Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging.

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging / Recomendações da Sociedade Brasileira de Cirurgia Torácica, Sociedade Brasileira de Pneumologia e Tisiologia e Colégio Brasileiro de Radiologia e Diagnóstico por Imagem para o rastreamento do câncer de pulmão no Brasil

ABSTRACT Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

RESUMO O câncer de pulmão (CP) é uma das neoplasias mais comuns e letais no Brasil, e apenas 15% dos pacientes são diagnosticados nos estágios iniciais. O tabagismo persiste como o responsável por mais de 85% de todos os casos. O rastreamento do CP (RCP) por meio da TC de baixa dosagem de radiação (TCBD) reduz a mortalidade do CP em 20%, e, quando combinado com a cessação do tabagismo, essa redução chega a 38%. Na última década, diversos países adotaram o RCP como recomendação de saúde populacional. No Brasil, embora ainda incipiente, a discussão sobre o tema é cada vez mais ampla e necessária. Com o intuito de aumentar o conhecimento e estimular o debate sobre o RCP, a Sociedade Brasileira de Cirurgia Torácica, a Sociedade Brasileira de Pneumologia e Tisiologia e o Colégio Brasileiro de Radiologia e Diagnóstico por Imagem constituíram um painel de especialistas para elaborar as recomendações para o RCP. As recomendações aqui apresentadas foram baseadas em revisão narrativa da literatura, com ênfase em grandes estudos populacionais, em revisões sistemáticas e em recomendações de diretrizes internacionais, sendo construídas após ampla discussão pelo grupo de especialistas. Os temas revisados foram os seguintes: porque rastrear, considerações gerais sobre tabagismo, epidemiologia do CP, critérios de elegibilidade, achados incidentais, lesões granulomatosas, modelos probabilísticos, requisitos mínimos da TCBD, aquisições volumétricas, riscos do rastreamento, estrutura mínima e papel da equipe multidisciplinar, conduta segundo o Lung CT Screening Reporting and Data System (Lung-RADS), custos vs. benefícios e perspectivas do rastreamento.

Predictors of overall survival in non-small-cell lung cancer patients with metastatic spinal cord compression treated with short-course radiotherapy.

Metastatic spinal cord compression (MSCC) is a condition that impacts directly on the patient's prognosis. OBJECTIVE: The study purpose was to identify predictors of overall survival in non-small-cell lung cancer (NSCLC) patients with MSCC. METHODS: A cohort study involving NSCLC patients enrolled between 2008 and 2017 was performed. Sixty-four patients treated with short-course radiotherapy were included. Clinical and socio-demographic data were extracted from medical records. Data were analysed using survival analysis and Cox proportional hazard regression analysis. RESULTS: The median survival time was 2.5 months (95% CI: 1.6-3.5). Patients >60 years had shorter survival than younger patients (HR 1.85; 95% CI 1.06-3.24; p = 0.02), and patients with performance status (PS) >2 had shorter survival than those with PS≤2 (HR 1.93; 95% CI 1.12-3.33; p = 0.01). CONCLUSION: This study found worse PS and higher age are independent predictors of overall survival in NSCLC patients with MSCC treated with short-course radiotherapy after adjusting the potential confounding factors (PS, age and target therapy).

Impact of different patterns of metastasis in non-small-cell lung cancer patients.

Aim: The aim of this study was to evaluate the frequency and median time for the development of metastases and prognosis by metastatic site after the diagnosis of non-small-cell lung cancer (NSCLC). Patients & methods: This cohort study was conducted with 1096 patients diagnosed with NSCLC between 2006 and 2014. Results: The most prevalent site of NSCLC metastases was the respiratory system. The nervous and adrenal systems presented the longest median time for the development of metastases. The 6-month survival varied from 68.2% for liver to 79.9% for the nervous system. Bone metastases were associated with a higher risk of death. Conclusion: The respiratory system was the most prevalent site of metastases. OS and risk of death varied according to the metastatic site.

