Repositório RCAAP

Carta Editor No último número da Acta Radiológica Portuguesa o seu artigo de introdução sobre o tema da revista – “A subespecialização em Radiologia/Subespecialização em Radiologia de Intervenção” suscita alguns comentários da minha parte, enquanto membro cessante da actual Direcção do Colégio de Neurorradiologia da Ordem dos Médicos e presidente da Sociedade Portuguesa de Neurorradiologia Diagnóstica e Terapêutica (SPNR). Carta Resposta Editor Agradeço o interesse que o editorial lhe despertou sobre um tema importante para ambas especialidades, nomeadamente o da subespecialização, em concreto em Radiologia de Intervenção, havendo provavelmente o paralelismo na especialidade de Neurorradiologia, com a Neurorradiologia de Intervenção.  

A 49-year-old woman with history of bicytopenia (anemia and leukopenia) and monoclonal gammopathy (IgG lambda) not fully clarified presents with portal hypertension and splenomegaly of unclear cause. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) were performed for further investigation.

and leukopenia) and monoclonal gammopathy (IgG lambda) not fully clarified presents with portal hypertension and splenomegaly of unclear cause. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) were performed for further investigation.

No dia 9 de Janeiro de 2021 faleceu o nosso distinto Colega, Dr. José Carlos de Carvalho Telo de Morais.

We present a 78-years-old male patient with a normal digital rectal exame, showing progressive PSA elevation (currently 14.2 ng/ml). The patient had previously performed ultrasound guided biopsy (TRUS) with negative results. He was then referred to JCC - Hospital Particular de Viana do Castelo to undergo a prostate MRI scan (3T) and subsequent MRI guided biopsy (in-bore system). On T2 weighted imaging we could depict a nodular hypointense lesion with 10 mm of greater diameter, in the anterior gland, at the apex level (Figure 1). The lesion showed restricted diffusion (b 1600) (Figure 2) and reduced ADC value (Figure 3). It was classified PI-RADS 4 (PI-RADS 2.1).

A 68-year-old patient with a history of chronic kidney disease and kidney transplantation due to autosomal dominant polycystic kidney disease (ADPKD) was referred to a Gastroenterology consultation for the evaluation of bile duct dilatation detected in abdominal ultrasound. Laboratory results did not reveal significant changes on liver tests. Abdominal computed tomography (CT) was initially performed followed by magnetic resonance imaging (MRI).

Neste Editorial, recordo as palavras escritas num outro Editorial, em 2017: “Nas últimas décadas, a Medicina Baseada na Evidência assumiu um papel importante na prática clínica, nas diversas áreas da Medicina. Assim, a prática clínica (e radiológica!) não deve ser baseada em impressões ou opiniões, mas antes em resultados de investigação científica, publicados após avaliação e crítica inter-pares rigorosa.”

46-year-old female, referred to our hospital due to a 20-year history of right neck swelling. On physical examination, a pulsating firm painless mass was found on the right side of her neck, near the angle of the mandible. There was no pressure symptom and it was more mobile horizontally than vertically (Fontaine sign). Pulsations were felt on deep palpation and a faint bruit was heard on auscultation.

Introdução – A TC das cavidades paranasais acompanha a endoscopia para avaliar a retenção mucoide, tendo em vista a restituição da drenagem mucociliar e consequente arejamento. Este estudo orienta-se para o infundíbulo etmoidal e para os óstios meatais que suportam a FES (Functional Endoscopic Surgery).1,2 Objetivo – Conhecer a morfologia individual do complexo meatal anterior para explicar a retenção sinusal enquanto confinada; contribuir deste modo para a endoscopia nasal corretiva a ser proposta pelo clínico. Material e método – São 110 TC com perda da permeabilidade do meato médio e células vizinhas. Alta resolução da TC sob três planos ortogonais com leitura simultânea. Resultados – Repartidos pela prevalência, pelo teor da retenção e pelo grau de estenose meatal. Existe: predomínio das variantes da apófise unciforme e seu contacto com a bula etmoidal na retenção diminuta (60% dos casos); contacto da apófise unciforme-órbita que é mais frequente do que o contacto apófise unciforme-concha média, 17% vs 7%; retenção frontal em 12% da estenose hiatal com retenção etmoidal. Discussão – Argumentada na relação da anatomia nasossinusal com a patofisiologia da retenção. Conclusão – Considerada a dualidade da TC com a endoscopia segundo matriz de partilha clínica.

