Linfadenopatia pode estar presente em qualquer fase da infecção pelo HIV a apresenta uma variedade de diagnósticos diferenciais possíveis, desde manifestações secundárias ao próprio HIV até doenças oportunistas ou neoplasias. Foi realizado um estudo de corte transversal de pacientes que realizaram biópsias de linfonodo periférico no Hospital de Clínicas de Porto Alegre entre Janeiro de 2004 a Dezembro de 2008. Foram realizadas 210 biópsias, 131 (61,9%) pacientes eram do sexo masculino, a mediana da idade foi 36 (18-74) anos e da contagem de CD4 149 (1-756) cels/mm3. Cento e seis (50,5%) biópsias foram realizadas na região cervical. Os diagnósticos mais prevalentes incluíram micobacteriose 105 casos (50,2%) sendo que mais de 90% dos casos foram tuberculose; hiperplasia reacional (HR) 48 casos (22,7%), linfoma 19 casos (9,0%) e micoses sistêmicas 12 casos (5,7%) que incluíram a histoplasmose, paracoccidioidomicose e criptococose. Esse estudo demonstra que a biópsia de linfonodos periféricos em pacientes com infecção pelo HIV é uma importante ferramenta no diagnóstico de doenças oportunistas no nosso meio. / Peripheral lymphadenopathy is commonly present in HIV- infected patients and has a wide spectrum of differential diagnoses. We performed a cross-sectional study of peripheral lymph node biopsies performed from 2004 to 2008 in HIV patients assisted in a public hospital in Southern Brazil. Two hundred and ten biopsies were performed, 131(61.9%) patients were male, median of age was 36 years old with a mean of lymphocyte CD4 count of 149 (1-756) cells/mm3. Most of biopsies were performed in the cervical site 106 (50.5%). The most prevalent diagnosis were mycobacteriosis 105 (50.2%), more than 90% was tuberculosis; reactive follicular hyperplasia 48 (22.7%); lymphoma 19 (9.0%); systemic mycosis 12 (5.7%), including histoplasmosis, paracoccidioidomycosis and cryptococcosis. Peripheral lymph node biopsy is a useful tool to diagnose opportunistic diseases such as mycobacteriosis, HIV related malignancies and invasive fungal infections in HIV-infected patients.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / estudar o linfonodo sentinela em pacientes portadoras de cÃncer na mama localmente avanÃado e que foram submetidos a quimioterapia neoadjuvante, compararando-o com os linfonodos axilares nÃo-sentinelas. Verificar a taxa de identificaÃÃo do linfonodo sentinela nestas pacientes, assim como estimar a sensibilidade, especificidade, falso-negativo, valor preditivo negativo e acurÃcia do mÃtodo. Metodologia: estudo transversal de validaÃÃo de teste diagnÃstico, envolvendo 34 pacientes oriundas do AmbulatÃrio da Maternidade-Escola Assis Chateaubriand. As pacientes portadoras de cÃncer na mama localmente avanÃado foram submetidas a quimioterapia neoadjuvante e aquelas que apresentaram axila clinicamente negativa para metÃstase de cÃncer de mama foram submetidas a biopsia do linfonodo sentinela e linfadenectomia axilar, utilizando administraÃÃo subareolar de azul patente, e este, apÃs sua identificaÃÃo, foi estudado mediante o exame de citologia de contato e parafina e comparado com conteÃdo linfÃtico axilar nÃo-sentinela. Realizada anÃlise descritiva e anÃlise dos testes utilizando teste t de Student, as proporÃÃes dos testes foram consideradas significativamente diferentes quando a probabilidade de estas serem semelhantes foi menor ou igual a 0,05. Resultados: Quando foi testada a citologia de contato intra-operatÃrio e parafina linfonodo sentinela e padrÃo-ouro os linfonodos sentinelas e nÃo-sentinelas, a taxa de identificaÃÃo do linfonodo sentinela foi de 85,3%. A sensibilidade foi de 84,62% e a especificidade de 100%. O valor preditivo negativo de 87,99% e taxa de falso-negativo de 12,01%. A acurÃcia foi de 92,77%. Dado observado na amostra foi a diferenÃa significativa do nÃmero mÃdio do total de linfonodos observados entre o grupo de pacientes com tempo de intervenÃÃo cirÃrgica Ãtimo p=0,037. Quando foi testada apenas a citologia de contato intraoperatÃria do linfonodo sentinela e padrÃo-ouro, a parafina dos linfonodos sentinelas e nÃo-sentinelas a sensibilidade foi de 62,50%, a especificidade de 100%, valor preditivo negativo de 75,04%, falso-negativo de 24,96% e acurÃcia de 82,38%. ConclusÃo: a citologia de contato intraoperatÃrio do linfonodo sentinela para pacientes com cÃncer de mama localmente avanÃados com axila clinicamente negativa apÃs quimoterapia neoadjuvante apresenta baixa sensibilidade e taxa de falso-negativo elevada. / Aims: investigating sentinel lymph node in patients with locally advanced breast cancer whom were administered neoadjuvant chemotherapy, by contrast to non-sentinel axillary lymph nodes. Verifying the identification of sentinel lymph node rate in these patients, as well as estimating methodâs sensibility, specificity, false-negative and accuracy. Methodology: transversal study for validation of a diagnostic test, with 34 patients from Maternidade-Escola Assis Chateaubriandâs ambulatory. The locally advanced breast cancer patients were treated with neoadjuvant chemotherapy, and the ones with cancer metastasis clinically negative axilla were submitted to sentinel lymph node biopsy and axillary lymphadenectomy, using subareolar patent blue, and, after its identification, it was studied with contact cytology and paraffin and it was compared with non-sentinel axillary lymph content. The descriptive analysis of tests used Studentâs t-test, and tests proportions were considered significantly different when their similarity possibility was less or equal to 0.05. Results: When intraoperatory contact cytology study, paraffin sentinel lymph node and gold standar, sentinel and non-sentinel lymph nodes, the sentinel lymph node identification rate was 85.3%. Sensibility was 84.62%, and specificity was 100%. The predictive negative value was 87.99%, and the false-negative rate was 12.01%. Accuracy rate was 92.77%. The study points the significant difference of total lymph nodes mean number observed among the group with optimal time of surgical intervention p=0.037. When only the intraoperatory contact cytology of sentinel lymph node and gold pattern, the paraffin of sentinel and non-sentinel lymph nodes, sensibility was 62.50%, specificity 100%, predictive negative value 75.04%, false-negative 24.96%, and accuracy 82.38%. Conclusion: intraoperatory contact cytology of sentinel lymph node to locally advanced breast cancer patients with clinically negative axilla after neoadjuvant chemotherapy presents low sensibility and high false-negative rates.

