Mediastinal Node Involvement Research Articles

P-OGC22 Incidence and relevance of clinically indeterminate non-regional lymph nodes in the treatment of oesophageal cancer

Abstract Background Metastatic involvement of non-regional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare, but has important implications for prognosis and management. The management of non-regional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimetre nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up, and clinical significance of non-regional clinically indeterminate FDG avid lymph nodes. Methods A single centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with non-regional FDG avid nodes were identified. Subsequent work-up, management, and outcomes were retrieved from electronic health records. Results Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery, and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false negative lymph node sampling. Conclusions EBUS and US-FNA are effective means of sampling clinically indeterminate non-regional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued.

Survival prognostic and recurrence risk factors after single pulmonary metastasectomy

BackgroundIdentification of the prognostic factors of recurrence and survival after single pulmonary metastasectomy (PM).MethodsRetrospective analysis of all consecutive patients who underwent PM for a single lung metastasis between 2003 and 2018.ResultsA total of 162 patients with a median age of 64 years underwent single PM. Video-Assisted Thoracic Surgery (VATS) was performed in 83.9% of cases. Surgical resection was achieved by wedge in 73.5%, segmentectomy in 7.4%, lobectomy in 17.9% and pneumonectomy in 1.2% of cases. The median durations of hospital stay and of drainage were 4 days (IQR 3–7) and 1 day (IQR 1–2), respectively. During the follow-up (median 31 months; IQR 15–58), 93 patients (57.4%) presented recurrences and repeated PM could be realized in 35 patients (21.6%) achieved by VATS in 77.1%. Non-colorectal tumour (HR 1.84), age < 70 years (HR 1.77) and previous extra-thoracic metastases (HR 1.61) were identified as prognostic factors of recurrence. Overall survival at 5-year was estimated at 67%. Non-colorectal tumour (HR 2.40) and mediastinal lymph nodes involvement (HR 3.42) were significantly associated with an increased risk of death.ConclusionsDespite high recurrence rates after PM, surgical resection shows low morbidity rate and acceptable long-term survival, thus should remain the standard treatment for single pulmonary metastases.Trial registration: The Local Ethics Committee approved the study (No. 2019–02,474) and individual consent was waived.

Outcomes of surgical treatment for isolated adrenal metastasis from non-small cell lung cancer.

ObjectiveLong-term survival of patients who undergo surgical resection of isolated adrenal metastasis instead of nonsurgical treatment has shown higher values than those described for stage IVA. The primary endpoint was to evaluate overall survival (OS) of patients with single adrenal metastasis from non-small cell lung cancer (NSCLC), who underwent surgical treatment. The secondary endpoint was to evaluate and compare the OS and disease-free survival (DFS) according to: pathological lung tumour size, histology, lymph node involvement, type of metastasis at the time of diagnosis and laterality of the metastasis according to the primary lung tumour.MethodsFrom August 2007 to March 2020, 13 patients with isolated adrenal gland metastasis were identified. We performed a descriptive observational study including patients with diagnosed single adrenal gland metastasis of resectable primary lung cancer and no history of other malignant disease. Clinical data obtained included patient demographics, metastases characteristics, laterality of the metastasis, time between surgeries, length of follow-up, survival status, pathological lung tumour size, histology and lymph node involvement. The variables analysed were OS and DFS.ResultsMedian global OS was 31.9 months (interquartile range (IQR), 19.1–51.4). The 2- and 5-year OS estimated was 54% (95% CI: 29.5%–77.4%) and 36% (95% CI: 13.4%–68.1%), respectively. In patients with NSCLC without mediastinal lymph node involvement, we obtain a median OS of 40 months (IQR, 27.4–51.4) and a 2- and 5-year OS estimated of 75% (95% CI: 43.2%–92.2%) and 50% (95% CI: 18.7%–81.2%), respectively. Recurrence was detected in five patients with a median DFS of 11.9 months (IQR, 6–34.2).ConclusionThe resection of the adrenal metastasis should be considered if the primary lung cancer is resectable. Presence of mediastinal lymph node involvement should be ruled out through invasive staging of the mediastinum before performing adrenal and lung surgery. Proper selection of patients who would benefit from surgery is essential to obtain better survival results.

