Interlobar Node Research Articles

7277 Diabetic Ketoacidosis As The First Manifestation Of Ectopic Cushing’s Syndrome

Abstract Disclosure: R.S. Medeiros: None. Introduction: Ectopic Cushing’s Syndrome (ECS) represents 10-20% of all ACTH-dependent CS, and the majority of cases arise from lung carcinoids. These indolent lesions usually evolve clinically over 6-24 months, whereas carcinomas are associated with faster onset of ECS. Diabetic Ketoacidosis (DKA) as a presenting manifestation of Cushing’s Syndrome (CS) is very rare, with the few cases published to date related to Cushing’s disease. Clinical Case: A 42-year-old woman was admitted in the emergency room with DKA and COVID-19. During stabilization, florid CS was clinically suspected. She reported a 6-month history of secondary amenorrhea, lack of concentration and memory, easy bruising, proximal myopathy with frequent falls evolving to daily life dependency from relatives. She also reported a 2-month diagnosis of dyslipidemia, Diabetes and hypertension, and a diagnosis of atypical pneumonia 6 months ago. Physical exam showed typical cushingoid appearance, especially for marked limb sarcopenia and proximal myopathy. An overnight dexamethasone suppression test (morning cortisol: 25.7 ug/dL), 24h urinary free cortisol (UFC; 1072.5 ug/dL; reference: <176) and serum cortisol at 23h00 (25.5 ug/dL) confirmed CS. ACTH-dependent CS was diagnosed. She had non-suppressible serum cortisol in high dose dexamethasone suppression test, and CRH stimulation test was suggestive of Cushing’s disease only by a 20% rise of cortisol at 30 minutes. Pituitary MRI was normal. Inferior Petrosal Sinus sampling was postponed for several months due to healthcare strikes. The patient started 750 mg of metyrapone in three divided doses but rapidly decreased the dose and stopped it due to clinical resolution of CS, a dramatic improvement of all glucocorticoid-related comorbidities leading to discontinuation of statin, insulin, main oral anti-hyperglycemic and antihypertensive medications, and normal midnight salivary cortisol and 24h UFC. She remained in this eucortisolemic state for 12 months. Thoracic CT scan revealed thymic hyperplasia and a 25x15 mm well-defined nodule in the lingula. A 68Ga-DOTANOC PET/CT showed a single uptake in the same lung region. The patient underwent lingulectomy plus excisional biopsy of interlobar lymph nodes, and pathology revealed a low-grade neuroendocrine tumor (Ki67<2%, <2 mitosis) without involved lymph nodes. The patient is weaning off from physiologic doses of hydrocortisone. Conclusion: DKA can rarely be the presenting manifestation of severe CS, including ECS. Clinicians should suspect on this etiology of DKA based on clinical signs and cumulative morbidity not typical of a young patient. This hint would lead to the expedite implementation of targeted therapies for initial stabilization of the CS patient, and the timely institution of a proper diagnostic approach and definitive treatment of this challenging patients. Presentation: 6/2/2024

The lymph node will be my friend (easy). Careful dissection of lymph nodes in station 7 right until visualization of left main bronchus. Right interlobar lymph node dissection and removal allow for a safe fissure passage between A6 and A2, while avoiding V2.

The lymph node will be my friend (easy). Careful dissection of lymph nodes in station 7 right until visualization of left main bronchus. Right interlobar lymph node dissection and removal allow for a safe fissure passage between A6 and A2, while avoiding V2.

Wedge extended bronchoplasty with caliber adjustment by membranous suture.

Extended bronchoplasty for the left lower lobe lung tumors with interlobar lymph node involvement is a useful surgical technique for avoiding pneumonectomy. Typically, sleeve bronchoplasty, in which the superior division bronchus and the left main bronchus are separated and anastomosed, is chosen due to the difference in caliber of the anastomosis; herein, we report a wedge extended bronchoplasty in which the superior division bronchus and the left main bronchus were not completely separated. The main point of this technique is to adjust the difference in caliber by suturing the main bronchial membranes.

