Posterior Mediastinal Nodes Research Articles

Posterior mediastinal melanoma causing severe dysphagia: A case report

IntroductionWe describe an original case of progressive severe dysphagia caused by a posterior mediastinal metastatic melanoma of unknown origin. To the best of our knowledge, such an event has never been described before in the literature.Case presentationA progressive severe dysphagia case is reported induced by a melanoma of unknown origin (metastatic to a posterior mediastinal lymph node). At the time of diagnosis, the lesion appeared as a large posterior mediastinal mass mimicking a neurogenic tumour with oesophageal involvement. After complete resection, pathological assessment of the tumour by immunohistochemistry was consistent with nodal metastatic melanoma.ConclusionThis report of a posterior mediastinal lymph node melanoma is unique. The nodal origin is definitely unusual: a primary melanoma should always be carefully ruled out. In fact no other evidence, a part from the absence of the tumour elsewhere, can support the diagnosis of a primary nodal melanoma.

Long‐term Results after Dissection of Positive Thoracic Lymph Nodes in Patients with Esophageal Squamous Cell Carcinoma

Although thoracic lymph node metastasis in patients with thoracic esophageal squamous cell carcinoma (SCC) has been reported to be a negative risk factor for long-term survival, only a few studies have evaluated the clinicopathologic difference between the impact of metastasis to the paraesophageal lymph nodes and to the nonparaesophageal lymph nodes. The purpose of this study was to evaluate surgical outcome after the clearance of metastatic thoracic lymph nodes. Retrospectively reviewed were 164 consecutive patients with thoracic esophageal SCC who had not had preoperative treatment and underwent surgery from 1980 to 2005 and were found to have thoracic lymph node metastases. Of these patients, 83 underwent surgery from 1980 to 1994 and 81 from 1995 to 2005. Univariate and multivariate analyses were performed to evaluate the impact of nonparaesophageal lymph node metastasis on survival. Univariate analysis revealed that T3/T4 tumors and the presence of nonparaesophageal node metastases were associated with only a 20% overall five-year survival rate. The overall five-year survival for the most recent period was significantly better than for the former period (42% vs. 13%, p<0.01). Based on a multivariate analysis of prognostic impact of each nonparaesophageal node, the presence of metastatic subcarinal and/or posterior mediastinal nodes was an independent risk factor for reduced survival. Surgical outcome for patients with thoracic esophageal cancer and metastatic thoracic lymph nodes has improved during the last 25 years. Although postoperative chemotherapy might improve survival, the presence of T3/T4 tumors and/or metastatic nonparaesophageal nodes were unfavorable factors for survival.

TBNA Versus TENA in the Diagnosis and Staging of Bronchogenic Carcinoma: “A Comparative Study”

Transbronchial needle aspiration (TBNA) through the flexible bronchoscope still remains underused and a poorly understood procedure. Recently, transesophageal needle aspiration (TENA) under ultrasound guidance has been used to help stage the posterior mediastinal lymph nodes. TBNA and TENA have both been used for the diagnosis and staging of bronchogenic carcinoma. This study is to compare the efficacy and complimentary potential of these techniques. Retrospective review and comparison of a series of consecutive patients. Tertiary referral hospital. Nineteen adult patients with mediastinal adenopathy. TBNA and TENA. Specific diagnostic yield of TBNA compared with TENA in adenopathy of the left paratracheal and subcarinal locations. Out of 19 patients, specific diagnosis was made in 15 patients (79%) by TBNA and in 13 patients (68%) by TENA. TBNA and TENA were both positive in 5 patients. TBNA alone was positive in 7 patients and TENA alone was positive in 1 patient. In the comparative study group lymph node stations 7, 8, and 5 (L4), there were no significant differences in the diagnostic yield of TBNA and TENA. Small sample size. TBNA remains highly effective for sampling mediastinal lymph node stations. TENA is limited for subcarinal, paraesophageal, and aorto-pulmonary window lymph nodes, which are adjacent to the esophagus. Adding TENA to TBNA did not increase the diagnostic yield even in these subgroups of lymph nodes in our study.

