CHEST WALL RESECTION FOR LOCOREGIONAL RECURRENCE OF BREAST CANCER: A FEASIBLE AND EFFECTIVE / Ressecção da parede torácica para recidiva locorregional de câncer de mama: um método efetivo e reprodutível

Objective: The aim of this study was to evaluate survival after chest wall resection for breast cancer locoregional recurrence. Secondary endpoints were symptomatic control and safety of the procedure. Method: This was a retrospective review including all patients who underwent chest wall resection for breast cancer local recurrence at the Division of Thoracic Surgery of the School of Medicine of São Paulo University, from January 1998 to November 2011. Full thickness chest wall resection involving bones and/or soft tissues was performed to achieve macroscopical free margins. Results: Eighteen patients were included in this study with a mean followup of 83.5 months. The interval between mastectomy and chest wall recurrence (CWR) was 4.2 years (0.5 to 9 years). The resection was complete in 12 patients (66%) and incomplete in 6 (33%), in whose resection would involve amputation of an upper limb. Mean tumor size was 8.25 cm and resection of the costal arch was necessary in 10 patients. There was no operation death and after two years, 66% of patients were alive. Six patients died due to distant recurrence of breast cancer on patients who died to inflammatory acute abdomen. The mean survival among patients who died was 25.2 months (12 to 42 months). At the last follow up visit, eleven patients were alive. Conclusion: CWR for locally recurrent breast cancer is feasible and safe in selected patients, who did not develop metastatic disease, allowing good quality of life for a considerable period. Larger and prospective series are needed to endorse our findings.

Objetivo: O objetivo deste estudo foi avaliar a sobrevida após ressecção da parede torácica para recidiva locorregional de c âncer de mama. Desfechos secundários foram controle dos sintomas e a segurança do procedimento. Métodos: Estudo retrospectivo de todos os pacientes submetidos à ressecção da parede torácica para recidiva local do câncer de mama na Divisão de Cirurgia Torácica da Faculdade de Medicina da Universidade de São Paulo, de janeiro de 1998 a novembro de 2011. A ressecção da parede torácica foi realizada com espessura total podendo envolver ossos e/ou tecidos moles, a fim de atingir margens livres macroscópicas. Resultados: Dezoito pacientes foram incluídos neste estudo, com seguimento médio de 83,5 meses. O intervalo entre a mastectomia e a recidiva da parede torácica (RPT) foi de 4,2 anos (0,5 a 9 anos). A ressecção foi completa em 12 pacientes (66%) e incompleta em 6 (33%), cuja ressecção envolveria a amputação do membro superior. O tamanho médio do tumor foi de 8,25cm e a ressecção do arco costal foi necessária em 10 pacientes. Não houve óbito devido à operação e, após dois anos, 66% dos pacientes estavam vivos. Seis pacientes morreram devido à recorrência sistêmica do câncer de mama e uma paciente morreu devido a um abdome agudo inflamatório. A sobrevida média entre os pacientes que morreram foi de 25,2 meses (12 a 42 meses). Na última consulta de acompanhamento, onze pacientes estavam vivos. Conclusões: A RPT para a recidiva locorregional do câncer de mama é factível e segura em pacientes selecionados, que não desenvolveram doença metastática, permitindo boa qualidade de vida por um período considerável. São necessárias séries maiores e prospectivas para endossar nossas achados

Protocolo fisioterapêutico aplicado no pós-operatório imediato para recuperação acelerada de pacientes submetidos à procedimentos cirúrgicos torácicos no Hospital Santa Marcelina ­ Itaquera (PROSM): estudo clínico randomizado / Physiotherapeutic protocol applied in the immediate postoperative period for accelerated recovery of patients submitted to thoracic surgery at the Hospital Santa Marcelina (Brazil): randomized clinical trial