Prognostic nomogram incorporating radiological features for predicting overall survival in patients with AIDS-related non-Hodgkin lymphoma.

Background:Acquired immune deficiency syndrome (AIDS)-related non-Hodgkin lymphoma (AR-NHL) is a high-risk factor for morbidity and mortality in patients with AIDS. This study aimed to determine the prognostic factors associated with overall survival (OS) and to develop a prognostic nomogram incorporating computed tomography imaging features in patients with acquired immune deficiency syndrome-related non-Hodgkin lymphoma (AR-NHL).Methods:A total of 121 AR-NHL patients between July 2012 and November 2019 were retrospectively reviewed. Clinical and radiological independent predictors of OS were confirmed using multivariable Cox analysis. A prognostic nomogram was constructed based on the above clinical and radiological factors and then provided optimum accuracy in predicting OS. The predictive accuracy of the nomogram was determined by Harrell C-statistic. Kaplan–Meier survival analysis was used to determine median OS. The prognostic value of adjuvant therapy was evaluated in different subgroups.Results:In the multivariate Cox regression analysis, involvement of mediastinal or hilar lymph nodes, liver, necrosis in the lesions, the treatment with chemotherapy, and the CD4 ≤100 cells/μL were independent risk factors for poor OS (all P < 0.050). The predictive nomogram based on Cox regression has good discrimination (Harrell C-index = 0.716) and good calibration (Hosmer–Lemeshow test, P = 0.620) in high- and low-risk groups. Only patients in the high-risk group who received adjuvant chemotherapy had a significantly better survival outcome.Conclusion:A survival-predicting nomogram was developed in this study, which was effective in assessing the survival outcomes of patients with AR-NHL. Notably, decision-making of chemotherapy regimens and more frequent follow-up should be considered in the high-risk group determined by this model.

Effects of mediastinal lymph node dissection in colorectal cancer-related pulmonary metastasectomy.

BackgroundThe benefits of mediastinal lymph node dissection (MLND) in colorectal cancer‐related pulmonary metastasectomy (PM) have been poorly reported. This study aimed to determine whether MLND affects survival in patients undergoing PM and to identify the prognostic factors for survival.MethodsWe retrospectively reviewed 275 patients who had undergone colorectal cancer‐related PM from January 2010 to December 2016. MLND was defined as the resection of at least six mediastinal lymph node stations according to the International Association for the Study of Lung Cancer criteria (N1, ≥3 stations; N2, ≥3 stations). The propensity score matching method was used to reduce bias.ResultsThirty‐three (12%) patients underwent MLND, and 13 (4.7%) patients had mediastinal lymph node involvement. This study showed no difference in 5‐year overall survival (no MLND, 52.7% vs. MLND, 53.5%; p = 0.81). On multivariable analysis, negative prognostic factors for overall survival were preoperative carcinoembryonic antigen (CEA) level (p < 0.001), a higher number of metastatic nodules (p < 0.001), metastatic nodule size ≥2 cm (p < 0.001), and lymph node involvement (p = 0.006).ConclusionsMediastinal lymph node involvement, preoperative CEA level, higher metastatic nodule number, and nodule size negatively affected survival whereas MLND in PM was not associated with survival.