Transesophageal EUS and EUS-FNA for Lung Cancer

Transesophageal EUS and EUS-FNA for Lung Cancer

Solitary Nodal Recurrence in the Dorsal Area of the Thoracic Aorta After a Curative Resection of Esophageal Cancer: Report of Two Cases

Although locoregional recurrence is often observed in the cervicothoracic area even after an esophagectomy with three-field lymph node dissection (3FL), recurrence in the mediastinal lymph nodes is relatively rare. We experienced two cases of solitary recurrence in a posterior mediastinal node (No 112-ao) after a curative resection for thoracic esophageal cancer. The lymph node recurrence was located in the connective tissue adjacent to the left posterior wall of the thoracic aorta, and thus could not have been removed by the conventional approach of an esophagectomy through a right thoracotomy. These two patients underwent surgical removal of the tumor through left thoracotomy, and survived for 5 years and 1 year without recurrence, respectively. Because the rate of metastasis in this area appears to be low, it is not always necessary to perform complete nodal dissection of the left side of the descending aorta at the initial surgery in cases of thoracic esophageal cancer. However, our experience suggests the importance of periodic computed tomography scans to check for any nodal recurrence in this area, since a surgical resection may be effective when the recurrence is detected as a solitary metastasis.

Gemella Morbillorum Associated Mediastinitis following EUS-FNA of a Posterior Mediastinal Lymph Node

Background: Only a few reports of mediastinitis after EUS-FNA of mediastinal reports have been reported in the literature. We present the first reported case of Gemella morbillorum mediastinitis following EUS-FNA of a posterior mediastinal lymph node (LN). Methods: Case report using retrospective review of medical records. Results: A 78-year-old man with a history of a T3N0M0 adenocarcinoma of the colon removed four years earlier underwent routine surveillance PET scan and was found to have intense activity corresponding to a 1cm diameter aorto-pulmonary window LN which was suspicious for malignancy. The patient had a history of non-insulin dependent diabetes and hypertension. Trans-esophageal EUS-FNA (5 passes, 22G needle) of the LN revealed benign lymphoid tissue. No antibiotic prophylaxis was given. 5 days later, he presented with retrosternal chest pain, fever, chills and leukocytosis. A chest CT scan demonstrated inflammatory changes consistent with mediastinitis adjacent to the enlarged lymph node which had undergone EUS-FNA. Blood cultures grew Gamella morbillorum which was sensitive to penicillin and ceftriaxone. The patient was treated with ceftriaxone and metronidazole. Clinical symptoms resolved, and blood cultures were negative. A follow-up CT scan, 2 weeks post-discharge, revealed persistent posterior mediastinal inflammation with spondylitis and diskitis at the T6-T7 level. Conclusions: 1) Mediastinitis can occur after trans-esophageal EUS/FNA of posterior mediastinal lymph nodes. 2) Gemella morbillorum should be considered in the list of bacteria that may be associated with infective complications following EUS-FNA. 3) Endosonographers should keep a high index of suspicion for infection following EUS/FNA of mediastinal lymph nodes, and not only cystic lesions. 4) Prophylactic antibiotics may be considered in selected patients undergoing trans-esophageal EUS/FNA.

The Celestin tube in the palliation of carcinoma of the oesophagus and cardia.

A series of 105 patients with dysphagia due to inoperable carcinoma of the oesophagus or cardia of the stomach, and 11 patients with dysphagia secondary to malignant medistinal nodes, was treated by intubation with a Celestin tube. The hospital mortality was high but 81 patients left hospital and 29 were still alive at 6 months. The prognosis for those with dysphagia due to malignant posterior mediastinal nodes was very poor, with no survivors at 6 months. Oesophageal perforation was a serious operative complication, with a hospital mortality of 83 per cent. Chest and wound infections were the most common postoperative complications occurring in 28 and 20 per cent of the patients, respectively. The restoration of swallowing was satisfactory in the majority of survivors although readmission with a blocked or displaced tube was not uncommon.

Improving the Inaccuracies of Clinical Staging of Patients with NSCLC: A Prospective Trial

Clinical stage affects the care of patients with nonsmall cell lung cancer. This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy. There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes). Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning.

