Pseudodextrocardia: una nueva defifinición / Pseudo-dextrocardia: a new defifinition

La pseudodextrocardia se ha definido como un desplazamiento irregular del corazón y sus estructuras vasculares hacia la derecha por causas extracardiacas. Es un hallazgo ocasional en estudios imagenológicos de tórax o abdomen y varía acorde con las diferentes relaciones causales. Se presenta el caso de un paciente con una neumopatía crónica, quien a su ingreso presenta pseudodextrocardia como hallazgo incidental.

Pseudo-dextrocardia has been defined as an unusual displacement of the heart and its vascular structures to the right secondary to extracardiac causes. It is an occasional finding in thoracic or abdominal imaging studies and varies according to the various causal relationships. We report a case of pseudo-dextrocardia as an incidental finding in a patient admitted with chronic pulmonary disease.

Value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of lung and mediastinal lesions

SUMMARY OBJECTIVE: To evaluate the value of EBUS-TBNA in the diagnosis of lung and mediastinal lesions. METHODS: Prospective cohort study that included 52 patients during a 2-year period (2016 to 2018) who underwent EBUS-TBNA. RESULTS: Among the 52 individuals submitted to the procedure, 22 (42.31%) patients were diagnosed with locally advanced lung cancer (N2 or N3 lymph node involvement). EBUS-TBNA confirmed the diagnosis of metastases from other extrathoracic tumors in the mediastinum or lung in 5 patients (9.61%), confirmed small cell lung cancer in 3 patients (5.76%), mediastinal sarcoidosis in 1 patient (1.92%), and reactive mediastinal lymph node in 8 patients (15.38%); insufficient results were found for 3 patients (5.76%). Based on these results, EBUS-TBNA avoided further subsequent surgical procedures in 39 of 52 patients (75%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 77%, and 90%, respectively. No major complications were observed. CONCLUSIONS: EBUS-TBNA is a safe, effective, and valuable method. This technique can significantly reduce the rate of subsequent surgical procedures required for the diagnosis of lung and mediastinal lesions.

RESUMO OBJETIVO: Avaliar a importância da ecoendoscopia endobrônquica com punção por agulha fina (Ebus-TBNA) no diagnóstico das lesões pulmonares e mediastinais. MÉTODOS: Estudo prospectivo e do tipo coorte, no qual foram incluídos 52 pacientes, durante o período de dois anos (2016 a 2018), submetidos ao procedimento de Ebus-TBNA. RESULTADOS: Do total de 52 indivíduos submetidos ao procedimento, 22 (42,31%) pacientes foram diagnosticados com neoplasia pulmonar localmente avançada (N2 ou N3). O método confirmou o diagnóstico de metástases de outros tumores extratorácicos no mediastino ou pulmão em cinco pacientes (9,61%), três pacientes (5,76%) com carcinoma de pequenas células, um paciente (1,92%) com sarcoidose, oito pacientes (15,38%) com linfonodomegalias reacionais/inflamatórias e resultado insuficiente em três pacientes (5,76%). O Ebus-TBNA evitou a realização de outros procedimentos cirúrgicos subsequentes em 39 de 52 (75%) pacientes. Foram calculados os valores de sensibilidade de 86%, especificidade de 100%, valor preditivo positivo de 100%, valor preditivo negativo de 77% e acurácia de 90%. Não foram observadas complicações maiores pelo método neste estudo. CONCLUSÃO: O Ebus-TBNA é um método seguro, eficaz e de relevante importância. Este exame pode reduzir significativamente o número de procedimentos invasivos subsequentes necessários para o diagnóstico das lesões pulmonares e mediastinais.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in isolated intrathoracic lymphadenopathy in non-neoplastic patients: a common dilemma in clinical practice / O papel da aspiração transbrônquica com agulha guiada por ultrassonografia endobrônquica na linfonodomegalia intratorácica isolada em pacientes não neoplásicos: um dilema comum na prática clínica