A estenose traqueal congênita (ETC) é uma entidade rara e com significativa mortalidade. É definida como um estreitamento intrínseco do lúmen traqueal, devido à presença de anéis cartilagíneos traqueais completos. Por causar obstrução respiratória, o diagnóstico é feito na infância estando, geralmente, associada a outras anomalias congénitas, sobretudo cardiovasculares. A Tomografia computorizada desempenha um papel importante no diagnóstico desta entidade, bem como na determinação da extensão da estenose e do calibre luminal, elementos fundamentais para a decisão terapêutica e aumento da sobrevida. Os achados típicos na imagem são um estreitamento circunferencial da traqueia e fusão dos anéis traqueais cartilaginosos posteriormente, dando uma aparência em traqueia em forma de O em corte axial. Relatamos um caso de estenose traqueal congénita diagnosticada numa criança com história de tetralogia de Fallot, que foi admitida na sala de emergência por quadro de dificuldade respiratória grave, com necessidade de ventilação mecânica invasiva.

Durante as fases habitualmente destinadas à aprendizagem somos mais suscetíveis às influências externas, o que tem inevitáveis implicações no que nos tornamos. O que aprendemos na infância e na adolescência tem uma importância fulcral no que fazemos na idade adulta. Sendo esta uma verdade incontornável e óbvia, convém relembrar que também nos molda o futuro o ambiente que nos rodeia, quem nos transmite a sabedoria e os valores que nos são incutidos. Cada um de nós encontra nas suas memórias alguém que teve uma influência particular, alguém que não se limitou apenas à transmissão dos conhecimentos supostos. Alguém que, pelo seu exemplo, se tornou um modelo e que tornou mais fácil as decisões binárias a tomar.

O tema da subespecialização em Radiologia não é novo. Contudo, tendo em conta a evolução da Radiologia (e a sua ubiquidade), das outras especialidades e da Medicina em geral, talvez nunca tenha sido tão relevante discuti-lo. Neste artigo tenta-se refletir sobre a importância, premência e vantagens da subespecialização na nossa especialidade, abordando-se igualmente determinadas dificuldades que lhe estão associadas, bem como algumas potenciais soluções para as mesmas. Por fim, faz-se ainda uma breve reflexão sobre os meios necessários à implementação da subespecialização na Radiologia Portuguesa. Todos os pontos de vista são pessoais e resultam em grande parte de uma vivência de 7 anos a trabalhar num serviço de Radiologia subespecializado.

Introduction: We aim to study the effect of fatty acid amide hydrolase (FAAH) blockade on bladder hyperactivity and on fatty acid amides levels during cystitis. Material and Methods: Cystitis was induced in female Wistar rats using 5 mg/mL lipopolysaccharide (LPS). Control group were intravesical instilled with saline. LPS and control groups received intravenously (caudal vein) during cystometry: URB 937 (URB; FAAH antagonist) in doses of 0.007, 0.07, 0.7 and 7 mg/kg (cumulative, with 10 minutes interval). Using the maximal effective dose of URB (0.7 mg/kg, see below) animals received 10 uM MJ15 (CB1 receptor antagonist) or 0.3 mg SR144528 /kg (SR; CB2 receptor antagonist). At dose of 7 mg/kg, animals receive 1.4 μg SB366791/kg (SB; TRPV1 antagonist). Control and inflamed (without and with 0.7 and 7 mg/kg URB) group were euthanized and the bladder was harvested for the determination of anandamide (AEA) and palmitoylethanolamide (PEA) by mass spectrometry. Results: Frequency of control was not changed by URB treatment at any dose. LPS increase bladder frequency. 0.007 mg and 0.07 mg URB decrease bladder frequency of LPS-inflamed rats. 0.7 URB reversed LPS-induced bladder hyperactivity. At 7 mg, URB was unable to reverse or reduce LPS-induced bladder hyperactivity. The administration of CB1, CB2 and TRPV1 antagonists did not change the frequency of voiding contractions of naïve animals. CB1 antagonist reversed the effect of 0.7 URB while TRPV1 antagonist reduced the effect of 7 URB. AEA levels increase during inflammation. Treating LPS-inflamed animals with 0.7 mg URB brought AEA levels to control levels. Treating LPS-inflamed animals with 7 mg URB did not change AEA levels, compared to LPS-inflamed animals. PEA levels decrease during inflammation. Treating LPS-inflamed animals with 0.7 mg URB brought AEA levels to control levels. Treating LPS-inflamed animals with 7 mg URB, decreased PEA levels to values similar to the ones observed in LPS- -inflamed animals. Conclusion: During cystitis, the FAAH inhibitor raises the levels of PEA and reverses the urinary frequency by a CB1 receptor- mediated mechanism. When used in very high doses, the FAAH antagonist raises the levels of AEA and increases the urinary frequency by a TRPV1-dependent mechanism. Therefore, the choice of FAAH inhibitor dosage to be used in the clinics should consider the putative effects over the endocannabinoid levels in the system.

