-
Cancers Feb 2024Combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided tissue acquisition (EUS-TA) are accurate...
Improved Accuracy and Sensitivity in Diagnosis and Staging of Lung Cancer with Systematic and Combined Endobronchial and Endoscopic Ultrasound (EBUS-EUS): Experience from a Tertiary Center.
BACKGROUND
Combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided tissue acquisition (EUS-TA) are accurate procedures for the diagnosis and staging of mediastinal lymph nodes (MLNs) in lung cancer. However, the respective contribution of separate and combined procedures in diagnosis and staging has not been fully studied. The aim of this study was to assess their respective performances.
METHODS
Patients with suspected malignant MLNs in lung cancer or recurrence identified by PET-CT who underwent combined EBUS-TBNA and EUS-TA were retrospectively reviewed.
RESULTS
A total of 141 patients underwent both procedures. Correct diagnosis was obtained in 82% with EBUS-TBNA, 91% with EUS-TA, and 94% with the combined procedure. The overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of EBUS-TBNA, EUS-TA, and the combined procedure for diagnosing malignancy were [75%, 100%, 100%, 58%], [87%, 100%, 100%, 75%], and [93%, 100%, 100%, 80%], respectively, with a significantly better sensitivity of the combined procedure ( < 0.0001). Staging (82/141 patients) was correctly assessed in 74% with EBUS-TBNA, 68% with EUS-TA, and 85% with the combined procedure. The overall sensitivity, specificity, PPV, and NPV of EBUS-TBNA, EUS-TA, and the combined procedure for lung cancer staging were [62%, 100%, 100%, 55%], [54%, 100%, 100%, 50%], and [79%, 100%, 100%, 68%], respectively, significantly better in terms of sensitivity for the combined procedure ( < 0.001).
CONCLUSION
The combined EBUS-EUS approach in lung cancer patients showed better accuracy and sensitivity in diagnosis and staging when compared with EBUS-TBNA and EUS-TA alone.
PubMed: 38398119
DOI: 10.3390/cancers16040728 -
Anatomy & Cell Biology Dec 2023The azygos vein can be formed as a single root, two roots, and three roots, namely lateral, intermediate and the medial roots respectively. The hemiazygos vein and the...
The azygos vein can be formed as a single root, two roots, and three roots, namely lateral, intermediate and the medial roots respectively. The hemiazygos vein and the accessory hemiazygos vein are the tributaries of azygos vein rather than its left side equivalents. Its variations, especially in young persons without any relevant risk factors, may result in thromboembolic illness. This study aimed to describe the morphological and morphometric variations of azygos system of veins. The present study was conducted on thirty formalin fixed adult human cadavers by dissecting azygos vein from formation to termination and variations were noted. The azygos vein was formed by a single root in 56.7%, by two roots: the lateral root and intermediate root in 36.7% cases and by the lateral root and medial root in 6.6%. The vertebral level of termination of azygos vein was seen at the level of T4 vertebrae in 70% cases, at the level of T3 vertebrae in 20% of cases and at the level of T5 vertebrae in 10% cases. The course of azygos vein was varying in 13.3%. These morphological variations can be useful while performing mediastinal surgery, mediastinoscopy, surgery of the deformations of the vertebral column, neurovascular surgeries of the retroperitoneal organs, disc herniation and fracture of thoracic vertebrae.
PubMed: 37710917
DOI: 10.5115/acb.23.074 -
Journal of Microscopy and Ultrastructure 2023Concomitant Hodgkin's lymphoma with tuberculosis is an exceedingly rare clinical scenario and a condition that is difficult to manage due to similar clinical...
Concomitant Hodgkin's lymphoma with tuberculosis is an exceedingly rare clinical scenario and a condition that is difficult to manage due to similar clinical presentation. This case report describes the same in a 44-year-old male patient diagnosed with Koch's and initiated on antituberculosis therapy, based on confirmation of findings from the spine biopsy and culture. The patient's clinical condition worsened despite being on treatment for tuberculosis. Hence, further work up of the patient was done which included mediastinoscopy and endobronchial ultrasound. Biopsy samples from a conglomerate mass in the lower cervical region and mediastinum revealed Hodgkin's lymphoma of the nodular sclerosis type. This time, the patient showed significant improvement following treatment with chemotherapy and radiotherapy along with antituberculosis therapy.
