Análise quantitativa da saturação de gordura em ressonância magnética mamária: comparação das técnicas SPAIR e DIXON

Mestrado em Radiações Aplicadas às Tecnologias da Saúde - Ramo de especialização: Ressonância Magnética

Efeitos auditivos em doentes com tumores de cabeça e pescoço e tumores cerebrais sujeitos a Radioterapia e terapia combinada

Introdução: A capacidade auditiva dos doentes com neoplasias de cabeça e pescoço e tumores cerebrais pode ser comprometida com os tratamentos antineoplásicos realizados. A Quimioterapia com cisplatina pode provocar perda auditiva de condução ou neurossensorial, podendo agravar-se quando combinada com Radioterapia (RT). O objectivo deste trabalho foi a análise da relação entre a Terapia Combinada (Cisplatina+RT) e a Radioterapia isolada, e os seus efeitos adversos sobre a audição tendo em consideração a inclusão das estruturas do ouvido no campo de tratamento de RT. Métodos: Foram seguidos 10 doentes submetidos a Terapia Combinada (grupo TC) e 11 a Radioterapia isolada (grupo RT). A avaliação audiológica realizou-se antes do inicio (M1), no fim (M2) e um mês após (M3) o termo dos tratamentos e incluiu anamnese audiológica, otoscopia e audiometria tonal. Resultados: No grupo TC, 94,4% dos doentes apresentaram uma relação directamente proporcional entre a dose de radiação na cóclea e a perda auditiva. Esta relação só se verificou em 31% dos doentes do grupo RT, tendo-se verificado diferenças significativas entre grupos (p <0,001). Conclusões: Verificou-se maior incidência da perda auditiva no grupo TC relativamente ao grupo RT. Sugere-se um melhor planeamento do tratamento de RT, reduz - indo a dose à cóclea com o objectivo de minimizar a perda auditiva neurossensorial irreversível, sobretudo quando são utilizadas as duas modalidades de tratamento.

Histopathological patterns of the liver involvement in visceral leishmaniasis

The hepatic changes observed in liver specimen from either biopsy or necropsy of 47 patients with visceral leishmaniasis permited us to define three different histopathological patterns of involvement: typical, nodular, and fibrogenic. These patterns seem to be representative of different evolutive stages of the hepatic involvement in the disease either towards a more benign evolution or to more chronic stage with fibrosis and "cirrhosis". These histopathological evolutive stages are related to the prognosis of the disease.

Tuberculosis in renal transplant patients

Tuberculosis (TB) was diagnosed in 25 of 466 patients who underwent renal transplant over a period of 15 years. TB developed from 1 month to 9 years post-transplant. In 56% of the cases the onset was within the first post-transplant year. TB affected several isolated or combined organs. Pulmonary involvement was present in 76% of cases, either as isolated pleuro-pulmonary (56%) or associated with other sites (20%). The non-pulmonary sites were: skin, joints, tests, urinary tract, central nervous system and lymphonodules. The diagnosis was confirmed by biopsy in 64% of the cases, by identification of tubercle bacilli in 24% and only at necropsy in 12% Biopsy specimens could be classified in three histological forms: exudative, that occurred in early onset and more severe cases granulomatous in late onset and benign cases; and mixed in intermediate cases. Azathioprine dosages were similar along post-transplant time periods in TB patients and in the control groups; and in TB patients who were cured and who died. The number of steroid treated rejection crises was greater in TB than in the control group. Prednisone doses were higher and the number of rejection crises was greater in TB patients who died than in those who were cured. Fifteen patients were cured and ten died, two of them of causes unrelated to TB. Six of the eight TB-related deaths occurred in the first 6 post-transplant months. The outcome was poor in patients in whom TB arose early in post-transplant period and where the exudative or mixed forms were present; whereas the prognosis was good in patients with late onset and granulomatous form of TB. In one patient TB was transmitted by the allograft.

