-
The Thoracic and Cardiovascular Surgeon... Jan 2023The so-called nonintubated or awake video-assisted thoracoscopic surgery (NIVATS) is performed on spontaneously breathing patients, which was shown to reduce...
The so-called nonintubated or awake video-assisted thoracoscopic surgery (NIVATS) is performed on spontaneously breathing patients, which was shown to reduce postoperative complications and shorten hospital stay. Awake uniportal VATS was indicated for the evacuation of an extensive, superinfected hemothorax with symptomatic mediastinal shift in a patient with advanced mediastinal SMARCA4-deficient tumor and declined condition, who did not allow a general anesthetic procedure and was not a candidate for extensive surgery. This short microinvasive intervention was a prerequisite to stabilize the threat to the patient's life and thus potentially enable any further tumor-specific therapy.
PubMed: 37877100
DOI: 10.1055/a-2178-0485 -
Diseases (Basel, Switzerland) Oct 2023A teratoma is a neoplasm composed of cell populations or tissues that are reminiscent, in their appearance, of normal elements derived from at least two embryonic...
A teratoma is a neoplasm composed of cell populations or tissues that are reminiscent, in their appearance, of normal elements derived from at least two embryonic layers. Fetal mature teratomas are normally benign, cystic, and typically occur along the midline, while they are rare in the posterior mediastinum. Teratomas are frequently solitary; however, they may sometimes be associated with other congenital anomalies and/or with chromosomal abnormalities. Clinically, they are often asymptomatic but can occasionally cause compression symptoms. Prenatal diagnoses are uncommon and made with ultrasonography; differential diagnosis with other congenital conditions is mandatory. We report the case of a 21 weeks of gestational age old fetus with a mature triphyllic fetal cystic teratoma, grade 0, located in the right posterior mediastinum. The tumor presented as a 3 cm wide cystic mass that caused a contralateral shift of the surrounding structures. Histological examination later revealed the presence of derivatives of the three germ layers, such as hyaline cartilage, smooth muscle, nervous tissue, and a respiratory-type epithelium.
PubMed: 37873788
DOI: 10.3390/diseases11040144 -
Clinical Lymphoma, Myeloma & Leukemia Jan 2024The emergence of immune checkpoint inhibitors (ICIs) has led to a dramatic paradigm shift within the landscape of cancer treatment, igniting significant interest in... (Review)
Review
The emergence of immune checkpoint inhibitors (ICIs) has led to a dramatic paradigm shift within the landscape of cancer treatment, igniting significant interest in their potential application in treating hematologic malignancies. This comprehensive review critically has examined the existing body of literature to shed light on the evolving understanding of the efficacy and safety of ICIs, both as a single agent and in combination regimens in hematologic malignancies. Across distinct lymphoma subtypes, the observed treatment responses exhibit diversity, and conflicts. Notably, Hodgkin lymphoma and certain non-Hodgkin lymphomas such as primary mediastinal B-cell lymphoma, emerge as remarkable cases, showing encouraging response rates and outcomes. However, the efficacy of ICIs reveals variations among subtypes such as chronic lymphocytic leukemia and multiple myeloma. Combination therapies consistently demonstrated superior outcomes compared to monotherapy in several malignancies. While the potential benefits of ICIs in hematologic malignancies are evident, the safety profile warrants careful consideration. Immune-related and other adverse events, though generally tolerable and manageable, highlight the necessity of meticulous monitoring and appropriate intervention. The discussions prompted by these findings underscore the need for tailored treatment approaches, driven by disease subtype, patient characteristics, and potential biomarkers. Moreover, the emerging realm of combination therapies involving immune checkpoint inhibitors holds promise for enhanced treatment outcomes, and ongoing research endeavors aim to unravel the optimal strategies.
Topics: Humans; Immune Checkpoint Inhibitors; Antibodies, Monoclonal; Hematologic Neoplasms; Lymphoma, Non-Hodgkin; Lymphoma
PubMed: 37863681
DOI: 10.1016/j.clml.2023.09.002 -
Cureus Sep 2023Background Chest X-rays (CXRs) are widely used for cost-effective screening of active pulmonary tuberculosis despite their limitations in sensitivity and specificity...
