Mediastinal Research Articles

FRI564 Thymic Hyperplasia In Graves' Disease: An Under-recognized Association

Abstract Disclosure: S. Nachum: None. A. Rivadeneira: None. K.N. Kobaly: None. Association of thymic hyperplasia (TH) with Graves’ disease (GD) is rare and underrecognized. In an era of increased diagnostic imaging, incidental findings of thymic masses in patients with GD may be increasingly identified and awareness of this association may reduce unnecessary interventions. We report three cases of GD with TH at presentation, one of which includes resolution of TH. CASE 1: 56 year-old man with unintentional weight loss, palpitations and eye discomfort was diagnosed with GD (TSH <0.015, FT4 4.47, TRAB 8.18, TSI 8.51). He had an incidental 3x3 cm anterior mediastinal mass on a chest CT. MRI chest suggested TH. Myasthenia gravis antibodies were negative. I-123 uptake and scan showed diffusely increased uptake within the thyroid gland and no increased uptake in the upper chest corresponding to mediastinal mass. Initiation of methimazole normalized thyroid function. CT chest at 9 months showed near resolution of the anterior mediastinal soft tissue density compatible with resolving TH. CASE 2: 23 year-old woman presented with insomnia, palpitations, and neck pain and was found to have GD (TSH <0.01, FT4 2.75, TRAB 9.16, TSI 8.84). CT neck obtained due to pain showed diffuse enlargement of the thyroid and a soft tissue density in the partially imaged superior mediastinum. Methimazole was started. Further evaluation of mass is pending. CASE 3: 35 year-old man presented with atrial fibrillation and was diagnosed with hyperthyroidism (TSH < 0.01, FT4 5.55). Tc-99m pertechnetate scan showed diffuse uptake consistent with GD. Methimazole was started. CT chest obtained due to concern for pulmonary embolism showed a 12.6 x 3.0 cm anterior mediastinal mass. HCG was undetectable. Further evaluation of mass is pending. Discussion: TH is thought to occur due to hormonal excess stimulating the thymic cortex and immunological mechanisms that result in formation of medullary lymphoid follicles.1 The incidence of TH in GD is unknown as diagnostic imaging is not routinely obtained. A study of thymic biopsies in patients undergoing thyroidectomy found 38% of patients with thyrotoxicosis had histological evidence of TH.2 This benign condition improves with treatment of GD, with decreased thymic size after 5-24 months of treatment with antithyroid drugs.3 In the absence of a discrete mass, invasion of other tissues or calcifications, repeat imaging after 6 months with regression of TH by 50% obviates the need for biopsy.1 Biopsy and thymectomy should be deferred when thyrotoxic due to risk of precipitating thyroid storm4 and be reconsidered if thymus fails to regress on repeat imaging. Additional guidance for observation is needed as the differential diagnosis for mediastinal mass includes diseases warranting more urgent diagnosis and intervention. Identification of high-risk patient characteristics or imaging findings may be of clinical utility in this circumstance. Presentation: Friday, June 16, 2023

SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia

Abstract Disclosure: S. Aslam: None. M. Asif: None. I. Nadeem: None. W.J. Khan: None. Background Goiter, most often, is first noticed as a visible neck mass; however, some patients may present with signs and symptoms of hypothyroidism, or hyperthyroidism. Retrosternal extension can cause compression of the trachea, esophagus, and jugular veins resulting in dysfunction of these viscera. CaseA 68-year-old male presented with SOB, and weakness for 5 days. He had SaO2 79% on room air requiring oxygen, RR 28/min, HR 78/min and Temp.101.6 F, BP 94/48 mmHg. The lung exam revealed bilateral rhonchi and coarse crypts. Minimal non-tender nodularity was noted on the thyroid palpation not previously noticed by the patient or his family. Chest x-ray showed bilateral airspace opacities. CT chest revealed a large upper mediastinal mass displacing the trachea and esophagus to the right, a nodule in the left lobe of thyroid, subcarinal and right hilar lymphadenopathy and bilateral dependent consolidative opacities suggesting aspiration pneumonia but no PE. A barium esophagogram showed a 7.5 cm mediastinal mass causing 50% narrowing and displacement of esophagus and compression with left sided deviation of trachea. A barium swallow study was done, and the patient was found to have aspiration with all administered food types due to an abnormal swallowing mechanism. The patient was advised NPO and placed on NG tube feeding to prevent further aspiration. The patient underwent bronchoscopy and EBUS from station 4 lymph node, the pathology of which did not show any malignant cells. However, due to high clinical suspicion of a malignant process, the patient underwent a CT-guided biopsy of the mediastinal mass that showed bland thyroid tissue. Ultrasound of thyroid revealed multiple right and left lobe nodules. TSH and free T4, and calcitonin were WNL. The patient's hypoxia and fever resolved after completion of the antibiotics including ceftriaxone and doxycycline and being nothing per oral within 7 days. Due to persistent dysphagia, he was placed on PEG tube feeding and discharged from the hospital to a nursing home. The patient underwent ultrasound-guided fine needle biopsy of 1 right-sided and 2 left-sided thyroid nodules that resulted as papillary thyroid cancer. He underwent a successful right-sided thoracotomy and removal of large sized thyroid mass. The patient is seeing endocrinology as an outpatient for radioactive iodine and hormone replacement therapy. Conclusion We treated a patient of follicular carcinoma who presented with extrathyroidal symptoms. Retrosternal or ectopic thyroid tumors can present as euthyroid state without obvious enlargement of the normal thyroid gland. A meticulous clinical evaluation should include the differential diagnosis of retrosternal goiter or ectopic thyroid with cancer when treating patients who preset with sign and symptoms concerning for mediastinal disease. Presentation Date: Saturday, June 17, 2023

Socioeconomic Factors Associated With Thymoma Survival in the United States

IntroductionThe effects of socioeconomic factors on patients diagnosed with thymomas have not been previously studied. We propose these factors have an important association with survival. Thymoma is the most common tumor of the anterior mediastinum. Compared to other neoplasms which can integrate different therapeutic approaches for treatment, the most effective therapy for local and locally advanced thymoma is complete surgical resection. This study aimed to elaborate on socioeconomic variables and their potential effects on the survival outcomes in patients diagnosed with thymoma. MethodsClinical data from the Surveillance, Epidemiology, and End Results 22 registry from 1975-2019 was used to define overall and cancer-specific survival of thymoma. The unadjusted analysis was followed by fitting a Cox proportional hazards model that included all variables assessed with Kaplan–Meier curves. An unadjusted Kaplan–Meier analysis was performed first comparing time to death by decade, age, race, ethnicity, sex, income, and region separately. The primary outcome was survival measured in months. ResultsWe identified 1821 patients aged 18 y or over from the Surveillance, Epidemiology, and End Results database with a thymoma diagnosis between the years 1975 and 2019. The demographic variables considered were age, race, ethnicity (Hispanic/non-Hispanic), sex (male/female), inflation-adjusted income in 2019 dollars, and community size. We observed a decrease in mortality from thymic neoplasm across the decades. For each subsequent year, mortality risk decreased by 3.5% (P <0.001). The mortality risk of older patients was significantly higher. Compared to the youngest group, the mortality risk was 52.8% higher in the 50-year-old to 65-year-old category (P = 0.021). The mortality risk was 339% times higher in the 65 + age group (P <0.001). Income may be associated with risk reduction. Patients making greater than $75,000 had a 40.1% lower mortality risk than those making less than $50,000 (P = 0.029). The survival rate categorized by race was similar between Blacks and Whites but tended to be higher for the Asian and Pacific Islander groups without reaching statistical significance (P = 0.12). ConclusionsMedical advancements have improved the overall thymoma survival in the past four decades. Yet, demographic, and socioeconomic factors such as age, income, and race may also play a role.

