Mauro Zamboni

Teste de caminhada de seis minutos: uma ferramenta valiosa na avaliação do comprometimento pulmonar

Over the last few years, the use of exercise tests has come to be recognized as a convenient method of evaluating respiratory function, because the reserves of the various systems in the human body should be known in order to provide a more complete portrayal of the functional capacities of the patient. Because walking is one of the main activities of daily living, walk tests have been proposed in order to measure the state or the functional capacity of patients. The six-minute walk test has proven to be reproducible and is well tolerated by patients. It evaluates the distance a person can walk on a flat, rigid surface in six minutes. Its main objective is to determine exercise tolerance and oxygen saturation during submaximal exercise. In this review, we present various clinical areas in which the test can provide useful data.

Risk factors for lung cancer in Rio de Janeiro, Brazil: a case-control study

The association between the risk of lung cancer and tobacco smoking, dietary factors and occupational exposures was examined in a hospital-based case-control study. The study involved 123 consecutive cases and 123 controls, matched by age (+/- 3), sex, and race. In this first study of lung cancer risk in Brazil, we found that tobacco smoking is the strongest risk factor with an odds ratio (OR) for current and former smokers of 22 (CI, 6.5-76) and 7.7 (CI, 2.2-27), respectively. An OR of 2.8 (CI, 1.0-7.7) was found for users of black tobacco in the form of hand-rolled cigarettes) in combination with conventional cigarettes, after adjustment for life-time consumption of any kind of tobacco; users of conventional cigarettes only were considered as a reference group. Cessation of smoking had an important influence in reducing the lung cancer risk, whereas early initiation of smoking increased the risk. Among dietary factors, frequent consumption of meat (P < 0.01) and pasta (P = 0.02) were positively associated with lung cancer risk after adjusting for smoking and income. No association was found with green/yellow vegetables or fruits. We were unable to detect any significant association related to occupational exposures. This study confirmed the association of lung cancer with smoking as the most important predictor of risk. It also indicates the increase in risk associated with the use of black tobacco in combination with conventional cigarettes.

Palliative care in poor-performance status small cell lung cancer patients: is there a mandatory role for chemotherapy?

PurposeSmall cell lung cancer (SCLC) is an aggressive malignancy but with a high response rate to chemotherapy. Eastern Cooperative Oncology Group performance status (ECOG PS) has been recognized as one of the main prognostic factors in SCLC. There are few data about risk–benefit ratio of chemotherapy over exclusive best supportive care in ECOG PS 3 and 4 patients. This study was performed to assess the outcome of poor ECOG PS SCLC patients that received chemotherapy in our institution.MethodsA retrospective review of medical records from patients with ECOG PS 3–4 SCLC, who received systemic chemotherapy, was performed between January 2001 and December 2006 at the Instituto Nacional do Câncer, Rio de Janeiro, Brazil.ResultsA total of 40 patients were included. Extensive disease was observed in 85% of patients and 25% had PS 4. The median overall survival was 53 days (64 days for ECOG PS 3 and 7 days for ECOG PS 4). There were 30% of early deaths. On univariate analysis, lactate dehydrogenase value, need for hospital admission, and exposure to radiotherapy had impact on survival. ECOG PS 3 patients had better survival than PS 4 patients, even when adjusted for stage. On multivariate analysis, ECOG PS, combined with stage, sustained a major influence on survival.ConclusionsMedian survival for ECOG PS 4 patients treated with chemotherapy in our series was extremely short with a high rate of early deaths. ECOG PS 3 patients also showed a poor survival. These data suggest that we need a more comprehensive approach and further studies, regarding the palliative care of this high-risk population.

