Impact of Pleural Lavage Cytology Positivity on Early Recurrence After Surgery for Non-Small Cell Lung Cancer / Impacto de la positividad de la citología del lavado pleural en la recurrencia temprana después de la cirugía por cáncer de pulmón de células no pequeñas

Objective: The aim of this study was to elucidate the impact of pleural lavage cytology positivity on early recurrence in patients operated on non-small cell lung cancer (NSCLC). Methods: This is a multicentre prospective cohort study of 684 patients undergoing an anatomical lung resection for NSCLC between October 2015 and October 2017 at 12 national centres. A pleural lavage was performed before and after lung resection. The association between the different predictors of early recurrence and PLC positivity was performed using univariate and multivariate logistic regression models. A propensity score analysis was performed by inverse probability weighting (IPSW) using average treatment effect (ATE) estimation to analyse the impact of PLC positivity on early recurrence. Results: Overall PLC positivity was observed in 15 patients (2.2%). After two years, 193 patients (28.2%) relapsed, 182 (27.2%) with a negative PLC and 11 (73.3%) with a positive PLC (p<0.001). Factors associated to early recurrence were adenocarcinoma histology (OR=1.59, 95%CI 1.06–2.38, p=0.025), visceral pleural invasion (OR=1.59, 95%CI 1.04–2.4, p=0.03), lymph node involvement (OR=1.84, 95%CI 1.14–2.96, p=0.013), advanced pathological stage (OR=2.12, 95%CI 1.27–3.54, p=0.004) and PLC positivity (OR=4.14, 95%CI 1.25–16.36, p=0.028). After IPSW, PLC positivity was associated with an increased risk of early recurrence (OR=3.46, 95%CI 2.25–5.36, p<0.001). Conclusions: Positive pleural lavage cytology was found to be the strongest predictor of early recurrence.(AU)

Impact of Pleural Lavage Cytology Positivity on Early Recurrence After Surgery for Non-Small Cell Lung Cancer.

OBJECTIVE: The aim of this study was to elucidate the impact of pleural lavage cytology positivity on early recurrence in patients operated on non-small cell lung cancer (NSCLC). METHODS: This is a multicentre prospective cohort study of 684 patients undergoing an anatomical lung resection for NSCLC between October 2015 and October 2017 at 12 national centres. A pleural lavage was performed before and after lung resection. The association between the different predictors of early recurrence and PLC positivity was performed using univariate and multivariate logistic regression models. A propensity score analysis was performed by inverse probability weighting (IPSW) using average treatment effect (ATE) estimation to analyse the impact of PLC positivity on early recurrence. RESULTS: Overall PLC positivity was observed in 15 patients (2.2%). After two years, 193 patients (28.2%) relapsed, 182 (27.2%) with a negative PLC and 11 (73.3%) with a positive PLC (p<0.001). Factors associated to early recurrence were adenocarcinoma histology (OR=1.59, 95%CI 1.06-2.38, p=0.025), visceral pleural invasion (OR=1.59, 95%CI 1.04-2.4, p=0.03), lymph node involvement (OR=1.84, 95%CI 1.14-2.96, p=0.013), advanced pathological stage (OR=2.12, 95%CI 1.27-3.54, p=0.004) and PLC positivity (OR=4.14, 95%CI 1.25-16.36, p=0.028). After IPSW, PLC positivity was associated with an increased risk of early recurrence (OR=3.46, 95%CI 2.25-5.36, p<0.001). CONCLUSIONS: Positive pleural lavage cytology was found to be the strongest predictor of early recurrence.

The Significance of BRAF Mutation in the Epithelioid Glioblastoma Subtype: A Systematic Literature Review and a Case Report with a Unique Intraventricular Topography.