Comparison of the specimen quality of endobronchial ultrasound-guided intranodal forceps biopsy using standard-sized forceps versus mini forceps for lung cancer: A prospective study.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure with adequate performance; however, its ability to provide specimens of sufficient quality and quantity for treatment decision-making in advanced-stage lung cancer may be limited, primarily due to blood contamination. The use of a 0.96-mm miniforceps biopsy (MFB) permits true histological sampling, but the resulting small specimens are unsuitable for the intended applications. Therefore, we introduced a 1.9-mm standard-sized forceps biopsy (SFB) and compared its utility to that of MFB. We prospectively enrolled patients from three institutions who presented with hilar/mediastinal lymphadenopathy and suspected advanced-stage lung cancer, or those who were already diagnosed but required additional tissue specimens for biomarker analysis. Each patient underwent MFB followed by SFB three or four times through the tract created by TBNA using a 22-gauge needle on the same lymph node (LN). Two pathologists assessed the quality and size of each specimen using a virtual slide system, and diagnostic performance was compared between the MFB and SFB groups. Among the 60 enrolled patients, 70.0% were diagnosed with adenocarcinoma. The most frequently targeted sites were the lower paratracheal LNs, followed by the interlobar LNs. The diagnostic yields of TBNA, MFB and SFB were 91.7%, 93.3% and 96.7%, respectively. The sampling rate of high-quality specimens was significantly higher in the SFB group. Moreover, the mean specimen size for SFB was three times larger than for MFB. SFB is useful for obtaining sufficient qualitative and quantitative specimens.

Lymph node dissection in small peripheral lung cancer: Supplemental analysis of JCOG0802/WJOG4607L

ObjectiveThe optimal region of lymph node dissection (LND) during segmentectomy in patients with small peripheral non–small cell lung cancer requires clarification. Through a supplemental analysis of the Japan Clinical Oncology Group (JCOG) 0802/West Japan Oncology Group (WJOG) 4607L, we investigated the associated factors, distribution, and recurrence pattern of lymph node metastases (LNMs) and proposed the optimal LND region. MethodsOf the 1106 patients included in the JCOG0802/WJOG4607L, 1056 patients with LNDs were included in this supplemental analysis. We investigated the distribution and recurrence pattern of LNMs along with the radiologic findings (with ground-glass opacity, part-solid tumor; without ground-grass opacity component, pure-solid tumor). ResultsThe radiologic findings were the only significant factor for LNMs. Of 533 patients with part-solid tumors, 8 (1.5%) had LNMs. Further, only 3 (0.5%) patients had pN2 disease, and no patients had interlobar LNMs from nonadjacent segments. Of the 523 patients with pure-solid tumors, 55 (10.5%) had LNMs, and 28 (5.4%) had pN2 disease. Five patients had metastases to nonadjacent interlobar lymph nodes (LNs). Two (2.0%) patients with S6 tumors had upper mediastinal LNMs. In addition, the incidence of mediastinal LN recurrence in patients with S6 lung cancer was greater in those who underwent selective LND than those who underwent systematic LND (P = .0455). ConclusionsNonadjacent interlobar and mediastinal LND have little impact on pathologic nodal staging in patients with part-solid tumors. In contrast, selective LND is recommended at least for patients with pure-solid tumors.

