Mediastinal Nodes Research Articles

The role of wedge resection and lymph node examination in stage IA lung carcinoid tumors.

Current guidelines recommend anatomical resection and mediastinal lymph node resection for stage I to IIIA pulmonary carcinoids (PCs). The role of wedge resection in stage IA PCs remains controversial, previous studies focused on typical carcinoids (TCs) while differentiating histological subtypes preoperatively is not easy. We aimed to study the effect of wedge resection and lymph node examination (LNE) in patients with stage IA PCs. Patients who underwent anatomical and wedge resection for stage T1N0M0 lung carcinoid tumors between 2004 and 2019 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were also divided into a non-LNE group and an LNE group. Kaplan-Meier analysis and the log-rank test were used to calculate and compare overall survival (OS). Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to balance the variables between groups. Univariate and multivariate Cox proportional hazard models were developed to determine prognostic factors. A total of 2,029 patients with bronchopulmonary carcinoid tumors were included in this study, 1,450 underwent lobectomy, 147 underwent segmentectomy and 432 underwent wedge resection. Initially, 5-year survival differed marginally between wedge and anatomical resection (91% vs. 95%, P=0.051), but lost significance after adjustment. LNE improved 5-year survival (95% vs. 89%, P=0.003), and this remained significant after adjustment. In multivariate cox analysis, LNE remained a significant variable while extent of resection was not. This result also remained consistent after adjustment. OS was comparable between wedge resection and anatomical resection when at least 1 lymph node was examined. For early-stage PC, wedge resection was not inferior to anatomical resection in terms of OS, while LNE significantly increased the survival in both multivariate and matched studies. The relationship between surgical extent and survival in the unadjusted study may be attributed to the lower rate of LNE in wedge resection. Our findings support wedge resection with emphasis on LNE in early-stage PCs.

453. ROBOT ESOPHAGECTOMY WITH EXTENDED MEDIASTINAL LYMPH NODE DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background Radical surgical resection may play role in prognosis improvement of the esophageal squamous cell carcinoma (ESCC) patients. Because esophagectomy with radical lymphadenectomy is highly invasive, we introduced thoracoscopic esophagectomy in 1999, and have performed over 600 cases. In 2009, we developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy with extended LN dissection and reported good long-term outcomes especially in cT1bN0M0 ESCC patients. We reported 3y and 5y RFS was 96% and 96%, and 3y and 5y OS was 94% and 92% in those patients. We introduced robot-assisted esophagectomy (RMIE) using daVinci Xi system in June 2018 and have performed for 80 cases. We perform RMIE with the prone position instead of the hybrid position with same concept of thoracoscopic esophagectomy with extended LN dissection. Thanks to a three-dimensional magnified view, fully wristed dexterity and tremor filtration of da Vinci Xi system, the robotic system facilitates precise dissection especial for upper mediastinal lymph node dissection. We show safety introduction and technical pitfalls of robot-assisted esophagectomy with extended LN dissection. Methods: The patient is fixed on prone position. We use Monopolar curved scissors for superficial layer, bipolar cut for dissection with maryland bipolar forceps for deeper layer around Aorta and trachea, and Sharp dissection with Potts scissors around recurrent laryngeal nerves. After esophageal mobilization and mediastinal lymphadenectomy were completed, bilateral recurrent laryngeal nerve, bilateral subclavian artery, trachea, bilateral bronchus, aorta, left pulmonary artery and vein, left pleura, pericardium and hiatus are all skeletonized. Results: We could standardize surgical procedure in first 20 cases. Average operation time in the thoracic procedure is 234.4min and 190.2min in last 30 cases. Median blood loss is 0ml. Postoperative pneumonia and vocal cord palsy were occurred only 6 case in 80 cases. Conclusion: Robot assisted esophagectomy with extended LN dissection was safely introduced in our facility and it is feasible and beneficial for the lymph node dissection especially for lymph node dissection around the recurrent laryngeal nerve. https://www.dropbox.com/scl/fi/w8na39w6bo9ivwwz7x2rh/Hirofumi-Kawakubo-ISDE-2024.mp4?rlkey=p9mvt7dotyeaj6xfwvud8vcmr&dl=0

346. ESOPHAGOGASTRIC JUNCTION SIEWERT II TUMORS, A CHALLENGE FOR THE SURGEON: RESULTS OF TRANSHIATAL EXTENDED GASTRECTOMY VS. IVOR LEWIS ESOPHAGECTOMY