Epithelioid glioblastoma (E-GBM) is an exceedingly rare subtype of isocitrate dehydrogenase (IDH)-wildtype glioblastoma, first included in the WHO 2016 classification and characterized by a dominant population of epithelioid cells. Its histological and molecular defining features remain troublesome. The significance of BRAF mutations to pathological diagnosis and surgical outcome has drawn increasing attention given their promising potential for future adjuvant therapies. Herein, we describe a unique case of an E-GBM in the atrium of the left lateral ventricle and comprehensively analyze the importance of BRAF status in a cohort of 211 E-GBMs from the literature. Our patient was a 40-year-old man with occipital pain. His brain MRI revealed a large intraventricular tumor at the same location as a signal change found 10 years earlier with no additional follow-up. He underwent gross total tumor removal followed by conventional adjuvant treatment. Histopathological diagnosis was consistent with IDH-wildtype E-GBM WHO grade 4 with pleomorphic xanthoastrocytoma-like areas. BRAF p.V600 mutation was demonstrated in the tumoral genetic study. In the cohort analyzed, male patients predominated (63%), the median age was 32 years old, and the 5-year survival rate following diagnosis was 4.2%. BRAF mutations were found in 60.3% of the tumors overall, with this rate increasing to 78.3% in young adults (19-49 years, P < .001). Presence of BRAF mutations associated with tumor progression (P = .001), the event usually leading to death (P < .001). In conclusion, our study supports the importance of genetic BRAF p.V600 mutation analysis because its presence not only points to an E-GBM diagnosis but may also promote tumor progression.

Recommendations for optimizing the use of cytology in the diagnosis and management of patients with lung cancer.

Non-small cell lung cancer (NSCLC) is one of the oncological entities with the greatest evolution in molecular diagnosis due to the large number of diagnostic biomarkers and new treatments approved by international regulatory agencies. An accurate, early diagnosis using the least amount of tissue is the goal for the establishing and developing precision medicine for these patients. Rapid on-site evaluation (ROSE) provides cytological samples of optimal quantity and quality for a complete diagnosis of NSCLC. The usefulness of cytological samples has been demonstrated, not only for massive parallel sequencing but also for the quantification of the expression of programmed death-ligand 1 (PD-L1) and tumour mutational burden (TMB). Pre-analytical, analytical, and post-analytical recommendations are made for the management and appropriate use of cytological samples in order to obtain all the information necessary for the diagnosis and treatment of patients with NSCLC according to current quality parameters.

Recommendations for optimizing the use of cytology in the diagnosis and management of patients with lung cancer / Recomendaciones para optimizar el uso de la citología en el diagnóstico y manejo de pacientes con cáncer de pulmón

Non-small cell lung cancer (NSCLC) is one of the oncological entities with the greatest evolution in molecular diagnosis due to the large number of diagnostic biomarkers and new treatments approved by international regulatory agencies. An accurate, early diagnosis using the least amount of tissue is the goal for the establishing and developing precision medicine for these patients. Rapid on-site evaluation (ROSE) provides cytological samples of optimal quantity and quality for a complete diagnosis of NSCLC. The usefulness of cytological samples has been demonstrated, not only for massive parallel sequencing but also for the quantification of the expression of programmed death-ligand 1 (PD-L1) and tumour mutational burden (TMB).Pre-analytical, analytical, and post-analytical recommendations are made for the management and appropriate use of cytological samples in order to obtain all the information necessary for the diagnosis and treatment of patients with NSCLC according to current quality parameters.(AU)

El cáncer de pulmón de célula no pequeña es la patología oncológica que más está evolucionando con respecto al diagnóstico molecular por la ingente cantidad de biomarcadores diagnósticos y nuevos tratamientos aprobados por las agencias regulatorias internacionales. La incorporación de la valoración in situ (Rapid On Site Evaluation) de las muestras obtenidas por punción-aspiración con aguja fina permite la obtención de muestras citológicas en cantidad y calidad óptimas para acometer un diagnóstico completo del cáncer de pulmón de célula no pequeña. La citología ha demostrado su utilidad en la secuenciación masiva, la determinación de la expresión del ligando 1 de muerte programada (programmed death-ligand 1) y de la carga mutacional (tumour mutational burden).En este documento se establecen recomendaciones preanalíticas, analíticas y postanalíticas que permiten manejar y aprovechar adecuadamente la muestra citológica para obtener toda la información necesaria para el diagnóstico y tratamiento del paciente con cáncer de pulmón de célula no pequeña con los parámetros de calidad exigibles hoy en día.(AU)

Overview and update on molecular testing in non-small cell lung carcinoma utilizing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples.

