Mediastinal Research Articles

ODP494 Mediastinal Ectopic Thyroid Papillary Carcinoma with NTRK3 Fusion, Presenting with Thoracic Spine Metastasis

Abstract Background Ectopic thyroid tissue may be encountered anywhere from the base of the skull to the lower neck. It is rarely seen in the mediastinum. Thyroid cancer in ectopic thyroid tissue is a very rare entity. We report a patient with papillary thyroid cancer arising from upper mediastinal ectopic thyroid tissue. The patient presented with thoracic spine metastasis with cord compression. Molecular testing showed SQSTM1-NTRK3chromosomal rearrangement. Case Presentation The patient is a 67 -year-old female, presented with upper back pain. She reported no weakness or sensory changes. MRI showed suspected metastatic disease to the second and third thoracic vertebrae (T2 and T3). Therewasepidural extension of tumor with cord compression and severe stenosis at T2. She underwent laminectomy and decompression surgeryat T1-T3 level. Final pathology report showed Metastatic thyroid carcinoma with papillary features. She underwent external beam radiation to the affected spines. CT chest abdomen and pelvis showed 3. 0×2.8×2.3 cm soft tissue mass in the left superior mediastinum extending into the supraclavicular region. FDG-PET scan showedHypermetabolic foci in the upper mediastinum with SUV max of 25. Fine needle Aspiration (FNA) of the upper mediastinal mass was consistent with papillary thyroid cancer. Molecular testing from the FNA sample using Thyroseq V3 showed SQSTM1-NTRK3 chromosomal rearrangement. Total thyroidectomy was performed; however, the upper mediastinal mass was not resected due to proximity to vascular and neuronal structures. Pathology of the resected thyroid was benign. Recombinant TSH stimulatedI-123 scan showed intense uptake in the neck area, most likely represents remnant thyroid tissue. No clear uptake in the mediastinal mass or spine metastasis. She underwent removal of the upper mediastinal mass with lymph node dissection at a referral center. Pathology showed soft tissue involved by papillary thyroid carcinoma with focal tall cell features, forming a 4×2.5×2.5 cm mass. Surgery was followed by ablation with 100 mci of radioactive iodine (I-131). Thyroglobulin level decreased from a baseline of 15272 ng/ml to 1857 ng/ml, post-surgery, external beam radiation and radioactive iodine ablation. Conclusion This case highlights the possibility of developing thyroid cancer in ectopic thyroid tissue and the unique challenges in the diagnosis and management of such rare disease. Our patient has very aggressive disease presentation that required multimodality treatment including thoracic spine decompression, total thyroidectomy, mediastinal ectopic thyroid cancer resection, external beam radiation to the affectedspine area, and high dose radioactive iodine treatment. The use of molecular diagnostics is very important to improve the outcome in such patient. The tumor has SQSTM1-NTRK3 chromosomal rearrangement. This rearrangement causesconstitutive activation of the NTRK3 in the Ras-Raf-MEK-ERK Pathway. This fusioncan be targeted by medications like Larotrectinib and Endtrectinib. Presentation: No date and time listed

