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OBJECTIVE: To assess the beneficial effects of ischemic preconditioning (IPC) in liver resection and evaluate its applicability in clinical practice. SUMMARY BACKGROUND DATA: Liver surgeries are usually associated with intentional transient ischemia for hemostatic control. IPC is a surgical step that intends to reduce the effects of ischemia-reperfusion; however, there is no strong evidence about the real impact of the IPC, and it is necessary to effectively clarify what its effects are. METHODS: Randomized clinical trials were selected, comparing IPC with no preconditioning in patients undergoing liver resection. Data were extracted by three independent researchers according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/A79 . Several outcomes were evaluated, including postoperative peaks of transaminases and bilirubin, mortality, length of hospital stay, length of stay in the ICU, bleeding, and transfusion of blood products, among others. Bias risks were assessed using the Cochrane collaboration tool. RESULTS: Seventeen articles were selected, with a total of 1052 patients. IPC did not change the surgical time of the liver resections while these patients bled less (Mean Difference: -49.97 ml; 95% CI: -86.32 to -13.6; I2 : 64%), needed less blood products [relative risk (RR): 0.71; 95% CI: 0.53-0.96; I2 =0%], and had a lower risk of postoperative ascites (RR: 0.40; 95% CI: 0.17-0.93; I2 =0%). The other outcomes had no statistical differences or could not have their meta-analyses conducted due to high heterogeneity. CONCLUSIONS: IPC is applicable in clinical practice, and it has some beneficial effects. However, there is not enough evidence to encourage its routine use.
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Hepatectomia , Precondicionamento Isquêmico , Humanos , Hepatectomia/efeitos adversos , Fígado/cirurgia , Tempo de Internação , HemostasiaRESUMO
Polycystic liver disease (PLD) is a clinical condition characterized by the presence of more than 10 cysts in the liver. It is a rare disease Of genetic etiology that presents as an isolated disease or assoc\iated with polycystic kidney disease. Ductal plate malformation, ciliary dysfunction, and changes in cell signaling are the main factors involved in its pathogenesis. Most patients with PLD are asymptomatic, but in 2-5% of cases the disease has disabling symptoms and a significant reduction in quality of life. The diagnosis is based on family history of hepatic and/or renal polycystic disease, clinical manifestations, patient age, and polycystic liver phenotype shown on imaging examinations. PLD treatment has evolved considerably in the last decades. Somatostatin analogues hold promise in controlling disease progression, but liver transplantation remains a unique curative treatment modality.
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Autosomal dominant polycystic liver disease (ADPLD) is a rare disease with variable clinical presentations, characterized by cystic enlargement of the liver. The diagnosis is made based on family history, patient's age, and liver phenotype and is confirmed by imaging tests. The treatment aims to reduce symptoms caused by the increased liver volume and can be performed by aspiration with sclerotherapy, fenestration, and liver resection. Although ADPLD is a rare disease, it is an important differential diagnosis of cystic diseases such as polycystic kidney disease; therefore, the aim of this article was to present the diagnostic and therapeutic approach of a case of ADPLD and conducting a literature review. This is the case of a 32-year-old male patient, who was hospitalized due to abdominal pain, hepatomegaly, lack of appetite, and weight loss. Imaging propaedeutics showed a significant increase in the liver volume due to hepatic cysts. After a multidisciplinary evaluation, given the clinical changes and the location of the hepatic cysts, fenestration was performed by laparotomy. The postoperative period was uneventful. The treatment was efficient in promoting symptomatic relief and improving the quality of life in this patient. Case reports on this disease are quite limited in the currently available literature, and there are gaps in knowledge with regard to the diagnosis and management of ADPLD. The importance of this article is that it will highlight the limitations in treatment options and allow physicians to make a more informed decision when diagnosing and treating a patient with ADPLD in the future.
