Paratracheal Nodes Research Articles

Delayed diagnosis of lung cancer due to misdiagnosis as worsening of sarcoidosis: a case report

BackgroundThe concurrence of sarcoidosis and primary lung cancer is very rare. We report a very rare case with a delayed diagnosis of primary lung cancer due to its misdiagnosis as worsening of pulmonary sarcoidosis.Case presentationA 68-year-old man presented to the outpatient department for evaluation of a mass in the right hilar area with lymphadenopathies in subcarinal and both interlobar areas on chest computed tomography (CT). Sufficient core samples were obtained from subcarinal and bilateral interlobar lymph nodes using endobronchial ultrasonography (EBUS) guided transbronchial needle aspiration (TBNA). EBUS could not reach the right hilar lymph node due to its high angle. The pathologic findings were consistent with sarcoidosis. After 5 months, chest CT revealed aggravation of the right upper paratracheal lymphadenopathy. Assuming worsening of sarcoidosis, he was prescribed an oral corticosteroid for 5 months. However, follow-up chest CT showed a newly developed right lower paratracheal lymphadenopathy and worsening right hilar lymphadenopathy. Bronchoscopy and EBUS were performed once again. Transbronchial lung biopsy from the right upper lobe and EBUS-TBNA from the right lower paratracheal lymph node revealed adenocarcinoma from the lung.ConclusionsAlthough coexistence of sarcoidosis and lung cancer is very rare, the clinician should consider the possibility of accompanying lung cancer in sarcoidosis patients who are not responding to initial corticosteroid therapy.

VIRUS-ASSOCIATED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS – THE SEVERE COURSE EXPRESSION IN SARS-COV-2 INFECTION?

The SARS-CoV-2 pandemic has caught the world completely unprepared. Sustained efforts are being made to understand the mechanisms by which this virus acts. One of the oldest and most efficient methods to achieve this is the autopsy, which becomes even more important as their number is limited. We present the case of an 88-year-old man, who died in a car, and was later autopsied at SCJML Constanta. The suspicion of SARS-CoV-2 infection was raised (the man had returned from the most affected area in Romania - Suceava) and the test was performed on a lung fragment taken during the autopsy. The presence of viral pneumonia with diffuse alveolar lesions was found. Lymphohistiocytic hemophagocytosis phenomenon was observed in paratracheal lymph nodes. In SARS-CoV-2 infection, there is the cytokine storm theory, which has multi-organ manifestation. It can occur in severe forms of infection with various viruses (Ebstein-Barr, SARS, MERS) and is the consequence of a hyperactive immune system, especially regarding macrophages. A morphological expression of this aberrant macrophage activation may be lymphohistiocytic hemophagocytosis.

Clinical and morphological characteristics of mediastinal lymphadenopathy in granulomatous pulmonary diseases

The purposeof this study was to determine detection rate and clinical and morphological characteristics of mediastinal lymphadenopathy (ML) in patients with respiratory system sarcoidosis (RSS), disseminated pulmonary tuberculosis (DPT) and exogenic allergic alveolitis (EAA).Materials and Methods.Patients (n= 278) with established diagnosis RSS, DPT, EAA were investigated. The cumulative index parameters were determined, hematology test, assessments of pulmonary function, diffuse lung capacity, diffusion coefficient were performed in all patients. Computed tomography of chest organs and morphologic examination of mediastinal lymph node (LN) biopsy were performed.Results.Subjects with newly diagnosed (n= 72) and recurrent (n= 104) disease were observed among patients with RSS (n= 176). ML was observed in 95% of cases, involved bronchopulmonary, bifurcation, paratracheal and paraaortal groups; dimensions of intrathoracic LN (ITLN) were 20.0 ± 1.9 mm. Epitheliocellular granulomas (EG) without necrosis, not fusing with each other, were established morphologically; they were determined in recurrent disease course in association with background fibrosis. In patients with DPT (n= 41), subacute (n= 28) and chronic (n= 13) disease course was noted. With subacute course of DPT in 28.6% of cases, ML of paratracheal and bifurcation groups (dimensions of ITLN – 13.1 ± 0.3 mm) was observed, with chronic course – the enlargement of paratracheal and bronchopulmonary LN (7.7% of cases). EG with necrosis and tendency to fusion was verified histologically; inflammatory process involved LN capsule and could be spread to fatty tissue. In patients with EAA (n= 76), acute (n= 10), subacute (n= 38) and chronic (n= 28) disease courses were observed. With acute EAA course, hyperplasia of ITLN of bifurcation and tracheo-bronchial groups up to 13.5 ± 0.6 mm was observed in 20% of cases. Follicular hyperplasia with widening and edema of hermintative centers was observed at morphological investigation. With subacute EAA course, increased ITLN in bifurcation and broncho-pulmonary groups up to 13.6 ± 0.6 mm were observed in 46% of cases. Formation of histiocytic-macrophagal granulomas without epithelioid cells and deposit precipitation in the plasma cell aggregation areas was found at morphological evaluation. With chronic EAA, ML in broncho-pulmonary and paratracheal groups was detected in 17.8% of cases (enlargement of LN up to 11 ± 0.9 mm). The formation of diffuse and focal fibrosis and hyalinosis was noted morphologically.Conclusion.ML is observed in all granulomatous pulmonary diseases studied, however its rate and severity, composition of involved ITLN groups and character of morphological changes is different which is possible to use in diagnostics.