Lung carcinoma remains one of the most frequent and aggressive human neoplasms. Fortunately, in the last decades, the increasing knowledge of the molecular mechanisms leading to cancer development has allowed the use of targeted therapies with improvement of prognosis in many patients. Clinical management has also changed after the introduction of endobronchialultrasonographic bronchoscopy that allows a conservative staging of lung tumors, avoiding the need of mediastinoscopy for lymph node staging. Lung pathologists and cytopathologists are facing the challenge of giving the more comprehensive prognostic and predictive information with ever smaller tissue or cytological samples. The aim of this review is to summarize the molecular testing for non-small cell lung carcinoma and how pathologists can contribute to the patient's outcome with a conscious management of biological samples.

The effect of age on clinical outcomes in critically ill brain-injured patients.

PURPOSE: We studied the impact of age on survival and functional recovery in brain-injured patients. METHODS: We performed an observational cohort study of all consecutive adult patients with brain injury admitted to ICU in 8 years. To estimate the optimal cut-off point of the age associated with unfavorable outcomes (mRS 3-6), receiver operating characteristic (ROC) curve analyses were used. Multivariate logistic regression analyses were performed to identify prognostic factors for unfavorable outcomes. RESULTS: We included 619 brain-injured patients. We identified 60 years as the cut-off point at which the probability of unfavorable outcomes increases. Patients ≥ 60 years had higher severity scores at ICU admission, longer duration of mechanical ventilation, longer ICU and hospital stays, and higher mortality. Factors identified as associated with unfavorable outcomes (mRS 3-6) were an advanced age (≥ 60 years) [Odds ratio (OR) 4.59, 95% confidence interval (CI) 2.73-7.74, p < 0.001], a low GCS score (≤ 8 points) [OR 3.72, 95% CI 1.95-7.08, p < 0.001], the development of intracranial hypertension [OR 5.52, 95% CI 2.70-11.28, p < 0.001], and intracerebral hemorrhage as the cause of neurologic disease [OR 3.87, 95% CI 2.34-6.42, p < 0.001]. CONCLUSION: Mortality and unfavorable functional outcomes in critically ill brain-injured patients were associated with older age (≥ 60 years), higher clinical severity (determined by a lower GCS score at admission and the development of intracranial hypertension), and an intracerebral hemorrhage as the cause of neurologic disease.

Weaning Outcomes in Patients with Brain Injury.

BACKGROUND: Despite the need for specific weaning strategies in neurological patients, evidence is generally insufficient or lacking. We aimed to describe the evolution over time of weaning and extubation practices in patients with acute brain injury compared with patients who are mechanically ventilated (MV) due to other reasons. METHODS: We performed a secondary analysis of three prospective, observational, multicenter international studies conducted in 2004, 2010, and 2016 in adults who had need of invasive MV for more than 12 h. We collected data on baseline characteristics, variables related to management ventilator settings, and complications while patients were ventilated or until day 28. RESULTS: Among the 20,929 patients enrolled, we included 12,618 (60%) who started the weaning from MV, of whom 1722 (14%) were patients with acute brain injury. In the acutely brain-injured cohort, 538 patients (31%) did not undergo planned extubation, defined as the need for a tracheostomy without an attempt of extubation, accidental extubation, and death. Among the 1184 planned extubated patients with acute brain injury, 202 required reintubation (17%). Patients with acute brain injury had a higher odds for unplanned extubation (odds ratio [OR] 1.35, confidence interval for 95% [CI 95%] 1.19-1.54; p < 0.001), a higher odds of failure after the first attempt of weaning (spontaneous breathing trial or gradual reduction of ventilatory support; OR 1.14 [CI 95% 1.01-1.30; p = 0.03]), and a higher odds for reintubation (OR 1.41 [CI 95% 1.20-1.66; p < 0.001]) than patients without brain injury. Patients with hemorrhagic stroke had the highest odds for unplanned extubation (OR 1.47 [CI 95% 1.22-1.77; p < 0.001]), of failed extubation after the first attempt of weaning (OR 1.28 [CI 95% 1.06-1.55; p = 0.009]), and for reintubation (OR 1.49 [CI 95% 1.17-1.88; p < 0.001]). In relation to weaning evolution over time in patients with acute brain injury, the risk for unplanned extubation showed a downward trend; the risk for reintubation was not associated to time; and there was a significant increase in the percentage of patients who underwent extubation after the first attempt of weaning from MV. CONCLUSIONS: Patients with acute brain injury, compared with patients without brain injury, present higher odds of undergoing unplanned extubated after weaning was started, lower odds of being extubated after the first attempt, and a higher risk of reintubation.