ODP512 Renal Cell Carcinoma Metastatic to Thyroid: A Case Report

Abstract Introduction The thyroid gland is an uncommon site (0.7%) among all distant metastasis from renal cell carcinoma (RCC). Here we report a case of metastasis from RCC to the thyroid gland, diagnosed 15 years after treatment. Clinical Case A 63-year-old female, was referred to endocrine for evaluation of neck mass of several months’ duration. Thyroid function test revealed mildly low TSH and normal free T4. Recent thyroid ultrasound showed multinodular thyroid, the largest nodule was in mid to upper left thyroid lobe and measured 6cm in max diameter. Biopsy of 4 thyroid nodules was performed. Three nodules were benign (Bethesda 2), but the left mid to upper 6cm thyroid nodule showed Atypia of Undetermined Significance (Bethesda 3). Due to concern of large size, potential for further growth and gradual development of local compressive symptoms, total thyroidectomy was recommended. Patient was initially hesitant, however, within several months, she developed dysphagia and progressive neck swelling, and eventually had total thyroidectomy. Surgical pathology revealed metastatic RCC involved left thyroid lobe (8.4cm in greatest dimension) and right thyroid lobe (0.3cm in greatest dimension). Immunohistochemical stain were positive for CA9, CD10, PAX8, while negative for CKIT, CK7, TFT-1, thyroglobulin, synaptophysin, chromogranin, calcitonin, and PTH. Patient reported a history of right nephrectomy in 2005 and did not require adjuvant therapy at that time. Post-operative workup including CT neck/chest/abdomen/pelvis revealed a 2.4cm left superior mediastinum mass suspicious for metastasis. Patient was evaluated by genitourinary oncology and the decision was to continue surveillance with CT every three months. A new gallbladder lesion was detected after six months, laparoscopic cholecystectomy was performed, and pathology showed metastatic RCC. Conclusion This is an unusual case of metastatic RCC to thyroid gland, diagnosed 15 years after initial presentation with RCC that required only a nephrectomy. The cytology – pathology discrepancy in our case highlights the limitation of FNA in diagnosing rare thyroid masses of extra-thyroidal origin. A study has showed thyroid cytology was only diagnostic in 29.4% of population with RCC metastatsis(1). Especially when rapid growth is seen, surgery needs to be considered regardless of FNA results. Reference: 1. Khaddour K, Marernych N, Ward WL, Liu J, Pappa T. Characteristics of clear cell renal cell carcinoma metastases to the thyroid gland: A systematic review. World J Clin Cases. 2019 Nov 6;7(21): 3474-3485. doi: 10.12998/wjcc. v7. i21.3474. PMID: 31750330; PMCID: PMC6854394. Presentation: No date and time listed

Endobronchial Ultrasound-Guided Fine Needle Aspiration (EBUS-FNA) in the Diagnosis of Mediastinal Disease in Less Than or Equal To 50-Year-Old Patients

Endobronchial Ultrasound-Guided Fine Needle Aspiration (EBUS-FNA) in the Diagnosis of Mediastinal Disease in Less Than or Equal To 50-Year-Old Patients

Consolidative mediastinal radiotherapy for advanced-stage classical Hodgkin lymphoma with bulky disease in patients who achieve complete response after chemotherapy in PET-CT era.

The role of consolidation mediastinal radiotherapy (RT) for mediastinal bulky disease in advanced-stage classical Hodgkin lymphoma (cHL) is controversial in the positron emission tomography/computed tomography (PET-CT) era. We reviewed the medical charts of patients with advanced-stage (clinical stage IIX-IVX) cHL and mediastinal bulky that achieved a complete response after first line chemotherapy treatment between August 2010 and December 2020 and compared the results of those who received with those who did not receive consolidation mediastinal RT. Inclusion criteria required PET-CT imaging for staging and response assessment. We included 115 patients; 91 received mediastinal RT and 24 did not. Patient's characteristics were balanced between the two groups. The median age in patients that received and did not receive mediastinal RT was 28 years and 24.5 years, respectively. Median International Prognostic Score among patients that received and did not receive mediastinal RT was 2 and 2.5, respectively. Disease free survival (DFS) was statistically better in patients that received mediastinal RT (p = 0.013). Two-year DFS for patients that received and did not receive mediastinal RT was 95.2% [95% confidence interval (95% CI): 87.6-98.2%] and 76.4% (95% CI: 52.2-89.4%), respectively. Overall survival (OS) was not different between the two groups (p = 0.617). In multivariate analysis, not receiving mediastinal radiotherapy and only achieving partial response (vs. complete response) after 2 cycles of chemotherapy were factors predictive of lower DFS. DFS, but not OS, was superior in patients that received mediastinal RT.

Anesthetic management of patients undergoing mediastinal mass operation.

To summarize the anesthetic management of patients undergoing mediastinal mass operation. Electronic databases were searched to identify all case reports of patients undergoing mediastinal mass operation. Information such as clinical characteristics, perioperative management and patients' outcomes were abstracted and analyzed. Seventy-seven case reports with 85 patients aging from 34 days to 81 years were included. Mediastinal masses were located in anterior (n = 48), superior (n = 15), middle (n = 9) and posterior (n = 9) mediastinum, respectively. Clinical manifestations included dyspnea (n = 45), cough (n = 29), chest or radiating pain (n = 12), swelling (n = 8), fever (n = 7) and chest distress (n = 4). Most patients (n = 75) had signs of compression or invasion of vital structures. General anesthesia (n = 76) was the most commonly used method of anesthesia. Muscle relaxants were administered in 35 patients during anesthesia induction and spontaneous respiration was maintained in 37 patients. Mediastinal mass syndrome (MMS) occurred in 39 cases. Extracorporeal circulation was utilized in 20 patients intraoperatively. Three patients experienced cardiac arrest after ventilation failure and two patients died intraoperatively and one postoperatively. Peri-operative management of patients undergoing mediastinal mass operation could be challenging. Pre-operative multi-disciplinary discussion, well-planned anesthetic management and pre-determined protocols for emergency situations are all vital to patient safety.

