Mediastinal Research Articles

Locally advanced thyroid cancer. Issues of diagnosis and treatment

Background. From 10 to 20% of highly differentiated papillary thyroid cancer show signs of local prevalence: invasion into the surrounding fatty tissue, organs and tissues adjacent to the gland — the anterior muscles of the neck, recurrent nerve, esophagus, laryngopharynx, larynx, trachea. A tumor that has a massive spread, often with life-threatening symptoms in the form of dysphagia, stenosis of the trachea or larynx, has no alternatives to surgical treatment.Aim. Evaluation of the results of extended and extended-combined interventions for locally advanced highly differentiated thyroid cancer (immediate surgical and long-term results of treatment).Materials and methods. During the period from 2010 to 2021, 82 patients with locally advanced thyroid cancer were operated on. This cohort included patients in whom the tumor process spread not only to the neck, but also to the mediastinum: either in the region of the upper thoracic inlet, or there was a lesion of deeper parts of the mediastinum. The average age is 56.8 years. The ratio of men and women: 34 (41.5%) and 48 (58.5%), respectively. According to the prevalence of the tumor process, T4 tumors were diagnosed in 54.8% (n= 45). 37 patients had T3 (45.2%) tumors. In 57.3% (n= 47), the primary tumor was combined with the presence of a metastatic lesion in the regional lymph nodes of the neck. 34.1% (n 28) had distant metastases. In all cases it was a lesion of the lungs. Papillary thyroid cancer was verified in 89.6%. 21 patients underwent operations with resection of the larynx and trachea: in 7 cases, laryngectomy with resection of 5 to 8 rings of the trachea, in 4 cases, circular resections, in 6 cases, “shaving”, in 2 cases, “terminal” resections of the trachea with plasty of the defect of the sternum-clavicle-mastoid muscle, in 2 patients the plates of the thyroid cartilage were resected while maintaining the integrity of the organ. In 24 patients, mediastinal lymph node dissection (sternotomy) was performed; in 2 cases, mediastinal lymph node dissection was performed thoracoscopically. In 2 cases, resection of bone structures was performed — the manubrium of the sternum and sternoclavicular joints. In 33 patients, removal of the primary tumor, paratracheal, paraesophageal metastases and metastatic conglomerates from the posterior mediastinum (4 cases) was performed through the cervical approach.Results. The postoperative period in this group of patients was complicated by the development of pneumonia in 52 (63.4%) patients. Purulent mediastinitis developed in 6 (7.8%) patients, arrosive bleeding in 6% (n= 5), osteomyelitis of the sternum in 2 (2.4%) cases, gastric bleeding in 1 patient (1.5%), lymphorrhea in 2 (2.4%), parathyroid insufficiency developed in 70.7% (n 58) of observations. Postoperative mortality was 6% (n= 5).OS and disease-free survival amounted to 66.7% and 53.4%, respectively. Death from the progression of the disease occurred in all cases due to the growth of distant metastases against the background of resistance to radioactive iodine that developed during treatment or the implementation of new metastatic foci in terms of 2 to 5 years.Conclusions. This group of patients demonstrates satisfactory results of OS and disease-free survival, but requires further dynamic monitoring and evaluation of the effectiveness of drug treatment of radioiodine-resistant tumors.

A descriptive comparison of postoperative outcomes between hybrid mediastino-thoracoscopic approach and conventional thoracoscopic esophagectomy for esophageal cancer.

