Giant multilocular thymic cyst in an HIV-infected adolescent

A girl with vertically acquired HIV infection presented with a 6-month history of dyspnea and chest pain. Computed tomography of the thorax showed a heterogenous mass measuring 13 x 9 x 17 cm located in the anterior mediastinum. Complete surgical resection was accomplished with no complications. The final diagnosis was multilocular thymic cyst, a distinct pathologic entity that is morphologically distinguishable and unrelated to congenital thymic cyst. (C) 2011 Elsevier Inc. All rights reserved.

Long-term outcomes of radical cystectomy with preservation of prostatic capsule

We report our results of orthotopic ileal neobladder after radical cystectomy with prostatic adenomectomy with regard to urinary continence, sexual outcome and disease control. Between March 2003 and July 2004, 22 men with bladder transitional cell carcinoma (mean age 65.0) were analyzed. They underwent radical cystectomy with prostatic adenomectomy with preservation of the prostatic capsule, seminal vesicles and orthotopic ileal neobladder. Urinary continence was assessed after 2 days, 2 months, 6 months and 1 year. Preservation of sexual function was defined as the ability to have sexual intercourse and was assessed after 2-, 6-, and 12-months postoperatively. Overall survival and cancer-specific survival were assessed. Median postoperative follow-up was 60 months. Daytime and nighttime urinary continence after 48 h was 47 and 14%, respectively. After 2, 6 and 12 months, these rates were 74 and 16%, 85 and 26%, and 94 and 31%, respectively. Sexual intercourse was achieved in 69% of patients. Overall survival rate was 68%, and cancer-specific survival rate was 73%. Overall survival rates according to pathologic stage for pT0, pT1, pT2 and pT3 were 100, 60, 71 and 57%, and cancer-specific survival were 100, 80, 71 and 57%, respectively. Urinary continence and sexual function achieved by radical cystectomy with prostatic adenomectomy with orthotopic ileal neobladder seem to be similar to those achieved by the conventional technique with satisfactory oncologic results.

Translation and Cross-Cultural Adaptation of the Brazilian Version of the International Knee Documentation Committee Subjective Knee Form Validity and Reproducibility

Background: The perception of improvement by a patient has assumed a central role in functional evaluation after a variety of knee problems. One of the instruments most used in clinical research is the International Knee Documentation Committee (IKDC) Subjective Knee Form because its psychometric properties are considered to be excellent. Nonetheless, this questionnaire was originally developed for use in the English language. Therefore, to use this questionnaire in the Brazilian population, it is essential to translate and validate it. Purpose: The aim of this study was to translate the IKDC Subjective Knee Form into a Brazilian version and to test its validity and reproducibility. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The translation of the original IKDC Subjective Knee Form into a Brazilian version was accomplished in accordance with the American Orthopaedic Society for Sports Medicine guidelines and was tested in 32 patients with knee pathologic conditions to develop the first Brazilian version. To test validity and reproducibility, 117 patients with several knee complaints completed the Brazilian IKDC Subjective Knee Form, the Short Form 36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm score. From these patients, 85 were retested within a week to achieve reproducibility. The validation was addressed by correlating the Brazilian IKDC Subjective Knee Form to the other outcome measures. The reproducibility was tested by measuring internal consistency, test-retest reliability, and agreement. Results: The Brazilian IKDC Subjective Knee Form was highly related to the physical component summary of the SF-36, the Lysholm score, and the WOMAC, and weakly related to the mental component summary of SF-36 (r=.79, .89, .85, and .51, respectively). The internal consistency was strong, with a Cronbach a value of .928 and .935 in the test and retest assessment, respectively. The test-retest reliability proved to be excellent, with a high value of the intraclass correlation coefficient (.988), as well as the agreement, demonstrated by the low differences between the means of the test and retest, and the short limit of agreement, observed in the Altman-Bland and survival-agreement plots. Conclusion: The results of this study provide evidence that the Brazilian IKDC Subjective Knee Form has psychometric properties similar to the original version. In addition, it was a reliable evaluation instrument for patients with knee-related problems.

