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OBJECTIVE: The objective of this study was to establish the suitability of the apparent diffusion coefficient (ADC) as a parameter for evaluating early treatment response after percutaneous ablation of functional adrenal adenomas. SUBJECTS AND METHODS: Seventeen adult patients with functioning adrenal adenomas underwent radiofrequency ablation. Serum hormone levels were analyzed before and up to 6 months after ablation. MRI findings (nodule size in cm, signal intensity index, ADC maps, and nodule-to-muscle ADC ratio) were analyzed before and up to 30 days after ablation. A consensus review of all scans was performed by two attending abdominal imaging radiologists. The procedure was considered successful if serum hormone levels normalized and no contrast enhancement of the adrenal lesion was seen on follow-up MRI. RESULTS: Of 17 patients who underwent radiofrequency ablation, complete response was achieved in 16 patients with partial response in one patient. Of the four parameters of interest, only ADC maps and nodule-to-muscle ADC ratio showed statistically significant differences (p < 0.05). CONCLUSION: This prospective study suggests that apparent diffusion coefficient values may help radiologists monitor early treatment response after CT-guided radiofrequency ablation of functioning adrenal adenomas.

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Objetivo: Avaliar um protocolo de espectroscopia por ressonância magnética (ERM) do próton de hidrogênio (1H) bidimensional (2D) disponível comercialmente (Siemens Medical Systems; Erlangen, Alemanha), aplicado para nódulos adrenais e diferenciação das massas (adenomas, feocromocitomas, carcinomas e metástases). Materiais e Métodos: Um total de 118 pacientes (36 homens e 82 mulheres), apresentando-se com 138 nódulos/massas adrenais, foi avaliado prospectivamente (média de idade: 57,3 ± 13,3 anos). Uma sequência de ERM-1H-PRESS-CSI (espectroscopia por resolução de ponto-imagem por desvio químico) multivoxel foi utilizada. Análise espectroscópica foi realizada da esquerda-direita, sentido crânio-caudal, usando três sequências sagitais, além de sequências axiais e coronais T2-HASTE. Os seguintes índices foram calculados: colina (Cho)/creatina (Cr), 4,0–4,3 ppm/Cr, lipídio (Lip)/Cr, Cho/Lip e lactato (Lac)/Cr. Resultados: ERM-1H-2D foi bem sucedida em 123 (89,13%) lesões. Os valores de sensibilidade e especificidade encontrados para as proporções e pontos de corte avaliados foram: Cho/Cr ≥ 1,2, sensibilidade de 100% e especificidade de 98,2% (diferenciação de adenomas e carcinomas de feocromocitomas e metástases); 4,0–4,3 ppm/Cr ≥ 1,5, 92,3% de sensibilidade, especificidade de 96,9% (diferenciação de carcinomas e feocromocitomas de adenomas e metástases); Lac/Cr ≤ –7,449, sensibilidade de 90,9% e especificidade de 77,8% (diferenciação de feocromocitomas contra carcinomas e adenomas). Conclusão: Os dados da ERM-1H-2D foram eficazes e permitiram a diferenciação entre massas adrenais e nódulos na maioria das lesões com diâmetro > 1,0 cm. .

