Abstract Introduction Almost 20 % of patients with Non-Seminomatous Germinative Cell Tumors (NSGCT) will require intrathoracic metastasectomy after chemotherapy. The authors aim to determine their long-term survival rates. Methods Retrospective study including patients with NSGCT and intrathoracic metastasis after systemic therapy from January 2011 to June 2022. Treatment outcomes and overall survival were analyzed with the Kaplan-Meier method. Results Thirty-seven male patients were included with a median age of 31.8 years. Six presented with synchronous mediastinum and lung metastasis, nine had only lung, and 22 had mediastinal metastasis. Over half had retroperitoneal lymph node metastasis. Twenty-two had dissimilar pathologies, with a discordance rate of 62 %. Teratoma and embryonal carcinoma were the prevalent primary tumor types, 40.5 % each, while teratoma was predominant (70.3 %) in the metastasis group. Thoracotomy was the main surgical approach (39.2 %) followed by VATS (37.2 %), cervico-sternotomy (9.8 %), sternotomy (5.8 %), and clamshell (3.9 %). Lung resection was performed in 40.5 % of cases. Overall, 10-year survival rates were 94.3 % with no surgical-related mortality. Conclusion Multimodality treatment with systemic therapy followed by radical surgery offers a high cure rate to patients with intrathoracic metastatic testicular germ cell tumors. 2 NonSeminomatous Non Seminomatous (NSGCT chemotherapy longterm long term 201 2022 KaplanMeier Kaplan Meier method Thirtyseven Thirty seven 318 31 8 31. years Twentytwo Twenty two pathologies 6 types 405 40 5 40. each 70.3 703 70 3 (70. group 39.2 392 39 (39. 37.2 372 37 (37. %, , cervicosternotomy cervico 9.8 98 9 (9. 5.8 58 (5. 3.9 (3. . cases Overall 10year year 10 943 94 94. surgicalrelated related mortality tumors 202 4 70. 7 (70 39. (39 37. (37 9. (9 5. (5 3. (3 1 (7 (

Abstract Background and objective This study aims to quantify bedside pleural procedures performed at a quaternary teaching hospital describing technical and epidemiological aspects. Materials and methods The authors retrospectively reviewed consecutive patients who underwent invasive thoracic bedside procedures between March 2022 and February 2023. Results 463 chest tube insertions and 200 thoracenteses were performed during the study period. Most procedures were conducted by 1st-year Thoracic Surgery residents, with Ultrasound Guidance (USG). There was a notable preference for small-bore pigtail catheters, with a low rate of immediate complications. Conclusion Bedside thoracic procedures are commonly performed in current medical practice and are significant in surgical resident training. The utilization of pigtail catheters and point-of-care ultrasonography by surgical residents in pleural procedures is increasingly prevalent and demonstrates high safety. aspects 202 2023 46 20 period 1styear styear 1st year st USG. USG . (USG) smallbore small bore complications training pointofcare point care safety 4 2 (USG

