Mediastinal Lymphadenopathy In Patients Research Articles

Role of Mediastinoscopy in Determining the Cause of Mediastinal Lymphadenopathy in Patients Referred to Shahid Beheshti Hospital of Babol

Background and Objective: One of the most important steps in the treatment of patients with mediastinal lymphadenopathy is the definitive diagnosis using tissue sampling of the intra-mediastinal lesion. Mediastinoscopy is one of the methods used for this purpose. In this regard, this study aims to investigate the role of mediastinoscopy in determining the cause of mediastinal lymphadenopathy in patients referred to Shahid Beheshti Hospital in Babol, Iran. Materials and Methods: This cross-sectional study was conducted on 36 patients with mediastinal lymphadenopathy who were admitted to Shahid Beheshti Hospital in Babol (April 2009-March 2020) and underwent mediastinoscopy. Recorded medical information of all patients without known lung cancer under mediastinoscopy was reviewed. Mediastinoscopy was performed by a specialist doctor for all patients and the biopsy sample was sent to Shahid Beheshti Hospital Pathology for final diagnosis. Descriptive data were analyzed using SPSS25 software at a significance level of 0.05. Results: The mean age of the patients was 47.97±11.04 years (range: 28-76 years). The majority of patients were women (n=27; 75.00%). According to the pathology results, the final diagnosis for 33 people (91.67%) was benign, and 3 people (8.33%) were diagnosed with malignant. The most common pathology result was sarcoidosis with 23 cases (63.90%), active infection in 4 cases (11.11%), and squamous cell carcinoma in 3 cases (8.33%). Other benign results were reported with the frequency of one case (78.2%). Pathology findings had no significant relationship with the age and gender of patients (P<0.05). Conclusion: Based on the findings of the study, it can be concluded that mediastinoscopy can help determine the causes of mediastinal lymphadenopathy and it is still a reliable method for examining mediastinal lesions.

Sarcoidosis or sarcoid-like reaction with mediastinal lymphadenopathy in patients after breast cancer surgery

BackgroundPatients with breast cancer present with lymphadenopathy involving non-caseating epithelioid cell granulomas in the mediastinum or axilla, referred to as sarcoidosis or sarcoid-like reactions (SLRs). However, sarcoidosis/SLRs prevalence and clinical presentation remain unclear. This study aimed to determine the frequency and clinical presentation of sarcoidosis/SLRs among postoperative patients with breast cancer. MethodsAmong all patients who underwent surgery for early-stage breast cancer at St. Luke's International Hospital in Japan between 2010 and 2021, those who subsequently developed enlarged mediastinal lymph nodes and underwent bronchoscopy for suspected breast cancer recurrence were included. Patients were classified into sarcoidosis/SLR or metastatic breast cancer groups, and the clinical characteristics were compared. ResultsA total of 9,559 patients underwent breast cancer surgery; bronchoscopy was performed to diagnose enlarged mediastinal lymph nodes in 29 cases. Breast cancer recurrence was observed in 20 patients. Eight women with a median age of 49 years (range 38–75) and a median time from surgery to diagnosis of 4.0 years (range 0.2–10.8) were diagnosed with sarcoidosis/SLRs. Four of the eight patients underwent mammoplasty with silicone breast implants (SBIs), and two experienced postoperative recurrences of breast cancer before or after lymphadenopathy, which was considered inciting factors for SLRs. The remaining two cases could have developed sarcoidosis after breast cancer surgery with no underlying causes for SLR. ConclusionsPostoperative sarcoidosis/SLRs rarely occur in patients with breast cancer. An adjuvant action of SBI likely contributed to the progression of SLRs; few cases exhibited a causal relationship with breast cancer recurrence.