The purpose of this study was to compare the results of the hybrid mediastino-thoracoscopic approach with that of the conventional thoracoscopic approach and to identify the advantages and disadvantages of the hybrid approach. We retrospectively analyzed 172 patients who underwent thoracoscopic esophagectomy for esophageal cancer from July 2009 to June 2021, excluding salvage surgery. In the mediastinoscopic approach, the lymph nodes were dissected from a small incision in the left aspect of the neck to the aortic arch with supine double-lung ventilation. Thereafter, the middle-to-lower mediastinum and right superior mediastinum were dissected thoracoscopically in the prone position. The patients' demographics, surgical outcomes, postoperative complications, and postoperative recurrence patterns were compared between 51 patients in the hybrid approach and 121 patients in the conventional approach. The hybrid group had more elderly patients (71years vs. 67years; P = 0.010), more cardiovascular disease (33.3% vs. 16.7%; P = 0.021), lower rates of preoperative chemotherapy (49.0% vs. 69.4%; P = 0.015), and shorter right lung collapse time (196min vs. 264min; P < 0.001). Postoperative hoarseness was not different between the two groups (31.4% vs. 27.3%; P = 0.584), and there was a significant difference in the sternal-vertebral distance at the level of the sternal notch (41mm in the hybrid group vs. 48mm in the conventional group; P = 0.029). The sternal-vertebral distance of less than 45mm was an independent risk factor for postoperative hoarseness in the logistic analysis (odds ratio 3.636, 95% confidence interval 1.054-12.546; P = 0.041). The hybrid mediastino-thoracoscopic approach could be safely adapted to elderly or cardiopulmonary diseased patients; however, short sternal-vertebral distance might be a risk factor of postoperative recurrent laryngeal nerve palsy.

Novel intraoperative near-infrared imaging strategy to identify abnormalities in the anterior mediastinum

Thoracic surgeons are frequently asked to biopsy suspicious tissues in the anterior mediastinum to discriminate between a reactive versus malignant pathology such as lymph nodes. The most common benign cause of a mediastinal lymph node is a reactive lymph node from a prior infection or inflammatory process such as post-COVID or granulomatous disease. The most common malignant cause is a lymphoproliferative disorder but also metastatic disease from neck, breast and other regional cancers. Biopsies in this location are challenging because they are far from the trachea and the sternum is a barrier to most diagnostic procedures. Thus, a surgical biopsy is frequently required and a common procedure for Thoracic surgeons. Technically, identifying these lesions can be challenging, particularly for small lesions or those in patients with high body mass index. In order to improve contrast between diseased tissue in the anterior mediastinum and surrounding adipose tissue, we have been studying near-infrared imaging during surgery using indocyanine green (ICG) to give contrast to the abnormal tissues and to avoid an unnecessary extended resection. We developed a modified technique to give ICG to a patient during a biopsy in the anterior mediastinum to specifically highlight abnormal tissues. As a proof-of-principle, we present a case of a young woman with a suspicious 2cm mediastinal lymph node that required surgical biopsy.

Comparisons of minimally invasive esophagectomy and open esophagectomy in lymph node metastasis/dissection for thoracic esophageal cancer.

The study aimed to clarify the characteristics of lymph node metastasis (LNM) and to compare the oncologic outcomes of minimally invasive esophagectomy (MIE) with open esophagectomy (OE) in terms of lymph node dissection (LND) in thoracic esophageal cancer patients. The data from esophageal cancer patients who underwent MIE or OE from January 2016 to January 2019 were retrospectively reviewed. The characteristics of LNM in thoracic esophageal cancer were discussed, and the differences in numbers of LND, LND rate, and LNM rate/degree of upper mediastinum between MIE and OE were compared. For overall characteristics of LNM in 249 included patients, the highest rate of LNM was found in upper mediastinum, while LNM rate in middle and lower mediastinum, and abdomen increased with the tumor site moving down. The patients were divided into MIE ( n = 204) and OE groups ( n = 45). In terms of number of LND, there were significant differences in upper mediastinum between MIE and OE groups (8 [5, 11] vs. 5 [3, 8], P < 0.001). The comparative analysis of regional lymph node showed there was no significant difference except the subgroup of upper mediastinal 2L and 4L group (3 [1, 5] vs. 0 [0, 2], P < 0.001 and 0 [0, 2] vs. 0, P = 0.012, respectively). Meanwhile, there was no significant difference in terms of LND rate except 2L (89.7% [183/204] vs. 71.1% [32/45], P = 0.001) and 4L (41.2% [84/204] vs . 22.2% [10/45], P = 0.018) groups. For LNM rate of T3 stage, there was no significant difference between MIE and OE groups, and the comparative analysis of regional lymph node showed that there was no significant difference except 2L group (11.1% [5/45] vs . 38.1% [8/21], P = 0.025). The LNM degree of OE group was significantly higher than that of MIE group (27.2% [47/173] vs . 7.6% [32/419], P < 0.001), and the comparative analysis of regional LNM degree showed that there was no significant difference except 2L (34.7% [17/49] vs . 7.7% [13/169], P < 0.001) and 4L (23.8% [5/21] vs . 3.9% [2/51], P = 0.031) subgroups. MIE may have an advantage in LND of upper mediastinum 2L and 4L groups, while it was similar to OE in other stations of LND.