Endoscopic Ultrasound-Guided Fine Needle Aspiration in Patients with Lung Cancer and Prior Negative Mediastinoscopy

Background: Abnormal mediastinal lymph nodes (LNs) sampling is required prior to surgical resection in non-small cell lung cancer (NSCLC) patients. In patients with both anterior and posterior mediastinal LNs, the initial strategy to diagnose metastasis to ipsilateral (N2) or contralateral (N3) LNs remains unknown. Objectives: Our objectives were 1) To evaluate the yield of EUS-FNA in NSCLC patients with both anterior and posterior LNs that had prior negative mediastinoscopy. 2) To assess cost implications associated with alternative initial strategies: initial mediastinoscopy versus initial EUS-FNA. Methods: NSCLC patients first underwent thoracic CT, PET scan, and mediastinoscopy and then underwent EUS-FNA of the posterior mediastinal LNs. Reference standards included: thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging and/or long term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of a hypothetical cohort of NSCLC patients presenting with enlarged anterior and posterior mediastinal LNs. Results: There were thirty-five lung cancer patients (median age of 65 years, 80% male). Of the 35 NSCLC patients who had a prior negative mediastinoscopy, 13 patients (37.1%) (95% CI: 21.5–55.1) had malignant LNs. Lower lobe masses were more likely to have malignant LNs as compared to upper lobe masses (OR = 6.8; 95% CI: 1.2–42.7, P = 0.03). All patients with N2/N3 disease received initial chemotherapy and/or radiation. EUS-FNA yielded one false negative result and no false positives. Final diagnoses were confirmed by surgery in 16 patients (45.7%). Accuracy of EUS-FNA (98.1%; 95% CI: 89.9–100.0) was significantly higher than CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in an average costs per patient of $1,867 (SD ± 4308) while initial mediastinoscopy cost $12,900 (SD ± 4164). If initial EUS-FNA is utilized rather than initial mediastinoscopy, there would be an average cost saving of $11,033 per patient evaluated. Conclusions: In NSCLC patients with both anterior and posterior LNs, starting with EUS-FNA would obviate the need for mediastinoscopy in over one-third of patients. EUS-FNA is an outpatient procedure that is less invasive, safer and less costly than mediastinoscopy. These finding have major implications on resource utilization in NSCLC patients undergoing invasive tissue sampling for preoperative staging.

Complete Medical “Mediastinoscopy” Under Conscious Sedation Using Combined Endoscopic Ultrasound and Endobronchial Ultrasound

Background: Endoscopic ultrasound is effective in staging and FNA of lymph nodes in the posterior mediastinum but cannot visualize the anterior mediastinum. A prototype, small caliber linear array echoendoscope capable of real-time endobronchial ultrasound guided-FNA (Olympus Co., EBUS-FNA) has recently been developed to stage the anterior mediastinum. We hypothesized that combined EUS-EBUS-FNA would allow complete mediastinal staging in lung cancer patients and could be done safely under conscious sedation. Methods: Patients presenting with lung tumors and enlarged mediastinal lymph nodes underwent combined EUS-EBUS-FNA and bronchoscopy as indicated, all under a single conscious sedation with midazolam and meperidine. EBUS was performed by 2 pulmonologists. Three experience endosonographers performed EUS and assisted in the US interpretation of EBUS cases. Results: Twelve patients were found to have a total of 24 enlarged lymph nodes. EUS alone identified 8 (all lower mediastinum, celiac and AP window; 2 were malignant by FNA). EBUS alone identified 9 (5 pre-tracheal, 1 AP window, 3 hilar; 1 was malignant by FNA) and both procedures identified 8 (all subcarinal, 3 malignant by FNA by both procedures). EUS alone identified 1 enlarged (3 cm) adrenal gland (FNA: benign adenoma), 1 primary tumor (previous FNA positive by CT) and 1 pleural effusion (FNA negative). Bronchoscopy alone identified and FNA'd (negative) 1 tumor but no other lesions. Mean duration from sedation to completion of both procedures was 86 minutes (range 60-117) with mean sedation dose of midazolam, 8mg (5-10) and meperidine 116mg (15-175). No complications occurred. In 5 patients, the EUS examination was performed with both EBUS echoendoscope and the traditional (Olympus GF UCT130 or UCP130) echoendoscope. Both scopes were equally capable of imaging all posterior mediastinal lymph nodes, adrenal gland, celiac axis and left lobe of the liver. Conclusions: EUS and EBUS are highly complementary procedures which, in combination, appear to stage the entire mediastinum and relevant sub-diaphragmatic organs. The linear scanning EBUS scope is capable of performing both trans-esophageal and transbronchial ultrasound FNA, thus allowing single endoscope, single sedation mediastinal staging; a procedure that may be able to replace surgical staging of lung cancer.

