Accuracy of multidetector computed tomography with maximum intensity projection technique in the assessment of fissure integrity.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) is a potential treatment for patients with severe emphysema, performed through the placement of unidirectional endobronchial valves (EBVs). Their benefits are only achieved in patients that significantly reduce lobar volume, and it is mandatory that the fissures are complete. Fissure evaluation is preferably done by computed tomography, but little is known if its evaluation corresponds to the anatomical findings. The aim of this study is to evaluate the accuracy of thoracic radiologists in the identification of complete fissures by multidetector computed tomography (MDCT) using maximum intensity projection (MIP) technique, compared with direct anatomical evaluation. METHODS: Prospective study, conducted in a single institution. Patients submitted to thoracic surgery had their fissures classified as complete or incomplete by thoracic surgeons and their preoperative chest scans evaluated by three radiologists, blinded for surgical evaluation. With the intraoperative categorization as a reference, the accuracy and concordance of the three thoracic radiologists' evaluation were calculated. The most experienced radiologist evaluated the fissures at two different moments to estimate the intra-observer agreement. RESULTS: There were included 67 patients, being 37 (55%) males, with a mean age of 64 years. The accuracy of radiological identification of complete fissures ranged from 76.8% for left posterior oblique fissure to 85.1% for left anterior oblique fissure, with the best performance achieved by the most experienced radiologist. The concordance of the radiological evaluation for fissure integrity compared to the surgical assessment (k) was 0.53-0.68. Intra-observer agreement ranged from 0.74 to 0.87. CONCLUSIONS: The evaluation of the fissure integrity by MDCT analysis using MIP technique by thoracic radiologists had high accuracy among the thoracic radiologists.

Utilization of Quantitative Computed Tomography Assessment to Identify Bronchiolitis Obliterans Syndrome After Single Lung Transplantation.

OBJECTIVE: To evaluate quantitative chest computed tomography (CT) methods for the detection of air trapping (AT) and to assess its diagnostic performance for the diagnosis of bronchiolitis obliterans syndrome (BOS) in single lung transplant (SLT) patients. METHODS: Adult patients who had a SLT at a single transplant center and underwent CT scan after transplantation were retrospectively included. CT findings of air trapping were measured by three different methods: expiratory air-trapping index (ATIexp), mean lung density on expiratory acquisition (MLDexp) and expiratory to inspiratory ratio of mean lung density (E/I-ratio(MLD). Sensitivity, specificity and diagnostic accuracy of the three methods for the detection of BOS status evaluated by serial routine measures of pulmonary function tests (gold standard) were assessed. RESULTS: Forty-six SLT patients (52.2% females, mean age 58 ± 6 years) were included in the analysis, 12 (26%) patients with a diagnosis of BOS. Quantitative CT diagnosis of AT ranged from 26 to 35%. Sensitivity, specificity and accuracy of each method for the detection of BOS were 85.7%, 84.7% and 85.0% for ATIexp, 78.5%, 93.4% and 90.0% for MLD and 64.2%, 89.1% and 83.3% E/I-ratio(MLD), respectively. CONCLUSION: Quantitative measures of AT obtained from standard CT are feasible and show high specificity and accuracy for the detection of BOS in SLT patients.

Impact of angiotensin II type 1 and G-protein-coupled Mas receptor expression on the pulmonary performance of patients with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a severe interstitial disease with a mean survival of about 2.5-5 years after diagnosis. Its pathophysiology is still a major challenge for science. It is known that angiotensin II (Ang-II) binds AT1 receptor (AT1R) and its overactivation induces fibrosis, inflammation and oxidative stress. In contrast, activation of the Mas receptor (Mas-R) by angiotensin 1-7 opposes the harmful effects induced by Ang-II. Thus, our innovative objective was to analyze, in patients' lung with IPF, the balance between AT1R and Mas-R expression and their possible association with pulmonary spirometric parameters: forced expiratory volume in the first second (FEV1%) and forced vital capacity (FVC%). One cubic centimeter of lung tissue was obtained from IPF patients (n = 6) and from patients without IPF (n = 6) who underwent bronchial carcinoma resection. Receptor expression was quantified using western blot. AT1R expression was significantly higher (34 %) in patients with IPF (P = 0.006), whereas Mas-R was significantly less expressed (54 %) in these patients' lungs (P = 0.046). There was also a positive correlation between Mas-R expression and FEV1% (r = 0.62, P = 0.03) and FVC% (r = 0.58, P = 0.05). Conversely, AT1R expression was negatively correlated with FEV1% (r = 0.80, P = 0.002) and FVC% (r = 0.74, P = 0.006). In conclusion, our results demonstrated an increased expression of AT1R and reduced expression of Mas-R in the lung of patients with IPF. The dominance of AT1R expression is associated with reduced lung function, highlighting the role of the renin-angiotensin system peptides in the pathophysiology of IPF.