ABSTRACT Objective: The purpose of this study was to assess performance in the Brazilian Lung Cancer Registry Database by using the parsimonious EuroLung risk models for morbidity and mortality. Methods: The EuroLung1 and EuroLung2 models were tested and evaluated through calibration (calibration plot, Brier score, and the Hosmer-Lemeshow test) and discrimination (ROC AUCs), in a national multicenter registry of 1,031 patients undergoing anatomic lung resection. Results: The evaluation of performance in Brazilian health care facilities utilizing risk-adjustment models, specifically EuroLung1 and EuroLung2, revealed substantial miscalibration, as evidenced by calibration plots and Hosmer-Lemeshow tests in both models. In terms of calibration, EuroLung1 exhibited a calibration plot with overlapping points, characterized by a slope of 1.11 and a Brier score of 0.15; the Hosmer-Lemeshow test yielded a statistically significant p-value of 0.015; and the corresponding ROC AUC was 0.678 (95% CI: 0.636-0.721). The EuroLung2 model displayed better calibration, featuring fewer overlapping points in the calibration plot, with a slope of 1.22, with acceptable discrimination, as indicated by a ROC AUC of 0.756 (95% CI: 0.670-0.842). Both models failed to accurately predict morbidity and mortality outcomes in this specific health care context. Conclusions: Discrepancies between the EuroLung model predictions and outcomes in Brazil underscore the need for model refinement and for a probe into inefficiencies in the Brazilian health care system. Objective Methods HosmerLemeshow Hosmer Lemeshow AUCs, AUCs , AUCs) 1031 1 031 1,03 resection Results riskadjustment adjustment miscalibration 111 11 1.1 0.15 015 0 15 pvalue p value 0.015 0015 0678 678 0.67 95% 95 (95 CI 0.6360.721. 06360721 0.636 0.721 . 636 721 0.636-0.721) 122 22 1.22 0756 756 0.75 0.6700.842. 06700842 0.670 0.842 670 842 0.670-0.842) context Conclusions system 103 03 1,0 1. 0.1 01 0.01 001 067 67 0.6 9 (9 6360 0.6360.721 0636072 0636 0.63 0721 0.72 63 72 0.636-0.721 12 2 1.2 075 75 0.7 6700 0.6700.842 0670084 0670 0842 0.84 84 0.670-0.842 10 1, 0. 0.0 00 06 6 ( 0.6360.72 063607 063 072 7 0.636-0.72 07 0.6700.84 067008 084 0.8 8 0.670-0.84 0.6360.7 06360 0.636-0.7 0.6700.8 06700 08 0.670-0.8 0.6360. 0.636-0. 0.6700. 0.670-0. 0.6360 0.636-0 0.6700 0.670-0 0.636- 0.670-

ABSTRACT Objective: This study aims to evaluate the role of TUSG in the postoperative period and the detection of early complications after surgical treatment, pulmonary resection, or decortication for infectious and inflammatory thoracic diseases, comparing with the standard method (Chest Radiography ‒ CXR). Methods: Prospective non-randomized self-controlled study. Twenty-one patients over 16 years of age have undergone surgical treatment of inflammatory and infectious lung diseases. These patients were followed up with CXR and TUSG (performed on the 1st and 3rd postoperative days and/or after the chest tube removal). Results: Both exams demonstrated similar results regarding their ability to safely predict the adequate moment for chest drain removal. TUSG allowed chest drain removal in 30% of cases and CXR in 34%. Statistical analysis demonstrates that both exams have similar capabilities in detecting postoperative changes in the pleural space. However, the authors report that TUSG is statistically more accurate in detecting subcutaneous emphysema than CXR (p = 0.037, Kappa [κ = 0.3068]). The analysis of other parameters showed no statistical difference. Conclusion: The authors conclude that TUSG in trained hands is equivalent to CXR in searching for postoperative complications regarding the surgical treatment of infectious and inflammatory thoracic diseases and can be used as a complement, and not a substitute, to CXR, when CCT is not feasible, or a more urgent diagnosis is needed. Objective resection Chest CXR. . CXR) Methods nonrandomized non randomized selfcontrolled self controlled Twentyone Twenty one 1 performed st rd andor removal) Results 30 34 34% space However p 0037 0 037 0.037 κ 0.3068. 03068 0.3068 3068 0.3068]) difference Conclusion complement substitute feasible needed 3 003 03 0.03 0306 0.306 306 0.3068] 00 0.0 030 0.30 0. 0.3