Background Chest X-rays (CXRs) are widely used for cost-effective screening of active pulmonary tuberculosis despite their limitations in sensitivity and specificity when interpreted by clinicians or radiologists. To address this issue, computer-aided detection (CAD) algorithms, particularly deep learning architectures based on convolution, have been developed to automate the analysis of radiography imaging. Deep learning algorithms have shown promise in accurately classifying lung abnormalities using chest X-ray images. In this study, we utilized the EfficientNet B4 model, which was pre-trained on ImageNet with 380x380 input dimensions, using its weights for transfer learning, and was modified with a series of components including global average pooling, batch normalization, dropout, and a classifier with 12 image-wise and 44 segment-wise lung zone evaluation classes using sigmoid activation. Objectives Assess the clinical usefulness of our previously created EfficientNet B4 model in identifying lung zone-specific abnormalities related to active tuberculosis through an observer performance test involving a skilled clinician operating in tuberculosis-specific environments. Methods The ground truth was established by a radiologist who examined all sample CXRs to identify lung zone-wise abnormalities. An expert clinician working in tuberculosis-specific settings independently reviewed the same CXR with blinded access to the ground truth. Simultaneously, the CXRs were classified using the EfficientNet B4 model. The clinician's assessments were then compared with the model's predictions, and the agreement between the two was measured using the kappa coefficient, evaluating the model's performance in classifying active tuberculosis manifestations across lung zones. Results The results show a strong agreement (Kappa ≥0.81) seen for lung zone-wise abnormalities of pneumothorax, mediastinal shift, emphysema, fibrosis, calcifications, pleural effusion, and cavity. Substantial agreement (Kappa = 0.61-0.80) for cavity, mediastinal shift, volume loss, and collapsed lungs. The Kappa score for lung zone-wise abnormalities is moderate (0.41-0.60) for 39% of cases. In image-wise agreement, the EfficientNet B4 model's performance ranges from moderate to almost perfect across categories, while in lung zone-wise agreement, it varies from fair to almost perfect. The results show strong agreement between the EfficientNet B4 model and the human reader in detecting lung zone-wise and image-wise manifestations. Conclusion The clinical utility of the EfficientNet B4 models to detect the abnormalities can aid clinicians in primary care settings for screening and triaging tuberculosis where resources are constrained or overburdened.
PubMed: 37818499
DOI: 10.7759/cureus.44954 -
The Journal of Surgical Research Jan 2024Congenital lung malformations (CLMs) are readily identified early in pregnancy with a variable natural history. Monitoring for lesion size and mediastinal shift (MS) is...
INTRODUCTION
Congenital lung malformations (CLMs) are readily identified early in pregnancy with a variable natural history. Monitoring for lesion size and mediastinal shift (MS) is recommended following diagnosis. The purpose of this study is to propose a risk-stratified clinical algorithm for prenatal monitoring of CLM.
METHODS
After ethical approval, all fetuses with CLMs evaluated at our fetal center from January 2015 to June 2022 were retrospectively reviewed. Patient demographics, imaging characteristics, and fetal interventions were collected. Lesions were stratified by congenital lung malformation volume ratio (CVR) and the presence of MS. Descriptive statistics and receiver operating characteristic curves were employed in the analysis.
RESULTS
We analyzed 111 patients with a mean of 23.4 wk gestational age, a median CVR of 0.5 (interquartile range, 0.3-1.2), and MS in 76 of 111(68%) patients on initial evaluation. Among low-risk patients (CVR ≤1.1), 96% remained low-risk on final evaluation. No patients transitioned from low to high risk during the growth period. Patients with CVR >1.1 often had persistent MS (P < 0.001). Hydrops (5/111, 5%) and fetal intervention (4/111, 4%) only occurred in patients with CVR >1.1 (P < 0.001, P = 0.002) and MS (P = 0.144, P = 0.214). On receiver operating characteristic curve analysis, initial CVR >1.1 had 100% sensitivity and negative predictive value for hydrops and fetal intervention.
CONCLUSIONS
CLMs with initial CVR ≤1.1 are low risk for hydrops and fetal intervention. We propose a risk-stratified algorithm for the monitoring of CLM during the growth period based on CVR. While our experience suggests that patients with CLM and MS are at higher risk, the current subjective assessment of MS is not adequately predictive. Incorporating an MS grading system may further refine risk stratification in the management of CLM.
Topics: Pregnancy; Female; Humans; Retrospective Studies; Ultrasonography, Prenatal; Lung Diseases; Respiratory System Abnormalities; Lung; Edema
PubMed: 37806224
DOI: 10.1016/j.jss.2023.08.002 -
Surgical Endoscopy Nov 2023Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and...
BACKGROUND
Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC).
METHODS
Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed.
RESULTS
Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively.
CONCLUSION
RE with the outermost layer-oriented approach can provide safe short-term outcomes.
