Aortopulmonary Window Lymph Nodes Research Articles

Prognostic significance of mediastinal standardized uptake value on positron emission tomography/computed tomography in patients with left upper lobe non-small cell lung cancer: Is invasive staging of aortopulmonary window lymph nodes necessary?

Background: This study aims to investigate whether the invasive staging of aortopulmonary window lymph nodes could be omitted in the presence of a suspected isolated metastasis in the aortopulmonary window lymph node on positron emission tomography/computed tomography. Methods: Between January 2010 and January 2016, a total of 67 patients (54 males, 13 females; mean age: 59.9±8.7 years; range, 44 to 76 years) with metastatic left upper lobe tumors to aortopulmonary window lymph nodes were retrospectively analyzed. According to positron emission tomography/computed tomography findings in clinical staging, the patients were classified as positive (+) (n=33) and negative (-) (n=34) groups. Results: There was a statistically significant difference between the two groups in terms of sex distribution, lymph node diameter on computed tomography, maximum standardized uptake value of aortopulmonary window lymph nodes, and tumor diameter (p<0.001 for all). A trend toward significance was found to be in pT status, LN #6 metastases, and pathological stage between the two groups (p=0.067). The five-year overall survival rate for all patients was 42.4% and there was no significant difference between the groups (p=0.896). The maximum standardized uptake value of the aortopulmonary window lymph nodes was a poor prognostic factor for survival (area under the curve=0.533, 95% confidence interval: 0.407-0.675, p=0.648). Conclusion: Invasive staging of aortopulmonary window lymph nodes can be omitted in patients with isolated suspected metastasis to aortopulmonary window lymph nodes in non-small cell lung cancer of the left upper lobe.

Anthracosis, a Distinct Cause of Vocal Fold Paralysis: Case Series

Vocal fold paralysis (VFP) can happen in various conditions due to mediastinal LADs, however no study has proposed anthracosis as an etiology. Here we discussed the chest CT features of anthracosis related LADs causing VFP. Among 41 cases of pulmonary anthracosis, 10 had VFP that all were presented with hoarseness. The paralysis was unilateral (left side) in all cases. Extra-nodal infiltration and conglomeration of lymph nodes were significantly higher in patients with paralysis. Left paratracheal, pre-vascular, and aortopulmonary window lymph nodes were seen in all patients. We propose that mediastinal LADs secondary to anthracosis could be a reason for left side VFP.

PTH-159 The relevance of lymph node metastases in the proximal field of the chest in patients with adenocarcinoma of the gastro-oesophageal junction treated with neoadjuvant therapy followed by transthoracic oesophagectomy

<h3>Introduction</h3> The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement. Not only the amount of positive lymph nodes but also the location of postive nodes negatively influence survival. Earlier small studies revealed a poor survival for patients with positive nodes in the proximal field of the chest when treated with surgery alone. It is thus far unknown what the relevance of these nodes is after neoadjuvant therapy. The aim of the present study was to identify the incidence and prognostic significance of lymph node metastases in the proximal part of the chest in patients who underwent a transthoracic oesophagectomy after neoadjuvant therapy. <h3>Method</h3> From a prospectively collected database, a consecutive series of patients in two high volume centres in Europe was analysed. All patients with potentially curable adeno carcinoma of the gastro-oesophageal junction were treated with neoadjuvant chemo (radiation)therapy therapy followed by transthoracic oesophagectomy and two-field lymphadenectomy. <h3>Results</h3> Between January 2000 and September 2013 a consecutive series of 208 patients underwent an oesophagectomy after neoadjuvant therapy for adenocarcinoma of the gastro-oesophageal junction. 80 (38.5%) patients had no evidence of lymph node metastases (N0). There were 128 patients (61.5%) with positive nodes (N1=41 (19.7%), N2=44 (21.2%), N3=43 (20.7%)). Of the node positive patients, 25 (19.5%) had positive nodes in the proximal field of the chest (paratracheal, subcarinal, bronchial and aorto-pulmonary window lymph nodes). More advanced N-stage was significantly associated with positive nodes in the proximal field of the chest (p &lt; 0.001). Median survival was significantly (p = 0.003) worse for patients with positive nodes in the proximal part of the chest (12.4 months (95% CI: 11.4–13.32)) compared with patients with positive nodes on other locations (28.3 months (95% CI: 22.7–33.9)). <h3>Conclusion</h3> Lymph node metastases in the proximal part of the chest in patients is a common phenomonemon and a sign of advanced disease. Radical surgical resection can only be achieved with an extended transthoracic resection. Even after neoadjuvant therapy followed by transthoracic resection long-term survival is poor. <h3>Disclosure of interest</h3> None Declared.

