Surgical care of thoracic malignancies during the COVID-19 pandemic in México: An expert consensus guideline from the Sociedad Mexicana de Oncología (SMeO) and the Sociedad Mexicana de Cirujanos Torácicos Generales (SMCTG).

To date, the impact, timeline and duration of COVID-19 pandemic remains unknown and more than ever it is necessary to provide safe pathways for cancer patients. Multiple triage systems for nonemergent surgical procedures have been published, but potentially curative cancer procedures are essential surgery rather than elective surgery. In the present and future scenario of our country, thoracic oncology teams may have the difficult decision of weighing the utility of surgical intervention against the risk for inadvertent COVID-19 exposure for patients and medical staff. In consequence, traditional pathways of surgical care must be adjusted to reduce the risk of infection and the use of resources. It is recommended that all thoracic cancer patients should be offered treatment according to the accepted standard of care until shortage of services require a progressive reduction in surgical cases. Here, we present a consensus of recommendations discussed by a multidisciplinary panel of experts on thoracic oncology and based on the best available evidence, and hope it will provide a modifiable framework of guidance for local strategy planners in thoracic cancer care services in Mexico. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: This article provides recommendations to guarantee the continuity of surgical care for thoracic oncology cases during COVID-19 pandemic, whilst maintaining the safety of patients and medical staff. WHAT THIS STUDY ADDS: This guideline is the result of an expert consensus on thoracic surgical oncology with recommendations adapted to medical, economic and social realities of Mexico.

[Intrathoracic schwannoma]. / Schwannoma intratorácico.

The schwannoma (neurilemmoma) is a slow-growing benign tumor originating from Schwann sheath whose location in the chest cavity is exceptional. It is generally asymptomatic and is discovered incidentally but can cause symptoms when the lesion grows or invade underlying structures. Its importance lies in the possibility of confusion with malignant tumors. We present a patient who complains of chest pain caused by a prolonged course schwannoma. The tomographic image is suggestive of extrapulmonary tumor, so the schwannoma in this location should be considered in the differential diagnosis of metastatic or primary pleural tumors such as lipoma, solitary fibrous tumor and mesothelioma.

Schwannoma intratorácico / Intrathoracic schwannoma

El schwannoma (neurilemoma) es un tumor benigno de lento crecimiento originado en la vaina de Schwann, cuya localización en la cavidad torácica es excepcional. En general es asintomático y se descubre en forma incidental, aunque puede ocasionar síntomas cuando la lesión crece o invade estructuras subyacentes. Su importancia radica en la posibilidad de confusión con tumores malignos. Presentamos una paciente con dolor torácico de evolución prolongada causado por un schwannoma. La imagen tomográfica es sugestiva de tumor extrapulmonar, por ello el schwannoma en esta localización debe ser considerado en el diagnóstico diferencial de tumores pleurales metastásicos o primarios como el lipoma, el tumor fibroso solitario y el mesotelioma.

The schwannoma (neurilemmoma) is a slow-growing benign tumor originating from Schwann sheath whose location in the chest cavity is exceptional. It is generally asymptomatic and is discovered incidentally but can cause symptoms when the lesion grows or invade underlying structures. Its importance lies in the possibility of confusion with malignant tumors. We present a patient who complains of chest pain caused by a prolonged course schwannoma. The tomographic image is suggestive of extrapulmonary tumor, so the schwannoma in this location should be considered in the differential diagnosis of metastatic or primary pleural tumors such as lipoma, solitary fibrous tumor and mesothelioma.

Resección quirúrgica de plasmocitoma solitario del esternón asociado a cirugía de revascularización miocárdica: seguimiento a largo plazo / Surgical resection of solitary plasmacytoma of the sternum associated with coronary artery bypass grafting surgery: long-term follow up

The plasmacytomas tumors are caused by a malignant proliferation of plasma cells. Primary tumors of the sternum are uncommon, being this kind of tumors exceptional. We present the case of a 72 years old man with a sternal plasmacytoma, that after 2 years of receiving radiotherapy treatment, had tumor growth, associated with coronary artery disease. In this case, surgical resection of solitary sternal plasmacytoma was performed associated with coronary artery bypass grafting surgery. The chest wall reconstruction was done with a polypropylene mesh. More than 5 years long-term follow up was completed and the patient is asymptomatic and free of malignant proliferation of plasma cells.

