Mediastinal Nodes Research Articles

Pathomorphological changes in the organs of the peripheral immune system in mycobacteriosis of cattle

Conducting routine allergy tests of cattle with a simultaneous sample in TB-prone farms is necessary to confirm the stage of the epizootic process. The purpose of the research – to explore the pathomorphological changes in cows upon detection of para allergic reactions during diagnostic testing for tuberculosis. The diagnosis of tuberculosis in animals was performed comprehensively using all methods for tuberculosis control provided for in the guidelines – epidemiological, clinical, allergic, pathological, histomorphological, bacteriological and biological. It allowed establishing that the reactions to tuberculin in cows were of a paraallergic nature, caused by nontuberculous mycobacteria or so-called atypical mycobacteria. It was determined that cows that reacted positively to tuberculin and an atypical mycobacterial allergen and were sent for slaughter for diagnostic purposes did not demonstrate pathological changes characteristic of tuberculosis. However, pathological changes (granulomatous foci, atrophy of lymphoid and epithelioid tissue, hyperplasia of varying intensity and nature, dotted haemorrhages in the cortical zone) were observed in many lymph nodes, including mediastinal, mesenteric, pharyngeal and mandibular lymph nodes, indicating an active infectious process in the body of animals caused by nontuberculous mycobacteria. Therewith, several changes were observed in the lymph nodes during histomorphological examination: development of primary nodules of lymphocytes and reticular tissue in reactive centres, degradation and necrosis of lymphocytes, the establishment of cellular detritus in the centre of the nodules and capsules of epithelioid elements around the nodules, etc., which can be used to confirm the patterns of pathology development and, indirectly, the mechanism of sensitisation of the cow’s body, and therefore the nature of paraallergic reactions in animals. The obtained results are important for the timely detection and identification at the histomorphological level of a complex of changes in the organs and tissues of cows due to the penetration of nontuberculous mycobacteria, which is the key to the successful diagnosis of primary foci of mycobacteriosis and their effective prevention

Prognosis of Patients with Esophageal Carcinoma After Routine Thoracic Duct Resection: A Propensity-matched Analysis of 12,237 Patients Based on the Comprehensive Registry of Esophageal Cancer in Japan.

To clarify whether routine thoracic duct (TD) resection improves the prognosis of patients with esophageal cancer after radical esophagectomy. Although TD resection can cause nutritional disadvantage and immune suppression, it has been performed for the resection of surrounding lymph nodes. We analyzed 12,237 patients from the Comprehensive Registry of Esophageal Cancer in Japan who underwent esophagectomy between 2007 and 2012. TD resection and preservation groups were compared in terms of prognosis, perioperative outcomes, and initial recurrent patterns using strict propensity score matching. Particularly, the year of esophagectomy and history of primary cancer of other organs were added as covariates. After propensity score matching, 1638 c-Stage I-IV patients participated in each group. The 5 year overall survival and cause-specific survival rates were 57.5% and 65.6% in the TD-resected group and 55.2% and 63.4% in the TD-preserved group, respectively, without significant differences. The TD-resected group had significantly more retrieved mediastinal nodes (30 vs 21, P < 0.0001) and significantly fewer lymph node recurrence (376 vs 450, P = 0.0029) compared with the TD-preserved group. However, the total number of distant metastatic organs was significantly greater in TD-resected group than in the TD-preserved group (499 vs 421, P = 0.0024). TD resection did not improve survival in patients with esoph-ageal cancer. Despite having retrieved more lymph nodes, TD resection caused distant metastases in more organs compared to TD preservation. Hence, prophylactic TD resection should not be recommended in patients with esophageal cancer.

