The authors report the case of a 28-year-old female patient with a giant cell tumor originating from the rib. The tumor, measuring 25 × 17 cm, occupied the entire hemithorax and caused atelectasis of the left lung. This tumor was a benign mesenchymal neoplasm, which rarely affects the ribs. A thoracotomy involving en bloc resection of the chest wall and tumor was performed. Despite the large dimensions of the tumor, complete resection was possible, and lung function was restored.

Keywords: Neoplasms; Giant cells; Mesoderm; Thoracotomy; Medical records.

We report the case of a 74-year-old female patient diagnosed with a giant cell tumor of the sternum. The clinical and radiological presentation was indicative of a primary tumor of the sternum. The patient underwent complementary tests and surgery. The pathological examination confirmed the diagnosis. Commonly observed in the long bones of the appendicular skeleton, this type of tumor is characterized by its local aggressiveness and metastatic potential. We also review the literature on the topic.

Keywords: Sternum; Giant cell tumors; Thorax.

Granular cell tumors are uncommon neoplasm arising from Schwann cell. They are uncommon in the respiratory tract and there are only 32 cases described with primary tracheal involvement. A case is described of a 28 year-old woman with granular cell tumor located primarily in the trachea. The tumor was treated surgically with good result.

Keywords: granular cell tumor; trachea

A 30 year old Caucasian male from São Paulo was admitted to the hospital He had been complaining about constant, moderate pain in the anterior and lateral left hemi-thoracic region for the last three months as well as associated great effort dyspnea over the last month.Investigation with chest X-rays, CT scans and MRI revealed a large anterior and medial mediastinal tumor suggesting large vessel invasion. The patient was submitted to a left side parasternal mediastinostomy and a biopsy of the mediastinal mass which was complicated by severe bleeding. An immediate median full sternotomy was elected in addition to a left anterior-lateral thoracotomy for total tumor resection and control of the bleeding. Evolution was good, with hospital discharge on the ninth postoperative day. The anatomical-pathological essay disclosed a hemangioendothelioma of the mediastinum.

Keywords: Hemangioendothelioma/diagnosis. Mediastinal neoplasms.

Carcinoid tumor of the skin, which is a malignant neoplasm originating in the neuroendocrine system and having its pathological substrate in the Merkel cells, is a rare occurrence. It is most frequently seen on the skin around the neck and head and is more common in the elderly. This study relates the case of a 35-year-old woman presenting with a visible and palpable tumor covering the upper third of the sternum. Resection of the tumor was indicated because the patient had experienced two significant episodes of bleeding and osseous invasion had occurred. Penetration of the full thickness of the chest wall at the sternum notch necessitated the implantation of a rigid prosthesis. The definitive histopathological diagnosis was made only through postoperative analysis of the excised section. Reconstruction using a surgical cement plate and interposition of a myocutaneous flap proved its usefulness as an alternative when resection is performed in an area important to the postoperative respiratory dynamic, a situation that typically requires a ventilatory prosthesis for up to 6 days. The stability of the chest wall, together with viability of the flap and the recuperation of pulmonary function, allowed the patient to be discharged after 18 days.

Keywords: Carcinoma, Merkel cell/surgery. Carcinoid tumor/ diagnosis. Carcinoid tumor/surgery. Immunohistochemistry. Sternun/surgery. Neoplasm metastasis.

The usefulness of serum tumor markers in lung cancer is not well defined. Objective: The aim of this study is to examine the correlation between serum tumor markers and tumor extension and its prognostic value. Patients and method: From February 1995 to September 1997, 103 patients with non-small cell lung carcinoma were evaluated at the Department of Thoracic Surgery. Serum levels of CEA, CYFRA21.1, CA15.3, CA19.9, CA72.4, and NSE were determined before treatment. Results: The serum level of CYFRA21.1 was the most frequent elevated tumor marker (55%). Patients with advanced tumor had higher mean serum level of CEA (90.8 ng/ml), CYFRA21.1 (20.3 ng/ml) and CA15.3 (56.5%) than those with localized carcinoma, respectively 10.2 ng/ml, 12.6 ng/ml and 22.2 ng/ml. Considering all serum tumor markers evaluated in this study, only patients with elevated CEA had greater chance (5.6) of presenting with advanced non-small lung carcinoma than patients with normal CEA. Overall survival was influenced by performance status (p = 0.001), tumor extension (p = 0.006), elevated serum level of CEA (p = 0.043), more than two elevated serum tumor markers (p < 0.001), and type of treatment (p < 0.001). The prognostic value of anatomical tumor extension reached the limit of significance (p = 0.052); however, two or more elevated serum tumor markers and type of treatment had independent prognostic value (respectively, p = 0.035 and p = 0.005). Conclusion: None of these serum tumor markers had clinical value in the management of NSCLC patients.

