Renato de Oliveira

Role of video-assisted thoracoscopic sympathectomy in the treatment of primary hyperhidrosis

CONTEXT Essential hyperhidrosis is a frequent disorder causing significant functional impairment. The advent and development of video-assisted thoracoscopic techniques now allows thoracic sympathectomy to be carried out precisely and safety with good results and minimal morbidity. OBJECTIVE To assess the impact of video-assisted thoracic sympathectomy in patients diagnosed as presenting severe and disabling hyperhidrosis. TYPE OF STUDY This was a longitudinal study of the clinical course of all hyperhidrosis cases selected for surgery between May 1999 and January 2003. SETTING Division of Thoracic Surgery, Universidade Federal de S o Paulo (UNIFESP). PARTICIPANTS 743 patients with surgery indicated due to palmar hyperhidrosis (49.8%), palmar-axillary hyperhidrosis (38.1%), craniofacial hyperhidrosis (8.9%) or isolated axillary hyperhidrosis (2.8%). PROCEDURES Video-thoracoscopic sympathectomy was performed, isolating the second thoracic ganglion (T2) in all patients, with additional sympathectomy of T3 and T4 if necessary. MAIN MEASUREMENTS The clinical course was followed up via questionnaires, phone calls, letters and statements. Simple questions were asked regarding the disappearance of symptoms and presence and intensity of compensatory sweating. RESULTS The surgery was regarded as efficient in all cases of palmar hyperhidrosis. In the craniofacial hyperhidrosis cases, partial recurrence of the symptoms occurred in 2 cases (3.0%). Partial recurrence or persistence of symptoms occurred in 20% of the patients with predominantly axillary symptomatology. The compensatory sweating was considered disagreeable or uncomfortable by about 30% of the patients, but it only reached the level of regretting the operation for 3% of them. This occurred more frequently in patients with axillary hyperhidrosis. Ten cases of complications occurred. CONCLUSION Thoracoscopic sympathectomy provides very good results in most patients, with a very low complication rate. However, the assessment of surgical results using conventional methods is imprecise and inaccurate. Different methodology, including quality of life assessment, must be used for comparing results and providing objective data on the results of this operation.

Forty-Year-Old Intrathoracic Gossypiboma After Cardiac Valve Surgery

A 59-year-old asymptomatic man, who had undergone cardiac valve surgery 40 years earlier, demonstrated a paracardiac mass on routine chest x-ray (Figure 1). Subsequently, a chest computed tomography scan was performed, which showed a 14.0×9.5 cm heterogeneous lesion, with lobulated contours, along the inferior aspect of the left and right ventricles (Figure 2). It was possible to identify areas of low density as well as high-density areas. Peripheral calcification was also present. There was mild peripheral enhancement after iodinated intravenous contrast injection. It was not possible to exclude cardiac invasion because this lesion had extensive contact with the cardiac ventricles. Figure 1. A, Posteroanterior chest radiograph showing an ill-defined opacity at the left pericardic region. B, This is better identified in the lateral projection (white arrows). Figure 2. …

The metastatic behavior of osteosarcoma by gene expression and cytogenetic analyses

Osteosarcoma is a malignant bone tumor with high metastatic potential. Metastasis at diagnosis is the most significant prognostic factor in predicting the clinical outcome of osteosarcoma. We compared the gene expression of metastases that were present at the time of initial diagnosis to those developed later in the course of the disease. We used quantitative real-time polymerase chain reaction to evaluate the gene expression of MDM2, CXCR4, RANKL, RB1, and OSTERIX in 98 samples of osteosarcoma taken from 47 patients (74 metastases and 24 primary tumors) and 30 nonmalignant lung tissues surrounding osteosarcoma metastases. In addition, we investigated the copy number changes of RB1 and MDM2 genes in 12 primary cultures of pulmonary metastases of osteosarcoma, using interphase fluorescence in situ hybridization. Metastases from metastatic patients at diagnosis were characterized by low expression of RB1 and RANKL (P = .0009 and P = .0109, respectively) and overexpression of CXCR4 and MDM2 (P = .0389 and P = .0325, respectively). The loss of RANKL and gain of CXCR4 could also be detected in the primary tumors of metastatic patients at diagnosis (P = .0121 and P = .0264, respectively). Thus, some early genetic events such as the loss of RANKL and the gain of CXCR4 expressions probably facilitate the metastatic progression concomitant with the primary tumor establishment, supporting the role of the CXCR4 receptor in directing osteosarcoma metastases to the lung. On the other hand, late events such as the loss of RB1 and gain of MDM2, crucial regulators of cell cycle, appear to be related to the final mechanisms contributing to the metastatic establishment of osteosarcoma.

Análise semiquantitativa de biópsias cirúrgicas de diferentes lobos pulmonares de pacientes com pneumonia intersticial usual/fibrose pulmonar idiopática

OBJECTIVE: To evaluate the differences between surgical biopsies of distinct lung lobes in terms of the histopathological features of usual interstitial pneumonia, using a semiquantitative score. METHODS: We selected all of the patients diagnosed with idiopathic pulmonary fibrosis and submitted to surgical biopsy in two distinct lobes between 1995 and 2005 at the Hospital Sao Paulo and other hospitals operated by the Federal University of Sao Paulo. In the histological evaluation of the specimens, we used a semiquantitative method based on previous studies, assigning a score to each of the biopsied sites. RESULTS: In this sample of patients, we found no statistically significant differences that would alter the stage of the disease, based on the score used. This finding was independent of the biopsy site (middle lobe or lingular segment). CONCLUSIONS: No significant histological differences were found between the lung lobes studied. The definitive histological diagnosis of usual interstitial pneumonia did not alter the stage of the disease.

