Surgical indications for upper mediastinal dissection by sternotomy in patients with papillary thyroid carcinoma.

Papillary thyroid carcinoma (PTC) is a relatively indolent disease, despite the high incidence of lymph node metastases. Although less frequent, some upper mediastinal metastases of PTC cannot be removed without sternal resection. In this study, we investigated the prognostic impact of upper mediastinal dissection (UMD) by sternotomy on patients with mediastinal metastases of PTC. Charts of patients with PTC who underwent surgical treatment at our institution between 2006 and 2018 were retrospectively reviewed. Fifty-eight patients with upper mediastinal metastases were enrolled. Kaplan-Meier survival curves were compared, and Cox hazard regression models were used for analyses. Of the 58 patients with mediastinal metastasis, 12 (20.7%) underwent dissection of the prevascular nodes, 51 (87.9%) underwent dissection of the upper paratracheal nodes, and 14 (24.1%) underwent dissection of the lower paratracheal node. The preferred site of mediastinal metastasis was the upper paratracheal nodes. The 5 and 10-year disease-specific survival rates for patients after UMD were 74.6% and 58.7%, respectively. Among 25 patients (43.1%) with locoregional recurrence, 12 (20.7%) had mediastinal recurrence and 7 were eligible for additional UMD. Although distant metastasis was the predominant poor prognostic factor, mediastinal recurrences were more frequently unresectable than cervical recurrences, suggesting that mediastinal recurrence is a poor prognostic factor. Mediastinal metastases larger than 30 mm or metastases to the lower paratracheal nodes are considered a risk factor for mediastinal recurrence. UMD by sternotomy for patient with upper mediastinal metastases which are difficult to resect via transcervical approach is an effective treatment option to improve patient prognosis.

Effects of mediastinal lymph node dissection in colorectal cancer-related pulmonary metastasectomy.

BACKGROUND: The benefits of mediastinal lymph node dissection (MLND) in colorectal cancer-related pulmonary metastasectomy (PM) have been poorly reported. This study aimed to determine whether MLND affects survival in patients undergoing PM and to identify the prognostic factors for survival. METHODS: We retrospectively reviewed 275 patients who had undergone colorectal cancer-related PM from January 2010 to December 2016. MLND was defined as the resection of at least six mediastinal lymph node stations according to the International Association for the Study of Lung Cancer criteria (N1, ≥3 stations; N2, ≥3 stations). The propensity score matching method was used to reduce bias. RESULTS: Thirty-three (12%) patients underwent MLND, and 13 (4.7%) patients had mediastinal lymph node involvement. This study showed no difference in 5-year overall survival (no MLND, 52.7% vs. MLND, 53.5%; p = 0.81). On multivariable analysis, negative prognostic factors for overall survival were preoperative carcinoembryonic antigen (CEA) level (p < 0.001), a higher number of metastatic nodules (p < 0.001), metastatic nodule size ≥2 cm (p < 0.001), and lymph node involvement (p = 0.006). CONCLUSIONS: Mediastinal lymph node involvement, preoperative CEA level, higher metastatic nodule number, and nodule size negatively affected survival whereas MLND in PM was not associated with survival.

Dual-Energy Computed Tomography for the Diagnosis of Mediastinal Lymph Node Metastasis in Lung Cancer Patients: A Preliminary Study.

OBJECTIVE: This study explored the feasibility of dual-energy computed tomography (DECT) for the diagnosis of mediastinal lymph node (LN) metastasis in patients with lung cancer. METHODS: Forty-two consecutive patients with lung cancer, who underwent DECT, were included in this retrospective study. The attenuation value (Hounsfield unit) in virtual monochromatic images and the iodine concentration in the iodine map were measured at mediastinal LNs. The slope of the spectral attenuation curve (K) and normalized iodine concentration (in thoracic aorta) were calculated. The measurement results were statistically compared using 2 independent samples t test. Receiver operating characteristic curve analysis, net reclassification improvement, and integrated discrimination improvement were used to evaluate the diagnostic performance of DECT for mediastinal LN metastasis. RESULTS: A total of 74 mediastinal LNs were obtained, including 33 metastatic LNs and 41 nonmetastatic LNs. The attenuation value at the lower energy levels of virtual monochromatic images (40-90 keV), K, and normalized iodine concentration demonstrated a significant difference between metastatic LNs and nonmetastatic LNs. The attenuation value at 40 keV was the most favorable biomarker for the diagnosis of mediastinal LN metastasis (area under curve, 0.91; sensitivity, 0.94; specificity, 0.81), which showed a much better performance than the LN diameter-based evaluation method (area under curve, 0.72; sensitivity, 0.66; specificity, 0.82; net reclassification improvement, 0.359; integrated discrimination improvement, 0.330). CONCLUSIONS: Dual-energy computed tomography is a promising diagnostic approach for the diagnosis of mediastinal LN metastasis in patients with lung cancer, which may help clinicians implement personalized treatment strategies.

