Women in thoracic surgery: perspectives from South America.

The thoracic surgery specialty is dominated by male surgeons worldwide, and South America is no exception. The training period to become a thoracic surgeon is long and requires a maximal commitment. Finding a balance between personal life and work is a challenge, especially for female surgeons. Consequently, the scarcity of female surgeons comes as no surprise. However, despite the low number of female thoracic surgeons who can serve as role models, the number of women participating in thoracic surgery residency programs in South America is growing.

PET-CT has low specificity for mediastinal staging of non-small-cell lung cancer in an endemic area for tuberculosis: a diagnostic test study (LACOG 0114).

BACKGROUND: The present study aims to assess the performance of 18F-FDG PET-CT on mediastinal staging of non-small cell lung cancer (NSCLC) in a location with endemic granulomatous infectious disease. METHODS: Diagnostic test study including patients aged 18 years or older with operable stage I-III NSCLC and indication for a mediastinal lymph node biopsy. All patients underwent a 18F-FDG PET-scan before invasive mediastinal staging, either through mediastinoscopy or thoracotomy, which was considered the gold-standard. Surgeons and pathologists were blinded for scan results. Primary endpoint was to evaluate sensitivity, specificity and positive and negative predictive values of PET-CT with images acquired in the 1st hour of the exam protocol, using predefined cutoffs of maximal SUV, on per-patient basis. RESULTS: Overall, 85 patients with operable NSCLC underwent PET-CT scan followed by invasive mediastinal staging. Mean age was 65 years, 49 patients were male and 68 were white. One patient presented with active tuberculosis and none had HIV infection. Using any SUV_max > 0 as qualitative criteria for positivity, sensitivity and specificity were 0.87 and 0.45, respectively. Nevertheless, even when the highest SUV cut-off was used (SUV_max ≥5), specificity remained low (0.79), with an estimated positive predictive value of 54%. CONCLUSIONS: Our findings are in line with the most recent publications and guidelines, which recommend that PET-CT must not be solely used as a tool to mediastinal staging, even in a region with high burden of tuberculosis. TRIAL REGISTRATION: The LACOG 0114 study was registered at ClinicalTrials.gov , before study initiation, under identifier NCT02664792.

An adaptation of the Hungarian model: the Brazilian model.

The Brazilian Society of Thoracic Surgery (BSTS) has the mission of improving patient care quality and thoracic surgery education. In order to achieve those goals, an overview of thoracic surgery activity in Brazil was necessary. BSTS had a clear need to start a national database. In 2015, BSTS joined European Society of Thoracic Surgeons (ESTS) Database platform. This partnership was a great choice not only for having a consolidated database, but also for allowing the development of shared educational and scientific projects. The strategy for BSTS database project was selecting committed group of surgeons, establishing implementation phases and setting milestones.

Management of lung nodules in Brazil-assessment of realities, beliefs and attitudes: a study by the Brazilian Society of Thoracic Surgery (SBCT), the Brazilian Thoracic Society (SBPT) and the Brazilian College of Radiology (CBR).

BACKGROUND: Pulmonary nodules are common; some are inconsequential while others are malignant. Management of solitary pulmonary nodule (SPN) in Brazil appears to be highly variable, potentially leading to suboptimal outcomes. Assessment of the variability and the association with the degree of availability of resources can provide a foundation for development of clinical guidelines for management of SPN specific for the Brazilian setting. METHODS: A web-based survey was developed by thoracic surgeons, pulmonologists and radiologists to evaluate SPN perception and management. This survey was sent to their respective national societies members and answers collected between August and December 2016. That included multiple choice questions regarding age, specialty, SPN management, accessibility to exams and interventional procedures characterizing public (SUS) and supplementary private working settings. RESULTS: A total of 461 questionnaires were answered. More than half of participants live in cities with over one million people. Specialties were reasonable equilibrated with 43.5% radiologists, 33.5% thoracic surgeons, 20.3% pulmonologists and 2.6% others. Most of the respondents work in both public and private sector (72.7%). Private has a similar reality compared to well-developed nations regarding exams accessibility and interventions. SUS setting has a significant variability access according to the participants. CT is only easily available in 31.9% of cases, PET-CT is easily available in 24.4%, bronchoscopy is easily available for 42.8%, transthoracic needle biopsy is only easily available in 13.9% and video-assisted thoracoscopic surgery (VATS) biopsy is not available in 19.5%. When there is a probability of malignancy of 50% or higher, 46.5% of participants would be comfortable recommending surgical biopsy. When the probability is higher than 10%, only 36.9% would be comfortable following up radiologically. CONCLUSIONS: Brazil has a very different setting for public and private patients regarding exams accessibility and management options. That might explain why participants have a higher tendency to choose interventional diagnosis and explains why current guidelines may not be applicable to developing countries reality.

