Paratracheal Nodes Research Articles

Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer.

Papillary and follicular thyroid carcinomas arising from the follicular epithelial cells and forming differentiated thyroid cancer (DTC) consist of >95% of thyroid cancers. Lymph node metastasis to the neck is common in DTC, especially in papillary thyroid cancer. The removal of only the metastatic lymph nodes (berry picking) does not help to achieve a potential positive contribution to the survival and recurrence of lymph node dissection in the DTC. Thus, systematic dissection of the cervical lymph nodes is needed. Today, according to the widely accepted and commonly used definitions and lymph node staging, the deep lymph nodes of the lateral side of the neck are divided into five regions. Based on the fact that some groups have biologically independent regions, Groups I, II, and V are divided into the A and B subgroups. The central region lymph nodes contain VI and VII region lymph nodes, which consist of the prelaryngeal, pretracheal, and right and left paratracheal lymph node groups.Radical neck dissection (RND) is accepted as the standard basic procedure in defining neck dissections. In this method, in addition to all the regions of the Groups I–V lymph nodes at one side, the ipsilateral spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle are removed. Sparing of one or more of the routinely removed non-lymphatic structures in the RND is called modified RND (MRND), whereas the preservation of one or more of the routinely removed lymph node groups in the RND is termed as selective neck dissection (SND). In difference, the procedure with an addition of a lymph node and/or non-lymphatic structures to routinely removed neck structures in RND is called extended RND. Generally, involving one or more regions of SND are applied for DTC.The removal of the paratracheal, prelaryngeal, and pretracheal lymph node groups at one side is termed as ipsilateral central dissection, whereas the removal of the bilateral paratracheal lymph node groups, in other words, the excision of four lymph node groups in the central region (Groups VI and VII), is defined as bilateral central dissection. In conclusion, bilateral central neck dissection (CND) is the SND in which the regions of VI and VII are removed.In the DTC, CND is prophylactically and therapeutically applied, whereas lateral neck dissection is performed only therapeutically in the presence of clinical metastasis (N1b) in the lateral neck region. Debates on the extent of SNDs to be made in the central and lateral neck regions are still ongoing. Central dissection should be made at least unilaterally. In the lateral side of the neck, SNDs can be applied in different combinations in which at least one region from Groups I to V is removed. The main variables that determine the extent of SND in the central and lateral regions in DTC are the complication rates, the effect of the procedure, and its effect on prognosis and recurrence.

TRANSMANUBRIAL THORACOTOMY FOR SUPERIOR MEDIASTINAL LESIONS

Background: We describe the technique of transmanubrial thoracotomy for superior mediastinal lesions. Methods: An L-shaped or reverse L-shaped skin incision, which consists of a median incision starting at the sternal notch and a horizontal incision along the upper edge of the second rib, is made. The manubrium is cut in an L-shape or reverse L-shape using a sternum striker. After the procedure, the manubrium is fixed with PDS Cord and the ribs are closed with Polysorb. Result: We applied this procedure for two patients. Case 1: A 37-year-old female with a benign superior mediastinal tumor such as neurinoma. Case 2: A 64-year-old female with an enlarged right paratracheal lymph node that persisted despite afatinib therapy for a primary lung cancer. Conclusion: This approach has the advantage of providing good visualization of the superior chest cavity and mediastinum.

Spontaneous Resolution of Idiopathic Panniculitis: Role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Diagnosis and follow-up.

We present the case of a-55-year-old female patient who presented with dry cough. High-resolution computed tomography chest revealed multiple nodules in both lungs. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) was done to look for the unknown primary. It showed hypermetabolic bilateral lung nodules, subcutaneous nodules involving lower limbs, an intramuscular nodule, enlarged paratracheal, and right axillary nodes. There was no primary tumor seen. The biopsy of subcutaneous nodule revealed panniculitis with the foreign body granuloma. Follow-up scans after 6 and 9 months showed spontaneous resolution of all lesions except for few right axillary nodes. There was no active treatment given, and the patient remains asymptomatic on follow-up. Here, PET/CT played a role in excluding a primary tumor, guiding the biopsy, and follow-up.