Paraneoplastic Neurologic Syndrome in Small Cell Lung Carcinoma

A 54-year-old male smoker, previously in good health, was admitted to the hospital due to a tingling sensation in his upper and lower extremities. He reported difficulty walking due to a loss of balance and numbness, leading to an initial diagnosis of chronic inflammatory demyelinating polyneuropathy. Brain and spine magnetic resonance imaging, along with needle electromyography, yielded inconclusive findings. However, a nerve conduction study indicated a length-dependent pattern of sensory-dominant polyneuropathy. A cerebrospinal fluid study did not reveal any specific findings in terms of cell numbers, proteins, or immune tests. Following hospitalization, the patient reported progressive dizziness upon standing, leading to a preliminary diagnosis of orthostatic hypotension. However, a positive anti-Hu autoantibody test, along with chest computed tomography and positron emission tomography scans, revealed a mass in the left interlobar lymph node, suggestive of lung cancer. An endoscopic biopsy confirmed the presence of small cell lung cancer (SCLC). The patient underwent chemo-radiation treatment for the SCLC and immunoglobulin therapy for sensory ganglionopathy. As a result, a definitive diagnosis of paraneoplastic neurologic syndrome was made. Although such cases are rare, our observations suggest that symptoms of dysautonomia and sensory ganglionopathy may be associated with the production of anti-Hu antibodies.

Microscopic feature of lymph node anthracosilicosis adherent with pulmonary artery: a case report

BackgroundAlthough thoracic surgeons occasionally encounter dense adhesions of interlobar lymph node anthracosilicosis with the pulmonary artery, adhesiolysis may be challenging. Besides, characteristic microscopic features of the adherent lesion remain limited.Case presentationDuring a thoracoscopic right upper lobectomy of a patient with stage IA3 primary lung adenocarcinoma, several interlobar lymph nodes adhered to the posterior ascending branch of the pulmonary artery to the right upper lobe were noted. After an unplanned conversion to a thoracotomy to avoid massive bleeding, the pulmonary artery branch was safely isolated. Microscopic examination revealed lymph node anthracosilicosis proximal to the peripheral pulmonary artery wall, with granulomatous inflammation. The adventitial stroma of the pulmonary artery developed into dense and borderless fibrous tissue with dust-laden macrophages.ConclusionsOur pathological findings on lymph node anthracosilicosis provide substantial evidence that adhesions between lymph nodes and the pulmonary artery walls may develop into dense and borderless fibrous tissue. This finding would remind thoracic surgeons that adhesiolysis could cause injury to the pulmonary artery.

Segmentectomy for ground-glass-dominant lung cancer with a tumour diameter of 3 cm or less including ground-glass opacity (JCOG1211): a multicentre, single-arm, confirmatory, phase 3 trial

Although segmentectomy is a widely used surgical procedure, lobectomy is the standard procedure for resectable non-small-cell lung cancer (NSCLC). This study aimed to evaluate the efficacy and safety of segmentectomy for NSCLC up to 3 cm in size, including ground-glass opacity (GGO) and predominant GGO. A multicentre, single-arm, confirmatory phase 3 trial was conducted across 42 institutions (hospitals, university hospitals, and cancer centres) in Japan. Segmentectomy with hilar, interlobar, and intrapulmonary lymph node dissection was performed as protocol surgery for patients with a tumour diameter of up to 3 cm, including GGO and dominant GGO. Eligible patients were those aged 20-79 years with an Eastern Cooperative Oncology Group performance score of 0 or 1 and clinical stage IA tumour confirmed by thin-sliced CT. The primary endpoint was 5-year relapse-free survival (RFS). This study is registered with the University Hospital Medical Information Network Clinical Trials (UMIN000011819), and is ongoing. A total of 396 patients were registered from Sept 20, 2013, to Nov 13, 2015, of whom 357 underwent segmentectomy. At a median follow-up of 5·4 years (IQR 5·0-6·0), the 5-year RFS was 98·0% (95% CI 95·9-99·1). This finding exceeded the 87% of the pre-set threshold 5-year RFS and the primary endpoint was met. Grade 3 or 4 early postoperative complications occurred in seven patients (2%), but no grade 5 treatment-related deaths occurred. Segmentectomy should be considered as part of standard treatment for patients with predominantly GGO NSCLC with a tumour size of 3 cm or less in diameter, including GGO even if it exceeds 2 cm. National Cancer Centre Research and Development Fund and Japan Agency for Medical Research and Development.

Human lymph node degeneration in the thoracic region: A morphometric and immunohistochemical analysis using surgically obtained specimens.