The value on SUV-derived parameters assessed on 18F-FDG PET/CT for predicting mediastinal lymph node metastasis in non-small cell lung cancer

PurposeTo explore valuable predictors for mediastinal lymph node metastasis in non-small cell lung cancer (NSCLC) patients, we analyzed the potential roles of standardized uptake value (SUV)-derived parameters from preoperative 18F-FDG PET/CT combined with clinical characteristics.MethodsData from 224 NSCLC patients who underwent preoperative 18F-FDG PET/CT scans in our hospital were collected. Then, a series of clinical parameters including SUV-derived features [SUVmax of mediastinal lymph node and primary-tumor SUVmax, SUVpeak, SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG)] were evaluated. The best possible cutoff points for all measuring parameters were calculated using receiver operating characteristic curve (ROC) analysis. Predictive analyses were performed using a Logistic regression model to determine the predictive factors for mediastinal lymph node metastasis in NSCLC and lung adenocarcinoma patients. After multivariate model construction, data of another 100 NSCLC patients were recorded. Then, 224 patients and 100 patients were enrolled to validate the predictive model by the area under the receiver operating characteristic curve (AUC).ResultsThe mediastinal lymph node metastasis rates in 224 patients for model construction and 100 patients for model validation were 24.1% (54/224) and 25% (25/100), respectively. It was found that SUVmax of mediastinal lymph node ≥ 2.49, primary-tumor SUVmax ≥ 4.11, primary-tumor SUVpeak ≥ 2.92, primary-tumor SUVmean ≥ 2.39, primary-tumor MTV ≥ 30.88 cm3, and primary-tumor TLG ≥ 83.53 were more prone to mediastinal lymph node metastasis through univariate logistic regression analyses. The multivariate logistic regression analyses showed that the SUVmax of mediastinal lymph nodes (≥ 2.49: OR 7.215, 95% CI 3.326–15.649), primary-tumor SUVpeak (≥ 2.92: OR 5.717, 95% CI 2.094–15.605), CEA (≥ 3.94 ng/ml: OR 2.467, 95% CI 1.182–5.149), and SCC (< 1.15 ng/ml: OR 4.795, 95% CI 2.019–11.388) were independent predictive factors for lymph node metastasis in the mediastinum. It was found that SUVmax of the mediastinal lymph node (≥ 2.49: OR 8.067, 95% CI 3.193–20.383), primary-tumor SUVpeak (≥ 2.92: OR 9.219, 95% CI 3.096–27.452), and CA19-9 (≥ 16.6 U/ml: OR 3.750, 95% CI 1.485–9.470) were significant predictive factors for mediastinal lymph node metastasis in lung adenocarcinoma patients. The AUCs for the predictive value of the NSCLC multivariate model through internal and external validation were 0.833 (95% CI 0.769- 0.896) and 0.811 (95% CI 0.712–0.911), respectively.ConclusionHigh SUV-derived parameters (SUVmax of mediastinal lymph node and primary-tumor SUVmax, SUVpeak, SUVmean, MTV and TLG) might provide varying degrees of predictive value for mediastinal lymph node metastasis in NSCLC patients. In particular, the SUVmax of mediastinal lymph nodes and primary-tumor SUVpeak could be independently and significantly associated with mediastinal lymph node metastasis in NSCLC and lung adenocarcinoma patients. Internal and external validation confirmed that the pretherapeutic SUVmax of the mediastinal lymph node and primary-tumor SUVpeak combined with serum CEA and SCC can effectively predict mediastinal lymph node metastasis of NSCLC patients.

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial.

Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking. Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, Pnoninferior < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality. Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; Pnoninferior = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; Pnoninferior = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first (P = .4940). On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.

The Role Of Serum Uric Acid And Uric Acid To Albumin Ratio For Predicting Of Lymph Node Metastasis In Lung Cancer Treated Surgically By Vats.

