Subcarinal Nodes Research Articles

RARE COMPLICATION OF BILATERAL BRONCHOESOPHAGEAL FISTULAS DUE TO INVASIVE MUCORMYCOSIS AFTER RENAL TRANSPLANTATION

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchoesophageal fistula (BEF) is a rare pathological connection between the esophagus and bronchi. Most are acquired due to esophageal or lung cancer. A small subset is caused by opportunistic infections in the immunocompromised. To our knowledge, this is the first case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. CASE PRESENTATION: 67 year old male with hypertension, diabetes, ESRD status post kidney transplant one month prior presents with two weeks of dysphagia, cough, and fatigue. Initial labs were significant for leukocytosis. Computed Tomography (CT) of the chest showed nonspecific pulmonary nodules and a mediastinal mass contiguous with the esophagus concerning for malignancy. EGD revealed an esophageal ulcer that was biopsied. Flexible bronchoscopy with bronchoalveolar lavage and EBUS of subcarinal lymph node was also obtained. Over the course of 72 hours, patient’s clinical status deteriorated. His oxygen requirements increased from nasal canula to high flow in a matter of hours and was ultimately intubated due to hypoxic respiratory failure. After intubation, patient had persistent air leak and remained hypoxic despite being on 100% FiO2. His ET tube was upsized from 7.5mm to 8.5mm due to concern for tracheomalacia. At this time, BAL cultures and esophageal cultures grew mucor. Amphotericin B was initiated. Repeat chest CT showed possible BEFs. Bedside bronchoscopy revealed bilateral white exudate at the level of the right and left mainstem bronchi. Gas bubbles from the esophagus were visible, confirming the bilateral BEFs. During this time patient developed septic shock requiring multiple pressors and persistent hypoxia despite maximal ventilatory settings. Cardiothoracic surgery team offered last-resort surgery including total esophagectomy and lobectomy with reconstruction of BEFs. However, given the extremely high mortality risk, the family declined. The patient passed away shortly after. DISCUSSION: Invasive mucormycosis is a rare, opportunistic fungal infection that presents in immunocompromised patients with underlying diabetes mellitus. Rhino-orbital-cerebral and pulmonary infections are the most common sources. Diagnosis can be made by tissue histopathology with culture confirmation. Due to its aggressive nature, local invasion often leads to multi-organ dysfunction. BEFs are extremely rare complications of invasive mucormycosis. Unfortunately, even with aggressive anti-fungal and surgical intervention, invasive mucormycosis carries extremely high mortality rate. CONCLUSIONS: To our knowledge, this is the first reported case of bilateral bronchoesophageal fistulas due to invasive mucormycosis in an immunocompromised patient. Our EGD and bronchoscopy images illustrate the aggressive nature of this fungi. Due to its high mortality rate, early detection, anti-fungal therapy, and surgical debridement are critical. Reference #1: Lee et al. Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report. Journal of Medical Case Reports (2016) 10:195 DISCLOSURES: No relevant relationships by Dafang Chen, source=Web Response No relevant relationships by Keith Killu, source=Web Response No relevant relationships by Brett Lindgren, source=Web Response No relevant relationships by Neha Mehta, source=Web Response

