Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer

Abstract Introduction Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. Methods Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. Results Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. Conclusion Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Current morbimortality and one-year survival after pneumonectomy for infectious diseases

Abstract Objective: Identify the one-year survival rate and major complications in patients submitted to pneumonectomy for infectious disease. Methods: Retrospective data from all cases of infectious disease pneumonectomy over the past 10 years were collected from two reference centers. The authors analyzed: patient demographics, etiology, laterality, bronchial stump treatment, presence of previous pulmonary resection, postoperative complications in the first 30 days, the treatment used in pleural complications, and one-year survival rate. Results: 56 procedures were performed. The average age was 44 years, with female predominance (55%). 29 cases were operated on the left side (51%) and the most frequent etiology was post-tuberculosis (51.8%). The overall incidence of complications was 28.6% and the most common was empyema (19.2%). Among empyema cases, 36.3% required pleurostomy, 27.3% required pleuroscopy and 36.3% underwent thoracoplasty for treatment. Bronchial stump fistula was observed in 10.7% of cases. From all cases, 16.1% were completion pneumonectomies and 62.5% of these had some complication, a significantly higher incidence than patients without previous surgery (p = 0.0187). 30-day in-hospital mortality was (7.1%) with 52 cases (92.9%) and 1-year survival. The causes of death were massive postoperative bleeding (1 case) and sepsis (3 cases). Conclusions: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. While morbidity is often significant, once the perioperative risk has passed, the one-year survival rate can be very satisfying in selected patients with benign disease.

Risk factors related to pleural empyema after talc slurry pleurodesis

Abstract Objective: Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. Methods: Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. Results: Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87-33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90-22.86; p = 0.067), and patients with 50-70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98-15; p = 0.053) after pleurodesis. Conclusion: The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country

Abstract Background: The use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. Methods: From August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. Results: 56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). Conclusion: IPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country. HIGHLIGHTS Indwelling pleural catheter represents a suitable option for patients with malignant pleural effusion and short life expectancy. It relieves respiratory symptoms without compromising the quality of life, and the complication rate is low, even in an emerging country, with a low socioeconomic and under-educated patient population. The rate of spontaneous pleurodesis was 45%. The analysis of the visual analog scale showed significant control of dyspnea (p = 0.001), but pain and quality of life did not change significantly.

Mesothelioma in a developing country: a retrospective analysis of the diagnostic process / Mesotelioma em um país em desenvolvimento: análise retrospectiva do processo diagnóstico

ABSTRACT Objective: To evaluate the process of diagnosing patients with malignant pleural mesothelioma (MPM) at a tertiary care hospital. Methods: This was a retrospective study involving patients referred to a tertiary-care cancer center in Brazil between 2009 and 2020. The diagnostic process was divided into four steps: onset of symptoms, referral to a specialist visit, histopathological diagnosis, and beginning of treatment. The intervals between each phase and the factors for delays were evaluated. Data including clinical status, radiological examinations, staging, treatment modalities, and survival outcomes were collected. Results: During the study period, 66 patients (mean age = 64 years) were diagnosed with MPM and underwent treatment. Only 27 (41%) of the patients had knowledge of prior exposure to asbestos. The median number of months (IQR) between the onset of symptoms and the first specialist visit, between the specialist visit and histopathological characterization, and between definite diagnosis and beginning of treatment was, respectively, 6.5 (2.0-11.4), 1.5 (0.6-2.1), and 1.7 (1.2-3.4). The knowledge of prior asbestos exposure was associated with a shorter time to referral to a specialist (median: 214 vs. 120 days; p = 0.04). A substantial number of nondiagnostic procedures and false-negative biopsy results (the majority of which involved the use of Cope needle biopsy) were found to be decisive factors for the length of waiting time. The mean overall survival was 11.9 months. Conclusions: The unfamiliarity of health professionals with MPM and the patient's lack of knowledge of prior asbestos exposure were the major factors to cause a long time interval between the onset of symptoms and beginning of treatment. An overall survival shorter than 1 year is likely to have been due to the aforementioned delays.

