Video-assisted superior mediastinal lymphadenectomy for papillary thyroid cancer: a case report.

Superior mediastinal lymph node metastases in papillary thyroid cancer are uncommon. The clinical characteristics and surgical strategy of superior mediastinal lymph node metastases remain unclear. Superior mediastinal lymphadenectomy can be accomplished either by a transcervical or transsternal approach. Transsternal approach for superior mediastinal lymphadenectomy can cause great damage; transcervical approach sometimes results in inadequate exposure. Here we report our experience of a papillary thyroid cancer patient with superior mediastinal lymph node metastases who underwent video-assisted superior mediastinal lymphadenectomy. A 49-year-old woman diagnosed with papillary thyroid cancer in left thyroid underwent unilateral lobectomy and ipsilateral central and lateral node dissection in the local hospital 4 years ago. Currently lymph node metastases were found in mediastinum and the right neck, some of which were adjacent to the right innominate vein. Unilateral lobectomy, ipsilateral central and lateral node dissection, and video-assisted superior mediastinal lymphadenectomy were successfully performed by transcervical approach. Subsequently, the patient received thyroxine suppression therapy and adjuvant radioiodine treatment. Video-assisted superior mediastinal lymphadenectomy, providing adequate exposure for a complete superior mediastinal lymphadenectomy, is proved to be safe and feasible.

Case report: pathological complete response in an IIIB non-small cell lung cancer patient after preoperative neoadjuvant nivolumab therapy combined with chemotherapy.

RATIONALE: For locally advanced non-small cell lung cancer (NSCLC), the neoadjuvant therapy strategy of preoperative nivolumab combined with chemotherapy has great potential, especially for locally advanced NSCLC which are initially unresectable. They may be cured after neoadjuvant immunotherapy, and this may become a new direction of treatment. We hope that this representative medical record and literature review can provide some assistance for clinicians using immune checkpoint inhibitors to treat lung cancer. PATIENT CONCERNS: A 50-year-old male patient was admitted to Zhongshan Hospital of Traditional Chinese Medicine on April 27, 2020 due to "coughing for more than one month.". The patient had nothing of note in either his medical history or that of his family, and no history of smoking. DIAGNOSIS: The diagnosis was cT4N2M0IIIB stage right lower lung NSCLC with right hilar and mediastinal lymph node metastasis. The stage was inoperable stage IIIB NSCLC, but the patient had a strong willingness for doing surgery. INTERVENTIONS: The patient received 3 rounds of the neoadjuvant nivolumab therapy combined with TP (paclitaxel plus cisplatin) regimen, on 5-14-21, 06-07-21 and 07-07-21. OUTCOMES: The tumor's area shrunk. Then the patient underwent thoracoscopic radical resection of the cancer in the right upper lung and postoperative pathology achieved pathological complete response (pCR). LESSONS: In this case, combined with the wishes of the patient and the latest research results, we confirmed pCR by radical surgery after 3 rounds of the neoadjuvant nivolumab therapy combined with chemotherapy. This may be a modality to cure more lung cancer patients in the future.

Unexpected radioactive iodine accumulation on whole-body scan after I-131 ablation therapy for differentiated thyroid cancer.

We retrospectively evaluated the frequency of unexpected accumulation of radioactive iodine on the post-therapy whole-body scan (Rx-WBS) after radioactive iodine (RAI) ablation therapy in patients with differentiated thyroid cancer (DTC). We searched our institutional database for Rx-WBSs of DTC patients who underwent RAI ablation or adjuvant therapy between 2012 and 2019. Patients with distant metastasis diagnosed by CT or PET/CT before therapy, and those had previously received RAI therapy were excluded. In total, 293 patients (201 female and 92 male, median age 54 years) were selected. Two nuclear medicine physicians interpreted the Rx-WBS images by determining the visual intensity of radioiodine uptake by the thyroid bed, cervical and mediastinal lymph nodes, lungs, and bone. Clinical features of the patients with and without the metastatic accumulation were compared by chi-square test and median test. Logistic regression analyses were performed to compare the association between the presence of metastatic accumulation and these clinical factors. Eighty-four of 293 patients (28.7%) showed metastatic accumulation. Patients with metastatic RAI accumulation showed a significantly higher frequency of pathological N1 (pN1) and serum thyroglobulin (Tg) > 1.5 ng/ml under TSH stimulation (p = 0.035 and p = 0.031, respectively). Logistic regression analysis indicated that a serum Tg > 1.5 ng/ml was significantly correlated with the presence of metastatic accumulation (odds ratio = 1.985; p = 0.033). In conclusion, Patients with Tg > 1.5 ng/ml were more likely to show metastatic accumulation. In addition, the presence of lymph node metastasis at the initial thyroid surgery was also associated with this unexpected metastatic accumulation.