PD-L1 in Cytological Samples: A Review and a Practical Approach.

With a growing number of predictive biomarkers needed to manage patients with non-small cell lung cancer (NSCLC), there has been a paradigm shift in care and handling of diagnostic samples. Among the various testing methods, immunohistochemistry (IHC) is the most cost- effective and widely available. Furthermore, over the past decade immunotherapy has emerged as one of the most promising cancer treatments. In this scenario IHC is the most used testing method available for PDL-1/PD1 immunotherapy. Several monoclonal antibodies targeting programmed death 1 (PD-1)/programmed death ligand-1 (PD-L1) pathways have been integrated into standard-of-care treatments of a wide range of cancer types, once provided evidence of PD-L1 expression in tumor cells by immunohistochemistry (IHC). Since currently available PD-L1 assays have been developed on formalin-fixed paraffin embedded (FFPE) histological specimens, a growing body of research is being dedicated to confirm the feasibility of applying PDL-1 assays also to cytological samples. Albeit promising results have been reported, several important issues still need to be addressed. Among these are the type of cytological samples, pre-analytical issues, cyto-histological correlation, and inter-observer agreement. This review briefly summarizes the knowledge of the role of cytopathology in the analysis of PD-L1 by immunocytochemistry (ICC) and future directions of cytopathology in the immunotherapy setting.

Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease.

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Non-celiac gluten sensitivity and chronic refractory low back pain with spondyloarthritis features.

OBJECTIVE: To propose the hypothesis that non-celiac gluten sensitivity is associated with chronic low-back pain related to spondyloarthritis, and a gluten free diet has a therapeutic benefit in a subgroup of patients. Gut involvement is a well-known association of spondyloarthritis but limited to a few disorders such as inflammatory bowel disease. Currently the therapeutic implication of this association is pharmacologic treatment for inflammation with immunosupresive drugs for both diseases. Here is a case series of patients with chronic low-back pain, spondyloarthritis related features, and response to gluten free diet despite celiac disease being ruled out. METHODS: Retrospective case report of 110 patients from a tertiary hospital rheumatology clinic specialized in chronic pain and gluten sensitivity. These are patients with refractory low-back pain and spondyloarthritis features who followed a gluten free diet despite celiac disease being ruled out. Demanding improvement was defined based on the achievement of at least one of the following objectives: asymptomatic status, remission of chronic low-back pain, returning to normal life, returning to work, changing from confinement to bed/wheelchair to being able to walk, returning to self-sufficiency for hygiene and personal care, discontinuation of opioids. RESULTS: Average age at low-back onset pain was 30. Average disease duration was 15 years. 87 (79%) of the patients experienced improvement. 69 (62%) of the patients achieved demanding improvement. Average duration of gluten-free diet in patients with demanding improvement was 60 months. 56 out of 69 patients with demanding improvement ingested gluten. Of these 56 patients, 54 experienced clinical worsening and were considered as having non-celiac gluten sensitivity. Oral aphthae and having a relative with celiac disease were associated with demanding improvement. Out of 28 patients retrospectively classified as having axial spondyloarthritis, 23 had demanding improvement. Out of 16 patients with uveitis, 13 had demanding improvement. Out of 83 patients with fibromyalgia, 48 had demanding improvement. CONCLUSION: These observational data support the proposed hypothesis and offer information regarding possible clinical predictors of response to diet.

Intraventricular cryptococcoma mimicking a neoplastic lesion in an immunocompetent patient with hydrocephalus: A case report.

