Programa multicéntrico de cribado de cáncer colorrectal en Chile / Results of a multicentric colorectal cancer screening program in Chile

Background: Colorectal Cancer Screening Programs (CRCSP) are widely accepted in developed countries. Unfortunately, financial restrictions, low adherence rate and variability on colonoscopy standardization hamper the implementation of CRCSP in developing countries. Aim: To analyze a multicentric pilot model of CRCSP in Chile. Material and Methods: A prospective model of CRCSP was carried out in three cities, from 2012 to 2015. The model was based on CRC risk assessment and patient education. Health care personnel were trained about logistics and protocols. The endoscopy team was trained about colonoscopy standards. A registered nurse was the coordinator in each center. We screened asymptomatic population aged between 50 and 75 years. Immunological fecal occult blood test (FIT) was offered to all participants. Subjects with positive FIT underwent colonoscopy. Results: A total of 12,668 individuals were enrolled, with a FIT compliance rate of 93.9% and 2,358 colonoscopies were performed. Two hundred and fifty high-risk adenomas and 110 cancer cases were diagnosed. One patient died before treatment due to cardiovascular disease, 74 patients (67%) underwent endoscopic resection and 35 had surgical treatment. Ninety one percent of patients had an early stage CRC (0-I-II). Among colonoscopy indicators, 80% of cases had an adequate bowel preparation (Boston > 6), cecal intubation rate was 97.7%, adenoma detection rate was 36.5%, and in 94.5% of colonoscopies, withdrawal time was adequate (> 8 min). Conclusions: This CRCS pilot model was associated to a high rate of FIT return and colonoscopy quality standards. Most CRCs detected with the program were treated by endoscopic resection.

Nephrogenic adenoma of the bladder: a single institution experience assessing clinical factors

ABSTRACT Introduction: Nephrogenic adenoma (NA) was first described by Davis in 1949 as a "hamartoma" of the bladder. There are many proposed predisposing factors for NA including chronic inflammation, renal transplantation, and bladder cancer. We examined our experience with NA to determine predisposing factors and determine if there was any increased risk for development of subsequent malignancy. Materials and Methods: All patients with a pathologic diagnosis of bladder NA from 2001-2013 were included. Patient history, clinical factors including possible predisposing factors for NA, and follow-up were reviewed. Results: Among 60 patients, 68% were males with an average age of 61, an average BMI of 28.7, and 60% had a smoking history. In evaluating pro-inflammatory factors, 26.7% underwent either Bacillus Calmette-Guerin or mitomycin C, 30% had recurrent urinary tract infections, and 25% had a history of catheterization. Recurrence of NA after initial resection occurred only in 14.7% of patients who underwent follow-up cystoscopy. A history of concurrent bladder cancer was seen in 41.7% of patients, but there were no cases of de novo bladder cancer diagnosed after NA. Conclusion: To the best of our knowledge, this is the largest series of patients with NA of the bladder. NA occurs in a heterogeneous population of patients, but most often with underlying inflammation. NA occurred concurrent with bladder cancer; however there were no cases of de novo bladder cancer after NA, reassuring that NA is likely a benign reactive condition.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

Carga de doença no Brasil: um olhar sobre o álcool e a cirrose não viral / Disease burden in Brazil: an investigation into alcohol and non-viral cirrhosis

O uso/dependência de álcool é importante fator de risco para o desenvolvimento da cirrose. O objetivo deste artigo é descrever e analisar o DALY (Disability Adjusted Life Years), o YLL (Years of Life Lost) e o YLD (Years Lived with Disability) de uso/dependência de álcool e da cirrose de etiologia não viral no Brasil, em 2008. O DALY foi calculado pela soma do YLL e do YLD. Para o YLL, foi utilizada a média dos óbitos de 2007-2009 no país. Através da revisão de dados epidemiológicos e do uso da ferramenta DisMod, a prevalência de cada um dos agravos foi modelada, gerando dados de incidência para o cálculo do YLD. O álcool e a cirrose foram responsáveis, respectivamente, por 3% e 1% do DALY total. Considerando-se as dez primeiras causas de DALY para homens, o uso/ dependência de álcool ocupou a segunda, terceira e sexta posições nas idades de 15-29, 30-44 e 45-59 anos, respectivamente. A cirrose ocupou a oitava posição no grupo de 30-44 anos; a quinta, no de 45-59 e a oitava, no de 60-69. A distribuição dos agravos por faixa etária sugere que intervenções direcionadas ao uso/dependência de álcool terão efeitos na carga de cirrose alcoólica no país.

