Mediastinal Involvement Research Articles

Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management.

Necrotizing fasciitis of the face is uncommon but potentially life threatening. With adequate multidisciplinary treatment, mortality and has significantly improved. This article highlights current concepts and supporting literature in the management of facial necrotizing fasciitis. Management of necrotizing fasciitis involving the face requires a multisciplinary team approach, including early medical and surgical intervention. With early haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement, mortality has reduced significantly. Soft-tissue reconstruction can be effectively utilized once the infection has been adequately treated. Although some adjunctive treatment such as vacuum assisted closure dressing has shown to be of benefit, other treatments such as hyperbaric oxygen remains controversial. Necrotizing fasciitis is an aggressive soft tissue involving that rapidly spreads along fascial planes. Necrotizing fasciitis involving the face is rare owing to its rich blood supply but is also difficult to manage due to the complex regional anatomy. Common sources are odontogenic, sinugenic, peritonsillar or salivary gland infections and often polymicrobial. The principles of treatment include early and aggressive haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement. Often times repeat debridements following close monitoring is required. Reconstructive options are viable only after the infection has been adequately treated. Although mortality has significantly improved, mediastinal involvement, multiple comorbidities and delayed treatment confers a worse prognosis.

Long-term clinical outcomes and prognostic factors of upfront surgery as a first-line therapy in biopsy-proven clinical N2 non-small cell lung cancer.

BackgroundMultimodality therapy offers the best opportunity to improve pathological N2 non-small cell lung cancer (NSCLC) prognosis. This paper aimed to evaluate the long-term clinical outcomes and the prognostic factors of upfront surgery as first-line therapy in biopsy-proven clinical N2.MethodsRetrospective review of biopsy-proven cN2 NSCLC patients operated between 2007 and 2017. Upfront surgery was considered if the primary tumour was deemed completely resectable, with mediastinal nodal involvement confined to a single station and no preoperative evidence of extranodal tumour invasion.ResultsTwo hundred eighty-five patients who underwent radical resections were included. One hundred fifty-nine patients (55.8%) received induction chemotherapy. At follow-up completion, 127 (44.6%) patients had died. For the induction chemotherapy group, the median overall survival (OS) was 49 months [95% confidence interval (CI): 38–70 months], and the 5-year OS was 44.4%. The median and 5-year OS for the up front surgery group was 66 months (95% CI: 40–119 months) and 66.3%, respectively. There were no statistically significant differences between treatment approaches (p = 0.48). One hundred thirty-four patients (47.0%) developed recurrence. The recurrence-free survival (RFS) at 5 years was 17% (95% CI: 11–25%) for induction chemotherapy and 22% (95% CI: 9–32%) for upfront surgery; there were no statistically significant differences between groups (p = 0.93). No significant differences were observed based on the clinical N status (OS, p = 0.36; RFS, p = 0.65).ConclusionsUpfront surgery as first-line therapy for biopsy-proven cN2 NSCLC showed favourable clinical outcomes, similar to those obtained after induction chemotherapy followed by surgery. Therefore, it should be considered one of the multimodality treatment options in resectable N2 NSCLC.

Diagnostic Value of Mediastinal Lymphadenopathy in Differentiating Pulmonary Tuberculosis from Community-Acquired Pneumonia in Children

Background: Diagnosis of childhood pulmonary tuberculosis (TB) is often based on clinical features in combination with radiologic findings because of paucibacillary nature of the disease in children. It may be difficult to make a clinical diagnosis because of the overlapping clinical features of pulmonary TB and community-acquired pneumonia (CAP). On computed tomography (CT) scanning, the presence of typical LAP can suggest TB as a possible cause. Objectives: To compare the features of mediastinal LAPs between two patient groups based on contrast-enhanced chest CT. Methods: A total of 45 pulmonary patients with TB and 38 patients with CAP (aged ≤ 18 years) were enrolled in this retrospective study. The presence and CT features of lymph node involvement and the incidence of associating parenchymal/pleural findings were analyzed in two groups. Results: All patients with TB and 36 of the 38 patients with CAP had at least one mediastinal LAP. There was no significant difference between the two groups according to the incidence of lymph node and multiple site involvement and also involved lymph node stations (P > 0.05). However, lymph node size was larger in the TB group (P = 0.04). Twenty-two percent of patients with TB had mediastinal LAP without parenchymal/pleural involvement. Conclusions: Although the lymph node size was larger in TB group than in CAP group, CT features of mediastinal lymph node involvement overlapped between two groups. Nevertheless, mediastinal LAP without parenchymal/pleural involvement on CT is seen in a significant number of TB patients.