Los plasmocitomas son tumores originados por una proliferación neoplásica de células plasmáticas. Los tumores primarios de esternón son infrecuentes, siendo los plasmocitomas solitarios de esternón excepcionales. Presentamos el caso de un hombre de 72 años con un plasmocitoma esternal que después de 2 años post tratamiento con radioterapia presentó aumento de tamaño tumoral asociado a enfermedad coronaria. Se realizó resección quirúrgica del plasmocitoma solitario del esternón asociada a cirugía de revascularización miocárdica con 4 bypass coronarios. La pared torácica fue reconstituida con una malla de polipropileno. A más de 5 años de seguimiento el paciente se encuentra asintomático cardiovascular y libre proliferación maligna de células plasmáticas.

Ectopic ACTH syndrome

Ectopic adrenocorticotropic secretion (EAS) is responsible for 12-17 percent of cases of Cushing's syndrome (CS) and covers a range of tumours, from undetectable benign lesions to widespread metastases. The syndrome is often associated with severe hypercortisolaemia, which aggravates the underlying condition. EAS requires a complete workup that includes the establishment of endogenous CS, diagnosis of adrenocorticotropic hormone (ACTH) dependency, localization of the source of ACTH secretion and rapid biochemical control of hypercortisolaemia. Dynamic endocrine tests should include inferior petrosal sinus sampling with CRH stimulation. Localization studies depend on the availability of reliable high-resolution cross-sectional imaging. This systematic review of the largest published series of patients with EAS (over 380 patients) reveals the common trends in the prevalence and management of this syndrome. The concept of 'occult' EAS has been revisited and the terms 'overt' and 'covert' EAS introduced. In addition to small cell lung carcinoma, the most common causes of ectopic EAS are bronchial carcinoids, thymic tumours, islet cell tumour of the pancreas, medullary thyroid carcinomas, and phaeochromocytomas. Their prevalence and the best localization modalities are presented. Medical and surgical management is discussed on the basis of the extensive experience of major referral centres.

A secreção ectópica de ACTH (SEA) é responsável por 12-17 por cento dos casos de síndrome de Cushing (SC), cobrindo uma variedade de tumores, desde lesões benignas indetectáveis a metástases disseminadas. A SEA está freqüentemente associada com hipercortisolemia grave, que agrava a condição de base e requer uma avaliação completa, que inclui a confirmação da SC endógena, o diagnóstico da dependência ao ACTH, a localização da fonte da secreção de ACTH e o controle bioquímico rápido da hipercortisolemia. Testes endócrinos dinâmicos devem incluir a coleta de amostras do seio petroso inferior com estímulo pelo CRH. O estudo da localização da fonte depende da disponibilidade de procedimentos de imagem de alta-resolução confiáveis. A revisão sistemática das maiores séries publicadas de pacientes com SEA (mais de 380 pacientes) revela tendências comuns na prevalência e manejo dessa síndrome. O conceito de SEA "oculta" está sendo revisado e os termos SEA "manifesta" e "latente" são introduzidos. Além do carcinoma pulmonar de pequenas células, as causas mais comuns de SEA são os carcinóides brônquicos, tumores tímicos, tumor de ilhotas pancreáticas, carcinoma medular de tiróide e feocromocitoma; sua prevalência e as melhores modalidades para localização são apresentadas. O manejo clínico e cirúrgico é discutido com base na vasta experiência dos principais centros de referência.

Ectopic ACTH syndrome.

Ectopic adrenocorticotropic secretion (EAS) is responsible for 12-17% of cases of Cushing's syndrome (CS) and covers a range of tumours, from undetectable benign lesions to widespread metastases. The syndrome is often associated with severe hypercortisolaemia, which aggravates the underlying condition. EAS requires a complete workup that includes the establishment of endogenous CS, diagnosis of adrenocorticotropic hormone (ACTH) dependency, localization of the source of ACTH secretion and rapid biochemical control of hypercortisolaemia. Dynamic endocrine tests should include inferior petrosal sinus sampling with CRH stimulation. Localization studies depend on the availability of reliable high-resolution cross-sectional imaging. This systematic review of the largest published series of patients with EAS (over 380 patients) reveals the common trends in the prevalence and management of this syndrome. The concept of 'occult' EAS has been revisited and the terms 'overt' and 'covert' EAS introduced. In addition to small cell lung carcinoma, the most common causes of ectopic EAS are bronchial carcinoids, thymic tumours, islet cell tumour of the pancreas, medullary thyroid carcinomas, and phaeochromocytomas. Their prevalence and the best localization modalities are presented. Medical and surgical management is discussed on the basis of the extensive experience of major referral centres.

