Mediastinum (Hong Kong, China)最新文献

Background and objective: Diagnosis of pathology in the mediastinum has proven quite challenging, given the wide variability of both benign and malignant diseases that affect a diverse array of structures. This complexity has led to the development of many different non-invasive and invasive diagnostic modalities. Historically, diagnosis of the mediastinum has relied on different imaging modalities such as chest X-ray, computed tomography (CT), magnetic resonance imaging, and positron emission topography. Once a suspicious lesion was identified with one of these techniques, the gold standard for diagnosis was mediastinoscopy for diagnosis and staging of disease. More recently, many minimally invasive techniques such as CT-guided biopsy, endobronchial ultrasound with transbronchial needle aspiration, and endoscopic ultrasound with fine needle aspiration have revolutionized the diagnosis of the mediastinum. This review provides a comprehensive analysis of all the modalities available for diagnosing mediastinal disease with an emphasis on bronchoscopic techniques.

Methods: Literature search was performed via the PubMed database. We included all types of articles and study designs, including original research, meta-analyses, reviews, and abstracts.

Key content and findings: Minimally invasive techniques such as endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-fine needle aspiration (EUS-FNA) have demonstrated high diagnostic yield and low complication rate and have made a significant difference in the time to diagnosis and lives of patients. There continues to be innovation in the field of bronchoscopy with the development of new technologies such as confocal laser endomicroscopy, optical coherence tomography, and artificial intelligence.

Conclusions: Bronchoscopy is and will continue to be an integral modality in minimally invasive diagnosis of the mediastinum.

Background and objective: Transesophageal endosonography, including endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA), has been applied to the diagnosis of benign as well as malignant diseases. This narrative review summarizes the recent use of EUS-(B)-FNA in diagnosing sarcoidosis.

Methods: A comprehensive and systematic online literature search of PubMed was conducted using the keywords ("sarcoidosis"), and ("EUS" OR "EUS-FNA" OR "EUS-B" OR "EUS-B-FNA" OR "endoscopic ultrasound guided fine needle aspiration" OR "endoscopic ultrasound using the EBUS scope guided fine needle aspiration" OR "endoscopic ultrasound using the EBUS bronchoscope" OR "transesophageal" OR "transesophageal endoscopic ultrasound guided fine needle aspiration" OR "transesophageal bronchoscopic ultrasound guided fine needle aspiration").

Key content and findings: Most EUS-FNA procedures were performed under moderate sedation, primarily using midazolam, with 22-gauge needles. The diagnostic sensitivity of sarcoidosis in mediastinal lymph node sampling is as high as 75-100% for EUS-FNA and 70-86% for EUS-B-FNA, much higher than that of traditional bronchoscopic procedures, such as transbronchial lung biopsy (TBLB) and conventional transbronchial needle aspiration (TBNA). The complications associated with EUS-(B)-FNA have thus far included only a few cases of mediastinitis, successfully treated with antibiotics, as well as lymph node hematoma, and sore throat.

Conclusions: EUS-FNA and EUS-B-FNA provide high diagnostic yields in patients with sarcoidosis. The safety profile is acceptable, although there is a slight risk of infectious complications. EUS-B-FNA, a minimally invasive and well-tolerated procedure, offers a viable alternative to endobronchial ultrasound-guided TBNA (EBUS-TBNA) for the diagnosis of sarcoidosis, particularly in patients with cough and poor respiratory function; this procedure can easily be performed by pulmonologists.

Background: Thymoma is a rare mediastinal neoplasm originating from thymic epithelial cells, often associated with paraneoplastic syndromes. These syndromes can manifest as a range of autoimmune disorders, including myasthenia gravis, pure red cell aplasia, and aplastic anemia. Clinical trials involving the use of immune checkpoint inhibitors (ICIs) in thymoma have been complicated by a high incidence of immune-related adverse effects (irAEs). As a result, the use of ICIs in the treatment of thymoma is not currently recommended.

