Objective: To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. Methods: Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. Results: The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. Conclusions: Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

Keywords: Thoracic surgery; Survival rate; Mediastinal neoplasms; Diagnostic imaging.

This article is a literature review of the psychological aspects of smoking behavior, highlighting personality characteristics of the smoker as an obstacle to smoking cessation. It describes the relation between smoking behavior and personality, and between smoking and the principal psychiatric disorders. Studies reveal that smokers tend to be more extroverted, anxious, tense, and impulsive, and show more traits of neuroticism and psychoticism than do ex-smokers or nonsmokers. The literature also reveals a strong association between smoking and mental disorders, such as schizophrenia and depression. Understanding the psychological factors associated with tobacco smoking and dependence can further the development and improvement of therapeutic strategies to be used in smoking-cessation programs, as well as of programs aimed at prevention and education.

Keywords: Personality; Mental disorders; Smoking.

Objective: To analyze determinants of prognosis in patients with bronchial carcinoid tumors treated surgically and the potential concomitance of such tumors with second primary neoplasms. Methods: This was a retrospective analysis of 51 bronchial carcinoid tumors treated surgically between 2007 and 2016. Disease-free survival (DFS) was calculated by the Kaplan-Meier method, and determinants of prognosis were evaluated. Primary neoplasms that were concomitant with the bronchial carcinoid tumors were identified by reviewing patient charts. Results: The median age was 51.2 years, 58.8% of the patients were female, and 52.9% were asymptomatic. The most common histology was typical carcinoid (in 80.4%). Five-year DFS was 89.8%. Ki-67 expression was determined in 27 patients, and five-year DFS was better among the patients in whom Ki-67 expression was ≤ 5% than among those in whom it was > 5% (100% vs. 47.6%; p = 0.01). Concomitant primary neoplasms were observed in 14 (27.4%) of the 51 cases. Among the concomitant primary neoplasms that were malignant, the most common was lung adenocarcinoma, which was observed in 3 cases. Concomitant primary neoplasms were more common in patients who were asymptomatic and in those with small tumors. Conclusions: Surgical resection is the mainstay treatment of bronchopulmonary carcinoid tumors and confers a good prognosis. Bronchial carcinoid tumors are likely to be accompanied by second primary neoplasms.

Keywords: Carcinoid tumor/diagnosis; Carcinoid tumor/surgery; Neoplasms, second primary; Lung neoplasms.

Objective: Primary benign tumors of the trachea and main bronchi are uncommon. Interventional bronchoscopy allows the diagnosis and the treatment of some of these lesions. Methods: We reviewed four cases endoscopically treated at our institution. Results: Two patients had hamartoma, and two patients had endobronchial lipoma. In all of the cases, the interventional technique for the resection was the use of a polypectomy snare and electrocautery. The only complication reported was one episode of bronchospasm. Conclusions: Minimally invasive bronchoscopic resection is a safe, effective method for treating selected benign tumors of the main airway and has a low complication rate.

Keywords: Bronchoscopy; Bronchial neoplasms; Hamartoma; Lipoma.

Objective: To evaluate the results of resection of tumors of the thymus by robotic thoracic surgery, analyzing the extent of resection, postoperative complications, time of surgery, and length of stay. Methods: Retrospective study from a database involving patients diagnosed with a tumor of the thymus and undergoing robotic thoracic surgery at one of seven hospitals in Brazil between October of 2015 and June of 2018. Results: During the study period, there were 18 cases of resection of tumors of the thymus: thymoma, in 12; carcinoma, in 2; and carcinoid tumor, in 1; high-grade sarcoma, in 1; teratoma, in 1; and thymolipoma, in 1. The mean lesion size was 60.1 ± 32.0 mm. Tumors of the thymus were resected with tumor-free margins in 17 cases. The median (interquartile range) for pleural drain time and hospital stay, in days, was 1 (1-3) and 2 (2-4), respectively. There was no need for surgical conversion, and there were no major complications. Conclusions: Robotic thoracic surgery for resection of tumors of the thymus has been shown to be feasible and safe, with a low risk of complications and with postoperativeymoma; Thymus neoplasms; Thymectomy; Thoracic surgery; R outcomes comparable to those of other techniques.

Keywords: Thymoma; Thymus neoplasms; Thymectomy; Thoracic surgery; Robotic surgical procedures.

