Posterior Mediastinal Nodes Research Articles

Advances and understanding pitfalls of laparoscopic transhiatal esophagectomy with en bloc mediastinal lymph node dissection

We began performing mediastinal lymph node dissection using the laparoscopic transhiatal approach in 2009. Following the initiation of the single-port mediastinoscopic cervical approach in 2014, we developed a technique for transmediastinal radical esophagectomy without a thoracic approach. We herein describe our surgical procedures for en bloc mediastinal lymph node dissection by the laparoscopic transhiatal approach with a focus on pitfalls. We opened the esophageal hiatus and the working space was secured using long retractors. During division of the right crus of the diaphragm, we made efforts to avoid damaging the left hepatic vein and inferior vena cava. Dissection of the posterior plane of the pericardium was extended to the cranial side, and the bilateral inferior pulmonary veins were identified. To avoid misorientation, the posterior plane was initially extended along the long axis of the esophagus. The anterior and posterior sides of the posterior mediastinal lymph nodes were then both dissected. These lymph nodes were lifted in a sheet-like form and then cut along the borderline of the left mediastinal pleura. The right side of the mediastinal lymph nodes was then dissected. To avoid damaging the arch of the azygos vein, it was identified at the dorsal side of the right main bronchus prior to lymph node dissection. This procedure decreased the total operative time, total operative bleeding, and postoperative respiratory complications without reducing the quality of lymphadenectomy. In conclusion, the procedure described herein resulted in a good surgical view and safe en bloc mediastinal lymph node dissection. A detailed understanding of mediastinal 3D anatomy and specific pitfalls is crucial for the successful use of this approach.

Accessory V6 during thoracoscopic middle lobectomy: "an uncomfortable presence".

Key messageThe identification of the accessory vein draining the superior segment of the right lower lobe (accessory V6), during the posterior mediastinal lymph node dissection, can help avoid operative complications.

Laparoscopic transhiatal lymphadenectomy in the lower mediastinum for adenocarcinoma of the esophagogastric junction.

Laparoscopic transhiatal esophagogastrectomy is difficult because the lower mediastinum is so deeply located that the operative field is narrow and restricted by surrounding organs. Therefore, we performed lymphadenectomy with opening of the bilateral mediastinal pleura to maintain safety and obtain better exposure of lymph nodes and important organs. We will present our technique for laparoscopic lower mediastinal lymphadenectomy and reconstruction for cancer of the esophagogastric junction. Five abdominal ports were used. Retraction of the left lobe of the liver exposed the esophageal hiatus. A long, narrow gastric tube (3cm wide) was formed, and regional abdominal lymph nodes (No. 1, 2, 3a, 7, 8a, 9, 19, and 20) were resected. The diaphragmatic hiatus was widely split and the opened bilateral mediastinal pleura enabled better exposure for lymph node dissection and reconstruction. The level where the inferior vena cava passed through the diaphragm into the chest was used as a landmark to identify supradiaphragmatic (No. 111) and lower thoracic paraesophageal nodes (No. 110), which were completely retrieved with this procedure. The posterior mediastinal nodes (No. 112pulR, 112pulL, and 112aoA) were also retrieved with bilateral opening of the mediastinal pleura and dissection of the inferior pulmonary ligaments. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis. This approach enabled safe and accurate laparoscopic lower mediastinal nodal dissection. With the advantage of a narrow gastric tube, the good working space made tension-free anastomosis possible.

An Unexpected Diagnosis from ERCP for Ascending Cholangitis and Ampullary Mass: Extranodal Diffuse Large B-Cell Lymphoma