PROGNOSTIC VALUE OF CARCINOEMBRYONIC ANTIGEN LEVELS IN TRANSOPERATIVE PERITONEAL LAVAGE IN PATIENTS WITH GASTRIC CANCER.

BACKGROUND: The carcinoembryonic antigen level in peritoneal lavage has been showing to be a reliable prognostic factor in gastric cancer. AIM: To identify any association between carcinoembryonic antigen level in peritoneal lavage, in gastric cancer patients, with mortality, peritoneal recurrence, tumor relapse or other prognostic factors. METHODS: In total, 30 patients (22 men, 8 women; median age 66 years) with resectable gastric cancer (mainly stage III and IV) were studied. Carcinoembryonic antigen level in peritoneal lavage was detected at operation by immunocytochemical method and a level over 210 ng/g of protein was considered as positive. RESULTS: There were detected 10 positive cases (33.3%) of plCEA levels. These levels were associated with mortality, RR: 2.1 (p=0.018); peritoneal recurrence, OR: 9.0 (p=0.015); and relapse or gastric cancer progression, OR: 27.0 (p=0.001). CONCLUSION: Increased levels of plCEA fairly predicts mortality, peritoneal recurrence tumor relapse or cancer progression.

Video-assisted thoracoscopic surgery yields better outcomes than thoracotomy for anatomical lung resection in Brazil: a propensity score-matching analysis using the Brazilian Society of Thoracic Surgery database.

OBJECTIVES: The use of video-assisted anatomical lung resection is increasingly widespread for lung cancer and non-neoplastic diseases, showing excellent results. Nonetheless, a comparative analysis of the benefits of this technique has yet to be conducted in Latin America, a region with a completely different case mix from the USA or Europe. The purpose of this study was to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT) for anatomical lung resection in patients included on the Brazilian Society of Thoracic Surgery (BSTS) database. METHODS: Using propensity score matching, we conducted an analysis of 1355 patients who underwent anatomical lung resection (704 OT and 651 VATS) registered in the BSTS database between August 2015 and December 2016. Propensity score matching was performed using the following baseline characteristics: age at surgery, gender, comorbidities, pulmonary lung function, type of resection and cancer and non-cancer diagnosis. The propensity score-matched sample comprised a well-matched group of 890 patients. The main outcomes tested were mortality, complications and major cardiopulmonary complications based on the European Society of Thoracic Surgeons (ESTS) database definitions and terminology. RESULTS: Standardized differences of means and proportions suggested that an adequate balance had been achieved. Major cardiopulmonary complications were shown to be more frequent in patients who underwent OT (16.0% compared with 9.2% in VATS patients; odds ratio = 1.87, 95% confidence interval 1.25-2.80) and the overall complications rate was higher among patients who underwent OT (30.1% compared with 21.8% in VATS patients; odds ratio = 1.55, 95% confidence interval 1.17-2.05). No statistically significant difference in mortality rate was observed between OT (2.5%) and VATS (1.8%) (odds ratio = 1.38, 95% confidence interval 0.54-3.50). CONCLUSIONS: In Brazil, the rate of complications associated with minimally invasive surgery (VATS) for anatomical lung resection is significantly lower than that of conventional OT.

