Ricardo Sales dos Santos

Margin and Local Recurrence After Sublobar Resection of Non-Small Cell Lung Cancer

BackgroundLocal recurrence is a major concern after sublobar resection (SR) of non-small cell lung cancer (NSCLC). We postulate that a large proportion of local recurrence is related to inadequate resection margins. This report analyzes local recurrence after SR of stage I NSCLC. Stratification based on distance of the tumor (<1 cm vs ≥1 cm) to the staple line was performed.MethodsWe reviewed 81 NSCLC patients (44 female) who underwent operation over an 89-month period (January 1997 to June 2004). Mean forced expiratory volume in one second percentiles (FEV1) was 57%. Mean age was 70 (46–86) years. There were 55 wedge and 26 segmental resections. There were 41 tumors with a margin <1 cm and 40 with a margin ≥1 cm. Local recurrence was defined as recurrence within the ipsilateral lung or pulmonary hilum.ResultsThere were no perioperative deaths. Mean follow-up was 20 months. Margin distance significantly impacted local recurrence; 6 of 41 patients (14.6%) developed local recurrence in the group with margin less than 1 cm versus 3 of 40 patients (7.5%) in the group with margin equal to or more than 1 cm (P = .04). Of the 41 patients with margins <1 cm, segmentectomy was used in 7 (17%), whereas in the 40 patients with the ≥1 cm margins, segmentectomy was used in 19 (47.5%).ConclusionsMargin is an important consideration after SR of NSCLC. Wedge resection is frequently associated with margins less than 1 cm and a high risk for locoregional recurrence. Segmentectomy appears to be a better choice of SR when this is chosen as therapy.

Long-Term Outcome of Lung and Heart-Lung Transplantation for Idiopathic Pulmonary Arterial Hypertension

BACKGROUND The survival after lung and heart-lung transplantation for idiopathic pulmonary arterial hypertension has been reportedly the lowest among the major diagnostic categories of lung transplant recipients. METHODS Retrospective analysis was performed for lung and heart-lung transplant recipients for idiopathic pulmonary arterial hypertension from 1982 to 2006. The patients were divided into 2 groups, based on the era; group 1: 1982 to 1993, and group 2: 1994 to 2006. Since 1994, we have introduced our current protocols including prostaglandin E1 and nitroglycerin for donor lung preservation, and lung protection with cold and terminal warm blood pneumoplegia as well as immunosuppression with alemtuzumab induction. These modifications were introduced in different years over a wide span of time (1994 to 2003). RESULTS Group 1 had 59 patients (35 +/- 1 years old, ranging 15 to 53, 20 male and 39 female) with 7 single lung, 11 double lung, and 41 heart-lung, whereas group 2 had 30 (43 +/- 2 years old, ranging 17 to 65, 9 male and 21 female) with 2 single, 20 double, and 8 heart-lung transplantations. The recipient age was significantly (p = 0.004) higher in group 2, and group 2 had significantly older (35 +/- 3 vs 26 +/- 1, p = 0.002) and more female donors (73% vs 41%, p = 0.007) compared with group 1. The actuarial survival was significantly (p = 0.004) better in group 2 with 86% at 1 year, 75% at 5 years, and 66% at 10 years compared with group 1 with 58% at 1 year, 39% at 5 years, and 27% at 10 years. CONCLUSIONS With our current pulmonary protection and immunosuppression, the long-term outcome of lung and heart-lung transplantation for idiopathic pulmonary arterial hypertension is excellent.