Impact of extended cervical mediastinoscopy in staging of left lung carcinoma.

Extended cervical mediastinoscopy (ECM) is a method for staging lung carcinoma. We aimed to demonstrate the impact of ECM in the staging of lung carcinoma. Between 1998 and 2011, 159 patients with left lung carcinoma who underwent ECM simultaneously with standard cervical mediastinoscopy (SCM), were retrospectively analyzed. Until 2006, ECM had been performed routinely (n = 90, routine ECM), however, after 2006 ECM was performed only in patients selected based on computed tomography and positron emission tomography scans (n = 69, selective ECM). Mediastinal lymph node metastasis was present in 36 patients by mediastinoscopy. Aortopulmonary window (APW) lymph node metastasis was present in 26 patients (10 in the routine group, 16 in the selective group), whereas the 10 patients who had mediastinal lymph node metastasis that could only be accessed by SCM, but had no APW lymph node metastasis, were excluded. The remaining 123 patients (72 in the routine group, 51 in the selective group) were identified as cN0/N1 by SCM/ECM, and lobectomy, pneumonectomy, and exploratory thoracotomy were performed on 64, 43, and 16 of these patients, respectively. According to the lymphadenectomy, APW lymph node metastasis was determined in 11 patients (seven in the routine group, four in the selective group). Sensitivity, negative predictive value (NPV), and accuracy of ECM were calculated as 0.70, 0.90, and 0.92, respectively. Staging values of routine/selective ECM protocols were 0.58/0.80, 0.89/0.91 and 0.91/0.94, respectively. The complication rate was 5% (n = 8). ECM has an adequate NPV and accuracy in determining metastasis to the APW lymph nodes in patients with left lung carcinoma.

Lung Cancer Staging

Lung cancer incidence has dramatically risen in the past century. It is now the leading cause of cancer death in the world, both among men and women. Accurate staging is important because treatment options and prognosis differ significantly by stage. If there are no distant metastases, the status of mediastinal lymph nodes is the critical point to distinct between patients who will benefit from surgical therapy, neoadjuvant therapy or clinical treatment. Noninvasive imaging studies including chest computed tomography and positron emission tomography scanning should be performed in all patients who are potentially candidates to pulmonary resection. The findings of these noninvasive studies are critical, and the invasive mediastinal staging must be performed according to the medical examination and the results of noninvasive tests. In patients with extensive mediastinal infiltration by lung cancer, the disease is considered advanced and invasive staging is not needed. In patients with mediastinal lymph node enlargement seen at computed tomography, a sample tissue of these nodes is necessary. In these cases there are several methods to invasive staging the mediastinum, but mediastinoscopy is the gold standard. In patients with clinical T2 or with central tumors, invasive staging of the mediastinal nodes is necessary. Patients with a peripheral clinical T1 lung cancer do not usually need invasive confirmation of mediastinal nodes unless there is an abnormal standard uptake value in the nodes, found on positron emission tomography scanning. The staging of patients with left upper lobe tumors should include an assessment of the preaortic and aortopulmonary window lymph nodes. Pancoast tumors always need invasive mediastinal staging if they are considered for surgical resection.

The Role of Extended Cervical Mediastinoscopy in Staging of Non-small Cell Lung Cancer of the Left Lung and a Comparison with Integrated Positron Emission Tomography and Computed Tomography: Does Integrated Positron Emission Tomography and Computed Tomography Reduce the Need for Invasive Procedures?