Objective: To evaluate a protocol for two-dimensional (2D) hydrogen proton (1H) magnetic resonance spectroscopy (MRS) (Siemens Medical Systems; Erlangen, Germany) in the detection of adrenal nodules and differentiation between benign and malignant masses (adenomas, pheochromocytomas, carcinomas and metastases). Materials and Methods: A total of 118 patients (36 men; 82 women) (mean age: 57.3 ± 13.3 years) presenting with 138 adrenal nodules/masses were prospectively assessed. A multivoxel system was utilized with a 2D point-resolved spectroscopy/chemical shift imaging sequence. The following ratios were calculated: choline (Cho)/creatine (Cr), 4.0–4.3/Cr, lipid (Lip)/Cr, Cho/Lip and lactate (Lac)/Cr. Results: 2D-1H-MRS was successful in 123 (89.13%) lesions. Sensitivity and specificity values observed for the ratios and cutoff points were the following: Cho/Cr ≥ 1.2, 100% sensitivity, 98.2% specificity (differences between adenomas/pheochromocytomas and carcinomas/ metastases); 4.0–4.3 ppm/Cr ≥ 1.5, 92.3% sensitivity, 96.9% specificity (differences between carcinomas/pheochromocytomas and adenomas/metastases); Lac/Cr ≤ –7.449, 90.9% sensitivity and 77.8% specificity (differences between pheochromocytomas and carcinomas/adenomas). Conclusion: Information provided by 2D-1H-MRS were effective and allowed for the differentiation between adrenal masses and nodules in most cases of lesions with > 1.0 cm in diameter. .

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BACKGROUND: In recent years, there has been renewed interest in using robotics in bariatric surgery for the treatment of morbid obesity. However, the high cost of a robotic surgical system has hindered its widespread use in developing countries. This study aims to compare the rate of morbidity, weight loss, and relative costs between laparoscopic (LSG) and robotic-assisted sleeve gastrectomy (RSG) performed for the treatment of obesity in a single center in Brazil. METHODS: From January 2011 to March 2013, 48 severely obese patients underwent either LSG or RSG at our institution and were prospectively followed up for 12 months. Patients were free to choose either approach and were informed of any extra costs that may be incurred. RESULTS: Thirty-two patients underwent LSG and 16 patients, RSG. No significant differences were observed between LSG and RSG groups regarding age, sex, BMI, incidence of comorbidities, duration of surgery, and length of hospital stay. Also, there were no significant between-group differences in BMI values evaluated at 6 and 12 months after surgery. Surgical costs were almost twice as high and total hospital costs were approximately 50 % higher in the robotic approach compared to the laparoscopic approach. CONCLUSION: Both RSG and LSG had excellent and similar post-operative clinical outcomes. However, the much higher costs of purchasing and maintaining the robotic system are still precluding the use of RSG as a routine approach in the treatment of morbid obesity in Brazil.

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BACKGROUND AND PURPOSE: Surgery continues to be the main form of treatment for patients with renal tumors. We create a more practical and intuitive score for renal tumor classification. PATIENTS AND METHODS: Eighty patients underwent surgery for renal tumors and were prospectively enrolled. The tumors were classified using the following variables: (1) tumor size, (2) endophytic or exophytic tumor, (3) longitudinal location of the tumor, (4) the extent of the impairment of the renal parenchyma, (5) relationship with the renal sinus, and (6) anterior or posterior. RESULTS: The mean operative time, tumor size,and bleeding increased proportionally to the increased complexity of the tumor measured by scores (P<0.0001, P<0.0001, and P=0.036, respectively). The mean total score was 8.7 points for patients undergoing partial nephrectomy (PN) and 14.4 points for those undergoing radical nephrectomy (RN) (P<0.0001). Patients with larger tumors, completely endophytic, which exceeded the renal medulla, and were centrally located, underwent RN more often (86.7% - P<0.0001, 64% - P=0.01, 77% - P<0.0001, and 78.9% - P<0.0001, respectively). In univariate analysis, RN was associated with tumors larger than 7 cm (P=0.001), tumors that exceeded the renal medullary (<0.001), centrally located tumors (odds ration [OR]=150, P<0.001), and tumors of high complexity (P<0.001). Analysis showed no association between complications and variables in the score. The findings were similar when the tumors were evaluated with the R.E.N.A.L. score system. CONCLUSION: Surgical Approach Renal Ranking is a simple, practical and intuitive classification for renal tumors that can be used in the decision-making process and to predict outcomes in the surgical treatment of patients with renal tumors.

