Effectiveness of mediastinal lymphadenectomy in surgical treatment of generalized destructive pulmonary tuberculosis

Endoscopic and Endobronchial Ultrasonography According to the Proposed Lymph Node Map Definition in the Seventh Edition of the Tumor, Node, Metastasis Classification for Lung Cancer

The objective: to study effectiveness of surgical methods for treatment of various forms of destructive pulmonary tuberculosis (meta-analysis).Subjects and Methods. A systematic search was performed in electronic bibliographic databases, including PubMed and Google Scholar. Cohort studies published from January 1, 2019 to June 20, 2023 were selected, those studies were aimed to assess effectiveness of surgical treatment in patients with destructive tuberculosis using resections of various volume. For meta-analysis, 9 studies published in 2019 - 2023 were selected.Results. The effectiveness of comprehensive treatment with resections of various volume in destructive pulmonary tuberculosis patients made 85.3%. The success of surgical treatment in patients with fibrous cavernous pulmonary tuberculosis was somewhat less – 80.3%. At the same time, the incidence of postoperative complications in patients with fibrous cavernous pulmonary tuberculosis was higher and could reach 42.5%, while in the group patients with destructive tuberculosis, it was 27.3%. Some postoperative complications required repeated operations. The ratio of surgeries to patients was the following: 3263 surgical interventions per 1564 patients (average 2.08 surgeries per patient). Hospital lethality among patients with fibrous cavernous pulmonary tuberculosis after surgical treatment was 2.6%, and tuberculosis mortality within 5 years after surgery was 4.8%. The relapse rate among patients with fibrous cavernous pulmonary tuberculosis after surgical treatment was 7.1%.

The OBJECTIVE was to study the features of intraoperative and postoperative periods as well as the immediate results of extrapleural thoracoplasty among patients with destructive tuberculosis in combination with human immunodeficiency virus (HIV).METHODS AND MATERIALS. A retrospective analysis of the results of extrapleural thoracoplasty for destructive pulmonary tuberculosis was performed in 46 patients with HIV infection and in 44 patients with tuberculosis without HIV infection. The groups were comparable in age and gender composition. The following variables were analyzed: the duration of the operation, the volume of blood loss, the volume of loss through drainage, the duration of postoperative drainage, the severity of postoperative pain syndrome, intra- and postoperative complications.RESULTS. We noted that, despite the longer tuberculosis duration, the frequency of bacterial excretion, the prevalence of extensive drug resistance (XDR), immune dysfunctions, high prevalence of drug addiction and chronic viral hepatitis, the results of extrapleural thoracoplasty in patients with HIV infection did not significantly differ from the results of patients without HIV infection operated for destructive pulmonary tuberculosis. Postoperative complications were few, temporary and treatable, and there was no postoperative mortality.CONCLUSION. Extrapleural thoracoplasty in patients with destructive pulmonary tuberculosis and HIV infection is not accompanied by severe, life-threatening complications. It also contributes to a significant reduction in destruction cavities in half of the operated patients. This operation does not make the course of HIV infection more difficult.