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BACKGROUND: Setting up new liver transplant (LT) centers is essential for countries with organ shortages. However, good outcomes require experience, because LT learning depends on a high number of surgeries. This study aims to describe how a new center was set up from a partnership between the new center and an experienced one. The step-by-step preparation process, the time needed and the results of the new center are depicted. MATERIAL AND METHODS: The mentoring process lasted 40 months, in which half of the 52 patients included on the transplant list received LT. After the mentorship, a 22-month period was also analyzed, in which 46 new patients were added to the waiting list and nine were operated on. RESULTS: The 30-day survival rates during (92.3%) and after (66.7%) the partnership were similar to the other LT centers in the same region, as well as the rates of longer periods. The waiting time on the LT list, the characteristics of the donors and the ischemia times did not differ during or after the mentorship. CONCLUSION: The partnership between universities is a suitable way to set up LT centers, achieving good results for the institutions and the patients involved.
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Transplante de Fígado , Obtenção de Tecidos e Órgãos , Humanos , Mentores , Estudos Retrospectivos , Universidades , Listas de EsperaRESUMO
Abstract Systemic amyloidosis secondary to psoriatic arthritis is rare, and published data are based mainly on case reports and are associated with increased mortality. This is the report of a patient with long-term psoriatic arthritis and chronic sialadenitis, who showed an inadequate response to therapy. The diagnosis of secondary amyloidosis was attained through biopsies of genital skin lesions. Although very rare, it is important that dermatologists and general practitioners consider the possibility of amyloidosis in patients with chronic inflammatory diseases, since an early intervention can be implemented, and thus, the prognosis of this condition can be improved.
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Humanos , Psoríase , Artrite Psoriásica/complicações , Amiloidose de Cadeia Leve de Imunoglobulina , Amiloidose/complicações , Amiloidose/diagnóstico , PeleRESUMO
Reactivation of chronic Trypanosoma cruzi infection in solid organ transplant recipients (SOTRs) has been reported. The patient presented with a 2-week history of two painful erythematous, infiltrated plaques with central ulceration and necrotic crust on the left thigh. She had a history of chronic indeterminate Chagas disease (CD) and had received a kidney transplant before 2 months. Skin biopsies revealed lobular panniculitis with intracellular amastigote forms of T. cruzi. The patient was diagnosed with CD reactivation. Treatment with benznidazole significantly improved her condition. CD reactivation should be suspected in SOTRs living in endemic areas with clinical polymorphism of skin lesions.
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Doença de Chagas , Transplante de Rim , Paniculite , Trypanosoma cruzi , Doença de Chagas/diagnóstico , Feminino , Humanos , Transplante de Rim/efeitos adversos , Coxa da PernaRESUMO
Systemic amyloidosis secondary to psoriatic arthritis is rare, and published data are based mainly on case reports and are associated with increased mortality. This is the report of a patient with long-term psoriatic arthritis and chronic sialadenitis, who showed an inadequate response to therapy. The diagnosis of secondary amyloidosis was attained through biopsies of genital skin lesions. Although very rare, it is important that dermatologists and general practitioners consider the possibility of amyloidosis in patients with chronic inflammatory diseases, since an early intervention can be implemented, and thus, the prognosis of this condition can be improved.