Clinical Study on Prelaryngeal Lymph Node Metastasis in Papillary Thyroid Carcinoma.

ObjectiveThis study aims to investigate the risk factors of prelaryngeal lymph node metastasis in papillary thyroid carcinoma and its clinical application value.MethodsThe clinical pathological features and metastatic risks were statistically analyzed by reviewing 254 patients with papillary thyroid carcinoma, who received their first operation and prelaryngeal lymph node dissection in our department.ResultsThe detection of prelaryngeal lymph nodes, tumor size and any paratracheal lymph node metastasis were correlated with the number of paratracheal lymph node metastasis (P<0.05), but these were not correlated with age, gender, multiple foci, tumor size, any paratracheal lymph node metastasis, metastatic location, or foci location (P>0.05).ConclusionParatracheal lymph node metastasis indicates a high possibility of prelaryngeal lymph node metastasis. Paratracheal lymph node dissection combined with prelaryngeal lymph node dissection should be simultaneously considered in operations for thyroid papilla carcinoma.

SAĞLIKLI ÇOCUKLARDA MEDİASTİNAL LENF GANGLİONLARI; YAŞA GÖRE SIKLIK, BOYUT ARALIĞI VE DAĞILIM

<div><!--block-->Objective: Decision making about clinically significant lymph nodes (LN) is crucial. We elaborated the mediastinal LNs based on location, size and age groups.&nbsp;<br><br>Material and Method: Contrast enhanced chest computed tomography scans of 150 children who were referred to the radiology department after trauma, were evaluated retrospectively. All participants were divided into five age groups (0-24, 25-60, 61120, 121-180 and 181-216 months) which included thirty children each. We documented the shortest and longest axis diameters of the largest LNs and their location along with the age and gender of the children. Kolmogorov-Smirnov test, t test, Spearman’s correlation analysis assessment and descriptive statistics were expressed using SPSS 22.&nbsp;<br><br>Results: Mean ages were 11.53±10.1, 39.4±11.1, 84±15.9, 154.9±17.6, 190±9.3 months in consecutive age groups and 96±69.17 months in general. The most frequent locations with detectable LNs were subcarinal (n:98, 64%), right lower paratracheal (n:88, 57%), right tracheobronchial (n:82, 56%), right upper paratracheal (n:75, 49%) and left tracheobronchial (n:61, %39) lymphatic stations. Mean short and long axis diameters were 3.97±1mm (interquartile range:3.4-5.2) and 7.48±1.98mm (interquartile range:6.3-9.1) among detected 648 LNs, respectively. Both short and long axis diameters of LNs in low cervical, prevascular, subcarinal, right-left paratracheal and right-left tracheobronchial locations were correlated with the age (p&lt;0.05). Both short and long axis diameters of subcarinal LNs (4.78±1.05mm, 9.30±1.8mm) were significantly larger than right lower paratracheal (4.03±0.9mm, 7.94±1.6mm; p:0.001), right tracheobronchial (4.42±1.26mm, 8.59±2.1mm; p:0.04) and right upper paratracheal LNs (3.64±0.79mm, 7.1±1.49mm).&nbsp;<br><br>Conclusion: Being aware of the size range for normal mediastinal LNs according to ages and locations would facilitate management and reduce unnecessary interventions and medications.</div>

Memory problems and weight loss: A case report

This interesting case report illustrates a paraneoplastic syndrome presenting as dementia. A 75-year-old Malaysian lady with a 45-pack year smoking history presented with unintentional weight loss of three stone in three months with generalised aches and pains and short-term memory problems. Her inflammatory markers were raised, liver function tests were deranged, and her thyroid stimulating hormone was low. Cerebrospinal fluid examination revealed a mild increase in protein. On the Addenbrookes Cognitive Scale her score was 39/100 and she also had clinical features to suggest mild depression. A Computed Tomography of the thorax showed a 34mm mass anterior to the trachea and an enlarged right para-tracheal lymph node. Subsequent endo-bronchial ultrasound biopsy confirmed metastatic small-cell lung cancer. She had positive autoantibodies for anti-Hu and anti-Sox 1; indicating a paraneoplastic syndrome or limbic encephalitis. Paraneoplastic syndromes are rare and difficult to diagnose. In this case, the paraneoplastic manifestations mimicked a dementia illness.