Prone position thoracoscopic-assisted total mesoesophageal excision: initial experiences and benefits of lymph node dissection.

Total mesoesophageal excision (TME) is a promising procedure. Prone position thoracoscopic-assisted TME might be a good choice, even without robust evidence yet. Therefore, it is necessary to explore the safety and efficacy of this procedure. We retrospectively analyzed the short-term outcomes regarding intraoperative unplanned events, postoperative complications, and lymphadenectomy in 61 patients who underwent prone position thoracoscopic-assisted TME from June, 2020 to August, 2021. The learning curve was also defined. Of these sixty-one patients, there were 10, 24 and 27 cases of tumor in the upper, middle, and lower thoracic, respectively. Although there were five cases of unplanned events during surgery, no conversion to thoracotomy occurred. The median thoracic operation time was 113(43-161) minutes, R0 resection rate was 93.4% (57/61), and negative circumferential resection margin rate was 96.7% (59/61). Median overall lymph node dissection was 21(9-47), with 13(5-41) thoracic lymph node dissection. Incidence of postoperative pulmonary complications, cardiovascular complications, and leakage were 9.8%, 3.3%, and 9.8%, respectively, with no death within 30days after operation. The positive rate of middle and lower mediastinal lymph nodes was 1.1%, 3.5%, and 2.4% for upper, middle, and lower tumors, and 5.5%, 1.8%, and 1.3% for pT3-4, pT2, and pT1 patients. Learning curve showed that 36 cases are the best cut-off value for proficiency of prone position thoracoscopic-assisted TME. The prone position thoracoscopic-assisted TME is a safe procedure that is more conducive to thoracic lymph node dissection, especially for middle and lower mediastinum.

A Phase 2 Study of Palbociclib for Recurrent or Refractory Advanced Thymic Epithelial Tumors (KCSG LU17-21)

IntroductionThymic epithelial tumors (TETs) are rare but are the most common tumors of the anterior mediastinum. Platinum-based combination chemotherapy is the standard of care for such tumors and is associated with a 50% to 90% objective response rate (ORR) in metastatic disease. Nevertheless, there is no standard chemotherapeutic option after failure of platinum-based combination chemotherapy. Genetic alterations associated with the cell cycle, including pRB, p16INK4A, and cyclin D1, are most often observed in TETs. On the basis of these results, we conducted a phase 2 trial to evaluate the efficacy and safety of palbociclib in patients with recurrent or refractory advanced TETs. MethodsThis is a phase 2, multicenter, open-label, single-arm study of palbociclib monotherapy in patients with recurrent or metastatic advanced TETs who failed one or more cytotoxic chemotherapies. The patients received 125 mg of oral palbociclib daily for 21 days, followed by a 7-day break. The primary end point was progression-free survival (PFS). The secondary end points were ORR, duration of response, overall survival, and safety. ResultsBetween August 2017 and October 2019, a total of 48 patients were enrolled. The median number of previous chemotherapies was one (range: one to four), and 21 (43.7%) of 48 patients received thymectomy. By the WHO classification, the patients were type A (n = 1), type B1 (n = 2), type B2 (n = 8), type B3 (n = 13), thymic carcinoma (n = 23), and unknown (n = 1). With a median follow-up of 14.5 months (range: 0.8–38.2), the median number of cycles of palbociclib monotherapy was 10 (range: 1–40). The ORR was 12.5% (four partial responses in thymoma and two partial responses in thymic carcinoma). The PFS at 6 months was 60.2%, and the median PFS was 11.0 months (95% confidence interval: 4.6–17.4). The median overall survival was 26.4 months (95% confidence interval: 17.4–35.4). The most common treatment-related adverse events of any grade were neutropenia (62.5%), anemia (37.5%), and thrombocytopenia (29.1%), and the most common grade 3/4 treatment-related hematologic adverse event was neutropenia (41.7%). Neutropenia above grade 3 was reversible, and there were no cases with neutropenic fever. ConclusionsPalbociclib monotherapy was well tolerated and had encouraging efficacy in patients with TETs who failed platinum-based combination chemotherapy.

Transbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: a multicentre, open-label, randomised trial

Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases. We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984. Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04-1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05-1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96-1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14-1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3-4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11-3·96]; p=1·00). There were no severe complications causing death or disability. The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases. National Natural Science Foundation of China.

Location, Location, Location: A Treatment Planning Study Comparing OAR Sparing between IMRT and PBS Plans Based on Disease Location Using the Ann Arbor Staging System for Hodgkin and Aggressive Non-Hodgkin Lymphoma

<h3>Purpose/Objective(s)</h3> Radiotherapy (RT) is often used as a component pf combined-modality therapy for patients with Hodgkin (HL) and aggressive non-Hodgkin(aNHL) lymphoma. RT options include photon intensity-modulated (IMRT) or proton (PT) RT. While the latter offers improved organ-at-risk (OAR) sparing, PT is a limited resource. As such, to guide provider and patient decision-making, it is important to identify cases in which PT has the greatest impact. Accordingly, we sought to assess the difference in OAR sparing between photon IMRT and pencil-beam-scanning (PBS) PT based on disease location using the Ann Arbor staging system. <h3>Materials/Methods</h3> Patients with HL or aNHL treated using either photon or proton RT at a single institution between 2007 and 2020 were considered for analysis. Of these, a preliminary subset of 43 patients, all with mediastinal disease, was selected for a comparative dosimetric analysis. Two plans—IMRT and PBS PT—were developed for each patient using consistent planning techniques. OAR differences were assessed based on disease location using the Ann Arbor staging system. Lower mediastinal disease referred to disease below the aortic valve. <h3>Results</h3> The initial dosimetric analysis focused on 6 disease locations and 5 OARs, including the heart, two cardiac substructures, lungs, and breast (female patients only). Table 1 shows PBS plans relative to IMRT, providing the percent decrease in mean dose to the 5 OARs when employing PBS. <h3>Conclusion</h3> The use of PBS resulted in a substantial decrease in the mean dose to OARs, the magnitude of which depended on the disease location. Sparing in the left hilar and right hilar locations did not vary substantially from the general cohort, while patients with left axillary disease did receive a meaningful increase in sparing to the left ventricle when compared to the general cohort. Sparing was less prominent in patients with lower mediastinal disease. However, the absolute dose to the OARs was higher for these patients and sparing may still be clinically valuable. This preliminary analysis represents a portion of the total cohort available to the study. Further work will be performed to fully establish patterns and evaluate statistical significance.

Pattern of Lymph Node Metastases and its Implication in Radiotherapeutic Clinical Target Volume in Patients with Small Cell Carcinoma of the Esophagus

<h3>Purpose/Objective(s)</h3> In order to study the pattern of lymph node metastases after esophagectomy of small cell carcinoma of the esophagus (SCCE) and clarify the clinical target volume (CTV) delineation of definite radiotherapy for SCCE. <h3>Materials/Methods</h3> From January 2007 to December 2020, 286 patients with SCCE who had undergone esophagectomy and lymphadenectomy were retrospectively examined from 14 cancer centers in China. The distribution of lymph node metastases was evaluated and the clinicopathologic factors related to lymph node metastasis were analyzed using logistic regression analysis. <h3>Results</h3> 177 patients (61.9%) occurred lymph node metastases in the 286 patients, including 1 positive lymph node (n=58), 2 positive lymph nodes (n=32), 3 positive lymph nodes (n=32) and more than 4 positive lymph nodes (n=55). The mean number of dissected lymph nodes was 17.0, with a rage of 7-60. The incidence of lymph node metastasis was 12.3% (597/4850). The rates of lymph node metastases in patients with upper thoracic tumors were 0% cervical, 32.1% (9/28) upper mediastinal, 7.1% (2/28) middle mediastinal, 0% lower mediastinal, 3.6% (1/28) abdominal, respectively. The rates of lymph node metastases in patients with middle thoracic tumors were 4.3% (6/139), 20.9% (29/139) , 26.6% (37/139) , 2.9% (4/139) , 25.9% (36/139), respectively. The rates of lymph node metastases in patients with lower thoracic tumors were 0%, 12.6% (15/119) , 41.2% (49/119) , 5.0% (6/119) , 47.9% (57/119), respectively. T stage and the length of tumor were the statistically significant risk factors of lymph node metastases of SCCE (<i>P</i><0.05). <h3>Conclusion</h3> To our known, this is a first study about investigating the pattern of lymph node metastases after esophagectomy and guiding the CTV delineation of definite radiotherapy for SCCE. Regardless of tumor location, the upper middle mediastinum is high incidence area of lymph node metastases, abdominal is also high incidence area of lymph node metastases for middle and lower thoracic tumors. The rate of lymph node metastasis of the SCCE increased with the T stage and the length of tumor. These factors and the correlated lymphatic drainage regions should be considered when designing the CTV for Selective regional irradiation of SCCE.