Lymph node degeneration was examined in 539 mediastinal and intrapulmonary nodes removed from 78 patients, aged 49–82 years, without cancer metastasis. Medullary sinus hyalinization observed in 36.2% of the hilar and 38.5% of the interlobar nodes. Early and smaller lesions were eosinophilic and factor VIII-positive, whereas advanced and large lesions contained a bulky mass of collagenous fiber bundles with few slender cells positive for smooth muscle actin (SMA) and factor VIII, as well as anthracotic macrophages. Subcapsular sinus hyalinization, observed in 4.3% of hilar nodes, was detected as a thick fibrous layer (over 0.2 mm) between the surface cortex and the thickened capsule. The fibrous layer contained SMA-positive slender cells, whereas the thickened capsule contained fibers positive for elastin and factor VIII. These hyalinization lesions occupied 3.6% and 0.8% of the sectional areas of hilar and lower paratracheal nodes, respectively. Areas of early and small cortical degeneration, surrounded by fibers positive for SMA and vimentin, did not contain lymphocytes and macrophages, but contained abundant small stromal cells. Silver staining suggested that advanced cortical degeneration was composed of collagen fibrils other than type I. Fatty tissues, seen in 47.8% of hilar nodes, often extended into and replaced medullary sinus tissue. Island-like remnants of medullary sinuses in areas of fatty degeneration contained various stromal cells positive for SMA, elastin, factor VIII and/or CD34. These degenerative morphologies, however, did not correlate with either age or smoking index. The present cortical degeneration usually seemed to follow hyalinization, but both were likely to occur independently.

Clinical utility of EBUS‐TBNA of hilar, interlobar, and lobar lymph nodes in patients with primary lung cancer

BackgroundEndobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is used to evaluate hilar/interlobar/lobar lymph nodes. This study aimed to assess the clinical utility of EBUS‐TBNA for station 10/11/12 lymph nodes (LNs) in patients with primary lung cancer.MethodsThis was a retrospective analysis of a prospectively collected database of patients with primary lung cancer who underwent EBUS‐TBNA for station 10/11/12 LNs from January 2015 to December 2019. Patients with benign results from EBUS‐TBNA who did not undergo surgical sampling/clinical follow‐up or who received radiotherapy/chemotherapy were excluded.ResultsThe analyses were conducted on 889 LNs from 797 patients. The overall diagnostic sensitivity, specificity, accuracy, negative predictive value (NPV), and positive predictive value of EBUS‐TBNA were 95.7, 100, 97.3, 93.2, and 100%, respectively. Diagnostic sensitivity was significantly lower for LNs <10 mm than ≥10 mm in size (90.1% vs. 97.8%; p < 0.001). There was no significant difference in diagnostic performance according to the nodal station (10 vs. 11/12) and left‐ versus right‐sided LNs. The diagnostic sensitivity (100 vs. 95.5%; p = 0.221) and specificity (100 vs. 100%) of N3 LNs was not significantly different from those of N1 LNs. In this study, eight (8/91, 8.8%) patients with cN1 NSCLC received neoadjuvant treatment based on the results of EBUS‐TBNA.ConclusionEBUS‐TBNA accurately evaluates station 10/11/12 LNs of both N1 and N3 disease. The diagnostic performances of EBUS‐TBNA for station 10/11/12 LNs seem to be comparable to those of EBUS‐TBNA for mediastinal LNs.

Non-adjacent interlobar lymph node metastasis distant from small-sized peripheral non-small cell lung cancer.