Alcohol use/dependence are an important risk factor for cirrhosis of the liver. The article aims to describe and conduct a comparative analysis of Disability Adjusted Life Years (DALY), Years of Life Lost (YLL) and Years Lived with Disability (YLD) of alcohol use disorders and non-viral cirrhosis in Brazil in 2008. DALY was calculated as the sum of YLL and YLD. For YLL estimates, the mean number of deaths from 2007- 2009 in the country was considered. After revision of epidemiological data, prevalence of each disease was modelled with the DisMod tool, which generated incidence data for YLD estimates. Alcohol and non-viral cirrhosis were responsible for 3% and 1% of total DALYs, respectively. In both diseases, men contributed to a greater proportion of DALYs. Among the first ten causes of DALYs, alcohol use disorders occupied the second, third and sixth positions at the ages of 15-29, 30-44 and 45- 59, respectively. Non-viral cirrhosis was the eighth cause of DALY in the 30-44 age group in men; the fifth, in the 45-59 group and the eighth, in the 60-69 group. Age distribution suggests that interventions directed against alcohol use/dependence would have effects on the burden of alcoholic cirrhosis in the country.

Physical activities in daily life and functional capacity compared to disease activity control in acromegalic patients: impact in self-reported quality of life / Avaliação da atividade física na prática de vida diária comparada com o nível de atividade da doença em pacientes acromegálicos: impacto na percepção da qualidade de vida

OBJECTIVE: To evaluate the quality of life and its association with daily physical activity and disease control in acromegalic patients. SUBJECTS AND METHODS: A cross-sectional, case series study, composed of 42 patients recruited from the Neuroendocrinology Unit of the University Hospital of Brasilia. Level of physical activity was accessed by the International Physical Activity Questionnaire (IPAQ 6-short-form), which evaluates the weekly time spent on physical activity of moderate to vigorous intensity in different contexts of life. Quality of life was evaluated by The Medical Outcome Study Questionnaire Short Form (SF-36). Data was compared to growth hormone (GH) and insulin-like growth factor (IGF-1) levels. Students' t test and Fisher test were used, p < 0.05, SPSS 17.0. RESULTS: Twenty-two women, aged 51.33 ± 14.33 and 20 men, aged 46.2 ± 13.18 were evaluated. Arthralgia was present in 83% of cases. In men, the most common sites of pain were the knees (73%), spine (47% lumbar, and 53% thoracic and cervical segments), hands and wrists (40%). Higher scores on SF-36 were observed in patients with intermediate or high levels of physical activity, in the domains social functioning (75 CI 57.3-92.6), general health (75.5 CI 60.4-90.5), mental health (70 CI 57.8-82.1). CONCLUSIONS: In this study, the presence and severity of physical disability and pain were not associated with initial GH and IGF-1 levels or time of exposure to GH excess. However, the patients considered controlled, with normal a normal age-adjusted IGF-1, presented higher scores in SF-36, in physical and emotional domains, compared with patients with persistent hypersomatotrophism. These findings suggest benefits of metabolic control in self-reported quality of life.

OBJETIVO: Avaliar a qualidade de vida e sua associação com a prática de vida diária e controle metabólico em pacientes portadores de acromegalia. SUJEITOS E MÉTODOS: Estudo seccional de série de casos, composto por 42 pacientes recrutados na Unidade de Neuroendocrinologia do Hospital Universitário de Brasília. O nível de atividade física foi estimado pelo Questionário Internacional de Atividade Física (IPAQ-6), que avalia o tempo gasto semanalmente em atividades físicas que variam de intensidade em diferentes contextos de vida. A qualidade de vida foi avaliada pelo questionário SF-36. Os dados obtidos foram comparados aos níveis de hormônio do crescimento (GH) e fator de crescimento semelhante à insulina (IGF-1). Os testes t Students e Fisher foram aplicados e p < 0,05 foram considerados significativos, SPSS 17.0. RESULTADOS: Avaliaram-se 22 mulheres com idades de 51,33 ± 14,33 e 20 homens com idades de 46,2 ±13,18. Artralgia foi relatada em 83% dos pacientes. Em homens, os sítios de dor mais comuns foram os joelhos (73%), coluna vertebral (47% lombar, 53% segmentos torácico e cervical), mãos e quadris (40%). Os maiores escores no SF-36 foram observados em pacientes com níveis intermediário ou alto de atividade física, sobretudo nos domínios social (75 CI 57,3-92,6), saúde geral (75,5 CI 60,4-90,5), saúde mental (70 CI 57,8-82,1). CONCLUSÕES: A presença e a severidade do prejuízo no desempenho físico e dor não se associaram com Gh e IGF-1 no diagnóstico, tempo de exposição prévio à doença. Todavia, pacientes considerados controlados apresentaram melhores escores nos domínios físico e emocional, comparados com pacientes com hipersomatotrofismo persistente. Tais achados sugerem benefícios do controle metabólico na qualidade de vida.

