Adriana Magalhães

Survival predictors in advanced non-small cell lung cancer

The authors studied the influence on survival of 21 clinical, anatomical, haematological and biochemical factors evaluated, at diagnosis, of 411 patients (pts) with advanced Non Small Cell Lung Cancer (NSCLC) followed in our department between 1984 and 1990. Most of the patients were male (347--84.4%) and only 64 (15.6%) were females. Median age was 62 years, but was slightly higher in females. Only 34 patients were aged under 45 years. Squamous cell carcinoma (215 pts--52%) and adenocarcinoma (152 pts--37%) were the most frequent histologic types. Performance status was poor--only 103 (25%) continued active; 120 (29%) spent at least half of the time in bed; 188 (46%) were severely limited. After staging, 179 (44%) presented locally advanced disease (stage IIIB) and 232 (56%) metastatic dissemination (stage IV). Therapy was defined by the oncologic group according to individual characteristics and based on clinical grounds. Anti-neoplastic therapy was performed in 225 (55%), chemotherapy alone in 121 (30%), radiation therapy alone in 67 (16%), and sequential combined treatment (chemotherapy and thoracic radiation) in 37 (9%). Until 1987, the main chemotherapy regimen was MACC (Metrotrexate + Adriamycine + Cyclophosphamide + Lomustin), afterwards VP(M) (Cisplatin + Vimblastin + Mitomycine). Radiation therapy was performed using Co60, 2 Gy/day, 5 days a week, for 4 weeks (approximately 45 Gy total). The response rate was poor--four complete responses (2%), 42 (19%) partial responses. The overall median survival was 4.3 months and only 5% of patients were alive after 18 months of follow up. Prognostic importance of each characteristic studied was initially done by unifactorial analysis, followed by multifactorial analysis according to two methods: Cox proportional hazards model and recursive partitioning amalgamation--RECPAM. Regardless of the method used, the main determinants of survival were found to be performance status (Zubrod), weight loss and serum albumin. Other factors such as the staging (presence or absence of metastasis), lymphocytes, lactic dehydrogenase, and hoarseness were also significant. It is noteworthy that age and histological type were irrelevant; sex and hoarseness only proved important when integrated within a multifactorial model. The overall prognostic evaluation and therapeutic decision of advanced NSCLC patients could be improved by combining the prognostic value of TNM with that of performance status, weight loss and serum albumin. These prognostic guidelines must be taken into account when designing new clinical trials.

Concentração plasmática de lidocaína durante a broncofibroscopia

Lidocaine is commonly used for local anesthesia during fiberoptic bronchoscopy (FOB). It has been suggested that the total dose of lidocaine should be limited to 300-400 mg (or < 8.2 mg/kg). Lidocaine toxicity is directly correlated with its concentration in the blood and a threshold above which the side effects become more likely has been put at a plasma level of 5 μg/ml. The aim of our study was to determine plasmatic lidocaine concentrations (PLC), how often the PLC fall into the potentially toxic range and its correlation with adverse reactions. PLC were recorded in 30 patients undergoing FOB. Lidocaine was administered as a 2% gel, 10% spray and 2% solution. Venous blood samples were taken before the beginning of local anesthesia and at 20, 30 and 40 min thereafter. The mean total amount of lidocaine administered was 746.3 ± 159.5 mg (11.6 ± 3.1 mg/kg). Before the beginning of anesthesia, no significant levels of lidocaine were measurable in the patients. PLC were 3.2 ± 1.7 μg/ml at 20 min., 3.3 ± 1.7 μg/ml at 30 min. and 3.0 ± 1.5 μg/ml at 40 min. The PLC exceeded toxic levels in 6 patients, but no complications were observed. Our data show that although the amount of lidocaine used in this study exceeded the recommended highest dose, no subjects had signs of toxicity. A maximum dose of lidocaine for topical anesthesia should be determined despite the fact that an average total dose superior to 400 mg appears to be safe in patients undergoing FOB. REV PORT PNEUMOL 2004; X (4): 287-296