The purposeof this study was to determine detection rate and clinical and morphological characteristics of mediastinal lymphadenopathy (ML) in patients with respiratory system sarcoidosis (RSS), disseminated pulmonary tuberculosis (DPT) and exogenic allergic alveolitis (EAA).Materials and Methods.Patients (n= 278) with established diagnosis RSS, DPT, EAA were investigated. The cumulative index parameters were determined, hematology test, assessments of pulmonary function, diffuse lung capacity, diffusion coefficient were performed in all patients. Computed tomography of chest organs and morphologic examination of mediastinal lymph node (LN) biopsy were performed.Results.Subjects with newly diagnosed (n= 72) and recurrent (n= 104) disease were observed among patients with RSS (n= 176). ML was observed in 95% of cases, involved bronchopulmonary, bifurcation, paratracheal and paraaortal groups; dimensions of intrathoracic LN (ITLN) were 20.0 ± 1.9 mm. Epitheliocellular granulomas (EG) without necrosis, not fusing with each other, were established morphologically; they were determined in recurrent disease course in association with background fibrosis. In patients with DPT (n= 41), subacute (n= 28) and chronic (n= 13) disease course was noted. With subacute course of DPT in 28.6% of cases, ML of paratracheal and bifurcation groups (dimensions of ITLN – 13.1 ± 0.3 mm) was observed, with chronic course – the enlargement of paratracheal and bronchopulmonary LN (7.7% of cases). EG with necrosis and tendency to fusion was verified histologically; inflammatory process involved LN capsule and could be spread to fatty tissue. In patients with EAA (n= 76), acute (n= 10), subacute (n= 38) and chronic (n= 28) disease courses were observed. With acute EAA course, hyperplasia of ITLN of bifurcation and tracheo-bronchial groups up to 13.5 ± 0.6 mm was observed in 20% of cases. Follicular hyperplasia with widening and edema of hermintative centers was observed at morphological investigation. With subacute EAA course, increased ITLN in bifurcation and broncho-pulmonary groups up to 13.6 ± 0.6 mm were observed in 46% of cases. Formation of histiocytic-macrophagal granulomas without epithelioid cells and deposit precipitation in the plasma cell aggregation areas was found at morphological evaluation. With chronic EAA, ML in broncho-pulmonary and paratracheal groups was detected in 17.8% of cases (enlargement of LN up to 11 ± 0.9 mm). The formation of diffuse and focal fibrosis and hyalinosis was noted morphologically.Conclusion.ML is observed in all granulomatous pulmonary diseases studied, however its rate and severity, composition of involved ITLN groups and character of morphological changes is different which is possible to use in diagnostics.

The objective: to specify indications for extrapleural thoracoplasty in patients with destructive pulmonary tuberculosis and comorbid HIV infection.Subjects and Methods. Results of surgical treatment of 78 destructive pulmonary tuberculosis patients were studied. Those patients underwent extrapleural thoracoplasty in Pulmonary Tuberculosis Surgery Unit of City Tuberculosis Hospital No. 2 in St. Petersburg from 2009 to 2022.Results. The article clarifies the indications for extrapleural thoracoplasty in patients with destructive pulmonary tuberculosis and comorbid HIV infection, in whom contraindications to pulmonary resections have been identified. Medical records of 78 patients with destructive tuberculosis were retrospectively analyzed, the patients were divided into two groups according to their HIV status. It has been established that with combination of adequate preoperative preparation and postoperative management, rational anti-tuberculosis chemotherapy and ART, extrapleural thoracoplasty for HIV-positive patients can be performed in accordance with general practice.

Surgical Assessment and Intraoperative Management of Mediastinal Lymph Nodes in Non-Small Cell Lung Cancer

To analyze the impact of surgical sanation of patients with destructive tuberculosis on the prevalence of tuberculosis and mortality of these patients. Treatment strategy for destructive pulmonary tuberculosis de novo was developed in the Sechenov First Moscow State Medical University. This strategy was applied at the Surgical Department of the Regional Tambov Tuberculosis Dispensary in 2013-2017. We formed a register of patients with pulmonary destruction and bacterial excretion and developed a personal treatment plan. All patients were divided into 3 groups (group A - surgical treatment, group B - no surgery due to refusal or discontinuation of treatment, group C - patients with contraindications or no indications for surgical treatment). Treatment efficacy considering closure of destruction cavities and abacillation was maximal in group A - 97.2%, 41.4% in group B and 39.8% in group C. The number of patients with pulmonary destruction and bacterial excretion has decreased by 3.3 times (from 516 to 158) or 69.8% for 4 years of extensive application of surgical treatment protocol. A significant reduction of 'bacillary core' interrupted infection chain and affected the main epidemiological characteristics. Short-term reduction of the incidence of tuberculosis may be expected. However, even more significant impact of this factor should be expected in the long-term period. Surgical treatment of destructive pulmonary tuberculosis improves efficacy of the management of these patients and reduces mortality rate.

