Mediastinal Research Articles

Double tracheoesophageal fistula after prolonged intubation during COVID-19: surgical treatment by colonic transposition in the retrosternal space

This is a patient with 2 tracheoesophageal fistulas following prolonged intubation due to COVID-19 with severe evolution and indication for surgical treatment due to failure of endoscopic treatment. Patient in a long hospital stay, unable to eat an oral diet, malnourished, chronic cough, developing persistent pneumonia due to recurrent salivary bronchoaspiration. The case was treated by complex surgical intervention consisting of proximal and distal partial esophagectomy with reconstruction of food transit by colonic bypass in the anterior mediastinum, resection and tracheal reanastomosis. The final result was good, with the patient being discharged from the hospital on a restored oral diet and free spontaneous breathing. The resolution of an extremely serious case through a complex and exceptional surgical approach, which imposed enormous challenges in pre-operative preparation and detailed therapeutic planning, with single-stage surgical action by two surgical teams (Digestive System Surgery and Thoracic Surgery).

Hepatic cholera: a case report with literature review

BackgroundVasoactive intestinal peptide-secreting tumors (VIPomas), also known as WDHA syndrome (or “pancreatic cholera”), are rare neuroendocrine tumors (NETs) with an incidence of 0.05 to 2%. It secretes excessive amounts of VIP, leading to watery diarrhea, hypokalemia, and hypochlorhydria. In adults, they occur most commonly between the ages of 30 and 50 years and are mostly intrapancreatic, occurring in the tail of the pancreas, and rarely located in other segments of the gastrointestinal tract, such as the adrenal glands (35%), paraspinal retroperitoneal ganglia (30–35%), posterior mediastinum (20%), head and neck (1–5%), pelvis (2–3%), and rarely (1%) thymus, lung, kidney, anterior mediastinum, and liver.Case presentationOur patient, a 22-year-old man, was admitted with recurrent episodes of large-volume chronic watery diarrhea, generalized muscle weakness, and significant weight loss. After a complete workup, a solitary primary hepatic VIPoma was diagnosed. The patient underwent surgical resection of the liver lesion. Following surgery, there was immediate regression of diarrhea and electrolyte abnormalities, with no recurrence at the 1-year follow-up.ConclusionNeuroendocrine tumors, particularly VIPomas, are rare and mostly intrapancreatic. Solitary primary hepatic VIPoma is extremely rare, and to the best of our knowledge, only four cases without any evidence of a pancreatic lesion have been reported. Diagnosis remains challenging, as it is often not detected on conventional imaging. The prognosis mostly depends on tumor grade, stage, and surgical resectability.

Local Disease-Free Survival and Disease-Free Survival in Locally Advanced Cervical Cancer Diagnosed and Treated in Bihor County, Romania.

Cervical cancer is the fourth most dangerous malignancy worldwide in women and is diagnosed at the advanced stages in most cases. Oncological and surgical modalities when precisely employed together can prove to be helpful for determining the proper diagnosis and treatment strategies. Neoadjuvant chemotherapy (NACT) has been found to have a role in reducing tumor size and has evolved as a treatment regimen for locally advanced cervical cancer (LACC). The present study aimed to analyze the treatment strategies either with neoadjuvant platinum-based chemotherapy (NACT) administration or not and pathological responses in patients with LACC. We reviewed 100 patients of LACC from October 2018 to December 2022 at Bihor County Emergency Clinical Hospital. About 43 patients underwent radiation therapy in addition to NACT administration (NACT+/other) and 57 underwent other treatment regimens without neoadjuvant treatment (NACT-/ other). Various demographic parameters, FIGO staging, histological status, surgical interventions, and survival rate (local disease-free survival (LDFS) and disease-free survival (DFS)) were accessed in both groups. Statistical analysis was performed to analyze the significance of various parameters studied. The mean age range of the studied sample was 57.05 ± 12.51 in NACT+/other and 60.4±12.32 in NACT-/other. Among 100 patients, 90 cases of squamous carcinoma, eight of adenocarcinoma, and two cases of adenosquamous carcinoma were analyzed and treated. At stage IIIC1, 11 patients were accessed while 15 patients were at clinical stage IIIC2, and among these, 25.58% received neoadjuvant oncological treatment and very limited mediastinal disease. DFS rates are greater in the patients who have undergone surgery in the NACT+/other group, while in the LDFS, there is better survival in the case of surgery without any NACT treatment (NACT-/other). The effect of NACT can be suggested as another important treatment strategy and result in a good response in terms of DFS and LDFS in patients with LACC. This approach aims to reduce tumor size preoperatively, facilitating surgical removal and potentially improving patient outcomes compared to other treatment modalities. Thus, it can be concluded that NACT may be considered an important strategy to be opted for the treatment of LACC.

