[Duodenal type folicular lymphoma: case report and literature review]. / Linfoma folicular tipo duodenal: reporte de caso y revisión de la literatura.

Duodenal type follicular lymphoma is a rare malignancy accounting for less than 4% of primary non-Hodgkin lymphomas of the gastrointestinal tract and it is a new entity that was recently described in the new update WHO 2016. Data regarding long-term outcome are currently lacking, and for that reason, a consensus on the management of this disease has not been established and treatment. We report a case of a 57-year-old female patient diagnosed with duodenal- type follicular lymphoma grade 3a who was treated with R-CHOP. The aim of this study is to add more data for a greater characterization of the entity and thus select the best management for each case.

Effect of Ki-67 assessment in the distribution of breast cancer subtypes: Evaluation in a cohort of Latin American patients.

Breast cancer (BC) is a heterogeneous disease composed of four main subtypes with distinct clinical and epidemiological features. Although several reports have described the distribution of BC subtypes in Latin America, the majority of them have not included the cellular marker, Ki-67, in the immunohistochemical (IHC) panel. The aim of the present study was to describe the distribution of BC subtypes in a cohort of Latin American women using an IHC panel with Ki-67. A prospective cohort of 580 patients in three centers of Peru (the Hospital Nacional Edgardo Rebagliatti Martins, the Hospital Nacional Guillermo Almenara Irigoyen, the Hospital Nacional Alberto Sabogal, Lima) and one in Uruguay (Instituto Nacional del Cáncer, Montevideo) were evaluated. BC phenotypes were classified according to an IHC panel: Estrogen receptor (ER), progesterone receptor (PgR), HER2 and Ki-67. Silver in situ hybridization was used when the HER2 status, as determined by IHC, was equivocal. The associations between the BC phenotypes and their clinicopathological features were evaluated. ER was positive in 65% of the cases (n=377), and PgR in 50% (n=203). In total, 79.1% (n=459) were HER2-negative, 19.8% (n=115) were HER2-positive and 1% (n=6) had an equivocal status. With respect to Ki-67, 44.7% of the patients exhibited staining in >14% of the tumor cells (n=259). The distribution of subtypes was as follows: Luminal A, 31.9% (n=183); luminal B, 35% (n=201); HER2, 12.1% (n=70); and triple-negative, 20.9% (n=120). When Ki-67 was not included in the panel, the frequency of luminal A was 41.1% and luminal B, 25.8% (9.2% of the cases were misclassified). Ki-67 was most highly expressed in triple-negative and HER2 tumors. Inclusion of Ki-67 in the IHC panel to assign subtypes revealed a higher frequency of luminal B tumors than was reported previously for Latin American women with BC, whereas the distribution of triple-negative and HER2 tumors were similar to that previously reported. In conclusion, these results demonstrated that excluding Ki-67 from the panel of IHC markers may lead to an underestimation of the rates of luminal B tumors.

[Performance and prognosis assessment of the solid pseudopapillary tumors of the pancreas]. / Evaluación del comportamiento y pronóstico de los tumores sólidos pseudopapilares del pancreas.

INTRODUCTION: Solid pseudopapillary tumors (SPT) of the pancreas are rare neoplasms of low malignant potential that typically affect young women. These are slow-growing lesions and very often reach large size. RESULTS: Between June 2003 and July 2013 24 patients were submitted to surgery. Twenty three (96%) were females with a median age of 32.4 ± 13.2 years old (range 11 to 69 years old). The mean tumor size was 91.3 ± 49 mm (range 30 to 200 mm). The type of procedure performed was duodenopancreatectomy in 9 cases, middle pancreatectomy in 4, distal pancreatectomy in 8, duodenum preserving pancreatectomy in 2 and diagnostic laparoscopy in 1. SPT had a benign anatomopathology and behaviour in 17 cases, while 3 had a carcinoma pattern and 4 developed distant metastases. Median follow up was 58 months (range 5 to 128 months). Recurrence occurred in 4 patients (16.6%) as liver metastases in 2 and carcinomatosis in 2. The overall survival rate at 5 and 10 years was 94% and 63%, respectively. CONCLUSION. SPT are uncommon neoplasms which are mostly benign. However, up to 20% may display a malignant behavior. More studies are needed to investigate predicting factors of malignant potential. The overall survival is high, even after resection of metastases.

Large B-cell lymphoma arising in cardiac myxoma or intracardiac fibrinous mass: a localized lymphoma usually associated with Epstein-Barr virus?

Primary cardiac neoplasms are rare. However, among them, cardiac myxoma is the most common tumor. In contrast, primary cardiac lymphoma within a cardiac myxoma is extremely rare and might be difficult to diagnose because of non-specific clinical manifestations. We report the case of a previously healthy 52-year-old man who presented with acute onset of transient dysarthria and left hemiplegia. A transthoracic echocardiography showed a 6×2.5-cm solid mass in the left atrium, which was subsequently resected. Histological, immunohistochemical, and molecular analyses revealed an EBV-associated CD30-positive large B-cell lymphoma with anaplastic morphology within a cardiac myxoma and fibrinous material. Staging studies showed no evidence of lymphoma elsewhere. The patient achieved complete remission and is alive 42 months after diagnosis, and did not receive chemotherapy. We discuss the clinical and pathologic features of lymphoma arising in cardiac myxoma or in intra-atrial fibrinoid mass and the potential role of IL-6 in its pathogenesis.

