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Interactive Cardiovascular and Thoracic... Jun 2022Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies,...
Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies, infections or mediastinal neoplasm. We present a case of middle-aged male with no past medical history of note prior to developing heavy sweating, loss of weight and cough. A series of investigations were done including chest computed tomography which showed enlarged mediastinal lymph nodes leading to uncomplicated mediastinoscopy and lymph node biopsy. Six days after being discharged, he developed dyspnoea and chest pain. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was done and surprisingly revealed milky white chylous fluid. The patient was then successfully managed without the need for further intervention.
Topics: Chylothorax; Humans; Lymph Nodes; Male; Mediastinum; Middle Aged; Pericardial Effusion; Pericardiocentesis
PubMed: 34964452
DOI: 10.1093/icvts/ivab365 -
Journal of Clinical Oncology : Official... Aug 2023Journal of Clinical Oncology, Accurate staging of the mediastinal lymph nodes in resectable non-small-cell lung cancer (NSCLC) is critically important to determine the... (Review)
Review
Journal of Clinical Oncology, Accurate staging of the mediastinal lymph nodes in resectable non-small-cell lung cancer (NSCLC) is critically important to determine the overall stage of the tumor and guide subsequent management. The staging process typically begins with positron emission tomography (PET) or computed tomography imaging; however, imaging alone is inadequate, and tissue acquisition is required for confirmation of nodal disease. Mediastinoscopy was long considered the gold standard for staging of mediastinal lymph nodes, but, recently, endobronchial ultrasound-guided (EBUS) fine-needle aspiration (FNA) has become the standard of care. EBUS-FNA, in combination with supplementary technologies, such as intranodal forceps biopsy and esophageal ultrasonography, has a high sensitivity and specificity for the diagnosis of nodal metastases. EBUS-FNA is also capable of assessing N1 disease and obtaining adequate tissue for tumor genomic analysis to help guide treatment. In the case of negative findings on EBUS, a confirmatory video mediastinoscopy is still recommended by the European Society of Thoracic Surgeons guidelines. However, whether confirmatory mediastinoscopy is necessary is a matter of debate, and it is not commonly performed in North America. To address this question, Bousema and colleagues performed a randomized noninferiority trial to determine rates of unforeseen nodal metastases after EBUS alone versus EBUS with confirmatory mediastinoscopy in patients with resectable NSCLC. The authors concluded that EBUS alone is noninferior to EBUS with confirmatory mediastinoscopy. These findings affirm our current practice to forgo confirmatory mediastinoscopy after negative findings on EBUS.
Topics: Humans; Carcinoma, Non-Small-Cell Lung; Mediastinoscopy; Lung Neoplasms; Neoplasm Staging; Mediastinum; Endosonography; Lymph Nodes
PubMed: 37267507
DOI: 10.1200/JCO.23.00867 -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jan 2024Mediastinal tumors are the most common thoracic tumor in the pediatric population. They include a spectrum of tumors, and most are malignant. These lesions can be... (Review)
Review
Mediastinal tumors are the most common thoracic tumor in the pediatric population. They include a spectrum of tumors, and most are malignant. These lesions can be anatomically and radiologically classified by means of compartments; anterior, middle, and posterior. Symptoms, signs, localization of the tumor, age of the child, and tumor markers are key points of diagnosis. Surgical approaches are typically needed for diagnosis, but sometimes tru-cut needle biopsies may be sufficient. Mediastinoscopy, mediastinotomy, and video-assisted thoracoscopic surgery may be used in the diagnostic workup of mediastinal tumors in children as they are used in adults. Frequently, diagnosis and treatment are both established by means of surgery. Surgery remains the mainstay of treatment of most benign and malignant nonlymphoid tumors. Combined modality of treatment incorporating chemotherapy and radiotherapy is often required in malignant tumors and is associated with high survival rates in these patients.