Resección de pared torácica en patología tumoral y no tumoral: empleo de prótesis con resinas acrílicas / Chest wall resection in tumoral and non tumoral pathology: use of heterologous prothesis

Antecedentes: Las resecciones de pared torácica representan la forma terapéutica más eficaz para un número apreciable de pacientes portadores de patología tumoral o no tumoral. Objetivo: Reconstruir desde el punto de vista funcional y estético. Diseño: Retrospectivo, descriptivo. Población: 57 pacientes con patología de la pared torácica, 23 con lesiones benignas (12 tumorales; 11 no tumorales) y 35 con tumores malignos: 16 primarios; 5 metastásicos; 13 recidivas loco-regionales y 1 carcinoma mediastinal con invasión parietal. Entre los tumores primarios predominaron los sarcomas mientras que entre los secundarios los carcinomas. Método: Fueron resecados 55 pacientes: 33 por tumores malignos; 11 por tumores benignos y 11 por lesiones no tumorales (5 úlceras actínicas; 4 osteomielitis; 1 pseudo-tumor inflamatorio; 1 fractura patológica por rarefacción actínica). En 27 oportunidades se emplearon prótesis heterológicas: 24 Marlex-Metilmetacrilato, 2 Marlex exclusivamente y 1 Polipropileno. Dichas prótesis se cubrieron con colgajos miocutáneos, musculares únicamente, epiplón mayor o bien con tejidos vecinos. Resultados: El índice de morbilidad fue 20,3 por ciento, aunque el 82 por ciento consistió en complicaciones banales. Sólo 3 pacientes requirieron algún procedimiento adicional. La supervivencia global actuarial a 5 años de los pacientes con patología maligna fue de 63 por ciento para los sarcomas y 31 por ciento para los carcinomas. De los pacientes operados por recidiva loco-regional de Ca de mama, el 22 por ciento estaban vivos a los 5 años y el 11 por ciento a los 10 años, falleciendo el resto por pregresión de la enfermedad. Analizando los pacientes portadores de metástasis y recidiva loco-regional, la supervivencia media fue de 37,5 meses con una supervivencia a los 5 años de 23 por ciento. Conclusiones: En la patología tumoral de la pared torácica deben evitarse las resecciones económicas dado que exponen a soluciones oncológicas insuficientes. La evaluación de estos enfermos debe ser multidisciplinaria y la actuación de cirujanos reparadores no puede estar ausente

Resección de pared torácica en patología tumoral y no tumoral: empleo de prótesis con resinas acrílicas / Chest wall resection in tumoral and non tumoral pathology: use of heterologous prothesis

Antecedentes: Las resecciones de pared torácica representan la forma terapéutica más eficaz para un número apreciable de pacientes portadores de patología tumoral o no tumoral. Objetivo: Reconstruir desde el punto de vista funcional y estético. Diseño: Retrospectivo, descriptivo. Población: 57 pacientes con patología de la pared torácica, 23 con lesiones benignas (12 tumorales; 11 no tumorales) y 35 con tumores malignos: 16 primarios; 5 metastásicos; 13 recidivas loco-regionales y 1 carcinoma mediastinal con invasión parietal. Entre los tumores primarios predominaron los sarcomas mientras que entre los secundarios los carcinomas. Método: Fueron resecados 55 pacientes: 33 por tumores malignos; 11 por tumores benignos y 11 por lesiones no tumorales (5 úlceras actínicas; 4 osteomielitis; 1 pseudo-tumor inflamatorio; 1 fractura patológica por rarefacción actínica). En 27 oportunidades se emplearon prótesis heterológicas: 24 Marlex-Metilmetacrilato, 2 Marlex exclusivamente y 1 Polipropileno. Dichas prótesis se cubrieron con colgajos miocutáneos, musculares únicamente, epiplón mayor o bien con tejidos vecinos. Resultados: El índice de morbilidad fue 20,3 por ciento, aunque el 82 por ciento consistió en complicaciones banales. Sólo 3 pacientes requirieron algún procedimiento adicional. La supervivencia global actuarial a 5 años de los pacientes con patología maligna fue de 63 por ciento para los sarcomas y 31 por ciento para los carcinomas. De los pacientes operados por recidiva loco-regional de Ca de mama, el 22 por ciento estaban vivos a los 5 años y el 11 por ciento a los 10 años, falleciendo el resto por pregresión de la enfermedad. Analizando los pacientes portadores de metástasis y recidiva loco-regional, la supervivencia media fue de 37,5 meses con una supervivencia a los 5 años de 23 por ciento. Conclusiones: En la patología tumoral de la pared torácica deben evitarse las resecciones económicas dado que exponen a soluciones oncológicas insuficientes. La evaluación de estos enfermos debe ser multidisciplinaria y la actuación de cirujanos reparadores no puede estar ausente (AU)