Linfangioma cístico do mediastino

Resumo O linfangioma mediastinico e uma neoplasia vascular rara, correspondendo a 0,7 a 4,5% de todos os tumores do mediastino. E um tumor benigno, que ocorre geralmente como uma massa mediastinica de crescimento lento. A maioria dos doentes esta assintomatica, sendo diagnosticado incidentalmente, apos a realizacao de uma radiografia toracica de rotina. O tratamento de eleicao consiste na resseccao cirurgica completa. O prognostico depende do grau de ressecabilidade e, se a lesao for totalmente removida, nao se esperam recidivas. Rev Port Pneumol 2006; XII (6): 731-735

The value of rapid on-site evaluation during EBUS-TBNA

BACKGROUND Rapid on-site evaluation (ROSE) has the potential to increase endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) accuracy in the diagnosis of mediastinal lesions and lung cancer staging. However, studies have reported controversial results. The purpose of our study was to evaluate the influence of ROSE on sample adequacy and diagnostic accuracy of EBUS-TBNA. METHODS Prospective observational study that enrolled 81 patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions or lung cancer staging. The first 41 patients underwent EBUS-TBNA with ROSE (ROSE group) and the last 40 patients without ROSE (non-ROSE group). Sample adequacy and diagnostic accuracy of EBUS-TBNA in both groups were compared. RESULTS Adequate samples were obtained in 93% of the patients in the ROSE group and 80% in non-ROSE group (p=0.10). The diagnostic accuracy of EBUS-TBNA was 91% in ROSE group and 83% in non-ROSE group (p=0.08). Analyzing the EBUS-TBNA purpose, in the subgroup of patients who underwent EBUS-TBNA for investigation of hilo-mediastinal lesions, these differences between ROSE and non-ROSE group were higher compared to lung cancer staging, 93% of patients with adequate samples in the ROSE group vs. 75% in the non-ROSE group (p=0.06) and 87% of diagnostic accuracy in ROSE group vs. 77% in non-ROSE group (p=0.10). CONCLUSIONS Despite the lack of statistical significance, ROSE appears to be particularly useful in the diagnostic work-up of hilo-mediastinal lesions, increasing the diagnostic yield of EBUS-TBNA.

Tuberculose endobrônquica – alterações clínicas e broncoscópicas

Endobronchial tuberculosis (ET) is a serious complication of pulmonary tuberculosis and is a major cause of morbidity. The aim of our retrospective study was to characterize the clinical, radiological, microbiological and bronchoscopic features of ET. Between January 1999 and June 2002 a total of 14 patients were diagnosed as having ET in our hospital. There were 8 (57%) men and 6 women with a median age of 39.6 +/- 18.1 years (range from 20 to 78 years). Cough was the most common complain and it was present in 71.4% of patients. Only 5 patients were sputum smear positive. Five patients (35.7%) had parenchymal infiltration and this was the most common roentgenographic appearance. Forms of ET were classified into subtypes: actively caseating (n=4), granular (n=3), tumorous (n=3), edematous-hyperemic (n=2) and ulcerative (n=2). The upper lobes were affected in 9 (64.3%) patients. Nine patients had involvement of the left bronchial tree, 3 of the right and in 2 there were bilateral lesions. The diagnosis could be established in 11 (78.6%) cases by bronchial biopsy. All patients had positive bronchial lavage cultures for acid-fast bacilli. Clinical manifestations and roentgenographic appearance of ET are not specific and so bronchoscopy is mandatory for the prompt diagnosis and follow-up of its evolution.

Influência da distribuição do enfisema nos parâmetros de função pulmonar em pacientes com DPOC

A distribuicao do enfisema foi analisada em pacientes com DPOC, que foram classificados de acordo com um sistema de classificacao visual de cinco pontos a partir de achados de TC de torax. Avaliou-se a influencia do tipo de distribuicao do enfisema na apresentacao funcional e clinica da DPOC. Hipoxemia apos o teste da caminhada de seis minutos (TC6) foi tambem avaliada e a distância percorrida (DTC6) foi determinada.

