Aplicación clínica del manejo de los recursos en crisis / Clinical aplication of resources in crisis managment

Las situaciones de crisis en la sala de operaciones son eventos poco frecuentes, con personal trabajando rápido y bajo presión, intentando sobrellevar el incidente con los menores riesgos para el paciente. Se expone un caso clínico en el marco del trabajo de una unidad de anestesia para cirugía de tórax en la cual se presenta una crisis asistencial abordada por un equipo de trabajo capacitado mediante simulación en la aplicación de la herramienta de "Manejo de los Recursos en Crisis (CRM)". Planteamos que la aplicación de esta herramienta por un equipo capacitado en su utilización contribuyó al éxito y buena evolución de un paciente crítico.

Crisis situations on the operation room seldom happen, with staff working fast and under pressure, trying to overcome the incident at the same time as reducing the risks for the patient. Here we expose a clinical case on the frame of work of an anesthesia unit assembled for thorax surgery during which an asistential crisis occurs and is managed by a group of coworkers trained by means of simulation on the appliance of the tool called "Crisis Resource Management (CRM)". We support the idea that the appliance of this tool by a team of professionals trained on its use, contributed to the success and good evolution on a critical patient.

Síndrome de Klinefelter diagnosticado en un adulto a raíz del estudio de infección respiratoria recurrente y masa mediastínica: caso clínico / Thymoma in a patient with klinefelter syndrome: case report

Klinefelter syndrome (47, XXY in most cases) is a frequently underdiagnosed chromosomal anomaly associated with multiple comorbidities in adult life. Patients with Klinefelter syndrome have a higher risk of cancer. Specifically, these patients have a higher risk for mediastinal germ cell tumors. It is estimated that 8% of male patients with mediastinal tumors have Klinefelter. We report a 42-years-old male who suffered recurrent respiratory infections. During the study, a mediastinal mass was found, whose pathological study disclosed a type B thymoma. The patient had a history of infertility, high stature, gynecomastia, obesity with gynecoid distribution of body fat and testicular atrophy. A karyotype was requested (47, XXY), confirming the diagnosis of Klinefelter syndrome.

Carcinoma Embrionário de Mediastino Posterior com Metástase Pulmonar: Relato de Caso / Carcinoma Embrionario de Mediastino Posterior con Metástasis Pulmonar: Relato de Caso / Posterior Mediastinum Embryonal Carcinoma with Pulmonary Metastasis: Case Report

Introdução: Os carcinomas embrionários são os mais raros e, geralmente, se apresentam quando já estão associados com outros componentes de células germinativas. Possuem características clínicas e radiológicas similares aos tumores de saco vitelino. Relato do caso: Paciente G.A.S.L, sexo masculino, 30 anos, ex-tabagista e etilista. Iniciou com quadro de dores no hemitórax esquerdo em fevereiro de 2018 com extensão dos sintomas para a região da coluna torácica e lombar. Realizou tomografia de abdômen total e tórax, com resultado sugestivo de tumor de mediastino, nódulos pulmonares, material tecidual com densidade de partes moles no mediastino posterior e numerosas linfonodomegalias retroperitoneais, evoluiu com paraplegia de membros inferiores por compressão nervosa e com hipoestesia. Realizou biópsia de tumor de mediastino posterior à esquerda com resultado de neoplasia maligna epitelial e diagnóstico de carcinoma embrionário extragonodal pouco diferenciado. O paciente apresentou metástase pulmonar, confirmando que esses tumores frequentemente se infiltram nos órgãos adjacentes. A quimioterapia baseada em cisplatina é o tratamento padrão, levando à melhora da sobrevida em pacientes com esse tipo de tumor. Após a quimioterapia, houve diminuição do volume tumoral, porém, seguiu com a paraplegia de membros inferiores em razão da compressão nervosa. Conclusão: Este estudo relata o caso de um paciente jovem, com tumor raro de células germinativas e metástase pulmonar, que evoluiu clinicamente estável após tratamento específico com quimioterápicos. Por ainda haver uma escassa literatura acerca do tema, este estudo traz novas evidências e achados.

