Fabio José Haddad

When to remove a chest tube? ☆: A randomized study with subsequent prospective consecutive validation

BACKGROUND Operative procedures on the pleural space are usually managed by chest tube drainage. Timing for removing the tube is empirically established, with wide variation among surgeons. Our objective was to evaluate the effectiveness and safety of establishing a volume of 200 mL/d of uninfected drainage as a threshold for removal of chest tube, as compared with more frequently used volumes of 100 and 150 mL/d. STUDY DESIGN A prospective randomized study was performed in a single institution. Patients (n = 139) submitting to pleural drainage after surgical procedures were randomized to one of three groups, defined by the planned timing of chest tube removal (depending on the threshold volume per day of pleural fluid drained): G-100 (< or = 100 mL/d, n = 44); G-150 (< or =150 mL/d, n = 58); and G-200 (< or = 200 mL/d, n = 37). Subsequently, another 91 consecutive patients had chest tubes removed when drainage was less than 200 mL/d (G-val, prospective validation group). All patients had similar discharge and 60-day followup. Drainage time, hospital stay, and reaccumulation rate were registered. RESULTS Drainage time (median days: 3.5 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) and hospital stay (median days: 4 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) were not statistically different among groups. Radiologic reaccumulation rates were 9.1% for G-100, 13.1% for G-150, 5.4% for G-200, and 10.9% for G-val, and the thoracenteses rates were 2.3%, 0.8%, 2.7%, and 3.3%, respectively, with no major differences among groups (G-100 versus G-150 versus G-200; G-200 versus G-val). CONCLUSIONS Increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation. This volume (200 mL/d) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks.

Pleurodesis in Patients with Malignant Pleural Effusions: Talc Slurry or Bleomycin? Results of a Prospective Randomized Trial

The purpose of this study was to evaluate the efficacy, safety, and cost of bedside pleurodesis for malignant pleural effusions using talc slurry (TS) or bleomycin (BL) in a prospective randomized trial, and to determine prognosticators for procedure failure. From June 1997 to June 1999 a series of 71 patients entered this trial. They underwent 37 procedures with TS (4 g) and 34 with BL (60 units) via tube thoracostomy. Success was defined as no recurrence of pleural effusion or asymptomatic recurrence of a small amount of effusion. Pleural effusion-free survival curves were used to analyze the success rates and the prognosticators of failure. Follow-up ranged from 3 days to 26 months (median 2.5 months). No difference in success rates was detected between TS or BL (log-rank test: p = 0.724). There were no major complications related to the procedure. The independent prognosticators of failed pleurodesis were the use of steroids (p = 0.004) and the volume of pleural fluid drained during the first thoracentesis when it was more than 900 ml (p = 0.029). The average cost of intervention per patient was significantly lower for TS (p < 0.001). There was no significant difference between the success rates for TS and BL as agents of bedside pleurodesis for malignant pleural effusions. Because of its significantly lower cost, TS should be considered the agent of choice. The use of steroids and the volume drained during the first thoracentesis (if more than 900 ml) were independent prognosticators of pleurodesis failure. The role of this latter finding as a marker of pleurodesis failure awaits more data.

High frequency of immature dendritic cells and altered in situ production of interleukin-4 and tumor necrosis factor-α in lung cancer

IntroductionAntigen-presenting cells, like dendritic cells (DCs) and macrophages, play a significant role in the induction of an immune response and an imbalance in the proportion of macrophages, immature and mature DCs within the tumor could affect significantly the immune response to cancer. DCs and macrophages can differentiate from monocytes, depending on the milieu, where cytokines, like interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor (GM-CSF) induce DC differentiation and tumor necrosis factor (TNF)-α induce DC maturation. Thus, the aim of this work was to analyze by immunohistochemistry the presence of DCs (S100+ or CD1a+), macrophages (CD68+), IL-4 and TNF-α within the microenvironment of primary lung carcinomas.ResultsHigher frequencies of both immature DCs and macrophages were detected in the tumor-affected lung, when compared to the non-affected lung. Also, TNF-α-positive cells were more frequent, while IL-4-positive cells were less frequent in neoplastic tissues. This decreased frequency of mature DCs within the tumor was further confirmed by the lower frequency of CD14-CD80+ cells in cell suspensions obtained from the same lung tissues analyzed by flow cytometry.ConclusionThese data are discussed and interpreted as the result of an environment that does not oppose monocyte differentiation into DCs, but that could impair DC maturation, thus affecting the induction of effective immune responses against the tumor.

Pulmonary metastasectomy from soft tissue sarcomas

INTRODUCTION: Isolated pulmonary metastases from soft tissue sarcomas occur in 20-50% of these (the issue is about metastases, not lung cancer) patients, and 70% of these patients will present disease limited only to the lungs. Surgical resection is well accepted as a standard approach to treat metastases from soft tissue sarcomas isolated in the lungs, and many studies investigating this technique have reported an overall 5-year survival ranging from 30-40%. The most consistent predictor of survival in these patients is complete resection. The aim of the present study was to determine the demographics and clinical treatment-related variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy from soft tissue sarcomas. METHODS: We performed a retrospective review of patients admitted in the Thoracic Surgery Department with lung metastases who underwent thoracotomy for resection following treatment of the primary tumor. Data regarding primary tumor features, demographics, treatment, and outcome were collected. RESULTS: One hundred twenty-two thoracotomies and 273 nodules were resected from 77 patients with previously treated soft tissue sarcomas. The median follow-up time of all patients was 36.7 months (range: 10-138 months). The postoperative complication rate was 9.1%, and the 30-day mortality rate was 0%. The 90-month overall survival rate for all patients was 34.7%. Multivariate analysis identified the following independent prognostic factors for overall survival: the number of metastases resected, the disease-free interval, and the number of complete resections. CONCLUSION: These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after lung resection.