Bronquiolite constritiva ocupacional (?) em doente com exame físico, radiológico e funcional normal

Constrictive bronchiolitis is characterized by alterations in the walls of membranous and respiratory bronchioles. These changes lead to concentric narrowing or complete obliteration of the airway lumen. Suspicion of possible bronchiolar disorders may arise from clinical, funcional, and radiologic findings. However, constrictive bronchiolitis may be present even with normal physical, functional and image findings, which turns the diagnosis difficult. A high index of suspicion is necessary to justify invasive tests that lead to pulmonary biopsy. In this report, we describe a patient with cough and dyspnoea, with normal physical, functional and image findings, whose work-up leaded to the diagnosis of constrictive bronchiolitis. Rev Port Pneumol 2009; XV (4): 729-732

Primary cysts and tumors of the mediastinum

OBJECTIVE To assess results in patients with primary cysts and tumours of the mediastinum who under- went surgery. METHODS A retrospective single-centre study was undertaken into patients with primary cysts and tumours of the mediastinum who underwent surgery between January 1992 and December 2004. We analysed demographic data, clinical presentation, type of surgery carried out and procedure, lesion location and histological diagnosis. Predictive malignancy factors were also evaluated. Postoperative morbidity and mortality were noted, as was medium-term results. RESULTS 171 patients underwent surgery over a 13-year period; 73 female (43%) and 98 male (57%). Mean age was 40.3+/-19.7 years (20 days-78 years). A primary cystic lesion was present in 15 patients (9%). The pri- mary tumours included thymic neoplasms (31%), lymphoma (22%), neurogenic tumours (16%), germ cell tumours (9%) and a miscellaneous group (13%). Malignant neoplasms were present in 78 patients (46%). The antero-superior mediastinum was the most commonly involved site to have a primary cyst or tumour (58%), followed by the posterior mediastinum (24%) and the middle mediastinum (18%). Symptoms were present in 68% of the patients and included chest pain (20%), fever and chills (13%), myasthenia gravis (11%), cough (10%), dyspnoea (10%), and superior vena caval syndrome (7%). Univariate analysis identified symptoms as a predictive factors of malignancy (p<0.001). Types of surgery carried out included postero-lateral thoracotomy (64 patients), median sternotomy (51 patients), anterior mediastinostomy (27 patients), antero-lateral thoracotomy (18 patients), video-assisted thoracic surgery (9 patients) and mediastinoscopy (2 patients). Total excision was performed in 116 patients, enlarged resection in 8 patients, subtotal re- section in 7 patients and biopsy in 40 patients. There was one postoperative death (0.6%). Follow-up was available in 165 patients (96.5%) and ranged from 34 days to 13.4 years (mean 5.7+/-4.0 years). Complementary treatment with chemo and/or radiotherapy was provided in 75 patients. Six patients had to be reoperated on for local recurrence (3) or metastasis (3) of the primary lesion. Fifteen patients died of their disease during the follow-up period. Actuarial survival at five years was 97.6% for benign lesions and 76.4% for malignant tumours. CONCLUSION Results support surgical resection for benign lesions and an aggressive multimodal approach for malignant tumours.

Mediastinal cystic lymphangioma

Mediastinal lymphangioma is a rare vascular neoplasm, accounting for 0.7 to 4.5% of all the mediastinum tumors. It is a benign tumor, generally occur- ring as a mediastinal mass of slow growth. Most patients are asymptomatic, being incidentally diagnosed after a routine chest radiograph. The best treatment consists of complete surgical resection. Prognosis depends on the degree of resectability, and recurrence is not expected if the lesion is totally removed.

Tracheal lobular capillary hemangioma treated with laser photocoagulation

Lobular capillary hemangioma (LCH), also known as pyogenic granuloma, is a benign vascular tumor most commonly affecting the skin or mucous membranes (oral and nasal). It is extremely rare among all primary tracheal tumors, and there are only few case reports in the literature.(1) Here, we present the case of a rare benign tracheal tumor presenting with recurrent hemoptysis, which was diagnosed by and treated with bronchoscopic techniques.