ABSTRACT Objective: To determine the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in non-neoplastic patients with isolated intrathoracic lymphadenopathy (IL). Methods: This was a retrospective study of patients with isolated IL referred for EBUS-TBNA. We calculated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EBUS-TBNA in the diagnosis of granulomatous, reactive, and neoplastic lymphadenopathy. In cases of nonspecific granulomas, reactive lymphadenopathy, or inconclusive results, a definitive diagnosis was established by other diagnostic procedures or during a follow-up period of at least 18 months. Results: Among the 58 patients included in the study, EBUS-TBNA established a diagnosis of granulomatous disease in 22 (38%), reactive lymphadenopathy in 15 (26%), cancer in 8 (14%), and other diseases in 3 (5%). Results were inconclusive in 10 (17%), the diagnosis being established by other bronchoscopic procedures in 2 (20%) and by surgical procedures in 8 (80%). A final diagnosis of reactive lymphadenopathy was established in 12. Of those, 11 (92%) had their diagnosis confirmed during follow-up and 1 (8%) had their diagnosis confirmed by mediastinoscopy. In another 3, a final diagnosis of sarcoidosis or neoplasm was established. For the diagnosis of granulomatous disease, neoplasms, and reactive lymphadenopathy, EBUS-TBNA was found to have a sensitivity of 73%, 68%, and 92%, respectively; a specificity of 100%, 100%, and 93%, respectively; an accuracy of 86%, 93%, and 93%, respectively; a PPV of 100%, 100%, and 80%, respectively; and an NPV of 78%, 92%, and 98%, respectively. Conclusions: In non-neoplastic patients, granulomatous disease and reactive lymphadenopathy appear to be common causes of isolated IL. EBUS-TBNA shows promising results as a first-line minimally invasive diagnostic procedure. The results obtained by EBUS-TBNA can be optimized by examining clinical and radiological findings during follow-up or by comparison with the results obtained with other bronchoscopic methods.

RESUMO Objetivo: Determinar o rendimento diagnóstico da endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, aspiração transbrônquica com agulha guiada por ultrassonografia endobrônquica) em pacientes não neoplásicos com linfonodomegalia intratorácica (LI) isolada. Métodos: Estudo retrospectivo com pacientes com LI isolada encaminhados para EBUS-TBNA. Foram calculados a sensibilidade, especificidade, precisão, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) da EBUS-TBNA no diagnóstico de linfadenopatia granulomatosa, reacional e neoplásica. Em casos de granulomas inespecíficos, linfadenopatia reacional ou resultados inconclusivos, o diagnóstico definitivo foi estabelecido por meio de outros procedimentos diagnósticos ou ao longo de pelo menos 18 meses de acompanhamento. Resultados: Nos 58 pacientes incluídos, a EBUS-TBNA permitiu que se estabelecesse o diagnóstico de doença granulomatosa em 22 (38%), linfadenopatia reacional em 15 (26%), câncer em 8 (14%) e outras doenças em 3 (5%). Os resultados foram inconclusivos em 10 (17%), nos quais o diagnóstico foi feito por meio de outros procedimentos broncoscópicos, em 2 (20%), ou de procedimentos cirúrgicos, em 8 (80%). O diagnóstico final de linfadenopatia reacional foi feito em 12. Destes, 11 (92%) receberam confirmação diagnóstica durante o acompanhamento e 1 (8%), por meio de mediastinoscopia. Em outros 3, o diagnóstico final foi sarcoidose ou neoplasia. Para o diagnóstico de doença granulomatosa, câncer e linfadenopatia reacional, a EBUS-TBNA apresentou sensibilidade de 73%, 68% e 92%, respectivamente; especificidade de 100%, 100% e 93%, respectivamente; precisão de 86%, 93% e 93%, respectivamente; VPP de 100%, 100% e 80%, respectivamente; VPN de 78%, 92% e 98%, respectivamente. Conclusões: Em pacientes não neoplásicos, doenças granulomatosas e linfadenopatia reacional parecem ser causas comuns de LI isolada. A EBUS-TBNA apresenta resultados promissores como procedimento diagnóstico minimamente invasivo de primeira linha. Os resultados obtidos pela EBUS-TBNA podem ser otimizados pelos achados clínicos e radiológicos durante o acompanhamento ou pela comparação com os resultados de outros métodos broncoscópicos.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in diagnosis of mediastinal lesions / Punção aspirativa por agulha guiada por ultrassom endobrônquico (EBUS-TBNA) no diagnóstico de lesões do mediastino