Thymus gland and thymic dysfunctions in children

The thymus is the organ that has gained significant awareness in the last two centuries, being considered the main donor of cells for the lymphatic system, much like the bone marrow is the donor of cells for the cardiovascular system. Currently, knowledge regarding the thymus gland has considerably improved. Thymic dysfunctions encompass congenital and acquired conditions, which manifest through organ hypoplasia or hyperplasia, as well as formations/tumors of the anterior mediastinum.

MEDIASTINITIS, WHAT SHOULD WE KNOW: A CASE REPORT OF PNEUMOPYOTHORAX WITH SUSPECTED MEDIASTINITIS IN A 67-YEAR-OLD MALE

Mediastinal disease consists of various diagnoses that have different characteristics, and the severity is not the same. The mediastinal disease diagnosis is often delayed because of the non-specific and sometimes vague presentation and clinical symptoms. One of the commonly missed diagnoses is acute mediastinitis, which is usually presented with fever, pleuritic or retrosternal chest pain, and an inflammatory syndrome. Careful clinical evaluation and radiological correlation are essential when diagnosing mediastinitis, as well as the need to differentiate it from mediastinal infiltration due to malignancy. In this case report, we describe a 67-year-old male, who was referred with pyothorax, cough, and 10 kg of weight loss in the last 1 month. The patient then underwent a CT examination with contrast to establish the diagnosis. Finally, the patient was diagnosed with pneumopyothorax with suspicion of mediastinitis and abscess formation. The lessons learned from this case include the need for recognizing features of mediastinitis, such as fat stranding and fluid collection, which may contain gas locules, in the mediastinal region. The aim of this case report is to increase awareness of early signs of mediastinitis so that prompt management can be initiated as early as possible. Keywords: Mediastinitis, pneumopyothorax, CT thorax

Resection of pleural solitary fibrous tumors with distinct feeding vessels arising from the descending aorta: a case report

BackgroundPleural solitary fibrous tumors (pSFTs) are rare mesenchymal pleural tumors with rich vascularity. Surgical resection is the cornerstone of pSFTs treatment, requiring careful preoperative imaging to delineate lesion extent and vascular supply including contrast-enhanced computed tomography and other examinations depending on its size and characteristics.Case presentationThe patient was a 34-year-old female with a mass measuring approximately 67 × 42 × 65 mm in the left posterior mediastinum. Intraoperatively, the mass demonstrated rich vascularity. Two veins originating from the abdominal cavity entered the lower pole, one converged from the superior pole, draining into the brachiocephalic vein. Additionally, two arteries arose directly from the descending aorta, while several veins drained into the intercostal veins. In response to unexpected intraoperative vascular findings, vascular clips and silk threads were used to ligate them. Subsequently, the tumor was successfully dissected, with approximately 600 ml of blood loss recorded during the 4-hour surgery. The patient exhibited a satisfactory postoperative recovery, and follow-up spanning over six months revealed no indications of recurrence or metastasis.ConclusionsWe firstly present a case of successful resection of a pSFT in a 34-year-old woman with a distinct feeding vessel arising from the descending aorta and describe the related surgical procedures. This case highlights preoperative evaluation of mass vascularity based on contrast-enhanced computed tomography. When blood supply is challenging to clarify, angiography can offer additional details, especially for giant pSFTs. Despite this, thorough intraoperative exploration remains essential to detect unexpected vessels. Appropriate interventions should be customized based on the vascular origins and the surrounding anatomical structures.

Short-term outcomes of robotic subxiphoid-optical thymectomy.

To evaluate the usefulness of robotic subxiphoid-optical thymectomy (RST). Thirty-seven procedures (thymoma, n = 19; thymic carcinoma, n = 1; myasthenia gravis, n = 3; and others, n = 14) performed between October 2020 and December 2023 were included. The right and left 6th intercostal midclavicular lines and subxiphoid, with an assistant port placed in the right third intercostal anterior axillary line, were adapted. Postoperative pain was assessed using a numerical rating scale (NRS). A good view of the surgical field is obtained. The median console time was 113min and the time to roll-in was 30min. The body mass index (BMI) was 21.6. One patient with thymic carcinoma required combined resection of the left phrenic nerve and left brachiocephalic vein without conversion to thoracotomy, and 1 patient had post-pericardiotomy syndrome with bilateral pleural effusion. There was a correlation between the prolonged time to roll-in and BMI (ρ = 0.439; p = 0.007). Pain was controlled with oral medication on postoperative day 1 and significantly decreased at discharge and at the first outpatient visit without epidural anesthesia (median NRS scores: 4, 1, and 1, respectively). RST is a safe procedure that provides surgeons with a sufficient view of the anterior mediastinum and causes minimal postoperative pain.