Multi-Modality Imaging, Electrophysiological, Electroanatomical, and Histopathological Characterisation of Atrial Sarcoidosis Presenting with Sinus Node Dysfunction and Sinus Arrest

Introduction: A 42-year-old man presented via the emergency department for recurrent dizziness. His background included well-controlled type 2 diabetes mellitus. Electrocardiogram revealed junctional bradycardia at 40 bpm with aberrantly conducted premature atrial complexes. Telemetry further demonstrated episodes of atrial fibrillation and symptomatic sinus pauses for up to 8 seconds. Transthoracic echocardiogram revealed a structurally normal heart; however, cardiac magnetic resonance imaging showed diffuse multichamber T2 hyperintensities and diffuse late gadolinium enhancement. This correlated with multichamber hypermetabolism on Fludeoxyglucose positron emission tomography computed tomography. Electrophysiology study revealed severe sinus node dysfunction with sinus node recovery times up to 2,834 ms with intact AV nodal and His-Purkinje conduction. Serum angiotensin-converting enzyme level was elevated at 96 U/L (20–70 U/L) and fine-needle aspiration biopsy of a hypermetabolic paratracheal lymph node showed a non–caseating granuloma, confirming the diagnosis of sarcoidosis with cardiac involvement.

PUB028 The Use of an EBUS TBNA Friendly Larynx Mask

Optimal performance of endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS-TBNA) requires both anesthesia care and procedural sedation with the aim of providing patient with as much comfort as possible while also ensuring the operating physician has optimal working conditions. By managing the airway with a supraglottic airway, the upper para-tracheal nodes will be accessible. Deep anesthesia can be avoided, due to effective usage of local topical anesthesia will ensure stable operating conditions without coughing or other discomfort for the patient. The Ambu AuraGain is a second-generation supraglottic airway with a short wide airway tube, combined with a flat back plate creates stability after placement and a better access of the EBUS-TBNA scope. The oral part of the tube prevents the possibility of harming the scope if the patient bites the teeth together The objective of this study was to assess the clinical performance of the AuraGain used as a conduit for EBUS-TBNA. The study included 20 cases, ASA II-III, eligible for a size 3, 4 or 5 supraglottic airway. The assessment included insertion, working as a conduit for bronchoscopy, fiberoptic assessment of anatomic fit and complications. After each procedure the performance were evaluated by the anesthetist and the endoscopist. First attempt insertion success rate was 95% with an overall success rate of a 100%. Average intra cuff pressure to obtain seal was 55.55 cmH2O, and ventilation was performed without leak at up to pPeak of 35 cmH2O which was the maximum pressure permitted. Assessment of ease of maneuvering an EBUS scope via the AuraGain was evaluated. Especially the resistance to advance, retract and rotate the scope in the trachea and the bronchial tree was evaluated based on a 3-point scale, defined as: little resistance, moderate resistance or high resistance. 90% recorded passing a scope as being with little resistance, moderate resistance was felt in 2 cases, and no records of high resistance was experienced. One episodes of patient coughing and biting was recorded, which was due to inadequate anesthesia, but because of the integrated bite absorption area, no dental damage or damage to the scope occurred. Fiberoptically assessment of alignment of AuraGain and the trachea was recorded as 100% satisfactory to accommodate performance of the EBUS procedure with needle aspiration of lymphoid nodes of down 3.mm. The AuraGain was effectively utilized for airway management and with a high degree of success for as a conduit for EBUS-TBNA.

TB of Porta Hepatis Presenting With Obstructive Jaundice: A Case Report

Introduction: Mycobacterium Tuberculosis causes tuberculosis. The number of reported TB cases in United States has been decreasing each year in the last 2 decades. Extra pulmonary TB can present anywhere in the body, however isolated peri-pancreatic or hepatobiliary TB is rare. Case Report: 25-year-old Pakistani immigrant male presented with 2 weeks of vague RUQ pain, pruritus, fever, nausea, acolic stool and dark urine. On exam: RUQ abdominal tenderness, yellow skin discoloration. AST 107 IU/L, ALT 211 IU/L, ALP 273 IU/L, LDH 214 IU/L, total bilirubin 11.4 mg/dl, indirect bilirubin 4 mg/dl, direct bilirubin 7.4 mg/dl. US showed a mass in the pancreatic area. CT showed a 5.5x4.1x4.8 cm complex cystic mass in the region of Porta Hepatis with resultant intrahepatic biliary dilatation that extends to the level of mass as well as 1.4 cm intra-aortocaval lymph node. Emergency ERCP with biliary stent placement was performed. FNA of the intra-aortocaval lymph node was performed. Biopsy: granulomatous inflammation, negative for malignant cells, fungal or AFB stains; the PCR positive for M. Tuberculosis DNA. CT chest: bulky non-calcified right Para-tracheal lymph node (1.5x2.7 cm). Mediastinoscopy was performed with lymph node biopsy: granulomatous inflammation, stains for AFB and fungi negative, PCR positive for M.Tuberculosis. T spot TB test was positive. Patient improved with stent placement and started on Isoniazid, Rifampin, Pyrazinamide and Ethambutol (2 months), followed by INH and Rifampin (4 months). Follow up imaging: complete resolution of the porta hepatis mass and lymph nodes. Discussion; Abdominal TB presents in one or more of the following forms: tuberculous lymphadenopathy, peritoneal tuberculosis, GI tract tuberculosis and visceral tuberculosis. Abdominal TB can occur due to hematogenous route, inhaling the tuberculosis spores, tubercular focus can develop in the lung from which hematogenous spread to other body parts takes place or ingestion of bacteria and then translocation across the intestinal wall. Diagnosis is made by demonstration of granulomas or AFB on Zeil-Neelson stain (low diagnostic value). PCR can effectively detect mycobacterium DNA in tissue sample. Early treatment with Quadruple therapy can effectively treat abdominal TB. Conclusion: Porta hepatis TB diagnosis is challenging and often confused with malignancy with high mortality risk if left untreated. Clinical outcome improves significantly with anti-Tuberculosis drugs.Figure: CT Abdomen, axial section, showing mass in porta hepatis area.Figure: CT abdomen, coronal section, showing mass in porta hepatis area with resultant intrahepatic biliary dilatation.Figure: CT abdomen, axial section, showing CBD stent with resolution of porta hepatis mass.