Case description: We present a case of thymoma with paraneoplastic aplastic anemia that showed a remarkable response to atezolizumab following the discontinuation of cyclosporine. The patient was initially treated with cisplatin, doxorubicin, and cyclophosphamide (CAP), achieving a short-term partial response. However, this response was not sustained, and she developed aplastic anemia characterized by worsening anemia, reticulocytopenia, and thrombocytopenia. A bone marrow biopsy revealed erythroid hypoplasia without dysplasia, linked to her thymoma. Cyclosporine was initiated to manage the aplastic anemia, but the disease continued to progress, leading to a switch to capecitabine and gemcitabine. Restaging scans revealed further advancement, with extensive pleural metastasis. To manage the progressing disease, atezolizumab was introduced. Initially, no response was seen while on cyclosporine, but after discontinuing cyclosporine, the patient experienced a significant therapeutic response. Despite this success, immune-related dermatitis and hematological complications developed, requiring careful management. In clinical trials, ICI use alongside immunosuppressants is common for managing paraneoplastic manifestations in thymoma.

Conclusions: This case highlights the potential efficacy of ICI in thymoma treatment, emphasizing the delicate balance required between immunosuppression and immunotherapy for optimal outcomes. Achieving this delicate balance is vital for optimizing patient outcomes while minimizing the risk of severe complications and ensuring that both the paraneoplastic syndrome and the tumor itself are adequately managed. This consideration is particularly important when developing future clinical trials for thymoma, where the complex interplay between these therapies must be carefully evaluated to design effective and safe treatment protocols.

Thymic epithelial tumors (TETs) are rare neoplasms that include thymomas, thymic carcinomas (TCs), and thymic neuroendocrine neoplasms (TNENs). These three tumor categories differ in aggressiveness, the incidence of recurrence after resection, the pattern of recurrence, and survival outcomes. Owing to the tumor's rarity, randomized trials have not been performed in the initial treatment setting. Furthermore, such trials have never been performed in recurrent cases after the initial resection. Thymomas have indolent characteristics, with a wide range of biological spectra compared to TCs and TNENs; therefore, several authors have reported favorable outcomes after re-resection for recurrent thymomas. Common recurrent sites are the local site and pleura, and recurrent disease progresses slowly after detection. Additionally, long-term survivors are sometimes observed after recurrence, and whether re-resections contribute to post-recurrent and cause-specific survival remains unclear. Multimodal therapies are indicated in patients with locally or regionally advanced recurrence, similar to those performed in the initial treatment settings. TCs and TNENs exhibit more aggressive behavior than thymomas. Surgical resection was performed on selected patients who experienced recurrence. Currently, there are no guidelines on selecting patients for re-resection. Therefore, it is most likely that each physician selects based on favorable factors, including the extent of disease, disease-free intervals, and histology. No evidence of nonsurgical treatments, such as radiotherapy or chemotherapy, has yet to be established. This review article summarizes the limited evidence on managing recurrent TETs after resection compared to thymomas, TCs, and TNENs, focusing on re-resection.

Background and objective: Thymic epithelial tumors, including thymomas and thymic carcinomas, represent the most common mediastinal tumors and account for up to 50% of all anterior mediastinal tumors. For early stages of these thymic tumors, complete resection of the entire thymus is the recommended treatment. The transition from open surgery to video-assisted thoracoscopic surgery (VATS) and recently to robotic-assisted thoracic surgery (RATS) has fundamentally altered the treatment of thymic tumors. While RATS has been widely implemented due to its many advantages including good visualization with magnification and three-dimensional vision, improved maneuverability and precise instrument control, different techniques have been described. This narrative review focuses on the main approaches and outcomes of RATS thymectomy. It compares the technical, perioperative and clinical outcomes of RATS thymectomy, in particular, with VATS and open thymectomy.