Broncoscopia no Brasil

INTRODUCAO: Durante os ultimos anos a endoscopia respiratoria evoluiu consideravelmente. Inumeros trabalhos na area tem sido publicados, bem como a realizacao de simposios, congressos e cursos vem acompanhados de um renovado interesse pela endoscopia respiratoria. Entretanto, nao sabemos o impacto dessas iniciativas sobre a pratica da broncoscopia no Brasil. OBJETIVO: Obter informacoes sobre a pratica da broncoscopia no Brasil. METODO: um questionario contendo 56 perguntas foi enviado, pelo correio, para os 576 membros do Departamento de Endoscopia Respiratoria da Sociedade Brasileira de Pneumologia e Tisiologia. RESULTADOS: cento e onze (19,2%) dos questionarios foram respondidos e analisados. Todos os respondedores estavam familiarizados com a pratica da broncofibroscopia, mas somente 45% deles estavam aptos para a realizacao da broncoscopia rigida. Menos de 15% dos respondedores tinham alguma experiencia com a broncoscopia terapeutica. CONCLUSAO: A maioria dos respondedores (87,3%) acha que as sociedades e os centros de treinamento especializados deveriam estimular, otimizar, disseminar e aperfeicoar a pratica da endoscopia respiratoria incluindo ai a broncoscopia terapeutica.

Transbronchial needle aspiration of hilar and mediastinal lymph nodes

BACKGROUND Besides clarifying the etiology of unidentified lymphadenomegaly, puncturing hilar and mediastinal lymph nodes by a flexible bronchoscopic needle is an aid in diagnosing and staging broncho- genic cancer or other metastatic cancers. OBJECTIVE Our study had the principal objective to evaluate the positivity of transbronchial needle aspiration (TBNA). METHOD We evaluated retrospectively the effectiveness of all TBNA done in 74 consecutive patients. Forty-nine patients were male and the median age was 59. We used Wang-needles, 21-gauge (Bard, USA), and the same technique described for different authors. Of the 74 patients evaluated, 11(15%) showed mediastinal mass and 65 (85%) hilar mass. We observed 76 endoscopic abnormalities. RESULTS According to the classification of the specimens, we had 32/74 (43%) unsatisfactory specimens, 34/74 (46%) satisfactory and diagnostic specimens, and 8/74(11%) satisfactory and non-diagnostic specimens. Thirty four (46%) of the examinations were found to be positive out of the total amount of specimens. Of the positive results, 30/34 specimens (88%) contained malignant disease. Small-cell carcinoma was the most frequent finding, with 10/34 cases (29%); squamous cell carcinoma 7/34 (21%); adenocarcinoma 7/34 (21%), non- -small cell carcinoma 6/34 (17%); sarcoidosis 2/34 (6%) and tuberculosis 2/34 (6%). CONCLUSION Our study indicated that this method is safe, easy to per- form, with a minimum of complications and useful for the diagnosis and staging of pulmonary neoplasms.

Transthoracic biopsy with core cutting needle for the diagnosis of mediastinal tumors

OBJECTIVE: To determine the contribution of percutaneous biopsy with core cutting needle in the diagnosis of mediastinal tumors. METHOD: Retrospective review of 22 patients with mediastinal lesions who were submitted to percutaneous core cutting needle biopsy, oriented, but not guided by computer assisted tomography of the thorax, between 1999 and 2002. RESULTS: Percutaneous biopsy with core cutting needle provided adequate material in 18/22 cases, with a total positive sample rate of 82%. In 4/22 cases, the material was insufficient to define the diagnosis (18%). Percutaneous core cutting needle biopsy established a specific histologic diagnosis in 82% of the patients: 8/22 (36%) lymphoma; 5/22 (28%) thymoma; 2/22 (11%) thymic carcinoma; 1/22 (6%) metastatic adenocarcinoma; 1/22 (6%) neuroectodermic primitive tumor; and 1/22 (6%) plasmocytoma. All the patients were submitted to a thoracic X-ray after the biopsy. No complications were found in these patients. CONCLUSION: Percutaneous core cutting needle biopsy oriented, but not guided by computer assisted tomography of the thorax, is an easy and safe procedure which can provide a precise diagnosis in most mediastinal tumors, and can prevent the exploratory thoracic surgery in inoperable or chemotherapy-treated cases.

