Luis Alberto Magna

The impact of the 2005 international society of urological pathology consensus conference on standard Gleason grading of prostatic carcinoma in needle biopsies.

PURPOSE At an International Society of Urological Pathology consensus conference in 2005 the Gleason grading system for prostatic carcinoma underwent its first major revision. We compared the concordance of pattern and change of prognostic groups for the conventional and the modified Gleason grading, and checked the discriminative power of the modified Gleason grading. MATERIALS AND METHODS The grading was based on 172 prostatic needle biopsies of patients subsequently undergoing radical prostatectomy. Four prognostic Gleason grading groups were considered, divided into scores of 2-4, 5-6, 7 and 8-10. To check the discriminative power of the modified Gleason grading we compared the time of biochemical (prostate specific antigen) progression-free outcome according to prognostic groups between standard and revised grading. RESULTS The greatest impact of the International Society of Urological Pathology consensus recommendations for Gleason grading was seen on the secondary pattern which had the lowest percentage of concordance and was reflected in a change toward higher Gleason prognostic groups. Of 172 patients in whom the Gleason prognostic group was changed (to higher grades) based solely on the consensus criteria, 46 (26.7%) had higher preoperative prostate specific antigen, more extensive tumors and positive surgical margins, and higher pathological stage. The revised Gleason grading identified in this series a higher number of patients in the aggressive prognostic group Gleason score 8-10 who had a significantly shorter time to biochemical progression-free outcome after radical prostatectomy (log rank p = 0.011). CONCLUSIONS The findings of this study indicate that the recommendations of the International Society of Urological Pathology are a valuable refinement of the standard Gleason grading system.

Inflammatory Atrophy of the Prostate Prevalence and Significance

CONTEXT Recently, prostatic atrophy associated with chronic inflammation has been linked to carcinoma either directly or indirectly by first developing into high-grade prostatic intraepithelial neoplasia. OBJECTIVE The purpose of our study was to test this hypothesis in autopsies. DESIGN A step section method was used to cut the posterior lobe in coronal planes at intervals of 0.3 to 0.5 cm in 100 consecutive autopsies of men older than 40 years. Prostatic atrophy was classified as simple, hyperplastic (or postatrophic hyperplasia), and sclerotic and was analyzed for the presence of chronic inflammation. Prostatic atrophy without (group A) and with inflammation (group B) was correlated with the following variables: age, race, histologic (incidental) carcinoma, high-grade prostatic intraepithelial neoplasia, and extent of both these lesions. RESULTS Of the 100 prostates examined, 12%, 22% and 66%, respectively, had no atrophy, atrophy without inflammation (group A), and atrophy with inflammation (group B). There was no statistically significant difference between groups A and B for age (P =.55), race (P =.89), presence of histologic (incidental) carcinoma (P =.89), extensive carcinoma (P =.43), presence of high-grade prostatic intraepithelial neoplasia (P =.65), extensive high-grade intraepithelial neoplasia (P =.30), or subtypes of prostatic atrophy. Neither a topographical relation nor a morphologic transition was seen between prostatic atrophy and histologic carcinoma or high-grade intraepithelial neoplasia. Sclerotic atrophy either alone or combined with other subtypes was more frequent in the group with inflammation. A striking morphologic finding was a topographical relation of focal inflammation with sclerotic atrophy in areas with erosion of the epithelium. CONCLUSIONS Inflammatory prostatic atrophy does not appear to be associated with histologic (incidental) carcinoma or high-grade intraepithelial neoplasia. One possible cause of inflammatory infiltrate associated with prostatic atrophy may be the extravasated prostatic secretions, which were noted in areas of eroded epithelium, a common finding in the sclerotic type of prostatic atrophy.

Serum Leptin Levels After Bariatric Surgery Across a Range of Glucose Tolerance from Normal to Diabetes