Too Weak to Breathe: An Odd Case of Lambert Eaton Myasthenic Syndrome

SESSION TITLE: Critical Care 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Lambert Eaton Myasthenic Syndrome (LEMS) is a rare autoimmune disorder of the neuromuscular junction characterized by the presence of antibodies against voltage gated calcium channels (VGCC) often associated with an underlying neoplasm. CASE PRESENTATION: 52 year old Caucasian female was admitted to an outside hospital with lethargy, shortness of breath and was intubated for acute hypercapnic respiratory failure which ultimately resolved and she was extubated. Her discharge diagnosis was presumed obstructive sleep apnea. Three weeks later she presented to our hospital with the same symptoms. Physical exam was significant for diminished breath sounds bilaterally and musculoskeletal exam was normal on presentation. Arterial blood gas was 7.26/79/118/35 after 30 minutes on non-invasive positive pressure ventilation, prompting intubation. On the ventilator she was awake and alert without sedation, but failed repeated breathing trials due to apnea, low tidal volumes and a negative inspiratory force of -10 cmH2O. Her persistant, profound and unexplained respiratory muscle weakness, raised concerns for a neuromuscular disorder and neurology was consulted. Electromyogram and nerve conduction studies revealed a post exercise increase in compound muscle action potential response > 200%, her VGCC antibodies were positive and acetylcholine receptor antibodies were negative. Computerized Tomography of the chest demonstrated a right suprahilar mass with a paratracheal lymph node which was hypermetabolic on Positron Emission Tomography. Endobronchial Ultrasound with biopsy of the lymph node confirmed small cell lung carcinoma. She was treated with pyridostigmine and plasma exchange with excellent response and was extubated several days later. She received three cycles of etoposide, cisplatin, chest radiation and is currently on mestinon and 3,4 diaminopyridine for her LEMS. DISCUSSION: LEMS classically presents as proximal muscle weakness, autonomic dysfunction and areflexia. Respiratory failure is a common primary manifestation of Myasthenia Gravis, however the literature rarely documents LEMS as presenting this way. This case highlights the importance of considering occult neuromuscular diseases in cases of unexplained respiratory failure even if other classical symptoms such as muscle weakness are absent. Our patient had repeated episodes of respiratory failure requiring intubation that was initially misdiagnosed, leading to missed treatment opportunities, a poor quality of life and an unchecked pulmonary malignancy. CONCLUSIONS: LEMS often presents early in the neoplastic course, thus diagnosis has important implications. Treatment of LEMS can be effective in relieving the neuromuscular symptoms and early detection of the underlying malignancy can be lifesaving. Reference #1: Fatima. U., Shah. T., Dedhia.P., Devine. S., Lambert Eaton Syndrome: Unique Presentation of the Disease with Isolated Respiratory Muscle Weakness. CHEST. Abstract 326A. October 2013. DISCLOSURE: The following authors have nothing to disclose: Caryn Brehm, Christopher Barrios, James Caress, Daniel Files, Daniel LoVerde No Product/Research Disclosure Information

