Maria Teresa Ruiz Tsukazan

Role of gender in the survival of surgical patients with nonsmall cell lung cancer

PURPOSE: There are reports of greater survival rates in nonsmall cell lung cancer (NSCLC) patients of female gender. The objective of this study was to evaluate the role of gender in survival of NSCLC patients treated surgically with curative intent (stage I/II). METHODS: In a retrospective cohort design, we screened 498 NSCLC patients submitted to thoracotomies at the hospital Sγo Lucas, in Porto Alegre, Brazil from 1990 to 2009. After exclusion of patients that did not fit to all the inclusion criteria, we analyzed survival rates of 385 subjects. Survival was analyzed using the Kaplan-Meier method. The Cox regression model was used to evaluate potential confounding factors. RESULTS: Survival rates at 5 and 10 years were 65.3% and 49.5% for women and 46.5% and 33.2% for men, respectively (P = 0.006). Considering only stage I patients, the survival rates at 5 and 10 years were 76.2% and 55.1% for women and 50.7% and 35.4% for men, respectively (P = 0.011). No significant differences in survival rates were found among stage II patients. CONCLUSIONS: Our results show female gender as a possible protective factor for better survival of stage I NSCLC patients, but not among stage II patients. This study adds data to the knowledge that combined both genders survival rates for NSCLC is not an adequate prognosis.

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.

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.

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

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.

P1.20: Lung Resection Analysis From Brazilian Society of Thoracic Surgery Database: Track: Early Stage NSCLC (Stage I - III)

Results: This series included 11 patients aged 50y or less. Ten patients were women (90.9%), nine of them were never-smokers (90%). 81.8% had lung adenocarcinoma (n1⁄49), 9.1% large-cell carcinoma (n1⁄41) and 9.1% giant-cell carcinoma (n1⁄41). Nine patients were diagnosed at stage-IV and two patients at stages IA and IIB. Six patients (54.5%) were positive for either EGFR mutations (n1⁄43) or EML4-ALK fusions (n1⁄43) and two of them received TT with a tyrosine kinase inhibitor. Interestingly, all patients under 40y were mutated. Regarding to follow-up, 63.6% were not able to be followed, 27.3% died. Only one patient, who received TT with erlotinib, was followed-up at our institution (Table 1).

Intubação orotraqueal com tubo de duplo-lúmen pela via retrógrada

JUSTIFICATIVA Y OBJETIVOS: El manejo de la via aerea dificil en cirugia toracica es un asunto peculiar, debido a las exigencias de la ventilacion monopulmonar con el uso de tubos de doble lumen. El auxilio de la broncoscopia flexible es de enorme importancia, sin embargo no siempre esta disponible. El objetivo de este relato, es describir un caso de intubacion orotraqueal selectiva retrograda en la ausencia de un equipo de endoscopia especifico para el procedimiento. RELATO DEL CASO: Paciente con historial previo de retosigmoidectomia que fue ingresado para el abordaje quirurgico de la lesion pulmonar por toracotomia derecha. La evaluacion anestesica preoperatoria no revelaba particularidades ni en la historia clinica ni en el examen fisico. Despues de la induccion anestesica y ventilacion con mascara facial, en la laringoscopia derecha dos intentos de intubacion orotraqueal no tuvieron el efecto esperado debido a una dificil visualizacion de las cuerdas vocales (Cormack-Lehane grado III). En funcion de la indisponibilidad de un material especifico para la intubacion selectiva endoscopica, se opto por la tecnica retrograda utilizando un tubo de doble lumen. El paciente fue desentubado en quirofano enseguida que termino la operacion y no presento complicaciones provenientes de la tecnica alternativa. CONCLUSIONES: La intubacion orotraqueal selectiva retrograda fue una tecnica alternativa minimamente invasiva de bajo coste, segura e incluso extremadamente util cuando no se cuenta con la ayuda de la broncoscopia flexible.