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Hibernoma is a rare benign tumor that becomes from the vestiges of fetal brown adipose tissue. It can be located on different regions of the body, being tight the most frequent. Retroperitoneal region is approximately of 9.4%. The first person to describe this histological type was Merkel. To the present, there are only described 25 cases on this location. It has a slowly growth, so it is normally asymptomatic, and it usually presents doing compression of different structures. To diagnose the MRI is the best prove, although biopsy will provide definite diagnosis describing four possible variants. Immunochemistry of MDM2, CDK4 and p16 genes is really important to do the differential diagnosis with well-differentiated liposarcoma (WDLS). Only one extensive review of hibernoma with 170 cases on different regions is published. But there is no review on literature specifically of retroperitoneal region, so this is the purpose of the current study. Following we present three more cases of retroperitoneal hibernoma that we have treat on our Mesenchymal Tumours Unit and a revision of the previously published.

Resumen Introduccion La principal causa de hiperparatiroidismo primario en nuestro medio es el adenoma paratiroideo unico. La paratiroidectomia se considera el unico tratamiento potencialmente curativo y requiere de estudios de imagen de localizacion preoperatorios para un abordaje quirurgico dirigido. En pacientes con negatividad en pruebas convencionales, la PET-TC colina ha demostrado tasas de sensibilidad superiores respecto al gold-standard. Metodos Se diseno un estudio de cohortes prospectivo que incluyo a 34 pacientes con diagnostico de hiperparatiroidismo primario entre 2017 y 2019, candidatos a cirugia con pruebas de imagen con gammagrafia y SPECT-TC MIBI negativas. A todos se les realizo una PET-TC con 18F-fluorocolina. Los resultados se compararon con un grupo control de 30 pacientes con pruebas convencionales positivas intervenidos en el mismo periodo. Resultados La PET-TC colina detecto tejido paratiroideo hiperfuncionante en el 85% de los pacientes con gammagrafia previa negativa. Se realizo reseccion selectiva del adenoma identificado en estos pacientes, con criterio de curacion en el 87% de los casos, sin precisar de exploracion cervical bilateral. Los niveles de PTH, calcemia y el peso glandular fueron significativamente menores en este grupo con respecto al control. No se identificaron diferencias respecto al criterio de curacion ni a la via de abordaje en ambos grupos. Conclusion En nuestro estudio, la PET-TC colina demostro tasas superiores de deteccion que permitieron aumentar el numero de pacientes candidatos a cirugia dirigida con disminucion de la morbilidad quirurgica, especialmente en grupos con adenomas de menor tamano asociados a niveles mas bajos de calcemia y PTH preoperatorias y en pacientes con cirugias cervicales previas.

Background: In recent years, miRNAs have emerged as important regulators of many cellular processes, including the various steps of the metastatic process. In addition, circulating miRNAs appear to be surprisingly stable in peripheral blood making them ideal noninvasive biomarkers for disease diagnosis. Here, we investigated the expression profile of circulating miRNAs and their association with the metastatic lymph node status in early breast cancer patients. Methods: We designed a proof-of-principle study using 16 plasma samples from patients with known sentinel lymph node status (n=12 positive and n=4 negative). We performed RNA-sequencing and validated the results by qPCR. Gene Ontology term enrichment and KEGG pathway analyses were carried out using DAVID tools.Results: We found16 differentially expressed miRNAs after adjusting for false discovery correction (q < 0.01) in patients with positive samples. Thirteen miRNAs were down-regulated (miR-339-5p, miR-133a-3p, miR-326, miR-331-3p, miR-369-3p, miR-328-3p, miR-26a-3p, miR-139-3p, miR-493-3p, miR-664a-5p, miR-323b-3pmiR-1307-3p and miR-423-3p) and 3 were up-regulated (miR-101-3p, miR-146a-5p and miR-144-3p). Hierarchical clustering using differentially expressed miRNAs clearly distinguished patients according to their lymph node status. We did not find any difference in the miRNA expression profile between plasma samples associated with macrometastasis or micrometastasis. The expression of 9 miRNAs was validated by qPCR. Moreover, gene ontology analysis showed a significant enrichment of biological processes associated with the regulation of the epithelial mesenchymal transition, cell proliferation and transcriptional regulation. Conclusions: Our results indicated the potential role of several circulating miRNAs as surrogate markers of lymph node metastases in early breast cancer patients. Further validation in a larger cohort of patients will be necessary to confirm our results.