Diffuse large B cell lymphoma (DLBCL) is a histological subtype of non-Hodgkin lymphoma (NHL) that accounts for approximately 25% of all NHL cases. DLBCL usually presents as an enlarging mass, most commonly as nodal enlargement in the neck or axilla. Systemic B-symptoms are often reported, including severe night sweats, fever, and weight loss. Extranodal disease has been reported in up to 30 percent of cases, and the diagnosis of DLBCL is most commonly made with excisional lymph node biopsy. A 73 y/o F with a PMH of anemia presented with painless jaundice, abdominal pain, and weight loss. Physical was remarkable for jaundice and sclera icterus. Labs were positive for a WBC of 18.4, ALT of 73, AST of 57, ALKP of 786, total bilirubin of 3.7, direct bilirubin of 3.2, LDH of 247, and lipase of 859. US abdomen showed marked intra- and extra-hepatic biliary dilation, gallbladder distention, and abrupt termination of the CBD in the pancreatic head. CT scan confirmed biliary dilation with extensive peritoneal metastases or lymph nodes. A CA 19-9 level was 8894. An ERCP with cytology brushing and ampulla biopsy revealed an ampullary mass, a 1.5 cm dilated intrahepatic biliary tract, and a 5 cm distal and mid-common bile duct stricture beginning at the ampulla. A PET-CT scan was obtained, which showed abnormal uptake in posterior mediastinal, right axillary, right cardiophrenic, mesentery, and retroperitoneum lymph nodes, as well as in the right liver lobe and the pancreatic head and tail. Cytology brushing revealed atypical cells, and ampullary biopsy revealed DLBCL. This case of DLBCL was unique for multiple reasons. The initial symptoms of painless jaundice, abdominal pain, subjective fevers, and recent weight loss are not typical presenting symptoms of DLBCL; no rapidly enlargement mass or nodal enlargement of the neck and axilla was present. Her symptoms could have been explained solely by her ascending cholangitis. It was also remarkable how the clinical presentation resembled pancreatic adenocarcinoma but was actually due to a DLBCL with significant distant metastasis. This less common extranodal presentation would not have been expected given her complaints, as additional symptoms or a diagnosis would have presumably been previously suspected. Lastly, the majority of DLBCL diagnoses are made with excisional lymph node biopsy, but this case's diagnosis was interestingly made from an ampullary mass biopsy from an ERCP for ascending cholangitis.

Malignant Mesothelioma Pericardium

An observation of malignant mesothelioma of the pericardium is described. The tumour grew as papillomatous formations and thick plaques lining the inner surface of the pericardium with transition to the epicardium and the development of massive hemorrhagic pericarditis. The mixed nodular-plate form is histological close to adenocarcinoma. There were metastases in the pleura, paratracheal and posterior mediastinal lymph nodes. Clinically the disease ran a course with angina pectoris and simulated idiopathic myocarditis not confirmed histologically.

Oral, nasal and pharyngeal exposure to lipopolysaccharide causes a fetal inflammatory response in sheep.

BackgroundA fetal inflammatory response (FIR) in sheep can be induced by intraamniotic or selective exposure of the fetal lung or gut to lipopolysaccharide (LPS). The oral, nasal, and pharyngeal cavities (ONP) contain lymphoid tissue and epithelium that are in contact with the amniotic fluid. The ability of the ONP epithelium and lymphoid tissue to initiate a FIR is unknown.ObjectiveTo determine if FIR occurs after selective ONP exposure to LPS in fetal sheep.MethodsUsing fetal recovery surgery, we isolated ONP from the fetal lung, GI tract, and amniotic fluid by tracheal and esophageal ligation and with an occlusive glove fitted over the snout. LPS (5 mg) or saline was infused with 24 h Alzet pumps secured in the oral cavity (n = 7–8/group). Animals were delivered 1 or 6 days after initiation of the LPS or saline infusions.ResultsThe ONP exposure to LPS had time-dependent systemic inflammatory effects with changes in WBC in cord blood, an increase in posterior mediastinal lymph node weight at 6 days, and pro-inflammatory mRNA responses in the fetal plasma, lung, and liver. Compared to controls, the expression of surfactant protein A mRNA increased 1 and 6 days after ONP exposure to LPS.ConclusionONP exposure to LPS alone can induce a mild FIR with time-dependent inflammatory responses in remote fetal tissues not directly exposed to LPS.

Fluconazole treatment of intrauterine Candida albicans infection in fetal sheep.

