A medical epopee: recurrent fungal endocarditis, heart transplantation and chylopericardium.

BACKGROUND: Candida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection. Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example. CASE PRESENTATION: We report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge. CONCLUSIONS: Fungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

Predictors of hospital discharge in cancer patients with pericardial effusion undergoing surgical pericardial drainage.

INTRODUCTION: Pericardial effusion (PE) is a complication of late-stage cancer and some patients never leave the hospital despite drainage. The main objective of this study was to identify predictors of hospital discharge in cancer patients with (PE) who underwent pericardial drainage. We also report the occurrence of paradoxical hemodynamic instability (PHI). METHODS AND MATERIALS: A retrospective study was carried out in a cancer center. Patients included had malignancy, PE, and underwent surgical drainage. An institutional database was reviewed for preoperative variables, analyzed for hospital discharge. RESULTS: One-hundred and thirteen patients were included, with a mean age of 54 years old (SD 14.3). Sixty-three patients were discharged from hospital (55.7%). Age (odds ratio [OR], 1.04; P = 0.004), higher ECOG status (OR, 0.63; P = 0.019), recent chemotherapy (OR, 3.40; P = 0.007), and renal failure (OR, 0.14; P = 0.002) were associated with hospital discharge. Median survival was 43 days (IQ 25%-75%; 15-162). Patients with pulmonary embolism or neutropenia were at greater risk of developing PHI (OR, 10.11; P = 0.009 and OR, 12.13; P = 0.015, respectively). CONCLUSION: Almost half of the patients never left the hospital. Patients with no chemotherapy within 45 days of procedure, patients with renal failure and higher ECOG status are at greater risk of not getting discharged. PHI remains a serious condition with high mortality.

Building a Large Robotic Thoracic Surgery Program in an Emerging Country: Experience in Brazil.

BACKGROUND: In the last decade, robotic video-assisted thoracic surgery (R-VATS) has grown significantly and consolidated as an alternative to video-assisted thoracic surgery. The objective of this study is to present the implementation as well as the experience with R-VATS accumulated by 2 Brazilian groups. We also compared the outcomes of procedures performed during the learning curve and after a more mature experience. METHODS: Retrospective cohort study included all R-VATS procedures performed since April 2015 until April 2018. We describe the process of implantation of robotic surgery, highlighting the peculiarities and difficulties found in a developing country. Moreover, we reported our descriptive results and compared the first 60 patients to the subsequent cases. RESULTS: Two hundred and five patients included 101 females/104 males. Mean age was 61.7 years. There were hundred and sixty-four pulmonary resections, 39 resections of mediastinal lesions, 1 diaphragmatic plication, and 1 resection of a hilar tumor. Median operative times were 205 min for lung resections and 129 min for mediastinal. There was no conversion to VATS or thoracotomy or major intraoperative complications. Median length of stay was 3 days for pulmonary resections and 1 day for mediastinal. Postoperative complications occurred in 35 cases (17.0%)-prolonged air leak was the most common (17 cases). One fatality occurred in an elderly patient with pneumonia and sepsis (0.4%). Comparison of the first 60 patients (learning curve) with subsequent 145 patients (consolidated experience) showed significant differences in surgical and ICU time, both favoring consolidated experience. CONCLUSIONS: Our results were comparable to the literature. Robotic thoracic surgery can be safely and successfully implemented in tertiary hospitals in emerging countries provided that all stakeholders are involved and compromised with the implementation process.

Analysis of Quality of Life after Pleurodesis in Patients with Malignant Pleural Effusion.