Predictive Factors for Positive Surgical Margins and Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy

Background: Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). Objective: We sought to identify predictive factors for PSMs and their locations after RARP. Design, setting, and participants: We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. Intervention: All patients underwent RARP performed by a single surgeon with previous experience of > 1500 cases. Measurements: Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra-and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. Results and limitations: In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p < 0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p = 0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor(OR: 1.1; 95% CI, 1.0-1.3; p = 0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. Conclusions: Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs. (C) 2010 European Association of Urology. Published by Elsevier B. V. All rights reserved.

Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Multi-institutional Collaboration

Background: Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined. Objective: To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP. Design, setting, and participants: This is a retrospective, international, multi-institutional cohort analysis. There was amedian follow-up of 4.4 yr following SRP performed on 404 men with radiation-recurrent PCa from 1985 to 2009 in tertiary centers. Intervention: Open SRP. Measurements: BCR after SRP was defined as a serum prostate-specific antigen (PSA) >= 0.1 or >= 0.2 ng/ml (depending on the institution). Secondary end points included progression to metastasis and cancerspecific death. Results and limitations: Median age at SRP was 65 yr of age, and median pre-SRP PSA was 4.5 ng/ml. Following SRP, 195 patients experienced BCR, 64 developed metastases, and 40 died from PCa. At 10 yr after SRP, BCR-free survival, metastasis-free survival, and cancer-specific survival (CSS) probabilities were 37% (95% confidence interval [CI], 31-43), 77% (95% CI, 71-82), and 83% (95% CI, 76-88), respectively. On preoperative multivariable analysis, pre-SRP PSA and Gleason score at postradiation prostate biopsy predicted BCR (p = 0.022; global p < 0.001) and metastasis (p = 0.022; global p < 0.001). On postoperative multivariable analysis, pre-SRP PSA and pathologic Gleason score at SRP predicted BCR (p = 0.014; global p < 0.001) and metastasis (p < 0.001; global p < 0.001). Lymph node involvement (LNI) also predicted metastasis (p = 0.017). The main limitations of this study are its retrospective design and the follow-up period. Conclusions: In a select group of patients who underwent SRP for radiation-recurrent PCa, freedom from clinical metastasis was observed in > 75% of patients 10 yr after surgery. Patients with lower pre-SRP PSA levels and lower postradiation prostate biopsy Gleason score have the highest probability of cure from SRP. (C) 2011 European Association of Urology. Published by Elsevier B. V. All rights reserved.

Nonoperative Approaches to Rectal Cancer: A Critical Evaluation

A neoadjuvant multimodality approach with chemoradiation therapy (CRT) is the preferred treatment strategy for most distal rectal cancers. Significant downstaging and complete pathologic response may develop after this strategy, and there is still controversy regarding the management of these patients. In this setting, a nonoperative approach has been suggested in select patients with complete clinical response after thorough clinical, endoscopic, and radiologic assessment. However, the assessment of these patients is not straightforward and remains complex. Available data regarding this approach are limited to a single institution`s experience from retrospective analyses. Standardization of the assessment of tumor response and the development of radiological/molecular tools may clarify the role of no immediate surgery in patients with complete clinical response after neoadjuvant CRT. Advances in radiation and medical oncology could potentially lead to significant improvements in complete tumor regression rates, leading to an increase in importance of a minimally invasive approach in patients with rectal cancer. Semin Radiat Oncol 21:234-239 (C) 2011 Elsevier Inc. All rights reserved.

Evolution of Laparoscopic Colorectal Surgery in Brazil Results of 4744 Patients From the National Registry