Intrauterine Candida albicans infection causes severe fetal inflammatory responses and fetal injury in an ovine model. We hypothesized that intra-amniotic antifungal therapy with fluconazole would decrease the adverse fetal effects of intra-amniotic C. albicans in sheep. Sheep received an intra-amniotic injection of 10(7) colony-forming units C. albicans. After 2 d, animals were then randomized to: (i) intra-amniotic and fetal intraperitoneal saline with delivery after 24 h (3 d C. albicans group); (ii) intra-amniotic and fetal intraperitoneal injections of fluconazole with delivery after either 24 h (3 d C. albicans plus 1 d fluconazole group) or 72 h (5 d C. albicans plus 3 d fluconazole group). Controls received intra-amniotic injections of saline followed by intra-amniotic and fetal intraperitoneal fluconazole injections. Intra-amniotic C. albicans caused severe fetal inflammatory responses characterized by decreases in lymphocytes and platelets, an increase in posterior mediastinal lymph node weight and proinflammatory mRNA responses in the fetal lung, liver, and spleen. Fluconazole treatment temporarily decreased the pulmonary and chorioamnion inflammatory responses. The severe fetal inflammatory responses caused by intra-amniotic C. albicans infection were transiently decreased with fluconazole. A timely fetal delivery of antimicrobial agents may prevent fetal injury associated with intrauterine infection.

Middle and lower esophagectomy preceded by hand-assisted laparoscopic transhiatal approach for distal esophageal cancer

Respiratory morbidity is the most frequent complication following an esophagectomy. This study was designed to determine the efficacy of middle and lower esophagectomies preceded by the hand-assisted laparoscopic transhiatal approach (LTHA) regarding the perioperative outcomes of distal esophageal cancer. The esophageal hiatus was opened and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using the LTHA. Subsequently, a small thoracotomy (10 cm) was performed to divide the thoracic esophagus and allow middle mediastinal lymphadenectomy. Finally, reconstruction via the posterior mediastinal route with a gastric tube and anastomosis in the thoracic cavity were performed using a circular stapler. The treatment outcomes of 10 patients who underwent LTHA-preceded middle and lower esophagectomy were compared to those of 11 patients treated without prior LTHA (thoracotomy, 20 cm). The total operative time, the duration of one-lung ventilation and total operative blood loss were significantly decreased in the LTHA group. The number of resected lymph nodes did not differ significantly between the two groups. Postoperative respiratory complications occurred in 10.0% of patients treated with, and 36.3% of those treated without LTHA. The extubation time following surgery, the duration of thoracic drainage and postoperative hospital stay were significantly decreased by this method. In conclusion, middle and lower esophagectomies preceded by LTHA provides a good surgical view of the posterior mediastinum, markedly shortens the duration of one-lung ventilation and improves the perioperative outcome.

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand-assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA-preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.

NK Cells Regulate CD8+ T Cell Priming and Dendritic Cell Migration during Influenza A Infection by IFN-γ and Perforin-Dependent Mechanisms

An effective immune response against influenza A infection depends on the generation of virus-specific T cells. NK cells are one of the first-line defenses against influenza A infection. We set out to delineate the role of NK cells in T cell immunity using a murine model of influenza A infection with A/PR/8/34. We show that early T cell recruitment mainly occurs in the posterior mediastinal lymph node (pMLN). Depletion of NK cells significantly impaired both dendritic cell (DC) and T cell recruitment into the pMLN. A similar reduction of T cell recruitment was observed when migration was blocked by pertussis toxin, suggesting that migration of pulmonary NK cells and DCs regulates cell recruitment to the pMLN. T cell recruitment was dependent on IFN-γ, and transfer of IFN-γ-competent naive NK cells into IFN-γ-/- mice restored T cell recruitment, whereas IFN-γ-deficient NK cells failed to do so. In addition, NK cell depletion reduced the uptake and transport of influenza A virus by DCs, and significantly impaired the virus-specific T cell response. Both IFN-γ-/- and perforin-/- mice showed reduced viral Ag transport by DCs, suggesting that the ability of NK cells to influence virus transport depends on IFN-γ and perforin. In summary, our data suggest that NK cells play a critical role in the initiation and shaping of the T cell response after influenza A infection.

Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology

Thoracic surgeons are performing robotic resections for anterior mediastinal tumors; however, tumors located in the posterior and especially the inferior chest can be difficult to approach robotically. The objective of this study was to evaluate the efficacy of the robot for resection of these tumors. We performed a retrospective review of the evolution and outcomes of our surgical technique for inferior or posterior mediastinal pathology. During a 30-month period, 153 patients underwent robotic surgery for pathology in the mediastinum, located in the inferior or posterior mediastinum in 75 of these patients. The most common indications for surgery were posterior mediastinal mass or lymph node in 41 patients, esophageal or bronchogenic cysts in 11 patients, esophageal leiomyoma in 7 patients, and diaphragmatic elevation in 7 patients. The median tumor size was 4.4 cm, and the median length of stay was 1 day. One patient was converted to thoracotomy, but no patients were converted for bleeding. Morbidity occurred in 9 patients (12%), major in 1 patient (a delayed esophageal leak after epiphrenic diverticulectomy). There was no mortality. Technical improvements included using robotic arm 3 posteriorly for retraction, side-docking, or coming over the back of the patient for tumors inferior to the inferior pulmonary vein and for diaphragmatic plication and using the lateral decubitus position for extraction of tumors larger than 3 cm via an access port over the tenth rib above the diaphragmatic fibers. The robot affords safe access using a completely portal approach for resection of and surgical intervention for inferior and posterior chest pathology and for anterior tumors. Specific techniques can be used to improve the operation.

Posterior mediastinal lymph node dissection using the pneumomediastinum method for esophageal cancer

Although posterior mediastinal lymph node metastases are often observed in patients with esophageal cancer, their complete resection via a right thoracic approach is difficult and carries a risk of complications. We have developed a novel procedure for en-bloc dissection of the posterior mediastinal lymph nodes using the pneumomediastinum method. The patient was a 48-year-old female with middle thoracic esophageal cancer. A computed tomography scan showed a posterior mediastinal lymph node 1 cm in diameter. After division of the gastrosplenic ligament by hand-assisted laparoscopic surgery, the esophageal hiatus was opened, and carbon dioxide was introduced into the mediastinum. The anterior and left sides of the distal esophagus were separated, and a swollen posterior mediastinal lymph node was detected. Subsequently, the adventitia of the thoracic aorta was exposed, and the posterior side of the lymph node was separated. While lifting these nodes like a membrane, we cut them along the border of the left mediastinal pleura. Histopathological examination revealed a single squamous cell carcinoma metastasis in the resected lymph node. A good surgical view was obtained in our surgical procedure, and en-bloc dissection of the posterior mediastinal lymph nodes was safely performed.

Lung CD103+ Dendritic Cells Efficiently Transport Influenza Virus to the Lymph Node and Load Viral Antigen onto MHC Class I for Presentation to CD8 T Cells

The uptake, transport, and presentation of Ags by lung dendritic cells (DCs) are central to the initiation of CD8 T cell responses against respiratory viruses. Although several studies have demonstrated a critical role of CD11b(low/neg)CD103(+) DCs for the initiation of cytotoxic T cell responses against the influenza virus, the underlying mechanisms for its potent ability to prime CD8 T cells remain poorly understood. Using a novel approach of fluorescent lipophilic dye-labeled influenza virus, we demonstrate that CD11b(low/neg)CD103(+) DCs are the dominant lung DC population transporting influenza virus to the posterior mediastinal lymph node as early as 20 h postinfection. By contrast, CD11b(high)CD103(neg) DCs, although more efficient for taking up the virus within the lung, migrate poorly to the lymph node and remain in the lung to produce proinflammatory cytokines instead. CD11b(low/neg)CD103(+) DCs efficiently load viral peptide onto MHC class I complexes and therefore uniquely possess the capacity to potently induce proliferation of naive CD8 T cells. In addition, the peptide transporters TAP1 and TAP2 are constitutively expressed at higher levels in CD11b(low/neg)CD103(+) DCs, providing, to our knowledge, the first evidence of a distinct regulation of the Ag-processing pathway in these cells. Collectively, these results show that CD11b(low/neg)CD103(+) DCs are functionally specialized for the transport of Ag from the lung to the lymph node and also for efficient processing and presentation of viral Ags to CD8 T cells.