Epiplón mayor: su utilización para la reconstrucción de la pared torácica consecutiva a la exéresis de tumores / Greater omentum: your usefull in chest wall reconstruction after resected malignant tumors

Seis pacientes portadores de tumores parietales del tórax resecados, fueron reparados mediante prótesis cubiertas por epiplón mayor traspuesto. El empleo de este tejido fue de elección para casos en que debieron ser ser extirpados músculos contiguos invadidos y por consiguiente hubiera sido necesario colgajos musculares o miocutáneos distantes para una adecuada reconstrucción. En lugar de ellos, hemos elegido el epiplón, el cual además, produjo mejor resultado estético. No hemos observado complicaciones atribuibles al procedimiento

Epiplón mayor: su utilización para la reconstrucción de la pared torácica consecutiva a la exéresis de tumores / Greater omentum: your usefull in chest wall reconstruction after resected malignant tumors

Seis pacientes portadores de tumores parietales del tórax resecados, fueron reparados mediante prótesis cubiertas por epiplón mayor traspuesto. El empleo de este tejido fue de elección para casos en que debieron ser ser extirpados músculos contiguos invadidos y por consiguiente hubiera sido necesario colgajos musculares o miocutáneos distantes para una adecuada reconstrucción. En lugar de ellos, hemos elegido el epiplón, el cual además, produjo mejor resultado estético. No hemos observado complicaciones atribuibles al procedimiento (AU)

Síndrome de Kinsbourne secundario a neuroblastoma torácico: a propósito de un caso clínico / Kinsbourne syndrome secondary to a thoracic neuroblastoma

La encefalopatía opsomioclónica infantil o síndrome de Kinsbourne, es una entidad poco frecuente, que asocia clínicamente opsoclonus, polimioclonias y ataxia. Existen casos idiopáticos o vinculados a infecciones virales o a neuroblastoma. Se presenta el caso de una niña de 13 meses, que instala en forma aguda dicha sintomatología. Los estudios etiológicos confirman la presencia de un neuroblastoma torácico. Se realiza la resección tumoral y hormonoterapia, con buena respuesta clínica inicial. Presentamos la revisión bibliográfica, comentando los aspectos más importantes de la enfermedad

Síndrome de Kinsbourne secundario a neuroblastoma torácico: a propósito de un caso clínico / Kinsbourne syndrome secondary to a thoracic neuroblastoma

La encefalopatía opsomioclónica infantil o síndrome de Kinsbourne, es una entidad poco frecuente, que asocia clínicamente opsoclonus, polimioclonias y ataxia. Existen casos idiopáticos o vinculados a infecciones virales o a neuroblastoma. Se presenta el caso de una niña de 13 meses, que instala en forma aguda dicha sintomatología. Los estudios etiológicos confirman la presencia de un neuroblastoma torácico. Se realiza la resección tumoral y hormonoterapia, con buena respuesta clínica inicial. Presentamos la revisión bibliográfica, comentando los aspectos más importantes de la enfermedad(AU)

Long-term outcome in children with opsoclonus-myoclonus and ataxia and coincident neuroblastoma.