Optimal methods of diagnosis of mediastinal lymphadenopathy in patients with pulmonary cancer

Objective. To optimize the diagnostic algorithm in mediastinal lymphadenopathy in patients with pulmonary cancer, using modern diagnostic methods.
 Materials and methods. Into the investigation 106 patients with pulmonary gland cancer, ageing from 19 to 81 yrs old, were included. In all the patients the enlarged mediastinal lymph nodes were diagnosed, using CT, and in some – using PET with simultaneous CT. In the next stage cervical mediastinoscopy was performed (86 patients) or EBUS-TBNA (20 patients). In 29 patients radical operation for the lymph nodes excision was performed.
 Results. Sensitivity and specificity of PET, performed simultaneously with CT, versus CT have constituted 74.3 and 80.2% and 54.6 and 74.7%, accordingly. Accuracy of invasive method of EBUS-TBNA have constituted 87.5%. Sensitivity, specificity and accuracy of cervical mediastinoscopy have constituted 97.6, 98.9 and 96.7% accordingly.
 Conclusion. On the first stage of examination it is expedient to use CT and PET with simultaneous CT. EBUS-TBNA has great part of false-negative results. Cervical mediastinoscopy constitutes the most specific, sensitive and highly accurate diagnostic method for mediastinal lymphadenopathy.

Prevalence and significance of mediastinal lymphadenopathy in patients with Severe Acute Respiratory Syndrome Corona Virus-2 infection.

Severe Acute Respiratory Syndrome Corona Virus-2 is the causative factor of Coronavirus Disease 2019. Early in the pandemic, mediastinal lymphadenopathy was not considered to be a significant radiologic finding of the SARS-COV-2 disease. Nevertheless, most recent studies associate mediastinal lymphadenopathy with more severe COVID-19 disease and poorer patient outcomes.

Mediastinal lymphadenopathy in COVID-19: A review of literature.

A novel coronavirus disease 2019 (COVID-19) is a progressive viral disease that affected people around the world with widespread morbidity and mortality. Patients with COVID-19 infection typically had pulmonary manifestation but can also present with gastrointestinal, cardiac, or neurological system dysfunction. Chest imaging in patients with COVID-19 commonly show bilateral lung involvement with bilateral ground-glass opacity and consolidation. Mediastinal lymphadenopathy can be found due to infectious or non-infectious etiologies. It is commonly found to be associated with malignant diseases, sarcoidosis, and heart failure. Mediastinal lymph node enlargement is not a typical computer tomography of the chest finding of patients with COVID-19 infection. We summarized the literature which suggested or investigated the mediastinal lymph node enlargement in patients with COVID-19 infection. Further studies are needed to better characterize the importance of mediastinal lymphadenopathy in patients with COVID-19 infection.

The DIAMORFOSIS (DIAgnosis and Management Of lung canceR and FibrOSIS) survey: international survey and call for consensus.

BackgroundCurrently there is major lack of agreement on the diagnostic and therapeutic management of patients with idiopathic pulmonary fibrosis (IPF) and lung cancer. Our aim was to identify variations in diagnostic and management strategies across different institutions and provide rationale for a consensus statement on this issue.MethodsThis was a joint-survey by European Respiratory Society (ERS) Assemblies 8, 11 and 12. The survey consisted of 25 questions.ResultsFour hundred and ninety-four (n=494) physicians from 68 different countries and five continents responded to the survey. Ninety-four per cent of participants were pulmonologists, 1.8% thoracic surgeons and 1.9% oncologists; 97.7% were involved in multidisciplinary team approaches on diagnosis and management. Regular low-dose high-resolution computed tomography (HRCT) scan was used by 49.5% of the respondents to screen for lung cancer in IPF. Positron emission tomography (PET) scan and endobronchial ultrasound (EBUS) is performed by 60% and 88% to diagnose nodular lesions with mediastinal lymphadenopathy in patients with advanced and mild IPF, respectively. Eighty-three per cent of respondents continue anti-fibrotics following lung cancer diagnosis; safety precautions during surgical interventions including low tidal volume are applied by 67%. Stereotactic radiotherapy is used to treat patients with advanced IPF (diffusing capacity of the lung for carbon monoxide (DLCO) <35%) and otherwise operable nonsmall cell lung cancer (NSCLC) by 54% of respondents and doublet platinum regimens and immunotherapy for metastatic disease by 25% and 31.9%, respectively. Almost all participants (93%) replied that a consensus statement for the management of these patients is highly warranted.ConclusionThe diagnosis and management of IPF-lung cancer (LC) is heterogeneous with most respondents calling for a consensus statement.