Abstract Background Esophagogastric junction (EGJ) Siewert type II tumors pose unique challenges in terms of adequate surgical treatment due to their anatomical location and potential for abdominal and mediastinal lymph node metastasis. The optimal surgical approach for these tumors remains a topic of debate, with options including transhiatal extended gastrectomy or transthoracic esophagectomy. Understanding the different outcomes associated with these surgical interventions is crucial for informed decision-making and patient-tailored management. The aim of this study was to compare the perioperative and oncological outcomes of these two surgical technique to access which could be the treatment of choice for Siewert II type tumours. Methods This study is a retrospective non-randomized cohort study from a single center. We reviewed the data of all the patients who underwent surgery for EGJ Siewert type II tumors between December 2014 and February 2023. The patients were divided into two groups: those who underwent transthoracic esophagectomy were assigned to “TE group” (72 patients) and those who underwent transhiatal extended gastrectomy were assigned to “TEG group” (21 patients). Results Patients in the TEG group were older (p=0.011) and in worst clinical condition (Charlson Comorbidity Index 4.15±1.78 vs. 4.95±1.46, p=0.064). The tumour stage at the diagnosis was more advanced in the TE group (p=0.004), and upfront surgery was infrequent in this group (p<0.001). The average duration of surgery was higher in the TE group (p<0.001). No difference was seen in the tumour length (p=0.924), implying a statistically significant difference in the proximal margin length (p<0.001), and distal margin length (p<0.001), with a R0 resection rate higher in the TE group (93.1% vs. 66.7%, p=0.002). The higher rate of R1 resection in the TEG group was mainly due to proximal margin infiltration. No difference was seen in the number of harvested lymph nodes (p=0.339). Overall postoperative complications rates were similar (p=0.144). No differences were found in the length of ICU stay (p=0.676) and in hospital stay (p=0.075). At a median follow up of 20 months, there were no statistical differences in Overall Survival and Disease-Free Survival at 5 years. Conclusion Our data suggests that transthoracic esophagectomy for EGJ Siewert type II tumors should be the treatment of choice for patients in good clinical condition, but transhiatal extended gastrectomy could be a good choice for patients presenting in worse clinical condition. A multidisciplinary approach is essential for optimal patient care, and the selection of the surgical technique should be based on a thorough evaluation of the patient's condition and tumor characteristics

510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY

Abstract Background Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges. Methods A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler. Results The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery. Conclusion The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery. https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link

350. CONTINUOUS INTRAOPERATIVE NERVE MONITORING TO REDUCE THE LEFT RECURRENT LARYNGEAL NERVE PARALYSIS IN TRANSMEDIASTINAL ESOPHAGECTOMY

Abstract Introduction Transmediastinal esophagectomy (TME) is a curative option for esophageal cancer, and can achieve total mediastinal lymph node dissection (LND) with transcervical and transhiatal procedures. With the transcervical procedure, the upper mediastinal LND is highly associated with the risk of causing recurrent laryngeal nerve paralysis (RLNP). Continuous intraoperative nerve monitoring (CIONM) can visualize the risk procedure in real time, which may result in reducing postoperative RLNP. The aim of this study was to clarify the usefulness of CIONM in reducing postoperative left RLNP with TME. Material and methods A total of 227 patients who underwent TME for esophageal cancer (EC) or esophagogastric junction cancer (EGJC) between October 2017 and July 2022 at our institution were included in this study. Patients who did not undergo the upper and middle mediastinal LND (33 patients) and could not undergo CIONM (34 patients) were excluded from these 227 patients. Finally, we analyzed data on 160 patients. The clinicopathological data were reviewed from the medical record database of our institution. Results The technical implementation rate of CIONM was 87.4%. The diagnostic performance for RLNP with amplitude<100μV (LOS: loss of signal) at the end of transcervical procedure was as follows (sensitivity: 83.3%, specificity: 90.7%, positive diagnostic value: 88.8%). In the univariate analysis, the frequency of left RLNP was significantly higher in male, patients with primary tumor located at the upper thoracic esophagus, and patients with LOS (p<0.001, respectively). Moreover, the multivariate analysis identified patients with tumor located at the upper thoracic esophagus and patients with LOS (p<0.001) as independent risk factors for left RLNP. Conclusion In the present study, we showed the significant association between amplitude LOS and left RLNP. CIONM could contribute to reducing left RLNP by not only paying attention to amplitude reduction during surgery, but also learning the risk procedure that may cause nerve damage after surgery.