TRIPLE THREAT: A CASE OF MULTIPLE PRIMARY LUNG CANCERS

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Multiple primary lung cancers (MPLC) are a rare occurrence and have 2 forms – synchronous (sMPLC) and metachronous (mMPLC). The sMPLCs are physically distinct with different histological subtypes. If they are the same subtype, they must be in different lobes of the lung, originating from carcinoma in situ, and no tumor in common lymphatics and extrapulmonary metastases. The mMPLCs tumors must be histologically different or if they are histologically identical, there must be a >2 year cancer free interval, originate from carcinoma in situ, and second cancer must be in a different lobe or lung with no carcinoma in the common lymphatics and no extrapulmonary metastases. mMPLC is common and secondary to treatment of initial lesions. Tobacco smoke may also create a “field effect” in which multicentric lung cancers manifest more frequently. CASE PRESENTATION: A 66-year-old female presented for follow up of sMPLC Stage IB left upper lobe adenocarcinoma/Stage IA right middle lobe squamous cell carcinoma. Patient was treated in 2015 via left upper lobectomy and right middle lobe pulmonary wedge resection. Patient history includes 40-pack-years of smoking, COPD, and continued smoking after treatment of prior sMPLC. Surveillance chest CT showed increase in size of subcarinal lymph node and right lymph node conglomerate encasing the right upper lobe pulmonary artery, consistent with metastasis. Fine needle aspiration of level 4R lymph nodes revealed cells clusters with nuclear molding, high nuclear to cytoplasmic ratio, inconspicuous nuclei, minimal cytoplasm, and crush artifacts. Immunohistochemically tumor cells were positive for TTF-1 and synaptophysin, and negative for P40 – confirming diagnosis of small cell carcinoma. DISCUSSION: Small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are known to be linked with tobacco, creating a “field effect” that promotes the possibility of MPLCs. NSCLC include adenocarcinoma and squamous cell carcinoma (SCC). SCLC and NSCLC are differentiated based on morphology and immunohistochemical staining, the results of which confirmed diagnosis of small cell carcinoma and thus qualified as mMPLC in our case. Treatment of mMPLC is often surgical resection, however, feasibility must be assessed based on pulmonary reserve. Limited resections should be attempted in all cases as segmentectomies have similar outcomes to lobectomies in terms of recurrence-free survival, notably in tumors under 3 cm. CONCLUSIONS: In patients with a history of MPLC associated with smoking, physicians should be cognizant of additional malignancies different from the original lesion subtype. Biopsy and histopathology are the gold standard for diagnosis. Surgery is the standard treatment in MPLC, but clinicians should assess for sufficient pulmonary reserve to ensure viability. Reference #1: Chen C, Huang X, Peng M, Liu W, Yu F, Wang X. Multiple primary lung cancer: a rising challenge. Journal of thoracic disease. 2019; 11(Suppl 4):S523-S536. Reference #2: Chen TF, Xie CY, Rao BY, et al. Surgical treatment to multiple primary lung cancer patients: a systematic review and meta-analysis. BMC surgery. 2019; 19(1):185. Reference #3: Jiang L, He J, Shi X, et al. Prognosis of synchronous and metachronous multiple primary lung cancers: systematic review and meta-analysis. Lung cancer (Amsterdam, Netherlands). 2015; 87(3):303-10. DISCLOSURES: No relevant relationships by jayanth keshavamurthy, source=Web Response No relevant relationships by Diana Kozman, source=Web Response No relevant relationships by Samantha Mattox, source=Web Response No relevant relationships by Rohit Munagala, source=Web Response No relevant relationships by Nikhil Patel, source=Web Response No relevant relationships by Kanwar Singh, source=Web Response No relevant relationships by Asad Ullah, source=Web Response

Predictive factors of cough after uniportal video-assisted thoracoscopic pulmonary resection.

BackgroundCough is one of the shared complications after lung surgery. In this study, a prospective analysis was conducted for exploring the risk factors of persistent cough after uniportal video-assisted thoracoscopic pulmonary resection.MethodsOne hundred thirty-five patients with pulmonary nodules who underwent surgical treatment in the same surgical group from November 2019 to January 2020 were enrolled in this prospective study. The severity of cough and its impact on patients’ quality of life before and after surgery were assessed by the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), and postoperative cough was tested by the cough visual analog scale (VAS) and cough symptom score (CSS). Risk factors of cough after pulmonary resection (CAP) were determined by univariate and multivariate logistic regression analysis.ResultsThe incidence of postoperative cough was 24.4% (33 of 135 patients). Univariate analysis showed that gender (female), the surgical site (upper right), the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, length of hospitalization contributed to the development of CAP resection. Multivariate logistic regression analysis showed that the resection (lobectomy) (OR 3.590, 95% CI: 0.637–20.300, P=0.017), subcarinal lymph node dissection (OR 4.420, 95% CI: 1.342–14.554, P=0.001), postoperative acid reflux (OR 13.55, 95% CI: 3.186–57.633, P<0.001) and duration of anesthesia (over 153 minutes, OR 0.987, 95% CI: 0.978–0.997, P=0.011) were independent risk factors for postoperative cough.ConclusionsThe application of uniportal video-assisted thoracoscopic techniques to several types of lung surgery are conducive to enhanced recovery after surgery (ERAS). Postoperative cough is related to an ocean of factors, the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, and duration of anesthesia (over 153 minutes) are independent high-risk factors for CAP resection.Trial registrationThis study was registered on ClinicalTrials.gov (NCT04204148).