Santana, ANC. Estudo da trombose microvascular em biópsias pulmonares de pacientes com Granulomatose de Wegener. [tese]. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2008. A granulomatose de Wegener (GW) é associada com eventos trombo-embólicos. Neste trabalho, quantificamos os trombos em artérias pulmonares de pequeno/médio calibre de pacientes com GW (n:24), comparando com um grupo Controle normal (n:16). O resultado mostrou que a área total das artérias no grupo GW foi similar a do grupo Controle. Já a área do trombo foi significativamente maior no grupo GW em relação ao Controle. Em contrapartida, a área livre do lúmen do vaso foi significativamente menor no grupo GW em comparação ao Controle. Concluindo, este estudo demonstra uma obstrução da microcirculação pulmonar na GW, sugerindo um papel da trombose in situ na fisiopatologia desta doença / Wegeners granulomatosis (GW) is associated with thromboembolic events. In this work, we quantified the thrombus in small/medium-sized pulmonary arteries of patients with GW (n:24) compared to normal controls (n:16). The results showed that the GW and control arteries were similar regarding total area. The thrombus area was significantly increased in GW compared to controls; in contrast, the free lumen area was significantly decreased in GW compared to controls. In summary, this study shows obstruction of microvascular bed in GW, suggesting a possible role of thrombosis in situ in pathophysiology of this vasculitis

A colelitíase é uma doença frequente na população geral. Um dos seus fatores de risco é a diabetes melitus tipo 2, relacionada à anormalidades metabólicas associadas a sobrepeso, obesidade, resistência à insulina, hipertrigliceridemia e hábitos dietéticos. Fatores de risco semelhantes são encontrados na doença hepática gordurosa não alcoólica (DHGNA). A DHGNA engloba um espectro de condições patológicas que pode evoluir da esteatose, para esteato-hepatite (EHNA), fibrose, cirrose e neoplasia hepática. A distinção entre esteatose e EHNA é de grande relevância na prática clínica, em virtude de a primeira ser uma condição benigna e reversível, enquanto que a segunda apresenta potencial evolutivo para cirrose e carcinoma hepatocelular. Somente a biópsia hepática pode classificar e estadiar a DHGNA. A DHGNA e a colelitíase têm similaridade quanto à patogênese e aos fatores de risco, o que nos motivou a realizar este estudo. Os objetivos do trabalho foram: a) Definir a frequência da esteatose hepática e da EHNA em pacientes com colelitíase submetidos à colecistectomia laparoscópica. b) Avaliar as alterações histopatológicas da DHGNA nos pacientes com colelitíase. c) Avaliar a acurácia dos exames de imagem-ultrassonografia abdominal (US) e tomografia computadorizada (TC) no diagnóstico da DHGNA. d) Relacionar aspectos clínicos, laboratoriais e de imagem com diagnósticos histopatológicos de esteatose e EHNA em portadores de colelitíase. e) Analisar variáveis preditivas da DHGNA na indicação da biópsia hepática para os pacientes com colelitíase a serem submetidos à colecistectomia laparoscópica. Método: Foi realizado estudo prospectivo sequencial de pacientes portadores de colelitíase com indicação cirúrgica que assinaram o termo de consentimento livre e esclarecido. Foram analisados 161 pacientes submetidos à colecistectomia laparoscópica e à biópsia hepática. Os pacientes foram avaliados quanto ao sexo, à idade, história clínica e aos antecedentes pessoais, com ênfase nas comorbidades relacionadas à síndrome metabólica. Foram realizadas as seguintes medidas antropométricas: peso (kg), altura (m) e circunferência abdominal (cm), sendo calculado o Índice de Massa Corpórea (IMC). Além da avaliação bioquímica, foram avaliados parâmetros metabólicos através da dosagem da glicemia e insulinemia de jejum, índice de HOMA IR e perfil lipídico. Os pacientes foram submetidos a dois USs em momentos distintos, nos quais foram avaliados a vesícula biliar, as vias biliares e os possíveis diagnósticos qualitativo e quantitativo da esteatose hepática. Na tomografia abdominal, foram medidos os coeficientes de atenuação hepática e esplênica. O diagnóstico de esteatose foi determinado através de dois índices: TC1 (e-h) calculado pela diferença entre o valor da atenuação esplênica e hepática e o TC2 (h/e) medido pela fração da atenuação hepática sobre a esplênica. Antes da colecistectomia laparoscópica com exploração de vias biliares, foi realizada biópsia hepática com agulha de tru-cut no mesmo tempo cirúrgico. Os parâmetros histopatológicos utilizados para avaliar as biópsias hepáticas foram: esteatose macrovesicular, esteatose microvesicular, infiltrado inflamatório acinar e portal, balonização hepatocelular, corpúsculos hialino de Mallory, alterações ductulares e fibrose perissinusoidal, perivenular, portal, sobrecarga de ferro e pseudoinclusão nuclear de glicogênio. Para o diagnóstico de EHNA, foi utilizado o escore de atividade da doença hepática gordurosa não alcoólica (NAS). Os 161 pacientes foram distribuídos em três grupos formados a partir do resultado da histopatologia hepática: Grupo A - colelitíase sem esteatose (n = 98), Grupo B - colelitíase com esteatose (n = 51) e Grupo C - colelitíase com esteatohepatite (n = 12). Resultados: Entre os 161 pacientes submetidos à colecistectomia com biópsia hepática, 63 (39,1%) eram portadores de DHGNA, dentre eles, 12/161 (7,4%) com EHNA. Cento e trinta e sete (85%) pacientes eram do sexo feminino; 125 (78%) eram brancos. A idade média global foi de 45 anos. A hipertensão arterial sistêmica esteve presente em 40 (25%), diabetes mellitus tipo 2 em 17 (11%) e a síndrome metabólica em 39 (24%). Os aspectos clínicos, laboratoriais e comorbidades que apresentaram diferença estatística significantes entre o grupo A e os grupos B e C foram: idade, IMC, circunferência abdominal, glicemia em jejum, ALT. A síndrome metabólica, a resistência insulínica, diabetes mellitus tipo 2, AST e o colesterol total registraram diferença estatisticamente significante apenas entre os grupos A e C. Não existiram aspectos