Mediastinal Lymphadenopathy in a Patient With Acute Myeloid Leukemia

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute Myeloid Leukemia (AML) patients often present with respiratory symptoms and non-specific radiological findings. Extramedullary infitration (EMI) of soft tissues is a rarer form of presentation. CASE PRESENTATION: A 74-yo-white male farmer, ex-smoker, with a history of hypertension, hyperlipidemia and coronary artery bypass grafting presented with symptoms of weakness, shortness of breath on exertion and fatigue for 3 weeks. He did not report any chills, night sweats or fevers during this time. On examination, his vital signs were stable and he had bibasilar crackles on auscultation of his lungs. His WBC count was elevated at 38,700/mcL (predominantly monocytes 46%) with 12% blasts, hemoglobin level was 7.4 g/dL and platelet count 43,000/mcL. CT chest showed prominent mediastinal lymphadenopathy, involving the right paratracheal and subcarinal lymph nodes. A bone marrow aspirate showed 26% myeloid blasts with monocytic differentiation confirming the diagnosis of Acute Myeloid Leukemia (AML). The mediastinal lymphadenopathy persisted despite antibiotics and Decitabine chemotherapy. Bronchoscopy and transbronchial needle aspiration of the subcarinal lymph node confirmed the presence of myeloid blasts in the subcarinal lymph nodes. DISCUSSION: EMI occurs more commonly in the myelo-monoblastic subtypes of AML. Myeloid sarcoma (MS) and leukemia cutis (dermal infiltrates of blast cells) are 2 rare but well known manifestations of EMI. In MS, leukemic blasts infiltrate into various organ tissues (liver, spleen, gums, CNS), lymph node infiltration occurs in 12% cases of AML. Clinical features depend on the organs involved and the size of infiltration. Underlying molecular mechanisms and pathogenesis of EMI with spread of leukemic cells to certain specific tissues like the lymph nodes are not well understood. Diagnosis of EMI is made by immunohistochemistry of biopsy/cytology specimens demonstrating CD68-KP1 and MPO markers on malignant myeloid cells. Optimal therapy is unknown. For isolated MS, remission-induction chemotherapy same as AML is recommended. For MS concurrent with AML, induction chemotherapy +/- HCT are indicated. Targeted therapies do not have a clear role. CONCLUSIONS: EMI of lymph nodes is a rare cause of mediastinal lymphadenopathy in AML. Reference #1: Bakst RL, Tallman MS, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood. 2011 Oct 6;118(14):3785-93. Reference #2: Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic sarcoma: a systematic review. Am J Blood Res. 2013 Dec 18;3(4):265-70. DISCLOSURE: The following authors have nothing to disclose: Anirudh Aron, Khawaja Muddassir No Product/Research Disclosure Information

Second lung malignancy and Richter syndrome in chronic lymphocytic leukemia: case report and literature review

BackgroundChronic lymphocytic leukemia (CLL) is the most frequent lymphoproliferative disease. Transformation into Richter disease and occurrence of second malignancies involving the lungs are rare complications. The hallmarks of any thoracic involvement are still unknown.Case presentationWe report a case of a 56-year-old male patient, with history of tobacco smoking, who presented with recurrent hemoptysis, fatigue and weight loss. Physical examination was normal except a slightly enlarged supraclavicular lymph node. Chest x-ray revealed a mediastinal widening due to enlarged paratracheal nodes and a left parahilar infiltrate. Blood tests showed a hyperlymphocytosis and a biological inflammatory syndrome. CT scan showed bilateral mediastinal and axillary lymphadenopathy, as well as left supraclavicular lymphadenopathy, with a left upper lobe alveolar attenuation and a solitary contralateral pulmonary nodule. Examination of Virchow’s node and bone marrow biopsies confirmed metastasis of a pulmonary adenocarcinoma, as well as chronic lymphocytic leukemia with Richter’s transformation. The clinical course was unfavorable since the first days of therapy as the patient passed away in a matter of a few days.ConclusionsSteady surveillance of CLL patients and systematic screening for second solid tumors, particularly lung cancer, and Richter’s transformation seem to be relevant more than ever. Early diagnosis might help us understand the pathways leading to these complications and adapt therapy.

Stereotactic MR-Guided Adaptive Radiotherapy (SMART) for Ultra-Central Thorax Lesions: Results of a Phase 1 Trial