Lung Cancer in Never-Smokers: Epidemiological, Clinical, and Survival Patterns based on Gender / Câncer de Pulmão em Indivíduos não Fumantes: Padrões Epidemiológicos, Clínicos e de Sobrevida baseados no Gênero / Cáncer de Pulmón en Individuos no Fumadores: Patrones Epidemiológicos, Clínicos y de Supervivencia basados en el Género

Introduction: Tobacco smoke is the leading risk factor for the development of lung cancer (LC). However, several countries have recently reported increases in LC in never-smokers. Objective: The study aimed to verify epidemiological and survival characteristics in never-smoker LC patients. Method: The study was based on a historical cohort of never-smokers with LC diagnosed from 2000 to 2009. Overall survival was compared using log-rank test, and Cox regression analysis was used to identify independent prognostic factors. Results: A total of 254 never-smoker LC patients were studied (median age 65.5 years; 66.5% women). The most common histological type was adenocarcinoma (65.7% in women and 60.0% in men), and the majority of the patients had advanced stages (III-IV) (79.6% in women and 92.8% in men). 9.9% of the patients were treated with surgery (13.1% of women and 3.6% of men). The overall survival rates at one, three, and five years were 37.2%, 14.2%, and 9.5%, respectively. Median overall survival was 8.3 months. Women showed better survival than men (9.6 vs. 6.9 months; p=0.023). Non-surgical treatment (p<0.001), performance status 2-4 (p=0.038), and stages III and IV (p<0.001) were associated with worse overall survival. Conclusions: The majority of LC cases in never-smokers were advanced-stage adenocarcinoma, submitted to non-surgical treatment. Women showed better survival than men. Based on the low overall survival, the data emphasize the importance of early diagnosis of LC in never-smoker patients.

Introducción: El tabaquismo es el factor de riesgo predominante para el de cáncer de pulmón (CP). Sin embargo, un aumento reciente de CP en no fumadores es prominente en algunos países. Objetivo: El objetivo de este estudio fue verificar las características epidemiológicas y de sobrevida en no fumadores con CP. Método: Cohorte histórica de no fumadores con CP diagnosticados de 2000-2009. La supervivencia global fue comparada usando análisis de log-rank y la regresión de Cox para identificar factores pronósticos independientes. Resultados: Una muestra totalizando 254 pacientes no fumadores con CP fue estudiada (mediana de edad: 65,5 años, 66,5% de mujeres). El tipo histológico más común correspondió a adenocarcinoma (65,7% en las mujeres y el 60,0% en los hombres) y la mayoría en estadio avanzado (III-IV) (79,6% en las mujeres y el 92,8% en los hombres). Un total de 9,9% de pacientes fueron tratados con cirugía (13,1% en mujeres y 3,6% en hombres). Las tasas de supervivencia global de 1, 3 y 5 años fueron, respectivamente, el 37,2%, el 14,2% y el 9,5%. La supervivencia mediana global correspondió a 8,3 meses. Fue observada una mejor sobrevida en mujeres que em hombres (9,6 frente a 6,9 meses, p=0,023). El tratamiento no quirúrgico (p <0,001), el estado de equilibrio del estado 2-4 (p=0,038) y los estadios III-IV (p <0,001) se encontraron asociados con una peor sobrevida global. Conclusiones: Se encontró una mayor ocurrencia de adenocarcinoma, estadificación avanzada y tratamiento no quirúrgico. Las mujeres mostraron una sobrevida mejor que los hombres. En función de la baja sobrevida global, estos datos refuerzan la importancia del diagnóstico precoz del CP en no fumadores.

Introdução: O tabagismo é o fator de risco predominante para o desenvolvimento do câncer de pulmão (CP). Contudo, um aumento recente de CP em não fumantes é proeminente em alguns países. Objetivo:O objetivo deste estudo foi verificar as características epidemiológicas e de sobrevida em não fumantes com CP. Método: Coorte histórica de não fumantes com CP diagnosticados de 2000 a 2009. A sobrevivência global foi comparada usando o teste Log-rank e a análise de regressão de Cox foi usada para identificar fatores prognósticos independentes. Resultados: Um total de 254 pacientes com LC não fumantes foram estudados (mediana de idade: 65,5 anos, 66,5% de mulheres). O tipo histológico mais comum foi o adenocarcinoma (65,7% nas mulheres e 60,0% nos homens) e a maioria tinha estadiamento avançado (III-IV) (79,6% nas mulheres e 92,8% nos homens). Um total de 9,9% dos pacientes foi tratado com cirurgia (13,1% em mulheres e 3,6% em homens). As taxas de sobrevida global de 1, 3 e 5 anos foram, respectivamente: 37,2%, 14,2% e 9,5%. A sobrevida global mediana foi de 8,3 meses. As mulheres tiveram melhor sobrevida do que os homens (9,6 vs. 6,9 meses, p=0,023). O tratamento não cirúrgico (p<0,001), o performance status 2-4 (p=0,038) e os estádios III-IV (p<0,001) foram associados com uma sobrevida global pior. Conclusão: Encontrou-se uma maior ocorrência de adenocarcinoma, estadiamento avançado e tratamento não cirúrgico. As mulheres tiveram uma sobrevida maior do que os homens. Em razão da baixa sobrevida global, esses dados reforçam a importância do diagnóstico precoce do CP em não fumantes.