Endoscopic Ultrasound-Guided Fine Needle Aspiration of Mediastinal Lymph Node in Patients With Suspected Lung Cancer After Positron Emission Tomography and Computed Tomography Scans

The treatment of patients with non-small cell lung cancer (NSCLC) depends on the stage. Positron emission and computed tomography (CT) scans can identify suspicious lymph nodes that require biopsy. We prospectively evaluated the yield and accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in sampling mediastinal lymph nodes and compared its accuracy to that of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and CT in staging NSCLC. A consecutive series of patients with suspicious nodes on PET or CT scan in the posterior mediastinal lymph node stations (#5, 7, 8, or 9) were prospectively evaluated by EUS-FNA. The reference standard included thoracotomy with complete lymphadenectomy in patients with lung cancer or if EUS-FNA was benign, repeat clinical imaging, or long-term follow-up. There were 104 patients (63 men) with 125 lesions (117 lymph nodes, 8 left adrenal glands) who underwent EUS-FNA. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 92.5%, 100%, 100%, 94%, and 97%, respectively. EUS-FNA was more accurate and had a higher positive predictive value than the PET or CT (p < 0.001) scan in confirming cancer in the posterior mediastinal lymph nodes. EUS-FNA documented metastatic cancer to the left adrenal in all 4 patients with advanced disease. No deaths resulted from EUS-FNA. One patient experienced self-limited stridor. EUS-FNA is a safe, accurate, and minimally invasive technique that improves the staging of patients with NSCLC. It is more accurate and has a higher predictive value than either the PET scan or CT scan for posterior mediastinal lymph nodes.

Impact of EUS-guided FNA of enlarged mediastinal lymph nodes on subsequent thoracic surgery rates

Background A histopathologic diagnosis of metastasis in enlarged mediastinal lymph nodes usually results in non-surgical management. Cytologic specimens obtained by EUS-guided FNA can be used to detect malignancy in posterior mediastinal lymph nodes. The purpose of this study was to determine the rate of thoracic surgery after EUS-guided FNA of enlarged mediastinal lymph nodes. Methods A prospective observational study of patients with enlarged posterior mediastinal lymphadenopathy who were referred for EUS-guided FNA. All patients were candidates for mediastinoscopy. Patients were followed for 12 months to determine the subsequent rate of mediastinoscopy or thoracotomy and the diagnostic accuracy of EUS-guided FNA. Results Evaluation of cytologic specimens obtained by EUS-guided FNA revealed malignancy in 23 of 59 (39%) patients. The overall rate of surgery was 22% (13/59): 95% CI[0.12, 0.35]. The surgery rate for patients with a positive cytologic result was 4% (1/23) compared with 33% (12/36) for those with a negative result ( p = 0.009). Of patients with CT findings of a peripheral lung mass plus mediastinal lymphadenopathy, 22 of 26 (42%) underwent surgery after EUS-guided FNA, compared with two of 33 (6%) of those with mediastinal lymphadenopathy alone ( p = 0.0009). For cytologic evaluation of specimens obtained by EUS-guided FNA, the overall sensitivity, specificity, and accuracy for the diagnosis of malignant lymphadenopathy were 96%, 100%, and 98%, respectively. Conclusions Few patients who undergo EUS-guided FNA of enlarged posterior mediastinal lymph nodes require subsequent thoracic surgery.