Methods: A non-systematic review for full text studies written in the English language was conducted using the PubMed search engine and literature was summarized.

Key content and findings: We present an overview of robotic-assisted resection for thymomas and review the main approaches and outcomes of RATS thymectomy. Critical points of the RATS approach, including surgical specifics and pitfalls, are presented. Technical advantages and disadvantages of each technique are discussed. The perioperative and clinical outcomes of RATS thymectomy are compared, where possible, to those for VATS and open thymectomy. Currently, retrospective analyses demonstrate comparable or even more favorable outcomes following a RATS approach in comparison to VATS and open approaches in terms of operating time, conversion rates, intraoperative complications, completeness of resection and mortality. Certain analyses also report better outcomes for patients undergoing RATS thymectomy in terms of blood loss, postoperative complications, duration of pleural drainage and length of hospital stay compared to VATS and open thymectomy.

Conclusions: Overall, RATS has shown promising results and could become the preferred technique for resection of thymic tumors. It shows good outcomes compared to VATS and open thymectomy in the current literature. However, especially for extended tumors with the need for extended resection and reconstruction, open thymectomy remains a valuable approach.

Background and objective: Thymic epithelial tumors (TETs) are the most common neoplasm of the prevascular mediastinal compartment and are characterized by their rarity and variable clinical presentation. The present study aimed to explore the current management of patients with TET with a special focus on immunotherapy for advanced disease.

Methods: Relevant studies published between 1981 and 2024 were searched in PubMed using search terms "Thymoma", "Thymic cancer", "Myasthenia gravis", "Radiation therapy", "Surgery", and "Immunotherapy".

Key content and findings: The International Thymic Malignancy Interest Group and the International Association for the Study of Lung Cancer established the tumor-node-metastasis (TNM) staging system for TET based on an overall survival (OS) analysis of a retrospective international database. While complete surgical resection is the mainstay for resectable TET, there are currently no clear guidelines on systemic treatments for advanced TET because of the complexity, rarity, and heterogeneity of this disease and the lack of in vivo and in vitro models. With the development of immunotherapy, the application of the anti-programmed cell death-1 (anti-PD-1) antibody is expanding and includes TET. Clinical trials on immune checkpoint inhibitors (ICIs) are ongoing, and the acceptable clinical efficacy of the anti-PD-1 antibody for TET has been reported. On the other hand, there have been reports of a heightened frequency of severe immune-related adverse events (irAEs) in TET.

Conclusions: ICIs have the potential for patients with TET. The benefit-toxicity ratio of ICI treatment needs to be carefully evaluated for those patients.

Background and objective: There are several benign processes that affect the mediastinum with considerable morbidity that may range from reactive entities to neoplastic disorders. This review article will focus on non-neoplastic benign mediastinal diseases which include large vessel vasculitis such as Takayasu and giant cell arteritis, mediastinal granulomas, fibrosing mediastinitis and mediastinal infections. These diseases can cause significant morbidity and mortality; therefore, we aim to familiarize readers with the pathophysiology, epidemiology and diagnosis of these mediastinal diseases and provide an update on the treatment options available.

Methods: We searched various databases such as PubMed and Google Scholar from August 2023 until January 2024 for the various benign mediastinal disorders we wanted to discuss. Relevant articles that were written in English were shortlisted and used to help write this narrative review.

Key content and findings: We will briefly discuss the anatomy of the mediastinum along with some of the more common benign mediastinal disorders. We will discuss epidemiology, etiology, clinical features, and treatment. Relevant laboratory, and imaging findings important to make the diagnosis will be included as well.

Conclusions: Prompt diagnosis of these diseases is of the utmost importance as delay in care may be associated with increased mortality. Our article aims to provide an up-to-date review and summarize the current literature regarding these diseases.