In recent years, a correlation between prognosis of various cancers and inflammation has been emphasized in many studies. Uric acid which is a purine metabolite is one of the serum inflammation markers. Albumin is a major component of serum protein and it is used as a parameter reflecting nutritional status and cancer aggressiveness. Here, we have investigated whether preoperative serum uric acid levels, albumin levels, and uric acid to albumin ratio predict lymph node metastasis in non-small cell lung cancer treated surgically by VATS. The medical records of patients underwent VATS lobectomy-segmentectomy for non-small cell lung cancer between January 2015 and December 2020, were reviewed retrospectively. Cut-off values of preoperative serum uric acid, albumin and uric acid to albumin ratio were determined by Receiver Operating Characteristics (ROC) analysis. Groups with and without lymph node metastasis were created according to hilar and/or mediastinal lymph node metastasis. In addition, high and low groups were created according to preoperative uric acid levels and uric acid to albumin ratio. Pearson chi-square test was used investigate whether any significant correlation between the groups. A total of 115 patients were included in the study. Lymph node metastasis in N1 and N2 stations was detected in 11 and 18 patients, respectively. Cut-off values for uric acid and uric acid to albumin ratio were 5.97 mg/dL and 1.28x10-3, respectively. There was a statistically significant correlation between lymph node metastasis and high uric acid levels (p=0.008, OR: 3.2) and high uric acid to albumin ratio (p=0.03, OR: 2.6). Preoperative serum uric acid and uric acid to albumin ratio can predict the lymph node metastasis in non-small cell lung cancer treated surgically by video assisted thoracic surgery.

Abstract 4359: Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study

Abstract Introduction. Despite its importance, pathologic nodal (pN) staging of lung cancer remains poor. We evaluated the quality and survival impact of two interventions to improve pN staging. Methods. Using a non-randomized stepped-wedge design, we implemented use of a lymph node (LN) specimen collection kit to improve intraoperative LN collection (surgical intervention) and a novel gross dissection method for intrapulmonary LN retrieval (pathology intervention) in 12 hospitals in five contiguous Hospital Referral Regions in AR, MS and TN (2009-2021). With appropriate statistical methods we compared surgical quality and survival of patients among: neither (Group 1), pathology only (Group 2), surgical only (Group 3), and both (Group 4) interventions. Results. Of 4,019 patients, 50%, 5%, 21% and 24%, were in Groups 1-4 respectively. Rates of non-examination of LNs and non-examination of mediastinal LNs: 11%, 9%, 0% and 0%; 29%, 35%, 2% and 2% respectively in Groups 1-4 (p&amp;lt;0.0001). Attainment of American College of Surgeons Operative Standard 5.8: 22%, 29%, 72%, 85%; International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’: 14%, 21%, 53%, 61% (p&amp;lt;0.0001). Compared to Group 1, adjusted hazard ratios, aHR (95% CI), were: Group 2, 0.93 (0.76-1.15); Group 3, 0.91 (0.78-1.03); Group 4, 0.75 (0.64-0.87). Compared to Group 2, Group 4 aHR- 0.72 (0.57-0.91); compared to Group 3, was 0.83 (0.69-0.99). These relationships remained after excluding wedge resections. Discussion. Combining a LN collection kit and novel gross dissection method significantly improved pN evaluation and survival in a population-based cohort. Citation Format: Meredith A. Ray, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha Matthews, Amal Anga, Christopher Giampapa, Elizabeth Sales, Sherry Okun, Edward T. Robbins, Bradley Wolf, Paul Levy, Horace L. Wiggins, Thomas Ng, Vishal Sachdev, Ganpat Valaulikar, Hetal D. Patel, Nicholas R. Faris, Matthew Smeltzer, Raymond U. Osarogiagbon. Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4359.