Long-term survival of patients with central or > 7 cm T4 N0/1 M0 non-small-cell lung cancer treated with definitive concurrent radiochemotherapy in comparison to trimodality treatment

AbstarctBackgroundTo examine long-term-survival of cT4 cN0/1 cM0 non-small-cell lung carcinoma (NSCLC) patients undergoing definitive radiochemotherapy (ccRTx/CTx) in comparison to the trimodality treatment, neoadjuvant radiochemotherapy followed by surgery, at a high volume lung cancer center.MethodsAll consecutive patients with histopathologically confirmed NSCLC (cT4 cN0/1 cM0) with a curative-intent-to-treat ccRTx/CTx were included between 01.01.2001 and 01.07.2019. Mediastinal involvement was excluded by systematic EBUS-TBNA or mediastinoscopy. Following updated T4-stage-defining-criteria initial staging was reassessed by an expert-radiologist according to UICC-guidelines [8th edition]. Outcomes were compared with previously reported results from patients of the same institution with identical inclusion criteria, who had been treated with neoadjuvant radiochemotherapy and resection. Factors for treatment selection were documented. Endpoints were overall-survival (OS), progression-free-survival (PFS), and cumulative incidences of isolated loco-regional failures, distant metastases, secondary tumors as well as non-cancer deaths within the first year.ResultsAltogether 46 consecutive patients with histopathologically confirmed NSCLC cT4 cN0/1 cM0 [cN0 in 34 and cN1 in 12 cases] underwent ccRTx/CTx after induction chemotherapy (iCTx). Median follow-up was 133 months. OS-rates at 3-, 5-, and 7-years were 74.9%, 57.4%, and 57.4%, respectively. Absolute OS-rate of ccRTx/CTx at 5 years were within 10% of the trimodality treatment reference group (Log-Rank p = 0.184). The cumulative incidence of loco-regional relapse was higher after iCTx + ccRT/CTx (15.2% vs. 0% at 3 years, p = 0.0012, Gray’s test) while non-cancer deaths in the first year were lower than in the trimodality reference group (0% vs 9.1%, p = 0.0360, Gray’s test). None of the multiple recorded prognostic parameters were significantly associated with survival after iCTx + ccRT/CTx: Propensity score weighting for adjustment of prognostic factors between iCTx + ccRT/CTx and trimodality treatment did not change the results of the comparisons.ConclusionsPatients with cT4 N0/1 M0 NSCLC have comparable OS with ccRTx/CTx and trimodality treatment. Loco-regional relapses were higher and non-cancer related deaths lower with ccRTx/CTx. Definitive radiochemotherapy is an adequate alternative for patients with an increased risk of surgery-related morbidity.

Does mediastinal lymph node involvement influence the surgical outcome in malign pleural mesothelioma?

