Mediastinoscopic Biopsy Research Articles

Association of amyloidosis and lung cancer; a case of small cell lung cancer masked by amyloidosis with 18-fdg uptake

Amyloidosis is a rare and fatal disease that occurs with the accumulation of amyloid protein in the organs. The most common presentations are nephrotic syndrome, cardiomyopathy, and unexplained hepatomegaly. We present a case of small cell lung cancer as a result of mediastinoscopic biopsy in a patient who presented with a lung mass and 18-FDG uptake on PET/CT, and amyloidosis was found in the bronchoscopic biopsy result.

Atypical thymoma (epithelial-rich thymoma, well-differentiated thymic carcinoma, WHO type B3 thymoma): A conundrum.

Thymomas composed predominantly of epithelioid tumor cells with scattered lymphocytes have been well recognized in the literature. This subtype of thymoma has been variously termed epithelial-rich thymoma, well-differentiated thymic carcinoma, atypical thymoma, or World Health Organization (WHO) type B3 thymoma. Regardless of the designation however, these tumors are known to show a spectrum of histopathological growth patterns that may pose challenges in interpretation and diagnosis, particularly when dealing with small mediastinoscopic biopsies. Just like any other type of thymoma, those composed predominantly of epithelioid cells may present as encapsulated or invasive tumors. Nevertheless, compared to other subtypes of thymoma, they are uncommon neoplasms. Therefore, it becomes very important to sufficiently sample thymomas before making a diagnosis of a particular subtype, especially when the tumor is rich in epithelioid cells and only has a scant lymphocytic component. Because of the unusual occurrence of these tumors, there are only few large series of cases that attempt to highlight not only the more salient histopathological features but also the most important immunohistochemical and molecular characteristics.

Primary mediastinal germ cell tumors.

Mediastinal germ cell tumors share similar histopathological, immunohistochemical, and molecular features with their counterparts in the gonads. Therefore, proper clinical and radiological evaluation of patients with an anterior mediastinal mass becomes essential in the final interpretation of these tumors. The gold standard for the diagnosis of these tumors remains histopathological evaluation. However, immunohistochemical stains and molecular studies also provide an aid in cases in which the histology is not typical. It is also important to keep in mind that a small mediastinoscopic biopsy may not be representative of the entire neoplasm. In this review, we will provide our perspective regarding histopathological diagnosis, staging, immunohistochemical and molecular profile, and briefly family of tumors address pertinent epidemiological, clinical and treatment options. However, the main emphasis is to review the process of pathological assessment in pre and post-treated tumors. Knowledge of the different growth patterns and histological associations is important, mainly when confronted with mediastinoscopic biopsies, which ultimately will determine treatment options.

Unilocular thymic cyst with features of intra-thymic bronchogenic cyst: A clinicopathological correlation of 4 cases.

Four cases of primary unilocular thymic with features of bronchogenic cyst are presented. The patients are three men and a woman between the ages of 43 and 57 years. All the patients presented with symptoms of cough, chest pain, and dyspnea. Diagnostic imaging revealed the presence of an anterior mediastinal cystic lesion. Initial mediastinoscopic biopsies were non-diagnostic. Surgical resection of the anterior mediastinal cystic lesion was performed in all patients. Macroscopically, all the lesions were described as large cystic lesions measuring from 2 to 4cm in largest diameter and containing yellowish fluid. The surface of the cysts was described as corrugated and of brownish color. The walls of the cysts were not thickened and no other elements were described. Histologically, the cystic lesions were characterized by single cystic structures lined by ciliated epithelium. No atypia or mitotic activity was present in any of the cases. Immunohistochemical stains show positive staining of the respiratory epithelium with keratin and negative staining for GATA3, PAX-8, TTF-1, and Napsin. All the patients have recovered well after surgical resection.

Thymoma: Histologically a heterogenous group of tumors.

