Tumor Fibroso Localizado da Pleura: Análise de 11 Novos Casos

Pretende-se neste trabalho fazer uma revisão retrospectiva duma patologia, rara na sua incidência(5% de todos os tumores pleurais) e singular nas suas características, analisando na nossa casuística as formas de apresentação, terapêutica cirúrgica e resultados obtidos. Os tumores solitários da pleura são formações neoplásicas raras, cujo comportamento biológico não é obrigatoriamente correlacionável com características imuno-histoquímicas, pois os considerados benignos apresentam um sensível índice de recidiva e metastização, independentemente do volume que apresentam. A cirurgia é o único tratamento disponível e a excisão cirúrgica completa é decisiva para a cura. De Agosto de 1995 a Janeiro de 2003, na casuística do Serviço de Cirurgia Cardiotorácica do Hospital de Santa Marta, foram analisados todos os doentes com o diagnóstico de tumor fibroso localizado da pleura (TFLP). Neste contexto, identificaram-se 11 doentes com idade média de 57,54 anos, dos quais 6 do sexo feminino, em que foi colocado o diagnóstico de tumor fibroso localizado da pleura; 6 dos tumores foram classificados como malignos e 5 como benignos. Nesta série, todos os doentes foram submetidos a intervenção cirúrgica, com técnicas variadas, sem mortalidade intra-operatória ou morbilidade intra-hospitalar significativas, apesar da dificuldade da cirurgia nos tumores mais volumosos (um dos tumores pesava 2,5 kg). O follow up decorreu entre os 4 e os 84 meses (média – 39,4 meses). Um doente faleceu 13 meses após a intervenção, por embolia pulmonar maciça, depois de várias crises de tromboembolismo pulmonar (sem relação determinável com a cirurgia ou a patologia base), apesar da anticoagulação iniciada e controlada na Consulta do Hospital.

Tumor de Células da Granulosa. A Propósito de um Caso Clínico

Os tumores de células da granulosa constituem 1 a 2% dos tumores do ovário. Clinicamente caracterizam-se pela sua longa história natural, baixo grau de malignidade e pela capacidade de recorrer muitos anos após uma cura clínica aparente. O diagnóstico é geralmente intra-operatório. A maioria dos tumores encontram-se no estadio I, sendo o prognóstico excelente. O tratamento inicial é geralmente cirúrgico. Descreve-se um caso clínico paradigmático deste tipo de tumor.

Anal squamous carcinoma: a new AIDS-defining cancer? Case report and literature review

Squamous anal cell carcinoma is a rare malignancy that represents the 1.5% to 2% of all the lower digestive tract cancers. However, an increased incidence of invasive anal carcinoma is observed in HIV-seropositive population since the widespread of highly active antiretroviral therapy. Human papillomavirus is strongly associated with the pathogenesis of anal cancer. Anal intercourse and a high number of sexual partners appear to be risk factors to develop anal cancer in both sexes. Anal pain, bleeding and a palpable lesion in the anal canal are the most common clinical features. Endo-anal ultrasound is the best diagnosis method to evaluate the tumor size, the tumor extension and the infiltration of the sphincter muscle complex. Chemoradiotherapy plus antiretroviral therapy are the recommended treatments for all stages of localized squamous cell carcinoma of the anal canal in HIV-seropositive patients because of its high rate of cure. Here we present an HIV patient who developed a carcinoma of the anal canal after a long time of HIV infection under highly active antiretroviral therapy with a good virological and immunological response.