Abstract Objective: Identify the one-year survival rate and major complications in patients submitted to pneumonectomy for infectious disease. Methods: Retrospective data from all cases of infectious disease pneumonectomy over the past 10 years were collected from two reference centers. The authors analyzed: patient demographics, etiology, laterality, bronchial stump treatment, presence of previous pulmonary resection, postoperative complications in the first 30 days, the treatment used in pleural complications, and one-year survival rate. Results: 56 procedures were performed. The average age was 44 years, with female predominance (55%). 29 cases were operated on the left side (51%) and the most frequent etiology was post-tuberculosis (51.8%). The overall incidence of complications was 28.6% and the most common was empyema (19.2%). Among empyema cases, 36.3% required pleurostomy, 27.3% required pleuroscopy and 36.3% underwent thoracoplasty for treatment. Bronchial stump fistula was observed in 10.7% of cases. From all cases, 16.1% were completion pneumonectomies and 62.5% of these had some complication, a significantly higher incidence than patients without previous surgery (p = 0.0187). 30-day in-hospital mortality was (7.1%) with 52 cases (92.9%) and 1-year survival. The causes of death were massive postoperative bleeding (1 case) and sepsis (3 cases). Conclusions: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. While morbidity is often significant, once the perioperative risk has passed, the one-year survival rate can be very satisfying in selected patients with benign disease. Objective oneyear one year Methods 1 centers analyzed demographics laterality resection 3 days Results 5 4 55%. 55 55% . (55%) 2 51% 51 (51% posttuberculosis post tuberculosis 51.8%. 518 51.8% 8 (51.8%) 286 28 6 28.6 19.2%. 192 19.2% 19 (19.2%) 363 36 36.3 pleurostomy 273 27 27.3 107 7 10.7 161 16 16.1 625 62 62.5 complication p 0.0187. 00187 0.0187 0 0187 0.0187) 30day day inhospital hospital 7.1% 71 (7.1% 92.9% 929 92 9 (92.9% 1year ( case cases) Conclusions highrisk high indications significant passed (55% (51 51.8 (51.8% 28. 19.2 (19.2% 36. 27. 10. 16. 62. 0018 0.018 018 7.1 (7.1 92.9 (92.9 (55 (5 51. (51.8 19. (19.2 001 0.01 01 7. (7. 92. (92. (51. (19. 00 0.0 (7 (92 (19 0. (9

Abstract Objective: Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study’s objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. Methods: Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. Results: Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87–33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90-22.86; p = 0.067), and patients with 50–70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98–15; p = 0.053) after pleurodesis. Conclusion: The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.

RESUMO Objetivo: Avaliar o processo de diagnóstico de pacientes com mesotelioma pleural maligno (MPM) em um hospital terciário. Métodos: Estudo retrospectivo envolvendo pacientes encaminhados a um centro oncológico terciário no Brasil entre 2009 e 2020. O processo diagnóstico foi dividido em quatro etapas: início dos sintomas, encaminhamento para consulta especializada, diagnóstico histopatológico e início do tratamento. Foram avaliados os intervalos entre as etapas e os fatores de atraso. Os dados coletados incluíram estado clínico, exames radiológicos, estadiamento, modalidades de tratamento e resultados de sobrevida. Resultados: Durante o período do estudo, 66 pacientes (média de idade = 64 anos) foram diagnosticados com MPM e submetidos a tratamento. Apenas 27 (41%) dos pacientes tinham conhecimento de exposição prévia ao amianto. A mediana de meses (IIQ) entre o início dos sintomas e a primeira consulta especializada, entre a consulta especializada e a caracterização histopatológica e entre o diagnóstico definitivo e o início do tratamento foi, respectivamente, de 6,5 (2,0-11,4), 1,5 (0,6 -2,1) e 1,7 (1,2-3,4). Conhecimento de exposição prévia ao amianto associou-se a menor tempo para encaminhamento a um especialista (mediana: 214 vs. 120 dias; p = 0,04). O número substancial de procedimentos não diagnósticos e as biópsias falso-negativas (a maioria envolvendo o uso de biópsia com agulha de Cope) foram considerados fatores decisivos para o tempo de espera. A sobrevida global média foi de 11,9 meses. Conclusões: A falta de familiaridade dos profissionais de saúde com o MPM e o desconhecimento dos pacientes em relação à exposição prévia ao amianto foram os principais fatores que ocasionaram um longo intervalo de tempo entre o início dos sintomas e o início do tratamento. A sobrevida global inferior a 1 ano provavelmente se deve aos atrasos supracitados.