Mediastinal lymph node dissection in segmentectomy for peripheral c-stage IA (≤2 cm) non–small-cell lung cancer

ObjectiveAlthough recent trials on intentional segmentectomy have made mediastinal lymph node dissection (MLND) mandatory, the necessity of MLND in segmentectomy remains uncertain. We conducted a retrospective study to evaluate the necessity of MLND in segmentectomy for patients with peripheral stage IA (≤2 cm) non–small cell lung cancer. MethodsOf the 5222 surgical cases for non–small cell lung cancer from 3 institutions between 2010 and 2021, 1457 patients met the JCOG0802 trial eligibility criteria. Initially, we analyzed 574 patients who underwent lobectomy with MLND to identify preoperative risk factors for cN0-pN2 occurrence (cohort 1). Subsequently, we evaluated the relationship between these factors and the cumulative postoperative recurrence in 390 patients who underwent segmentectomy (cohort 2). ResultsIn cohort 1, risk factors for cN0-pN2 occurrence were consolidation-to-tumor ratio = 1.0 and maximum standardized uptake value ≥2.0. When classifying patients into 3 groups (group A, without any factors, group B, with either factor, and group C, with both factors), the occurrence of cN0-pN2 was significantly greater in group C than in the other groups (0.9%, 3.4%, and 8.4%, respectively, P = .005). When classifying patients in cohort 2 using the classification identified in cohort 1 (117, 131, and 142 were categorized into group A, group B, and group C, respectively), the 5-year cumulative incidence of recurrence rate was significantly greater in group C than in others (2.0%, 2.0%, and 15.9%, respectively, P < .001). ConclusionsMLND is unlikely to be beneficial in intentional segmentectomy for patients with tumors showing consolidation-to-tumor ratio <1.0 and maximum standardized uptake value <2.0.

525. PALLIATIVE MULTIMODALITY-THERAPY, EVEN WITH ABBREVIATED IMMUNOTHERAPY CAN MAKE CURATIVE SURGERY FOR SYNCHRONOUS LUNG AND ESOPHAGEAL CANCER POSSIBLE: A CASE REPORT

Abstract Background Synchronous lung and esophageal carcinomas are problematic. When both cancers are locally advanced, combined surgical treatment is rarely possible because of high-risk or insufficient respiratory reserve. Palliative treatment including immunotherapy can sometimes offer significant tumor response and potentially prolong survival in patients with PDL-1 tumor expression. However the place of immunotherapy for potentially rendering inoperable patients operable is still unknown. Methods Case report: A 78-year-old male with smoking history was diagnosed with synchronous locally advanced adenocarcinoma of the Gastroesophageal Junction (GEJ) cT3cN1cM0 and bilateral lung adenocarcinomas stage 4a, cT2cN1cM1a (right lower lobe 43mm confirmed by CT-guided biopsy, left upper lobe 32mm and additional S6 left lower lobe nodule). The patient was considered incurable by MDT and palliative treatment was offered as both cancers had significant PDL-1 expression (GEJ: CPS score &amp;gt;1, Lung: PDL-1 expression 90%). Pembrolizumab immunotherapy was started but poorly tolerated (severe myositis) and stopped again after only 6 weeks. The left-sided lung cancer had by then already regressed and stereotactic irradiation (SBRT 5x12Gy) of the right-side lung cancer was administered resulting in further local tumor control (figure). Endoscopic tumor re-evalution showed a Siewert type 2 tumor (uT3N1) similar to the initial endoscopy 15 months before. Both side lung adenocarcinomas remained regressed and the left lower lobe nodule was unchanged (6mm). Mediastinal lymph node staging by EBUS was negative. Thirteen months after initial diagnosis, 4 cycles of neo-adjuvant chemotherapy (FLOT) were administered. Combined synchronous surgery was finally done 16 months after initial diagnosis. A minimally invasive combined resection included a laparoscopic &amp; thoracoscopic Ivor-Lewis MIE, left thoracoscopic wedge of the lower lobe nodule and a right lower lobectomy with radical lymph node dissection. Post-operative course was smooth: Clavien-Dindo score 1, hospital stay 18 days. Final pathology Distal third adenocarcinoma (1.5x1.2cm above Z-line) with major partial response ypT2N0M0, R0, 0/43 lymph nodes (subcarinal signs of nodal response), right lower lobe tumor of 60x55mm with residual 1.2mm focus of residual viable adenocarcinoma (ypTisN0M0, R0) and left lower lobe hamartoma (6mm). Follow-up showed no recurrence 9 months after surgery (25 months from initial diagnosis). Conclusions: 1) Despite much abbreviated palliative immunotherapy (6 weeks), SBRT and FLOT our patient was down-staged within 16 months from an initially palliative situation to a potential cure with complete resection of all tumors. 2) Synchronous combined radical laparoscopic &amp; thoracoscopic Ivor-Lewis esophagectomy with lung lobectomy can be feasible after immuno-, chemo- and radiotherapy even in elderly patients.