clínicos, laboratoriais ou de comorbidades que diferenciaram os portadores de esteatose e EHNA. Os exames de US I e II nas duas ocasiões revelaram sensibilidade de 57% e 59%, especificidade de 91% e 90%, respectivamente, e em ambos USs a acurácia foi de 78%. No exame de TC, o índice e o nível de corte de maior sensibilidade (50%), especificidade, (90,72%) e acurácia (74,53%) foi o índice TC 2 (h/e), com nível de corte menor que 1,0 para o diagnóstico da DHGNA. Os parâmetros histopatológicos que apresentaram diferença estatística significante entre os grupos A e C e entre os grupos B e C foram: corpúsculos hialino de Mallory, infiltrado inflamatório portal e fibrose perivenular, perissinusoidal e portal. Houve maior grau de intensidade do infiltrado inflamatório portal nos pacientes do grupo C. Houve diferença estatística significante entre os grupos B e C com relação à esteatose microvesicular e a pseudoinclusão nuclear de glicogênio. Pela regressão logística, foi avaliada a probabilidade de os pacientes portadores de colelitíase apresentarem DHGNA. Os fatores preditivos foram: aumento da glicemia, HOMA-IR, colesterol total, circunferência abdominal e esteatose ao US. Na presença de três ou quatro destes fatores de risco a probabilidade de DHGNA foi de 91%. Conclusão: A prevalência de EHNA em pacientes com colelitíase foi de 7,4% neste grupo de pacientes Assim, é de fundamental importância o reconhecimento dos fatores de risco para a DHGNA em pacientes com colelitíase que serão submetidos à intervenção cirúrgica. Assim sendo, a biópsia hepática durante o procedimento cirúrgico deve ser preconizada na vigência de fatores preditivos, pois é o único método para diferenciar esteatose de EHNA / Cholelithiasis is a very common disease in the population at large, and one of the risk factors is type II diabetes mellitus, which is related to metabolic disorders associated with overweight, obesity, insulin resistance, hypertriglyceridemia and dietary abnormalities. Similar risk factors are found in non-alcoholic fatty liver disease (NAFLD). NAFLD covers a spectrum of pathological conditions that can range from steatosis to steatohepatitis (NASH), fibrosis, cirrhosis and even liver cancer. The distinction between steatosis and NASH is of great importance in clinical practice because the former is a benign, reversible condition whereas the latter can progress to cirrhosis and hepatocellular carcinoma. Only a liver biopsy, however, can be used to classify and stage NAFLD. NAFLD and cholelithiasis have similar pathogenesis and risk factors, a fact which led us to undertake this study, the aims of which were: a) to define the frequency of hepatic steatosis and NASH in patients with cholelithiasis undergoing laparoscopic cholecystectomy; b) to assess the accuracy of abdominal ultrasound imaging (US) and computed tomography (CT) in the diagnosis of NAFLD; c) to assess histological alterations caused by NAFLD in patients with cholelithiasis; d) to relate clinical, laboratory and imaging findings to histopathological diagnoses of steatosis and NASH in cholelithiasis; and e) to analyze predictors of NAFLD used when referring patients with cholelithiasis already scheduled for laparoscopic cholecystectomy for liver biopsy as well. Methods: We performed a prospective sequential study of patients with cholelithiasis who had been referred for surgery and had signed a voluntary informed-consent form. A total of 161 patients were analyzed after they had undergone a laparoscopic cholecystectomy and liver biopsy. Besides sex and age, clinical and medical history were recorded, with emphasis being placed on comorbidities related to metabolic syndrome. The anthropometric measurements weight (kg), height (m) and abdominal circumference (cm) were recorded during the physical examination and the body mass index was calculated. Biochemical and metabolic assessment parameters, including fasting blood sugar and fasting insulin, which were used to calculate the HOMA-IR index, and fasting lipid profile, were evaluated. Patients had two ultrasounds at different times to assess the gallbladder and bile ducts as well as the quantitative and qualitative diagnosis of hepatic steatosis. In the abdominal tomography, the attenuation coefficients of the liver and spleen were measured for diagnosis of steatosis based on two indices: CT1 (S-L), given by the difference between spleen and liver attenuations, and CT2 (L/S), given by the attenuation of the liver divided by the attenuation of the spleen. Before laparoscopic cholecystectomy with bile duct exploration, a liver biopsy with a tru-cut was performed. The following histological parameters were used to evaluate the liver biopsies: macrovesicular steatosis, microvesicular steatosis, acinar and portal inflammatory infiltrate, hepatocellular ballooning, Mallory bodies, ductal changes, perisinusoidal, perivenular and portal fibrosis, iron overload and glycogenated nuclei. The NAFLD activity score was used to diagnose NAFLD in the steatosis or NASH phases. A comparative analysis of the 161 patients was carried out after they had been divided into three groups according to the results of the liver histopathology: group A cholelithiasis without steatosis (n=98), group B - cholelithiasis with steatosis (n=51) and group C - cholelithiasis with NASH (n=12). Results: Of the 161 patients subjected to cholecystectomy with a liver biopsy, 63 (39.1%) had NAFLD, of whom 12 (7.4%) also had NASH. A total of 137 (85%) of the patients were female, and 125 (78%) were Caucasian. Average age was 45 years. Arterial hypertension was observed in 40 (25%) patients, 17 (11%) had diabetes mellitus and 39 (24%) had metabolic syndrome. The clinical and laboratory findings with a statistically significant difference between group A and/or groups B and C were age, BMI, abdominal circumference, fasting blood sugar, total cholesterol, ALT and AST. Metabolic syndrome, insulin resistance and diabetes mellitus only exhibited a statistically significant difference between groups A and C. There were no clinical or