A novel procedure of thoracoscopic 4L lymph node dissection: 4L posterior first technique

Background: Left lower paratracheal (4L) lymph node dissection for left lung cancer is difficult because of the anatomic configurations of the aortic arch, pulmonary artery, and left recurrent nerve. This study aimed to describe a novel procedure of thoracoscopic 4L lymph node dissection and determine its surgical outcomes. Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared. Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs . 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs . 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%). Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.

Elective Central Compartment Lymph Node Dissection Does not Increase the Risk of Postoperative Hypoparathyroidism in Patients Treated for Differentiated Thyroid Cancer

SUMMARYAimThe aim of this study was to compare the incidence of postoperative hypoparathyroidism in two groups of patients who were treated for differentiated thyroid cancer.MethodsA retrospective analysis of 179 patients who were treated for differentiated thyroid cancer in our institution from January 2011 until December 2018 was performed. Only patients initially treated with total thyroidectomy and those who did not have preoperatively confirmed central compartment and lateral neck lymph node metastases were included in this study. Two main groups of patients were analysed. The patients who were treated with total thyroidectomy and elective central compartment lymph node dissection simultaneously were included in the first group. The patients who were treated only with total thyroidectomy were included in the second group. The rate of transitory and persistent postoperative hypoparathyroidism was compared between the two groups.ResultsA total of 117 patients (65.4%) underwent total thyroidectomy and elective central compartment lymph node dissection simultaneously (TT + CCLNd group). The remaining 62 patients (34.6%) underwent total thyroidectomy only (TT group). A total of 22.6% patients in the TT group developed postoperative hypoparathyroidism compared with 25.6% in the TT + CCLNd group. The rate of persistent hypoparathyroidism in the TT and TT + CCLNd groups was 3.2% and 6.0%, respectively. The difference in the rate of transient and persistent postoperative hypoparathyroidism was not statistically significant between the two groups. Within the TT + CCLNd group, 82.9% of patients underwent ipsilateral paratracheal lymph node dissection and 17.1% underwent bilateral paratracheal lymph node dissection. The rate of postoperative hypoparathyroidism was analysed in those two subgroups of patients and did not prove to be statistically significant.DiscussionWhile its impact on the local recurrence rate is still controversial, elective central compartment lymph node dissection could be a great tool for selection of patients who could profit from adjuvant radioiodine treatment. On the other hand, central compartment lymph node dissection could potentially increase the risk of hypoparathyroidism due to involuntary injury to parathyroid glands and/or their blood supply. Our study did not find a statistically significant difference regarding postoperative hypoparathyroidism between patients who underwent central compartment lymph node dissection compared with patients who underwent total thyroidectomy only. Our data are not in accordance with some of the previously published studies.ConclusionOur results demonstrated that elective central compartment lymph node dissection is a safe procedure and does not significantly increase the risk of postoperative hypoparathyroidism when it is performed simultaneously with total thyroidectomy.

Total Thyroidectomy with Central Node Dissection is a Valuable Option in Papillary Thyroid Cancer Treatment.

SUMMARYIntroductionPapillary thyroid cancer is one of the cancers with favorable prognosis, although the long-term recurrence rate in the paratracheal region is reported to be as high as 30%. The use of 131I is considered to be a reliable treatment option for lymph node metastases in the paratracheal region. According to the majority of internationally accepted guidelines, it is not recommended to perform central node dissection (CND) routinely. Total thyroidectomy (TT) remains an adequate treatment for these patients. According to many studies, CND is associated with higher rates of hypoparathyroidism. However, CND improves staging.MethodsWe performed a retrospective study. We included 248 patients treated for papillary thyroid cancer during a 20-year period. Data were collected on patient (age, sex) and tumor (size, focality) characteristics, presence of metastases in the central neck compartment, incidence of postoperative hypoparathyroidism, and locoregional failure. We divided patients into two groups based on pathological analysis: those without positive lymph nodes (N0) and those with positive paratracheal lymph nodes (N1). We compared patient and tumor characteristics and risk of recurrence between the two groups. Results: There were 39.5% patients with central neck metastases in our series. In the central neck dissection specimen, 5.5 nodes were found on average. Hypoparathyroidism was found in 23.4% of patients and remained permanent in 3.2% of patients. Female and older patients had a lower chance of central compartment metastases, as did patients with smaller and unifocal tumors. Recurrence risk was doubled for the N1 group. All tested differences between the groups reached statistical significance.Discussion and conclusionIn our hands, CND was a safe and effective surgical procedure. It improved staging and postsurgical management. Efforts should be made to improve the preoperative work-up in order to more accurately identify high-risk patients.