BACKGROUND: Malignant pleural effusion is one of the most important complications of metastatic cancer, and recurrent pleural effusions do not only have an impact on survival but also cause a huge repercussion on a patient's quality of life. OBJECTIVES: The main objective was to describe quality of life status before and after pleurodesis in patients with malignant pleural effusion. Secondary, we aimed to find predictors of quality of life improvement in such a population. METHODS: Retrospective analysis of a database collected prospectively. We included patients who underwent pleurodesis from June 2004 to July 2014. Quality of life was evaluated through the WHOQOL-BREF questionnaire and applied before and 30 days after pleurodesis. We used a paired t test and the Wilcoxon rank-sum to compare pre-/post-pleurodesis results, Kaplan-Meier curves for survival analysis, and multiple linear regressions to find predictors of quality of life improvement. RESULTS: 183 patients were included (145 were women). Mean age was 58.3 ± 12.3 years, the most numerous primary tumor was breast cancer. Median survival time was 9 months. Dyspnea was the most prevalent symptom. Baseline results showed that patients had low quality of life scores. After pleurodesis, there was a significant improvement in respiratory symptoms, physical domain, and general health. Linear regression showed an improvement in physical domain with the sclerosing agent nitrate (p = 0.005). Male gender (p = 0.002) and a higher lymphocyte count (p = 0.01) were inversely associated with improvement in physical domain. CONCLUSIONS: Pleurodesis improved symptoms and quality of life in patients with malignant pleural effusion. Gender, lymphocyte count, and sclerosing agent might interfere with quality of life improvement.

Pleural Fluid Adenosine Deaminase (ADA) Predicts Survival in Patients with Malignant Pleural Effusion.

PURPOSE: Systemic and local inflammations have been described as relevant prognostic factors in patients with cancer. However, parameters that stand for immune activity in the pleural space have not been tested as predictors of survival in patients with malignant pleural effusion. The objective of this study was to evaluate pleural lymphocytes and Adenosine Deaminase (ADA) as predictors of survival in patients with recurrent malignant pleural effusion. METHODS: Retrospective cohort study includes patients who underwent pleurodesis for malignant pleural effusion in a tertiary center. Pleural fluid protein concentration, lactate dehydrogenase, glucose, oncotic cytology, cell count, and ADA were collected before pleurodesis and analyzed. Survival analysis was performed considering pleurodesis as time origin, and death as the event. Backwards stepwise Cox regression was used to find predictors of survival. RESULTS: 156 patients (out of 196 potentially eligible) were included in this study. Most were female (72 %) and breast cancer was the most common underlying malignancy (53 %). Pleural fluid ADA level was stratified as low (<15 U/L), normal (15 ≤ ADA < 40), and high (≥40). Low and high ADA levels were associated with worse survival when compared to normal ADA (logrank: 0.0024). In multivariable analysis, abnormal ADA (<15 or ADA ≥ 40) and underlying malignancies different from lymphoma, lung, or breast cancer were associated with worse survival. Pleural fluid cell count and lymphocytes number and percentage did not correlate with survival. CONCLUSIONS: Pleural fluid Adenosine Deaminase levels (<15 or ≥40 U/L) and neoplasms other than lung, breast, or lymphoma are independent predictors of worse survival in patients with malignant pleural effusion who undergo pleurodesis.

A modified experimental model of malignant pleural disease induced by lung Lewis carcinoma (LLC) cells.

BACKGROUND: Malignant pleural effusion resulting mainly from pleural metastases of lung adenocarcinoma has clinical relevance, being a sign of poor prognosis and low life expectancy. Experimental models can mimic the human condition, contributing to advances in current understanding of the mechanisms patients' pleural fluid accumulation and possible therapeutic strategies. The objective of this study is to evaluate the role of different concentrations of Lewis lung carcinoma cells (LLC cells) at the time of induction of experimental MPE and the main effects on survival of animals. METHODS: C57BL/6 mice received intrapleural injection of 0.1, 0.5 or 1.5 × 10(5) LLC cells and survival curve, biochemical and pathological analyses of pleural fluid and tissue were analyzed. RESULTS: Evaluation of weight loss, mobility and survival showed that animals that received 0.5 × 10(5) cells maintained more stable condition up to day 14 and a gain of 6 days survival over mice that received the highest concentration. CONCLUSION: This study may allow a better understanding the mechanisms involved in the development of malignant pleural effusion and it may be promising in evaluating therapy to avoid recurrence, as the best time to indicate pleurodesis or target therapies.

Safety Profile of the Use of Iodopovidone for Pleurodesis in Patients with Malignant Pleural Effusion.