ABSTRACT Objective To describe the results of endobronchial ultrasound-guided transbronchial needle aspiration in making diagnosis of mediastinal injuries associated to different causes. Methods A retrospective cross-sectional study of patients submitted to Endobronchial ultrasound-guided transbronchial needle aspiration at a private organization, between June 2013 and October 2016. All cases referred for collection of lymph nodes or peritracheal/peribronchial masses by endobronchial ultrasound-guided transbronchial needle aspiration, and evaluated through tomography or PET-CT were included. Interventional pulmonologists and thoracic surgeons with experience in the method did the procedures. Rapid on-site evaluation of fine needle aspiration was performed by an experienced pathologist. Material analysis included cytological smear and cytopathological analysis of paraffin-embedded cell blocks. Other specific analyses (immunocytochemistry, tests and cultures of infectious agents) were performed whenever necessary. Results We included 72 patients; 6 were excluded for presenting endobronchial lesions in which bronchoscopic biopsy could be performed, or intrathoracic lesions that were not accessible by endobronchial ultrasound-guided transbronchial needle aspiration. The mean age of 66 patients included for analysis was 61.17 years (±14.67 years), with a predominance of males (64%). Endobronchial ultrasound-guided transbronchial needle aspiration was definitive for diagnosis in 60 cases (91%). Three cases (4.5%) had inconclusive test results. There were no major complications related to the procedure. Conclusion Endobronchial ultrasound-guided transbronchial needle aspiration had a high diagnosis yield, with minimal morbidity, being an excellent option for diagnostic approach of patients with lymphadenopathy or intrathoracic lesions, and for neoplasm staging.

RESUMO Objetivo Descrever os resultados da utilização de punção aspirativa por agulha guiada por ultrassom endobrônquico na definição do diagnóstico em casos de lesões mediastinais por diferentes causas. Métodos Estudo transversal retrospectivo de pacientes submetidos à punção aspirativa por agulha guiada por ultrassom endobrônquico em instituição privada, entre junho de 2013 e outubro de 2016. Foram incluídos todos os casos referenciados para coleta de materiais de linfonodos ou massas peritraqueais/peribrônquicas por punção aspirativa por agulha guiada por ultrassom endobrônquico, estudados com tomografia ou PET-CT. Os procedimentos foram realizados por pneumologistas intervencionistas e cirurgiões torácicos com experiência no método. Rapid on-site evaluation da punção aspirativa por agulha fina foi realizada por patologista experiente. A análise do material incluiu citologia dos esfregaços em lâminas e análise citopatológica do emblocado celular. Outras análises específicas (imunocitoquímica, pesquisas e culturas de agentes infecciosos) foram realizadas se necessárias. Resultados Foram incluídos 72 pacientes; destes, 6 foram excluídos por apresentarem lesões endobrônquicas passíveis de biópsia broncoscópica convencional ou lesões intratorácicas não acessíveis a punção aspirativa por agulha guiada por ultrassom endobrônquico. Assim, a média de idade dos 66 pacientes incluídos para análise foi 61,17 anos (±14,67 anos), com predomínio do sexo masculino (64%). A punção aspirativa por agulha guiada por ultrassom endobrônquico foi definitivo para o diagnóstico em 60 casos (91%). Três casos (4,5%) foram inconclusivos. Não houve complicações maiores relacionadas ao procedimento. Conclusão A punção aspirativa por agulha guiada por ultrassom endobrônquico teve elevado rendimento diagnóstico, com mínima morbidade, constituindo excelente opção na abordagem diagnóstica de pacientes com linfadenopatia ou lesões intratorácicas e no estadiamento de neoplasias.

Yolk sac primary tumor of mediastino: a rare case in a young adult / Tumor de saco vitelínico primário do mediastino: raro caso em um adulto jovem

ABSTRACT Germ cell tumors are rare neoplasms that mostly occur in the gonads, although they can also affect other body sites, especially the anterior mediastinum (50 to 70% of all extragonadal germ cell tumors). We report a case of a primary mediastinal yolk sac tumor, a rare and aggressive germ cell tumors subtype. This was a 38-year-old man who was admitted to Hospital do Servidor Público Estadual "Francisco Morato de Oliveira", complaining about dyspnea and dry cough for 1 year. The computed tomography scan of his chest revealed a large mass in the anterior mediastinum with heterogeneous enhancement to the contrast associated with pleural effusion. There were also high serum levels of alpha-fetoprotein. After neoadjuvant chemotherapy, the patient underwent surgical resection of the mass, followed by pathological examination, which confirmed a primary mediastinal yolk sac tumor, a nonseminomatous subtype of germ cell tumors. Primary mediastinal yolk sac tumors have poor prognosis, despite advances in therapy with surgical resection and cisplatin-based chemotherapy. This poor prognosis is due to the degree of invasion and unresectability in most patients by the time of the diagnosis.