Laparoscopia em Tumor Quístico Gigante do Ovário na Adolescência. A Propósito de um Caso Clínico

A eficácia e segurança da cirurgia laparoscópica na resolução dos tumores quísticos benignos do ovário tem sido demonstrada por inúmeros estudos. As dimensões do tumor quístico do ovário foi, até há algum tempo atrás, factor limitante na opção cirúrgica: se superior a 10 cm a laparotomia era a indicação. Actualmente, a cirurgia laparoscópica está associada a muitas vantagens: redução da hemorragia operatória, menos complicações pós-operatórias, menor tempo de hospitalização, mais rápida recuperação e melhor resultado estético. Os autores descrevem o caso de uma adolescente de 15 anos de idade, com um tumor quístico gigante do ovário (mais de 30 cm), ocupando todos os quadrantes do abdómen, e que foi tratado laparoscopicamente com sucesso após punção/drenagem aspirativa sob controle ecográfico. Conclusão: Com uma criteriosa selecção dos doentes, a laparoscopia cirúrgica é segura em doentes com quistos benignos gigantes do ovário.

Tumor Ovárico de Células de Leydig. Um Caso Raro de Hiperandrogenismo

Os tumores ováricos secretores de androgénios são raros constituindo cerca de 1% de todas as neoplasias do ovário. Descreve-se o caso clínico de uma doente do sexo feminino, 67 anos de idade, que recorre à consulta por queixas de hirsutismo (score 23) e alopécia com padrão androgenético A avaliação laboratorial revelou níveis séricos elevados de testosterona. A ecografia ginecológica por via transvaginal permitiu identificar a presença de um nódulo sólido no ovário esquerdo com características imagiológicas sugestivas de malignidade pelo que, a doente foi submetida a ooforectomia bilateral. O exame histopatológico revelou a presença de células de Leydig. O seguimento clínico posterior da doente permitiu constatar melhoria do quadro clínico e normalização dos níveis séricos de testosterona.

Segmentectomia Pulmonar Anatómica por Videotoracoscopia: Experiência Inicial de um Centro

The use of minimally invasive surgery for the treatment of lung cancer has been growing worldwide. Between May 2008 and November 2012, we performed 24 videothoracoscopic anatomical lung resections in our department. This includes 22 lobectomies and 2 anatomic segmentectomies, which is known to be a more complex surgery, since it demands a finer dissection of sub-lobar structures. We report the clinical cases of two patients who underwent anatomic segmentectomies. The first one was a 63 year old woman, smoker and with a history of breast cancer 20 years earlier. An incidental 9 mm node was found in the lingula. The patient underwent an anatomic lingulectomy and the frozen section was suggestive of a primary lung cancer. Therefore, we proceeded to a full lymphadenectomy. The final pathology evaluation showed a typical carcinoid tumour (pT1aN0). The second patient was a 50 year old woman, a smoker and with a heavy family history of lung cancer. In a screening CT scan a 8 mm ground glass opacity was identified in the left lower lobe (segment VI). After a VATS wedge resection of the node the frozen section evaluation was compatible with adenocarcinoma. We then proceeded to an anatomic segmentectomy with lymphadenectomy. The definitive pathology evaluation confirmed that it was a pT1a N0 bronchioloalveolar adenocarcinoma. The patients now have 5 and 2 months of follow up respectivelly and neither of them has signs of recurrence and the surgical incision showed a good aesthetic result. Anatomic segmentectomy is the indicated surgery especially in patients with low grade tumours, in early stage lung cancers or in patients without pulmonary function for a lobar resection, and it can be done safely using VATS.

Community-Associated Methicillin-Resistant Staphylococcus Aureus Lacking PVL, as a Cause of Severe Invasive Infection Treated with Linezolid

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging public health problem worldwide. Severe invasive infections have been described, mostly associated with the presence of Panton-Valentine leukocidin (PVL). In Portugal limited information exists regarding CA-MRSA infections. In this study we describe the case of a previously healthy 12-year-old female, sport athlete, who presented to the hospital with acetabulofemoral septic arthritis, myositis, fasciitis, acetabulum osteomyelitis, and pneumonia.The MRSA isolated from blood and synovial fluid was PVL negative and staphylococcal enterotoxin type P (SEP) and type L (SEL) positive, with a vancomycin MIC of 1.0mg/L and resistant to clindamycin and ciprofloxacin. The patient was submitted to multiple surgical drainages and started on vancomycin, rifampicin, and gentamycin. Due to persistence of fever and no microbiological clearance, linezolid was started with improvement. This is one of the few reported cases of severe invasive infection caused by CA-MRSA in Portugal,which was successfully treated with linezolid. In spite of the severity of infection, the MRSA isolate did not produce PVL.