Clinical and epidemiological aspects of abdominal angiostrongyliasis in Southern Brazil

Most of the cases of abdominal angiostrongyliasis in Brazil were reported from the southern States of São Paulo, Paraná, Santa Catarina and Rio Grande do Sul (RS). A study in 27 cases from RS revealed a distinct local epidemiology. Peasants were usually affected, either adults or children, from the mountainous areas in the north of the Suite. There was a seasonal increase in the number of cases, from late spring to autumn, that does not coincide with the rainy season. Besides the most common clinical features of abdominal pain, fever and cosinophilia in the leucogram, painful relapsing episodes were detected in some patients. The abdominal pain could be either localized or diffuse during the rapid evolution to a surgical abdominal condition, with a letality of 7.4%. The use of a serological test and the greater awareness of physicians working in endemic areas is expected to improve the recognition of uncomplicated and benign courses of the disease. This study confirms the known clinical manifestations of abdominal angiostrongyliasis and demonstrates the diversity of its epidemiology.

P53 and Cancer-Associated Sialylated Glycans Are Surrogate Markers of Cancerization of the Bladder Associated with Schistosoma haematobium Infection

BACKGROUND: Bladder cancer is a significant health problem in rural areas of Africa and the Middle East where Schistosoma haematobium is prevalent, supporting an association between malignant transformation and infection by this blood fluke. Nevertheless, the molecular mechanisms linking these events are poorly understood. Bladder cancers in infected populations are generally diagnosed at a late stage since there is a lack of non-invasive diagnostic tools, hence enforcing the need for early carcinogenesis markers. METHODOLOGY/PRINCIPAL FINDINGS: Forty-three formalin-fixed paraffin-embedded bladder biopsies of S. haematobium-infected patients, consisting of bladder tumours, tumour adjacent mucosa and pre-malignant/malignant urothelial lesions, were screened for bladder cancer biomarkers. These included the oncoprotein p53, the tumour proliferation rate (Ki-67>17%), cell-surface cancer-associated glycan sialyl-Tn (sTn) and sialyl-Lewisa/x (sLea/sLex), involved in immune escape and metastasis. Bladder tumours of non-S. haematobium etiology and normal urothelium were used as controls. S. haematobium-associated benign/pre-malignant lesions present alterations in p53 and sLex that were also found in bladder tumors. Similar results were observed in non-S. haematobium associated tumours, irrespectively of their histological nature, denoting some common molecular pathways. In addition, most benign/pre-malignant lesions also expressed sLea. However, proliferative phenotypes were more prevalent in lesions adjacent to bladder tumors while sLea was characteristic of sole benign/pre-malignant lesions, suggesting it may be a biomarker of early carcionogenesis associated with the parasite. A correlation was observed between the frequency of the biomarkers in the tumor and adjacent mucosa, with the exception of Ki-67. Most S. haematobium eggs embedded in the urothelium were also positive for sLea and sLex. Reinforcing the pathologic nature of the studied biomarkers, none was observed in the healthy urothelium. CONCLUSION/SIGNIFICANCE: This preliminary study suggests that p53 and sialylated glycans are surrogate biomarkers of bladder cancerization associated with S. haematobium, highlighting a missing link between infection and cancer development. Eggs of S. haematobium express sLea and sLex antigens in mimicry of human leukocytes glycosylation, which may play a role in the colonization and disease dissemination. These observations may help the early identification of infected patients at a higher risk of developing bladder cancer and guide the future development of non-invasive diagnostic tests.