[Colonic intussusception by leiomyosarcoma]. / Intususcepción colónica por leiomiosarcoma.

We report the case of female patient, 34 years old, occupation Secretary. BACKGROUND: Polycystic ovary and chronic anemia. No family history of cancer. The patient reported three weeks abdominal pain, fever, bloody loose stools, nausea and vomiting. Abdominal pain is located in flank and right lower quadrant, is colicky, intensity 5 / 10, associated with abdominal distension. On physical examination, vital functions indicated T 38.6 ° FC 98 x min, FR 18 x min, BP 120/80, was awake, she looked pale, in generally fair condition, lucid and oriented. The abdomen was distended, the increased bowel sounds, tympanic to percussion, with tenderness in the right abdomen (more intense in the right iliac fossa), palpable mass is not defined edges lower right quadrant of about 6cm. CLINICAL DIAGNOSIS: abdominal pain syndrome (appendicular mass, intestinal obstruction, intussusceptions). In examinations auxiliars highlighted in 9.1 g of hemoglobin with decreased corpuscular constants. Reviewed by history "rectal bleeding", DRE: yellow stool, no trace of blood, so that colonoscopy was deferred. Reassessed at 24 hours, we decide surgery with a presumptive diagnosis of intestinal obstruction, intussusception. In surgery, we identified a transverse colon tumor (with colo-colonic intussusception) and 10cm of colon was resected and meso tumor: TT anastomosis was performed in transverse colon. The lesion was a tumor of the middle region of the transverse colon, proliferative fibroid appearance, which almost completely obstructed the intestinal lumen, measuring about 7x5cm. The study of pathology with immunohistochemistry indicated that the tumor corresponded to leiomyosarcoma of the colon. Was discharged in good condition. The rarity of this type of malignancy and this type of presentation led us to make this report.

Intususcepción colónica por leiomiosarcoma / Colonic intussusception by leiomyosarcoma

Reportamos el caso de una paciente mujer de 34 años, secretaria, con historia de anemia crónica y ovario poliquístico; sin historia familiar de cáncer. La paciente refería desde tres semanas antes del ingreso: náusea, vómito, dolor abdominal, fiebre y deposiciones sueltas con sangre. El dolor abdominal estaba localizado en flanco y fosa iliaca derecha, era tipo cólico, de intensidad 5/10 y asociado a distensión abdominal. En el examen clínico las funciones vitales indicaban T 38,6 °, FC 98 x min, FR 18 x min y PA 120/80; estaba despierta, lucida, pálida, en regular estado general. El abdomen estaba distendido, los ruidos hidroaéreos aumentados, timpánico a la percusión y con dolor a la palpación en hemiabdomen derecho (más intenso y con rebote positivo en fosa iliaca derecha); se palpaba masa de bordes no definidos en cuadrante inferior derecho, de aproximadamente 6cm. Diagnóstico clínico: Síndrome doloroso abdominal (¿plastrón apendicular, obstrucción intestinal: intususcepción?). En los exámenes auxiliares resaltaba la hemoglobina en 9,1 gr, con las constantes corpusculares disminuidas. El tacto rectal fue negativo, por lo que la colonoscopia fue diferida. Reevaluada a las 24 horas se decide cirugía. Se identificó una tumoración de colon transverso (con intususcepción colo-colónica), se resecó 10cm de colon y meso de tumoración; se realizó anastomosis T-T de colon transverso. La lesión era una tumoración proliferativa de 7x5 cm, que obstruía la luz del intestino casi totalmente. El estudio de anatomía patológica con inmunohistoquímica indicó que la lesión invaginada correspondía a un leiomiosarcoma de colon. Salió de alta en buenas condiciones. La rareza de éste tipo de neoplasia maligna de colon y lo esporádico de este tipo de presentación, nos indujo a realizar el presente reporte.

We report the case of female patient, 34 years old, occupation Secretary. Background: Polycystic ovary and chronic anemia. No family history of cancer. The patient reported three weeks abdominal pain, fever, bloody loose stools, nausea and vomiting. Abdominal pain is located in flank and right lower quadrant, is colicky, intensity 5 / 10, associated with abdominal distension. On physical examination, vital functions indicated T 38.6 ° FC 98 x min, FR 18 x min, BP 120/80, was awake, she looked pale, in generally fair condition, lucid and oriented. The abdomen was distended, the increased bowel sounds, tympanic to percussion, with tenderness in the right abdomen (more intense in the right iliac fossa), palpable mass is not defined edges lower right quadrant of about 6cm. Clinical diagnosis: abdominal pain syndrome (appendicular mass, intestinal obstruction, intussusceptions). In examinations auxiliars highlighted in 9.1 g of hemoglobin with decreased corpuscular constants. Reviewed by history “rectal bleeding”, DRE: yellow stool, no trace of blood, so that colonoscopy was deferred. Reassessed at 24 hours, we decide surgery with a presumptive diagnosis of intestinal obstruction, intussusception. In surgery, we identified a transverse colon tumor (with colo-colonic intussusception) and 10cm of colon was resected and meso tumor: TT anastomosis was performed in transverse colon. The lesion was a tumor of the middle region of the transverse colon, proliferative fibroid appearance, which almost completely obstructed the intestinal lumen, measuring about 7x5cm. The study of pathology with immunohistochemistry indicated that the tumor corresponded to leiomyosarcoma of the colon. Was discharged in good condition. The rarity of this type of malignancy and this type of presentation led us to make this report.

