Multimodal treatment of oligometastatic non-small cell lung cancer.

The management of patients with oligometastatic non-small cell lung cancer has undergone significant improvement in recent years. The combination of increase in sensitivity of diagnostic tests, development in systemic therapies, surgical techniques and radiotherapy allowing radical ablative treatment of metastases have significantly influenced the treatment of advanced lung cancer, mainly in the patients in which these treatment modalities converge.We report a rare case of a young patient with an oligometastatic lung adenocarcinoma with a single synchronous brain metastasis, who underwent aggressive locoregional and systemic therapies and is still in annual follow-up with excellent quality of life and progression-free survival of 164 months.

GIANT THORACIC MASS - THE STORY OF A SOLITARY FIBROUS TUMOUR.

The tumours of the pleura are a vast and diverse field. One of the lesser known and less common tumour is the solitary fibrous tumour of the pleura, representing about 5% of these types of tumours. The authors present the case of a woman admitted to the emergency department with symptoms of dizziness and vomits. Imaging studies showed a giant thoracic mass on the left hemithorax, with a biopsy indicating a solitary fibrous tumour. The patient was referred for surgery, which was performed via thoracotomy. In the postoperative period she developed an acute pulmonary oedema secondary to lung reexpansion and fluid overload, with a good response to fluid restriction and intravenous diuretics.

VIDEO-ASSISTED THORACOSCOPIC SURGERY WITHOUT CHEST DRAIN PLACEMENT.

BACKGROUND: Placement of chest drain following thoracoscopic procedures has been the gold standard. Nevertheless, a drainless approach may be safe and feasible in selected patients and procedures. In this study we aim to report our clinical experience after drainless video-assisted thoracoscopic surgery. METHODS: We retrospectively analyzed data of all subjects submitted to drainless video-assisted thoracoscopic surgery at our centre between January 1, 2010 and December 31, 2019. The preoperative clinical and surgical data and the immediate postoperative data were retrospectively evaluated through the consultation of the clinical processes and the computer registry system. We used descriptive statistics: mean or median, according to data distribution, and absolute or relative frequencies. RESULTS: We included 161 patients, mean age of 31 years (min:15; max:78). We analyzed data from patients submitted to: thoracic sympathectomy(67.1%), wedge resection, for lung biopsy, metastasis or small nodules resection (21.7%), mediastinal cysts removal (6.2%), pleural lesions resection (3.7%) and emphysematous bullae resection (1.2%). The average length of stay was 1 day. Residual pneumothorax was noted in 15 patients (9.3%). Postoperative pleural drain placement due to pneumothorax occur in 4 patients (2.5%). There was no intra-hospitalar mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery without postoperative chest drain seems to be valid and safe according to our results.

GIANT THORACIC MASS - THE STORY OF A SOLITARY FIBROUS TUMOUR.

The tumours of the pleura are a vast and diverse field. One of the lesser known and less common tumour is the solitary fibrous tumour of the pleura, representing about 5% of these types of tumours. The authors present the case of a woman admitted in the emergency department with symptoms of dizziness and vomits. Imaging studies show a giant thoracic mass on the left hemithorax, with a biopsy indicating a solitary fibrous tumour. The patient was referred for surgery, which was performed via thoracotomy. In the postoperative period she developed an acute pulmonary oedema secondary to lung reexpansion and fluid overload, with a good response to fluid restriction and intravenous diuretics.

Safety And Risk Factors For The Morbidity And Mortality Of Pneumonectomy: A Retrospective 10- Year Study In A Single Institution.

OBJECTIVES: Pneumonectomy is a procedure with high post-operative morbidity and mortality. This study aims to assess and identify possible risk factors that can affect post-operative outcome, therefore determining the safety of pneumonectomy in specific groups. METHODS: A total of 63 patients submitted to pneumonectomy at our centre, from February 2008 to February 2018, were included in our retrospective study. Age, gender, side of intervention, diagnosis, pre-operative symptoms, substance abuse and comorbidities were assessed. Early and late post-operative complications, as well as death were our major outcomes. We analysed the impact of preoperative variables on major outcomes using SPSS statistics. RESULTS: We found a 9,8% surgery-related mortality and 1-year survival rate of 76,2%. The incidence of early complications in our population was of 35% while eleven patients (17,4%) developed late post-operative complications. No statistical difference was found when comparing survival time between genders or age groups. Right sided pneumonectomies seem to be associated with an higher mortality risk. No other association between risk factors and outcomes reached statistical significance in both univariate and multivariate analysis. CONCLUSIONS: Pneumonectomy is a viable option regardless of age whenever the patient has a good functional and cardiopulmonary status. Gender and diagnostic group do not seem to influence adverse event risk, although right-sided pneumonectomies show an increased risk for post-operative death. Care should be taken with patients submitted to neoadjuvant therapy. All patients should be encouraged to cease smoking as early as possible before surgery, given the increased risks for post-operative complications.