ABSTRACT Objective: To evaluate the process of diagnosing patients with malignant pleural mesothelioma (MPM) at a tertiary care hospital. Methods: This was a retrospective study involving patients referred to a tertiary-care cancer center in Brazil between 2009 and 2020. The diagnostic process was divided into four steps: onset of symptoms, referral to a specialist visit, histopathological diagnosis, and beginning of treatment. The intervals between each phase and the factors for delays were evaluated. Data including clinical status, radiological examinations, staging, treatment modalities, and survival outcomes were collected. Results: During the study period, 66 patients (mean age = 64 years) were diagnosed with MPM and underwent treatment. Only 27 (41%) of the patients had knowledge of prior exposure to asbestos. The median number of months (IQR) between the onset of symptoms and the first specialist visit, between the specialist visit and histopathological characterization, and between definite diagnosis and beginning of treatment was, respectively, 6.5 (2.0-11.4), 1.5 (0.6-2.1), and 1.7 (1.2-3.4). The knowledge of prior asbestos exposure was associated with a shorter time to referral to a specialist (median: 214 vs. 120 days; p = 0.04). A substantial number of nondiagnostic procedures and false-negative biopsy results (the majority of which involved the use of Cope needle biopsy) were found to be decisive factors for the length of waiting time. The mean overall survival was 11.9 months. Conclusions: The unfamiliarity of health professionals with MPM and the patient’s lack of knowledge of prior asbestos exposure were the major factors to cause a long time interval between the onset of symptoms and beginning of treatment. An overall survival shorter than 1 year is likely to have been due to the aforementioned delays.

Abstract Background: The use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. Methods: From August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. Results: 56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). Conclusion: IPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country. HIGHLIGHTS Indwelling pleural catheter represents a suitable option for patients with malignant pleural effusion and short life expectancy. It relieves respiratory symptoms without compromising the quality of life, and the complication rate is low, even in an emerging country, with a low socioeconomic and under-educated patient population. The rate of spontaneous pleurodesis was 45%. The analysis of the visual analog scale showed significant control of dyspnea (p = 0.001), but pain and quality of life did not change significantly.

ABSTRACT Objective To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room. Methods A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm. Results A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients. Conclusion Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

RESUMO Objetivo: Comparar a morbidade em 90 dias de pacientes submetidos à lobectomia pulmonar por robotic-assisted thoracic surgery (RATS, cirurgia torácica robótica) ou por video-assisted thoracic surgery (VATS, cirurgia torácica videoassistida). Complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória, qualidade de vida pós-operatória e reinternações em 90 dias também foram comparados. Métodos: Ensaio clínico randomizado, com dois braços, incluindo pacientes com lesões pulmonares (câncer de pulmão primário ou metástase pulmonar) candidatos à lobectomia pulmonar. Foram excluídos pacientes com comorbidades que impossibilitassem o tratamento cirúrgico. Todos os pacientes seguiram o mesmo protocolo pós-operatório. Resultados: A amostra total foi composta por 76 pacientes (39 no grupo VATS e 37 no grupo RATS). Os dois grupos foram semelhantes quanto a sexo, idade, IMC, VEF1 em % do previsto e comorbidades. Complicações pós-operatórias em 90 dias tenderam a ser mais frequentes no grupo VATS do que no grupo RATS, mas a diferença não foi significativa (p = 0,12). No entanto, quando analisadas apenas as complicações maiores, essa tendência desapareceu (p = 0,58). Quanto aos desfechos pós-operatórios, o grupo VATS apresentou um número significativamente maior de reinternações em 90 dias do que o grupo RATS (p = 0,029). Não foram encontradas diferenças significativas quanto a complicações intraoperatórias, tempo de drenagem, tempo de internação hospitalar, dor pós-operatória e qualidade de vida pós-operatória. Conclusões: A lobectomia por RATS e a lobectomia por VATS apresentaram desfechos em 90 dias semelhantes. No entanto, a lobectomia por RATS foi associada a uma redução significativa na taxa de reinternação hospitalar em 90 dias. Estudos maiores são necessários para confirmar esse achado. (Identificador ClinicalTrials.gov: NCT02292914 [http://www.clinicaltrials.gov/])

