Antonio Piñero

Extrathyroid spread in papillary carcinoma of the thyroid: Clinicopathological and prognostic study

INTRODUCTION: The extrathyroid spread (ETS) is one of the risk factors that influence mortality and recurrence in patients with papillary carcinoma of the thyroid (PCT). The aim of this study is to analyze the clinical and histologic features and follow-up of a series of patients with ETS undergoing surgery for PCT and to identify patients with a greater risk of presenting with ETS. MATERIAL AND METHODS: Retrospective study of a series of 200 patients undergoing surgery for PCT, of whom 47 (23.5%) presented with ETS. The clinical and histologic features and follow-up of the patients with ETS were compared with those without ETS using the Pearson χ 2 test. We used a logistics regression model to perform a multivariant analysis for ETS. The survival and disease-free interval rates were calculated using the Kaplan-Meier method. RESULTS: ETS is most associated with patients over 50 years of age, with tumors over 4 cm that are not encapsulated, with lymph node metastasis, and with certain PCT histologic subtypes after the multivariant analysis. The overall rate of recurrence and mortality in patients with ETS was much higher than in patients without ETS. CONCLUSIONS: PCT patients with ETS have a greater risk of tumor-related recurrence and mortality than patients without ETS. There are patients with certain clinical and histologic features who have a greater risk of presenting with ETS.

Amniotic membrane induces epithelialization in massive posttraumatic wounds.

Large‐surface or deep wounds often become senescent in the inflammatory or proliferation stages and cannot progress to reepithelialization. This failure makes intervention necessary to provide the final sealing epithelial layer. The best current treatment is autologous skin graft, although there are other choices such as allogenic or autologous skin substitutes and synthetic dressings. Amniotic membrane (AM) is a tissue of interest as a biological dressing due to its biological properties and immunologic characteristics. It has low immunogenicity and beneficial reepithelialization effects, with antiinflammatory, antifibrotic, antimicrobial, and nontumorigenic properties. These properties are related to its capacity to synthesize and release cytokines and growth factors. We report the use of AM as a wound dressing in two patients with large and deep traumatic wounds. Negative pressure wound therapy followed by AM application was capable of restoring skin integrity avoiding the need for skin graft reconstruction. AM induced the formation of a well‐structured epidermis. To understand this effect, we designed some assays on human keratinocyte‐derived HaCaT cells. AM treatment of HaCaT induced ERK1/2 and SAP/JNK kinases phosphorylation and c‐jun expression, a gene critical for keratinocytes migration; however, it did not affect cell cycle distribution. These data suggest that AM substantially modifies the behavior of keratinocytes in chronic wounds, thereby allowing effective reepithelialization.

Insular carcinoma: an infrequent subtype of thyroid cancer

BACKGROUND Insular carcinoma is a little-known thyroid cancer, characterized by the presence of well-defined nidi of small uniform cells with frequent areas of tumor necrosis and microfollicles with thyroglobulin. It was described by Carcangiu in 1984, but its prognosis is not yet clear. STUDY DESIGN Six of 335 patients undergoing surgery for thyroid carcinoma had the insular type. We studied age, gender, treatment, histology (tumor size, coexistence of another tumor, extrathyroid spread, vascular invasion, multicentricity, and metastatic adenopathies), TNM, and followup (recurrences, mortality, and survival). These results were compared with those published in the literature. RESULTS Insular carcinoma was more common in women (4 of 6), and mean patient age was 32 years. Three patients had metastatic adenopathies. Four patients presented with other thyroid tumors (2 papillary, 1 follicular, and 1 anaplastic) and 2 were simple. Two patients had vascular invasion, and another 2 were extrathyroid. Only 1 case was multicentric. Three recurrences were detected in 2 patients over 50 years old: 1 lymph node at 60 months, 1 pulmonary at 132 months, and the other a bone recurrence at 8 months. Two patients died at 12 and 140 months. CONCLUSIONS Insular carcinoma is a special type of thyroid cancer, and the prognosis is poorer than for the classic differentiated thyroid carcinoma.

Selective sentinel lymph node biopsy and primary systemic therapy in breast cancer.

AIMS AND BACKGROUND Sentinel lymph node biopsy has become an ordinary method for breast cancer staging. Neoadjuvant chemotherapy has been considered one of the contraindications for sentinel lymph node biopsy due to potential secondary fibrosis and lymphatic distortion. Timing and influence on sentinel lymph node biopsy result by primary systemic therapy are current and controversial topics. METHODS AND STUDY DESIGN The experience in the medical literature is reviewed. A search was performed in the following databases: Medline (through Pubmed), EMBASE, Tripdatabase and Cochrane Library, between January 1998 and December 2008. RESULTS AND CONCLUSIONS After analyzing the conclusions from 42 series and waiting for the end of related prospective trials, it could be concluded that sentinel lymph node biopsy is a useful diagnostic tool that should be integrated in the algorithm for the management of breast cancer patients when primary systemic therapy is needed.