BACKGROUND: The aim of this study is to highlight the importance of cryptococcosis as one of the most common fungal infections of the central nervous system, stressing the consideration of a cryptococcoma within the list of differential diagnosis of intraventricular masses in immunocompetent hosts. CASE DESCRIPTION: We present the case of an immunocompetent 41-year-old female from Philippines with an intraventricular cryptococcoma due to Cryptococcus neoformans, mimicking an intraventricular primary brain tumor, who had hydrocephalus. She was approached as having a neoplastic lesion and underwent surgical resection plus third ventriculostomy through endoscopy. Later in her evolution, we realized the infectious nature of the lesion, and antifungal systemic therapy was initiated. In the end, she needed the placement of a ventriculoperitoneal shunt to maintain a good neurologic status. Despite all our efforts, she had a fatal outcome due to various complications. CONCLUSION: Our case is the first intraventricular cryptococcoma due to C. neoformans, as far as we know, to be reported in English, German, or Spanish literature. Our report stresses the importance to consider this kind of infection in immunocompetent patients, to raise the level of suspicion of this diagnosis, and to know the complications and management options.

Invasive aspergillosis in critically ill patients: An autopsy study.

Autopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty-five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante-mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty-three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.

Autopsy-detected diagnostic errors over time in the intensive care unit.

We evaluate the evolution over time of discrepancies between clinical diagnoses and postmortem findings in critically ill patients and assess the factors associated with these discrepancies. We conducted a prospective study of all consecutive patients who underwent autopsy in a medical-surgical intensive care unit (ICU) between January 2008 and December 2015. Among 7655 patients admitted to our ICU, 671 (8.8%) died. Clinical autopsy was performed in 215 (32%) patients. Major missed diagnoses were noted in 38 patients (17.7%). Eighteen patients (8.4%) had class I discrepancies, and 20 patients (9.3%) had class II discrepancies. The most frequently missed diagnoses were invasive aspergillosis, intestinal ischemia, myocardial infarction, cancer, and intra-abdominal abscesses. We did not find a statistically significant correlation between any premortem factor, including age, sex, severity of illness, length of hospital stay before ICU admission, length of ICU stay before death, duration of mechanical ventilation, or admitting unit, and the level of agreement between clinical and pathological diagnosis. In the last decades, the discrepancies between clinical and autopsy diagnoses persisted despite advances in medical skills and technology. Specific clinical entities such as invasive aspergillosis, mesenteric ischemia, myocardial infarction, intra-abdominal abscesses, and neoplastic diseases remain a diagnostic challenge in critically ill patients. Clinical level of diagnostic certainty does not increase with specific premortem characteristics.

Thymoma dissemination through the thoracic intervertebral foramen: Pleural recurrence resulting in spinal cord compression.

BACKGROUND: Spinal dissemination of thymic tumors is rare but should be considered in the differential diagnosis of thoracic dumbbell-shaped lesions and/or vertebral tumors, irrespective of the time since the initial diagnosis. CASE DESCRIPTION: A 63-year-old man, with a history of invasive type AB thymoma treated 21 years ago, newly presented to the hospital with a dumbbell-shaped T8-T9 lesion compressing the spinal cord. A review of the literature showed only 16 previous cases of thymic tumors with thoracic spine involvement. Here, we report the lengthiest interval between the initial tumor diagnosis and the detection of spinal involvement, that was secondary to a pleural recurrence from his thymoma. The patient did well following successful excision of the intraspinal mass which had encased the T8 nerve root. CONCLUSION: Spinal dissemination of thymic tumors can occur due to vertebral metastasis or to extension of a pleural recurrence through the intervertebral foramen. Definitive treatment for spinal lesions should be considered to provide adequate cord decompression.

Association between ventilatory settings and development of acute respiratory distress syndrome in mechanically ventilated patients due to brain injury.

PURPOSE: In neurologically critically ill patients with mechanical ventilation (MV), the development of acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality, but the role of ventilatory management has been scarcely evaluated. We evaluate the association of tidal volume, level of PEEP and driving pressure with the development of ARDS in a population of patients with brain injury. MATERIALS AND METHODS: We performed a secondary analysis of a prospective, observational study on mechanical ventilation. RESULTS: We included 986 patients mechanically ventilated due to an acute brain injury (hemorrhagic stroke, ischemic stroke or brain trauma). Incidence of ARDS in this cohort was 3%. Multivariate analysis suggested that driving pressure could be associated with the development of ARDS (odds ratio for unit increment of driving pressure 1.12; confidence interval for 95%: 1.01 to 1.23) whereas we did not observe association for tidal volume (in ml per kg of predicted body weight) or level of PEEP. ARDS was associated with an increase in mortality, longer duration of mechanical ventilation, and longer ICU length of stay. CONCLUSIONS: In a cohort of brain-injured patients the development of ARDS was not common. Driving pressure was associated with the development of this disease.