RESUMO Os tumores de células germinativas são neoplasias raras que acometem mais frequentemente as gônadas, embora possam também ocorrer em outras localizações do corpo, destacando-se o mediastino anterior (50 a 70% de todos os tumores de células germinativas extragonadais). No presente artigo, relatamos um caso de tumor de saco vitelínico mediastinal primário, de subtipo raro e agressivo de tumor de células germinativas. Tratava-se de um homem, 38 anos, admitido no Hospital do Servidor Público Estadual "Francisco Morato de Oliveira", com quadro de dispneia e tosse seca há 1 ano. Na investigação clínica, foi solicitada tomografia computadorizada de tórax, que mostrou volumosa massa no mediastino anterior com realce heterogêneo ao meio de contraste associada a derrame pleural. Havia ainda aumento dos níveis séricos da alfafetoproteína. Após quimioterapia neoadjuvante pré-operatória, o paciente foi submetido à ressecção cirúrgica, seguida de estudo anatomopatológico da peça, no qual demonstrou tratar-se de um tumor de saco vitelínico primário do mediastino. Os tumores de saco vitelínicos primários do mediastino têm prognóstico reservado, apesar do avanço na terapêutica com a ressecção cirúrgica e a quimioterapia à base de cisplatina. Isto se deve ao grau de invasão e de irressecabilidade na maioria dos pacientes no momento do diagnóstico.

Síntomas de miastenia grave en un paciente con antecedente de timectomía por timoma invasor / Symptoms of myasthenia gravis in a patient with a history of thymectomy for invasive thymoma

Introducción. La miastenia grave es una enfermedad autoinmunitaria mediada por anticuerpos. Entre 10 y 15 % de quienes la padecen tienen timoma y su presencia se asocia con una mayor gravedad de los síntomas, crisis miasténicas y fracaso del tratamiento de primera línea. La timectomía se recomienda en pacientes jóvenes con miastenia grave generalizada y en todos los pacientes con timoma. Caso clínico. Se presenta el caso de una mujer de 43 años que, en el 2005, presentó una primera crisis miasténica asociada con un timoma invasor que se trató con timectomía y radioterapia. Durante los siguientes tres años, presentó síntomas graves y dos crisis más, que obligaron a suministrarle respiración mecánica asistida e inmunoglobulina. Al cabo del tratamiento, no se evidenciaron signos de recurrencia en las tomografías de tórax con contraste. Entre el 2009 y el 2012, la gravedad de los síntomas fue menor. En el 2013, estos se exacerbaron y una resonancia magnética de tórax con contraste reveló una lesión en el mediastino anterior, ya observada en el 2011, sugestiva de tejido residual o fibrosis. Se inició el tratamiento usual con inmunoglobulina y se hizo una tomografía por emisión de positrones cuyos resultados no fueron concluyentes, por lo que se llevó a cabo una nueva resección y se constató que no había recurrencia del tumor. Conclusiones. Los pacientes con miastenia grave y aquellos con timoma asociado, deben someterse a la timectomía como parte del tratamiento. Sin embargo, la exacerbación de los síntomas o su reaparición después del procedimiento no necesariamente implica una nueva alteración en el timo.