Clinical and laboratorial characterization and post-surgical follow-up of 87 patients with non-functioning pituitary macroadenomas / Caracterização clínica e laboratorial e seguimento pós-cirúrgico de 87 portadores de macroadenomas hipofisários não funcionantes

Objective: It was to assess the main characteristics of patients undergoing pituitary tumor surgery. Method: Eighty-seven patients (44 men; 44.8±13 years old) were included. Results: The main symptoms were visual alterations (87.3%), headache (70.1%), diminished libido (34.4%), galactorrhea (22.9%) and hair loss (19.5%). The axes affected were gonadotropic (72.6%), thyrotropic (48.4%) and corticotropic (38.7%), without significant changes after surgery. The average largest tumor diameter was 3.1 cm before surgery and 1.56 cm after surgery. The most frequent postoperative complications were hydro-electrolyte and acid-base disorders (12%), diabetes insipidus (9%), visual field alterations (9%), liquoric fistula (8%) and nasal obstruction (7%). The patients were affected by more than one complication. Conclusion: Although a decrease in tumor volume was achieved through surgery, hormonal deficiencies persisted in most of the patients and new surgical approaches were necessary for dealing with tumor recurrence or persistence. .

Objetivo: Avaliar as principais características de pacientes operados de tumor de hipófise. Método: Foram incluídos 87 pacientes (44 homens; 44,8±13 anos). Resultados: Os principais sintomas foram alterações visuais (87,3%), cefaleia (70,1%), diminuição da libido (34,4%), galactorreia (22,9%) e queda de pelos (19,5%). Os eixos afetados foram gonadotrófico (72,6%), tireotrófico (48,4%) e corticotrófico (38,7%). Não houve mudanças significativas após a cirurgia. A média do maior diâmetro do tumor foi 3,1 cm antes da cirurgia e 1,56 cm após a cirurgia. As complicações pós-cirúrgicas mais frequentes foram distúrbios hidroeletrolíticos e ácido-básicos (12%), diabetes insipidus (9%), alterações do campo visual (9%), fístula liquórica (8%) e obstrução nasal (7%). Ocorreu mais de uma complicação no mesmo paciente. Conclusão: Embora tenha obtido diminuição da massa tumoral com a cirurgia, as deficiências hormonais persistiram na maioria dos pacientes e ocorreu necessidade de novas abordagens por recidiva ou persistência do tumor. .

La secuencia adenoma-carcinoma, consideraciones clínicas, patológicas y de vigilancia endoscópica / The adenoma-carcinoma sequence. Clinical, pathological and endoscopic surveillance

A case of a 84 year-old woman with a history of colonoscopy performed in May 2008, where a 5 mm polyp was detected from the hepatic flexure. It was removed by biopsy and histology showed a tubular adenoma with low-grade dysplasia. In May 2011, the patient consulted due to mild to moderate pain in both hypochondria of 6 months of duration accompanied by bloating and belching. A control colonoscopy was indicated, which was held in June 2011, and showed a 2 cm polyp in ascending colon, this was resected with polypectomy snare. In the vicinity there was a 3-mm polyp that was removed with biopsy forceps. Histological examination showed in the bigger lesion a moderately differentiated grade 2 invasive tubular adenocarcinoma, with superficial and focal invasion of the submucosa, developed in adenoma with free surgical margin (1.7 mm), no vascular, lymphatic invasion or tumor budding were found. The smaller lesion was reported as tubular adenoma with low grade dysplasia. Colorectal cancer epidemiology, indications for controls after colonoscopic polypectomy of adenomas, especially those at high risk, histopathological risk factors for adenocarcinomas developed in adenomas and the need to monitor these patients annually with occult blood test stool are discussed between the control colonoscopies indicated.

