The association of visceral pleural invasion with skip N2 metastasis on clinical stage IA NSCLC

Abstract Background Lung lymphatic drainage occurs mainly through a peribronchial path, but it is hypothesized that visceral pleural invasion could alter this path. This study aims to investigate the association between visceral pleural invasion, node upstaging, and N2 skip metastasis and the impact on survival in a population of patients with non-small cell lung cancer of 3 cm or smaller. Methods We retrospectively queried our institutional database of lung cancer resection for all patients with clinical stage IA NSCLC between June 2009 and June 2022. We collected baseline characteristics and clinical and pathological staging data. Patients were classified into two groups: The non-VPI group with negative visceral pleural invasion and the VPI group with positive. The primary results analyzed were the occurrence of nodal upstaging, skip N2 metastasis and recurrence. Results There were 320 patients analyzed. 61.3 % were women; the median age was 65.4 years. The pleural invasion occurred in 44 patients (13.7 %). VPI group had larger nodules (2.3 vs. 1.7 cm; p < 0.0001), higher 18F-FDG uptake (7.4 vs. 3.4; p < 0.0001), and lymph-vascular invasion (35.7 % vs. 13.5 %, p = 0.001). Also, the VPI group had more nodal disease (25.6 % vs. 8.7 %; p = 0.001) and skip N2 metastasis (9.3 % vs. 1.8 %; p = 0.006). VPI was a statistically independent factor for skip N2 metastasis. Recurrence occurred in 17.2 % of the population. 5-year disease-free and overall survival were worse in the VPI group. Conclusions The visceral pleural invasion was an independent factor associated with N2 skip metastasis and had worse disease-free and overall survival.

External validation of the parsimonious EuroLung risk models: analysis of the Brazilian Lung Cancer Registry

ABSTRACT Objective: The purpose of this study was to assess performance in the Brazilian Lung Cancer Registry Database by using the parsimonious EuroLung risk models for morbidity and mortality. Methods: The EuroLung1 and EuroLung2 models were tested and evaluated through calibration (calibration plot, Brier score, and the Hosmer-Lemeshow test) and discrimination (ROC AUCs), in a national multicenter registry of 1,031 patients undergoing anatomic lung resection. Results: The evaluation of performance in Brazilian health care facilities utilizing risk-adjustment models, specifically EuroLung1 and EuroLung2, revealed substantial miscalibration, as evidenced by calibration plots and Hosmer-Lemeshow tests in both models. In terms of calibration, EuroLung1 exhibited a calibration plot with overlapping points, characterized by a slope of 1.11 and a Brier score of 0.15; the Hosmer-Lemeshow test yielded a statistically significant p-value of 0.015; and the corresponding ROC AUC was 0.678 (95% CI: 0.636-0.721). The EuroLung2 model displayed better calibration, featuring fewer overlapping points in the calibration plot, with a slope of 1.22, with acceptable discrimination, as indicated by a ROC AUC of 0.756 (95% CI: 0.670-0.842). Both models failed to accurately predict morbidity and mortality outcomes in this specific health care context. Conclusions: Discrepancies between the EuroLung model predictions and outcomes in Brazil underscore the need for model refinement and for a probe into inefficiencies in the Brazilian health care system.

Resident physician training in bedside pleural procedures: A one-year experience at a teaching hospital

Abstract Background and objective This study aims to quantify bedside pleural procedures performed at a quaternary teaching hospital describing technical and epidemiological aspects. Materials and methods The authors retrospectively reviewed consecutive patients who underwent invasive thoracic bedside procedures between March 2022 and February 2023. Results 463 chest tube insertions and 200 thoracenteses were performed during the study period. Most procedures were conducted by 1st-year Thoracic Surgery residents, with Ultrasound Guidance (USG). There was a notable preference for small-bore pigtail catheters, with a low rate of immediate complications. Conclusion Bedside thoracic procedures are commonly performed in current medical practice and are significant in surgical resident training. The utilization of pigtail catheters and point-of-care ultrasonography by surgical residents in pleural procedures is increasingly prevalent and demonstrates high safety.

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

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

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

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

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

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

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

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

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

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

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

Robotic pulmonary lobectomy for lung cancer treatment: program implementation and initial experience / Lobectomia pulmonar robótica para tratamento do câncer de pulmão e de metástases pulmonares: implantação do programa e experiência inicial

ABSTRACT Objective: To describe the implementation of a robotic thoracic surgery program at a public tertiary teaching hospital and to analyze its initial results. Methods: This was a planned interim analysis of a randomized clinical trial aimed at comparing video-assisted thoracoscopic surgery and robotic surgery in terms of the results obtained after pulmonary lobectomy. The robotic surgery program developed at the Instituto do Câncer do Estado de São Paulo, in the city of São Paulo, Brazil, is a multidisciplinary initiative involving various surgical specialties, as well as anesthesiology, nursing, and clinical engineering teams. In this analysis, we evaluated the patients included in the robotic lobectomy arm of the trial during its first three months (from April to June of 2015). Results: Ten patients were included in this analysis. There were eight women and two men. The mean age was 65.1 years. All of the patients presented with peripheral tumors. We performed right upper lobectomy in four patients, right lower lobectomy in four, and left upper lobectomy in two. Surgical time varied considerably (range, 135-435 min). Conversion to open surgery or video-assisted thoracoscopic surgery was not necessary in any of the cases. Intraoperative complications were not found. Only the first patient required postoperative transfer to the ICU. There were no deaths or readmissions within the first 30 days after discharge. The only postoperative complication was chest pain (grade 3), in two patients. Pathological examination revealed complete tumor resection in all cases. Conclusions: When there is integration and proper training of all of the teams involved, the implementation of a robotic thoracic surgery program is feasible and can reduce morbidity and mortality.

RESUMO Objetivo: Descrever a implantação de um programa de cirurgia torácica robótica em um hospital terciário público universitário e analisar seus resultados iniciais. Métodos: Este estudo é uma análise interina planejada de um ensaio clínico aleatorizado cujo objetivo é comparar resultados da lobectomia pulmonar por videotoracoscopia com a robótica. O programa de cirurgia robótica do Instituto do Câncer do Estado de São Paulo, localizado na cidade de São Paulo (SP), foi uma iniciativa multidisciplinar que envolveu diversas especialidades cirúrgicas e equipes de anestesia, enfermagem e engenharia clínica. Nesta análise, avaliamos os pacientes incluídos no braço lobectomia robótica durante os primeiros três meses do estudo (de abril a junho de 2015). Resultados: Dez pacientes foram incluídos nesta análise. Eram oito mulheres e dois homens. A média de idade foi de 65,1 anos. Todos apresentavam tumores periféricos. Foram realizadas lobectomia superior direita, em quatro pacientes; lobectomia inferior direita, em quatro; e lobectomia superior esquerda, em dois. Os tempos cirúrgicos variaram bastante (variação, 135-435 min). Não foi necessária a conversão para técnica aberta ou videotoracoscópica em nenhum paciente. Não foram observadas complicações intraoperatórias. Apenas o primeiro paciente foi encaminhado à UTI no pós-operatório. Não houve mortalidade nem reinternações em 30 dias após a alta. A única complicação pós-operatória observada foi dor torácica (grau 3), em dois pacientes. O exame anatomopatológico revelou a ressecção completa do tumor em todos os casos. Conclusões: A implantação de um programa de cirurgia torácica robótica, quando há integração e treinamento adequado de todas as equipes envolvidas, é factível e pode reduzir a morbidade e a mortalidade.