RESUMO Objetivo: Avaliar o processo de diagnóstico de pacientes com mesotelioma pleural maligno (MPM) em um hospital terciário. Métodos: Estudo retrospectivo envolvendo pacientes encaminhados a um centro oncológico terciário no Brasil entre 2009 e 2020. O processo diagnóstico foi dividido em quatro etapas: início dos sintomas, encaminhamento para consulta especializada, diagnóstico histopatológico e início do tratamento. Foram avaliados os intervalos entre as etapas e os fatores de atraso. Os dados coletados incluíram estado clínico, exames radiológicos, estadiamento, modalidades de tratamento e resultados de sobrevida. Resultados: Durante o período do estudo, 66 pacientes (média de idade = 64 anos) foram diagnosticados com MPM e submetidos a tratamento. Apenas 27 (41%) dos pacientes tinham conhecimento de exposição prévia ao amianto. A mediana de meses (IIQ) entre o início dos sintomas e a primeira consulta especializada, entre a consulta especializada e a caracterização histopatológica e entre o diagnóstico definitivo e o início do tratamento foi, respectivamente, de 6,5 (2,0-11,4), 1,5 (0,6 -2,1) e 1,7 (1,2-3,4). Conhecimento de exposição prévia ao amianto associou-se a menor tempo para encaminhamento a um especialista (mediana: 214 vs. 120 dias; p = 0,04). O número substancial de procedimentos não diagnósticos e as biópsias falso-negativas (a maioria envolvendo o uso de biópsia com agulha de Cope) foram considerados fatores decisivos para o tempo de espera. A sobrevida global média foi de 11,9 meses. Conclusões: A falta de familiaridade dos profissionais de saúde com o MPM e o desconhecimento dos pacientes em relação à exposição prévia ao amianto foram os principais fatores que ocasionaram um longo intervalo de tempo entre o início dos sintomas e o início do tratamento. A sobrevida global inferior a 1 ano provavelmente se deve aos atrasos supracitados.

A Brazilian randomized study: Robotic-Assisted vs. Video-assisted lung lobectomy Outcomes (BRAVO trial) / Estudo brasileiro randomizado: desfechos da lobectomia pulmonar robótica vs. videoassistida (estudo BRAVO)

ABSTRACT Objective: To compare 90-day morbidity in patients undergoing lung lobectomy performed by either robotic-assisted thoracic surgery (RATS) or video-assisted thoracic surgery (VATS). Intraoperative complications, drainage time, length of hospital stay, postoperative pain, postoperative quality of life, and readmissions within 90 days were also compared. Methods: This was a two-arm randomized clinical trial including patients with lung lesions (primary lung cancer or lung metastasis) who were candidates for lung lobectomy. Patients with comorbidities that precluded surgical treatment were excluded. All patients followed the same postoperative protocol. Results: The overall sample comprised 76 patients (39 in the VATS group and 37 in the RATS group). The two groups were similar regarding gender, age, BMI, FEV1 in % of predicted, and comorbidities. Postoperative complications within 90 days tended to be more common in the VATS group than in the RATS group, but the difference was not significant (p = 0.12). However, when only major complications were analyzed, this tendency disappeared (p = 0.58). Regarding postoperative outcomes, the VATS group had a significantly higher number of readmissions within 90 days than did the RATS group (p = 0.029). No significant differences were found regarding intraoperative complications, drainage time, length of hospital stay, postoperative pain, and postoperative quality of life. Conclusions: RATS and VATS lobectomy had similar 90-day outcomes. However, RATS lobectomy was associated with a significant reduction in the 90-day hospital readmission rate. Larger studies are necessary to confirm such a finding. (ClinicalTrials.gov identifier: NCT02292914 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Comparar a morbidade em 90 dias de pacientes submetidos à lobectomia pulmonar por robotic-assisted thoracic surgery (RATS, cirurgia torácica robótica) ou por video-assisted thoracic surgery (VATS, cirurgia torácica videoassistida). Complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória, qualidade de vida pós-operatória e reinternações em 90 dias também foram comparados. Métodos: Ensaio clínico randomizado, com dois braços, incluindo pacientes com lesões pulmonares (câncer de pulmão primário ou metástase pulmonar) candidatos à lobectomia pulmonar. Foram excluídos pacientes com comorbidades que impossibilitassem o tratamento cirúrgico. Todos os pacientes seguiram o mesmo protocolo pós-operatório. Resultados: A amostra total foi composta por 76 pacientes (39 no grupo VATS e 37 no grupo RATS). Os dois grupos foram semelhantes quanto a sexo, idade, IMC, VEF1 em % do previsto e comorbidades. Complicações pós-operatórias em 90 dias tenderam a ser mais frequentes no grupo VATS do que no grupo RATS, mas a diferença não foi significativa (p = 0,12). No entanto, quando analisadas apenas as complicações maiores, essa tendência desapareceu (p = 0,58). Quanto aos desfechos pós-operatórios, o grupo VATS apresentou um número significativamente maior de reinternações em 90 dias do que o grupo RATS (p = 0,029). Não foram encontradas diferenças significativas quanto a complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória e qualidade de vida pós-operatória. Conclusões: A lobectomia por RATS e a lobectomia por VATS apresentaram desfechos em 90 dias semelhantes. No entanto, a lobectomia por RATS foi associada a uma redução significativa na taxa de reinternação hospitalar em 90 dias. Estudos maiores são necessários para confirmar esse achado. (Identificador ClinicalTrials.gov: NCT02292914 [http://www.clinicaltrials.gov/])