Se presenta el caso de una mujer de 84 años, con antecedentes de colonoscopia efectuada en mayo de 2008 donde se le detectó un pólipo de 5 mm del ángulo hepático del colon, el que fue extraído por biopsia y cuyo estudio histológico demostró un adenoma tubular con displasia de bajo grado. En mayo de 2011, consulta por dolor leve a moderado en ambos hipocondrios de 6 meses de evolución acompañados de meteorismo y eructos. Se indicó ileocolonoscopia, la que se realizó en junio de 2011 y demostró un pólipo del colon ascendente de 2 cm, que fue resecado con asa de polipectomía; y cercano a éste, un pólipo de 3 mm que se extirpó con pinza biopsia. El examen histológico informó adenoma tubular con displasia moderada en la lesión de menor tamaño y adenocarcinoma tubular invasor moderadamente diferenciado grado 2 de Broders, con invasión focal superficial de la submucosa, desarrollado en adenoma. Límites quirúrgicos libres de lesión, sin invasión vascular sanguínea, linfática ni budding tumoral con límite quirúrgico profundo a 1,7 mm de la lesión. Se comentan la epidemiología del cáncer rectocolónico, la indicación de los controles colonoscópicos luego de la polipectomía de los adenomas, en especial de aquellos de alto riesgo, los factores de riesgo anatomopatológicos de carcinomas desarrollados en adenomas, y la necesidad de controlar anualmente a estos pacientes con colonoscopias de vigilancia.

Microcirurgia endoscópica transanal no tratamento dos tumores do reto: estudo prospectivo em 50 pacientes / Transanal endoscopic microsurgery in the treatment of rectal tumors: a prospective study in 50 patients

RACIONAL: A literatura médica aceita ressecção local como opção válida em casos selecionados de tumores de reto. A seleção dos pacientes requer exata estimativa dos riscos e avaliação pré-operatória precisa, tanto no aspecto clínico como histopatológico. OBJETIVO: Avaliar os resultados da microcirurgia endoscópica transanal em seguimento de 18 meses. MÉTODOS: De abril de 2002 a abril de 2006, 50 pacientes com tumores de reto foram submetidos a microcirurgia endoscópica transanal, selecionados por suas características clínicas e histopatológicas. Os critérios de inclusão foram: adenomas sésseis maiores do que 3 cm e menores do que 8 cm não-circunferenciais; neoplasia intra-epitelial de alto grau; carcinoma retal pT1, e em casos especiais pT2. Todos esses tumores foram submetidos ao mesmo procedimento cirúrgico. RESULTADOS: O resultado histopatológico final revelou 9 adenomas, 26 neoplasias intra-epiteliais de alto grau, 13 carcinomas (9 pT1 e 4 pT2) e 2 carcinóides. A menor idade foi de 25 anos e a maior de 92. O menor tumor ressecado tinha 64 mm² (carcinóide) e o maior (adenoma) 90 mm². O tempo médio de operação foi de 90 minutos e o de internamento 5 dias. Houve uma morte não relacionada ao método. Um paciente com carcinoma de baixo risco pT1 apresentou recidiva 18 meses após microcirurgia endoscópica transanal e foi submetido a retossigmoidectomia curativa. Foi observado tumor residual em dois pacientes e a complicação mais grave foi uma fístula retovaginal. A taxa de complicação global foi de 9 por cento. CONCLUSÃO: Atualmente a microcirurgia endoscópica transanal é a técnica de escolha para o tratamento de adenomas sésseis, neoplasias intra-epiteliais de alto grau e carcinoma retal pT1 de baixo risco.

BACKGROUND: The medical literature accepts local resection as a valuable option in selected cases of rectal tumors. Selection of patients requires an exact perioperative estimation of risks with clinical and histopathological examination. Transanal endoscopic microsurgery aims a safe resection of the tumoral area which leads up to the cure. AIM: To evaluate transanal endoscopic microsurgery results in a follow-up time of 18 months. METHODS: From April 2002 to April 2006, 50 patients with rectal tumors were submitted to transanal endoscopic microsurgery, chosen by clinical history and lesion characteristics. The inclusion criteria were: sessile adenomas larger than 3 cm and smaller than 8 cm, not circumferentially distributed; intra epithelial neoplasia of high degree; and rectal carcinoma pT1, and special cases of pT2. All these rectal tumors were submitted to the same surgical act. RESULTS: The final histopathological results reveal 9 adenoma, 26 intra-epithelial neoplasia of high degree, 13 carcinoma (9 pT1-4 pT2) and 2 carcinoid. The lowest age was 25 and the higher, 92 years-old. The smallest resected tumor had 64 mm² (carcinoid) and the largest (adenoma), 90 cm². Operating time was in average 90 minutes and the overall time statement, 5 days. There was one death not related with the method. One patient with low risk carcinoma pT1 presented recurrence 18 months after transanal endoscopic microsurgery and was submitted to curative rectosigmoidectomy. It was proven a residual tumor after local surgery in two patients and the most important complication was one recto-vaginal fistula. The overall complications rate was 9 percent. CONCLUSION: Today transanal endoscopic microsurgery is chosen as the ideal technique for the treatment of sessile adenomas, intraepithelial neoplasia of high degree and rectal carcinoma pT1.