We reviewed the neurologic and developmental courses in 10 children with opsoclonus-myoclonus ("dancing eyes syndrome") and neuroblastoma. All patients are alive without evidence of neoplastic disease after 8+ to 111+ months of follow-up. All had localized disease and 50% had extraabdominal tumors. Neuroblastomas of nine children had favorable Shimada histologic characteristics, and all tumors had single copies of the N-myc oncogene. After neuroblastoma resection, all patients had persistent opsoclonus-myoclonus or ataxia that responded to therapy with adrenocorticotropic hormone. Nine children had relapses of neurologic symptoms. Three years after resection, six of seven patients with sufficient follow-up were free of symptoms and had discontinued therapy. However, nine children had chronic neurologic deficits, including cognitive and motor delays, language deficits, and behavioral abnormalities. All six patients in educational programs required special assistance. Five children required physical, occupational, or speech therapy. Long-term developmental and cognitive problems should be anticipated in patients with neuroblastoma who have opsoclonus-myoclonus or ataxia or both, and early intervention should be instituted to try to minimize these deficits.

Hipoglicemia associada a tumor extrapancreático / Hypoglycemya associated with extra-pancreatic tumor

Os autores descrevem o caso de uma mulher de 51 anos, portadora de massa torácica extrapulmonar, que apresentou episódios de hipoglicemia sintomática dejejum. Esse quadro reverteu após a retirada cirúrgica de um mesotelioma pleural benigno, que pesava 1.800g. Sao discutidos os mecanismos de hipoglicemia tumoral extrapancreática em face de níveis indetectáveis de insulina, como em nosso caso.

[Carcinomas of internal organs and their relationship to arsenical drinking water in the Republic of Argentina]. / Los carcinomas de los órganos internos y su relación con las aguas arsenicales de consumo en la República Argentina.

Presently exist only four regions where the supply of drinking water with an abnormally high content of arsenic and/or its salts, produces cutaneous signs generically termed "arsenical toxidermias" or "chronic arsenism"; they are: Mexico, Taiwan, Chile and Argentina. In this paper details are given of the typical skin lesions of hydroarsenism and the generally multiple epitheliomas of varied histological and clinical pattern in 340 patients; the diseases characterized for not being acute but chronic and the relanodermia holds a secondary place. Among histologically diagnosed carcinomas, deep basal-cell (276) and superficial multiple basal-cell (130) carcinomas predominate over the squamous-cell carcinomas (239) and Bowen disease (113); 18 mixed carcinomas were found. In these 340 patients, 51 carcinomas of the internal organs (15%), 34 of lungs, 8 of larynx, 3 of stomach, 2 of liver and 1 of pharynx, trachea, esophagus and breast in a man were diagnosed, which evolved in a similar manner to that of not arsenical patients.

[Chemical and hematological changes in pheochromocytoma]. / Alteraciones químicas y hematológicas en el feocromocitoma.

We report the laboratory findings from studies carried out on 37 pheochromocytoma patients; (20 males and 17 females whose age ranged from 11 to 55 years). Among the parameters measured, fasting hyperglycemia was one of the alterations most frequently encountered (59%), the difference with the normal values was highly significant (p less than 0.001). The levels found for the other parameters measured were also elevated in some cases and the difference between them and the normal values was statistically significant, the assays included were serum cholesterol and creatinine, haemoglobin, hematocrit and white blood cell and platelet counts. The response to the oral glucose load was normal in 9 patients, 6 showed a diabetic curve and 2 had a glucose intolerance response. Data from our observations and from the literature shows that these alterations may be a source of erroneous diagnosis, mainly in cases where symptoms are atypical or infrequent such as fever of unknown etiology, shock and others. Therefore recognizing these abnormalities as a sign of pheochromocytoma is very important both from the diagnostic and therapeutic points of view.

Sexual precocity in a male due to thoracic polyembryoma.

A 7-year-old boy with sexual precocity of recent onset was found to have elevated levels of chorionic gonadotropin, alpha fetoprotein, and testosterone. Removal of a retropleural, posterior mediastinal mass with an intraspinous epidural extension was followed by prompt declines in the plasma concentrations of the tumor markers and cessation of adolescent development. The neoplasm proved to be a polyembryoma, unusual in the multiplicity of its embryoid bodies and extra gonadal location. Following local irradiation and two years of systemic chemotherapy, the patient, now 13 years of age, has done well except for evidence of testicular tubular insufficiency.