DYSPHAGIA: AN ALARMING SYMPTOM OF SARCOIDOSIS

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a granulomatous inflammatory disorder with multisystem involvement and can present with a myriad of symptoms. Esophageal involvement and dysphagia are extremely rare, and therefore are often overlooked as manifestations of this complex disease. The following series of cases highlights presentations of this rare manifestation. CASE PRESENTATION: Three patients with biopsy-proven sarcoidosis presented with dysphagia. Case #1 A 31-year-old male presented with fatigue. Chest Computed Tomography (CT) revealed mediastinal lymphadenopathy (LAD) encasing the esophagus but without narrowing of the lumen. Lymph node (LN) biopsy was consistent with sarcoidosis. He was not treated with steroids due to lack of symptoms. However, he presented again four weeks later with severe dysphagia and chest pain. Chest CT showed enlarged mediastinal LAD, now resulting in near occlusion of the esophageal lumen with concern for perforation. He underwent surgery for esophageal perforation due to LN compression. Case #2 A 45-year-old male was admitted for dyspnea and dysphagia. Chest CT showed mediastinal LAD. LN biopsy was suggestive of sarcoidosis. Videofluoroscopic swallowing study and esophagogastroduodenoscopy (EGD) were unremarkable, and etiology of dysphagia was attributed to LAD. The patient was started on oral steroids. He reported complete resolution of dysphagia at follow-up visit three months later. Case #3 A 50-year old male with pulmonary sarcoidosis was asymptomatic on immunosuppressive agents for nine years. He later developed new dysphagia and chest pain. Chest CT showed bulky mediastinal and hilar LAD. LN biopsy revealed granulomatous inflammation suggestive of known sarcoidosis. Barium esophagram and EGD were unrevealing. Dysphagia was attributed to mechanical compression from bulky mediastinal LAD. He was started on anti-tumor necrosis factor alpha with marked improvement in dysphagia after six months. DISCUSSION: Gastrointestinal involvement is an uncommon manifestation of sarcoidosis with a prevalence of 0.1 to 0.9% of patients with the disease, and esophageal involvement is relatively unheard of with only a handful of case reports to date. Dysphagia is the most common symptom of esophageal involvement. It can be seen at any stage of the disease and while on therapy. While this symptom can be attributed to various mechanisms such as extrinsic compression, direct esophageal wall infiltration, and cranial neuropathy, it remains an important point of consideration as these underlying issues can manifest as near-fatal complications of sarcoidosis. CONCLUSIONS: As clinicians managing this complex disease, it is important to keep sarcoidosis-induced dysphagia in the differential diagnosis. While consensus on management of this issue remains unclear, new data and therapies may emerge that could have a significant impact on those patients who are identified with this rare entity. Reference #1: Albin Abraham. “Esophageal Sarcoidosis: A Review of Cases and an Update.” ISRN Gastroenterology, Vol. 2013, 2013. Reference #2: Faisal Inayat. “Dysphagia Caused by Extrinsic Esophageal Compression from Mediastinal Lymphadenopathy in Patients with Sarcoidosis”. Clinical Gastroenterology and Hepatology, Vol. 15, Issue 7: e119-120, Jun. 2017. DISCLOSURES: No relevant relationships by Poorvi King, source=Web Response No relevant relationships by Ogugua Obi, source=Web Response No relevant relationships by Mitra Sahebazamani, source=Web Response

Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice?

IntroductionMediastinal lymphadenopathy in patients with extrathoracic malignancy is common. To obtain tissue proof of metastatic spread, EBUS-TBNA is an alternative to mediastinoscopy or thoracoscopy, but there are limited data about its diagnostic performance. The aim of this study was to determine the diagnostic accuracy of EBUS-TBNA for the evaluation of mediastinal lymphadenopathy in patients with extrathoracic cancers. MethodsWe performed a multicenter retrospective study based on an online questionnaire to collect data from January 2011 to December 2012 in all patients with proven extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases who underwent EBUS-TBNA for diagnosis. ResultsHundred and eighty-five patients were included. Extrathoracic malignancies observed were urological (43), breast (35), gastrointestinal (33), head and neck (30), melanoma (11), lymphoma (6), and others (27). EBUS-TBNA confirmed malignancy in 93 patients (50.3%): concordant metastases in 67 (36.2%); new lung cancer in 25 (13.5%); and 1 unidentified cancer. The diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value were respectively 54.6%, 68.4%, 100%, 53.3%, and 100%. ConclusionMediastinoscopy remain the reference, but EBUS-TBNA may be considered as first line investigation in patients with suspected mediastinal lymph node metastases and extrathoracic malignancy. It prevented a surgical procedure in 50.3% of patients.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Diagnosis of Breast Cancer Thoracic Metastases and Detection of Receptor Discordance