Fatores prognósticos para a sobrevida dos pacientes com derrame pleural maligno / Prognostic factors for survival in patients with malignant pleural effusion

Introdução: O tratamento paliativo dos pacientes com Derrame Pleural Maligno (DPM) deve ser individualizado uma vez que esses pacientes têm sobrevida reduzida. O objetivo deste estudo foi desenvolver um modelo capaz de identificar os fatores prognósticos relacionados à sobrevida dos pacientes com DPM. Métodos: É um estudo retrospectivo, descritivo, observacional para identificar fatores prognósticos relacionados ao DPM em pacientes com diagnóstico confirmado de câncer oriundos do banco de dados do Instituto Nacional do Câncer (INCA), vinculado ao Ministério da Saúde. A análise multivariada de Kaplan-Meier e o modelo de regressão de Cox foram utilizadas para determinar os fatores com potencial prognóstico relacionados à sobrevida desses pacientes. A sobrevida foi definida como o tempo do diagnóstico anátomo patológico até o óbito. Resultados: Cento e sessenta e cinco pacientes foram incluídos no estudo; 77 homens (47%), e 88 mulheres (53%). A mediana da idade foi de 60 anos (1,0 ­ 95,0), e todos os pacientes tinham DPM confirmados por exames cito e/ou histopatológicos. O carcinoma de pulmão, do tipo não pequenas células (36%), a neoplasia de mama (26%) e os linfomas (13%) foram os tumores mais frequentemente diagnosticados. A mediana da sobrevida global dos pacientes a partir do diagnóstico foi de 5 meses (1,0-96,0). A análise univariada de Kaplan-Meier demonstrou que a sobrevida dos pacientes estava significativamente relacionada com os seguintes fatores prognósticos: a escala de capacidade funcional (PS) da Eastern Cooperative Oncology Group (ECOG) (HR 10,0, IC 95%: 5,96 a 18,50, p < 0,0001), local do tumor primário (HR 1,99, IC 95%: 1,23 a 3,22, p < 0,01), citologia oncótica do líquido pleural positiva (HR 1,25, IC 95%: 0,88 a 1,78, p = 0,04), e exame histológico da pleura positivo (HR 1,33, IC 95%: 0,97 a 1,81, p = 0,04). Outros fatores prognósticos independentes avaliados não tiveram influência na sobrevida. A análise de regressão de Cox demonstrou que somente a escala da capacidade funcional (PS) da ECOG estava altamente relacionada com a sobrevida dos pacientes (HR 73,58, IC 95%: 23,44 a 230,95, p < 0,0001). Conclusões: a escala da capacidade funcional (PS) da ECOG foi um fator previsor independente de sobrevida para os pacientes com DPM no momento do diagnóstico inicial. Este fator prognóstico pode auxiliar os médicos na seleção dos pacientes para o tratamento paliativo apropriado da síndrome do DPM. AU