PULMONARY ACTINOMYCOSIS PRESENTING AS A SUBCARINAL MASS IN A HEALTHY FEMALE

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary actinomycosis, a rare chronic infection, is often misdiagnosed due to non-specific presentation. Here we present a case of a woman initially treated for aspiration pneumonia and histoplasmosis and was eventually found to have pulmonary actinomycosis on biopsy. CASE PRESENTATION: A healthy 38-year-old woman, 35-weeks-pregnant, was admitted for chest pain. Computerized tomography (CT) of the chest revealed a 4 cm subcarinal mass adjacent to the esophagus. Endobronchial ultrasound revealed multiple enlarged heterogeneous subcarinal lymph nodes. Transbronchial needle aspiration was negative for malignancy. The patient had an aspiration event 2 weeks prior to admission and completed a 14 day course of clindamycin. The mass significantly regressed radiographically after treatment. Upon follow-up, histoplasma antibody titer was positive at 1:32 (normal < 1:8) and she was started on a 3 month course of Itraconazole. Three months after discharge, she was readmitted for stabbing chest pain. CT chest re-demonstrated the subcarinal mass. Transbronchial needle aspiration specimens grew Actinomyces on tissue cultures. She was treated with a 4 month course of amoxicillin with complete resolution of symptoms and subcarinal mass on imaging. DISCUSSION: Actinomycosis is a slowly progressive granulomatous disease caused by actinomyces, a Gram–positive, filamentous microaerophilic bacterium. This bacteria normally colonizes the mouth and colon. Pulmonary actinomycosis is believed to be a result of inhalation or aspiration of oropharyngeal or upper gastrointestinal materials, and account for 15% of all actinomycosis cases. The clinical presentation, laboratory tests and radiological findings of pulmonary actinomycosis are non-specific, resulting in misdiagnosis with other chronic suppurative lung diseases and/or malignancies [1]. The infection can occur at all ages, with higher incidences in patients with poor oral hygiene, alcohol abuse disorder and underlying respiratory disorders. It starts as an acute inflammation followed by a chronic indolent phase with necrosis, fibrosis and pulmonary cavitation, and can progress to invasion of the pleura and chest wall [2]. There are no guidelines regarding the appropriate duration or route of antibiotic treatment; penicillin G for 2–6 weeks followed by oral penicillin or amoxicillin for 6-12 months, based on clinical and radiological response, has been the most common treatment regimen [3]. CONCLUSIONS: A high index of suspicion is required in order to diagnose pulmonary actinomycosis. Clinicians must be aware of its chronic and persistent presentation if left untreated, as early diagnosis will prevent significant physical and psychological morbidity. Reference #1: Farrokh D, Rezaitalab F, Bakhshoudeh B. Pulmonary actinomycosis with endobronchial involvement: a case report and literature review. Tanaffos. 2014; 13(1):52-6. Reference #2: Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Eur Respir J. 2003; 21(3):545-51. Reference #3: Choi J, Koh WJ, Kim TS, et al. Optimal duration of IV and oral antibiotics in the treatment of thoracic actinomycosis. Chest. 2005; 128(4):2211-7. DISCLOSURES: No relevant relationships by Violeta Alvarez-Retamales, source=Web Response No relevant relationships by Moses Hayrabedian, source=Web Response No relevant relationships by Jessica Moja, source=Web Response No relevant relationships by Suhayb Ranjha, source=Web Response

A CASE OF FATAL SEPTIC SHOCK IN SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) ASSOCIATED WITH BACTERIAL INFECTION IN THE ICU SETTING