Abstract 4651: Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing

Abstract Background/Purpose: Previous studies have analyzed the tumor and local immune microenvironments in lung cancers and suggest immune modulation is associated with worse clinical outcome. However, the tumor-immune microenvironment in early stage lung tumors and lymph nodes (LNs) have not been fully described. We aim to compare cell states in the immune microenvironments between lung tumors and LNs through multi-modal profiling of the transcriptome and surface proteins. Methods: Needle biopsy samples were taken from 10 treatment-naive early stage lung cancer patients undergoing lung cancer resections. Tissues were obtained from normal lung, lung tumor, and multiple mediastinal LNs, and processed for scRNA-seq including labeling with Total-Seq C CITE-seq panel to quantify the levels of 130 cell surface proteins. In total, 76,721 cells (4,462 normal lung; 39,019 tumor; 33,240 LN) were identified with a median of 1,673 genes and 92 protein features detected per cell. Protein expression was decontaminated through the decontX algorithm. Weighted-Nearest Neighbor analysis from the Seurat R package was applied to integrate the CITE-seq and RNA-seq level data for clustering cells into subpopulations. Results: Six broad cell populations were identified including T/NK, myeloid (CD14+), B (CD19+), mast (TPSAB1+), pDC (IRF8+), and epithelial (EPCAM+) cells. Among 8 CD4+ T lymphocyte subpopulations and 11 CD8+ T lymphocyte subpopulations observed through clustering, a naïve CD4+ and a CD8+ T subpopulation (LEF1+, TCF7+) was observed respectively. These naïve T lymphocyte populations displayed increased proportions in LNs in comparison to tumors. In addition, 5 of the 8 observed CD4+ T lymphocyte populations were enriched in LNs. Immune populations enriched in LNs were largely shared and uniform across different patients. In contrast, a single CD4+ and CD8+ T lymphocyte subpopulation displayed expression of T lymphocyte exhaustion markers (TIGIT+, LAG3+, PD-1+) and were enriched in tumors. 6 of the 11 observed CD8+ T lymphocyte populations were enriched in tumor samples in comparison to LNs. Two alveolar macrophage populations (MARCO+) were enriched in normal lung tissue, in which one showed a heightened stress response. Conclusion: Single-cell profiling reveals diversity in immune cell populations between LNs, tumor, and adjacent normal tissue in early-stage LUAD. The results suggest the composition of immune cell type is fairly consistent across LNs but more heterogeneous in the tumor and adjacent normal tissue in early-stage patients. In the future, we aim to determine if these immune subpopulations are associated with survival, recurrence, aggressiveness, and predict responses for neoadjuvant treatments, which could improve prognosis and patient quality of life. Citation Format: Zhanhao Xi, Yusuke Koga, Shannon McDermott, Jennifer Beane, Sarah A. Mazzilli, Kei Suzuki, Joshua D. Campbell. Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4651.

Supracarinal lymph node positivity in esophageal squamous cell carcinoma (ESCC) and factors predicting metastasis in supracarinal compartment nodes: Should a total mediastinal node dissection be the standard of care?

Adequate lymphadenectomy in middle- and lower-third esophagus cancer is still a matter of debate. This study aims to find out the extent of histopathological supracarinal lymph nodes positivity rate to establish an adequate lymph node dissection in esophageal squamous cell carcinoma cases operated up-front or after neoadjuvant chemotherapy (CT) + radiotherapy (RT) and its short-term oncological outcome. After approval from institutional board review, a retrospective study was conducted from April 2017 to September 2019. A total of 76 patients having mid- or lower-third carcinoma esophagus were operated at our institute for partial/total esophagectomy with extended two-field lymph node dissection were followed. Intraoperative nodal stations were harvested separately and lebeled individually according to the Japanese Esophageal Classification and sent for histopathological examination. The patients had an average age of 52 years. Histologically all were squamous cell carcinoma (SCC). Forty-four patients received preoperative concurrent RT plus drug therapy, whereas 18 cases were operated up-front. Fourteen patients were operated after palliative treatment (CT/RT). The average total lymph node yield was 22 nodes (range 3-69). In 26 patients (34.2%), lymph nodes were positive (N+ disease). Supracarinal nodes were positive in 20 cases (26.31%). The average supracarinal lymph node yield was 10.33 nodes (range 2-32). Five patients (6.5%) had only supracarinal lymph nodes positive on histopathological examination. Seventeen patients had a complete pathological response rate (pCR). In cases of mid-third esophageal carcinoma, extended two fields with supracarinal lymphadenectomy is strongly recommended even after the patient has received neoadjuvant treatment, although the same for lower-third/gastroesophageal (GE) junction tumors should be considered.

