Sarcoidosis or sarcoid-like reaction with mediastinal lymphadenopathy in patients after breast cancer surgery.

BACKGROUND: Patients with breast cancer present with lymphadenopathy involving non-caseating epithelioid cell granulomas in the mediastinum or axilla, referred to as sarcoidosis or sarcoid-like reactions (SLRs). However, sarcoidosis/SLRs prevalence and clinical presentation remain unclear. This study aimed to determine the frequency and clinical presentation of sarcoidosis/SLRs among postoperative patients with breast cancer. METHODS: Among all patients who underwent surgery for early-stage breast cancer at St. Luke's International Hospital in Japan between 2010 and 2021, those who subsequently developed enlarged mediastinal lymph nodes and underwent bronchoscopy for suspected breast cancer recurrence were included. Patients were classified into sarcoidosis/SLR or metastatic breast cancer groups, and the clinical characteristics were compared. RESULTS: A total of 9,559 patients underwent breast cancer surgery; bronchoscopy was performed to diagnose enlarged mediastinal lymph nodes in 29 cases. Breast cancer recurrence was observed in 20 patients. Eight women with a median age of 49 years (range 38-75) and a median time from surgery to diagnosis of 4.0 years (range 0.2-10.8) were diagnosed with sarcoidosis/SLRs. Four of the eight patients underwent mammoplasty with silicone breast implants (SBIs), and two experienced postoperative recurrences of breast cancer before or after lymphadenopathy, which was considered inciting factors for SLRs. The remaining two cases could have developed sarcoidosis after breast cancer surgery with no underlying causes for SLR. CONCLUSIONS: Postoperative sarcoidosis/SLRs rarely occur in patients with breast cancer. An adjuvant action of SBI likely contributed to the progression of SLRs; few cases exhibited a causal relationship with breast cancer recurrence.

Prevalence and significance of mediastinal lymphadenopathy in patients with Severe Acute Respiratory Syndrome Corona Virus-2 infection.

Severe Acute Respiratory Syndrome Corona Virus-2 is the causative factor of Coronavirus Disease 2019. Early in the pandemic, mediastinal lymphadenopathy was not considered to be a significant radiologic finding of the SARS-COV-2 disease. Nevertheless, most recent studies associate mediastinal lymphadenopathy with more severe COVID-19 disease and poorer patient outcomes.

Time-to-isolation-guided cryoballoon ablation reduces oesophageal and mediastinal alterations detected by endoscopic ultrasound: results of the MADE-PVI trial.

AIMS: Cryoballoon ablation is safe and efficient for achieving pulmonary vein isolation (PVI) in atrial fibrillation. Structural oesophago-mediastinal lesions, which seem to be associated with an increased risk of the lethal complication of an atrio-oesophageal fistula, have been described. MADE-PVI (Mediastino-oesophageal Alterations Detected by Endosonography after PVI) aimed at evaluating safety of cryoballoon PVI in relation to two different freeze protocols. As time-to-isolation-(TTI)-guided protocol has been reported to be as effective as conventional 'two freeze protocol', we hypothesized a TTI-guided protocol causes less oesophago-mediastinal lesions. METHODS AND RESULTS: Seventy consecutive patients were scheduled for cryoballoon (2nd generation) PVI employing either a conventional protocol (n = 35: 2 × 180 s per vein) or a TTI-guided approach (n = 35: TTI + 120 s per vein or 1 × 180 s in case TTI could not be measured). Oesophagogastroduodenoscopy and endoscopic ultrasound, assessing oesophago-mediastinal alterations (e.g. ulceration, oedema) were performed blinded prior and post-ablation. Post-interventional mediastinal oedematous alterations were detected in 70% with a mean diameter of 14 mm (±0.9 mm), while only 15% revealed large mediastinal oedema >20 mm. Oesophageal lesions due to PVI occurred in 5%. Freeze protocols had a distinct impact on oesophago-mediastinal alterations as mean diameter and frequency of large oedema were significantly increased in patients after conventional protocol PVI (17 mm vs. 11 mm; 26% vs. 6%). Furthermore, every oesophageal lesion was detected in patients with conventional protocol (9%). No major complication occurred in either group. CONCLUSION: The present prospective study demonstrates a significant impact of freeze protocol on oesophago-mediastinal alterations. A TTI-guided protocol reduces mediastino-oesophageal lesions and may reduce short- and long-term complications of cryoballoon PVI.

