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Hasnaoui A, Trigui R, Hassine MB, Kacem S, Bellamine H. A giant gastrointestinal stromal tumor revealed by a life-threatening hematemesis: A case report of a rare entity and a challenging management. Int J Surg Case Rep 2024; 114:109142. [PMID: 38096702 PMCID: PMC10758854 DOI: 10.1016/j.ijscr.2023.109142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/25/2023] [Accepted: 12/02/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GIST) are the most common mesenchymal malignancies in the digestive tract. Despite the stomach being their site of predilection, only a few giant GISTs have been discovered in hypovolemic shock and require urgent surgery. CASE PRESENTATION A 62-year-old patient was admitted for hematemesis. Initial examination revealed a compensated hemodynamic shock with a mass in the left hemi abdomen of 20 cm without signs of portal hypertension or peritonitis. After resuscitation, an abdominal CT scan was performed, showing an exophytic mass of the gastric antrum without local or distant lymph node involvement. Later, the patient went into hemodynamic shock, requiring vasoactive drugs. An urgent midline laparotomy was performed, revealing a 20-cm gastric GIST in the anterior wall of the antrum. Wedge resection was performed. The anatomopathological report confirmed the diagnosis of gastric GIST with a moderate risk of recurrence. The patient received adjuvant therapy for 3 years. No recurrence was detected. CLINICAL DISCUSSION Bleeding gastric GISTs revealed by a hypovolemic shock is a rare yet critical scenario. Considering GISTs as an etiology of digestive bleeding in life-threatening cases requires a high index of clinical suspicion. Prompt intervention is vital to control hemostasis and ensure patient stability. CONCLUSION Open surgery is mandatory for large bleeding GISTs. The surgical approach must be tailored to the tumor's specific location. Diligent execution of the surgical procedure is vital to prevent tumor rupture. Despite their size, these tumors have a favorable prognosis, enhanced by adjuvant therapy for moderate to high recurrence risk.
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Affiliation(s)
- Anis Hasnaoui
- Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebel Lakhdar, 1006 Tunis, Tunisia; Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
| | - Racem Trigui
- Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebel Lakhdar, 1006 Tunis, Tunisia.
| | - Mohamed Ben Hassine
- Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebel Lakhdar, 1006 Tunis, Tunisia
| | - Salma Kacem
- Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebel Lakhdar, 1006 Tunis, Tunisia; Faculty of Medicine of Tunis, Tunis El Manar University, Tunisia
| | - Houda Bellamine
- Department of Anatomopathology, Menzel Bourguiba Hospital, Rue Djebel Lakhdar, 1006 Tunis, Tunisia
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Jovanovic MM, Stefanovic AD, Sarac D, Kovac J, Jankovic A, Saponjski DJ, Tadic B, Kostadinovic M, Veselinovic M, Sljukic V, Skrobic O, Micev M, Masulovic D, Pesko P, Ebrahimi K. Possibility of Using Conventional Computed Tomography Features and Histogram Texture Analysis Parameters as Imaging Biomarkers for Preoperative Prediction of High-Risk Gastrointestinal Stromal Tumors of the Stomach. Cancers (Basel) 2023; 15:5840. [PMID: 38136387 PMCID: PMC10742259 DOI: 10.3390/cancers15245840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The objective of this study is to determine the morphological computed tomography features of the tumor and texture analysis parameters, which may be a useful diagnostic tool for the preoperative prediction of high-risk gastrointestinal stromal tumors (HR GISTs). METHODS This is a prospective cohort study that was carried out in the period from 2019 to 2022. The study included 79 patients who underwent CT examination, texture analysis, surgical resection of a lesion that was suspicious for GIST as well as pathohistological and immunohistochemical analysis. RESULTS Textural analysis pointed out min norm (p = 0.032) as a histogram parameter that significantly differed between HR and LR GISTs, while min norm (p = 0.007), skewness (p = 0.035) and kurtosis (p = 0.003) showed significant differences between high-grade and low-grade tumors. Univariate regression analysis identified tumor diameter, margin appearance, growth pattern, lesion shape, structure, mucosal continuity, enlarged peri- and intra-tumoral feeding or draining vessel (EFDV) and max norm as significant predictive factors for HR GISTs. Interrupted mucosa (p < 0.001) and presence of EFDV (p < 0.001) were obtained by multivariate regression analysis as independent predictive factors of high-risk GISTs with an AUC of 0.878 (CI: 0.797-0.959), sensitivity of 94%, specificity of 77% and accuracy of 88%. CONCLUSION This result shows that morphological CT features of GIST are of great importance in the prediction of non-invasive preoperative metastatic risk. The incorporation of texture analysis into basic imaging protocols may further improve the preoperative assessment of risk stratification.