Background This study examined the effect of metastatic mediastinal lymph node involvement on the prognosis of patients with malignant pleural mesothelioma (MPM) who underwent extrapleural pneumonectomy (EPP) or extended pleurectomy (E/P) and also to assess the effect of metastatic mediastinal lymph node involvement on the prognosis of patients with MPM in these group of patients. Methods This retrospective study included 84 patients with MPM (66 men [78.6%] and 18 women [21.4%]) who underwent EPP (n = 44) or E/P (n = 40) at our institution between January 2001 and July 2019. Survival analyses were performed according to histopathology, nodal status, and surgical approach. Results In the EPP group, patients with T2-N2 status had a significantly better mean survival (17 ± 2.1 months) than patients with T3-N2 (7.3 ± 1.6 months) or T4-N2 (3.2 ± 1.1 months) status (p = .001). In the E/P group, patients with T2-N2 status had a mean survival of 18 ± 1.1 months, while patients with T3-N2 and T4-N2 status had mean survival durations of 6.6 ± 1.6 and 4.8 ± 1.2 months, respectively (p = .159). In both treatment groups, the survival rates of patients with epithelial tumors were better than those of patients with non-epithelial tumors, independent of N status. None of the patients with N2 disease survived until 5 years postoperatively. Conclusion In summary, our results suggested that mediastinal lymph node metastasis negatively influenced the prognosis of patients with T3 MPM, regardless of treatment by EPP or E/P. Under these circumstances, preoperative cervical mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration may be considered for patients with high-stage MPM who are scheduled for surgery with curative intent. In our study, N2 status was spotted as a significant factor affecting survival, nevertheless its significance in survival of pleural mesothelioma patients should be analyzed in multi-centered studies.

Comparison between diffusion-weighted magnetic resonance and positron-emission tomography in the evaluation of treated lymphomas with mediastinal involvement

BackgroundThe persistence of residual tissue after treatment is frequent in patients with mediastinal lymphomas and it is often characterized by 18F-Flurodeoxyglucose Positron Emission Tomography (18F-FDG PET) uptake. This study aims to investigate the usefulness of diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) sequence in residual tissues of treated mediastinal lymphomas and to compare it with 18F-FDG PET-CT.ResultsWe included 21 patients with mediastinal Hodgkin and non-Hodgkin lymphomas who showed residual masses on PET-CT imaging at end of treatment and underwent DWIBS-Magnetic Resonance Imaging (MRI). SUVmax and Apparent Diffusion Coefficient (ADC) values of residual masses were assessed quantitatively, including measurement of mean ADC. 15 patients showed radiotracer uptake at 18F-FDG PET-CT, among them only 3 had positive DWIBS-MRI with low ADC values (median value: 0.90 mm2/s). The mediastinal biopsy in these 3 “double positive” patients confirmed pathological residual tissue. All the patients with positive 18F-FDG PET-CT but negative DWIBS-MRI (n = 18) with high ADC values (median value: 2.05 mm2/s) were confirmed negative by biopsy.ConclusionsDWIBS-MRI examination combined with ADC measurement allowed to discriminate pathological and non-pathological residual tissue in patients with treated mediastinal lymphoma. These preliminary results seem to pave the way for a leading role of the MRI which could be a useful alternative to the 18F-FDG PET/CT.

Treatment of early and locally advanced stages of non-small cell lung cancer

Treatment concepts for patients with localized and locally advanced non-small cell lung cancer (NSCLC) are based on local treatment, surgery and/or radiotherapy, with curative intent. An adjuvant systemic treatment is added after primary resection of an operable NSCLC primarily to reduce the systemic risk of relapse. Locally advanced stages with mediastinal lymph node involvement carry asubstantial risk of local and distant recurrence and require multimodal treatment strategies in an interdisciplinary approach. Recently, immunotherapy with programmed cell death1 (PD-1)/programmed cell death1 ligand1 (PD-L1) checkpoint inhibitors is increasingly being integrated into adjuvant, neoadjuvant or perioperative treatment concepts.

Surgical resection, radiotherapy and percutaneous thermal ablation for treatment of stage 1 non-small cell lung cancer: protocol for a systematic review and network meta-analysis

IntroductionNon-small cell lung cancer (NSCLC) makes up the majority of lung cancer cases. Currently, surgical resection is the gold standard of treatment. However, as patients are becoming medically more complex...

