Mediastinum (Hong Kong, China)最新文献

Background and objective: Complete thymectomy is the established treatment for thymic epithelial tumors (TET) and often included in the management of myasthenia gravis. Minimally invasive approaches, including robotic-assisted techniques, have gained acceptance for their benefits in reducing postoperative pain and recovery time. Thymectomy poses risks due to the proximity of the thymus to critical mediastinal structures, and intraoperative complications confronted on the robotic platform can be precarious. Current literature on intraoperative complications is fragmented and limited, and lacks emphasis on the nuance brought about by the robotic platform specifically. The aim of this narrative review is to comprehensively explore such possible complications and to discuss their distinct management strategies in a systematic manner.

Methods: We review the literature by examining the PubMed database between 2000 and 2024 for relevant studies that report the intraoperative and postoperative complications of robotic thymectomy. The technique of robotic thymectomy is also described.

Key content and findings: Robotic thymectomy offers a safe and oncologically effective approach to treatment. It is met with a low complication rate that is not increased compared to the open approach. Common complications include injury to nearby structures such as the internal mammary vessels, brachiocephalic vein (BCV), superior vena cava (SVC), phrenic nerve, and recurrent laryngeal nerve. Each complication requires a distinct management strategy that is concordant with an understanding of the limitations of the robotic platform.

Conclusions: This narrative review focuses on the intraoperative complications encountered during robotic thymectomy and provides an in-depth review of strategies for managing these complications, emphasizing the importance of preoperative planning, understanding the robotic platform's limitations, and the need for a well-coordinated surgical team. Reviewing the complexity of such complications and their nuanced management strategies is not only beneficial for surgeons in their clinical practice, but also to develop scientific curiosities surrounding this topic to ultimately improve patient outcomes. As such, studies elaborating on the details of such complications while on the robotic platform are necessary.

Background and objective: Phrenic nerve resection is sometimes necessary during tumor removal when the nerve is infiltrated by malignancies. However, this can result in diaphragmatic paralysis and respiratory insufficiency. While mechanical ventilation and diaphragmatic pacing may temporarily support respiratory function, phrenic nerve reconstruction offers a potential long-term solution. Nevertheless, its use during tumor resection remains underreported. This review assesses current evidence on phrenic nerve reconstruction, focusing on surgical techniques, nerve graft selection, and the feasibility of minimally invasive approaches.

Methods: A literature search was conducted in PubMed for phrenic nerve reconstruction studies. English-language studies published between January 1, 1980 and January 30, 2025, that focused on immediate phrenic nerve reconstruction following tumor resection were included in the review.

Key content and findings: Phrenic nerve reconstruction can be performed either immediately after nerve resection or as a delayed procedure. Immediate reconstruction, especially when conducted concurrently with tumor resection, has been shown to promote optimal nerve regeneration and functional recovery. In contrast, delayed reconstruction is generally associated with greater technical challenges and less predictable outcomes. Direct anastomosis is preferable when feasible; however, nerve grafting is often required due to insufficient residual nerve length to achieve a tension-free repair. Among graft options, the intercostal nerve is favorable due to its anatomical proximity and minimal additional surgical burden, whereas the use of other nerves, such as the sural nerve, requires an additional incision at a separate site, which may be less desirable. Successful reconstruction can also be achieved using minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). Notably, the additional time required for reconstruction in minimally invasive procedures is manageable and does not significantly affect patient outcomes.

Conclusions: Immediate phrenic nerve reconstruction, either by direct suturing or intercostal nerve grafting, is a feasible and effective method for preserving respiratory function. The ability to perform reconstruction using minimally invasive techniques further supports its clinical adoption. Given its advantages in functional recovery and its relatively low additional surgical burden, phrenic nerve resection followed by immediate reconstruction may be considered in most cases involving phrenic nerve invasion.

Background and objective: While surgery remains a cornerstone of thymoma treatment, its role as a standalone therapy is limited in ensuring adequate local disease control, particularly in cases involving serous dissemination or recurrence. For disseminated disease, various multidisciplinary approaches have been explored, including systemic chemotherapy and radiotherapy, either as standalone treatments or in combination with surgery. The efficacy is unsatisfactory, and the management is anything but standardized. However, recently, a promising technique has been introduced within the therapeutic algorithm of advanced stage thymomas: the hyperthermic intrathoracic chemotherapy (HITHOC) as an adjunct to surgery. By combining cytoreductive surgery with localized heated chemotherapy perfusion, HITHOC may help in treating residual disease, providing a targeted approach to pleural dissemination. HITHOC has demonstrated efficacy in managing stage IVA thymomas and thymoma-related pleural recurrences, establishing itself as a potential critical component of modern multimodal treatment strategies. This narrative review aims at providing a detailed examination of the mechanisms, indications, procedural aspects, and outcomes of HITHOC in pleural localization of thymomas, as well as its future potential in thoracic oncology.