Metastasis of breast cancer to mediastinal lymph nodes is common and biopsy of suspicious lesions can have important diagnostic, prognostic, and therapeutic implications, particularly with respect to tumor receptor status. Our aim was to show that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be used for the diagnosis of metastatic breast cancer and demonstrate reliable receptor evaluation that can result in change of therapy. A retrospective review of consecutive adult patients undergoing EBUS-TBNA from May 2007 to September 2012 was performed. Data collected for patients with a history of breast cancer included patient demographics, tumor pathology, receptor analysis, imaging, and bronchoscopy or surgical results. Sixty-four patients with a history of breast cancer aged from 31 to 81 years underwent EBUS-TBNA for the evaluation of mediastinal lymphadenopathy of which 16 patients had not been previously treated for their breast cancer with systemic therapy. Eighty suspicious lymph nodes were biopsied measuring 0.8 to 3.1 cm in diameter. Fifty-nine (92%) patients had diagnostic cytology for malignancy or benign lymphoid tissue. Breast malignancy was identified in 33 (52%) patients and 23 (70%) of these had sufficient samples for the evaluation of estrogen, progesterone, and human epidermal growth factor receptor 2 status. Overall 48% of the patients with receptors analyzed had discordance between the primary tumor and metastasis. EBUS-TBNA is a useful tool for evaluating mediastinal lymphadenopathy in patients with a history of breast cancer and can provide information on the concordance of receptors status between the primary tumor and metastatic sites in the thorax.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal metastases of clear cell renal cell carcinoma

Evaluation of mediastinal lymphadenopathy in patients with a previous diagnosis of renal cell carcinoma (RCC) is critical for the determination of further treatment. A minimally invasive method of cytology sampling of mediastinal lymph nodes using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a useful tool in diagnosis. Between January 2010 and April 2018, we performed 1744 EBUS-TBNA studies of mediastinal and hilar lymph nodes for a variety of clinical indications including mediastinal malignancy. Sixteen patients (93.7% males, mean age 59.1 years, range 44–81 years) were diagnosed by cytological and cell block study to have metastatic clear cell RCC. Twelve patients had been diagnosed with clear cell RCC in the past (mean 39 months, range 4–89 months) while in four, the tumor was primarily diagnosed in the staging phase on the basis of EBUS-TBNA. The EBUS features of the mediastinal nodal masses included increase of size (mean 2.5 cm, range 1.6–3.8 cm), irregular, inhomogeneous, hypervascular, and hyperechoic echotexture. EBUS-TBNA is a procedure safe and effective for evaluating mediastinal lymphadenopathy in patients with clear cell RCC. Immunohistochemistry in the cell block is decisive for proper diagnosis. The cytologist plays a key role in the diagnosis of metastatic clear cell RCC due to the treatment implications that this neoplasm encompasses.

Endobronchial Ultrasound-Transbronchial Needle Aspiration for Lymphoma in Patients With Low Suspicion for Lung Cancer and Mediastinal Lymphadenopathy

Although the role for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for metastatic lung cancer is well described, the usefulness of EBUS-TBNA for diagnosing lymphoma is less well defined. We aimed to determine the diagnostic accuracy for lymphoma of EBUS-TBNA with rapid, on-site evaluation in the evaluation of mediastinal lymphadenopathy in patients with a low-suspicion for lung cancer. Medical records for all EBUS-TBNA (381 total procedures) from 2007 to 2013 were reviewed, and procedure indication, prior workup, cytologic diagnosis, histologic follow-up, and available ancillary studies were abstracted. Intraoperative rapid on-site evaluation was performed for 170 of 173 patients (98%), and evaluations for 133 (78%) were adequate for diagnosis. Of 381 patients, 173 (45.4%) underwent mediastinal tissue sampling to evaluate indeterminate mediastinal lymphadenopathy; 208 patients with known or suspected lung cancer were excluded. EBUS-TBNA provided a definitive diagnosis (predominantly carcinoma and granulomatous inflammation) in 71%. EBUS-TBNA was diagnostic in 8 of 16 patients (50%) where the final diagnosis of lymphoma in 16 was confirmed (9 non-Hodgkin, 6 Hodgkin, and 1 posttransplant lymphoproliferative disorder). EBUS-TBNA was indeterminate in 3 (19%), inadequate in 4 (25%), and falsely negative in 1 (6%). Histologic follow-up was available in 10 patients (63%). When the specimen was adequate for diagnosis, sensitivity for lymphoma was 89%. EBUS-TBNA has high sensitivity and a low false-negative rate for lymphoproliferative disorders when specimens are adequate for analysis and provides alternative diagnoses in most cases, thus reducing the need for mediastinoscopy. Rapid, on-site evaluation was nondiagnostic in approximately 25% of patients; performing EBUS-TBNA in the operating room facilitated conversion to mediastinoscopy and definitive diagnosis in this setting.