Keywords: biological tumor markers, neoplasm staging, non-small cell lung carcinoma, prognosis

Granular cell tumor (GCT) is a term used to describe a tumor with distinctive histology, characteristic immunohistochemical profile, and peculiar ultrastructural findings. This tumor has an ample topographic distribution and its localization in the airways is considered common. The authors report on the case of a 40-year old woman who had been presenting productive cough and fever for two months and seemed normal at physical examination. Computerized tomography evidenced thickened intermediary bronchial wall and bronchoscopy showed, at this level, hyperemia and elevation of the endobronchial mucosa. Histopathological and immunohistochemical examination of the tissued established the diagnosis of GCT. The purpose of this report is to call attention to the possibility of diagnosing this kind of tumor by small endoscopic biopsies.

Keywords: Neoplasm muscle tissue. Granular cell tumor. Biopsy. Diagnosis

Objective: To determine the levels of the tumor markers carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1) and carbohydrate antigen 15-3 (CA 15-3) in the blood and pleural fluid of patients with benign or malignant pleural effusion, evaluating the sensitivity of each marker in these fluids. Methods: We prospectively evaluated 85 patients with pleural effusion. The study of the pleural fluid observed the criteria established in the literature. Levels of the markers were determined using electrochemiluminescence. The sensitivity was determined on the condition that the specificity was ≥ 90%. Results: Of the 85 cases, 36 (42.4%) were malignant, 30 (35.3%) were benign, and the results were inconclusive in 19 (22.3%). In the malignant cases, the CEA and CYFRA21-1 levels were higher in the pleural fluid than in the blood, which was not observed for CA 15-3. In the benign cases, the CYFRA21-1 levels were higher in the pleural fluid than in the blood, whereas the opposite was found for CEA and CA 15-3. There were significant differences between malignant and benign cases for all markers, in pleural fluid and blood. In the pleural fluid, the sensitivity of CEA, CYFRA21-1 and CA 15-3 was 69.4, 69.4 and 66.7%, respectively, and the combined sensitivity was 80.6%. In the blood, the sensitivity was 57.1%, 71.4% and 48.6% for CEA, CYFRA21-1 and CA 15-3, respectively, and the combined sensitivity was 77%. Conclusion: The results suggest that these markers might be useful in the differentiation between malignant and benign pleural effusion.

Keywords: Biological tumor marker; Cyfra 21.1; CEA; CA 15.3; Pleural effusion.

Objective: To establish the accuracy of frozen section examination in identifying tumor spread through air spaces (STAS), as well as to propose a reproducible technical methodology for frozen section analysis. We also aim to propose a method to be incorporated into the decision making about the need for conversion to lobectomy during sublobar resection. Methods: This was a nonrandomized prospective study of 38 patients with lung cancer who underwent surgical resection. The findings regarding STAS in the frozen section were compared with the definitive histopathological study of paraffin-embedded sections. We calculated a confusion matrix to obtain the positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity and accuracy. Results: The intraoperative frozen section analysis identified 7 STAS-positive cases that were also positive in the histopathological examination, as well as 3 STAS-negative cases that were positive in the in the histopathological examination. Therefore, frozen section analysis was determined to have a sensitivity of 70%, specificity of 100%, PPV of 100%, NPV of 90.3%, and accuracy of 92% for identifying STAS. Conclusions: Frozen section analysis is capable of identifying STAS during resection in patients with lung cancer. The PPV, NPV, sensitivity, and specificity showed that the technique proposed could be incorporated at other centers and would allow advances directly linked to prognosis. In addition, given the high accuracy of the technique, it could inform intraoperative decisions regarding sublobar versus lobar resection.