Introduction: Embryonal carcinomas are the rarest, and usually present when they are already associated with other components of germ cells. They have clinical and radiological features similar to yolk sac tumors. Case report: Patient G.A.S.L, male, 30 years old, former smoker and alcoholic. Initially, the patient reported pain in the left hemithorax in February 2018 with extension of the symptoms to the region of the thoracic and lumbar spine. A tomography of the total abdomen and chest was performed, with result suggestive of mediastinal tumor, pulmonary nodules, tissue material with soft tissue density in the posterior mediastinum and numerous retroperitoneal lymph node enlargement, which evolved with paraplegia of the lower limbs by nerve compression and hypoesthesia. It was conducted a biopsy of a mediastinal tumor posterior to the left with result of malignant epithelial neoplasia and diagnosis of extragonadal embryonic carcinoma very little differentiated. The patient presented pulmonary metastasis confirming that these tumors frequently infiltrate into the adjacent organs. Cisplatin-based chemotherapy is the standard treatment, leading to improved survival in patients with this type of tumor. After chemotherapy, the tumor volume decreased, but the patient continued with paraplegia of lower limbs due to nerve compression. Conclusion: This study reports the case of a young patient with a rare germ cell tumor and pulmonary metastasis who evolved clinically stable after specific chemotherapy treatment. Because there is still scarce literature on the subject, this study brings new evidences and findings.

Introducción: Los carcinomas embrionarios son los más raros y generalmente se presentan cuando ya están asociados con otros componentes de células germinativas. Se presentan características clínicas y radiológicas similares a los tumores de saco vitelino. Relato del caso: Paciente G.A.S.L, sexo masculino, 30 años, ex tabaquista y etilista. Se inició con cuadro de dolores en el hemitórax izquierdo en febrero de 2018 con extensión de los síntomas para la región de la columna torácica y lumbar. Se realizó una tomografía de abdomen total y tórax, con resultado sugestivo de tumor de mediastino, nódulos pulmonares, material tisular con densidad de partes blandas en el mediastino posterior y numerosas linfonodomegalias retroperitoneales, evolucionó con paraplejia de miembros inferiores por compresión nerviosa y con hipoestesia. Se realizó biopsia de tumor de mediastino posterior a la izquierda con resultado de neoplasia maligna epitelial y diagnóstico de carcinoma embrionario extra gonodal poco diferenciado. El paciente presentó metástasis pulmonar confirmando que estos tumores frecuentemente se infiltran en los órganos adyacentes. La quimioterapia basada en cisplatino es el tratamiento estándar, llevando a la mejora de la supervivencia en pacientes con este tipo de tumor. Después de la quimioterapia hubo la disminución del volumen tumoral, sin embargo, siguió con la paraplejia de miembros inferiores debido a la compresión nerviosa. Conclusión: Este estudio informa el caso de un paciente joven con un tumor raro de células germinales y metástasis pulmonar que evolucionó clínicamente estable después de un tratamiento de quimioterapia específico. Debido a que todavía hay poca literatura sobre el tema, este estudio aporta nuevas pruebas y hallazgos.

Comparative study of computed tomography (CT) and pathological diagnosis toward mediastinal lymph node metastasis in esophageal carcinoma

Summary Objective: To investigate the diagnostic criteria of mediastinal lymph node metastasis (MLNM) in esophageal carcinoma (EC) by comparing the lymph node sizes measured by computed tomography (CT) and obtained by postoperative pathological examination. Method: A total of 305 EC patients were selected. MLNM location, shortest diameter and number were investigated one week before surgery, and then compared with their pathological findings. Results: The receiver operating characteristic (ROC) curve analysis revealed that the minimum diameters of MLNM in the thoracic cavity was 8 mm (area under curve [AUC] = 0.766, Youden index = 0.424), 5 mm in supraclavicular fossa (AUC = 0.785, Youden index = 0.494), 6 mm in tracheoesophageal groove (AUC = 0.755, Youden index = 0.405); the sensitivity was increased significantly, and the Youden index was increased significantly when compared with 10 mm. Conclusion: The shortest diameter of diagnostic criteria of lymph nodes in EC could be less than 10 mm on CT.

