A Utilização de Endopróteses na Síndrome da Veia Cava Superior por Neoplasia do Pulmão

Apresentam-se seis casos de síndrome da veia cava superior causado por neoplasia do pulmão e que foram tratados por endopróteses colocadas por via percutânea. Descreve-se a técnica e avaliam-se os resultados. Num caso ocorreu trombose aguda da endoprótese que foi tratada por uroquinase. Não se registaram outras complicações. Um doente faleceu 1 mês depois por progressão da doença. Os restantes mantinham-se sem queixas de síndrome da veia cava superior durante mais do que 6 meses. Conclui-se que a colocação de endopróteses é uma técnica pouco invasiva, eficaz e com melhoria imediata no síndrome da veia cava superior.

Prostatic Arterial Supply: Anatomic and Imaging Findings Relevant for Selective Arterial Embolization

PURPOSE: To describe the anatomy and imaging findings of the prostatic arteries (PAs) on multirow-detector pelvic computed tomographic (CT) angiography and digital subtraction angiography (DSA) before embolization for symptomatic benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: In a retrospective study from May 2010 to June 2011, 75 men (150 pelvic sides) underwent pelvic CT angiography and selective pelvic DSA before PA embolization for BPH. Each pelvic side was evaluated regarding the number of independent PAs and their origin, trajectory, termination, and anastomoses with adjacent arteries. RESULTS: A total of 57% of pelvic sides (n = 86) had only one PA, and 43% (n = 64) had two independent PAs identified (mean PA diameter, 1.6 mm ± 0.3). PAs originated from the internal pudendal artery in 34.1% of pelvic sides (n = 73), from a common trunk with the superior vesical artery in 20.1% (n = 43), from the anterior common gluteal-pudendal trunk in 17.8% (n = 38), from the obturator artery in 12.6% (n = 27), and from a common trunk with rectal branches in 8.4% (n = 18). In 57% of pelvic sides (n = 86), anastomoses to adjacent arteries were documented. There were 30 pelvic sides (20%) with accessory pudendal arteries in close relationship with the PAs. No correlations were found between PA diameter and patient age, prostate volume, or prostate-specific antigen values on multivariate analysis with logistic regression. CONCLUSIONS: PAs have highly variable origins between the left and right sides and between patients, and most frequently arise from the internal pudendal artery.

Prostatic Artery Embolization in the Treatment of Benign Prostatic Hyperplasia: Short and Medium Follow-Up

To evaluate the short and mid-term results of prostatic artery embolization in patients with benign prostatic embolization. Retrospective study between March 2009 and June 2011 with 103 patients (mean age 66.8 years, 50-85) that met our inclusion criteria with symptomatic benign prostatic hyperplasia. The clinical outcome was evaluated by the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function, prostate volume (PV), prostate-specific antigen (PSA), peak urinary flow (Q(max)), and post-void residual volume (PVR) measurements at 3 and 6 months, 1 year, 18 months, and 2 years after PAE and comparison with baseline values was made. Technical and clinical successes, as well as poor clinical outcome definitions, were previously defined. In this review, we evaluate the short and mid-term clinical outcomes and morbidity of patients treated only with non-spherical polyvinyl alcohol. Six months after the procedure, the PV decreased about 23%, IPSS changed to a mean value of 11.95 (almost 50% reduction), the QoL improved slightly more than 2 points, the Q(max) changed to a mean value of 12.63mL/s, the PVR underwent a change of almost half of the baseline value, and the PSA decreased about 2.3ng/mL. In the mid-term follow-up and comparing to the baseline values, we still assisted to a reduction in PV, IPSS, QoL, PVR, and PSA, and an increase in Q(max). Prostatic Artery Embolization is a safe procedure with low morbidity that shows good short- and mid-term clinical outcome in our institution.

Unilateral Versus Bilateral Prostatic Arterial Embolization for Lower Urinary Tract Symptoms in Patients with Prostate Enlargement