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review

ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

Robotic thoracic surgery for inflammatory and infectious lung disease: initial experience in Brazil / Cirurgia torácica robótica para doença pulmonar inflamatória e infecciosa: experiência inicial no Brasil

ABSTRACT Objective: in Latin America, especially Brazil, the use of a robotic platform for thoracic surgery is gradually increasing in recent years. However, despite tuberculosis and inflammatory pulmonary diseases are endemic in our country, there is a lack of studies describing the results of robotic surgical treatment of bronchiectasis. This study aims to evaluate the surgical outcomes of robotic surgery for inflammatory and infective diseases by determining the extent of resection, postoperative complications, operative time, and length of hospital stay. Methods: retrospective study from a database involving patients diagnosed with bronchiectasis and undergoing robotic thoracic surgery at three hospitals in Brazil between January of 2017 and January of 2020. Results: a total of 7 patients were included. The mean age was 47 + 18.3 years (range, 18-70 years). Most patients had non-cystic fibrosis bronchiectasis (n=5), followed by tuberculosis bronchiectasis (n=1) and lung abscess (n=1). The performed surgeries were lobectomy (n=3), anatomic segmentectomy (n=3), and bilobectomy (n=1). The median console time was 147 minutes (range 61-288 min.) and there was no need for conversion to open thoracotomy. There were no major complications. Postoperative complications occurred in one patient and it was a case of constipation with the need for an intestinal lavage. The median for chest tube time and hospital stay, in days, was 1 (range, 1-6 days) and 5 (range, 2-14 days) respectively. Conclusions: robotic thoracic surgery for inflammatory and infective diseases is a feasible and safe procedure, with a low risk of complications and morbidity.

RESUMO Objetivo: na América Latina, especialmente no Brasil, a adoção da plataforma robótica para cirurgia torácica está aumentando gradativamente nos últimos anos. No entanto, apesar da tuberculose e doenças pulmonares inflamatórias serem endêmicas em nosso país, faltam estudos que descrevam os resultados do tratamento cirúrgico robótico das bronquiectasias. Este estudo tem como objetivo avaliar os resultados cirúrgicos da cirurgia robótica para doenças inflamatórias e infecciosas, determinando a extensão da ressecção, complicações pós-operatórias, tempo operatório e tempo de internação hospitalar. Métodos: estudo retrospectivo a partir de um banco de dados envolvendo pacientes com diagnóstico de bronquiectasia e submetidos à cirurgia torácica robótica em três hospitais brasileiros entre janeiro de 2017 e janeiro de 2020. Resultados: foram incluídos 7 pacientes. A média de idade foi 47 + 18,3 anos (variação, 18-70 anos). A maioria dos pacientes apresentou bronquiectasia não fibrose cística (n=5), seguida de bronquiectasia tuberculosa (n=1) e abscesso pulmonar (n=1). As cirurgias realizadas foram lobectomia (n=3), segmentectomia anatômica (n=3) e bilobectomia (n=1). O tempo médio do console foi de 147 minutos (variação de 61-288 min.) e não houve necessidade de conversão para toracotomia. Complicação pós-operatória ocorreu em um paciente, tratando-se de obstipação com necessidade de lavagem intestinal. A mediana do tempo de drenagem torácica e internação hospitalar, em dias, foi de 1 (variação, 1-6 dias) e 5 (variação, 2-14 dias), respectivamente. Conclusões: a cirurgia torácica robótica para doenças inflamatórias e infecciosas é um procedimento viável e seguro, com baixo risco de complicações e morbidade.

