LYMPH NODE UPSTAGING AFTER SURGERY IN PATIENTS WITH NEGATIVE MEDIASTINAL STAGING BY EBUS.

INTRODUCTION: Mediastinal staging is a hot topic in thoracic oncology. According to the guidelines, and besides other criteria, in the presence of a primary lung cancer with increased mediastinal lymph node uptake on PET-CT, a negative result after lymph node sampling by Endobronchial Ultrasound (EBUS) is not enough to rule out mediastinal lymph node involve- ment, demanding a cervical mediastinoscopy to vouch for the results. METHODS AND OBJECTIVES: In order to study the percentage of lymph node surgical upstaging in patients with neg- ative mediastinal node staging by EBUS and evaluate the role of mediastinoscopy in these patients, we conducted a search in our department's database using the key-word EBUS in the period concerned between January 2014 and August 2020. A total of 302 patients were found. After applying defined criteria, we obtained 42 cases. RESULTS: Lymph node surgical upstaging occurred in 11 (26%) patients, of which 8 were upstaged to N2 and 3 to N1. Most of the cases were single station. Only in 5 (12% of the total) of the 11 patients, the upstaging was related to lymph node stations previously sampled by EBUS. Upstaging was more frequent among males and lower lobe tumours. DISCUSSION AND CONCLUSIONS: Regarding the 8 upstage cases for N2, 5 were single station. Of these 8 cases, only 5 would be approachable by cervical mediastinoscopy. Furthermore, 2 of them were single station, eligible for upfront surgery. Then, only in 3 (7%) of the 42 cases cervical mediastinoscopy would be of foremost importance.

Surgical Treatment of Complications 55 Years After Extraperiosteal Lucite Ball Plombage for Pulmonary Tuberculosis.

INTRODUCTION: In the 1930-50s, before the introduction of antimicrobial drugs and development of techniques of pulmonary resssection, collapse therapy was the mainstream of treatment for cavitary pulmonary tuberculosis. The methods to achieve the collapse included artificial pneumothorax with air refills, phrenic nerve crush, thoracoplasty and extrapleural plombage. The plombage involves creating a cavity surgically under the ribs in the upper chest wall and filling the space with inert material, such fat, paraffin wax, rubber ballons, oil and methyl-methacrylate (Lucite) balls. The theory behind Plombage treatment is that collapse of the lung promote de healing process and limit the spread of tuberculous infection to other areas of the lung. However, with time, the presence of these materials for a prolonged period of time resulted in complications, such as erosion of major vessels, respiratory insufficiency, infection and migration. METHODS: We present a clinical case of one patient presented with a late complication of lucite ball plombage after 55 years. RESULTS: An 78-year-old man with a history of pulmonary tuberculosis treated with plombage in 1962, ischemic heart disease, hypertension and diabetes mellitus, was admitted to hospital for axillary swelling and pleurocutaneous fistula. The x-ray of the chest and computed tomography showed the apex of the left hemithorax filled with multiple lucite balls, each approximately 2,5cm in diameter, and extrusion of a ball into the axillary fistuluous tract. In this context, the patient complied with multiple antibiotic regimens without success. So, the patient was submitted to surgical extraction of 21 lucite balls, pleurocutaneous drainage and thoracoplasty (7 ribs and the tip of the scapula was remove). The cultures turned out to be negative and the patient made an uneventful recovery with discharge on the 19th postoperative day. Pathologic examination revealed active chronic inflammatory process and negative microorganism screening. CONCLUSION: Despite the rapid decline in collapse therapy since the appearance of antitubercular chemotherapy, there are still such elderly patients who remain asymptomatic while carrying residual plombage material. There is no need for routine ablation of any this material, however if any foreign material becames a source of complication should be extracted without delay. As the number of living patients treated by plombage is attenuating rapidly, fewer and fewer will be seen in the future, and no one is likely to accumulate considerable experience with this problem.

Surgical Treatment for Elderly Patients with Lung Cancer.