Clinical report of a patient with primary mediastinal B-large cell lymphoma

Primary mediastinal B-cell lymphoma is a variant of non-Hodgkin's lymphoma with the predominant involvement of mediastinal lymph nodes, which affects young women. Diagnosis of this nosology is difficult due to the rare involvement of peripheral lymph nodes, as well as the rapid increase of clinical manifestations, such as the syndrome of compression of the vena cava superior and the development of the respiratory failure. The article presents a clinical case of a patient who was operated and complications that occurred due to inadequate diagnostic and therapeutic tactics. There aren`t any descriptions of the clinical manifestations of the disease which could led to a diagnostic error in literature. We present our own observation of a patient with PMBCL and discuss a practical diagnostic algorithms for mediastinal tumors. The diagnosis of PMBCL can be established only as a result of morphological examination, it is important that surgeons and pathologists remember about it. This case is important not only because it provides information about such a lymphoproliferative disease as PMBCL, but also reminds about such a diagnostic error in oncology-treatment without verification. We tried to emphasize the nesessary of strict implementation of the algorithm for differential diagnosis of the anterior mediastinal neoplasms, especially for young people. I hope that this case will contribute to the expansion of knowledge and the prevention of errors in order to achieve better results.

Propensity score matched analysis for the role of surgery in stage Ⅲ small cell lung cancer based on the eighth edition of the TNM classification: a population study of the US SEER database and a Chinese hospital

ObjectivePatients with very early stage small cell lung cancer (SCLC) can benefit from surgery. However, the role of surgery in local advanced SCLC patients remains controversial. We designed this study to investigate the role of surgery on survival of this subset population. MethodsThe included patients were identified from the Surveillance, Epidemiology, and End Results SEER database from 1998 to 2016 and Shanghai Chest Hospital of China from 2009 to 2016. Propensity score matching(PSM) was used to balance clinical bias. The overall survival (OS) and lung cancer-specific survival (LCSS) were compared by the Kaplan–Meier analysis. Cox proportional hazards regression was used to identify factors associated with survival. ResultsAmong the 3005 stage Ⅲ patients, 570 (18.97%) patients underwent surgery. Compared with non-surgical group, patients undergoing surgery were more likely to be male, had smaller tumor size, mediastinal lymph node involvement and lower pathologic stage. The Kaplan-Meier analysis showed that surgical patients had a better OS and LCSS before and after PSM. 418 surgical patients were well matched with non-surgical patients. In matched surgical group, there were 224 (53.59%) patients who underwent lobectomy (LB), 147 (35.17%) patients who received sublobectomy (SLB), 31 (7.41%) patients who underwent pneumonectomy and 16 (3.83%) patients with unknown surgery type. The 5-year OS of the 4 subgroups were 28.80%, 12.50%, 8.70% and 13.50%, respectively (P = 0.002). In a multivariable Cox model, SLB (hazard ratio, 1.53; 95%CI, 1.20–1.96; P = 0.001) and pneumonectomy (hazard ratio, 1.72; 95%CI, 1.12–2.65; P = 0.013) were associated with worse OS compared with LB. ConclusionSurgical resection significantly improved OS and LCSS of stage Ⅲ SCLC patients in our study. Furthermore, LB had advantage over other surgery type but further exploration in larger prospective clinical trials is needed.

Gastrointestinal: Autoimmune enteropathy associated with thymoma.