Electromagnetic Navigation to Aid Radiofrequency Ablation and Biopsy of Lung Tumors

PURPOSE We evaluated an electromagnetic (EM) navigation system (Veran Medical Technologies Inc, St. Louis, MO) to determine its potential to reduce the number of skin punctures and instrument adjustments during computed tomographic-guided percutaneous ablation and biopsy of lung nodules. DESCRIPTION Ten patients undergoing lung percutaneous ablation were prospectively enrolled. The mean age was 70 years. Positioning of the needle device was verified with computed tomographic fluoroscopy prior to the execution of any biopsy or ablation. Each EM navigation-guided procedure was defined as an EM-intervention. EVALUATION Nineteen EM interventions were performed. When an EM-guided biopsy was performed, the intervention was done immediately prior to ablation. For all 19 EM interventions, only one skin-puncture was required. The mean number of instrument adjustments required was 1.2 (range, 0 to 2). The mean time for each EM intervention was 5.2 minutes (range, 1 to 20 minutes). Pneumothorax occurred in 5 patients (50%). Only the number of instrument adjustments was significantly related to the pneumothorax rate (p = 0.005). CONCLUSIONS The EM navigation is feasible and seems to be a useful aid for image-guided procedures. Early experience suggests a low number of skin-puncture and instrument adjustments using the EM navigation system. Instrument adjustments were a key factor in pneumothorax development.

Radiofrequency ablation for Barrett's esophagus and low-grade dysplasia in combination with an antireflux procedure: a new paradigm.

OBJECTIVE Radiofrequency ablation for Barretts esophagus in combination with an antireflux procedure has not been widely documented. We report our initial experience with radiofrequency ablation in association with antireflux procedure for Barretts metaplasia and low-grade dysplasia. METHODS A total of 14 patients (10 male and 4 female patients) presented with Barretts metaplasia (n=11) or low-grade dysplasia (n=3). Median age was 60 years (38-80 years). The severity of Barretts esophagus was classified by length (in centimeters), appearance (circumferential/noncircumferential), and histology (1, normal; 2, Barretts metaplasia; and 3, low-grade dysplasia). Radiofrequency ablation was performed with the HALO 360 degrees or 90 degrees systems (BARRX Medical, Sunnyvale, Calif). RESULTS Median follow-up was 17 months. The mean number of ablative procedures undertaken was 2.6 (range, 1-6). There was no mortality, but there were 2 perioperative complications after the antireflux procedure (pneumonia, 1; atrial fibrillation, 1). One patient had mild dysphagia requiring a single dilation 2 months after ablation. The mean length of Barretts esophagus decreased from 6.2 to 1.2 cm after treatment (P=.001). Barretts grade decreased significantly (P=.003). Before therapy, circumferential Barretts esophagus was present in 13 patients. At last endoscopy, only 1 patient had circumferential Barretts esophagus present. The number of radiofrequency ablation treatments was significantly (P < .05) associated with success. All patients receiving 3 or more treatments had complete resolution of Barretts metaplasia. CONCLUSIONS Radiofrequency ablation performed either before or after an antireflux procedure is safe. This approach is effective for reducing or eliminating metaplasia and dysplasia. Long-term studies will be necessary to determine whether this approach can provide durable control of both reflux and Barretts esophagus.

Feasibility of spray cryotherapy and balloon dilation for non-malignant strictures of the airway