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Amiloidose , Artrite Psoriásica , Amiloidose de Cadeia Leve de Imunoglobulina , Psoríase , Amiloidose/complicações , Amiloidose/diagnóstico , Artrite Psoriásica/complicações , Humanos , PeleRESUMO
BACKGROUND: Polyomaviruses (PyVs) were initially described in animals. They have also been detected in humans with some evidence that could play a role in skin carcinogenesis. OBJECTIVES: This study aimed to verify the presence of PyVs in different skin tumour samples and to make clinical correlations with patients' epidemiological data from Clinics Hospital of Medical School of University of São Paulo, Brazil. METHODS: This is a cross-sectional study. A random selection was performed of 120 patients with histopathological exams of different cutaneous neoplasms equally divided into 6 groups and 20 patients with normal skin. The available skin specimens were analysed with 2 different techniques of PCR (conventional and real time) for detection of PyV DNA. Concomitantly, retrospective analysis of the respective medical records for the collection of epidemiological data was done. Analyses suitable for categorical data were used to compare the proportion of patients in each group. RESULTS: PyV DNA was found in 25.69% of the samples: 15% in basal cell carcinoma group, 15% in squamous cell carcinoma, 28.57% in melanoma, 15% in dermatofibrosarcoma protuberans, 13.33% in Kaposi sarcoma, 65% in Merkel cell carcinoma (MCC), and none in normal skin. Merkel cell PyV detection was statistically significant in MCC patients (p value <0.01), but no correlations were found between PyVs and others skin tumours. CONCLUSION: This study demonstrated the presence of PyVs in different skin tumours; however, no association of any PyVs found in any skin tumour with epidemiological data could be shown. Further studies are still needed to elucidate the mechanisms of PyVs in skin carcinogenesis.
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Carcinoma de Célula de Merkel , Poliomavírus das Células de Merkel , Infecções por Polyomavirus , Polyomavirus , Neoplasias Cutâneas , Animais , Estudos Transversais , Humanos , Polyomavirus/genética , Infecções por Polyomavirus/epidemiologia , Estudos Retrospectivos , Neoplasias Cutâneas/epidemiologiaRESUMO
Solid organ transplant recipients (SOTRs) are susceptible to various cutaneous side effects as a consequence of long-term immunosuppressive therapy. Skin cancers and infections are well-studied complications that can cause death and/or allograft rejection. Other cutaneous drug reactions, such as inflammatory manifestations, have a high prevalence but are rarely studied. We analyzed these manifestations' prevalence and their association with immunosuppressants in transplant recipients from a Brazilian tertiary center. Among 532 SOTRs followed at our dermatology clinic, 60 (11.3%) developed some cutaneous adverse reactions to the immunosuppressants, with a median age at transplantation of 50.5 years and a median life span posttransplantation of seven years. Acneiform eruption was the most common drug reaction found (21 patients, 30.4%), followed by diffuse non-scarring alopecia (16 patients, 23.1%), lymphedema (10 patients, 14.5%), gingival hyperplasia (7 patients, 10.1%), hypertrichosis (6 patients, 8.7%) and sebaceous hyperplasia (9 patients, 13.1%). Adequate immunosuppression is an essential prerequisite for successful organ transplantation. In the immediate post-transplant period, significant immunosuppression is needed, but after that, the complications of excessive immunosuppression outweigh the risk of organ rejection. SORTs may present with a broad spectrum of inflammatory and cosmetic findings due to immunosuppressants that can impair life quality.
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Erupções Acneiformes/epidemiologia , Alopecia/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Rejeição de Enxerto/tratamento farmacológico , Imunossupressores/efeitos adversos , Linfedema/epidemiologia , Transplante de Órgãos , Pele/patologia , Erupções Acneiformes/etiologia , Adolescente , Adulto , Idoso , Brasil/epidemiologia , Feminino , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Pele/efeitos dos fármacos , Adulto JovemRESUMO
Abstract Reactivation of chronic Trypanosoma cruzi infection in solid organ transplant recipients (SOTRs) has been reported. The patient presented with a 2-week history of two painful erythematous, infiltrated plaques with central ulceration and necrotic crust on the left thigh. She had a history of chronic indeterminate Chagas disease (CD) and had received a kidney transplant before 2 months. Skin biopsies revealed lobular panniculitis with intracellular amastigote forms of T. cruzi. The patient was diagnosed with CD reactivation. Treatment with benznidazole significantly improved her condition. CD reactivation should be suspected in SOTRs living in endemic areas with clinical polymorphism of skin lesions.