Pulmonary rehabilitation improves survival in patients with idiopathic pulmonary fibrosis undergoing lung transplantation.

This study was conducted to evaluate whether a pulmonary rehabilitation program (PRP) is independently associated with survival in patients with idiopathic pulmonary fibrosis (IPF) undergoing lung transplant (LTx). This quasi-experimental study included 89 patients who underwent LTx due to IPF. Thirty-two completed all 36 sessions in a PRP while on the waiting list for LTx (PRP group), and 53 completed fewer than 36 sessions (controls). Survival after LTx was the main outcome; invasive mechanical ventilation (IMV), length of stay (LOS) in intensive care unit (ICU) and in hospital were secondary outcomes. Kaplan-Meier curves and Cox regression models were used in survival analyses. Cox regression models showed that the PRP group had a reduced 54.0% (hazard ratio = 0.464, 95% confidence interval 0.222-0.970, p = 0.041) risk of death. A lower number of patients in the PRP group required IMV for more than 24 hours after LTx (9.0% vs. 41.6% p = 0.001). This group also spent a mean of 5 days less in the ICU (p = 0.004) and 5 days less in hospital (p = 0.046). In conclusion, PRP PRP completion halved the risk of cumulative mortality in patients with IPF undergoing unilateral LTx.

What is expected in lung function after lung transplantation due to end-stage pulmonary silicosis?

In this study, we aimed to determine the impact of lung transplantation (LTx) on pulmonary function tests (PFTs) and survival among patients with end-stage silicosis. We included patients with end-stage silicosis on the wait list for LTx, between January 1989 and July 2015 (N = 26). Sixteen of these patients received LTx; 10 were eligible, but did not undergo LTx (non-LTx) during the study period. Retrospective information on PFTs (spirometry [volumes and flows], 6-minute walking test [6MWT], and DLCO) was retrieved from patients' medical charts, including baseline information for all patients and follow-up information for the LTx. At baseline, most patients presented with spirometric and 6MWT values that were suggestive of severe disease (FEV1 /FVC 76.5 ± 29.7; 6MWT 267.4 ± 104.5 m). Significant increases in these values were observed at follow-up in the LTx (P = .036 and .151, respectively). The overall median survival of patients in the LTx and non-LTx was 3.35 years (95% CI: 0.16-14.38) and 0.78 years (95% confidence interval [CI]: 0.12-3.65) (P = 0.002), respectively. For patients with end-stage silicosis, LTx offers significant benefits regarding pulmonary function and survival when compared to non-LTx, and is a reliable tool to help this critical population of patients, whose only treatment option is LTx.

Anatomic pulmonary resection via video-assisted thoracic surgery: analysis of 117 cases at a referral center in Brazil.

OBJECTIVE:: To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil. METHODS:: All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed. RESULTS:: A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients. CONCLUSIONS:: Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil. OBJETIVO:: Relatar a experiência com cirurgia torácica videoassistida (CTVA) para ressecções pulmonares anatômicas em um centro nacional de referência de cirurgia torácica no Brasil. MÉTODOS:: Foram incluídos todos os pacientes tratados com ressecções pulmonares anatômicas por CTVA entre 2010 e 2015 e analisados dados clínicos e patológicos, assim como complicações pós-operatórias. RESULTADOS:: Foram realizadas 117 ressecções pulmonares por CTVA, sendo 98 lobectomias e 19 segmentectomias anatômicas. A média de idade foi de 63,6 anos (variação, 15-86 anos), sendo a maioria mulheres (n = 69; 59%). A média de tempo de permanência com dreno foi de 2,47 dias e a de estada em UTI foi de 1,88 dias. A média de tempo de internação foi de 4,48 dias. Sangramento ≥ 400 ml ocorreu em 15 pacientes. Houve conversão para toracotomia em 4 pacientes. CONCLUSÕES:: Nossos resultados vão ao encontro de publicações em grandes séries internacionais, corroborando que a CTVA é uma importante via de execução de ressecções pulmonares e que pode ser realizada com segurança quando há treinamento adequado, devendo ser mais utilizada no Brasil para o tratamento das doenças pulmonares.