Groove pancreatitis is a very uncommon type of chronic pancreatitis of uncertain etiology that occurs in the pancreatoduodenal groove. Despite the great advances in imaging techniques, making a definitive diagnosis is difficult because of the complex anatomy of this area. Therefore, surgical treatment is often required due to the impossibility of excluding malignancy. We present the case of a patient with a history of chronic pancreatitis admitted due to duodenal obstruction. The diagnosis was difficult, especially for the need to exclude the neoplasms of the duodenal-pancreatic area. Endoscopic ultrasound was essential to establish a definitive diagnosis, allowing FNAP and correct assessment of the duodenal wall.

Chronic expansive retroperitoneal hematoma is a hematoma that grows progressively sometime after the original trauma. It can appear in different locations. The mechanism of onset is unclear, but experimental evidence favours an inflammatory cause. For diagnostic imaging, magnetic resonance imaging is more useful than computed tomography (CT). However, it is difficult to differentiate it from other soft tissue tumors, sarcomas, actinomycosis or inflammatory pseudotumors, due to the uneven central uptake. Histopathological analysis of the lesion usually shows a dense fibrous tissue capsule containing numerous old clots without finding clear atypia or signs suggestive of malignancy. The treatment of choice is complete resection of the lesion (including the capsule), as incomplete treatments (such as drainage or curettage of the hematoma contents) may cause recurrence.

Introduction Single parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. Methods A prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical, and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. Results Hyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia, and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2 groups. Conclusion In our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery.

Objective To compare detectability of hyperfunctioning parathyroid tissue (HPT) by digital and analog 18F-fluorocholine PET/CT in patients with primary hyperparathyroidism and negative/inconclusive 99mTc-MIBI scintigraphy-SPECT/CT. Materials and methods Thirty-three patients with primary hyperparathyroidism and negative/inconclusive 99mTc-MIBI scintigraphy-SPECT/CT were prospectively included. All patients accepted to be scanned by digital and analog PET/CT in the same imaging session after a single injection of 18F-fluorocholine. Three nuclear medicine physicians evaluated the digital and analog PET/CT datasets to assess the detection rate of HPT. Maximum standard uptake values (SUVmax) of HPT and locoregional lymph nodes were measured in both systems. Results HPT was detected in 30/33 patients by the digital system, whereas it was detected in 22/33 patients by the analog system (p < 0.01). Moreover, in 21 of these 33 patients, both systems detected one focal 18F-fluorocholine uptake, and in one patient the digital system detected two foci. Histopathology demonstrated HPT in 32 patients and it was inconclusive in one patient. The digital PET/CT detected HPT in 29 of the 32 patients, and the analog system in 22 of the 32 (p < 0.01). All HPT suspected lesions resected and detected only by the digital system (n = 8) were < 10 mm (7.5 +/- 1.3 mm), while those detected by both systems (n = 22) were > 10 mm (13 +/- 3.8 mm). SUVmax of HPT lesions was significantly higher than SUVmax of locoregional lymph node independently of the PET/CT system used (4.5 +/- 1.9 vs. 2.9 +/- 1.3, p < 0.0001). Conclusions Digital PET/CT offers superior performance over analog system in patients with suspected HPT and previous negative/inconclusive imaging examinations, particularly in sub-centimeter lesions. SUVmax can help in the differentiation between HTP and locoregional lymph nodes.

The correct administered activity of 18F-FCH is 0.1-0.14 mCi/Kg, which is equivalent to 3.7-5.2 MBq/kg.

Background and objectives: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. Patients and methods: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. Results: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. Conclusions: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized.Introducción y objetivos: las prótesis biliares plásticas suelen emplearse tras una sesión de CPRE sin extracción completa de coledocolitiasis. En ocasiones, el calibre de drenaje con estas prótesis puede ser insuficiente. Presentamos nuestra experiencia en la utilización de prótesis metálicas autoexpandibles totalmente recubiertas (PMATR) en coledocolitiasis no extraídas. Pacientes y métodos: se insertó una PMATR (Wallflex biliar) en algunos pacientes con coledocolitiasis difíciles no extraídas tras una sesión de CPRE cuando se consideró que la esfinterotomía biliar y una prótesis plástica no aportaban un calibre de drenaje adecuado. Resultados: estudio retrospectivo en el que se utilizó una PMATR en 29 pacientes, edad media 81 años. Las coledocolitiasis no pudieron extraerse por la esfinterotomía biliar debido a su gran tamaño (n = 18) o por la presencia de estenosis distal inflamatoria (n = 11). Se consideró que era preciso el mayor drenaje biliar con el menor tiempo posible de CPRE debido a la situación de inestabilidad clínica de los pacientes y/o a la mala tolerancia a la sedación consciente administrada por el endoscopista. Se obtuvo un drenaje biliar adecuado en todos los casos. Las PMATR se retiraron tras una mediana de 199,5 días en 16 pacientes, obteniéndose una extracción completa de las coledocolitiasis en 15 (93,7%). No se extrajeron las PMATR en los 13 restantes debido a su situación clínica, manteniéndose una conducta expectante. Conclusiones: en casos seleccionados, la utilización de PMATR extraíbles es una buena opción para obtener un drenaje biliar adecuado y rápido en coledocolitiasis difíciles. El mayor coste de estas prótesis precisa que se individualice su utilización.