Total Aortic Arch Replacement With E-Vita OPEN PLUS Hybrid Prosthesis - Initial Experience From A Single Surgical Center.

We report a rare case of an advanced stage thymoma with right superior pulmonary lobe, superior vena cava, innominate vein and pericardium invasion in a patient with Good's syndrome. In a multidisciplinary discussion, surgical resection was deemed the best initial approach, since invaded structures could be safely managed. The tumor was fully resected and included partial resection of the superior pulmonary lobe, superior vena cava and innominate vein. The encircled right phrenic nerve was dissected from the tumor and preserved. The superior vena cava and innominate vein were reconstructed using autologous pericardium patch. Immunoglobulin replacement and radiotherapy were initiated afterwards. No signs of relapse at 6 months follow-up. In such advanced cases, aggressive surgical intervention should be considered as first line of treatment, as long as full resection can be anticipated, since complete resection is the leading factor for long-term prognosis.

Uniportal Video-assisted Thoracic Surgery Anatomical Resections - Does Previous Tobacco Exposure Adversely Influence Post-Operative Outcomes?

A high percentage of patients presenting for lung surgery are either current or former smokers, which is typically associated with many anatomical and physiological pulmonary changes. The influence of tobacco on postoperative pulmonary complications remains controversial. The main goal of this study was to analyse the effects of smoking on the risk of post-operative complications and morbidity in patients submitted to lung resection surgery through uniportal VATS. Peri-operative data on all cases of anatomical lung resection surgery through single-port VATS performed between December 2013 and July 2018 at three Portuguese institutions were collected and retrospectively reviewed Demographic data, diagnosis, pre-operative lung function tests, in-hospital length of stay (LOS) and intra and post-operative drainage levels were registered. Patients were divided in two groups according to tobacco exposure. Post-operative complications and morbidity were compared through statistical analysis We performed 313 procedures, 303 of which were evaluated in regard to outcome. Mean age at time of surgery was of 62,85 years (SD=12,24). One hundred and sixty patients (52,81%) had a history of tobacco use, while 47,19% (n=143) had never smoked. Non-smokers had significantly better lung function than smokers (p<0,05). Smoking history showed a contribution to post-operative prolonged air leaks (p=0,025) morbidity (p=0,05), 2-day longer LOS (µ=5,36 days vs. µ =7,53 days; p<0,05), longer operative times and higher intra and post-operative drainage levels. A history of smoking during a patient's life negatively impacts morbidity in patients submitted to uniportal VATS for anatomical lung resection, increasing early post-operative complications and prolonging in-hospital stays.

Surgical treatment of concomitant severe heart disease and lung cancer.

The concomitant presentation of lung cancer and severe heart disease requiring intervention is a scenario that many clinicians have to face. Its common physiopathological substratum is unknown and it is believed that tobacco plays a role. From a surgical point of view, these patients pose various technical challenges and medical literature is scarce in providing solid answers. The aim of this report is to review our experience with cases undergoing combined surgical treatment of both heart disease and lung cancer, aiming to analyse patients' characteristics, operative technical considerations and related outcomes. A total of five patients were included, with two synchronous procedures, two cases with lung surgery being performed first and one case commenced with cardiac surgery. All cancers were non-small-cell lung carcinoma or carcinoid tumors and cardiac disease was mostly represented by severe aortic stenosis. Lobectomy was performed in two thirds of patients and minimally invasive techniques were used in 60% of the procedures. All valvular patients received a bioprosthesis. There was one immediate complication, with good recovery on follow-up, and there were no late events (median follow-up of 1,8 ±1,1 months). The analysis of these cases highlights the complex nature of these challenging patients and reinforces the importance of devoting efforts to offer the most suitable solutions for each scenario.