Background: Emphysematous esophagitis is a very rare disease and there are only a few previous reports in the literature. Previously reported cases have resulted in emphysematous esophagitis following anterior cervical procedures or ingestion of hydrogen peroxide (HP). In this report, we describe a case in which a patient with emphysematous esophagitis accompanied by gastritis without the above predisposing factors was treated with conservative treatment.

Case description: A 65-year-old woman was admitted to Inje University Sanggye Paik Hospital with general weakness, abdominal discomfort, nausea and chest discomfort. On chest and abdominal radiographs, there were abnormal air density in upper mediastinum and abdomen. Chest and abdomen computed tomography (CT) revealed mural air at entire esophagus and stomach. The patient managed with proton pump inhibitor (PPI), broad spectrum antibiotic therapy, and total parenteral nutrition (TPN).

Conclusions: Emphysematous gastritis occurs mainly along with emphysematous gastritis, with a mortality rate of up to 62%. It is mainly known to be caused by infection of the esophageal wall by gas forming bacteria, but there are also cases where there is no ingestion or exact cause. There is still controversy about treatment methods due to the high death rate, but if detected early like the reported patient, a good outcome can be expected with conservative treatment alone.

Background: Thymic cysts can be classified as congenital or acquired. Most thymic cysts do not change in size over a short period of time. Although very rare, thymic cyst rupture is associated with serious complications, such as mediastinal hemorrhage and hemothorax. We experienced a case of partial rupture of a secondary thymic cyst, in an asymptomatic patient.

Case description: A 60-year-old woman visited Inje University Sanggye Paik Hospital with left hilar bulging detected on routine chest radiograph. A chest computed tomography (CT) scan revealed a 6 cm well-defined cystic mass with partial septation in the prevascular mediastinum. Thus, secondary thymic cyst was suggested. On the follow-up chest CT scan taken 3 months later, the size of the thymic cyst decreased, while the solid portion increased slightly, suggesting the potential presence of malignancy. Consequently, surgery was conducted. Adhesion to the lung and aorta was observed, but they were relatively well separated. The pathological findings revealed a partially ruptured thymic cyst with fat necrosis and multifocal granulomas.

Conclusions: There are controversies in the treatment of thymic cysts. Some clinicians prefer strict medical supervision to avoid unnecessary surgery, while others advocate immediate excision to avoid complication. However, if any changes are observed during the follow-up of the thymic cyst, it may indicate malignant transformation or rupture, necessitating prompt surgical excision.

This review article comprehensively examines the diagnostic approach to thymic epithelial tumors (TETs) and other mediastinal masses, focusing on imaging modalities and differential diagnosis. Beginning with a discussion on traditional and contemporary classification systems for mediastinal tumors, including the Japanese Association for Research on the Thymus (JART) and International Thymic Interest Group (ITMIG) classifications, it highlights the shift towards computed tomography (CT)-based categorizations. Emphasis is placed on the importance of distinguishing between solid and cystic lesions in the anterior mediastinum, with detailed insights into imaging characteristics and histological features of various TET subtypes such as thymomas, thymic carcinomas, and thymic neuroendocrine tumors (NETs). The review also elucidates common differential diagnoses, including lymphomas and germ cell tumors, providing guidance on key imaging findings and considerations for accurate diagnosis. Furthermore, it underscores the significance of patient background and blood tests in differential diagnosis, discussing age-related prevalence patterns and tumor marker assessment. After addressing the diagnostic challenges posed by thymic cysts offering insights into their radiological features, management considerations, and potential complications, this review extends to other rare mediastinal lesions highlighting the need for a comprehensive evaluation for accurate identification and management of these tumors. Finally, as illustrative examples, we present six cases highlighting various aspects of anterior mediastinal tumors, including TET. These cases provide valuable insights into the diagnostic challenges, imaging characteristics, and management considerations encountered in clinical practice. The cases presented herein do not all illustrate typical images, courses, and diagnoses. However, they each contain significant implications. Thus, we present them with the belief that they will aid in understanding the intricate nuances of image diagnosis in actual clinical practice.