Over the years the nomenclature of thymomas has been debated regarding the best manner in which these tumors should be grouped. In every schema presented thus far, the main issue has been the presence or lack of lymphocytes and accordingly, the tumors have been place into a specific category. However, even though this concept applies for most of the cases, there are numerous tumors that do not necessarily fit into those categories as either the thymomas show another cellular proliferation associated with the epithelial cells or the epithelial cell themselves are arranged in a pattern that departs from the conventional features of the classic thymoma. Herein we will emphasize those features, which in some circumstances, mainly with small mediastinoscopic biopsies may pose a considerable problem in interpretation. We do consider that the most important issue is to be familiar with the different growth pattern that these tumors may show in order to avoid misdiagnosis. In addition, we consider that regardless of the growth pattern or cellular composition of the tumor, it is highly recommended that these tumors just like any other be carefully sampled and properly stage. Although we are fully aware of the different growth pattern and specific cellular details that thymoma may show, the discussion of each one of those tumors is beyond the scope of this review. Therefore, we have placed more emphasis in those, which in our judgment are more commonly encountered in the daily practice.

The risk of tuberculosis bacilli seeding during mediastinoscopy in mediastinal tuberculosis: Is it clinically important?

Mediastinoscopy is the gold standard for diagnosis in the absence of parenchymal lesions in mediastinal tuberculosis lymphadenitis. During mediastinoscopy biopsy, tuberculous bacillus seeding into the mediastinum is a rare complication. This study aimed to test the safety of mediastinoscopy in terms of Mycobacterium tuberculosis seeding in the mediastinum by microbiologically evaluating mediastinal lavage samples taken before and after biopsy. Classical cervical mediastinoscopy was performed all of patients and who were reported as granulomatous inflammatory events results of histopathological examinations and who underwent mediastinal lavage before and after biopsy, were included in the study. All the lavage fluids were tested for AFB and subjected to Mycobacterium tuberculosis PCR DNA testing and standard tuberculosis culture. The patients were divided into two groups, Group 1: Necrotizing granulomatous inflammation, Group 2: non-necrotizing granulomatous inflammation. The microbiological tests of the patients in Group 1 were negative before biopsy. However, in two patients of Group 1, the results of cultures of lavage fluids that taken from after biopsy were positive for tuberculosis. In all patients in Group 2, all microbiological tests of the lavage fluids were negative (Power of the decision: 99.8%, with 5% error). All of patients in group 1, Antituberculosis treatment was initiated and continued for 6 months. There weren’t seen any serius complications due to treatment and recurrence during the follow-up period. Mediastinoscopy can be used safely, with low morbidity and mortality rates and a high success rate for the diagnosis of mediastinal tuberculosis.

Correlation between CT finding and mediastinoscopic biopsy results for diagnosis of mediastinal lymphadenopathy

Background Mediastinal lesions are difficult to detect on radiograph because these lesions are of soft tissue densities and are surrounded by soft tissue structures. Here is where computed tomography (CT) can provide the answer. It provides information on the anatomical extent of the lesion and the nature of the lesion. Aim The aim of this work is to evaluate the possibility of anticipation of histopathological tissue diagnosis for a mediastinal lymphadenopathy specimen taken by mediastinoscopy on the basis of preoperative CT findings for patients admitted in Al-Zahraa University Hospital in the Cardiothoracic Surgery Department. Patients and methods Thirty patients were included in this study, admitted in the Cardiothoracic Surgery Department of Al-Zahraa University Hospital from December 2019 to May 2020. All patients had received a diagnosis by CT chest and invasive method in the form of mediastinoscopy; then, histopathological results of the mediastinoscopic biopsy were correlated with the CT chest finding to estimate the relationship between both methods of diagnosis in cases with mediastinal lymphadenopathy. Results There is no definitive sign in CT imaging either using the size or shape or distribution to help in reaching the final diagnosis. Therefore, the biopsy is inevitable in all cases. Conclusion The CT remains the most important noninvasive tool for the diagnosis of mediastinal lymphadenopathies with good sensitivity, specificity, and diagnostic accuracy. Despite this, it does not exceed the prediction, and the cause of lymphadenopathy must be diagnosed to be able to start the appropriate treatment.