Objective: To describe the results of the surgical treatment of children with necrotizing pneumonia. Methods: A retrospective analysis of the medical charts of 20 children diagnosed with necrotizing pneumonia and submitted to surgical treatment between March of 1997 and September of 2008 in the thoracic surgery departments of two hospitals in the city of Manaus, Brazil. We compiled data regarding age, gender, etiologic agent, indications for surgery, type of surgical resection performed, and postoperative complications. Results: The mean age of the patients was 30 months. Of the 20 patients studied, 12 (60%) were female. The most common etiologic agents were Staphylococcus aureus, in 5 patients (25%), and Klebsiella sp., in 2 (10%). The indications for surgery were sepsis, in 16 patients (80%), and bronchopleural fistula, in 4 (20%). The types of surgical procedures performed were lobectomy, in 12 patients (60%), segmentectomy, in 7 (35%), and bilobectomy, in 1 (5%). There were 8 patients (40%) who also underwent decortication. The postoperative complications were as follows: bronchopleural fistula, in 4 patients (20%); empyema, in 1 (5%); pneumatocele, in 1 (5%); and phlebitis of the left arm, in 1 (5%). Four (20%) of the patients died. Conclusions: Surgical resection should be considered in patients with evidence of pulmonary necrosis. Resection is indicated in cases of severe sepsis, high output bronchopleural fistula, or acute respiratory failure that are refractory to clinical treatment.

Keywords: Pneumonia; Necrosis; Lung abscess; Empyema, pleural.

Objective: To determine the prevalence of factors associated with difficult-to-control asthma. Methods: Patients with severe asthma were selected from the outpatient asthma clinic of the Ribeirão Preto School of Medicine Hospital das Clínicas. The patients were divided into two groups: controlled severe asthma and difficult-to-control severe asthma. After new attempts to optimize the severe asthma treatment, a questionnaire was applied, and additional tests for factors associated with difficult-to-control asthma, such as environmental and occupational exposure, smoking history, social factors, rhinitis/sinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea, congestive heart failure (CHF), pulmonary embolism, cystic fibrosis, vocal cord dysfunction, α-1 antitrypsin deficiency, and Churg-Strauss syndrome, were performed. Results: 77 patients with severe asthma were selected, of which 47 suffered from hard-to-control asthma, being 68.1% female, with mean age of 44.4 years (±14.4), and forced expiratory volume in one second of 54.7% (±18.3). The most factors most often associated with difficult-to-control asthma were noncompliance with treatment (68%), rhinitis/sinusitis (57%), GERD (49%), environmental exposure (34%), occupational exposure (17%), smoking history (10%), obstructive sleep apnea (2%), and CHF (2%). At least one of these factors was identified in every case. Conclusions: Noncompliance with treatment was the factor most often associated with difficult-to-control asthma, underscoring the need to investigate comorbidities in the evaluation of patients with this form of the disease.

Keywords: Asthma; Smoking; Gastroesophageal reflux; Patient compliance; Rhinitis; Sinusitis.

Surgical resection is the primary treatment option for early-stage non-small cell lung cancer, lobectomy being considered the standard of care. In elderly patients, physiological characteristics can limit the suitability for surgery and the extent of resection. Sublobar resection (SLR) can be offered as an alternative. The aim of this real-world analysis was to compare lobectomy and SLR in terms of recurrence and survival rates in patients over 70 years of age.

Keywords: Carcinoma, non-small-cell lung/mortality; Carcinoma, non-small-cell lung/surgery; Recurrence; Aged; Aged, 80 and over.

Background: Synergism between tuberculosis and HIV is responsible for the increased morbidity-mortality rate in AIDS patients. Objective: To delineate the profile of patients with tuberculosis and AIDS in the city of Rio Grande by relating demographic, clinical and laboratory data. Method: The sample comprised all cases of tuberculosis defined by identification of Mycobacterium tuberculosis that occurred in the AIDS Service of the University Hospital/FURG between September, 1997 and December, 2000, which added to a total of 31 patients confirmed as definite cases of AIDS. Using the Ogawa-Kudoh culture method and the Kinyoun bacilloscopy, 33 clinical pulmonary and extrapulmonary specimens were analyzed. Identification of M. tuberculosis was made by the usual phenotype methods. The method of proportions was chosen to establish resistance of isolated strains. Results: The mean age was of 33.8±9.9 years, with a man/woman ratio of 2.87:1 and 80.7% of Caucasians. All patients (n=31) exhibited overall or specific clinical manifestations of turberculosis at the time of suspicion diagnosis. In 20 of the cases risk factors were observed: use of injected drugs, alcoholism, malnutrition, imprisonment. Pulmonary disease occurred in 19 cases, extrapulmonary in 10 and the association of both in two. Lymph node commitment was more frequent among those with extrapulmonary disease. The isolated strains (33) were identified as M. tuberculosis and 28 were tested and showed sensibility to Isoniazid and Rifampin. Conclusion: In AIDS patients, tuberculosis appeared with various clinical manifestations, jeopardizing both men and women of less favored social conditions while at a fully productive stage of their lives.