BACKGROUND: Iodopovidone is an alternative agent used to promote pleurodesis in patients with malignant pleural effusion (MPE). However, safety is a concern, and many authors still reject its use. OBJECTIVES: Our main objective is to describe the occurrence of common and severe adverse events after pleurodesis with two different doses of iodopovidone in patients with MPE. Our secondary objective is to evaluate dose dependency, efficacy, quality of life, and systemic inflammation. METHODS: We conducted a double-blind, randomized clinical trial including patients with recurrent MPE. Patients underwent chest tube insertion and were randomized into two groups according to the doses of iodopovidone: group 1 received 1% iodopovidone, and group 2 received 2% iodopovidone. During follow-up, adverse events, inflammatory markers, quality of life, and imaging exams were systematically evaluated and registered. RESULTS: Sixty patients were analyzed (55 females, 5 males, median age 55.9 years). Overall, 227 adverse events possibly related to pleurodesis were registered, including 47 serious adverse events (in 34 patients). Pleuritic pain and hypertensive peaks were the most frequently observed serious adverse events (11 and 10 episodes, respectively). Grade 3/4 metabolic events such as hyponatremia and an increase in alkaline phosphatase, AST and ALT levels were also common. C-reactive protein (CRP) levels increased substantially and peaked 48 h after pleurodesis. No difference was observed between groups with regard to adverse events, CRP levels, efficacy, or quality of life. CONCLUSIONS: Adverse events after iodopovidone pleurodesis in patients with MPE are common and similar in the two doses studied.

Safety and systemic consequences of pleurodesis with three different doses of silver nitrate in patients with malignant pleural effusion.

BACKGROUND: Silver nitrate (SN) is an alternative to talc pleurodesis in patients with malignant pleural effusion (MPE). Nevertheless, SN complications have not been thoroughly investigated so far. OBJECTIVE: To evaluate frequent adverse events (AE) of SN treatment at three different doses for pleurodesis in patients with MPE. The secondary objective was to evaluate systemic inflammation, efficacy and quality of life in these patients. METHODS: A double-blind, randomized, clinical trial was conducted in patients with recurrent MPE at a tertiary university hospital. The study patients underwent pleural catheter insertion and were randomly assigned to one of the three pleurodesis groups treated with 30 ml 0.3%, 30 ml 0.5% or 60 ml 0.3% SN. Patients were discharged 3 days after the procedure, and returned to follow-up visits on days 10 and 30. During follow-up, AE, inflammatory markers, quality of life and CT scans were systematically assessed and documented. RESULTS: Sixty patients (11 males and 49 females, median age 62.13 years) were included. Overall, 199 AE were observed, including 23 serious AE. Grade 1/2 metabolic AE, such as increases in creatinine and liver enzymes, were the most frequent. Grade 3/4 hypoxia was observed in 13 patients. Four patients died, 3 due to disease progression and in 1 patient death was possibly related to pleurodesis. C-reactive protein levels increased in a dose-dependent manner and peaked 48 h after pleurodesis. No significant difference was observed among groups regarding quality of life or clinical/radiological recurrence. CONCLUSION: Hypoxia was the most significant AE following SN pleurodesis; mild metabolic events were very common. SN instillation causes substantial dose-dependent systemic inflammatory responses.

Brazilian airway surgery survey indicates low overall numbers and need for improved teaching skills.

OBJECTIVES: The Brazilian Society of Thoracic Surgeons conducted an online survey to determine the number of surgeons that perform adult and paediatric airway surgery and to understand the practice patterns along the country. METHODS: Active members were electronically invited to complete the questionnaire through the REDCapR platform. Invitations were sent from January to April 2020. The survey encompassed 40 questions that explored 4 different topics in the assessment of tracheal diseases: (i) surgeon's demography; (ii) institutional profile, (iii) education and training in laryngo-tracheal surgery and (iv) preoperative and postoperative evaluation. RESULTS: Eighty-nine percentage of the responders declared to perform tracheal surgery with a median of 5 tracheal resection procedures per year [interquartile range (IQR) 3-12]. Interaction with other specialties occurs in 37.3% of cases. Access to technology and devices is highly variable across the country. Resident training in airway surgery consists in traditional lectures in 97% of the cases. Training in animals (15.2%), cadavers (12.1%) and simulators (6.1%) are rare. Preoperatory evaluation encompasses flexible bronchoscopy (97.8%) and/or computed tomography (CT) scan of the airways (90.6%). Swallowing (20.1%) and voice (14.4%) disorders are rarely evaluated. Eighty-nine percentage of the surgeons consider bronchoscopy to be the preoperatory gold-standard exam, followed by CT scan (38.8%) and CT-3D reconstruction (37.4%). CONCLUSIONS: Brazilian surgeons refer that airway resection and reconstruction are part of their current practice, but the total number of procedures per surgeon per year is low. Access to high-end technology and equipment is heterogenous. Training offered to residents in most academic institutions relies on traditional lectures.