A apresentação concomitante de cancro do pulmão e doença cardíaca severa necessitando intervenção é um cenário frequente na prática clínica. O seu substrato fisiopatológico comum é desconhecido e acredita-se que o tabagismo possa ser um agente associado. Do ponto de vista cirúrgico, estes pacientes colocam vários desafios técnicos e a literatura médica é escassa em providenciar respostas robustas. O objetivo deste relato consiste em rever a nossa experiência com casos submetidos a tratamento cirúrgico combinado das patologias supracitadas, visando analisar as características dos pacientes, considerações das técnicas operatórias e eventos relacionados. Um total de cinco pacientes foram incluídos, com dois procedimentos síncronos, dois casos que tiveram a cirurgia pulmonar como primeiro procedimento e um caso iniciado com cirurgia cardíaca. Histologicamente, todos os cancros eram carcinomas pulmonares de não pequenas células ou tumores carcinóides e a patologia cardíaca mais representativa foi a estenose valvular aórtica. A lobectomia foi executada em 2/3 dos pacientes e em 60% dos casos foram utilizadas técnicas minimamente invasivas. Todos os pacientes valvulares receberam próteses biológicas. Houve uma complicação pós-operatória imediata, com recuperação favorável, e não ocorreram eventos tardios no seguimento (duração mediana de 1,8 ±1,1 meses). A análise destes casos enfatiza a complexa natureza destes pacientes desafiantes e reforça a importância em dedicar esforços para oferecer as soluções mais adequadas para cada cenário.

Three-year Experience on 477 Patients Undergoing Uniportal Video-Assisted Thoracoscopic Surgery.

INTRODUCTION: Uniportal video-assisted thoracic surgery (VATS) technique has been described both for diagnostic and therapeutic indications. Outcomes after uniportal VATS have never been reported in Portuguese large series. We review the safety and efficiency of our initial experience with uniportal VATS. METHODS: In a retrospective study of prospectively collected data, 477 uniportal VATS procedures were analyzed between June 2014 and June 2017. All procedures were performed without rib spreading. Patients' demographic data, preoperative and postoperative management as well as results were analyzed. RESULTS: The mean age of patients was 47,9 years (range, 10 to 86), and 155 (32,5%) patients were female. The uniportal VATS procedures included 156 (32,7%) anatomical major lung resections, 80 (16,8%) one or multiple wedge resections, 172 (36,1%) blebectomies and/ or pleurectomies, 24 (5%) mediastinal lesions, 16 (3,3%) empyema drainage and decortications and other indications in 29 (6,1%) cases. Median operative ime and surgical drainage for uniportal VATS for anatomical major lung resections was 95 minutes (range, 40 to 245) and 100 ml (range, 0 to 650), respectively. Conversion to either 2 or 3 port VATS or mini-thoracotomy was necessary in 7.1% of the surgeries, often due to adhesions, incomplete lung collapse or bleeding. The chest drain was removed after a median of 3 days (range, 0 to 34). Median hospital stay was 3 days (range, 1 to 41). Postoperative complication rate was 12,4% mainly due to prolonged air leak 8,4% (n=40). There was no perioperative mortality. CONCLUSION: Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. Excellent results with minimal morbidity and short hospital stay are amongst its strong points. It can be performed by thoracic surgeons experienced in the postero-lateral thoracotomy approach.

Uniportal Video-Assisted Thorascoscopic Surgery - The New Paradigm in the Surgical Treatment of Lung Cancer.