Purpose: We aimed to characterize the population with primary high-grade non muscle invasive bladder cancer followed in a Portuguese Central Hospital and simultaneously identify recurrence and progression rates and associated risk factors. Material and Methods: The analysis included 79 patients who were diagnosed with primary high-grade non muscle invasive bladder cancer on first transurethral resection between 2006 and 2010. Several variables were statistically analyzed to evaluate their prognostic importance. Results: With a median follow-up of 54 months, 19 patients (24.1%) recurred, four (5.1%) progressed to muscle-invasive disease and two (2.5%) underwent radical cystectomy. The most important prognostic factor of recurrence was the duration of intravesical bacillus Calmette-Guérin (BCG) treatment while the presence of carcinoma in situ was the most important prognostic factor of progression. Residual disease on second-look transurethral resection showed to reduce the recurrence-free-survival. Conclusion: In our population, recurrence and progression rates were much lower than those described in other studies. Residual disease on second-look transurethral resection is associated with decreased recurrence-free-survival while the presence of carcinoma in situ is related with higher risk of progression. The duration of treatment with BCG seems to reduce the risk of recurrence.

IntroductionOver the past few years, the increasing use of cross‐sectional imaging, including ultrasound and computed tomography imaging, resulted in an increase incidental diagnosis of renal tumors, especially small renal masses (<4cm). The knowledge that 30% of these masses may be benign, including oncocytomas led to the investigation for more effective methods of diagnosis in order to avoid overtreatment situations.ObjectivesThe authors decided to analyse and compare contrast enhancement patterns of oncocytomas and clear‐cell renal cell carcinoma (ccRCC) to predict histology.Material and methodsBetween 2004‐2015 we retrospectively identified 32 patients with either histological confirmation of renal oncocytoma (N=16) or ccRCC (N=16) who underwent percutaneous biopsy, total or partial nephrectomy. The relative attenuation of solid renal lesions and normal renal cortex was determined in the unenhanced and nephrographic phase. Statistical comparison was carried out by Mann‐Withney test.ResultsThe oncocytomas and cc‐RCC average size was 3.7cm [1.8 to 14] and 3.5cm [1.9 to 8.4], respectively. The average attenuation in the unenhanced phase was 33HU and 32HU, respectively. In nephrographic phase, the average contrast enhancement was 47.5 and 47.4H, respectively. In nephrographic phase, the attenuation difference between the oncocytomas and normal renal cortex was 43.5HU and the attenuation difference between the cc‐RCC and normal renal cortex was 59.7HU. These results were statistically significant (p<0.05).ConclusionsIn the nephrographic phase, URO‐CT reveals that oncocytomas have greater isodensity to the normal renal cortex compared to cc‐RCC. This finding can help us to determine which lesions we should biopsy or not.

Introduction Fibroepithelial polyps are extremely rare benign tumors arising from mesodermal tissue in the ureteral wall in children, that can cause ureteropelvic junction obstruction.Case reportIn this report, we present an 11‐year‐old boy complaining of left intermitent lumbar pain related with ipsilateral hydronephrosis. Surgical exploration revealed several endoluminal polyps located at the ureteropelvic junction, obstructing the lumen of the ureter.DiscussionStandard treatment consists in resection of the affected ureteral segment followed by open or laparoscopic dismembered pyeloplasty. The prognosis is excellent.

Introduction: The characterization of renal masses by biopsy before a surgical procedure is currently an option. Without this prior characterization, patients with benign renal masses may be likely to undergo unnecessary surgeries. The purpose was to determine the diagnostic accuracy and safety of renal mass biopsy. Material and Methods: Prospective uni-institutional study of 38 patients submitted to renal mass biopsy in the period from July 2014 to May 2016. Results: The biopsy was diagnostic in 76.3% (n = 29) of the cases. In 21.7 %% (n = 6) of the diagnostic biopsies, histology showed benign lesions, namely oncocitoma. In patients undergoing surgery, there was a 100% overall agreement between the biopsy result and the pathological outcome of the surgical specimen. The complication rate was 5.3% (n = 2), classified as Clavien-Dindo I. Conclusion: Renal mass biopsy showed high diagnostic acuity and safety, which may prevent unnecessary surgeries. This procedure may be part of the evaluation prior to the decision to treat patients with renal masses.