Reduced re-exploration and blood product transfusion after the introduction of the Papworth haemostasis checklist†.

OBJECTIVES: Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery. METHODS: The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes. RESULTS: Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit. CONCLUSIONS: The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.

[What contribution for mediastinoscopy in non-tumor specific mediastinal lesions?] / Quelle contribution pour la médiastinoscopie dans les lésions médiastinales spécifiques non tumorales ?

INTRODUCTION: The aim of our study was to assess the interest of cervical mediastinoscopy in the management of benign mediastinal lymphadenopathy. METHOD: We performed a single-center retrospective descriptive study over a period of 5 years (2013-2017) in the department of thoracic surgery of university hospital Hassan II of Fez. RESULTS: During this period, a total of 137 cervical mediastinoscopies were performed among which 68 for a benign disease. This represents a frequency of 49.63 %. There were 22 men and 46 women with a mean age of 43.76 years±17.08. Chest CT showed isolated mediastinal lymphadenopathy in 52 %, associated with pulmonary images in 35 %. Cervical mediastinoscopy led to pathological diagnosis in 94 %. The pathological results showed a sarcoidosis in 51.5 %, tuberculosis in 41.2 % and a lymph node echinococcosis in 1 case. CONCLUSION: Cervical mediastinoscopy remains a low risk modality in expert hands, which allows pathological diagnosis with excellent sensitivity, acceptable morbidity and no mortality in our experience.

Study of the radiologic features of Legionnaires' disease with mediastinal adenopathy: Legionella or lymphoma?

An index case of Legionnaires's disease with mediastinal adenopathy prompted us to review our recent experience with Legionnaires' disease to determine the incidence of mediastinal adenopathy of this finding in Legionnaires' disease. We reviewed the radiographic findings of 90 hospitalized adults with Legionnaires' disease from 2015 to 2017. Excluded were 11 patients with mediastinal adenopathy due to non-Legionnaires' disease causes, e.g., lymphoma. Thirty-seven of the remaining patients had both chest films and chest computed tomography (CT) scans. Of the 37 Legionnaires' disease cases, 13/37 (35%) had mediastinal adenopathy and 8/27 (24%) also had unilateral hilar adenopathy. These chest CT findings were not seen on chest films. Chest CT scans are needed to detect mediastinal adenopathy in Legionnaires' disease. Mediastinal adenopathy may be due to Legionnaires' disease or a malignancy. Some findings in Legionnaires' disease are also present in mediastinal adenopathy due to lymphomas, e.g., highly elevated erythrocyte sedimentation rate (ESR), lactate dehydrogenase (LDH), and ferritin. Hospitalized adults with Legionnaires' disease and mediastinal adenopathy should have serial chest CT scans to monitor resolution of the mediastinal adenopathy. In hospitalized adults with otherwise unexplained persistent mediastinal adenopathy, they should be considered as being due to another etiology, e.g., lymphoma, until proven otherwise.

Therapeutic alternatives after aborted sternotomy at the time of surgical aortic valve replacement in the TAVI Era-Five centre experience and systematic review.

BACKGROUND: We aimed to analyze causes, management, and outcomes of the unexpected need to abort sternotomy in aortic stenosis (AS) patients accepted for surgical aortic valve replacement (SAVR) in the transcatheter aortic valve implantation (TAVI) era. METHODS: Cases of aborted sternotomy (AbS) were gathered from 5 centers between 2009 and 2014. A systematic review of all published cases in the same period was performed. RESULTS: A total of 31 patients (71% males, 74±8years, LogEuroSCORE 11.9±7.4%) suffered an AbS (0.19% of all sternotomies). Main reasons for Abs included previously unknown porcelain aorta (PAo) in 83.9%, mediastinal fibrosis due to radiotherapy in 12.9%, and chronic mediastinitis in 3.2%. Median time between AbS and next intervention was 2.3months (IQR: 0.7-5.8) with no mortality within this period. Only a case was managed with open surgery. In 30 patients (96.8%) TAVI was performed with a rate of success of 86.7%. Three patients (9.7%) presented in-hospital death and 17 (54.8%) had in-hospital complications including heart failure (9.6%), major bleeding (6.9%), and acute kidney injury (9.6%). Older patients (76±8 vs. 70±8years, p=0.045), previous cardiac surgery (60% vs. 15.4%, p=0.029), and shorter time from AbS to next intervention (5.1±5 vs. 1±0.7months, p=0.001) were related to higher six-month mortality (22.6%). CONCLUSIONS: The main reason for AbS was PAo. This entity was associated to a higher rate of complications and mortality, especially in older patients and with prior cardiac surgery. A preventive strategy in these subgroups might be based on imaging evaluation. TAVI was the most extended therapy.