laboratory findings or image abnormalities that differentiated steatosis from NASH. The first and second ultrasounds, which were carried out at different times, had sensitivities of 57% and 59% and specificities of 91% and 90%, respectively; both had accuracies of 78%. In the computed tomography, the index with the greatest sensitivity (50%), specificity (90.72%) and accuracy (74.53%) was CT2 (L/S), with a cutoff level of 1.0 for diagnosis of NAFLD. The histopathological parameters with statistically significant differences between the group without steatosis and group C and between groups B and C were Mallory bodies, portal inflammation and perivenular, perisinusoidal and portal fibrosis. Portal inflammation was more intense in patients in group C. There was a statistically significant difference in the intensity of macrovesicular steatosis between groups B and C; this was mild in 42 (82.4%) of the patients in the former group and in only 2 (3.9%) in the latter. There was a statistically significant difference in microvesicular steatosis and glycogenated nuclei between groups B and C. Logistic regression revealed that the associated risk factors for determining the probability of patients with cholelithiasis having NAFLD are increased values of blood glucose, HOMA-IR, total cholesterol abdominal circumference and steatosis on ultrasound. In the presence of three or four risk factors the probability of NAFLD was 91%. Conclusion: The prevalence of NASH in cholelithiasis patients was 7.4%, indicating that NAFLD is a serious problem in this group of patients. It is therefore very important to determine the risk factors for NAFLD in cholelithiasis patients who will be submitted to surgery in order to decide whether a liver biopsy should be performed, as this is the only diagnostic method for differentiating between steatosis and NASH

Introdução: A moléstia de Hirschsprung (MH) se caracteriza pela ausência de neurônios intramurais em segmentos variáveis do intestino grosso, levando a suboclusão intestinal. Na forma mais frequente o reto-sigmoide está comprometido. A biopsia retal é o método histológico de escolha no diagnóstico da MH. O método da hematoxilina e eosina (HE) é classicamente utilizado na prática histopatológica. Nessa técnica, um fragmento de parede total do reto é processado através de parafinização, para posteriormente ser seccionado e corado por HE. Esta coloração evidencia células neurais em intestinos normais e troncos nervosos hipertrofiados nos casos de MH. É uma técnica muito simples, ainda hoje muito utilizada no diagnóstico da doença, necessitando de fragmentos grandes de reto para um maior acerto no diagnóstico. Este detalhe torna o diagnóstico do recém-nascido mais difícil. Outro método de coloração utilizado no diagnóstico da MH é o método histoquímico de pesquisa de atividade de Acetilcolinesterase (AChE). Nesta técnica é necessário apenas um pequeno fragmento de mucosa e submucosa que será congelado e depois processado. A pesquisa de AChE, nos casos de MH mostrará a presença desta enzima em quantidade aumentada, corando troncos e ou fibrilas de cor acastanhado. Este método já vem sendo utilizado pelo Instituto da Criança - HCFMUSP há mais de 30 anos e possui um acerto diagnóstico superior a 90%. Porém, por ser uma técnica mais elaborada, pouquíssimos centros no Brasil a utilizam no diagnóstico da MH. Um outro método mais recente, e que também pode ser realizado em fragmentos menores, é a marcação imunohistoquímica da calretinina, que permite a visualização dos neurônios do plexo submucoso e das fibrilas finas na região da lâmina própria em não doentes. Esta técnica também apresenta maior complexidade e, portanto, não é utilizada. A possibilidade de realizar o diagnóstico da MH através da coloração HE em fragmentos menores poderia ser uma alternativa para os serviços que não dispõe de técnicas mais especificas. Objetivos: Avaliar a concordância dos resultados obtidos pelo método de coloração HE e da calretinina com a pesquisa de atividade de AChE em fragmentos de mucosa e submucosa no diagnóstico da Moléstia de Hirschsprung. Métodos: Para este trabalho foram selecionados 50 casos arquivados em nosso laboratório. O material encontrava-se emblocado em parafina. Foram feitos 60 níveis de cada fragmento para o HE e mais 3 níveis para a calretinina. Essas lâminas foram analisadas em microscópio, fotografadas e classificadas como positivas para MH quando não foram encontradas células neurais e houve a presença de troncos nervosos, e em negativas nos casos de visualização dos neurônios. Foi realizado estudo cego por dois pesquisadores. Os resultados da leitura das lâminas foram comparados com o da AChE. Resultados: Dos 50 casos avaliados pela técnica do HE, apenas 5 discordaram do diagnóstico realizado pela AChE, com um valor de Kappa de 0,800 e acurácia 90%. Na comparação entre a calretinina e a AChE 8 casos discordaram, com um valor de Kappa de 0,676 e acurácia de 84%. Conclusões: A concordância obtida entre os métodos da AChE e HE foi satisfatória. Tornando possível a utilização do método do HE em 60 níveis de fragmento de mucosa e submucosa como alternativa para o diagnóstico da MH. A técnica imunohistoquímica da Calretinina não apresentou a concordância esperada com a pesquisa de atividade de AChE em nosso estudo / Introduction: Hirschsprung disease (HD) is characterized by the absence of intramural neurons in variable segments of the large intestine, leading to intestinal subocclusion. In the most frequent form the rectum-sigmoid is compromised. Rectal biopsy is the histological method of choice in the diagnosis of HD. The hematoxylin and eosin (HE) method is classically used in histopathological practice. In this technique, a full-thickness rectum wall fragment is processed through paraffinization, to be later sectioned and stained by HE. This staining shows neural cells in normal intestines and hypertrophied nerve trunks in cases of HD. It is a very simple technique, still used today in the diagnosis of the disease, requiring large fragments of the rectum