Rapid on-site evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of hilar and mediastinal lymphadenopathy in patients with lung cancer

The purpose of this study was to assess the usefulness of rapid on-site evaluation (ROSE) during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and the interpretation of its results. Based on the criterion of using ROSE or not, 236 patients with known or suspected lung cancer undergoing EBUS-TBNA were allocated into the ROSE group (122 patients with 252 lymph nodes) and non-ROSE group (114 patients with 260 lymph nodes). In the ROSE group, the percentages of the suspicious specimens on cytology and non-diagnostic specimens on pathology were both significantly lower than that in the non-ROSE group (8.7% vs. 14.6%, p = 0.038; and 0.9% vs. 4.4%, p = 0.018, respectively), and 13 out of 22 suspicious lesions on ROSE were confirmed with definite diagnoses on TBNA pathology. The diagnostic yield stratified by pathology was significantly higher in the ROSE group than that in the non-ROSE group (90.5% vs. 81.2%, p = 0.003). These results suggest that ROSE during EBUS-TBNA allows for a low rate of suspicious results and therefore improves the diagnostic yield stratified by pathology when sampling hilar or mediastinal lymphadenopathy in patients with lung cancer.

Endobronchial ultrasound-guided transbronchial needle biopsy for the diagnosis of mediastinal lymphadenopathy in patients with extrathoracic malignancies.

Mediastinal lymphadenopathy is common in extrathoracic malignancies and should not always be considered a metastatic lesion. The purpose of this study is to determine the diagnostic value of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) in patients with extrathoracic malignancies. This study included 54 consecutive patients with extrathoracic malignancies who had suspected mediastinal metastases and had undergone EBUS-TBNA for diagnosis. Using EBUS-TBNA, 27 of 54 patients (50%) were diagnosed with mediastinal metastases. Among patients with mediastinal metastases, 2 (3.7%) had a sarcoid-like reaction, 5 (9.3%) had tuberculosis, and 17 (31.5%) had reactive lymph nodes. In 3 cases (5.5%), a specific diagnosis could not be determined following EBUS-TBNA. Two patients underwent surgical staging of their mediastinal lymphadenopathy, which allowed the detection of mediastinal metastases in 1 patient and that of reactive lymph nodes in the other. The sensitivity, specificity, negative predictive value, and diagnostic accuracy of EBUS-TBNA for the diagnosis of extrathoracic malignancies were calculated as 93%, 100%, 92.6%, and 96.3%, respectively. EBUS-TBNA is a safe and effective procedure. We should consider whether EBUS-TBNA should be the primary diagnostic tool for the diagnosis of mediastinal lymphadenopathy in patients with extrathoracic malignancies.

An Algorithm for Approaching Mediastinal Lymphadenopathy in Pulmonary Hypertension: Response