Methods: A literature search was performed using the MEDLINE and Google Scholar databases, including original full-length articles, meta-analyses, review articles, and case reports published up to January 2025.

Key content and findings: HITHOC has been developed as an adjunct to macroscopic radical pleural tumor resection. By enhancing local tumor control and lowering recurrence rates, HITHOC provides a valuable addition to the multimodal treatment of advanced thymomas.

Conclusions: HITHOC may represent a promising approach in the treatment of advanced thymomas with pleural dissemination. By combining cytoreductive surgery with localized hyperthermic chemotherapy, it may address the limitations of conventional therapies, potentially offering improved local disease control and survival.

Background: Thymic carcinoma (TC) is a rare and aggressive malignancy, accounting for approximately 6% of thymic neoplasms. Due to its frequent late-stage diagnosis and poor prognosis, standard treatment typically involves multimodal therapy, including platinum-based chemotherapy, radiotherapy, and surgery. However, effective treatment options remain limited, with response rates being unsatisfactory. Recent studies have highlighted the potential of immune checkpoint inhibitors (ICIs) in treating thymic epithelial tumors, particularly in tumors with high programmed cell death ligand 1 (PD-L1) expression. Despite this, the role of ICIs in TC is still under investigation, and further research is needed to assess their efficacy and safety in clinical practice.

Case description: We present the case of a 31-year-old male diagnosed with stage IVA squamous TC. Following disease progression after first-line chemotherapy with paclitaxel, carboplatin, and ramucirumab as part of the RELEVENT phase II trial, PD-L1 assessment revealed an 85% expression, leading to the initiation of off-label pembrolizumab (200 mg every 3 weeks). The patient subsequently developed oligoprogression with local sternal infiltration, prompting the addition of radiotherapy (10×3 Gy) alongside continued pembrolizumab. Over the following months, imaging demonstrated progressive response to treatment, culminating in a near-complete metabolic response. A residual mediastinal lesion was later surgically resected, revealing no viable tumor cells, indicative of a complete pathological response. Nine months after surgery, the patient is disease-free, with no reported immune-related adverse events.

Conclusions: This case highlights the potential of immune checkpoint inhibition combined with radiotherapy and surgery in the management of advanced TC. The patient's complete pathologic remission underscores the importance of a multidisciplinary approach. Further studies are warranted to establish ICIs as a standard treatment and optimize patient selection while mitigating immune-related toxicities.

Background and objective: Accurate diagnosis of mediastinal tumors is of critical importance to establish appropriate therapy. However, these lesions are relatively uncommon and may be challenging to evaluate, particularly in small biopsy specimens. Thymomas and thymic carcinomas are the most common primary malignant tumors of the mediastinum, but the site can be affected by many other neoplasms that can pose significant difficulty in diagnosis. The objective of this article is to bring awareness to these rarer tumors and offer a diagnostic approach using ancillary techniques guided by clinical and morphological features.

Methods: We discuss and review six challenging cases of mediastinal tumors with overlapping morphologic features. We discuss their unique morphologic, immunophenotypic, and relevant molecular characteristics to support their definitive diagnosis, based on current literature. Sources were obtained via PubMed search and include original studies and review articles published in the English language between 1990 and 2025. Search terms include the diagnostic entities discussed in the article.

Key content and findings: Judicious use of immunohistochemistry and molecular studies is necessary to accurately diagnose mediastinal neoplasms with overlapping histologic features, such as those seen in the cases discussed.

Conclusions: Diagnosis of uncommon mediastinal lesions may be challenging, particularly in small biopsies, as morphological features may be shared among different entities. Awareness of these rare entities, their clinical characteristics and presentation, and differential diagnosis can guide in the selection of appropriate immunohistochemical panels, molecular markers, and molecular diagnostics when appropriate to support the diagnoses.

Background and objective: Linear endobronchial ultrasound (EBUS) has become a key tool for diagnosing pulmonary diseases, offering high diagnostic yield for both malignant and non-malignant conditions. With its increased use, more complications are being reported. The objective of this narrative review is to discuss the complications associated with linear EBUS.

Methods: A literature search using PubMed and Google Scholar from 2009 to 2024 was done. We included case reports, prospective, and retrospective studies reporting linear EBUS complications.

Key content and findings: Overall complications from EBUS range from 0.04% to 17%. Most common are infectious complications which are 0.04-4%. These include mediastinitis, pneumonia, pericarditis, bacteremia, tumor bed infection, lung abscess, empyema, and septic shock. Other complications include pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, and subcutaneous emphysema. Complications due to anesthesia or equipment malfunction can occur as well. Hemorrhagic complications have been reported as well. Mortality is low 0.01-0.04%, and four cases have been reported that led to death from complications.

Conclusions: With increased use of EBUS as a diagnostic tool, number of complications will increase. Clinicians performing the procedures should be aware of types of possible complications that can occur and follow the patients closely after the procedure. Rapid diagnosis and treatment should be done to avoid fatal outcomes.