for a better diagnosis. This detail makes the diagnosis of the newborn more difficult. The staining histochemical methods more used are the research of acetylcholinesterase activity (AChE) and staining of calretinin. However, these techniques are not available in all centers and the possibility of diagnosing HD through HE staining in smaller fragments could be valuable alternative for services that do not have more specific techniques. Objectives: To evaluate the concordance of the results obtained by the HE staining and the calretinin method with the investigation of AChE activity in fragments of mucosa and submucosa in the diagnosis of Hirschsprung\'s disease. Methods: For this study, 50 cases from our laboratory were selected. The material was embedded in paraffin. Sixty levels of each fragment were made for HE and other 3 levels for calretinin. These slides were analyzed under microscope, photographed and classified as positive for HD when no nerve cells were found and there were nerve trunks present, and in negative in cases of visualization of the neurons. A blind study was carried out by two researchers. The results of reading the slides were compared with that of AChE. Results: Of the 50 cases evaluated by the HE technique, only 5 disagreed with the diagnosis performed by AChE, with a Kappa value of 0.800 and accuracy of 90%. In the comparison between calretinin and AChE, 8 cases disagreed, with a Kappa value of 0.676 and an accuracy of 84%. Conclusions: The concordance of results from AChE and HE methods was satisfactory, allowing the possibility of the use of the HE method in fragments of mucosa and submucosa as valid alternative for the diagnosis of HD. The immunohistochemical technique of Calretinin did not show a good agreement with the AChE activity in our study

OBJETIVO: avaliar a histomorfometria do endométrio na fase lútea de mulheres férteis e inférteis. MÉTODOS: foram triadas 40 pacientes, 30 inférteis e 10 férteis, em seguimento na Clínica Ginecológica do HC-FMUSP, que concordaram em participar deste estudo. Foi realizada avaliação ultrassonográfica seriada a partir da menstruação, para determinação da ovulação. Na fase lútea as pacientes eram submetidas à histeroscopia. Foram excluídas 14 pacientes sendo 12 por falta durante a avaliação ultrassonográfica e 2 pela presença de pólipos. A casuística foi composta por 6 controles férteis, que foram comparadas a 20 casos inférteis (endometriose-8, causa tubo-peritoneal-5, causa masculina-5, sem causa aparente-2). Na histeroscopia foram coletadas duas biópsias dirigidas (sistema de Bettocchi) da parede posterior (terço distal), e da parede anterior (terço médio), e uma biópsia aspirativa com Pipelle. Foram avaliados parâmetros histomorfométricos endometriais. RESULTADOS: as duas formas de biópsia foram apropriadas para análise endometrial; a dirigida coletou menor área tecidual, porém sem sangue. Nenhum paciente fértil apresentou heterogeneidade endometrial (atraso de fase em algum sítio); isto ocorreu em 7 (35%) das inférteis (p=0,11). Foi diagnosticada endometrite em 2 (10%) casos. CONCLUSÃO: não foram observadas diferenças histomorfométricas entre o endométrio de mulheres férteis e inférteis na fase lútea. Parte das pacientes inférteis mostrou heterogeneidade endometrial e endometrite. A biópsia dirigida, assim como a aspirativa, foi adequada ao estudo endometrial na fase lútea / Objective: to evaluate the endometrial histomorphometry of fertile and infertile women during their luteal period. Methods: 40 female patients- 30 infertile and 10 fertile- who were being followed-up at the Gynecological Clinic at the Hospital das Clinicas (HC),-Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), agreed to participate in the study. Serial ultra sonograms, starting from their menstrual period, were performed to identify their ovulation. In the luteal phase the patients underwent hysteroscopy. From the initial sample, 14 patients were excluded from the study, 12 of whom for being absent during scheduled ultra sonograms and 2 for presenting polyps. The final sample thus consisted of 6 fertile females (control subjects) who were compared to 20 patients with infertility, categorized as follows: 8 due to endometriosis, 5 due to peritoneal tube conditions, 5 due to male infertility, and 2 with no apparent cause. During the hysteroscopy 2 directed biopsies (Bettocchis System) of the posterior wall (distal third section) and of the anterior wall (medial third) were performed, as well as Pipelle sampling. Endometrial histomorpholometric parameters were evaluated. Results: the two forms of endometrial sampling performed were appropriate for the endometrial analysis. The directed biopsy collected tissue from a smaller area, but it had no blood. None of the fertile patients presented endometrial heterogeneity, i.e., phase delay in any site. In contrast, this occurred in 7(35%) of the infertile females (p=0.11). Endometritis was diagnosed in 2 (10%) of the cases. Conclusions: no histomorphometric differences were observed in the endometrium of the fertile and infertile female patients during their luteal phase. About a third of infertile cases (35%) displayed endometrial heterogeneity and a small percentage of which (10%) had endometritis. Both the directed biopsy and Pipelle sampling were found satisfactory for studies of endometrium during the luteal phase