We are grateful for the thoughtful commentary by Dr Medford relating to our recent article in CHEST.1Moua T Levin DL Carmona EM Ryu JH Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension.Chest. 2013; 143: 344-348Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar We agree that because procedural risk in patients with idiopathic pulmonary arterial hypertension (IPAH) is high, pretest suspicion for a more ominous diagnosis is warranted prior to invasive studies of associated mediastinal lymphadenopathy (MLAD). Specifically, exclusion of malignancy (lymphoma, lung primary, metastatic primary, and so forth) should be the only immediate justification for invasive assessment in this setting. Unfortunately, few studies have commented on MLAD associated with pulmonary hypertension. Our observed frequency of close to one in five patients with IPAH (18%) involved a selected cohort with both right-sided heart catheterization and chest CT scan for the purposes of correlating lymphadenopathy with severity of cardiac hemodynamics. This may underestimate the true prevalence of MLAD in all patients with IPAH. We did find a similar distribution and size of abnormal lymph nodes when compared with left-sided congestive adenopathy,2Ngom A Dumont P Diot P Lemarié E Benign mediastinal lymphadenopathy in congestive heart failure.Chest. 2001; 119: 653-656Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar and, although others have shown resolution or improvement in adenopathy following heart failure treatment,3Chabbert V Canevet G Baixas C et al.Mediastinal lymphadenopathy in congestive heart failure: a sequential CT evaluation with clinical and echocardiographic correlations.Eur Radiol. 2004; 14: 881-889Crossref PubMed Scopus (28) Google Scholar only one of nine patients with MLAD and follow-up CT scanning in our study had regression, despite receiving therapy. These specific findings from our study contribute to the clinical understanding of MLAD associated with pulmonary hypertension and may be applicable to MLAD with pulmonary hypertension from other causes. As Dr Medford noted, enlarged nodes of <2 cm on short axis with known left- or right-sided heart disease may justify observation with directed heart failure management for 1 to 3 months prior to invasive assessment. This approach appears reasonable for MLAD and pulmonary hypertension from most causes. For example, pulmonary hypertension associated with sarcoidosis may be a unifying diagnosis in some patients presenting with persistent MLAD.4Handa T Nagai S Miki S et al.Incidence of pulmonary hypertension and its clinical relevance in patients with sarcoidosis.Chest. 2006; 129: 1246-1252Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar PET scanning and other studies may be suggestive in this setting,5Prabhakar HB Rabinowitz CB Gibbons FK O'Donnell WJ Shepard JA Aquino SL Imaging features of sarcoidosis on MDCT, FDG PET, and PET/CT.AJR Am J Roentgenol. 2008; 190: S1-S6Crossref PubMed Scopus (85) Google Scholar although sarcoidosis without pulmonary parenchymal findings is unlikely to be immediately life threatening, again justifying a period of observation prior to biopsy assessment if not regressing. There is a known frequent association of MLAD with interstitial lung disease,6Souza CA Müller NL Lee KS Johkoh T Mitsuhiro H Chong S Idiopathic interstitial pneumonias: prevalence of mediastinal lymph node enlargement in 206 patients.AJR Am J Roentgenol. 2006; 186: 995-999Crossref PubMed Scopus (76) Google Scholar and, as such, diagnostic assessment without other clinical features of malignancy is likely unjustified. We suggest and agree with a cautious approach to MLAD associated with pulmonary hypertension of any cause, particularly if pretest suspicion for malignancy is low. Further prospective and observational work to refine a safe approach to MLAD in this setting is needed, as noted by Dr Medford. An Algorithm for Approaching Mediastinal Lymphadenopathy in Pulmonary HypertensionCHESTVol. 144Issue 1PreviewThe recently published article by Moua et al1 (February 2013) is timely but raises more questions about how to study patients with mediastinal lymphadenopathy (MLAD) and idiopathic pulmonary arterial hypertension (IPAH). It would be particularly helpful for clinicians who treat such patients to be able to perform a risk assessment of the need for mediastinal sampling in a patient group where even minimally invasive endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) or conventional TBNA2 is likely to be tolerated less well compared with patients without IPAH. Full-Text PDF

Frequency of Mediastinal Lymphadenopathy in Patients With Idiopathic Pulmonary Arterial Hypertension

The objective of this study was to assess the frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension (IPAH) and describe the correlative clinical features. We conducted a retrospective review of patients with IPAH who underwent right-sided heart catheterization (RHC) and chest CT scan within 3 months of each other. Patients were from a single tertiary institution. CT scans were reviewed for the presence of mediastinal lymphadenopathy (MLAD) with correlating demographic and clinical data, including lymph node size and location, right atrial pressure (RAP), mean pulmonary arterial pressure (mPAP), and the presence of pleural and pericardial effusion. The study population included 85 patients with a mean age of 48 17.3 years; 70 (82%) were women. Fifteen patients (18%) had MLAD on chest CT scan. The mean short-axis diameter of the largest lymph node in these patients was 13.6 mm (range, 11-20 mm). The enlarged lymph nodes were located predominantly in the lower paratracheal and subcarinal stations. There was no association of MLAD with age, sex, RAP, or mPAP. MLAD was associated with presence of pleural effusion ( P , .02) but not pericardial effusion. Mean left ventricular ejection fraction for those with lymphadenopathy was 63% (range, 45%-76%). MLAD without other identifiable causes is seen in approximately one in fi ve patients with IPAH and is associated with pleural effusion but not mPAP, RAP, or left ventricular function.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A study in a tuberculosis-endemic country