SBRT is an effective treatment for oligometastatic or unresectable primary malignancies, although target proximity to organs-at-risk (OAR) within the ultra-central thorax (UCT) limits safe delivery of ablative dose. SMART may improve the therapeutic ratio using reoptimization to account for daily variation in target/OAR anatomy. This study characterizes dosimetric and clinical outcomes in patients treated with SMART to UCT lesions on a prospective phase I trial. Five patients with oligometastatic (n = 4) or unresectable primary (n = 1) UCT malignancies were treated with SMART as part of a phase I trial (NCT02264886) from 4/2015 to 10/2015, using a clinical MR-IGRT system. Initial SBRT plans (PI) were created at CT/MRI simulation. Prescribed dose was 50 Gy/5 fractions (fx), with goal 95% PTV coverage by 95% of prescription, subject to hard OAR constraints. For fx1, PI was applied to the daily setup MR dataset and dose to PTV/OAR was recalculated and verified by the physician. When application of PI to fx1 anatomy resulted in OAR violation or reduced PTV coverage, daily adaptive plans subject to identical OAR constraints were created (PA). Online re-planning, QA, and delivery of a new plan were performed with the patient on-table. For subsequent fx, the delivered plan from the preceding fx was used as the new PI. When favorable daily anatomy was observed, PTV dose escalation was allowed in PA, provided all OAR constraints were met. PTV/OAR dose resulting from application of PI and PA to anatomy from each fx were compared to characterize the dosimetric impact of online adaptation. Patients were evaluated at three and six months for lesion control by RECIST criteria and monitored for acute grade >=3 toxicity. All PI and PA met hard OAR constraints based on simulation and daily setup MRI anatomy, respectively. Of four patients evaluated for plan adaptation, all received >=1 adapted fx and 10/20 fx were adapted. One patient was not adapted due to physician preference and was treated with MR-localization and cine MR-gating alone. Fifty percent of plan adaptations performed were for improved PTV coverage; 50% were for reversal of >=1 OAR violations of the esophagus (n = 3), trachea (n = 4), and stomach (n = 1) that occurred when PI was applied to the daily anatomy. Median on-table time for all fxs was 69 minutes (range 22-117 min). Local control by RECIST was 100% at three and six months. One locoregional failure was observed at eight months follow-up. Zero Grade >=3 acute toxicities were observed. At median follow-up of 14 months, only one patient treated to a paratracheal node had late toxicity with a benign esophageal stricture at 15 months post-treatment. Overall survival at 6 and 12 months was 100% and 60%. SMART allows PTV coverage improvement and/or OAR sparing compared to non-adaptive SBRT, and may widen the therapeutic index of UCT SBRT. This technique is clinically feasible and offers excellent local control with no observed acute Grade>=3 toxicity.

Surgical treatment for mediastinal abscess induced by endobronchial ultrasound-guided transbronchial needle aspiration: a case report and literature review

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a useful and less invasive procedure for the definitive diagnosis of mediastinal and hilar lymph nodes. However, infectious complications can occur after EBUS-TBNA, although they are extremely rare.Case presentationA 66-year-old man with necrotic and swollen lower paratracheal lymph nodes underwent EBUS-TBNA. A mediastinal abscess developed 9 days post-procedure. Surgical drainage and debridement of the abscess were performed along with lymph node biopsy followed by daily washing of the thoracic cavity. Surgical treatment was effective, leading to remission of the abscess. Biopsy revealed that the tumor was squamous cell carcinoma with no radiologically detected cancer elsewhere in the body. Mediastinal lung cancer was thus confirmed. Subsequent chemoradiotherapy led to the remission of the tumor.ConclusionsMediastinitis after EBUS-TBNA is rare but should be considered, particularly if the target lymph nodes are necrotic. Mediastinitis can lead to serious and rapid deterioration of the patient’s condition, for which surgical intervention is the treatment of choice.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy for esophageal cancer in the upper mediastinum

Background: Patients with upper third esophageal cancer or esophageal cancer with upper mediastinal paratracheal lymph node metastases are often precluded from surgery because of technical difficulties. With the aid of robotic surgery, an excellent overview and reach of the thoracic inlet can be accomplished. In this way, patients with upper mediastinal esophageal cancer are eligible for esophageal resection with curative intent. The aim of this study was to review the results of a consecutive series of patients who underwent robot-assisted minimally invasive esophagectomy (RAMIE) for tumors of the upper 1/3 of the esophagus or positive lymph nodes in the upper mediastinum. Methods: Between 2007–2016, 31 patients who underwent RAMIE in the UMC Utrecht for proximal esophageal cancer or proximal thoracic lymphadenopathy were identified from a prospective surgical database. Perioperative characteristics and oncologic outcomes were collected. Results: The majority of patients had a squamous cell carcinoma. Clinical tumor stage was cT3 or higher in 25 (81%) of patients. Clinically positive lymph nodes (cN1–3) were observed in 29 (94%) patients. Neoadjuvant treatment was administered in 27 (87%) patients. Median duration of the surgical procedure was 435 min (range 299–874 min). Pulmonary complications were most frequent and occurred in 13 (42%) patients. Median intensive care (ICU stay) was 1 day (range 1–65 days) and median overall postoperative hospital stay was 15 days (range 10–118 days). In hospital mortality was 10%. Causes of mortality were tracheo-neo-esophageal fistula, sepsis after abdominal wall drainage due to leakage of the jejunal fistula resulting in respiratory and kidney failure, after which refraining further treatment resulting in death, and irreversible ARDS in a patient with COPD Gold III needing extracorporeal life support. Radical resection was achieved in 30 (97%) of the patients. Median number of retrieved lymph nodes was 22 (range 9–57). Median time of follow up was 18 months (range 3–81 months). Median disease-free survival was 13 months (range 0–81 months) and median overall survival was 16 months (range 0–81 months). Tumor recurrence occurred in 15 patients (48%) and was locoregional only in 3 patients, systemic only in 5 patients and combined locoregional and systemic in 7 patients. Conclusions: Robot assisted thoraco-laparoscopic esophagectomy with curative intent in patients with upper mediastinal esophageal cancer is feasible, but associated with increased in hospital mortality. Short-term oncologic results are encouraging.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy for esophageal cancer in the upper mediastinum.