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Humanos , Feminino , Trypanosoma cruzi , Paniculite , Transplante de Rim/efeitos adversos , Doença de Chagas/diagnóstico , Coxa da PernaRESUMO
Epidermodysplasia verruciformis (EV) is a genodermatosis related to human beta-papillomavirus (beta-HPV), with a high risk of cutaneous squamous cell carcinoma (cSCC). Claudins are transmembrane proteins expressed in epithelia and may be altered during carcinogenesis. For a better understanding of the role of beta-HPV in cutaneous carcinogenesis, this claudin expression study was conducted on lesions of patients with and without EV. In this study, claudins-1, -2, -3, -4, -5, -7 and -11 expressions were analyzed by applying the immunohistochemistry technique, in samples of 108 normal skin, 39 flat warts and 174 cSCC. The cSCC samples were organized in tissue microarrays. We found that claudin-1 and claudin-3 focal expressions were associated with cSCC (p < 0.001), and claudin-2 focal or negative expression with flat wart (p < 0.001), in EV and NEV (non-EV) groups. For claudin-5, EV group showed a lower chance of focal and negative expression (p < 0.001), and its negative expression was associated with flat wart (p < 0.001) and lower mean age (p < 0.001). Claudins-4, -7 and -11 showed a diffuse expression in almost all studied samples. Our findings suggest that claudin-5 increased expression observed on normal skin, flat wart and cSCC showed association with EV. Claudin-1 and -3 down expression were also observed, but they could not be related to beta-HPV infection.
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Carcinoma de Células Escamosas/metabolismo , Claudinas/metabolismo , Epidermodisplasia Verruciforme/metabolismo , Neoplasias Cutâneas/metabolismo , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Criança , Pré-Escolar , Epidermodisplasia Verruciforme/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Cutâneas/patologia , Adulto JovemRESUMO
Despite progress in treatment strategies, only ~24% of pancreatic ductal adenocarcinoma (PDAC) patients survive >1 year. Our goal was to elucidate deregulated pathways modulated by microRNAs (miRNAs) in PDAC and Vater ampulla (AMP) cancers. Global miRNA expression was identified in 19 PDAC, 6 AMP and 25 paired, histologically normal pancreatic tissues using the GeneChip 4.0 miRNA arrays. Computational approaches were used for miRNA target prediction/identification of miRNA-regulated pathways. Target gene expression was validated in 178 pancreatic cancer and 4 pancreatic normal tissues from The Cancer Genome Atlas (TCGA). 20 miRNAs were significantly deregulated (FC≥2 and p<0.05) (15 down- and 5 up-regulated) in PDAC. miR-216 family (miR-216a-3p, miR-216a-5p, miR-216b-3p and miR-216b-5p) was consistently down-regulated in PDAC. miRNA-modulated pathways are associated with innate and adaptive immune system responses in PDAC. AMP cancers showed 8 down- and 1 up-regulated miRNAs (FDR p<0.05). Most enriched pathways (p<0.01) were RAS and Nerve Growth Factor signaling. PDAC and AMP display different global miRNA expression profiles and miRNA regulated networks/tumorigenesis pathways. The immune response was enriched in PDAC, suggesting the existence of immune checkpoint pathways more relevant to PDAC than AMP.