The objective : to assess the functional outcomes of extrapleural thoracoplasty among patients with destructive tuberculosis and comorbid human immunodeficiency virus (HIV) 6 months after the performed surgery. Subjects and Methods. 49 HIV/TB co-infected patients were subjected to a retrospective study 6 months after the extrapleural thoracoplasty. A control group comprised similar 49 patients with destructive pulmonary tuberculosis but without HIV infection. The following functional characteristics were analyzed: dynamics of dyspnea, vital capacity of lungs (VC), forced expiratory volume of the air exhaled in the first second (FEV1), the Tiffeneau-Pinelli index and indicators of the pulmonary capillary blood flow (PCB). Results . In MG, extrapleural thoracoplasty contributed to the healing of cavities by 6 months in 30.6% (15/49 patients) and sputum conversion in 46.9% (23/49 patients). Those parameters did not differ significantly from those in patients from Comparison Group (with HIV-negative status). Deterioration of spirometry results was recorded in 28.3±14.6% of patients in MG and 29.5±14.6% in CG, p>0.05; PCB remained at the preoperative level in both groups. A subgroup of 14 (28.6%) patients with limited (insufficient) effect after extrapleural thoracoplasty showed a significant decrease in the degree of dyspnea as well no significant changes in the spirometric values. Thus, extrapleural thoracoplasty can be considered functionally safe.

The condition of the mediastinal lymph nodes is an important factor in the selection of patients with non-small cell lung cancer for surgical treatment. Of particular concern are patients with not enlarged mediastinal lymph nodes according to CT-scan. The frequency of their “occult” pN2-N3 lesions can reach 22–41%. The aim of the study was to assay the possibilities of endobronchial ultrasono­graphy with transbronchial needle aspiration (EBUS/TBNA) of mediastinal lymph nodes and video-­assisted mediastinal lymphadenectomy (VAMLA) in detecting “occult” N2-N3 metastasis in patients with NSCLC. Materials and methods: 51 patients with proved NSCLC were included in this study. Inclusion criteria were: central tumor localization, peripheral cT2 tumors of more, cN1 stage, absence of mediastinal lymphadenopathy according to CT-scan. All patients performed EBUS/TBNA. Upon confirmation of the N2-N3 stage according to the data of a planned morphological study, the patient was referred to neoadjuvant therapy. With negative results, radical lung resection was performed. With inadequate results of an aspiration biopsy, VAMLA was performed with a frozen section study of one selective lymph node from stations 4R, 4L, 7. If their metastatic lesion was excluded in the same anesthesia, anatomical lung resection with systematic lymphodissection was performed. Results. The overall level of pN2-N3 lesion was 18.6% (9/51). Metastases to the mediastinal lymph nodes statistically prevailed in the group of patients with cN1 stage — 40% of cases (6/15). The fact of metastatic lesion of the lymph nodes did not depend on the adequacy of the aspiration biopsy. A metastatic lesion of the lymph nodes removed during VAMLA was revealed after the fact according to the results of a planned histological examination. The sensitivity of VAMLA was 71%, and PNV — 91%. Sensitivity and PNV of EBUS/TAB were 11% and 84%, respectively. Conclusion. cN1-stage is a factor of extremely high risk of "occult" metastasis. To exclude a regional lesion of not enlarged mediastinal lymph nodes, EBUS/TBNA is not enough. A necessary condition for the use of VAMLA in the framework of N-staging of patients with a high risk of “occult” metastasis is its use as an independent operation, with a mandatory planned study of all removed lymph nodes.

Complete mediastinal lymph node dissection—does it make a difference?