Prospective evaluation of transsphenoidal pituitary surgery in 108 patients with Cushing's disease

Transsphenoidal pituitary surgery (TSS) remains the treatment of choice for Cushing's disease (CD). Despite the widespread acceptance of this procedure as the first line treatment in CD, the indication of a second TSS in not cured or relapsed DC patients is not consensus. We report the results of TSS in 108 patients with CD (a total of 117 surgeries). The mean postoperative follow-up period was 6 years. Remission was defined as clinical and laboratorial signs of adrenal insufficiency, period of glucocorticoid dependence, serum cortisol suppression on oral 1-mg dexamethasone overnight suppression test and clinical remission of hypercortisolism. We evaluated 103 patients with CD by the time of the first TSS. Fourteen patients underwent second TSS (5 had already been operated in others centers; in 5 patients the first surgery was not curative; in 4 patients CD relapsed). Remission rates were 85.4 percent and 28.6 percent (p < 0.001) after first and second TSS, respectively. In microadenomas, remission rates were higher than macroadenomas (94.9 percent vs. 73.9 percent; p = 0.006). In patients with negative pituitary imaging remission rates were 71.4 percent (p = 0.003; vs. microadenomas). Postoperative complications were: transient diabetes insipidus, definitive diabetes insipidus, hypopituitarism, stroke and one death. Only hypopituitarism was more frequent after second TSS (p = 0.015). In conclusion, TSS for CD is an effective and safe treatment. The best remission rates were observed at the first surgery and in microadenomas. The low remission rates after a second TSS suggest that this approach could not be a good therapeutic choice when the first one was not curative.

O tratamento de escolha para a doença de Cushing (DC) ainda é a cirurgia transesfenoidal (CTE) para ressecção do adenoma hipofisário produtor de ACTH. Porém, a indicação de uma segunda CTE representa uma questão controversa, tanto nos pacientes não curados após a primeira cirurgia quanto nos casos de recidiva. Neste trabalho, relatamos os resultados da CTE em 108 pacientes com DC (totalizando 117 cirurgias). O tempo médio de seguimento foi de 6 anos. Critérios de cura: ocorrência de insuficiência adrenal (clínica ou laboratorial), período de dependência ao glicocorticóide, supressão do cortisol sérico pós-1 mg de dexametasona overnight e remissão clínica do hipercortisolismo. Foram avaliados 103 pacientes com DC submetidos à primeira CTE. Quatorze pacientes foram submetidos a uma segunda CTE (5 já tinham sido operados em outros centros; a primeira cirurgia não fora curativa em 5; 4 pacientes com recidiva da DC). Índices de cura: 85,4 por cento e 28,6 por cento (p < 0,001) após a primeira e segunda CTE, respectivamente. Nos microadenomas, remissão maior que nos macroadenomas (94,9 por cento vs. 73,9 por cento; p = 0,006). Nos pacientes com imagem hipofisária negativa, cura foi de 71,4 por cento (p = 0,003; vs. micro). Complicações pós-operatórias: diabetes insipidus transitório e definitivo, hipopituitarismo, acidente vascular cerebral e um óbito. Apenas a ocorrência de hipopituitarismo foi mais freqüente após a segunda CTE (p = 0,015). Assim sendo, a CTE para a DC representa uma terapêutica efetiva e segura. Os melhores índices de cura foram obtidos na primeira cirurgia e em microadenomas. O baixo índice de cura após a segunda CTE sugere que esta abordagem não deve ser considerada uma boa opção terapêutica quando a primeira cirurgia não for curativa.