Estrogen receptor dependent genetic and epigenetic factors of tamoxifen resistance

Resumo: A decisão da terapêutica hormonal no tratamento do cancro da mama baseiase na determinação do receptor de estrogénio alfa por imunohistoquímica (IHC). Contudo, a presença deste receptor não prediz a resposta em todas as situações, em parte devido a limitações do método IHC. Investigámos se a expressão dos genes ESR1 e ESR2, bem como a metilação dos respectivos promotores, pode estar relacionada com a evolução desfavorável de uma proporção de doentes tratados com tamoxifeno assim como com a perda dos receptores de estrogénio alfa (ERα) e beta (ERß). Amostras de 211 doentes com cancro da mama diagnosticado entre 1988 e 2004, fixadas em formalina e preservadas em parafina, foram utilizadas para a determinação por IHC da presença dos receptores ERα e ERß. O mRNA total do gene ESR1 e os níveis específicos do transcrito derivado do promotor C (ESR1_C), bem como dos transcritos ESR2_ß1, ESR2_ß2/cx, and ESR2_ß5 foram avaliados por Real-time PCR. Os promotores A e C do gene ESR1 e os promotores 0K e 0N do gene ESR2 foram investigados por análise de metilação dos dinucleotidos CpG usando bisulfite-PCR para análise com enzimas de restrição, ou para methylation specific PCR. Atendendo aos resultados promissores relacionados com a metilação do promotor do gene ESR1, complementamos o estudo com um método quantitativo por matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) suportado pelo software Epityper para a medição da metilação nos promotores A e C. Fez-se a avaliação da estabilidade do mRNA nas linhas celulares de cancro da mama MCF-7 e MDA-MB-231 tratadas com actinomicina D. Baixos níveis do transcrito ESR1_C associaram-se a uma melhor sobrevivência global (p = 0.017). Níveis elevados do transcrito ESR1_C associaram-se a uma resposta inferior ao tamoxifeno (HR = 2.48; CI 95% 1.24-4.99), um efeito mais pronunciado em doentes com tumores de fenótipo ERα/PgR duplamente positivo (HR = 3.41; CI 95% 1.45-8.04). A isoforma ESR1_C mostrou ter uma semi-vida prolongada, bem como uma estrutura secundária da região 5’UTR muito mais relaxada em comparação com a isoforma ESR1_A. A análise por Western-blot mostrou que ao nível da 21 proteína, a selectividade de promotores é indistinguivel. Não se detectou qualquer correlação entre os níveis das isoformas do gene ESR2 ou entre a metilação dos promotores do gene ESR2, e a detecção da proteína ERß. A metilação do promotor C do gene ESR1, e não do promotor A, foi responsável pela perda do receptor ERα. Estes resultados sugerem que os níveis do transcrito ESR1_C sejam usados como um novo potencial marcador para o prognóstico e predição de resposta ao tratamento com tamoxifeno em doentes com cancro da mama. Abstract: The decision of endocrine breast cancer treatment relies on ERα IHC-based assessment. However, ER positivity does not predict response in all cases in part due to IHC methodological limitations. We investigated whether ESR1 and ESR2 gene expression and respective promoter methylation may be related to non-favorable outcome of a proportion of tamoxifen treated patients as well as to ERα and ERß loss. Formalin-fixed paraffin-embedded breast cancer samples from 211 patients diagnosed between 1988 and 2004 were submitted to IHC-based ERα and ERß protein determination. ESR1 whole mRNA and promoter C specific transcript levels, as well as ESR2_ß1, ESR2_ß2/cx, and ESR2_ß5 transcripts were assessed by real-time PCR. ESR1 promoters A and C, and ESR2 promoters 0N and 0K were investigated by CpG methylation analysis using bisulfite-PCR for restriction analysis, or methylation specific PCR. Due to the promising results related to ESR1 promoter methylation, we have used a quantification method by matrixassisted laser desorption/ionization time-of-flight mass spectrometry (MALDITOF MS) together with Epityper software to measure methylation at promoters A and C. mRNA stability was assessed in actinomycin D treated MCF-7 and MDA-MB-231 cells. ERα protein was quantified using transiently transfected breast cancer cells. Low ESR1_C transcript levels were associated with better overall survival (p = 0.017). High levels of ESR1_C transcript were associated with non-favorable response in tamoxifen treated patients (HR = 2.48; CI 95% 1.24-4.99), an effect that was more pronounced in patients with ERα/PgR double-positive tumors (HR = 3.41; CI 95% 1.45-8.04). The ESR1_C isoform had a prolonged mRNA half-life and a more relaxed 5’UTR structure compared to ESR1_A isoform. Western-blot analysis showed that at protein level, the promoter selectivity is undistinguishable. There was no correlation between levels of ESR2 isoforms or ESR2 promoter methylation and ERß protein staining. ESR1 promoter C CpG methylation and not promoter A was responsible for ERα loss. We propose ESR1_C levels as a putative novel marker for breast cancer prognosis and prediction of tamoxifen response.

