Uniportal VATS removal of a giant mediastinal goitre.

We demonstrate the technical nuances and operative strategy of uniportal video-assisted thoracoscopic surgical excision of a giant mediastinal goitre in a patient with a complex medical history, including a prior total thyroidectomy for multinodular goitre and partial gastrectomy for gastrointestinal stromal tumour. The video tutorial presents the surgical removal of a substantial mediastinal goitre, persisting post-total thyroidectomy performed 2 years prior via a collar incision. We opted for a thoracoscopic technique for the removal of the residual mediastinal mass. A 3-cm uniportal incision was made at the fifth intercostal space along the mid-axillary line. Pleural exploration confirmed the absence of adhesions. Subsequent dissection revealed a large retrocaval goitre adjacent to the trachea. Utilizing a combination of LigaSure technology for sharp dissection, and blunt dissection techniques using the peanuts, we severed the goitre's attachments to surrounding critical structures, including the trachea, superior vena cava and oesophagus. The dissection continued, extending into the cervical region from the thoracic approach. The mass was safely enclosed within an endobag and extracted through the uniportal incision. This case demonstrates the feasibility and effectiveness of the uniportal thoracoscopic approach for complex mediastinal pathology. This approach was successfully executed with an uneventful perioperative course and no complications, indicating positive outcomes in complex thoracic cases despite a minimally invasive approach for the resection of mediastinal masses.

Left Thoracoscopic Robot-Assisted Excision of a Left Lower Paratracheal Parathyroid Adenoma for Cure of Primary Hyperparathyroidism.

We present a case of a 38-year-old male patient with symptomatic hypercalcemia secondary to primary hyperparathyroidism. After evaluation, the source of the excess parathyroid hormone was found to be an adenoma localized to the middle mediastinum. Specifically, it was located in the left paratracheal space along the lesser curve of the aortic arch. We discuss this case with a corresponding video to demonstrate the necessary equipment and setup as well as the 5 operative steps recommended to access this paratracheal subaortic location from a minimally invasive transthoracic approach. The pitfalls for this operation are also discussed. The purpose is to make this operation more reproducible for other surgeons.

Insulinoma-associated protein-1 (INSM-1) is a useful diagnostic marker for the evaluation of primary thymic neuroendocrine neoplasms: an immunohistochemical study of 27 cases.

Insulinoma-associated protein 1 (INSM1) immunohistochemistry has been established as a sensitive and reliable immunohistochemical marker for detecting neuroendocrine differentiation in tumors across various organ systems. However, this marker has not been adequately investigated in primary thymic neuroendocrine tumors. We have studied a series of 27 cases of primary neuroendocrine carcinomas of the thymus, including 3 typical carcinoids, 18 atypical carcinoids, 4 large cell neuroendocrine carcinomas, and 2 small cell carcinomas. Immunostaining on whole tissue sections for INSM-1 was evaluated. Results of immunostaining for chromogranin and synaptophysin were also evaluated. 26/27 tumors (96%) demonstrated nuclear positivity for INSM1. 18 tumors (67%) showed strong and diffuse nuclear staining (3 +), 3 tumors (11%) moderate (2 +) nuclear staining, and 5 tumors (19%) showed weak (1 +) nuclear staining. The average percentage of tumor cells positive for INSM1 was 76%. Only one tumor, a small cell carcinoma, was negative. All tumors were positive for synaptophysin, and 26/27 (96%) were positive for chromogranin A. This study confirms that INSM1 immunohistochemistry is a sensitive marker of neuroendocrine differentiation in primary thymic neuroendocrine neoplasms and demonstrates similar performance characteristics compared to other organ systems. The nuclear staining with this marker offers the advantage of eliminating some of the ambiguity in the interpretation sometimes encountered with other markers. An added advantage is the consistent staining across the entire spectrum of neuroendocrine tumors of this organ.

More than chest pain: A case of oesophageal foreign body ingestion.

BACKGROUND:  Physicians often focus on possible cardiac causes in patients presenting with chest pain. However, this case highlights a patient who presented with chest pain caused by ingestion of a foreign body after an uneventful meal eaten an hour prior to presentation. The fishbone was discovered after imaging. The article aims to raise awareness regarding the potential origins of chest pain, highlighting that it may stem from non-cardiac conditions. METHODS:  The methodology employed in this study involved conducting a case study that meticulously examined the repercussions and management strategies associated with foreign body ingestion. RESULTS:  The case report delineates the scenario of a 27-year-old male patient who inadvertently ingested a fishbone during a routine meal. It details the swift decline in clinical status, the meticulous diagnostic procedures employed, the subsequent management strategies implemented and the ultimate discharge of the patient in a stable condition. CONCLUSION:  This case highlights the importance of comprehensive history taking and considering a wide range of causes of chest pain when evaluating a patient. The foreign body ingested with the resulting cardiac complications could have been fatal if not promptly diagnosed.Contribution: This study contributed to advancing awareness surrounding foreign body ingestion, shedding light on potential complications and offering valuable insights into effective management strategies.

