent wider excision of the surgical margins. The patient received adjuvant radiotherapy. After four years of follow-up, the patient developed mild pain with skin retraction around the former incision. A local recurrence was diagnosed by imaging. In a multidisciplinary team meeting, a decision to resect the lesion with preservation of the anus and the pelvic floor was taken. The patient underwent a laparoscopic defunctioning loop ileostomy and a resection of the recurrent tumor in the ischiorectal fossa with preservation of the anal sphincter. The defect was covered utilizing a superior gluteal artery perforator flap and a partial gluteus maximus muscle rotation. The tumor was completely excised with negative margins. The patient was discharged without complications after 25 days due to flap management. After one year of follow-up, the patient is recurrence-free, and the ileostomy was closed.

[A successful multidisciplinary approach to a recurrent ischiorectal fossa sarcoma]. / Tratamiento multidisciplinario de un sarcoma recurrente de la fosa isquiorrectal.

Ischiorectal fossa tumors are rare lesions, mostly described in case reports or case series. These lesions represent a diagnostic and therapeutic challenge. Hence, an appropriate preoperative study and multidisciplinary discussion are essential to achieve good oncologic and functional results. We report a case of a 73-year-old male operated on five years before in another health center due to the diagnosis of a left gluteal tumor. The lesion was excised, and biopsies confirmed a high-grade epithelioid sarcoma with a close margin, requiring a subsequent wider excision of the surgical margins. The patient received adjuvant radiotherapy. After four years of follow-up, the patient developed mild pain with skin retraction around the former incision. A local recurrence was diagnosed by imaging. In a multidisciplinary team meeting, a decision to resect the lesion with preservation of the anus and the pelvic floor was taken. The patient underwent a laparoscopic defunctioning loop ileostomy and a resection of the recurrent tumor in the ischiorectal fossa with preservation of the anal sphincter. The defect was covered utilizing a superior gluteal artery perforator flap and a partial gluteus maximus muscle rotation. The tumor was completely excised with negative margins. The patient was discharged without complications after 25 days due to flap management. After one year of follow-up, the patient is recurrence-free, and the ileostomy was closed.

Colgajo perforante en hélice basado en arteria peronea para reconstrucción distal de extremidad inferior / Peroneal artery propeller perforator flap for distal lower limb reconstruction

Introduction: propeller flaps are local pedicle flaps, based on a perforator vessel, which acts as the pivot point for the skin island that can be rotated up to 180°. These flaps can be performed wherever a perforator vessel of adequate size is encountered, expanding the reconstructive options for lower limb defects. Clinical case: we present a case of reconstruction of soft-tissue defect of the leg using a peroneal artery propeller perforator flap. A review of the main advantages of this technique for reconstruction of lower limb defects is also presented.

Introducción: el colgajo en hélice (propellerflap) corresponde a un tipo de colgajo local pediculado, basado en vasos perforantes, que actúan como punto pivote sobre el cual se rota la isla cutánea hasta en 180°. Este tipo de colgajo puede ser efectuado en cualquier sitio donde exista un vaso perforante de calibre adecuado, ampliando las alternativas de cobertura para defectos de extremidad inferior. Caso clínico: presentamos un caso de cobertura de defecto de partes blandas secundario a aplastamiento de tobillo, utilizando un colgajo en hélice basado en perforante de arteria peronea. Se discuten las principales consideraciones respecto al uso de esta técnica en reconstrucción de extremidad inferior.

Fístula aortocava como complicación de aneurisma aórtico abdominal / Aortocaval fistula as a complication of abdominal aortic aneurysm

Aortocaval fistula (ACF) is an infrequent complication of abdominal aortic aneurysm (AAA). Diagnosis is suspected by the presence of a continuous abdominal bruit and pulsatile abdominal mass, with variable signs of venous congestion and acute heart failure. Multislice computed tomography (MSCT) is useful in establishing the diagnosis, showing early enhancement of inferior vena cava and, in some cases, identifying the arteriovenous comunication. Surgical treatment is usually complex, with high morbidity and mortality rates. Endovascular treatment seems to be a promising alternative for the management of these patients. We report a case of ACF treated with open surgery and a literature review of this rare condition.