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Affiliation(s)
- Milica Mitrovic Jovanovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Aleksandra Djuric Stefanovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Dimitrije Sarac
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
| | - Jelena Kovac
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Aleksandra Jankovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Dusan J. Saponjski
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Boris Tadic
- Department for HBP Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Milena Kostadinovic
- Center for Physical Medicine and Rehabilitation, University Clinical Centre of Serbia, Pasterova Street, No. 2, 11000 Beograd, Serbia
| | - Milan Veselinovic
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
| | - Vladimir Sljukic
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
| | - Ognjan Skrobic
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
| | - Marjan Micev
- Department for Pathology, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street, No. 6, 11000 Belgrade, Serbia
| | - Dragan Masulovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Centre of Serbia, Pasterova No. 2, 11000 Belgrade, Serbia; (M.M.J.)
- Department for Radiology, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
| | - Predrag Pesko
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
| | - Keramatollah Ebrahimi
- Department for Surgery, Faculty of Medicine, University of Belgrade, Dr Subotica No. 8, 11000 Belgrade, Serbia
- Department of Stomach and Esophageal Surgery, Clinic for Digestive Surgery, University Clinical Centre of Serbia, Koste Todorovica Street No. 6, 11000 Belgrade, Serbia
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Wang L, Ni Z, Xu W, Mei Y, Li C, Zhu Z, Liu W. Clinical characteristics and outcomes of gastrointestinal stromal tumor patients receiving surgery with or without TKI therapy: a retrospective real-world study. World J Surg Oncol 2023; 21:21. [PMID: 36691015 PMCID: PMC9869533 DOI: 10.1186/s12957-023-02897-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To retrospectively analyze the clinical characteristics of patients undergoing surgical treatment for gastrointestinal stromal tumors (GISTs) in Ruijin Hospital and explore the relevant prognosis clinical factors after surgical treatment. METHODS We screened out 1015 patients with GISTs diagnosed and treated during January 2010 to December 2019. We performed univariate analysis by the log-rank test and multivariate analysis by COX regression. The Kaplan-Meier method was used to estimate the disease-free survival (DFS) and overall survival (OS) of the whole group. RESULTS All 1015 patients in the whole group received radical surgery, and the proportion of patients with high, intermediate, and low risk was 31.1%, 21.7%, and 47.3%, respectively. Among the 480 low-risk patients, surgery could achieve radical therapy; only the Ki-67 index was related to DFS and OS (DFS: p = 0.032, OS: p = 0.009) among the 140 intermediate-risk patients with tumors located in the stomach, whether received Tyrosine kinase inhibitors (TKIs) therapy did not affect the prognosis of patients (DFS: p = 0.716, OS: p = 0.848). Among the 331 high-risk patients, those with non-gastric tumors (those outside the stomach, duodenum, and small intestine, HR 1.55, 95% CI 1.19-2.00, p < 0.001), tumor diameter > 10 cm (hazard ratio, HR 2.63, 95% confidence interval, CI 2.09-4.03, p < 0.001), as well as high-risk patients with mitotic rate > 10/50 HPF (HR 2.74, 95% CI 2.00-3.76, p < 0.001), the overall prognosis was obviously worse than that of other patients. For some high-risk patients, prolonged postoperative imatinib therapy could significantly improve the survival of patients (HR 0.43, 95% CI 0.15-0.66, p < 0.001). CONCLUSIONS For the vast majority of GIST patients, surgery can be curative; but in intermediate-risk patients, the Ki-67 index and postoperative TKI treatment are closely related to prognosis. For intermediate-risk patients whose primary tumor is the stomach, the value of TKI-targeted therapy after surgery seem be not necessary in our study. However, for some high-risk patients, the prognosis of patients can be improved by appropriately prolonging the treatment time of TKI.