Adaptive radiotherapy in locally advanced esophageal cancer with atelectasis: a case report.

BACKGROUND: To the best of our knowledge, no study has reported mediastinal shift accompanied with obstructive atelectasis due to bulky primary esophageal tumor components treated with adaptive radiotherapy and concurrent chemotherapy. CASE PRESENTATION: Here we report the case of a 65-year-old male patient diagnosed with locally advanced thoracic esophageal squamous cell cancer, clinical T4bN1M0, stage IVA. Bronchoscopy and computed tomography (CT) revealed an almost complete obstruction of the lumen of the left bronchus due to compression by bulky primary esophageal tumor components. On admission, the patient presented with dyspnea and decreased arterial oxygen saturation. Chest radiography and CT on admission revealed mediastinal shift with left atelectasis, as opposed to findings from the chest radiography performed 26 days before admission. Because of the patient's overall good condition, we recommended definitive chemoradiotherapy instead of palliative bronchial stent placement. After obtaining the patient's consent, chemoradiotherapy was initiated on the following day and it comprised three-dimensional conformal radiotherapy with 60 Gy in 30 fractions with concurrent administration of cisplatin and 5-fluorouracil. During chemoradiotherapy, tumor location was monitored with cone-beam CT and chest radiography. Chemoradiotherapy on day 8 revealed no evidence of the mediastinal shift. CT simulation was reperformed to adjust the radiotherapy fields to account for geometrical changes induced by the absence of the mediastinal shift. Subsequently, the mediastinal shift and bronchial obstruction did not recur during the course of chemoradiotherapy. The patient completed the planned radiotherapy with concurrent and adjuvant chemotherapy, and no non-hematological grade ≥ 3 adverse events were observed. Complete response was confirmed 7 months after initiating chemoradiotherapy. Currently, no disease recurrence, dysphagia, or respiratory symptoms have been reported at 13 months after initiating chemoradiotherapy. CONCLUSIONS: In this study, a bulky primary esophageal tumor caused mediastinal shift due to ipsilateral bronchial obstruction. The close follow-up for monitoring resolution of the mediastinal shift during the course of chemoradiotherapy enabled adequate dose delivery to targets, thus reflecting the geometrical changes induced by the absence of the mediastinal shift. Adaptive radiotherapy technique was crucial for favorable patient outcomes in this challenging clinical situation.

Continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters as adjuvant therapy for anaerobic descending necrotizing mediastinitis: a case report.

BACKGROUND: We describe a combinatorial intensive care approach and discuss the critical factors that allowed us to successfully manage a life-threatening case of acute anaerobic septic shock triggered by descending necrotizing mediastinitis. CASE PRESENTATION: We admitted a 38-year-old critically ill Kosovar Albanian man to our intensive care unit because of clinical manifestations of severe sepsis. His condition had worsened in the previous 2 weeks following unsuccessful antibiotic therapy for tonsillitis complicated by retropharyngeal abscesses. Computed tomography and intraoperative observations identified abscesses in the anterior and middle mediastinum regions and the distal part of the neck, directly on the border with the left lobe of the thyroid gland. Cultures indicated infections with α-hemolytic Streptococcus and Clostridium species: High procalcitonin and lactate levels, blood gas analysis, poor peripheral capillary oxygen saturation, and severe hemodynamic instability pointed to a case of acute septic shock. The entire treatment consisted of an aggressive antibiotic regimen, transthoracic and mediastinal surgical evacuation of the abscess, vacuum sealing drainage with a pleural chest tube, continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters, and extracorporeal blood hyperoxygenation. CONCLUSIONS: Efficient treatment of severe anaerobic sepsis resulting from descending necrotizing mediastinitis should build on a multidisciplinary approach. In support of first-line therapies with targeted antibiotics and surgical debridement, clinicians should consider alternative therapies such as continuous venovenous hemodiafiltration with cytokine-adsorbing hemofilters and hyperoxygenation.