Human pulmonary dirofilariasis: a review

The authors presented a detailed summary of the geographical distribution, clinical and pathological aspects of human pulmonary dirofilariasis. Although benign, this zoonosis, of which Dirofilaria immitis is the major etiological agent, represents a medical problem since it produces symptoms which may be confused with neoplasia and thus may subject patients to unnecessary thoracic surgery. Of 229 cases cited in the literature, only 17 were reported in Brazil, despite the existence of highly favorable conditions for the transmission of this infection in man. Thus it may well be that this parasitic infection remains underdiagnosed. Finally, the importance of a differential diagnosis between dirofilariasis and pulmonary neoplasia is emphasized in cases where there is a solitary subpleural nodule ("coin lesion") present. In addition, the development and improvement of modern immunological diagnostic techniques are essential to distinguish this benign disease from other pathological conditions and thus avoid unneccessary surgery. These techniques may reveal the true prevalence of this parasitic infection in our environment.

Tumor-like lesion due to Chagas' disease in a patient with lymphocytic leukemia

A 73 year-old white male, living in the interior of the state of Mato Grosso do Sul, in central Bra­zil, after an initial diagnosis of sinusitis was transferred to the neurology service with a 3-day evolution of intracranial hypertension. Exams showed lymphocytic leukemia and a tumor-like lesion, either an expanding inflammatory process such as an abscess or a neoplasm. Treatment with Ceftriaxone and Decadron was started and intracranial hypertension was controlled. Methotrexate was injected on the occasion of the next puncture considering a possible leukemia infiltration. Flagellate forms of T. cruzi were observed in the CSF and treatment with Benznidazole was started. After 4 days the CSF presented fractionated forms of trypomastigotes. The protein level was 27%. Signs of intracranial hypertension ceased. Tomography and magnetic resonance images showed an important reduction of the tumor-like lesion. The clinical condition of the patient improved.

Jejunal perforation caused by abdominal angiostrongyliasis

The authors describe a case of abdominal angiostrongyliasis in an adult patient presenting acute abdominal pain caused by jejunal perforation. The case was unusual, as this affliction habitually involves the terminal ileum, appendix, cecum or ascending colon. The disease is caused by the nematode Angiostrongylus costaricensis, whose definitive hosts are forest rodents while snails and slugs are its intermediate hosts. Infection in humans is accidental and occurs via the ingestion of snail or slug mucoid secretions found on vegetables, or by direct contact with the mucus. Abdominal angiostrongyliasis is clinically characterized by prolonged fever, anorexia, abdominal pain in the right-lower quadrant, and peripheral blood eosinophilia. Although usually of a benign nature, its course may evolve to more complicated forms such as intestinal obstruction or perforation likely to require a surgical approach. Currently, no efficient medication for the treatment of abdominal angiostrongyliasis is known to be available. In this study, the authors provide a review on the subject, considering its etiopathogeny, clinical picture, diagnosis and treatment.