Anti-Tumor Necrosis Factor Alpha-Induced Drug Eruptions: One Patient, More Than a Pattern

Background: Tumor necrosis factor alpha (TNFα) antagonists are effective in treating several immune-inflammatory diseases, including psoriasis and inflammatory bowel disease. The paradoxical and unpredictable induction of psoriasis and psoriasiform skin lesions is a recognized adverse event, although of unclear aetiology. However, histological analysis of these eruptions remains insufficient, yet suggesting that some might constitute a new pattern of adverse drug reaction, rather than true psoriasis. Case report: The authors report the case of a 43-year-old woman with severe recalcitrant Crohn disease who started treatment with infliximab. There was also a personal history of mild plaque psoriasis without clinical expression for the past eight years. She developed a heterogeneous cutaneous eruption of psoriasiform morphology with pustules and crusts after the third infliximab infusion. The histopathological diagnosis was of a Sweet-like dermatosis. The patient was successfully treated with cyclosporine in association with both topical corticosteroid and vitamin D3 analogue. Three weeks after switching to adalimumab a new psoriasiform eruption was observed, histologically compatible with a psoriasiform drug eruption. Despite this, and considering the beneficial effect on the inflammatory bowel disease, it was decided to maintain treatment with adalimumab and to treat through with topicals, with progressive control of skin disease. Discussion: Not much is known about the pathogenesis of psoriasiform eruptions induced by biological therapies, but genetic predisposition and Koebner phenomenon may contribute to it. Histopathology can add new facets to the comprehension of psoriasiform reactions. In fact, histopathologic patterns of such skin lesions appear to be varied, in a clear asymmetry with clinical findings. Conclusion: The sequential identification in the same patient of two clinical and histopathologic patterns of drug reaction to TNFα antagonists is rare. Additionally, to the authors’ knowledge, there is only one other description in literature of a TNFα antagonist-induced Sweet-like dermatosis, emphasizing the singularity of this case report.

TUBERCULOSIS INFECTION MIGHT INCREASE THE RISK OF INVASIVE CANDIDIASIS IN AN IMMUNOCOMPETENT PATIENT

Deep Candida infections commonly occur in immunosuppressed patients. A rare case of a multiple deep organ infection with Candida albicansand spinal tuberculosis was reported in a healthy young man. The 19-year-old man complained of month-long fever and lower back pain. He also had a history of scalded mouth syndrome. Coinfection with Mycobacterium tuberculosis and Candida albicans was diagnosed using the culture of aspirates from different regions. Symptoms improved considerably after antifungal and antituberculous therapy. This case illustrates that infection with tuberculosis might impair the host's immune system and increase the risk of invasive candidiasis in an immunocompetent patient.

Tumor de Buschke-Löwenstein: um Caso em Doente com Coinfeção Vírus da Imunodeficiência Humana e Vírus Papiloma Humano

O tumor de Buschke-Löwenstein (TBL) é uma variante rara de condiloma acuminatum que possui comportamento maligno pelo crescimento local, mas não apresenta potencial metastático. Afeta primariamente a área genital e, menos frequentemente a região perianal. Os fatores de risco para o seu desenvolvimento incluem a terapêutica imunossupressora e a infeção VIH. Possui elevada taxa de recorrência e de transformação maligna, sendo a cirurgia o tratamento inicial recomendado. Apresenta-se um caso de TBL perianal e anal num doente com infeção VIH cuja histologia não revelou transformação maligna e para o qual a terapêutica cirúrgica isolada foi eficaz. Revê-se o conhecimento atual sobre esta entidade tendo em atenção a história natural nos indivíduos infetados pelo VIH.