A rare case of ectopic ACTH syndrome with rhabdomyolysis

BackgroundManifestations of hypokalaemia in ectopic adrenocorticotropic hormonesyndrome(EAS) vary from mild muscle weakness to life-threatening arrhythmia. Herein, we present a rare case of EAS with concomitant rhabdomyolysis(RM) as a result of intractable hypokalaemia.Case presentationA 64-year-old man was admitted for limb weakness and facial hyperpigmentation for 2 weeks. Lab tests revealed intractable hypokalaemia (lowest at 1.8 mmol/L) and metabolic alkalosis. The diagnosis of RM was based on a creatine kinase(CK)level of 5 times the upper limit. The elevated CK and myohemoglobin (Mb) levels returned to within the normal range after the alleviation of hypokalaemia. The patient was diagnosed with ACTH-dependent Cushing’s syndrome (CS) based on unsuppressed serum cortisol after a low-dose dexamethasone suppression test(LDDST) and remarkably elevated ACTH levels. The diagnosis of EAS was made based on the results of a high-dose dexamethasone suppression test(HDDST) and bilateral inferior petrosal sinus sampling(BIPSS). Multiple lymph nodes in the left supraclavicular fossa, right root of neck, mediastinum and bilateral hili of the lung were found with abnormal uptake of 68Ga-DOTA-NOC. Mediastinoscopic lymph node biopsy was performed. The pathological diagnosis was small-cell and large-cell neuroendocrine carcinoma with positive ACTH staining. The patient was prescribed mifepristone and received one cycle of chemotherapy. The patient could not tolerate subsequent chemotherapy and died of dyscrasia.ConclusionsRM is a rare complication of EAS with insidious onset and atypical clinical manifestations. Serum potassium levels should be vigilantly monitored to avoid RM in EAS.

Patient out-of-pocket costs for suspicious pulmonary nodule biopsy in lung cancer patients

Aims Dynamic changes in the payer landscape have resulted in increasing out-of-pocket costs (OOPC). Little is known about OOPC for patients undergoing biopsy for suspicious pulmonary nodules in the U.S. This study seeks to describe the spectrum of OOPC for diagnostic tissue sampling for suspicious pulmonary nodule with an ultimate diagnosis of lung cancer. Methods Retrospective cohort study of adult patients with a primary lung cancer diagnosis and treatment who underwent diagnostic biopsy for suspicious pulmonary nodule utilizing IBM Marketscan® Databases (2013 to 2017). Claims data included both total hospital and physician billed costs, insurer reimbursement and OOPC. Out-of-pocket costs were further stratified by type of biopsy, whether the patient underwent a single or multiple biopsies, and year of biopsy. Results A total of 22,870 patients age 18-95 who underwent diagnostic lung biopsy were identified. The gender ratio was 49 to 51 for female;male, and 50% of patients were aged 65 or above. 78% of patients had a co-morbidity. The median OOPC for a patient receiving a single biopsy (any type) was $600, two biopsies: $706, three biopsies: $811, four biopsies: $1177. By biopsy type, the median OOPC for a patient requiring a single biopsy was $604 for percutaneous biopsy, $316 for surgical biopsy, $674 for bronchoscopic biopsy, and $545 for mediastinoscopic biopsy. Limitations Under-estimation of OOP expenses from costs of transportation, job loss, and loss of productivity. Over-estimation of OOPC from lack of individual claim adjudication. Conclusion The median OOPC for lung cancer patient requiring a single diagnostic lung biopsy is $600. Prior research indicates that almost 50% of the lung cancer patient population undergoes multiple biopsies increasing costs anywhere between 20-100% resulting in further patient financial burden for each episodic biopsy attempt. Further cost effectiveness research is needed to differentiate various diagnostic technologies for lung biopsy.