Clinical impact of abdominal versus mediastinal metastases as a prognostic factor for poor outcomes following esophageal cancer surgery: a retrospective study.

BACKGROUND: Surgery is still the mainstay of radical treatment for resectable esophageal cancer (EC). It is apparent that the presence or spread of lymph node metastasis (LNM) is a powerful prognostic factor in patients with EC who are eligible for curative treatment. Although the importance and efficacy of lymph node dissection in radical esophagectomy have been reported, the clinical or prognostic relevance of specific metastatic patterns within the mediastinal cavity and abdomen remains unclear. METHODS: We retrospectively analyzed the association of postoperative survival with clinical mediastinal LNM (cMLNM) and abdominal LNM (cALNM) in 157 patients who underwent radical EC surgery at our hospital between May 2012 and March 2018. RESULTS: A significant difference in cause-specific survival (CSS) was observed between patients with and without cALNM (log-rank p = 0.000). A multivariate Cox regression analysis revealed that cALNM and thoracic surgery (mediastinal lymphadenectomy via conventional open right thoracotomy or video-assisted thoracoscopic surgery) independently predicted CSS (p = 0.0007 and 0.021, respectively). Moreover, a significant difference in systemic recurrence-free survival was observed between those with and without cALNM (log-rank p = 0.000). Multivariate Cox regression analysis revealed that cALNM and sex independently predicted systemic recurrence-free survival (p = 0.000 and 0.015, respectively). CONCLUSION: cALNM was an independent poor prognostic factor for CSS after EC surgery. It may also be an independent prognostic factor for postoperative systemic recurrence, which can shorten the CSS. For patients with cALNM-positive EC who have a high potential risk of systemic metastases, more extensive treatment besides the conventional perioperative systemic chemotherapy may be necessary.

Graves disease and metastatic hormonal-active Hürthle cell thyroid cancer: A case report.

RATIONALE: A hormone-active metastatic Hürthle cell thyroid carcinoma (HCTC) and Graves disease (GD) present a therapeutic challenge and is rarely reported. PATIENT CONCERNS: We present a 64-year-old male patient, who had dyspnea and left hip pain lasting 4 months. He had clinical signs of hyperthyroidism and a tumor measuring 9 cm in diameter of the left thyroid lobe, metastatic neck lymph node and metastases in the lungs, mediastinum, and bones. DIAGNOSIS: Laboratory findings confirmed hyperthyroidism and GD. Fine-needle aspiration biopsy and cytological investigation revealed metastases of HCTC in the skull and in the 8th right rib. A CT examination showed a thyroid tumor, metastatic neck lymph node, metastases in the lungs, mediastinum and in the 8th right rib measuring 20 × 5.6 × 4.5 cm, in the left acetabulum measuring 9 × 9 × 3 cm and parietooccipitally in the skull measuring 5 × 4 × 2 cm. Histology after total thyroidectomy and resection of the 8th right rib confirmed metastatic HCTC. INTERVENTIONS: The region of the left hip had been irradiated with concomitant doxorubicin 20 mg once weekly. When hyperthyroidism was controlled with thiamazole, a total thyroidectomy was performed. Persistent T3 hyperthyroidism, most likely caused by TSH-R-stimulated T3 production in large metastasis in the 8th right rib, was eliminated by rib resection. Thereafter, the patient was treated with 3 radioactive iodine-131 (RAI) therapies (cumulative dose of 515 mCi). Unfortunately, the tumor rapidly progressed after treatment with RAI and progressed 10 months after therapy with sorafenib. OUTCOMES: Despite treatment, the disease rapidly progressed and patient died due to distant metastases. He survived for 28 months from diagnosis. LESSONS: Simultaneous hormone-active HCTC and GD is extremely rare and prognosis is dismal. Concomitant external beam radiotherapy and doxorubicin chemotherapy, followed by RAI therapy, prevented the growth of a large metastasis in the left hip in our patient. However, a large metastasis in the 8th right rib presented an unresolved problem. Treatment with rib resection and RAI did not prevent tumor recurrence. External beam radiotherapy and sorafenib treatment failed to prevent tumor growth.

