Papel de la tomografía por emisión de positrones/tomografía computarizada con análogos radiomarcados de colina en el cáncer de próstata

Introductionprostate cancer is the most frequent solid malignant tumor in Western Countries. Positron emission tomography/x-ray computed tomography imaging with radiolabeled choline analogues is a useful tool for restaging prostate cancer in patients with rising prostate-specific antigen after radical treatment (in whom conventional imaging techniques have important limitations) as well as in the initial assessment of a selected group of prostate cancer patients. For this reason a literature review is necessary in order to evaluate the usefulness of this imaging test for the diagnosis and treatment of prostate cancer.Evidence acquisitiona MEDLINE (PubMed way) literature search was performed using the search parameters: «Prostate cancer» and «Choline-PET/CT». Other search terms were «Biochemical failure» and/or «Staging» and/or «PSA kinetics». English and Spanish papers were selected; original articles, reviews, systematic reviews and clinical guidelines were included.Conclusionsaccording to available data, radiolabeled choline analogues plays an important role in the management of prostate cancer, especially in biochemical relapse because technique accuracy is properly correlated with prostate-specific antigen values and kinetics. Although is an emerging diagnostic technique useful in treatment planning of prostate cancer, final recommendations have not been submitted.     

La tomografía computarizada helicoidal sin contraste en comparación con la ecografía y la radiografía simple de abdomen en el estudio del paciente con dolor lumbar agudo

Objective: Evaluation the diagnostic ability of unenhanced helical computed tomography in the evaluation of patients with acute flank painPatients and methodsProspectively evaluation of 82 patients referred for acute flank pain between january 1999 and june 2000. 78 patients were imaged with, 73 abdominal ultrasound and 46 with TCHNCResultsPlain radiography shows 49.1% of diagnosed lithiasis. Ultrasound was 48% sensitive and 96% specific. TCHNC was 100% sensitive and 84% specific in the diagnosis of lithiasis, allowing in 11 patients a diagnosis unrelated to stone diseaseConclusionsTCHNC is a valuable radiologic technique for patients presenting with acute flank pain and consider the TCHNC as initial evaluation technique in patients with acute flank pain, allowing not only the localization of the stone as well as the diagnosis of extraurinary pathologies     

Utilidad de la tomografía de emisión de positrones / tomografía computarizada con 18F-colina en el manejo terapéutico de pacientes con recidiva bioquímica de adenocarcinoma de próstata tratados con braquiterapia

ObjectiveThe objective of the study was to evaluate the usefulness of 18F-choline PET/CT in biochemically recurrent prostate cancer patients treated with brachytherapy, as well as to assess the changes in therapeutic management derived from its outcome.Material and methodsRetrospective study of 20 patients between 51 and 78 years old, with a history of prostate adenocarcinoma that had been treated with brachytherapy and presented biochemical recurrence (PSA 3.1-12  ng/ml) and staging tests (CT and bone scan) without alterations, were included. The findings visualized in the PET/CT scan with ¹⁸F-choline were correlated with the histopathology and/or the evolution of the PSA after therapy.Results¹⁸F-choline PET/CT scan only detected local recurrence in 15 patients. Local and regional recurrences were seen in 4 patients, and 1 patient presented local and bone recurrence. Local recurrence detected in PET was confirmed by anatomopathological studies in 85% of the cases. In one patient, these findings (PET scan) turned out to be prostatitis, and it could not be confirmed in another patient. Of the cases with local and regional recurrence, local recurrence was histologically confirmed in 3 out of 4 patients. ¹⁸F-choline PET/CT changed the therapeutic management in 25% of the patients, discarding the initially planned salvage surgery in 3 cases, 1 radiotherapy and 1 brachytherapy.Conclusion¹⁸F-choline PET/CT could be a useful technique in the group of patients with biochemical recurrence after brachytherapy, providing locoregional and distant involvement findings which had not been detected with conventional imaging tests, thus determining a more adequate therapeutic management.     

Resección hepática con trombectomía en el tratamiento del carcinoma hepatocelular con invasión vascular macroscópica

IntroductionMacrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI.MethodsRetrospective cohort study of patients who underwent liver resection for HCC in the period 2007-2015 (n = 120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1 patient in the common portal vein (Vp4), 8 patients in first-order portal branches (Vp3), 1 patient in a sectorial branch (Vp2), 1 patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2).ResultsPatients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P < .0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P = .034).Global survival at 1, 3 and 5 years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P = .009), respectively.ConclusionsHepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity.     

Hipertensión endocraneal asociada a la sedación con sevoflurano mediante el dispositivo AnaConDa®en un paciente con traumatismo craneoencefálico severo

Sedation in neurocritical patients remains a challenge as there is no drug that meets all the requirements. Since the appearance of the AnaConDa^® device, and according to the latest recommendations, sevoflurane has become an alternative for patients with brain injury. The use of AnaConDa^® produces an increase in the anatomical dead space that leads to a decrease in alveolar ventilation. If the decrease in the alveolar ventilation is not offset by an increase in minute volume, there will be an increase in PaCO₂. We report the case of a patient with severe traumatic brain injury who suffered an increase in intracranial pressure as a result of increased PaCO₂ after starting sedation with the AnaConDa^® device.     

Diez mandamientos fisiológicos a lograr durante el traumatismo craneoencefálico grave

Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient.Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.     