INTRODUCTION: The progressive development and improvement of minimally invasive approaches in the field of thoracic surgery allowed to establish video-assisted thoracoscopic (VATS) anatomic lung resections as the present technique of choice in the treatment of early stage lung cancer. METHODS: The purpose of this study was to evaluate the surgical outcomes of patients who performed uniportal VATS anatomic lung resections for the treatment of primary lung cancer. The patients' demographics, approach and type of surgery, postoperative morbidity and mortality and overall survival were analyzed. RESULTS: From December 2013 through September 2017, 173 patients underwent uniportal VATS anatomic lung resections for the treatment of lung cancer. Surgery was performed in 92 male and 81 female with a mean age of 63.5 years (range 19- 83 years). All surgeries began by a single- -port VATS approach, being necessary to add an extra port in 9 surgeries and conversion to mini-thoracotomy in 10 procedures (conversion rate of 5.8%) due to bleeding and/ or technical difficulties. All kinds of anatomic lung resection were performed: 154 lobectomies, which represents 89.0% of the procedures (93 upper lobectomies, 12 middle lobectomies and 49 lower lobectomies), 10 bilobectomies (5.8%) and 9 anatomic segmentectomies (5.2%). Mean lymph node stations dissected was 2.48 stations (range 1-8 stations). The mean surgical time was 112.2 minutes (range 40-245 minutes) and mean intra-operative drainage was 155.6ml (range 0-1400ml). Median hospitalization time was 5 days (range 2-28 days). There was no operative or 30-days mortality and the main complication observed was persistent air leakage in 38 patients (22.0%). Non-small-cell lung cancer (NSCLC) was the main histologic type of cancer (n=149; 86.1%), followed by carcinoid tumours (n=20; 11.6%) and other histologic type (n=4; 2.3%). The mean follow-up time was 15 months (range 0-45 months) and the overall survival was 94.5%. CONCLUSION: We believe that uniportal VATS anatomic lung resection with systematic lymphadenectomy is technically safe and feasible and it is an alternative approach to thoracotomy or conventional thoracoscopic in the treatment of lung cancer. This approach has demonstrated to be reproducible, comprising all the advantages of a minimal invasive surgery, without jeopardizing the efficiency of the oncologic treatment. Therefore, we suggest that this technique could have a broader implementation and development in all national surgical centers. The issues of patient acceptability, cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future throughout multi-institution randomized controlled trials and long-term follow-up.

Surgical management of primary spontaneous pneumothorax: 11-years experience.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a pathology with a high recurrence rate. Surgical treatment allows the resolution of the acute episode and prevention of its recurrence. The main objective of the present study was to evaluate the outcomes of patients submitted to surgery due to PSP. METHODS: A retrospective case series review was undertaken on all patients submitted to thoracotomy or video-assisted thoracoscopic surgery (VATS) for PSP at our thoracic surgery center between January 2005 and December 2016. RESULTS: A total of 319 surgeries were performed in 298 patients with a mean age of 29.0±12.7 years. Surgical approach was thoracotomy in 30 surgeries and VATS in 289 procedures. Surgical technique included bullectomy or apical resection in 98.1% of the surgeries in combination with some kind of pleurodesis, mainly partial parietal pleurectomy plus pleural abrasion in 38.9% and only pleural abrasion in 38.9%. Median postoperative stay was 4 days. Postoperative complications occurred in 14.7% of cases, primarily due to persistent air leak (30 of the 47 complications). Recurrence rate was 4.7% (15 cases). There was no association between surgical approach or surgical technique and recurrence. CONCLUSION: Surgical treatment remains one important cornerstone for definitive treatment of PSP. Our study demonstrated that a VATS approach, particularly uniportal VATS, to perform bullectomy or apical wedge resection along with pleural abrasion can be a safe and efficient choice in the treatment and prevention of recurrence of the PSP.

Introdução: O pneumotórax espontâneo primário (PEP) é uma patologia com uma elevada taxa de recorrência. O trata- mento cirúrgico possibilita a resolução do episódio agudo e previne a sua recorrência. O principal objectivo do presente estudo foi avaliar os resultados cirúrgicos dos doentes submetidos a cirurgia devido a PEP. Métodos: Foram revistos retrospectivamente todos os doentes submetidos a toracotomia ou cirurgia vídeo-assistida (VATS) para o tratamento de PEP no nosso centro cirúrgico no período compreendido entre Janeiro de 2005 e Dezembro de 2016. Resultados: Um total de 319 cirurgias foram realizadas em 298 doentes com idade média de 29,0±12,7 anos. A abordagem cirúrgica utilizada foi toracotomia em 30 cirurgias e VATS em 289 cirurgias. A técnica cirúrgica incluiu a ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar em 98,1% das cirurgias, em combinação com uma técnica de pleurodese, principalmente pleurectomia parietal parcial associado a abrasão pleural em 38,9% dos casos e apenas abrasão pleural em 38,9% dos casos. O tempo mediano de internamento foi 4 dias. Ocorreram complicações pós operatórias em 14,7% dos procedimentos, sobretudo fuga aérea prolongada (30 dos 47 casos de complicações). A taxa de recorrência foi de 4,7% (15 casos). Não foi encontrada nenhuma associação estatisticamente significativa entre a abordagem ou técnica cirúrgica e a ocorrência de recorrência de PEP. Conclusão: O tratamento cirúrgico é uma das opções fundamentais no tratamento definitivo de PEP. O nosso estudo demonstrou que a VATS, sobretudo a VATS uniportal, para a realização de ressecção de bolhas enfisematosas ou ressecção atípica do ápex pulmonar associada a abrasão pleural pode ser considerada uma escolha segura e eficaz para o tratamento e prevenção de recidiva de PEP.