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

Background: Chronic 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 presentation: We 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. Conclusions: Steady 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.

CLINICAL MANIFESTATIONS OF PARATHYROID CANCER IN 29 YEARS OLD MAN

Parathyroid cancer is an extremely rare cause of primary hyperparathyroidism, accounting less than 1% of cases. The neoplasm is detected in people 40-50 years old. Ratio of men and women is 1: 1, in contrast to hyperparathyroidism caused by adenoma of epithelial bodies, when there are 3-4 times more women than men among the patients. Due to the rarity of this disease, surgeons and morphologists may have difficulties in verification of the tumor. Distinctive features of the course of the disease include the extremely rapid progression of bone changes, the development of hypercalcemic crises with a high level of blood calcium and serum parathyroid hormone. Radical surgery involves the removal of malignant parathyroid tumor in a single block with the ipsilateral thyroid gland, as well as paratracheal lymph nodes. The aim of investigation is to show a rare observation of bone manifestations of parathyroid cancer. Material and methods. Parathyroid cancer was diagnosed in 2 (0.7%) of 283 patients with primary hyperparathyroidism, operated in the Center of Endocrine Surgery. Male 29 years old was operated on in January 2016. Disease duration was about 2 years. The clinical picture was characterized by multiple bone fractures, generalized cystic osteodistorofy, renal failure, severe electrolyte disorders, cachexia. The diagnosis was confirmed by high values of total calcium and blood parathyroid hormone. The patient underwent removal of the parathyroid tumor, during the histological and immunohistochemical study of which parathyroid cancer was verified. The patient was able to sit on his own after 3 months, get up with support after 6 months and walk with the help 10 months later after the operation. In May 2017 an increase of parathyroid hormone to 1900 pg / ml was detected with a normal value of blood calcium, which indicates recurrence of parathyroid cancer. Findings. The high grade of the disease is due to both the aggressive course of parathyroid cancer and the late diagnosis.

Rabbit VX2 lung tumor models can form early nodal metastases

BackgroundThe rabbit squamous cell cancer line, VX2, has been used to generate various tumor models in rabbits. It is notable for its ability to generate nodal metastases. However, the timing and extent of nodal metastases vary by primary inoculation site and methodology. The development of metastases specifically in lung cancer models has not been well-described. We sought to characterize the generation of nodal metastases in rabbit transbronchial VX2 lung tumor models.MethodsRabbit VX2 lung tumor models were created in the right lung via transbronchial injection and serially imaged by computed tomography. Rabbits (n = 15) were sacrificed from between 5 and 24 days post-inoculation for collection of the ipsilateral and contralateral paratracheal lymph nodes. These underwent histopathological evaluation for metastases using hematoxylin and eosin as well as cytokeratin AE1/AE3 immunohistochemical staining.ResultsNodal metastases were detectable as early as 1 week after inoculation but were more prevalent with longer inoculation; all rabbits at > 2 weeks post-inoculation had nodal metastases. Contralateral metastases were in general seen later than ipsilateral metastases. Lymph node volume did not predict the likelihood of nodal metastases (p = 0.4 and p = 0.07 for ipsilateral and contralateral nodal metastases, respectively), but primary tumor volume was significantly associated with the likelihood of nodal metastases (p = 0.001 and p = 0.005 for ipsilateral and contralateral nodal metastases, respectively). Ipsilateral metastases were detectable at a tumor diameter of 1 cm; contralateral metastases were more variable but in general required a tumor diameter of 2 cm.ConclusionsRabbit transbronchial VX2 lung tumor models generate nodal metastases relatively early after inoculation. These results suggest such models may be valuable tools in the investigation of novel therapeutic modalities relevant for the treatment of both early-stage and locally advanced lung cancer.