Hyperbaric oxygen therapy in a case of cervical abscess extending to anterior mediastinum, with isolation of Prevotella corporis.

We present a case of an odontogenic abscess, first spreading at the lateral cervical level and then in mediastinum. We isolated an anaerobic bacterium, Prevotella corporis, rarely documented in literature. The mortality rates of cervical abscesses secondary to odontogenic infections and complicated by mediastinitis vary from 10% to 40%. Treatment of descending mediastinitis involves multidisciplinary teams such as otorhinolaryngology, thoracic surgeons, infectious disease physicians, anesthetists and intensivists. Due to the combined treatment with surgical drainage within 48 hours of hospitalisation, antibiotics and subsequent hyperbaric oxygen therapy, we have achieved complete recovery of the patient.

A case report of mediastinal ectopic parathyroid adenoma presented as parathyroid crisis localized by SPECT/CT.

INTRODUCTION: Parathyroid crisis due to ectopic parathyroid adenomas can pose diagnostic and management challenges, since it is quite rare in clinical practice. CLINICAL FINDINGS/PATIENT CONCERNS: A 67-year-old Chinese male presented as a parathyroid crisis due to an ectopic mediastinal parathyroid adenoma with his serum calcium and PTH markedly increased in short time. An ultrasonography and computed tomography (CT) scan of the neck did not reveal any parathyroid adenoma. Thoracic CT detected a contrast-enhanced mass in the mediastinum. Although the ectopic location is difficult to appreciate on anterior planar technetium-99m-sestamibi scintigraphy views but has been accurately localized with single photon-emission computed tomography/computed tomography. After fluid resuscitation, loop diuretic, and calcitonin treatment, a thoracoscope surgery was performed. The histopathology of the mediastinal nodule was consistent with a parathyroid adenoma. Hypocalcemia due to hungry bone syndrome occurred after surgery and was resolved quickly with large-dose calcium and calcitriol supplementation. He is asymptomatic and has normal serum calcium and PTH levels on regular follow-up. DIAGNOSES: The ultrasonography, CT, sestamibi, and single photon-emission computed tomography/computed tomography provide limited sensitivity in the detecting ectopic parathyroid adenomas alone. The combination of these techniques has incremental value in localizing ectopic parathyroid adenomas over either technique alone. CONCLUSION: Any parathyroid crisis without parathyroid adenoma in the neck should alert physicians to search for ectopic locations through combination of imaging techniques.

Development of a video-assisted thoracoscopic lobectomy program in a single institution: results before and after completion of the learning curve.

BACKGROUND: The development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases. METHODS: From June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case. RESULTS: Mean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B. CONCLUSIONS: We confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages.

Can Drainage Using a Negative-Pressure Wound Therapy Device Replace Traditional Sample Collection Methods?

BACKGROUND: In 2015 a new device for the collection of mediastinal fluid from patients with deep sternal wound infection (DSWI) in the presence of negative-pressure wound therapy (NPWT) became available. The present study was designed to evaluate whether changing sample collection devices increased micro-organism detection in patients undergoing NPWT. METHODS: During 2013-2014, 207 samples were collected and cultured from NPWT patients (n = 23) to demonstrate the presence of DSWI using reticulated polyurethane sponge culture, a swab, and blood culture. In 2015, a new collection device was introduced for specimen collection. A total of 357 samples (n = 17) were collected using the ESwab(™) (Copan, Murrieta, CA) for deep and superficial wound sample collection. In addition, blood culture devices were used for collecting mediastinal fluid aspirated directly from the wound and biologic fluid obtained from the NPWT device. Fisher exact test was performed to test the rate of independence rate of micro-organism identification using the NPWT sponge device and taking blood culture results as a reference for micro-organism identification. RESULTS: After the introduction of the new collection device in our hospital, an overall increase in the detection of micro-organisms (46.7%) was reported. During 2013-2014 our traditional microbiologic collection method did not detect a pathogen in 30.4% of patients. During 2015, the new sample collection approach, direct from the NPWT device, improved micro-organism detection by 10.4% and reduced DSWIs with undetected pathogens to 17.6% (p < 0.01). CONCLUSIONS: As a result of proficiency gained in the last year, the most representative specimen in wound infection was represented by mediastinal fluid collected directly from the wound and the NPWT device. Given the correlation between the blood culture of micro-organisms detected using the ESwab device from the wound, mediastinal drainage, and drainage from the NPWT device, we can assume that the NPWT device may replace the other biologic sampling devices.

