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Pulmonary metastasectomy for malignant melanoma: Prognostic factors for long-term survival

More than 80% of patients with metastatic melanoma initially show only one distant organ site involvement, most commonly the lungs. Several studies on patients with pulmonary metastatic diseases have determined prognostic factors for survival; however, these studies included patients with a variety of primary tumor types and failed to discriminate melanoma-specific prognostic factors. Surgical therapy has been shown in several studies to be associated with a 5-year survival rate as high as 39%. We retrospectively analyzed 48 patients with previously treated melanoma who developed pulmonary metastases and were admitted between 1990 and 2006. The overall survival was estimated using Kaplan–Meier analysis. Log-rank and Breslow’s tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model, as identified by the univariate analyses. The median overall survival for all patients was 32 months, with an estimated 5-year survival rate of 36%. Multivariate analyses identified the type of resection and the number of malignant nodules resected as independent prognostic factors for overall survival. We observed a significant survival benefit from pulmonary metastasectomy for a subset of patients with metastatic pulmonary melanoma.

Pulmonary metastasectomy for colorectal cancer: Long-term survival and prognostic factors

BACKGROUND Despite the development of novel chemotherapy and biological agents, surgery is still an important option for patients with pulmonary metastases. Predictors of survival usually include disease-free interval, histology of the primary tumor, number of metastases and complete resection. The aim of this study was to report the outcomes of patients with pulmonary metastases from colorectal carcinoma submitted to surgical resection, and to identify prognostic factors that significantly affect overall survival. METHODS We retrospectively analyzed 120 patients with previously treated colorectal carcinoma that had developed pulmonary metastases, admitted between 1990 and 2006. Overall survival was estimated using Kaplan-Meier analysis. The log-rank and Breslow tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model as identified by the univariate analyses. RESULTS The median follow-up was 20.3 months (range: 3.27-134.2 months). The patients included in this study underwent a total of 165 thoracotomies (mean of 1.37 thoracotomies/patient). The median overall survival for all patients was 34.73 months, with an estimated 5-year survival rate of 24.39%. Multivariate analyses identified unilateral lesions, neoadjuvant chemotherapy at lung resection and complete resection as independent prognostic factors for overall survival. CONCLUSIONS These results indicate that prognostic factors identified in studies on pulmonary metastasectomy for all primary tumors should be interpreted carefully for patients with possibility of pulmonary metastasectomy from colorectal carcinoma.

Role of adenosine deaminase and the influence of age on the diagnosis of pleural tuberculosis

OBJECTIVE 1) To determine factors affecting adenosine deaminase (ADA) levels in pleural fluid (PF), and 2) to establish the optimal ADA cut-off level for a Brazilian population. DESIGN ADA levels in PF of 309 patients were analysed to investigate pleural effusion. All patients were evaluated for age, sex and presence of tuberculosis (TB) based on a positive pleural biopsy. Differences in ADA levels between groups were analysed using Kruskal-Wallis one-way analysis of variance. Logistic regression analysis was also carried out to predict the occurrence of TB. ADA cut-off levels were selected using the receiver operating characteristic (ROC) curve. RESULTS The mean PF ADA level was significantly higher in the tuberculous pleural group than in non-tuberculous pleural patients (63.3 ± 29 IU/l vs. 19 ± 31 IU/l, P < 0.001). There was a significant correlation between PF ADA levels and age: for patients aged ⩾45 years, the ROC curve for ADA had an area under the curve of 0.91. An ADA level of 29 IU/l resulted in a sensitivity of 88.6% and specificity of 91.5%. CONCLUSIONS There is a significant negative correlation between PF ADA level and age. The use of a lower ADA cut-off reduces the number of false-negative results.