Extended cervical mediastinoscopy (ECM) is a method for sampling aortopulmonary window (APW) mediastinal lymph nodes. In this study, the efficacy of integrated positron emission tomography/computed tomography (PET/CT) was compared with ECM for the detection of APW lymph node metastasis. Fifty-five patients diagnosed of non-small cell lung cancer in whom APW or hilar lymph nodes had been reported to be positive on PET/CT, and/or who had had central tumor and/or in whom ECM had been performed for mediastinal staging due to the presence of APW lymph nodes larger than 1 cm in diameter on the CT between 2005 and 2009, were retrospectively analyzed. All patients underwent PET/CT scanning. Thirty-eight patients were identified as cN0 by standard cervical mediastinoscopy/ECM, and lobectomy, pneumonectomy, and exploratory thoracotomy were performed on 19, 13, and six of these patients, respectively. Mediastinal lymphadenectomy revealed APW lymph node metastases in four patients (ECM false negative). Seventeen patients identified as cN2 by mediastinoscopy, APW lymph node metastasis was present in nine, whereas eight had mediastinal lymph node metastasis that could only be accessed by standard cervical mediastinoscopy but had no APW lymph node metastasis were excluded from the analysis. Sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of ECM/PET/CT were calculated as 0.69/0.53, 1/0.91, 0.89/0.83, 1/0.70, and 0.91/0.80, respectively. ECM, which is an effective technique used in the determination of APW lymph node metastasis, was enough to rule out nodal disease with negative predictive value. PET/CT does not reduce the need for invasive procedures in detecting APW lymph node metastasis.

18F-FDG PET/CT for the diagnosis of sarcoidosis in a patient with bilateral inflammatory involvement of the parotid and lacrimal glands (panda sign) and bilateral hilar and mediastinal lymphadenopathy (lambda sign)

A 43-year-old man was hospitalized for Sjogren’s syndrome whichwas suspected to be of paraneoplastic aetiology. F-FDG PET/CT revealed grossly enlarged lacrimal (a) and parotid glands (b) with significantly increased FDG uptake while the submandibular glands (c) were only minimally enlarged with faint FDG uptake. Furthermore, hypermetabolic intrathoracic lymphadenopathy was detected with a typical lambda appearance (h) involving right paratracheal (e), left paratracheal and aortopulmonary window lymph nodes (f) of the mediastinum and bihilar lymph nodes (g). The imaging findings were suggestive of sarcoidosis and bronchoscopic evaluation with biopsy was proposed. Histopathology of a transbronchial biopsy specimen confirmed the diagnosis of sarcoidosis. In 1990 Sulavik et al. first described the panda sign, i.e. normal accumulation of the radionuclide (Ga-citrate) in the nasopharynx combined with increased symmetric accumulation in the parotid and lacrimal glands, giving the impression of the mottled colouring of the giant panda [1–3]. Intrathoracic lymphadenopathy typically manifests as bilateral hilar adenopathy with predominantly right paratracheal adenopathy, referred to as the lambda appearance [4]. With F-FDG PET/CT the appearance of hypermetabolic mediastinal and bihilar lymphadenopathy in sarcoidosis is comparable to the lambda sign of Ga-citrate scintigraphy [5]. Bilateral inflammatory involvement of the parotid and lacrimal glands is also present, resulting in an increased FDG uptake, although the typical panda appearance is partially obscured due to the physiologic FDG avidity of the brain (d). The finding of typical lambda and panda patterns supports the diagnosis of sarcoidosis and reinforces the indication to perform an appropriate biopsy.

Endoscopic ultrasound‐guided fine needle aspiration is useful for nodal staging in patients with pleural mesothelioma

Patients with malignant pleural mesothelioma and negative N2 stage lymph nodes may benefit from extrapleural pneumonectomy with adjuvant therapy. The objective of this study is to describe the use of EUS-FNA to determine N2 stage status in patients with mesothelioma and its impact in the management of such patients. Six patients (mean age, 62 yr; median age, 63 yr; range, 52-70 yr; 5 men; 1 woman) underwent EUS-FNA for staging of N2 lymph nodes from July 2000 to July 2006. Follow-up included operative notes, treatment summaries, and surgical pathology. Eight sites were aspirated: four subcarinal lymph nodes, three aorto-pulmonary window lymph nodes, and one paraesophageal mass. Two of 8 (25%) aspirates were positive for metastatic disease in two different patients. Two false negative EUS-FNAs were observed and were attributed to sampling error not diagnostic error. No complications were observed. EUS-FNA is a safe N2 node staging technique in patients with mesothelioma. A positive N2 lymph node by EUS-FNA may be a contraindication to definitive surgery in patients with malignant mesothelioma.