EUS-guided fine-needle aspiration in the mediastinum

The evaluation and management of esophageal and mediastinal disease has changed considerably since the introduction of EUS. EUS provides precise imaging of the histologic layers of the esophageal wall and surrounding mediastinal structures. EUS is now a well-established modality for the staging of a variety of GI and pancreaticobiliary malignancies. Furthermore, it has been reported to play an important role in the evaluation of mediastinal lesions and in the detection of metastasis to lymph nodes.1-9 Traditionally, the mediastinum has been evaluated by radiographic imaging such as CT and by invasive studies like bronchoscopy and mediastinoscopy. Evaluation of the mediastinum using EUS has been reported to be useful for a number of indications. Most notable is the assessment of enlarged lymph nodes that are detected by other imaging modalities such as CT or magnetic resonance imaging. Probably the most important indication for mediastinal imaging is the detection and/or staging of lung cancer. Documentation of lymph node involvement with metastatic disease is crucial in the staging and management of non-small cell lung cancer (NSCLC). The introduction of the curved linear array echoendoscope approximately 8 years ago led to the development of EUS-guided fine-needle aspiration (FNA), which is now becoming recognized as an integral part of endosonography. EUS-guided FNA has been reported to be a safe and effective approach for evaluation of lymph nodes and masses in the posterior mediastinum.10-13 Tissue diagnosis from these lesions has been difficult to obtain by conventional methods such as mediastinoscopy, which is an invasive and tedious procedure, or percutaneous CT-guided puncture, which has a low yield and increased risk, especially in the case of smaller lesions.14 The objectives of this article are twofold: to discuss the clinical utility of EUS and EUS-guided FNA biopsy for evaluating the mediastinum in benign and malignant disease processes including the detection of posterior mediastinal lymph node metastases in patients with NSCLC and to describe the technique for performing safe EUS-guided FNA biopsy in the mediastinum.

4466 Effectiveness of eus/fna for diagnosing lung cancer in a managed care setting.

Background: Trans-esophageal endoscopic ultrasound-guided fine needle aspiration (EUS/FNA) is an accurate method to diagnose malignant posterior mediastinal lymph nodes. Previous studies have shown the efficacy of EUS/FNA for lung cancer nodes in tertiary referral centers. The purpose of this study was to assess the effectiveness of EUS/FNA for diagnosing patients with mediastinal adenopathy in a managed care setting. Methods: Patients who received care from a large staff-model HMO and had CT findings of enlarged posterior mediastinal lymph nodes (LN) located adjacent to the esophagus were referred by a pulmonologist and thoracic surgeon for EUS/FNA. All patients were candidates for surgical biopsy (mediastinoscopy, thoracotomy, etc) if EUS/FNA were negative. Patients with prior EUS/FNA or recent chemotherapy were excluded. Data was prospectively collected with follow-up at 3-month intervals. Results: 44 patients underwent EUS/FNA (25 male/19 female, mean age 64). 82% had prior bronchoscopy. FNA was performed in 54 sites (43 LN, 9 masses, 3 other). Malignancy was diagnosed in 28/54 (52%) of FNA sites. There were 23 nonsmall cell lung cancer (NSCLC), 3 small cell lung cancers, and 2 lymphomas diagnosed. EUS/FNA made a new cancer diagnosis in 25/44 (57%) (95% CI: 42%,71%) patients. Cancer was diagnosed in 11% of patients before EUS/FNA, and in 68% of patients after EUS/FNA. 15/25 (60%) (95% CI: 41%, 79%) of patients with a final diagnosis of NSCLC had stage N2 nodes diagnosed. A thoracic surgical procedure was subsequently performed in 9/44 (20%) (95% CI: 68%,91%) of patients during a median follow-up of 6.5 months (1-14 months). There was one false negative LN FNA which was later diagnosed by repeat EUS/FNA as small cell carcinoma. The sensitivity was 96%, specificity 100%, and accuracy 98% for diagnosing malignant LNs. There were no complications. Conclusion: 1) EUS/FNA made a new diagnosis of lung cancer in 57% of patients. 2) EUS/FNA diagnosed malignant lymph nodes in 60% of patients with NSCLC, making surgical benefit unlikely. 3) Only 20% of EUS/FNA patients underwent subsequent thoracic surgery, compared to an expected rate of 100% if EUS/FNA were not performed. 4) In this managed care setting, EUS/FNA of selected patients with mediastinal adenopathy was an accurate, safe, minimally invasive method of diagnosing and staging malignancy, and resulted in patients undergoing fewer thoracic surgical procedures. This work was supported by a grant from the ASGE/ADHF.