A primary cardiac osteosarcoma: Case report and review of the literature.

Primary cardiac osteosarcoma is a rare and aggressive neoplasm that can be difficult to diagnose. We report a case of a previously healthy 49-year-old woman who presented with dyspnea, atrial flutter, and heart failure. A mass was visualized in her left atrium by echocardiography and cardiac computed tomography, and the diagnosis of cardiac myxoma was raised. The patient subsequently underwent surgical resection of the mass and atrial reconstruction. Surprisingly, histological and immunohistological analyses revealed the mass to be an osteosarcoma. The patient received chemotherapy and radiotherapy. Eight months later, she has shown evidence of local recurrence. We briefly discuss primary osteosarcomas in the cardiac cavity and their management. .

Tumores estromales gastrointestinales: evaluación clinicopatológica y sobrevida en el Hospital Rebagliati / Gastrointestinal stromal tumors: clinicopathologic and survival evaluation in Rebagliati Hospital

OBJETIVO: Determinar las manifestaciones clínicas, radiológicas, histopatológicas y sobrevida de los pacientes con Tumor Estromal Gastrointestinal (GIST) en el Hospital Nacional Edgardo Rebagliati Martins (HNERM), de Lima, Perú. MATERIAL Y MÉTODOS: El presente es un estudio descriptivo, retrospectivo. El cual se realizó a partir de las historias clínicas de 103 pacientes con GIST confirmado por inmunohistoquímica que fueron evaluados y tratados en el HNERM, desde Enero del 2002 hasta Diciembre de 2010. RESULTADOS: En los 103 pacientes el promedio de edad fue 64 años (entre 30 y 88 años). Predominó en mujeres (52%). El tiempo de enfermedad promedio fue 7 meses. La forma de presentación más frecuente fue sangrado digestivo (48.3%). El diagnóstico se hizo más por endoscopía (50.5%). La prevalencia por órganos fue más frecuente en estómago 56.3%. El promedio de tamaño fue 98mm, (49% entre 50mm y 100mm), el tumor de mayor tamaño alcanzaba 260 mm. El estadio tumoral más frecuente fue localizado (70.9%). Presentaron otro cáncer asociado el 9.7% de pacientes El patrón histológico predominante fue fusiforme 73.8%. El 84.5% tuvo bajo índice mitótico. La inmunohistoquímica mostró la expresión de KIT (CD 117) 94.17%, CD 34 77.5%, Vimentina 96.6%, NSE 84.9%, Alfa actina 52.7%, CD56 44.4%, S-100 32.3% y Actina 20.0%. La característica tomográfica más frecuente fue tumor heterogéneo (43.6%). La distribución según clasificación de riesgo fue: muy bajo riesgo 3.9%, bajo riesgo 28.2%, riesgo intermedio 37.7% y alto riesgo 30.1%. La resección quirúrgica completa se realizó en 87.4% de pacientes, 4.9% de pacientes recibió Imatinib. La sobrevida global acumulada a 5 años fue 31.07%. En el análisis bivariado se encontró asociación estadística entre el haber sobrevivido con: ausencia de cáncer asociado p= 0.004, CD 34 p=0.01, índice mitótico bajo p=0.00 y tratamiento quirúrgico recibido p= 0.000. En el análisis multivariado se encontró asociación estadística de mayor sobrevida con: los de menor tamaño del tumor p=0.015 (IC -3.67, -0.41), estadio tumoral localizado p=0.036 (IC -5.83, -0.19), menor índice mitótico p=0.038 (IC -0.86, 0.02), paciente asintomático p=0.009 (IC 1.25, 8.62), no recidiva del tumor p=0.01 (IC -8.49, -1.17) y el no presentar metástasis p=0.001 (IC 2.66, 10.62). CONCLUSIONES: Los resultados de nuestro estudio fueron similares a lo que reporta la literatura internacional. Los factores que se asociaron a mayor sobrevida fueron: haber recibido tratamiento quirúrgico, pacientes con menor tamaño tumoral, estadio tumoral localizado, índice mitótico bajo, paciente asintomático, no recidiva del tumor, no metástasis y no cáncer asociado.