552. COMPARING ROBOTIC ESOPHAGECTOMY TO VIDEO-ASSISTED THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA: RESULTS FROM THE REVATE RANDOMIZED CLINICAL TRIAL

Abstract Background The treatment of esophageal squamous cell carcinoma (ESCC) includes dissecting lymph nodes along the recurrent laryngeal nerve (RLN), which is oncologically important but is technical demanding. Vocal cord palsy as a result from RLN injury, carries significant morbidities. This randomized clinical trial (RCT) compared the efficacy and safety of robotic esophagectomy (RE) and video-assisted thoracoscopic esophagectomy (VATE) for performing RLN lymph node dissection (LND) Methods We conducted a multicenter RCT(NCT03713749) from November 2018 to March 2022, enrolling patients with ESCC who required McKeown esophagectomy. The primary endpoint was to determine the success rate of left RLN LND. Success was defined as the removal of lymph nodes confirmed by pathology, without causing permanent nerve palsy (duration &amp;gt; 6 months). Secondary endpoints encompassed perioperative and oncological outcomes. Results The per-protocol analysis included data from 203 patients (RE group: n=103; VATE group: n=100). The primary endpoint was achieved in 88.3% of the RE group and 69% of the VATE group (p&amp;lt;0.001). Additionally, the RE group had a higher mediastinal lymph node harvest (16 [12−22] versus 14 [10−20], p=0.04), shorter thoracic operating time (110 [89−137] min versus 124[103.5−154] min, p=0.004), and earlier drainage removal (4 [3−7] days versus 6 [4−9] days, p=0.007) compared to the VATE group. The two study arms exhibited comparable complication rates with no recorded in-hospital deaths in either group. Conclusion This multicenter trial demonstrates the effectiveness of RE in enhancing the feasibility and safety of RLN LND in ESCC. Additionally, RE leads to an improved mediastinal lymphadenectomy, shorter operating times, and earlier removal of drainage.

622. COMPARISON OF ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY WITH CONVENTIONAL MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A MULTI-INSTITUTIONAL COHORT STUDY

Abstract Background The Japanese public insurance system approved robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer in 2018. Since then, an increasing number of RAMIE has been performed every year. However, it is unclear whether RAMIE is more beneficial than conventional minimally invasive esophagectomy (MIE) in terms of short-term and long-term outcomes. Methods A total of 396 patients (RAMIE, 145; MIE, 251) with resectable esophageal cancer who underwent esophagectomy between 2016 and 2019 at 6 institutions were included. A propensity score matching analysis was performed to compare the short-term outcome. Two-stage esophagectomy, salvage surgery, and palliative resection were excluded. Individual propensity scores were calculated based on the following 15 variables: age, sex, body mass index, American Society of Anesthesiologists Physical Status (ASA-PS), hemodialysis, oral steroid use, obstructive pulmonary disease, histology, tumor location, clinical T, N, M classification, preoperative therapy, field of lymphadenectomy, and organ used for reconstruction. Results After matching 272 patients were analyzed. RAMIE took the significantly longer operating time (629min; 570min, p=0.0005), but the amount of blood loss (90g; 84g), number of harvested mediastinal nodes (24; 25), and in-hospital mortality (1.5%; 0.7%) were comparable. RAMIE group showed a trend of less severe post-operative morbidity (Clavien–Dindo grade III or higher) (18%; 27%) and significant reduction of recurrent laryngeal nerve palsy (23%; 35%, p=0.046). The 5-year overall and relapse-free survival in the RAMIE and MIE groups were 65%; 61% [hazard ratio (HR), 0.77; 95% CI: 0.51, 1.17], and 61%; 51% (HR, 0.73; 95% CI: 0.51, 1.06), respectively. Conclusion RAMIE was safely performed even during the early period of its application. Despite the longer operating time, RAMIE would be a promising alternative to MIE, with a better trend of short- and long-term outcomes, including a significantly lower incidence of postoperative recurrent laryngeal nerve palsy.

Impact of imaging features on selecting limited lymph node resection for cT1N0M0 lung cancer.