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: HLH is a rare systemic inflammatory disease with a high rate of mortality. Early diagnosis and urgent intervention are therefore crucial for survival. Primary HLH is mostly seen in children and is caused by an underlying genetic mutation. Secondary HLH is a rare clinical condition, and its underlying pathophysiology isn’t well studied, but common triggers include underlying infections, malignancies, and autoimmune diseases. We present a case of an 80 yo F presenting with altered mental status (AMS) and fever progressing to septic shock. CASE PRESENTATION: 80 yo F from Bangladesh with PMH of HTN, Asthma, Afib, CVA admitted with worsening AMS for 3 months. Urine culture grew E.coli. Chest X-ray revealed bilateral pneumonia. She was started on antibiotics. Labs on presentation were notable for pancytopenia, requiring transfusion of blood products, ferritin >9900, Total Bilirubin/Direct/ALKP/ALT/AST - 20.4/16.3/857/808/3485. HIV, Hep A, B, C negative with unremarkable right upper quadrant ultrasound. CT chest showing mediastinal lymphadenopathy with the largest subcarinal node of 2.5 cm. Despite aggressive treatment, the patient developed septic shock. Her hemodynamic status deteriorated requiring mechanical ventilation and vasopressors. Bone marrow biopsy (BMP) was considered to rule out underlying hematologic disorder given mediastinal lymphadenopathy and bicytopenia. The patient expired before the biopsy results were reported. BMP confirmed the diagnosis of HLH showing histiocytes with hemophagocytosis. DISCUSSION: Secondary HLH can be triggered by infections, autoimmune diseases and malignancies, with the majority of cases occurring in ICU going underdiagnosed and carrying a poor prognosis with a high mortality rate. Manifestation varies between individual cases and It can present with a combination of various symptoms and signs. Secondary HLH is difficult to identify as it can mimic septic shock with progressive multiorgan failure. HLH 2004 diagnostic criteria require 5/8 findings (Table 1). Modified criteria are useful as it’s common for a patient with HLH to exhibit only 3-4/8. Retrospective studies have identified infections as common precipitating factors, with one study showing bacterial organisms to be the predominant trigger among infectious agents, and another one showing viral infection as a more common provoking factor. The mainstay of treatment involves immuno/myelosuppressive agents. CONCLUSIONS: Secondary HLH is a multisystem disorder caused by uncontrolled immune activation. Although big prospective studies for data analysis of diagnostic modalities and prognostic factors are lacking, a high index of suspicion for HLH should be maintained for adults presenting with the above-mentioned manifestations. Further understanding and refined diagnostic criteria are important for early diagnosis and implementing disease-modifying therapies for this life-threatening syndrome. Reference #1: Raschke RA1, Garcia-Orr R2. Hemophagocytic lymphohistiocytosis: a potentially underrecognized association with systemic inflammatory response syndrome, severe sepsis, and septic shock in adults. Chest. 2011 Oct;140(4):933-938. Reference #2: Jae-Ho Yoon, Sung-Soo Park, Young-Woo Jeon, Sung-Eun Lee, Byung-Sik Cho, Ki-Seong Eom, Yoo-Jin Kim, Hee-Je Kim, Seok Lee, Chang-Ki Min, Seok-Goo Cho, and Jong Wook Lee. Treatment outcomes and prognostic factors in adult patients with secondary hemophagocytic lymphohistiocytosis not associated with malignancy. Chest. 2011 Oct;140(4):933-938. Reference #3: Sameer A Parikh, Prashant Kapoor, Louis Letendre, Shaji Kumar, Alexandra P Wolanskyj. Prognostic Factors and Outcomes of Adults With Hemophagocytic Lymphohistiocytosis. Mayo Clinic Proceedings 2014, 89 (4): 484-92 DISCLOSURES: No relevant relationships by Mariam Agladze, source=Web Response No relevant relationships by Theo Trandafirescu, source=Web Response

Metastatic Patterns of Mediastinal Lymph Nodes in Small-Size Non-small Cell Lung Cancer (T1b).

Background: Lymph node metastasis (LNM) status is critical to the treatment. Fewer studies has focused on LNM in patients with small-size non-small cell lung cancer (NSCLC). This study aims to investigate clinicopathological characteristics associated with skip N2 (SN2) and non-skip N2 (NSN2) metastasis, and their metastatic patterns in NSCLC with tumor size of 1–2 cm.Methods: We reviewed the records of NSCLC patients with tumor size of 1–2 cm who underwent lobectomy with systematic lymph node dissection (LND) between January 2013 and June 2019. Clinical, radiographical, and pathological characteristics were compared among N1, SN2, and NSN2 groups. Metastatic patterns of mediastinal lymph node were analyzed based on final pathology.Results: A total of 63 NSCLC patients with tumor size of 1–2 cm were staged as pN2, including 25 (39.7%) SN2 and 38 (60.3%) NSN2. The incidence rates of SN2 and NSN2 were 2.8% (25/884) and 4.3% (38/884), respectively. For all clinicopathological characteristics, no significant difference was observed among the groups of N1, SN2, and NSN2. For the tumor located in each lobe, specific nodal drainage stations were identified: 2R/4R for right upper lobe; 2R/4R and subcarinal node (#7) for right middle lobe and right lower lobe; 4L and subaortic node (#5) for left upper lobe; #7 for left lower lobe. However, there were still a few patients (10.9%, 5/46) had the involvement of lower zone for tumors of upper lobe and the involvement of upper zone for lower lobe.Conclusions: SN2 occurs frequently in patients with small-size NSCLC. Whether lobe-specific selective LND is suitable for all small-size patients deserves more studies to confirm. Surgeons should be more careful when performing selective LND for tumors located in the lower and upper lobes.

EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial.

Endobronchial Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B-FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches. We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS-TBNA or EUS-B-FNA (50 to each group). Co-Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups. Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS-TBNA 46/50; 92% and EUS-B-FNA 48/50;96%, P=0.4) and diagnostic aspirates (EBUS-TBNA 38/50; 76% and EUS-B-FNA 36/50;74%, P=0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS-B-FNA approach. Procedure duration was significantly shorter with EUS-B-FNA [18.1(14.4) minutes versus 16.4 (49.6) minutes, P<0.001]. Minor complications occurred in one patient in the EBUS-TBNA group and none in the EUS-B-FNA group. During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS-B-FNA as compared with EBUS-TBNA provides greater patient comfort with a similar diagnostic yield.

THE STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF VISCERALES LYMPH NODES IN THE HUMAN OF OLD AGE

The problem of age-related involution of the structures of the immune system is now becoming more and more urgent. The aim of this study is the structural and functional characteristics of the visceral lymph nodes of an elderly person. Using immune morphological methods, the structure and cellular composition of the subcarinal and mesenteric lymph nodes of an elderly person were studied. A pronounced development of fibrous connective tissue is shown, which leads to fragmentation of the parenchyma of the nodes and a reduction in the area of the cortex. In the cortex, small lymphoid nodules and a narrow para-cortical zone are revealed. In lymphoid nodules, the absence of light centers with dividing and poorly differentiated lymphocytes and a high concentration of mature CD20 B-lymphocytes are noted. In the para-cortical zone, CD4 T-helpers are not detected. In all structural components of the lymph node, Ki67-positive cells are absent, which indicates the extinction of lymphocyte-poietic function, which is due to the replacement of the reticular tissue of the microenvironment with fibrous connective tissue and the absence of CD4 T-lymphocytes, which regulate the reactions of cellular and humoral immunity. Destruction of the reticular stroma in the sinus system, which is a biological filter, leads to impaired lymph purification function.

Mediastinal lymphadenectomy under laparoscopic assisted single-port inflatable mediastinoscopy through left neck approach.

Minimally invasive esophagectomy (MIE) has been developed for decades. However, conventional MIE requires transthoracic surgery, which can increase the risk of many perioperative cardiopulmonary complications. Therefore, mediastinoscopy-assisted transhiatal esophagectomy has been proposed, but the traditional surgical methods have shortcomings, such as unclear vision, especially during the dissection of mediastinal lymph nodes (LNs). A new approach for mediastinal lymphadenectomy under single-port inflatable mediastinoscopy with one left-neck incision is proposed. There are three difficulties in this procedure. (I) LNs along the left recurrent laryngeal nerve (RLN). After establishing pneumomediastinum, esophagectomy is performed over the aortic arch to the level of the lower edge of the left main bronchus, and lymphadenectomy along the left RLN is also accomplished during this process. (II) LNs along the right RLN. At the level of the lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, instruments are used to access the right RLN. Lymphadenectomy of up to 2 cm can be accomplished at the upper edge of the RSA. (III) Subcarinal LNs. Between the trachea and esophagus, the left and right main bronchi are exposed along the trailing edge of the trachea down to the carina, and lymphadenectomy can be performed here. The surgical procedure described here in detail is the first mediastinal lymphadenectomy under mediastinoscopy with one single left-neck incision.

Correlation between clinicopathological parameters of lung adenocarcinoma and lymph node metastasis

Abstract Objective The aim of the study was to study the correlation between the clinicopathological parameters of lung adenocarcinoma and lymph node metastasis and identify the risk factors of lymph node metastasis. Methods The data of 258 patients with postoperative lung adenocarcinoma (mainly based on their pathological data) were collected and analyzed, and their basic information was counted. Results Maximum tumor diameter was found to be an independent risk factor for lymph node metastasis. The larger the maximum diameter of the tumor in patients with lung adenocarcinoma, the higher the likelihood of lymph node metastasis. Solid predominant adenocarcinoma with mucin production is as an independent risk factor for superior mediastinal and subcarinal lymph node metastasis. Primary adenocarcinomas in the lower lobe of the lung may have a higher rate of lymph node metastasis than those in the upper lobe. Conclusion The known pathological subtypes of lung adenocarcinoma can be used for the prediction of lymph node metastasis in various regions and guide the dissection of lymph nodes that would improve patients' prognosis.