Our Interstitial Lung Disease Experiences

Objective: Interstitial lung diseases is the name given to the acute or chronic disease group that affects the lung parenchyma as diffuse, causing inflammation, fibrosis and structural disorders in the parenchyma. Diseases in this group show common characteristics clinically, radiologically, pathologically and functionally. It is a heterogeneous group of diseases whose etiology is not fully clarified. Difficulties are experienced in its diagnosis, treatment and follow-up. In this study, we aimed to evaluate 240 patients diagnosed with interstitial lung diseases retrospectively in terms of diagnosis and treatment. Material and methods: In this study, patients diagnosed with interstitial lung diseases in our clinic between January 2017 and January 2020, age, gender, smoking, diagnostic methods, operation type, radiological appearance, histopathological diagnosis types, immune marker positivity, pulmonary function tests and In terms of treatment methods applied, it was retrospectively analyzed. Results: 109 (45.4%) of the patients were women, 131 (54.6%) were male and the mean age was 65 ± 14.3 (18-95). 77 (32.1%) patients were diagnosed by performing transbronchial needle aspiration biopsy with flexible fiberoptic bronchoscopy, transbronchial needle aspiration biopsy was performed in 6 (2.5%) patients by endobronchial ultrasonography and diagnosis was made, 8 (3.3%) patients were diagnosed by mediastinoscopy biopsy, 4 (1.6%) patients by scalene lymph node biopsy, and 10 (4.2%) patients by video assisted thoracoscopic surgery biopsy. Out of 240 patients, 105 (43.75%) pathological definitive diagnosis was reached. The diagnoses were idiopathic pulmonary fibrosis (IPF), sarcoidosis, collogen tissue diseases, cryptogenic organized pneumonia, respectively. The diagnosis of 135 (56.25%) patients who could not be diagnosed pathologically was made with clinical and radiological findings. Conclusion: It is difficult to make a specific diagnosis in interstitial lung diseases and only 25-30% of patients can be detected etiological factor. Failure to apply invasive diagnostic methods, especially in patients with respiratory distress, makes diagnosis more difficult. Therefore, detailed examination of clinical, radiological and physiological parameters is required in these patients.

Fibrosing/Sclerosing Lesions of the Mediastinum: A Review.

Fibrosing lesions of the mediastinum represent a small but challenging group of lesions that range in etiology from infectious to idiopathic to neoplastic. The diagnosis of such lesions becomes more challenging in the setting of mediastinoscopic biopsies. In addition, over the years, there has been further accumulation of knowledge of the clinical aspects of these lesions that needs to be incorporated into their evaluation. Therefore, it is essential that in the general evaluation of these fibrosing processes, one not only carefully examines the histopathologic features of the lesion, that of a fibroinflammatory process with the appropriate histochemical and immunohistochemical studies, but also carefully evaluates the clinical presentation and imaging findings. Needless to say, as will be illustrated in this review, determining a definitive unequivocal diagnosis on a small mediastinoscopic biopsy may be difficult, and often one needs to provide guidance on the perspective of the histologic features present. In some cases, mainly tumoral conditions with extensive fibrosis, a conclusive diagnosis can be made; however, it is those cases in which the extensive fibrosis is the only histopathologic feature where more appropriate guidance is required. While this review will focus more on the non-neoplastic fibroinflammatory lesions of the mediastinum, within the discussion of differential diagnoses, we will discuss some neoplastic conditions that commonly show extensive fibrosing features.

Adjuvant Chemotherapy Following Surgical Resection Improves Survival in Patients With Early Stage Small Cell Lung Cancer.

The purpose of this study was to determine the effects of resection coupled with standard chemotherapy on the survival prognosis of patients with early stage small cell lung carcinoma (SCLC). Patients (n = 110) with mediastinal lymph node-negative SCLC were enrolled in this study. The baseline clinical data of patients with surgery were retrospectively reviewed. Overall survival (OS) and progression-free survival (PFS) were measured by Kaplan–Meier and log-rank test analyses. Ninety-eight patients received mediastinoscopy biopsy, and pulmonary lobectomy or sublobar resection, and 67 patients underwent adjuvant chemotherapy after pulmonary lobectomy. Adjuvant chemotherapy after surgical intervention was associated with longer OS (median OS: 42.14 vs. 33.53 months, p = 0.01) and PFS (median PFS: 25.20 vs. 13.48 months, p = 0.000) compared to resection alone for all patients. Adjuvant chemotherapy was associated with improvement of survival for N1 patients with stage II (median OS: 36.42 vs. 26.68 months, p = 0.021). The median PFS was 19.02 m (16.08, 21.96) and 13.25 m (10.19, 16.30) (p = 0.031), respectively, for patients of N1 stage who received chemotherapy and those who did not. Cox regression analysis demonstrated that age, TNM stage (N stage, not T stage), and chemotherapy were independent risk factors that might affect overall survival in patients with mediastinal lymph node-negative SCLC. These findings suggest that the application of adjuvant chemotherapy following pulmonary lobectomy is associated with improvements of survival prognoses for patients with SCLC. The combination of surgical intervention with conventional therapy should be taken into consideration as a prospective multidisciplinary regimen for early stage SCLC.

