Beatriz Febrero

Value of 18-FDG-positron emission tomography/computed tomography before and after transarterial chemoembolization in patients with hepatocellular carcinoma undergoing liver transplantation: initial results.

INTRODUCTION Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures. PATIENTS AND METHODS From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE. RESULTS The median SUV (standardized uptake value) in the lesions studied were 4 (range, 2.79-6.95) before TACE with a median post-TACE SUV of 0 (range, 0-4). Among patients whose post-TACE SUV decreased to <3, the percentage of necrosis after studying the hepatectomy was >80%. CONCLUSION Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE.

Are prognostic scoring systems of value in patients with follicular thyroid carcinoma

PURPOSE Most prognostic systems for differentiated carcinoma have been designed for papillary carcinoma. OBJECTIVE To analyze the value of the existing prognostic systems for evaluating follicular carcinoma and to determine whether any of them have a better predictive effect. METHODS A total of 66 follicular carcinomas were analyzed. The following prognostic systems were studied: EORTC, AGES, AMES, MACIS, TNM, and NTCTCS. RESULTS The AGES and AMES systems did not demonstrate a good prognostic correlation. In the EORTC system, the rate of disease-free patients was 89% in group 1, 75% in group 2, 69% in group 3, and 0% in group 4. The MACIS system showed 83, 60, 67, and 0% of disease-free patients respectively. The TNM system showed 81, 71, 50, and 0% of disease-free patients respectively. Finally, the NTCTCS system demonstrated 100, 84, 53, and 0% of disease-free patients respectively. Coxs regression analysis was used to calculate the proportion of variation in survival time explained (PVE). The prognostic classification system with the greatest survival prediction was EORTC at 67.64% of PVE, followed by TNM at 62.5% of PVE, and MACIS at 57.82% of PVE. CONCLUSIONS MACIS and TNM are good prognostic systems for evaluating follicular thyroid carcinoma, although the one with the most prognostic value was the EORTC system.

Giant Amyloid Goiter in Crohn’s Disease

Crohn’s disease is one of the causes of secondary amyloidosis, which can lead to amyloid infiltration of the thyroid gland. It is essential to follow strict controls to prevent the appearance of a large amyloid goiter. Two patients with amyloid goiter secondary to Crohn’s disease, with a large adipose tissue component and who required surgical treatment, were studied. Both surgical interventions were difficult because of the fragility of the thyroid tissue. A patient with Crohn’s disease and secondary amyloidosis could begin to develop amyloid goiter. This is usually fast growing and commonly causes compressive symptoms, although in some cases it only grows in the neck with no evidence of these symptoms. When surgery is indicated, patients should be remitted to hospitals with experienced endocrine surgeons, given that there is a high risk of developing complications.

Metástasis a distancia como forma de inicio de un carcinoma folicular de tiroides