Standard procedures in nonoperating room anesthesia.

This article provides an overview of standard procedures currently performed in nonoperating room anesthesia (NORA) and highlights anesthetic implications. Novel noninvasive interventional procedures remain on the rise, accelerating demand for anesthesia support outside the conventional operating room. The field of interventional oncology has introduced a variety of effective minimally invasive therapies making interventional radiology gain a major role in the management of cancer. Technical innovation brings newer ablative and embolotherapy techniques into practice. Flexible bronchoscopy has replaced rigid bronchoscopy for many diagnostic and therapeutic indications. Endobronchial ultrasonography now allows sampling of mediastinal, paratracheal, or subcarinal lymph nodes rendering more invasive procedures such as mediastinoscopy unnecessary. Similarly, endoscopic ultrasonosgraphy currently plays a central position in the management of gastrointestinal disease. Sophisticated catheter techniques for ablating cardiac arrhythmias have become state of the art; Watchman procedure gaining position in the prevention of stroke resulting from atrial fibrillation. NORA is a rapidly evolving field in anesthesia. Employing new technology to treat a wide variety of diseases brings new challenges to the anesthesiologist. Better understanding of emerging interventional techniques is key to safe practice and allows the anesthesia expert to be at the forefront of this swiftly expanding multidisciplinary arena.

AB0439 LUNG FINDINGS IN PATIENTS WITH PRIMARY SJOGREN’S SYNDROME

Background:Sjogren’s syndrome (SS) is a systemic, autoimmune disease and can affect many organs and systems.Objectives:In this study, we planned to present the lung findings of primary SS (pSS) patients who are being followed in our outpatient clinic.Methods:Chest radiographs and thorax CTs of 151 patients who were admitted to the rheumatology outpatient clinic between 2004 and 2017 and diagnosed as pSS according to the classification criteria of the American-European consensus group Sjogren’s syndrome were retrospectively scanned.Results:In our study, 97% of pSS patients were female and 3% were male and the mean age was 56 ± 12 years, disease duration was 10.5 ± 5 years.It was observed dry eye in 86% of patients, dry mouth in 88%, parotitis in 17%, arthritis in 29%, vasculitis in 4%, neuropathy in 6%, myositis in 1%, lymphadenopathy in 29% (LAP), and 20% of patients had Raynaud phenomenon. In 50% of the patients, chest radiography was normal, and there were no respiratory complaints. Thorax CT was requested due to suspicious appearance on 50% chest x-ray.According to CT findings, 23% had nodules in the lung, nodule sizes were less than 1 cm, and patients were followed up for an increase in size. Hiler and subcarinal lymph nodes were present in 6% of patients and their sizes was ranged from 5 mm to 15 mm. Bronchoscopy was performed for two patients due to mediastinal LAP. Biopsy results were evaluated as reactive changes.Interstitial lung disease (ILD) findings were present in 16 patients. (69% NSIP, 25% LIP, 6% UIP). All patients with ILD received steroid therapy. Two patients received 6 cycles of cyclophosphamide treatment for active alveolitis and azathioprine (AZA) was used in maintenance therapy. Due to ILD, one patient was receiving rituksimab, one patient was receiving mycophenolate mofetil, while nine patients were using AZA.It was found bronchiectasis in 3% of patients, emphysema in 5%, sequelae fibrotic changes in 13%, and 1% patients had thickening of the pleura. One patient was diagnosed with hypersensitivity pneumonia and two patients had lung cancer (Table-1).There was a smoking history in 21% of the patients. There was a significant relationship between smoking and development of emphysema and malignancy. The relationship between smoking and lung cancer development could not be assessed due to the absence of lung cancer in the non-smoking group (Table-2).Conclusion:Lung findings are detected in 9-12% of patients in pSS, which can increase to 75% with the use of tomography, pulmonary function tests and bronchoscopy.Since pSS has a wide spectrum from airway disease or interstitial lung disease to BALT lymphoma lung involvement of the disease has been emphasized.