Profiling of innate and adaptive immune cells during influenza virus infection reveals sex bias in invariant natural killer T (iNKT) cells.

Influenza A virus (IAV) infection leads to significant morbidity and mortality. Biological sex influences the immune responses to IAV infection, resulting in higher mortality in women of reproductive age. Previous studies revealed increased activation of T and B cells in female mice after IAV infection, but extensive analysis of sex differences in both innate and adaptive immune cells over time is lacking. Invariant natural killer T (iNKT) cells are fast-reacting forces and modulators of immune responses that are important to IAV immunity, but it is not known if the presence and function of iNKT cells differ between females and males. The aim of this study was to determine immunological mechanisms that contribute to the increased disease severity in female mice during IAV infection. Female and male mice were infected with mouse-adapted IAV and monitored for weight loss and survival. Immune cell populations and cytokine expression in bronchoalveolar lavage fluid, lung, and mediastinal lymph node were determined at three time points after infection using flow cytometry and ELISA. The results reveal increased severity and mortality in adult female mice compared to age-matched males. Female mice show larger increases in innate and adaptive immune cell populations and cytokine production in lung compared to mock on Day 6 postinfection. On Day 9 postinfection, female mice express higher numbers of iNKT cells in lung and liver compared to males. This comprehensive analysis of immune cells and cytokines over time following IAV infection reveals increased leukocyte expansion and stronger proinflammatory cytokine responses in female mice during disease initiation. Furthermore, this is the first study to report a sex bias in iNKT cell populations after IAV infection. The data suggests that the process of recovery from IAV-induced airway inflammation is associated with increased expansion of several different iNKT cell subpopulations in female mice.

Abscopal effect of radiation in metastatic esophageal carcinoma: fourth reported case.

Abscopal or bystander effect of radiotherapy is a rare and unpredictable outcome encountered during treatment of metastatic cancer where tumor regression is observed distant from irradiated volume. While it has been more frequently reported with malignancies like melanoma, lymphoma, and renal cell carcinoma, data regarding metastatic esophageal cancers are sparse. We describe a case of abscopal regression of distant mediastinal and upper abdominal lymph nodes in a 65-year-old gentleman whose primary esophageal tumor was irradiated with hypo-fractionated radiotherapy in an attempt to achieve local palliation. Our case study emphasizes the systemic benefit of local radiotherapy and the need for future research to investigate its utility as this clinical event poses widespread response in an otherwise dismal Stage-IV cancer with minimal treatment-related side effects.

Pulmonary artery resection with autologous pericardial conduit to avoid pneumonectomy in lung neoplasms surgery: How to do it

Pulmonary artery resection with autologous pericardial conduit to avoid pneumonectomy in lung neoplasms surgery: How to do it

Latent Mycobacterial fortuitum infection presenting as ocular sarcoidosis

A 62-year-old lady presented with bilateral granulomatous uveitis and cystoid macular edema. A diagnosis of ocular sarcoidosis was made (revised International Workshop on Ocular Sarcoidosis [IWOS] criteria) on the basis of lymphopenia, negative Mantoux, and QuantiFERON TB gold tests. Enlarged mediastinal lymph nodes, subpleural nodules, and nodular interstitial thickening were seen on high-resolution computed tomography (HRCT) thorax. Non-necrotizing granulomato us inflammation, negative for mycobacteria on staining and GeneXpert, was noted on endobronchial ultrasound-guided transbronchial lymph node aspiration (EBUS-TBNA). However, culture grew Mycobacterium fortuitum after 3 weeks. This case highlights a rare presentation of latent M. fortuitum infection presenting as ocular sarcoidosis, speculating the coexistence of two diseases in an individual, one possibly triggering the other.