Anterior mediastinal masses — A multidisciplinary pathway for safe diagnostic procedures

ObjectiveThe objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM). MethodsA retrospective review of patients with AMM at a tertiary pediatric surgical oncology centre (January 2011–December 2016) was performed. We analyzed data on clinical presentation, mode of tissue diagnosis, anesthetic techniques, and complications. ResultsOf the 44 patients admitted with AMM (median age 11 years, 27 males and 17 females), 22 had respiratory symptoms. Imaging revealed tracheobronchial compression in 26 children. Twenty patients had a lymph node biopsy. Ten patients had image-guided core biopsy of the mediastinal mass, and 2 had mediastinoscopic biopsy of a paratracheal lymph node. One patient with likely recurrence of a relapsed metastatic ethmoid carcinoma did not have a biopsy. The diagnosis was made from alternative tissues, such as pleural fluid in 4 and peripheral blood in 7 patients. Twenty-five anesthetics were assessed, as 14 patients required no or only local anesthesia, and 5 had unavailable anesthetic notes. Eighteen of 25 patients were anesthetized maintaining spontaneous breathing, mostly by means of ketamine sedation. There were no major anesthetic complications. ConclusionSafe tissue diagnosis of anterior mediastinal masses can be obtained by a personalized multidisciplinary approach. Use of alternative tissues, local anesthesia, and ketamine sedation help minimize the need for general anesthesia, muscle paralysis, and controlled ventilation. Level of evidenceIV (Case Series with no Comparison Group).

Modified Chamberlain Procedure Is an Alternative Option with or Without VATS Still a Gold Standard Technique: A 10 Years Experience

Introduction: Mediastinum is divided in anterior, middle and posterior part. Mediastinum contains heart, lung, thymus, lymph nodes and nerves. A varied spectrum of disease can arise from these organs. It poses a challenge to the clinicians to confirm the diagnosis. A Mediastinal lesion grows beyond the individual division of origin in advanced stages. It is the biopsy and histopathological study that gives us an idea about probable site or organ of origin and nature of the lesion. Diagnostic biopsy approach for such cases would be CT guide FNAC, Mediastinoscopy, Video Assisted Thoracoscopic Surgery, Chamberlain procedure and Thoracotomy. Anterior mediastinotomy known as chamberlain procedure is time tested technique for confirmation of the mediastinal lesions. Objective: To re-evaluate the technique of chamberlain procedure and its modifications to confirm the diagnosis of various lesions found in the mediastinum. Chamberlain procedure and other mediastinoscopic biopsy techniques have been replaced with VATS in most centres. In view of difficulties in gaining VATS instruments as they are expensive and its steep learning curve, we continue to do chamberlain procedure for mediastinal lesions biopsy. Method: We studied 75 patients, presented with various mediastinal mass or lung lesions. Most of these lesions were not identified from another mode of investigations. Chamberlain Procedure adopted to confirm the diagnosis, asses the stage of disease, operability status and to plan the treatment. Conclusion: Chamberlain procedure is still a gold standard over multiple other techniques in diagnosis and confirmation of the mediastinal diseases. It allows accessing any plane and location in the mediastinum. Result: Chamberlain procedure and biopsy can be done for diagnosis and confirmation of all kinds of mediastinal lesions. Compared to VATS, chamberlain procedure results and outcomes are similar.