OBJECTIVE: To determine the clinical, radiological, histopathological manifestations and survival of patients with gastrointestinal stromal tumor (GIST)in the National Hospital Edgardo Rebagliati Martins (HNERM) from Lima, Perú. MATERIAL AND METHODS: This is a descriptive and retrospective study, which was based on the medical records of 103 patients with confirmed GIST with immunohistochemical. All the patients were evaluated and treated at the HNERM, from January 2002 until December 2010. RESULTS: In 103 patients between 30 and 88 years the average age was 64 years. The tumor was more frequent in females (52%). The mean disease duration was 7 months. The most frequent form of presentation was gastrointestinal bleeding (48.3%). The diagnosis was made more by endoscopy (50.5%). The prevalence of GISTs by organs was more frequent in stomach (56.3%). The average size of the tumors was 98mm, 49% had a size between 50mm and 100mm, the largest tumor was 260 mm. Tumor stage more frequent was localized (70:9%). GIST associated with another cancer was 9.7% of patients. The predominant histologic pattern was fusiform (73.8%). The 84.5% had low mitotic index. Immunohistochemistry showed expression KIT (CD 117) was 94.17%, CD34 77.5%, Vimentin 96.6%, NSE 84.9%, alpha actin 52.7%, CD56 44.4%, S-100 32.3% and Actin 20%. The tomographic characteristic more frequent was heterogeneous tumor (43.6%).The distribution according to risk classification was: very low risk 3.9%, low risk 28.2, intermediate risk 37.7% and high risk 30.1%. Complete surgical resection was performed in 87.4% of patients and 4.9% of patients received imatinib. The cumulative overall survival at 5 years was 31.07%. In bivariate analysis statistical association was found between surviving with: no presence of cancer associated p = 0.004, CD 34 p = 0.01, low mitotic index p = 0.00 and received surgical treatment p = 0.000. In multivariate analysis one found statistical association of longer survival with smaller tumor size p = 0.015 (CI -3.67, -0.41), localized tumor stage p = 0.036 (CI -5.83, -0.19), lower mitotic index p = 0.038 (CI -0.86, 0.02), asymptomatic patient p=0.009 (CI 1.25, 8.62), no tumor recurrence p = 0.01 (CI -8.49, -1.17), and no metastasis p = 0.001 (CI 2.66, 10.62). CONCLUSIONS: The results of our study were similar to what was reported in international literature. Factors that were associated with longer survival were receiving surgical treatment, patients with smaller tumor size, tumor stage localized, low mitotic index, asymptomatic patient, not tumor recurrence, not metastasis and no cancer associated.

[Gastrointestinal stromal tumors: clinicopathologic and survival evaluation in Rebagliati Hospital]. / Tumores estromales gastrointestinales: evaluación clinicopatológica y sobrevida en el Hospital Rebagliati.

OBJECTIVE: To determine the clinical, radiological, histopathological manifestations and survival of patients with gastrointestinal stromal tumor (GIST) in the National Hospital Edgardo Rebagliati Martins (HNERM) from Lima, Perú. MATERIAL AND METHODS: This is a descriptive and retrospective study, which was based on the medical records of 103 patients with confirmed GIST with immunohistochemical. All the patients were evaluated and treated at the HNERM, from January 2002 until December 2010. RESULTS: In 103 patients between 30 and 88 years the average age was 64 years. The tumor was more frequent in females (52%). The mean disease duration was 7 months. The most frequent form of presentation was gastrointestinal bleeding (48.3%). The diagnosis was made more by endoscopy (50.5%). The prevalence of GISTs by organs was more frequent in stomach (56.3%). The average size of the tumors was 98 mm, 49% had a size between 50 mm and 100 mm, the largest tumor was 260 mm. Tumor stage more frequent was localized (70:9%). GIST associated with another cancer was 9.7% of patients. The predominant histologic pattern was fusiform (73.8%). The 84.5% had low mitotic index. Immunohistochemistry showed expression KIT (CD 117) was 94.17%, CD34 77.5%, Vimentin 96.6%, NSE 84.9%, alpha actin 52.7%, CD56 44.4%, S-100 32.3% and Actin 20%. The tomographic characteristic more frequent was heterogeneous tumor (43.6%).The distribution according to risk classification was: very low risk 3.9%, low risk 28.2, intermediate risk 37.7% and high risk 30.1%. Complete surgical resection was performed in 87.4% of patients and 4.9% of patients received imatinib. The cumulative overall survival at 5 years was 31.07%. In bivariate analysis statistical association was found between surviving with: no presence of cancer associated p = 0.004, CD 34 p = 0.01, low mitotic index p = 0.00 and received surgical treatment p = 0.000. In multivariate analysis one found statistical association of longer survival with smaller tumor size p = 0.015 (CI -3.67, -0.41), localized tumor stage p = 0.036 (CI -5.83, -0.19), lower mitotic index p = 0.038 (CI -0.86, 0.02), asymptomatic patient p=0.009 (CI 1.25, 8.62), no tumor recurrence p = 0.01 (CI -8.49, -1.17), and no metastasis p = 0.001 (CI 2.66, 10.62). CONCLUSIONS: The results of our study were similar to what was reported in international literature. Factors that were associated with longer survival were receiving surgical treatment, patients with smaller tumor size, tumor stage localized, low mitotic index, asymptomatic patient, not tumor recurrence, not metastasis and no cancer associated.