A Case of Ruptured Aneurysm of the Proper Esophageal Artery with Symptomatic Mediastinal Hematoma.

Mediastinal aneurysms are rare but potentially life-threatening. Among these, bronchial artery aneurysms are most frequently reported, whereas up to now aneurysms of the proper esophageal artery had never been reported. A 69-year-old woman was referred to our hospital for treatment of a massive mediastinal hematoma. Enhanced computed tomography and selective proper esophageal arteriography revealed a 5-mm aneurysm in the proper esophageal artery that arises from the thoracic aorta at the Th8 level and has an anastomotic branch with the bronchial artery peripherally. Transcatheter arterial embolization was successfully performed using a mixture of N-butyl cyanoacrylate and lipiodol (1:3 ratio, 0.3 ml). Post-embolization angiography showed no filling into the aneurysm. The patient recovered with no complications and was discharged on the 25th post-procedure day.

Prognostic significance of visible cardiophrenic angle lymph nodes in the presence of peritoneal metastases from colorectal cancers.

BACKGROUND: Visible cardiophrenic angle lymph nodes (CPALN) (enlarged or not), detected on CT scan are correlated with the presence of peritoneal metastases (PM), and contribute to the diagnosis of PM in colorectal cancer patients. OBJECTIVE: To study whether visible CPALN exert a prognostic impact on survival after complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CCRS + HIPEC) treating PM. PATIENTS AND METHODS: From 1999 to 2010, 114 patients with colorectal cancer and PM were treated with CCRS + HIPEC. CPALN were depicted in 64% of cases. The impact of visible CPALN on survival was investigated retrospectively. RESULTS: The mean peritoneal cancer index (PCI) score was 9.2, 21% of the patients had presented with associated liver metastases, and 71% of the women with ovarian metastases. Median follow-up was 3.9 years. Visible CPALN had no impact on OS nor on DFS, unlike the PCI score which was unequivocably the most potent prognostic factor in the multivariate analysis. CONCLUSION: Although some arguments might suggest that CPALN are malignant, paradoxically, we found that visible CPALN did not exert a positive nor a negative impact on survival after CCRS + HIPEC. SYNOPSIS: Visible cardiophrenic angle lymph nodes (CPALN) on CT-scan are strongly associated with the presence of peritoneal metastases. But this study demonstrates that the presence of CPALN has no prognostic impact after optimal cytoreductive surgery plus HIPEC.

Evolução clínica de pacientes com mediastinite pós-cirurgia de revascularização miocárdica submetidos à oxigenoterapia hiperbárica como terapia adjuvante / Clinical evolution of mediastinitis in patients undergoing adjuvant hyperbaric oxygen therapy after coronary artery bypass surgery

OBJETIVO: Avaliação da utilização de oxigenoterapia hiperbárica, como tratamento adjuvante, em casos de mediastinite, em pós-operatório de cirurgia de revascularização miocárdica. MÉTODOS: Estudo descritivo retrospectivo, no período entre outubro de 2010 e fevereiro de 2012. A oxigenoterapia hiperbárica foi indicada nos casos de difícil manejo clínico a despeito da antibioticoterapia. RESULTADOS: Identificaram-se 18 pacientes com mediastinite, nos quais 33 microrganismos foram isolados, estando a infecção polimicrobiana presente em 11 casos. Enterobactérias foram os germes mais prevalentes e seis agentes multirresistentes. Ocorreu 1 óbito, na evolução, 7 meses após o término da oxigenoterapia, por septicemia, não relacionado à terapêutica. O tratamento foi bem tolerado. CONCLUSÃO: Os resultados clínicos iniciais foram favoráveis.