Complications of Convex-Probe Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Multi-Center Retrospective Study.

BACKGROUND: Infrequent serious complications of convex-probe endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been reported. The aim of this study was to assess serious complications related to convex-probe EBUS-TBNA and to determine the complication rate in a large group of subjects. METHODS: In this retrospective study, a 15-item questionnaire on features of cases with EBUS-TBNA complications was sent to experienced bronchoscopists performing convex-probe EBUS-TBNA at 3 pulmonary centers. The medical records were then reviewed by these bronchoscopists to complete the questionnaire. Hemorrhage responsive to topical treatment, temporary laryngospasm/bronchospasm, transient oxygen desaturation, and fever lasting <24 h were excluded. Only complications requiring further treatment/intervention were considered serious. The rate of serious complications was calculated from the obtained data. RESULTS: In a total of 3,123 cases within a 5-y period, EBUS-TBNA was performed for staging lung cancer in 15.8%, diagnosis in 67.5%, and diagnosis and staging in 16.3%. Of the 3,123, 11.6% had parenchymal lesions adjacent to major airways. EBUS-TBNA was performed 11,753 times (3.76/case) at 6,115 lymph node stations and lesions (1.92/station or lesion). Five serious complications were recorded (0.16%): fever lasting >24 h, infection of bronchogenic cyst, mediastinal abscess, pericarditis, and pneumomediastinitis with empyema, each in one case. Four complications occurred in cases diagnosed with benign disease by EBUS-TBNA. All complications were treated with broad-spectrum antibiotics. Four subjects were hospitalized for 21.7 ± 20.7 d. CONCLUSIONS: Convex-probe EBUS-TBNA is a safe method in general. However, serious complications, including infections, can be encountered rarely. All precautions should be taken for complications before and during the procedure.

High prevalence of malignancy in HIV-positive patients with mediastinal lymphadenopathy: a study in the era of antiretroviral therapy.

BACKGROUND AND OBJECTIVE: Mediastinal lymphadenopathy (MLN) in human immunodeficiency virus (HIV) infection has a wide spectrum of aetiologies with different prognoses and treatments. The decision to pursue a histopathological diagnosis represents a clinical challenge as patients present with non-specific symptoms. This study aimed to determine the aetiology and predictive factors of MLN in a cohort of HIV-infected patients in the combination antiretroviral therapy (cART) era. METHODS: Single-centre retrospective cohort study of 217 consecutive HIV-infected patients who underwent computed tomography (CT) of the chest between January 2004 and December 2009. Fifty-two patients were identified to have MLN (>10 mm in short axis). CT images were re-reviewed by an independent radiologist blinded to the clinical information. Final diagnoses of MLN were obtained from clinical records. Multivariate analysis was performed to identify predictors of aetiology of MLN. RESULTS: Seventeen patients (33%) had a diagnosis of malignancy. Consolidation on CT was associated with a reduced likelihood of malignancy odds ratio (OR) 0.03 (95% confidence interval 0.002-0.422), and larger lymph nodes were associated with an increase in the odds of malignancy (OR 2.89; 95% confidence interval 1.24-6.71). CD4 count was found not to be a predictor of aetiology of MLN. CONCLUSIONS: In the era of combination cART, opportunistic infections and malignancy remain to be the frequent causes of MLN in HIV-positive patients, but the prevalence of non-HIV related malignancy has increased compared with previous studies. Although certain findings are predictors of non-malignant disease, pathological diagnosis of MLN in HIV-positive patients should be pursued whenever possible.

[Focus on mediastinal Castleman disease]. / Maladie de Castleman médiastinale : mise au point.