Surgical Resection of Lung Metastases.

INTRODUCTION: The aim of this study was to report our experience and outcomes in patients previously diagnosed with primary malignant solid tumors who subsequently underwent surgical resection of lung nodules whose final result on the pathological exam was a metastasis. METHODS: Between January of 2008 and September of 2016, seventy-one patients underwent pulmonary resection by video-assisted thoracic surgery (VATS) or by thoracotomy, for lung metastasis. Data were collected regarding demographics, tumor features, treatment and outcome. RESULTS: The patients included in this retrospective study (n=71) underwent a total of 79 surgeries. The study sample included 44 (62%) male and 27 (38%) female with a mean age of 60.8 years (range, 20-82 years). The primary tumor site was colorectal in 46 patients, lung in 6, soft tissue in 4, kidney in 3 and others tumors in 12. Sixty-four surgeries (81%) were performed due to a solitary metastasis. Ten (13%) surgeries were performed by VATS and 69 (87%) were performed by thoracotomy. We performed 50 (63%) wedge excisions, 20 (26%) lobectomies, 8 (10%) anatomical segmentectomies and 1 (1%) right pneumonectomy. Median hospital stay was 5 days (range, 2-21 days). Postoperative complication rate was 7.6%. Postoperative mortality was 1.3%. Median follow-up was 32 months (range 0 to 86 months). Overall 3 and 5 year survival regardless of the primary tumor site was 70% and 45%, respectively. Overall 3 and 5 year survival for the colorectal carcinoma was 73% and 42%, respectively. CONCLUSION: These results support that lung metastasectomy is a safe and effective procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after resection.

Introdução: O objectivo do estudo foi descrever a nossa experiência e resultados em doentes submetidos à ressecção cirúrgica de nódulos pulmonares cujo resultado anatomo-patológico revelou tratar-se de metástases pulmonares. Métodos: Entre Janeiro de 2008 e Setembro de 2016, setenta e um doentes foram submetidos a ressecção de metástases pulmonares por cirurgia torácica vídeo-assistida (VATS) ou por toracotomia. Os dados foram colhidos atendendo à demografia, às características tumorais, ao tratamento e outcome dos doentes. Resultados: Os doentes incluídos neste estudo retrospectivo (n = 71) foram submetidos a um total de 79 cirurgias. A amostra do estudo incluiu 44 (62%) homens e 27 (38%) mulheres com uma idade média de 60,8 anos (intervalo, 20-82 anos). O local do tumor primário foi o sistema colorretal em 46 doentes, o pulmão em 6, os tecidos moles em 4, o rim em 3 e outros tumores em 12. Sessenta e quatro cirurgias (81%) foram realizadas devido a uma metástase solitária. Dez (13%) cirurgias foram realizadas por VATS e 69 (87%) foram realizadas por toracotomia. No total foram realizadas 50 (63%) ressecções em cunha, 20 (26%) lobectomias, 8 (10%) segmentectomias anatómicas e 1 (1%) pneumonectomia direita. A mediana de internamento hospitalar foi de 5 dias (intervalo, 2-21 dias) com uma taxa de complicações pós-operatórias de 7,6%. A mortalidade pós-operatória foi de 1,3%. O seguimento mediano foi de 32 meses (intervalo de 0 a 86 meses). A sobrevivência global independente do tipo de tumor primário aos 3 e 5 anos foi de 70% e 45%, respectivamente. A sobrevivência global aos 3 e 5 anos para o carcinoma colorretal foi de 73% e 42%, respectivamente. Conclusão: Estes resultados apoiam que a metastasectomia pulmonar é um procedimento seguro e eficaz para doen- tes com tumores primários tratados. E que uma selecção adequada de doentes pode alcançar uma sobrevivência a longo prazo após a ressecção.