Reseccion toracoscopica de una glandula paratiroidea hipersecretante mediastinal / Thoracoscopic resection of mediastinal hypersecretant parathyroid gland

In general experienced hands, the inferior parathyroid glands, localized in the thymus or low extrathymus are the main cause or surgical therapeutic failure. When they could not be approached through cervicotomy, or when they were diagnosed after surgery the sternotomy or the angiographic ablation were chosen as treatment. The limited number of thoracoscopic approach whit good results published so far, moved us to use this method. MATERIAL AND METHOD: Patient of 49 years with a 7 year secondary hiperprathyroidism due to CRI. After a sub total parathyroidectomy with bilateral thimectomy, the patient did not present clinical or laboratory improvement. Through a thoracic centellogram sixth MIBI, NMR and CAT, a tumor in the middle mediastinum was fond. The mediastinal structures have been easily identified through a left thoracoscopic approach. At the level of the aortopulmonary window, a tumoral mass is located and, with a simple dissection, et is easily extracted in bag. The biopsy through freezing confirms the parathyroid etiology of the gland. RESULT: Clinical and laboratory evolution has been favorable, with hospital discharged at the 3 day, and being asymptomatic after two years. CONCLUSION: The hipersecretant parathyroid glands, located in middle mediastinum, that can not be approach through cervicotomy, can be successfully approach through thoracoscopic technique.

Por lo general en manos experimentadas las paratiroides inferiores. de localización tímica o extratímica baja, son la principal causa de fracaso terapéutico quirúrgico. Cuando no son accesibles por cervicotomía o bien se diagnosticaron posteriormente. la esternotomía o la ablación angiográfica eran considerados como los tratamientos de elección. El haberse publicado limitadas experiencias de abordaje toracoscópico con buenos resultados nos motivo al empleo de esta VÍa. Material y método: paciente de 49 años con hiperparatiroidismo secundario por IRC de 7 años de evolución. Luego de una paratiroidectomía sub-total con timectomía bilateral. no presenta mejoría clínica ni de laboratorio. Al ser estudiada con centellograma sesta-MIBI. RMN y TAC torácica es localiza un tumor en mediastino meido. Abordaje toracoscópico izquierdo. identificándose con facilidad las estructuras mediastinales. A nivel de la ventana aortopulmonar se localiza una masa tumoral que con simples maniobras de disección es fácilmente extraída en bolsa. La biopsia por congelación confirma la etiología paratiroidea de la misma. Resultado: Evolución clínica y de laboratorio favorable con alta de sala al 3- día. encontrándose a los dos años asintomático. Conclusión: vemos con entusiasmo el abordaje toracoscópico de glándulas paratiroideas hipersecretantes ubicadas en medias tino medio que no hayan podido ser extraídas por cervicotomía.

Neoplasias y displasias de vesícula biliar y su relación con litiasis. Estudio clinicopatológico de casos y controles / Neoplasm and dysplasia of the gallbladder and their relation with lithiasis. A case-control clinical-pathological study

Antecedentes. la litiasis es uno de los mayores factores de riesgo para cambios inflamatorios, metaplásicos, displásicos y neoplásicos de vesícula biliar, con frecuencia variable en diferenes poblaciones. Objetivo. determinar la frecuencia de asociación de los principales procesos patológicos y datos clínicos con litiasis vesicular. Material y métodos. estudio transveral, descriptivo de 1,367 piezas de colecistectomía, con (1,096) y sin (271) litiasis fue la siguiente: metaplasia psudopilórica 50 por ciento y 25 por ciento; metaplasia intestinal 16 por ciento y 2 por ciento; displasia de bajo grado 40 por ciento y 17 por ciento; displasia de alto grado 16 por ciento y 2 por ciento; carcinoma in situ 1.5 por ciento y 0 por ciento y carcinoma invasor 2.6 por ciento y 0 por ciento. El 80 por ciento de los casos con litiasis, el 65 por ciento de los casos de carcinoma in situ y el 90 por ciento de los casos de carcinoma invasor correspondieron a mujeres. La edad media de los pacientes con displasia de bajo y alto grado, carcinoma in situ y carcinoma invasor fue de 42, 48, 53 y 61 años, en ese orden. Conclusiones. la frecuencia de procesos inflamatorios agudos, colecititis crónica xantogranulomatosa, adenomiomatosis, metaplasia pseudopilórica e intestinal, pólipos hiperplásicos, displasia de bajo y alto grado, adenomas tubulares, carcinoma in situ y carcinoma invasor fue mayor en vesículas con litiasis que en vesículas sin litiasis (p<.05)