Tumor lamination in mediastinal giant tumors / Laminação tumoral nos tumores gigantes do mediastino

ABSTRACT Mediastinum tumors may grow slowly and reach giant proportions without symptoms, hindering surgical removal. Tumor big dimensions difficult surgical maneuvers, with risk of uncontrollable bleeding and prejudice to surrounding structures. It may be necessary the use of exceptional measures such as venous-venous circulatory deviation, pre-operatory embolization and total extracorporeal circulation. We describe the technique of tumor lamination that allows for complete or almost complete resection of such tumors that in many occasions are not resectable. The description is based on the results of four patients treated with mediastinum giant tumors.

RESUMO Tumores do mediastino podem crescer lentamente e atingir proporções gigantes sem apresentar sintomas, tornando a remoção cirúrgica problemática. As dimensões exacerbadas da neoplasia dificultam as manobras cirúrgicas, com risco de hemorragia incontrolável e comprometimento de estruturas adjacentes, levando à utilização de medidas de exceção, como a derivação circulatória veno-venosa, a embolização pré-operatória e a circulação extracorpórea total. Diante disto, descrevemos a técnica de laminação tumoral, que permite a ressecção total ou quase total de tumores considerados, muitas vezes, irressecáveis, tendo por base os resultados alcançados em quatro pacientes portadores de neoplasias gigantes do mediastino.

Yolk sac primary tumor of mediastino: a rare case in a young adult / Tumor de saco vitelínico primário do mediastino: raro caso em um adulto jovem

ABSTRACT Germ cell tumors are rare neoplasms that mostly occur in the gonads, although they can also affect other body sites, especially the anterior mediastinum (50 to 70% of all extragonadal germ cell tumors). We report a case of a primary mediastinal yolk sac tumor, a rare and aggressive germ cell tumors subtype. This was a 38-year-old man who was admitted to Hospital do Servidor Público Estadual "Francisco Morato de Oliveira", complaining about dyspnea and dry cough for 1 year. The computed tomography scan of his chest revealed a large mass in the anterior mediastinum with heterogeneous enhancement to the contrast associated with pleural effusion. There were also high serum levels of alpha-fetoprotein. After neoadjuvant chemotherapy, the patient underwent surgical resection of the mass, followed by pathological examination, which confirmed a primary mediastinal yolk sac tumor, a nonseminomatous subtype of germ cell tumors. Primary mediastinal yolk sac tumors have poor prognosis, despite advances in therapy with surgical resection and cisplatin-based chemotherapy. This poor prognosis is due to the degree of invasion and unresectability in most patients by the time of the diagnosis.

RESUMO Os tumores de células germinativas são neoplasias raras que acometem mais frequentemente as gônadas, embora possam também ocorrer em outras localizações do corpo, destacando-se o mediastino anterior (50 a 70% de todos os tumores de células germinativas extragonadais). No presente artigo, relatamos um caso de tumor de saco vitelínico mediastinal primário, de subtipo raro e agressivo de tumor de células germinativas. Tratava-se de um homem, 38 anos, admitido no Hospital do Servidor Público Estadual "Francisco Morato de Oliveira", com quadro de dispneia e tosse seca há 1 ano. Na investigação clínica, foi solicitada tomografia computadorizada de tórax, que mostrou volumosa massa no mediastino anterior com realce heterogêneo ao meio de contraste associada a derrame pleural. Havia ainda aumento dos níveis séricos da alfafetoproteína. Após quimioterapia neoadjuvante pré-operatória, o paciente foi submetido à ressecção cirúrgica, seguida de estudo anatomopatológico da peça, no qual demonstrou tratar-se de um tumor de saco vitelínico primário do mediastino. Os tumores de saco vitelínicos primários do mediastino têm prognóstico reservado, apesar do avanço na terapêutica com a ressecção cirúrgica e a quimioterapia à base de cisplatina. Isto se deve ao grau de invasão e de irressecabilidade na maioria dos pacientes no momento do diagnóstico.