Usefulness of combined endobronchial and endoscopic ultrasound-guided needle aspiration in the diagnosis of sarcoidosis: a prospective, multicenter trial

Needle biopsy of enlarged lymph nodes is an accepted method for the diagnostic workup of sarcoidosis, but the optimal endosonography‑guided approach is yet to be determined. The aim of our study was to assess the relative diagnostic yield of combined ultrasound‑guided needle aspiration (CUS‑b‑NA), which includes endobronchial ultrasound‑guided transbronchial needle aspiration (EBUS‑TBNA) with endoscopic ultrasound fine‑needle aspiration (EUS‑b‑FNA), as well as the role of the cell block (CB) technique and lymph node localization in the diagnostic workup of sarcoidosis. This was a prospective multicenter study including consecutive patients with clinical suspicion of stage I or II sarcoidosis. CUS‑b‑NA with smears and CB technique were performed in the whole study group. If a biopsy result was not conclusive, an invasive diagnostic workup and a 6-month follow‑up were scheduled. Out of 77 screened patients, 54 signed written consent and 50 were enrolled for the final analysis. The overall sensitivity of EBUS‑TBNA, EUS‑b‑FNA, and CUS‑b‑NA was 76.6%, 70.2%, and 91.7%, respectively. There were no differences between EBUS‑TBNA and EUS‑b‑FNA (P = 0.52) but CUS‑b‑NA had a higher diagnostic yield (P = 0.005 and P = 0.001, respectively). Adding the CB method to smear technique (P = 0.008) and biopsy of the subcarinal lymph nodes increased the diagnostic yield (P = 0.001). Conclusions: The diagnostic yield of CUS‑b‑NA is higher than that of endosonographic techniques alone in the diagnostic workup of stage I and II sarcoidosis. The preparation of cytological material including CB and the choice of the subcarinal lymph node station for the biopsy increase the diagnostic efficacy.

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.

Is lobe specific lymph node dissection adequate for cN0\u20131 non-small cell lung cancer?

PurposeThis study aims to explore whether lobe specific lymph node dissection (LND) is adequate for cN0–1 non-small cell lung cancer (NSCLC) or not.MethodsAmong 5613 cN0–1 NSCLC patients, 394 cases (7.0%) with pN2 were enrolled and the distribution of mediastinal lymph node metastasis was analyzed. The included patients were divided into the non-lobe specific lymph node metastasis (NLSLNM) group and the lobe specific lymph node metastasis (LSLNM) group. The clinicopathological characteristics were compared between two groups and multivariable analysis was performed to find independent factors predicting NLSLNM.ResultsThe incidence of pN2 cases deserved serious attention. The proportion of upper zone lymph node metastases was not rare in right (55.0%) and left (35.7%) lower lobe tumors. The proportion of subcarinal zone lymph node involvement was also high in right (21.8%) and left (25.8%) upper lobe tumors. Multivariable analysis showed that elevated carcinoembryonic antigen (CEA) level (P = 0.034), right lower lobe (RLL) tumors (P = 0.022) and station 11 involvement (P = 0.030) were independent risk factors for NLSLNM.ConclusionSystematic LND seems to be superior to lobe specific LND in the assessment of lymph node status and high CEA level, RLL tumors and station 11 involvement are predictors for NLSLNM.

Uniportal Thoracoscopic McKeown Esophagectomy.

We performed the technique of uniportal thoracoscopic McKeown esophagectomy. The incision was located in the fourth intercostal space on the right axillary midline. The right recurrent laryngeal nerve lymph nodes were dissected. Four hemlocks were applied to clamp the proximal and distal ends of the aortic arch. The esophagus was suspended with purse-string at the level of the azygos vein arch to assist the dissection of the left recurrent laryngeal nerve lymph nodes. A silk thread was drawn out from the incision in order to remove the subcarinal lymph nodes. A thoracic drainage tube was placed at the back of the incision at the end.