Sr. Director: El cáncer diferenciado de tiroides es la enfermedad tumoral tiroidea más frecuente y tiene un excelente pronóstico, con larga supervivencia a largo plazo. De las 2 variantes, papilar y folicular, esta última es más infrecuente y agresiva. En la mayoría de los casos el tumor está localizado en el tiroides o, como mucho, con afección local; son infrecuentes las metástasis a distancia. Cuando éstas ocurren, aparecen durante la evolución de dicho tumor, y son excepcionales como inicio del cuadro1. Por ello, presentamos 2 casos de carcinomas foliculares diagnosticados como consecuencia de la detección de una metástasis a distancia. Caso 1: varón de 59 años, sin antecedentes de interés, que consultó por tumoración en el glúteo derecho de 1 año de evolución. A la exploración se objetiva una tumoración sin signos inflamatorios, hipervascularizada y con latido a la palpación. La tomografía computarizada (TC) mostró una gran tumoración glútea derecha con afección de sacro y pala ilíaca, y en la arteriografía se observó que la vascularización dependía de la arteria hipogástrica derecha (fig. 1A). Se realizó una biopsia que informó de metástasis de carcinoma folicular de tiroides. La gammagrafía con difosfo-99Tc mostró acumulaciones focales patológicas en la articulación coxofemoral y la cresta ilíaca derecha. En la zona cervical se objetivó un nódulo tiroideo derecho, el cual se puncionó e informó de sospecha de carcinoma folicular. Se intervino al paciente mediante tiroidectomía total bilateral y vaciamiento ganglionar yugular. La masa glútea se consideró irresecable dada la afección ósea y su vascularización. La histología mostró un carcinoma folicular de 4 × 2 cm con un nódulo satélite de 0,3 cm. Se administraron 200 mCi de 131I como tratamiento adyuvante y radioterapia en el área glútea (30 Gy). Al año y medio presentó metástasis en la vértebra dorsal VIII y IX, con rastreo cervical normal, y se lo trató con radioterapia dorsal hasta completar los 30 Gy. La evolución fue lenta; a los 4,5 años presentó síndrome de compresión medular, y falleció por evolución de la enfermedad 6 meses después. Caso 2: mujer de 68 años, sin antecedentes médicoquirúrgicos de interés, que ingresó por fractura patológica de cabeza de fémur (fig. 1B). El análisis inicial no objetivó ninguna causa de la fractura; fue intervenida por el servicio de traumatología que le colocó una prótesis de cadera. El estudio histológico de la pieza ósea remitida fue de metástasis ósea de carcinoma folicular de tiroides. El estudio tiroideo mostró un nódulo izquierdo de 3 cm de diámetro, y el estudio de extensión mostró metástasis pulmonares bilaterales, hepáticas bilaterales y óseas (pelvis y vértebras en diferentes áreas), y adenopatías mediastínicas y retroperitoneales. Se realizó una tiroidectomía total bilateral con vaciamiento ganglionar central y yugulolateral bilateral y luego se administró yodoterapia con 131I a altas dosis (200 mCi). La histología confirmó un carcinoma folicular. La evolución fue tórpida, con deterioro progresivo, y falleció a los 4 meses de la intervención. Las metástasis a distancia1 en el carcinoma folicular se presentan en el 10-15% de los casos y se localizan, sobre todo, en áreas pulmonar y ósea; son menos frecuentes los cerebrales, hepáticos y cutáneos. La mayo-

A multicenter study of the attitude of secondary school teachers toward solid organ donation and transplantation in the southeast of Spain

Teachers play a fundamental role in providing information to adolescents and could influence their attitudes.

Perfil histológico e inmuno-histoquímico del carcinoma medular de tiroides esporádico y familiar

INTRODUCTION The histological and immunohistochemical profile of medullary thyroid carcinoma is ill-defined. The objective of this study was to determine the epidemiological, histological, and immunohistochemical characteristics of medullary carcinoma and to analyze whether differences exist between sporadic and familial carcinomas. PATIENTS AND METHODS Fifty-five histologically confirmed tumors were studied. Histological slides were reviewed and immunohistochemical staining of the archival paraffin blocks was performed. RESULTS Nineteen of the 55 carcinomas (35%) were sporadic, and 36 (65%) familial. Sex distribution was similar, but familial carcinoma was more common in patients under 40 years of age (p<0.001). A solid growth pattern and plasmacytoid cells were found in most cases. C-cell hyperplasia and multicentricity were more frequent findings in familial carcinoma, while tumor necrosis, hemorrhagic foci, vascular invasion, and neovascularization were more common in the sporadic type. Immunohistochemical staining was positive for calcitonin, CEA, bcl-2, and p53 protein. With regard to staging, familial carcinomas were diagnosed in the earliest stages, when they were smaller and there were no lymph node metastases (p<0.01). CONCLUSIONS Familial cases were more frequent when there was more C-cell hyperplasia and multicentricity. Sporadic cases more frequently showed foci of necrosis, hemorrhage, vascular invasion, and neovascularization. Neither histopathological nor immunohistochemical criteria are useful for differentiating between familial and sporadic forms.

Knowledge of the Brain Death Concept Among Adolescents in Southeast Spain

BACKGROUND The concept of brain death (BD) is not very well known in the population, making it one of the main psychosocial barriers to favorable attitudes toward donation. Adolescents are a key sector of the population for future organ donation. For this reason it is important to find out what they know about this concept. OBJECTIVES The aim of this study was to analyze the concept of BD among adolescents in the southeast of Spain and to determine their influence on attitude toward organ donation. METHODS In the southeast of Spain a random sample was stratified according to Compulsory Secondary Education (CSE) schools. In the 10 selected schools, we performed a random sampling of each of the classes from the 1st to the 4th years of CSE. Knowledge of the concept of BD and attitude toward donation were analyzed with the use of a validated questionnaire, which was self-administered and completed anonymously. Statistical analyses used the Student t test and the χ(2) test. RESULTS Of 3,547 adolescents surveyed, 38% (n = 1,337) of the respondents knew the BD concept, considering it to be the death of an individual. Of the rest, 54% (n = 1,930) did not know this concept and the remaining 8% (n = 280) thought it did not mean a persons death. The respondents who were more in favor of deceased donation had a better knowledge of the concept of BD than those who had doubts (40% vs 35%, respectively; P = .007). The knowledge of the concept of BD was associated with variables directly and indirectly related with donation and transplantation (P < .05). CONCLUSIONS Most adolescents in the southeast of Spain do not know the concept of BD, and this adversely affects the attitude toward organ donation.