The optimal extent of lymph node dissection (LND) during segmentectomy is unclear. During segmentectomy, it is more challenging to dissect the non-adjacent interlobar lymph node (non-aiLN) away from the primary tumor than to dissect the adjacent interlobar lymph node (aiLN), as injury to the preserved parenchyma and bronchus may occur. We examined whether dissection of non-aiLNs was required during intentional segmentectomy. This retrospective cohort study included 310 patients who underwent lobectomy and mediastinal LND for non-small cell lung cancer of ≤ 2cm at the Osaka International Cancer Institute during January 2006 to December 2015. We investigated LN metastasis distribution and evaluated metastases in non-aiLNs distant from the primary lesion. Six (1.9%) patients had iLN metastasis. Patients with iLN metastasis did not have primary lesions in the right upper lobe or left upper segment. Of the six patients with iLN metastasis, three had non-aiLN metastasis with a tumor diameter of ≥ 15mm, with high positron emission tomography standard uptake values (> 3.5). Two patients had multiple LN metastases, and one had solitary LN metastasis. Non-aiLN dissection may be unnecessary during segmentectomy of the right upper lobe or left upper segment; however, it should be considered during lower-lobe segmentectomy.

Strategies of Lymph Node Dissection During Sublobar Resection for Early-Stage Lung Cancer.

The standard surgical treatment of NSCLC remains lobectomy combined with lymph node (LN) dissection (LND), even for early stage tumors (1). However, there is a growing interest in sublobar resections (SLR), even in patients who can tolerate a lobectomy, as reflected by the increasing number of publications referenced in PubMed (2) as well as changing practices. Thus, in our department, the average rate of SLR varies between 25 and 35% (3). Trials comparing lobectomy and RSL are underway (4–6) and the favorable results of the JCOG-0802 study has recently been announced (publication pending at the time of writing this article). Until now, the published survival results of SLR have been less satisfactory than those of lobectomies. For several years, after the publication of the Lung Cancer Study Group comparing lobectomies and SLR, which showed poor results on local recurrence and survival, lobectomy has been considered the gold standard treatment (7). Subsequent cohort studies have confirmed this attitude. In particular, the SEER database study of over 14,000 patients with NSCLC demonstrated significantly better survival after lobectomy, regardless of tumor size (8). Surgeons have until now considered lobectomy to be the standard treatment for NSCLC–apart from cases requiring pneumonectomy for location reasons–not only because of the above-mentioned findings, but also to apply the recommendations and with the consideration that a lobectomy provides satisfactory safety margins and allows removal of the lymphatic networks and intralobar nodes. Several years ago, the presence of invaded interlobar nodes led to the extension of the resection to pneumonectomy. The poor oncological benefit and the high morbidity and mortality of pneumonectomies have led to abandon this dogma. However, many recent monocentric studies have demonstrated the non-inferiority, or even a slight superiority of SLR over lobectomies for early-stage NSCLC (9–13). Currently, more and more teams are performing SLR for selected early-stage tumors. Presumably, they apply, or should apply, the same oncological rules as for lobectomies, which have been clearly defined (14–16), i.e., performing a macroscopically complete resection with free margins and a systematic lymph node dissection, according to the guidelines (14). One of the questions is therefore why intersegmental LN dissection and analysis of the resection margins are not routinely performed during SLR for cancer. The latter point is not the subject of this article and we will focus here on lymph node dissection during SLR. The reasons for the possible inferiority of SLR compared to lobectomy, at least in some cohort studies, are the following (and these reasons can be correlated): (1) some SLRs are actually wedge resections, (2) insufficient resection margins, (3) low number of nodes being examined, (4) absence of analysis of the so-called “adjacent” nodes and (5) non-practice of frozen section on margins and on the segmental nodes, which does not allow for extension to lobectomy during the procedure (Positivity nodes on final pathological examination rarely leads to a reoperation). All in all, as emphasized by P. Thomas, lymph node dissection might be the key point in performing a “radical segmentectomy” (17). In this article, we will look at the four areas of concern and end-up with proposals.