The safety and efficacy of Cyberknife® for thymic malignancy.

PURPOSE: To evaluate the safety and efficacy of Cyberknife® (CK) for the treatment of primary or recurring thymic tumours. MATERIALS AND METHODS: We retrospectively reviewed 12 patients (16 tumour lesions) with primary or recurring thymic tumours who were treated with CK between March 2008 and October 2017. Their data was stored in prospectively collected database. Kaplan-Meier method was used to calculate survival curves. RESULTS: Five patients (41.7%), who had inoperable disease or refused surgery, were treated with CK initially, and 7 patients (58.3%) were treated with CK when they had recurrence diseases. The disease sites treated with CK were primary tumour site (5), regional lymph nodes (4), tumour bed (3), chest wall (2), pleura (1), and bone (1). The median target volume was 43.8 cm3 (range, 13.1-302.5cm3) for the 16 tumour lesions. The median follow-up time was 69.3 months (range, 9.7-124.8 months). The median survival time was 48.2 months, and the 5-year and 10-year OS rates were 68.2% and 45.5%, respectively. A high response rate for the tumour lesions irradiated with CK was obtained. Only one patient (8%) experienced in-field recurrence, and the 5-year local recurrence free survival was 90.9%. A case indicated that CK may induce the abscopal effect, which provides the potential to combine CK and immunotherapy. No severe radiation related toxicities were observed, and no treatment related death occurred. CONCLUSION: CK treatment resulted in good outcomes, particularly local control, with minimal side effects, in highly selected patients with primary and recurring thymic tumours. More studies with larger sample are needed.

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest.

OBJECTIVE: Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery. METHODS: A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018. RESULTS: Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03). CONCLUSIONS: The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Changes of the hepatic subcapsular blood flow in a case of high-grade retroperitoneal liposarcoma: what to expect?

Changes of the hepatic subcapsular blood flow with the early appearance of hypervascularity near the falciform ligament are rare radiologic findings. They present most frequently in cases of superior vena cava (SVC) obstruction and are related to the recruitment of the cavo-mammary-phrenic-hepatic-capsule-portal and the cavo-superficial-umbilical-portal pathways. We present the case of a 52-year-old female patient with an highly aggressive retroperitoneal liposarcoma with SVC obstruction caused by external compression due to a mediastinal metastatic mass. The patient exhibited no symptoms of SVC obstruction due to the collateral cavo-portal pathways.

Mediastinal small cell carcinoma with a metastasis to the orbit: A rare carcinoma with an unusual metastatic progression.

Extraocular muscle (EOM) is a rare site for orbital metastasis. We presented a case of solitary EOM metastasis from mediastinal small cell cancer (MSCC) for the first time. A 49-year-old man presented with hoarseness. Thorax computed tomography (CT) revealed a mediastinal mass. A fine-needle aspiration biopsy (FNAB) confirmed the diagnosis of MSCC. The patient staged as limited-stage MSCC with a positron emission computed tomography (PET-CT). The patient received radical chemo-radiotherapy (CRT). PET-CT showed a complete response after CRT. Afterward, the patient presented with double vision and a headache. Brain magnetic resonance imaging (MRI) demonstrated a 2 cm metastatic lesion at the left inferior rectus muscle. A 30 Gy palliative RT was applied. The full regression of the mass was achieved 3 months after the palliative RT. Although solitary EOM metastasis is rare, the timing of accurate diagnosis and appropriate treatment can help to preserve the patient's vision and relieve complaints related to the mass.

Anterior and Posterior Mediastinum Leiomyomas Arising From the Parietal Pleura.

A 72-year-old male patient was found with enlarged nodes in the anterior and posterior mediastinum on screening imaging studies of the chest. The anterior node appeared as a single cystic lesion without significant metabolic activity on scintigraphy images. The posterior node was a single solid lesion in the lower left periesophageal space above the diaphragmatic crura with moderate metabolic uptake. Endoscopic ultrasound allowed a transesophageal endosonography-guided fine needle aspiration of the posterior node. The anterior lesion was sampled via percutaneous transthoracic approach. Biopsy revealed aggregates of mesenchymal cells with spindle nuclei; immunohistochemistry confirmed two primary leiomyomas of the mediastinum.