A 50-year-old gentleman presented with 4 months of chronic watery, non-bloody diarrhea up to 10 times a day, and weight loss. He had a history of a thymoma first diagnosed 7 years earlier, which was resected with positive histological margins. There was no macroscopic residual disease or vascular invasion. He did not receive any adjuvant treatment and developed recurrent Masaoka-Koga stage IVa thymoma with pleural, pericardial, and lung invasion requiring further treatment with resection, chemotherapy (3 cycles of cisplatin, doxorubicin, and cyclophosphamide), and radiotherapy (54 Gy in 30 fractions). There was no mediastinal lymph node involvement or evidence of distant hematogenous metastasis. Histopathology demonstrated multiple nodules of mixed WHO type B1 and B2, but predominantly type B1 thymoma. His diarrhea commenced after his thymoma recurrence. He did not have any features suggesting other autoimmune diseases associated with thymoma including myasthenia gravis. Physical examination and initial laboratory investigations were unremarkable. Stool cultures were negative for bacterial, viral, and parasitic infections. A computed tomography (CT) scan of the abdomen revealed wall thickening and fat stranding affecting the small intestine and colon (Fig. 1a). Correspondingly, mild patchy erythematous colitis in the rectum and sigmoid colon was seen on colonoscopy (Fig. 1b). Histologically, colonic biopsies showed active colitis with prominent regenerative changes. Goblet cells were noticeably absent, and there was prominent apoptosis, features typical of autoimmune enteropathy (Fig. 1c). Patient serum was incubated with frozen sections of normal small intestinal mucosa, showing strong staining by immunofluorescence for human IgA and IgG with a goblet cell distribution (Fig. 2). A diagnosis of thymoma-associated autoimmune enteropathy was made, and the patient was commenced on a weaning dose of prednisone starting at 25 mg daily leading to resolution of his symptoms. Thymomas are associated with concomitant autoimmune diseases in up to 30% of patients, possibly due to defective immune regulation. Differentials for thymoma-associated autoimmune conditions causing diarrhea include autoimmune enteropathy and Good's syndrome (thymoma-associated hypogammaglobulinemia). Thymoma-associated autoimmune enteropathy is rare with only five reported cases in the literature. Proposed diagnostic criteria include chronic diarrhea lasting over 6 weeks, malabsorption, and abnormal histology of the small bowel (villous blunting, deep crypt lymphocytosis, minimal intraepithelial lymphocytosis, and increased crypt apoptotic bodies). A spectrum of changes can be seen in the colon including increased mononuclear inflammatory infiltrate, active inflammation including neutrophilic cryptitis and microabscesses, intraepithelial lymphocytosis, and increased crypt epithelial apoptosis. Changes of chronicity including crypt architectural distortion and Paneth cell metaplasia have also been described. The presence of anti-enterocyte or anti-goblet antibodies is supportive, but the sensitivity and specificity of these markers are unknown. Steroids are the first-line management for autoimmune enteropathy; however, further immunosuppression (azathioprine, cyclosporin, tacrolimus, or infliximab) may be required in up to 90% of cases. For patients with thymoma-associated autoimmune enteropathy, resection of the thymoma may also improve symptoms.

S2051 Primary Esophageal Lymphoma or Lymphoma Presenting as an Esophageal Mass: Rare Disease or Rare Presentation of a Disease?

Introduction: GI tract is the most common site of extra nodal non Hodgkin lymphoma (NHL) with the usual sites being stomach, small intestine and colon. Esophageal involvement has been reported in < 1% of cases and mostly occurs as an extension of mediastinal or gastric lymphoma. Here, we present a case of diffuse large B cell lymphoma (DLBCL) presenting with obstructive esophageal symptoms and diagnosed on esophageal ulcer biopsy. Case Description/Methods: A 72-year-old White male with history of 84 pack years smoking, GERD, presented with a month of shortness of breath, dysphagia to solids, odynophagia, loss of appetite, and 20 lbs. weight loss. Labs revealed WBC count 7000/µL. CT chest without contrast showed a large mediastinal mass with hilar extension, causing esophageal obstruction and two masses within the right lobe of liver. Endoscopy showed a mid-esophageal ulcer without bleeding, and atypical lymphoid cells on biopsy. Immunohistochemistry was positive for CD20, PAX5, BCL2 and BCL6, MUM1 and negative for CD10, cyclinD1 with MIB1 90%, thus consistent with DLBCL. Biopsy of liver mass showed similar histology and immunohistochemistry. HIV testing was negative. He was started on EPOCH based chemotherapy for the DLBCL. On chart review, CT Lung screening a year ago showed several filling defects in mid esophagus, however the filling defects were not evaluated as he was lost to follow up. Discussion: Primary esophageal DLBCL is a rare NHL with only handful of cases reported in literature to date. Our patient did not satisfy Dawson’s criteria for diagnosis of primary GI lymphoma which requires absence of peripheral and mediastinal lymphadenopathy, lack of liver and spleen involvement, and normal peripheral blood count. However, the utility of Dawson’s criteria for diagnosis of primary esophageal lymphoma has been questioned. Esophagus is a mediastinal structure and has rich lymphatic network, thus, predisposing to early mediastinal lymph nodes involvement. Also, esophageal cancers have been known to spread to liver via venous channels. Our patient had several mid esophageal filling defects a year ago and now presented with a large mediastinal mass encasing esophagus, thus, supporting the diagnosis of primary esophageal lymphoma. This case highlights the importance of endoscopic evaluation of esophageal filling defects seen on imaging.Figure 1.: Low dose CT lung screening performed a year prior shows filling defects in mid esophagus (red arrow) as seen in (A) axial section and (B) sagittal section. (C) CT chest without contrast on presentation showing large mediastinal mass, at the same level as image A causing esophageal obliteration. (D) Endoscopic biopsy of esophageal ulcer showing atypical lymphoid cells.

