Melanoma maligno gastrointestinal en paciente albino: a propósito de un caso

Los albinos tienen predisposición al padecimiento de determinados tipos de cáncer cutáneo, pero el melanoma no es común. Entre los pocos artículos que documentan su aparición en estos pacientes, la afección gastrointestinal por melanoma aparece con relativa frecuencia, ya sea en forma de tumor primario o metástasis. Se presenta el caso de una paciente mujer de 70 años con una lesión gástrica y otra intestinal, detectadas mediante tomografía computada. El estudio anatomopatológico fue compatible con el diagnóstico de melanoma amelanótico. Pese a su escasa incidencia en albinos, el melanoma es una opción que no puede descartarse. Es importante, además, revisar los diferentes componentes del tracto gastrointestinal ante la existencia (o no) de un melanoma primario conocido.(AU)

Albinos are predisposed to suffer certain types of skin cancer, but not usually melanoma, with just a few reports documenting it .Gastrointestinal tract is a relatively frequent site of melanoma occurrence, weather as a primary tumour or metastasis. We report a case of a 70 year-old female patient who underwent a computed tomography where a gastric and a bowel tumor were found. The pathology study was compatible with the diagnosis of an amelanotic melanoma. Despite that the diagnosis of melanoma in albine patients is a rare finding, it must be considered. It is also important to search through the digestive system even if there is no primary melanoma known.(AU)

Melanoma maligno gastrointestinal en paciente albino: a propósito de un caso / Gastrointestinal melanoma in an albino patient: Report of a case

Los albinos tienen predisposición al padecimiento de determinados tipos de cáncer cutáneo, pero el melanoma no es común. Entre los pocos artículos que documentan su aparición en estos pacientes, la afección gastrointestinal por melanoma aparece con relativa frecuencia, ya sea en forma de tumor primario o metástasis. Se presenta el caso de una paciente mujer de 70 años con una lesión gástrica y otra intestinal, detectadas mediante tomografía computada. El estudio anatomopatológico fue compatible con el diagnóstico de melanoma amelanótico. Pese a su escasa incidencia en albinos, el melanoma es una opción que no puede descartarse. Es importante, además, revisar los diferentes componentes del tracto gastrointestinal ante la existencia (o no) de un melanoma primario conocido...

Spontaneous resolution of intrarenal pseudoaneurysm.

A case of intrarenal pseudoaneurysm after blunt trauma in a 12-year-old girl is reported. Clinical evolution was characterised by gross hematuria and colic pain bouts, and several pseudoaneurysms were confirmed through computerised tomography and Doppler ultrasound. In spite of strict bedrest, hematuric episodes occurred on day 11 and day 21 after admission. The pseudoaneurysms were confirmed by Doppler ultrasound and conservative treatment was rejected. 48 hours later, a therapeutic arteriography was performed, but no pseudoaneurysm could be identified, only an arteriovenous fistula that was embolised with coils. To our knowledge this is the first case of documented spontaneous resolution of intrarenal pseudoaneurysm. This case raises the possibility of continuing conservative treatment even in the presence of an intrarenal pseudoaneurysm.

[Surgical management of posterior communicating artery aneurysms based on computed tomographic angiography with three-dimensional reconstruction and without preoperative angiography]. / Tratamiento quirúrgico de los aneurismas de la arteria comunicante posterior basado en el estudio de angio-tac con reconstrucción tridimensional y sin angiografía preoperatoria.

OBJECTIVE: To demonstrate the usefulness of three-dimensional computed tomographic angiography (CT-3D-angiography) in the microsurgical management of aneurysms of the posterior communicating artery (PComA). MATERIALS AND METHODS: A series of 27 patients with aneurysms of the PComA diagnosed by means of CT-3D-angiography and without preoperative angiography (group A) were compared with a series of 34 cases diagnosed by cerebral angiography. The findings of the CT-3D-angiography, angiography, microsurgical exploration and clinical data were evaluated. RESULTS: A total of 75 aneurysms were diagnosed preoperatively in 66 patients and 3 additional lesions were found postoperatively in group A. The sensitivity of the CT-3D-angiography was 91.7% for diagnosis of any aneurysm with an specifity of 100%, being the snsibility of angiography a 100% and its specifity 94.9%. Mortality rate was 4.5% without differences between groups regarding clinical results or complications. Both the preoperative timing and hospitalization time were shorter in group A. CONCLUSION: The study of patients with acute subarachnoid hemorrhage with CT-3D-angiography allows a reliable diagnosis of PComA aneurysms. Moreover, provides usefull information for the microsurgical clipping. When compared with angiography in the diagnosis of PComA aneurysms, CT-3D-angiography allows to improve some health indicators with similar clinical results and complications.