The influence of 10-year Nuss bar placement on bar removal: a case report

BackgroundThe Nuss bar is commonly used for minimally invasive correction of pectus excavatum and is usually removed within 2–3 years. Here, we report a case of 10-year bar placement after the Nuss procedure accompanied by unique complications of thoracic malformation that have not been described before. The asymmetric pectus carinatum caused by bar displacement and significant rib periosteal hyperplasia is described for the first time.Case presentationA 23-year-old man was admitted to our hospital due to the main complaint of obvious chest discomfort when lifting heavy weights. The bar removal was seriously delayed due to his loss to follow-up. Chest asymmetry and distant heart sounds were found during a physical examination. A chest CT scan demonstrated that the right end of the lower bar originally fixed outside the ribs had shifted into the thoracic cavity, and the left costal cartilage was obviously protruding. Additionally, the displaced bars were separated from the sternum and tightly attached to the pericardium, resulting in abnormalities of the anterior mediastinum. These secondary thoracic deformities made the patient extremely prone to massive hemorrhage or multiple rib fractures when sliding the bars out. However, serious consequences were avoided due to reasonable adjustments to the usual bar removal procedures.ConclusionThis case demonstrates a specific type of bar displacement caused by prolonged placement of the bars and highlights the importance of rigorous follow-up of patients after the Nuss procedure.

Surgical resection of a tuberculoma in the diaphragm: a case report

BackgroundExtrapulmonary tuberculosis commonly affects the lymphatic system, nervous system, and gastrointestinal system. Tuberculous infection in the muscle is very rare. Moreover, tuberculous infection in the diaphragm is extremely rare. We herein report a case of tuberculomas in the diaphragm and posterior mediastinum that were successfully diagnosed and treated.Case presentationWe encountered a 62-year-old woman with a tuberculoma in the diaphragm. The patient presented with mild dyspnea. Computed tomography showed a mass in the left diaphragm, focal thickening of the posterior mediastinum, and multiple nodules in the lungs. Positron emission tomography–computed tomography showed increased uptake in the left diaphragm mass and thickening of the posterior mediastinum; therefore, we considered the masses to be malignant and planned surgical resection. However, the patient was diagnosed with tuberculosis from a sputum culture, and she was treated with anti-tuberculous therapy. The masses in the diaphragm and posterior mediastinum had become enlarged after 6 months of anti-tuberculous therapy; therefore, the patient underwent resection of both masses. Tuberculous infection was histologically confirmed in each lesion. She was pathologically diagnosed with tuberculous abscesses in the diaphragm and posterior mediastinum and began treatment with anti-tuberculosis drugs.ConclusionsPreoperative diagnosis of a tuberculoma in the diaphragm is usually difficult, and surgical intervention is important for both diagnosis and treatment.

Role of diffusion-weighted MRI in differentiation between benign and malignant anterior mediastinal masses.