P44 THE EXTENT AND CONSEQUENCES OF LYMPHADENECTOMY IN ESOPHAGEAL CANCER SURGERY: A CASE VIGNETTE SURVEY

Abstract Background Lymph node dissection (LND) is part of standard operating procedure in resectable esophageal cancer patients regardless of lymph node status. The aim of this case vignette survey was to acquire expert opinions on current practice of LND, and to determine potential consequences of non-invasive lymph node staging on the extent of LND and postoperative morbidity. Methods An online survey including 5 short clinical cases (case vignettes) was sent to 272 esophageal surgeons worldwide. Extent of standard LND, potential changes in LND based on accurate lymph node staging and consequences for postoperative morbidity were evaluated. Results 86 esophageal surgeons (median experience in esophageal surgery of 15 years) participated in the survey (response rate 32%). Standard LND varied considerably between experts, for example pulmonary ligament, splenic artery, aortopulmonary window and paratracheal lymph nodes are routinely dissected in less than 60%. The omission of (parts of) LND is expected to decrease the number of chyle leakages, pneumonias laryngeal nerve pareses and reduce operating time. In order to guide surgical treatment decisions, a diagnostic test for lymph node staging after neoadjuvant therapy requires a minimum sensitivity of 92% and specificity of 90%. Conclusion This expert case vignette survey study shows that there is no consensus on the extent of standard LND. Esophageal surgeons seem more willing to extend LND rather than omit LND, based on accurate lymph node staging. The majority of surgeons expect that less extensive LND can reduce post-operative morbidity.

P192 CROSS REGIMEN FOR ADENOCARCINOMA OF THE ESOPHAGUS AND CARDIA: DOES PATHOLOGICAL RESPONSE INFLUENCE OVERALL AND DISEASE FREE SURVIVAL? MULTICENTER RETROSPECTIVE ANALYSIS

Abstract Aim Primary aim is to evaluate the relationship between pathological response after CROSS regimen for locally advanced esophageal adenocarcinomas and overall and disease-free survival. Secondary endpoint is to analyze the principal sites of relapse after surgery in this group of patients. Background &amp; Methods The CROSS trial showed an improvement of overall survival after neoadjuvant chemoradiation and subsequent surgical resection compared to surgery alone for patients with esophageal cancer, representing the benchmark [1]. Patients submitted to CROSS regimen for adenocarcinoma of the esophagus and cardia followed by esophagectomy with a transthoracic extended lymphadenectomy were analyzed. The patients were treated in 4 centers part of Italian Group for the Study of Esophageal Diseases (SISME). Actuarial Overall survival (OS) and actuarial disease-free survival (DFS) were analyzed and stratified according to yp Stage (1 – stage I and II; 2 – stage IIIA and IIIB and 3 - stage IVA) as described in the 8th edition of TNM. Kaplan-Meier method was used to estimate overall and progression-free survival, with the log-rank test to ascertain significance (p&lt;0.05). Median and range were used. Statistical analysis was done with SPSS version 21.0. Results 132 patients, from January 2014 to February 2019, were analyzed. Median age was 63 years (range 42-82). The site of the neoplasm was the distal esoghagus-EGJ in 127 cases and the middle esophagus in 5. Ivor Lewis was the procedure adopted. Fifty-month OS and DFS were respectively 42% and 6.7% respectively. No difference emerged when overall survival was analyzed according to yp Stages. Time to relapse is significantly longer for ypStage I and II. Recurrence occurred in 48 cases (36.3%) with 9 months as median time to relapse. Local and distal relapse were 10 (paratracheal nodes) and 38 respectively (7.5% and 28.7%, p&lt;0.001). Conclusion Pathological response after CROSS regimen doesn’t relate to OS and DFS. Time to recurrence is significantly longer for yp Stage 1 e 2 rather than other ypStages. Chemoradiotherapy in a neoadjuvant setting may influence the site of relapse.

Thoracoscopic en bloc resection of left upper lobe lung cancer

In this video tutorial we demonstrate our procedure for en bloc resection of the left upper lobe and the regional lymph nodes via video-assisted thoracic surgery in patients with primary lung cancer and outline some key surgical points. First, the operation should start with dissection of the posterior portion of the hilar and lower paratracheal nodes, which will provide excellent visualization of the left recurrent laryngeal nerve and also facilitate dissection of the subaortic and para-aortic (aorto-pulmonary) nodes. Second, the lower paratracheal nodes and aorto-pulmonary nodes should be mobilized together with their dominant lymphatic drainage pathways from the left upper lobe. During this procedure, care must be taken not to divide the peribronchial lymphatic pathway toward the lower paratracheal nodes or the subpleural lymphatic pathway toward the aorto-pulmonary nodes. By following these guidelines, the left upper lobe and the regional lymph nodes can be resected en bloc without any division of their lymphatic connection. We believe that this procedure will help prevent pleural dissemination as well as prevent the surgeon's missing any metastatic lymph nodes.