Heterogeneity of stage IIIA non-small cell lung cancer—different tumours, different nodal status, different treatment, different prognosis: a narrative review

: Stage IIIA non-small cell lung cancer (NSCLC) consists of a heterogeneous group of disease, ranging from small T1a tumours with ipsilateral mediastinal lymph node involvement over T3 tumours with chest wall invasion, up to T4 tumours with mediastinal invasion with or without positive hilar lymph nodes. Based on this heterogeneity, treatment approaches as well as prognosis are very dependent on specific subgroups. Therapy recommendations should be based on multidisciplinary case discussions in high volume centres including medical and radiation oncologists, pneumologists and experienced thoracic surgeons specialized in thoracic cancer surgery. Recommendations may differ from standards in highly selected cases. Therefore, independent of age, in medically fit (operable) patients with resectable stage IIIA tumours, an aggressive approach in a curative setting is key to obtain good overall survival rates. Moreover, maintaining quality of life is essential. In this narrative review, the different aspects of all the subgroups of stage IIIA NSCLC and their heterogeneity as well as the variety of treatment modalities, their combined treatment approaches and survival rates are discussed. Again, the reported 5-year survival rates, ranging from 5% in patients with bulky N2 disease, up to 50% for patients with superior sulcus tumours with hilar lymph node disease, reflect the heterogeneity of stage IIIA NSCLC.

Pleomorphic sarcoma of the chest wall: A case report

Primary pleomorphic liposarcoma of the chest wall is a rare entity. Most of the reported cases of the chest wall liposarcomas are low grade, well differentiated with mediastinal extension. Majority of these develop from a subcutaneous lipoma. Complete surgical resection is the preferred treatment modality. The benefit of adjuvant radiotherapy or chemoradiotherapy for these tumors is a subject of debate. We report, an unusual case of high grade primary pleomorphic subtype of liposarcoma in a 50-year-old male presenting with a painful swelling in the anterior thoracic wall extending into the pleura but without any mediastinal involvement or distant metastasis.

PHACE syndrome: a frequently overlooked entity

<p>Infantile hemangiomas are the commonest vascular tumors of infancy. About 10% are associated with PHACE syndrome, a rare condition presenting with multiple systemic anomalies along with large cervicofacial hemangiomas<strong>.</strong> We present two case reports of this rare entity. First, a six year old female, with cutaneous hemangiomas involving the face and oral cavity, and extracutaneous hemangiomas involving the parotid glands, choroid and peripapillary region of the eye. MRI brain revealed presence of vascular malformations in the circle of Willis along with impingement of optic nerve. MRI head and neck region confirmed the presence of hemangiomas in bilateral parotid gland, right upper eyelid near medial canthus and in the suprasternal region. Second, a three-month-old female presenting with stridor along with hemangiomas involving segment 3 of face, oral cavity and parotid glands. CECT neck and Chest showed hemangiomas involving bilateral parotid and submandibular glands. Mediastinal involvement with extraluminal compression of airway was noted. Microlaryngobronchoscopy did not reveal presence of any airway hemangiomas. Ophthalmological examination showed signs of optic nerve hypoplasia. In both the cases, all the clinico-radiological findings were put together to establish the diagnosis. Both of them also showed significant response to the oral propranolol therapy. Due to the rarity and overlapping features of this syndrome, there is a high chance to overlook this diagnosis. A high index of suspicion and awareness about the features is needed to identify this condition and provide specific treatment.</p>

Role of Adjuvant Radiotherapy in Non-Small Cell Lung Cancer-A Review.