Diffusion-weighted imaging (DWI) is considered to be a useful biomarker to characterize the cellularity of lesions, yet its application in the thorax to evaluate anterior mediastinal lesions has not been well investigated. The aims of our study were to describe the magnetic resonance (MR) characteristics of anterior mediastinal masses and to assess the role of apparent diffusion coefficient (ADC) value in distinguishing benign from malignant lesions of the anterior mediastinum. We conducted a retrospective cross-sectional study including 55 patients with anterior mediastinal masses who underwent preinterventional MR scanning with the following sequences: T1 VIBE DIXON pre and post-contrast, T2 HASTE, T2 TIRM, DWI-ADC map (b values of 0 and 2000 sec/mm2). The ADC measurements were obtained by two approaches: hot-spot ROI and whole-tumor histogram analysis. The lesions were grouped by three distinct ways: benign versus malignant, group A (benign lesions and type A, AB, B1 thymoma) versus group B (type B2, B3 thymoma and other malignant lesions), lymphoma versus other malignancies. The study was composed of 55 patients, with 5 benign lesions and 50 malignant lesions. The ADCmean, ADCmedian, ADC10, ADC90 in the histogram-based approach and the hot-spot-ROI-based mean ADC of the malignant lesions were significantly lower than those of benign lesions (P values< 0.05). The hot-spot-ROI-based mean ADC had the highest value in differentiation between benign and malignant mediastinal lesions, as well as between group A and group B; the ADC cutoffs (with sensitivity, specificity) to differentiate malignant from benign lesions and group A from group B were 1.17 x 10-3 mm2/sec (80%, 80%) and 0.99 x 10-3 mm2/sec (78.4%, 88.9%), respectively. The ADC values obtained by using the hot-spot-ROI-based and the histogram-based approaches are helpful in differentiating benign and malignant anterior mediastinal masses.

A Single Center Analysis of Thymic Neuroendocrine Tumors

Simple SummaryThymic neuroendocrine tumors are extremely rare and therefore few published studies currently exist. This study sought to investigate the basic clinical characteristics, treatment and prognosis of TNETs using single-center retrospective data and to address this gap in the literature. We found that thymic neuroendocrine tumors are a rare and aggressive disease with a high recurrence rate even in typical carcinoid tumors that are usually considered to have a good prognosis, with local recurrence and bone metastases being a common mode of treatment failure. Despite the widely accepted view that surgical resection should be the treatment of choice for thymic neuroendocrine tumors, we found that combination therapy including radiotherapy and chemotherapy is necessary to address the high recurrence rate of this typically aggressive tumor. In addition, patients who suffered from large vessel invasion in our study had a lower rate of overall survival and a high risk of tumor progression, other therapeutic regimes should be explored for these patients.Purpose: Thymic neuroendocrine tumors (TNETs) are a collection of slow-progressing neoplasms located in the anterior mediastinum. Relatively few previously published studies have focused on thymic carcinomas. This study investigated the basic clinical characteristics, treatment, and prognosis of TNETs. Methods: Patients were enrolled in the study from January 2003 to December 2017 who had been diagnosed with TNETs through pathological screening and treated at our institution. Demographic data from each patient, the Masaoka stage, histology and size of the tumor, tumor invasion characteristics, and therapeutic strategies were gathered. The Kaplan–Meier method was used to assess patient survival. In addition, the log-rank test was used to carry out univariate analyses. Results: Twenty-six patients were eligible for inclusion in the study. The median age of the patients was 46.5 (25–69) years. The tumor median maximum diameter was 7.9 cm (from 3 to 19 cm). Twenty-four patients were treated surgically. Nineteen patients completed radiation therapy, and sixteen patients underwent chemotherapy. A median follow-up time of 54.95 months was observed. The survival rate for three years was 75.0% and 70.6% for five years. The corresponding progression-free survival rates for three and five years were 55.7% and 37.7%, respectively. The local, regional recurrence-free survival (LRFS) rates were 87.2% and 81.7%, and the distant metastasis-free survival (DMFS) rates were 55.7% and 37.7%, at three and five years, respectively. Local recurrence (six patients) and bone metastasis (six patients) were observed as the most frequent failures. Conclusion: TNET was observed to be an aggressive but rare malignant lesion. While the predominant treatment was complete resection, chemotherapy and radiotherapy were also required due to the high recurrence rate.

Combined use of the GlideScope and flexible fiberoptic bronchoscope after several failed intubation attempts for a retrosternal thyroid mass: a case report