Ovarian Borderline Tumor and Fertility-Sparing Surgery

Ovarian borderline tumors (OBTs) are frequently diagnosed in women of reproductive age. There is no consensus about their management, and it sometimes represents a dilemma aboutwhat should be done: fertility sparing surgery or a hysterectomy with salpingo-oophorectomy? Case: A 32-year-old nulligravida, diagnosed with a right ovarian borderline tumor is presented. She underwent pelvic washings, right salpingo-oophorectomy, appendectomy, and omental and peritoneal biopsies (laparotomic approach). Macroscopically, the left ovary was normal and subsequent exploration for staging was also normal, including the lymph nodes. Intraoperatively, frozen section examination was unclear, suggesting an OBT. Results: The final histopathologic diagnosis was ovarian borderline tumor, stage IIC (International Federation of Gynecology and Obstetrics [FIGO] staging). The patient expressed a desire to preserve her fertility. Thirty-six months postsurgery, she became pregnant spontaneously and delivered a healthy newborn at term. Conclusions: Conservative surgery can be performed in young patients treated for an OBT, provided they are closely followed up and that this surgery is performed after careful consideration and informed consent. It is, however, controversial with respect to performing hysterectomy and salpingo-oopherectomy upon the patient’s completion of childbearing.

Invasive Assessment of the Coronary Microcirculation Using the Index of Microcirculatory Resistance: Description and Validation of an Animal Model

INTRODUCTION: The index of microcirculatory resistance (IMR) enables/provides quantitative, invasive, and real-time assessment of coronary microcirculation status. AIMS: The primary aim of this study was to validate the assessment of IMR in a large animal model, and the secondary aim was to compare two doses of intracoronary papaverine, 5 and 10 mg, for induction of maximal hyperemia and its evolution over time. METHODS: Measurements of IMR were performed in eight pigs. Mean distal pressure (Pd) and mean transit time (Tmn) were measured at rest and at maximal hyperemia induced with intracoronary papaverine, 5 and 10 mg, and after 2, 5, 8 and 10 minutes. Disruption of the microcirculation was achieved by selective injection of 40-μm microspheres via a microcatheter in the left anterior descending artery. RESULTS: In each animal 14 IMR measurements were made. There were no differences between the two doses of papaverine regarding Pd response and IMR values - 11 ± 4.5 U with 5 mg and 10.6 ± 3 U with 10 mg (p=0.612). The evolution of IMR over time was also similar with the two doses, with significant differences from resting values disappearing after five minutes of intracoronary papaverine administration. IMR increased with disrupted microcirculation in all animals (41 ± 16 U, p=0.001). CONCLUSIONS: IMR provides invasive and real-time assessment of coronary microcirculation. Disruption of the microvascular bed is associated with a significant increase in IMR. A 5-mg dose of intracoronary papaverine is as effective as a 10-mg dose in inducing maximal hyperemia. After five minutes of papaverine administration there is no significant difference from resting hemodynamic status.

A Rare Abdomino-Pelvic Tumor: Paraganglioma

Paragangliomas are rare tumors, with a reported incidence of 2–8 per million. They are chromaffin cell tumors that develop from the neural crest cells and may be divided in tumors derived from the parasympathetic or sympathetic ganglia. We report a case a of a 32-year-old nulliparous woman, referred to our Infertility Clinic. Abdomino-pelvic ultrasound identified a large abdominopelvic tumor, without ovarian origin (both ovaries were identified and had normal morphology). Magnetic Resonance Imaging suggested a right adnexal multicystic, vascularized mass close to iliac vessels and questioning an ovarian origin. At exploratory laparotomy, a 10 cm encapsulated and vascularized mass was found beginning just below right renal artery and extending to the level of the broad ligament. This mass was totally excised and histopathology was consistent with Paraganglioma.