Summary Objective Ultrasonography and cytology obtained by fine‐needle aspiration are part of the basic study of the thyroid nodule. Although they are not diagnostic in every case, they are cost‐effective methods that inform surgical treatment and its extent. The purpose of this study was to evaluate the accuracy of ultrasonography associated with fine‐needle aspiration to predict malignancy in nodular thyroid pathology. Design and patients We collected prospective data from patients undergoing thyroidectomy by single nodule or multinodular goitre between 2006 and 2016. A total of 417 patients were included. Ultrasounds were classified as suspected of malignancy if they had 2 or more of the following characteristics: hypoechogenicity, microcalcifications, intranodular central hypervascularization, irregular margins and poorly defined edges. Measurements Ultrasound and fine‐needle aspiration accuracy. Results In the postoperative study, 40% presented malignant pathology. 33% of patients with nonsuspicious ultrasound and 73% of those with suspicious ultrasound had malignant disease. Among patients with single nodule and suspicious ultrasound, the malignancy rate reached 80%. As for cytology, 100% of Bethesda VI patients, 88% of V, 63% of IV, 31% of III and 12% of II were found to have carcinoma. The combination of the 2 tests showed a high predictive value, particularly in cases of Bethesda IV cytology. Conclusions Thyroid cytology provides high predictive value of the presence of carcinoma. The predictive value of ultrasound is also high, mainly in the study of isolated nodules. The combination of the 2 tests results in increased diagnostic accuracy.

Resumen Antecedentes y objetivo Las protesis metalicas autoexpandibles se estan utilizando, cada vez con mas frecuencia, para resolver la obstruccion colonica tumoral. Despues, los pacientes pueden intervenirse de forma electiva o bien, en casos no aptos para la cirugia, la protesis sirve como tratamiento paliativo definitivo. Presentamos la experiencia de esta tecnica en un hospital de nivel II del Sistema Nacional de Salud. Pacientes y metodos Estudio retrospectivo de un periodo de 42 meses (desde mayo de 2002 hasta octubre de 2005), durante el cual se trato de resolver la obstruccion colonica en 43 ocasiones a 40 pacientes, mediante la insercion endoscopica de protesis. Resultados La insercion fue tecnicamente posible en 41 intentos (95%) y se obtuvo un buen resultado clinico en 37 ocasiones (86%). Se utilizo solo endoscopia 23 veces (53,5%), y en las otras 20 (46,5%) tambien fluoroscopia. De los 38 pacientes en que se obtuvo un buen resultado con la insercion, 34 lograron un exito clinico total. Se intervino de forma electiva a 24 (63%) pacientes y la protesis se considero un tratamiento paliativo definitivo en 14 (37%). Hubo que intervenir finalmente a uno de estos pacientes por una fistula colovesical. Ademas de esta complicacion, hubo otras 8: 3 protesis migraron, una se obstruyo, 2 pacientes tuvieron tenesmo, otro presento una bacteriemia tras la insercion, y se descubrio una perforacion silente por la protesis en una cirugia electiva. No hubo mortalidad derivada de las complicaciones. Conclusiones En nuestra experiencia, la insercion endoscopica de protesis parece un metodo seguro y eficaz en el tratamiento inicial de la obstruccion colonica tumoral.

Background and objectives: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. Patients and methods: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. Results: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. Conclusions: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized.