A GlideScope® and a flexible fiberoptic bronchoscope (FOB) were successfully used in combination, to intubate a 73-year-old female patient in which repeated previous intubation attempts with conventional laryngoscope had failed. GlideScope®, and FOB were used sequentially. She had been scheduled for an elective total thyroidectomy to remove a huge retrosternal goiter. A computed tomography (CT) scan revealed a large necrotic mass (measuring 10 x 16 cm) with heterogeneous enhancement involving the thyroid gland and extending to the anterior mediastinum, causing significant tracheal compression and left deviation. Endotracheal intubation was successfully performed while she was awake using a combination of GlideScope and FOB. The operation lasted for two hours and was uneventful. The patient was then transferred to the intensive care unit (ICU) and kept intubated, sedated, and mechanically ventilated overnight. She was awakened and extubated the following day with no airway complications.&#x0D; Key words: Adult; Failed intubation; Female; Fiberoptic bronchoscope; GlideScope; Humans; Intubation, Intratracheal; Retrosternal thyroid mass&#x0D; Citation: Abaalkhayl MS. Combined use of the GlideScope and flexible fiberoptic bronchoscope after several failed intubation attempts for a retrosternal thyroid mass: a case report. Anaesth. pain intensive care 2022;26(4):554-558; DOI: 10.35975/apic.v26i4.1965&#x0D; Received: July 05, 2022; Reviewed: July 14, 2022; Accepted: July 16, 2022&#x0D;

P025: RADAR: An international phase III, PET response-adapted, randomised trial in progress, comparing ABVD±ISRT with brentuximab vedotin+AVD±ISRT in patients with previously untreated limited-stage classical Hodgkin lymphoma

Figure 1: RADAR trial schema Background: Limited-stage classical Hodgkin lymphoma (lsHL), stages I or II without B-symptoms or mediastinal bulk disease, has excellent long-term survival (≥90%) with modern treatment. Commonly used approaches, based on GSHG and EORTC trials, include 2–4 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) plus 20 or 30 Gy radiotherapy (RT), but there are concerns about the impact of using RT in all patients (pts) on the incidence of 2nd cancers and cardiovascular disease. In the UK NCRI RAPID trial, pts who had a -ve PET scan after 3 cycles of ABVD were randomised between RT and no RT; outcomes in the no RT arm were very good but the non-inferiority margin of -7% was not achieved. The RADAR trial is building on the PET-adapted approach of RAPID but intending to make the chemotherapy more effective by replacing bleomycin with the CD30 targeted antibody drug conjugate, brentuximab vedotin (BV), in the BV+AVD regimen. Early phase trials of BV+AVD in lsHL and the phase III ECHELON-1 trial in advanced HL have demonstrated its efficacy and safety. In addition, RT will be integrated on an individualised basis to pts in RADAR who are PET -ve after initial chemotherapy but with larger nodal masses at baseline. Methods: RADAR comprises 2 parallel identical phase III randomised multicentre trials in the UK, Europe, Australia, New Zealand (trial 1; 642 pts), Canada and the USA (trial 2; 400 pts). Eligibility: age 16–69 years, previously untreated stage IA/IIA HL above the diaphragm, any mediastinal mass ≤0.33 of internal thoracic diameter, informed consent. Pts will be randomised to receive either ABVD or BV+AVD. A centrally-reviewed PET-CT scan after cycle 2 (PET2) will determine further treatment (Deauville score (DS) 1–3: total 3 cycles +/- individualised RT; DS 4: total 4 cycles + 30 Gy ISRT; DS 5: treatment failure, subsequent treatment of clinician’s choice). 1y endpoint is progression free survival (PFS) and the trial will have 85% power to show an improvement from 90 to 95% PFS at 3 years (HR of 0.49) with 2-sided 5% alpha. 2y endpoints are CMR rate at PET2, event-free survival (progression, death, PET2 DS 4–5), OS, safety and toxicity including cardiovascular disease and second cancers. Exploratory endpoints: predictive value of PET after 1 cycle, prognostic value of baseline metabolic tumour volume. Embedded translational research aims to identify biomarkers predictive of treatment failure. RADAR opened to recruitment in April 2022.

Proton Radiation Therapy After Chemotherapy in the Management of Aggressive Mediastinal Non-Hodgkin Lymphomas: A Particle Therapy Cooperative Group Lymphoma Subcommittee Collaboration