Thymic Rosai-Dorfmann disease: a case report

BackgroundRosai-Dorfman disease (RDD), known as sinus histiocytosis with massive lymphadenopathy, commonly involves lymph nodes in the neck or mediastinum, although extranodal involvement is observed in approximately 40% of RDD patients. RDD involving only the thymus has rarely been reported. Here, we report a case of RDD originating in the thymus. The lesion was surgically removed, and a cure was finally achieved. There was no recurrence after telephone follow-up for 3 years.Case presentationA 52-year-old male was accidentally found to have a 7 × 6 cm anterior mediastinum lump by chest computed tomography (CT). The mediastinal lesion was resected by surgery, and postoperative pathology revealed RDD originating from the thymus. Regular telephone follow-up after surgery lasted 3 years and showed that the patient remained in good condition without any relevant symptoms.ConclusionsRDD originating in the thymus cannot be characterized from CT images and is easily misdiagnosed as a traditional mediastinal tumor. This is mainly because there is so little disease in this area that physicians are not aware of it. We report this case with the hope that clinicians will have a better understanding of this disease. According to our follow-up results, surgery is an effective means of treatment.

Ectopic Cervical Thymus in Adult: An Incidental Finding.

Thymus is a paired organ which develops during the sixth week of fetal life, attains maximum size by three years and involutes in adult life. Anatomically it is situated in superior mediastinum. Thymus can be present at ectopic sites like neck, skull base, middle ear, submandibular gland and tonsil. Ectopic Cervical Thymus (ECT) is very rare in adults and can present as a solid mass, cyst or thymoma. ECT occurs due to failure of descent during embryonic development. ECT can mimic any pathologic mass, metastatic deposit or lymph node enlargement. We report a case of ECT discovered incidentally in an adult during histopathological examination of thyroid carcinoma. In addition, we described the role of immunohistochemistry markers to confirm the various thymic components.

Insulinoma-Associated Protein-1 Expression in Lymphoepithelial Carcinoma of the Thymus: A Potential Pitfall for Diagnosis With Neuroendocrine Carcinomas of the Thymus.

Insulinoma-associated protein-1 (INSM1) is a recently developed immunohistochemical marker claimed to be highly specific and sensitive for the diagnosis of neuroendocrine malignancies. Recent studies, however, have demonstrated that this marker can also be expressed in non-neuroendocrine neoplasms including squamous cell carcinoma of the thymus. To examine INSM1 expression in lymphoepithelial thymic carcinomas. Thirty-four cases of lymphoepithelial carcinoma of the thymus were examined by immunohistochemistry or in situ hybridization for INSM1, synaptophysin, chromogranin, CD5, CD117, Epstein-Barr virus-encoded small ribonucleic acid (EBER), and Ki-67. Basic clinical information was abstracted from the medical record. The patients were 14 women and 20 men, aged 20 to 85 years. The tumors arose in the anterior mediastinum without any previous history or evidence of malignancy at other sites. Immunohistochemical staining showed moderate to strong positivity of the tumor cells for INSM1 in 65% of cases (22 of 34), focal weak positivity in 20% (7 of 34), and negative staining in 5 cases. Chromogranin staining was focally and weakly positive in 1 case, and synaptophysin showed only focal weak positivity in scattered tumor cells in 12 cases. No significant correlation could be identified between the pattern and intensity of staining for INSM1 and staining for CD5, CD117, and Ki-67. INSM1 positivity in lymphoepithelial carcinoma of the thymus may represent a pitfall for diagnosis, particularly in small biopsy samples. Awareness of this finding may be of importance to avoid misdiagnosis of neuroendocrine malignancy.