Keywords: Neoplasm invasiveness; Frozen sections; Lung neoplasms/pathology; Lung neoplasms/surgery.

Objectives: The 9th edition of the Tumor, Node, Metastasis (TNM-9) lung cancer classification is set to replace the 8th edition (TNM-8) starting in 2025. Key updates include the splitting of the mediastinal nodal category N2 into single- and multiple-station involvement, as well as the classification of multiple extrathoracic metastatic lesions as involving a single organ system (M1c1) or multiple organ systems (M1c2). This study aimed to assess how the TNM-9 revisions affect the final staging of lung cancer patients and how these changes correlate with overall survival (OS). Methods: This retrospective cohort study included patients diagnosed with lung cancer between 2018 and 2021, who were staged according to both TNM-8 and TNM-9 criteria. The staging classifications were analyzed and compared in relation to OS. Results: Among a total of 914 patients, 42 were re-staged using TNM-9. Of the 382 patients classified as stage IVB, 55.9% were reclassified as M1c2. Despite an absolute increase in mean OS for patients re-staged from IIB to IIA and from IIIA to IIB, the observed differences were not statistically significant. Median OS differed significantly both within stage IVB and between patients with M1c2 disease and other stage IV subgroups. Multi-organ metastatic disease was an independent predictor of poorer OS, regardless of age, sex, performance status, and oncologic treatment. Conclusions: TNM-9 improves prognostic accuracy in lung cancer. Although patients with multiple extrathoracic metastases involving different organ systems are not yet independently staged from IVB, they demonstrated significantly poorer OS compared to other advanced-stage patients.

Keywords: Lung cancer, Metastasis, Lymph nodes, Prognosis, Survival.

Pneumatoceles usually have a benign presentation. The authors describe an uncommon case of a 3-month-old boy who had a first episode of pneumonia and left pleural effusion. At the age of 2, he had another episode of pneumonia with pneumatoceles formation. He progressed with wheezing and enlargement of the pneumatoceles, chickenpox, urinary infection, liver abscess and toxocariasis. When he was 3 years old, the patient was admitted to hospital with pneumonia, giant bilateral pneumatoceles, status asthmaticus and possible immunodeficiency. Due to a restrictive pulmonary disorder, a chest tube was placed in one of the pneumatoceles, but there was no improvement in his respiratory status. He progressed to sepsis and respiratory failure, needing mechanical ventilation. The patient was submitted to bilateral bullectomy with expansion of the collapsed lung. However, he died soon after the surgery. This was an uncommon case with pneumatoceles that evolved to respiratory failure requiring surgical intervention.

Keywords: Pneumatoceles. Bullous lung disease. Cysts. Staphyloccocal pneumonia. Ventilatory insufficiency. Bullectomy.

Incidence of metastatic disease to the hypothalamic-pituitary area is low (1 to 6% in most studies), the lung and the prostate being the most common primary sites in men. Clinical presentation as panhypopituitarism is rare (0.2 to 0.8%) in patients with bronchogenic carcinoma. The authors describe a case of a man with diagnosis of squamous cell carcinoma of the lung that, during the clinical course of the disease, presented clinical and laboratorial evidence of panhypopituitarism, with an expansive sellar and supra-sellar lesion image in the CT scan of the brain.

Keywords: Panhypopituitarism. Bronchogenic carcinoma. Hypothalamic-pituitary metastases.

Acute chest syndrome is an affection, specially in young adults, of sickle cell disease and is responsible for 25% of the deaths. The authors report the case of an alcoholic 45-year-old mulatto man, without any previous manifestation of sickle cell disease, who presented with a pneumonia-like clinical picture with seven days of duration. The chest X-ray revealed bilateral lung infiltrates and spots of consolidation with air bronchograms, and left pleural effusion. The patient also had anemia and leukocytosis with neutrophilia. Treated with cefoxitin and amicacin, the patient developed acute respiratory insufficiency and died 14 hours after hospitalization. The necropsy showed lungs with intense congestion, intra-alveolar hemorrhage, diffuse alveolar damage, and sickle red blood cells. The progressive, fast, and severe character of the acute chest syndrome, which is frequently mimicked by other illnesses, makes the disease a dramatic and severe event of difficult earlier diagnosis. Therefore, in countries like Brazil, with a large black population, the physicians must always be aware of this possibility.