PubMed: 38584788
DOI: 10.5606/tgkdc.dergisi.2024.25799 -
Abdominal Radiology (New York) Aug 2022Percutaneous image-guided biopsy is an invaluable technique in the management of a myriad of different conditions; however, percutaneous access to some targets remains... (Review)
Review
Percutaneous image-guided biopsy is an invaluable technique in the management of a myriad of different conditions; however, percutaneous access to some targets remains challenging. Trans-osseous biopsy provides safe, high-yield access to many challenging lesions in the chest, abdomen, and pelvis which might otherwise require more invasive procedures, such as mediastinoscopy or surgery to establish a histological diagnosis. Additionally, trans-osseous biopsy is well tolerated and may reduce the risk of injury to intervening vital structures as compared to other percutaneous techniques. In this article we review the indications, technical challenges, alternative techniques, and potential complications of trans-sternal, trans-costal, trans-scapular, trans-vertebral, trans-iliac, and trans-sacral biopsies.
Topics: Abdomen; Humans; Image-Guided Biopsy; Pelvis; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 34132879
DOI: 10.1007/s00261-021-03167-9 -
Journal of Clinical Oncology : Official... Aug 2023Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence... (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
Resectable non-small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking.
METHODS
Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality.
RESULTS
Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first ( = .4940).
CONCLUSION
On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.
Topics: Humans; Lung Neoplasms; Carcinoma, Non-Small-Cell Lung; Mediastinoscopy; Endosonography; Neoplasm Staging; Lymph Nodes
PubMed: 37018653
DOI: 10.1200/JCO.22.01728 -
Saudi Journal of Anaesthesia 2021The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications... (Review)
Review
The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.
PubMed: 34764836
DOI: 10.4103/sja.SJA_350_20 -
Chest Mar 2020There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to...
BACKGROUND
There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort.
METHODS
We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis.
RESULTS
Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776).
CONCLUSIONS
When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.
Topics: Bronchoscopy; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Female; Health Care Costs; Health Expenditures; Hemothorax; Humans; Lung Neoplasms; Lymph Nodes; Male; Mediastinoscopy; Middle Aged; Mortality; Neoplasm Staging; Pneumothorax; Postoperative Complications; Respiratory System; Retrospective Studies; Vascular System Injuries; Vocal Cord Paralysis
PubMed: 31605700
DOI: 10.1016/j.chest.2019.09.021 -
World Journal of Surgical Oncology Aug 2021To avoid the inconvenience of triangulation among various rigid operating instruments in mediastinoscopy-assisted esophagectomy, we invented a new technique: used a...
BACKGROUND
To avoid the inconvenience of triangulation among various rigid operating instruments in mediastinoscopy-assisted esophagectomy, we invented a new technique: used a flexible endoscope to mobilize thoracic esophagus and dissected mediastinal lymph nodes through the left cervical incision. This technology has not been reported so far. In this study, we introduce our long-term experience and demonstrate this new technique.
METHODS
Twenty-nine patients with early esophageal cancer underwent mediastinoscopy-assisted esophagectomy in our hospital from June 2018 to September 2020. Among them, 12 patients used flexible mediastinoscopy, and 17 patients used conventional rigid mediastinoscopy and instruments to observe their therapeutic effect.
RESULTS
There were no significant differences between the two groups in gender, average age, body mass index, incidence of adverse reactions, bleeding volume, and postoperative hospital stay. The operation time of flexible mediastinoscopy group was significantly shorter than that of rigid mediastinoscopy group (192.9 ± 13.0 vs 246.8 ± 6.9 min, p < 0.01). The number of lymph nodes removed by flexible endoscopy was significantly more than that of rigid endoscopy (8.5 ± 0.6 vs 6.0 ± 0.3, P < 0.01). Postoperative follow-up was completed for all patients, and the average follow-up time was 11.6 ± 7.2 months. During the follow-up period, no recurrence or death was observed.
CONCLUSIONS
Mediastinoscopy-assisted esophagectomy is an effective way to treat early esophageal cancer. The application of flexible mediastinoscopy provides more convenience and better stability. It can facilitate the operation of the surgeon and lymph node dissection, which proved to be a feasible technology.
Topics: Esophageal Neoplasms; Esophagectomy; Humans; Lymph Node Excision; Mediastinoscopy; Neoplasm Recurrence, Local; Prognosis; Technology
PubMed: 34364369
DOI: 10.1186/s12957-021-02352-w