Evaluación de la TC helicoidal en la estadificación preoperatoria del adenocarcinoma gástrico / Helical CT evaluation in the preoperative staging of gastric adenocarcinoma

Introducción: el objetivo del estudio es evaluar la TC helicoidal como prueba preoperatoria básica para la estadificación del adenocarcinoma gástrico. Material y método: reclutamos 50 pacientes diagnosticados de adenocarcinoma gástrico, evaluando la TC helicoidal y comparando sus hallazgos con los macroscópicos de la laparotomía confirmados anatomopatológicamente. Se ha utilizado la clasificación TNM 5ª edición de la UICC (mayo 1997). Resultados: el mejor resultado en cuanto a la Sensibilidad lo obtenemos para el diagnóstico de adenopatías 83 por ciento (69-92 por ciento), respecto a la especificidad obtenemos un 92 por ciento (79-98 por ciento) para T4 y un 89 por ciento (77-96 por ciento) para la detección de metástasis. Para T1-T2 la exactitud fue del 70 por ciento y para T3 del 62 por ciento. Conclusiones: 1. La TC helicoidal para la categoría T se muestra eficaz para detectar los casos avanzados clasificados como irresecables.2. La predicción en la categoría N de la TC helicoidal es mejor que la obtenida hasta ahora con las generaciones anteriores de TC. 3. En la categoría M, la TC helicoidal es una prueba útil para identificar la existencia de metástasis hepáticas que harían la cirugía innecesaria (AU)

Helical CT evaluation in the preoperative staging of gastric adenocarcinoma.

INTRODUCTION: The aim of this study is to evaluate helical CT as a basic preoperative test for the staging of gastric adenocarcinoma. MATERIAL AND METHOD: We enrolled 50 patients with a diagnosis of gastric adenocarcinoma, evaluated helical CT scans, and compared their findings to the microscopic, pathology-confirmed ones obtained by laparotomy. UICC's TNM classification, 5th edition (May 1997), was used. RESULTS: Best results regarding Sensitivity were obtained in the diagnosis of lymph node disease (83%; 69-92%); regarding specificity we obtained 92% (79-98%) for T4, and 89% (77-96%) in metastasis detection. Accuracy was 70% for T1-T2, and 62% for T3. CONCLUSIONS: 1. For the T category, helical CT effectively detects advanced cases classified as non-resectable. 2. For the N category, helical CT prediction is better than ever before with previous CT generations. 3. For the M category, helical CT is a useful test to identify the presence of liver metastases that would render surgery unnecessary.

[Surgical management of anterior communicating artery aneurysms based on computed tomographic angiography with three-dimensional reconstruction and without preoperative angiography]. / Tratamiento quirúrgico de los aneurismas de la arteria comunicante anterior basado en el estudio de angio-TAC eon reconstrucción tridimensional y sin angiografía preoperatoria.

OBJECTIVE: To demonstrate the usefulness of threedimensional computed tomographic angiography (CT- 3D-angiography) in the microsurgical management of aneurysms of the anterior communicating artery (AComA). MATERIALS AND METHODS: A total of 28 consecutive patients with ruptured aneurysms of the AComA diagnosed by means of CT-3D-angiography and without preoperative angiography were operated on. The findings of the CT-3D-angiography, microsurgical exploration and clínical data were evaluated. RESULTS: There were no false positive findings nor false negative findings in the diagnosis of the AComA aneurysms. The global sensibility of the examination was 87.9%. The CT-3D-angiography study shows a left A1 segment dominance in 53.6% of cases, a right A1 dominance in 14.3% of cases and both A1 segments of the same diameter in 32.1%. Aneurysms growing on the traject of the AComA were associated with both A1 segments of the similar diameter and an AComA traject pararell to the transverse plane. Aneurysms implanted on the A1-A2 junction were associated with a dominant homolateral A1 segment and an oblique AComA traject. Microsurgical management of the lesions was done a mean of 3.7 days after bleeding. CONCLUSION: The study of patients with acute subarachnoid hemorrhage with CT-3D-angiography allows a reliable diagnosis of AComA aneurysms. The examination gives some anatomical data that allow the study of the hemodinamic changes involved in the development of the aneurysms. Moreover, provides usefull information for the microsurgical clipping. CT-3D-angiography allows to improve some health indicators but its impact in the final result of the patients needs more clinical data.

[Echography-guided percutaneous biopsy of pleural lesions and effusions]. / Biopsia percutánea de lesiones y derrames pleurales dirigida por ecografía.