Background: Since its introduction, laparoscopic colorectal surgery has raised intense debate and controversies regarding its safety and effectiveness. Methods: This multicentric registry reports the experience of 28 Brazilian surgical teams specializing in laparoscopic colorectal surgery. Results: Between 1992 and 2007, 4744 patients (1994 men-42% and 2750 women-58%) were operated upon, with ages ranging from 13 to 94 years (average 57.5y). Benign diseases were diagnosed in 2356 patients (49.6%). Most diseases were located in 50.7% of the left and sigmoid colon, 28.2% in the rectum and anal canal. 8.0% in the right colon, and diffuse 7.0%. There were 181 (3.8%) intraoperative complications (from 0% to 14%). There were 261 (5.5%) reported conversions to laparotomy (from 0% to 16.5%), mainly during the early experience (n = 119 - 59.8%). Postoperative complications were registered in 683 (14.5%) patients (from 5.0% to 50%). Mortality occurred in 43 patients (0.8%). Surgeons who performed less than 50 cases reported similar rates of intraoperative (4.2% vs. 3.8%,- P = 0.7), postoperative complications (20.8% vs. 14.3%; P = 0.07), and mortality (1.0% vs. 0.9%; P = 0.5) but the conversion rate was higher (10.4% vs. 5.4%; P = 0.04). Two thousand three hundred and eighty-nine (50.4%) malignant tumors were operated upon, and histologic classification showed 2347 (98%) adenocarcinomas, 30 (0.6%) spinocelular carcinomas, and 12 (0.2%) other histologic types. Tumor recurrence rate was 16.3% among patients followed more than I year. After an average follow-Lip of 52 months, 19 (0.8%) parietal recurrences were reported, 18 of which were in port sites and I in a patient with disseminated disease. There was no incisional recurrence in the ports used to withdraw the pathologic specimen. Compared with other registries, there was a 75% increase in the number of groups pet-forming laparoscopic colorectal surgery and a decrease in conversions (from 10.5%. to 5.5%) and mortality (from 1.5% to 0.9%) rates. Conclusions: (1) The number of patients operated upon increased expressively during the last years; (2) operative indications for benign and malignant diseases were similar, and diverticular disease of the colon comprised 40% of the benign ones; (3) conversion and mortality rates decreased over time; (4) Surgeon`s experience did not influence the complication rates, but was associated with a lower conversion; and (5) oncologic outcome expressed by recurrence rates showed results similar to those reported in conventional surgery.

Laparoscopic Enucleation of Liver Tumors. Corkscrew Technique Revisited

Background: Enucleation of small lesions located near the hepatic surface can be achieved with low morbidity and mortality. This article describes a simple laparoscopic technique for enucleation of liver tumors. Methods: After inspection and intraoperative ultrasonography, Glisson`s capsule is marked with eletrocautery 2 cm away from the tumor margin. Ultrasonography is used to ascertain surgical margin right before liver transection. Hemihepatic ischemia is applied and marked area is anchored by stitches. The suture is held together by metallic clips and upward traction is performed, facilitating the transection of the parenchyma and correct identification of vascular and biliary structures. Results: This technique has been successfully employed in six consecutive patients. There were four men and two women, mean age 50.3 years. Four patients underwent liver resection for malignant disease and two for benign liver neoplasm. Pathologic surgical margins were free in all cases and mean hospital stay was 2 days. No postoperative mortality was observed. Conclusion: This technique may facilitate laparoscopic nonanatomical liver resection and reduce risk of positive surgical margins. It is also useful in combination with anatomical laparoscopic liver resections such as right or left hemihepatectomies in patients with bilateral liver tumors as occurred in one of our patients.

Polymerase chain reaction compared to other laboratory findings and to clinical evaluation in the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin infection

Cutaneous tuberculosis has re-emerged in the last 15 years together with the higher incidence of pulmonary tuberculosis and multidrug resistance. The choice for a single diagnostic tool among the many available today is a challenge. Our objective was to compare polymerase chain reaction (PCR) with other exams in the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin infection. PCR and a set of five different exams were performed in 32 patients (34 samples of paraffin-embedded tissue) evaluated for 3 years in a university hospital, considering the response to mycobacterial infection treatment as a positive case. PCR was the most sensitive (88%) and specific (83%) exam. Culture, immunohistochemistry and acid-fast bacilli were not in agreement with clinical response to treatment. Although PCR is a useful tool, careful clinical exam is still the gold standard for the evaluation and treatment of cutaneous tuberculosis and mycobacteria skin infection.

