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To date, the impact, timeline and duration of COVID-19 pandemic remains unknown and more than ever it is necessary to provide safe pathways for cancer patients. Multiple triage systems for nonemergent surgical procedures have been published, but potentially curative cancer procedures are essential surgery rather than elective surgery. In the present and future scenario of our country, thoracic oncology teams may have the difficult decision of weighing the utility of surgical intervention against the risk for inadvertent COVID-19 exposure for patients and medical staff. In consequence, traditional pathways of surgical care must be adjusted to reduce the risk of infection and the use of resources. It is recommended that all thoracic cancer patients should be offered treatment according to the accepted standard of care until shortage of services require a progressive reduction in surgical cases. Here, we present a consensus of recommendations discussed by a multidisciplinary panel of experts on thoracic oncology and based on the best available evidence, and hope it will provide a modifiable framework of guidance for local strategy planners in thoracic cancer care services in Mexico. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: This article provides recommendations to guarantee the continuity of surgical care for thoracic oncology cases during COVID-19 pandemic, whilst maintaining the safety of patients and medical staff. WHAT THIS STUDY ADDS: This guideline is the result of an expert consensus on thoracic surgical oncology with recommendations adapted to medical, economic and social realities of Mexico.

Resumen. El cáncer de pulmón es una de las principales causas de mortalidad alrededor del mundo. Su historia natural, con la manifestación de síntomas en etapas avanzadas y el retraso en su diagnóstico hacen que una gran proporción de pacientes se diagnostiquen en estadios tardíos de la enfermedad, lo que hace muy complicado el tratamiento exitoso de la misma. De esto deriva la importancia de dar origen a recomendaciones basadas en evidencia para soportar la toma de decisiones clínicas por parte de los grupos interdisicplinarios que se encargan del manejo de este padecimiento. Objetivos. Esta Guía de Práctica Clínica (GPC) contiene recomendaciones clínicas desarrolladas de forma sistematizada para asistir la toma de decisiones de médicos especialistas, pacientes, cuidadores de pacientes y elaboradores de políticas pú­blicas involucrados en el manejo de pacientes con cáncer de pulmón en estadios tempranos, localmente avanzados y metastásicos. Material y métodos. Este documento se desarrolló por parte de la Sociedad Mexicana de Oncología en colaboración con el Centro Nacional de Excelencia Tec­nológica de México (Cenetec) a través de la dirección de integración de Guías de Práctica Clínica en cumplimiento a estándares internacionales como los descritos por el Ins­tituto de Medicina de EUA (IOM, por sus siglas en inglés), el Instituto de Excelencia Clínica de Gran Bretaña (NICE, por sus siglas en inglés), la Red Colegiada para el Desarrollo de Guías de Escocia (SIGN, por sus siglas en inglés), la Red Internacional de Guías (G-I-N, por sus siglas en inglés); entre otros. Se integró en representación de la Sociedad Mexicana de Oncología un Grupo de Desarrollo de la Guía (GDG) de manera interdisciplinaria, considerando oncólogos médicos, cirujanos oncólogos, cirujanos de tórax, radio-oncólogos, y metodólogos con experiencia en revisiones sistemáticas de la literatura y guías de práctica clínica. Resultados. Se consensuaron 62 preguntas cllínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente la misma, antes de ser incorporada en el cuerpo de evidencia de la Guía. El GDG acordó mediante la técnica de consenso formal de expertos Panel Delphi la redacción final de las recomendaciones clínicas. Conclusión. Esta Guía de Práctica Clínica pretende proveer recomendaciones clínicas para el manejo de los distintos estadios de la enfermedad y que asistan en el proceso de toma de decisiones compartida. El GDG espera que esta guía contribuya a mejorar la calidad de la atención clínica en las pacientes con cáncer de pulmón de células no pequeñas.