Variations in Azygos Venous System in The Eastern Indian Population: A Cadaveric Study

Background: This study aimed to classify Azygos vein patterns in the Eastern Indian population. Methods: During the routine dissection of MBBS in the 2018–2020 academic year, 20 formalin embalmed cadavers aged 50–70 were used to classify the azygos system. The cadaver’s age was verified by its entry into our institute’s anatomy register. The register confirmed that all cadavers used for dissection were of Indian origin. Though gender was not compared in this study, it was noted for record purposes by identifying the external genitalia and confirming it to the records. These were the exclusion criteria: 1) No major thoracic surgeries; 2) No major thoracic deformities. Azygos, hemiazygos, and accessory hemiazygos veins were also examined. Results: The Anson &amp; McVay system was used to classify the recruited cadavers’ azygos system. The cadavers were classified into Type-1, Type-2, and Type-3. Type 2 was again subdivided into 5 subgroups and Type-3 into2 sub-groups. In one cadaver, Type-1 was observed, 17 cadavers had Type-2 azygos system, and 2 cadavers showed Type-3. Of the 17 cadavers of Type-2, 3 and 7 cadavers had Type-2A and -2B, respectively. Similarly, 4 and 1 cadavers had 2C and 2D patterns, respectively. Also, 2 cadavers showed 2E type. Of the 2 cadavers of Type-3, one was Type -3A and one Type-3B. The termination of the azygos vein vertebral level was between T2 and T4, of the hemiazygos vein was T8 to T11, and accessory hemiazygos veins were between T7 and T10. Conclusion: These variations should be well studied to avoid misinterpretation during radiological investigations and surgical interventions. KEY WORDS: Azygos vein, Hemiazygos vein, Posterior mediastinum, Radiological investigation, Variation.

A case report of anterior mediastinal signet ring cell carcinoma

Anterior mediastinal signet ring cell carcinoma (SRCC) is a rare tumor that has only been reported in two cases of thymic cancer. Positive immunohistochemistry (IHC) staining for caudal-type homeobox (CDX) 2, cytokeratin (CK) 20 and special AT-rich binding protein (SATB) 2 usually indicate gastrointestinal tumors but begin to appear in thymic cancers with enteric differentiation. Here, we describe a case of the anterior mediastinal SRCC with enteric differentiation who was correctly treated with surgery and chemo-radiation and was alive after four months. A 48-year-old female presented without chest and lung symptoms had an anterior mediastinal mass during a routine physical examination. Laboratory examinations showed an elevated level of serum carbohydrate antigen (CA)-125 at 73.63 U/mL. Chest computed tomography (CT) showed an irregular soft tissue density shadow with heterogeneous enhancement in the anterior mediastinum. The tumor had invaded the pericardium, the left septal nerve and the innominate and was completely removed after anterior mediastinal surgery. Postoperative pathological examinations revealed signet ring cell features and positive staining for CDX2, CK20, SATB2 and Ki-67 (Li: 70%). The samples were negative for cluster of differentiation (CD)-5, CK7, thyroid transcription factor (TTF) 1, NapsinA, CerbB-2, P53 and PD-L1 by IHC examinations. The suspected diagnosis was an anterior mediastinal SRCC that had originated in the digestive system. The patient was diagnosed with anterior mediastinal SRCC. The patient was treated with surgery and combined chemo-radiotherapy. The patient had no recurrence or metastasis after five months. We describe a rare case of the anterior mediastinal SRCC of unknown origin. Our case, for the first time shows that surgery combined with chemo-radiotherapy is an effective treatment regimen for anterior mediastinal SRCC.

