Eduardo Haruo Saito

Biópsia aspirativa transtorácica por agulha fina guiada por TC de lesões pulmonares: resultados e complicações

OBJECTIVE To analyze the cytological findings of CT-guided percutaneous fine-needle aspiration biopsies of the lung, to demonstrate the diagnostic feasibility of the method in the investigation of pulmonary lesions, and to determine the complications of the procedure, evaluating its safety. METHODS A retrospective analysis of 89 patients with various types of pulmonary lesions who underwent 97 procedures over a period of five years. The patients were divided into groups regarding the indication for the procedure: suspicion of primary lung cancer (stages IIIB or IV); suspicion of lung cancer (stages I, II, or IIIA) and clinical contraindications for surgery; suspicion of pulmonary metastasis from other organs; and pulmonary lesions with benign radiological aspect. All of the procedures were performed with 25-gauge needles and were guided by spiral CT. The final diagnosis was confirmed by surgical biopsy and clinical/oncological follow-up. For the analysis of complications, the total number of procedures was considered. RESULTS The main indication for the procedure was suspicion of advanced-stage primary lung cancer. The accuracy of the method for malignant lesions was 91.5%. The lesion was confirmed as cancer in 73% of the patients. The major complication was pneumothorax (27.8%), which required chest tube drainage in 12.4% of the procedures. CONCLUSIONS The principal indication for CT-guided fine-needle biopsy was suspicion of primary lung cancer in patients who were not surgical candidates. The procedure has high diagnostic feasibility for malignant pulmonary diseases. The most prevalent complication was pneumothorax. However, in most cases, chest tube drainage was unnecessary. No deaths were related to the procedure.

CPAP increases 6-minute walk distance after lung resection surgery.

BACKGROUND: The application of CPAP has been used to minimize postoperative pulmonary complications after lung resection surgery. The aim of this study was to quantify both the CPAP effects upon lung function and functional capacity in early postoperative lung resection, as well as to evaluate if CPAP prolongs air leak through the chest drain. METHODS: Thirty patients in the postoperative period of lung resection were allocated into 2 groups: an experimental group, consisting of 15 patients who underwent a 10 cm H2O CPAP, and a 15 patient control group, who performed breathing exercises. Arterial blood gas analysis, peak expiratory flow (PEF), respiratory muscle strength, spirometry, and 6-min walk test (6MWT) were assessed in the preoperative period, and repeated postoperatively on the first and on the seventh day (6MWT was repeated only on the seventh day). RESULTS: Significant increases in PEF, muscle strength, and FEV1 between the first and seventh postoperative day were observed, both in the experimental and in the control group, whereas FVC and PaO2 increased significantly between the first and seventh postoperative day only in the experimental group. The average loss in 6-min walk distance (6MWD) from preoperative to postoperative day 7 in the experimental group was significantly lower than in control group. When comparing the 2 groups, only 6MWD was statistically different (P < .001). There was no air leakage increase through the drain with the early use of CPAP. CONCLUSION: When compared to breathing exercises, CPAP increases the 6MWD in postoperative lung resection patients, without prolonging air leak through the chest drain.

A utilidade da TC de tórax no diagnóstico do sequestro pulmonar

Pulmonary sequestration is a rare congenital anomaly, characterized by nonfunctional embryonic pulmonary tissue. Pulmonary sequestration accounts for 0.15-6.40% of all congenital pulmonary malformations. This anomaly, which is classified as intralobar or extralobar, involves the lung parenchyma and its vascularization. We report the case of a 56-year-old male presenting with hemoptysis. A chest X-ray showed an area of opacity behind the cardiac silhouette in the base of the left hemithorax. Chest CT scans with intravenous contrast revealed pulmonary sequestration. The patient underwent surgery, in which the anomalous tissue was successful resected. The postoperative evolution was favorable, and the patient was discharged to outpatient treatment.