Individualized Prediction Of Metastatic Involvement Of Lymph Nodes Posterior To The Right Recurrent Laryngeal Nerve In Papillary Thyroid Carcinoma.

PurposeWe aimed to establish a prediction model based on preoperative clinicopathologic features and intraoperative frozen section examination for precise prediction of metastatic involvement of lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) in patients with papillary thyroid carcinoma (PTC).MethodsClinicopathologic data pertaining to patients with PTC who underwent initial thyroid surgery between July 2015 and December 2017 were collected from electronic medical records. Multivariate logistic regression analysis was performed to identify independent predictors of LN-prRLN metastasis for incorporation in the nomogram. The performance of the model was assessed using discriminative ability, calibration, and clinical application.ResultsA total of 592 patients were enrolled in this study. The LN-prRLN metastatic positivity was 19% (95% confidence interval [CI], 15.61–21.89%). On multivariate analysis, ultrasonography-reported LN status, extrathyroid extension, Delphian lymph node metastasis, and number of metastatic pretracheal and paratracheal lymph nodes were independent predictors of LN-prRLN metastasis. The nomogram showed good discriminative ability (C-index: 0.87; [95% CI, 0.84–0.91]; bias-corrected C-index: 0.86 [through bootstrapping validation]) and was well calibrated. The decision curve analysis indicated potential clinical usefulness of the nomogram.ConclusionThis study demonstrates that the risk of LN-prRLN metastasis in individual patients can be robustly predicted by a nomogram that integrates readily available preoperative clinicopathologic features and intraoperative frozen section examination. The nomogram may facilitate intraoperative decision-making for patients with PTC.

P2.18-08 The Necessity and Technique of the Upper Zone Lymph Node Dissection for Non-Small-Cell Carcinoma of the Left Upper Lobe

The removal of the whole regional lymphatic system together with primary tumor is one of the important rules in oncological surgery. According to the study of regional lymphatic drainage, we considered reasonable lymphadenectomy contributes the post-operative survival of the Left lung cancer patients with mediastinal lymph node metastasis. Due to anatomical limitations imposed by arch of aorta, it is difficult to perform complete dissection of upper zone mediastinal lymph nodes through the left thoracotomy in the left lung cancer. We had devised Systematic extended bilateral mediastinal dissection through a median sternotomy (ND3 operation) for patient with NSCLC of the left lung. This report aimed to introduce procedure of our operation and investigate the prognostic impact of Upper zone lymph node dissection for left upper lobe NSCLC. The our operative procedure is as follows. In the supine position, made a median sternotomy. We dissect the meidastinal nodes before pulmonary resection. The dissection is started on the highest area. Tape the right and left recurrent laryngeal nerve and dissect the highest paratracheal lymph nodes in the thoracic inlet. After making the pericardiotomy, the ascending aorta is retracted to the left. Remove the whole upper zone tissue lying in front of the trachea. And dissect the pre and paratracheal nodes, together with bilateral highest nodes. Then, dissect the subcarinal nodes. Tie off the blood vessels (arteries and veins) and airways leading to the affected lobe, and then remove the lobe. We retrospectively studied 213 patients [157 male and 61 female, mean ages 60.4 years (range, 29-75)], underwent ND3 operation due to NSCLC of the left upper lobe, from January 1990 till December 2017. The patients with NSCLC who are estimated to be able to conventional radical operation and aged 75 year-old or less becomes the adaptation of our operation. Overall 5-year survival rate in the 218 patients of left upper lung primary was 65.1%. Operative mortality in 218 patients was 2.8%. Lymph node metastasis to the mediastinum was confirmed in 70 (32.1%) patients (pN2 was 43, pN3α was 18, pN3γ was 9). According to pathological stages, five-year survival rate was 92.7% in stage IA ,80.1% in stage IB, 53.8% in stage IIA, 66.7% in stageIIB, 51.7% in stageIIIA, 38.4% in stageIIIB. And it was 52.1% in pN2 cases, and 55.0% in pN3α cases. Five-year disease free survival rate was was 85.6% in p-stage IA ,74.0% in p-stage IB,49.7% in p-stage IIA, 49.4% in p-stageIIB, 33.3% in p-stageIIIA, 19.4% in p-stageIIIB, 32.6% in pN2 cases, and 27.8% in pN3α cases. In this nonrandomized comrarision, the post-operative survival of patients with pN2 and pN3α NSCLC of the left upper lung primary would be remarkably improved by our Systematic Bilateral Mediastinal Dissection. And better local tumor control by our operation does not increase mortality. When faced with a patient with resectable mediastinal lymph node metastasis, we should consider Extended bilateral mediastinal lymph node dissection through a median sternotomy. To improve survival rate, it is important to perform curative operation with upper zone mediastinal dissection.