Magnetic Resonance Elastography of Anterior Mediastinal Tumors

BackgroundPreoperative differentiation of the types of mediastinal tumors is essential. Magnetic resonance (MR) elastography potentially provides a noninvasive method to assess the classification of mediastinal tumor subtypes.PurposeTo evaluate the use of MR elastography in anterior mediastinal masses and to characterize the mechanical properties of tumors of different subtypes.Study TypeProspective.Subjects189 patients with anterior mediastinal tumors (AMTs) confirmed by histopathology (62 thymomas, 53 thymic carcinomas, 57 lymphomas, and 17 germ cell tumors).Field Strength/SequenceA gradient echo‐based 2D MR elastography sequence and a diffusion‐weighted imaging (DWI) sequence at 3.0 T.AssessmentStiffness and apparent diffusion coefficients (ADC) were measured in AMTs using MR elastography‐derived elastograms and DWI‐derived ADC maps, respectively. The aim of this study is to identify whether MR elastography can differentiate between the histological subtypes of ATMs.Statistical TestsOne‐way analysis of variance (ANOVA), two‐way ANOVA, Pearson's linear correlation coefficient (r), receiver operating characteristic (ROC) curve analysis; P < 0.05 was considered significant.ResultsLymphomas had significantly lower stiffness than other AMTs (4.0 ± 0.63 kPa vs. 4.8 ± 1.39 kPa). The mean stiffness of thymic carcinomas was significantly higher than that of other AMTs (5.6 ± 1.41 kPa vs. 4.2 ± 0.94 kPa). Using a cutoff value of 5.0 kPa, ROC analysis showed that lymphomas could be differentiated from other AMTs with an accuracy of 59%, sensitivity of 97%, and specificity of 38%. Using a cutoff value of 5.1 kPa, thymic carcinomas could be differentiated from other AMTs with an accuracy of 84%, sensitivity of 67%, and specificity of 90%. However, there was an overlap in the stiffness values of individual thymomas (4.2 ± 0.71; 3.9–4.5), thymic carcinomas (5.6 ± 1.41; 5.0–6.1), lymphomas (4.0 ± 0.63; 3.8–4.2), and germ cell tumors (4.5 ± 1.79; 3.3–5.6).Data ConclusionMR elastography‐derived stiffness may be used to evaluate AMTs of various histologies.Level of Evidence4.Technical EfficacyStage 2.

Update on thymic epithelial tumors: a narrative review.

Thymoma, thymic carcinoma and thymic neuroendocrine tumors originate from the epithelial cells of the thymus and account for the thymic epithelial tumors (TETs). Although TETs are uncommon, they are the most frequent tumor type in the anterior mediastinum. Multidisciplinary approach is essential for their correct management. The aim of the present review is to summarize the update management for TETs. For this review, we searched in Excerpta Medica database (EMBASE) and MEDLINE until 6 September 2023. The terms used in the search included thymoma, thymic carcinoma, thymic epithelial tumors, management, immunotherapy, multiple tyrosine kinases inhibitors. The therapeutic approach is based on histology and tumor stage and may involve surgery with or without neoadjuvant or adjuvant treatment. In the metastatic setting, platinum-based chemotherapy is the standard of care and patients who do not respond to first-line treatment have limited treatment options mainly because of the poor efficacy shown in subsequent lines of therapy. Future research should focus on identifying predictive biomarkers for patients with TETs, and should implement multicenter collaborations and appropriate clinical trials tailored for rare tumor types. Immune check point inhibitors, mammalian target of rapamycin (mTOR) and antiangiogenic multikinase inhibitors have also been studied in this clinical setting.

Metastatic right atrial mass in the presence of atrial septal defect: A rare clinical coincidence

Key Clinical MessageThe key takeaway from this clinical scenario is to choose the most appropriate and reasonable treatment plan when dealing with a patient who has atrial septal defect (ASD) and concurrent atrial and mediastinal masses. In such cases, a heart‐oncology team should make the therapeutic decision.AbstractRight atrial masses are not pretty rare and might be a diagnostic challenge. Thrombosis, tumors, and vegetations are primary differential diagnoses. Workup for these masses usually includes multimodality imaging and biopsy in selected cases. We report a case of a 37‐year‐old lady who presented with cough, dyspnea, and head and neck swelling after a cesarean section. Echocardiography revealed a right atrial mass accompanied by a secundum type atrial septal defect (ASD). Pulmonary CT Angiography was performed, in which a lobulated mass in the anterior mediastinum was detected, and a heart‐oncology team made the therapeutic decision. The patient was scheduled for surgical ASD closure and concomitant tissue biopsy. The pathology results were in favor of poorly differentiated germ cell tumors, and chemotherapy was started following the surgery. After two sessions of chemotherapy, the tumor did not respond to the primary regimen. Thus, an updated regimen was initiated. Compliance with the updated regimen was acceptable, and the patient is currently under treatment and follow‐up.