Review of Sarcoidosis in a Province of South Korea from 1996 to 2014

BackgroundSince the introduction of endobronchial ultrasound (EBUS)–guided transbronchial needle aspiration (TBNA) of mediastinal lymph nodes, the incidence of histopathologically-confirmed sarcoidosis has increased.MethodsThe electronic medical records of Chonnam National University (CNU) Hospital and CNU Hwasun Hospital (CNUHH) were searched for confirmed cases of sarcoidosis diagnosed between 1996 and 2014. Cases were selected using a combination of clinical, radiological, and pathological evidence. Of 115 cases with the relevant disease codes, 16 cases were excluded, as they had not been confirmed pathologically or had no definitive clinical features of sarcoidosis.ResultsAmong 99 cases of confirmed sarcoidosis, only nine patients were diagnosed with sarcoidosis before 2008; the rest were diagnosed from 2008 onward, after the introduction of EBUS-TBNA. EBUS-TBNA was used in 75.8% of patients, open surgical biopsy in 13.2%, and mediastinoscopic biopsy in 5.1%. At the time of diagnosis, 42.4% of sarcoidosis cases were at stage I, 55.6% at stage II, and 2% at stage III. Spontaneous remission of sarcoidosis was observed in 33.3% of cases, and stable disease in 37.4%; systemic steroid treatment was initiated in 23.2% of cases. Of the patients treated with systemic steroids, 69.6% showed improvement. The median duration of steroid treatment was 5 months.ConclusionFollowing the introduction of EBUS-TBNA, the number of newly diagnosed sarcoidosis patients has increased. Clinical features of sarcoidosis were similar to those previously reported. Spontaneous remission occurred in about one-third of patients, while one-fourth of patients required systemic steroid treatment.

Recurrent Tuberculous Fistular Granuloma During Antituberculous Drug Therapy, Managed With Repeated Bronchoscopy

SESSION TITLE: Tuberculosis Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: In tuberculous (TB) lymphadenitis, caseous nodes attach to the bronchial wall and erode through it, leading to a fistulous tract and endobronchial granuloma. Drug therapy often has little impact on its progression. From 2007 to 2013, we experienced the cases of recurrent endobronchial TB granulomas associated with bronchial invasion of lymphadenitis. CASE PRESENTATION: Case 1. A 26-year-old woman was diagnosed with TB lymphadenitis via mediastinoscopic biopsy. No parenchymal lesions were observed. After 2 months of medication, cough worsened and two endobronchial granulomas of the proximal right intermediate bronchus were found on flexible bronchoscopy (FOB). One month later, wheezing developed and repeated FOB revealed a granuloma obstructing the proximal right main bronchus. Two months later, cough worsened again and granulomas were observed in the proximal left and right main bronchi. Four months later, tubular breathing sounds were noted; a granuloma also recurred in the proximal right main bronchus. AntiTB medication was administered for 18 months. Chest CT demonstrated improved lymphadenitis with no abnormal findings in the tracheobronchial tree. The patient refused follow-up bronchoscopy. Spirometric findings were normal. When she visited again because of throat trouble 38 months later, she had no respiratory symptoms and breath sounds were clear. Chest X-ray revealed no remarkable findings. Case 2. A 16-year-old boy was diagnosed with TB lymphadenitis via bronchoscopic biopsy of an endobronchial granuloma obstructing the apicoposterior segment of the left upper lobe, which developed from intraluminal invasion of mediastinal lymphadenitis. No parenchymal lesions were observed. After 1 month of medication, hemoptysis recurred and FOB revealed a granuloma in the distal left main bronchus. Follow-up FOB after 3 months confirmed the absence of residual lesions. AntiTB medication was administered for 18 months. Follow-up chest CT and spirometric findings were unremarkable. Case 3. A 31-year-old man was diagnosed with miliary TB, with lymphadenitis and bilateral pleural effusion. After 3 months of medication, dyspnea worsened and chest CT showed progression of lymphadenitis. FOB revealed several granulomas with obstruction or stenosis at all segments of the left upper lobe. Seven months later, chest CT scan demonstrated aggravated paraaortic lymphadenitis and FOB revealed a granuloma in the left main bronchus. After 2, 4, and 6 months, this granuloma developed repeatedly at the same site in the left main bronchus. Two months after that, the granuloma recurred at the lingular division of the left upper lobe. AntiTB medication was administered for 24 months. Follow-up chest CT scan showed well-healed lymphadenitis. FOB revealed residual obstruction and stenosis at 3 segments of the left upper lobe. FEV1 improved from 46 to 66% of the predicted normal, and FVC improved from 49 to 83%. DISCUSSION: The total number of recurrences was 10 in 3 cases. Six granulomas recurred at the same site and four recurred at a different site. Once an endobronchial granuloma was found, we removed as much as possible, via bronchoscopic procedures, to relieve bronchial stenosis. Follow-up FOB was performed in cases 1 and 2 if there were any findings suggestive of recurrence, and was performed after 2 months in case 3 because the risk of recurrence was high. Ultimately, significant stenosis remained in case 3, but this patient exhibited improved spirometric findings. Prolonging antiTB medication until lymphadenitis improves sufficiently is important even though drug therapy may not be entirely effective against progression of fistulous granulomas. CONCLUSIONS: In the case of TB lymphadenitis, particularly in cases of bronchus invasion, endobronchial granuloma can develop, and can recur even after almost complete removal because a fistulous tract has already formed. Aggressive bronchoscopic procedures should be considered to relieve significant bronchial stenosis. Therefore, if TB lymphadenitis is observed adjacent to the bronchus, close follow-up is advised even when drug therapy is administered. Reference #1: Polesky A, Grove W, Bhatia G. Peripheral Tuberculous Lymphadenitis; Epidemiology, Diagnosis, Treatment, and Outcome. Medicine 2005 ; 84 : 350-362 Reference #2: Gupta PR. Difficulties in managing lymph node tuberculosis. Lung India 2004; 21 : 50-53. Reference #3: Lincoln EM, Harris LC, Bovornkitti S, et al. Endobronchial tuberculosis in children. Am Rev Tuberc Pulm Dis 1958 ; 77 : 39-61 DISCLOSURE: The following authors have nothing to disclose: Hong Lyeol Lee, Jung Soo Kim No Product/Research Disclosure Information