Spirometric assessment of lung transplant patients: one year follow-up

OBJECTIVE: The purpose of this study was to compare spirometry data between patients who underwent single-lung or double-lung transplantation the first year after transplantation. INTRODUCTION: Lung transplantation, which was initially described as an experimental method in 1963, has become a therapeutic option for patients with advanced pulmonary diseases due to improvements in organ conservation, surgical technique, immunosuppressive therapy and treatment of post-operative infections. METHODS: We retrospectively reviewed the records of the 39 patients who received lung transplantation in our institution between August 2003 and August 2006. Twenty-nine patients survived one year post-transplantation, and all of them were followed. RESULTS: The increase in lung function in the double-lung transplant group was more substantial than that of the single-lung transplant group, exhibiting a statistical difference from the 1st month in both the forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) in comparison to the pre-transplant values (p <0.05). Comparison between double-lung transplant and single lung-transplant groups of emphysema patients demonstrated a significant difference in lung function beginning in the 3rd month after transplantation. DISCUSSION: The analyses of the whole group of transplant recipients and the sub-group of emphysema patients suggest the superiority of bilateral transplant over the unilateral alternative. Although the pre-transplant values of lung function were worse in the double-lung group, this difference was no longer significant in the subsequent months after surgery. CONCLUSION: Although both groups demonstrated functional improvement after transplantation, there was a clear tendency to greater improvement in FVC and FEV1 in the bilateral transplant group. Among our subjects, double-lung transplantation improved lung function.

Hemangioma of the Rib

An asymptomatic 48-year-old woman presented to our hospital with a tumor of the rib incidentally diagnosed on a chest roentgenogram. The patient was investigated and underwent tumor resection of the chest wall. The pathologic study revealed that it was cavernous hemangioma. This tumor of the bone is a distinctly uncommon benign vascular tumor, generally occurring in the spine or skull. Hemangiomas involving the rib are even more rare, with only 22 cases described in the literature. However, we suggest that this tumor of the rib should be considered in the differential diagnosis, principally in asymptomatic patients.

Isolated Epithelioid Trophoblastic Tumor Mimicking Non-small Cell Lung Cancer

A 31-year-old Bolivian woman, nonsmoker, mother of two children, whose last pregnancy had occurred 8 years before, presented in our hospital with vaginal bleeding and high levels of -human chorionic gonadotropin ( hCG) 320 mIU/ml (normal value 3 mIU/ml). She was submitted to a curettage due to suspected miscarriage. At this moment, the endometrial biopsy showed normal glands, without atypical cells. The gynecology team chose to perform seriated hCG measurements and carry out the clinical follow-up. After 2 months, a new bleeding episode occurred, and the hCG level was 700 mIU/ml; a new curettage was performed, which disclosed proliferative endometrium. At this time, radiological assessment was requested to investigate a second source of hCG production. A transvaginal ultrasound disclosed no abnormalities; however, a thoracic computed tomographic scan showed a mass with 5 cm in the right lower lobe (Figure 1). Percutaneous biopsy of this mass showed squamous cell carcinoma, which was confirmed by immunohistochemical analysis (positive immunoreactivity for p63 and cytokeratin but negative for hCG, human placental lactogen, placental alkaline phosphate, and thyroid transcription factor-1). In the absence of metastasis, after staging for non-small cell lung cancer, the patient was scheduled for complete tumor resection. The tumor was exposed through right posterolateral thoracotomy approach. Intraoperatively, a large mass without extensive involvement of other structures was identified. The right lower lobe was removed, and systematic mediastinal lymphadenectomy was performed. The anatomopathological study demonstrated that the tumor was an epithelioid trophoblastic tumor (ETT), which confirmed by immunohistochemical analysis (Figure 2), without mediastinal lymph node involvement. The patient had an uneventful recovery and was discharged 5 days after the surgery. The gynecology team chose not to perform a hysterectomy, as there was no histological evidence of tumor in any sample analyzed from the curettage procedure. One year after the surgery, the patient has had no further episodes of vaginal bleeding or signs of uterine or lung recurrence. The hCG levels normalized, and she did not require adjuvant chemotherapy.

Desmoid tumors of the chest wall: surgical challenges and possible risk factors

Desmoid tumors account for approximately 0.3% of all solid tumors.1 The chest wall represents 8-10% of all cases, and surgery is the primary treatment modality for sporadic resectable desmoid tumors.2,3 Currently, the term “sarcoma with low-grade malignancy” is preferred, due the tendency of these tumors toward local invasion and frequent recurrence, even after complete surgical resection.4 There have been few specific studies on chest wall tumors. However, its treatment may involve peculiarities, such as a difficulty in obtaining free surgical margins (particularly in the axillary region and in the cervicothoracic transition). We present our experience over the past eleven years in an attempt to identify the risk factors for recurrence in patients with desmoid tumors located exclusively on the chest wall.