A 16-year-old Adolescent With Mediastinal Seminoma: A Case Report and Literature Review

Germ cell tumors (GCTs) are a heterogeneous group of neoplasms that arise from the primordial germ cells of the human embryo, which are normally destined to produce reproductive cells sperm, or ova. GCTs can be present in both gonadal GCTs and extragonadal GCT sites. Pediatric GCTs are relatively rare tumors with an incidence of 2%-3%. Primary mediastinal germ cell tumors GCTs are very rare extragonadal GCTs that arise in the anterior mediastinum. In this report, we present the case of a 16-year-old boy with primary seminoma arising in the anterior mediastinum. The patient presented with the symptoms of cough, fever, and chest tightness. CT finding was in favor of a large expansive process measuring 12.4x6.7x14.2 cm in the anterior mediastinum, accompanied by a conglomeration of hilar lymph nodes in the level of brachiocephalic veins juncture. Fine needle biopsy and core biopsy were performed transthoracically, under the control of MSCT. Based on histology and immunohistochemistry, the diagnosis of mediastinal germ cell tumor with immunophenotype of seminoma was made. The patient was treated with 4 cycles of chemotherapy by BEP protocol without significant side effects and toxicities. The patient remained disease-free for 16 months. The purpose of reporting this case is to confirm that chemotherapy with cisplatin-based regimens has markedly improved the outcome of adults and children with GCTs as well.

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

Mediastinal Mass as First Clinical Manifestation of Medullary Thyroid Microcarcinoma in a Patient With Hashimoto’s Thyroiditis

Medullary thyroid cancer is a rare neuroendocrine tumor with aggressive behavior and an uncertain prognosis. Calcitonin is the associated tumor marker; however, neuroendocrine tumors of the lung or intestine can also present high values. We report the case of a 53-year-old patient presenting with dry cough for 3 years. Computed tomography (CT) showed a 58-mm expansive lesion in the right anterior mediastinum and cervical ultrasound informed a 9-mm hypoechoic nodule with a lobulated edge and thick calcifications. Cytology reported Hashimoto’s thyroiditis. He underwent emergent surgery for respiratory failure. The pathological study informed G2 neuroendocrine carcinoma, immunohistochemistry showed: cytokeratin (+), vimentin (+), alpha-actin (-), synaptophysin (+), chromogranin (+), Ki-67: 10%. He progressed with bone metastasis visualized in scintigraphy and mediastinal tumor remnants, adenopathy, and pulmonary nodules on CT scan, prompting chemotherapy. Due to elevated and increasing calcitonin, an ultrasound study with needle washout for calcitonin resulted in 1,724 pg/mL, and cytology of the nodule reported medullary carcinoma. He was finally diagnosed with medullary thyroid microcarcinoma with metastasis to the mediastinum. Coexistence with Hashimoto’s thyroiditis could alter the initial fine-needle aspiration results. We conclude that in the case of calcitonin-secreting neuroendocrine tumors or medullary thyroid cancer, calcitonin fine needle aspirate washout may be helpful in elucidating a diagnosis. Due to its severity, medullary thyroid cancer should always be approached and managed aggressively, even microcarcinomas. J Endocrinol Metab. 2022;12(6):198-201 doi: https://doi.org/10.14740/jem841

Surgical indications for mediastinal cysts-a narrative review.