La reseccion traqueal y anastomosis es el estandar de oro en el tratamiento de la estenosis traqueal. Las complicaciones que se reportan son: recurrencia de la estenosis en el 5 al 22% de los casos, dehiscencia de la estenosis en alrededor del 4 al 7.5%, la mortalidad es de 1.8 a 5%. El objetivo de este estudio fue evaluar la recurrencia, despues la reseccion traqueal por estenosis traqueal benigna y determinar los factores que predicen la reestenosis. Material y metodos: Se realizo un estudio retrospectivo que incluyo pacientes con estenosis traqueal o laringotraqueal benigna sometidos a reseccion quirurgica y reconstruccion, en un periodo comprendido entre el 1 de enero de 2008 al 31 de diciembre de 2012. Se estudio la recurrencia de estenosis traqueal. Las variables categoricas se presentan como porcentajes, las variables continuas como media y desviacion estandar. Para los factores predictores de recurrencia se realizo un analisis de regresion logistica univariado y multivariado. Se tomo una p < 0.05 para considerar las diferencias como estadisticamente significativas. Resultados: Se incluyeron 155 pacientes (103 hombres/52 mujeres). Las complicaciones ocurrieron en 52 pacientes (33.5%). La complicacion mas comun fue la recurrencia de la estenosis, que se encontro en 21% de los casos. El compromiso laringeo y la longitud de reseccion mayor de 4 cm fueron los factores de riesgos identificados como predictores de recurrencia para reestenosis. El compromiso laringeo fue el factor que mas se asocia con recurrencia de la estenosis (OR 2.9, IC 95%: 1.2-6.6, p: 0.01). Al final del estudio 94% de los casos respiraban normalmente. No hubo muertes en nuestra serie. Conclusiones: La recurrencia de estenosis traqueal fue la complicacion mas frecuente de los pacientes operados de reseccion y anastomosis traqueal. El compromiso traqueal y la reseccion mayor de 4 cm de traquea son los factores

Lung cancer is one the leading causes of mortality worldwide. Symptomatic manifestations of the disease generally occur in the advanced-stage setting, and therefore an important number of patients have advanced or metastatic disease by the time they are diagnosed. This situation contributes to a poor prognosis in the treatment of lung cancer. Evidencebased clinical recommendations are of great value to support decision-making for daily practice, and thus improving health care quality and patient outcomes.This document was an initiative of the Mexican Society of Oncology (SMEO) in collaboration with Mexican Center of Clinical Excellence (Cenetec) according to Interna- tional Standards. Such standards included those described by the IOM, NICE, SIGN and GI-N. An interdisciplinary Guideline Development Group (GDG) was put together which included medical oncologists, surgical oncologistsc, radiation therapists, and methodologists with expertise in critical appraisal, sys- tematic reviews and clinical practice guidelines development.62 clinical questions were agreed among members of the GDG. With the evidence identified from systematic reviews, the GDG developed clinical recommendations using a Modified Delphi Panel technique. Patients' representatives validated them.These Clinical Practice Guideline aims to support the shared decision-making process for patients with different stages of non-small cell lung cancer. Our goal is to improve health-care quality on these patients.El cáncer de pulmón es una de las principales causas de mortalidad alrededor del mundo. Su historia natural, con la manifestación de síntomas en etapas avanzadas y el retraso en su diagnóstico hacen que una gran proporción de pacientes se diagnostiquen en estadios tardíos de la enfermedad, lo que hace muy complicado el tratamiento exitoso de la misma. De esto deriva la importancia de dar origen a recomendaciones basadas en evidencia para soportar la toma de decisiones clínicas por parte de los grupos interdisicplinarios que se encargan del manejo de este padecimiento.Este documento se desarrolló por parte de la Sociedad Mexicana de Oncología en colaboración con el Centro Nacional de Excelencia Tec- nológica de México (Cenetec) a través de la dirección de integración de Guías de Práctica Clínica en cumplimiento a estándares internacionales como los descritos por el Ins- tituto de Medicina de EUA (IOM, por sus siglas en inglés), el Instituto de Excelencia Clínica de Gran Bretaña (NICE, por sus siglas en inglés), la Red Colegiada para el Desarrollo de Guías de Escocia (SIGN, por sus siglas en inglés), la Red Internacional de Guías (G-I-N, por sus siglas en inglés); entre otros. Se integró en representación de la Sociedad Mexicana de Oncología un Grupo de Desarrollo de la Guía (GDG) de manera interdisciplinaria, considerando oncólogos médicos, cirujanos oncólogos, cirujanos de tórax, radio-oncólogos, y metodólogos con experiencia en revisiones sistemáticas de la literatura y guías de práctica clínica.Se consensuaron 62 preguntas cllínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente la misma, antes de ser incorporada en el cuerpo de evidencia de la Guía. El GDG acordó mediante la técnica de consenso formal de expertos Panel Delphi la redacción final de las recomendaciones clínicas. C.Esta Guía de Práctica Clínica pretende proveer recomendaciones clínicas para el manejo de los distintos estadios de la enfermedad y que asistan en el proceso de toma de decisiones compartida. El GDG espera que esta guía contribuya a mejorar la calidad de la atención clínica en las pacientes con cáncer de pulmón de células no pequeñas.