The complete anatomy of the azygos vein: a meta-analysis with clinical implications.

BACKGROUND: The azygos vein (AV) plays a crucial role in the mediastinal region, exhibiting considerable variability in its anatomy and relationship with surrounding structures. This study aims to assess the morphometry and anatomy of the AV through a comprehensive meta-analysis of studies reporting extractable data on this vessel. MATERIALS AND METHODS: Major online medical databases such as PubMed, Scopus, ScienceDirect, Web of Science, SciELO, BIOSIS, Current Content Connect, Korean Journal Database and Wiley online library were searched to gather all relevant studies regarding the anatomical characteristics of the AV. RESULTS: The results of the present meta-analysis comprised 40 studies, categorized into eight groups for data analysis. The mean AV diameter at its origin was set at 3.86 mm (SE = 0.84). The most prevalent was type IIB, with a prevalence of 40.23% (95% CI: 29.06-51.92%). The pooled prevalence of the right subcostal and right ascending lumbar veins forming the AV was 73.82% (95% CI: 55.77-88.67%). CONCLUSIONS: The AV exhibits a high degree of variability regarding its origin, trajectory, and connections with the hemiazygos system. The most prevalent type of AV, according to the Anson and McVay classification, was Type II (transitional type). Moreover, the vein was found to be formed by the right subcostal and the right ascending lumbar veins in the majority of the cases. This is the most comprehensive and current assessment of AV morphometry and anatomy to date. The findings are a valuable resource for physicians, especially surgeons performing various procedures in the mediastinum.

Robotic radical thymectomy-right-sided approach for a thymoma.

The utilization of a radical robotic thymectomy, with clearance of the mediastinal tissue between the two phrenic nerves for a thymoma, is well established. The complex mediastinal anatomy, limited space and the location of the heart introduce a distinctive challenge, particularly when adopting a right-sided approach to identify and dissect along the left phrenic nerve. We present our technique for performing a robotic radical thymectomy from a right-sided approach, tailored for a localized thymoma. Our goal is to showcase the efficacy and safety of this method, offering insights that can enhance surgical outcomes.

Brachiocephalic Vein Reconstruction Following the Excision of a Large Suspicious Anterior Mediastinal Mass.

Superior vena cava syndrome (SVCS) is a clinical condition characterized by signs and symptoms resulting from the blockage or narrowing of the thin-walled superior vena cava (SVC). This obstruction can lead to significant morbidity and mortality. In this case, we report a 58-year-old patient who was diagnosed with SVCS due to a massive compressing anterior mediastinal mass leading to signs and symptoms of SVCS, including shortness of breath, dizziness, palpitations, and neck swelling, which was managed surgically by excision of the mass and reconstruction of the brachiocephalic vein using a synthetic graft.

Atypical Thymoma (WHO Type B3) with Prominent Microcystic and Mucoid Changes Mimicking Thymic Mucoepidermoid Carcinoma: A Clinicopathological and Immunohistochemical Study of Five Cases.

Five atypical thymomas (WHO type B3) with prominent microcystic and mucoid changes are presented. The patients were four men and one woman between the ages of 57 and 72 years. The patients presented with non-specific symptoms of cough, chest pain, and dyspnea. None of the patients had a history of myasthenia gravis. Diagnostic imaging revealed the presence of anterior mediastinal masses and surgical resection was accomplished in all patients. Macroscopically, the tumors ranged in size from 3.5 to 5.0 cm in greatest diameter; four of these were well circumscribed but unencapsuled, tan colored tumors without evidence of necrosis, hemorrhage, or gross cystic changes. One tumor had more infiltrative borders and was involving the mediastinal pleura. Microscopically, the low power view was characterized by prominent microcysts that were filled with a mucoid granular material. Higher magnification demonstrated a homogenous epithelial proliferation with mild cytologic atypia but lacking mitotic activity. Focal areas of squamoid differentiation were identified but perivascular spaces were absent. Histochemical staining confirmed mucinous material in the microcysts but no intracytoplasmic mucin. Immunohistochemical stains showed positive staining of the tumor cells with keratin AE1/AE3, keratin 5/6, p63, and p40. No terminal deoxynucleotidyl transferase+/CD3 + immature lymphocytes were identified. Clinical follow-up demonstrated that four patients have remained alive without recurrence while one patient was lost to follow-up. This report highlights histological features in atypical thymoma that may be confused with other tumors, especially thymic mucoepidermoid carcinoma. Separation of these tumors may be important for patient management and prognosis.