Whether and when surgical intervention is indicated for mediastinal cysts is a matter of some debate. While most mediastinal cysts are found incidentally, the anatomic location, clinical presentation, and symptoms, as well as the potential for malignancy, are important considerations that inform decisions related to whether to intervene surgically. The objective of this review is to summarize the current literature regarding the criteria for surgical excision of mediastinal cysts and provide a framework for the clinician and surgeon to arrive at a decision regarding the appropriateness of surgical intervention of mediastinal cysts. A review of the published literature in the last 45 years (1977-2022) was conducted through PubMed, MeSh and Google Scholar. We included retrospective reviews, meta-analyses, and case studies published in the English language. A single author identified eligible studies, and those identified were reviewed by the team until consensus was met. Pediatric literature was excluded from this review. The current literature predominantly contains case studies, small retrospective studies, and meta-analyses describing mediastinal cysts. In the anterior mediastinum, multiloculated thymic cysts should be resected to rule out thymic malignancy. Intralesional fat, smooth borders, and a more midline location are features suggestive of a benign process, while asymmetric cystic wall thickening has been associated with malignancy. Both esophageal and bronchogenic cysts should be excised, taking into account the risk of complications (up to a 45% risk) of infection, rupture, or compression, as well as the rare risk of associated malignancy. Simple thymic and small pericardial cysts can be observed and followed with serial radiographic tools and should be resected if they increase in size, compress surrounding structures, or lead the patient to develop symptoms. Since mediastinal cysts are rare and often asymptomatic, there are no formal guidelines outlining when surgical intervention should be undertaken. Based on our review of the literature, surgical intervention should be pursued if the patient's symptoms correlate with radiographic findings of a mediastinal cyst, there is compression of the surrounding structures, and concern of malignancy is present.

Thymic Seminoma with Regressive Changes Obscured by Granulomatous Reaction.

Primary thymic seminoma is an exceedingly rare tumour. There are few case reports about mediastinal thymic seminoma accompanied by secondary changes. We report a case of a 29-year male admitted to our hospital because of chest pain and dyspnea for 8 months. Computed tomography of the thorax revealed hypodense, solid masses showing calcification and cystic degeneration in the anterior mediastinum. Histopathological examination of the resected specimen revealed a diagnosis of thymic seminoma with regressive and reactive changes. The present case was unique in its presentation as a primary seminoma showing combination of cystic degeneration, follicular hyperplasia, fibrosis, calcification and granulomatous reaction in one case. High level of suspicion is necessary to identify seminomas in a thymic lesion accompanied by secondary changes. Excluding the possibility of metastasis from testicular seminoma is very important before making this diagnosis. Key Words:Thymus, Seminoma, Granuloma, Calcification, Cyst.

Giant tumors of the posterior mediastinum: a narrative review of surgical treatment.

The posterior mediastinum is a potential space along the paravertebral sulci or between the posterior aspect of the pericardium and the vertebrae. This compartment is classically the most frequent location site of neurogenic tumors. Whereas neurofibroma and schwannoma are neurogenic tumors that commonly arise from peripheral nerves, sympathetic nerves are the origin of ganglioneuroma, neuroblastoma, ganglioneuroblastoma, and neuroectodermal cells closely associated with autonomic nerves are the origin of paragangliomas and pheochromocytomas. Additionally, tumors from the esophagus, tumors of mesenchymal origin, lymphoma, ectopic goiter, and diseases with lymph node hyperplasia may also settle on this compartment. The objectives are to identify term "giant posterior mediastinal tumor" and the etiology, clinical features, diagnostic methods, pathological types, surgical methods applied, and technical details of these methods for the treatment of these tumors. In this review, the term "giant tumor" was used to define tumors larger than 10 cm settled in the posterior mediastinum. PubMed database was searched with keywords "posterior mediastinum, giant mass" or "posterior mediastinum, tumor, giant" limited to English language and full-text available studies published between years 1984-2021. As a result of the literature review with the relevant terms, 23 case reports were found in accordance with the inclusion criteria. We detected the most common giant posterior mediastinum tumors were neurogenic origin (schwannoma, ganglioneuroma, ganglioneuroblastoma, triton tumor) in that review. The most common surgical approach was posterolateral thoracotomy. Treatment response to surgical total excision was good in most of cases. The definitive diagnosis and treatment of giant posterior mediastinal tumors is made by surgical excision. Diagnostic procedures and subsequent surgical planning may vary depending on the origin and localization. Adjuvant treatment and follow-up should be conducted on the histopathological features.