Topics: Humans; Male; Middle Aged; Female; Retrospective Studies; Robotic Surgical Procedures; Esophagectomy; Lymph Node Excision; Esophageal Neoplasms; Paralysis; Recurrent Laryngeal Nerve
PubMed: 37770607
DOI: 10.1007/s00464-023-10437-8 -
Cureus Sep 2023Superior vena cava syndrome (SVCS) is an obstruction of the venous return through the superior vena cava (SVC) or any other significant branches. The obstruction may be...
Superior vena cava syndrome (SVCS) is an obstruction of the venous return through the superior vena cava (SVC) or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. A 54-year-old female presented from the university medical center with weight loss and solid food dysphagia for three months. Chest-CT scan showed a mediastinal mass of 10 x 9 x 8 cm. A transbronchial biopsy was attempted. The patient was arrested during the bronchoscopy lab procedure. Cardiopulmonary resuscitation (CPR) was initiated, and venoarterial-extracorporeal membrane oxygenation (VA-ECMO) was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery and the left femoral vein cannula size 23 Fr. During the night shift, the ECMO flow was hard to maintain with fluids, which was realized with the ECMO outflow volume issue. The next day, in the hybrid operating room, a fenestrated SVC stent was placed in the SVC, brachiocephalic, and internal jugular veins. The patient's hemodynamics improved post-stenting, especially ECMO outflow. This case illustrates that stenting in SVCS is a valid therapeutic option to increase the ECMO flow in this patient group.
PubMed: 37766775
DOI: 10.7759/cureus.46008 -
Clinical Radiology Dec 2023Anterior mediastinal masses can be difficult to characterise on computed tomography (CT) due to the wide spectrum of normal appearances of thymic tissue as well as the... (Review)
Review
Anterior mediastinal masses can be difficult to characterise on computed tomography (CT) due to the wide spectrum of normal appearances of thymic tissue as well as the challenge of differentiating between benign and malignant pathologies. Additionally, attenuation of cystic mediastinal lesions can be misinterpreted on CT due to varying attenuation values. Anecdotally, non-vascular magnetic resonance imaging (MRI) of the thorax is underutilised across radiology departments in the UK, but has been shown to improve diagnostic certainty and reduce unnecessary surgical intervention. T2-weighted MRI is useful in confirming the cystic nature of lesions, whereas chemical shift techniques can be utilised to document the presence of macroscopic and intra-cellular fat and thus help distinguish between benign and malignant pathologies. In this review article, we present a practical approach to using MRI for the characterisation of anterior mediastinal lesions based on our clinical experience in a UK district general hospital.
Topics: Humans; Mediastinal Neoplasms; Magnetic Resonance Imaging; Thymus Gland; Tomography, X-Ray Computed; Mediastinum
PubMed: 37709611
DOI: 10.1016/j.crad.2023.08.015 -
Cureus Aug 2023Multiple myeloma (MM) is a relatively common malignancy that primarily affects the bone marrow, while extramedullary disease (EMD) occurs in the skin and muscle, lung...
Multiple myeloma (MM) is a relatively common malignancy that primarily affects the bone marrow, while extramedullary disease (EMD) occurs in the skin and muscle, lung pleura, lymph nodes, liver, and CNS. Myelomatous pleural effusion (MPE) is a rare extramedullary manifestation of MM in which pleural fluid is composed almost entirely of abnormal plasma cells. MPE and other types of EMD are associated with poor prognosis, and MPE can present emergently due to tension physiology. We report a case of a patient with massive MPE presenting with contralateral midline shift. There are exceedingly few such cases and this report highlights a unique presentation of this rare clinical entity. Epidemiology, radiographic features, diagnosis, treatment, and implications for the prognosis of the disease are discussed.
PubMed: 37680422
DOI: 10.7759/cureus.43040 -
Case Reports in Pediatrics 2023Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial...
Successful Elective Thoracoscopic Resection of Complicate Extralobar Bronchopulmonary Sequestration after Intrafoetal Vascular Laser Ablation: The Paediatric Surgeon's Point of View.
Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery, have been published. Additionally, very few of them focus also on the postnatal management, with results limited and controversial. Postnatal treatment of residual malformation remains debated, hence the need to share our experience of a combined pre- and postnatal approach to complicated extra-lobar BPS. We report the case of a female foetus with the diagnosis of a pulmonary lesion. Due to mediastinal shift, unilateral compressive hydrothorax, ascites, and hydrops, a foetal treatment with ultrasound-guided laser coagulation of the anomalous vessel was performed. At birth, due to the persistence of the malformation, an elective delayed thoracoscopical surgery was performed. Prenatal laser ablation for complicated BPS is a life-saving procedure not always resulting in lesion disappearance. Thoracoscopical surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe.
PubMed: 37664529
DOI: 10.1155/2023/4959022