INTRODUÇÃO: A cirurgia torácica pode causar uma série de complicações pulmonares após o processo cirúrgico. O momento e a circunstância ideais para sedestação fora do leito e suas implicações clínicas, após cirurgias no tórax, ainda necessitam de padronização. Assim, faz-se necessário um tratamento de mobilização precoce adequado visando minimizar as complicações no período pós-operatório. OBJETIVOS: Objetivamos avaliar o efeito do atendimento fisioterapêutico no pós-operatório imediato de pacientes submetidos à cirurgia torácica. MATERIAIS E MÉTODOS: Este será um ensaio clínico randomizado, no qual um grupo de pacientes submetidos às cirurgias de ressecções pulmonares eletivas (segmentectomias, lobectomias ou pneumonectomias) com idade superior a dezoito anos receberão atendimento fisioterapêutico através do PROSM. Serão excluídos os pacientes incapazes de assinar o termo de consentimento livre esclarecido, com performance status comprometido (ECOG superior à 2), com peso corporal inferior à 60 Kg ou superior à 120 Kg, com alergia a qualquer uma das drogas utilizadas na anestesia, portadores de disfunção renal, disfunção hepática (Child B e C) e Insuficiência Cardíaca (classe Funcional III e IV). O instrumento de classificação do grau da dor por meio da Escala Visual Analógica (EVA) e instrumento de classificação da independência funcional por meio da Escala MIF (medida de independência funcional) serão aplicados antes do início e após o término de cada sessão de fisioterapia. Também será analisado o número de sessões de cada paciente e o tempo de internação. Para análise estatística será utilizado o programa SPSS Statistics e o teste de Shapiro-Wilk será usado para identificar a normalidade dos dados coletados. Espera-se um menor tempo de internação e melhor independência funcional na alta hospitalar nos pacientes submetidos ao PROSM. [AU]

INTRODUCTION: Thoracic surgery can cause a series of pulmonary complications after the surgical procedure. The ideal timing and circumstance for out-of-bed sedation and its clinical implications, after chest surgeries, still require standardization. Thus, an appropriate early mobilization treatment is necessary in order to minimize complications in the postoperative period. OBJECTIVES: We aimed to evaluate the effect of physical therapy care in the immediate postoperative period of patients undergoing thoracic surgery. METHODS AND MATERIALS: This will be a randomized clinical trial in which a group of patients undergoing elective pulmonary resections (segmentectomies, lobectomies or pneumonectomies) aged over eighteen years will receive physiotherapeutic care through PROSM. Patients under the age of eighteen years, unable to sign the informed consent form, with compromised performance status (ECOG greater than 2), with a body weight below 60 kg or greater than 120 kg, with a history of allergy to any of the drugs used in anesthesia, patients with renal dysfunction, liver dysfunction (Child B and C) and Heart Failure (Functional class III and IV). The instrument of classification of pain grade by means of the Visual Analogue Scale (EVA) and instrument of classification of functional independence by means of the MIF Scale (functional independence measure) will be applied before the beginning and after the end of each physiotherapy session. We will also analyze the number of sessions of each patient and the length of hospital stay. For statistical analysis, the SPSS Statistics program will be used and the Shapiro-Wilk test will be used to identify the normality of the data collected. It is expected a shorter hospitalization time and better functional independence at hospital discharge in patients submitted to PROSM. [AU]

Impact of the delay to start treatment in patients with lung cancer treated in a densely populated area of Brazil

OBJECTIVES: The aim of this study is to evaluate the access of patients with lung cancer in a densely populated area of São Paulo to the Brazilian Public Health System, focusing on the time spent from symptom onset or initial diagnosis until the beginning of treatment. METHODS: We retrospectively reviewed 509 patients with malignant lung neoplasms who were admitted to a single reference oncology center of the public health system between July 2008 and December 2014. Patients were considered eligible for this study if they were older than 18 years and had not undergone any previous oncology treatment when they were admitted to the institution. The following data were collected from all patients: age, gender, smoking status, tumor staging, time from the when the first symptoms were experienced by the patient to when the patient was diagnosed with cancer, time from the first appointment to cancer diagnosis, and time from when the patient was diagnosed with cancer to the initiation of treatment. RESULTS: The median time from symptom onset to diagnosis was three months. From the first appointment to diagnosis, the median time interval was one month; however, 79% of patients were diagnosed in up to two months. The median time from diagnosis to the start of treatment was one month, but most patients (82.5%) started treatment in up to two months. CONCLUSION: In our highly populated region with preferential access to the public health system, patients are required to wait a relatively long time to effectively begin treatment for lung cancer. This type of study is important to alert medical societies and government health agencies.