CASE REPORT OF ANAESTHETIC MANAGEMENT OF BRONCHOGENIC CYST IN 11-MONTH OLD CHILD

Introduction: Bronchogenic cysts are foregut-derived cystic malformations of the respiratory tract, are the most common cystic mediastinal lesion in children.Case: We report a case of 11-month old child who presented with repeated lower respiratory tract infections for last 3-4 months. She underwent CT chest which revealed a cystic lesion measuring 2.2 x 1.8 x 2.5cm in the posterior mediastinum. Patient was posted for Right postero-lateral thoracotomy with excision of cyst. Thorough Pre-anaesthetic evaluation was done and antibiotics and bronchodilators were continued. General anaesthesia with one lung ventilation was planned. Patient was intubated with Inj.propofol 10mg, Inj.succinylcholine 10mg and uncuffed no.4 endotracheal tube using no.0 Macintosh blade and Inj.vecuronium 0.4 mg given. Patient was maintained on sevourane+O2+ air. Patient was placed in left lateral position. Right T4 intercostal space postero-lateral incision was taken, right lung collapsed and cyst was tried to excised – suddenly we noticed fall in ETco2, followed by severe bradycardia and hypoxia (Spo2 not recordable) Accidental rent in trachea was noticed. Cardiac massage/Inj.Adrenaline/ventilation with 100% oxygen started. Tracheal rent was sutured. Patient was revived successfully. Surgery later was completed uneventfully. Patient was extubated on table and shifted to Paediatric ICU. CONCLUSION: Airway management in paediatric age group is very challenging to anaesthetist. In our scenario resuscitation from asystole and airway management becomes a vital role.

Akiyama Procedure as a Surgical Option for Esophageal Cancer

Background The purpose of this study is to introduce our experience with the Akiyama procedure as a surgical option for treatment of esophageal cancer in the Mother Theresa Hospital Center of Tirana, Albania. Selection of the suitable site for anastomosis after esophagectomy, whether cervical or thoracic is the key for optimal oncological results. The goal is to minimize recurrence in oncological patients and to avoid complications related to surgery. Controversy still exists among surgeons as the optimal site for anastomosis as well as whether the anastomosis is done manually or with a stapler. Material and methods From October 2018 to June 2021, 27 surgical interventions of esophageal cancer were performed in our surgical unit. In 15 patients, subtotal esophagectomy Ivor-Lewis with a mediastinal esophago-gastric anastomosis was performed. In 8 patients, distal esophagectomy and proximal gastrectomy with an abdominal esophago-gastric anastomosis was performed. In 4 patients, subtotal esophagectomy with a cervical esophago-gastric anastomosis, Akiyama procedure was performed. In this study we are evaluating the Akiyama procedure with description of the technique, patient criteria of inclusion, oncological protocol and postoperative care. Discussion In our practice we used chemotherapy and radiotherapy as part of a multimodality treatment plan. All of our patients with carcinoma had radiation and chemotherapy prior to surgery. The use of stapler devices in cervical anastomoses in some studies is linked with higher rate of leakage but we consider it a preferential choice of the surgeon. We opted for a one-layer esophagogastric anastomosis in the neck as shown in some studies instead of the two-layer technique because of lower rates of stricture formation. The level of exposure in the cervical route is advantageous in making an accurate anastomosis. In our patients we used the retrosternal space for esophageal replacement to avoid local tumor recurrence in the posterior mediastinum. Conclusion As in other cancers there is a mandatory evaluation in congruence to the guidelines in order to each patient have a surgical or adjuvant therapy according to its stage. As per guidelines patients in a T1-2, N0 stage are treated with surgery alone and a close follow up for recurrence and patients in a T3 or N1/M1 stage should be considered for adjuvant therapy prior to surgery. In patients that have extensive disease and are not surgical candidates are considered for chemotherapy and radiation alone. It is advised that the type of surgery performed is the one in which the surgeon is more experienced and has the best outcome in terms of surgical strategy in terms of morbidity and mortality. Keywords: General surgery, Esophageal cancer, Akiyama procedure, Cervical esophago-gastric anastomosis. DOI: 10.7176/ALST/96-02 Publication date: December 31 st 2022

Amyloidoma Presenting as Compressive Myelopathy.