Primary Epidural Lumbar Ewing Sarcoma: Case Report and Review of the Literature.

STUDY DESIGN: Case report. OBJECTIVE: We present a case of isolated primary epidural lumbar Ewing sarcoma and review the current literature on the standard management. We also propose laminoplasty as safe procedure in this patient population that can provide good stabilization in young people. SUMMARY OF BACKGROUND DATA: Primary epidural Ewing's sarcoma is a very rare entity. The best generally accepted treatment option in sarcomas is to achieve a gross total resection with safe margins followed by local radiotherapy and chemotherapy. A total resection with safe margins is a great challenge in neurosurgical patients. METHODS: We present a previously healthy 17-year-old girl who complained of right sciatica with an epidural lumbar mass at L3-L4. She underwent complete resection of the tumor and a laminoplasty, which, in our experience, is a good way to preserve stability. RESULTS: At surgery, an isolated and noninvasive lesion was identified. Histopathological confirmation of Ewing sarcoma was obtained by immunohistochemical study and EWSR1 gene rearrangement detection. Treatment with 6 months of chemotherapy resulted in no further identifiable lesions by PET and MRI imaging at 4 years postsurgery. The laminoplasty has remained stable. CONCLUSION: Primary epidural Ewing sarcoma is extremely rare. The detection of the EWSR1 gene rearrangement can help to diagnose these tumors. The decision on how to treat these patients is difficult and can hardly be based on data from the current literature because of the small number of patients. The laminoplasty procedure can be safely performed in the setting of sarcoma of the epidural space.

Sensibilidad al gluten no celíaca y enfermedades reumatológicas / Non-celiac gluten sensitivity and rheumatic diseases

La enfermedad celíaca es una enfermedad autoinmune sistémica que tiene entre sus manifestaciones clínicas síntomas frecuentes en las enfermedades reumatológicas, como dolor musculoesquelético crónico, astenia y fatiga mental. Se asocia a otras enfermedades autoinmunes, como la enfermedad de Sjögren. Es una enfermedad bien caracterizada con pruebas diagnósticas específicas. La sensibilidad al gluten no celíaca es una entidad emergente, con sintomatología similar a la de la enfermedad celíaca, pero sin pruebas diagnósticas específicas. Se revisan el concepto y los problemas diagnósticos de la sensibilidad al gluten no celíaca y se propone como hipótesis la asociación de la sensibilidad al gluten no celíaca a la fibromialgia, las espondiloartropatías y las enfermedades autoinmunes. Se describen observaciones clínicas que apoyan esta hipótesis, destacando el beneficio clínico del tratamiento de la sensibilidad al gluten (AU)

Celiac disease is an autoimmune systemic disease having among its clinical manifestations frequent symptoms common to rheumatologic diseases such as musculoskeletal pain, asthenia, and cognitive fatigue. It is associated with other autoimmune diseases like Sjögren disease. It is a well-characterized disease with specific diagnostic tests. Non-celiac gluten sensitivity is an emerging entity with symptoms similar to celiac disease, but without specific diagnostic tests. The concept of non-celiac gluten sensitivity and its diagnostic problems are reviewed, and the hypothesis of its association with fibromyalgia, spondyloarthritis, and autoimmune conditions is proposed. Clinical observations supporting the hypothesis are described, highlighting the benefit of treating non-celiac gluten sensitivity (AU)

Non-celiac gluten sensitivity and rheumatic diseases.

Celiac disease is an autoimmune systemic disease having among its clinical manifestations frequent symptoms common to rheumatologic diseases such as musculoskeletal pain, asthenia, and cognitive fatigue. It is associated with other autoimmune diseases like Sjögren disease. It is a well-characterized disease with specific diagnostic tests. Non-celiac gluten sensitivity is an emerging entity with symptoms similar to celiac disease, but without specific diagnostic tests. The concept of non-celiac gluten sensitivity and its diagnostic problems are reviewed, and the hypothesis of its association with fibromyalgia, spondyloarthritis, and autoimmune conditions is proposed. Clinical observations supporting the hypothesis are described, highlighting the benefit of treating non-celiac gluten sensitivity.