First case of lung cancer with pneumoconiosis and endobronchial leiomyoma complicating the diagnosis

BackgroundIn the treatment of lung cancer, the presence or absence of mediastinal lymph node involvement has a significant bearing on the indication for surgery. In addition, if a tumor is found in the trachea during preoperative scrutiny of lung cancer, the possibility of intratracheal metastasis should be considered, since this kind of metastasis is a contraindication for surgery. In the present study, we experienced a case of lung cancer associated with pneumoconiosis and a rare intratracheal leiomyoma. In this case, preoperative staging was difficult, but endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and intratracheal tumor biopsy were helpful in determining the treatment strategy.Case presentationA 65-year-old man was referred to our hospital for evaluation of abnormal chest X-ray shadows. Sputum cytology indicated squamous cell carcinoma. PET-CT scan showed fluorodeoxyglucose uptake in a right upper lobe mass and the hilar, mediastinal and right supraclavicular lymph nodes, and bronchoscopy revealed a protuberant lesion in the left bronchus. Hence, EBUS-TBNA for the mediastinal lymph nodes and simultaneous evaluation of the protuberant lesion in the left bronchus were performed. The bronchial tumor was histopathologically diagnosed as leiomyoma. Since mediastinal lymph node biopsy showed no malignant cells, a right upper lobectomy and a right S6 segmentectomy were performed. Postoperative pathological evaluation of the dissected lymph nodes revealed pneumoconiosis but no metastasis. He was, thus, diagnosed with squamous cell lung carcinoma (pT2bN0M0, pStage IIA).ConclusionsWe report a patient with lung cancer and coexistence of a rare endobronchial leiomyoma and pneumoconiosis, who underwent surgery after preoperative evaluation using EBUS-TBNA.

Incidence and relevance of clinically indeterminate nonregional lymph nodes in the treatment of oesophageal cancer.

Metastatic involvement of nonregional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare but has important implications for prognosis and management. The management of nonregional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimeter nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up and clinical significance of nonregional clinically indeterminate FDG avid lymph nodes. A single-centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with nonregional FDG avid nodes were identified. Subsequent work-up, management and outcomes were retrieved from electronic health records. Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine-needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false-negative lymph node sampling. EBUS and US-FNA are effective means of sampling clinically indeterminate nonregional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued. Nonregional clinically indeterminate lymph nodes represent a diagnostic dilemma in oesophageal cancer staging. Additional investigations in the form of endobronchial ultrasound are effective at providing additional staging information, and can substantially influence patient care.

Magnetic resonance imaging for the study of mediastinal adenopathies in lung cancer: Comparison with standard tests.