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Affiliation(s)
- Lingquan Wang
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhentian Ni
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wei Xu
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yu Mei
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Chen Li
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Zhenggang Zhu
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China. .,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Wentao Liu
- Department of General Surgery, Shanghai Institute of Digestive Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China. .,Shanghai Key Laboratory of Gastric Neoplasms, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Balogun OS, Osinowo AO, Abdulkareem FB, Ajayi OO, Atoyebi OA, Rocha-Afodu JTD. Clinicopathological features, risk profile assessment, and the surgical outcome of gastrointestinal stromal tumors in Lagos, Nigeria. Ann Afr Med 2022; 21:432-438. [PMID: 36412347 PMCID: PMC9850878 DOI: 10.4103/aam.aam_172_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs originate from the interstitial cells of Cajal and are most commonly found in the stomach. Most available reports on GISTs in the Sub-Sahara Africa were in case reports and case series. Aim To report our local experience and challenges in the management of GISTs in 33 patients in Lagos, Nigeria. Methodology This is a descriptive study of adult patients of 16 years and above managed for GISTs at the Lagos University Teaching Hospital and some Lagos private hospital facilities between January 2015 and March 2021. Information on the patients' demographic characteristics, clinicopathological features, surgery performed, and postoperative complications were retrieved from the hospital's medical records for analysis. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 23.0., Armonk, NY, USA: IBM Corp. Results Thirty-three patients comprising 19 males and 14 females with a male: female ratio of 1.4:1 were included in the study. The mean age at presentation was 52.5 years. Abdominal pain (69.7%) and anemic symptoms (45.4%) were the principal modes of presentation. Abdominal computed tomography (CT) scan revealed stomach as the primary source of GISTs in 75.8% of patients. Forty-five percent of the patients had CT features of local organ invasion and 27.2% had features of metastasis. Surgical resection was feasible in 28 (84.8%) patients. Postoperative mortality was recorded in two patients with recurrent GISTs. Histological cell types were spindle cell (57.6%), mixed spindle and epithelioid (24.2%), and epithelioid (18.2%). Joensuu high-risk tumors (64. 3%) were the most prevalent in our series. Conclusion Advanced-stage disease and features of anemia were hallmarks of GISTs among patients in this series. Surgical resection of GIST may be possible in some cases of advanced disease. Spindle cell types and high-risk GISTs were the most common pathological varieties in our patients.
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Affiliation(s)
- Olanrewaju Samuel Balogun
- Department of Surgery, General Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria,Address for correspondence: Dr. Olanrewaju Samuel Balogun, Department of Surgery, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Nigeria. E-mail:
| | - Adedapo Olumide Osinowo
- Department of Surgery, General Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Olugbenga O. Ajayi
- Department of Anatomic and Molecular Pathology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Oluwole Ayoola Atoyebi
- Department of Surgery, General Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria
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Uzunoglu H, Tosun Y, Akinci O, Baris B. Gastrointestinal stromal tumors of the stomach: A 10-year experience of a single-center. Niger J Clin Pract 2021; 24:1785-1792. [PMID: 34889786 DOI: 10.4103/njcp.njcp_558_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Gastrointestinal tract stromal tumors (GIST) are the most common mesenchymal tumors in the gastrointestinal tract (GIS). GISTs may cause significant morbidity and mortality rates. Aim In this study, it was aimed to evaluate 10 years of gastric GIST cases followed in our hospital, and to analyze the prognostic factors. Subjects and Methods In this single-center retrospective study, a total of 64 patients who were operated between May 2010 and May 2020 due to gastric GIST tumor were reviewed. Clinical and pathological features, risk classifications, overall survival (OS) and disease-free survival (DFS) were evaluated. Results According to the risk classification, 18.8% of the patients were in the high-risk group. The overall 5-year OS and DFS rates were 85.7%. The mean OS of the patients was 47.9 SD36.2 months, and the duration of DFS was 45.5 months. Patients with a 5-year OS rate above 5 cm in diameter (P = 0.024), with a mitotic index above 5/50 high power field (HPF) (P = 0.038), and those with a high-risk group (P = 0.011) were significantly lower than the other group. In the correlation analysis, it was found that tumor diameter correlated significantly with OS (P = 0.034; r = -0.317). Tumor diameter and mitotic index were found to be inversely correlated with DFS duration (P = 0.004; r = -0.425 and P = 0.035; r = -0.316, respectively). Conclusion Our findings showed that in gastric GIST cases, as the primary tumor diameter and mitotic index increase, correlate with survival rates and the mean overall and disease-free survival times decrease.