Kidney Function and 24-Hour Proteinuria in Patients with Fabry Disease during 36 Months of Agalsidase Alfa Enzyme Replacement Therapy: A Brazilian Experience

Background. Prior to the introduction of enzyme replacement therapy (ERT), management of Fabry disease (FD) consisted of symptomatic and palliative measures. ERT has been available for several years using recombinant human agalsidase alfa, an analogue of alpha-galactosidase A (GALA). However, the limitations of ERT in improving kidney function have not been established. This study evaluates the safety and therapeutic effect of agalsidase alfa replacement in terms of kidney function and reduction in 24-hour proteinuria. Methods. During the period between January 1, 2002, and August 1, 2005, nine Fabry patients (7 male, 2 female) were treated according to protocol, receiving 0.2 mg/kg agalsidase alfa IV every two weeks. Kidney function was evaluated by measuring the glomerular filtration rate (GFR) using chromium ethylene diamine tetra-acetate clearance ((51)Cr-EDTA mL/min/1.73 m(2)) at baseline, 12, 24, and 36 months. 24-hour proteinuria was measured at baseline, 3, 6, 12, 18, 24, and 36 months of ERT. Kidney disease was classified according to National Kidney Foundation Disease Outcome Quality Initiative (NKF/DOQI) Advisory Board criteria, which define stage I chronic kidney disease (CKD) as GFR >= 90mL/min/1.73 m(2), stage II as 60-89 mL/min/1.73m(2), stage III as 30-59 mL/min/1.73 m(2), stage IV as 15-29 mL/min/1.73m(2), and stage V as < 15 mL/min/1.73m(2). Results. Six patients completed 36 months of therapy, 2 patients completed 18 months, and 1 patient completed 12 months. Mean patient age at baseline was 34.6 +/- 11.3 years. During the study period, kidney function remained stable in patients with stages I, II, or III CKD. One patient, who entered the study with stage IV CKD, progressed to end-stage chronic kidney disease, beginning hemodialysis after 7 months and receiving a kidney transplant after 12 months of ERT. Proteinuria also remained stable in the group of patients with pathologic proteinuria. The use of agalsidase alfa was well tolerated in 99.5% of the infusions administered. Conclusion. Over the course of 36 months of ERT, there was no change in kidney function and 24-hour proteinuria. This suggests thatagalsidase alfa may slow or halt the progression of kidney disease when used before extensive kidney damage occurs. No significant side effects were observed with ERT during the course of the study.

Are the recommendations from three-dimensional gait analysis associated with better postoperative outcomes in patients with cerebral palsy?

This study was performed to check if recommendations based on three-dimensional gait analysis (3DGA) are associated with better postoperative outcomes in patients with cerebral palsy (CP). Thirty-eight patients who underwent orthopedic surgery and assessment at the Gait Analysis Laboratory were evaluated retrospectively. The patients were divided in four groups according to the agreement between the recommendations from gait analysis and the procedures actually carried out. Fifteen patients with diplegic spastic cerebral palsy and indication for orthopedic surgery to improve walking - and whose surgical intervention was postponed - were also included in the study as a control group. Fourteen gait parameters recorded before and after treatment, were included in the statistical analysis. No gait improvement was noted in the control group or inh patients on whom no procedures recommended by the gait exam were performed (agreement of 0%). In the other groups, agreements averaged 46.71%, 72.2%, and 100%, respectively. Improvement of gait parameters after treatment was observed in these groups, with more significant values directly related to increased agreement percentage. Therefore, in this study the patients whose treatment matched the recommendations from three-dimensional gait analysis showed a more significant improvement in walking. (c) 2008 Elsevier B.V. All rights reserved.

The effect of the number of biopsy cores on the concordance between prostate biopsy and prostatectomy Gleason score - A prostate volume-controlled study