Our experience in the use of ultrasonic echography (UE) is exposed as a guide for directing small lesions and pleural effusions percutaneous lesions with an unknown grounds. We have done pleural percutaneous biopsy using UE as guide in 45 patients. The needle diameter ranges between 17 and 19.5 G. Lesions were benign for 16 patients and malignant for 29. The right result was obtained in 93% of the cases. There were not complications. We conclude that echography-directed pleural biopsy presents an excellent diagnostic profitability, it improves the results obtained with blind biopsy with Cope's needle and it must precede thoracoscopy by means of its less aggressiveness.

Characterization of solid liver lesions with color and pulsed Doppler imaging.

BACKGROUND: To assess the usefulness of color Doppler and duplex sonography in the characterization of solid liver lesions. METHODS: We performed color Doppler and duplex sonography on 106 solid hepatic lesions. With color Doppler, we evaluated the aspect and distribution of tumoral vessels. The pulsed Doppler parameters considered were only those showing the highest systolic peak velocity values. RESULTS: Intratumoral color and pulsed Doppler signals were obtained in 81% (59/73) of malignant tumors (p < 0. 0001) but only in 18% (6/33) of benign tumors. Ninety-six percent (45/47) of the lesions with arterial intratumoral and peritumoral signals were malignant, whereas 4% were benign (p < 0.0001). Only eight (11%) malignant lesions had intratumoral venous signal vis-a-vis 23 (70%) benign. Twelve cases showing intratumoral venous Doppler signal as a single finding were benign. No statistically significant differences were observed in the quantitative parameters recorded by pulsed Doppler (Student t test, p < 0.05), there having been a clear overlapping in the values obtained in benign and malignant lesions. CONCLUSIONS: (a) The type of signal (arterial or venous) and its distribution detected by color and pulsed Doppler is more helpful than the assessment of the spectral quantitative parameters obtained by pulsed Doppler. (b) The presence of intratumoral venous flow remarkably suggests benignancy. (c) The presence of both intra- and peritumoral arterial flow in the same lesion strongly suggests malignancy.

Heart transplantation in Chagas' disease. 10 years after the initial experience.

BACKGROUND: Heart transplantation (HT) as a therapeutic option for end-stage chronic Chagas' heart disease (CCHD) is controversial. Reactivation of Trypanosoma cruzi infection and recurrence of the disease in the allograft are likely to occur. Furthermore, active myocarditis has been reported to predispose patients to an increased incidence and severity of rejection. METHODS AND RESULTS: We prospectively investigated the long-term follow-up of 10 patients with CCHD who underwent HT. Immunosuppression was based on cyclosporine A and azathioprine. T cruzi reactivation was prevented with benzonidazole. Besides allograft rejection surveillance, T cruzi infection was monitored through blood tests, myocardial biopsies, and serological tests. Over a mean follow-up period of 34 +/- 38 months (range, 73 to 124 months), 7 patients are alive and in NYHA functional class I. Life expectancy was 78% for the second year and 65% for 10 years. Rejection was less frequent in chagasic than in age- and sex-matched control patients (mean +/- SD, 1.60 +/- 1.26 versus 5.70 +/- 1.89 episodes per patient, respectively; P = .0001); decreased severity of rejection was also observed (P = .006). T cruzi parasitemias detected on three occasions were successfully treated with benzonidazole. There were no signs of recurrence of the disease in the allograft. CONCLUSIONS: These results suggest an important role of HT in the treatment of CCHD. There was a low frequency of T cruzi infection reactivation and no signs of recurrence of the disease in the allograft. The surprisingly decreased rejection incidence and severity require further studies for elucidation.

Transplante cardíaco heterotópico / Heterotopic heart transplantation

A resistência vascular pulmonar elevada, que ocorre na fase final das miocardiopatias, tem sido um dos maiores obstáculos para a realizaçäo do transplante cardíaco ortotópico pelo risco de falência precoce do ventrículo direito do órgäo transplantado. A aplicaçäo clínica do transplantado cardíaco heterotópico, com início na era pré-ciclosporina, ampliou a possibilidade dos transplantes cardíacos nesse grupo de pacientes. Dentre outras indicaçöes desse procedimentos, podemos citar sua utilizaçäo nasisfunçöes ventriculares potencialmente reversíveis e em casos de desproporçäo de tamanho entre o doador e o receptor. Nossa experiência clínica com o transplante cardíaco heterotópico teve início em Outubro de 1992, e consiste de três pacientes com miocardiopatia em fase final e com resistência vascular pulmonar fixa elevada. O primeiro paciente teve indicaçao de transplante heterotópico reforçada pelo encontro de um doador de tamanho inferior. Utilizamos uma inovaçäo tácnica original em um dos paciets, permitindo a anastomose entre as artérias pulmonares sem emprego de tubo protético. Houve um óbito precoce e um óbito tardio após um retransplante heterotópico. Um deles está em perfeitas condiçöes clínicas, praticando esportes regularmente. O transplante cardíaco heterotópico pode ser considerado alternativa terapêutica em portadores de cardiopatia em fase terminal com resistência vascular pulmonar elevada, especialmente naqueles com boa funçäo ventricular direita.