Effectiveness and toxicity of adjuvant chemotherapy in patients with non-small cell lung cancer / Eficácia e toxicidade da quimioterapia adjuvante em pacientes com câncer de pulmão de células não pequenas

ABSTRACT Objective: Adjuvant chemotherapy (AC) improves survival of patients with resected non-small cell lung cancer (NSCLC). However, the cisplatin-vinorelbine regimen has been associated with a significant risk of clinically relevant toxicity. We sought to evaluate the effectiveness, safety, and feasibility of AC for NSCLC patients in a real-world setting. Methods: This was a single-center, retrospective cohort study of patients with stage I-III NSCLC undergoing surgery with curative intent between 2009 and 2018. AC was administered at the discretion of physicians. The patients were divided into two groups: AC group and no AC (control) group. Study outcomes included overall survival (OS) and recurrence-free survival (RFS), as well as the safety profile and feasibility of the cisplatin-vinorelbine regimen in a real-world setting. Results: The study involved 231 patients, 80 of whom received AC. Of those, 55 patients received the cisplatin-vinorelbine regimen. Survival analyses stratified by tumor stage showed that patients with stage II NSCLC in the AC group had better RFS (p = 0.036) and OS (p = 0.017) than did those in the no AC group. Among patients with stage III NSCLC in the AC group, RFS was better (p < 0.001) and there was a trend toward improved OS (p = 0.060) in comparison with controls. Of those who received the cisplatin-vinorelbine regimen, 29% had grade 3-4 febrile neutropenia, and 9% died of toxicity. Conclusions: These results support the benefit of AC for NSCLC patients in a real-world setting. However, because the cisplatin-vinorelbine regimen was associated with alarming rates of toxicity, more effective and less toxic alternatives should be investigated.

RESUMO Objetivo: A quimioterapia adjuvante melhora a sobrevida de pacientes com câncer pulmonar de células não pequenas (CPCNP) ressecado. No entanto, o esquema cisplatina-vinorelbina está relacionado com risco significativo de toxicidade clinicamente relevante. Nosso objetivo foi avaliar a eficácia, segurança e viabilidade da quimioterapia adjuvante para pacientes com CPCNP em um cenário de mundo real. Métodos: Estudo retrospectivo de coorte realizado em um único centro com pacientes com CPCNP em estágio I-III submetidos a cirurgia com intuito curativo entre 2009 e 2018. A quimioterapia adjuvante foi administrada a critério dos médicos. Os pacientes foram divididos em dois grupos: quimioterapia adjuvante e sem quimioterapia adjuvante (grupo controle). Os desfechos estudados foram sobrevida global (SG) e sobrevida livre de recidiva (SLR), bem como o perfil de segurança e viabilidade do esquema cisplatina-vinorelbina em um cenário de mundo real. Resultados: O estudo envolveu 231 pacientes, 80 dos quais receberam quimioterapia adjuvante. Destes, 55 receberam o esquema cisplatina-vinorelbina. As análises de sobrevida estratificadas pelo estágio do tumor mostraram que os pacientes com CPCNP em estágio II que receberam quimioterapia adjuvante apresentaram melhor SLR (p = 0,036) e SG (p = 0,017) do que os do grupo controle. Entre os pacientes com CPCNP em estágio III que receberam quimioterapia adjuvante, a SLR foi melhor (p < 0,001) e houve uma tendência a melhor SG do que no grupo controle (p = 0,060). Dos que receberam o esquema cisplatina-vinorelbina, 29% apresentaram neutropenia febril de grau 3-4, e 9% morreram em virtude de toxicidade. Conclusões: Os resultados confirmam o efeito benéfico da quimioterapia adjuvante em pacientes com CPCNP em um contexto real. No entanto, o esquema cisplatina-vinorelbina relacionou-se com taxas alarmantes de toxicidade e alternativas mais eficazes e menos tóxicas devem ser investigadas.