Lung cancer is the second most common cancer in both men and women. Mediastinal lymph node involvement in these patients, determined by imaging tests, indicates prognosis and modifies therapeutic attitude. The aim of this study was to analyze the diagnostic capacity of magnetic resonance imaging (MRI) in the study of the mediastinum in comparison with conventional tests (computed tomography [CT] and positron-emission tomography [PET] or PET/CT scans), taking histology as the gold standard. An observational study was conducted on 16 patients with suspicion of primary lung cancer (June 2016 through December 2018). We studied their demographic characteristics and used CT, PET, or PET/CT scans and MRI (diffusion-weighted imaging-MRI sequence) to examine mediastinal disease and compare MRIs diagnostic yield and percentage agreement to that of conventional tests. As compared to CT and PET scanning, MRI displayed a very low sensitivity and a specificity of 90 and 88%, respectively; positive predictive value was 0.67 (both) and negative predictive value (NPV) was 0.28 and 0.22, respectively. MRI showed a high degree of agreement in lymph node diagnosis when compared with histology (91.2%; P = 0.001): specificity in this case was high (E = 0.94), as was the NPV (NPV = 0.97). The results of this study would appear to indicate that MRI could play a relevant role in mediastinal staging of lung cancer. More prospective, multicenter studies are, however, needed to be able to draw up firm recommendations about the role of MRI and its place in lung cancer staging.

Incidental lung findings in a COVID-19 patient on 18F-FDG PET/CT done for preoperative evaluation of Marjolin's ulcer-first report from Chhattisgarh.

The aim of this case is to illustrate the18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography findings of a patient who was admitted in AIIMS, Raipur, for the preoperative evaluation of Marjolin ulcer and was later diagnosed with COVID-19 infection. Apart from the primary lesion in the right foot and pelvic lymph nodes, the scan revealed mild FDG-avid basal ground-glass opacities in bilateral lung fields with mediastinal and hilar lymph nodal involvement, in an otherwise asymptomatic patient.

Diagnostic accuracy of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal lymph node staging of lung cancer.

Lung cancer is one of the leading causes of cancer-related mortality around the world. A prompt diagnosis and accurate staging are of the essence in order to establish the appropriate treatment plan. Mediastinal lymph nodes involvement is the most important parameter to define the therapeutic path, and particularly to decide whether a patient can be offered a potentially curative surgery. Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), together with oesophageal ultrasound (EUS), has a pivotal role in the diagnosis and staging of lung cancer. These procedures have excellent diagnostic performances, can be performed without requiring general anaesthesia, and are far less invasive than mediastinoscopy and video-assisted thoracic surgery (VATS). Moreover, EBUS-TBNA allows to biopsy intrapulmonary lymph nodes. Different studies have been investigated the diagnostic accuracy of EBUS-TBNA for the diagnosis and staging of lung cancer, with always good but heterogeneous results. In some studies, EBUS-TBNA has shown to yield adequate samples for molecular testing and immunocytochemistry too. Rapid on site cytologic evaluation (ROSE) can be used to assess the adequacy of samples during the endoscopic procedure. The aim of this review article is to describe the current evidence on the diagnostic accuracy of EBUS-TBNA for the diagnosis of lung cancer. We also reported our centre’s experience and the results of 456 EBUS-TBNA performed between April 2016 and March 2020.

High Flow Priapism on ¹⁸FDG PET/CT in a Patient with Urothelial Carcinoma: Case Report

We studied a 52-year-old man diagnosed with a high-grade urothelial carcinoma of the upper urinary tract treated with nephroureterectomy and chemotherapy who presented a benign high-flow priapism with intensive 18F-fluorodeoxyglucose (FDG) uptake as an unusual finding in the positron emission tomography (PET)/computed tomography (CT) that also showed mediastinal and lumbo-aortic node involvement and liver metastases. Upon examination, the patient had a painless erection that lasted for five days with no episode of recurrence at two-month follow-up.