4588 Endoscopic ultrasound as a first-line diagnostic and staging test after ct in patients with suspected or proven lung cancer: yield in 122 consecutive patients.

Background: 50% of lung cancer patients have mediastinal lymph node metastases. Proof of ipsilateral node (N2) or contralateral node (N3) involvement contraindictates surgery as primary treatment, but usually requires mediastinoscopy. EUS-guided fine needle aspiration (FNA) provides access to posterior mediastinal nodes and may therefore prevent mediastinoscopy and document surgically incurable disease. Aim: To verify the yield of EUS as a first-line diagnostic and staging modality in patients with suspected or proven lung cancer by CT and/or bronchoscopy. Methods: EUS-FNA was used as a first-line diagnostic and/or staging test in consecutive patients with suspected or proven lung cancer in whom CT showed mediastinal disease accessable for EUS-FNA. Results: 122 consecutive patients had disease that appeared amenable to EUS-FNA: 70 with suspected and 52 with proven lung cancer. Overall, EUS was attempted in 118 (97%) cases: 10 masses and 108 nodes (47% level 7 [AP window]; 32% level 5 [subcarina]; 15% levels 5 & 7; and 6% other node levels). There were no complications. A cytological diagnosis of cancer was obtained in 46/70 (69%) of suspected cancers. The yield for nodal staging was calculated on an "intent to stage" basis. Mediastinal node involvement was documented cytologically in 73/112 (60%) cases where staging was the aim: 37/112 (33%) N2 and 36/112 (32%) N3 nodes. See Table. Conclusions: 1) EUS has a high yield in patients with suspected or proven lung cancer with mediastinal disease by CT. 2) A cytological diagnosis of cancer is obtained in 2/3 patients with suspected cancer. 3) Cytological proof of mediastinal ipsilateral or contralateral disease is obtained in 2/3 patients.

The Lesions of Hepatic Fatty Cirrhosis in Sheep

During a natural outbreak of hepatic fatty cirrhosis (HFC) in western Texas, 500 2-6-year-old Rambouillet ewe sheep were sequentially studied to determine the pattern of lesion development. All sheep developed lesions of HFC. Grossly, changes first began in the subcapsular hepatic parenchyma along the porta hepatis and spread peripherally until, in the final stages of the disease, approximately 80% of the liver was affected. Ascites, hydropericardium, and acquired hepatic vascular shunts were present in sheep with severe HFC. Light microscopic lesions initially appeared as accumulations of fine lipid droplets in the cytoplasm of periacinar hepatocytes but, with time, involved all hepatocytes of the lobule. The fat vacuoles in the periacinar hepatocytes coalesced to form larger vacuoles; and after rupture of adjacent fat-laden hepatocytes, fatty cysts appeared. Fibrosis began in the periacinar zone associated with the ruptured fatty cysts and continued until there was widespread bridging periacinar fibrosis. Islands of regenerating hepatocytes were frequently sequestered within the bands of fibrous tissue. Characteristically, the hepatic and posterior mediastinal lymph nodes, lung, and spleen contain ceroid. No lesions of hepatic encephalopathy were found in any animal. HFC is a progressive, chronic disease of sheep, and the morphology of the hepatic lesions is similar to lipotrope-deficient forms of nutritional cirrhosis. These findings are discussed in relation to similar nutritional deficiencies and toxicoses in sheep.