Objective. To evaluate the risk, diagnostic capabilities and surgical tactics for silicone lymphadenopathy following implant rupture. Material and methods. Silicone breast implant ruptures were diagnosed in 72 patients after primary surgery. The period until rupture ranged from 6 months to 25 years. To assess the incidence of silicone changes, we analyzed ultrasound, CT and MRI data in 50 patients. Silicone lymphadenopathy was detected in two cases 5 and 6 years after implantation. A review of the literature for recent years is presented. Results. MRI-verified lymph node enlargement following implant rupture was found in 40% of patients (20/50). There were non-specific changes in 16 cases (32%). Two patients had lymph node enlargement corresponding to silicone lymphadenopathy without morphological confirmation. Lymphadenopathy involved axillary, supraclavicular and intrathoracic lymph nodes with their enlargement up to 1.5—2.5 cm in two patients with implant ruptures 5 and 6 years after augmentation mammoplasty. Lymph node biopsy excluded cancer. In this patient, implants were removed simultaneously with lymph nodes. Histological examination revealed asteroid-like bodies and foreign body particles (silicone) in lymph nodes typical for silicone lymphadenopathy. Among 72 patients with implant ruptures, the incidence of silicone lymphadenopathy was 2% (2/72). Conclusion. Silicone lymphadenopathy can complicate breast implant ruptures ≥ 5 years after mammoplasty. This complication requires differential diagnosis with malignancies. Lymph node biopsy is usually required for definitive diagnosis. Lymph node removal is necessary if clinical symptoms are present.

BackgroundIt is difficult to examine mild to moderate feline intra-thoracic lymphadenopathy via and thoracic radiography. Despite previous information from computed tomographic (CT) images of intra-thoracic lymph nodes, some factors from animals and CT setting were less elucidated. Therefore, this study aimed to investigate the effect of internal factors from animals and external factors from the CT procedure on the feasibility to detect the intra-thoracic lymph nodes. Twenty-four, client-owned, clinically healthy cats were categorized into three groups according to age. They underwent pre- and post-contrast enhanced CT for whole thorax followed by inter-group evaluation and comparison of sternal, cranial mediastinal, and tracheobronchial lymph nodes.ResultsPost contrast-enhanced CT appearances revealed that intra-thoracic lymph nodes of kittens were invisible, whereas the sternal, cranial mediastinal, and tracheobronchial nodes of cats aged over 7 months old were detected (6/24, 9/24 and 7/24, respectively). Maximum width of these lymph nodes were 3.93 ± 0.74 mm, 4.02 ± 0.65 mm, and 3.51 ± 0.62 mm, respectively. By age, lymph node sizes of these cats were not significantly different. Transverse lymph node width of males was larger than that of females (P = 0.0425). Besides, the detection score of lymph nodes was affected by slice thickness (P < 0.01) and lymph node width (P = 0.0049). Furthermore, an irregular, soft tissue structure, possibly the thymus, was detected in all juvenile cats and three mature cats.ConclusionsDespite additional information on intra-thoracic lymph nodes in CT images, which can be used to investigate lymphatic-related abnormalities, age, sex, and slice thickness of CT images must be also considered.

Background: Staging of non-small cell lung cancer (NSCLC) is important for determining choice of treatment and prognosis. The accuracy of FDG-PET scans for staging of lymph nodes is too low...