A Wolf in Sheep's Clothing - A Rare Case of an Angiosarcoma Arising from a Schwannoma in the Posterior Mediastinum: A Case Report

Introduction: Schwannoma is one of the benign tumors occurring in the posterior mediastinum. However, angiosarcoma is a malignant tumor of vascular origin and presents as an infiltrating mass. Primary angiosarcoma of the mediastinum is very rare. Few cases have been reported in the atrium, pulmonary vein, and lung and present with chest pain. Angiosarcoma arising from a benign tumor like a schwannoma is very rare; only a handful of cases have been reported in the literature. This case is presented for its rarity and awareness that even a schwannoma presenting as well-circumscribed mediastinal mass can harbor a life-threatening malignancy. Case Report: A 51-year-old male presented with chest pain, and on investigation, there was an extrapulmonary and posterior mediastinal mass in the left paravertebral region with a benign appearance and his serum tumor markers were normal. However, a needle biopsy showed evidence of an angiosarcoma. Hence, with these contradicting results, a surgical exploration was done and since it was well delineated was excised completely. Grossly, it was a well-circumscribed mass measuring 12.5 cm × 9.5 cm × 6.5 cm with a variegated appearance with pale–yellow and hemorrhagic areas. A diagnosis of an epithelioid angiosarcoma arising from a schwannoma was made by light microscopic and immunohistochemical findings. Conclusion: Epithelioid angiosarcoma is a rare malignant transformation occurring in a schwannoma. It can also have a deceptively benign appearance as in our case, and in any symptomatic long-standing posterior mediastinal schwannoma, this differential should be kept in mind when planning surgery and further treatment.

The Role of Radiation Therapy in the Management of Gray Zone Lymphoma.

Gray zone lymphoma (GZL) is a relatively rare disease predominantly affecting young adults with purportedly poor outcomes with current treatment approaches. The role of radiation therapy (RT) in the management of GZL is not well established. This is the largest study to report on the outcomes of GZL patients treated with and without RT. A retrospective review of 30 patients with GZL treated across 3 institutions from 2009 to 2021 was performed. Event-free survival (EFS) was defined from initiation of frontline chemotherapy (CHT) to disease progression/relapse, initiation of salvage therapy, or death. Local control (LC) was defined from RT start date to in-field recurrence. The median age was 32 (range: 18-86) years, and 16 (53%) patients had early stage (I-II) disease. Bulky mediastinal disease was present in 63% of patients, and the median tumor diameter was 10 (range: 1.5-18) cm. Patients received ABVD (20%), RCHOP (33%), or REPOCH (47%) as frontline CHT. Among 25 patients with interim PET/CT scan, there were 6 rapid early responders and 14 slow early responders (SER), with 2-year EFS of 33% and 24%, respectively (p = 0.13). After the completion of CHT, 15 (50%) patients achieved complete response (CR) and 10 (33%) achieved partial response (PR), with 2-year EFS of 46% and 10%, respectively (p = 0.004). RT was given to 9 patients in CR (n = 3) or in PR (n = 6). The median RT dose was 36 (30.6-48.6) Gy, at 1.8-2 Gy/fraction. Those receiving RT had bulkier disease at diagnosis (p = 0.049) and lower rates of CR following CHT (p = 0.03). After RT, 3/6 (50%) PR patients converted to CR. At a median follow-up of 4 years, the 2-year EFS was 26% for all patients, 33% for RT and 23% for noRT (p = 0.44). Among patients who did not receive upfront RT and experienced progression (n = 17), 16 (94%) relapsed in pre-existing sites. The 5-year OS was 80% for all patients, 88% for RT and 78% for no RT (p = 0.63). Patients who achieved PR to CHT and received RT had better 2-year EFS (17% vs 0%, p = 0.007) compared to patients who did not receive RT. Similarly, patients with SER who received RT had superior 2-year EFS (33% vs 13%, p = 0.038). Patients with bulky mediastinal disease had a 2-year EFS of 43% with RT and 11% without RT (p = 0.08). After 1st line treatment, 22 (73%) patients relapsed and 18 were successfully salvaged with a sustained CR. The most common salvage regimen involved high dose CHT followed by hematopoietic cell transplantation (HCT) (n = 15). RT was given for 7 patients in the relapsed/refractory setting (consolidative peri-HCT n = 4; definitive salvage n = 3) and 5 (71%) achieved a sustained CR. Among the 16 patients who received RT in the upfront (n = 9) or salvage (n = 7) setting, 3 patients experienced in-field recurrence translating to 2-year LC of 79%. GZL patients have high risk of relapse and maximal upfront combined modality therapy should be considered. RT provides good local control and improves EFS particularly for SER, PR, and bulky mediastinal disease.