Breath on the Brink: Navigating Anaesthesia Management in a Case With a Mediastinal Mass.

Mediastinal teratomas are rare, often asymptomatic, but clinically significant neoplasms that can manifest with a spectrum of symptoms, frequently attributed to the compression of surrounding critical anatomical structures. Here, we present the case of a 19-year-old male with respiratory distress and chest pain attributed to a large anterior mediastinal mass, ultimately diagnosed as a benign mature teratoma of the thymus. Radiological imaging revealed a large, partially cystic mass compressing the pulmonary arteries, aortic arch, and left main bronchus. Surgical excision was deemed necessary due to symptomatic presentation. Anaesthesia management during mediastinal mass excision posed significant challenges, with prompt sternotomy due to ventilation difficulties after induction. Immediate decompression of the mass improved ventilation and saturation. Despite postoperative complications, including pulmonary leaks necessitating tracheostomy, the patient achieved significant recovery. Anaesthesia strategy was to prioritise avoiding muscle relaxants and maintaining spontaneous ventilation to mitigate airway collapse and hemodynamic instability during induction. Collaboration between anaesthesia, surgical, and intensive care teams is vital for comprehensive preoperative assessment, intraoperative readiness, and postoperative care. This case underscores the importance of interdisciplinary collaboration and meticulous planning to optimise outcomes in patients undergoing surgery for mediastinal teratomas.

Co-existing Mediastinal Venous Malformation and Fusiform Superior Vena Cava Aneurysm in a Patient with Ischemic Stroke: A Case Report and Review of Literature.

BACKGROUND: Mediastinal venous malformation (MVM) and fusiform superior vena cava aneurysm (F-SVCA) are both rare congenital vascular anomalies. CASE PRESENTATIONS: A 46-year-old male presented with acute ischemic stroke of unknown etiology. Computed tomography (CT) angiography revealed the coexistence of MVM and F-SVCA. Diagnostic venography demonstrated a significant reduction in blood flow velocity within the F-SVCA, but failed to identify a direct connection to the left heart system or pulmonary vein. The patient expired due to extensive brain damage caused by a stroke. CONCLUSION: This case may increase the necessity of meticulous radiological evaluation and preventive management for these anomalies, as mediastinal vascular anomalies can result in thromboembolic complications.

Primary mucinous adenocarcinoma of the anterior mediastinum with HER-2 mutation: A rare case report.

We report the case of a 68-year-old male whose Computed Tomography (CT) scan presented a mass (68*62*54 mm) of the right anterior mediastinal and pathologically diagnosis was mucinous adenocarcinoma(MA). The peripheral vessels are surrounded by the big mass in the anterior mediastinum which was associated with multiple metastases, thus we performed palliative chemoradiotherapy and we tried Human Epidermal Growth Factor Receptor-2 (HER-2) inhibitors based on the Next Generation Sequencing. The patient passed away 16 months after the onset of the disease. In this report, we review the rare case of anterior mediastinum MA as well as perspectives for potential future treatments.

Metaplastic thymoma in the middle mediastinum: a rare case report and surgical treatment analysis of a 32-year-old female patient.

Background: Metaplastic thymoma (MT), an exceedingly rare variant of primary thymic epithelial neoplasms, is distinguished by its indolent progression and unique histopathological profile. It presents a biphasic pattern characterized by solid epithelial and spindle cell components, potentially leading to diagnostic confusion with type A thymomas or the type A component of type AB thymomas. Accurate diagnosis is pivotal for optimal therapeutic strategies and prognostication. Case Description: We document an exceptional case of a 32-year-old woman, incidentally discovered to have a mediastinal nodule in the middle compartment on chest computed tomography (CT). The lesion was excised via video-assisted thoracoscopic surgery. Histological evaluation revealed a biphasic cellular architecture comprising epithelioid and spindle cells. Immunohistochemical analysis demonstrated significant positivity for CK5/6 and P40 in epithelial cells, and vimentin and epithelial membrane antigen in spindle cells, with a low proliferation index marked by Ki-67. Noteworthy, fluorescence in situ hybridization (FISH) analysis identified a YAP1::MAML2 gene fusion, with a predominant pattern suggestive of fusion gene presence, thus corroborating the diagnosis of MT. Conclusions: This report underscores the critical role of a multifaceted diagnostic approach, including histopathological, immunohistochemical, and genetic analyses, in the identification of MT. The detection of the YAP1::MAML2 gene fusion through FISH analysis provides a robust diagnostic marker, highlighting the necessity for clinical and pathological vigilance for this rare tumor.