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

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.

Prolonged survival after thoracic metastasectomy in patients with nonseminomatous testicular cancer.

INTRODUCTION: Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. METHODS: Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. RESULTS: Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. CONCLUSION: Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors.

Characteristics of the learning curve in robotic thoracic surgery in an emerging country.

It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.

Practice patterns and trends in surgical treatment for chronic lung infections: a survey from the Brazilian Society of Thoracic Surgery.

Background: Chronic lung infections represent a diversity of clinical entities that combined respond to significant public health, particularly in developing countries. However, there is no data regarding the practice patterns, surgeons' preferences, and technological usage, especially among Brazilian surgeons, in the setting of the surgical treatment of chronic lung infections. We, therefore, surveyed Brazilian thoracic surgeons from the Brazilian Society of Thoracic Surgery (SBCT) about practice patterns and trends in surgical treatment for chronic lung infections. Methods: A cross-sectional anonymous survey of all thoracic surgeons from the Brazilian Society was conducted in 2019. As the study was purely descriptive no further statistical evaluation was performed. Results: The responsive rate was 34% (259/766) from 23 of the 26 states in Brazil. A total of 141 (54.4%) participants reported their institution as a surgical reference for chronic infection lung disease, only 13.1% of surgeons have a high-volume service (more than 11 cases operated annually). The majority (76.2%) of respondents performed 1-5 surgical resection to treat tuberculosis (TB) sequelae, but only 62 (30.1%) had performed more than one resection to treat active TB. Chronic lung infection (76%) and hemoptysis (66%) were the most common symptoms as surgical indications. A proportion of 42.2% of the respondents do not have and/or perform routine drug sensitivity tests. In addition, 19.3% of respondents were not familiar with the recommendations of surgery in the treatment of pulmonary TB. Video-assisted thoracoscopic surgery (VATS) is available for 80% of respondents, while robotic surgery is for only 10%. Most (86%) surgeons have access to surgical staplers. Among the structural resources, respiratory isolation beds in the intensive care unit (ICU) (80%) and ward (79%) are frequently available resources. However, less than 12% of surgeons have in their institution a specific operating room for sputum-positive patients. Conclusions: Lung resection for chronic infectious disease is an essential area of activity for thoracic surgeons in Brazil, which occurs mainly in the public sphere, with no concentration of cases per surgeon or institution. The lack of adequate resources in many centers justifies the creation of reference centers for improving care for these patients.

Current morbimortality and one-year survival after pneumonectomy for infectious diseases.

OBJECTIVE: Identify the one-year survival rate and major complications in patients submitted to pneumonectomy for infectious disease. METHODS: Retrospective data from all cases of infectious disease pneumonectomy over the past 10 years were collected from two reference centers. The authors analyzed: patient demographics, etiology, laterality, bronchial stump treatment, presence of previous pulmonary resection, postoperative complications in the first 30 days, the treatment used in pleural complications, and one-year survival rate. RESULTS: 56 procedures were performed. The average age was 44 years, with female predominance (55%). 29 cases were operated on the left side (51%) and the most frequent etiology was post-tuberculosis (51.8%). The overall incidence of complications was 28.6% and the most common was empyema (19.2%). Among empyema cases, 36.3% required pleurostomy, 27.3% required pleuroscopy and 36.3% underwent thoracoplasty for treatment. Bronchial stump fistula was observed in 10.7% of cases. From all cases, 16.1% were completion pneumonectomies and 62.5% of these had some complication, a significantly higher incidence than patients without previous surgery (p = 0.0187). 30-day in-hospital mortality was (7.1%) with 52 cases (92.9%) and 1-year survival. The causes of death were massive postoperative bleeding (1 case) and sepsis (3 cases). CONCLUSIONS: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. While morbidity is often significant, once the perioperative risk has passed, the one-year survival rate can be very satisfying in selected patients with benign disease.