Surgical access to the mediastinum-all roads lead to Rome: a literature review.

The mediastinum is a complex, heterogeneous area, which leads vertically across the thoracic cavity between the bilateral mediastinal pleurae, connecting the head and neck region with the thoracic cavity. Different classifications have been published to differentiate between the so-called mediastinal compartments while the most used classification surely is the 4-compartments Gray`s classification, dividing it into the superior, anterior, middle and posterior mediastinum. Mediastinal abnormalities include infections (mediastinitis) and solid or cystic mediastinal masses. These masses can be divided into benign and malignant lesions originating from mediastinal structures/organs or represent manifestations of metastatic disease, often metastatic non-small cell lung cancer (NSCLC). This review aims to explore the different mediastinal pathologies along with indications and surgical approaches. We performed literature research in PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases. Only papers written in English were included. Depending on the indication for surgical intervention and the localization of the pathology, surgical approach may differ immensely. Mediastinal staging of lung cancer, primary lesions of the mediastinum, mediastinitis and traumatic mediastinal injuries display the most frequent indications for mediastinal surgery. Surgical approaches trend towards minimally invasive, video- or robotic-assisted techniques and are becoming increasingly refined to adapt to the special characteristics of the mediastinum. However, certain indications still require open access for best possible mediastinal exposure or oncological reasons. To guide optimal surgical approach selection to the mediastinum, the following overview will present all published surgical approaches to the mediastinum and discuss their practical relevance and indications aiming to help surgeons in the management of patients with mediastinal pathologies who should undergo surgery.

A Rare Presentation of Primary Thymic Small Cell Carcinoma Found after Trauma: A Case Report

Thymic small cell carcinoma is an exceedingly rare diagnosis with undefined treatment options and, typically, poor prognosis. A 69-year-old female presented to the Emergency Department with chest pain and was found on Computed Tomography (CT) to have a multilobulated cystic mass in the anterior mediastinum. Magnetic Resonance Imaging (MRI) demonstrated a 7 x 8 x 8 cm mediastinal mass suspicious for thymoma. Biopsies of enlarged lymph nodes in levels 4L and 7 were negative for malignancy. The patient was taken for surgical resection of the mediastinal mass. After standard sternotomy, the mass was noted to be contiguous with the thymus. The specimen was removed en bloc and surgical pathology revealed high grade neuroendocrine carcinoma, measuring 9.0 cm in greatest dimension, consistent with small cell carcinoma of the thymus. Fibrous adhesions to the lung were noted but all margins and lymph nodes were negative for malignancy. Brain MRI was unremarkable and multidisciplinary tumor board decided to proceed with adjuvant chemotherapy. Patient is currently doing well without symptoms of recurrence one year post-operatively.

The number of resected lymph nodes from the upper mediastinal area predicts long-term outcomes of esophageal squamous cell carcinoma after minimally invasive esophagectomy.

The total number of resected lymph nodes (LNs) is an important determinant of longer survival after esophagectomy for esophageal squamous cell carcinoma (ESCC). However, the resected LN counts from areas that affect long-term outcomes remain unclear. This study included 406 patients who underwent minimally invasive esophagectomies (MIEs) at Kobe University Hospital. Resected LN counts were evaluated in the following areas: upper mediastinal (UM), middle mediastinal (MM), lower mediastinal (LM), and abdominal (Abd). Cut-off values for LN counts from each area were determined using receiver operating characteristics analysis of the survival status. Cox proportional hazards regression analyses were performed to identify prognostic factors. The cut-off values for large or small numbers of resected LN counts in the UM, MM, LM, and Abd areas were 4, 8, 5, and 18, respectively, in patients with upper and middle thoracic (Ut/Mt) ESCC and 7, 6, 5, and 24, respectively, in patients with lower thoracic (Lt) ESCC. Multivariate analysis in patients with Ut/Mt ESCC revealed that tumor invasion depth, LN metastasis, and the resected LN count from the UM area were independent risk factors for overall survival [hazard ratio (HR), 7.04; 95% confidence interval (CI) 4.47-11.1; HR, 4.01; 95% CI 1.96-8.21; HR, 2.18; 95% CI 1.24-3.82, respectively]. In patients with Lt ESCC, tumor invasion depth, LN metastasis, and pulmonary complications were independent risk factors for overall survival (HR, 4.23; 95% CI 2.14-8.35; HR, 3.83; 95% CI 1.75-8.38; HR, 2.80; 95% CI 1.38-5.65, respectively). Resected LN counts from no areas were prognostic factors. The number of resected LNs from the UM area influenced the survival outcomes of patients with Ut/Mt ESCC after MIE.