Simple SummaryThe role of postoperative radiotherapy (PORT) in completely resected non-small cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (pN2) is controversial. The aim of our review was to study the literature relating to PORT for completely resected NSCLC patients with pN2 involvement. The Lung ART and PORT-C trials indicate better locoregional control with PORT, but this has not yet translated into survival benefits. Given the conflicting results, guidelines do not recommend the use of PORT routinely. Future research should focus on identifying subgroups of patients who might benefit from PORT.Background: For patients with completely resected non-small cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (pN2), the administration of adjuvant chemotherapy is the standard of care. The role of postoperative radiation therapy (PORT) is controversial. Methods: We describe the current literature focusing on the role of PORT in completely resected NSCLC patients with pN2 involvement and reflect on its role in current guidelines. Results: Based on the results of the recent Lung ART and PORT-C trials, the authors conclude that PORT cannot be generally recommended for all resected pN2 NSCLC patients. A substantial decrease in the locoregional relapse rate without translating into a survival benefit suggests that some patients with risk factors might benefit from PORT. This must be balanced against the risk of cardiopulmonary toxicity with potentially associated mortality. Lung ART has already changed the decision making for the use of PORT in daily practice for many European lung cancer experts, with lower rates of recommendations for PORT overall. Conclusions: PORT is still used, albeit decreasingly, for completely resected NSCLC with pN2 involvement. High-level evidence for its routine use is lacking. Further analyses are required to identify patients who would potentially benefit from PORT.

Hodgkin Lymphoma in Children Under 5 Years: Do They Behave Differently?

The median age of presentation for Hodgkin lymphoma (HL) is lower in developing countries with a higher proportion under 5 years of age possibly attributable to the high prevalence of Epstein-Barr virus-driven disease. It is unclear whether the clinical presentation and outcomes of this cohort are different with concern regarding late effects being most pronounced in this age group. We report the outcome of children under 5 years of age enrolled in the InPOG-HL-15-01, the first multicentric collaborative study for newly diagnosed children and adolescents with HL from India. Thirty-five (9%) of the study population was younger than 5 years with a striking male preponderance of 34:1. They were less likely to have bulky disease, mediastinal or splenic involvement. The outcomes appear to be at least as favorable as in the older patient group. Efforts need to be made to evolve treatment strategies that spare this very young cohort from potential late effects.

Role of Radiosurgery and Stereotactic Ablative Radiotherapy for Oligometastatic Non-Oncogene Addicted NSCLC.

Simple SummaryThe definition and management of oligometastatic NSCLC have been incorporated into current guidelines on lung cancer, supporting the use of a definitive treatment with curative intent, including the focal ablation of all sites of oligometastatic involvement. Clinical evidence highlighting the use of local ablative treatment (LAT), alone or in combination with systemic therapies, demonstrated significant benefit in local control and progression-free survival, especially in “oncogene-addicted” patients, who benefit the most from the local treatment of oligoprogressive or oligorecurrent sites to restore the overall sensitivity of the metastatic disease to target therapies. On the other hand, only a few studies, with limited numbers, focused specifically on “non-oncogene” addicted patients. The aim of this study is to assess the role of LAT, referred to stereotactic ablative radiotherapy, and to report clinical outcomes of the largest retrospective series, to date, of patients with oligometastatic EGFR/ALK/ROS1 wild type NSCLC.Local ablative therapy (LAT), intended as stereotactic ablative radiotherapy or stereotactic radiosurgery, is a well-recognized effective treatment for selected patients with oligometastatic NSCLC. Current clinical evidence supports LAT alone or in combination with systemic therapies. Our retrospective mono-institutional study aims to assess the role of LAT with a peculiar focus on the largest series of non-oncogene addicted oligometastatic NSCLC patients to date. We included in this analysis all patients with the mentioned disease characteristics who underwent LAT for intracranial and/or extracranial metastases between 2011 and 2020. The main endpoints were local control (LC), progression free survival (PFS) and overall survival (OS) in the whole population and after stratification for prognostic factors. We identified a series of 245 consecutive patients (314 lesions), included in this analysis (median age 69 years). In 77% of patients, a single metastasis was treated with LAT and intracranial involvement was the most frequent indication (53% of patients) in our series. The overall response rate (ORR) after LAT was 95%. In case of disease progression, 66 patients underwent new local treatments with curative intent. With a median follow-up of 18 months, median PFS was 13 months (1-year PFS 50%) and median OS was 32 months (1-year OS 75%). The median LC was not reached (1-year LC 89%). The presence of brain metastases was the only factor that negatively affected all clinical endpoints, with a 1-year LC, PFS and OS of 82%, 29% and 62% respectively, compared to 95%, 73% and 91%, respectively, for patients without BMs (p < 0.001 for each endpoint). At the multivariate analysis, mediastinal nodal involvement at baseline (p = 0.049), ECOG PS = 1 (p = 0.011), intracranial disease involvement (p = 0.001), administration of chemotherapy in combination with LAT (p = 0.020), and no delivery of further local treatment for progression or delivery of focal treatment for intracranial progression (p < 0.001) were related to a poorer OS. In our retrospective series, which is to our knowledge the largest to date, LAT showed encouraging results and confirmed the safety and effectiveness of focal treatments in non-oncogene addicted oligometastatic NSCLC patients.