OBJECTIVE Benign airway strictures can be complex and challenging to manage. Although resection is preferred, this is not always feasible, and hence, endoscopic therapies are often performed. However, endoscopic therapies can be problematic, with granulation tissue and fibrosis leading to early failure. Spray cryotherapy (SC) is a new approach that may modulate the healing response leading to less fibrosis and decrease the need or the duration of time to intervention. We report the initial results of SC for benign airway strictures. METHODS Over a 22-month period, 35 patients underwent SC. Median age was 51(18-81) years. Prior therapy had been undertaken in 14 (41.2%) of patients. Stricture etiology included post intubation (n=5), prior tracheostomy (n=6), radiation induced (n=2), prior surgery (n=3), other causes (n=12), or unknown etiology (n=7). Airway narrowing was graded as follows: 1=0-25%, 2=26-50%, 3=51-75%, and 4=76-100%. For the purpose of analysis, this was treated as a continuous variable. The usual treatment algorithm consisted of ×3-4 SC cycles, followed by balloon dilation, and then by additional SC cycles. RESULTS Stricture locations were subglottic (n=18), tracheal (n=9), and bronchial (n=8). Seventeen (49%) patients required additional SC therapy, resulting in a total of 63 SC treatment sessions. Only two (3.2%) complications occurred and these included pneumothorax (n=1) and intra-operative tracheostomy (n=1). Mean follow-up was available in 33/35 patients at a mean of 8.2 (1-19) months. Twelve (of 33) patients (36.4%) were asymptomatic, 16/33 (48.5%) were improved, 4/33(12.1%) had no improvement or were worse, and 1/33(3%) patient died from an unrelated cancer. On follow-up bronchoscopy, performed in 28 patients, airway narrowing improved significantly from 3.5 to 2.03 (p<0.001). CONCLUSIONS Initial experience with SC for benign airway strictures suggests that this can be used safely. This is effective in improving symptoms and reducing the severity of airway narrowing. Re-intervention is still required. Further study should be undertaken to determine factors that may be associated with success or failure as well as the relative efficacy of SC compared with other endoscopic therapies.

Análise semiquantitativa de biópsias cirúrgicas de diferentes lobos pulmonares de pacientes com pneumonia intersticial usual/fibrose pulmonar idiopática

OBJECTIVE: To evaluate the differences between surgical biopsies of distinct lung lobes in terms of the histopathological features of usual interstitial pneumonia, using a semiquantitative score. METHODS: We selected all of the patients diagnosed with idiopathic pulmonary fibrosis and submitted to surgical biopsy in two distinct lobes between 1995 and 2005 at the Hospital Sao Paulo and other hospitals operated by the Federal University of Sao Paulo. In the histological evaluation of the specimens, we used a semiquantitative method based on previous studies, assigning a score to each of the biopsied sites. RESULTS: In this sample of patients, we found no statistically significant differences that would alter the stage of the disease, based on the score used. This finding was independent of the biopsy site (middle lobe or lingular segment). CONCLUSIONS: No significant histological differences were found between the lung lobes studied. The definitive histological diagnosis of usual interstitial pneumonia did not alter the stage of the disease.

Microwave ablation of lung tissue: impact of single-lung ventilation on ablation size.

BACKGROUND Thermal ablation is increasingly used to treat pulmonary tumors in medically inoperable patients. Most procedures are performed with sedation in the radiology suite. Ideally, the ablation should encompass the entire tumor volume with a surrounding margin of necrosis; however, ablation may not be as effective in the normal aerated lung surrounding a denser tumor. Inducing atelectasis of the lung may potentially increase ablation volumes and increase local cancer control. This study examines the effect of single-lung ventilation on ablation size using a microwave system. METHODS Twenty microwave ablation procedures were performed in the lungs of 10 swine. Bilateral thoracotomy using a clamshell approach was used. In one lung, ablation was performed with continuous ventilation. In the contralateral lung, single-lung ventilation was achieved by clamping the bronchus before ablation. The ablated lobes were resected and sent for pathologic analysis. Routine and supravital staining was performed. RESULTS The ablation zone was clearly demarcated on gross examination, and in all cases 100% ablation occurred, without skip areas of viability. The ablation zones were elliptical with the long axis parallel to the axis of the ablation probes (active tip, 3.7 cm). Ablation diameters and volume were compared between the ventilated and nonventilated lungs. Ablation volume was superior in nonventilated lungs (10.74 cm(3) versus 7.35 cm(3); p = 0.039) primarily because of differences in the short axis of the ablation zone. CONCLUSIONS Microwave energy can effectively ablate normal pulmonary parenchyma without skip areas of viable tissue within the gross ablation field. The volume of necrosis is increased in nonventilated lungs, suggesting that ablation results can be improved in patients by using general anesthesia with single-lung ventilation. Future studies will be required to confirm this hypothesis.