1980 A Case of Downhill Esophageal Varices Secondary to Metastatic Disease From Renal Cell Carcinoma and Resultant Superior Vena Cava Syndrome

INTRODUCTION: Downhill esophageal varices (DEV) are a rare form of varices associated with superior vena cava (SVC) obstruction. Obstruction leads to retrograde blood flow through collateral channels, including the esophageal venous plexus. This case describes a patient with hematemesis due to DEV from an enlarged paratracheal lymph node (PLN) secondary to metastatic disease (mets) from renal cell carcinoma (RCC). CASE DESCRIPTION/METHODS: A 65 year old male with past medical history of RCC s/p right nephrectomy with mets to the brain and mediastinum presented with a one day history of hematemesis and significant drop in hemoglobin. Esophagogastroduodenoscopy (EGD) was remarkable for large DEV in the proximal to mid-esophagus with white nipple sign. Band ligation was deferred given no active bleeding. Liver function tests were normal, vascular duplex of the abdomen was unremarkable, and CT chest with IV contrast showed extrinsic compression of the distal brachiocephalic veins (BV) and proximal SVC from a 4.6 cm necrotic right PLN. Radiotherapy was used to decrease the lymph node size and resultant extrinsic venous compression. DISCUSSION: DEV are a rare entity compared to uphill varices (UV) found in the distal esophagus due to portal hypertension. Hematemesis is more common with UV because of their location in the superficial sub-epithelium and increased acid exposure. DEV are located proximally in the submucosa, have more protection against acid, and have less than a 0.1% chance of causing hematemesis. After diagnosis with EGD, there are no clear guidelines on management. In this patient, banding was deferred given high risk of bleeding and perforation due to weakness in the proximal esophageal posterior wall and lack of serosa. After diagnosis on EGD, CT chest revealed the underlying cause of bleeding: SVC obstruction. The gold standard imaging study is direct venography but CT chest is an adequate alternative study. No surgical intervention was performed given the precarious nature and location of the lymph node and stenting of the SVC was deferred given the risk for re-bleed if placed on anticoagulation. Thus, radiotherapy was ultimately determined to be the next best step to decrease the extrinsic compression of the SVC from the lymph node. Chakinala RC, Kumar A, Barsa JE, et al. Downhill esophageal varices: a therapeutic dilemma. 2018 Nov 1. 1–6. Gebreselassie A, Awan A, Yaqoob H, Laiyemo A. Superior Vena Cava Obstruction: A Rare Cause of Recurrent Esophageal Variceal Bleeding. 2018 Feb 26. 2226.

WHERE DID THE HISTIOCYTES COME FROM? A CASE OF DIFFUSE LUNG INFILTRATES WITH HISTIOCYTOSIS IN BRONCHOALVEOLAR LAVAGE

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Analyzing bronchoalveolar lavage (BAL) fluid provides useful information for diffuse bilateral pulmonary infiltrates with unclear etiologies. We report a case of bilateral interstitial lung disease with histiocytes predominant in BAL in an otherwise healthy female. CASE PRESENTATION: 59 y/o female, never smoked, with no significant past medical history who presented with persistent cough of 2 months. She denied weight loss, night sweats, fever, chills, chest pain, shortness of breath, sick contacts, travel. Physical exam is unremarkable. Initial labs showed neutrophilic predominant leukocytosis. Chest x-ray showed patchy right lower lobe infiltrates. CT chest revealed diffuse bilateral pulmonary parenchymal abnormalities and mildly enlarged right paratracheal and right hilar lymph nodes. The patient underwent bronchoscopy and bronchoalveolar lavage (BAL), cultures grew alpha strep and Capnocytophaga species, BAL cytology revealed mainly histiocytes( 98%). Further testing negative for: influenza, tuberculosis, fungal panel, urine Legionella. Positive for Mycoplasma antibody IgG. She was treated for community acquired pneumonia with ceftriaxone and azithromycin with good clinical response. Patient had a repeat chest x-ray 2 weeks later which showed resolution of her right sided infiltrates, and blood work revealing restoration of leukocytosis. She reported improvement of her symptoms. All of these indicating resolution of her right sided pneumonia. DISCUSSION: Histiocytes are part of the mononuclear phagocyte system aka the reticuloendothelial system. In normal circumstances, histiocytes are mainly found as pulmonary alveolar macrophages. However, they actively participate in all inflammatory reactions of the lung. In some cases, risks factors like smoking could predispose patients to a specific histiocytic predominant pathology. Histiocytic pulmonary lesions present as nodular and/or diffuse proliferations in the lung. Pulmonary lesions with histiocytes predominant can be neoplastic, for example- histiocytic sarcoma; or non-neoplastic such as pulmonary Langerhans’ cell histiocytosis, desquamative interstitial pneumonia, pneumoconiosis, infections, diffuse panbronchiolitis, crystal storing histiocytosis, respiratory bronchiolitis, alveolar hemorrhage, eosinophilic pneumonia, obstructive pneumonia, exogenous lipoid pneumonia, some drug reactions, and other metabolic/storage disorders. Our patient presented with atypical pneumonia, cough for 2 months, diffuse interstitial infiltrates with histiocytosis in BAL. IgM for Mycoplasma pneumoniae negative, IgG with high titer. She had good clinical and radiological response with conservative management. CONCLUSIONS: In our case, Mycoplasma pneumoniae was etiology. Multidisciplinary approach and mechanism-based therapeutic strategies are important for diffuse interstitial lung disease with histiocytosis in BAL. Reference #1: Wang, C. and Colby, T. (2007). Histiocytic lesions and proliferations in the lung. Seminars in Diagnostic Pathology, [online] 24(3), pp.162-182. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17882900. Reference #2: Andrea Morelli et al. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock: A Randomized Clinical Trial. JAMA.2013;310(16):1683-1691. https://doi.org/10.1001/jama.2013.278477. Reference #3: Moon J, du Bois RM, Colby TV, et al. Clinical significance of respiratory bronchiolitis on open lung biopsy and its relationship to smoking related interstitial lung disease. Thorax 1999; 54:1009. DISCLOSURES: No relevant relationships by Violeta Alvarez-Retamales, source=Web Response No relevant relationships by Phyo Kyaw, source=Web Response