[Celiac disease and intestinal obstruction by T cell lymphoma]. / Enfermedad celiaca y obstrucción intestinal por linfoma de células T.

A male patient, 55 years old, born in Ayacucho, with Spanish ancestors, was hospitalized through emergency referring abdominal pain, and 10 kilograms weight loss. Six months before he was diagnosed as having irritable bowel syndrome. His previous diseases were rheumatoid arthritis and intolerance to lactose. Laboratory results were: Hb 12 gr./dL, white cells 5200 per mm3, albumin 2.7 gr./dL, erythrocyte sedimentation rate 32 mm/hr., and tumor markers were negative. Radiographic study of the small bowel showed barium fragmentation, and a focal dilation in distal jejunum. Chest X-ray and CT scan of thorax, abdomen and pelvis were normal. Colonoscopy was normal for colonic mucosa, but in ileum it showed an irregular mucosa, little nodules and fewer folds than usual. Biopsy from ileum demonstrated unspecific inflammation. Upper endoscopy showed gastritis, a duodenum scar ulcer and an irregular mosaic pattern pink and white. Duodenum biopsy demonstrated short villi, chronic inflammation and an increase in the number of intraepithelial lymphocytes, all these was consistent with celiac disease Marsh 3. Antibodies anti-endomisium and anti-transglutaminase were positive. After some days he developed signs of bowel obstruction and was operated.

[Relationship between histologic type and location of gastric adenocarcinoma in the Rebagliati Hospital]. / Relación entre tipo histológico y la localización del adenocarcinoma gástrico en el Hospital Rebagliati.

INTRODUCTION: There is epidemiologic evidence that suggest the relation between the histological type and location of gastric adenocarcinoma. Knowing that there is a predominance of Helicobacter pylori infection in the antral region and this is considered an environmental factor; make us suppose that there is a relation among intestinal type and distal location. OBJECTIVE: The aim of this study is to investigate the relation among histological type and location of gastric cancer, using the Lauren classification and the Japanese Gastric Cancer Association classification. METHOD: During the period between January 1st 2007 and December 31th 2010, 460 patients with the proven diagnostic of adenocarcinoma were admitted for surgical treatment at the gastric cancer specialized ward of Rebagliati National Hospital, Lima, Peru. RESULTS: Female was more frequent in diffuse type (39% vs. 33%; p: 0,153), the mean age among intestinal type is greater than diffuse type (70,7 vs. 62,6 años; p<0,001). There is association among poorly differentiated with upper location (22% vs. 12,7%; p = 0,009), signet cell with middle location (50% vs. 32,5%; p: 0,006), tubular type with distal location (57,6% vs. 42,8%; p: 0,002), intestinal type with distal location (58,3% vs. 44,1%; p: 0,004), and diffuse type with upper location (19,3% vs. 12,5%; p: 0,049). CONCLUSION: Adenocarcinomas histologically differentiated or intestinal type are associated with distal location. Poorly differentiated type and signet ring cell type are associated with upper and middle location respectively.

Enfermedad Celiaca y Obstrucción Intestinal por Linfoma de Células T / Celiac disease and intestinal obstruction by T cell lymphoma

Paciente varón de 55 años, raza blanca (ascendencia española), natural y procedente de Ayacucho, que ingresó por una enfermedad de seis meses de evolución, caracterizada por dolor abdominal tipo cólico y baja ponderal de 10 Kg. Había estado hospitalizado seis meses antes y dado de alta con el diagnóstico de síndrome de intestino irritable. Entre sus antecedentes refería intolerancia a la lactosa y artritis reumatoidea. Los exámenes mostraron: Hb:12 g/dl, leucocitos: 5260 cel/mm, abastonados: 11%, albúmina: 2,7 mg/ml y VSG: 33mm/h. El resto de exámenes -incluyendo los marcadores tumorales- fueron normales. El tránsito gastrointestinal mostraba las asas delgadas con fragmentación del bario y dilatación focal moderada de un asa yeyunal distal. La tomografía de tórax, abdomen y pelvis sin alteraciones; Rx tórax normal. La colonoscopia fue normal; el íleon tenía pocos pliegues y pequeñas nodulaciones, las biopsias indicaron "ileitis inespecífica". La endoscopia mostró gastritis y una cicatriz de úlcera duodenal; la mucosa duodenal mostraba áreas con aspecto de mosaico rosado-blanquecino. La biopsia duodenal evidenció acortamiento de vellosidades, infiltrado inflamatorio crónico e incremento de linfocitos intraepiteliales, hallazgos compatibles con los criterios de celiaquía Marsh-tipo 3. Los anticuerpos IgA antiendomisio y antitransglutaminasa tisular estaban incrementados. Durante su hospitalización aumentó el dolor y aparecieron signos de obstrucción. En la laparotomía se encontraron una tumoración yeyunal estenosante y una perforación adyacente. El espécimen mostró un linfoma intestinal de células T. Se ha demostrado que existen más celiacos subclínicos que celiacos con esprue clásico; el conocimiento de esta situación nos debe llevar a tenerla presente por sus complicaciones o asociaciones, una de las cuales es el linfoma primario intestinal.