Mediastinal lymphadenopathy in patients with malignancy is a common clinical problem in tuberculosis-endemic countries. The recently developed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedure enables direct and real-time aspiration of mediastinal and hilar lymph nodes. The aim of the study was to determine the efficacy of EBUS-TBNA results in the evaluation of mediastinal lymph nodes in patients with extrathoracic malignancy. Retrospective analysis was performed in 40 patients with proven (n = 38) or suspected metastasis of unknown origin (n = 2) who underwent EBUS-TBNA between July 2007 and August 2011. All 40 patients successfully underwent EBUS-TBNA and no complications were observed. EBUS-TBNA diagnosed metastasis from extrathoracic malignancy in 16 (40%) patients, new lung cancer in 2 (5%), reactive lymph node in 9 (22.5%), sarcoidosis in 5 (12.5%), anthracosis in 5 (12.5%) and tuberculosis in 3 (7.5%). The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EBUS-TBNA based on the number of patients were 90.0%, 100%, 100%, 90.9% and 95.0%, respectively. In 33 patients with available data of fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) scans, the diagnostic sensitivity, specificity, PPV, NPV and accuracy of PET/CT scan based on the number of patients were 94.7%, 35.7%, 66.6%, 83.3%, and 69.6%, respectively. The association between larger lymph node size on EBUS and malignancy of lymph node sample on pathological examination was statistically significant (P = 0.018). EBUS-TBNA is a sensitive, specific, minimally invasive and a safe procedure for the diagnosis of mediastinal and hilar metastasis from extrapulmonary malignancy in a tuberculosis-endemic country.

Does the presence of mediastinal adenopathy confer a risk for disseminated infection in immunocompetent persons with pulmonary coccidioidomycosis?

Pulmonary coccidioidomycosis is caused by inhaling airborne arthroconidia of Coccidioides, a soil-dwelling fungus endemic to the desert southwestern United States. Although uncommon, disseminated coccidioidal infection can be associated with well-defined risk factors, such as cell-mediated immunodeficiency, certain racial heritages (e.g. African or Filipino), male sex, or pregnancy. Before widespread use of computed tomography (CT), the presence or persistence of mediastinal lymphadenopathy was postulated to be a risk factor for disseminated coccidioidal infection. To investigate the use of CT scanning to identify the presence of mediastinal lymphadenopathy in patients with pulmonary coccidioidomycosis, and to correlate such lymphadenopathy with disseminated coccidioidal infection, we performed a retrospective review of patients with pulmonary coccidioidomycosis who were evaluated by chest CT. Two radiologists independently interpreted 150 CT scans from patients with pulmonary coccidioidomycosis. Forty-nine patients met CT criteria for mediastinal lymphadenopathy, whereas 101 patients did not. Disseminated coccidioidal infection was observed in 5 (10%) of the 49 patients with mediastinal lymphadenopathy and in 6 of the 101 (6%; P = .34) without such adenopathy. Among patients with coccidioidomycosis, patients with mediastinal lymphadenopathy, as assessed by CT, had a higher rate of disseminated infection, but the difference was not statistically significant.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Intrathoracic Lymphadenopathy in Patients with Extrathoracic Malignancy: A Multicenter Study