Background: A longitudinal, clinical intervention study with bariatric surgery was done to investigate the relationship between leptin levels, BMI, and insulin during weight loss across a range of glucose tolerance from normal to diabetes. Methods: 43 morbidly obese patients (BMI: 42-75 kg/m2) undergoing vertical banded gastroplasty Roux-en-Y gastric bypass (VBG-RGB), were divided into 3 groups: 21 normal (NGT), 12 impaired glucose tolerance (IGT) and 10 type 2 diabetes (DM). Leptin, insulin, glucose, lipids and uric acid were measured at baseline and 2, 4, 6, and 12 months following surgery. Results: BMI fell from 54.1 ± 9.1 to 34.6 ± 6.3 kg/m2, similarly in all groups. Leptin decreased from 73.9 ± 8.7 to 16.9 ± 10.2 ng/ml and was strongly correlated with BMI during 1-year follow-up (r=0.78; p<0.001). Linear univariate analysis for repeated evaluation showed a positive correlation between leptin and glucose, triglycerides, uric acid, and insulin. Multivariate regression analysis indicated that BMI was independently correlated with the decrease in leptin (p<0.001), accounting for 66% of the variance in leptin levels during weight loss. These results were found in the NGT and IGT groups. In the DM group, a small additional influence in leptin levels was attributed to glucose decrease. Conclusions: A strong link between leptin and BMI was found after surgery. BMI was the main determinant of the decrease of leptin. In these patients submitted to bariatric surgery, ranging from normal glucose tolerance to diabetes, changes in insulin levels and metabolic parameters, except for glucose in the DM group, did not appear to be correlated with changes in leptin levels.

A Portaria nº 822/01 do Ministério da Saúde e as peculiaridades das hemoglobinopatias em saúde pública no Brasil

By including hemoglobinopathies in the National Neonatal Screening Program (PNTN), Brazilian Ministry of Health Directive # 822/01 has taken an important step towards recognition of their relevance for public health in the country. However, except at a few specialized centers, the public health care system is unprepared to meet the goals laid out under the directive. As the first step to effectively implement the guidelines, it is thus necessary to disseminate information on hemoglobinopathies among health professionals working in public health, especially those involved in neonatal screening. This article discusses some of the unique characteristics of hemoglobinopathies in comparison to other metabolic disorders included in the National Neonatal Screening Program. The authors also analyze potential sources of misunderstanding that could jeopardize the programs outcome.

Neonatal care of infants with cleft lip and/or palate: feeding orientation and evolution of weight gain in a nonspecialized Brazilian hospital.

Objectives: To survey the feeding orientation received during the postnatal period by the parents of cleft babies, as well as the location where they receive the orientation; to identify resources used in feeding; and to assess the correlation of the childs weight with the surgical procedure schedule. Design: During consultation for diagnosis and genetic counseling in a general tertiary hospital, 26 parents of cleft babies born in different hospitals were interviewed based on a semistructured protocol and spontaneous reports. Results: Cleft palate was present in 42.31% (11/26), cleft lip/palate in 50% (13/26), and cleft lip in 7.69% (2/26) of the cases. Feeding orientation was given in maternities to 72% (18/25) and in specific rehabilitation centers to 24% (6/ 25) of the parents. Breast-feeding was encouraged in every case. Nevertheless, other feeding resources were necessary, especially bottles. Surgical procedure delays caused by poor weight gain occurred in 66.7% (12/18). Conclusions: Neonatal feeding orientation was not systematically given in every case. Because it is an important way to achieve an effective weight gain, educational programs for nonspecialized health professionals, as well as regular pediatric follow-up and specialized multi-professional teams, could improve nutritional intake and could move the schedule for surgical procedures forward. The results also suggest that specific neonatal health care for cleft babies should be part of health policy.

Bone mineral density, vitamin D and anticonvulsant therapy

UNLABELLED The aim of this study was to assess bone mineral density and vitamin D metabolism in patients on chronic anticonvulsant therapy. METHODS Sixty-nine men, outpatients on chronic anticonvulsant therapy, who had been treated for at least 5 years, were studied, comparing them to thirty healthy controls. Bone mineral density was measured as well as serum levels of calcium, ionized calcium, alkaline phosphatase, PTH, 25-hydroxycholecalciferol and 1, 25-dihydroxycholecalciferol. RESULTS No differences in bone mineral density, serum levels of vitamin D and intact-PTH were observed between patients and controls. Bone mineral density was not associated with chronic anticonvulsant therapy. CONCLUSION Those adult patients who were on chronic anticonvulsant therapy and who lived in low latitude regions had normal bone mineral density as well as vitamin D serum levels.

Correlation between tumor extent in radical prostatectomies and preoperative PSA, histological grade, surgical margins, and extraprostatic extension: application of a new practical method for tumor extent evaluation