Controversy still exists in the medical community regarding the performance of limited mediastinal lymphadenectomy (LML) in early-stage lung cancer. The objective of this study was to identify predictors of mediastinal lymph node (mLN) status and analyze its role in guiding surgical strategy. A retrospective cohort study was conducted on 2,834 surgical patients with peripheral cT1N0M0 non-small cell lung cancer between 2016 and 2018. Logistic regression was employed to identify predictors of N2 metastasis. Prognosis was compared between groups and independent prognostic factors were identified using Kaplan-Meier and multivariate Cox analysis. There were 2,126 patients with systematic mLN dissection and 708 with LML. The multivariate analysis showed that N2 metastasis were associated with tumor size and consolidation tumor ratio (CTR). Patients in group A, with CTR >0.5 and tumor size ≤1 cm or CTR ≤0.5, had a significantly lower rate of N2 metastasis compared to those in group B, with CTR >0.5 and tumor size >1 cm (14.2% vs. 0.2%, P<0.001). Additionally, LML demonstrated comparable recurrence-free survival (RFS) and overall survival (OS) in group A, but a worse prognosis in group B compared to systematic lymph node dissection (SND). Furthermore, multivariate Cox regression analysis indicated that SND (vs. LML) was a favorable prognostic predictor for patients in group B [RFS: hazard ratio (HR) =0.71, P=0.005; OS: HR =0.66, P=0.01]. But univariate analysis in group A showed no significant difference in prognosis between SND and LML (RFS: P=0.24; OS: P=0.10). The combination of CTR and tumor size can predict mLN metastasis and procedure-specific outcome (SND vs. LML). This information may assist surgeons in identifying suitable candidates for LML.

Primary pulmonary carcinoma in a dog presenting with hypertrophic osteopathy

AbstractA 9‐year‐old dog was presented for a 2‐month history of bilateral carpal, stifle and tarsal swelling and a large thyroid mass. Carpal radiographs indicated hypertrophic osteopathy, thoracic radiographs revealed an intrathoracic mass, fine‐needle aspirate of the thoracic mass diagnosed carcinoma, and subsequent cervical, thoracic and abdominal computed tomographies revealed widespread hypertrophic osteopathy, bilateral thyroid cystic structures and a soft tissue mass in the right cranial mediastinum or lung. After unilateral thyroidectomy and thoracotomy for a lung lobectomy and mediastinal lymph node extirpation, the dog was diagnosed with a benign cyst of the thyroid and a completely excised grade II pulmonary carcinoma with no metastasis to the mediastinal lymph node. After 135 days of presentation, the dog presented with increased respiratory effort, and pleural effusion was diagnosed. Thoracocentesis was performed, and cytology of the fluid was concerning for carcinoma. The dog further declined rapidly and was euthanased 178 days after the initial presentation.

What alters prognosis in patients who were operated for lung cancer with lymph node metastasis?

In this study, we investigated the clinical outcomes of patients who underwent surgery with proven lymph node metastasis. Patients who were operated for lung cancer with pN1 or pN2 were examined in the study. The clinicopathological features and survival of the subjects were evaluated according to pN1-pN2 status, presence of neoadjuvant treatment, Positron emission tomography and computed tomography (PET/CT) avidity on mediastinal lymph nodes and specific lymph node stations. The study examines 100 patients operated from January 2016 to December 2021. Number of cases with pN1 and pN2 disease were 45 (45%) and 55 (55%) respectively. Thirty (30%) patients received neoadjuvant treatment. The 5-year overall survival (OS) and disease-free survival (DFS) of the patients were computed as 42.5% and 42.4% correspondingly. The 5-year cancer-related survival was 55.3%. In pN2 cohort, 5-year DFS was 67.9% in the neoadjuvant group and 15.9% in the non-neoadjuvant group (P = 0.042). In non-neoadjuvant group, 5-year DFS was 19.9% in cases with mediastinal PET/CT avidity and 56.3% in patients without mediastinal PET/CT avidity (P = 0.018). In pN2 disease, the presence of subcarinal or paratracheal lymph node metastasis did not create a significant difference in 5-year OS or DFS, but pulmonary ligament lymph node metastasis was found to be linked with worse survival in both 5-year OS (P = 0.005) and DFS (P = 0.017). The main elements related with poor prognosis were absence of neoadjuvant treatment and pulmonary ligament lymph node metastasis in pN2 disease, detecting PET/CT avid mediastinal lymph nodes in non-neoadjuvant group.

Application of tissue pneumoperitoneum technique around lymph nodes in thoracoscopic lung cancer resection.