Anatomic pulmonary resection via video-assisted thoracic surgery: analysis of 117 cases at a referral center in Brazil / Ressecções pulmonares anatômicas por cirurgia torácica videoassistida: experiência de 117 casos em um centro de referência no Brasil

ABSTRACT Objective: To describe our experience with video-assisted thoracic surgery (VATS) for anatomic pulmonary resection at a referral center for thoracic surgery in Brazil. Methods: All patients who underwent anatomic pulmonary resection by VATS between 2010 and 2015 were included. Clinical and pathological data, as well as postoperative complications, were analyzed. Results: A total of 117 pulmonary resections by VATS were performed, of which 98 were lobectomies and 19 were anatomic segmentectomies. The mean age of the patients was 63.6 years (range, 15-86 years). Females predominated (n = 69; 59%). The mean time to chest tube removal was 2.47 days, and the mean length of ICU stay was 1.88 days. The mean length of hospital stay was 4.48 days. Bleeding ≥ 400 mL occurred in 15 patients. Conversion to thoracotomy was required in 4 patients. Conclusions: Our results are similar to those published in major international studies, indicating that VATS is an important strategy for pulmonary resection. They also show that VATS can be safely performed with adequate training. This technique should be used more often for the treatment of lung diseases in Brazil.

RESUMO Objetivo: Relatar a experiência com cirurgia torácica videoassistida (CTVA) para ressecções pulmonares anatômicas em um centro nacional de referência de cirurgia torácica no Brasil. Métodos: Foram incluídos todos os pacientes tratados com ressecções pulmonares anatômicas por CTVA entre 2010 e 2015 e analisados dados clínicos e patológicos, assim como complicações pós-operatórias. Resultados: Foram realizadas 117 ressecções pulmonares por CTVA, sendo 98 lobectomias e 19 segmentectomias anatômicas. A média de idade foi de 63,6 anos (variação, 15-86 anos), sendo a maioria mulheres (n = 69; 59%). A média de tempo de permanência com dreno foi de 2,47 dias e a de estada em UTI foi de 1,88 dias. A média de tempo de internação foi de 4,48 dias. Sangramento ≥ 400 ml ocorreu em 15 pacientes. Houve conversão para toracotomia em 4 pacientes. Conclusões: Nossos resultados vão ao encontro de publicações em grandes séries internacionais, corroborando que a CTVA é uma importante via de execução de ressecções pulmonares e que pode ser realizada com segurança quando há treinamento adequado, devendo ser mais utilizada no Brasil para o tratamento das doenças pulmonares.

Síndrome incompleto de Carney / Incomplete Carney's triad

El síndrome de Carney es una enfermedad rara, con diferentes formas de presentación, que afecta principalmente al sexo femenino y es asintomática en la mayoría de los casos. Se caracteriza por la aparición de tumores, generalmente benignos, principalmente en el pulmón, la glándula suprarrenal y el estómago; sin embargo, se pueden afectar otros órganos como el esófago. Su tratamiento es principalmente quirúrgico. Se presenta el caso de una paciente con síndrome incompleto de Carney, manejada quirúrgicamente, con excelente resultado posoperatorio. Se hace una revisión de la literatura científica actual.

Carney's triad is a rare condition with multimodal presentations, which affects mainly females and remains asymptomatic in most cases. It is characterized by the appearance of tumors, usually benign, in lung, adrenal, and stomach, but it can also affect other organs like the esophagus. Treatment of these lesions is primarily surgical. The objective of this paper is to review the current literature and to report a case of an incomplete Carney's triad managed surgically with excellent postoperative results.

Round pneumonia: a rare condition mimicking bronchogenic carcinoma. Case report and review of the literature.