Spinal cord compression is a common problem in clinical practice. Sometimes puzzling symptoms may mislead the clinician in the initial days. We present a 59 year old lady who presented with progressive numbness of both feet and abdomen, walking difficulties for which the initial evaluation did not yield any result. The work up at our facility showed collapsed D3 vertebra, prevertebral collection and cord compression. She was tentatively started on antituberculous treatment, based on the radiologist opinion. Two months later, the patient had further progression of symptoms and had to undergo D3 laminectomy and surgical decompression. She also developed hypertension and diabetes in the meantime. Histopathology did not favour tuberculous process, but showed amyloid deposition. Antituberculous treatment was halted and she was evaluated for plasma cell dyscrasias. The serum protein electrophoresis with immunofixation was in favour of IgG Kappa light chain monoclonal gammopathy. She was further subjected to bone marrow aspiration and biopsy at a Cancer institute. The result was negative for plasma cell malignancy, and was suggestive of only reactive lymphocytosis. On the advice of oncologist, antituberculous treatment was started again and continued as RH- two drug regimen for 9 months along with supportive care. She improved symptomatically, able to walk independently and attended regular follow up. Three years later, a repeat MRI scan showed enlargement of the lesion to involve the posterior mediastinum. The oncology service decided to irradiate the lesion, only if she develops new symptoms. This outcome suggests the unusual presentation of the disease, and the so litary amyloidoma is probably a primary disease in itself or secondary to a neoplastic process.

December 2022 Pulmonary Case of the Month: New Therapy for Mediastinal Disease

No abstract available. Article truncated after the first page. History of Present Illness A 43-year-old woman complained of persistent cough over 1 year with mild increasing dyspnea on exertion. She denied fever, sweats or weight loss. She had noted fatigue and dry cough, as well as shortness of breath, particularly when supine. Past Medical History (PMH), Social History (SH), Family History (FH) • An outside bronchoscopy done in 2019 with washings and biopsy showing only some non-specific inflammation • Life-long nonsmoker • Not on any chronic medications • Had only lived in Arizona, although has travelled in other states • There is no significant family history Physical Examination • Prominent vascularity on anterior chest What should be done at this time? 1. Chest X-ray 2. Obtain old x-rays 3. Pulmonary function testing 4. Serology for coccidioidomycosis 5. All of the above …

December 2022 Pulmonary Case of the Month: New Therapy for Mediastinal Disease

No abstract available. Article truncated after the first page. History of Present Illness A 43-year-old woman complained of persistent cough over 1 year with mild increasing dyspnea on exertion. She denied fever, sweats or weight loss. She had noted fatigue and dry cough, as well as shortness of breath, particularly when supine. Past Medical History (PMH), Social History (SH), Family History (FH) • An outside bronchoscopy done in 2019 with washings and biopsy showing only some non-specific inflammation • Life-long nonsmoker • Not on any chronic medications • Had only lived in Arizona, although has travelled in other states • There is no significant family history Physical Examination • Prominent vascularity on anterior chest What should be done at this time? 1. Chest X-ray 2. Obtain old x-rays 3. Pulmonary function testing 4. Serology for coccidioidomycosis 5. All of the above …