Role of Cine-Magnetic Resonance Imaging in the Assessment of Mediastinal Masses with Uncertain/Equivocal Findings from Pre-Operative Computed Tomography Scanning.

BACKGROUND: Malignant neoplasms originating from or involving the mediastinum represent a diagnostic and therapeutic challenge when they are in contact with nearby cardiovascular structures. We aimed to test the diagnostic accuracy of cine-magnetic resonance imaging (cine-MRI) in detecting the infiltration of cardiovascular structures in cases with uncertain or equivocal findings from contrast-enhanced Computed Tomography (CT) scanning. METHODS: Fifty patients affected by tumors with a suspected invasion of mediastinal cardiovascular structures at the pre-operative chest CT scan stage underwent cine-MRI before surgery at our Institution. Intraoperative findings and the histological post-surgical report were used as a reference standard to define infiltration. Inter- and intra-observer agreement for CT scans and cine-MRI were also computed over a homogenous sample of 14 patients. RESULTS: Cine-MRI had a higher negative predictive value (93% vs. 54%, p < 0.001) than CT scans, higher sensitivity (91% vs. 16%, p < 0.001), as well as greater accuracy (66% vs. 50%, p < 0.001) in detecting cardiovascular invasion. Cine-MRI also showed better inter- and intra-observer agreement for infiltration detection. CONCLUSIONS: Cine-MRI outperforms conventional contrast-enhanced chest CT scans in the preoperative assessment of cardiovascular infiltration by mediastinal or pulmonary tumors, making it a useful imaging modality in the preoperative staging and evaluation of patients with equivocal findings at the chest CT scan stage.

Dedifferentiated Mediastinal Liposarcoma: A Case Report.

Liposarcoma is the most common soft tissue sarcoma type in adults, originating mainly from the retroperitoneum and lower extremities. Mediastinal liposarcomas constitute an extremely rare clinical entity of mesenchymal origin. Among subtypes, dedifferentiated liposarcoma is characterized by poor survival, but little is known about its biological behavior. We present the case of a 78-year-old male patient who presented with vague symptoms, predominantly dyspnea and chest pain. Imaging revealed a large mediastinal mass and surgical resection was performed in a piecemeal manner due to the inability to achieve a microscopically negative surgical margin (R0 resection) for the residual tumor. Histological examination confirmed the diagnosis of dedifferentiated liposarcoma. The patient's postoperative course was uneventful, with discharge from the hospital on the 10th postoperative day. However, local recurrence was detected after two months and the patient died four months after the operation. The present case report highlights the importance of radical excision for the prevention of local recurrence and the presentation of histological characteristics of this tumor. Radical surgical resection remains the fundamental treatment, while chemo and radiotherapy may have an adjuvant role. In cases of inability to obtain negative margins, surgical debulking can offer symptomatic relief.

Prediction of metastases in confusing mediastinal lymph nodes based on flourine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) imaging using machine learning.

Background: For patient management and prognosis, accurate assessment of mediastinal lymph node (LN) status is essential. This study aimed to use machine learning approaches to assess the status of confusing LNs in the mediastinum using positron emission tomography/computed tomography (PET/CT) images; the results were then compared with the diagnostic conclusions of nuclear medicine physicians. Methods: A total of 509 confusing mediastinal LNs that had undergone pathological assessment or follow-up from 320 patients from three centres were retrospectively included in the study. LNs from centres I and II were randomised into a training cohort (N=324) and an internal validation cohort (N=81), while those from centre III patients formed an external validation cohort (N=104). Various parameters measured from PET and CT images and extracted radiomics and deep learning features were used to construct PET/CT-parameter, radiomics, and deep learning models, respectively. Model performance was compared with the diagnostic results of nuclear medicine physicians using the area under the curve (AUC), sensitivity, specificity, and decision curve analysis (DCA). Results: The coupled model of gradient boosting decision tree-logistic regression (GBDT-LR) incorporating radiomic features showed AUCs of 92.2% [95% confidence interval (CI), 0.890-0.953], 84.6% (95% CI, 0.761-0.930) and 84.6% (95% CI, 0.770-0.922) across the three cohorts. It significantly outperformed the deep learning model, the parametric PET/CT model and the physician's diagnosis. DCA demonstrated the clinical usefulness of the GBDT-LR model. Conclusions: The presented GBDT-LR model performed well in evaluating confusing mediastinal LNs in both internal and external validation sets. It not only crossed radiometric features but also avoided overfitting.