Dysphagia due to mediastinal granulomas: Diagnosis with endoscopic ultrasonography

Background & Aims: Mediastinal granulomas due to histoplasmosis can cause dysphagia and can be difficult to diagnose. The aim of this study was to describe the endoscopic ultrasonography (EUS) findings of suspected mediastinal granulomas. Methods: Eleven patients with dysphagia were referred for EUS because endoscopy showed a midesophageal submucosal mass or stricture. Results: All patients had similar EUS findings of a large mass of matted, posterior mediastinal lymph nodes that were adherent to a focally thickened esophageal wall. The cause of the mediastinal granulomas was believed to be histoplasmosis because 3 of the patients had positive complement fixation titers of 1:32, 1 of whom had a surgical resection showing a caseating granuloma. The diagnosis of histoplasmosis mediastinal granulomas was also supported by the findings of lymph node calcification on EUS in 7 patients, the presence or development of midesophageal traction diverticula in 5 patients, and clinical improvement after oral antifungal drug therapy in 7 patients. No patient developed evidence of malignancy during a mean follow-up period of 20.5 months. Conclusions: Based on characteristic EUS findings, mediastinal granulomas are believed to occur in patients with dysphagia who have a midesophageal submucosal mass or stricture on endoscopy and who live in a highly endemic area for histoplasmosis.

Regional lymph drainage routes from the diaphragm in the rat

AbstractAbsorption from the peritoneal cavity by lymphatics of the diaphragm is of considerable surgical importance. The pattern of lymphatic drainage from the diaphragm of the rat, used as an experimental model, was studied following intraperitoneal injection of diluted India ink. Peritoneal absorption of ink was remarkably rapid. Within 1 minute, subperitoneal lymphatic lacunae filled with ink. The lacunae ran radially between muscular fibers of the diaphragm and were confined only to the muscular part of the diaphragm. The regional lymph drainage from the diaphragm was predominantly to the mediastinal lymph nodes (parathymic and posterior mediastinal nodes) by way of the retrosternal and intercosto‐paravertebral lymph trunks, and also to retroperitoneal lymph nodes (cisternal and renal nodes) by the retroperitoneal lymphatic trunks. These data indicate that the cranial drainage of lymph from the peritoneal cavity, mainly by way of the retrosternal lymphatic trunks, predominates over the caudal drainage route and thoracic duct; the intercosto‐paravertebral, mediastinal, and retroperitoneal lymphatic channels are only secondary pathways. Knowledge of these lymphatic routes may prove valuable clinically in peritoneal dialysis and in the prediction of the spread of the animal's own cells (e.g., lymphocytes and macrophages), of tumor cells and of bacteria from the peritoneal cavity. © 1994 Wiley‐Liss, Inc.

Preoperative staging of non-small cell lung cancer: transesophageal US-guided fine-needle aspiration biopsy of mediastinal lymph nodes.

To evaluate the usefulness of transesophageal real-time ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) in staging non-small cell lung carcinoma. Two patients (a 64-year-old man and a 48-year-old woman) with non-small cell lung carcinoma and mediastinal lymphadenopathy detected at computed tomography underwent preoperative evaluation with transesophageal real-time US-guided FNAB. Two aspirates were obtained from each patient. Diagnostic tissue from a contralateral posterior mediastinal lymph node was obtained from the first aspirate in each case. Neither patient experienced a complication as a result of this technique, and both were subsequently referred for palliative therapy in light of these findings. Real-time US-guided FNAB is useful in the preoperative staging of disease in selected patients with non-small cell lung cancer.

Hilar and mediastinal adenopathy in sarcoidosis as detected by computed tomography

CT of the chest was performed in 25 patients with chest radiographs suspicious for hilar or mediastinal adenopathy, who subsequently proved to have sarcoidosis. In each case, CT detected more extensive adenopathy than suspected on chest radiographs. Adenopathy greater than 1.0 cm was present in the right paratracheal and pretracheal regions in all cases. Adenopathy was also frequently seen in the hilar (92%), anteroposterior window (88%), subcarinal (64%), anterior mediastinal (48%), and posterior mediastinal (16%) lymph node groups. The adenopathy occurred in multiple and varying combinations without a consistent identifiable pattern suggestive of sarcoidosis. It is concluded that while CT detects adenopathy more consistently, it does not offer a clear advantage over chest radiography in confirming a diagnosis of mediastinal and hilar involvement by sarcoidosis.