Thoracoscopic surgery is a primary treatment for lung cancer, with lobectomy and mediastinal lymph node dissection being the predominant surgical approaches for invasive lung cancer. While many thoracic surgeons can proficiently perform lobectomy, thorough and standardized lymph node dissection remains challenging. This study aimed to explore a safer and more efficient surgical method for mediastinal lymph node dissection in lung cancer. A prospective randomized controlled study was conducted, involving 100 patients with right lung cancer who were admitted to our hospital from January 2021 to April 2024 and met the inclusion criteria. These patients were randomly divided into an observation group (tissue pneumoperitoneum technique around lymph nodes group) and a control group (conventional surgery group). Thoracoscopic lobectomy and mediastinal lymph node dissection were performed. Intraoperative and postoperative related indicators were observed to validate the effectiveness and safety of the tissue pneumoperitoneum technique around lymph nodes. The observation group showed a significantly shorter lymph node dissection surgery time compared to the control group, with a statistically significant difference (p < 0.05). The number of lymph nodes dissected in the observation group was significantly higher than that in the control group, with a statistically significant difference (p < 0.05). Although the observation group had slightly more mediastinal lymph node stations dissected than the control group, the difference was not statistically significant (p > 0.05). The total drainage volume within three days postoperatively was comparable between the two groups, with no statistically significant difference (p > 0.05). The observation group had shorter chest tube indwelling time and postoperative hospital stay than the control group, with statistically significant differences (p < 0.05). The incidence of surgical complications was similar between the two groups, and there were no perioperative deaths. The tissue pneumoperitoneum technique around lymph nodes is a more efficient method for mediastinal lymph node dissection in lung cancer, demonstrating safety and feasibility, and is worthy of promotion.

S. mansoni -derived omega-1 prevents OVA-specific allergic airway inflammation via hampering of cDC2 migration.

Chronic infection with Schistosoma mansoni parasites is associated with reduced allergic sensitization in humans, while schistosome eggs protects against allergic airway inflammation (AAI) in mice. One of the main secretory/excretory molecules from schistosome eggs is the glycosylated T2-RNAse Omega-1 (ω1). We hypothesized that ω1 induces protection against AAI during infection. Peritoneal administration of ω1 prior to sensitization with Ovalbumin (OVA) reduced airway eosinophilia and pathology, and OVA-specific Th2 responses upon challenge, independent from changes in regulatory T cells. ω1 was taken up by monocyte-derived dendritic cells, mannose receptor (CD206)-positive conventional type 2 dendritic cells (CD206+ cDC2), and by recruited peritoneal macrophages. Additionally, ω1 impaired CCR7, F-actin, and costimulatory molecule expression on myeloid cells and cDC2 migration in and ex vivo, as evidenced by reduced OVA+ CD206+ cDC2 in the draining mediastinal lymph nodes (medLn) and retainment in the peritoneal cavity, while antigen processing and presentation in cDC2 were not affected by ω1 treatment. Importantly, RNAse mutant ω1 was unable to reduce AAI or affect DC migration, indicating that ω1 effects are dependent on its RNAse activity. Altogether, ω1 hampers migration of OVA+ cDC2 to the draining medLn in mice, elucidating how ω1 prevents allergic airway inflammation in the OVA/alum mouse model.

Intrapulmonary T Cells Are Sufficient for Schistosoma-Induced Pulmonary Hypertension.

Schistosomiasis is a parasitic infection that can cause pulmonary hypertension (PH). Th2 CD4 T cells are necessary for experimental Schistosoma-PH. However, if T cells migrate to the lung to initiate, the localized inflammation that drives vascular remodeling and PH is unknown. Mice were sensitized to Schistosoma mansoni eggs intraperitoneally and then challenged using tail vein injection. FTY720 was administered, which blocks lymphocyte egress from lymph nodes. T cells were quantified using flow cytometry, PH severity via heart catheterization, and cytokine concentration through ELISA. FTY720 decreased T cells in the peripheral blood, and increased T cells in the mediastinal lymph nodes. However, FTY720 treatment resulted in no change in PH or type 2 inflammation severity in mice sensitized and challenged with S. mansoni eggs, and the number of memory and effector CD4 T cells in the lung parenchyma was also unchanged. Notably, intraperitoneal Schistosoma egg sensitization alone resulted in a significant increase in intravascular lymphocytes and T cells, including memory T cells, although there was no significant change in parenchymal cell density, IL-4 or IL-13 expression, or PH. Blocking T cell migration did not suppress PH following Schistosoma egg challenge. Memory CD4 T cells, located in the lung intravascular space following egg sensitization, appear sufficient to cause type 2 inflammation and PH.