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Imunidade Adaptativa/genética , Carcinoma Ductal Pancreático/genética , Imunidade Inata/genética , MicroRNAs/metabolismo , Neoplasias Pancreáticas/genética , Adulto , Idoso , Ampola Hepatopancreática/patologia , Carcinoma Ductal Pancreático/patologia , Biologia Computacional , Regulação para Baixo , Feminino , Perfilação da Expressão Gênica , Regulação Neoplásica da Expressão Gênica/imunologia , Redes Reguladoras de Genes/imunologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Sequência com Séries de Oligonucleotídeos , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Regulação para CimaRESUMO
BACKGROUND: Merkel cell carcinoma (MCC) is a rare but aggressive primary cutaneous carcinoma with high mortality rates. The present study intends to delineate the epidemiological profile of patients with MCC seen at the Clinics Hospital of the Medical School at the University of São Paulo, Brazil, and its association with Merkel cell polyomavirus (MCPyV). METHODS: This is a retrospective study. A search was performed in the hospital's medical index for all cases of MCC from January 1994 to December 2012. Among patients with MCC, the available tumoral skin specimens were analyzed with two different techniques of polymerase chain reaction (PCR) (conventional and real-time) for detection of MCPyV DNA. Additionally, paraffin-embedded samples of patients with non-MCC skin cancers were also analyzed. Analyses suitable for categorical data (i.e., x² of Fisher) were used to compare the proportion of patients in each group. RESULTS: Nineteen patients with MCC and 20 patients with non-MCC skin cancers entered the study. All MCC samples available (13) tested positive for the presence of MCPyV DNA; however, in the non-MCC skin cancer samples, the MCPyV DNA was detected in 4 of 20 samples (20%). MCPyV DNA detection rate was higher in patients with MCC than in the other group, and its analysis was statistically significant (P < 0.01). CONCLUSIONS: This study demonstrates the association of MCPyV in Brazilian patients with MCC. However, further studies are necessary to determine the exact involvement of MCPyV in MCC pathogenesis and to define the significance of viral DNA detection in non-MCC skin cancers.
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Carcinoma de Célula de Merkel/virologia , Poliomavírus das Células de Merkel/isolamento & purificação , Infecções por Polyomavirus/virologia , Neoplasias Cutâneas/virologia , Infecções Tumorais por Vírus/virologia , Idoso , Idoso de 80 Anos ou mais , Brasil/epidemiologia , Carcinoma de Célula de Merkel/epidemiologia , DNA Viral/isolamento & purificação , Feminino , Humanos , Masculino , Poliomavírus das Células de Merkel/genética , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Infecções por Polyomavirus/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores Sexuais , Pele/virologia , Neoplasias Cutâneas/epidemiologia , Infecções Tumorais por Vírus/epidemiologiaRESUMO
BACKGROUND: Skin lesions are very common among organ transplant recipients (OTR), particularly infections and tumors, because of the immunosuppressive state these patients are put in. METHODS: 177 OTR were examined. Skin lesions were categorized into neoplastic, infectious, and inflammatory diseases. RESULTS: The mean age of OTR was 52 years, the mean age at transplantation was 42.7 years, and kidney was the most common organ transplanted (72%). Skin lesions were found in 147 patients (83%). Cutaneous infections were seen in 106 patients (60%). Warts (30%) had the larger incidence and were associated with azathioprine (P = 0.026), cyclosporine (P = 0.006), and tacrolimus (P = 0.009). Superficial mycoses occurred in 16% of OTR, mostly onychomycosis, which was associated with tacrolimus (P = 0.040). Actinic keratosis (AK) occurred in 31% of patients and cutaneous tumors in 56%. Squamous cell carcinoma (SCC) was the most common tumor type affecting 36% of OTR (n = 64), with invasive SCC predominating over in situ SCC, whereas basal cell carcinoma (BCC) accounted for 17%. Both SCC and BCC were more numerous in patients' skin type I (P < 0.05). SCC was more frequent (36%) in combined kidney and liver recipients (P = 0.004), and BCC was associated with cyclosporine (P = 0.047). Inflammatory complications (acne, alopecia, hypertrichosis, and gingival overgrowth) were observed in 17.5% of patients. CONCLUSIONS: Organ transplant recipients must be regularly evaluated by dermatologists, who should be alert to the onset of infections and skin (pre)malignant diseases in these patients.