Low Cellular Sclerosis of Anterior Mediastinum

Conducting a CT-guided interventional procedure involving retrosternal pleural hydro-dissection of the juxta-aortic anterior mediastinum under local anesthesia revealed a rare histopathological condition known as benign mediastinal sclerosis. This challenging CT-guided intervention within the anterior mediastinum is scarcely documented in the existing scientific literature. In this presentation, we share our case along with relevant clinical data. What makes this case distinctive is that the clinicians initially questioned the representativeness of the biopsy sample we obtained. Consequently, an additional sample was acquired through a highly invasive video-assisted mediastinoscopy procedure under intubation anesthesia. Remarkably, this second sample yielded the same histopathological result. Mediastinal sclerosis is an exceedingly rare condition, often referred to as the "burnt-out" stage of sclerosing mediastinitis. While infectious etiologies are frequently identified (Tab.1), the majority of cases remain idiopathic [23].

Long-Term Outcomes in a Phase II Study of Hypofractionated IGRT 60Gy/ 20F in Patients with Isolated Lymph Node Recurrence after Surgery for Esophageal Carcinoma

In oligo metastases in lymph node recurrence after surgery for esophageal cancer, since SBRT (BED>100 Gy10) to mediastinal and abdominal lymph node lesions was not an option due to toxicities in the organs at risk (OAR) such as vessels and gastrointestinal tract, we performed a prospective cohort study of hypofractionated IGRT for isolated lesions. The primary end-points of this study are disease specific survival (DSS) and late treatment toxicities. From 2011 to 2021, 60 Gy/20F/4-4.5wks (78 Gy10) hypofractionated IGRT was performed in a total ITT population of 70 patients after radical surgery (67 cases) and ESD (3 cases), who were diagnosed by CT/PET-CT as having solitary lymph node recurrence (62 cases) or up to 2 adjacent nodes (8 cases). The mean time from surgery to recurrence was 17.9 months (SD 18.1) with a mean age of 67.5 years (SD 9.3), and male to female ratio was 62:8. Pathological results showed that 63 patients (90%) had squamous cell carcinoma. The mean maximum diameter of lesions was 2.5 cm (SD; 1.1 cm). And 51 cases (73%) were treated with CRT concurrently using 5FU plus CDDP (FP), and the rest were treated with RT alone. Lymph node location was lower neck or upper mediastinum in 42 cases, middle and lower mediastinum in 16 cases, and abdomen in 12 cases, respectively. Treatment planning was performed by taking 4DCT fusing PET or MRI images. The Kaplan-Meier method and the Cox proportional hazards regression model were used for overall survival (OS), DSS, and progression free survival (PFS). The mean observation period was 38 months. Primary efficacy was CR in 45 cases (64%), but CR was maintained only in 29 cases (41%). Twenty-two of the 70 patients were relapse-free. OS were 53% and 34% at 2 and 5 years, DSS were 56% and 38% at 2 and 5 years, and PFS were 40% and 39% at 2 and 5 years, respectively. The site of first recurrence was the same or adjacent lymph nodes in 33 cases (47%) and distant metastases in 9 cases (13%). Number of tumors (1 vs. 2), age, and CRT were not significant prognostic factors for OS, DSS, or PFS. In a multivariate analysis, the time from surgery to recurrence ≥12 months was the only significant prognostic factor for PFS (p = 0.018, HR0.50). The same multivariate analysis showed that the only significant prognostic factor for DSS was the location of the recurrent lymph node in the neck and upper mediastinal regions (p = 0.009, HR 0.59). The only late adverse events of Grade 2 or higher were Grade 2 pleural effusion (little and transient) in 6 cases and Grade 2 radiation pneumonitis in 1 case. No acute adverse events were observed other than hematologic toxicity due to FP administration. In locally advanced esophageal cancer, a relatively reliable regional lymph node dissection is often performed, so there is still a chance to aim for cure in cases of solitary recurrence. We found that if the lesion is solitary, localized RT of about 60 Gy/20F/4-4.5 weeks with IGRT can achieve a long-term survival in 40% of patients without any significant adverse events.