Évolution des pratiques concernant l’exploration ganglionnaire médiastinale

While mediastinoscopy is considered the gold standard for mediastinal node sampling, it is to some extent being superseded by endobronchial ultrasound. The objective of this study was to evaluate the different practices in our center regarding mediastinal lymph node sampling in lung cancer patients. Data were collected from patients having undergone mediastinal lymph node sampling by video-assisted-mediastinoscopy (VM) or by endobronchial ultrasound (EBUS) in our center between August 2020 and July 2023. The modalities of the two procedures and their diagnostic accuracy were analyzed, as was their evolution over time. The 362 patients comprised 217 who were sampled by EBUS and 145 by VM. Overall, the procedures became more frequent, with EBUS tending to supersede VM. The number of harvested lymph nodes gradually grew, and less unforeseen lymph node invasion and upstaging occurred. The arrival in our center of endobronchial ultrasound yielded an overall increase of lymph node sampling despite a decrease in the number of mediastinoscopy procedures performed. Reinforced compliance with guidelines is needed to improve the diagnostic accuracy of these techniques and to better ensure quality of care.

Distant recurrence of non-muscle invasive bladder cancer 8 years after initial treatment.

Distant recurrence of non-muscle invasive bladder cancer is a rare condition that is poorly understood and difficult to detect in follow-up protocols. A 73-year-old female with a history of T1N0M0 bladder cancer 8 years ago suffered from a left axillary tumor, a left lung tumor, left mediastinal lymph node swelling, and bilateral adrenal gland tumors. Initially, she was diagnosed with metastatic left breast cancer of the left accessory mamma by needle biopsy of an axillary tumor. Subsequent bronchoscopic biopsy of the mediastinal lymph node revealed metastatic urothelial carcinoma, although no recurrence was detected in the urinary tract. She underwent systemic therapy, and all regions shrank without reprogression. Non-muscle invasive bladder cancer should be managed considering distant metastasis. If the origin of the metastatic lesions is unknown, this disease should be considered as a possible origin, even in the absence of urinary tract recurrence.

Can computed tomography findings and radiomics analysis of mediastinal lymph nodes differentiate between sarcoidosis and lymphoma?

To assess the ability of computed tomography (CT) findings and radiomics analysis to differentiate mediastinal lymphadenopathies as sarcoidosis versus lymphoma. 94 patients with lymphoma and 97 patients with sarcoidosis, who had > 1cm mediastinal lymph node were included. Size, location of lymph nodes, and distribution of the largest lymph nodes in two groups were compared. A total of 636 lymphadenopathies in four different regions were segmented for radiomics. Lesion segmentation was semiautomatically performed with a dedicated commercial software package on chest CT images. 149 patients were grouped as a training cohort, while 42 patients who underwent CT in the oncology hospital were used for external validation. The least absolute shrinkage and selection operator (LASSO) analysis was used to perform feature selection. Using selected features, the classification performance of various data mining methods in separating groups of sarcoidosis and lymphoma was investigated. Distribution and size of lymphadenopathies were significantly different in sarcoidosis and lymphoma groups (<0.05). Radiomics and data mining methods showed excellent performance in differentiating lymph nodes of sarcoidosis and lymphoma according to both the largest lymphadenopathy and lymphadenopathies in four different mediastinal regions (AUC >0,95). Distribution and size of lymphadenopathies can help differential diagnosis in patients with sarcoidosis and lymphoma. CT radiomics analysis can discriminate the lymph nodes of sarcoidosis and lymphoma with great performance regardless of lymph node size and location and it can be used safely in the diagnosis of these diseases, which can sometimes be challenging to distinguish from each other.

The dilemma of mediastinal lymphadenopathy between invasive and non-invasive procedures: ROC analysis of T2WI and DWI-MRI advanced parameters correlated with PET-CT and biopsy