CONTEXT: Round pneumonia is a condition usually described in children, with few reports addressing adult patients. It is an oval-shaped consolidation that, due to its radiological appearance, simulates bronchogenic carcinoma. Its evolution tends to be benign, although diagnostic dilemmas have sometimes required exploratory thoracotomy. Deaths caused by this condition have even been reported. To the best of our knowledge, there have been 31 previous cases of round pneumonia in adults reported in the English and Portuguese-language literature, of which only one was completely asymptomatic. CASE REPORT: The case of a 54-year-old female patient presenting a lung mass found on routine imaging evaluation is reported. Respiratory symptoms and signs were absent, but the patient had a significant history of smoking. Her physical examination gave normal results. On chest radiographs, a mass located in the middle third of the right lung was observed. Three weeks after the initial evaluation, the patient was admitted for a complete evaluation and for staging of a pulmonary malignancy, but repeated chest radiographs showed complete resolution.

Surgical maneuvers for the management of bronchial complications in lung transplantation.

BACKGROUND: Many advances have substantially improved the clinical results of lung transplantation. However, the incidence of bronchial complications is still high, with significant impact on survival and limited interventional strategies for complex cases. Our aim is to evaluate the surgical management of bronchial complications following lung transplantation. METHODS: From May 1989 to June 2007, 251 patients were submitted to lung transplantation at our institution. In five cases, the bronchial complications observed were dealt with open surgical procedures. RESULTS: Complications surgically dealt were one broncho-arterial fistula and four stenosis. One left upper sleeve lobectomy, one right upper sleeve lobectomy and three segmental bronchial resections with anastomosis were performed. In all five cases the surgical procedure was successful and optimal bronchial healing was observed. Three patients died due to causes unrelated to the bronchial anastomosis 5, 21 and 32 months after the bronchoplastic procedure. Two patients are still alive and functionally well at 52 and 70 months post-bronchoplasty. CONCLUSIONS: Surgical management of bronchial complications after lung transplantation may be the last resort in complex, recalcitrant cases, nevertheless it is a feasible procedure and can provide good results not only on short- but also long-term follow-up.

Round pneumonia: a rare condition mimicking bronchogenic carcinoma: case report and review of the literature / Pneumonia redonda: uma condição rara simulando carcinoma broncogênico: relato de caso e revisão de literatura

CONTEXT: Round pneumonia is a condition usually described in children, with few reports addressing adult patients. It is an oval-shaped consolidation that, due to its radiological appearance, simulates bronchogenic carcinoma. Its evolution tends to be benign, although diagnostic dilemmas have sometimes required exploratory thoracotomy. Deaths caused by this condition have even been reported. To the best of our knowledge, there have been 31 previous cases of round pneumonia in adults reported in the English and Portuguese-language literature, of which only one was completely asymptomatic. CASE REPORT: The case of a 54-year-old female patient presenting a lung mass found on routine imaging evaluation is reported. Respiratory symptoms and signs were absent, but the patient had a significant history of smoking. Her physical examination gave normal results. On chest radiographs, a mass located in the middle third of the right lung was observed. Three weeks after the initial evaluation, the patient was admitted for a complete evaluation and for staging of a pulmonary malignancy, but repeated chest radiographs showed complete resolution.

CONTEXTO: A pneumonia redonda é uma condição encontrada normalmente em crianças, sendo que relatos envolvendo adultos são raros. Ela é definida como uma consolidação pulmonar ovalada que, pelo aspecto radiográfico, simula o carcinoma broncogênico. Sua evolução tende a ser benigna, entretanto, dificuldades diagnósticas demandando toracotomia exploradora e até mesmo óbitos têm sido descritos. Em revisão de literatura de língua inglesa e portuguesa, foram encontrados somente 31 casos relatados, com apenas um único caso de paciente com apresentação assintomática. RELATO DE CASO: Os autores relatam o caso de uma paciente de 54 anos com achado de massa pulmonar em exame radiológico de rotina. A paciente negava sinais e sintomas respiratórios, entretanto referia uma importante história de tabagismo. No exame físico, nada digno de nota. Na radiografia de tórax se observava uma lesão arredondada no terço médio do pulmão direito. Três semanas após a avaliação inicial, a paciente foi internada para completar a avaliação e estadiamento de uma possível neoplasia pulmonar, entretanto, o raio-x da entrada mostrou completa resolução do processo.