Background: The approach to palliative treatment of malignant pleural effusion (MPE) should be individualized because these patients generally have poor survival. This study aimed to develop a model to identify prognostic factors for survival time in patients with MPE. Methods: This is a retrospective, descriptive, observational study to identify prognostic factors related to MPE in patients with a confirmed diagnosis of cancer. Cox regression analysis was used to determine significant potential prognostic factors with respect to survival time. Survival time was defined as the time from pathological diagnosis to death. Results: One hundred and sixty-five patients were included; 77 were men (47%) and 88 were women (53%). The median age was 60 years (1.0 ­ 95.0), and all of the patients were pathologically proven to have MPE. Non-small-cell lung cancer (36.0%), breast carcinoma (26%), and lymphoma (13.0%) were the most frequently diagnosed tumors. The median overall survival of patients from the initial diagnosis was 5 months (range: 1.0­96.0 months). The Kaplan­Meier univariate analysis showed that survival was significantly related to the following prognostic factors: Eastern Cooperative Oncology Group - Performance Status (ECOG - PS) (HR 10.0; 95% CI: 5.96 to 18.50, p < 0.0001); primary cancer site (HR 1.99; 95% CI: 1.23 to 3.22, p < 0.01); positive pleural cytology (HR 1.25; 95% CI: 0.88 to 1.78, p = 0.04); and positive histology (HR 1.33; 95% CI: 0.97 to 1.81, p = 0.04). Other potential independent diagnostic factors that were examined did not affect survival. Cox regression analysis showed that only the ECOG PS was highly predictive of survival (HR 73.58; 95% CI: 23.44 to230.95, p < 0.0001). Conclusions: ECOG PS is an independent predictor of survival in patients with MPE at initial diagnosis. This prognostic factor can help physicians select patients for appropriate palliative treatment of this syndrome. AU

Important prognostic factors for survival in patients with malignant pleural effusion.

BACKGROUND: The approach to palliative treatment of malignant pleural effusion (MPE) should be individualized because these patients generally have poor survival. Our study aimed to develop a model to identify prognostic factors or survival time in patients diagnosed with MPE. METHODS: This is a retrospective, descriptive, observational study to identify prognostic factors related to MPE in patients with a confirmed cancer diagnosis. Cox regression analysis was used to determine significant potential prognostic factors with respect to survival time. Survival time was defined as the time from pathological diagnosis to death. RESULTS: One hundred and sixty-five patients were included; 77 were men (47%) and 88 were women (53%). The median age was 60 years, and all of the patients were pathologically proven to have MPE. Non-small-cell lung cancer (36.0%), breast carcinoma (26%), and lymphoma (13.0%) were the most frequently diagnosed tumors. The median overall survival of patients from the initial diagnosis was 5 months (range: 1.0-96.0 months). Kaplan-Meier univariate analysis showed that survival was significantly related to the following prognostic factors: ECOG PS (hazard ratio [HR] 10.0, 95% confidence interval [95% CI] 5.96 to 18.50, p < 0.0001), primary cancer site (HR 1.99, 95% CI 1.23 to 3.22, p < 0.01), positive pleural cytology (HR 1.25, 95% CI 0.88 to 1.78, p = 0.04), and positive histology (HR 1.33, 95% CI 0.97 to 1.81, p = 0.04). Other potential independent diagnostic factors that were examined did not affect survival. Cox regression analysis showed that only the ECOG PS was highly predictive of survival (HR 73.58, 95% CI 23.44 to 230.95, p < 0.0001). CONCLUSIONS: ECOG PS is an independent predictor of survival in patients with MPE at initial diagnosis. This prognostic factor can help physicians select patients for appropriate palliative treatment of this syndrome.

Consumo de tabaco e de álcool como fatores de risco para o surgimento de segundo tumor primário maligno no pulmão