SMALL CELL LUNG CANCER PRESENTING AS ENDOTRACHEAL MASS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Tracheal tumors are most often adenoid cystic or squamous cell carcinoma in origin. Far less commonly, they may be due to high grade neuroendocrine carcinomas, which are divided into large and small cell carcinoma subtypes. Although both are often metastatic at time of diagnosis, high grade neuroendocrine carcinomas are rarely found endotracheal or endobronchial on initial presentation. Therefore, the natural history and approach to management for such lesions has yet to be clearly defined. CASE PRESENTATION: 60 year old male with history of hypertension, 40 pack year tobacco smoking history and frequent alcohol abuse presented with dyspnea, cough, wheezing and weakness for the past two months. Exam notable for stridorous respiratory sounds. Computed tomography of his chest revealed an 1.6 cm x 1.8 cm intraluminal tracheal mass, 2.0 x 1.0 cm right lower paratracheal lymph node, and 1.6 x 1.1 subcarinal lymph node. Bronchoscopy disclosed a tracheal mass just proximal to the carina. This lesion was biopsied. Cytologic examination returned as high-grade neuroendocrine carcinoma with submucosal invasion. Multidisciplinary discussion at tumor board concluded pathology to be small cell lung cancer (SCLC). After completing staging workup, patient determined to be limited stage SCLC as positron emission tomography with computed tomography was only notable for the intratracheal lesion. Patient started on radiation and chemotherapy with cisplatin and etoposide. One week later, patient presented to the hospital again for worsening shortness of breath. Repeat bronchoscopy revealed roughly 90% luminal narrowing. He underwent tumor debulking with argon plasma coagulation and cryotherapy with subsequent balloon dilation of the trachea, right mainstem bronchus, and bronchus intermedius. His symptoms of dyspnea and wheezing markedly improved. Cytologic examination of the tracheal mass again returned with diagnosis of high-grade neuroendocrine carcinoma. Patient is currently undergoing chemoradiation. DISCUSSION: We report the case of small cell lung cancer presenting as an endotracheal mass with mediastinal lymphadenopathy. After determining the patient to be limited stage SCLC, we took an interventional approach with tumor debulking as opposed to a surgical one. CONCLUSIONS: Due to the infrequency with which SCLC presents as a tracheal mass, the optimal approach to treatment has yet to be determined. However, this case suggests in distal trachea, an endoscopic approach followed by adjuvant chemoradiation may be appropriate. Reference #1: Chua, W, et al. A Case of Primary Small Cell Carcinoma of the Trachea. J Bronchol 2008;15:49-51. Reference #2: Heikal, M. Small-Cell Cancer Presenting as a Tracheal Polyp A Case Report and Review of the Literature. J Bronchol Intervent Pulmonol 2012;19:132-136. DISCLOSURES: No relevant relationships by Sarung Kashyap, source=Web Response No relevant relationships by Essam Mekhaiel, source=Web Response