Relation of biochemical, cytologic, and morphologic parameters to the result of gammagraphy with technetium 99m sestamibi in primary hyperparathyroidism ☆

The aim of this study was to analyze the possible relation of biochemical, cytologic, and morphologic parameters to the results of parathyroid gammagraphy with Tc 99m sestamibi in primary hyperparathyroidism. We studied 46 consecutive patients with primary hyperparathyroidism who were undergoing surgery. All the patients were given a preoperative parathyroid gammagraphy with Tc 99m sestamibi and a complete preoperative biochemical study. During the surgical intervention we recorded the weight and size of the pathologic glands to calculate the volume of each. We also determined the percentage of the chief and oxyphil cells in the pathologic glands. Tc 99m sestamibi sensitivity is higher in adenomas (91%) than in hyperplasia (67%) or double adenomas (50%). No relation was found between biochemical or cytologic parameters and gammagraphic results. Weight and gland volume were significantly greater for adenomas than for hyperplasia (P < 0.0014 and P < 0.0004, respectively), and statistically significant differences in both of them were observed between the glands with positive and negative sestamibi.

La hipertensión intraabdominal y el síndrome compartimental abdominal: ¿qué debe saber y cómo debe tratarlos el cirujano?

Resumen El seguimiento adecuado de los pacientes criticos medico-quirurgicos facilita el diagnostico temprano y un tratamiento adecuado de la hipertension intraabdominal (HIA) y del sindrome compartimental abdominal (SCA). La cavidad abdominal y el retroperitoneo actuan como compartimentos estancos, y cualquier cambio en el volumen de su contenido puede elevar la presion intraabdominal (PIA). La HIA es solo una medida elevada de la PIA, y el SCA supone el punto final de una HIA sostenida con la aparicion de disfunciones organicas. Para el diagnostico de la HIA y del SCA se requiere medir la PIA, la presion de perfusion abdominal y el pH intramucoso gastrico, y correlacionar estos datos con signos de deterioro clinico en el paciente. Las medidas terapeuticas medicas en el SCA son limitadas, y la descompresion abdominal es el tratamiento del SCA sintomatico establecido.

Surgical Treatment of Solitary Metastasis in the Male Breast from Non‐Small Cell Lung Cancer

Abstract:  Detection of metastases in the breast from extramammary neoplasms is rare. We present a case of metastases in breast tissue from surgically treated non‐small cell bronchogenic carcinoma. A histologic and immunohistologic study was essential for choosing the appropriate treatment for the patient. The patient is alive and disease‐free 18 months after the breast surgery. 

Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience

BackgroundThis study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach.MethodsThis was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up.ResultsNo significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic.ConclusionsRetroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients’ bedside as many times as necessary, and has advantages over other retroperitoneal approaches.

Immediate Reconstruction after Mastectomy for Breast Cancer: Which Factors Affect Its Course and Final Outcome?

I p t i o c o u p urgery is one of the main pillars in the multidisciplinary reatment of breast cancer. Advances in diagnosis and aduvant treatment have made less aggressive operations posible without affecting survival or tumor recurrence, and owadays, conservative surgery is the technique of choice n women with breast cancer. But mastectomy is still necssary in a significant percentage of patients (women at igh risk because of a family or personal history of breast ancer, contraindication to adjuvant radiotherapy, large tuors relative to breast size, diffuse disease, or patient prefrence) in whom breast reconstruction should be one of the everal therapeutic options available. Since the mid 1980s, immediate reconstruction techiques have been developed.These are defined as any breast econstruction procedure performed at the same time as astectomy. Immediate reconstruction presents some adantages, in particular, the decrease in emotional and psyhological impact of a mastectomy. In addition, there are ewer surgical procedures and hospital admissions, implyng a financial benefit and, in general, an overall esthetic esult superior to that obtained with delayed reconstrucion. But even though it is a technique that is becoming ore common, there is no consensus on indications for mmediate reconstruction or any guidelines that enable us o select the ideal candidate for either immediate or delayed reast reconstruction. There are many studies in the literature that attempt to nswer the uncertainties that can arise when treating breast athology, such as the impact of immediate reconstruction n survival; the possibility of delaying the diagnosis of

Reunión de consenso sobre la biopsia selectiva del ganglio centinela en el cáncer de mama. Socidad española de senología y patología mamaria

Selective biopsy of the sentinel node is a useful diagnostic technique in the management of breast cancer that has been introduced into the clinical practice and is widely used and accepted. Based on its results, adequate staging can be made with less associated morbidity. However, at present, there are many methodological variations in how it is done that are pending to be answered in on-going trials and investiga- tions. This involves making Consensus Meetings to try to ho- mogenize the aspects related with the method and indication of the technique. The conclusions of the Consensus Meeting held in Murcia and organized by The Spanish Society of Senol- ogy and Breast Disease are expressed in this document.