Use of indwelling pleural catheters for the definitive treatment of malignant pleural effusion / Utilização de cateter pleural de longa permanência para o tratamento definitivo de derrame pleural neoplásico

ABSTRACT Objective: To evaluate the safety and feasibility of the use of indwelling pleural catheters (IPCs) in patients with malignant pleural effusion (MPE). Methods: We prospectively collected data from patients with MPE undergoing IPC placement between January of 2014 and July of 2015. All patients submitted to IPC placement had a life expectancy > 30 days, in accordance with the MPE treatment guidelines established by the British Thoracic Society. The data collected included gender, age, body mass index, primary cancer site, duration of IPC drainage, IPC-related complications, length of hospital stay, pleural effusion recurrence, and occurrence of spontaneous pleurodesis. Results: A total of 19 patients underwent IPC placement during the study period. Median overall survival after IPC insertion was 145 days. The median follow-up among the surviving patients was 125 days (range, 53-485 days), and the median time between catheter insertion and removal was 31 days (range, 2-126 days). There were IPC-related complications in 5 patients (26.2%), and spontaneous pleurodesis was achieved in 8 (42.0%). Among those 8 patients, the IPC was removed between days 30 and 126 in 4, and spontaneous pleurodesis occurred within the first 30 days in 4. Conclusions: The use of IPCs seems to be feasible and safe in patients with MPE.

RESUMO Objetivo: Avaliar a segurança e a viabilidade do uso de cateter pleural de longa permanência (CPLP) em pacientes com derrame pleural neoplásico (DPN). Métodos: Dados referentes a pacientes com DPN que receberam CPLP entre janeiro de 2014 e julho de 2015 foram colhidos prospectivamente. Todos os pacientes que receberam CPLP tinham expectativa de vida > 30 dias, em conformidade com as diretrizes de tratamento de DPN da Sociedade Torácica Britânica. Foram colhidos dados sobre sexo, idade, índice de massa corporal, local do câncer primário, tempo de drenagem com o CPLP, complicações relacionadas com o CPLP, tempo de internação hospitalar, recidiva do derrame pleural e ocorrência de pleurodese espontânea. Resultados: Dezenove pacientes receberam CPLP durante o período de estudo. A mediana de sobrevida global após a inserção do CPLP foi de 145 dias. A mediana de tempo de acompanhamento dos pacientes sobreviventes foi de 125 dias (variação: 53-485 dias), e a mediana de tempo decorrido entre a inserção e a remoção do cateter foi de 31 dias (variação: 2-126 dias). Houve complicações relacionadas com o CPLP em 5 pacientes (26,2%) e pleurodese espontânea em 8 (42,0%). Nesses 8 pacientes, o CPLP foi retirado entre os dias 30 e 126 em 4, e a pleurodese espontânea ocorreu nos primeiros 30 dias em 4. Conclusões: O uso de CPLP parece ser viável e seguro em pacientes com DPN.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES: To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team. METHOD: A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position. RESULTS: There were no deaths in any of the series. Minor complications occurred in six (4.9 percent) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5 percent) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series. CONCLUSION: The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Tumor glômico endobrônquico com atelectasia de lobo superior direito / Bronchial glomus tumor with right upper lobe atelectasis

Tumores glômicos são raras neoplasias benignas de tecidos moles. Relatamos o caso de um paciente de 32 anos de idade que apresentava atelectasia em lobo superior direito devido a um tumor endobrônquico. O paciente foi submetido a lobectomia superior direita e broncoplastia em cunha. O diagnóstico patológico foi de tumor glômico endobrônquico. Até onde sabemos, essa apresentação com atelectasia em lobo superior direito nunca foi relatada. O tumor glômico deve ser considerado no diagnóstico diferencial de lesões endobrônquicas que causam atelectasia lobar.