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Carcinoma Basocelular/epidemiologia , Carcinoma de Células Escamosas/epidemiologia , Ceratose Actínica/epidemiologia , Transplante de Órgãos/estatística & dados numéricos , Dermatopatias Infecciosas/epidemiologia , Neoplasias Cutâneas/epidemiologia , Adolescente , Adulto , Idoso , Azatioprina/uso terapêutico , Brasil/epidemiologia , Carcinoma de Células Escamosas/patologia , Criança , Ciclosporina/uso terapêutico , Dermatomicoses/epidemiologia , Feminino , Humanos , Terapia de Imunossupressão , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Neoplasias Cutâneas/patologia , Tacrolimo/uso terapêutico , Verrugas/epidemiologia , Adulto JovemRESUMO
Abstract: The oncogenic role of high-risk HPV in anogenital, head and neck, and cervical cancer is well recognized, but not in skin cancer in the general population. Some authors have demonstrated their appearance mainly on the hands and feet, particularly in the area of the nail bed, which could be due to contamination with HPV types from anogenital regions. Here, we describe a case of genital HPV associated with SCC on the nose tip in an immunocompetent young man, which was confirmed by histopathological findings and in situ hybridization. The importance of this report is to highlight the potential role of HPV in the etiology of skin cancer in an immunocompetent individual.
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Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Cutâneas/virologia , Carcinoma de Células Escamosas/virologia , Neoplasias Nasais/virologia , Infecções por Papillomavirus/complicações , Imunocompetência , Neoplasias Cutâneas/imunologia , Neoplasias Cutâneas/patologia , Carcinoma de Células Escamosas/imunologia , Carcinoma de Células Escamosas/patologia , Neoplasias Nasais/imunologia , Neoplasias Nasais/patologia , Infecções por Papillomavirus/patologia , Doenças dos Genitais Masculinos/patologia , Doenças dos Genitais Masculinos/virologiaRESUMO
The oncogenic role of high-risk HPV in anogenital, head and neck, and cervical cancer is well recognized, but not in skin cancer in the general population. Some authors have demonstrated their appearance mainly on the hands and feet, particularly in the area of the nail bed, which could be due to contamination with HPV types from anogenital regions. Here, we describe a case of genital HPV associated with SCC on the nose tip in an immunocompetent young man, which was confirmed by histopathological findings and in situ hybridization. The importance of this report is to highlight the potential role of HPV in the etiology of skin cancer in an immunocompetent individual.
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Carcinoma de Células Escamosas/virologia , Imunocompetência , Neoplasias Nasais/virologia , Infecções por Papillomavirus/complicações , Neoplasias Cutâneas/virologia , Carcinoma de Células Escamosas/imunologia , Carcinoma de Células Escamosas/patologia , Doenças dos Genitais Masculinos/patologia , Doenças dos Genitais Masculinos/virologia , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Nasais/imunologia , Neoplasias Nasais/patologia , Infecções por Papillomavirus/patologia , Neoplasias Cutâneas/imunologia , Neoplasias Cutâneas/patologiaRESUMO
Epidermodysplasia verruciformis (EV) is a rare genodermatosis associated with susceptibility to beta-human papilloma virus (HPV) infection. EV patients develop disseminated warts and non-melanoma skin cancer, mainly squamous cell carcinomas (SCC) that are locally aggressive. EV pathogenesis is not yet fully understood, but alterations in the p16 gene play a role in the pathogenesis of neoplasms caused by high-risk genital HPV. To explore its role in EV lesions, we compared p16 expression in SCC from patients with and without EV. Tissue microarray slides composed of 27 SCC from EV patients, and 35 from non-EV patients were stained with an anti-p16 antibody. Twenty (74%) EV tumors exhibited diffuse (nuclear and cytoplasmic) p16 expression, one (4%) displayed focal expression, and six (22%) displayed no p16 staining. Eleven (31%) SCC from non-EV patients presented diffuse p16 staining, 14 (40%) displayed focal expression and 10 (29%) did not express p16. The frequency of diffuse p16 expression was higher in EV tumors than in SCC from patients without EV. The frequency of diffuse p16 expression in moderately and poorly differentiated EV-SCC was similarly higher than non-EV tumors with the same degree of differentiation. The diffuse expression of p16 in EV-SCC suggests that changes in the p16 gene, probably resulting in a functionally defective protein, may be one factor determining the locally aggressive clinical behavior of SCC in young EV patients.