PURPOSE: This study was designed to compare baseline data and clinical outcome between patients with prostate enlargement/benign prostatic hyperplasia (PE/BPH) who underwent unilateral and bilateral prostatic arterial embolization (PAE) for the relief of lower urinary tract symptoms (LUTS). METHODS: This single-center, ambispective cohort study compared 122 consecutive patients (mean age 66.7 years) with unilateral versus bilateral PAE from March 2009 to December 2011. Selective PAE was performed with 100- and 200-μm nonspherical polyvinyl alcohol (PVA) particles by a unilateral femoral approach. RESULTS: Bilateral PAE was performed in 103 (84.4 %) patients (group A). The remaining 19 (15.6 %) patients underwent unilateral PAE (group B). Mean follow-up time was 6.7 months in group A and 7.3 months in group B. Mean prostate volume, PSA, International prostate symptom score/quality of life (IPSS/QoL) and post-void residual volume (PVR) reduction, and peak flow rate (Qmax) improvement were 19.4 mL, 1.68 ng/mL, 11.8/2.0 points, 32.9 mL, and 3.9 mL/s in group A and 11.5 mL, 1.98 ng/mL, 8.9/1.4 points, 53.8 mL, and 4.58 mL/s in group B. Poor clinical outcome was observed in 24.3 % of patients from group A and 47.4 % from group B (p = 0.04). CONCLUSIONS: PAE is a safe and effective technique that can induce 48 % improvement in the IPSS score and a prostate volume reduction of 19 %, with good clinical outcome in up to 75 % of treated patients. Bilateral PAE seems to lead to better clinical results; however, up to 50 % of patients after unilateral PAE may have a good clinical outcome.

Embolisation of Prostatic Arteries as Treatment of Moderate to Severe Lower Urinary Symptoms (LUTS) Secondary to Benign Hyperplasia: Results of Short- and Mid-Term Follow-Up

OBJECTIVES: To evaluate the short- and medium-term results of prostatic arterial embolisation (PAE) for benign prostatic hyperplasia (BPH). METHODS: This was a prospective non-randomised study including 255 patients diagnosed with BPH and moderate to severe lower urinary tract symptoms after failure of medical treatment for at least 6 months. The patients underwent PAE between March 2009 and April 2012. Technical success is when selective prostatic arterial embolisation is completed in at least one pelvic side. Clinical success was defined as improving symptoms and quality of life. Evaluation was performed before PAE and at 1, 3, 6 and every 6 months thereafter with the International Prostate Symptom Score (IPSS), quality of life (QoL), International Index of Erectile Function (IIEF), uroflowmetry, prostatic specific antigen (PSA) and volume. Non-spherical polyvinyl alcohol particles were used. RESULTS: PAE was technically successful in 250 patients (97.9 %). Mean follow-up, in 238 patients, was 10 months (range 1-36). Cumulative rates of clinical success were 81.9 %, 80.7 %, 77.9 %, 75.2 %, 72.0 %, 72.0 %, 72.0 % and 72.0 % at 1, 3, 6, 12, 18, 24, 30 and 36 months, respectively. There was one major complication. CONCLUSIONS: PAE is a procedure with good results for BPH patients with moderate to severe LUTS after failure of medical therapy. KEY POINTS: • Prostatic artery embolisation offers minimally invasive therapy for benign prostatic hyperplasia. • Prostatic artery embolisation is a challenging procedure because of vascular anatomical variations. • PAE is a promising new technique that has shown good results.

Prostatic Arterial Embolization to Treat Benign Prostatic Hyperplasia

PURPOSE: To evaluate whether prostatic arterial embolization (PAE) might be a feasible procedure to treat lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Fifteen patients (age range, 62-82 years; mean age, 74.1 y) with symptomatic BPH after failure of medical treatment were selected for PAE with nonspherical 200-μm polyvinyl alcohol particles. The procedure was performed by a single femoral approach. Technical success was considered when selective prostatic arterial catheterization and embolization was achieved on at least one pelvic side. RESULTS: PAE was technically successful in 14 of the 15 patients (93.3%). There was a mean follow-up of 7.9 months (range, 3-12 months). International Prostate Symptom Score decreased a mean of 6.5 points (P = .005), quality of life improved 1.14 points (P = .065), International Index of Erectile Function increased 1.7 points (P = .063), and peak urinary flow increased 3.85 mL/sec (P = .015). There was a mean prostate-specific antigen reduction of 2.27 ng/mL (P = .072) and a mean prostate volume decrease of 26.5 mL (P = .0001) by ultrasound and 28.9 mL (P = .008) by magnetic resonance imaging. There was one major complication (a 1.5-cm(2) ischemic area of the bladder wall) and four clinical failures (28.6%). CONCLUSIONS: In this small group of patients, PAE was a feasible procedure, with preliminary results and short-term follow-up suggesting good symptom control without sexual dysfunction in suitable candidates, associated with a reduction in prostate volume.