A male patient, 55 years old, born in Ayacucho, with Spanish ancestors, was hospitalized through emergency referring abdominal pain, and 10 kilograms weight loss. Six months before he was diagnosed as having irritable bowel syndrome. His previous diseases were rheumatoid arthritis and intolerance to lactose. Laboratory results were: Hb 12 gr./dL, white cells 5200 per mm3, albumin 2.7 gr./dL, erythrocyte sedimentation rate 32 mm/hr., and tumor markers were negative. Radiographic study of the small bowel showed barium fragmentation, and a focal dilation in distal jejunum. Chest X-ray and CT scan of thorax, abdomen and pelvis were normal. Colonoscopy was normal for colonic mucosa, but in ileum it showed an irregular mucosa, little nodules and fewer folds than usual. Biopsy from ileum demonstrated unspecific inflammation. Upper endoscopy showed gastritis, a duodenum scar ulcer and an irregular mosaic pattern pink and white. Duodenum biopsy demonstrated short villi, chronic inflammation and an increase in the number of intraepithelial lymphocytes, all these was consistent with celiac disease Marsh 3. Antibodies anti-endomisium and anti-transglutaminase were positive. After some days he developed signs of bowel obstruction and was operated. A tumor was found in jejunum with a bowel perforation. Pathological study showed a small bowel T-cell lymphoma. Fortunately this patient did well, and was sent home to continue treatment on ambulatory basis. Celiac disease is more common than what is thought, and it has been demonstrated that there are more persons with subclinical celiac disease, than those with the typical clinical pattern. It is necessary to be aware of this disease to improve diagnosis in order to avoid late complications as small bowel lymphoma.

Relación entre tipo histológico y la localización del adenocarcinoma gástrico en el Hospital Rebagliati / Relationship between histologic type and location of gastric adenocarcinoma in the Rebagliati Hospital

INTRODUCCIÓN: Existe evidencia epidemiológica que sugiere la asociación entre un tipo histológico y la localización del adenocarcinoma gástrico. Sabiendo que existe un predominio de infección por Helicobacter pylori en la región antral y ésta es considerada como un factor ambiental, es válido sospechar la existencia de una relación entre el tipo histológico intestinal y la localización distal. OBJETIVO: El objetivo de este estudio es investigar la relación entre el tipo histológico y la localización del cáncer gástrico, utilizando la clasificación propuesta por la Asociación Japonesa de Cáncer Gástrico y la clasificación propuesta por Lauren. MATERIALES Y MÉTODO: durante el periodo de Enero 2007 a Diciembre 2010, 460 pacientes con diagnostico probado de adenocarcinoma admitidos en el Servicio especializado de Cirugía de Estómago del Hospital Rebagliati parta tratamiento quirúrgico. RESULTADOS: El sexo femenino fue más frecuente en el tipo difuso (39 por ciento vs 33 por ciento; p: 0,153), la media de edad en el tipo intestinal es mayor al tipo difuso (70,7 vs 62,6 años; p<0,001). Existe asociación entre el tipo histológico pobremente diferenciado con la localización proximal (22 por ciento vs 12,7 por ciento; p: 0,009), el tipo de células en anillo de sello con la localización media (50 por ciento vs 32,5 por ciento; p: 0,006), el tubular con la localización distal (57,6 por ciento vs 42,8 por ciento; p: 0,002), el tipo intestinal con la localización distal (58,3 por ciento vs 44,1 por ciento; p: 0,004), y el difuso con la localización proximal (19,3 por ciento vs 12,5 por ciento; p: 0,049). CONCLUSIÓN: Los adenocarcinomas de tipo diferenciado ó de tipo intestinal están asociados con la localización distal. Los pobremente diferenciados y con células en anillo de sello se asocian con la localización proximal y media respectivamente.

INTRODUCTION: There is epidemiologic evidence that suggest the relation between the histological type and location of gastric adenocarcinoma. Knowing that there is a predominance of Helicobacter pylori infection in the antral region and this is considered an environmental factor; make us suppose that there is a relation among intestinal type and distal location. OBJECTIVE: The aim of this study is to investigate the relation among histological type and location of gastric cancer, using the Lauren classification and the Japanese Gastric Cancer Association classification. METHOD: During the period between January 1st 2007 and December 31th 2010, 460 patients with the proven diagnostic of adenocarcinoma were admitted for surgical treatment at the gastric cancer specialized ward of Rebagliati National Hospital, Lima, Peru. RESULTS: Female was more frequent in diffuse type (39 percent vs. 33 percent; p: 0,153), the mean age among intestinal type is greater than diffuse type (70,7 vs. 62,6 años; p<0,001). There is association among poorly differentiated with upper location (22 percent vs. 12,7 percent; p = 0,009), signet cell with middle location (50 percent vs. 32,5 percent; p: 0,006), tubular type with distal location (57,6 percent vs. 42,8 percent; p: 0,002), intestinal type with distal location (58,3 percent vs. 44,1 percent; p: 0,004), and diffuse type with upper location (19,3 percent vs. 12,5 percent; p: 0,049). CONCLUSION: Adenocarcinomas histologically differentiated or intestinal type are associated with distal location. Poorly differentiated type and signet ring cell type are associated with upper and middle location respectively.