Functional analysis of polymorphisms in the COX‑2 gene and risk of lung cancer

The enzyme cyclooxygenase 2 (COX-2) is known to be involved in tumorigenesis and metastasis in certain types of cancer. Nevertheless, the prognostic value of COX-2 overexpression and its polymorphisms in patients with non-small cell lung cancer (NSCLC) have yet to be fully elucidated. The aim of the present study was to investigate the association between the three most commonly studied COX-2 gene polymorphisms (−1195 G/A, −765 G/C and 8473 T/C) with COX-2 expression and lung cancer risk in a Brazilian cohort. In the present hospital based, case-control retrospective study, 104 patients with NSCLC and 202 cancer free control subjects were genotyped for −1195 G/A, −765 G/C and 8473 T/C polymorphisms using allelic discrimination with a reverse transcription quantitative polymerase chain reaction method. COX-2 mRNA expression was analyzed in surgically resected tumors from 34 patients with NSCLC. The results revealed that COX-2 expression levels were higher in tumor tissue compared with normal lung tissue. However, this overexpression of COX-2 was not associated with the patient outcome, and furthermore, none of the analyzed polymorphisms were associated with the risk of developing lung cancer, COX-2 overexpression, or the overall survival of the patients with NSCLC. Taken together, the findings described in the present study do not support a major role for COX-2 polymorphisms and COX-2 overexpression in lung carcinogenesis within the Brazilian population.

Biópsia transtorácica com agulha cortante (Trucut) para o diagnóstico dos tumores mediastínicos

Resumo Objetivo: Determinar a contribuicao da biopsia percutânea com agulha cortante (Trucut) no diagnostico das massas mediastinicas. Metodo: Revisao retrospectiva de 56 doentes com massas mediastinicas submetidos a biopsias com agulha cortante orientadas, mas nao guiadas, pela tomografia computadorizada do torax, no periodo de 1999 a 2008. Resultados: A biopsia percutânea com agulha cortante forneceu material adequado para o diagnostico em 49/56 casos, com indice de positividade de 88%. Em 7/56, o material colhido foi insuficiente para definir o diagnostico (12%). Este metodo foi capaz de definir o diagnostico em 88% dos doentes: 23/56 (41%) linfomas; 12/56 (21%) timomas; 5/56 (3%) carcinomas timicos; 3/56 (2%) carcinoma indiferenciado de pequenas celulas e 1/56 (0,6%) adenocarcinoma metastatico, carcinoma epidermoide metastatico, carcinoma neuroendocrino primitivo, plasmocitoma, teratoma, bocio. Apos a biopsia, os doentes foram submetidos a radiografia do torax. Nao houve nenhum tipo de complicacao nestes doentes. Conclusao: A biopsia transtoracica com agulha cortante (Trucut) orientada, mas nao guiada pela tomografia computadorizada, tem alto rendimento, esclrrecendo o diagnostico na maioria dos portadores de massas mediastinicas e pode ser util, evitando a toracotomia exploradora, nos casos de tumores do mediastino inoperaveis ou de tratamento quimioterapico. Rev Port Pneumol 2009; XV (4): 589-595

A Sociedade Brasileira de Pneumologia e Tisiologia e as suas relações internacionais