Prognostic value of carcinoembryonic antigen levels in transoperative peritoneal lavage in patients with gastric cancer / Valor prognóstico dos níveis transoperatórios de antígeno carcinoembriônico em lavagem peritoneal de pacientes com câncer gástrico

ABSTRACT Background: The carcinoembryonic antigen level in peritoneal lavage has been showing to be a reliable prognostic factor in gastric cancer. Aim: To identify any association between carcinoembryonic antigen level in peritoneal lavage, in gastric cancer patients, with mortality, peritoneal recurrence, tumor relapse or other prognostic factors. Methods: In total, 30 patients (22 men, 8 women; median age 66 years) with resectable gastric cancer (mainly stage III and IV) were studied. Carcinoembryonic antigen level in peritoneal lavage was detected at operation by immunocytochemical method and a level over 210 ng/g of protein was considered as positive. Results: There were detected 10 positive cases (33.3%) of plCEA levels. These levels were associated with mortality, RR: 2.1 (p=0.018); peritoneal recurrence, OR: 9.0 (p=0.015); and relapse or gastric cancer progression, OR: 27.0 (p=0.001). Conclusion: Increased levels of plCEA fairly predicts mortality, peritoneal recurrence tumor relapse or cancer progression.

RESUMO Racional: Os níveis do antígeno carcinoembriônico no lavado peritoneal têm sido demonstrados como possível fator prognóstico de recidiva e mortalidade em pacientes com câncer gástrico. Objetivos: Medir seus níveis em lavado peritoneal durante operação de ressecção de câncer gástrico e ver se eles aumentados estão relacionados com mortalidade, recorrência, recidiva e outros fatores prognósticos. Métodos: Foi realizado lavado peritoneal durante ressecções de câncer gástrico; os níveis do antígeno carcinoembriônico nesse lavado maiores ou iguais a 210 ng/g foram considerados aumentados ou positivos. Resultados: Foram estudados 30 pacientes, destes, 33,33 % apresentaram níveis aumentados, os quais foram fator de risco para mortalidade em seis meses OR: 8,5 (1,458-49,539) IC 95%, mortalidade geral RR: 2,111 (1,314-3,391) IC 95%, mortalidade devido à doença OR: 12 (1,885-76,376) IC 95%, recorrência peritoneal OR: 9 (1,325-61,138) IC 95%, e recidiva ou progressão da doença OR: 27 (2,705-269,460) IC 95%. Conclusões: Os níveis aumentados do antígeno carcinoembriônico no lavado peritoneal foram fatores de risco para mortalidade, recorrência peritoneal, recidiva e progressão da doença em pacientes com câncer gástrico.

Lung cancer: changes in histology, gender, and age over the last 30 years in Brazil.

OBJECTIVE: To describe the trends in tumor histology, gender and age among patients with non-small cell lung cancer (NSCLC) treated with lung resection. The histology of lung cancer has changed in developed countries, and there is still little information available on the topic for developing countries. METHODS: This was a retrospective study of 1,030 patients with NSCLC treated with lung resection between 1986 and 2015 at a university hospital in southern Brazil. Differences in histology, stage, and type of surgery were analyzed by gender and for three periods (1986-1995, 1996-2005, and 2006-2015). RESULTS: Most (64.5%) of the patients were males, and the main histological types were squamous cell carcinoma (in 40.6%) and adenocarcinoma (in 44.5%). The mean age at surgery during the first period was 56.4 years for women and 58.9 years for men, compared with 62.2 for women and 64.6 for men in the third period (p < 0.001). The proportion of females increased from 26.6% in the first period to 44.1% in the third. From the first to the third period, the proportion of patients with squamous cell carcinoma decreased from 49.6% to 34.8% overall (p < 0.001), decreasing to an even greater degree (from 38.9% to 23.2%) among men. Among the NSCLC patients in our sample, females with adenocarcinoma accounted for 11.9% in the first period and 24.0% in the third period (p < 0.001). CONCLUSIONS: As has been seen in developed countries, the rates of lung cancer in females in southern Brazil have been rising over the last three decades, although they have yet to surpass those observed for males in the region. The incidence of squamous cell carcinoma has decreased in males, approaching adenocarcinoma rates, whereas adenocarcinoma has significantly increased among women.