A rare case: 47-years-old male with mature Mediastinal Teratom

Introduction: Mediastinal teratoma is a tumor originating from germ cells. The global incidence of teratoma is 1 per 4000 births. In the mediastinum, germ tumors account for 1% to 3% of all cases. The anterior mediastinum is where extragonadal germ cell tumors are most prevalent and are often benign. The symptoms are manifestations of pushing the tumor into the surrounding environment. Case Presentation: Our hospital received a referral for a 47-year-old male bus driver for diagnostic purposes with complaints of shortness of breath 3 months before his admission to the hospital, which has been getting worse in the last 1 month. A chest X-ray was performed in previous hospital showed a mediastinal mass. Bronchoscopy showed no source of bleeding. A contrast chest CT scan showed a mass in the superior anterior mediastinum with a well-defined, lobulated that deviated the trachea to the right and compressed the heart. Open thoracotomy was performed followed by pathology examination which shows mature teratoma. The patient was given antibiotics and discharged three days later with pretty good outcome. No mass or infiltration was found. Conclusion: Mature mediastinal teratoma is a rare case. These tumors might cause compression to the adjacent organs and structures and cause symtoms. Chest CT scan is considered good modality choice to evaluate compression of the surrounding organs and post-treatment comparation.

Risk Factors of Descending Necrotizing Mediastinitis in Deep Neck Abscesses.

Background and Objectives: Cervical space infection could also extend to the mediastinum due to the anatomical vicinity. The mortality rate of descending necrotizing mediastinitis is 85% if untreated. The aim of this study was to identify risk factors for the progression of deep neck abscesses to descending necrotizing mediastinitis. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing surgical treatment of deep neck abscesses from August 2017 to July 2022. Computed tomography (CT) was performed in all patients. Before surgery, lab data including hemoglobulin (Hb), white blood cell count, neutrophil percentage, C-reactive protein (CRP) level, and blood glucose were recorded. Patients' characteristics including gender, age, etiology, and presenting symptoms were collected. Hospitalization duration and bacterial cultures from the wound were also analyzed. Results: The C-reactive protein (CRP) level was higher in patients with a mediastinal abscess than in patients without a mediastinal abscess (340.9 ± 33.0 mg/L vs. 190.1 ± 72.7 mg/L) (p = 0.000). The submandibular space was more commonly affected in patients without a mediastinal abscess (p = 0.048). The retropharyngeal (p = 0.003) and anterior visceral (p = 0.006) spaces were more commonly affected in patients with a mediastinal abscess. Conclusions: Descending necrtotizing mediastinitis results in mortality and longer hospitalization times. Early detection of a mediastinal abscess on CT is crucial for treatment. Excluding abscesses of the anterior superior mediastinum for which transcervical drainage is sufficient, other mediastinal abscesses require multimodal treatment including ENT and thoracic surgery to achieve a good outcome.

The surgical treatment of locally advanced angiosarcoma of the anterior mediastinum. A clinical case

Tumors of the mediastinum is a collective term that includes neoplasms of various degrees of malignancy, different morphogenesis, originating from heterogeneous tissues and combined into one nosological form according to anatomical localization. Angiosarcoma is a rare malignant tumor originating from a vessel wall. In the general structure of sarcomas, its frequency is estimated at 1%. The tumor is characterized by an aggressive course, local recurrence, hematogenous metastasis, poor sensitivity to chemotherapy and radiotherapy. Surgery remains the main treatment for angiosarcomas. The article presents a clinical case. A 55-year-old patient has multiple primary malignant neoplasms: cancer of the body of the uterus pT1aN0M0 IA stage. Surgical treatment from 12.15.2020 panhysterectomy; angiosarcoma of the anterior mediastinum with lesions of the manubrium, body of the sternum and the 1st rib on the left, invasion into the left brachiocephalic vein with the formation of a tumor thrombus in it, growing into the upper lobe of the left lung, T3N0M0, G1. Surgical treatment from 08.12.2021 resection of the manubrium and body of the sternum with resection of the anterior segments I, II, III ribs on both sides, resection of the left brachiocephalic vein, removal of an anterior mediastinal tumor, atypical resection of the upper lobe of the left lung en bloc, reconstruction of the sternum and ribs with an individual titanium 3D prosthesis. The patient was discharged from the hospital in a satisfactory condition.