Ha aproximadamente cinco anos a Sociedade Brasileira de Pneumologia e Tisiologia (SBPT) percebeu que, apos significativo amadurecimento e desenvolvimento internos, seria fundamental e obrigatorio para aumentar a sua visibilidade externa um maior contato com as sociedades internacionais da especialidade. Contamos com um numero expressivo de associados – aproximadamente 3.000 – que impressiona, por sua magnitude, ate mesmo os diretores das sociedades norte-americanas. Temos uma producao cientifica comparada a dos grandes centros internacionais, se nao em numero, certamente na qualidade do que produzimos. Nosso contato inicial foi com a Asociacion Latino Americana de Torax (ALAT), cujo primeiro congresso foi realizado em Sao Paulo SP, naquela ocasiao ainda em criacao e sem o desenvolvimento que hoje tem. Em seguida, nos aproximamos da American Thoracic Society (ATS), famosa sociedade norteamericana, que com seus prestigiosos congressos anuais sempre seduziram os pneumologistas brasileiros. Seus congressos pautam por uma abordagem que privi legia especialmente a pesquisa na pneumologia e sao os que maior atracao exercem sobre nossos especialistas. Desde entao, as di retor ias da SBPT, durante os congressos da ATS, realizam uma reuniao com sua diretoria no sentido de estreitarmos nossas relacoes, nos fazermos conhecidos e aumentarmos, de forma solida e continua, nossa parceria. Essa parceria, de maneira pratica e especial, tem dado frutos especiais: resultou na vinda de professores com passagem aerea patrocinada por eles para os nossos congressos brasileiros e a cobranca de uma taxa de adesao diferenciada para os pneumologistas brasileiros. Logo depois, realizamos a primeira reuniao entre as diretorias da SBPT e da European Respiratory Society. (ERS), a qual tambem realiza um congresso anual, em moldes menores do que o da ATS, mas que nos permite entrar em contato com a tradicional pneumologia europeia e tambem com um grupo de especialistas provenientes de paises com situacoes politico-economicas semelhantes as nossas, os paises do leste europeu. Do mesmo modo que com a ATS, a ERS mantem estreita a parceria com a SBPT, tanto no patrocinio para a vinda de convidados internacionais para os nossos congressos, como tambem com taxa diferenciada para os pneumologistas brasileiros a ela se associarem. Relacao cada vez mais estreita tem a SBPT com o American College of Chest Physicians (ACCP), que tambem realiza um congresso anual, o CHEST, com numero menor de participantes do que o congresso da ATS, mas com uma visao da pneumologia mais voltada para seus aspectos praticos da clinica do dia a dia. Talvez o ACCP seja, atualmente, o parceiro mais proximo e com maiores possibilidades de crescimento entre todas essas sociedades. Tanto o intercâmbio de palestrantes da ACCP no congresso da SBPT quanto o de brasileiros no CHEST vem aumentando a cada ano que passa. Desse modo, e muito importante que os nossos associados procurem tambem participar desse evento. A atual diretoria da SBPT, assim que tomou posse, entrou em contacto oficialmente com a diretoria da Asian Pacific Respirology Society (APRS) seguramente a sociedade de pneumologia com maior numero de associados em todo o mundo demonstrando seu interesse em manter tambem com ela o mesmo tipo de relacionamento que vem mantendo com as outras sociedades internacionais. A receptividade foi otima, mas ainda nao tivemos a oportunidade de reunir as duas diretorias. Claro que uma reuniao da diretoria da SBPT com a da APRS esta nos nossos planos, mas um problema a ser superado e a enorme distância territorial que nos separa.

Factores preditivos de risco para surgimento de segundo tumor maligno primário no pulmão em 104 casos

Objectives: The objective of our study was to identify the risks factors for the de development of a second pulmonary primary cancer. Methods: It was a primary, observational, multicentric and retrospective study with 104 patients from the Cancer National Institute and the Antonio Pedro Universitary Hospital, in Rio de Janeiro, Brazil. Results: The sites of primary tumors were: head and neck(56.7%); with laryngeal carcinoma (42.4%); lungs (15.5%); bladder (8.6%); uterine cervix (7.6%); stomach (4.8%); others (6.8%). Male patients represented 84.6%. Average age 56.7 ± 10.7 years, with a coefficient of variation 18.8%.Among the patients 91.4% were smokers and 92.0% were alcohol consumers. Multiple logistic regression model: site of primary tumor (OR:8.22; CI 95% - 2.21 to 30.56; p = 0,0017); specific histologic of primary cancer (OR:0.21; IC 95%: 0.04 to 0.99; p = 0.0498); sex (OR: 0.25; CI 95%: 0.03 to 1.81; p = 0.1711); age (OR: 0.98; CI 95%: 0.92 to 1.04; p = 0.6318); smoking (OR: 2.80; CI 95%: 0.44 to 17.55; p = 0.2711) and alcohol consumption (OR:0.76; CIIC 95%: 0.19 to 2.95; p = 0.6964). Asjusted model: odds ratio of the site of the primary tumor was 4.14,; CI 95%; from 1.36 and 12.78 and p = 0.0123 (p < 0.05). Accuracy or the model: 82. 69%. Conclusion: In this study teh site of the primary tumor was the only predictor of risk for the second pulmonary primary cancer. REV PORT PNEUMOL 2004; X (4): 297-303