PurposeCombined modality therapy with multiagent chemotherapy and radiation therapy is a standard treatment option for aggressive mediastinal non-Hodgkin lymphomas (AMNHLs); however, concerns regarding acute and late radiation toxicities have fueled an effort to use systemic therapy alone. The use of proton therapy (PT) is a promising treatment option, but there are still limited data regarding clinical outcomes with this treatment modality. In this Particle Therapy Cooperative Group lymphoma subcommittee collaboration, we report outcomes of patients with AMNHL treated with pencil-beam scanning PT or double-scatter PT after chemotherapy. Methods and MaterialsThis was a multi-institutional retrospective observational cohort study of patients with AMNHL treated with PT following chemotherapy between 2011 and 2021. Progression-free survival (PFS), local recurrence–free survival (LRFS), and overall survival (OS) rates were estimated with the Kaplan-Meier method. PT toxicity was graded by the Common Terminology Criteria for Adverse Events version 5.0. A 2-tailed paired t test was used for dosimetric comparisons. ResultsTwenty-nine patients were identified. With a median follow-up time of 4.2 years (range, 0.2-8.9 years), the estimated 5-year PFS for all patients was 93%, 5-year LRFS was 96%, and estimated 5-year OS was 87%. Maximum acute grade 1 (G1) toxicities occurred in 18 patients, and 7 patients had maximum G2 toxicities. No G3+ radiation-related toxicities were observed. Average mean lung dose and lung V20 Gy were lower for patients treated with pencil-beam scanning PT compared with double-scatter PT (P = .016 and .006, respectively), while patients with lower mediastinal disease had higher doses for all evaluated dosimetric heart parameters. ConclusionsPT after chemotherapy for patients with AMNHL resulted in excellent outcomes with respect to 5-year PFS, LRFS, and OS without high-grade toxicities. Future work with larger sample sizes is warranted to further elucidate the role of PT in the treatment of AMNHL.

S369 Dysphagia From an Ischemic Colonic Segment in a Patient With Colon Interposition

Introduction: Colon interposition of the esophagus in adults may lead to future complications including chronic ischemia, stricture formation, and adenocarcinoma. Case Description/Methods: A 39-year-old male immigrant presented with progressive dysphagia, in the setting of a remote history of emergent colon interposition following gunshot wounds of the esophagus. In the prior 6 months, he developed dysphagia with solids and then liquids, with associated weight loss and regurgitation. On admission, he had stable vitals with an unremarkable physical exam and labs. Esophagram revealed a severe high-grade, upper-mid esophageal stricture with proximal dilation (Figure 1A). Computed Tomography (CT) imaging showed an esophageal conduit in the anterior mediastinum with proximal conduit distension and distal conduit narrowing (Figure 1B). Esophagoduodenoscopy (EGD) revealed a stricture (6 mm) at the esophago-colonic anastomosis, 19 cm from the incisors (Figure 1C). This was traversed with an ultra-thin endoscope which also revealed a severe stenosis distally in the colon segment with a partially obstructing inflammatory polyp. The proximal stricture was dilated in a staged fashion to advance the upper endoscope to the colonic stenosis. A wire was advanced and the stenosis length was estimated to be 11 cm under fluoroscopy. This was successfully stented with 20 mm x 12 cm covered metal stent. The stent was removed one month following the procedure with initial improvement in dysphagia and a normalized diet. However, the patient had re-occurring symptoms and a repeat EGD with dilation and stenting was performed one week later. The multidisciplinary team recommended definitive treatment for the chronic ischemic segment-related complications. Discussion: Conduit ischemia with anastomotic strictures can occur in patients with a history of colonic interposition. Evaluation with double contrast studies may reveal ischemic changes including loss of haustration and stricture formation in the colon graft with dilation being an effective treatment. Chronic ischemia can be a delayed complication of the interposed colon resulting from non-necrotic vascular insufficiency leading to fibrosis, stricture formation, and dysphagia. Additionally, given the patient’s stricture and mass, there was concern for underlying malignancy, which highlights the utility of adenocarcinoma screening in this patient population. Watch the video at https://tinyurl.com/ACGAbstractS369Figure 1.: 1A: Esophagram showing severe high-grade stricture at the junction of the cranial one third and distal two thirds of the esophagus. 1B: CT chest showing conduit extending along anterior mediastinum and deep into the sternum with anastomosis in upper neck and abrupt caliber change in mid esophageal conduit at level of right main pulmonary artery with associated wall thickening, fat stranding, and small adjacent lymph nodes measuring up to 5mm (red arrow). 1C: Esophago-colonic anastomosis found in the middle/lower third of the esophagus at 29cm from incisors.

RARE PRESENTATION OF A THYMOMA AT AN INFREQUENT LOCATION

RARE PRESENTATION OF A THYMOMA AT AN INFREQUENT LOCATION

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME

IATROGENIC PNEUMOMEDIASTINUM AND PNEUMOTHORAX AFTER SMALL-BORE FEEDING TUBE PLACEMENT IN A PATIENT WITH EHLERS-DANLOS SYNDROME