Vagal electrostimulation in postoperative thoracic surgery reduces the systemic inflammatory response and cardiopulmonary complications: an experimental study in pigs.

Background: Conventional thoracotomy (CT) often leads to systemic inflammatory response syndrome (SIRS), which induces several clinical complications. CT remains widely used in low-income institutions. Although minimally invasive surgical procedures, such as robotic surgery (RS), have been used to prevent many of the complications inherit from the surgical procedure. Here, we investigated the protective effect of vagus nerve stimulation (VNS) in a pre-clinical model during CT or RS and postoperative period (POP) relative to clinical complications and inflammatory control. The objective was to compare hemodynamic features and cytokine levels in the blood, lung, and bronchoalveolar lavage (BAL) fluids of animals subjected to CT or RS with or without VNS. Methods: Twenty-four minipigs were subjected to 12 animals CT and 12 animals RS, with or without VNS, and accompanied 24 h later by pulmonary lobectomy. Blood samples for evaluating the hemodynamic parameters were collected before the surgical preparation, immediately after the beginning of VNS, and every 4 h until 24 h after the lobectomy. BAL fluid and lung tissue were collected at the end of the experiment. Cytokine levels were evaluated in the blood, BAL fluid, and lung tissues. Results: VNS maintained a more stable heart rate during POP and decreased the incidence of overall cardiac complications while preventing increase in IL-6 levels 12 h after lobectomy, compared to sham animals. No differences were found in cytokine expression in the BAL fluid and lung tissue in any of the studied groups. Conclusions: Taken together, our data suggested that VNS should be considered a non-pharmacological tool in the prevention of the exacerbated inflammatory response responsible for severe clinical complications, especially in more aggressive surgical procedures.

Exploration of a novel prognostic model based on nomogram in non-small cell lung cancer patients with distant organ metastasis: implications for immunotherapy.

Background: Evidence for the effects of immunotherapy in non-small cell lung cancer (NSCLC) patients with distant organ metastasis is insufficient, and the predictive efficacy of established markers in tissue and blood is elusive. Our study aimed to determine the prognostic factors and develop a survival prognosis model for these patients. Methods: A total of 100 advanced NSCLC patients with distant organ metastases, who received single or combination immune checkpoint inhibitors (ICIs) in Xijing Hospital between June 2018 and June 2021, were enrolled for retrospective analysis. The major clinicopathological parameters were collected, and associated survival outcomes were followed up by telephone or inpatient follow-up for nearly 3 years to assess prognoses. The survival prognosis model was established based on univariate and multivariate Cox regression analyses to determine the candidate prognostic factors. Results: From the start of immunotherapy to the last follow-up, 77 patients progressed and 42 patients died, with a median follow-up of 18 months [95% confidence interval (CI): 15-19.9]. The median progression-free survival (PFS) and overall survival (OS) were 8 months (95% CI: 5.6-10.4) and 21 months (95% CI: 8.9-33.1), respectively. Multivariate Cox proportional hazards analysis showed Eastern Cooperative Oncology Group performance status (ECOG PS), body mass index (BMI), age-adjusted Charlson comorbidity index (ACCI), lactate dehydrogenase (LDH), and absolute neutrophil count (ANC) were correlated significantly with OS. Based on these five predictive factors, a nomogram and corresponding dynamic web page were constructed with a concordance index (C-index) of 0.81 and a 95% CI of 0.778-0.842. Additionally, the calibration plot and time-receiver operating characteristic (ROC) curve validated the precision of the model at 6-, 12-, and 18-month area under the curves (AUCs) reached 0.934, 0.829, and 0.846, respectively. According to the critical point of the model, patients were further divided into a high-risk total point score (TPS) >258, middle-risk (204< TPS ≤258), and low-risk group (TPS ≤204), and significant OS differences were observed among the three subgroups (median OS: 4.8 vs. 13.0 vs. 32.9 months). Conclusions: A feasible and practical model based on clinical characteristics has been developed to predict the prognosis of NSCLC patients with distant organ metastasis undergoing immunotherapy.

Robotic lung resection: a narrative review of the current role on primary lung cancer treatment.