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Affiliation(s)
- H Uzunoglu
- Department of General Surgery, Kartal Dr Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Y Tosun
- Department of General Surgery, Kartal Dr Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - O Akinci
- Department of General Surgery, Kartal Dr Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - B Baris
- Department of General Surgery, Kartal Dr Lütfi Kırdar City Hospital, Istanbul, Turkey
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Costa RDD, Kemp R, Santos JSD, Costa DAPD, Ardengh JC, Ribas-Filho JM, Ribas CAPM. THE ROLE OF CONVENTIONAL ECHOENDOSCOPY (EUS) IN THERAPEUTIC DECISIONS IN PATIENTS WITH NEUROENDOCRINE GASTROINTESTINAL TUMORS. ACTA ACUST UNITED AC 2020; 33:e1512. [PMID: 32844878 PMCID: PMC7448866 DOI: 10.1590/0102-672020190001e1512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/23/2020] [Indexed: 12/14/2022]
Abstract
Background:
Gastrointestinal neuroendocrine tumors are rare, usually presented as
subepithelial or polypoid tumors. Accurate diagnosis and indication of the
type of resection are still challenging.
Aim:
To determine the effectiveness of echoendoscopy in determining the depth of
the lesions (T) identified by endoscopy in order to evaluate surgical and/or
endoscopic indication, and to evaluate the results of endoscopic removal in
the medium term.
Methods:
Twenty-seven patients were included, all of whom underwent echoendoscopy for
TN tumor staging and the evaluation of possible endoscopic resection. The
parameters were: lesion size, origin layer, depth of involvement and
identified perilesional adenopathies. The inclusion criteria for endoscopic
resection were: 1) high surgical risk; 2) those with NET <2 cm; 3)
absence of impairment of the muscle itself; and 4) absence of perilesional
adenopathies in echoendoscopy and in others without distant metastases.
Exclusion criteria were TNE> 2 cm; those with infiltration of the muscle
itself; with perilesional adenopathies and distant metastases. The
techniques used were: resection with polypectomy loop; mucosectomy with
saline injection; and mucosectomy after ligation with an elastic band. The
anatomopathological study of the specimens included evaluation of the
margins and immunohistochemistry (chromogranin, synaptophysin and Ki 67) to
characterize the tumor. Follow-up was done at 1, 6 and 12 months.
Results:
Resections with polypectomy loop were performed in 15 patients; mucosectomy
in five; mucosectomy and ligation with elastic band in three and the
remaining four were referred for surgery. The anatomopathological specimens
and immunohistochemical analyzes showed positive chromogranin and
synaptophysin, while Ki 67 was less than 5% among all cases. The medium-term
follow-up revealed three recurrences. The average size of tumors in the
stomach was 7.6 mm and in the duodenum 7.2 mm. Well-demarcated, hypoechoic,
homogeneous lesions occurred in 75%; mucous layer in 80%; and the deep and
submucosal mucosa in 70%.
Conclusions:
Echoendoscopy proved to be a good method for the study of subepithelial
lesions, being able to identify the layer affected by the neoplasm, degree
of invasion, echogenicity, heterogeneity, size of the lesion and
perilesional lymph node involvement and better indicate the treatment
option.
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Affiliation(s)
- Rodrigo Dias da Costa
- Medical Research Institute, University Evangelical Hospital of Curitiba, Evangelical Faculty of Paraná, Curitiba, PR, Brazil
| | - Rafael Kemp
- Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - José Sebastião Dos Santos
- Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | | | - José Celso Ardengh
- Medical Research Institute, University Evangelical Hospital of Curitiba, Evangelical Faculty of Paraná, Curitiba, PR, Brazil
| | - Jurandir Marcondes Ribas-Filho
- Medical Research Institute, University Evangelical Hospital of Curitiba, Evangelical Faculty of Paraná, Curitiba, PR, Brazil
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