Endoscopy Ultra- Sonography -guided biliary drainage in the surgical -endoscopy era.

BACKGROUND: US-guided hepatico - gastrostomy, choledocho-duodenostomy and choledocho-antrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepatico - gastrostomy is indicated in cases of hiliar obstruction, while the procedure of choice is choledocho - duodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. AIMS: To clarify to the readers about indication of these procedures, they must be made under a multidisciplinary view while sharing information with the patient or legal guardian. METHODS: All series cases report and selected cohort studies were selected according to the DDTS system in which key words were EUS biliary drainage, choledocho-duodenostomy, hepatico-gastrostomy, EUS, palliation and pancreatic biliary advanced cancer. RESULTS: Separately it was stated definition on the EUS biliary drainage procedures and it includes the techniques details and critical analysis. CONCLUSION: Hepatico- gastrostomy and Choledocho- duodenostomy are feasible when performed by endoscopists with expertise in bilio pancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Blastoma pleuropulmonar: reporte de caso y revisión de la literatura / Pleuropulmonary blastoma: case report and review of the literature

The pleuropulmonary blastoma is an aggressive primary lung tumor. Is most frequent in paediatric population, and there are a few cases reported worldwide. It consists of embrionary primitive mesenquimal tissue, and is different of the adult Pulmonary Blastoma. The clinical presentation can be missed by other prevalent diseases or may be an accidental diagnosis. The outcome following diagnosis is poor, overall for types ii and iii, with bad response to surgery and quimiotherapy, high rates or recurrence to more aggressive forms (eg. BPP type i to type ii o iii). This report describes the clinical picture of a two years old preschool child with aggressive BPP. We reviewed the actual literature about this topic.

El blastoma pleuropulmonar (BPP), es un tumor agresivo primario de pulmón. Afecta sobre todo en la edad pediátrica, habiendo sido reportado pocos casos a nivel mundial. El BPP consiste de tejido mesenquimal primitivo embrionario, de características diferentes al blastoma pulmonar del adulto. La presentación clínica suele confundirse con otras patologías frecuentes o puede ser incidental. La sobrevida luego del diagnóstico es pobre, sobre todo para los tipos ii y iii, con poca respuesta a la quimioterapia- cirugía, y alta frecuencia de recaídas a formas más agresivas. Se describe el caso de una pre-escolar de 2 años, con diagnóstico de BPP, que presentó una evolución clínica agresiva, se realizó la revisión de la literatura sobre los principales tópicos concernientes a esta patología.

[Clinical, endoscopic and histologic profile of the Gastrointestinal Stromal Tumours in the Rebagliati Hospital]. / Perfil Clínico, Endoscópico e Histológico de los Tumores Estromales Gastrointestinales en el Hospital Rebagliati.

INTRODUCTION: Gastrointestinal Stromal Tumors (GIST) are lesions which origin from Intersticial Cells of Cajal that may be asymptomatic or cause complications like digestive bleeding or malignant transformation. AIM: To determine the clinical, endoscopic and histological profile, as well as the main demographic features of patients with GIST in Hospital Edgardo Rebagliati (Lima-Perú) from January 2002 to December 2004. METHODS: Descriptive, transversal and retrospective study in which we reviewed clinical and anatomopathological archives from 34 patients with GIST during the above mentioned period. The collected data were placed on a sheet of recollection. RESULTS: There was male predominance (58.82%).The most affected age group was 71-80 years old (26.47%). The average age was 64.7 years old. The most frequent clinical presentation was abdominal pain (47.06%) followed by melena (44.12%). Diagnosis was made by endoscopic method in 58.82%. The main histological type was spindle (47.06%). There was high risk of malignancy in 50% and the most often involved site was stomach (61.77%). Endoscopicall the characteristic image was a submucosal tumor with ulceration, the average size was 6.44 cm. There was significant statistical relation (p<0.05) between endoscopic method and melena. CONCLUSION: Patients with GIST in HNERM are mostly men, older than 60 years that come with abdominal pain and melena, being endoscopy the best method to diagnose if patients present melena. Predominating histology was fusiform.

Perfil clínico, endoscópico e histológico de los humores estromales gastrointestinales en el Hospital Rebagliati / Clinical, endoscopic and histologic profile of the gastrointestinal stromal tumours in the Hospital Rebagliati