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OBJECTIVE: To evaluate a protocol for two-dimensional (2D) hydrogen proton (1H) magnetic resonance spectroscopy (MRS) (Siemens Medical Systems; Erlangen, Germany) in the detection of adrenal nodules and differentiation between benign and malignant masses (adenomas, pheochromocytomas, carcinomas and metastases). MATERIALS AND METHODS: A total of 118 patients (36 men; 82 women) (mean age: 57.3 ± 13.3 years) presenting with 138 adrenal nodules/masses were prospectively assessed. A multivoxel system was utilized with a 2D point-resolved spectroscopy/chemical shift imaging sequence. The following ratios were calculated: choline (Cho)/creatine (Cr), 4.0-4.3/Cr, lipid (Lip)/Cr, Cho/Lip and lactate (Lac)/Cr. RESULTS: 2D-1H-MRS was successful in 123 (89.13%) lesions. Sensitivity and specificity values observed for the ratios and cutoff points were the following: Cho/Cr ≥ 1.2, 100% sensitivity, 98.2% specificity (differences between adenomas/pheochromocytomas and carcinomas/ metastases); 4.0-4.3 ppm/Cr ≥ 1.5, 92.3% sensitivity, 96.9% specificity (differences between carcinomas/pheochromocytomas and adenomas/metastases); Lac/Cr ≤ -7.449, 90.9% sensitivity and 77.8% specificity (differences between pheochromocytomas and carcinomas/adenomas). CONCLUSION: Information provided by 2D-1H-MRS were effective and allowed for the differentiation between adrenal masses and nodules in most cases of lesions with > 1.0 cm in diameter.

OBJETIVO: Avaliar um protocolo de espectroscopia por ressonância magnética (ERM) do próton de hidrogênio (1H) bidimensional (2D) disponível comercialmente (Siemens Medical Systems; Erlangen, Alemanha), aplicado para nódulos adrenais e diferenciação das massas (adenomas, feocromocitomas, carcinomas e metástases). MATERIAIS E MÉTODOS: Um total de 118 pacientes (36 homens e 82 mulheres), apresentando-se com 138 nódulos/massas adrenais, foi avaliado prospectivamente (média de idade: 57,3 ± 13,3 anos). Uma sequência de ERM-1H-PRESS-CSI (espectroscopia por resolução de ponto-imagem por desvio químico) multivoxel foi utilizada. Análise espectroscópica foi realizada da esquerda-direita, sentido crânio-caudal, usando três sequências sagitais, além de sequências axiais e coronais T2-HASTE. Os seguintes índices foram calculados: colina (Cho)/creatina (Cr), 4,0­4,3 ppm/Cr, lipídio (Lip)/Cr, Cho/Lip e lactato (Lac)/Cr. RESULTADOS: ERM-1H-2D foi bem sucedida em 123 (89,13%) lesões. Os valores de sensibilidade e especificidade encontrados para as proporções e pontos de corte avaliados foram: Cho/Cr ≥ 1,2, sensibilidade de 100% e especificidade de 98,2% (diferenciação de adenomas e carcinomas de feocromocitomas e metástases); 4,0­4,3 ppm/Cr ≥ 1,5, 92,3% de sensibilidade, especificidade de 96,9% (diferenciação de carcinomas e feocromocitomas de adenomas e metástases); Lac/Cr ≤ ­7,449, sensibilidade de 90,9% e especificidade de 77,8% (diferenciação de feocromocitomas contra carcinomas e adenomas). CONCLUSÃO: Os dados da ERM-1H-2D foram eficazes e permitiram a diferenciação entre massas adrenais e nódulos na maioria das lesões com diâmetro > 1,0 cm.