Neurogenic tumours of the posterior mediastinum and differential diagnosis considerations.

The mediastinal compartment harbours vital organs and structures, including the heart, great vessels, major airways, and thymus. These structures are embedded in and associated with soft-tissue elements consisting of adipose and fibro-collagenous tissue in which soft-tissue tumours may develop. A detailed inventory of soft-tissue tumours that may be encountered in the mediastinum based on the WHO 2013 classification was published in 2015. In addition, several comprehensive reviews on mediastinal soft-tissue pathology are available, including reviews focusing specifically on a single tumour type. This review will focus on primary neurogenic and spindle cell tumours of the somatic soft tissue of the posterior mediastinum and provide a discussion of the pertinent differential diagnoses.

Single-Stage Surgical Treatment of Acute Type A Aortic Dissection and Blunt Abdominal Trauma: A Case Report.

A 53-year-old man suddenly developed chest and back pain while driving, resulting in an accident. Computed tomography revealed acute type A aortic dissection with malperfusion of the left lower extremity, retroperitoneal extravasation, hematoma in the anterior mediastinum, and ascites in the rectovesical pouch. Exploratory laparotomy before aortic repair revealed intestinal perforation and retroperitoneal bleeding, which were repaired, and an ascending aortic replacement was performed. Visceral trauma with active bleeding should be treated with priority, even if the need for systemic heparinization accompanies acute type A aortic dissection during surgery for aortic dissection.

A case of a thoracic duct cyst extending from the mediastinum to the cisterna chyli resected using bilateral thoracoscopic surgery in the prone position

BackgroundThoracic duct cysts are extremely rare mediastinal tumors. We report a case of a thoracic duct cyst extending from the caudal aspect of the left main bronchus to the left renal artery that was safely and completely resected via bilateral thoracoscopic surgery in the prone position.Case presentationA 77-year-old male was referred to our hospital for follow-up computed tomography (CT) of prostate cancer, which revealed a mediastinal tumor and fatty low-density along the posterior mediastinum of the para-aortic artery with a slightly high-density component. Magnetic resonance imaging revealed a T2-weighted image with high intensity. The preoperative radiological diagnosis was lipoma or well-differentiated liposarcoma. CT in the prone position suggested that the tumor could be resected from the thoracic cavity to the caudal side, and bilateral thoracoscopic surgery was performed in the prone position. Based on the surgical findings, the tumor was diagnosed as a thoracic duct cyst rather than a lipoma. Dissection around the thoracic duct cyst was performed using a vessel-sealing system to prevent leakage of the chyle, and reliable clipping was performed to resect the cisterna chyli. Histopathological examination revealed smooth muscle structures around the cyst, suggestive of a thoracic duct cyst. The diagnosis of a thoracic duct cyst was made based on a high triglyceride level of 1310 mg/dL on examination of the milky-white cyst fluid. The patient's postoperative course was uneventful, and he was discharged 4 days postoperatively. A CT scan performed 13 months after surgery showed no recurrence.ConclusionsA rare thoracic duct cyst extending from the mediastinum to the cisterna chyli was safely and completely resected using bilateral thoracoscopic surgery, with the patient in the prone position.

Thymoma: An Overview.