Background: Although lymph node metastasis may be an adverse prognostic factor for survival after resection of thymic epithelial malignancies, recommendations for intraoperative lymph node dissection (LND) lack consistency across various guidelines. This study aimed to investigate feasibility and characteristics of LND.

Methods: This is a work-in-progress report of our prospective, multi-institutional observational study to evaluate the feasibility and characteristics of LND in patients with resectable thymic epithelial malignancies that exhibit radiological invasive features such as size >5 cm, standardized uptake value >5, or suspected invasion of surrounding organs.

Results: In total, 25 patients were enrolled in this study. All patients underwent complete resection of the primary lesion with N1-level or N2-level LND. Among these, 22 (88%) patients underwent N1-level LND, and 20 (80%) patients underwent N2-level LND. No significant differences between the open and minimally invasive approaches were observed in the number of dissected stations (P=0.71), N1-level LND (P=0.49), or N2-level LND (P=0.69).

Conclusions: Intraoperative LND may be feasible in both approaches and may contribute to accurate nodal staging in resectable thymic malignancies with radiologically invasive features.

Many studies have demonstrated that 18-fluorine fluorodeoxyglucose positron emission tomography (FDG-PET) is useful for predicting the grade of malignancy of thymic epithelial tumors (TETs), and there is a close relationship between the maximum standardized uptake value (SUVmax) and tumor stage. However, more specific usage of FDG-PET for TETs has not been proposed, and the actual value of FDG-PET in routine clinical practice should be firmly clarified. In this review, following three cutoff values of SUVmax that may be helpful in determining treatment strategies in cases of anterior mediastinal masses, particularly presented as discrete and resectable lesions, are identified: (I) SUVmax of 7.5 as an indicator for pretreatment biopsy: differential diagnosis between TETs and mediastinal lymphoma (ML); (II) SUVmax of 4.2 as an indicator for a minimally invasive approach (MIA): differentiation of noninvasive TETs and invasive TETs; and (III) SUVmax of 5.9 as a reference value for the necessity of lymph node dissection (LND). There are still several challenges in using FDG-PET for routine clinical practice that need to be addressed, such as variations between instruments and institutions, leading to lower reproducibility. Harmonization methods should be applied to make clinical practice more uniform. Due to the rarity of these diseases, multi-institutional studies are warranted.

Mediastinal masses are a common finding in patients and can represent a diagnostic challenge for thoracic surgeons. The differential diagnosis for these masses is broad and ranges from benign solid or cystic lesions to aggressive cancers. They can present with vague symptoms, but these masses are often found incidentally in asymptomatic people. Patients with mediastinal masses should be evaluated by a multidisciplinary team of specialists, including thoracic surgeons. Determining the etiology of the mass is essential since this heavily determines the management and prognosis. The work up involves clinical evaluation, laboratory work and always involves imaging, but deciding which imaging modality will offer the most information about the lesions and guide management is not always clear. The most common imaging studies for mediastinal masses are computed tomography (CT) scans, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans. The role of PET scans in the work up of these masses is not well-established, but these scans have been shown to be especially useful in certain circumstances and can help guide further work up and decision making. This review article evaluates how and when PET scans can be used to guide work up and management in a variety of mediastinal masses.

Background and objective: The formation of pathologic communication between respiratory and digestive tracts is a morbid condition which possesses management challenges regardless of its etiology. Severity of the symptoms related to contamination of the respiratory tract with oral and gastric secretions calls for timely seal and closure translating into improved mortality. The aim of this article is to review the latest data in regards of tracheoesophageal fistulas (TEFs) and the endoscopic methods of their management.

Methods: A literature review was conducted in the National Institute of Health's PubMed database in July 2024. Only studies published in English with abstracts available were included. Over 2,700 articles were found. The first 800 abstracts for "tracheoesophageal fistula" were reviewed and used to guide more detailed searches. Fifty-seven publications were considered relevant, and their full text studied to collate information for this review.

Key content and findings: We summarized the endoscopic approaches to management of both benign and malignancy associated TEFs as reported in the literature to this date. Despite several new non-operative approaches, esophageal stenting with or without airway stenting remains the mainstem of the endoscopic treatment of the fistulas. Self-expanding metallic stents are the mainstay of this approach. Esophageal stenting in particular has been associated with improved fistula closure and quality of life, as well as possible improvement in mortality for malignancy associated fistulas. More novel methods such as suturing or clips, occluding devices, and tissue adhesives also show promise. The quality control after the initial endoscopic management sets the future steps. Early multidisciplinary discussion among aerodigestive specialists including endoscopists and surgeons with involvement of palliative care team is strongly recommended.

Conclusions: The ever-evolving landscape of endoscopic therapies offers minimally invasive approach to TEFs especially for patients with prohibitive conditions to surgery or for patients needing a temporizing measure until the definitive surgical treatment is possible.