Avaliação quantitativa das fibras elásticas na doença pulmonar obstrutiva crônica

OBJECTIVE To quantify elastic fibers (EFs) and smooth muscle (SM) cells, as well as CD4+ and CD8+ T lymphocytes, in stable chronic obstructive pulmonary disease (COPD). METHODS Surgical specimens were obtained from 15 COPD patients, 18 smokers without airflow limitation, and 14 nonsmokers. Histological and immunohistochemical methods were employed in order to quantify EFs, SM cells, CD4+ T cells, and CD8+ T cells. RESULTS There was no significant difference in EF numbers among the three groups (p > 0.05). The number of EFs per unit area of lung tissue (mm(2)) and the percentage of EFs in the lung tissue were similar among the three groups. The numbers of SM cells were found to be higher in the COPD patients than in the smokers (p = 0.003) or in the nonsmokers (p = 0.009). There was a tendency toward an increase in CD8+ T-cell counts in the COPD patients. In specimens collected from the COPD patients, CD4+ T-cell counts were lower than in those collected from the smokers (p = 0.015) or from the nonsmokers (p = 0.003). There was a weak correlation between CD4+ T-cell count and the ratio of forced expiratory volume in one second to forced vital capacity (r(2) = 0.003). CONCLUSIONS The EF counts were similar among the three groups. Hypertrophy/hyperplasia of airway wall SM cells was found in the COPD patients and in the smokers, indicating that airway remodeling occurs in smokers. The CD4/CD8 ratio was lower in the COPD patients.

The surprising outcome of a giant primary mediastinal synovial sarcoma treated with neoadjuvant chemotherapy

There are only a few cases of primary mediastinal synovial sarcoma in the literature. Normally, they do not respond well to chemotherapy. In our case, a 30-year-old patient was admitted due to thoracic pain, dyspnea, orthopnea, cough, hoarseness and weight loss over a 3-month period as well as a dramatic worsening a week before the admission. A chest radiography showed a completely white left hemithorax and contralateral mediastinal shift; in addition, a chest tomography revealed a giant heterogeneous mediastinal mass, lung atelectasia and a small pleural effusion. The patient was submitted to Chamberlain procedure (biopsy) under local anesthesia and the diagnosis of a synovial sarcoma was obtained after immunohistochemical analysis. Due to his poor general condition, he received chemotherapy first, with a dramatic response, after what, the mass that had been reduced was removed surgically. After a 5-year- follow-up period there are no signs of disease recurrence.

Lung cancer with chest wall invasion: retrospective analysis comparing en-bloc resection and 'resection in bird cage'

BackgroundInvasion of the chest wall per se is not a contraindication for tumor resection in non-small cell lung cancer (NSCLC), provided there is no mediastinal lymph node or vital structure involvement. Although widely known to Brazilian surgeons, the ‘resection in bird cage’ technique has never been widely studied in terms of patient survival. Thus, the objective of this study was to evaluate the postoperative consequences and overall survival of extra-musculoperiosteal resection compared with en-bloc resection in NSCLC patients with invasion of the endothoracic fascia.MethodsBetween January 1990 and December 2009, 33 NSCLC patients with invasion of the thoracic wall who underwent pulmonary resection were retrospectively analyzed. Of the 33 patients evaluated, 20 patients underwent en-bloc resection and 13 underwent ‘resection in bird cage.’ For each patient, a retrospective case note review was made.ResultsThe median age at surgery, gender, indication, rate of comorbidities, tumor size and the degree of uptake in the costal margin were similar for both groups. The rate of postoperative complications and the duration of hospitalization did not differ between the groups. Regarding the outcome variables, the disease-free interval, rate of local recurrence, metastasis-free time after surgery, overall mortality rate, mortality rate related to metastatic disease, duration following surgery in which deaths occurred, and overall survival were also similar between groups. The cumulative survival curves between the ‘resection in bird cage’ and en-bloc resection and between stages Ia + Ib and IIb + IIIa + IV were not significantly different (p = 0.68 and p = 0.64, respectively). The cumulative metastasis-free survival curves were not significantly different between the two types of surgery (p = 0.38).ConclusionsIn NSCLC patients with invasion of the endothoracic fascia, ‘resection in bird cage’ is a less aggressive procedure that yields similar results in terms of morbidity and mortality compared with en-bloc resection. Thus, ‘resection in bird cage’ meets the oncologic principles of resection and does not adversely affect the patients in terms of cure.