Surgical Management of Retrocrural Disease in Germ Cell Tumors: Outcomes and Evolution of Practice.

INTRODUCTION: Residual retrocrural disease in testis cancer following chemotherapy is a surgical challenge. We sought to assess the outcomes and evolution with surgical management of residual retrocrural disease. MATERIALS AND METHODS: We identified 2,788 testicular cancer patients from 1990 to 2010 who underwent retroperitoneal surgery for metastatic testicular cancer at our institution. Patients who also underwent postchemotherapy staged or concurrent retrocrural dissections were stratified for analysis. Surgical approach, clinical characteristics, additional procedures, complications and outcomes were evaluated. RESULTS: Retrocrural dissection was performed in 211 patients. Histology of retrocrural disease demonstrated teratoma in 72%, necrosis in 15.2%, active germ cell cancer in 8.1% and malignant transformation in 2.4%. Our preferred surgical approach to the retrocrural space has evolved over time. Earlier approaches from 1990 to 1995 favored a single thoracoabdominal incision (17, 25%), midline transabdominal incision (22, 32.4%), or with a concurrent or staged thoracotomy (29, 42.6%). A transabdominal/transdiaphragmatic approach at the time of midline retroperitoneal lymph node dissection has been used more frequently in 55% of contemporary cases, decreasing the need for thoracotomies. Patients undergoing a transabdominal/transdiaphragmatic approach had fewer complications (p=0.006) and required fewer associated procedures (p=0.001) and a shorter length of stay (5 vs 6 days, p=0.184). CONCLUSIONS: Metastatic testis cancer to the retrocrural space is surgically challenging however complete resection is needed to maintain an expected excellent oncologic outcome. Coordination between urological and thoracic surgeons for an individualized approach is important. We have found that a transabdominal/transdiaphragmatic approach where appropriate has resulted in fewer complications.

Stereotactic Body Radiation Therapy for Mediastinal and Hilar Lymph Node Metastases.

PURPOSE: Stereotactic body radiation therapy (SBRT) to metastatic mediastinal and hilar lymphadenopathy (MHL) is challenging owing to the proximity of centrally located organs-at-risk. As limited data exist on the safety and efficacy of SBRT for MHL, a retrospective review of clinical outcomes was conducted from a large academic center. METHODS AND MATERIALS: Eligible patients received SBRT to MHL between 2014 to 2019 for the following indications: oligometastases, oligoprogression, or local control of a dominant area of progression. The primary endpoint was grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0). The cumulative incidence function evaluated local failure (LF) and starting or changing systemic therapy (SCST). Kaplan-Meier methodology estimated progression-free survival (PFS) and overall survival (OS). RESULTS: Fifty-two patients (84 metastases) were included. Median follow-up was 20 months. Primary cancer sites included kidney (53.8%), lung (13.4%), breast (7.7%), and other (25.1%). Indications for SBRT were oligoprogression (n = 35; 67.3%), oligometastases (n = 10; 19.2%), or local failure of a dominant area of progression (n = 7; 13.5%). The majority (n = 31; 59.6%) received SBRT to a single lymph node metastasis. Median SBRT dose was 35 Gy (range, 30-50 Gy) with a median biologically effective dose of 59.5 Gy (range, 48-100 Gy). All treatments were in 5 fractions. Seven grade ≥3 toxicities were experienced by 6 patients (11.5%) and were mostly transient (5/7; 71%). There was a single (1.9%) grade 5 toxicity (radiation pneumonitis). The cumulative incidence of LF was 9.0% at 2 years. The cumulative incidence of SCST was 33.2% and 57.1% at 1 and 2 years, respectively. Median PFS was 4.0 months (95% confidence interval, 2.8-7.3) and median OS was 31.7 months (95% confidence interval, 23.8-87.5). CONCLUSIONS: In one of the largest single institutional series of SBRT for MHL, moderate rates of grade ≥3 toxicity were observed, although the majority were transient. This treatment resulted in low LF rates and potentially delayed SCST for many patients.

Echoendoscopic appearance of mediastinal metastasis from papillary renal carcinoma.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is being increasingly used in the diagnostic workup of mediastinal diseases. Here, we report a patient with cystic lesions located in the mediastinum, the sampling of which facilitated the diagnosis of renal neoplasm. This paper confirms the usefulness and safety of EBUS/TBNA on cystic lesions and describes a rare presentation of intrathoracic metastases from carcinoma of the kidney.