Mediastinal lymphadenopathy in patients with an extrathoracic malignancy is a common clinical scenario. Invasive sampling of intrathoracic lymph nodes may be performed by mediastinoscopy or endoscopic ultrasound-guided fine needle aspiration. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an alternative to mediastinoscopy and endoscopic ultrasound in patients with lung cancer and sarcoidosis. The utility of EBUS-TBNA in patients with extrathoracic malignancy was evaluated. Consecutive patients who were suspected to have intrathoracic lymph node metastases from an extrathoracic malignancy underwent EBUS-TBNA. When EBUS-TBNA did not provide a specific diagnosis, patients underwent mediastinoscopy or clinical follow-up of at least 6 months duration. One hundred sixty-one patients meeting the inclusion criteria underwent EBUS-TBNA in five UK centers over a 3-year period. EBUS-TBNA diagnosed mediastinal or hilar metastases in 71 (44%) patients, new lung cancer in 20 (12%) patients, and sarcoidosis in 14 (9%) patients. The sensitivity, negative predictive value for malignancy, and overall accuracy for EBUS-TBNA were 87%, 73% and 88%, respectively. One hundred ten (68%) patients in the study had a final diagnosis of malignant intrathoracic lymphadenopathy. Because of the high prevalence of alternative diagnoses, pathological evaluation is important in patients with extrathoracic malignancy and suspected mediastinal or hilar lymph node metastases. EBUS-TBNA is a safe and sensitive technique and may be considered a first-line investigation in these patients.

Mediastinal Lymphadenopathy in Patients Undergoing Cardiac Transplant Evaluation

We evaluated the association between hemodynamic parameters of chronic congestive heart failure (CHF) and mediastinal lymphadenopathy (MLA) in heart transplantation (HT) candidates and the effect of HT on MLA. We also described the results of lymph node (LN) biopsies of MLA in the patients. Patients who underwent HT evaluation over an 8-year period and had chest CT scans were evaluated retrospectively. Data collected included LN sizes pre-HT and post-HT, echocardiographic measurements, radionuclide-derived ejection fraction, and right-sided heart catheterization hemodynamics. MLA was defined as LNs > 1 cm in smallest dimension. Of 118 patients, 53 patients had MLA. MLA had weak statistically significant correlations with elevated mean pulmonary artery pressure (MPAP), mitral regurgitation (MR), tricuspid regurgitation (TR), right atrial pressure (RAP), and pulmonary capillary wedge pressure (PCWP). Thirty-six patients with MLA underwent HT, and nine of the 36 had post-HT chest CT scans. All nine patients showed a decrease in LN size post-HT (mean LN diameter pre-HT = 1.16 ± 0.137 cm, post-HT = 0.75 ± 0.32 cm). Seven of 53 patients with MLA underwent biopsies. Four had benign LNs, one had sarcoidosis, and two had lung cancer. MPAP, MR, TR, RAP, and PCWP had weak statistically significant correlations with MLA. HT led to regression of MLA in patients who underwent CT scans post-HT, implying that MLA is related to CHF. However, we also identified clinically important causes of MLA; therefore, biopsy should be considered if enlarged LNs fail to regress after maximal medical management of CHF.

Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center

Background:Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is used to stage mediastinal lymph nodes in cancer patients to optimize treatment strategies. In this retrospective study, the authors determined the utility of EBUS-TBNA biopsy in the evaluation of mediastinal lymphadenopathy at a high-volume cancer center.Materials and Methods:The pathology database was searched for all patients who had undergone EBUS-TBNA biopsy of mediastinal lymph nodes over a one-year period. Cytologic diagnoses were correlated with clinical histories, subsequent resection, and clinical follow-up data.Results:Of 928 lymph node samples, 226 (24%) were diagnosed as malignant, 4 (0.4%) were suspicious for malignancy, 9 (1%) were atypical, 640 (69%) were benign, and 47 (5%) were insufficient for evaluation. In 89 (9.6%) cases, the patients had surgical resection. There was one false positive, in which the primary tumor contained infiltrating lymphocytes, had been sampled. There were five false-negative cases, which resulted from sampling errors, including two with micrometastases. The sensitivity, specificity, and positive and negative predictive value rates for EBUS-TBNA biopsy in the evaluation of mediastinal lymph nodes were 68.7% and 98.6% and 91.6% and 93.5%, respectively on a per lymph node basis. The overall clinical sensitivity, specificity, and positive and negative predictive value rates after one year clinical/radiological and histologic follow-up were 97%, 99.3%, 96.7% and 99.4%, respectively.Conclusions:EBUS-TBNA biopsy is a sensitive and specific method for evaluating mediastinal lymphadenopathy in patients with lung and other primary tumors.