Introduction: Myasthenia gravis is an antibody-mediated autoimmune disease. Approximately 10-15% of patients present with a thymoma, the presence of which is associated with greater severity of symptoms, myasthenic crisis, and irresponsiveness to front-line therapy. A thymectomy is recommended in young patients with generalized myasthenia gravis and in all patients presenting with thymoma. Clinical case: The patient was a 43-year-old woman, who first showed symptoms of myasthenic crisis in 2005 and presented with invasive thymoma managed with thymectomy and radiotherapy. In the subsequent three years, the patient presented with severe symptoms and two myasthenic crises that required mechanical ventilation and immunoglobulin treatment. Contrast chest computed tomography examinations showed no recurrence. Between 2009 and 2012, the patient experienced decreased symptom severity. In 2013, the patient presented with an exacerbation of symptoms; a contrast chest magnetic resonance scan showed a lesion in the anterior mediastinum, previously observed in 2011, suggestive of residual tissue as opposed to fibrosis. Regular management was started with immunoglobulins; a positron emission tomography scan was inconclusive, requiring a new resection, which showed no evidence of tumor recurrence. Conclusions: Patients with myasthenia gravis and those with myasthenia-related thymoma both share thymectomy as an element of treatment. However, following the procedure, exacerbation or reappearance of symptoms does not necessarily represent new alterations in the thymus.

Prediction of Pathologic Grade and Prognosis in Mucoepidermoid Carcinoma of the Lung Using 18F-FDG PET/CT

OBJECTIVE: The maximum standardized uptake value (SUVmax) of pulmonary mucoepidermoid carcinoma (PMEC) in fluorine-18fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was evaluated as a preoperative predictor of pathologic grade and survival rate. MATERIALS AND METHODS: Twenty-three patients who underwent preoperative PET/CT and complete resection for PMEC were enrolled. The optimal cut-off SUVmax for tumor grade was calculated as 6.5 by receiver operating characteristic curve. The patients were divided into a high SUV group (n = 7) and a low SUV group (n = 16). Clinicopathologic features were compared between the groups by chi2 test and overall survival was determined by Kaplan-Meier analysis. RESULTS: The mean SUVmax was 15.4 +/- 11.5 in the high SUV group and 3.9 +/- 1.3 in the low SUV group. All patients except one from the low SUV group had low grade tumors and all had no nodal metastasis. The sensitivity and specificity of SUVmax from PET/CT for predicting tumor grade was 85.7% and 93.8%, respectively. During the follow-up period (mean, 48.6 +/- 38.7 months), four patients from the high SUV group experienced cancer recurrence, and one died of cancer. In contrast, none of the low SUV group had recurrence or mortality. Five-year overall survival rate was significantly higher in the low SUV group (100% vs. 71.4%, p = 0.031). CONCLUSION: Pulmonary mucoepidermoid carcinoma patients with high SUVmax in PET/CT had higher tumor grade, more frequent lymph node metastasis and worse long-term outcome. Therefore, PMEC patients with high uptake on PET/CT imaging might require aggressive mediastinal lymph node dissection and adjuvant therapies.

Localized Thymic Amyloidosis Presenting with Myasthenia Gravis: Case Report

A mediastinal mass was incidentally found on chest radiography in a 46-yr-old woman who had had myasthenia gravis (MG) for 2 months. Computed tomography revealed a 4-cm in size, well-defined, and lobulating mass with nodular calcification that was located in the thymus. Microscopically, the mass consisted of diffuse amorphous eosinophilic materials. These deposits exhibited apple-green birefringence under polarized light microscopy after Congo red staining. Immunohistochemical analysis revealed that they were positive for both kappa and lambda light chains and negative for amyloid A. A diagnosis of localized primary thymic amyloidosis was finally made. After thymectomy, the symptoms of MG were controlled with reduced corticosteroid requirements. Localized thymic amyloidosis associated with MG has not been reported to date.

Limited Role of Bone Marrow Aspiration and Biopsy in the Initial Staging Work-up of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma in Korea

BACKGROUND/AIMS: The aim of this study was to investigate the frequency of disseminated gastric mucosa-associated lymphoid tissue (MALT) lymphoma and the role of bone marrow study in the initial staging work-up. METHODS: A total of 194 patients with gastric MALT lymphoma was enrolled. The incidence of disseminated disease was evaluated in the initial staging work-up. The demographic data and tumor characteristics were compared according to Helicobacter pylori infection status. RESULTS: Localized disease of Lugano stage I accounted for 97.4% of the enrolled cases. Abdominal computed tomography revealed abdominal lymph node metastasis in five patients (2.6%). Bone marrow (BM) involvement was found in only one patient without H. pylori infection (0.5%). No patient showed positive findings on chest computed tomography or positron emission tomography. H. pylori-negative cases showed a significantly higher frequency of advanced-stage disease than H. pylori-positive cases (10.0% vs 0.6%). In patients achieving complete remission, no extragastric recurrence occurred during follow-up. CONCLUSIONS: The incidence of disseminated disease, including BM involvement, was very low in Korean gastric MALT lymphoma patients. It might be beneficial to perform BM aspiration and biopsy as a part of staging work-up only in patients with risk factors for advanced disease such as H. pylori negativity.