OBJECTIVE: To evaluate the use of hyperbaric oxygen therapy as an adjunctive treatment in mediastinitis after coronary artery bypass surgery. METHODS: This is a retrospective descriptive study, performed between October 2010 and February 2012. Hyperbaric oxygen therapy was indicated in difficult clinical management cases despite antibiotic therapy. RESULTS: We identified 18 patients with mediastinitis during the study period. Thirty three microorganisms were isolated, and polymicrobial infection was present in 11 cases. Enterobacteriaceae were the most prevalent pathogens and six were multi-resistant agents. There was only 1 hospital death, 7 months after the oxygen therapy caused by sepsis, unrelated to hyperbaric oxygen therapy. This treatment was well-tolerated. CONCLUSION: The initial data showed favorable clinical outcomes.

Usefulness of severe cardiac sympathetic dysfunction to predict the occurrence of rapid atrial fibrillation in patients with Wolff-Parkinson-White syndrome.

Atrial fibrillation (AF) can be a potentially life-threatening arrhythmia when it conducts rapidly through the accessory pathway, which was not predicted by the noninvasive method. We evaluated the cardiac sympathetic activity for predicting the occurrence of AF in patients with Wolff-Parkinson-White (WPW) syndrome. Iodine-123 metaiodobenzylguanidine scintigraphy was performed under stable sinus rhythm conditions at rest <1 week before an electrophysiologic study (EPS) to assess the sympathetic activity using the heart/mediastinum (H/M) ratio in 45 consecutive patients with WPW who had a history of supraventricular tachycardia (mean ± SD, age: 47 ± 17 years, 42.2% women). The study also included 15 normal healthy volunteers (56 ± 17 years, 40% women). The H/M ratio was lower in patients with WPW syndrome than in the normal control group, and in the 15 patients with AF induced during EPS than in the 30 patients without AF (p <0.0001). The sensitivity of H/M ratio ≤2.8 for predicting the AF induced during EPS was 75% in 12 of 16 patients, and the specificity was 89.7% in 26 of 29 patients. The H/M ratio was positively correlated with anterograde effective refractory period (r = 0.514, p <0.0001). The sensitivity of H/M ratio ≤2.75 for predicting the AF with a short anterograde effective refractory period (≤250 ms) was 91.7% in 11 of 12 patients, and the specificity was 90.9% in 30 of 33 patients. In conclusion, the severe cardiac sympathetic dysfunction was associated with the occurrence of AF, particularly in those with rapid AF and in patients with WPW syndrome.

Propolis-induced descending necrotizing mediastinitis and aspiration pneumonia.

Propolis is a resinous substance collected by bees as a sealant for their hives. It is also used in traditional medicine as an antioxidant and antiinflammatory agent to treat ulcers, superficial burns, and microbial diseases. In this report, a 40-year-old woman who took liquid propolis for relief of her common cold experienced severe sore throat, dysphagia, and easy choking followed by fever and chills. Descending necrotizing mediastinitis and concomitant aspiration pneumonia were evident on the image studies. We performed video-assisted thoracoscopic surgery to achieve immediate and adequate drainage, and the patient resumed normal deglutition 2 months later. Early diagnosis and prompt video-assisted thoracoscopic surgery intervention are paramount to manage this life-threatening situation.

Solitary bulky mediastinal lymph node metastasis from colon cancer.

A 75 year-old man underwent right hemicolectomy for colon cancer 3 yrs and 6 months ago, followed by chemotherapy with capecitabine. One year and 10 months later, solitary liver metastasis was resected. Five months later, a bulky mediastinal mass of 6 cm in diameter was detected by chest computed tomography and he was referred to our department. The tumor was successfully extirpated by videothoracoscopy-assisted right axillary approach. Histopathology disclosed poorly-differentiated tubular adenocarcinoma and diagnosed as metastatic mediastinal lymph node from the colon cancer. He was discharged on the day 5 and alive without disease 13 months after the mediastinal surgery.