Embolização das artérias prostáticas no tratamento da hiperplasia benigna da próstata : estudo anátomo-clínico

Resumo: A hiperplasia benigna da próstata (HBP) tem elevada prevalência nos homens entre os 50 e 79 anos de idade, sendo ubiquitária com o envelhecimento. Devido à significativa morbi-mortalidade associada aos tratamentos médicos e cirúrgicos currentemente disponíveis, são necessárias novas tecnologias para melhorar os resultados e minimizar o desconforto dos doentes. Recentemente, estudos preliminares de experimentação animal e em 3 doentes tratados, sugeriram a embolização arterial prostática selectiva (EAPS) como hipótese terapêutica para a HBP. Decidimos investigar se a EAPS poderia ser um procedimento bem sucedido no tratamento da HBP gravemente sintomática. Para tal realizámos um estudo anátomo-radiológico e clínico em 63 doentes com recurso a uma terapêutica inovadora minimamente invasiva guiada pela imagem. Avaliámos 126 hemipélvis com recurso a Angio-RM, Angio-TC e Angiografia Digital de Subtracção, com o intuito de definir os padrões básicos de bifurcação das artérias ilíacas internas até agora apenas descritos em estudos cadavéricos. Estudámos ainda o suprimento vascular arterial prostático, identificando: 1 as artérias prostáticas; 2 origem e direcção; 3 os ramos intra-prostáticos; 4 anastomoses com outras artérias. Em relação aos resultados anatómicos, identificámos 181 artérias prostáticas, já que em 43.7% das hemipélvis existiam dois pedículos arteriais prostáticos com origens independentes. A origem mais frequente foi a artéria pudenda interna (39.7%), seguida do tronco comum glúteo-pudendo (21%) e da artéria vesical superior (18.2%). Origens menos frequentes foram a artéria obturadora (12.1%), as artérias glúteas inferior (3.9%)ou superior (1.7%), ramos rectais provenientes da artéria mesentérica inferior (1.7%) e a artéria pudenda acessória (1.7%). Identificaram-se anastomoses com as artérias adjacentes em 57.9% dos casos: com a terminação da artéria pudenda interna (41.6%),artérias prostáticas contra-laterais (18.2%) e homo-laterais (11.7%), com ramos rectais (15.6%) e com artérias vesicais (12.9%). Em relação ao estudo clínico tratámos 63 doentes (idades compreendidas entre 52 - 82 anos, média 69.5 anos) com HBP gravemente sintomática refractária à terapêutica médica há mais de 6 meses. Foi possível avaliação após o tratamento em 37 doentes: média de seguimento de 4.7 meses (variando entre 1 e 12 meses). A EAPS unilateral foi possível em todos os doentes, com embolização bilateral em 73% dos casos. A embolização bilateral não foi possível em 27% dos casos devido a tortuosidade, alterações ateroescleróticas e pequeno calibre das artérias ilíacas e/ou prostáticas. Em média houve uma melhoria do International Prostate Symptom Score (IPSS) de 10.8 pontos, da QoL de 1.5 pontos e do Internationl Index of Erectile Function (IIEF) de 2.1 pontos. Houve uma redução média do PSA de 30% (2.4 ng/mL), um aumento do pico de fluxo urinário (Qmax) de 3.1 - 3.85 mL/s e uma redução média do volume prostático de 21% (18.5 mL). Registou-se uma complicação major: pequena área de isquémia da parede vesical tratada cirurgicamente. Em 75% dos doentes tratados obteve-se sucesso clínico com franca melhoria dos sintomas, enquanto 25% dos doentes foram considerados insucesso clínico por se ter registado uma fraca ou ausente melhoria sintomática após a embolização. Os restantes doentes tratados estão sob controlo evolutivo, pararam toda a medicação prostática, sem qualquer caso de disfunção sexual associada com o tratamento. Este trabalho constitui o primeiro estudo anatómico descritivo in vivo das artérias prostáticas, conseguido devido à utilização de técnicas de imagem nunca usadas para este fim. O uso clínico dos dados anatómicos acima referidos permitiu a implementação de técnicas de Radiologia de Intervenção no tratatamento de uma doença de elevada prevalência. ------------------------------- ABSTRACT: Benign prostatic hyperplasia (BPH) has high prevalence in men aged 50–79 years being ubiquitous with aging. Due to significant morbi-mortality associated with currently available medical and surgical treatments, there is the need for innovative technologies to continue to improve outcomes and minimize patient discomfort and morbidity. Recently, prostatic arterial embolization (PAE) was suggested as a treatmentoption for BPH based on preliminary results from animal studies and 3 treated patients. We decided to investigate if PAE might be a successful treatment option for severely symptomatic BPH patients. We performed a clinical and anatomical-radiological study in 63 patients with the use of an inovative image-guided minimally invasive technique. We evaluated 126 pelvic sides using Angio-MR or Angio-CT and Catheter Angiography before embolisation to treat symptomatic BPH. We aimed to define the main branching patterns of the male internal iliac arteries, so far only studied in the cadaver. We also evaluated the prostatic arterial supply, identifying: 1 the prostatic arteries; 2 origin and direction; 3 intra-prostatic branches; 4 anastomoses with surrounding arteries. Regarding the anatomical study we identified 181 prostatic arteries, because in 43.7% of pelvic sides 2 separate prostatic vascular pedicles were found. The most frequent origin was the internal pudendal artery (39.7%) with the common glutealpudendal trunk (21%) and superior vesical arteries (18.2%) the next commonest. Less frequent origins were the obturator artery (12.1%), the inferior (3.9%) or superior (1.7%) gluteal arteries, rectal branches from the inferior mesenteric artery (1.7%) and the accessory pudendal artery (1.7%). There were anastomoses with the surrounding arteries in 57.9% of cases: termination of the internal pudendal artery (41.6%), contralateral prostatic arteries (18.2%), same-side prostatic arteries (11.7%), rectal branches (15.6%), and vesical arteries (12.9%).Regarding the clinical study, we treated 63 patients aged 52–82 years (mean 69.5 years) who presented with symptomatic BPH refractory to medical treatment for at least 6 months. Follow-up evaluation (mean 4.7 months, range 1-12 months) was possible in 37 patients. PAE was achieved in all patients with bilateral embolization in 73%. In 27% PAE was performed unilaterally due to tortuosity, atherosclerotic changes and small size of iliac and prostatic arteries. There was a mean decrease in the IPSS of 10.8 points, a mean improvement in QoL of 1.5 points, and a mean increase in the sexual function score of 2.1 points. There was a mean PSA reduction of 30% (2.4 ng/mL), a Qmax increase of 3.1 to 3.85 mL/sec, and a mean prostate volume decrease of 21% (18.5 mL). There was one major complication: a small area of bladder wall ischemia treated by surgery. Overall, 75% of patients were considered clinical success with major improvement after PAE, while 25% of patients were considered clinical failure with little or no improvement after PAE. All remaining patients are under follow-up, stopped all prostatic medication, and reported no sexual dysfunction. This study is the first one to describe the radiological anatomy of the prostatic arteries, with the use of imaging techniques never used for this purpose before. The clinical use of the anatomical findings allowed the implementation of Interventional Radiology tehniques in the treatment of a disease with a high prevalence.