Utilidad del ultrasonido endobronquial para el diagnóstico y etapificación del cáncer pulmonar / Endobronchial ultrasound-guided transbronchial needle aspiration

In the last years, several techniques have been developed to obtain a prompt diagnosis or rule out lung cancer. Endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for mediastinal and central pulmonary lesions. This procedure is especially useful for lung cancer diagnosis and mediastinal staging. Two different types of EBUS are currently available: Radial EBUS and lineal EBUS. Each one has technical differences together with a range of clinical indications. The aim of this review is to discuss about EBUS-TBNA and its current clinical indications, evidence about the accuracy of the procedure for lung cancer diagnosis and staging, and evaluation of the pathological and molecular studies (EGFR, ALK, and ROS1) obtained through EBUS-TBNA and rapid on-site evaluation (ROSE).

Anesthetic management of a large mediastinal mass for tracheal stent placement / Manejo anestésico de grande massa mediastinal para a colocação de stent traqueal

ABSTRACT The anesthetic management of patients with large mediastinal masses can be complicated due to the pressure effects of the mass on the airway or major vessels. We present the successful anesthetic management of a 64-year-old female with a large mediastinal mass that encroached on the great vessels and compressed the trachea. A tracheal stent was placed to relieve the tracheal compression under general anesthesia. Spontaneous ventilation was maintained during the perioperative period with the use of a classic laryngeal mask airway. We discuss the utility of laryngeal mask airway for anesthetic management of tracheal stenting in patients with mediastinal masses.

RESUMO O manejo anestésico de pacientes com grandes massas situadas no mediastino pode ser complicado por causa dos efeitos da pressão da massa sobre as vias aéreas ou grandes vasos. Relatamos o manejo anestésico bem-sucedido de uma paciente de 64 anos com uma grande massa mediastinal que invadiu os grandes vasos e comprimiu a traqueia. Um stent traqueal foi colocado para aliviar a compressão da traqueia, sob anestesia geral. A ventilação espontânea foi mantida durante o período perioperatório com o uso de uma máscara laríngea clássica. Discutimos a utilidade da máscara laríngea para o manejo da colocação de stent traqueal em pacientes com massas situadas no mediastino.

Exuberant Vasculoconnective Component in Mediastinal Mixed Germ Cell Tumors

We aimed to evaluate the histologic components of primary mediastinal mixed germ cell tumors. A total of 221 patients diagnosed with a mediastinal germ cell tumor (GCT) were retrospectively reviewed. Among them, 14 patients underwent surgical resection after chemotherapy and 8 patients were diagnosed with mixed GCT, who were then selected for further evaluation. Clinical chart review and histologic review of biopsy and surgical specimens of 8 patients were performed. All 8 patients were young males and showed a mature teratoma or a mature teratoma with a focal immature teratoma in the resected specimens. Serum alpha-feto protein was variably elevated. Seven patients experienced an increase in tumor size after the chemotherapy. In 5 patients, a variable amount of vasculoconnective tissue was found along with the mature teratoma occupying average 66.3% of resected mass, and 3 of them showed an identical vasculoconnective component on biopsy before chemotherapy. We suggest that vasculoconnective tissue might be the intrinsic component of primary mediastinal mixed GCT. When vasculoconnective tissue is obtained on small biopsy of an anterior mediastinal mass of a young male, the possibility of underlying mixed GCT should be considered and further clinical work up should be performed.

Improving CT-guided transthoracic biopsy of mediastinal lesions by diffusion-weighted magnetic resonance imaging

OBJECTIVES: To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions. METHODS: Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion. RESULTS: In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6-1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas. CONCLUSION: Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques. .