Lung carcinoid tumors with Diffuse Idiopathic Pulmonary NeuroEndocrine Cell Hyperplasia (DIPNECH) exhibit pejorative pathological features

IntroductionDiffuse Idiopathic Pulmonary NeuroEndocrine Cell Hyperplasia (DIPNECH) is a rare disease often associated with carcinoid tumors. We aimed at evaluating the impact of DIPNECH on characteristics and prognosis of patients who underwent radical treatment of pulmonary carcinoid tumors. Material and methodsWe reviewed all patients operated on for curative-intent resection of carcinoid tumor in our department from 2001 to 2020. Cases exhibiting both pathological and radiological features of DIPNECH, as assessed by respective thoracic expert physicians, were analyzed separately. Results172 cases of resected carcinoid tumors were identified, including 25 (14.5 %) harboring pathological criteria of DIPNECH and radiologic features like mosaic attenuation (92.0 %), multiple nodules < 5 mm (76.0 %), and mucoid impactions (32 %). In DIPNECH patients, major pulmonary resections were usually performed (92.0 %) and resected tumors were mostly classified as pT1 (92 %). Mean Ki67 staining was 3.7 ± 5.2 %. The early postoperative period was mostly uneventful (96.0 %) and 5-year survival was 92.9 ± 6.9 %. Compared to non-DIPNECH cases, we found that patients were older (mean 65.6 ± 9.3 versus 54.1 ± 17.9, p = 0.002), more frequently female (84.0 % versus 56.5 %, p = 0.009), and exhibiting diabetes mellitus (45.8 % versus 18.5 %, p < 0.001) or hypertension (45.8 % versus 24.1 %, p = 0.039). The rate of atypical carcinoid tumors was significantly higher in DIPNECH patients (40.0 % versus 19.9 %, p = 0.027), as well as rate of mediastinal lymph-nodes involvement (pN2+) (36.0 % versus 4.1 %, p < 0.001). At multivariate analysis, only DIPNECH pattern and atypical histology were independent factors of pN2 invasion which was the only predictor of poorer prognosis on Log-Rank test. ConclusionCarcinoid tumors with proven DIPNECH are associated with negative pathological features and may deserve a dedicated perioperative management.

Stage III N2 non-small cell lung cancer treatment: decision-making among surgeons and radiation oncologists.

BackgroundStage III N2 non-small cell lung cancer (NSCLC) is a very heterogeneous disease associated with a poor prognosis. A number of therapeutic options are available for patients with Stage III N2 NSCLC, including surgery [with neoadjuvant or adjuvant chemotherapy (CTx)/neoadjuvant chemoradiotherapy (CRT)] or CRT potentially followed by adjuvant immunotherapy. We have no clear evidence demonstrating a significant survival benefit for either of these approaches, the selection between treatments is not always straightforward and can come down to physician and patient preference. The very heterogeneous definition of resectability of N2 disease makes the decision-making process even more complex.MethodsWe evaluated the treatment strategies for preoperatively diagnosed stage III cN2 NSCLC among Swiss thoracic surgeons and radiation oncologists. Treatment strategies were converted into decision trees and analysed for consensus and discrepancies. We analysed factors relevant to decision-making within these recommendations.ResultsFor resectable “non-bulky” mediastinal lymph node involvement, there was a trend towards surgery. Numerous participants recommend a surgical approach outside existing guidelines as long as the disease was resectable, even in multilevel N2. With increasing extent of mediastinal nodal disease, multimodal treatment based on radiotherapy was more common.ConclusionsBoth, surgery- or radiotherapy-based treatment regimens are feasible options in the management of Stage III N2 NSCLC. The different opinions reflected in the results of this manuscript reinforce the importance of a multidisciplinary setting and the importance of shared decision-making with the patient.

Lymphadenectomy in pulmonary metastasectomy.