Patients with upper third esophageal cancer or esophageal cancer with upper mediastinal paratracheal lymph node metastases are often precluded from surgery because of technical difficulties. With the aid of robotic surgery, an excellent overview and reach of the thoracic inlet can be accomplished. In this way, patients with upper mediastinal esophageal cancer are eligible for esophageal resection with curative intent. The aim of this study was to review the results of a consecutive series of patients who underwent robot-assisted minimally invasive esophagectomy (RAMIE) for tumors of the upper 1/3 of the esophagus or positive lymph nodes in the upper mediastinum. Between 2007-2016, 31 patients who underwent RAMIE in the UMC Utrecht for proximal esophageal cancer or proximal thoracic lymphadenopathy were identified from a prospective surgical database. Perioperative characteristics and oncologic outcomes were collected. The majority of patients had a squamous cell carcinoma. Clinical tumor stage was cT3 or higher in 25 (81%) of patients. Clinically positive lymph nodes (cN1-3) were observed in 29 (94%) patients. Neoadjuvant treatment was administered in 27 (87%) patients. Median duration of the surgical procedure was 435 min (range 299-874 min). Pulmonary complications were most frequent and occurred in 13 (42%) patients. Median intensive care (ICU stay) was 1 day (range 1-65 days) and median overall postoperative hospital stay was 15 days (range 10-118 days). In hospital mortality was 10%. Causes of mortality were tracheo-neo-esophageal fistula, sepsis after abdominal wall drainage due to leakage of the jejunal fistula resulting in respiratory and kidney failure, after which refraining further treatment resulting in death, and irreversible ARDS in a patient with COPD Gold III needing extracorporeal life support. Radical resection was achieved in 30 (97%) of the patients. Median number of retrieved lymph nodes was 22 (range 9-57). Median time of follow up was 18 months (range 3-81 months). Median disease-free survival was 13 months (range 0-81 months) and median overall survival was 16 months (range 0-81 months). Tumor recurrence occurred in 15 patients (48%) and was locoregional only in 3 patients, systemic only in 5 patients and combined locoregional and systemic in 7 patients. Robot assisted thoraco-laparoscopic esophagectomy with curative intent in patients with upper mediastinal esophageal cancer is feasible, but associated with increased in hospital mortality. Short-term oncologic results are encouraging.

Utility of endoscopic ultrasound-guided fine-needle aspiration of regional lymph nodes that are proximal to and far from the primary distal esophageal carcinoma.

Implications of assessing the proximal and far para-tracheal or sub-carinal nodes (para-tracheal [PTN] or sub-carinal [SCN]) associated with lower primary esophageal carcinomas (ECs) are unclear. To evaluate the value of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for PTN and SCN, we analyzed results by positron emission tomography (PET) avidity, 4 EUS node malignancy features, and EUS-FNA results in all patients with Siewert’s I or II EC. Of 133 patients (PTN, n=102; SCN, n=31) with EUS-FNA, 47 (35%) patients had malignant node, leading to treatment modifications. EUS-FNA diagnosed significantly more patients with malignant nodes (p=0.02) even when PET and EUS features were combined. Among 94 PET-negative and EUS-negative patients, 9 (10%) had malignant EUS-FNA. At a minimum follow-up of 1 year, only 3 (5%) of 62 patients with benign EUS-FNA had evidence of malignancy in the nodal area of prior EUS-FNA. Patients with malignant EUS-FNA independently had a much shorter overall survival (OS) than those with benign EUS-FNA (p<0.001). Our data suggest that a benign EUS-FNA is highly accurate and need not be pursued further. However, malignant EUS-FNA of PTN/SCN was independently prognostic, conferred a shorter OS, and altered the management of 35% of patients.

