Mediastinum (Hong Kong, China)最新文献

While it is not uncommon to see central mediastinal diseases on cross-sectional imaging, it is important to understand the pathway influencing the spread of disease at a radiological point of view. The advent of minimally invasive thoracic surgeries has led to the discovery of unknown tissue planes in the mediastinum such as the aorto-esophageal (AE) and aorto-pleural (AP) ligaments. In particular, the AE ligament is a portion of the mediastinal visceral fascia, which courses from the anterior aspect of the aorta to the left lateral aspect of the esophagus. It can be visualized on computed tomography (CT) and magnetic resonance imaging (MRI); it courses longitudinally from the level of the aortic arch to the level of the diaphragm. This recently discovered unknown anatomy aids us in understanding the possible pathway of spread of disease processes such as air, fluid, and soft tissue in the mediastinum. In addition, it acts as an important anatomical landmark in determining the location of lymph node metastases from esophageal cancer, which will further influence the possibility of thoracic duct resection/sparing. Finally, the AE ligament can be utilized in the preoperative planning of minimally invasive thoracic surgeries and can potentially be used as a dissection plane during esophagectomies.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the preferred initial method to diagnose and stage non-small cell lung cancer. EBUS-guided transbronchial cryobiopsy (EBUS-TBC) is a newer technique with the potential to address the limitations of EBUS-TBNA. Only a few studies have explored this technique and compared its diagnostic yield to that of EBUS-TBNA. This review aims to summarize the existing literature and provide insights into the optimal yield and technique for performing EBUS-TBC. A comprehensive search of the PubMed database was conducted for studies published up to May 2024 related to EBUS-TBC. The PICO framework (Participants, Intervention, Comparison, and Outcome) was used to evaluate the diagnostic yield, techniques employed, and associated complications. Eleven studies involving 857 patients were identified. In these trials, EBUS-TBC was performed after EBUS-TBNA at the same lymph node station. Techniques varied among bronchoscopists, with most procedures conducted under moderate sedation. The TBNA needle sizes ranged from 19G to 22G. Three trials used a needle knife for the initial mucosal incision, while others utilized the initial puncture site for cryoprobe insertion. Nine studies employed a 1.1-mm Erbe cryoprobe, with a median freezing time of 4 seconds (range, 3-7 seconds). The overall diagnostic yield of EBUS-TBC was 91.9%, compared to 76.6% for EBUS-TBNA alone, with EBUS-TBC yielding larger specimens. Mild bleeding was the most common complication reported. The addition of EBUS-TBC to EBUS-TBNA enhances the diagnostic yield without significantly increasing complications. The larger biopsy samples obtained can be particularly valuable for next-generation sequencing in lung cancer and for improving diagnostic accuracy in benign diseases and rare malignancies like lymphoma.

Background and objective: Thymectomy continues to be a standard treatment strategy for patients with thymic neoplasms and myasthenia gravis. The total thymectomies performed has exponentially increased by 69.8% between 2012 and 2019. Trans-sternal and minimally invasive thymectomy increased by 62.8% and 83.7%, respectively. Our objective is to provide a narrative overview of the various approaches of thymectomy. We have briefly described the indications for thymectomy, discussed important preoperative considerations and an operative description of the different techniques of the procedure. We have aimed to summarize the pros and cons of each approach and narrated the technique we have adopted at the University of Minnesota.

Methods: A literature search was conducted encompassing original full-length articles, meta-analyses, review articles and case reports up to July 2024 from the MEDLINE and Google Scholar databases.

Key content and findings: Complete surgical resection remains the goal to decrease the risk of recurrence for non-myasthenic thymomas and thymic carcinomas. Surgical procedures have evolved from traditional open approaches to a wide variety of minimally invasive methods. A variety of factors specific to the tumor, patient and surgeon have to be considered while planning a thymectomy.

Conclusions: As of today, there is no consensus on the best surgical technique, with each approach providing specific pros and cons. Each technique may be a viable option in the management of thymic pathologies, thus preoperative evaluation in patients is necessary to optimize prognosis and outcomes.

Background and objective: Descending necrotizing mediastinitis (DNM) is a severe and life-threatening infection that originates from oropharyngeal or cervical infections and spreads downward into the mediastinum. Despite advancements in medical and surgical treatments, DNM remains a condition with high morbidity and mortality. This narrative review aims to summarize the etiology, diagnostic strategies, and management approaches for DNM, emphasizing the importance of a multidisciplinary approach.

Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Western University Libraries, and Google Scholar databases, without restriction on publication date. Articles were included if they discussed: (I) the etiology of mediastinitis, focusing on anatomy and pathogens; (II) the diagnosis of DNM; and (III) the treatment and surgical approach to mediastinitis.