PubMed: 38213655
DOI: 10.4103/jmau.jmau_128_20 -
Journal of Thoracic Disease Apr 2024Esophageal malignancies have a high morbidity rate worldwide, and minimally invasive surgery has emerged as the primary approach for treating esophageal cancer. In...
BACKGROUND
Esophageal malignancies have a high morbidity rate worldwide, and minimally invasive surgery has emerged as the primary approach for treating esophageal cancer. In recent years, there has been increasing discussion about the potential of employing inflatable mediastinoscopic and laparoscopic approaches as an option for esophagectomy. Building on the primary modification of the inflatable mediastinoscopic technique, we introduced a secondary modification to further minimize surgical trauma.
METHODS
We conducted a retrospective analysis of patients who underwent inflatable mediastinoscopy combined with laparoscopic esophagectomy at the Second Affiliated Hospital of Naval Medical University from March 2020 to March 2023. The patients were allocated to the following two groups: the traditional (primary modification) group, and the secondary modification group. Operation times, intraoperative bleeding, and postoperative complications were compared between the groups.
RESULTS
The procedure was successfully performed in all patients, and conversion to open surgery was not required in any case. There were no statistically significant differences in the surgical operation time, intraoperative bleeding, number of dissected lymph nodes, and rate of postoperative anastomotic leakage between the two groups. However, a statistically significant difference was observed in the length of the mobilized esophagus between the two groups. The mobilization of esophagus to the level of diaphragmatic hiatus via the cervical incision was successfully achieved in more patients in the secondary modification group than the primary modification group.
CONCLUSIONS
Inflatable mediastinoscopy combined with single-incision plus one-port laparoscopic esophagectomy is a safe and effective surgical procedure. The use of a 5-mm flexible endoscope, ultra-long five-leaf forceps, and LigaSure Maryland forceps facilitates esophageal mobilization and lymph node dissection through a single cervical incision.
PubMed: 38738243
DOI: 10.21037/jtd-24-309 -
Respirology (Carlton, Vic.) Feb 2024To evaluate the diagnostic accuracy and clinical usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of...
BACKGROUND AND OBJECTIVE
To evaluate the diagnostic accuracy and clinical usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer (NSCLC) clinically staged with positron emission tomography/computed tomography (PET/CT).
METHODS
We conducted a study that included patients with centrally located T1N0M0 NSCLC, clinically staged with PET/CT who underwent EBUS-TBNA for mediastinal staging. Patients with negative EBUS-TBNA underwent mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and/or lung resection with systematic nodal dissection, that were considered the gold standard. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), overall accuracy of EBUS-TBNA for diagnosing mediastinal metastases (N2 disease) and the number needed to treat (NNT: number of patients needed to undergo EBUS-TBNA to avoid a case of pathologic N2 disease after resection) were calculated.
RESULTS
One-hundred eighteen patients were included. EBUS-TBNA proved N2 disease in four patients. In the remaining 114 patients who underwent mediastinoscopy, VAMLA and/or resection there were two cases of N2 (N2 prevalence 5.1%). The sensitivity, specificity, NPV, PPV and overall accuracy for diagnosing mediastinal metastases (N2 disease) were of 66%, 100%, 98%, 100% and 98%, respectively. The NNT was 31 (95% CI: 15-119).
CONCLUSION
EBUS-TBNA in patients with central clinically staged T1N0M0 NSCLC presents a good diagnostic accuracy for mediastinal staging, even in a population with low prevalence of N2 disease. Therefore, its indication should be considered in the management of even these early lung cancers.
Topics: Humans; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Positron Emission Tomography Computed Tomography; Mediastinum; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Neoplasm Staging; Lymph Nodes; Retrospective Studies; Endosonography
PubMed: 37885329
DOI: 10.1111/resp.14613 -
Respiratory Medicine Case Reports 2023Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, manifesting with bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint or eye...
Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, manifesting with bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint or eye lesions. Heerfordt-Waldenström Syndrome - a constellation of facial palsy, fever, uveitis and parotitis - is a rare presentation of this disorder. A 47-year-old Chinese woman presented with unintentional weight loss, lethargy with mediastinal and hilar lymphadenopathy. Biopsy of the right paratracheal lymph node via mediastinoscopy showed mycobacterial granulomatous lymphadenitis consistent with tuberculosis with several acid-fast bacilli identified. Lymphoproliferative disorder was ruled out. She was started on treatment for tuberculosis. Eleven weeks into treatment, she developed a right facial palsy accompanied with fever, uveitis and occipital headache. At this juncture, further history revealed a background of recurrent alternating facial palsy and parotid gland enlargement which was treated for Bell's palsy by three different doctors. New nodules appeared in the left lobe of the thyroid gland. Biopsy of a palpable thyroid nodule and a right supraclavicular lymph nodule showed histological features suggestive of sarcoidosis. Fungal and mycobacterial infections were ruled out. In addition, examination of her cerebral spinal fluid showed lymphocytic inflammation. The serum ACE level was not raised. A diagnosis of sarcoidosis with incomplete features of Heerfordt-Waldenström Syndrome along with thyroid and meningeal involvement was made. The patient was commenced on prednisolone and azathioprine and her symptoms responded shortly after. We present a rare case of Heerfordt-Waldenström Syndrome with thyroid and meningeal involvement in a Chinese woman.
PubMed: 37942172
DOI: 10.1016/j.rmcr.2023.101939 -
Indian Journal of Anaesthesia Sep 2023Translaryngeal ultrasonography (TLUSG) for diagnosis of vocal cord palsy, a relatively new, safe and noninvasive bedside technique with minimal risk of respiratory...
A single-arm, prospective study comparing translaryngeal ultrasonography with direct visualisation by flexible laryngoscopy for vocal cord assessment in patients undergoing oesophagectomy or mediastinoscopy.
BACKGROUND AND AIMS
Translaryngeal ultrasonography (TLUSG) for diagnosis of vocal cord palsy, a relatively new, safe and noninvasive bedside technique with minimal risk of respiratory infection transmission, has been effective in patients with thyroid disease. We studied its use as an alternative method to visual inspection by flexible laryngoscopy (FL) for vocal cord assessment in patients undergoing thoracic surgeries.
METHODS
After Institutional Ethics Committee approval and trial registration, in this single-arm, prospective study, the vocal cord function of 110 patients who underwent either total oesophagectomy or mediastinoscopy was assessed immediately after extubation by both FL and TLUSG. A follow-up assessment was done by laryngoscopy using Hopkin's endoscope (HL) and a repeat TLUSG. The primary outcome was the concordance between direct visualisation (FL or HL) and TLUSG.
RESULTS
Vocal cords were successfully visualised by TLUSG in 90% of male and all female patients. Findings of FL and TLUSG done at the first assessment matched in 89 (86.4%) out of 103 patients, and the degree of concordance was 0.69 (95% confidence interval [CI] =0.52-0.83). At the second assessment, HL and TLUSG findings matched in 83 (94.3%) out of 88 patients, and the degree of concordance was 0.89 (95% CI = 0.77-0.98).
CONCLUSION
TLUSG is an effective noninvasive alternative to direct visualisation for vocal cord assessment in both male and female patients undergoing thoracic surgery.
PubMed: 37829773
DOI: 10.4103/ija.ija_316_23 -
Heliyon Feb 2024Sarcoidosis and the overlap syndrome of autoimmune hepatitis and primary biliary cholangitis (PBC) share common clinical, biological, and histological features. The...
