[Thymectomy in myasthenia gravis]. / Timectomía en la miastenia gravis.

OBJECTIVE: To analyze outcome after thymectomy in patients with myasthenia gravis (MG). MATERIAL AND METHODS: Thirty-five patients with MG underwent surgery in our service between June 1987 and June 1998. Ten had associated thymomas. Preoperative Osserman classification showed 2 at level I, 20 at level IIA, 11 at level IIB and 2 at level III. Extended thymectomy through a medial sternotomy was performed in all. RESULTS: Postoperative complications developed in three patients (1 medullary aplasia, 1 postoperative reintubation, 1 myasthenic crisis). Mean follow-up was 89 months, with 22.8% achieving complete remission and 97.1% reporting improvements. The results were similar in the 10 patients with thymomas (20% full remission and 90% showing improvement). By DeFilippi classification, 22.8% were in class 1, 22.8% in class 2, 51.4% in class 3 and 2.8% in class 4. By Osserman classification, 9 were in the same category before and after surgery, 12 had improved one level, 10 had improved 2 levels, 3 had improved 3 levels and 1 patient had improved 4 levels. CONCLUSION: Thymectomy is an appropriate therapeutic procedure in the multidisciplinary treatment of patients with MG and it is the approach of choice for patients with associated thymomas. The intra- and post-operative complication rate is low and the rate of clinical improvement is high.

Timectomía en la miastenia gravis / Thymectomy in myasthenia gravis

OBJETIVO: Analizar los resultados de la timectomía en pacientes con miastenia gravis. MATERIAL Y MÉTODOS: Entre junio de 1987 y junio de 1998, se intervinieron en nuestro servicio 35 pacientes con miastenia gravis, en 10 de los cuales se asociaban timomas. Los pacientes se clasificaron en el preoperatorio según la clasificación de Osserman (dos grado I, 20 grado IIA, 11 grado IIB y dos grado III). En todos se realizó timectomía ampliada por esternotomía media. RESULTADOS: En 3 pacientes hubo complicaciones postoperatorias (una aplasia medular, una reintubación postoperatoria y una crisis miasténica). Tras una mediana de seguimiento de 89 meses, el 22,8 por ciento estaba en remisión completa y el 97,1 por ciento había mejorado. Los resultados son similares en los 10 pacientes con timoma (un 20 por ciento de remisiones completas y un 90 por ciento de mejorías). Según la clasificación de DeFilippi un 22,8 por ciento se encontraba en clase 1; un 22,8 por ciento, en clase 2; un 51,4 por ciento, en clase 3, y un 2,8 por ciento, en clase 4. Según la clasificación de Osserman, 9 pacientes presentaban el grado previo a la cirugía, 12 habían mejorado un grado, 10 habían mejorado 2 grados, 3 habían mejorado 3 grados y un paciente había mejorado 4 grados. CONCLUSIÓN: La timectomía es una opción terapéutica adecuada en el tratamiento multidisciplinario de los pacientes con miastenia gravis y es el tratamiento de elección en los pacientes en que se asocian timomas. El porcentaje de complicaciones intra y postoperatorias es bajo, y se obtiene un índice elevado de mejorías clínicas (AU)

Síndrome de Cushing secundario a tumor carcinoide bronquial: valor de la gammagrafía con 111In-DTPA octreotide en el diagnóstico de localización / Cushing´s syndrome secondary to bronchial carcinoid tumor: scintigraphy with 111IN-DTPA octreotide in the localizations diagnosis

El carcinoide bronquial (CB) es una causa excepcional de síndrome de Cushing y a menudo plantea problemas de diagnóstico diferencial con la enfermedad de Cushing por adenoma hipofisario. Presentamos dos casos en los que la gammagrafia con octreoscan fue de gran ayuda diagnóstica: en el primero, la tomografia computerizada (TC) mostró un nódulo pulmonar de 1 cm de características indeterminadas, que fue gammagráficamente positivo, que se confirmó tras la intervención. El segundo paciente es un varón de 60 años previamente operado CB secretor de ACTH, en el que persisten niveles elevados de ACTH y que presenta estudios de localización negativos. La gammagrafia mostró una captación compatible con recidiva tumoral. En nuestra opinión, la gammagrafia con octreoscan debe considerarse en pacientes con sospecha de síndrome de ACTH ectópico aunque existan lesiones torácicas demostrables en la TC (AU)

[Cushing's syndrome secondary to bronchial carcinoid tumor: contribution of gammagraphy with 111In-DTPA octreotide in the localization diagnosis]. / Síndrome de Cushing secundario a tumor carcinoide bronquial: valor de la gammagrafía con 111In-DTPA octreotide en el diagnóstico de localización.

Bronchial carcinoid (BC) is a rare etiology of Cushing syndrome, and difficulties in differential diagnosis with Cushing's disease are often present. We report two cases in which octreotide scintigraphy was an important diagnostic tool. The first patient showed a 1 cm non-specific pulmonary nodule on CT scan that was positive on scintigraphy, being confirmed by surgery. The second case was a man that had been operated but not cured of an ACTH secreting BC that continued with high ACTH levels and negative localization imaging studies. A subsequent scintigraphy showed a positive image suggestive of recurrence. Octreotide scintigraphy may be considered in patients with suspicion of ectopic ACTH syndrome although a positive image in CT scan be present.

[Granular cell myoblastoma localized in the thoracic wall]. / Mioblastoma de células granulosas localizado en la pared torácica.