Despite a decrease in the incidence of pulmonary tuberculosis in the Russian Federation in recent years, among the newly diagnosed patients there remains a significant proportion of patients with bacterial excretion and destructive pulmonary tuberculosis. In patients with destructive pulmonary tuberculosis, surgical treatment is often the only possible method for saving lives. We studied the results of extrapleural posterosuperior thoracoplasty in 42 patients with destructive pulmonary tuberculosis. The comparison group consisted of 30 patients who received medicamentous therapy. The mortality rate for 3 years of follow-up in the conservative treatment group was 36.7%, in the surgical treatment group it was 23.8%, p = 0.237. Among patients with more than 2 years of disease experience, mortality was 45% in the main group, 88% in the comparison group, p = 0.070. In the absence of drug resistance, mortality in the main group was 4%, that in the comparison group – 14.2%, p = 0.283. Mortality in individuals with normal body weight was lower in the group of patients who underwent thoracoplasty than in the comparison group: 17.6% vs. 33.3% (p = 0.202). Among those who did not achieve sputum negative reaction, mortality was lower, and passing to the 3rd group of dispensary care was more common in the surgical treatment group – 41.7% vs. 71.4% (p = 0.077) and 33.3% vs. 21.4% (p = 0.426). Among patients with drug resistance or low body weight or unachieved sputum negative reaction, mortality rates were comparable in both groups. Thus, thoracoplasty, in comparison with conservative therapy, makes it possible to improve treatment results in patients regardless of the length of the disease in groups with Mycobacterium tuberculosis sensitive process, with normal body weight, with preservation of elimination of bacilli. The effectiveness of thoracoplasty decreases in patients with an increase in the disease duration.

To measure the intrafraction displacement of the mediastinal metastatic lymph nodes of non-small cell lung cancer (NSCLC) based on four-dimensional computed tomography (4D-CT), and to provide the basis for the internal margin of metastatic mediastinal lymph nodes. Twenty-four NSCLC patients with mediastinal metastatic lymph nodes confirmed by contrast enhanced CT (short axis diameter ≥ 1 cm) were included in this study. 4D-CT simulation was carried out during free breathing and 10 image sets were acquired. The mediastinal metastatic lymph nodes and the dome of ipsilateral diaphragma were separately delineated on the CT images of 10 phases of breath cycle, and the lymph nodes were grouped as the upper, middle and lower mediastinal groups depending on the mediastinal station. Then the displacements of the lymph nodes in the left-right, anterior-posterior, superior-inferior directions and the 3-dimensional vector were measured. The differences of displacement in three directions for the same group of metastatic lymph nodes and in the same direction for different groups of metastatic lymph nodes were compared. The correlation between the displacement of ipsilateral diaphragma and mediastinal lymph nodes was analyzed in superior-inferior direction. The displacements in left-right, anterior-posterior and superior-inferior directions were (2.24 ± 1.55) mm, (1.87 ± 0.92) mm and (3.28 ± 2.59) mm for the total (53) mediastinal lymph nodes, respectively. The vectors were (4.70 ± 2.66) mm, (3.87 ± 2.45) mm, (4.97 ± 2.75) mm and (5.23 ± 2.67) mm for the total, upper, middle and lower mediastinal lymph nodes, respectively. For the upper mediastinal lymph nodes, the displacements in left-right, anterior-posterior and superior-inferior directions showed no significant difference between each other (P > 0.05). For the middle mediastinal lymph nodes, the displacements merely in anterior-posterior and superior-inferior directions showed significant difference (P = 0.005), while the displacements were not significantly different in the left-right and anterior-posterior, left-right and superior-inferior directions (P > 0.05). The displacements of the total and the lower mediastinal lymph nodes in left-right and superior-inferior, or anterior-posterior and superior-inferior directions were significantly different (P < 0.05), but was not significantly different in left-right and anterior-posterior directions (P > 0.05). The displacements of different group of mediastinal lymph nodes in a single direction or vector showed no significant difference (P > 0.05). In the superior-inferior direction, the correlation between the displacements of ipsilateral diaphragma and mediastinal lymph nodes were not statistically significant (P > 0.05). During free breathing, the differences between the intrafractional displacement of mediastinal metastatic lymph nodes in the same direction and its station were not statistically significant. The displacements of the total mediastinal metastatic lymph nodes in the superior-inferior direction were greater than that in the left-right and anterior-posterior directions, especially for the middle and lower mediastinal metastatic lymph nodes. There was no significant correlation between the displacements of ipsilateral diaphragma and the mediastinal metastatic lymph nodes in the superior-inferior direction, so it was unreasonable to estimate and predict the displacement of mediastinal metastatic lymph nodes by the displacement of ipsilateral diaphragma.