P183 Histiocytic sarcoma of interdigitating reticular cells in the mediastinum - case report

Reticular dendritic cells are present in the germinal center of lymph nodes, with the function of pathogens phagocytation. They present antigens to B and T lymphocytes, acting, among other fronts, in the cellular memory. Histiocytic sarcoma is a rare malignant neoplasm with proliferation of cells with morphological and immunophenotypic characteristics of mature histiocytes derived from dendritic cells. In the mediastinum, histiocytic sarcoma of interdigitating reticular cells (HSIRC) are even more infrequent, with only 2 reports in the literature. Its histological diagnosis is considered a challenge, since it must be differentiated from other causes of mediastinal neoplasms, such as lymphomas, germinal tumors, and even lymph node metastases from carcinoma. The report is about a male patient, 69 years old, in schedule of radical prostatectomy due to a prostate adenocarcinoma. In his oncologic staging, he underwent chest tomography that demonstrated a mediastinal tumor suggestive of lymph node enlargement in the right paratracheal chain, of 2.8 cm. The patient was submitted to resection, which showed, in histological analysis, a highly pigmented, slightly differentiated fusiform neoplasm and bands of fibrous tissue, without necrosis and with slight atypia. The immunohistochemical panel showed no specific markers of epithelial, vascular, myogenic, neural or melanocytic histogenesis; In addition, CD21 and CD23 were negative, and CD68 positive. Thus, a diagnosis of HSIRC was made. Surgical resection was the only therapeutic modality performed, currently it is under ambulatory follow-up, with no signs of recurrence. HSIRC is mainly found in lymph nodes, as a localized disease or in disseminated form. It is extremely rare in mediastinal localization. The greatest difficulty reported in this type of sarcoma is its differential diagnosis. Most patients are asymptomatic or have nonspecific symptoms, and imaging is the main diagnostic tool. Current treatment protocols suggest optimal treatment as surgery alone, without radiotherapy or chemotherapy. However, a few studies described in the literature are not enough to guide unequivocally the treatment of these neoplasms. The patient is being followed up in the outpatient clinic for about 6 months after surgery, with no signs of recurrence. In conclusion, this is an extremely rare disease, poorly described in the literature, and should be included among the differential diagnoses of mediastinal lesions.

Optimal extent of prophylactic central neck dissection for papillary thyroid carcinoma: Comparison of unilateral versus bilateral central neck dissection

The aim of the study was to determine the optimal extent of prophylactic central neck dissection (pCND) in papillary thyroid carcinoma (PTC). We studied 384 patients with clinically node-negative unilateral PTC who had undergone total thyroidectomy with pCND. Of these, 169 patients underwent unilateral pCND, and 215, bilateral pCND. Age, sex, and TNM stage did not differ between the two groups. The rates of occult central lymph node metastasis were 34.3% and 37.2% in the unilateral and bilateral pCND groups, respectively (p=0.558). Metastasis to the contralateral paratracheal lymph node occurred in 4.2% of the bilateral pCND group. Major complication rates did not differ between the two groups, except for transient hypoparathyroidism, which was higher in the bilateral group (43.7% vs. 33.7%, p=0.047). Stimulated thyroglobulin and RAI ablation uptake rates were similar in the two groups, as were recurrence and disease-free survival. Contralateral paratracheal node dissection may be not indicated for prophylactic central neck dissection in clinically node-negative unilateral PTC because the rate of contralateral paratracheal node metastasis is low and transient hypoparathyroidism is higher following bilateral dissection.

Airway eosinophil migration into lymph nodes in mice depends on leukotriene C4.

We previously demonstrated in mice that airway eosinophils traffic from the airway lumen into lung-draining paratracheal lymph nodes. However, mechanisms whereby eosinophils traverse from the lungs and home to paratracheal lymph nodes remain unclear. We investigated roles of cysteinyl leukotrienes in mediating eosinophil trafficking from lungs to paratracheal lymph nodes. The expression of CCR7 was determined by flow cytometry. Transwell assays were used to test chemotactic responses of leukotriene C4 synthase-deficient and control airway eosinophils to the chemokine CCL19 ex vivo. Eosinophils from the spleens of IL-5 transgenic mice, fluorescently labeled ex vivo, were intratracheally injected into ovalbumin-sensitized and ovalbumin aerosol-challenged leukotriene C4 synthase-deficient and control mice. Eosinophils were identified by microscopy and flow cytometry in the lungs and paratracheal lymph nodes. Mouse eosinophils expressed CCR7, the receptor for CCL19, and responded chemotactically to CCL19. Leukotriene C4 synthase-deficient eosinophils exhibited impaired chemotaxis to CCL19 that was restored by exogenous leukotriene C4 . The migration of intratracheally injected eosinophils into paratracheal lymph nodes from distal alveolar lung was diminished in leukotriene C4 synthase-deficient mice compared with wild-type mice, with increased retention of eosinophils in the lungs of leukotriene C4 synthase-deficient mice. Exogenous administration of leukotriene C4 restored trafficking of eosinophils to paratracheal lymph nodes in leukotriene C4 synthase-deficient mice. Our findings that cysteinyl leukotrienes are involved in regulating airway and lung eosinophil migration into paratracheal lymph nodes identify previously unrecognized roles for the cysteinyl leukotrienes in regulating the pulmonary trafficking of eosinophils in experimental allergic asthma.