PURPOSE To evaluate a new method designed for estimating the tumor extent in radical prostatectomy specimens. The tumor extent was correlated to preoperative PSA and to several pathologic findings in the surgical specimens as well. MATERIALS AND METHODS Tumor extent was estimated in 118 consecutive radical prostatectomies through a simple point-count method. Drawn on a sheet of paper, each quadrant of the whole mount sections contained 8 equidistant points. During the microscopic slides examination, the tumor area was drawn over the correspondent quadrant of the paper sheet. According to the extent, tumors were classified in 5 groups: 1) very limited: </= 10 positive points; 2) limited: 11-19 positive points; 3) moderately extensive: 20-35 positive points; 4) extensive: 36-39 positive points; 5) very extensive: 70 positive points. This classification was based on a previous analysis of tumor extent in 109 radical prostatectomies. The distribution was quite normal up to 69 positive points, but asymmetric above that number, including cases exceeding far above that value. We considered the quartiles of the normal distribution up to 69 positive points (groups 1 to 4), and above that value a fifth group was considered. RESULTS There was a statistically significant and direct correlation between the tumor extent and all variables studied: preoperative PSA (p = 0.03), Gleason score (p < 0.0001), primary grade in high-grade tumors (p < 0.01), surgical margins (p < 0.0001), extraprostatic extension (pT3a) (p < 0.0001), and seminal vesicle invasion (pT3b) (p = 0.01). CONCLUSIONS The method, which is simple and well correlated to other prognostic factors, is accessible to those pathologists working in routine pathology laboratories. Whether this method will be used by other urology centers is yet to be seen.

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

BACKGROUND Endoscopic sclerotherapy is widely accepted as an effective treatment for the eradication of esophageal varices in patients with portal hypertension and a history of upper gastrointestinal bleeding. The objective of this study was to assess the effectiveness and safety of absolute ethanol as an alternative sclerosing agent to the commonly used 5% ethanolamine oleate. METHODS One hundred fifty-seven patients with portal hypertension and a history of variceal bleeding were randomly assigned to sclerotherapy with absolute ethanol (n = 66) or 5% ethanolamine oleate (n = 91) between January 1992 and July 1994. Once eradication was achieved, these patients were prospectively followed until September 1998. RESULTS Sclerotherapy with both sclerosants resulted in similar eradication rates (approximately 90%), with comparable numbers of sessions required for eradication (5.4 and 5.9 sessions for absolute ethanol and 5% ethanolamine oleate, respectively). Similar complication and recurrent bleeding rates were observed among both groups. CONCLUSION Sclerotherapy with absolute ethanol is as effective as with 5% ethanolamine oleate in preventing further bleeding in patients with portal hypertension.

Prostate cancer pathologic stage pT2b (2002 TNM staging system): does it exist?

OBJECTIVE In the 1997 TNM staging system, tumors were classified into a single subdivision: T2a, and bilateral tumor involvement (T2b). In the 2002 TNM staging system, tumors are subclassified as T2a (less than one half of one lobe involvement), T2b (more than one half of one lobe involvement), and T2c (bilateral involvement). A recent study questioned the existence of a true pathologic pT2b tumor. The aim of our study is to verify this question. MATERIALS AND METHODS The study population consisted of 224 men submitted to radical retropubic prostatectomy. The surgical specimens were histologically evaluated by complete embedding and whole-mount processing. Tumor extent was evaluated by a point-count method. The surgical specimens were staged according to the 2002 TNM staging system. RESULTS Using the 2002 TNM criteria, the surgical specimens were classified as pT2a, 28 (12.50%); pT2b, 0 (0%); pT2c, 138 (61.61%); pT3a, 30 (13.39%); and, pT3b, 28 (12.50%). Using the point-count method for tumor extent evaluation, the minimum and maximum total points obtained in unilateral tumors were 192 and 368 points, respectively; the most extensive unilateral tumor showed 68 positive points (less than half the minimum total point-count). CONCLUSIONS Using the point-count method for tumor extent, our study questions a real existence for pathologic stage pT2b tumors (unilateral tumors involving greater than one-half of one lobe).

Late morbidity in upper limb function and quality of life in women after breast cancer surgery

BACKGROUND Breast cancer is the most common malignancy in Brazilian women. In recent years, there has been great progress in and an increasing number of breast-conserving surgical techniques; however, immediate or late morbidity after surgery, in the form of functional impairment and pain, remains a significant clinical problem. OBJECTIVE To investigate the relationship between late upper limb functional impairment and the quality of life in women subjected to breast cancer surgery. METHOD A total of 81 women participated in the study, with the length of time since surgery ranging from one to five years. A survey of upper limb complaints reported by patients was conducted, and the questionnaires Disabilities of the Arm, Shoulder, and Hand (DASH) and the European Organization for Research and Treatment of Cancer (EORTC QLQC-30 and BR23) were applied. RESULTS The correlation between the DASH score and the length of time since surgery determined that the longer the time since surgery, the greater the difficulties in functionality of the upper limb (r=0.459; p<0.0001). A statistically significant correlation was observed between the DASH score and health-related quality of life. CONCLUSION Late functional impairment had a significant impact on upper limb function in everyday life and health-related quality of life for women who underwent breast cancer surgery.