La fístula aortocava (FAC) es una complicación infrecuente del aneurisma aórtico abdominal (AAA). El diagnóstico se sospecha por la detección de un soplo continuo en el hemiabdomen inferior, asociado a masa abdominal pulsátil y signos variables de congestión venosa e insuficiencia cardíaca. La tomografía computada multicorte (TCM) permite confirmar el diagnóstico, evidenciando contraste de la vena cava inferior en fase arterial e identificando la zona anatómica de la comunicación arteriovenosa, en algunos casos. La reparación quirúrgica suele ser compleja, reportándose una alta morbi-mortalidad asociada. El uso de técnicas endovasculares pareciera mejorar el pronóstico de esta entidad. Reportamos un caso de FAC tratado mediante cirugía abierta. Se incluye una revisión de la literatura respecto a esta rara condición.

[Lymphomas associated with human immunodeficiency virus infection: retrospective review of medical records]. / Linfomas asociados a infección por Virus de Inmunodeficiencia Humana: experiencia de un centro hospitalario de la V región, Chile.

BACKGROUND: The incidence of lymphoma increases enormously in patients infected with the human immunodeficiency virus (HIV). AIM: To describe the incidence, clinical and histological characteristics, treatments and survival of lymphomas associated with HTV infection. MATERIAL AND METHODS: Retrospective review of medical records of patients with HIV and lymphoma, treated in a public hospital, between January 2001 and June 2009. RESULTS: Twenty-two male patients were included but 14 had immunohistochemical confirmation of the lymphoma. The accumulated incidence for this period was 2.8%. The median age at lymphoma diagnosis was 39.5 years. Twelve patients (86%) had non-Hodgkin lymphoma (NHI) and two (14%) Hodgkin lymphoma. The main pathological type of non-Hodgkin lymphomas was diffuse large B cell in seven cases (50%). The mean CD4 cell count and viral load were 83 cell/mm³ (33.5-113.5) and 26.000 RNA copies/ml (1210-196500), respectively Twelve patients (86%) had B type symptoms of lymphoma at the moment of diagnosis. Eleven patients (29%) received chemotherapy with or without radiotherapy, one patient (7%) received radiotherapy alone and two patients (14%) received palliative symptomatic treatment. Six cases (43%) received highly active antiretroviral therapy simultaneously with chemotherapy. Global mortality in this series was 57% (8 patients) with a median survival time of 5.8 months (2.6-26.2). CONCLUSIONS: In this series of patients infected with HIV, a predominance of aggressive histological subtypes of lymphomas and low complete remission rates, were observed.

Linfomas asociados a infección por Virus de Inmunodeficiencia Humana: Experiencia de un centro hospitalario de la V región, Chile / Lymphomas associated with human immunodeficiency virus infection: Retrospective review of medical records

Background: The incidence oflymphoma increases enormously inpatients infecten with the human immunodeficiency virus (HIV). Aim: To describe the incidence, clinical and histológica! characteristics, treatments and survival of lymphomas associated with HTV infection. Material and Methods: Retrospective review of medical records ofpatients with HIV and lymphoma, treated in a public hospital, between January 2001 and June 2009. Results: Twenty-two mole patients were included but 14 had immunohistochemical confirmation ofthe lymphoma. The accumulated incidence for thisperiod was 2.8 percent. The median age at lymphoma diagnosis was 39.5 years. Twelvepatients (86 percent) had non-Hodgkin lymphoma (NHI) and two (14 percent) Hodgkin lymphoma. The main pathological type of non-Hodgkin lymphomas was diffuse large B cell in seven cases (50 percent). The mean CD4 cell count and viral load were 83 cell/mm³ (33.5-113.5) and 26.000 RNA copies/ml (1210-196500), respectively Twelve patients (86 percent) had B type symptoms of lymphoma at the moment of diagnosis. Eleven patients (29 percent) received chemotherapy with or without radiotherapy, onepatient (7 percent) received radiotherapy alone and two patients (14 percent) received palliative symptomatic treatment. Six cases (43 percent) received highly active antiretroviral therapy simultaneously with chemotherapy. Global mortality in this series was 57 percent (8patients) with a median survival time of 5.8 months (2.6-26.2). Conclusions: In this series ofpatients infected with HIV, a predominance of aggressive histológica! subtypes of lymphomas and low complete remission rates, were observed.