Not always a miracle - The case of the missing metastasis.

Spontaneous regression of malignant neoplasms is extremely rare, but renal cell carcinomas (RCC) are most often associated with this phenomenon. We report a case of a patient with personal history of RCC, who underwent nephrectomy and no other oncological treatment. One year after nephrectomy, a lung metastasis was detected and kept under follow-up for 3 years. Its size increased over time until a needle biopsy was performed, and its metastatic nature confirmed. Wedge resection of the lung nodule was performed, and no neoplastic cells were found, suggesting its spontaneous regression after biopsy. Different theories have been proposed to explain this phenomenon and, in most cases, the mechanism seems to involve the activation of the immune system. This case supports the importance of reducing tumor burden and the impact of the disturbance of the tumor microenvironment caused by instrumentation, in improving immune system activation and its essential role in neoplasm regression.

Solitary Diaphragmatic Metastasis of a Previously Excised Chest Wall Chondrosarcoma.

Chest wall chondrosarcomas are relatively infrequent tumours. Diaphragmatic metastasis are rarer still, and are generally associated with disseminated disease, usually involving the liver and the lungs. The authors present the case of a 65 year old man with a prior history of a chest wall chondrosarcoma, which on a routine chest CT was identified a single diaphragmatic metastasis. A redo thoracotomy was performed, with partial resection and reconstruction of the diaphragm. The post-resection histopathological examination revealed a conventional chondrosarcoma metastasis, centred in the diaphragmatic muscle, not reaching the pleura or the peritoneum.

Not Always a Thymoma - About a Mediastinal Cavernous Hemangioma.

A mediastinal cavernous hemangioma is difficult to distinguish from other types of mediastinal tumours. They are usually asymptomatic and incidentally discovered in an imaging study but can present with compressive symptoms or by infiltration of adjacent structures. A 64-year-old woman with a prior history of triple negative invasive carcinoma of the breast, under surveillance was referred after a Chest CT-scan showed a soft tissue 40x20 mm mediastinal mass, suggestive of a thymoma, and as such no tissue biopsy was obtained. A right-side uniportal VATS was performed, the anterior mediastinum dissected and the mass was exposed, and several anomalous veins were identified. Histopathology showed 36x31x15 mm mass, compatible with a cavernous hemangioma of the anterior mediastinum. This case, whilst not questioning the NCCN statement suggesting not doing a tissue biopsy, points to the fact that rare differential diagnosis, like a Cavernous Hemangioma do exist, and a careful and sound judgement is needed at all times.

Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy: Analysis of Perioperative Risk Factors and Impact on Outcome.

Background Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is an effective treatment option for appropriately selected patients with peritoneal carcinomatosis. Our aim was to analyze a multidisciplinary approach and to study the perioperative risk factors associated with morbidity and mortality. Methods We reviewed all patients who underwent CRS + HIPEC from January 2019 till December 2020 at our oncologic center. Patient demographics, risk scores, intraoperative variables, postoperative care, analgesia protocol, and adverse events (AE) within 30 days after treatment were collected and statistically analyzed. Results Of the 98 patients evaluated preoperatively by a multidisciplinary team, 39 patients required active optimization. The median age was 61 years, and 67 were women. Most tumors were appendiceal in origin. The median peritoneal cancer index (PCI) score was 12, and the median operative time length (OTL) was 400 minutes. Body mass index, Physiological and Operative Severity Score for the enUmeration of morbidity, PCI score, crystalloid volume, cell concentrates, and OTL were associated with postoperative intensive care unit admission (p <0.05). Epidural analgesia was given to 74 patients. AEs occurred in 39 patients, and 25 of the AEs were classified as mild or moderate. The intraoperative variables associated with development of AEs were anesthesia technique, estimated blood loss, crystalloid volume, cell concentrates, OTL, and analgesia protocol (p <0.05). On multivariate analysis, crystalloid volume >6 L, intravenous sufentanil analgesic protocol, and OTL were associated with 67%, 38%, and 15% increased risk of AE, respectively. Conclusion Our study highlighted the importance of a perioperative protocol with a standardized multidisciplinary approach in order to decrease the incidence of postoperative AE.

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.

Floristic survey of vascular plants of a poorly known area in the Brazilian Atlantic Forest (Flona do Rio Preto, Espírito Santo).

BACKGROUND: The Atlantic Forest is one of the most threatened biomes in the world. Despite that, this biome still includes many areas that are poorly known floristically, including several protected areas, such as the "Floresta Nacional do Rio Preto" ("Flona do Rio Preto"), located in the Brazilian State of Espírito Santo. This study used a published vascular plant species list for this protected area from the "Catálogo de Plantas das Unidades de Conservação do Brasil" as the basis to synthesise the species richness, endemism, conservation and new species occurrences found in the "Flona do Rio Preto". NEW INFORMATION: The published list of vascular plants was based on field expeditions conducted between 2018 and 2020 and data obtained from herbarium collections available in online databases. Overall, 722 species were documented for the "Flona do Rio Preto", 711 of which are native to Brazil and 349 are endemic to the Atlantic Forest. In addition, 60 species are geographically disjunct between the Atlantic and the Amazon Forests. Most of the documented species are woody and more than 50% of these are trees. Twenty-three species are threatened (CR, EN and VU), while five are Data Deficient (DD). Thirty-two species are new records for the State of Espírito Santo. Our results expand the knowledge of the flora of the Atlantic Forest and provide support for the development of new conservation policies for this protected area.