Glomus tumors are uncommon benign soft tissue neoplasms. We report the case of a 32-year-old male who presented with right upper lobe atelectasis due to an endobronchial tumor. The patient underwent right upper lobectomy and wedge bronchoplasty. The pathological diagnosis was bronchial glomus tumor. To our knowledge, this presentation (with right upper lobe atelectasis) has never before been reported. Glomus tumor should be considered in the differential diagnosis of endobronchial lesions causing lobar atelectasis.

Utilidade da pericardioscopia no diagnóstico de derrame pericárdico / Usefulness of pericardioscopy in the diagnosis of pericardial effusion

O pericárdio pode ser afetado por doenças infecciosas, neoplásicas, inflamatórias e metabólicas. Muitas condições exigem tratamentos específicos, de forma que um diagnóstico preciso é importante. Assim, a biópsia do pericárdio tem um papel importante na avaliação dos derrames pericárdicos. A pericardioscopia oferece a vantagem da tradicional abordagem subxifóide ao permitir acesso a partes do pericárdio que não poderiam ser alcançadas através de palpação digital, bem como visibilização direta através da janela subxifóide ou toracoscopia. Reportamos o caso de um paciente com grande derrame pericárdico e massa mediastinal não-diagnosticada, em quem a pericardioscopia videoassistida foi fundamental no diagnóstico e tratamento da doença.

The pericardium can be affected by infectious, neoplastic, inflammatory and metabolic diseases. Many conditions require specific treatment and, consequently, an accurate diagnosis is important. Therefore, the pericardial biopsy has an important role in the evaluation of pericardial effusions. The pericardioscopy offers the advantage of the traditional subxiphoid approach, as it allows access to parts of the pericardium that would not be reached by digital palpation, as well as direct visualization through the subxiphoid window or thoracoscopy. We report the case of a patient with a large pericardial effusion and an undiagnosed mediastinal mass, in which video-assisted pericardioscopy was fundamental in the diagnosis and treatment of the disease.

Spirometric assessment of lung transplant patients: one year follow-up

OBJECTIVE: The purpose of this study was to compare spirometry data between patients who underwent single-lung or double-lung transplantation the first year after transplantation. INTRODUCTION: Lung transplantation, which was initially described as an experimental method in 1963, has become a therapeutic option for patients with advanced pulmonary diseases due to improvements in organ conservation, surgical technique, immunosuppressive therapy and treatment of post-operative infections. METHODS: We retrospectively reviewed the records of the 39 patients who received lung transplantation in our institution between August 2003 and August 2006. Twenty-nine patients survived one year post-transplantation, and all of them were followed. RESULTS: The increase in lung function in the double-lung transplant group was more substantial than that of the single-lung transplant group, exhibiting a statistical difference from the 1st month in both the forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) in comparison to the pre-transplant values (p <0.05). Comparison between double-lung transplant and single lung-transplant groups of emphysema patients demonstrated a significant difference in lung function beginning in the 3rd month after transplantation. DISCUSSION: The analyses of the whole group of transplant recipients and the sub-group of emphysema patients suggest the superiority of bilateral transplant over the unilateral alternative. Although the pre-transplant values of lung function were worse in the double-lung group, this difference was no longer significant in the subsequent months after surgery. CONCLUSION: Although both groups demonstrated functional improvement after transplantation, there was a clear tendency to greater improvement in FVC and FEV1 in the bilateral transplant group. Among our subjects, double-lung transplantation improved lung function.