Lung cancer: changes in histology, gender, and age over the last 30 years in Brazil / Câncer de pulmão: mudanças na histologia, sexo e idade nos últimos 30 anos no Brasil

ABSTRACT Objective: To describe the trends in tumor histology, gender and age among patients with non-small cell lung cancer (NSCLC) treated with lung resection. The histology of lung cancer has changed in developed countries, and there is still little information available on the topic for developing countries. Methods: This was a retrospective study of 1,030 patients with NSCLC treated with lung resection between 1986 and 2015 at a university hospital in southern Brazil. Differences in histology, stage, and type of surgery were analyzed by gender and for three periods (1986-1995, 1996-2005, and 2006-2015). Results: Most (64.5%) of the patients were males, and the main histological types were squamous cell carcinoma (in 40.6%) and adenocarcinoma (in 44.5%). The mean age at surgery during the first period was 56.4 years for women and 58.9 years for men, compared with 62.2 for women and 64.6 for men in the third period (p < 0.001). The proportion of females increased from 26.6% in the first period to 44.1% in the third. From the first to the third period, the proportion of patients with squamous cell carcinoma decreased from 49.6% to 34.8% overall (p < 0.001), decreasing to an even greater degree (from 38.9% to 23.2%) among men. Among the NSCLC patients in our sample, females with adenocarcinoma accounted for 11.9% in the first period and 24.0% in the third period (p < 0.001). Conclusions: As has been seen in developed countries, the rates of lung cancer in females in southern Brazil have been rising over the last three decades, although they have yet to surpass those observed for males in the region. The incidence of squamous cell carcinoma has decreased in males, approaching adenocarcinoma rates, whereas adenocarcinoma has significantly increased among women.

RESUMO Objetivo: Descrever as tendências da histologia do tumor, do gênero e da idade em pacientes com câncer de pulmão de células não pequenas (CPCNP) tratados com ressecção pulmonar. A histologia do câncer de pulmão mudou em países desenvolvidos, e ainda há pouca informação disponível sobre o tema em países em desenvolvimento. Métodos: Estudo retrospectivo com 1.030 pacientes com CPCNP tratados através de ressecção pulmonar entre 1986 e 2015 em um hospital universitário no sul do Brasil. As diferenças em histologia, estádio e tipo de cirurgia foram analisadas por gênero e em três períodos (1986-1995, 1996-2005 e 2006-2015). Resultados: A maioria dos pacientes (64,5%) era do sexo masculino, e os principais tipos histológicos foram carcinoma de células escamosas (40,6%) e adenocarcinoma (44,5%). A média de idade à cirurgia durante o primeiro período foi de 56,4 anos para mulheres e de 58,9 anos para homens, enquanto essa foi de 62,2 para mulheres e 64,6 para homens no terceiro período (p < 0,001). A proporção de mulheres aumentou de 26,6% no primeiro período para 44,1% no terceiro. Do primeiro ao terceiro período, a proporção de pacientes com carcinoma de células escamosas diminuiu de 49,6% para 34,8% no total (p < 0,001), diminuindo para um grau ainda maior (de 38,9% para 23,2%) entre os homens. Entre os pacientes com CPCNP em nossa amostra, mulheres com adenocarcinoma representaram 11,9% no primeiro período e 24,0% no terceiro período (p < 0,001). Conclusões: Como se observa em países desenvolvidos, as taxas de câncer de pulmão em mulheres no sul do Brasil têm aumentado nas últimas três décadas, embora ainda não tenham superado as observadas em homens na região. Entre homens no sul do Brasil, a incidência de carcinoma de células escamosas diminuiu, aproximando-se a de adenocarcinoma. A incidência de adenocarcinoma entre mulheres no sul do Brasil aumentou significativamente.