Transplante cardiopulmonar / Heart-lung transplantation

O transplante cardiopulmonar é modalidade terapêutica aceita internacionalmente para o tratamento de pacientes com doença que comprometem irreversivelmente os pulmöes e o coraçäo. As cardiopatias congênitas complexas, as cardiomiopatias primárias e as secundárias à doença valvar associadas a hiper-resistência vascular pulmonar irreversíveis säo indicaçöes precisas desse procedimento. Já no grupo de portadores de funçäo cardíaca preservada, como na doença pulmonar parenquimatosa primária e na hipernsäo pulmonar primária ou secundária à cardiopatia congênita de fácil correçäo, os transplantes pulmonares unilaterais ou bilaterais têm sido preferidos como forma de tratamento cirúrgico. Nossa experiência pessoal consiste de seis pacientes, três com diagnóstico de hipertensäo pulmonar primária, dois com miocrdiopatia e hipertensäo pulmonar e um com doença pulmonar isolada, todos em fase terminal da donça. Houve um óbito precoce e quatro óbitos tardios. A sobrevivência variou de 5 dias a 40 meses e todsapresentaram rejeiçäo pulmonar durante sua evoluçäo. O último paciente, atualmente no 26o. mês de evoluçäo, foi submetido no oitavo mês de pós-operatório a transplante pulmonar bilateral, devido a insuficiência respiratória progressiva por rejeiçäo pulmonar crônica. Os resultados do transplante cardiopulmonar, a longo prazo, säo ruins, tanto no tempo de sobrevivência quanto na qualidade de vida. Isso se deve, principalmente, à rejeiçäo pulmonar crônica, expressa pelo quadro clínico de insuficiência resirtória progressiva e histologicamente definida como bronquiolite obliterante. Podemos concluir que o transplante cardiopulmonar é uma forma de tratamento a ser considerada em pacientes terminais, porém limitada ao controle da rejeiçäo pulmonar a longo prazo.

[Heterotopic heart transplantation. Initial clinical experience]. / Transplante cardíaco heterotópico. Experiência clínica inicial.

PURPOSE: To report our initial clinical experience with heterotopic heart transplantation, stressing its indications and a new modification in surgical technique. METHODS: We studied three patients underwent heterotopic heart transplantation, using an original technique in one of them. This new technique allows to connect both pulmonary arteries without any prosthetic tube. RESULTS: One early death and two late survivors, with 17 and 20 months of follow-up. One of them is clinically well and practices sports, regularly. CONCLUSION: Heterotopic heart transplantation could be considered as a good therapeutic option for end-stage patients with cardiomyopathy and right pulmonary vascular resistance, specially those with right ventricle. It can improve general results of heart transplantation because it reduces the early risks related to hemodynamic problems in a selected group of patients.

[High-resolution electrocardiogram in the study of early rejection of heart transplant by spectral temporal mapping]. / Eletrocardiograma de alta resolução no estudo da rejeição precoce do transplante cardíaco pelo mapeamento espectro-temporal.

At the present time there is great interest in seeking non invasive methods for reduction and precise orientation of the endomyocardial biopsy after heart transplant. Two cases of orthotopic heart transplant followed by spectro temporal mapping of signal averaging electrocardiography and integral calculation are reported. The results that identified the rejection process are presented and several aspects of this method are discussed.

[The heart-lung transplant. Initial clinical experience]. / Transplante cardiopulmonar. Experiência clínica inicial.

PURPOSE: To assess this initial clinical experience with heart-lung transplantation in Brazil. METHODS: Four patients underwent heart-lung transplantation from December 1988 to March 1990, one patient with cardiomyopathy and high pulmonary resistance, two patients with primary pulmonary hypertension and another with pulmonary silicosis. The heart lung blocks were harvested from the donor using cardiopulmonary bypass and deep hypothermia. They were transplanted to the recipient by anastomosing the trachea, right atrium or venae cavae, and the ascending aorta. RESULTS: The second patient died on the 5th postoperative day due to respiratory insufficiency with consequent brain lesions. The first and third patients had survived nine months and 42 days respectively. The 4th patients is asymptomatic eight months after the operation. The main complications were bleeding in two patients, acute pulmonary rejection in three of them and obliterans bronchiolitis in one patients. CONCLUSION: The heart lung transplantation is a challenging procedure which results are progressively improving with the development of better surgical technique and clinical concepts.