TBNA Versus TENA in the Diagnosis and Staging of Bronchogenic Carcinoma: “A Comparative Study”

Transbronchial needle aspiration (TBNA) through the flexible bronchoscope still remains underused and a poorly understood procedure. Recently, transesophageal needle aspiration (TENA) under ultrasound guidance has been used to help stage the posterior mediastinal lymph nodes. TBNA and TENA have both been used for the diagnosis and staging of bronchogenic carcinoma. This study is to compare the efficacy and complimentary potential of these techniques. Retrospective review and comparison of a series of consecutive patients. Tertiary referral hospital. Nineteen adult patients with mediastinal adenopathy. TBNA and TENA. Specific diagnostic yield of TBNA compared with TENA in adenopathy of the left paratracheal and subcarinal locations. Out of 19 patients, specific diagnosis was made in 15 patients (79%) by TBNA and in 13 patients (68%) by TENA. TBNA and TENA were both positive in 5 patients. TBNA alone was positive in 7 patients and TENA alone was positive in 1 patient. In the comparative study group lymph node stations 7, 8, and 5 (L4), there were no significant differences in the diagnostic yield of TBNA and TENA. Small sample size. TBNA remains highly effective for sampling mediastinal lymph node stations. TENA is limited for subcarinal, paraesophageal, and aorto-pulmonary window lymph nodes, which are adjacent to the esophagus. Adding TENA to TBNA did not increase the diagnostic yield even in these subgroups of lymph nodes in our study.

Invasive Mediastinal Staging of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available. The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians. Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this. In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.

The role of FDG-PET scan in staging patients with nonsmall cell carcinoma

Background To assess the role of flourodeoxyglucose–positron-emission tomography (FDG-PET) scan in staging patients with nonsmall cell lung cancer (NSCLC). Methods We prospectively studied 400 patients with NSCLC. Each patient underwent a computed tomography (CT) scan of the chest and upper abdomen, other conventional staging studies and had a FDG-PET scan within 1 month before surgery. All suspicious N2 lymph nodes by either chest CT or by FDG-PET scan were biopsied. Patients that were N2 and M1 negative underwent pulmonary resection and complete thoracic lymphadenectomy. Results The FDG-PET had a higher sensitivity (71% vs 43%, p < 0.001), positive predictive value (44% vs 31%, p < 0.001), negative predictive value (91% vs 84%, p = 0.006), and accuracy (76% vs 68%, p = 0.037) than CT scan for N2 lymph nodes. Similarly, FDG-PET had a higher sensitivity (67% vs 41%, p < 0.001), but lower specificity (78% vs 88%, p = 0.009) than CT scan for N1 lymph nodes. FDG-PET led to unnecessary mediastinoscopy in 38 patients. FDG-PET was most commonly falsely negative in the subcarinal (#7) station and the aortopulmonary window lymph node (#5, #6) stations. It accurately upstaged 28 patients (7%) with unsuspected metastasis and it accurately downstaged 23 patients (6%). Conclusions The FDG-PET scan allows for improved patient selection. It more accurately stages the mediastinum, however there are many false positives lymph nodes and it may be more likely to miss N2 disease in the #5, #6, and #7 stations. A positive FDG-PET scan means a tissue biopsy is indicated in that location.

Temporary Cardiac Arrest during a Pulmonary Lobectomy

A 49-year-old man with a left upper lobe mass lesion was admitted for evaluation. An open thoracotomy biopsy confirmed tuberculosis. A left upper lobectomy was then performed under general anesthesia. The operative procedure was remarkable for a 15-second acute episode of cardiac asystole during the aortopulmonary window lymph node dissection. After injection of epinephrine and open cardiac massage, sinus rhythm was restored. The rest of the patient's hospital course was uneventful. A vasovagal reflex due to the operative procedure, anesthetic medications, and undiagnosed underlying heart disease could be considered for the possible etiology.