DIAGNOSTIC CAPABILITIES OF FINE NEEDLE ASPIRATION OF LYMPH NODES METASTASES OF PRIMARY PULMONARY LYMPHOEPITHELIAL CARCINOMAS

Introduction. Primary pulmonary lymphoepithelial carcinoma is a poorly differentiated squamous cell carcinoma admixed with variable amounts of lymphoplasmacytic infiltrate, frequently associated with EBV. It is a rare cancer and have a better prognosis than other non-small cell lung cancer. The tumor can mimic metastatic non-keratinizing SCC of the naso-pharynx, poorly differentiated non-small cell carcinoma and NUT carcinoma arising in the lung, and non-Hodgkin lymphomas. Materials and methods. A 75-year-old man presented with peripheral mass of left lower lobe, maximal diameter was 5.1 cm, involving lingula and medial pleura, with mediastinal, and retroperitoneal lymphadenopathy revealed by computer tomography. Fine needle aspiration-EBUS was performed from hilar and interlobar lymph nodes. Papanicolaou smears and cell blocks were prepared. Additional CT-guided cor-needle biopsy and FNA were performed from lung lesion later. Results. A few large malignant epithelial cells, consistent with non-small lung cancer, were found on a background of lymphocytes in fine-needle aspiration from lymph nodes. Immunostain results: Pan-CK (AE1/AE3), p63 and Ki67 were positive in malignant cells, leukocyte common antigen (CD45) was positive in lymphocytes (negative in tumor cells), and negative markers were TTF1, chromogranin and synaptophysin. Cytological diagnosis was metastatic non-small lung cancer, favor squamous cell carcinoma. Biopsy and aspiration from left lung showed syncytial groups of large malignant epithelial cells with scant cytoplasm and prominent nucleoli on a background of prominent inflammatory infiltrate,consistent with lymphoepithelial carcinoma. Conclusion. It is impossible to correctly diagnose metastasis of lymphoepithelial carcinoma in lymph node by FNA only without FNA or biopsy of primary lesion, because cytological features and immunostains are identical to non-keratinizing squamous cell carcinoma.

The left main bronchus transected incorrectly during video-assisted thoracoscopic lobectomy: a case report

BackgroundSeveral severe intraoperative complications of lung cancer surgery have been reported, but the incorrect transection of the main bronchus is a very rare and serious complication. We report a surgical case of a patient with left lower lobe lung cancer invading the inferior segment of the lingula, with fused interlobar fissure and dense pleural adhesion, in which the left main bronchus was mistaken for the left lower lobe bronchus and was transected.Case presentationA 64-year-old woman with lung adenocarcinoma was referred to our hospital for surgical treatment. Chest computed tomography (CT) scan showed a 30-mm nodule with a clear border and irregular margins in the center of the anterior (S8) segment of the lower lobe of the left lung and another similar 30-mm nodule in the lateral (S9) segment of the same lobe. Metastasis within the same lobe was suspected. A thoracoscopic left lower lobectomy was scheduled for the patient. As the patient had a moderately, fused fissure, dense pleural adhesion, and suspicious tumor invasion from the left S8 segment to the left S5 segment, and the interlobar node tightly adhered to the main PA at the site of basilar artery origin of the LLL, we performed left lower lobectomy and a left S5 segmentectomy using the fissureless fissure-last technique. During surgery, the left main bronchus was mistaken for the left lower lobe bronchus and was transected. After transecting the left main bronchus, we performed a sleeve bronchoplasty to prevent pneumonectomy.ConclusionsWe experienced the rare and serious intraoperative complication of the incorrect transection of the main bronchus. There are few reports of this intraoperative complication, and it should not be overlooked by surgeons.

Delayed diagnosis of lung cancer due to misdiagnosis as worsening of sarcoidosis: a case report