INTRODUCTION: Non-small cell lung cancer is a very common disease in the elderly population and its incidence in this particular population is expected to increase further, because of the ageing of the Western population. Pulmonary resection is often not recommended in the elderly, even though they have no medical contraindications to surgery. Such patients are postulated to have a limited life expectancy, the rate of complications and perioperative death is considered to be higher than younger population. However, decision making is extremely difficult, since this group in under- represented in clinical trials. METHODS: This study aim to do a retrospective analysis of comorbidity, surgical procedures and pos- operative complications for surgery in patients older than 70 years of age who underwent a pulmonary resection for lung cancer. We analysed the clinical records of all patients with Non-small cell lung cancer submitted to surgery during the period 2012 to 2016 in our department and divide them in 2 groups: elderly group (more than 70 years old) and group control. RESULTS: In the five years study period, our department performed pulmonary resection in 601 patients with NSCLC, of whom 209 (34,8%) were 70 years and older. The mean age was 74,6 years old in the elderly group and 58,6 in the control group. Preoperative comorbidities such as cardiac and previous neoplasic diseases were more frequent in the elderly group, and the percentage of smokers was higher in the control group (80,1% vs 61,7%). A segmentar or wedge resection was performed more frequent for the elderly group (16,7%) than in the control group (6,6%), whereas pneumonectomies and lobectomies were performed more frequently. The ratio of pos-operative complications, especially cardiac complications, was higher in the elderly patients (12,9% vs 8,2%), however, there was no significant difference in prevalence of pulmonary/ respiratory complications, such pulmonary leakage, pneumonia or empyema between the 2 groups. There was no operative or hospital death in any of the groups. CONCLUSION: Advanced age alone is not a contraindication to surgical resection on NSCLC. Elderly patients should be offered the best treatment possible, considering surgical risk on an individualized basis, and keeping in mind that surgery offers the best results when the disease is resectable.

Unusual Behavior of a Lung Inflammatory Myofibroblastic Tumor: Case Report.

INTRODUCTION: 55 years old, male patient. History of heavy smoking (65 UMA) and COPD. Admitted to hospital due to a left pneumonia. Thoracic CT and PET-Scan, showed left lower lobe mass measuring 92x89 mm (SUVmax 49). Several mediastinal node groups presented increased uptake of FDG. A fiberoptic bronchoscopy was performed. Citology of the bronchoalveolar lavage suggested a squamous carcinoma. EBUS of node stations 4R, 4L e 7 without evidence of malignancy. METHODS: The case was taken to a multidisciplinary meeting staged as IIIA (T3N2M0). Neoadjuvant therapy (four cycles cysplatine and gemcitabine) was decided based on station 5, suspected disease. A left lower lobectomy was performed after a cervical mediastinoscopy excluded metastasis of node stations 4R and 4L. Histology of the specimen was compatible with inflammatory myofibroblastic tumor (IMT). No lymph node involvement was reported. It was restaged as IIB (ypT3N0M0). RESULTS: Three months after surgery one de novo nodule in the lingula with 12,7 of SUVmax was reported. The nodule was removed confirming a IMT metastasis. Four months after the nodule ressection a CT showed new lung and liver nodules. A total oclusion of the left main bronchus was documented and bronchoscopic debulking of the endobronchial mass again revealed IMT. Paliative radiotherapy was decided in the multidisciplinar group targeting the left main bronchus (five sessions of radiotherapy on a dose of 20Gy in 4Gy daily fractions). Ten months after surgery due to the onset of back pain, a CT revealed a sacrum lesion whose needle biopsy was suspicious for multiple myeloma. The patient was referred to another oncological center where previous non-surgical cases had been sent in the past. The patient is now proposed for histology reassessment and discussion by the hematology and pneumology medical teams. CONCLUSION: Inflammatory myofibrobastic tumors are considered benign or low-grade malignant tumors. The size of the tumour (cut-off of 3 cm) and secure surgical resection with free margins are the major determinants for recurrence and survival. There are some cases reported in the literature of distant metastasis and sarcomatous transformation after multiple recurrences. In our patient, the lesion was bigger than 3 cm and he underwent a complete resection. Nothing could foresee this aggressive metastatic behavior, especially when the recurrence did not show a sarcomatous transformation.

Gastrointestinal Fistula as First Presentation of Lung Cancer.

The initial manifestation of lung cancer as gastrointestinal tract metastasis is an extremely rare event. In most cases, these metastases are diagnosed after the primary lung tumor, when potentially life-threatening complications develop, often requiring emergency surgery. Regardless of treatment, these patients have a poor prognosis, due to the advanced stage of their disease. We report a clinical case of a gastrointestinal fistula arising from a small bowel non-small cell lung cancer (NSCLC) metastasis as a first manifestation of the disease, in a 43-years-old man. He underwent laparatomy with segmental small bowel and colon resection, followed by pulmonary lobectomy. A few months later the patient presented a cerebellum metastasis and was submitted to metastasectomy and holocranial radiation. After that event, systemic chemotherapy was prescribed, due to bone metastasis. Twenty-nine month after diagnosis, the patient is alive with a stable general condition. Aggressive surgical treatment of both primary and metastatic tumors can provide palliation and may improve short-term survival.