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

Clinical case of severe visceral complications with atypical localization in a patient with gout

The diagnosed gout is a signal to search for unrecognized concomitant conditions and their underlying causes and mechanisms of development. Due to the fact that gout is a common metabolic disorder with symptoms of localized inflammation caused by chronic and/or episodic deposition of monosodium urate crystals (MSU) in joints and soft tissues, the understanding of the inflammation interaction in metabolic disorders has changed. In cases of severe visceral complications of gout, the most common sites of tophl are kidneys, liver, spleen, lungs, pericardium, subcutaneous tissue and other soft tissues. The aim of this study was to outline the features of severe visceral complications with atypical localization in a patient with gout (identification of MSU crystals with polarization microscopy) and to determine the role of videothoracoscopy in this case. Patient N., 55 years old, complained of moderate chest pain, shortness of breath during exercise, general weakness and occasional cough. The patient was hospitalized in a multidisciplinary clinical institution. Examinations were performed, including polarization microscopy, spiral computed tomography (polytopic foci, formations), videothoracoscopy. Endoscopic resection of SVII of the lower lobe of the left lung with a biopsy of the lungs formations and mediastinal lymph nodes was performed. Results of histologic examination: amorphous masses are presented in combination with the organized chronic giant cell granulomatous structure (tophus), which contains clusters of crystals of MSU. Cytological examination of pleural cavity fluid revealed the presence of crystals of MSU. The presence of crystals of MSU was confirmed by polarization microscopy. From the anamnesis of the disease it became known that at the age of 38 the patient consulted a rheumatologist for moderate joint syndrome. On the basis of anamnesis, laboratory and instrumental data (X-ray, ultrasound examination) the diagnosis of gout, chronic gouty arthritis was established. Urate lowering therapy was prescribed. The patient took the drugs periodically without re-consultation with the doctor. The presented case of untreated gout has led to significant structural disorders in organs such as lungs, pleura. Endoscopic resection of the lower lobe of the left lung and revision of the thoracic cavity revealed atelectasis, hemorrhage, inflammatory infiltration, fibrous changes in tissues, amorphous masses with organized chronic giant cell granulomatous structure, presented by crystals of MSU. During the surgery, a powdery substance was found on the pleura surfaces. A video thoracoscopy in this case was a means to present a visceral damage in gout. The search for diagnostic tools to diagnose a severe visceral complications with atypical localization in gout still remains unsolved. Undoubtedly, the central role in the development of gout is played by the deposition of numerous crystals of MSU. In the patient under observation, crystals of MSU were found in pleural fluid and sputum consisting of sodium urate, like the known facts of their appearance in the joint fluid and urine. Uric acid salt crystals were also detected in the areas of pulmonary fibrosis formation according to the results of radiological examination, as well as endoscopic intervention in the lower lobe of the left lung.

Comparison of thoracoabdominal versus abdominal-transhiatal surgical approaches in Siewert type II adenocarcinoma at the esophagogastric junction: Protocol for a prospective multicenter randomized controlled trial.

Siewert type II adenocarcinoma of the esophagogastric junction (Siewert II AEG) can be resected by the right thoracoabdominal surgical approach (RTA) or abdominal-transhiatal surgical approach (TH) under minimally invasive conditions. Although both surgical methods achieve complete tumor resection, there is a debate as to whether the former method is superior to or at least noninferior to the latter in terms of surgical safety. Currently, a small number of retrospective studies have compared the two surgical approaches, with inconclusive results. As such, a prospective multicenter randomized controlled trial is necessary to validate the value of RTA (Ivor-Lewis) compared to TH. The planned study is a prospective, multicenter, randomized clinical trial. Patients (n=212) with Siewert II AEG that could be resected by either of the above two surgical approaches will be included in this trial and randomized to the RTA group (n=106) or the TH group (n=106). The primary outcome will be 3-year disease-free survival (DFS). The secondary outcomes will include 5-year overall survival (OS), incidence of postoperative complications, postoperative mortality, local recurrence rate, number and location of removed lymph nodes, quality of life (QOL), surgical Apgar score, and duration of the operation. Follow-ups are scheduled every three months for the first 3 years after the surgery and every six months for the next 2 years. Among Siewert II AEG patients with resectable tumors, this is the first prospective, randomized clinical trial comparing the surgical safety of minimally invasive RTA and TH. RTA is hypothesized to provide better digestive tract reconstruction and dissection of mediastinal lymph nodes while maintaining a high quality of life and good postoperative outcome. Moreover, this trial will provide a high level of evidence for the choice of surgical procedures for Siewert II AEG. Chinese Ethics Committee of Registering Clinical Trials, identifier (ChiECRCT20210635); Clinical Trial.gov, identifier (NCT05356520).