Volume-Based Assessment With 18F-FDG PET/CT Improves Outcome Prediction for Patients With Stage IIIA-N2 Non-Small Cell Lung Cancer.

We evaluated the prognostic impact of volume-based assessment by pretreatment (18)F-FDG PET/CT in patients who had clinical stage IIIA-N2 non-small cell lung cancer (NSCLC) treated with neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgical resection. We reviewed 161 consecutive patients who had stage IIIA-N2 NSCLC treated with neoadjuvant CCRT followed by surgery. In all cases, N2 disease was pathologically confirmed by mediastinoscopic biopsy, endobronchial ultrasound-guided transbronchial needle aspiration, or video-assisted thoracoscopic surgery. We measured the total metabolic tumor volume (total MTV) and the maximum standardized uptake value (SUVmax), including a primary tumor and metastatic nodes on the pretreatment scan. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan-Meier method. The association of PET parameters with OS and DFS was determined by univariable and multivariable analyses performed using the Cox regression model. A higher total MTV was significantly associated with poor DFS (hazard ratio [HR], 1.82; p = 0.036) and OS (HR = 2.97; p = 0.012) in the multivariable analysis. In contrast, a higher SUVmax was not significantly associated with poor DFS and OS. Patients with a high total MTV (> 22 cm(3)) had a median survival time that was significantly shorter than that of patients with a low total MTV (median DFS, 11.3 vs 42.0 months, respectively [p < 0.001]; median OS, 38.3 months vs not reached [p < 0.001]). Kaplan-Meier curves showed significant differences on the basis of total MTV in patients with or without mediastinal downstaging after CCRT. Patients with a high total MTV had significantly worse DFS when they had post-neoadjuvant pathologic (yp) stage 0-II disease (p = 0.020) or yp stage III disease (p = 0.036). Higher total MTV was also associated with worse OS in patients with yp stage 0-II disease (p = 0.013) or yp stage III disease (p = 0.007). A higher pretreatment total MTV is associated with worse outcome, independent of yp stage, in patients with stage IIIA-N2 NSCLC treated with neoadjuvant CCRT followed by surgery.