Risk-Prediction Model for Transfusion of Erythrocyte Concentrate During Extracorporeal Circulation in Coronary Surgery

Abstract Introduction: Our objective was to identify preoperative risk factors and to develop and validate a risk-prediction model for the need for blood (erythrocyte concentrate [EC]) transfusion during extracorporeal circulation (ECC) in patients undergoing coronary artery bypass grafting (CABG). Methods: This is a retrospective observational study including 530 consecutive patients who underwent isolated on-pump CABG at our Centre over a full two-year period. The risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) test, respectively. Results: EC transfusion during ECC was required in 91 patients (17.2%). Of these, the majority were transfused with one (54.9%) or two (41.8%) EC units. The final model covariates (reported as odds ratios; 95% confidence interval) were age (1.07; 1.02-1.13), glomerular filtration rate (0.98; 0.96-1.00), body surface area (0.95; 0.92-0.98), peripheral vascular disease (3.03; 1.01-9.05), cerebrovascular disease (4.58; 1.29-16.18), and hematocrit (0.55; 0.48-0.63). The risk model developed has an excellent discriminatory power (AUC: 0,963). The results of the H-L test showed that the model predicts accurately both on average and across the ranges of deciles of risk. Conclusions: A risk-prediction model for EC transfusion during ECC was developed, which performed adequately in terms of discrimination, calibration, and stability over a wide spectrum of risk. It can be used as an instrument to provide accurate information about the need for EC transfusion during ECC, and as a valuable adjunct for local improvement of clinical practice. OR=odds ratio Key Question: What is the risk of the need for use of erythrocyte concentrate (EC) during cardiopulmonary bypass? Key Findings: Risk factors with the greatest prediction for EC transfusion. Take-Home Message: The implementation of this model would be an important step in optimizing and improving the quality of surgery.

Risk-Prediction Model for Transfusion of Erythrocyte Concentrate During Extracorporeal Circulation in Coronary Surgery.

INTRODUCTION: Our objective was to identify preoperative risk factors and to develop and validate a risk-prediction model for the need for blood (erythrocyte concentrate [EC]) transfusion during extracorporeal circulation (ECC) in patients undergoing coronary artery bypass grafting (CABG). METHODS: This is a retrospective observational study including 530 consecutive patients who underwent isolated on-pump CABG at our Centre over a full two-year period. The risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) test, respectively. RESULTS: EC transfusion during ECC was required in 91 patients (17.2%). Of these, the majority were transfused with one (54.9%) or two (41.8%) EC units. The final model covariates (reported as odds ratios; 95% confidence interval) were age (1.07; 1.02-1.13), glomerular filtration rate (0.98; 0.96-1.00), body surface area (0.95; 0.92-0.98), peripheral vascular disease (3.03; 1.01-9.05), cerebrovascular disease (4.58; 1.29-16.18), and hematocrit (0.55; 0.48-0.63). The risk model developed has an excellent discriminatory power (AUC: 0,963). The results of the H-L test showed that the model predicts accurately both on average and across the ranges of deciles of risk. CONCLUSIONS: A risk-prediction model for EC transfusion during ECC was developed, which performed adequately in terms of discrimination, calibration, and stability over a wide spectrum of risk. It can be used as an instrument to provide accurate information about the need for EC transfusion during ECC, and as a valuable adjunct for local improvement of clinical practice. Key Findings: Risk factors with the greatest prediction for EC transfusion. Take-Home Message: The implementation of this model would be an important step in optimizing and improving the quality of surgery.

BRONCHOPLASTY FOR A TYPICAL CARCINOID: AN UNUSUAL CHOICE FOR AN UNUSUAL PATIENT.

Primary carcinoid tumours of the lung are rare tumours and when typical are associated with a benign behaviour and should be classified as low-grade neuroendocrine tumour/carcinoma. A 67-year old HIV-positive female was admitted due to a typical carcinoid tumour on the distal third of the main left bronchus, occupying two thirds of the lumen. Given she was HIV positive, had a moderately compromised lung function and in order to minimize surgical events, postoperative complications and to maximize postoperative lung function, the authors opted for a bronchoplasty using a patch. The surgery was uneventful and as the resected area of the bronchus was small, patency was assured and the distortion was minimal. During extubation, resistance was felt upon trying to the remove the bronchial blocker. After performing bronchoscopy it was seen that the loop at the end of the bronchial blocker was caught in the patch suture. Fortunately it was possible to cut the loop, freeing the blocker and avoiding a redo surgery. There were several possible options, ranging from left pneumonectomy, superior left lobe sleeve lobectomy, resection of the left main bronchus with a Y bronchial reconstruction or a bronchoplasty using a patch. The chosen technique has several advantages: From an oncological standpoint a typical carcinoid is indolent and needs only a clear resection margin. From a functional standpoint lung tissue resection was prevented. From a surgical standpoint it is less challenging, easy to perform and less prone to surgical events, essential considering the particular case of an AIDS patient.

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.

Ganglioneuroma Of The Right Cervicothoracic Transition.

A 26 year old male, submitted to resection of a ganglioneuroma of the right pulmonary apex through a right Grunenwald approach. The mass insinuated through the innominate vessels, extending posteriorly to the subclavian artery, which it encircled for over 180 degrees, and the right thyrocervical arterial trunk, which was ligated.

Percutaneous Pericardial Drain: A Deadly Embrace Of The Heart.

Pericardial effusions have multiple causes and when significant percutaneous drainage is standard. Usually removal is a simple and quick procedure with reduced risks. Still, the authors present a case were the drain surrounded the heart and great vessels, causing severe pain, bradycardia and hypotension when pulled, forcing a surgical removal of the same.