Background Infectious lung cavities are a common entity for the respiratory physician. Sometimes these lesions require surgical treatment, but surgery is challenging, and complications are common. Methods Patients with infectious lung cavities amenable to surgical treatment were included in a case-control study. The control group included patients with no complications. The cases group comprised patients with any of the following complications up to 90 days after surgery: death, persistence of hemoptysis, empyema, operative blood loss > 500 mL, vascular lesion requiring repair, massive transfusion (>5 units of packed red blood cells per 48 h) or reoperation for bleeding, postoperative mechanical ventilation, intensive care unit stay > 48 h, prolonged air leak, and persistent atelectasis. The potential risk factors for complications analyzed were demographic data, exposure to contaminants, comorbidities, preoperative embolization, surgical indication, spirometry results, and sputum test positive for Mycobacterium tuberculosis. Results Forty-five patients were included in the study and divided into 24 cases and 21 controls. We found a significant difference in the time to removal of chest tubes in favor of the noncomplicated cases (6.45 vs. 4.05 days, p = 0.030), and persistent active infection at the time of surgery tended to be a risk factor for complications (odds ratio = 6.6, 95% confidence interval: 0.7–60, p = 0.061). Conclusion The presence of persistent active infection at the time of surgery could be a risk factor for complications in resection surgery for infectious lung cavities.

Antecedents: Curative intended surgical treatment of lung cancer, in patients with cardiac disease that is also amenable to a surgical procedure, is a controversial hot topic inside the cardiothoracic surgery. Since the order of the interventions could carry different problems during its performance, multiple approaches to this situations, have been described. Material and methods: Review of the litera- ture published in PubMed. Results: There is a high volume of case reports that shows tendency towards an increasing performance of both procedures with the same anesthesia without a signifi cative increase of the complications. Conclusion: There is a lack of enough clinical studies of good quality for give a recommendation, the case reports must be taken in count with reservation.

Introduction: Primary malignant tumors of the trachea are rare, but they represent 90% of all tumors of the trachea. The ad- enoid cystic carcinoma is the second most frequent hystologic type of tumor growing in the trachea with aproximately 10 to 15% of all cases. Symptoms are unspecifi c and the most frequent are cough, hoarseness, dyspnea, wheezzing and stridor. Bronchoscopy is the study of choice to obtain tissue for histopathologic study. Surgery is the treatment of choice when possible. Methods: We present the case of a 59 years old female with an adenoid cystic carcinoma of the middle third of the trachea, treated with surgical resection, obtaining a complete resection, with no adyuvant therapy, and with 14 months follow-up without recurrence. Discussion and conclusions: Treatment of adenoid cystic carcinoma should be multidisciplinary. In our patient had forecast a rate of 5-year survival of 91% because it was a localized disease. We consider that patients with any type of tracheal tumor should be referred to a specialized center with experience in the treatment of tracheal pathology.

Lung metastasectomy is an area of interest and controversy in surgical oncology. Most of the available evidence derives from small cohorts with short follow-up. The aim of this study was to evaluate the oncologic outcomes in an 18-year cohort from a single center. We retrospectively reviewed 398 patients with several malignancies who underwent lung metastasectomy between January 1990 and December 2008. Demographic, clinical, and surgical variables were evaluated. Uni- and multivariate analyses were performed to identify factors associated with overall survival (OS). Mean follow-up was 20 months. Wedge resection was performed in 297 cases and 101 required anatomic resections. In 303 patients the disease-free interval (DFI) was6 months meanwhile 95 patients had a DFI ≤6 months. Complete resection was achieved in 351 patients (88.2%). Median OS for all patients was 81.9 months (95% CI, 36.9-126.9). On multivariate analysis, factors associated with a poor overall survival were DFI6 months (HR, 1.74; 95% CI, 1.24-2.4; p=0.001) and incomplete resection (HR, 1.58 95% CI, 1.01-2.5; p=0.0047). Independent prognostic factors associated with better survival were DFI6 months and complete resection. Size and number of metastases as well as re-do metastasectomy were not associated with worse survival.

Tracheobronchial stenosis is common in the thoracic surgery service, and iatrogenic injury of the airway after manipulation is not infrequent. When a digital thoracic drainage system came onto the market, many advantages were evident. A 24-year-old woman with critical right main bronchial stenosis underwent airway dilation that was complicated by a tear with a massive air leak, resulting in a total right pneumothorax. We employed a pleural drain connected to a digital thoracic drainage system. The drain was removed 2 days after successful resolution of the air leak.