Sarcoidosis and the overlap syndrome of autoimmune hepatitis and primary biliary cholangitis (PBC) share common clinical, biological, and histological features. The simultaneous occurrence of these diseases have been reported in few cases and suggests that a common pathway which may contribute to granuloma formation in both conditions. We report the cases of two female patients having an association of sarcoidosis and inflammatory liver diseases. The first case is of a 61-year-old woman had been monitored for an overlap syndrome of PBC and autoimmune hepatitis (AIH). Therefore, treatment with azathiprine has been initiated associated with ursodeoxycholic acid (UDCA). Azathioprine had to be discontinued due to digestive intolerance, specifically chronic diarrhea and abdominal pain. The patient remained clinically stable on UDCA and her liver function tests were stable for years, until she developed symptoms of progressive dyspnea without any other associated signs. Chest computed tomography (CT) revealed mediastinal enlargement, bilateral pulmonary nodules, and symmetrical adenomegalies in the mediastinum. The bronchoalveolar lavage (BAL) revealed increased cellularity, with a notable elevation in lymphocyte count (48 %) and a CD4/CD8 ratio of 4. The patient underwent mediastinoscopy; a biopsy of the right laterotracheal (4R) adenomegaly was performed. Histological examination of the lymph node showed epithelioid and giant-cell tuberculoid lymphadenitis without necrosis, compatible with sarcoidosis. Ophthalmological and cardiac assessments were normal. Plethysmography test was normal and there was no need for corticosteroid treatment; a surveillance was planned. Treatment with UDCA was pursued. The second case is of a 50-year-old woman with no medical history presented symptoms including dry eyes and mouth, inflammatory-type polyarthralgia affecting knees and wrists, bilateral Raynaud's phenomenon, right hypochondrium pain, and worsening dyspnea over six months. Liver analysis showed elevation of alkaline phosphatase (ALP) to three times upper limit of normal (ULN) and gamma-glutamyltransferase (GGT) to 5 times ULN. This cholestasis was associated with an increase in transaminase activity to 5 times ULN for over six months. Immunological tests revealed positive anti-nuclear antibodies (ANA), anti-Ro52, anti-M23E, and anti-centromere antibodies. Chest-CT showed multiple bilateral bronchiolar parenchymal micronodules mostly in the upper and posterior regions without any mediastinal adenomegaly. Bronchial endoscopy was normal, and biopsies indicated chronic inflammation. The BAL revealed increased cellularity, characterized by a high lymphocyte count (51.7 %) and a CD4/CD8 ratio of 2.8. Biopsy of minor salivary gland revealed grade 4 lymphocytic sialadenitis. Skin biopsy revealed an epithelioid granuloma without caseous necrosis. Liver biopsy performed in the presence of cytolysis and moderate hepatic insufficiency, revealed granulomatous hepatitis and cholangitis lesions along with septal fibrosis suggestive of PBC. The diagnosis of cutaneous and pulmonary sarcoidosis with PBC and Sjögren's syndrome was retained. The spirometry and diffusing capacity for carbon monoxide value were normal. Treatment involved UDCA, corticosteroids, and azathioprine, leading to clinical and biological improvement. Sarcoidosis shares some clinical manifestations with autoimmune liver diseases, primarily PBC. A hepatic granuloma with a different appearance and location can guide the diagnosis. Early diagnosis and appropriate management can avoid serious complications and improve prognosis.
PubMed: 38390068
DOI: 10.1016/j.heliyon.2024.e25826 -
Cureus Jan 2024Lofgren syndrome is a clinically distinct phenotype of sarcoidosis. It is characterized by the triad of bilateral hilar lymphadenopathy, arthritis (usually the ankles),...
Lofgren syndrome is a clinically distinct phenotype of sarcoidosis. It is characterized by the triad of bilateral hilar lymphadenopathy, arthritis (usually the ankles), and fever. We present the case of a 31-year-old male patient who presented with fever and edema in both lower limbs, with palpation of subcutaneous nodules. A chest contrast-enhanced computerized axial tomography (CECT) scan revealed perihilar and mediastinal lymphadenopathy. In making the diagnosis, tuberculosis and lymphoma were both ruled out. A mediastinoscopy confirmed Lofgren syndrome. In medicine, a good differential diagnosis is important, as it will help inform the best treatment for the patient.
PubMed: 38322058
DOI: 10.7759/cureus.51801 -
Respirology Case Reports May 2024EBUS-TBNA has represented a revolution in the diagnosis of intrathoracic pathologies, particularly in lung cancer staging, replacing more invasive methods such as...
EBUS-TBNA has represented a revolution in the diagnosis of intrathoracic pathologies, particularly in lung cancer staging, replacing more invasive methods such as mediastinoscopy. However, its role in diagnosing rare benign or malignant mediastinal disorders is still a matter of debate. Over the past few years, the role of EBUS-guided cryobiopsy has been increasingly emerging as an innovative and minimally invasive technique in diagnosing these disorders, with an excellent safety profile. In this case report, we present the case of a young man brought to our attention after already undergoing a non-diagnostic trans thoracic needle aspiration (TTNA) procedure for lung consolidations. In our department, he underwent an initial EBUS-TBNA procedure with inconclusive rapid on-site evaluation (ROSE), leading to the decision to perform an EBUS-guided cryobiopsy, which yielded a diagnosis of granulomatosis with polyangiitis without complications. This clinical case demonstrates that in specific contexts, EBUS-cryobiopsy represents an excellent diagnostic tool.
PubMed: 38751968
DOI: 10.1002/rcr2.1385