Teratoma to Angiosarcoma: A Metamorphosis in the Mediastinum.

We describe a rare and remarkable transformation of an immature mediastinal teratoma into high-grade angiosarcoma in a 21-year-old male. Mediastinal teratomas, particularly immature ones, are exceedingly rare, representing a small fraction of germ cell tumors (GCTs). Our case describes the clinical journey of the patient, who initially presented with acute chest pain and was subsequently diagnosed with an immature teratoma following imaging studies and elevated tumor markers. Despite an initial positive response to cisplatin-based chemotherapy, surveillance imaging revealed liver masses, which a biopsy confirmed as angiosarcoma. This transformation underscores the aggressive nature of immature teratomas and the propensity for sarcomatous differentiation, particularly in the mediastinum. The case contributes valuable insight into the management and surveillance of mediastinal non-seminoma germ cell tumors (MNGCT), a subset of GCTs with limited literature. We believe this case is the first in the literature to describe a transformation from an immature teratoma in the mediastinum to a high-grade angiosarcoma.

Quantitative assessment of cardiac 123iodo-metaiodobenzylguanidine SPECT/CT in patients with arrhythmogenic right ventricular cardiomyopathy: Novel insight in disease monitoring.

BACKGROUND: The heart-to-mediastinum ratio (H/M-Ratio) of 123iodo-metaiodobenzylguanidine (123I-MIBG) represents state-of-the-art assessment for sympathetic dysfunction in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). This study aims to evaluate quantitative reconstruction of 123I-MIBG uptake and to demonstrate its correlation with echocardiographic parameters. METHODS: Cardiac innervation was assessed in 23 patients diagnosed with definite ARVC or borderline ARVC and 12 patients with other cardiac disease presenting arrhythmia, using quantitative 123I-MIBG Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) imaging. Tracer uptake was evaluated in the left (LV) and right ventricle (RV) based on a CT scan after quantitative image reconstruction. The relationship between tracer uptake and echocardiographic parameter data was examined. RESULTS: Absolute quantification of 123I-MIBG uptake in the LV and RV is feasible and correlates accurately with the gold standard H/M Ratio. When comparing sensitivity and specificity, the area under the curve (AUC) favors standardized uptake value (SUV) of the RV over the right-ventricle-to-mediastinum-ratio (RV/M-Ratio) for diagnosing ARVC. A reduced RV-SUV in patients with definite ARVC is associated with reduced RV function. RV polar maps revealed globally reduced 123I-MIBG uptake without segment-specific reduction in the RV. CONCLUSIONS: Quantitative 123I-MIBG SPECT in ARCV patients offers robust potential for clinical reporting and demonstrates a significant correlation with RV function. Segmental RV analysis needs to be evaluated in larger samples. In summary, cardiac 123I-MIBG imaging using SUV could facilitate image-guided therapy in patients diagnosed with ARVC.

Prevalence and quantity of lymph nodes at mediastinal stations in patients with lung cancer: lessons from 181 bilateral mediastinal lymphadenectomies.

BACKGROUND: This study evaluated the prevalence and quantity of lymph nodes at particular stations of the mediastinum in patients with lung cancer. These data are important to radiologists, pathologists, and thoracic surgeons because they can serve as a benchmark when assessing the completeness of lymph node dissection. However, relevant data in the literature are scarce. METHODS: Data regarding the number of lymph nodes derived from two randomised trials of bilateral mediastinal lymph node dissection, the BML-1 and BML-2 study, were included in this analysis. Detectable nodes at particular stations of the mediastinum and the number of nodes at these stations were analysed. RESULTS: The mean number of removed nodes was 28.67 (range, 4-88). Detectable lymph nodes were present at stations 2R, 4R, and 7 in 93%, 98%, and 99% of patients, respectively. Nodes were rarely present at stations 9 L (33%), and 3 (35%). The largest number of nodes was observed at stations 7 and 4R (mean, 5 nodes). CONCLUSION: The number of mediastinal lymph nodes in patients with lung cancer may be greater than that in healthy individuals. Lymph nodes were observed at stations 2R, 4R, and 7 in more than 90% of patients with lung cancer. The largest number of nodes was observed at stations 4R and 7. Detectable nodes were rarely observed at stations 3 and 9 L. TRIAL REGISTRATION: ISRCTN 86,637,908.