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PURPOSE: To assess glutamine/glutamate (Glx) and lactate (Lac) metabolism using proton magnetic resonance spectroscopic imaging (1H-MRS) in order to differentiate between adrenal gland nodules and masses (adenomas, pheochromocytomas, carcinomas, and metastases). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. A total of 130 patients (47 men) with 132 adrenal nodules/masses were prospectively assessed (54 ± 14.8 years). A multivoxel system was used with a two-dimensional point-resolved spectroscopy/chemical-shift imaging sequence. Spectroscopic data were interpreted by visual inspection and peak amplitudes of lipids (Lip), choline (Cho), creatine (Cr), Lac, and Glx. Lac/Cr and Glx/Cr were calculated. Glx/Cr was assessed in relation to lesion size. RESULTS: Statistically significant differences were observed in Glx/Cr results between adenomas and pheochromocytomas (P < 0.05), however, with a low positive predictive value (PPV). Glx levels were directly proportional to lesion size in carcinomas. A cutoff point of 1.44 was established for the differentiation between carcinomas larger versus smaller than 4 cm, with 75% sensitivity, 100% specificity, 100% PPV, and 80% accuracy. Lac/Cr results showed no differences across lesions. A cutoff point of -6.5 for Lac/Cr was established for carcinoma diagnosis. CONCLUSION: Glx levels are directly proportional to lesion size in carcinomas. A cutoff point of -6.5 Lac/Cr differentiates carcinomas from noncarcinomas.

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OBJECTIVE: To evaluate the results of screening and diagnostic mammography in a geographically defined population attending a regional mastology referral hospital of the State Public Service of São Paulo. METHODS: A total of 7508 women, who received screening or diagnostic mammography examinations from 06/2004 to 06/2005, with follow-up until 06/2006, were included in this study. Data corresponding to age, the Breast Imaging-Reporting and Data System (BI-RADS), biopsy, surgery and the stage of breast cancer were collected. Five-year survival of patients with breast cancer was posteriorly calculated during this period. RESULTS: This study included a total of 713 diagnostic and 6795 screening mammograms. The average age of the population was 51.2 years, with a BI-RADS end result of 4 and 5 (abnormal) in 1.9% of the screening and 11.4% of the diagnostic mammograms, respectively. All BI-RADS category zero was complemented. Of the 228 nonsurgical biopsies performed (71 CNB, 94 mammotomy and 63 FNAB), 63 (27.6%) biopsies were malignant findings. Among the 33 surgical biopsies, 10 (30.3%) biopsies were malignant findings, and of the 82 surgeries, 55 (67, 1%) procedures showed malignant findings. Seventy-one (0.9%) breast cancers (25/6795 on screening exams and 46/713 on diagnostics) were diagnosed. A total of 28.6% small cancers (≤ 10 mm) were observed, with 27% of the cancers in stages zero and I. Approximately 47.6% of the cases showed nodal invasion, and 4.5% of cases were not staged. Overall detection rate of breast cancer was 8.8/1000 (3.2/1000 screening and 61.7/1000 diagnostic). The overall 5-year survival rate of patients with breast cancer in this population was 79.1%. CONCLUSION: Survival is a key index of the overall effectiveness of health services in the management of patients with cancer. Our results suggest that this approach is feasible and can potentially improve breast cancer outcomes for many women in São Paulo.