Myofibroblastic inflammatory tumors (MIT) of location in carina represent a diagnostic, classification, and treatment challenge, due to the scarcity of reports. The actual evidence supports the theory that MITs are lower-grade sarcomas. Here we present the case of a 23-year-old man with MIT in carina who was treated with tumor resection by carinectomy and tracheobronchial reconstruction. In spite of the few reports of these tumors in that location, the surgical treatment looking for complete resection is the gold standard of treatment.

Lung cancer is the leading cause of death from malignant diseases worldwide, with the non-small cell (NSCLC) subtype accounting for the majority of cases. NSCLC is characterized by frequent genomic imbalances and copy number variations (CNVs), but the epigenetic aberrations that are associated with clinical prognosis and therapeutic failure remain not completely identify. In the present study, a total of 55 lung cancer patients were included and we conducted genomic and genetic expression analyses, immunohistochemical protein detection, DNA methylation and chromatin immunoprecipitation assays to obtain genetic and epigenetic profiles associated to prognosis and chemoresponse of NSCLC patients. Finally, siRNA transfection-mediated genetic silencing and cisplatinum cellular cytotoxicity assays in NSCLC cell lines A-427 and INER-37 were assessed to describe chemoresistance mechanisms involved. Our results identified high frequencies of CNVs (66–51% of cases) in the 7p22.3–p21.1 and 7p15.3–p15.2 cytogenetic regions. However, overexpression of genes, such as MEOX2, HDAC9, TWIST1 and AhR, at 7p21.2–p21.1 locus occurred despite the absence of CNVs and little changes in DNA methylation. In contrast, the promoter sequences of MEOX2 and TWIST1 displayed significantly lower/decrease in the repressive histone mark H3K27me3 and increased in the active histone mark H3K4me3 levels. Finally these results correlate with poor survival in NSCLC patients and cellular chemoresistance to oncologic drugs in NSCLC cell lines in a MEOX2 and TWIST1 overexpression dependent-manner. In conclusion, we report for the first time that MEOX2 participates in chemoresistance irrespective of high CNV, but it is significantly dependent upon H3K27me3 enrichment probably associated with aggressiveness and chemotherapy failure in NSCLC patients, however additional clinical studies must be performed to confirm our findings as new probable clinical markers in NSCLC patients.

Lung cancer remains the most progressive malignant disease strongly resistant to oncological therapies including platinum-derived cancer drugs and Epidermal Growth Factor Receptor (EGFR)-Tyrosine Kinases Inhibitors (TKIs). Homeobox-related gene (HOX) transcription factors as Mesenchyme HOX-2 (MEOX2) have previously been associated with cancer-drug resistance, progression and/or clinical prognosis in lung cancer patients. However, transcriptional mechanisms epigenetically modulated have not totally been elucidated in lung cancer therapy resistance. Here an epigenomic strategy was conducted to identify a novel MEOX2 gene sequence-promoter targets profile, associated or involved in therapy resistance mechanisms in human lung cancer. For that chromatin from human non-small cell lung carcinomas (NSCLC), MEOX2 versus RNA Pol II immunoprecipitation and hybridization assays using gene promoter tiling-arrays and bioinformatics analyses were performed, while a set of quantitative and functional assays with clinical-outcome prognosis validation predictions analyses, were assessed. Stringent bioinformatics results identified a common profile of 13 gene promoter sequences, which included in others Sonic Hedgehog-GLI-1, ALDH1A2, MMP24, RUFY3 and ZEB1 (FDR≤0.1) in NSCLC patients with different clinical outcome data. GLI-1 gene promoter-sequences upstream -2,192 to -109 quantitatively validated, were occupied by MEOX2 and RNA Pol II in both NSCLC cell lines and NSCLC patients, as well as consistently enriched with the histone activation marks H3K27Ac and H3K4me3, in addition, confirmed by the ENCODE database bioinformatics analyses. Furthermore, a set of genetic silencing functional assays validated a novel transcriptional MEOX2-GLI1 axis in a cisplatinum dose-dependent manner, involved in cellular migration, invasion, and proliferation capacity. Finally, MEOX2-GLI1 axis expression was clinically validated and analyzed using Kaplan-Maier survival analyses on an independent cohort of 90 NSCLC patients, identifying a significant MEOX2-dependent GLI-1 overexpression statistically associated with clinical poorer overall survival prognosis and treatment response into cisplatinum-based first-line therapy and/or second-line EGFR-TKIs target therapy protocols. In conclusion, a chromatin-immunoprecipitation and epigenome-wide analysis based on the MEOX2-transcriptional occupation study, identified novel MEOX2-transcriptional gene promoter axes involved in embryonic development, oxidoreductase activity, matrix metalloprotease, cellular polarity, epithelial-mesenchyme phenotype, cancer cell migration and invasion pathways. Promoting cisplatinum-based resistance mechanisms and EGFR-TKIs based therapy response prognosis in human lung cancer. Note: This abstract was not presented at the meeting. Citation Format: Federico Avila Moreno, Leonel Armas lopez, Patricia Piña-Sánchez, Oscar Arrieta, Enrique Gúzman de Alba, Abril Marcela Herrera-Solorio, Blanca Ortiz-Quintero, Patricio Santillán-Doherty, David C Christiani, Joaquín Zúñiga. Novel Mesenchyme Homeobox2-target transcription axes are involved in cancer-drug resistance, overall survival and therapy prognosis in lung cancer patients: a functional epigenome wide study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 682. doi:10.1158/1538-7445.AM2017-682