Pulmonary and systemic inflammatory responses to intra-amniotic IL-1α in fetal sheep

Clinical and epidemiological studies implicate IL-1 as an important mediator of perinatal inflammation. We tested the hypothesis that intra-amniotic IL-1α would induce pulmonary and systemic fetal inflammatory responses. Sheep with singleton fetuses were given an intra-amniotic injection of recombinant sheep IL-1α (100 μg) and were delivered 1, 3, or 7 days later, at 124 ± 1 days gestation ( n=5–8/group). A separate group of sheep were given two intra-amniotic IL-1α injections (100 μg dose each): 7 days and again 1 day prior to delivery. IL-1α induced a robust increase in monocytes, neutrophils, lymphocytes, and IL-8 protein in bronchoalveolar lavage fluid. H2O2secretion was increased in inflammatory cells isolated from lungs of IL-1α-exposed lambs upon LPS challenge in vitro compared with control monocytes. T lymphocytes were recruited to the lung. IL-1β, cyclooxygenase-1, and cyclooxygenase-2 mRNA expression increased in the lung 1 day after intra-amniotic IL-1α exposure. Lung volumes increased 7 days after intra-amniotic IL-1α exposure, with minimal anatomic changes in air space morphology. The weight of the posterior mediastinal lymph node draining the lung and the gastrointestinal tract doubled, inducible nitric oxide synthase (NOSII)-positive cells increased, and Foxp3-positive T-regulatory lymphocytes decreased in the lymph node after IL-1α exposure. In the blood, neutrophil counts and plasma haptoglobin increased after IL-1α exposure. Compared with a single exposure, exposure to intra-amniotic IL-1α 7 days and again 1 day before delivery had a variable effect (increases in some inflammatory markers, but not pulmonary cytokines). IL-1α is a potent mediator of the fetal inflammatory response syndrome.

Translocation of Intratracheally Instilled Multiwall Carbon Nanotubes to Lung-Associated Lymph Nodes in Rats

In order to assess the extrapulmonary effects of multiwall carbon nanotubes (MWCNT), deposition of MWCNT and histopathologic changes in lung-associated lymph nodes (LALN) were examined in MWCNT-administered rats. At the age of 13 wk, male F344 rats were intratracheally instilled with MWCNT at a dose of 0 (vehicle), 40 or 160 μg/rat. The rats were sacrificed on Day 1, 7, 28 or 91 after instillation and light microscopic examinations were performed on LALN tissues. MWCNT was translocated to right and left posterior mediastinal lymph nodes and parathymic lymph nodes. Deposition of MWCNT was greater in the posterior mediastinal lymph node than in the parathymic lymph node, and the amount of MWCNT deposited in these two lymph nodes increased gradually and dose-dependently with time. MWCNT was phagocytosed by nodal macrophages, and some of the MWCNT-laden macrophages were aggregated. Transmission electron microscopic (TEM) observation confirmed the presence of MWCNT fibers with a characteristic multi-walled cylindrical structure.

Inflammation in fetal sheep from intra-amniotic injection of Ureaplasma parvum

Bronchopulmonary dysplasia is associated with chorioamnionitis and fetal lung inflammation. Ureaplasma species are the bacteria most frequently isolated from chorioamnionitis. Very chronic ureaplasma colonization of amniotic fluid causes low-grade lung inflammation and functional lung maturation in fetal sheep. Less is known about shorter exposures of the fetal lung. Therefore, we hypothesized that ureaplasmas would cause an acute inflammatory response that would alter lung development. Singleton ovine fetuses received intra-amniotic Ureaplasma parvum serovar 3 or control media at 110, 117, or 121 days and were delivered at 124 days gestational age (term = 150 days). Inflammation was assessed by 1) cell counts in bronchoalveolar lavage fluid (BALF), and 2) cytokine mRNA measurements, immunohistochemistry, and flow cytometry for inflammatory cells and elastin and α-smooth muscle actin (α-SMA) staining in lung tissue. Neutrophils were increased in BALF 3 days after exposure to ureaplasmas (P = 0.01). Myeloperoxidase-positive cells increased after 3 days (P = 0.03), and major histocompatibility complex (MHC) class II-positive cells increased after 14 days of ureaplasma exposure (P = 0.001). PU.1 (macrophage marker)- or CD3 (T lymphocyte marker)-positive cells were not induced by ureaplasmas. CD3-positive cells in the posterior mediastinal lymph node increased in ureaplasma-exposed animals at 3, 7, and 14 days (P = 0.002). Focal elastin depositions decreased in alveolar septa at 14 days (P = 0.002), whereas α-SMA increased in arteries and bronchioli. U. parvum induced a mild acute inflammatory response and changed elastin and α-SMA deposition in the lung, which may affect lung structure and subsequent development.