Thymomas are considered one of the most prevalent types of mediastinal epithelial tumors, which frequently develop in the anterior mediastinum. Due to their rarity, these tumors' nomenclature, classification, and staging are likely to be the subject of debate and argument for most expert pathologists. Furthermore, the significance of thymoma histologic classifications have been debated over the past twenty years. While certain advocates argue that staging at the time of diagnosis is more significant, others believe that histologic subtyping has a significant impact on how patients behave clinically. In this review, we will focus on some of the challenges that diagnostic surgical pathologists may experience while evaluating the histopathology of thymomas and staging these tumors. We will additionally glance over the clinical characteristics of these distinct tumors and the current management strategy.

Exéresis de timoma gigante adherido al pericardio y pulmón izquierdo

Thymoma is an uncommon condition characterized by being the most frequent neoplasm of the anterior mediastinum. It classically appears as a well-demarcated, lobulated tumor mass encapsulated by a fibrous capsule. A 46-year-old female was diagnosed with thymoma by aspiration biopsy. Surgery was performed through a median sternal incision. The left location of the tumor required the placement of the mammary artery retractor to achieve better exposure. The cancer was freed from adhesions to the pericardium, lung and left pleura. Blood vessel ligation was performed at the level of the left brachycephalic venous trunk, pericardium and in the medial anterior region related to thymic vessels. Total removal of the tumor was achieved with excellent postoperative evolution. Keywords: Chest tumor, thymoma, median sternotomy.

Teratoma Mediastinum

Teratomas are germ cell tumors consisting of somatic tissue derived from two or three germinal layers (ectodermal, endodermal, and mesodermal). Teratomas can be classified as mature teratomas and immature teratomas. Teratomas usually arise in the gonads but can also be extra-gonadal. Extragonadal teratomas can occur in the anterior mediastinum, retroperitoneum, pineal, and anterior suprasellar. The general incidence of teratomas is sacrococcygeal 40%, ovarian 25%, testicular 12%, brain 5%, and others including neck and mediastinum 1%. The etiology of teratoma is unknown, but there is a theory that gonadal and midline teratomas originate from totipotent primordial germ cells. Usually teratomas are found incidentally on thoracic photographs. If symptoms are present, it is generally due to mass effect which may cause coughing, dyspnea or chest pain. Mediastinal teratomas may cause perforation, however this complication is rare but a very serious condition. Large anterior mediastinal teratomas that rupture into the pleural cavity can cause lung infection, pleural effusion and mediastinitis. After complete excision, both mature and immature teratomas have an excellent prognosis.

Extracorporeal membrane oxygenation in the surgical management of large mediastinal masses: a narrative review.

The management of large mediastinal tumors requires a complex multidisciplinary approach, particularly in the perioperative setting due to increased risk of hemodynamic compromise. The utilization of extracorporeal membrane oxygenation (ECMO) provides a useful adjunct in the surgical management for biopsy and resection of these mediastinal masses. The objective of this article is to review indications and implementation of ECMO in the surgical management of mediastinal disease. A literature review of the PubMed database was completed evaluating articles discussing 'extracorporeal circulation', 'cardiopulmonary bypass', 'anesthesia', 'mediastinal disease', and 'mediastinal cancer'. These articles were evaluated for contribution to the discussion of indications and implementation of ECMO in the management of these patients. Large mediastinal tumors place patients at risk of hemodynamic collapse on induction of anesthesia due to compression of vascular structures, tracheobronchial tree and creation of V/Q mismatch. Patients may be stratified regarding their risk of perioperative complications by evaluation of postural symptoms, cross sectional imaging findings and pulmonary function tests. Those patients at elevated perioperative risk may benefit from the utilization of ECMO, most commonly veno-arterial (V-A) ECMO. Guidewires or ECMO cannulas may be placed under local anesthesia prior to induction. Those patients with hemodynamic compromise may receive mechanical circulatory support to allow completion of the operation. The use of a multidisciplinary team consisting of surgeons, anesthesiologists, perfusionists and OR team is critical to the success in the use of ECMO in the resection of mediastinal masses. With diligent preparation, these high-risk patients may be optimally managed at the time of resection.