We report the case or a 40-year-old man with a large right parasternal tumor. Computerized tomography (CT) and magnetic resonance (MR) imaging showed a soft tissue mass infiltrating contiguous structures with no sign of adenopathy and with disease limited the chest wall. The histological type was granular cell tumor (GCT) with discrete cell pleomorphism and nuclei that varied in form and size, with prominent nucleoli. Eighteen months after surgery, the patient was asymptomatic and disease free. GCT is a rare entity that is uncommonly found on the chest wall. A diagnosis of malignancy is established when metastasis is found to be of the same histological type as that of the primitive tumor. Neither cell pleomorphism or nuclei with nucleoli allows for a diagnosis of malignancy; only a size greater than 5 cm and locally invasive behavior should lead to an assumption that these tumors are of unspecified malignancy. We believe the treatment of choice for these lesions is radical removal

[Malignant pleural effusions: a description of an alternative method of external drainage with a fine-caliber catheter]. / Derrames pleurales malignos: descripción de un método alternativo de drenaje externo con catéter fino.

We describe the results of treating symptomatic pleural effusion by implanting a Pleurocath-type small-caliber catheter connected to a three-way valve for external evacuation. The method was used in 6 patients with advanced neoplastic disease and dyspnea related to pleural effusion that could not be treated with the usual methods of pleurodesis. Dyspnea disappeared or was significantly relieved in 5 of the 6 patients, such that follow-up could be continued on an outpatient basis for 3. Catheters remained in position for periods of time ranging from 14 days to 10 months. Survival varied from 14 days to 14 months. The only important complication was one case of infection in the area of catheter insertion. We describe the extremely simple technique used and the results that have encouraged us to continue using the method in cases that meet the necessary conditions.

[Short and long term follow-up of spontaneous pneumothorax treated using video-thoracoscopy]. / Seguimiento a corto y largo plazo del neumotórax espontáneo tratado por videotoracoscopia.

The outcome of video-assisted thoracoscopic treatment of spontaneous pneumothorax was analyzed. Eighty-three procedures were performed in 79 patients (58 men, 21 women: mean age 28.3 years, range 16 to 76 years). The reasons for intervention were recurring pneumothorax in 53 patients, contralateral pneumothorax in 10 (one of whom was treated on both sides), bilateral involvement in 3, and persistent air leakage in 13. Seven patients (8.4%) also required open thoracotomy. In 72 (88%) of the remaining 76 procedures, only video thoracoscopy was used. Three patients (3.6%) underwent video-assisted thoracotomy. Mean postoperative hospital stay was 5.1 days (2 to 24 days). No related deaths occurred but surgical complications were reported for 3 (3.9%). Significant postoperative complications developed in 9 cases (11.8%). One patient with prolonged air leakage underwent a second procedure, video-assisted thoracotomy, 12 days after the first intervention. Seventy-one of the 72 patients received follow-up examinations, with a mean follow-up period of 28.1 months (range 54 days to 54 months). Three recurrences (3.9%) were recorded but there were no cases of chronic pain requiring analgesia. We conclude that video thoracoscopy is an effective approach, with the advantage of being minimally invasive. We therefore believe it should be the procedure of choice, once improved morbidity and recurrence rates are observed, as these factors are influenced by the learning curve.

[Severe hypoglycemia secondary to a fibrous pleural tumor]. / Hipoglucemias severas secundarias a tumor fibroso pleural.

A case with recurrent hypoglycemias following a thoracic tumor is presented. Neurologic symptoms due to hypoglycemia were dominant. Subcutaneous somatostatin was administrated preoperatively and hypoglycemia was controlled following tumor resection. Histology analysis shows a localized fibrous pleural tumor. Origin has been widely questioned but now it is accepted to be mesenchymal and not mesothelial. Lung disease owing to chronic compression of the tumor made necessary a lobectomy. Postoperative atelectasis required reoperation and a pneumonectomy was performed. To date insulin-like factors secreted by the tumor are supposed to be responsible for hypoglycemics discharges.

[Necrotizing descendent mediastinitis of oropharyngeal origin]. / Mediastinitis descendente necrosante de origen orofaríngeo.

The spread of oropharyngeal infections to the mediastinum can give rise to descending necrotizing mediastinitis (DNM), which causes a high rate of mortality (around 40%), particularly when diagnosis is late and drainage inadequate. In the first case we report, successful drainage of the mediastinum was achieved at the cervical and sub-xiphisternum levels and by thoracotomy. Given the condition of the second patient, transcervical drainage alone was considered the best option, but this treatment was inadequate. Rapid start of appropriate drainage of the mediastinum is of great importance. Cervical drains, which may be adequate when there is perforation of the cervical esophagus, is insufficient in DNM, which calls for more aggressive, early drainage, such as can be achieved by thoracotomy. Computerized axial tomography of the chest is essential for rapid diagnosis, to plan the most appropriate surgical approach and for follow-up and evaluation of drainage.

Atypical bronchial carcinoid with oncocytoid features. Its ultrastructure, with special reference to its granular content.

A case of atypical bronchial carcinoid with oncocytoid features was studied. The tumor contained mitochondria-laden cells with scanty neurosecretory granules, heavily granulated cells, and intermediate forms. The neurosecretory granules were of three types as reported in previous cases: type P, type 3, and a double-core granule. The ultrastructural findings are characteristic of this type of tumor.