Nonsmall cell lung cancer: evaluation of 737 consecutive patients in a single institution

OBJECTIVE To analyze surgical and pathological parameters and outcome and prognostic factors of patients with nonsmall cell lung cancer (NSCLC) who were admitted to a single institution, as well as to correlate these findings to the current staging system. METHOD Seven hundred and thirty seven patients were diagnosed with NSCLC and admitted to Hospital do Cancer A. C. Camargo from 1990 to 2000. All patients were included in a continuous prospective database, and their data was analyzed. Following staging, a multidisciplinary team decision on adequate management was established. Variables included in this analysis were age, gender, histology, Karnofsky index, weight loss, clinical stage, surgical stage, chemotherapy, radiotherapy, and survival rates. RESULTS 75.5% of patients were males. The distribution of histologic type was squamous cell carcinoma 51.8%, adenocarcinoma 43.1%, and undifferentiated large cell carcinoma 5.1%. Most patients (73%) presented significant weight loss and a Karnofsky index of 80%. Clinical staging was IA 3.8%, IB 9.2%, IIA 1.4%, IIB 8.1%, IIIA 20.9%, IIIB 22.4%, IV 30.9%. Complete tumor resection was performed in 24.6% of all patients. Surgical stage distribution was IA 25.3%, IB 1.4%, IIB 17.1%, IIIA 16.1%, IIIB 20.3%, IV 11.5%. Chemotherapy and radiotherapy were considered therapeutic options in 43% and 72%, respectively. The overall 5-year survival rate of nonsmall cell lung cancer patients in our study was 28%. Median survival was 18.9 months. CONCLUSIONS Patients with NSCLC who were admitted to our institution presented with histopathologic and clinical characteristics that were similar to previously published series in cancer hospitals. The best prognosis was associated with complete tumor resection with lymph node dissection, which is only achievable in earlier clinical stages.

Primary monophasic synovial sarcoma of the pleura: Neoadjuvant chemotherapy followed by complete resection

We describe a rare case of primary pleural synovial sarcoma in a 27‐year‐old man with a 4‐month history of dry cough and left‐sided chest pain. A CT scan showed a large cystic mass in the left pleural cavity. The patient underwent two video‐assisted thoracoscopic biopsies and the diagnosis of synovial sarcoma of the pleura was established. After neoadjuvant chemotherapy, which resulted in a partial response, the tumor was completely resected with extrapleural pneumonectomy. Pathological findings showed less than 5% of viable cancer and free surgical margins. The patient is clinically well 24 months after surgery, with no evidence of recurrent disease.

Expression of a dendritic cell maturation marker CD83 on tumor cells from lung cancer patients and several human tumor cell lines: is there a biological meaning behind it?

The present paper shows, for the first time, the membrane expression of the dendritic cell maturation marker CD83 on tumor cells from lung cancer patients. CD83 was also detected on freshly cultured fibroblast-like cells from these tissues and on several adherent human tumor cell lines (lung adenocarcinomas P9, A459 and A549, melanomas A375 and C81-61, breast adenocarcinomas SKBR-3 and MCF-7 and colon carcinoma AR42-J), but not in the non-adherent MOT leukemia cell line. CD83 may have immunosuppressive properties and its expression by cancer cells could have a role in facilitating tumor growth.

Ressecção cirúrgica de metástases pulmonares: estudo prospectivo em 182 pacientes

PURPOSE: The present study evaluates the results of surgical treatment of lung metastases, as well as attempts to identify subgroups of patients who would benefit the most from the operation. CASE AND METHODS: This is a prospective analysis of patients with history of neoplasia, submitted to resection of pulmonary nodules, with the diagnosis or suspicion of metastases. The 182 patients were operated upon through a lateral thoracotomy. RESULTS: The patients submitted to pulmonary resection for suspected metastases showed no malignant tissue in 34 patients (18.6%), and in six patients (3.2%) were diagnosed a second lung primary tumor. Overall survival of the patients was 28% at 56 months, and disease-free survival was 9%. Multivariate analysis showed that disease free interval (p=0.002), complete resection (p=0.039), and number of malignant nodules resected (p=0.016) significantly affected overall survival. Disease-free survival was affected only by complete resection (p=0.0001) and number of malignant nodules resected (p=0.004). CONCLUSION: Resection of pulmonary metastasis improve survival in a selected group of patients. More studies are necessary to define the value of other therapies in the results of survival in resected pulmonary metastasis.

Characteristics associated with complete surgical resection of primary malignant mediastinal tumors

OBJECTIVE To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. METHODS Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. RESULTS The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3 cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. CONCLUSIONS Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

Bócio de tireóide intratorácico e timoma invasivo: apresentação simultânea incomum

We present a rare situation in which two mediastinal tumors of different topology and histology were found during the resection of an extensive mediastinal tumor in an asymptomatic patient. Different histologies within the same mass have been reported, although, to our knowledge, there have been no reports of different tumors at distinct locations. Thymomas and intrathoracic goiters account for a large proportion of the tumors found in the mediastinum. When feasible, surgical resection plays a fundamental role in effecting a cure. In order to identify concomitant lesions and perform a complete resection, detailed surgical exploration is required.