The Role of Accessory Obturator Arteries in Prostatic Arterial Embolization

In 9 of 491 patients (1.8%) who underwent prostatic arterial embolization (PAE) for benign prostatic hyperplasia from March 2009-November 2013, prostatic arteries arose from the external iliac artery via an accessory obturator artery (AOA). Computed tomography angiography performed before the procedure identified the variant and allowed planning before the procedure. The nine AOAs were catheterized from a contralateral femoral approach. Bilateral PAE was technically successful in the nine patients. There was a mean decrease in international prostate symptom score of 6.5 points and a mean prostate volume reduction of 15.1% (mean follow-up, 4.8 mo) in the nine patients.

Utilidade da Broncofibroscopia no Diagnóstico de Neoplasia do Pulmão em Doentes com Pneumonia Arrastada

A broncofibroscopia (BF) é frequentemente efectuada em doentes com pneumonias de evolução arrastada com o objectivo de excluir patologia endobrónquica de etiologia neoplásica. Dado que a resolução radiográfica das pneumonias da comunidade é variável, sendo dependente de vários factores (agente etiológico, idade, doenças associadas) a decisão para efectuar uma BF é muitas vezes empírica. Com o objectivo de descrever a nossa experiência neste problema estudámos retrospectivamente 123 doentes com o diagnóstico de pneumonia da comunidade baseado em critérios clínicos e radiográficos e que, apesar da antibioferapia considerada adequada, não apresentavam melhoria radiográfica significativa ao fim de pelo menos 2 semanas. Obtivemós um diagnóstico histológico de neoplasia maligna do pulmão em 7 doentes (5,6° o), sendo todos do sexo masculino, com idade superior a 55 anos efuínadores de pelo menos 40 U.M.A. A análise comparativa com os restantes doentes mostrou diferenças com significado~estatístico em relação à idade e ao consumo tabágico. O tempo de evolução da doença,valores médios de hemoglobina, leucocitos, VS, existência ou não de alterações da função renal ou hepática não foram significativamente diferentes nos dois grupos. Concluimos que a BF deve ser efectuada precocemente nos doentes pertencentes ao grupo de risco identificado (fumadores, com mais de 55 anos) não se justificando a sua realização nos restantes doentes antes das 4 a 8 semanas de evolução, a menos que estejam presentes critérios clínicos objectivos tais como progressão da doença ou agravamento do estado geral.

Hiperplasia Benigna da Próstata

Os autores fazem a revisão da clínica, do registo da sintomatologia e impacto na qualidade de vida, dos meios auxiliares ao diagnóstico e das atitudes terapêuticas da Hiperplasia benigna da Próstata. Fundamentados nestes dados propõem Orientações Terapêuticas e Recomendações, para quando e como enviar os doentes portadores desta patologia a Urologia. Assim, segundo os critérios definidos neste trabalho, devem ser enviados à Urologia os doentes com sintomatologia importante ou grave, idade inferior a 50 anos, antecedentes de diabetes ou alterações neurológicas, micção francamente alterada, globo vesical, toque rectal com palpação prostática suspeita de neoplasia, hematúria, infecção urinária, insuficiência renal, ou PSA> 4 nglml para idade inferior a 70 anos.

Mutational Analysis of Portuguese Families with Multiple Endocrine Neoplasia Type 1 Reveals Large Germline Deletions

OBJECTIVE: To determine the spectrum of MEN1 mutations in Portuguese kindreds, and identify mutation-carriers. PATIENTS, DESIGN AND RESULTS: Six unrelated MEN1 families were studied for MEN1 gene mutations by single-strand conformational polymorphism (SSCP) and DNA sequence analysis of the coding region and exon-intron boundaries of the MEN1 gene. These methods identified 4 different heterozygous mutations in four families: two mutations are novel (mt 1539 delG and mt 655 ims 11 bp) and two have been previously observed (mt 735 del 46p and mt 1656 del C) all resulting in a premature stop codon. In the remaining two families, in whom no mutations or abnormal MEN1 transcripts were detected, segregation studies of the 5' intragenic marker D11S4946 and codon 418 polymorphism in exon 9 revealed two large germline deletions of the MEN1 gene. Southern blot and tumour loss of heterozygosity analysis confirmed and refined the limits of these deletions, which spanned the MEN1 gene at least from: exon 7 to the 3' untranslated region, in one family, and the 5' polymorphic site D11S4946 to exon 9 (obliterating the initiation codon), in the other family. Twenty-six mutant-gene carriers were identified, 6 of which were asymptomatic. CONCLUSIONS: These results emphasize the importance of the detection of MEN1 germline deletions in patients who do not have mutations of the coding region. Important clues indicating the presence of such deletions may be obtained by segregation studies using the intragenic polymorphisms D11S4946 and at codon 418. The detection of these mutations will help in the genetic counselling of clinical management of the MEN1 families in Portugal.