Spindle cell thymoma and its histological mimickers.

Spindle cell thymomas are the most common spindle cell neoplasms of the anterior mediastinum. These tumors belong to the group of thymic epithelial neoplasms and are known for their wide histomorphologic spectrum. This histological heterogeneity is the reason why unequivocal diagnosis can be challenging, especially when dealing with small biopsy material. Conversely, less conventional patterns of the tumor may also pose significant diagnostic problems in resected material and the differential diagnosis often includes other spindle cell neoplasms that are known to arise in the mediastinal cavity. These can be of variable origin and may share overlapping pathological features with spindle cell thymoma. Since spindle cell thymomas are tumors that primarily affect the adult population and predominantly arise from the thymic gland in the anterior mediastinum, this review will focus on the differential diagnosis with other spindle cell neoplasms that share similar demographic characteristics and, for the most part, originate from the anterior mediastinal compartment. These include other epithelial spindle cell tumors of thymic origin (sarcomatoid thymic carcinoma and spindle cell carcinoid tumor), mesenchymal neoplasms [solitary fibrous tumor (SFT), synovial sarcoma, and dedifferentiated liposarcoma] and various other tumors with spindle cell morphology, that may occasionally involve the anterior mediastinum. The clinical, pathological, immunohistochemical and molecular hallmarks of these lesions will be discussed and useful tips for the differential diagnosis with spindle cell thymoma will be provided.

A Child with a Large Posterior Mediastinal Mass with Intraspinal Extension—Perioperative Anesthetic Challenges and Importance of Postoperative Analgesia

AbstractA 4-year-old girl child with a large posterior mediastinal mass with intraspinal extension (T2–T5) presented with paraplegia and bowel and bladder dysfunctions. She was planned for T1 to T6 laminoplasty and excision of the intraspinal tumor, followed by thoracotomy and excision of the posterior mediastinal tumor. Neurogenic tumors are common posterior mediastinal masses in children. These children pose many anesthetic challenges because of their size, location, and invasiveness. Challenges include difficult intubation, ventilation due to compression of the tracheobronchial tree, hemodynamic fluctuations because of compression of vital structures, associated autonomic dysfunction, and intraoperative bleeding. Pediatric lung isolation for thoracotomy and excision, obtaining motor evoked potential response in a child with poor functional grade status, and selecting appropriate analgesia techniques in the presence of neurological deficits are some of the added challenges. Anesthetic management and the use of a continuous erector spinae plane block for postoperative analgesia are highlighted in this report.

Estadificación quirúrgica del cáncer de pulmón de células no pequeñas: ¿cuándo deberíamos realizar de rutina la resección de los ganglios supraclaviculares?

Background: Accurate staging after the diagnosis of lung carcinoma is essential to select an appropriate therapy. Objective: The aim of the present study is to describe the characteristics of patients with non-small cell lung carcinoma in whom supraclavicular lymph node resection would detect non-palpable (N3 supraclavicular disease) lymph node metastases. Material and methods: Data from patients undergoing mediastinal surgical staging for non-small cell lung cancer using cervical mediastinoscopy and resection of supraclavicular lymph nodes were collected between December 2016 and December 2019. Results: A total of 60 patients were included; 76.6% were men. Mean tumor size was 4.7 cm ad mean lymph node stations evaluated by mediastinoscopy was 2.37 ± 1.44 (SD). All the patients underwent supraclavicular lymph node resection and the result was positive for epithelial carcinoma in 21 cases (35%). Of the 21 cases with N3 supraclavicular disease, 2 patients were recorded as skip metastases and the remaining cases were association with mediastinal N2 disease (p = 0.0424). There was a significant association between central tumor and N3 supraclavicular disease (p = 0.0148). Conclusion: Supraclavicular lymph node resection may be recommended in patients with suspected or confirmed N2 lymph node disease and central tumors, before considering a multimodal therapeutic approach including surgery.

The predictive value of a computed tomography-based radiomics model for the surgical separability of thymic epithelial tumors from the superior vena cava and the left innominate vein.