Keywords: Tuberculosis/epidemiology. Tuberculosis/complications. Acquired immunodeficiency syndorme/tuberculosis. Mycobacterium tuberculosis/indicators of morbidity and mortality.

Objective - To verify the incidence of the wounds of the pulmonary hilum in a public hospital Emergency Unit, and the mortality rate. Means of access, operative techniques and tatics of operation used were also evaluated. Patients and methods - One thousand, one hundred and twenty-four patients with chest trauma were registered at the thoracic surgery unit from April, 1992 to October, 1996. A hundred eighty-two thoracotomies (16.19%) were performed and indication for lung resection was present in only four cases (2.20%). Results - The way of access most commonly used was anterolateral, in three cases, and posterolateral in another case. Two lobectomies and one pneumonectomy were performed. In only one patient a clamping of the hilum was utilized, but the patient died due to massive bleeding. Two other patients died in a total of three deaths. There was only one survivor in this series, who did not present any complication. Conclusion - A low incidence of indication for lung resections was observed in trauma, however, mortality was extremely high due to the lesion involving a high life risk. The most commonly used access was the anterolateral because of the short time needed to clamp the pulmonary hilum, and it was used for all cases of success.

Keywords: Thoracic trauma. Lobectomy. Pneumonectomy.

Objectives: Thoracoscopic management of mediastinal tumors is still subject to analysis. Seventy-three patients were submitted to thoracoscopy for the treatment of mediastinal masses and were analyzed retrospectively, in order to evaluate the effectiveness and complications of the procedure. Methods: Between 1983 and 1999, 21 conventional thoracoscopies and 52 video-assisted thoracic surgeries were performed (33 for diagnostic purposes and 40 for therapy). Patient ages ranged from two to 81 years (mean 43.8) with a slight predominance of females over males (41 versus 32). All underwent general anesthesia using simple (22) or double lumen (51) intubation. Results: The histological type of tumor was identified in all patients. For therapeutic purposes, conversion to thoracotomy was necessary in nine patients. The reasons were tumor size and invasion of nearby structures, difficulty to continue dissection, to perform an upper lobectomy, and to suture the iatrogenic diaphragm lesion. Four patients died during the first 30 postoperative days as a consequence of their primary pathology. Conclusions: Thoracoscopy was confirmed to be an effective diagnostic and therapeutic alternative for the treatment of mediastinal disorders.

Keywords: Thoracoscopy, thoracic surgery, mediastinal neoplasms, mediastinal cysts.

Malignant neurogenic mediastinal tumors in adults are uncommon and extremely aggressive. We report the case of a 61-year-old male patient with the simultaneous occurrence of malignant mediastinal schwannoma and bronchioloalveolar carcinoma. Although bronchioloalveolar carcinoma is present in 4-7% of the resected synchronous thoracic tumors, this association has never been reported in the literature. However, it is a common finding in patients presenting apparently inflammatory infiltrates and ground-glass opacities, as in the case presented here.

Keywords: Mediastinal neoplasms; Nerve sheath neoplasms; Neurilemmoma; Neoplasms, multiple primary; Adenocarcinoma, bronchiolo-alveolar.

Sclerosing mediastinitis is a rare disorder characterized by an extensive fibrotic reaction involving the mediastinum. Due to the compression or invasion of mediastinal structures, the disorder mimics neoplasia. We present three cases of superior vena cava syndrome in which sclerosing mediastinitis was confirmed. The pathophysiological process is related to enlarged mediastinal lymph nodes, fibroblast proliferation and collagen deposition. The main causes of sclerosing mediastinitis are histoplasmosis and tuberculosis, both of which are prevalent in Brazil. It is difficult to make an accurate histopathological diagnosis using minimally invasive methods, and there is no effective treatment for this condition. In order to make a definitive diagnosis and resolve the aerodigestive tract obstruction, exploratory surgery is indicated.

Keywords: Mediastinitis/physiopathology; Mediastinum; Pulmonary fibrosis; Mediastinal neoplasms; Diagnosis, differential; Case reports [Publication type].