Lung cancer and the COVID-19 pandemic: recommendations from the brazilian thoracic oncology group

New cases of the novel coronavirus disease 2019 (COVID-19), also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), continue to rise worldwide following the declaration of a pandemic by the World Health Organization (WHO). The current pandemic has completely altered the workflow of health services worldwide. However, even during this critical period, patients with other diseases, like cancer, need to be properly treated. A few reports have shown that mortality due to SARS-CoV-2 is higher in elderly patients and those with other active comorbidities, including cancer. Patients with lung cancer are at risk of pulmonary complications from COVID-19, and as such, the risk/benefit ratio of local and systemic anticancer treatment has to be considered. For each patient, several factors, including age, comorbidities, and immunosuppression, as well as the number of hospital visits for treatment, can influence this risk. The number of cases is rising exponentially in Brazil, and it is important to consider the local characteristics when approaching the pandemic. In this regard, the Brazilian Thoracic Oncology Group has developed recommendations to guide decisions in lung cancer treatment during the SARS-CoV-2 pandemic. Due to the scarcity of relevant data, discussions based on disease stage, evaluation of surgical treatment, radiotherapy techniques, systemic therapy, follow-up, and supportive care were carried out, and specific suggestions issued. All recommendations seek to reduce contagion risk by decreasing the number of medical visits and hospitalization, and in the case of immunosuppression, by adapting treatment schemes when possible. This statement should be adjusted according to the reality of each service, and can be revised as new data become available.

Segmentectomia pulmonar anatômica robótica: aspectos técnicos e desfechos / Robotic anatomic pulmonary segmentectomy: technical approach and outcomes

RESUMO Objetivo: relatar nossa experiência inicial com a segmentectomia robótica, descrevendo a técnica operatória, a colocação preferencial dos portais, os resultados iniciais e desfechos. Métodos: dados clínicos de pacientes submetidos à segmentectomia robótica, entre janeiro de 2017 e dezembro de 2018, foram obtidos de um banco de dados prospectivo de cirurgia robótica. Todos os pacientes tinham câncer de pulmão, primário ou secundário, ou doenças benignas, e foram operados usando o sistema Da Vinci com a técnica de três portais mais uma incisão utilitária de 3cm. As estruturas hilares foram dissecadas individualmente e as ligaduras dos ramos arteriais e venosos, dos brônquios segmentares, assim como, a transecção do parênquima, realizadas com grampeadores endoscópicos. Dissecção sistemática dos linfonodos mediastinais foi realizada para os casos de câncer de pulmão não de pequenas células (CPNPC). Resultados: quarenta e nove pacientes, dos quais 33 mulheres, foram submetidos à segmentectomia robótica. A média de idade foi de 68 anos. A maioria dos pacientes tinha CPNPC (n=34), seguido de doença metastática (n=11) e doenças benignas (n=4). Não houve conversão para cirurgia aberta ou vídeo, ou conversão para lobectomia. A mediana do tempo operatório total foi de 160 minutos e do tempo de console foi de 117 minutos. Complicações pós-operatórias ocorreram em nove pacientes (18,3%), dos quais sete (14,2%) tiveram internação prolongada (>7 dias) devido à fístula aérea persistente (n=4; 8,1%) ou complicações abdominais (n=2; 4%). Conclusão: a segmentectomia robótica é um procedimento seguro e viável, oferecendo curto período de internação e baixa morbidade.

ABSTRACT Objective: to report our initial experience with pulmonary robotic segmentectomy, describing the surgical technique, the preferred positioning of portals, initial results and outcomes. Methods: we collected data, from a prospective robotic surgery database, on patients undergoing robotic segmentectomy between January 2017 and December 2018. All patients had lung cancer, primary or secondary, or benign diseases, and were operated on with the Da Vinci system, by the three portals technique plus one utilitarian incision of 3cm. We dissected the hilar structures individually and performed the ligatures of the arterial and venous branches, of the segmental bronchi, as well as a parenchymal transection, with endoscopic staplers. We carried out systematic dissection of mediastinal lymph nodes for non-small cell lung cancer (NSCLC) cases. Results: forty-nine patients, of whom 33 were women, underwent robotic segmentectomy. The average age was of 68 years. Most patients had NSCLC (n=34), followed by metastatic disease (n=11) and benign disease (n=4). There was no conversion to laparoscopic or open surgery, or to lobectomy. The median total operative time was 160 minutes, and the median console time, 117 minutes. Postoperative complications occurred in nine patients (18.3%), of whom seven (14.2%) had prolonged hospitalization (>7 days) due to persistent air fistula (n=4; 8.1%) or abdominal complications (n=2.4%). Conclusion: robotic segmentectomy is a safe and viable procedure, offering a short period of hospitalization and low morbidity.

Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy / Minipleurostomia com curativo a vácuo: uma opção minimamente invasiva a pleurostomia

ABSTRACT Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.

RESUMO A pleurostomia é uma opção frequente de tratamento para pacientes com empiema pleural fase III que não toleram decorticação pulmonar. Todavia, esse tratamento é considerado mutilante por envolver a confecção de um stoma torácico, que pode demorar anos para se fechar ou requerer nova cirurgia. Descreveu-se recentemente uma técnica minimamente invasiva que associa uso intrapleural de curativo a vácuo como opção a pleurostomia. A presente comunicação objetiva demonstrar o resultado de uma série inicial de pacientes tratados com a minipleurostomia associada ao uso de curativo a vácuo no que tange a sua efetividade e segurança.

Lung cancer in Brazil / Câncer de pulmão no Brasil

ABSTRACT Lung cancer is one of the most incident types of cancer and a leading cause of cancer mortality in Brazil. We reviewed the current status of lung cancer by searching relevant data on prevention, diagnosis, and treatment in the country. This review highlights several issues that need to be addressed, including smoking control, patient lack of awareness, late diagnosis, and disparities in the access to cancer health care facilities in Brazil. We propose strategies to help overcome these limitations and challenge health care providers, as well as the society and governmental representatives, to work together and to take a step forward in fighting lung cancer.

RESUMO O câncer de pulmão é um dos tipos de câncer com maior incidência e uma das principais causas de mortalidade por câncer no Brasil. Revisamos a situação atual do câncer de pulmão por meio de pesquisa de dados relevantes a respeito de prevenção, diagnóstico e tratamento no país. Esta revisão mostra várias questões que precisam de atenção, tais como controle do tabagismo, educação dos pacientes, desconhecimento por parte dos pacientes, diagnóstico tardio e desigualdade de acesso ao tratamento de câncer no Brasil. Propomos estratégias para ajudar a superar essas limitações e desafiamos os profissionais de saúde, a sociedade e os representantes do governo a trabalhar em conjunto e dar um passo à frente na luta contra o câncer de pulmão.

Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion / Posicionamento intrapleural, guiado por ultrassonografia, de cateteres pleurais: influência na expansão pulmonar imediata e na pleurodese em pacientes com derrame pleural maligno recorrente

ABSTRACT Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

RESUMO Objetivo: Avaliar o papel do posicionamento intrapleural do cateter pleural na expansão pulmonar precoce e no sucesso da pleurodese em pacientes com derrame pleural maligno recorrente (DPMR). Métodos: Trata-se de um estudo retrospectivo aninhado em um estudo prospectivo de coorte maior com pacientes com DPMR recrutados em um hospital-escola universitário terciário entre junho de 2009 e setembro de 2014. Os pacientes foram submetidos a inserção de cateter pleural e, em seguida, pleurodese à beira do leito. A TC de tórax foi realizada duas vezes: imediatamente antes da pleurodese (TCi) e 30 dias após a pleurodese (TC30). Com base na TCi, a posição do cateter foi classificada em posterolateral, anterior, fissural e subpulmonar. Usamos o volume pleural na TCi para estimar a expansão pulmonar precoce e a diferença entre os volumes pleurais na TC30 e na TCi a fim de avaliar o sucesso radiológico da pleurodese. Considerou-se que a pleurodese teve êxito clínico quando não foi necessário realizar nenhum outro procedimento pleural. Resultados: Dos 131 pacientes elegíveis do estudo original, 85 foram incluídos neste estudo aninhado (64 mulheres; média de idade: 60,74 anos). A posição da ponta do cateter foi subpulmonar em 35 pacientes (41%), anterior em 23 (27%), posterolateral em 17 (20%) e fissural em 10 (12%). Não houve diferenças significativas entre os grupos quanto à expansão pulmonar precoce (mediana da cavidade pleural residual = 377 ml; intervalo interquartil: 171-722 ml; p = 0,645), sucesso radiológico da pleurodese (mediana do volume = 33 ml; intervalo interquartil: −225 a 257 ml; p = 0,923) e sucesso clínico da pleurodese (85,8%; p = 0,676). Conclusões: Nossos resultados sugerem que a posição da ponta do cateter pleural não influencia nem a expansão pulmonar precoce nem o sucesso da pleurodese à beira do leito em pacientes com DPMR.