We read with interest the article by Yang et al. [1]. We appreciate the novelty of the technique and how important it is to incorporate the development of new technologies into daily practice, and we also know how hard it is to convince colleagues to begin using new technologies. Surgeons who have already learned and mastered a technique are reluctant to start using a new one because of the inconvenience that this represents, the difficulty in obtaining new materials and learning a new surgical technique, and the trouble of convincing patients and families of the efficacy of the new method. After reviewing the article and taking into consideration the details of the variables to be analyzed, the homogeneity of the sample, and the extensive literature on the matter, we would like to make some comments. To our knowledge, there are very few published studies of the use of the single-incision laparoscopic surgery (SILS) port in thoracic surgery. There are case reports [2] and the retrospective series published by Yang et al. However, one of us (JMM) has recently had accepted for publication in this journal a prospective, nonrandomized, comparative pilot study [3]. This forthcoming series and the study of Yang et al. have several results in common that we would like to highlight. Both the duration of hospital stay and the cost were similar in our forthcoming series and in the study by Yang et al. Although they did not mention it, presumably the permanence of the chest tube drainage was also similar to that found in our study. Our results differ from their series in regard to pain. We used the visual analog scale for pain assessment, as did Yang et al., but we obtained significantly better results for patients with a SILS port than the three-port technique. In support of the finding that in the SILS technique pain and scarring satisfaction is better than with the classic three-port technique, Yang et al. mentioned that six of their patients had been previously operated on the contralateral side, and five of them were more satisfied with the SILS method than with the classic three-port method. The SILS port had lower postoperative neurological sequelae such as paresthesia and better cosmetic results. However, our study found higher rates of surgical wound complications, which we attribute to the fact that, with the SILS port being a single port, the tissues are compressed, and in addition it is the same wound used for chest tube placement. We find two points that diverge from the study of Yang et al.. First is the routine use of fibrin glue spray in all patients. Even after making the air leak test under the solution and finding none, we regard this as an excessive measure. It also raises intraoperative costs significantly, and there is no current evidence to suggest that this practice is universally accepted. Second is the fact that some of the cases of pneumothorax in patients who underwent surgery were their first event of pneumothorax. According to some of the most often used protocols in the world, such as the SEPAR guidelines for pneumothorax [4], surgery is only considered in the first event if the first episode is hypertensive pneumothorax, if there is prolonged air leak ([7 days), and if the patient is at risk as a result of practices involving changes in atmospheric pressure, among others. A disadvantage of the SILS technique is the requirement of prior training in the simulator provided by Covidien SILS (Tyco Health-Care, Norwalk, CT, USA) for the use of an instrumental angular tip. J. M. Mier (&) G. F. S. Otaola E. G. de Alba P. S. Doherty Thoracic Surgery Department, Instituto Nacional de Enfermedades Respiratorias ‘‘Ismael Cosio Villegas’’ (INER), Calzada de Tlalpan 4502. Col. Seccion XVI., Tlalpan, Mexico D.F., Mexico e-mail: jmmo50@hotmail.com

“The First Minimally Invasive Thoracic Surgery Uniportal Course” in Mexico was held from July 13th to 15th in Mexico City, at the National Institute of Respiratory Diseases (INER). Thoracic surgeons from around Mexico assisted the course. The special guests were the Spanish doctor Diego González-Rivas and the Brasilian doctor Joao Carlos das Neves-Pereira. The course included live surgery and wet lab. Demonstration of the uniportal video-assisted thoracic surgery (VATS) technique was done. The course was a success and Mexican thoracic surgeons were ready to adopt this technique.