Aseptic meningitis in a large MMR vaccine campaign (590,609 people) in Curitiba, Paraná, Brazil, 1998

The aseptic meningitis after Measles-Mumps-Rubella vaccine (MMR) is a well recognized complication, and different incidences have been observed in several studies. We retrospectively analyzed forty cases of aseptic meningitis, during a large public immunization campaign (1998) in Curitiba, Southern Brazil (590,609 people), admitted in our Service. The vaccine utilized was Leningrad-3-Zagreb mumps strain, Edmonston-Zagreb measles strain, and RA 27#3 rubella strain. In all county, a total number of 87 cases were reported, resulting in a incidence of 1.7 cases per 10,000 given doses . The mean age was 23.7 ± 12.8 years. The female:male ratio was 1.35:1. Severe headache with meningismus (92.5%), fever (87.5%), nausea/vomiting (82.5%) were the most common clinical findings. Three cases (7.5%) developed mild mumps. All patients underwent cerebrospinal fluid (CSF) tap with the following findings: mononuclear pleocytosis from 100 to 500 cells/mm³ in 17 cases (42.5%; 257.5 ± 260.6 cells/mm³); increased protein 28 cases (67.5%; 92.1 ± 76.9 mg/dL); glucose was normal in all cases (56.8 ± 11.2 mg/dL) except in 4 (10%) cases, which presented less than 44 mg/dL. All serological tests (latex to bacterial meningitis, Cryptococcus, cysticercosis, VDRL) and bacteriological cultures were negative. Virus identification were also negative in 8 samples. None of the patients had neurological deficits or related symptoms after one year of onset. We believe the benefit of vaccination clearly outweights the incidence of benign vaccine-associated meningitis.