Timectomia estendida por cirurgia torácica videoassistida e cervicotomia no tratamento da miastenia

* Trabalho realizado na Faculdade de Ciencias Medicas da Universida-de do Estado do Rio de Janeiro – UERJ/HUPE.1. Professor Adjunto Doutor – Disciplina de Cirurgia Toracica. Titulode especialista pela Sociedade Brasileira de Cirurgia Toracica.2. Professor Assistente – Disciplina de Cirurgia Toracica. Titulo de es-pecialista pela Sociedade Brasileira de Cirurgia Toracica.3. Professor Adjunto Doutor – Disciplina de Cirurgia Toracica. Titulode especialista pela Sociedade Brasileira de Cirurgia Toracica.

Prospective Analysis of Patients with Axillary, Palmar and Axillary-Palmar Hyperhidrosis who Underwent Bilateral R4-R5 Video-Assisted Thoracoscopic Sympathicotomy

Background: Video-assisted thoracoscopic sympathicotomy is a safe, effective and minimally invasive procedure, and its emergence greatly changed hyperhidrosis treatment. However, the possibility of standardizing interruption levels on the sympathetic chain has not yet been evaluated. This study sought to evaluate the frequency of compensatory sweating and the recurrence and satisfaction rates after bilateral R4-R5 video-assisted thoracoscopic sympathicotomy in patients with primary focal hyperhidrosis with involvement of the axillary, palmar, or both regions. Methods: From November 2010 to February 2013, an observational prospective cohort study was conducted with 42 patients who underwent bilateral video-assisted thoracoscopic sympathicotomy. During the procedure, electrocautery was performed along the sympathetic chain at the levels R4-R5, and the nerve of Kuntz and the path between levels R4-R5 were also sectioned. Results: No cases in which the video-assisted thoracoscopy had to be converted to thoracotomy were observed. Compensatory sweating was observed in 47.6% of patients within the first six months after surgery, decreasing to 30.9% at the end of this period. Hyperhidrosis recurrence occurred in only two patients. In total, 24.1% of patients with associated plantar hyperhidrosis reported that the condition disappeared after surgery. The satisfaction rate was 89.7% in the immediate postoperative period. Conclusions: The frequency of compensatory sweating, the recurrence rate of symptoms and the satisfaction rate after sectioning by cauterization with electrocautery at the R4-R5 levels were similar to those reported for other types of interruption and other levels studied. Moreover, the interruption level adopted also had beneficial effects on plantar hyperhidrosis.

An Unexpected Subglottic Foreign Body Diagnosed Two Years after Aspiration

A 56-year-old patient came to our hospital seeking treatment for his long-lasting condition. He presented with marked stridor, use of accessory musculature for breathing, and difficulty sleeping due to dyspnea. Treatment for asthma that had been initiated approximately 2 years before had not improved his condition. Therefore, his previous physician ordered computed tomography of his trachea, which revealed submucosal thickening in the subglottic region and the cervical trachea and a high-density lesion that touched the wall and occupied the lumen (Fig. 1). The patient was referred for treatment with corticosteroids and antibiotics, which also did not improve his condition. Because he did not feel better, he had independently searched for other medical assistance over the preceding 18 months. Interestingly, the patient had been a heavy drinker for the past 30 years. He could not report the specific starting point of his symptoms but only that they had gradually worsened. Based on the time of onset, the history of alcohol intake, and the high endemic rates of tuberculosis in our country, a diagnosis of a granulomatous infection of the upper airway was formulated. Because the clinical picture of the patient was critical, we opted to perform a tracheotomy with local anesthesia to obtain samples for microbiological cultures and histopathologic studies and to allow posterior ventilation. During the procedure, a solid, fixed structure was identified in the posterior wall of the trachea above the tracheotomy. Mobilizing the object was very painful for the patient with only local anesthesia so we interrupted the procedure and contacted the thoracic team. While waiting, we interrogated the patient specifically about episodes of aspiration. Only then did he report that he had lost a dental prosthesis after an episode of heavy drinking about the same time the symptoms began. With the thoracic team in the operating room, a cuffed tube was placed in the tracheotomy so that the lower airway was protected. A rigid bronchoscope was then inserted, which encountered large granulomas