ABSTRACT Objective: To compare 90-day morbidity in patients undergoing lung lobectomy performed by either robotic-assisted thoracic surgery (RATS) or video-assisted thoracic surgery (VATS). Intraoperative complications, drainage time, length of hospital stay, postoperative pain, postoperative quality of life, and readmissions within 90 days were also compared. Methods: This was a two-arm randomized clinical trial including patients with lung lesions (primary lung cancer or lung metastasis) who were candidates for lung lobectomy. Patients with comorbidities that precluded surgical treatment were excluded. All patients followed the same postoperative protocol. Results: The overall sample comprised 76 patients (39 in the VATS group and 37 in the RATS group). The two groups were similar regarding gender, age, BMI, FEV1 in % of predicted, and comorbidities. Postoperative complications within 90 days tended to be more common in the VATS group than in the RATS group, but the difference was not significant (p = 0.12). However, when only major complications were analyzed, this tendency disappeared (p = 0.58). Regarding postoperative outcomes, the VATS group had a significantly higher number of readmissions within 90 days than did the RATS group (p = 0.029). No significant differences were found regarding intraoperative complications, drainage time, length of hospital stay, postoperative pain, and postoperative quality of life. Conclusions: RATS and VATS lobectomy had similar 90-day outcomes. However, RATS lobectomy was associated with a significant reduction in the 90-day hospital readmission rate. Larger studies are necessary to confirm such a finding. (ClinicalTrials.gov identifier: NCT02292914 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: na América Latina, especialmente no Brasil, a adoção da plataforma robótica para cirurgia torácica está aumentando gradativamente nos últimos anos. No entanto, apesar da tuberculose e doenças pulmonares inflamatórias serem endêmicas em nosso país, faltam estudos que descrevam os resultados do tratamento cirúrgico robótico das bronquiectasias. Este estudo tem como objetivo avaliar os resultados cirúrgicos da cirurgia robótica para doenças inflamatórias e infecciosas, determinando a extensão da ressecção, complicações pós-operatórias, tempo operatório e tempo de internação hospitalar. Métodos: estudo retrospectivo a partir de um banco de dados envolvendo pacientes com diagnóstico de bronquiectasia e submetidos à cirurgia torácica robótica em três hospitais brasileiros entre janeiro de 2017 e janeiro de 2020. Resultados: foram incluídos 7 pacientes. A média de idade foi 47 + 18,3 anos (variação, 18-70 anos). A maioria dos pacientes apresentou bronquiectasia não fibrose cística (n=5), seguida de bronquiectasia tuberculosa (n=1) e abscesso pulmonar (n=1). As cirurgias realizadas foram lobectomia (n=3), segmentectomia anatômica (n=3) e bilobectomia (n=1). O tempo médio do console foi de 147 minutos (variação de 61-288 min.) e não houve necessidade de conversão para toracotomia. Complicação pós-operatória ocorreu em um paciente, tratando-se de obstipação com necessidade de lavagem intestinal. A mediana do tempo de drenagem torácica e internação hospitalar, em dias, foi de 1 (variação, 1-6 dias) e 5 (variação, 2-14 dias), respectivamente. Conclusões: a cirurgia torácica robótica para doenças inflamatórias e infecciosas é um procedimento viável e seguro, com baixo risco de complicações e morbidade.

ABSTRACT Objective: in Latin America, especially Brazil, the use of a robotic platform for thoracic surgery is gradually increasing in recent years. However, despite tuberculosis and inflammatory pulmonary diseases are endemic in our country, there is a lack of studies describing the results of robotic surgical treatment of bronchiectasis. This study aims to evaluate the surgical outcomes of robotic surgery for inflammatory and infective diseases by determining the extent of resection, postoperative complications, operative time, and length of hospital stay. Methods: retrospective study from a database involving patients diagnosed with bronchiectasis and undergoing robotic thoracic surgery at three hospitals in Brazil between January of 2017 and January of 2020. Results: a total of 7 patients were included. The mean age was 47 + 18.3 years (range, 18-70 years). Most patients had non-cystic fibrosis bronchiectasis (n=5), followed by tuberculosis bronchiectasis (n=1) and lung abscess (n=1). The performed surgeries were lobectomy (n=3), anatomic segmentectomy (n=3), and bilobectomy (n=1). The median console time was 147 minutes (range 61-288 min.) and there was no need for conversion to open thoracotomy. There were no major complications. Postoperative complications occurred in one patient and it was a case of constipation with the need for an intestinal lavage. The median for chest tube time and hospital stay, in days, was 1 (range, 1-6 days) and 5 (range, 2-14 days) respectively. Conclusions: robotic thoracic surgery for inflammatory and infective diseases is a feasible and safe procedure, with a low risk of complications and morbidity.