Neoplasia de Esôfago / Esophageal Neoplasm

Objetivos: Apresentar uma atualização naepidemiologia, apresentação clínica, diagnóstico e conduta terapêutica do paciente com neoplasia esofágica. Métodos: Revisão da literaturareferente à neoplasia de esôfago por meio de pesquisa no PubMed, de artigos publicados durante o período de 2013 a 2017,e no site do Instituto Nacional do Câncer (INCA). Resultados: O câncer de esôfago vem aumentando sua incidência nos últimos anos. O tipo histológico mais comum no mundo é o carcinoma de células escamosas (CCE), seguido pelo adenocarcinoma. Os principais fatores de risco são tabagismo e alcoolismo para o CCE; e doença do refluxo gastroesofágico e obesidade para adenocarcinoma. A apresentação clínica inclui disfagia progressiva, perda de peso e astenia; sendo mais característicos de estágios avançados. O diagnóstico é feito por endoscopia digestiva alta e biópsia. O estadiamento, com base no TNM, compreende ultrassonografia endoscópica (EUS), tomografia (TC) de tórax e abdome com contraste e tomografia por emissão de pósitrons (PET-CT). A escolha do tratamento depende do estágio da doença. Conclusões: A melhora da acurácia do estadiamento, surgimento de novas drogas oncológicas, evolução da radioterapia e técnicas cirúrgicas permitiu uma melhora na sobrevida nas últimas décadas. Entretanto, mais estudos são necessários nesta área, sobretudo com ênfase em marcadores tumorais.

Aims: Esophageal cancer update on epidemiology, clinical presentation, diagnosis and therapy. Methods: Esophageal cancer literature review on PubMed and on the website of the National Cancer Institute (INCA). Results: Esophageal cancer has increased its incidence in recent years. The most common histological type worldwide is squamous cell carcinoma (SCC), followed by adenocarcinoma. The main risk factors are: smoking and alcoholism for SCC; and gastroesophageal reflux disease and obesity for adenocarcinoma. Clinical presentation includes progressive dysphagia, weight loss, and asthenia; however, they are more characteristic in advanced stages. Diagnosis is made through a esophagogastroduodenoscopy (EGD) and biopsy. Staging, based on TNM, includes endoscopic ultrasonography, thorax and abdominal CT-Scan and PET-CT. The choice of treatment depends on the stage of the disease. Conclusions: The advance in diagnosis accuracy, newly oncologic drugs, radiotherapy and surgical techniques was responsible for survival improvement in recent decades. However, more studies are needed in this area, especially with an emphasis on tumor markers.

Intubação orotraqueal com tubo de duplo-lúmen pela via retrógrada / Retrograde orotracheal intubation with a double-lumen tube / Intubación orotraqueal con tubo de doble lumen por la vía retrógrada

JUSTIFICATIVA E OBJETIVOS: O manejo da via aérea difícil em cirurgia torácica é um assunto peculiar, devido às exigências da ventilação monopulmonar com o uso de tubos de duplo-lúmen. O auxílio da broncoscopia flexível é de enorme importância, porém nem sempre está disponível. O objetivo deste relato é descrever um caso de intubação orotraqueal seletiva retrógrada na ausência de equipamento de endoscopia específico para o procedimento. RELATO DO CASO: Paciente com história prévia de retossigmoidectomia internou-se para abordagem cirúrgica de lesão pulmonar por toracotomia direita. Avaliação anestésica pré-operatória não revelava particularidades nem na história clínica nem no exame físico. Após indução anestésica e ventilação com máscara facial, à laringoscopia direta duas tentativas de intubação orotraqueal mostraram-se inefetivas devido à difícil visualização das pregas vocais (Cormack-Lehane grau III). Em função da indisponibilidade de material específico para intubação seletiva endoscópica optou-se pela técnica retrógrada utilizando tubo de duplo-lúmen. O paciente foi extubado na sala cirúrgica logo após o término da cirurgia e não apresentou complicações decorrentes da técnica alternativa. CONCLUSÕES: A intubação orotraqueal seletiva retrógrada mostrou-se uma técnica alternativa minimamente invasiva, de baixo custo, segura e, ainda, extremamente útil quando não se conta com o auxílio da broncoscopia flexível.