Giant mediastinal haemangiopericytoma: An uncommon case.

Haemangiopericytoma is a rare soft tissue tumour characterised by tightly packed tumour cells situated around thin walled endothelial lined vascular channels, ranging from capillary sized vessels to large gaping sinusoidal spaces. The tumour cells are surrounded by reticulin and are negative for muscle, nerve and epithelial markers. The diagnosis of extra-pulmonary intra-thoracic, extra-pleural mediastinal mass is difficult. It constitutes only 6% of all primary tumours and cysts of the mediastinum. We report the rare occurrence of primary intra-thoracic, extra-pulmonary mediastinal haemangiopericytoma of mesenchymal origin with perivascular localisation. The patient underwent right postero-lateral thoracotomy and postoperatively received chemotherapy with adriamycin (60 mg/m2) on day 1 and ifosfamide (1.5 g/m2) on day 1 to 3. Thirtyseven months after the operation, the patient has been well with evidence of a single recurrence in the left lower lobe.

Conducta en el síndrome de vena cava superior (SVCS) / Management in superior vena cava syndrome

Objetivos: Mostrar la conducta realizada en este síndrome. Material y Métodos: Serie retrospectiva de 5 casos tratados entre el 1 de abril de 1995 y el 31 de marzo de 2013. Diagnóstico por imágenes y toma de biopsia con tratamiento específico posterior. Resultados: Todos se debieron a causas tumorales: 2 timomas (uno irresecable), 1 linfoma Hodgkin, 1 leiomiosarcoma de vena cava y 1 caso de cáncer pulmonar a pequeñas células. Fallecieron por progresión de enfermedad 2 casos, 2 están libres de enfermedad a 12 y 11 meses de tratamiento y 1 enfermo se perdió en el seguimiento. Conclusiones: Se define la necesidad de seguir un algoritmo que determine los pasos a seguir ante la presencia de este síndrome.

Objectives: Management in this syndrome. Material and Methods: Retrospective series of 5 cases treated between April 1, 1995 to March 31, 2013. Diagnostic imaging and taking biopsy with subsequent specific treatment. Results: All patients were due to tumor causes: 2 thymomas (one unresectable), 1 lymphoma Hodgkin, 1 Leiomyosarcoma of vena cava and 1 case of small cell lung cancer. Died of disease progression 2 cases, 2 are free of disease to 12 and 11 months of treatment and 1 patient was lost to follow-up. Conclusions: The need to follow an algorithm which determines the steps to follow in the presence of this syndrome is defined.

Características clínicas y patológicas de los tumores de mediastino en un hospital universitario / Clinical and pathological characteristics of tumors of the mediastinum in a university hospital

Las neoplasias mediastinales son tumores poco comunes que pueden aparecer a cualquier edad, pero son más comunes entre la tercera y la quinta década de la vida. Aproximadamente 40% de las masas son asintomáticas y se descubren incidentalmente en una radiografía de tórax de rutina. El objetivo de este trabajo es establecer la frecuencia y características de este tipo de tumores en un hospital universitario general. PACIENTES Y MÉTODO: estudio observacional, retrospectivo, descriptivo de corte transversal. Fueron incluidos todos los pacientes con diagnóstico de tumor mediastinal primario, con confirmación anatomopatológica, durante el periodo 2008-2012. RESULTADOS: De los 795 pacientes adultos registrados en el Departamento de Oncología, 27 (3,4%) padecían patologías tumorales mediastinales. 19 (70%) pertenecían al sexo masculino y la edad promedio fue 41 años. La ubicación topográfica más frecuente corresponde en un 63% (17 casos) al mediastino anterior. Los tipos histológicos más frecuentes fueron: el de origen germinal con 6 casos (22%) y los linfomas (Hodgkin y no Hodgkin) se presentaron en 4 casos cada uno (24% en total). CONCLUSIONES: La frecuencia de tumores mediastinales fue de 3,4%. En su mayoría aparecen en pacientes del sexo masculino (70%), y la edad promedio de aparición es de 41 años. La ubicación topográfica más frecuente es el mediastino anterior (63%). El tipo histológico más frecuente son los linfomas y el tumor de origen germinal.