Pediatric primary mediastinal lymphoma – a descriptive study of a single cancer center of Bangladesh

Lymphomas involving the mediastinum occur in a wide age range and represent heterogeneous histological subtypes with various clinical symptoms and complex radiological findings. However, this cross sectional study that describes the clinical, pathological and radiological features of Bangladeshi pediatric patients aged less than 18 years. The study conducted in National Institute of Cancer Research and Hospital with 71 primary pediatric mediastinal masses, diagnosed between 2014 and 2018 and evaluated at enrollment or admission in the department of Pediatric Hematology and Oncology (PHO). The presence of extra thoracic lymph node involvement was excluded from the study. All patients were underwent computerized tomography (CT) or ultra sound (USG) guided needle biopsy. Only diagnosed cases of lymphoma (N-38) with mediastinal mass on chest radiography or CT scan were taken for analysis. Mediastinal lymphoma was 38 in number which, 16.30% of total (N-233) pediatric lymphoma of PHO. The median age of the patients was 11.43 years with mostly (68.42%) in 10-17 years age group. Males and females were equal in number. Common symptoms of the patients were fever, cough, dyspnea, chest pain. Most common side involved by tumors were anterior mediastinum 68.42% (N-26) followed by middle mediastinum 50% (N-19), Posterior mediastinum 10.53% (N-4) and superior mediastinum 7.9% (N-3). More than one mediastinal anatomical side involvement was in 34.21% (N-13) cases. Tissue biopsy revealed non Hodgkin Lymphoma were 86.84% (N-33), Hodgkin Diseases 10.53% (N-4) and T-lymphoblastic lymphoma (LBL) 2.63% (N-1). All tumors were malignant with 73.68% metastasis. Pediatric mediastinal mass is a troublesome condition for doctors during emergency management at presentation, for interventional radiologists during tissue biopsy, pathologists during histopathological examination and oncologists during treatment planning. A few publications narrated the pediatric mediastinal oncological conditions but in Bangladesh no such study has conducted before addressing the pediatric mediastinal lymphoma. So we conducted this study to show the importance of development of infrastructure to manage these type of tumors successfully.

CHOLESTATIC JAUNDICE AS A CLINICAL PRESENTATION OF HODGKIN’S LYMPHOMA IN A 20-YEAR-OLD SAUDI MALE PATIENT, A CASE REPORT

Background: Hodgkin lymphoma (HL) represents approximately 10% of lymphomas and is curable in most, but not all, patients. It has a bimodal incidence, although it most commonly presents in young adults. Presentation with mediastinal, cervical, and supraclavicular involvement is particularly common for the nodular sclerosing subtype. Patients may also present with B symptoms, although that is more commonly seen in elderly patients with more advanced disease. Pruritus may also be a presenting symptom. The diagnosis is established with a lymph node biopsy specimen showing Reed-Sternberg cells, malignant cells that originate from germinal center B cells and are seen in an inammatory inltrate. Case Report: We report a case of a 20 years old Saudi male presented to our emergency department with jaundice without clinical lymphadenopathy, accompanied with laboratory investigations that is showing intrahepatic cholestasis. The patient was admitted initially to evaluate the causes of jaundice that he has mainly by investigating hepatic and post-hepatic diseases. Months later, he has developed palpable lymphadenopathy. Surgical excisional biopsy result concluded that the patient is having Hodgkin's lymphoma. Conclusion:Although it is thought to be an uncommon cause of intrahepatic cholestatic, lymphomas should be considered in evaluating a patient who came with similar presentation.