Anterior mediastinal metastasis of primary fallopian tube adenocarcinoma: a case report.

BACKGROUND: Primary fallopian tube carcinoma (PFTC) is a malignant tumor of the female genital tract that mostly presents intraperitoneal dissemination in clinical practice. The incidence of upper anterior mediastinal metastasis in PFTCs is extremely rare. We herein report a rare case of PFTC mediastinal metastasis after radical resection. When anterior mediastinal metastasis of an unknown origin is encountered, the possibility of PFTC should be considered. CASE PRESENTATION: A 68-year-old female who was previously diagnosed with PFTC after radical resection of a primary tumor in the fallopian tube was admitted to our department with a right anterior mediastinum mass. Radical resection of the mediastinal mass was performed, and poorly differentiated metastatic adenocarcinoma of the fallopian tube was confirmed. There was no recurrence in the 24 months after the curative operation. CONCLUSION: To our knowledge, no mediastinal metastasis of PFTC has been reported yet. Thus, we presented this rare case indicating the heterogeneity of this malignant disease and to draw attention to the occasional distant metastasis of PFTC in clinical practice.

Detection of Mediastinal Lymph Node Metastases Using Indocyanine Green (ICG) Fluorescence Imaging in an Orthotopic Implantation Model.

BACKGROUND: The method of quickly identifying metastatic mediastinal lymph nodes has become an urgent problem for lung cancer surgery. Indocyanine green (ICG) has the characteristic of being retained in or around the lymph nodes; its pharmacokinetic characteristics and optimal imaging time have not yet been elucidated. MATERIALS AND METHODS: The IVIS Lumina Imaging System was used to detect near infrared (NIR) fluorescence signals at different ICG doses, times and excitation/emission wavelengths in vitro. An artificial lymphogenous metastatic model of squamous lung carcinoma was established in 32 SCID-CB17 mice using Ma44.3 cells. An intratracheal injection of 1.25 ml/kg ICG (1.25×10-2 mg/ml) was performed, then 780 nm Ex and 845 nm Em were used to visualize ICG at four different times. The metastatic mediastinal lymph nodes and the implanted local tumor site in the left lung were confirmed with bioluminescence and hematoxylin and eosin (H&E) staining of pathological specimens. RESULTS: ICG had the strongest NIR fluorescence signal when using 780 nm Ex and 845 nm Em at 2 to 4 h after administrating 1.25×10-2 mg/ml ICG in vitro. Combined with pathological H&E examination, fluorescence imaging of ICG reflected true-positive mediastinal metastasis of the mediastinum at 0.5 h and 2 h after the injection of ICG in vivo. While true-positive local tumor growth at the site of implantation in the left lung was reflected within 4 h after the injection of ICG. CONCLUSION: ICG was able to display the metastatic mediastinal lymph nodes within 2 h after endotracheal injection in an orthotopic squamous lung carcinoma implantation model.

Skip N2 Metastasis in Pulmonary Adenocarcinoma: Good Prognosis Similar to N1 Disease.

INTRODUCTION: The prognostic effect and mechanism of skip N2 lung cancer remain unclear. Our study aimed to elucidate the influence of skip N2 on overall survival (OS) and disease-free survival (DFS) compared with N1 and non-skip N2 in patients with lung adenocarcinoma. PATIENTS AND METHODS: Patients with lung adenocarcinoma and lymph node involvement between May 2011 and December 2015 were retrospectively analyzed. The outcomes of skip N2 patients were compared with N1 and non-skip N2 patients. Prognosis was further investigated according to the N status in different adenocarcinoma subtypes. Univariate and multivariate analyses were carried out to define independent risk factors for OS and DFS. RESULTS: A total of 456 patients with lung adenocarcinoma, 169 with N1 disease, 81 with skip N2 disease, and 206 with non-skip N2 disease, were enrolled in this study. All tumors were invasive adenocarcinoma, and the predominant subtypes were acinar in 252, papillary in 42, solid in 119, micropapillary in 20, and invasive mucinous adenocarcinoma in 23 patients. The DFS and OS of N1 and skip N2 diseases were similar and significantly better than those of patients with non-skip N2 disease. The prognosis according to lymph node status was significantly different in acinar-predominant subtypes in terms of both OS and DFS. CONCLUSIONS: Skip N2 disease has a similar prognosis to N1 disease and is significantly better than that of non-skip N2 disease in relation to OS and DFS. Skip N2 has a prognostic advantage in patients with the acinar-predominant subtype.