Objective: To retrospectively analyze the medical charts of patients with pulmonary malformations submitted to surgical treatment and to investigate the clinical evolution prior to the definitive diagnosis. Methods: We analyzed the medical charts of patients with pulmonary malformations operated on at the São Paulo Hospital-Federal University of São Paulo/Paulista School of Medicine-from 1969 to 2004. Each medical chart was analyzed as to the following aspects: clinical profile; diagnosis; previous treatment; surgical treatment; and nosocomial complications. The inclusion criteria were having received a diagnosis of pulmonary malformation, having undergone pulmonary resection, and chart data being complete. Results: The analysis of the medical charts revealed that 60 patients diagnosed with pulmonary malformations-27 cases of bronchogenic cyst, 14 cases of congenital lobar emphysema, 10 cases of pulmonary sequestration, and 9 cases of cystic adenomatoid malformation-underwent surgery. Ages ranged from 4 days to 62 years (mean, 17.9 years). There was a predominance of males (55%). Ninety-two percent of the patients presented symptoms (mean duration, 15.37 months). Of the 60 patients undergoing surgery, 27 (45%) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23%, and mortality was 3.3%. Surgical times ranged from 1 to 8 h (mean, 3.2 h). Conclusions: Misdiagnosis or delayed diagnosis of pulmonary malformations resulted in unnecessary treatments and hospitalizations, as well as in frequent, recurrent infectious complications. We believe that the definitive treatment is surgery, which is curative and has low morbidity and mortality rates.

Keywords: Bronchogenic cyst; Bronchopulmonary sequestration; Cystic adenomatoid malformation of lung, congenital; Respiratory tract infections; Thoracic surgery.

Objective: To analyze the characteristics of patients with lung cancer. Methods: A retrospective descriptive study of patients receiving a histopathological diagnosis of lung cancer between 1995 and 2002 in the city of Manaus, Brazil. Data were collected from the medical archives of three hospitals. Statistical analyses were carried out, and survival curves were generated by means of an actuarial estimator. Results: Of the 352 patients selected, 262 (74.4%) were male and 90 (25.6%) were female. The mean age was 62 years. The following histological types were identified: squamous cell carcinoma, 62.8%; adenocarcinoma, 24.7%; small cell carcinoma, 9.1%; and large cell carcinoma, 3.4%. The most common stages were stages IIIB and IV, in 45% and 21.5%, respectively. Of the total sample, 73.4% were submitted to treatment. Of these, 51.4% underwent radiotherapy; 16.6%, surgery; 15.8%, chemotherapy; and 16.2%, radiotherapy in association with chemotherapy. Cumulative survival rates were low: three-year survival was 6.5%, and five-year survival was 3.5%. Conclusions: In this group of patients with lung cancer, survival rates were considerably lower than those reported in the literature. This might be attributable to the limited access to the specialized health care system and the advanced stage of the disease at diagnosis.

Keywords: Lung neoplasms; Neoplasm staging; Survival.

Objective: To investigate the characteristics of and risk factors for mortality among non-HIV-infected immunocompromised patients with an in-hospital diagnosis of tuberculosis. Methods: This was a two-year, retrospective cohort study of patients with an in-hospital diagnosis of tuberculosis. The predictive factors for mortality were evaluated. Results: During the study period, 337 hospitalized patients were diagnosed with tuberculosis, and 61 of those patients presented with immunosuppression that was unrelated to HIV infection. Extrapulmonary tuberculosis was found in 47.5% of cases. In the latter group, the in-hospital mortality rate was 21.3%, and the mortality rate after discharge was 18.8%. One-year survival was significantly higher among the immunocompetent patients than among the HIV patients (p = 0.008) and the non-HIV-infected immunocompromised patients (p = 0.015), although there was no such difference between the two latter groups (p = 0.848). Among the non-HIV-infected immunocompromised patients, the only factor statistically associated with mortality was the need for mechanical ventilation. Among the patients over 60 years of age, fibrosis/atelectasis on chest X-rays and dyspnea were more common, whereas fever and consolidations were less common. Fever was also less common among the patients with neoplasms. The time from admission to the initiation of treatment was significant longer in patients over 60 years of age, as well as in those with diabetes and those with end-stage renal disease. Weight loss was least common in patients with diabetes and in those using corticosteroids. Conclusions: The lower prevalence of classic symptoms, the occurrence of extrapulmonary tuberculosis, the delayed initiation of treatment, and the high mortality rate reflect the diagnostic and therapeutic challenges of tuberculosis in non-HIV-infected immunocompromised patients.

Keywords: Hospitalization; Immunosuppression; Risk factors; Tuberculosis/mortality; Immunocompromised host.

Objective: To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). Methods: This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. Results: Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). Conclusions: Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.

Keywords: Community-acquired infections; Pneumonia; Pleural Effusion.