Extensão Cardíaca de Carcinoma de Células Renais

Apresenta-se o caso de um homem de 62 anos de idade com um episódio de dispneia súbita que motivou estudo ecocardiográfico, o qual revelou uma massa na aurícula direita. A avaliação posterior demonstrou tratar-se de extensão de neoplasia do rim direito. A massa tumoral foi removida através duma abordagem multidisciplinar, com cirurgia torácica e abdominal. O estudo anatomopatológico mostrou tratar-se de um carcinoma de células renais.

Tumores do Corpo Carotídeo. Experiência de um Serviço no Diagnóstico e Tratamento nos Últimos 10 Anos

INTRODUCTION: Carotid body tumours (CBT) are neoplasms that develop from paragangionic cells of this structure. They are rare, with an estimated incidence of 1:30000 and can be associated with other neuro-endocrine neoplasia. The authors report their experience in the management of the disease, in the last 10 years. MATERIAL AND METHODS: Eight patients (with eight tumours) were treated, all submitted to tumour resection. 75% were female and the mean age was 56 years. We report a 12,5% incidence of neurological sequelae from surgery, and no mortality. In the follow-up (which varied between 1 and 10 years), no local or contralateral recurrence or metastasis were registered. Also, we did not found family cases of this disease. CONCLUSIONS: The authors noticed an unusually high proportion of female patients. The tumour resection was curative in all patients, with a rate of neurological complications inferior to that reported in other published series. These neurological sequelae were reported in patients with large tumours, thus reinforcing the outmost importance of an early diagnosis. Pre-operative selective embolization of these tumours can be helpful in the resection of large tumours, allowing a potential reduction in neurological complications.

Cistadenocarcinoma do Ovário. A Propósito de um Caso Clínico

Os autores apresentam o caso clínico de uma doente de 49 anos, internada por poliadenopatias e sintomatologia respiratória, cujo diagnóstico definitivo de cistadenocarcinoma seroso do ovário, foi efectuado através do exame necrópsico. O quadro clínico era dominado por extensa invasão linfática predominantemente supradiafragmática, apresentação não habitual deste tipo de neoplasia.

Metástases da Coluna. Revisão de uma População Hospitalar

As lesões metastáticas extradurais são o tipo de tumor mais frequente a nível dos diferentes segmentos da coluna. Entre Janeiro de 1989 e Junho de 1996, foram observados a nível hospitalar 209 doentes com metástases da coluna. Com base num protocolo de avaliação individual, foi efectuado um estudo retrospectivo destes doentes, incidindo primordialmente sobre o respectivo quadro clínico e alterações neuro-imagiológicas encontradas, bem como sobre o tipo de neoplasia primária e a resposta à terapêutica instituída. Tivemos como objectivo fundamental o de tentar caracterizar a semiologia e evolução mais habituais deste tipo de lesões, no sentido da obtenção dum diagnóstico rápido e da instituição duma terapêutica em tempo útil, permitindo um índice de sobrevida com o mínimo de qualidade.

Sarcoma de Kaposi. Envolvimento Visceral na Sida

O Sarcoma de Kaposi (SK) é uma neoplasia multifocal, de expressão predominantemente cutânea, mas que pode atingir órgãos viscerais. Estão descritas quatro variantes: o SK clássico, o endémico africano, o iatrogénico e o epidémico. Esta última variante surgiu com a associação deste tumor à SIDA e tomou proporções importantes, tanto pela sua frequência como pela expressão clínica disseminada com atingimento visceral marcado. Os homossexuais constituem o grupo de risco mais afectado e admitem-se várias hipóteses etiológicas para esta neoplasia. Existe uma correlação entre o grau de deficiência imunológica e a extensão da doença. O SK associado à SIDA apresenta envolvimento visceral em 50 a 70% dos casos. No entanto, o envolvimento visceral isolado é raro. Descrevem-se as expressões gastro-intestinal, pulmonar e cardíaca da doença, por serem os órgãos mais frequentemente atingidos. A terapêutica é meramente paliativa e pode ser local ou sistémica. O SK raramente é causa de morte, com excepção do envolvimento pulmonar, vindo o doente a falecer em consequência de infecções oportunistas.