Mediastinal neoplasms are rare tumors that can occur at any age but are most common between the third and fifth decade of life. Approximately 40% of the masses are asymptomatic and are discovered incidentally on a routine chest radiograph. The aim of this work is to determine the frequency and characteristics of this type of tumors in a general university hospital. PATIENTS AND METHODS: An observational, retrospective, cross- sectional descriptive. We included all patients diagnosed with primary mediastinal tumor with pathologic confirmation, during the period 2008-2012. RESULTS: Of the 795 adult patients registered with the Department of Oncology, 27 (3.4%) had mediastinal tumor pathologies. 19 (70%) were male and the average age was 41 years. The most common topographic location corresponds to 63% (17 cases) the anterior mediastinum. The most common histological types were: the germinal source with 6 cases (22%) and lymphomas (Hodgkin and non-Hodgkin) occurred in 4 cases each (24% total). CONCLUSIONS: The frequency of mediastinal tumors was 3.4%. They mostly appear in male patients (70%), and the average age of onset is 41 years. The most common topographic location is the anterior mediastinum (63%). The most common histological type are lymphomas and germ cell tumor origin.

Posterior mediastinal mass: Do we need to worry much.

Anesthetic management of mediastinal masses is challenging. There is abundant literature available on anesthesia management of anterior mediastinal mass. Anesthetic management of posterior mediastinal mass lesions normally have uneventful course. We describe airway collapse and difficult mechanical ventilation in the postoperative period in a patient with posterior mediastinal mass.

Adenocarcinoma (somatic-type malignancy) in mature teratoma of anterior mediastinum.

Mature teratoma is a common anterior mediastinal tumour. However, occurrence of transformed malignant component within it is very rare. We report a case of a 32-year-old female presenting with dry cough and chest pain. Contrast-enhanced computed tomography (CT) showed a large thin-walled cystic lesion measuring 11.4cmx10.6cmx10.0cm in the anterior mediastinum. Right postero-lateral thoracotomy was performed and the tumour was completely excised. Histopathological examination of the excised specimen was suggestive of mature teratoma with transformed malignant component, adenocarcinoma (somatic-type malignancy).

Clinical Implication of Microscopic Anthracotic Pigment in Mediastinal Staging of Non-Small Cell Lung Cancer by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Microscopic anthracotic pigment (MAP) is frequently observed in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimen in non-small cell lung cancer, but its clinical interpretation is not well-known. The aim of this study was to evaluate the clinical implication of MAP in mediastinal staging of non-small cell lung cancer. From May 2010 to July 2011, consecutive potentially operable non-small cell lung cancer patients who underwent EBUS-TBNA for mediastinal staging were recruited. Of the total 133 patients, 102 (76.7%) were male patients. Median age was 68 yr. Total 279 mediastinal lymph nodes were sampled by EBUS-TBNA; station 4R (100, 35.8%) and station 7 (86, 30.8%) were the most common sites. Malignant lymph nodes were 100 (35.8%). MAP was observed in 61 (21.7%) lymph nodes, and among them only 3 were malignant lymph nodes (P < 0.001). The lymph nodes with MAP were smaller (9.0 vs 10.8 mm, P = 0.001) and showed low standard uptake values on FDG-PET (4.4 vs 4.7, P = 0.256). In multivariate analysis, MAP was negatively associated with malignant lymph node (adjusted OR, 0.12; 95% CI, 0.03-0.42; P < 0.001). In potentially operable non-small cell lung cancer patients, MAP in endobronchial ultrasound-guided transbronchial needle aspiration specimens is strongly associated with benign mediastinal and hilar lymph nodes.