A biópsia por agulha fina é um procedimento importante na investigação de tumores, considerado de baixo-custo, minimamente invasivo e ideal para o fornecimento de um diagnóstico preciso em casos de nódulos da glândula tireóide. Para a realização bem sucedida da biópsia por agulha, a exatidão é essencial e a prática proporciona benefícios significativos tanto na recuperação do paciente, quanto na obtenção de resultados acurados. Esta tese investigou a possibilidade do desenvolvimento de um simulador de realidade virtual para treinamento de biópsia guiada por ultrassom de nódulos da glândula tireóide. O simulador de realidade virtual proposto e desenvolvido é também uma ferramenta educativa, pois além de praticar o procedimento, o usuário pode visualizar tanto um modelo da tireóide para sentir sua textura, quanto um modelo completo do pescoço com todos os seus órgãos internos, podendo ser rotacionado. O sistema consiste de duas interfaces: uma tridimensional, apresentando os modelos virtuais com estereoscopia na mesa de visualização, cuja interação do usuário é feita através do teclado ou dispositivo háptico (Phantom OmniTM); e uma segunda que simula o exame de ultrassom, com todas as funcionalidades de um exame real, sendo manipulada pelo mouse. As duas se comunicam e todo o processo é mostrado na janela do instrutor, que substitui o supervisor orientando o usuário durante o treinamento. O simulador de realidade virtual foi avaliado experimentalmente por profissionais da área médica e tecnológica, sendo aprovado como uma ferramenta para treinamento e ensino de biópsia de nódulos da glândula tireóide. / The fine needle biopsy is an important procedure to investigations in tumors, low-cost considered, minimally invasive and ideal for supplying an accurate diagnosis in cases of thyroid gland nodules. The exactness is essential for the successful accomplishment of the needle biopsy and the practice provides significant benefits in the recovery of the patient, as well as in attainment of accurate results. This thesis investigated the possibility of the development of virtual reality simulator for the training of the ultrasound guided needle biopsy of thyroid gland nodules. The proposed and developed virtual reality simulator is also an educative tool, because besides practicing the procedure, the user can visualize thyroid model to feel its texture, as well as a complete model of the neck with all its internal organs and it can be rotated. The system consists of two interfaces: first is a three-dimensional which presents the virtual models with stereoscopy in the visualization table, whose interaction of the user is made through the keyboard or haptic device (Phantom OmniTM); and second one that simulates the ultrasound images, with all the functionalities of a real examination, manipulated by the mouse. The two interfaces communicate with each other and all the process is shown in the instructor window that substitutes the supervisor and guides the user during the training. The virtual reality simulator was experimentally evaluated by professionals of the medical and technological areas, being approved as a tool for training and education in needle biopsy of the thyroid gland nodules.

Nódulos de tireoide são achados clínicos comuns e, atualmente, o método diagnóstico de escolha para diferenciar lesões benignas de lesões malignas é a análise citopatológica dos nódulos através de punção aspirativa por agulha fina (PAAF). Estudos prévios já indicaram que os níveis séricos de TSH podem estar associados ao risco de malignidade nodular. O objetivo deste estudo foi avaliar se o TSH sérico é um preditor de malignidade em nódulos de tireoide em pacientes submetidos à PAAF. A amostra contemplou 100 indivíduos puncionados consecutivamente no Centro de Pronto Diagnóstico Ambulatorial, CPDA, HCPA e que apresentavam níveis de TSH dentro da normalidade. Todos os pacientes foram submetidos à PAAF da tireoide com controle ultrassonográfico e tiveram, posteriormente, a análise citopatológica da PAAF e a avaliação histopatológica do bloco celular. A análise estatística baseou-se em dados de frequências e testes não-paramétricos foram utilizados para correlacionar as variáveis. A população de estudo foi composta por 100 pacientes, sendo 89 mulheres e 11 homens. A média de idade foi de 54,1 ± 14,2 anos e o tamanho médio dos nódulos foi de 2.53 ± 1.36 centímetros. Vinte e seis % destes pacientes apresentavam algum tipo de doença tireoidiana prévia. A média do nível de TSH sérico entre os 100 indivíduos foi de 1.81 ± 1.08 uUI/mL. De acordo com o diagnóstico citopatológico da PAAF complementado pelos achados do bloco celular foram classificados como malignos 8% dos nódulos, 70% benignos, 11% suspeitos/ indeterminados, 8% insuficientes e 3% lesões foliculares. A média de TSH para os grupos maligno, benigno, suspeito/indeterminado, insuficiente e lesão folicular foi de, respectivamente, 2.48, 1.59, 2.21, 2.35 e 2.20 uUI/ml (p>0.05). Não houve diferença estatística significante entre os grupos diagnósticos avaliados, apesar de haver uma variação entre os níveis de TSH entre os grupos refletindo, provavelmente, o pequeno tamanho da amostra. / Thyroid nodules are common and currently the first choice of investigation in distinguishing benign from malignant disease is the cytological analysis of fine needle aspiration biopsy (FNAB). Previous studies have indicated that serum TSH levels might be associated with the likelihood of malignancy. The aim of this study was to evaluate whether serum TSH is a predictor of malignancy of thyroid nodules in patients undergoing FNAB. One hundred consecutive patients, who underwent FNAB as part of clinical investigation of thyroid nodule in a multidisciplinary setting tertiary hospital, underwent ultrasonography followed by FNAB, cytology and cell block analysis. Independent-Samples Kruskal-Wallis test was used to compare the groups. The study population comprised of 89 female and 11 male patients. The mean age was 54.1 ± 14.2 years. 26% had previous thyroid disease. Mean TSH levels was 1.81 ± 1.08 uUI/mL and the mean nodule size was 2.53 ± 1.36cm. Final cytology/cell block diagnosis classified 8% as malignant, 70% as benign, 11% suspicious/indeterminate, 8% insufficient and 3% follicular lesion. The mean TSH values for malignant, benign, suspect, insufficient and follicular lesion group were as follows: 2.48, 1.59, 2.21, 2.35 and 2.20 uUI/ml, respectively. No statistical significance was detected between TSH levels and final cytology/cell block diagnosis, possibly reflecting the small sample size (P>0.05). We observed a variation between TSH levels among the groups covered in this study, but there was no statistically significant difference among them.