Aim: to study the possible differences in the final diagnosis of chronic pancreatitis by using standard classification described by Wiersema et al. and the new classification proposed recently by Rosemont. Material and methods: forty-seven patients with the diagnosis of chronic pancreatitis were included in this study. The parenchymal and ductal criteria were studied, the patients were divided in two groups for Wiersema criteria: < 4 criteria, non-diagnostic for chronic pancreatitis and ≥ 4 criteria, diagnosis of chronic pancreatitis. The same patients were divided in four groups according to Rosemont classification: normal pancreas, indeterminate, suggestive and consistent with chronic pancreatitis. We analyzed these data with Chi-square test reported with 95% confidence intervals (CI). Results: in patients with chronic pancreatitis the most frequent criteria observed were lobularity in 66% of cases and pancreatic duct dilatation and calcifications in 57.4% of cases each. We found a significant statistical association between the results of both classifications (p < 0.05). The highest association is found in patients with more than 4 standard criteria and definitive diagnostic of chronic pancreatitis according to Rosemont classification. In patients who have less than 4 standard criteria the diagnosis is suggestive of chronic pancreatitis by using the Rosemont classification in 27.66% (p < 0.05). Conclusion: these results show that no significant statistical differences are found for patients with > 4 criteria diagnosis by standard criteria. But 27.66% patients with less than 4 standard criteria would be suggestive according to Rosemont classification (p < 0.05). Hence, the new classification would be useful in patients with high suspicion of chronic pancreatitis with < 4 standard criteria but with more significance such as parenchymal lithiasis, lobularity or ductal calcifications.

Background: the clinical impact of small-bowel angiodysplasia has not been defined. We present a prospective study to determine the features of individuals with a higher risk of rebleeding or a worse clinical outcome. Patients and methods: thirty patients with angiodysplasia found on CE were included and followed for 12 months. Angiodysplasia were classified by their size as small (≤ 10 mm) or large (> 10 mm). We also studied angiodysplasia lesion numbers in each patient. Rebleeding was defined as a hemoglobin drop of more than 2 g/dl in the absence of melena or hematochezia in the case of occult GI bleeding, or with any or both manifestations. Results: a therapeutic procedure was carried out in 13 patients (43.4%). Individuals with large angiodysplasia had higher transfusion requirements, a higher proportion of therapeutic procedure performed after CE, lower hemoglobin concentration, and a lower rebleeding rate. Patients with ten or more angiodysplasia lesions had also higher transfusion requirements and lower hemoglobin levels, but we found no differences in the number of therapeutic procedures or rebleeding rate between both groups. On follow up rebleeding was detected in 5 patients (16.7%), all of them with small angiodysplasias. Rebleeding was more frequent in patients who did not receive further interventions (23.53 vs. 7.69%; p = 0.037). Conclusions: angiodysplasia size ≥ 10 mm determines a worse clinical impact and more possibilities of receiving a therapeutic procedure. Our findings support that patients with large lesions would benefit from therapeutic interventions with a reduction in rebleeding rate.

Self-expanding metal stents are being increasingly used to resolve malignant colonic obstruction. Subsequently, patients can either undergo elective surgery, or the stent can serve as a definitive palliative treatment in patients unfit for surgery. We present our experience with this technique in our hospital, a level II center within the Spanish National Health Service, which can be considered a community hospital.A retrospective study was performed of a 42-month period (May 2002 to October 2005), during which malignant colonic obstruction was treated by means of endoscopically inserted stents on 43 occasions in 40 patients.Stent insertion was successfully performed in 41 attempts (95%) and good clinical results were obtained on 37 occasions (86%). Endoscopic means alone were used on 23 occasions (53.5%) and in the remaining 20 (46.5%), both endoscopy and fluoroscopy were employed. Of 38 patients with successfully inserted stents, clinical success was achieved, as a whole, in 34. Twenty-four of these patients (63%) subsequently underwent elective surgery while the stent served as a definitive palliative treatment in the remaining 14 (37%). One of these patients had to undergo further surgery due to a fistula between the colon and the bladder. There were eight other complications: three stent migrations and one stent obstruction occurred, two patients had tenesmus, one patient developed bacteremia after stent insertion, and a silent bowel perforation by the stent was found in an elective surgical procedure. There was no mortality.In our experience, endoscopically inserted stents seem to be a safe and effective method for the initial treatment of malignant colonic obstruction.

This study assessed diagnostic yield and impact of capsule endoscopy on patient management. Seventy-five patients with obscure gastrointestinal bleeding were included. Clinical and followup information was collected by review of patient records and with personal contact with the referring physicians. All previous clinical information and interventions after capsule endoscopy and clinical outcome were noted. The indication was obscure-overt gastrointestinal bleeding in 36 patients (48%) and obscure-occult gastrointestinal bleeding in 39 patients (52%). Overall diagnostic yield was 66.7% considering relevant lesions. Followup was available in 31 patients. Capsule endoscopy changed clinical management in 61.4%. Multivariate analysis showed that patients with another potential source of bleeding and patients whose onset was hematochezia were not good candidates for capsule endoscopy. Capsule endoscopy has a high diagnostic yield and a positive influence on clinical management in a high proportion of patients with obscure gastrointestinal bleeding.