Context.-Studies analyzing the concordance of biopsy and radical prostatectomy (RP) Gleason scores have limitations. Some included 2 or more centers, used historical controls from the early prostate specific antigen era or lacked a clear definition of the biopsy schemes. Furthermore, most did not control the results for prostate volume. Objective.-To confirm whether prediction of RP Gleason score can be optimized by taking more biopsy cores in a contemporary series of patients, with pathologic samples analyzed by the same pathologist, and controlling these results for prostate volume. Design.-The study comprised a retrospective case-control analysis of 393 patients with prostate cancer treated with RP. Patients were divided into 3 groups: those in group 1 underwent a 6-core biopsy; group 2, an 8-core biopsy; and group 3, a 10 or more-core biopsy. Concordance rates between biopsy and RP Gleason scores, as well as the rates of undergrading and overgrading, were determined for each biopsy scheme. Results.-Concordance rates were 60.9%, 58.3%, and 64.6% for patients from groups 1, 2, and 3, respectively (P = .18). When we analyzed patients with prostate volumes of less than 50 cm(3), concordance rates were 58.3%, 58.3%, and 65.1% for each group, respectively (P = .03). Among patients with prostate volumes of 50 cm3 or more, concordance rates were 70%, 58.1%, and 63.6%, respectively (P = .66). Conclusions.-Taking 10 or more cores can improve the prediction of RP Gleason score in patients with prostate volumes of less than 50 cm3. For patients with prostate volumes of 50 cm3 or more, increasing the biopsy cores to 10 or more did not improve prediction of RP Gleason score.

Secondary Lymphangiectasia of the Small Bowel: Utility of Double Balloon Enteroscopy for Diagnosis and Management

Sporadic lymphangiectasias are commonly found throughout the small bowel and are considered to be normal. Not uncommonly, lymphangiectasias are pathologic and can lead to mid-gastrointestinal bleeding, abdominal pain and protein-losing enteropathy. Pathologic lymphangiectasias of the small bowel include primary lymphangiectasia, secondary lymphangiectasia and lymphaticovenous malformations. In this report we present three different cases of small bowel lymphangiectasia detected by double balloon enteroscopy. The patients were diagnosed with South American blastomycosis, tuberculosis and primary small bowel lymphangioma. Copyright (C) 2009 S. Karger AG, Basel

Is Full Postpleurodesis Lung Expansion a Determinant of a Successful Outcome After Talc Pleurodesis?

Study objectives: To analyze and compare radiologic lung expansion after tale pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary end points evaluated were its follows: clinical efficacy; quality of life; safety; and survival. Methods: Prospective randomized study that included 60 patients (45 women, 15 men; mean age, 55.2 years) with recurrent malignant pleural effusion between January, 2005 and January 2008. They were randomized into the following two groups: video-assisted thoracic surgery (VATS) talc poudrage; and tale slurry (TS) administered through a chest tube. Lung expansion was evaluated through chest CT scans obtained 0, 1, 3 and 6 months after pleurodesis. Complications, drainage time, hospital stay,and quality of life (Medical Outcomes Study 36-item short form and World Health Organization quality-of-life questionnaires) were also analyzed. Results: There were no significant differences in preprocedure clinical and pathologic variables between groups. The immediate total (ie, > 90%) lung expansion was observed in 27 patients (45%) and wits more frequent in the VATS group (60% vs 30%, respectively; p = 0.027). During follow-up, 71% of the patients showed unaltered or improved lung expansion and 9 patients (15%) needed new pleural procedures (VATS group, 5 recurrences; TS group, 4 recurrences; p = 0.999). No differences, were found between groups regarding quality of life, complications, drainage time, hospital stay, and survival. Immediate lung expansion (lid not correlate with radiologic recurrence, clinical recurrence, or complications (p = 0.60, 0.15, and 0.20, respectively). Conclusion: Immediate partial lung expansion was a frequent finding and was more frequent after TS. Nonetheless, no correlation between immediate lung expansion and clinical outcome was found in this study. (CHEST 2009; 136:361-368)

Hemangioma of the Rib

An asymptomatic 48-year-old woman presented to our hospital with a tumor of the rib incidentally diagnosed on a chest roentgenogram. The patient was investigated and underwent tumor resection of the chest wall. The pathologic study revealed that it was cavernous hemangioma. This tumor of the bone is a distinctly uncommon benign vascular tumor, generally occurring in the spine or skull. Hemangiomas involving the rib are even more rare, with only 22 cases described in the literature. However, we suggest that this tumor of the rib should be considered in the differential diagnosis, principally in asymptomatic patients. (Ann Thorac Surg 2011;91:595-6) (C) 2011 by The Society of Thoracic Surgeons