Introdução: o carcinoma de endométrio é uma das neoplasias ginecológicas mais comuns nos países industrializados. O tratamento desta doença é primariamente cirúrgico. Segundo a normatização da Federação Internacional de Ginecologia e Obstetrícia (FIGO), a cirurgia ideal consiste na realização de histerectomia total, anexectomia bilateral, linfadenectomia retroperitonial e coleta de citologia peritoneal. No entanto, a realização sistemática da linfadenectomia tem sido contestada. Alguns centros de referência acreditam que deva ser realizada apenas em um grupo de pacientes com alto risco para disseminação linfática da doença. O desafio é encontrar marcadores pré-operatórios que possam ser preditivos da presença de doença linfonodal e, assim , virem a ser utilizados para a definição da necessidade da linfadenectomia. Objetivos: verificar se a expressão imuno-histoquímica (IMH) positiva da p53 na amostra endometrial diagnóstica e, se o valor sérico do CA 125 obtido no tempo pré-operatório, podem ser efetivos para prever a presença de doença linfonodal. Métodos: um estudo transversal restrospectivo foi realizado. Foram incluídas 111 pacientes com carcinoma de endométrio submetidas a histerectomia com anexectomia bilateral e linfadenectomia com ou sem citologia peritoneal. Noventa pacientes apresentavam CA 125 pré-operatório e 73, a avaliação da p53. Cinquenta e quatro pacientes apresentavam as duas variáveis em combinação. Foram estabelecidas as associações entre o valor de CA 125 e da expressão IMH da p53 com o envolvimento linfonodal. Uma curva ROC foi construída para identificar o valor de CA 125 com melhor Sensibilidade (S) e Especificidade (E) para doença linfonodal. / Introduction: endometrial carcinoma is one of the most common gynecological malignancies in industrialized countries. The treatment of this disease is primarily surgical. According to the International Federation of Gynecology and Obstetrics surgery ideal consists in performing total hysterectomy, bilateral adnexectomy, retroperitoneal lymphadenectomy and peritoneal cytology. However, the systematic lymphadenectomy has been disputed, and should only be performed in a group of patients at high risk of lymphatic spread of the disease. The challenge is to find preoperative markers that may be predictive of the presence of lymph node disease and thus come to be used to determine the necessity of lymphadenectomy. Objectives: to determine whether the positive immunohistochemical expression (IMH) of p53 in diagnostic endometrial sample and, if the value of serum CA 125, obtained during pre-operative, can be effective to predict the presence of lymph node disease. Methods: a cross-sectional study was conducted. The final sample consisted of 111 patients with endometrial carcinoma undergoing hysterectomy with bilateral adnexectomy and lymphadenectomy with or without peritoneal cytology. Ninety two patients had preoperative CA 125 and 73, evaluation of p53. Fifty four patients had both variables in combination. Associations have been established between the value of CA 125 and IMH expression of p53 with lymph node involvement. A ROC curve was constructed to identify the value of CA 125 with better sensitivity (S) and specificity (E) for lymph node disease.

Background Idiopathic pulmonary fibrosis (IPF) is a devastating form of chronic lung injury of unknown aetiology characterised by progressive lung scarring. A diagnosis of definite IPF requires High Resolution Computed Tomography (HRCT) appearances indicative of usual interstitial pneumonia (UIP), or in patients with 'possible UIP' CT appearances, histological confirmation of UIP. However the proportion of such patients that undergo SLB varies, perhaps due to a perception of risk of biopsy and additive diagnostic value of biopsy in individual patients. We hypothesised that an underlying UIP pathological pattern may result in increased risk of death and aimed to explore this by comparing the risk of SLB in suspected idiopathic interstitial pneumonia, stratified according to HRCT appearance. Additionally we sought to determine the positive-predictive value of biopsy to diagnose IPF in patients with 'possible UIP HRCT' in our population. In patients with possible UIP who are not biopsied, the clinical value of bronchoalveolar lavage (BAL) is uncertain. We aimed to prospectively study the diagnostic and prognostic value of BAL differential cell count (DCC) in suspected IPF and determine the feasibility of repeat BAL and the relationship between DCC and disease progression in two successive BALs. We hypothesised that BAL DCC between definite and possible IPF was different and that baseline DCC and change in BAL DCC predicted disease progression. Alveolar macrophages (AMs) are an integral part of the lung's reparative mechanism following injury, however in IPF they contribute to pathogenesis by releasing pro-fibrotic mediators promoting fibroblast proliferation and collagen deposition. Expansion of novel subpopulations of pulmonary monocyte-like cells (PMLCs) has been reported in inflammatory lung disease. We hypothesised that a distinct AM polarisation phenotype would be associated with disease progression. We aimed to perform detailed phenotyping of AM and PMLCs in BAL in IPF patients. Several prognostic scoring systems and biomarkers have been described to predict disease progression in IPF but most were derived from clinical trial patients or tertiary referral centres and none have been validated in separate cohorts. We aimed to identify a predictive tool for disease progression utilising physiological, HRCT and serum biomarkers in a unique population of incident treatment naïve IPF patients. Methods Between 01/01/07 and 31/12/13, 611 consecutive incident patients with suspected idiopathic interstitial pneumonia (IIP) presented to the Edinburgh lung fibrosis clinic. Of these patients 222 underwent video-assisted thoracoscopic lung biopsy and histological pattern was determined according to ATS/ERS criteria. Post-operative mortality and complication rates were examined. Fewer than 2% received