Introduction: During radical cystectomy of patients with muscle-invasive bladder cancer, pelvic lymphadenectomy is used not only for an accurate staging, but also to provide local and regional control of the disease. Although recent studies evaluating the anatomical extent of lymphadenectomy recommend an extended template, the relation between the extent of lymphadenectomy and the number of dissected nodes remains controversial. The aim of this study was to determine the main predictors of the extent of lymphadenectomy in patients with bladder cancer submitted to radical cystectomy. Material and Methods: Retrospective analysis of 119 patients with muscle-invasive or selected high-risk non-muscle invasive bladder cancer submitted to radical cystectomy between 2010 and 2015 at our institution. Results: Standard and extended lymphadenectomy was performed in 87 and 22 patients, respectively. Extended template was statistically associated with a higher number of lymph nodes dissected when compared to standard lymphadenectomy, (14 vs 11 lymph nodes; p < 0.05) and showed a trend toward better overall survival, although without statistical significance (HR = 0.52, 95% CI 0.23-1.21). Extended lymphadenectomy was performed preferentially in patients undergoing an orthotopic bladder substitution (47.8%) relatively to other types of urinary diversion (around 10% - 11%). These patients had more lymph nodes dissected relatively to cutaneous ureterostomy (15 vs 8 lymph nodes), on average. Conclusion: The surgeon’s decision about the type of urinary diversion to be performed is the main determinant of the extent of lymphadenectomy in patients with bladder cancer undergoing radical cystectomy The number of retrieved lymph nodes was associated with the extent of lymphadenectomy and with a trend toward better overall survival.

Introduction: Renal calculi is a prevalent disease and has some causes described. The drug calculi origin are rare, accounting for around 1% to 2% of cases. The crystals of sulfadiazine are formed in 20% to 45% of cases, but between 0.4% and 4.5% are associated with renal failure. We present a case report and a review of the literature on diagnosis and treatment of this entity, given its rarity and specificity. Case Report: A 48-year-old male, diabetic, during treatment for acute toxoplasmosis with sulfadiazine initiated renal colic associated with renal failure. The hypothesis of drug calculation was considered, because during the diagnostic investigation of toxoplasmosis, imaging studies were performed and presented without renal calculi. Initially he was treated conservatively with hyperhydration and alpha-blocker, but since he did not present improvement in the exams, he underwent ureterolithotripsy and double j stent. Conclusion: We present a report of urinary lithiasis of pharmacological origin associated with renal insufficiency and a review of the literature.

The aim of this work was to determine the potential of phytoremediation of Vetiveria zizanioides and Oryza sativa to nitrate (NO3 −-N) and organic matter (COD – chemical oxygen demand) removal in subsurface vertical flow constructed wetland systems (VFCWs). The tests were carried out in models of 2 beds with a surface of 0.24m2 and depth 0.70m each at various hydraulic loads (HL) and COD constant in influente wastewater. The VFCW-1 bed was planted with the Vetiveria zizanioides and the VFCW-2 bed with the Oryza sativa. During the 22 weeks of research, the hydraulic load of the analyzed beds was: HL1=148 m3·m−2·d−1, HL2=239 dm3·m−2·d−1, HL3=350 dm3·m−2·d−1, HL4=473 dm3·m−2·d−1. The VFCWs were fed from two reservoirs, one with mineral medium and nitrate, and the other one with fructose as organic matter. Based on the conducted tests, it was found that in both analyzed systems (VFCW-1 and VFCW-2) the highest NO3 −-N removal rate was found under HL2 – the median is 59 and 42% respectively. The most effective removal of COD in the VFCW-1 system was obtained at a HL2 – 55%, while in the system VFCW-2 at a HL1 – 43%. The research shows that the low HL and high COD/NO3 −-N ratio ensures good effects of nitrate and organic matter removal in VF type constructed wetland systems. It has been shown that the analyzed plants, especially Vetiveria zizanioides have good phytoremediation potential in the field of nitrate nitrogen and organic substance removal and can be recommended for use on a full scale of technology.