BackgroundThe concurrence of sarcoidosis and primary lung cancer is very rare. We report a very rare case with a delayed diagnosis of primary lung cancer due to its misdiagnosis as worsening of pulmonary sarcoidosis.Case presentationA 68-year-old man presented to the outpatient department for evaluation of a mass in the right hilar area with lymphadenopathies in subcarinal and both interlobar areas on chest computed tomography (CT). Sufficient core samples were obtained from subcarinal and bilateral interlobar lymph nodes using endobronchial ultrasonography (EBUS) guided transbronchial needle aspiration (TBNA). EBUS could not reach the right hilar lymph node due to its high angle. The pathologic findings were consistent with sarcoidosis. After 5 months, chest CT revealed aggravation of the right upper paratracheal lymphadenopathy. Assuming worsening of sarcoidosis, he was prescribed an oral corticosteroid for 5 months. However, follow-up chest CT showed a newly developed right lower paratracheal lymphadenopathy and worsening right hilar lymphadenopathy. Bronchoscopy and EBUS were performed once again. Transbronchial lung biopsy from the right upper lobe and EBUS-TBNA from the right lower paratracheal lymph node revealed adenocarcinoma from the lung.ConclusionsAlthough coexistence of sarcoidosis and lung cancer is very rare, the clinician should consider the possibility of accompanying lung cancer in sarcoidosis patients who are not responding to initial corticosteroid therapy.

Discussion

Discussion

POLICY CHANGES AFTER A RARE COMPLICATION OF EBUS-TBNA: EXPECTORATION OF A METAL SHEATH

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Since the first application of ultrasound in the airway in 1992, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a widely-used effective and minimally invasive method of diagnosing and staging mediastinal lymph nodes and masses. The procedure is generally well-tolerated. Major complications involving EBUS-TBNA are low, but there are increasing reports of procedure-related complications. We present a case of a retained inner metal sheath of the Olympus EBUS-TNBA needle catheter after instrument malfunction. CASE PRESENTATION: A 47-year old male was referred for EBUS-TBNA for worsening cough for the past year. A computed tomography of the chest revealed bilateral hilar and mediastinal adenopathy concerning for sarcoidosis. Endobronchial ultrasound was used to assist with guiding biopsy of hilar and mediastinal regions. An EBUS-TBNA was performed using an Olympus EBUS-TBNA 22-gauge needle. Specimens were obtained from the 7, 10R, and 11L lymph nodes. During sampling of the left interlobar lymph node, there was unexpected resistance when attempting to advance the needle. The needle was repositioned and the lymph node was aspirated without further difficulty. Rapid On-Site Evaluation revealed non-necrotic granulomatous tissue of the subcarinal lymph node. The tracheobronchial tree was examined to at least the first sub-segmental level. Bronchial mucosa and anatomy were normal with no endobronchial lesions, secretions or foreign bodies visualized. The patient tolerated the procedure well and was discharged. On his way home, the patient reported expectorating “a metal sheath.” The Olympus EBUS-TBNA needle catheter was examined and it was discovered that the inner metal sheath located in the distal plastic sheath of the needle catheter was missing which corresponded to the inner metal sheath of the needle catheter. The patient did not have any complications from this event. DISCUSSION: EBUS-TBNA is the preferred modality in the diagnosis and staging of mediastinal lymph nodes and masses with high specificity and sensitivity. Serious EBUS complication rates range from 0.15-0.16%, including mediastinal abscess, empyema, needle fracture, and hemo-pneumomediastinum, Literature review showed a single case report of an expectorated “stent” from EBUS-TBNA. Due to the malfunction of the needle catheter, a root-cause analysis was performed and protocol changes were subsequently made to our institutional policy. CONCLUSIONS: EBUS-TBNA is accepted as a safe, well-tolerated procedure with low major complication rates. Our case is only the second reported case of assembly malfunction causing unexpected deployment of the inner metal sheath into the bronchi. While no serious complications resulted from this, providers performing EBUS-TBNA need to be aware of this potential device malfunction. We recommend routine inspection of the needle apparatus pre- and post-procedure. Reference #1: Caglayan BYilmaz A, et al. Complications of Convex-Probe Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Multi-Center Retrospective Study. Respir Care. 2016 Feb;61(2):243-8. Reference #2: Zamora FD, Moughrabieh A, et al. An Expectorated "Stent": An Unexpected Complication of EBUS-TBNA. J Bronchology Interv Pulmonol. 2017 Jul;24(3):250-252. Reference #3: Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14:50 DISCLOSURES: No relevant relationships by Michael Ayers, source=Web Response No relevant relationships by Ngoc-Tram Ha, source=Web Response No relevant relationships by Cynthia Tsai, source=Web Response