BackgroundThe characterization of pathologically enlarged mediastinal lymph nodes is clinically essential for effective disease management and accurate prognosis. Malignancy (metastases and lymphoma) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. Magnetic resonance imaging (MRI) is a good modality to characterize the mediastinal pathologically enlarged lymph nodes based on the excellent soft tissue contrast. It can save high-risk patients from radiation exposure and hazards of intervention such as general anesthesia and biopsy.Aim of the workTo estimate the accuracy of different advanced MRI quantitative parameters in the differentiation between benign and malignant mediastinal lymphadenopathy. This would involve the lesion-to-cord signal intensity ratio (SIR) in the T2-WI and diffusion weighted image (DWI), the lesion-to-chest wall muscle SIR in T2-WI and DWI, and the mean apparent diffusion coefficient (ADC) values. These values would be correlated with the prospective pathological data and the results of the positron emission tomography (PET-CT).ResultsProspectively, the study was conducted during the period between June 2022 and September 2023 on 45 patients with indeterminate or suspicious mediastinal lymphadenopathy identified by CT. MRI examination, PET-CT, and biopsy were applied for all patients. The intra-class correlation coefficient ranged between 0.89 and 0.95. (A) The lesion-to-cord SIR in T2-WI in the malignant group (1.49 ± 0.30) was higher than that in the benign group (0.83 ± 0.24) with P < 0.001. The statistically calculated cutoff value (> 1.2) estimated 90% sensitivity, 100% specificity, with AUC = 0.989. (B) The lesion-to-chest wall muscle SIR in T2-WI in malignant nodes (3.13 ± 0.84) was significantly higher than that in the benign nodes (1.90 ± 0.80) with P < 0.001. The statistically calculated cutoff value (> 2.4) estimated 86.67% sensitivity, 86.67% specificity, with AUC = 0.88. (C) The lesion-to-cord signal SIR in b500-DWI in the malignant node (1.80 ± 0.54) was higher than that in the benign group (0.75 ± 0.29) with P < 0.001. The statistically calculated cutoff value (> 1.2) estimated 100% sensitivity and specificity with AUC = 1.00. (D) The lesion-to-chest wall SIR in b500-DWI in the malignant node (6.43 ± 1.28) was higher than that in the benign node (2.63 ± 0.94) with P < 0.001. The statistically calculated cutoff value (> 4.1) estimated 96.67% sensitivity, 100% specificity, with AUC = 0.997. € The mean ADC values in the malignant nodes (0.83 ± 0.20 × 10–3 mm2/s) were significantly lower than that in the benign nodes (1.85 ± 0.19 × 10−3 mm2/s) with P < 0.001. The statistically calculated cutoff value (≤ 1.2) estimated 100% sensitivity and specificity with AUC = 1.00.ConclusionsBiopsy remains the main diagnostic modality for the characterization of mediastinal lymphadenopathy despite its hazards and limitations. This study proved that MRI could be accepted as an alternative non-invasive imaging tool that can overcome the PET-CT limitations. The lesion signal-to-cord and to-muscle ratios in both T2-WI and DWI-MRI side by side with the mean ADC value showed high statistical accuracy.

Biodistribution of cerium dioxide and titanium dioxide nanomaterials in rats after single and repeated inhalation exposures

BackgroundPhysiologically based kinetic models facilitate the safety assessment of inhaled engineered nanomaterials (ENMs). To develop these models, high quality datasets on well-characterized ENMs are needed. However, there are at present, several data gaps in the systemic availability of poorly soluble particles after inhalation. The aim of the present study was therefore to acquire two comparable datasets to parametrize a physiologically-based kinetic model.MethodRats were exposed to cerium dioxide (CeO2, 28.4 ± 10.4 nm) and titanium dioxide (TiO2, 21.6 ± 1.5 nm) ENMs in a single nose-only exposure to 20 mg/m3 or a repeated exposure of 2 × 5 days to 5 mg/m3. Different dose levels were obtained by varying the exposure time for 30 min, 2 or 6 h per day. The content of cerium or titanium in three compartments of the lung (tissue, epithelial lining fluid and freely moving cells), mediastinal lymph nodes, liver, spleen, kidney, blood and excreta was measured by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS) at various time points post-exposure. As biodistribution is best studied at sub-toxic dose levels, lactate dehydrogenase (LDH), total protein, total cell numbers and differential cell counts were determined in bronchoalveolar lavage fluid (BALF).ResultsAlthough similar lung deposited doses were obtained for both materials, exposure to CeO2 induced persistent inflammation indicated by neutrophil granulocytes influx and exhibited an increased lung elimination half-time, while exposure to TiO2 did not. The lavaged lung tissue contained the highest metal concentration compared to the lavage fluid and cells in the lavage fluid for both materials. Increased cerium concentrations above control levels in secondary organs such as lymph nodes, liver, spleen, kidney, urine and faeces were detected, while for titanium this was found in lymph nodes and liver after repeated exposure and in blood and faeces after a single exposure. Conclusion: We have provided insight in the distribution kinetics of these two ENMs based on experimental data and modelling. The study design allows extrapolation at different dose-levels and study durations. Despite equal dose levels of both ENMs, we observed different distribution patterns, that, in part may be explained by subtle differences in biological responses in the lung.