La relación albúmina/globulina preoperatoria como factor pronóstico en pacientes con cáncer testicular

Introduction and objectivesIn recent years, the incidence of testicular cancer has increased, but mortality rates have decreased thanks to the improvements in treatment. Although primary tumor characteristics and serum tumor markers are associated with metastasis and relapse, their predictive value is not reliable. Therefore, there is a need for new biomarkers that predict prognosis. In this study, we aimed to investigate the role of preoperative albumin to globulin ratio (AGR) in predicting retroperitoneal lymph node (RPLN) involvement, distant metastasis and prognosis in testicular cancer.Material and methodsWe retrospectively analyzed the medical records of all patients that underwent radical inguinal orchiectomy at our hospital between 2007 and 2018. AGR was calculated using the equation: AGR = serum albumin / (serum total protein − serum albumin). The predictive value of AGR for RPLN involvement and distant metastasis was evaluated using receiver operating characteristic analysis and its prognostic value was evaluated using Kaplan-Meier survival analysis.ResultsA total of 115 patients with a mean age of 33.4 ± 7.7 years were included in the study. In multivariate analysis, AGR less than 1.47 and the presence of lymphovascular invasion were detected as the factors predicting RPLN involvement and distant metastasis. The AGR of patients who had died was significantly lower than AGR of those who were alive, 1 ± 0.2 versus 1.6 ± 0.3 (P = .001). In Kaplan-Meier survival analysis, the mean survival of patients with higher AGR (> 1.47) was found longer than patients with lower AGR (< 1.47).ConclusionsPreoperative AGR is a biomarker that may be used in predicting RPLN involvement, distant metastasis and prognosis in testicular cancer.     

Correlación de hallazgos preoperatorios en la tomografía axial computarizada con la presencia de vía aérea difícil en pacientes intervenidos mediante cirugía otorrinolaringológica de cabeza y cuello

Objectives

To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery.

Tratamiento con óxido nítrico,levosimendán y sildenafilo en paciente con disfunción ventricular derecha e hipertensión pulmonar severa tras cirugía cardíaca

Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery.The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators.A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT.We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115 mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well.Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations.     

Resección extendida y exenteración pélvica en el cáncer de recto del tercio inferior

Approximately 10% of all low rectal cancer needs surgical resection extended to other pelvic structures. Indication for extended resection should be given according to a precise systemic and local preoperative staging. Magnetic Resonance Imaging is the most important instrument utilized by the Multidisciplinary Team to decide therapeutic strategy according to the surgical risk. The status of the pathological circumferential resection margin is the most important prognostic factor determining local recurrence risk and oncological outcome and for this reason it should be considered pivotal in the decision of the strategy of treatment. When extended resection is performed, the presence of an expert colorectal surgeon is mandatory, often coordinating a group of specialists including urologist, plastic surgeon, vascular surgeon and orthopaedist when sacrectomy is necessary. The most frequent extended resection in women with low rectal cancer is the partial resection of vagina. In men, the infiltration of the prostate could be treated with partial prostatectomy, total prostatectomy with bladder preservation or pelvic exenteration, total or posterior, when the bladder is infiltrated. Rectal cancer infiltration of the pelvic sidewalls or of the sacrum is less frequent and obliges to perform a total pelvic exenteration including sometimes the hypogastric vessel or extended to the sacrum.     

La simulación como modelo de enseñanza en cirugía

Teaching of surgery has been affected by many factors over the last years, such as the reduction of working hours, the optimization of the use of the operating room or patient safety.Traditional teaching methodology fails to reduce the impact of these factors on surgeońs training. Simulation as a teaching model minimizes such impact, and is more effective than traditional teaching methods for integrating knowledge and clinical-surgical skills.Simulation complements clinical assistance with training, creating a safe learning environment where patient safety is not affected, and ethical or legal conflicts are avoided.Simulation uses learning methodologies that allow teaching individualization, adapting it to the learning needs of each student. It also allows training of all kinds of technical, cognitive or behavioural skills.     

Marcadores inflamatorios como factor pronóstico en el cáncer de próstata resistente a la castración metastásico

IntroductionInflammatory markers have prognostic value in various tumors due to the role of inflammatory phenomena at different stages of tumor development. The aim of this study is to demonstrate the prognostic value of these markers, as well as other clinical and analytical variables in patients with metastatic castration-resistant prostate cancer (mCRPC).Material and methodsProspective cohort study carried out on 80 patients diagnosed with mCRPC. Clinical and analytical data were collected, and the following inflammatory markers were estimated: Absolute Neutrophil Count (ANC), Neutrophil-Lymphocyte Ratio (NLR), Total Platelet Count (TPC), Platelet-Lymphocyte Ratio (PLR), Lymphocyte-Monocyte Ratio (LMR) and Systemic Inflammation Index (SII). The values of albumin, hemoglobin (Hb), alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were also determined.ResultsPatients with ANC>7500, NLR>3, PLR>150, LMR>3 and/or SII>535,000, presented significantly lower median survival time than the remaining patients, and TPC was the only marker which did not show a significant association. Moreover, NLR, PLR and SII were inversely correlated with survival time. Patients with hypoalbuminemia, anemia, and elevated LDH values had significantly lower median survival time. Albumin and hemoglobin were directly correlated to overall survival time. The need for analgesia was also associated with shorter survival.ConclusionThe values of certain inflammatory markers are associated with shorter survival time in patients with mCRPC, and their use in clinical practice can be considered to evaluate the prognosis and estimate survival.