The technique of thoracic lymph node dissection

Systematic mediastinal, hilar and interlobar lymph node dissection is required in the S3guidelines for the treatment of operable lung cancer. The lymph node involvement is considered one of the key prognostic factors. The type of lymph node resection is repeatedly the subject of controversially discussion. Lymph node dissection is essential for staging, prognosis, survival and recurrence rate. It should be standardized as a compartmental dissection with en bloc resection of lymph nodes including surrounding fat and connective tissue. Thus, exact knowledge of the anatomy of the thoracic organs with their peculiarities and high anatomical variability is necessary.

Clinicopathologic features and lymph node metastatic characteristics in patients with adenocarcinoma manifesting as part-solid nodule exceeding 3 cm in diameter

PurposeThe purpose of this study was to elucidate the clinicopathologic and lymph node metastatic characteristics in patients with adenocarcinoma manifested as persistent ground glass mass (GGM, ground glass opacity [GGO] exceeding 3 cm in diameter). Materials and Methods304 patients with adenocarcinoma manifested as persistent GGM > 3 cm, who underwent complete surgical resection between November 2013 and December 2017 were included in this study. We elucidated the lymph node metastatic incidence and characteristics according to the primary tumor lobe location and extracted the associated clinicopathological factors, especially thin-section computed tomographic findings, with lymph node involvement. ResultsAll of the GGMs were invasive adenocarcinoma in histopathology. The total incidence of lymph node metastasis was 2.0% (6/304). All of the 6 cases with hilar or mediastinal lymph node metastasis were manifested as solid-predominant GGM > 3 cm and no cases with lymph node metastasis were identified in GGO-predominant GGM > 3 cm. Lymph node metastases were more likely to present in younger patients (p = 0.032), tumors with solid size >2.0 cm (p = 0.000), more advanced clinical T stage (p = 0.000), radiological solid-predominant tumors (p = 0.002) and acinar-predominant or papillary-predominant adenocarcinoma (p = 0.002). As for solid-predominant GGMs >3 cm, lymph node metastases were more likely to be found in tumors with solid size >2.0 cm (p = 0.026), more advanced clinical T stage(p = 0.026), acinar-predominant or papillary-predominant adenocarcinoma (p = 0.029). Whole tumor size was not associated with the presence of lymph node metastases. There were 2 right upper-lobe cases with upper mediastinal lymph nodes skip metastasis without intrapulmonary, interlobar, and hilar lymph node metastasis. ConclusionAll of the GGMs >3 cm were invasive adenocarcinoma. The incidence of lymph node metastasis in GGO-predominant GGMs >3 cm was extremely low. Solid size would be a better predictor of lymph node metastasis than whole tumor size in sold-predominant GGMs >3 cm.

Extended bronchoplasty for locally advanced left lower lobe lung cancer: surgical technique and outcomes.

Extended bronchoplasty combined with left lower lobectomy plus lingulectomy can be indicated for some locally advanced left lower lobe cancers to avoid pneumonectomy, but its outcome has not been well studied. We retrospectively analysed the surgical outcomes of 10 patients since 2008, when we introduced this procedure. The median age was 67 years (range 42-80). Squamous cell carcinoma was the most common histology. The indication for this procedure was bulky or extranodal metastasis in an interlobar node in 9 patients and massive tumour invasion to the lingula in 1 patient. Bronchoplasty was performed by a sleeve (n = 7) or deep-wedge (n = 3) resection of the left main and superior division bronchi, according to the type of tumour extension. One of the sleeve cases resulted in anastomotic kinking and was converted to left pneumonectomy intraoperatively, but no postoperative morbidity or mortality was observed. Locoregional recurrence was not found with a median follow-up of 31 months (range 13-83). This type of extended bronchoplasty can be a safe alternative to left pneumonectomy for left lower lobe cancers invading an interlobar node or lingula in which R0 resection is difficult by a simple or standard sleeve left lower lobectomy.