Castleman disease is a rare lymph nodes disease whose name covers different clinical presentations. The most frequent histology is the hyaline vascular localized form. In this case, Castleman disease occurs in young adults, and is localized to the mediastinum in one third of the cases. The disease is often asymptomatic, but paraneoplasic pemphigus has been described. The management of this form of Castleman disease is based on complete surgical resection. Perioperative immunomodulating treatments may be discussed in case of paraneoplasic pemphigus, mostly when affecting the bronchial tree.

Disseminated nocardiosis mimicking exacerbation of pulmonary sarcoidosis.

Nocardiosis is a rare, mixed suppurative and granulomatous, bacterial infection that can affect various organs, but most commonly lungs. Clinical manifestation is usually uncharacteristic; can mimic fungal, parasitic and mycobacterial infections or malignancy. Presentation can be also similar to that of the other granulomatous diseases, among them sarcoidosis. We present an unusual case of disseminated nocardiosis in a patient diagnosed before with sarcoidosis and treated with glucocorticoids. Clinical symptoms initially mimicked exacerbation of pulmonary sarcoidosis. The course of disease was severe.

Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension.

OBJECTIVE: The objective of this study was to assess the frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension (IPAH) and describe the correlative clinical features. METHODS: We conducted a retrospective review of patients with IPAH who underwent right-sided heart catheterization (RHC) and chest CT scan within 3 months of each other. Patients were from a single tertiary institution. CT scans were reviewed for the presence of mediastinal lymphadenopathy (MLAD) with correlating demographic and clinical data, including lymph node size and location, right atrial pressure (RAP), mean pulmonary arterial pressure (mPAP), and the presence of pleural and pericardial effusion. RESULTS: The study population included 85 patients with a mean age of 48 17.3 years; 70 (82%) were women. Fifteen patients (18%) had MLAD on chest CT scan. The mean short-axis diameter of the largest lymph node in these patients was 13.6 mm (range, 11-20 mm). The enlarged lymph nodes were located predominantly in the lower paratracheal and subcarinal stations. There was no association of MLAD with age, sex, RAP, or mPAP. MLAD was associated with presence of pleural effusion ( P , .02) but not pericardial effusion. Mean left ventricular ejection fraction for those with lymphadenopathy was 63% (range, 45%-76%). CONCLUSIONS: MLAD without other identifiable causes is seen in approximately one in fi ve patients with IPAH and is associated with pleural effusion but not mPAP, RAP, or left ventricular function.

[Benign cysts of the mediastinum: series of 28 cases]. / Les kystes bénins du médiastin : à propos de 28 cas.

INTRODUCTION: Benign cystic mediastinal mass form a group of heterogeneous and uncommon lesions. Surgical resection is the gold standard in these conditions. We reported our institutional experience in management of these benign tumours. In this review, cardiac and ganglionary benign mass were excluded. METHODS: We retrospectively reviewed the records of 28 patients with benign cysts of the mediastinum, who are operated in our department between January 2003 and December 2009 (7years period). RESULTS: There were 13 females (46.4%) and 15 males (53.5%), with a mean age of 36.8years (range: 13-63years). Most lesions (n=22) were equally in the anterior and middle mediastinum, only six were in the posterior mediastinum. Seventeen patients (60.7%) were symptomatic, with chest pain and cough as the most common symptoms. The diagnosis of mediastinal cyst was fortuitous in 11 patients with the waning of an assessment made for another reason. Surgery was indicated in all patients in order to both diagnostic and therapeutic. Posterolateral thoracotomy incision is the most common. Complete resection of the cyst was possible only in 18 cases (64.3%), whereas in ten (35. 7%) other cases part of the cyst was left in place due to tight adhesions to vital structures. After histological study, there were: nine bronchogenic cysts (32.1%), seven hydatid cysts (25%), four cystic lymphangiomas (14.3%), three mature cystic teratomas (10.7%) and three pleuropericardial cysts, one thymic cyst and one parathyroid cyst. The postoperative course was uneventful and no recurrence has been observed until now. CONCLUSION: The benign cysts of the mediastinum is a rare entity, the hydatid etiology remains common in our context. Surgical treatment remains the treatment of choice for mediastinal cysts, when the patient is operable, to save the risk of complications or degeneration.