Gastric conduit reconstruction after esophagectomy.

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations.

Minimally-Invasive Robotic-Assisted Resection for Intrathoracic Goiter – A Feasible Alternative to Thoracotomy and Sternotomy

Abstract Background Goiter is a common presentation in daily clinical practice. It usually grows slowly and in rare cases with intrathoracic extension. There is no clear definition of intrathoracic goiters. The incidence in the literature varies from 3% to 7%. Most intrathoracic goiters are localized in the anterior mediastinum, with less than 25% are localized in the posterior mediastinum. This presents a challenge for surgical resection. Traditionally, the intrathoracic portions have been resected via sternotomy for anterior goiters and thoracotomy for posterior goiters. With the increasing use of robotic surgery, new possibilities for minimally invasive surgery and especially robotic procedures have emerged. This may reduce morbidity and length of hospital stay. Aims The study aims to show that minimal-invasive, robotic-assisted resection for intrathoracic goiter is safe and feasible. Methods During the study period from January 2021 to December 2023, 548 thyroid operations were performed in our clinic. All operations were prospectively recorded in the Eurocrine registry and retrospectively analyzed. Goiter was defined as intrathoracic according to perioperative findings (caudal border not visible on sonography and/ or further preoperative investigations ordered). Primary and secondary endpoints were outcome, conversion rate, and incidence of intrathoracic goiter. Results In our clinic, 19/548 patients (3.5%) presented with intrathoracic goiter. 17/19 patients were operated via conventional cervical approach. In 2 patients, minimal-invasive robotic mobilization of the large posterior portion of the goiter was performed in combination with conventional cervical thyroidectomy. No conversion was required. Based on our cases, we present robotic intrathoracic thyroid mobilization as a novel technique to avoid thoracotomy. The rate of recurrent nerve palsy in intrathoracic goiter was 1/28 (3.5%) nerves at risk and occurred with conventional approach. No secondary bleeding or other complications were observed. Conclusion The minimal-invasive robotic approach seems to be a promising alternative to open procedures such as thoracotomy and can reduce morbidity and length of hospital stay.

Sarcoidosis-like reactions in metastatic renal cell carcinoma patients treated with immune-based combinations.

Aim: The incidence of drug-induced sarcoidosis-like reactions (DISR) in patients treated with immune checkpoint inhibitors (ICIs) is rising. We determine the incidence and characteristics of DISR in ametastatic renal cell carcinoma(mRCC) population. Methods: We retrospectively reviewed clinico-radiological data of 83 mRCC patients treated at a single institution with immune-based combinations. Results: 15 patients received immune-doublet (ipilimumab-nivolumab), while 68 patients received other immune-based combinations. Two cases of DISR (2.4%) were evidenced, with enlargement of mediastinal lymph nodes thatmimicked disease progression, thus requiring a biopsy which showed histological features of DISR. Conclusion: In our series of the incidence of DISR, radiological and clinical features, are in line with literature. DISR diagnosis is often only radiological, and its occurrence is possibly associated with a better outcome.

Conservative management of complicated retropharyngeal abscess with Antitubercular Therapy

Retropharyngeal abscess, the infection of deep neck spaces, extends from the base of the skull to the posterior mediastinum. It develops as a sequela of dental infection, upper respiratory tract infection, or any interventional procedure like laryngoscopy, endotracheal intubation, etc. Retropharyngeal abscess is a rare presentation of Tuberculosis (TB), with an annual incidence rate of 2.64 per 100,000 population, and gender-based incidence rates of 3.34 for males, and 1.94 for females per 100,000 population.1 It, as a part of head and neck TB, has a prevalence of 0.1-1% among all forms of TB. If not managed timely, it may lead to the spread of its infection to the mediastinum, which can be life-threatening at times, owing to airway compromission and other catastrophic complications like mediastinitis, mediastinal abscess, pericarditis, pyopneumothorax pleuritis and empyema. We hereby present a case of a middle-aged woman diagnosed with a complicated retropharyngeal abscess but managed conservatively with Antitubercular Therapy (ATT).