Os tumores primários múltiplos são definidos como a coexistência ou a sucessão de dois ou mais tumores malignos distintos, em um mesmo órgão ou em órgãos diferentes, ou de tumores separados por mucosa normal quando no mesmo órgão. Nestes casos o carcinoma escamoso é o tipo histológico mais comumente envolvido. O tabaco é o agente carcinogênico isolado mais importante no trato aere-digestivo superior. O álcool acrescenta importante efeito sinérgico à carcinogenicidade do tabaco, quando utilizado em conjunto com ele. Objetivos: a) descrever o local e as freqüências dos tumores primários de pacientes com segundo tumor maligno primário no pulmão; b) descrever os tipos histológicos e a freqüência do segundo tumor maligno primário no pulmão; c) descrever a freqüência do consumo de álcool e de tabaco na casuística dos pacientes com segundo tumor primário maligno no pulmão; d) calcular as medidas de risco entre tabagismo e consumo de álcool para surgimento de segundo tumor maligno primário no pulmão; e) calcular a força de associação e previsão entre os fatores de risco - consumo de álcool e tabaco - em pacientes com segundo tumor maligno primário no pulmão. Pacientes e Métodos: estudo individualizado, observacional, longitudinal e de caso controle. Casos: pacientes do Hospital do Câncer-INCA/MS, no Rio de Janeiro e do Hospital Universitário Antônio Pedro, em Niterói, que tiveram o diagnóstico comprovado de um segundo tumor primário maligno no pulmão. Controles: o princípio da escolha foi o da máxima semelhança entre os casos e controles; foram selecionados com a mesma probabilidade de serem expostos aos fatores de risco - carga tabágica e consumo de álcool - e com história de um tumor maligno primário e, num determinado período de tempo, não terem desenvolvido um segundo tumor primário no pulmão. Resultados: no grupo de casos - 104 pacientes com segundo tumor primário no pulmão - o sítio do tumor primário inicial foi a região da cabeça e pescoço (56,7%); a laringe contribuiu com 42,3%. Em seguida vieram pulmões (15,4%); bexiga (8,6%); colo uterino (7,6%); estômago (4,8%); esôfago e Iinfonodos (1,9%) cada; pênis, osso e mama (0,9%) cada. Nesse grupo de pacientes 84,6% eram do sexo masculino e 15,3% do feminino. A faixa etária mais acometida foi a dos 40 aos 70 anos. 91,4% eram fumantes e 93,2% consumidores de álcool. Analisando a distribuição das variáveis sobre o fumo nos casos e controles, a estimativa indireta do risco relativo foi de 26,6(IC 95%; 13,03 a 54,55) p < 0,001 (X2 = 136,4670). 0 cálculo do risco atribuível ao fumo foi de 96,2%. O cálculo do risco atribuível populacional ou excesso de risco na população devido ao tabagismo foi de 88,4%. Analisando a distribuição das variáveis sobre o álcool nos casos e controles, a estimativa indireta do risco relativo foi de 63,0 (IC 95%; 28,12 a 141,17) p < 0,05(X2 = 209,3914). O cálculo do risco atribuível populacional ou excesso de risco na população devido ao consumo de álcool foi de 95,8%. Discussão e Conclusões...

Introduction: Multiple primary tumors are defined as the coexistence or the succession of two or more distinct malignant tumors in the same organ or in different organs, or tumors separeted by a normal mucosa in the same organ. Squamous carcinoma is the most commonly occuring hystologic type. Tobacco is the most important isolated carcinogenic factor in the superior aero-digestive tract. Alcohol adds important synergetic factor effect to tobacco carcinogenicity, when used simultaneously. Objectives: a) describe site and frequency of primary tumors in patients with a second lung malignant primary tumor; b) describe histologic types and frequency of a second lung malignant primary tumor; c) describe frequency of alcohol intake and tobacco use in casuistry of patients with a second lung malignant primary tumor; d) calculate risk measurements between tobacco use and alcohol intake for the onset of a second lung malignant primary tumor; e) calculate association and prediction force among risk factors - alcohol intake and tobacco use - in patients with a second lung malignant primary tumor. Patients and Methods: individual, observational, longitudinal study and case control. Cases: INCA/MS-Cancer Hospital patients, in Rio de Janeiro and University Hospital Antônio Pedro, in Niterói, with a confirmed diagnosis of cancer. Controls: the basic principle of choice was the high similarity between cases and controls; subjects were selected based on the same probability of being exposed to risk factors - tobacco load and alcohol intake. Patients had a primary malignant tumor and for a certain period of time, they did not develop a second lung primary tumor. Results: in cases groups - 104 patients with a lung second primary tumor - initial primary tumor site was head and neck area (56.7%) larynx accounted for 42.3%. Then there were lungs (15.4%); bladder (8.6%); cervix uteri (7.6%); stomach (4.8%); esophagus and lymph nodes (1.9%) each; penis, bone and breast (0.9%) each. 84.6% of patients were male and 15.3% females. Most affected age group was 40-70 years of age. 91.4% were smokers and 93.2% alcohol users. Through the analysis of variables distribuition over tobacco in cases and controls, the indirect estimate relative risk was 26.6 (CI 95%; 13.03 to 54.55) P < 0.001 (X2 = 136.4670). Tobacco assignable risk was 96.2%. Populational assignable risk calculation or excess of risk throughout population due to tobacco intake was 88.4%. Through the analysis of variables distribuition over alcohol in cases and controls, the indirect estimate of relative risk was 63.0 (CI 95%; 28.12 to 141.17) P < 0.05 (X2 = 209.3914). Population assignable risk calculation or excess of risk throughout population due to alcohol intake was 95.8%. Discussion and Conclusions: a) the most common site of a first primary malignant...