CYP genes in osteosarcoma: Their role in tumorigenesis, pulmonary metastatic microenvironment and treatment response

Osteosarcoma (OS) is the most common malignant bone tumor in children and adolescents. The present study investigated the expression of Cytochrome P-450 (CYP) genes: CYP1A2, CYP3A4 and CYP3A5 by qRT-PCR in 135 specimens obtained from OS patients, including biopsy (pre-chemotherapy), tumor resected in surgery (post-chemotherapy), adjacent bone to tumor (nonmalignant tissue), pulmonary metastasis and adjacent lung to metastasis (nonmalignant tissue). Normal bone and normal lung tissues were used as control. We also investigated in five OS cell lines the modulation of CYPs expression by cisplatin, doxorubicin and methotrexate. As result, the adjacent lung specimens presented CYP1A2 overexpression compared to the normal lung (p=0.0256). Biopsy specimens presented lower CYP3A4 expression than normal bone (p=0.0314). The overexpression of both CYP1A2 and CYP3A4 in post-chemotherapy specimens were correlated with better event free-survival (p=0.0244) and good response (p=0.0484), respectively. Furthermore, in vitro assays revealed that CYP1A2 was upregulated by doxorubicin (p=0.0034); CYP3A4 was upregulated by cisplatin, doxorubicin and methotrexate (p=0.0004, p=0.0024, p<0.0001, respectively); and CYP3A5 was downregulated by doxorubicin (p=0.0285) and upregulated in time-dependent manner by methotrexate (p=0.0239). In conclusion, our findings suggest that CYP genes play an important role in OS tumorigenesis, at primary and metastatic sites, as well in treatment response.

Massive thymic hyperplasia presenting with respiratory insufficiency in a 2-year-old child

A 2-year-old boy presented with fever, dry cough and dyspnoea for 3 days. Breath sounds were absent and thoracic percussion revealed dullness in the lower two-thirds of the left hemithorax. A chest x-ray showed almost complete opacification of these areas (figure 1). The boy was successfully treated with antibiotics for lower airways infection but tachypnoea persisted and the x-ray showed no change after 6 weeks. A CT scan was performed and showed a heterogeneous mass in the anterior mediastinum, predominantly on the left side, occupying most of the left hemithorax. This lesion showed areas of lower attenuation interspersed with areas of soft tissue attenuation (figure 2). The possibility of …

Giant pulmonary hamartoma.

A 61-year-old woman presented with dyspnea and intense cough. Chest radiography showed opacity of the entire left hemithorax and computed tomography of the chest confirmed a solid heterogeneous mass extending from apex to base, with foci of calcification and areas of low attenuation. Left upper lobe resection was performed, removing the tumor in large pieces. Histologic characteristics of the lesion were compatible with typical hamartoma. No signs of recurrence were detected 2.5 years after the operation.

Solitary fibrous tumour of the pleura causing bulging of the thoracic wall in a 44-year-old man

A 44-year-old male patient presented with right chest pain for 6 years, along with progressive swelling in the same region. He did not report fever, weight loss, trauma or previous surgery. On physical examination, a 5 cm focal bulge was observed in the right hemithorax just below and medial to the nipple (figure 1). Chest x-ray showed opacification of the anterior lower third of the right hemithorax (figure 2), which on CT scan corresponded to a heterogeneous mass, compressing the right lung parenchyma and the mediastinum, partially protruding through the chest …

Anestesia congênita de córnea: relatos de casos

Case series of nine patients with congenital corneal anesthesia, six of them showed systemic changes in association with the ocular status. Three patients were submitted to electromyography, two showed isolated bilateral ophthalmic ramus alteration. Two patients had initial visual acuity better than 20/60 and six had final best corrected visual acuity better than 20/60 at the last visit. All of them were treated surgically and developed cornea opacities of variable sizes. Treatment of corneal congenital anesthesia must be performed as soon as possible to avoid corneal opacification. Systemic investigation, close follow-up and preparing the family for longterm and multidisciplinary approach are crucial to maintain the ocular health.

Eficácia de um regime de administração de antibióticos tópicos na redução da microbiota conjuntival de pacientes sadios com catarata senil

PURPOSE: To evaluate the conjunctival bacterial flora of healthy patients and its antibiotic resistance pattern and determine the effective of a regime of topical antibiotics on reduction of endogenous microbiota. METHODS: Its a prospective non randomized study. Fourty eyes of 40 patients, divided in 4 groups of 10 eyes each, used four differents topical antibiotics (ciprofloxacin, tobramycin and gatifloxacin). One group served as a control group. Were performed conjunctival cultures before instillation of the antibiotics drops and after 15, 30 and 60 minutes. Were performed susceptibility tests of the specimes isolated to these antibiotics. We compared the reduction of bacterium growth by assessing the number of UFC (colonies forming units) before and after the instillation of antibiotics drops. RESULTS: Of the 40 eyes, 92,5% had positive cultures. The coagulase-negative Staphylococcus (CNS) was the most frequent organism isolated (50%), followed by Staphylococcus Aureus (23%) and gram-negative bacteria (26%). More than 81% of the isolates of this bacterium were susceptible to all antibiotics tested. Five bacterium isolates were resistant to ciprofloxacin and tobramycin and two to gatifloxacin. All groups had diminished the number of patients with positive culture specimes from the conjuntiva compared to moment zero and to placebo. CONCLUSION: The gram positive bacterium, specially the coagulase-negative Staphylococcus, were the most frequent microorganism found on conjunctiva of healthy patients. The most of the bacterium isolated were sensitivity to the antibiotics tested. The proposed regime of use of these antibiotics reduced the number of UFC (colonies forming units) compared to placebo although without statics relevance in most of cases.