ROBOTIC TRANSTHORACIC ESOPHAGECTOMY VERSUS THORACOSCOPIC ESOPHAGECTOMY IN COMBINED WITH LAPAROSCOPY FOR ESOPHAGEAL CANCER

Background: Extended mediastinal with bilateral recurrent laryngeal nerves (RLNs) lymph node dissection (LND) is critical to curative surgery in the treatment of esophageal squamous cell carcinoma (ESCC). Some reports in Robotic transthoracic esophagectomy (RTE) have some advantages over Thoracoscopic esophagectomy (TE) in increasing the exposure and accuracy of mediastinal LND. However, published data was still limited. Objectives: To evaluate early results of RTE combined with laparoscopy to treat ESCC. Methods: This was a prospective nonrandomized comparative study. All patients who underwent RTE or TE for esophageal squamous cell carcinoma were included in the study. The primary endpoints were operation results, morbidity, and mortality. The secondary endpoint was early oncological results, including lymph node harvested, lymph node metastasis, short-term local recurrence, and survival time. Results: From 8/2018 - 8/2020, at Cho Ray Hospital, we performed 109 cases of esophagectomy for esophageal SCC, of which 19 cases (17.4%) were RTE (group 1), and the other 90 cases (82.6%) were TE (group 2). There was no statistical difference in the staging of group 1 compared to group 2, with predominant cases at stages IB, IIA, and IIB (68.5% vs. 54.4%). Group 1 had a longer operation time than group 2 at the thoracic phase (480 (420-540) vs. 410 (380-450), p=0.001, Mann-Whitney test). Left LRN exposure was better in the RTE group than the TE group; however, LRN injuries seemed to be increased with the RTE group (p=0.028 Fisher’s exact test), probably due to the short learning curve. There was also no difference in the number of mediastinal lymph nodes harvested, including lymph nodes along bilateral LRN. Conclusion: RTE combined with laparoscopy is feasible, safe, and effective in treating esophageal SCC. RTE could be a good option in transthoracic esophagectomy for ESCC.

Mediastinal lymphadenopathy in sarcoidosis: Can diffusion MRI play a role in its evaluation?

BackgroundSarcoidosis is a multisystem disease defined by non-caseous epithelioid cell granulomas that can affect virtually all organs. Lung, mediastinal and hilar lymph node involvement is prevalent, occurring in around 90% of the patients, and is responsible for the majority of the morbidity and mortality related to the disorder. Sarcoidosis is one of the differential diagnoses of the benign mediastinal lymphadenopathy. This research aimed to detect the diagnostic value of magnetic resonance imaging (MRI) diffusion in evaluation of mediastinal lymphadenopathy in sarcoid patients.ResultsThis cross study involved a total of 30 patients known to have sarcoidosis: 6 males and 24 females aged between 18 and 50 years (with a mean age 38.97 ± 8.67); all of them presented with mediastinal lymphadenopathy. For all patients, each lymph node group was evaluated for the average size and average ADC value. The mean ADC measured was (1.76 ± 0.28) × 10−3 mm2/s. Eight patients showed concurrent activity with poor response to the treatment, and they showed different ADC values with one of them showing low ADC with pattern of diffusion restriction displaying mean ADC value of 1.28 × 10−3 mm2/s.ConclusionsDiffusion-weighted MRI is an established imaging technique that could be utilized to evaluate mediastinal lymphadenopathy in sarcoidosis as the benign counterpart of mediastinal lymphadenopathy.