The aim of this study was to develop a radiomics machine learning model based on computed tomography (CT) that can predict whether thymic epithelial tumors (TETs) can be separated from veins during surgery and to compare the accuracy of the radiomics model to that of radiologists. Patients who underwent thymectomy at our hospital from 2009 to 2017 were included in the screening process. After the selection of patients according to the inclusion and exclusion criteria, the cohort was randomly divided into training and testing groups, and CT images of these patients were collected. Subsequently, two-dimensional (2D) and three-dimensional (3D) regions of interest were labelled using ITK-SNAP 3.8.0 software, and Radiomics features were extracted using Python software (Python Software Foundation) and selected through the least absolute shrinkage and selection operator (LASSO) regression model. To construct the classifier, a support vector machine (SVM) was employed, and a nomogram was created using logistic regression to predict vascular inseparable TETs based on the radiomics score (radscore) and image features. To assess the accuracy of these models, area under receiver operating characteristic (ROC) curves of these models were calculated, and differences among the models were identified using the Delong test. In this retrospective study, 204 patients with TETs were included, among whom 21 were diagnosed with surgical vascularly inseparable TETs. The area under ROC curve (AUC) of the 2D model, 3D model, 2D + 3D model, and radiologist diagnoses were 0.94, 0.92, 0.95, and 0.87 in the training cohort and 0.95, 0.92, 0.98, and 0.78 in testing cohort, respectively. The Delong test revealed a significant improvement in the performance of the radiomics models compared to radiologists' diagnoses. The logistic regression selected 3 image features, namely maximum diameter of the tumor, degree of abutment of vessel circumference >50%, and absence of the mediastinal fat layer or space between the tumor and surrounding structures. These features, along with the radscore, were included to develop a nomogram. The AUCs of this nomogram were 0.99 in both the training set and testing set, and the Delong test did not find a significant difference between ROC plots of the nomogram and radiomics models. The proposed radiomics model could accurately predict surgical vascularly inseparable TETs preoperatively and was shown to have a higher predictive value than the radiologists.

Invasive Squamous Cell Carcinoma of Anterior Mediastinum of Unknown Primary Site

Invasive Squamous Cell Carcinoma of Anterior Mediastinum of Unknown Primary Site

Giant middle mediastinal lesions: when tumor size correlates with mesenchymal origin-a retrospective single-center analysis.

The International Thymic Malignancy Interest Group (ITMIG) proposed an internationally accepted division of the mediastinum into three compartments based on computed tomography (CT): anterior (prevascular), middle (visceral) and posterior (paravertebral) compartment. There is no generally accepted definition for the term "giant" when applied to middle mediastinal lesions. We defined the term "giant" and described our surgical experience in treating patients with giant lesions of the middle mediastinum. CT imaging of patients operated in our center from January 2016 to August 2021 for mediastinal lesions was reviewed. Lesions were categorized to one of the ITMIG-defined compartments. Lesion size at diagnosis was measured at its largest diameter on axial CT imaging. Giant middle mediastinal lesions were defined as lesions having a size ≥90th percentile of our middle mediastinal lesion cohort. Patients with giant middle mediastinal lesions were further analyzed. Thirty-six patients (23%) had lesions located in the middle mediastinal compartment. Most common diagnoses were mediastinal cysts (n=10, 28%), metastatic lesions (n=6, 17%), lymphomas (n=5, 14%), and sarcomas (n=3, 8%). Ninetieth percentile lesion size was 73 mm. As per definition, four patients had giant middle mediastinal lesions. All these four lesions were of mesenchymal origin including oesophageal leiomyoma, synovial sarcoma, leiomyosarcoma and undifferentiated round cell sarcoma. Resection was performed through posterolateral thoracotomy or sternotomy, with or without cardiopulmonary bypass. The term "giant" could be defined as a mass larger or equal to 73 mm. This definition selected specifically lesions with mesenchymal origin and may therefore guide diagnostic algorithm and patient management.