Lymph node (LN) removal during pulmonary metastasectomy is a prerequisite to achieve complete resection or at least collect prognostic information, but is not yet generally accepted. On average, the rate of unexpected lymph node involvement (LNI) is less than 10% in sarcoma, 20% in colorectal cancer (CRC) and 30% in renal cell carcinoma (RCC) when radical LN dissection is performed. LNI is a negative prognostic factor and presence of preoperative mediastinal disease usually leads to exclusion of the patient from metastasis surgery. Nonetheless, some authors found excellent prognoses even with mediastinal LNI in colorectal and RCC metastases when radical LN dissection was performed (median survival of 37 and 36 months, respectively). Multiple metastases, central location of the lesion followed by anatomical resections are associated with a higher LNI rate. The real prognostic influence of systematic LN dissection remains unclear. Two positive effects were described after radical lymphadenectomy: a trend for improved survival in RCC patients and a reduction of mediastinal recurrences from 23% to 0% in CRC patients. Unfortunately, there is a great number of studies that do not demonstrate any positive effect of lymphadenectomy during pulmonary metastasectomy except a pseudo stage migration effect. Future studies should not only focus on survival, but also on local and LN recurrence.

Spanish Lung Cancer Group SCAT trial: surgical audit to lymph node assessment based on IASLC recommendations

BackgroundThe Spanish Customized Adjuvant Therapy (SCAT) trial assessed the role of individualized adjuvant therapy in clinical N0 incidental pN1 and/or N2 non-small cell lung cancer (NSCLC) completely resected. We assessed surgical topics with an in-depth analysis of quality of lymphadenectomy based on International Association for the Study of Lung Cancer (IASLC) recommendations.MethodsPatients with information about lymphadenectomy available were included (N=451). Prospectively collected data about tumor, type of resection, and postoperative morbidity and quality of lymph node dissection (LND) were retrospectively evaluated. Role of lymph node assessment on survival was analyzed using Kaplan-Meier curves, using regression models to identify prognostic factors.ResultsIn 33.7%, 17.7% and 49.9% of cases, regions 7, 10 and 11 respectively were not assessed. In 21.1% of patients, less than three lymph node regions were biopsied, while in 19.6% of patients less than six lymph nodes were assessed. In 53,4% of patients only one N1 region was evaluated. From patients with positive N2, 8.9% had no N1 regions biopsied. Twenty-nine percent of patients with at least one N2 lymph node resected shown the highest region involved. Thirty-day postoperative mortality was unknown. Five-year overall survival (OS) was 61.7% (95% CI: 55.4–67.4%), 51.5% (95% CI: 39.2–62.4%) and 42.3% (95% CI: 32.1–52.2%) for patients with N1, N2 and N1+N2 disease, respectively (P<0.01). Both number of lymph nodes resected and number of lymph nodes involved by tumor were significantly related to prognosis.ConclusionsIASLC recommendations for surgical resections were not followed in a high proportion of surgical procedures. Hilar and mediastinal lymph node assessment and involvement showed to impact prognosis. Surgical issues such as postoperative mortality could not be evaluated owing to trial design.

Endobronchial Ultrasound in Evaluating Mediastinal Lymphadenopathy

AbstractTuberculosis can involve most of the body parts, and tubercular lymphadenitis is common. But isolated involvement of mediastinal lymph nodes without lung parenchymal involvement is rare in adults. A 45-year-old lady presented with subcarinal lymph node enlargement. A conventional transbronchial needle aspiration done at a local hospital was inconclusive. Endobronchial ultrasound-guided transbronchial needle aspiration was done. Cytology showed epithelioid histiocytes and caseous necrosis. Stain for acid-fast bacilli and cartridge-based nucleic acid amplification test for tuberculosis were positive. Endobronchial ultrasound-guided transbronchial needle aspiration is a minimally invasive bronchoscopic technique to visualize and sample mediastinal lymph nodes. However, its availability is limited to specific centers and expertise is required to interpret images and take diagnostic samples.