BACKGROUND AND OBJECTIVE: Difficult airway management in thoracic surgeries is a peculiar subject due to the demands of monopulmonary ventilation with double-lumen tubes. Flexible bronchoscopy guidance is extremely important, but it is not always available. The objective of this report was to describe a case of retrograde selective orotracheal intubation in the absence of specific endoscopy equipment for the procedure. CASE REPORT: This is a patient with a history of retosigmoidectomy, admitted for a right thoracotomy for a lung lesion. Preoperative anesthetic evaluation did not reveal any clinical and physical exam particularities. After anesthetic induction and ventilation with face mask, two attempts of orotracheal intubation under direct laryngoscopy were ineffective due to difficult visualization of the vocal folds (Cormack-Lehane grade III). Due to the unavailability of specific material for selective endoscopic intubation it was decided to use the retrograde technique using the double-lumen tube. The patient was extubated in the operating room shortly after the end of the surgery without complications secondary to the alternative technique. CONCLUSIONS: Retrograde selective orotracheal intubation is a minimally invasive technique, low cost, safe, and extremely useful whenever flexible bronchoscopy is not available.

JUSTIFICATIVA Y OBJETIVOS: El manejo de la vía aérea difícil en cirugía torácica es un asunto peculiar, debido a las exigencias de la ventilación monopulmonar con el uso de tubos de doble lumen. El auxilio de la broncoscopia flexible es de enorme importancia, sin embargo no siempre está disponible. El objetivo de este relato, es describir un caso de intubación orotraqueal selectiva retrógrada en la ausencia de un equipo de endoscopia específico para el procedimiento. RELATO DEL CASO: Paciente con historial previo de retosigmoidectomía que fue ingresado para el abordaje quirúrgico de la lesión pulmonar por toracotomía derecha. La evaluación anestésica preoperatoria no revelaba particularidades ni en la historia clínica ni en el examen físico. Después de la inducción anestésica y ventilación con máscara facial, en la laringoscopia derecha dos intentos de intubación orotraqueal no tuvieron el efecto esperado debido a una difícil visualización de las cuerdas vocales (Cormack-Lehane grado III). En función de la indisponibilidad de un material específico para la intubación selectiva endoscópica, se optó por la técnica retrógrada utilizando un tubo de doble lumen. El paciente fue desentubado en quirófano enseguida que terminó la operación y no presentó complicaciones provenientes de la técnica alternativa. CONCLUSIONES: La intubación orotraqueal selectiva retrógrada fue una técnica alternativa mínimamente invasiva de bajo coste, segura e incluso extremadamente útil cuando no se cuenta con la ayuda de la broncoscopia flexible.

Retrograde orotracheal intubation with a double-lumen tube.

BACKGROUND AND OBJECTIVES: Difficult airway management in thoracic surgeries is a peculiar subject due to the demands of monopulmonary ventilation with double-lumen tubes. Flexible bronchoscopy guidance is extremely important, but it is not always available. The objective of this report was to describe a case of retrograde selective orotracheal intubation in the absence of specific endoscopy equipment for the procedure. CASE REPORT: This is a patient with a history of retosigmoidectomy, admitted for a right thoracotomy for a lung lesion. Preoperative anesthetic evaluation did not reveal any clinical and physical exam particularities. After anesthetic induction and ventilation with face mask, two attempts of orotracheal intubation under direct laryngoscopy were ineffective due to difficult visualization of the vocal folds (Cormack-Lehane grade III). Due to the unavailability of specific material for selective endoscopic intubation it was decided to use the retrograde technique using the double-lumen tube. The patient was extubated in the operating room shortly after the end of the surgery without complications secondary to the alternative technique. CONCLUSIONS: Retrograde selective orotracheal intubation is a minimally invasive technique, low cost, safe, and extremely useful whenever flexible bronchoscopy is not available.

Sondas e drenos / Stents and drain

Os autores realizam uma revisão não-sistemática sobre os principais aspectos envolvidos no uso de drenos e sondas em pacientes cirúrgicos, utilizando a base de dados do MEDLINE e revisão da literatura

Trauma craniencefálico / Brain injuries

Neste artigo, os autores abordam o tema e seus principais aspectos. Apresentam uma revisão sobre a anatomia do crânio e encéfalo, a fisiopatologia e os tipos de lesão, bem como o tratamento cirúrgico e as últimas tendências do manejo clínico no trauma craniencefálico