Protocolo fisioterapêutico aplicado no pós-operatório imediato para recuperação acelerada de pacientes submetidos à procedimentos cirúrgicos torácicos no Hospital Santa Marcelina – Itaquera (PROSM): estudo clínico randomizado

INTRODUCTION: Thoracic surgery can cause a series of pulmonary complications after the surgical procedure. The ideal timing and circumstance for out-of-bed sedation and its clinical implications, after chest surgeries, still require standardization. Thus, an appropriate early mobilization treatment is necessary in order to minimize complications in the postoperative period. OBJECTIVES: We aimed to evaluate the effect of physical therapy care in the immediate postoperative period of patients undergoing thoracic surgery. METHODS AND MATERIALS: This will be a randomized clinical trial in which a group of patients undergoing elective pulmonary resections (segmentectomies, lobectomies or pneumonectomies) aged over eighteen years will receive physiotherapeutic care through PROSM. Patients under the age of eighteen years, unable to sign the informed consent form, with compromised performance status (ECOG greater than 2), with a body weight below 60 kg or greater than 120 kg, with a history of allergy to any of the drugs used in anesthesia, patients with renal dysfunction, liver dysfunction (Child B and C) and Heart Failure (Functional class III and IV). The instrument of classification of pain grade by means of the Visual Analogue Scale (EVA) and instrument of classification of functional independence by means of the MIF Scale (functional independence measure) will be applied before the beginning and after the end of each physiotherapy session. We will also analyze the number of sessions of each patient and the length of hospital stay. For statistical analysis, the SPSS Statistics program will be used and the Shapiro-Wilk test will be used to identify the normality of the data collected. It is expected a shorter hospitalization time and better functional independence at hospital discharge in patients submitted to PROSM.

Wet M1a non-small cell lung cancer: is it possible to predict recurrence of pleural effusion?

Background The propose was to recognize risk factors of malignant pleural effusion (MPE) recurrence in patients with symptomatic M1a non-small cell lung cancer (NSCLC). Methods All patients with NSCLC and MPE submitted to pleural palliative procedures were enrolled in a prospective study. Group I contained patients who had pleural recurrence, and Group II with no pleural recurrence. Prognostic factors for pleural recurrence were identified by univariable analysis, using Fishers exact test for categorical variables and Students t test for quantitative variables. Afterwards the significant variables were entered into a multivariable logistic regression analysis (with P<0.05 considered significant). Receiver operating characteristics (ROC) analysis determined the cutoff points for continuous variables. Results A total of 82 patients were included in the analysis. There were 15 patients (18.3%) in Group I and 67 patients (81.7%) in Group II. Univariable analysis regarding factors affecting postoperative recurrence was: adenosine deaminase concentration in pleural fluid <16 mg/dL (P=0.04), albumin concentration in pleural fluid <2.4 mg/dL (P=0.03), administration of second-line palliative chemotherapy (P=0.018) and type of procedure [therapeutic pleural aspiration (TPA)] (P=0.023). At the multivariable analysis, only the type of procedure (TPA) (P=0.031) was identified as independent predictor of recurrence. Conclusions The identification of this factor may assist the choice of the optimal palliative technique; at the first episode of MPE in NSCLC patients and definitive procedure as pleurodesis or indwelling pleural catheter are recommended.

Interaction between treatment delivery delay and stage on the mortality from non-small cell lung cancer

Background The aim of this study is to evaluate the interaction between treatment delay and stage on the mortality from non-small cell lung cancer (NSCLC). Methods We performed a survival analysis in a cohort of patients admitted to the reference cancer center. The following data were collected: age, gender, smoking status, tumor staging, type of lung cancer, and time from the date when the patient was diagnosed with cancer to the starting date of effective treatment. Univariable and multivariable Cox proportional hazard models were used to investigate the association between potential confounders identified during the study design. After the final adjusted model was determined, tests for interaction among all predictors were performed. Results Inclusion criteria were met by 359 patients. In the adjusted analysis, delayed treatment delivery was a protective factor for the risk of death, with a crude hazard ratio (HR) =0.75 (0.59-0.97; P=0.02) and an adjusted HR =0.59 (0.46-0.77; P<0.001). However, a statistically significant interaction with mortality was observed between timely treatment and tumor stage. Patients with stage II disease who received delayed treatment had a higher risk of death [HR =3.08 (1.05-9.0; P=0.04)]. On the other hand, stage IV patients who received delayed treatment had a 52% reduction in mortality [HR =0.48 (0.35-0.66; P<0.001)]. Conclusions Stage of disease influenced the association between start of the treatment and mortality, and only the subgroup of stage II patients seemed to benefit from early treatment.