IPF-directed therapy and less than 1% of the cohort were lost to follow-up. Disease progression was defined as death or ≥10% decline in VC within 12 months of BAL. Cells were obtained by BAL and a panel of monoclonal antibodies; CD14, CD16, CD206, CD71, CD163, CD3, CD4, CD8 and HLA-DR were used to quantify and selectively characterise AMs, resident PMLCs, inducible PMLCs, neutrophils and CD4+/CD8+ T-cells using flow cytometry. Classical, intermediate and non-classical monocyte subsets were also quantified in peripheral blood. Potential biomarkers (n=16) were pre-selected from either previously published studies of IPF biomarkers or our hypothesis-driven profiling. Linear logistic regression was used on each predictor separately to assess its importance in terms of p-value of the associated weight, and the top two variables were used to learn a decision tree. Results Based on the 2011 ATS/ERS criteria, 87 patients were categorised as 'definite UIP', of whom 3 underwent SLB for clinical indications. IPF was confirmed in all 3 patients based on 2013 ATS/ERS/JRS/ALAT diagnostic criteria. 222 patients were diagnosed with 'possible UIP'; 55 underwent SLB, IPF was subsequently diagnosed in 37 patients, 4 were diagnosed with 'probable IPF' and 14 were considered 'not IPF'. In this group, 30 patients were aged 65 years or over and 25/30 (83%) had UIP on biopsy. 306 patients had HRCTs deemed 'inconsistent with UIP', SLB was performed in 168 patients. Post6 operative 30-day mortality was 2.2% overall, and 7.3% in the 'possible UIP' HRCT group. Patients with 'definite IPF' based on HRCT and SLB appearances had significantly better outcomes than patients with 'definite UIP' on HRCT alone (P=0.008, HR 0.44 (95% CI 0.240 to 0.812)). BAL DCC was not different between definite and possible UIP groups, but there were significant differences with the inconsistent with UIP group. In the 12 months following BAL, 33.3% (n=7/21) of patients in the definite UIP group and 29.5% (n=18/61) in the possible UIP group had progressed. There were no significant differences in BAL DCC between progressor and non-progressor groups. Mortality in patients with suspected IPF and a BAL DCC consistent with IPF was no different to those with a DCC inconsistent with IPF (P=0.425, HR 1.590 (95% CI 0.502 to 4.967)). There was no difference in disease progression in either group (P=0.885, HR 1.081 (95% CI 0.376 to 3.106)). There was no statistically significant difference in BAL DCC at 0 and 12 months in either group. There was no significant change in DCC between 0 and 12 month BALs between progressors and non-progressors. Repeat BAL was well tolerated in almost all patients. There was 1 death within 1 month of a first BAL and 1 death within 1 month of a second BAL; both were considered 'probably procedure-related'. AM CD163 and CD71 (transferrin receptor) expression were significantly different between groups (P < 0.0001), with significant increases in the IPF group vs non fibrotic ILD (P < 0.0001) and controls (P < 0.0001 and P < 0.001 respectively). CD71 expression was also significantly increased in the IPF progressor vs non-progressor group (P < 0.0001) and patients with high CD71 expression had significantly poorer survival than the CD71low group (P=0.040, median survival 40.5 and 75.6 months respectively). CD206 (mannose receptor) expression was also significantly higher in the IPF progressor vs non-progressor group (P=0.034). There were no differences in baseline BAL neutrophil, eosinophil or lymphocyte percentages between IPF progressor or non-progressor groups. The percentage of rPMLCs was significantly increased in BAL fluid cells of IPF patients compared to those with non-fibrotic ILD (P < 0.0001) and healthy controls (P < 0.05). Baseline rPMLC percentage was significantly higher in IPF progressors vs IPF non-progressors (P=0.011). Baseline BAL iPMLC:rPMLC ratio was also significantly different between IPF progressor and non-progressor groups (P=0.011). Disease progression was confidently predicted by a combination of clinical and serological variables. In our cohort we identified a predictive tool based on two key parameters, one a measure of lung function and one a single serum biomarker. Both parameters were entered into a decision tree, and when applied to our cohort yielded a sensitivity of 86.4%, specificity of 92.3%, positive predictive value of 90.5% and negative predictive value of 88.9%. We also applied previously reported predictive tools such as the GAP Index, du Bois score and CPI Index to the Edinburgh IPF cohort. Conclusions SLB can be of value in the diagnosis of ILD, however perhaps due to the perceived risks associated with the procedure, only a small percentage of patients undergo SLB despite recommendations that patients have histological confirmation of the diagnosis. Advanced age is a strong predictor for IPF, and in our cohort 83% of patients aged over 65 years with 'possible UIP' HRCT appearances, had UIP on biopsy. BAL and repeat BAL in IPF is feasible and safe (< 1.5% mortality). Of those that underwent repeat BAL, disease progression was not associated with a change in DCC. However, 22% of lavaged patients died or were deemed too frail to undergo a second procedure at 12 months. These data emphasise the importance of BAL in identifying a novel human AM polarisation phenotype in IPF. Our data suggests there is a distinct relationship between AM subtypes, cell-surface expression markers, PMLC subpopulations and disease progression in IPF. This may be utilised to investigate new targets for future therapeutic strategies. / Disease progression in IPF can be predicted by a combination of clinical variables and serum biomarker profiling. We have identified a unique prediction model, when applied to our locally referred, incident, treatment naïve cohort can confidently predict disease progression in IPF. IPF is a heterogeneous disease and there is a definite clinical need to identify 'personalised' prognostic biomarkers which may in turn lead to novel targets and the advent of personalised medicines.