Utilização conjunta de mediastinoscopia cervical e videotoracoscopia para a avaliação linfática mediastinal em pacientes com carcinoma de pulmão não-pequenas células

To evaluate the efficacy of the joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the sampling of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC) and candidates for pulmonary resection. Sixty-two patients diagnosed with NSCLC were submitted to cervical mediastinoscopy and video-assisted thoracoscopy. The samples obtained (from paratracheal chains, anterior and posterior subcarinal chains, paraesophageal chains and pulmonary ligament) were submitted to frozen section analysis. The following variables were also evaluated: age; gender; weight loss; diagnostic method; tomographic findings; histological type; staging; and location and size of the primary tumor. In 11 patients, mediastinoscopy showed no involvement of the subcarinal chain, whereas such involvement was identified when video-assisted thoracoscopy was used: positive predictive value = 88.89% (95% CI: 51.75-99.72); negative predictive value = 94.34% (95% CI: 84.34-98.82); prevalence = 17.74% (95% CI: 9.2-29.53); sensitivity = 72.73% (95% CI: 39.03-93.98); and specificity = 98.77% (95% CI: 93.31-99.97). In 60% of the patients with involvement of the posterior subcarinal chain, the primary tumor was in the right inferior lobe. (p = 0.029) The joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the evaluation of posterior mediastinal lymph nodes proved to be an efficacious method. When there is no access to posterior chains by means of ultrasound with transbronchial or transesophageal biopsy, which dispenses with general anesthesia, this should be the method of choice for the correct evaluation of mediastinal lymph nodes in patients with NSCLC.

Modulation of fetal inflammatory response on exposure to lipopolysaccharide by chorioamnion, lung, or gut in sheep

We hypothesized that fetal lipopolysaccharide exposures to the chorioamnion, lung, or gut would induce distinct systemic inflammatory responses. Groups of 5-7 time-mated ewes were used to surgically isolate the fetal respiratory and the gastrointestinal systems from the amniotic compartment. Outcomes were assessed at 124 days gestational age, 2 days and 7 days after lipopolysaccharide (10 mg, Escherichia coli 055:B5) or saline solution infusions into the fetal airways or amniotic fluid. Lipopolysaccharide induced systemic inflammatory changes in all groups in the blood, lung, liver, and thymic lymphocytes. Changes in lymphocytes in the posterior mediastinal lymph node draining lung and gut, occurred only after direct contact of lipopolysaccharide with the fetal lung or gut. Fetal systemic inflammatory responses occurred after chorioamnion, lung, or gut exposures to lipopolysaccharide. The organ responses differed based on route of the fetal exposure.

Esophageal stenosis caused by T0 lung cancer with lymph node metastasis: a case report

T0 lung cancer is an intrathoracic tumor with an unknown primary site that is diagnosed as originating from lung tissue by histological examination. A 52-year-old man presented with esophageal stenosis. Esophagogastroscopy revealed severe stenosis of the upper esophagus with normal mucosa. Chest computed tomography showed a mass adjacent to the azygos vein and right main bronchus, and another mass in the posterior mediastinum that compressed the right main bronchus. Initially, we diagnosed esophageal cancer with mediastinal lymph node metastasis. The patient died 24 months after starting chemotherapy. At autopsy, lung cancer was diagnosed by histological examination and immunostaining for cytokeratin 7, cytokeratin 20, and thyroid transcription factor-1 (TTF-1), so the final diagnosis was T0 lung adenocarcinoma with metastases to the middle and posterior mediastinum. This is the first report of T0 lung cancer causing esophageal stenosis. We should consider T0 lung cancer with posterior mediastinal lymph node metastasis in patients with esophageal stenosis.

Accuracy of Endoscopic Ultrasound (EUS), Endobronchial Ultrasound (EBUS), and Bronchoscopy (TBNA) Guided Fine Needle Aspiration (FNA) in Patients with Enlarged Anterior vs. Posterior Mediastinal Lymph Nodes

Accuracy of Endoscopic Ultrasound (EUS), Endobronchial Ultrasound (EBUS), and Bronchoscopy (TBNA) Guided Fine Needle Aspiration (FNA) in Patients with Enlarged Anterior vs. Posterior Mediastinal Lymph Nodes