INTRODUCCIÓN: Los Tumores Estromales Gastrointestinales (GIST) son lesiones que se originan a partir de las células intersticiales de Cajal, y pueden tomar cursos asintomáticos o producir complicaciones, como hemorragia digestiva y degeneración maligna. OBJETIVO: Determinar el perfil clínico, endoscópico e histológico de los pacientes con GIST diagnosticados en el Hospital Nacional Edgardo Rebagliati Martins (Lima-Perú), en enero del 2002 y diciembre del 2004. MÉTODO: Estudio descriptivo, transversal, retrospectivo en el cual se revisaron las historias clínicas e informes anatomopatológicos de 34 pacientes con diagnóstico de GIST, vertiéndose los datos en una ficha de recolección. RESULTADOS: Predominó el sexo masculino (58.82%) sobre el femenino. El grupo etáreo más afectado fue el de 71-80 años, con 26.47%, la edad promedio fue 64.7 años, con un rango de 30 a 86 años. La forma de presentación más frecuente fue dolor abdominal (47.06%) seguido de melena (44.12%). El diagnóstico se hizo por método endoscópico en 58.82%. El tipo histológico predominante fue el fusiforme (47.06%). Hubo riesgo de malignidad alto en 50% de casos, y la localización más frecuente fue estómago (61.77%). Endoscópicamente se manifiesta por la presencia de tumoración submucosa con ulceración y tamaño promedio de 6.44 cm. Se halló relación estadísticamente significativa entre método endoscópico y melena como forma de presentación (p < 0.05). CONCLUSIÓN: Los pacientes con GIST en el HNERM son en su mayoría varones, mayoresde 60 años, que se presentan con dolor abdominal y melena, y es la endoscopía el mejor método para diagnosticarlos si acuden por melena (p < 0.05). Predomina la histología fusiforme.

INTRODUCTION: Gastrointestinal Stromal Tumors (GIST) are lesions which origin from Intersticial Cells of Cajal that may be asymptomatic or cause complications like digestive bleeding or malignant transformation. AIM: To determine the clinical, endoscopic and histological profile, as well as the main demographic features of patients with GIST in Hospital Edgardo Rebagliati (Lima-Perú) from January 2002 to December 2004. METHODS: Descriptive, transversal and retrospective study in which we reviewed clinical and anatomopathological archives from 34 patients with GIST during the above mentioned period. The collected data were placed on a sheet of recollection. RESULTS: There was male predominance (58.82%).The most affected age group was 71-80 years old (26.47%). The average age was 64.7 years old. The most frequent clinical presentation was abdominal pain (47.06%) followed by melen (44.12%). Diagnosis was made by endoscopic method in 58.82%. The main histological type was spindle (47.06%). There was high risk of malignancy in 50% and the most often involved site was stomach (61.77%). Endoscopicall the characteristic image was a submucosal tumor with ulceration, the average size was 6.44 cm. There was significant statistical relation (p < 0.05) between endoscopic method and melena. CONCLUSION: Patients with GIST in HNERM are mostly men, older than 60 years that come with abdominal pain and melena, being endoscopy the best method to diagnose if patients present melena. Predominating histology was fusiform.

[Early gastric cancer surgically treated at Rebagliati Hospital: study of 76 cases during 5 years]. / Cáncer gástrico temprano operado en el Hospital Rebagliati: estudio de 76 casos en el quinquenio 2004-2008.

This report describes the characteristics of early gastric cancer surgically treated in the Gastric Cancer Unit at Rebagliati National Hospital between January 2004 and December 2008. Mean age was 68 years; males, distal location, submucosa infiltration and intestinal histological type predominate in these patients. Lymph node involvement was 13%.

[Colonic histoplasmosis as a diagnostic manifestation of AIDS]. / Histoplasmosis colónica como manifestación diagnóstica de SIDA.

We report the case of 48 year old female patient without a history of significance importance.(refuses blood transfusion). She complaint of diarrhea of four months of duration and weight loss of 8 kg. she added episodes of hematochezia and severe anemia requiring transfusion. An intrahemorrhagic colonoscopy was performed detecting three ulcerated lesions. First at 10 cm from the anus, one in transverse colon distal, another similar ulcer in the proximal transverse The biopsies showed ulcer granulation tissue, abundant macrophages with intracytoplasmic structures consistent with histoplasmosis. Tests showed no tuberculosis or intestinal parasitosis. HIV testing (ELISA and Western Blot) were positive. The CD4 (78 cells) and extrapulmonary histoplasmosis were the criteria defined stage AIDS. The extrapulmonary histoplasmosis defines stage IV in immunosuppressed patients with HIV. Lower gastrointestinal bleeding colonic ulcer secondary to Histoplasma is a rare form presentation as a diagnostic manifestation of AIDS.

Cáncer gástrico temprano operado en el Hospital Rebagliati: estudio de 76 casos en el quinquenio 2004-2008 / Early gastric cancer surgically treated at Rebagliati Hospital: study of 76 cases during 5 years

El presente reporte describe las características del cáncer gástrico temprano sometido a tratamiento quirúrgico en el Servicio de Cirugía de Estómago del Hospital Nacional Rebagliati en el quinquenio comprendido entre enero del 2004 y diciembre del 2008. La edad promedio fue de 68 años; predomina el sexo masculino, la localización distal, la infiltración a submucosa y el tipo histológico intestinal. La metástasis ganglionar se presenta en el 13%.

This report describes the characteristics of early gastric cancer surgically treated in the Gastric Cancer Unit at Rebagliati National Hospital between January 2004 and December 2008. Mean age was 68 years; males, distal location, submucosa infiltration and intestinal histological type predominate in these patients. Lymph node involvement was 13%.