The evolution of therapeutic strategies for biliary tract complications after liver transplantation over a period of 20 years.

Despite the improved overall outcomes of liver transplantation as a result of advances in surgical techniques and improved immunosuppressive control, biliary complications (BCs) continue to be the most common cause of morbidity in liver transplant recipients. The objectives of this study were to analyze the incidence, type, and management of BCs over a 20-year period. We performed a comparative study of two groups of liver transplant patients in our unit operated on by the same surgical team: group I consists of the first 300 liver transplant patients (1989-1992), and group II is composed of the last 300 liver transplants (2007-2011). We found no significant differences in the number of cases of biliary leakage whether or not a Kehr T-tube was used. However, there was a significant relationship between a greater number of anastomotic strictures and less use of a Kehr T-tube. In our series, there has been a decrease over the years in the number of surgical interventions required to resolve these complications and an increase in radiologic and endoscopic treatment.

Secondary School Teachers' Assessment of the Introduction of an Educational Program About Organ Donation and Transplantation

INTRODUCTION It is essential to provide information about organ donation and transplantation (ODT) to encourage school pupils to have favorable attitudes toward this matter in the future. The role of the teacher is crucial in this respect. The objective of this study was to determine acceptance by secondary school teachers of an educational program about ODT. MATERIALS AND METHODS A random sample of secondary school teachers was taken from 10 secondary schools in the southeast of Spain. A total of 288 teachers were surveyed using a questionnaire that assessed the following; (1) acceptance of the educational program; (2) who should carry it out; and (3) some psychosocial variables related to ODT. RESULTS Of the 288 secondary teachers surveyed, 283 of them responded to the acceptance of an educational program on ODT. Approximately half (54%) of the respondents believed that it would be appropriate to introduce an educational program about ODT in secondary schools, 22% believed that there were currently other more important educational considerations, 20% had doubts, and 4% believed that it would not be useful. The vast majority (71%) believed that a collaborator from the Regional Transplant Team would be the best person to carry out the program followed by any teacher (11%) or a teacher of ethics (9%). The remaining 9% were not sure. There was greater acceptance of an educational program about ODT among teachers who had a favorable attitude toward the matter (P = .003). CONCLUSIONS An educational program about ODT in secondary education was not equally accepted by all teachers. Most teachers believed that the program should be delivered by the Transplant Coordination Center rather than teachers themselves.

Benefits of Group Psychotherapy in Cirrhotic Patients on the Liver Transplant Waiting List

INTRODUCTION It is well-known that patients on the liver transplant (LT) waiting list experience a high rate of psychopathologic symptoms. However, few studies have been published about the use of group psychotherapy for these patients. We sought to assess (1) the psychopathologic data in patients on the LT waiting list and (2) the attitude toward a group psychotherapy procedure and its efficacy. MATERIAL AND METHODS In the pretransplant consultation phase, group therapy was offered to 20 patients on the LT waiting list. Patients who received psychotherapy were assessed previously using the Beck Depression Inventory. RESULTS Fifteen patients were included in the study. Significant differences were found between the psychopathologic assessment and the level of hepatopathy. In the first session, we observed that patients with hepatocarcinoma were much more reluctant to participate in the group therapy. In the second session, the group showed a high level of anxiety connected with a fear of transplantation. In the third session, a transplant physician answered all their questions, and at the end of the session patient anxiety had decreased. During the following sessions, family bonds and sharing experiences with other transplant patients were emphasized. CONCLUSIONS Patients were initially reluctant to participate in the group psychotherapy, although this changed as sessions proceeded. It is necessary to provide more information about the transplant procedure itself to decrease anxiety. Group therapy was valued positively by all patients who participated.