An NRAS mutation in primary malignant melanoma of the lung: a case report

BackgroundPrimary malignant melanoma of the lung (PML) is extremely rare. No precursor lesions of PML have been identified, and little is known about the genetic mutations associated with the disease. Typically, 15–20% of malignant melanomas possess NRAS gene mutations, but no cases of NRAS-mutated PML have been reported in the English literature. We present a case of PML involving an NRAS mutation.Case presentationClinical summaryA 74-year-old Japanese female presented with worsening dyspnea and was admitted to hospital. Computed tomography (CT) revealed a right lung (S10) mass and pleural dissemination. Cytology of the pleural effusion in the right lung was performed, and malignant melanoma or clear cell sarcoma was suspected. A dermatological examination and gallium scintigraphy were conducted to determine the primary tumor site, but no suspicious lesions, expect for the right lung mass, were found. After admission, CT showed complicating bilateral pneumonia, and an antibiotic drug was administered, but the pleural effusion got worse. About 2 weeks later, the patient died of respiratory failure and cardiac arrest. An autopsy was performed to determine the histological diagnosis.Autopsy findingsA 26x15x20-mm black and pale yellow mass was found in the right lower lobe. Many disseminated nodules were found in the right lobe. The tumor had invaded the right diaphragm. Subcarinal lymph node metastasis was also detected. Immunohistochemically, the tumor cells exhibited positivity for S-100 and HMB45 staining. The patient was diagnosed with malignant melanoma. Sanger sequencing of the tumor detected an NRAS mutation.ConclusionsWe found an NRAS D54N mutation in PML, which has not been reported previously anywhere in the world. Previous reports indicated that most cases of PML can be classified into the triple-wild-type, but BRAF mutation status was only analyzed in a few cases. We should analyze the mutation patterns of PML to determine whether any subtypes other than the triple-wild-type exist. PML might be a form of de novo cancer.

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>

Subcarinal lymph node: is it better evaluated by endobronchial ultrasound or endoscopic ultrasound?

Introduction Mediastinal endosonography-guided aspiration has anteceded surgical staging as the step of choice for the diagnosis of mediastinal tissue disorders. Aim This study aimed to evaluate the diagnostic efficacy and safety of either endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA) or transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-FNA-B/E) in evaluating and biopsying the subcarinal region (station 7). Patients and methods Seventy-seven patients with enlarged subcarinal lymph nodes ‘short axis more than or equal to 1 cm’ as a preliminary station were divided randomly into two groups: group I included patients evaluated by EBUS-TBNA and group II included patients evaluated by EUS-FNA-B/E. The specimens were examined using the Rapid On Site Evaluation technique and then confirmed by the final histopathological and immunohistochemical evaluation. Results Fifty-one men and 26 women, mean±SD age (51.12±10.15 years), were divided into two groups. In group I, the mean±SD time spent during the procedure was 32.49±9.48 min, the mean±SD number of aspirations was 3.07±0.72, and the mean±SD O2 saturation was 83.59±4.34%; therefore, the mean±SD supplementary oxygen was 3.78±1.04 l/min. However, in group II, these values were 22.05±6.39 min, 2.00±0.67, 91.66±3.09%, and 1.71±1.19 l/min, respectively, with a significant difference. The sensitivity, negative predictive value, and diagnostic accuracy of EBUS-TBNA in diagnosing malignant lesions were 88, 67, and 90%, which were significantly less than those of EUS-FNA-B/E: 93, 86, and 95%, respectively. No severe complications were encountered with the use of both techniques. Conclusion The study recommends the usage of EUS-FNA-B/E than EBUS-TBNA in evaluating and biopsying the subcarinal region because of its better tolerability, higher diagnostic yield, and lower complication rate.

Selective lymph node dissection for clinical T1 stage non-small cell lung cancer.

BackgroundMore and more pulmonary nodules are detected by CT scan, and postoperative pathology reveals many lymph nodes without metastasis. The purpose of this study was to investigate the characteristics of T1 stage lymph node metastasis in non-small cell lung cancer (NSCLC) and to explore the indications for selective lymph node dissection (SLND).MethodsA total of 841 patients with stage T1 of NSCLC were performed lobectomy and systemic lymphadenectomy. We analyzed the types of lymph node metastases and the relationship between lymph node metastasis and pulmonary pleural invasion, thrombosis of vascular carcinoma and tumor size in all patients.ResultsAmong them, 257 cases of tumor in the right upper lobe (RUL) and 186 cases in the left upper lobe (LUL), and no metastasis was found in the inferior mediastinal lymph nodes. Tumor metastases occurred in subcarinal lymph nodes, with hilar and/or mediastinal lymph node metastasis. Among the 171 cases with right lower lobe (RLL) tumors and the 151 cases with left lower lobe (LLL) tumors, patients with superior lymph node metastasis were all associated with hilar and/or subcarinal lymph node metastasis. Among the 76 cases with right middle lobe (RML) tumors, no metastasis with inferior mediastinal lymph node was observed. Lymph node metastasis is much easier in patients with pulmonary pleural invasion or thrombosis of vascular cancer. The larger the tumor diameter, the greater the possibility of lymph node metastasis.ConclusionsSLND is a feasible treatment for clinical T1 stage NSCLC under the guidance of intraoperative frozen results of lobe-specific lymph nodes.