Key content and findings: DNM is commonly caused by oropharyngeal infections that spread downward through normal anatomical pathways. Diagnosis is challenging due to the subtle and varied presentation of symptoms. Diagnosis is primarily made with contrast-enhanced CT scans of the neck and thorax, but a convincing history should prompt appropriate suspicion and concern. Management requires a multidisciplinary approach, including sepsis management particularly with broad-spectrum antibiotics and early surgical intervention for source control. The choice of surgical technique, whether transcervical, thoracotomy, or video-assisted thoracoscopic surgery (VATS), is crucial for effective drainage and reducing mortality.

Conclusions: DNM is a complex and critical condition that demands prompt recognition and aggressive treatment. The high mortality associated with DNM underscores the need for a multidisciplinary approach. Surgical drainage, tailored to the extent of the infection, and comprehensive post-operative care are essential for improving patient outcomes. Future research should focus on optimizing diagnostic criteria, refining surgical techniques, and exploring adjunct therapies to further reduce morbidity and mortality in DNM.

Background: A thymoma is a tumor originating from thymic epithelial cells variably associated with non-neoplastic lymphocytes. T-lymphoblastic leukemia/lymphoma (T-LBL) is thought to arise from precursor T-cells from bone marrow-derived hematopoietic stem cells that migrate to the thymus. While the association of secondary hematopoietic malignancies in thymoma is well established, only rarely in the literature have T-LBL and thymoma been seen in association and the relationship is poorly understood. Occasionally, distinction between the two can be difficult as immature lymphocytes in thymoma resemble T-LBL both morphologically and immunophenotypically. An accurate diagnosis is essential as treatments vary between these two entities.

Case description: We present the interesting case of a 64-year-old male, former smoker, originally from Uzbekistan, with a mediastinal mass diagnosed as small cell carcinoma in his home country and treated with chemotherapy. After immigrating to the United States, a positron emission tomography (PET) scan demonstrated a large, metabolically active mediastinal mass. He presented to our institution where a biopsy with histomorphologic and immunohistochemical analysis was diagnostic of type B1 thymoma. He was lost to follow-up, but represented months later with B symptoms. Flow cytometry, cytogenetics, and bone marrow biopsy were diagnostic of T-LBL. Although he was started on chemotherapy, his disease progressed and he expired 6 months after initial presentation. Post-mortem analysis of the mediastinal mass revealed the co-occurrence of benign thymocytes and neoplastic T-LBL lymphoblasts, further confirmed as two distinct entities by T-cell receptor (TCR) sequencing.

Conclusions: Co-occurrence of thymoma and T-LBL is a well-documented, though poorly understood, phenomenon. Literature review for this phenomenon reveals that type B thymoma is most commonly associated with T-LBL in these co-occurrences. Most cases are diagnosed synchronously, though in metachronous cases, the diagnosis of thymoma has always preceded the diagnosis of T-LBL. Of note, recently developed LMO2 immunohistochemical stain is positive in malignant lymphoblasts but negative in benign thymocytes, allowing for post-mortem evaluation of this case to be determined as a synchronous presentation. These entities are difficult to distinguish and require a multimodal diagnostic approach including histology, immunohistochemistry, flow cytometry, cytogenetics, and TCR sequencing.

Background: Mediastinal tumors are a heterogenous group of unrelated neoplasms that share the mediastinal anatomical location. There are no local publications regarding mediastinal masses, as such the clinical and pathological characteristics of this group of tumors in our population has been overlooked. The study aims to describe the mediastinal masses clinicopathological spectrum in children and adults.

Methods: With the objective to compare the clinicopathological spectrum of mediastinal tumors among children and adults we retrospectively review the medical charts and pathology reports of 110 patients with primary mediastinal masses between 2010 and 2022 at Hospital San Vicente Fundación and University of Antioquia pathology laboratory (Medellín, Colombia).

Results: We found statistically significant differences, regarding tumor location, tumor type, histological type and presenting complaint. The anterior mediastinal compartment was the most frequent location considering all tumors, with a statistically significant difference (P=0.042) favoring the adult group. A significant difference was also present in adults' anterior compartment for malignant tumors (P=0.02), which can be explained in both situations by the exclusive incidence of thymic tumors in the adult's anterior compartment. In contrast, malignant tumors show statistically significant differences (P=0.001) in the posterior compartment of the child group, associated with the high incidence of neurogenic tumors in this group (P=0.001), specifically neuroblastoma (P=0.002). Fever in the child group (P=0.02), was the most statistically significant presenting complaint related exclusively with lymphoid tumors.

Conclusions: mediastinal mass epidemiological data vary according to populations; thus it is of utmost importance to acknowledge local patients' characteristics in order to narrow the clinical and pathological differential diagnosis.

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.