Systemic Amyloidosis with Unusual Mediastinal Involvement

Systemic Amyloidosis with Unusual Mediastinal Involvement

El papel de los parámetros metabólicos de la 18F-FDG PET/TC en el linfoma linfoblástico pediátrico

ObjectiveThis retrospective study aimed to evaluate the role of metabolic parameters of 18F-FDG PET/CT in pediatric lymphoblastic lymphoma (LBL). MethodsThirty patients with LBL underwent 42 scans. Metabolic parameters including maximum standardized uptake value (SUVmax), total metabolic tumor volume (TMTV), and total lesion glycolysis (TLG) were measured at baseline PET/CT. Univariate and multivariate analysis for survival were performed to assess their prognostic value. Twelve patients underwent PET/CT after reinduction regime, and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET/CT for predicting relapse were calculated. ResultsPatients with stage IV had a higher TMTV than those with stage III (P=0.031). Besides, patients with T-LBL or mediastinal involvement had a high TMTV and TLG (P<0.05). There was no significant difference in PET/CT metabolic parameters between patients with different outcomes (P>0.05). Children with a low TMTV (<242.91cm3) had a better 3-year EFS compared with those with a high TMTV (88.9% vs. 56.3%; P=0.036). SUVmax and TLG were not predictive of EFS (P=0.874; P=0.152). However, none of the metabolic parameters of baseline PET/CT were independent prognostic factors for outcomes of pediatric LBL. PET/CT underwent after reinduction regime present with higher sensitivity (50% vs. 0%) and NPV (90% vs. 83.3%) for predicting relapse than CT alone. ConclusionsMetabolic parameters of baseline PET/CT were not predictive of outcomes in children with LBL. PET/CT done after the reinduction regime had better sensitivity and NPV than CT alone, and a negative scan could be a reliable indicator for sustained remission.

SKIN LESION – A WINDOW TO A SYSTEMIC DISEASE

Sarcoidosis is considered as one of the “great masqueraders” in the eld of dermatology. Polymorphic cutaneous lesions are seen in around 20- 35 % of patients with sarcoidosis. We report a 49 year old male who presented with cough and hypopigmented atrophic plaques over the back. Serum ACE levels and CRP were elevated. HRCT chest revealed parenchymal and hilar, mediastinal lymph node involvement. Skin biopsy was done and showed multiple naked non- caseating granulomas in upper dermis. Pulmonary function test was suggestive of peripheral obstructive airway disease. Bronchoalveolar lavage identied CD4+ lymphocytosis. The patient was started on topical tacrolimus and topical corticosteroids with which he showed improvement. The patient was referred to pulmonology for further management. The case is presented for its rarity, with skin manifestations being one of the presenting signs of the disease.

Dysphagia as a Rare Presentation of Cervical Cancer with Mediastinal Metastasis.

Dysphagia has a broad aetiology and so it is essential to identify the precise cause. Cervical cancer metastasis is distinctive in that it usually involves local lymph node invasion; however, approximately 1% of cases have mediastinal involvement, which can cause severe compressive symptoms in rare situations. To highlight an uncommon severe manifestation of cervical cancer relapse, we describe a case of dysphagia in a woman with a history of cervical cancer. After a thorough investigation that included endoscopy, endoscopy with ultrasound, an oesophagogram and fine needle aspiration, we eventually reached the diagnosis of mediastinal metastatic cervical cancer. Following interventions, the patient’s condition gradually improved, both clinically and radiographically.LEARNING POINTSMediastinal lymph node enlargement causing dysphagia can be a presenting sign of a metastatic lesion from treated cervical cancer.A PEG tube is helpful in relieving dysphagia caused by metastatic mediastinal lymph node enlargement and as bridge for nutrition during chemotherapy.The VEGF inhibitor bevacizumab can be used in advanced metastatic cervical cancer.Check-point inhibitors like pembrolizumab can be used in metastatic cervical cancer.