Cystic well-differentiated squamous cell carcinoma of the thymus: a clinicopathological and immunohistochemical study of six cases.

To present six cases of cystic well-differentiated squamous cell carcinoma of the thymus. The patients were six men aged between 48 and 75 years (average: 61.5 years) who were symptomatic with chest pain, shortness of breath, and dyspnoea. Diagnostic imaging showed anterior mediastinal masses, and surgical resection was accomplished in all cases. Grossly, the tumours measured 40-90 mm in greatest diameter (average: 65 mm), and were described as ill-defined lesions with a prominent cystic component and focal areas of haemorrhage and necrosis. Histologically, they were characterized predominantly by their cystic architecture. The cyst walls were lined by squamous epithelium showing different degrees of cellular atypia. In focal, more solid areas, the tumours showed evidence of keratinization. By immunohistochemistry, tumour cells were positive for cytokeratin 5/6, p40, and Pax8. All tumours were staged as T1N0M0 according to the Weissferdt-Moran staging system. Clinical follow-up showed that four patients have remained alive and well after a period ranging from 1 to 2 years. Two patients were lost to follow-up. The current cases highlight an uncommon growth pattern of well-differentiated squamous cell carcinoma of the thymus that may cause diagnostic difficulty with mediastinoscopic biopsies.

Value of cytopathology in endobronchial ultrasound-guided transbronchial needle aspiration

To evaluate the role of cytopathology in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for lung tumor diagnosis and staging. Two-hundred consecutive cases of lung tumor with EBUS-TBNA performed during the period from April, 2009 to September, 2010 in Shanghai Cancer Hospital were retrospectively reviewed. The cytologic diagnoses were categorized as non-diagnostic, negative, suspicious and malignant. When available, cell block preparation and immunohistochemistry were performed. On the 22 positive cases diagnosed by on-site evaluation, epidermal growth factor receptor (EGFR) mutation study was carried out. In the 200 cases of cytology specimens, 122 cases (69.3%) were diagnosed as malignant, 42 cases (23.9%) as benign and 12 cases (6.8%) as suspicious for malignancy. The non-diagnostic rate was 12.0% (24/200). Amongst the 200 cases studied, 140 cases (70.0%) had histologic correlation available (via core biopsy, mediastinoscopic biopsy or surgical excision). The sensitivity and specificity of EBUS-TBNA cytologic diagnoses were 94.4% and 100%, when using histopathologic findings and clinical follow-up data as gold standard. The cell block preparation and immunohistochemistry were useful in subtyping and diagnosis of extrathoracic malignancy. EGFR mutations were detected in 8 cytology samples (36.4%). EBUS-TBNA is a sensitive and specific tool for diagnosis and staging of lung cancer. The cytology samples can be used for further ancillary investigations including cell block preparation, immunohistochemistry and molecular studies.

Case of Sarcoidosis-Related Hypercalcemia with Normal Serum 1,25(OH)2D

Diagnosing hypercalcemia is often challenging because a wide spectrum of diseases-such as malignancy, granulomatous disease, and primary hyperparathyroidism-should be considered. Sarcoidosis is a rare cause of hypercalcemia. The case of a 77-year-old male presenting with sarcoidosis-associated hypercalcemia whose serum 1,25(OH)2D level was normal is reported here. Despite a normal 1,25(OH)2D level and minimally enlarged hilar lymphadenopathy, the serum angiotensin-converting enzyme (ACE) level was increased. Mediastinoscopic biopsy of the right lower paratracheal lymph node revealed pathological findings compatible with sarcoidosis. Treatment with 30 mg/day oral prednisone was started. Currently, the patient is being treated with a tapered dose of oral prednisone and small doses of vitamin D and calcium. Despite its low incidence, sarcoidosis should be considered a cause of hypercalcemia. The important diagnostic factors are not only serum calcitriol levels but also serum ACE levels and pathological findings. (Korean J Med 2015;88:207-211)