McKeown esophagectomy for a thoracic esophageal carcinoma patient who has a history of definitive chemoradiotherapy for esophageal carcinoma and total pharyngolaryngectomy for hypopharyngeal cancer

A 64-year-old man, who had previously undergone definitive chemoradiotherapy (dCRT) and endoscopic resections for metachronous multiple esophageal squamous cell carcinoma (ESCC) and had also received total pharyngolaryngectomy (TPL) for hypopharyngeal cancer, was diagnosed with ESCC in the middle thoracic esophagus (cT3N0M0). Thoracoscopic McKeown esophagectomy was performed for the patient. Although the tumor was tightly adherent to the thoracic duct and both main bronchi, they were successfully mobilized. In order to maintain the blood supply to the trachea, we preserved the bilateral bronchial arteries and avoided prophylactic upper mediastinal lymph node dissection. Cervical end-to-side anastomosis between the jejunum and a gastric conduit was performed. Minor pneumothorax was managed conservatively, and the patient was discharged 44 days after the surgery. Overall, thoracoscopic McKeown esophagectomy was safely performed in a patient with a history of TPL and dCRT. Surgeons should be very careful to prevent tracheobronchial ischemia by optimizing the extent of lymph node dissection.

Thromboembolism An unusual way of tissue diagnosis of Squamous Cell Carcinoma of Lungs

Lung carcinoma presents in multifarious ways from incidental imaging finding to respiratory or systemic symptoms secondary to local invasion or metastasis. We report an atypical presentation of lung cancer. A 69-year-old male presented with sudden onset bilateral lower extremity weakness. He had cold bilateral lower extremity with no palpable pulses or Doppler signals in the lower extremity. A computed tomographic angiographic (CTA) scan revealed large thrombus in the infra-renal aorta and bilateral common iliac arteries with total occlusion. Bilateral endovascular thrombectomy along with fasciotomy was done. Immuno-histochemical staining of thrombectomy mass showed metastatic squamous cell carcinoma. Positron emission tomography (PET) scan revealed hypermetabolic right pulmonary hilar foci with hypermetabolic mediastinal nodes. Diagnosis of non-small cell lung carcinoma was made and subsequently, chemotherapy was started. Atypical presentation and tissue diagnosis of lung cancer via histopathological examination from endovascular thrombectomy are quite unique. Our case highlights the importance of analysis of thrombectomy mass.

A Comparative Evaluation of Mediastinal Nodal SUVmax and Derived Ratios from 18F-FDG PET/CT Imaging to Predict Nodal Metastases in Non-Small Cell Lung Cancer.

18F-FDG positron emission tomography with computed tomography (PET/CT) is a standard imaging modality for the nodal staging of non-small cell lung cancer (NSCLC). To improve the accuracy of pre-operative staging, we compare the staging accuracy of mediastinal lymph node (LN) standard uptake values (SUV) with four derived SUV ratios based on the SUV values of primary tumours (TR), the mediastinal blood pool (MR), liver (LR), and nodal size (SR). In 2015-2017, 53 patients (29 women and 24 men, mean age 67.4 years, range 53-87) receiving surgical resection have pre-operative evidence of mediastinal nodal involvement (cN2). Among these, 114 mediastinal nodes are resected and available for correlative PET/CT analysis. cN2 status accuracy is low, with only 32.5% of the cN2 cases confirmed pathologically. Using receiver operating characteristic (ROC) curve analyses, a SUVmax of N2 LN performs well in predicting the presence of N2 disease (AUC, 0.822). Based on the respective selected thresholds for each ROC curve, normalisation of LN SUVmax to that for mediastinum, liver and tumour improved sensitivities of LN SUVmax from 68% to 81.1-89.2% while maintaining acceptable specificity (68-70.1%). In conclusion, normalised SUV ratios (particularly LR) improve current pre-operative staging performance in detecting mediastinal nodal involvement.