Punção aspirativa guiada por ultrassom endobrônquico no diagnóstico e estadiamento de linfadenopatia mediastinal: experiência inicial no Brasil / Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and staging of mediastinal lymphadenopathy: initial experience in Brazil

OBJETIVO: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, punção aspirativa por agulha guiada por ultrassom endobrônquico) é um método novo em diagnóstico e estadiamento linfonodal mediastinal. O objetivo do estudo foi avaliar os resultados preliminares obtidos com EBUS-TBNA no diagnóstico de lesões e no estadiamento linfonodal mediastinal. MÉTODOS: Foram avaliados pacientes com tumores ou adenopatias mediastinais e com diagnóstico ou suspeita de câncer de pulmão. Os procedimentos foram realizados com os pacientes sob sedação ou anestesia geral. O material coletado foi preparado em lâminas fixadas em álcool absoluto para citologia e em formol para bloco de células. RESULTADOS: Foram incluídos 50 pacientes (30 do sexo masculino), com média de idade de 58,3 ± 13,5 anos. Foram realizadas 201 punções em 81 linfonodos ou massas mediastinais (média de 2,5 punções). O material obtido foi considerado adequado para análise citológica em 37 pacientes (74 por cento), dos quais 21 (57 por cento) foram diagnosticados com malignidade. Nos 16 pacientes remanescentes, 1 teve diagnóstico de tuberculose, 6 tiveram seguimento clínico, e 9 foram submetidos a investigação adicional (2 diagnosticados com neoplasia - resultados falso-negativos). O rendimento do exame foi maior nos procedimentos com objetivo diagnóstico, em pacientes com lesões em múltiplas estações, e nas punções da estação linfonodal subcarinal. Um paciente apresentou sangramento endobrônquico resolvido com medidas locais. Não houve mortalidade na série. CONCLUSÕES: Esta experiência preliminar confirmou que o EBUS-TBNA é procedimento seguro, e que o nosso rendimento diagnóstico, inferior ao da literatura, foi compatível com a curva de aprendizado do método.

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of mediastinal lymph nodes. The objective of this study was to evaluate the preliminary results obtained with EBUS-TBNA in the diagnosis of lesions and mediastinal lymph node staging. METHODS: We evaluated patients with tumors or mediastinal adenopathy, diagnosed with or suspected of having lung cancer. The procedures were performed with the patients under sedation or under general anesthesia. Material was collected by EBUS-TBNA, after which it was prepared on slides, fixed in either absolute alcohol (for cytology) or formalin (for cell-block analysis). RESULTS: We included 50 patients (30 males). The mean age was 58.3 ± 13.5 years. We performed 201 biopsies of 81 lymph nodes or mediastinal masses (mean of 2.5 punctures/biopsy). The quantity of material was considered sufficient for cytology in 37 patients (74 percent), 21 (57 percent) of whom were thus diagnosed with malignancy. Of the remaining 16 patients, 1 was diagnosed with tuberculosis, 6 entered clinical follow-up, and 9 underwent further investigation (2 diagnosed with neoplasm-false-negative results). The yield was higher when the procedure was performed for diagnostic purposes, as well as being higher in patients with lesions in multiple stations and in biopsies involving the subcarinal lymph node station. One patient had endobronchial bleeding, which was resolved with local measures. There were no deaths among the patients evaluated. CONCLUSIONS: This preliminary experience shows that EBUS-TBNA is a safe procedure. Our diagnostic yield, although lower than that reported in the literature, was consistent with the learning curve for the method.

Primary Malignant Melanoma of the Mediastinum: Radiologic and Pathologic Correlation in Two Case

Primary malignant melanoma of the anterior mediastinum is extremely rare, accounting for 0.1-0.5% of all primary malignant neoplasms. These tumors may be mistakenly diagnosed as lymphomas, thymic carcinomas and malignant germ-cell tumors of the mediastinum. We describe two cases of primary malignant melanomas of the anterior mediastinum and report their CT and pathology findings.