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BACKGROUND AND PURPOSE: Bosniak III and IV renal cysts have low mortality potential, and little is reported regarding the feasibility and safety of managing such tumors by laparoscopy and its comparison with open surgery. We report on the experience with 37 complex renal cysts managed in the era of laparoscopy. PATIENTS AND METHODS: A retrospective analysis of a prospective database from all patients with renal tumors who were operated on at our institution was evaluated after Institutional Review Board approval. The database comprises information for demographic, clinical, imaging, preoperative, intraoperative, histologic, and follow-up data. A comparison among all performed approaches was done for demographic, American Society of Anesthesiologists classification, operative time, estimated blood loss, ischemia time, hospital stay, oncologic and survival rate. The cysts removed by laparoscopic partial nephrectomy were compared with the solid tumors removed by the same approach at the same period. RESULTS: The database included 407 patients with renal tumors who were operated on from 2000 to 2009 at our institution. In 36 patients of the total cohort, there were 37 complex renal cysts. No patients with preoperative Bosniak type I or II underwent surgery. Of the cysts, 60% were Bosniak IV, and 86% were confirmed as malignant; 40% were Bosniak III, and 44% were confirmed as malignant. Laparoscopic partial nephrectomy was performed in 67.5%. The tumor size and hospital stay were significantly different in the laparoscopic group. No cyst spillage occurred either by laparoscopy or by the open approach, and no tumor recurrence was found in a mean follow-up of 43.7 months with overall survival of 100%. CONCLUSION: Laparoscopic surgery for complex cysts is safe, feasible, and effective. Nevertheless, regardless of surgical approach, patients with complex renal cysts have excellent overall survival with short-term follow-up.

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Primary Pigmented Nodular Adrenocortical Disease (PPNAD) is a rare form of bilateral adrenocortical hyperplasia that is inherited in an autosomal dominant manner and leads to ACTH-independent Cushing's syndrome (CS). PPNAD may be isolated or associated with Carney Complex (CNC). For the diagnosis of PPNAD and CNC, in addition to the hormonal and imaging tests, searching for PRKAR1A mutations may be recommended. The aims of the present study are to discuss the clinical and molecular findings of two Brazilian patients with ACTH-independent CS due to PPNAD and to show the diagnostic challenge CS represents in childhood. Description of two patients with CS and the many sequential steps for the diagnosis of PPNAD is provided. Sequencing analysis of all coding exons of PRKAR1A in the blood, frozen adrenal nodules (patients 1 and 2) and testicular tumor (patient 1) is performed. After several clinical and laboratory drawbacks that misled the diagnostic investigation in both patients, the diagnosis of PPNAD was finally established and confirmed through pathology and molecular studies. In patient 1, sequencing of PRKAR1A gene revealed a novel heterozygous 10-bp deletion in exon 3, present in his blood, adrenal gland and testicular tumor. The etiologic diagnosis of endogenous CS in children is a challenge that requires expertise and a multidisciplinary collaboration for its prompt and correct management. Although rare, PPNAD should always be considered among the possible etiologies of CS, due to the high prevalence of this disease in this age group.

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The purpose of this study is to determine how often breast magnetic resonance imaging (MRI) brings additional information that influences management of patients with breast cancer concerning surgical treatment, axillary lymph node approach, and systemic therapy. From July 2004 to July 2005, 99 patients recently diagnosed with breast cancer in clinical stages 0, I, and II were prospectively evaluated about their therapeutic plans, at first based on usual protocol (physical examination, mammography and ultrasound) and next going through bilateral breast MR. Examinations were carried out at 1.5 T on five sequences of FSPGR 3D for 90 seconds (four post-gadolinium diethylenetriaminepenta acetic acid 0.16 mM/Kg). Parameters analyzed on MRI were extension of primary lesion; detection of multifocality, multicentricity, or contra lateral lesion; muscular or skin involvement; and presence of lymph node involvement. Pathologic confirmation of additional lesions was achieved by core or excisional biopsy. MRI made 69 additional findings in 53 patients. Fifty-one findings were true-positives (51/69 = 73.9%) including 16 larger single lesions; 18 cases of multifocality; 7 cases of multicentricity; 3 cases of contra lateral lesion; 5 cases of lymph node involvement (one of them involved medial thoracic chain); 1 with muscular involvement; 1 with skin involvement. MRI has changed previous management plans in 44.4% of 99 patients. We observed increase in mastectomies (26.8%) on axillary lymph node dissection (25%) and changes on systemic therapy (20.2%), all because of additional MRI true-positive findings. Breast MRI alters significantly the rate of mastectomy, the approach of axillary chain for staging, and the use of systemic therapy because of its accuracy in evaluating breast cancer local extent.

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