Background and Objective: Robotic-assisted thoracic surgery (RATS) has increasingly been applied to primary lung cancer treatment. Given the many facilities provided by the robotic platform in the manipulation of tissues and precision of movements, there is continuous enquiring about its contribution to the improvement of surgical outcomes. Also, the possibility to perform complex resections in a minimally invasive way using a robotic approach starts to become possible as the centers' learning curve expands. We propose to perform a review of the current status of robotic surgery for lung cancer focusing on key frontier points: sublobar resections, quality of lymphadenectomy, complex resections, postoperative outcomes, and innovative technologies to arrive. Methods: We performed a narrative review of the literature aggregating the most current references available in English. Key Content and Findings: According to the current data, the flourishing of the robotic platform seems to be in line with the spread of sublobar resections. The technological benefits inherent to the platform, also seem to promote an increase in the quality of lymphadenectomy and a shorter learning curve when compared to video-assisted thoracic surgery (VATS) with equivalent oncological results. Its application in complex resections such as bronchial sleeve already presents consistent results and new technology acquisitions such as three-dimensional reconstructions, augmented reality and artificial intelligence tend to be implemented collaborating with the digitization of surgery. Conclusions: Robotic surgery for lung cancer resection is at least equivalent to the VATS approach considering the currently available literature. However, more practice time and prospective clinical trials are needed to identify more exact benefits.

Mesothelioma in a developing country: a retrospective analysis of the diagnostic process.

OBJECTIVE: To evaluate the process of diagnosing patients with malignant pleural mesothelioma (MPM) at a tertiary care hospital. METHODS: This was a retrospective study involving patients referred to a tertiary-care cancer center in Brazil between 2009 and 2020. The diagnostic process was divided into four steps: onset of symptoms, referral to a specialist visit, histopathological diagnosis, and beginning of treatment. The intervals between each phase and the factors for delays were evaluated. Data including clinical status, radiological examinations, staging, treatment modalities, and survival outcomes were collected. RESULTS: During the study period, 66 patients (mean age = 64 years) were diagnosed with MPM and underwent treatment. Only 27 (41%) of the patients had knowledge of prior exposure to asbestos. The median number of months (IQR) between the onset of symptoms and the first specialist visit, between the specialist visit and histopathological characterization, and between definite diagnosis and beginning of treatment was, respectively, 6.5 (2.0-11.4), 1.5 (0.6-2.1), and 1.7 (1.2-3.4). The knowledge of prior asbestos exposure was associated with a shorter time to referral to a specialist (median: 214 vs. 120 days; p = 0.04). A substantial number of nondiagnostic procedures and false-negative biopsy results (the majority of which involved the use of Cope needle biopsy) were found to be decisive factors for the length of waiting time. The mean overall survival was 11.9 months. CONCLUSIONS: The unfamiliarity of health professionals with MPM and the patient's lack of knowledge of prior asbestos exposure were the major factors to cause a long time interval between the onset of symptoms and beginning of treatment. An overall survival shorter than 1 year is likely to have been due to the aforementioned delays.

Tracheobronchial Surgery in Emerging Countries.

Tracheobronchial surgery is widely performed in emerging countries mainly as a consequence of the high number of airway-related complications and poor management in intensive care units. This has led to great expertise in the surgical management of postintubation tracheal stenosis, and opportunity for advancing scientific knowledge. Nonetheless, tracheal stenosis has a severe impact on a patient's quality of life, is a major burden to the health system, and should be prevented. Incorporation of innovative techniques, technologies, and prospective databases should prompt earlier diagnosis and lead to fewer complications.

Postoperative inverted intercostal hernia incidentally detected by chest computed tomography in a patient with COVID-19.

Inverted intercostal hernias are uncommon, and even more so when comprised of soft tissue instead of lung parenchyma in the postoperative context. This report demonstrates a case in with such a hernia was diagnosed through chest multidetector computerized tomography in a 48-year-old woman who presented to the emergency room with respiratory symptoms and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). She had positive surgical history for left lower lobectomy with bronchoplastic procedure and mediastinal lymphadenectomy, due to an endobronchial typical carcinoid tumor a few years ago. Therefore, it is important for radiologists to be aware of the imaging characteristics of inverted intercostal hernias, to avoid diagnostic errors.