A prospective study of cat-scratch disease in Lima-Peru

Cat-Scratch Disease (CSD) is a benign lymphadenitis that may progress to severe or recurrent forms, and it is occasionally associated with morbidity. Between January of 1998 and March of 1999, forty-three suspected CSD patients were assessed in the Hospital Cayetano Heredia and the Instituto de Salud del Niño, in Lima, Peru. Twelve patients had a confirmed diagnosis, 8 of whom were women, and the mean age was 10 years old. The majority (53%) of the cases were encountered in the summer. All patients reported having had contact with cats. Fever, malaise, lymphadenopathy and skin lesions were the most frequent clinical features. Twelve patients had indirect immunofluorescence antibody test titers of between 1/50 and 1/800 for Bartonella henselae and Bartonella clarridgeiae. Two lymph node biopsies were histologically compatible with CSD. No positive blood cultures could be obtained. This is the first Peruvian prospective study able to identify B. henselae and B. clarridgeiae in pediatric patients.

A retrospective study of histopathological findings in 894 cases of megacolon: what is the relationship between megacolon and colonic cancer?

Patients with megaesophagus (ME) have increased prevalence of cancer of the esophagus. In contrast, a higher incidence of colorectal cancer is not observed in patients with megacolon (MC). MC is very common in some regions of Brazil, where it is mainly associated with Chagas disease. We reviewed the pathology records of surgical specimens of all patients submitted for surgical resection of MC in the Hospital das Clínicas of the Faculty of Medicine of Ribeirão Preto (HC-FMRP), from the University of São Paulo. We found that 894 patients were operated from 1952 until 2001 for MC resection. Mucosal ulcers, hyperplasia and chronic inflammation were frequently found, while polyps were uncommon. No patients with MC presented any type of colonic neoplasm. This observation reinforces the hypothesis that MC has a negative association with cancer of the colon. This seems to contradict the traditional concept of carcinogenesis in the colon, since patients with MC presents important chronic constipation that is thought to cause an increase in risk for colon cancer. MC is also associated with other risk factors for cancer of colon, such as hyperplasia, mucosal ulcers and chronic inflammation. In ME these factors lead to a remarkable increase in cancer risk. The study of mucosal cell proliferation in MC may provide new insights and useful information about the role of constipation in colonic carcinogenesis.

Traumatic Clivus Epidural Hematoma: Case Report and Review of the Literature

BACKGROUND: Traumatic clival epidural hematoma is an extremely rare reported entity. CASE DESCRIPTION: We describe the case of a 26-year-old woman involved in a car accident who presented with a Glasgow Coma Scale score of 13, bilateral abducens palsy, bilateral numbness on the mandibular territory of the trigeminal nerve, and left hypoglossal palsy. Radiological examinations revealed a clival epidural hematoma. The patient was managed conservatively, with clinical improvement of her neurological condition. This is the first traumatic clival epidural hematoma reported in an adult. From a review of the literature, we found only 8 cases. CONCLUSION: The pathophysiology of these hematomas is still a subject of debate; occipitoatlantoaxial ligamentous instability may play a role in it. In one third of the cases, bilateral cranial nerve palsies were associated. Apparently, they have a benign outcome.