Do Current Lung Cancer Screening Guidelines Apply for Populations With High Prevalence of Granulomatous Disease? Results From the First Brazilian Lung Cancer Screening Trial (BRELT1)

BACKGROUND Low-dose computed tomography (LDCT) screening for lung cancer has been demonstrated to be effective in reducing cancer mortality. However, these studies have not been undertaken in countries where the incidence of granulomatous disease is high. The First Brazilian Lung Cancer Screening Trial (BRELT1) has completed initial accrual and is now in the follow-up phase. We present results from the initial prevalence round of screening. METHODS The inclusion criteria were the same as those for the National Lung Cancer Screening Trial (NLST). Pulmonary nodules larger than 4 mm were considered positive and required evaluation by a multidisciplinary team. Indeterminate nodules were evaluated with fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) or biopsy when indicated. Statistical analysis was performed with Fishers exact test to compare our positive findings with those of the NLST. RESULTS From January 2013 to July 2014, 790 participants were enrolled. Positive LDCT scans were reported in 312 (39.4%) participants, with a total of 552 nodules larger than 4 mm. The comparison between positive findings in the NLST (7,191 of 26,722 cases) and those in the BRELT1 (312 of 790 cases) showed a significant difference (p < 0.001). The positive predictive value was lower in BRELT1 than in the NLST (3.2% versus 3.8%, respectively). Follow-up imaging was indicated in 278 of 312 (89.1%) participants; 35 procedures were performed in 25 participants. In 15 cases, benign lesions were diagnosed. Non-small-cell lung cancer (NSCLC) was diagnosed in 10 patients (prevalence of 1.3%). In 8 patients (stage IA/IB disease), treatment was by resection only, in 1 patient neoadjuvant chemotherapy was used (stage IIIA), and in 1 patient advanced disease was diagnosed (stage IV). CONCLUSIONS Using NSLT criteria, a larger number of patients had positive scans (nodules), compared with previous lung cancer screening studies. However, the number of participants requiring surgical biopsy procedures and who were ultimately identified as having cancer was similar to other reports. This supports the role of screening in patient populations with a high incidence of granulomatous inflammation.

Understanding Lung-RADS 1.0: A Case-Based Review

Lung cancer is the leading cause of cancer death in both men and women in the United States. The National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (CT) screening reduces lung cancer mortality by 20% compared to screening with chest radiography. Currently, many institutions in the US are implementing lung cancer screening programs. The use of lung-RADS as a quality assurance tool allows standardization of lung cancer screening CT lexicon, reporting and management recommendations, and reduces confusion in lung cancer screening CT interpretations. Lung-RADS will also facilitate outcome monitoring and future auditing of lung cancer screening programs, assist research, and consequently refine and improve lung cancer screening practices. Familiarity with lung-RADS version 1.0 is essential not only for radiologists interpreting low-dose computed tomography screening studies, but all medical personnel involved in multidisciplinary lung cancer screening programs. This article reviews the Lung-RADS categories and management recommendations using a case-based approach.

Challenges in Lung Cancer Screening in Latin America

Lung cancer is the deadliest cancer worldwide and is of particular concern for Latin America. Its rising incidence in this area of the world poses myriad challenges for the region’s economies, which are already struggling with limited resources to meet the health care needs of low- and middle-income populations. In this environment, we are concerned that regional governments are relatively unaware of the pressing need to implement effective strategies for the near future. Low-dose chest computed tomography (LDCT) for screening, and routine use of minimally invasive techniques for diagnosis and staging remain uncommon. According to results of the National Lung Screening Trial, LDCT lung cancer screening provided a 20% relative reduction in mortality rates among at-risk individuals. Nevertheless, this issue is still a matter of debate, particularly in developing countries, and it is not fully embraced in developing countries. The aim of this article is to provide an overview of what the standard of care is for lung cancer computed tomography screening around the world and to aid understanding of the challenges and potential solutions that can help with the implementation of LDCT in Latin America.