Re-evaluation of the role of thoracoscopic esophagectomy as a Japanese-style radical surgery

PurposeTo investigate the value of thoracoscopic surgery in radical esophagectomy with three-field lymphadenectomy.Materials and methodThe subjects were 329 consecutive patients who, without preoperative chemoradiotherapy, underwent R0 radical esophagectomy with three-field lymphadenectomy for thoracic squamous cell esophageal cancers during 1998–2013. Open thoracotomy was applied in 212 (O), and thoracoscopic surgery in 117 (V). Survivals according to TNM Stages and Efficacy index (EI) were analyzed.ResultsHospital death rates of O/V were 1.9/0%. The survivals of V according to TNM Stages had significantly better prognosis in TNM6th cStage III and showed not worse prognosis in general. In the analysis using Cox proportional hazards model, “V or O” was a significant prognostic factor indicating better prognosis of V. More bilateral paratracheal lymph nodes along the recurrent laryngeal nerves tended to be classified as mediastinal instead of cervical in V. Efficacy index of mediastinal paratracheal nodes was higher in V than in O, while cervical lymphadenectomy maintained high EI.Discussion and conclusionThough our series have limitations of retrospective study and substantial bias, the feasibility and safety of thoracoscopic esophagectomy with three-field lymphadenectomy was shown. Higher paratracheal lymph nodes along the recurrent laryngeal nerves could be dissected from the mediastinal side in V group. Thoracoscopic esophagectomy, which is regarded as minimally invasive surgery in other countries, is being accepted in Japan mainly in the expectation of more thorough and meticulous lymphadenectomy. At the same time, the dissection range is continuously re-evaluated for safer surgery maintaining radicality.

Relationship of paratracheal lymph nodes with the progression of chronic autoimmune thyroiditis: 5-year follow-up results

Background/aim: To examine changes in paratracheal lymph nodes (PLNs) and the relationship with the course of the disease in patients with chronic autoimmune thyroiditis (CAT) 5 years after diagnosis. Materials and methods: A total of 169 patients with newly diagnosed CAT and 53 healthy subjects were included in the study. All patients underwent ultrasonographic (US) examinations of the thyroid, paratracheal regions, and examined thyroid function tests. Eighty-four patients who were euthyroid at baseline and who were contacted 5 years after the diagnosis were reevaluated by US and thyroid function tests. Results: The PLNs frequency was significantly higher in the CAT group than the controls (75.1 % vs. 30.1 %, P < 0.001). Among the 84 patients who were euthyroid at the time of diagnosis and were contacted again after 5 years, 15 developed hypothyroidism. Initially, PLNs were present in all patients who developed hypothyroidism and were significantly higher than in those who remained euthyroid (respectively 100% vs. 68.7%, P = 0.009). PLN presence and PLN volume in patients who were euthyroid at baseline predicted hypothyroidism at the end of 5 years. Conclusion: PLNs may be used as an indicator of disease progression. In addition, patient age and baseline TSH levels are other factors that predict the development of hypothyroidism in time.

A foreign body reaction to Surgicel® in a lymph node diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration

Surgicel® (Ethicon, North Ryde, NSW, Australia) is an absorbable sheet of oxidized cellulose polyanhydroglucuronic acid polymer used as an hemostatic in cardiovascular and thoracic surgery. In some cases, the retained material may cause foreign body granulomatous reactions and simulate tumor recurrence, an abscess, an hematoma, or an infection. We report the case of a 55-year-old patient who was operated of a lung adenocarcinoma. In the thoracic computed tomography scan 1 year after the surgery, a right paratracheal lymph node was detected, so endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed suspecting recurrence of the tumor. The cytology results of the lymph node showed a nonnecrotizing granulomatous reaction secondary to Surgicel®, used as an hemostatic during the surgery. The objective of presenting this case is to consider foreign body reaction to Surgicel® in the differential diagnosis of postoperative suspicion of neoplastic recurrence, and on the other hand, to note that EBUS-TBNA enables diagnosis.