Dual-Energy CT in the Assessment of Mediastinal Lymph Nodes: Comparative Study of Virtual Non-Contrast and True Non-Contrast Images

OBJECTIVE: To evaluate the reliability of virtual non-contrast (VNC) images reconstructed from contrast-enhanced, dual-energy scans compared with true non-contrast (TNC) images in the assessment of high CT attenuation or calcification of mediastinal lymph nodes. MATERIALS AND METHODS: A total of 112 mediastinal nodes from 45 patients who underwent non-contrast and dual-energy contrast-enhanced scans were analyzed. Node attenuation in TNC and VNC images was compared both objectively, using computed tomography (CT) attenuation, and subjectively, via visual scoring (0, attenuation the aorta; 2, calcification). The relationship among attenuation difference between TNC and VNC images, CT attenuation in TNC images, and net contrast enhancement (NCE) was analyzed. RESULTS: CT attenuation in TNC and VNC images showed moderate agreement (intraclass correlation coefficient, 0.612). The mean absolute difference was 7.8 +/- 7.6 Hounsfield unit (HU) (range, 0-36 HU), and the absolute difference was equal to or less than 10 HU in 65.2% of cases (73/112). Visual scores in TNC and VNC images showed fair agreement (kappa value, 0.335). Five of 16 nodes (31.3%) which showed score 1 (n = 15) or 2 (n = 1) in TNC images demonstrated score 1 in VNC images. The TNC-VNC attenuation difference showed a moderate positive correlation with CT attenuation in TNC images (partial correlation coefficient [PCC] adjusted by NCE: 0.455) and a weak negative correlation with NCE (PCC adjusted by CT attenuation in TNC: -0.245). CONCLUSION: VNC images may be useful in the evaluation of mediastinal lymph nodes by providing additional information of high CT attenuation of nodes, although it is underestimated compared with TNC images.

Measurement of Intra-Fraction Displacement of the Mediastinal Metastatic Lymph Nodes Using Four-Dimensional CT in Non-Small Cell Lung Cancer

OBJECTIVE: To measure the intra-fraction displacements of the mediastinal metastatic lymph nodes by using four-dimensional CT (4D-CT) in non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: Twenty-four patients with NSCLC, who were to be treated by using three dimensional conformal radiation therapy (3D-CRT), underwent a 4D-CT simulation during free breathing. The mediastinal metastatic lymph nodes were delineated on the CT images of 10 phases of the breath cycle. The lymph nodes were grouped as the upper, middle and lower mediastinal groups depending on the mediastinal regions. The displacements of the center of the lymph node in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions were measured. RESULTS: The mean displacements of the center of the mediastinal lymph node in the LR, AP, and SI directions were 2.24 mm, 1.87 mm, and 3.28 mm, respectively. There were statistically significant differences between the displacements in the SI and LR, and the SI and AP directions (p < 0.05). For the middle and lower mediastinal lymph nodes, the displacement difference between the AP and SI was statistically significant (p = 0.005; p = 0.015), while there was no significant difference between the LR and AP directions (p < 0.05). CONCLUSION: The metastatic mediastinal lymph node movements are different in the LR, AP, and SI directions in patients with NSCLC, particularly for the middle and lower mediastinal lymph nodes. The spatial non-uniform margins should be considered for the metastatic mediastinal lymph nodes in involved-field radiotherapy.

Cuerpo extraño deglutido localizado en el mediastino posterior y el retroperitoneo / Swallowed foreign body located in the posterior mediastinum and the retroperitoneum

La ingestión intencional de cuerpos extraños suele ocurrir en pacientes con trastornos psiquiátricos y en individuos de ciertos grupos poblacionales sometidos a régimen de internación carcelaria. El paciente que se presenta, hombre de 36 años, con antecedentes de trastornos psiquiátricos (psicosis paranoide), ingirió varios cuerpos extraños (3 alambres y 1 bolígrafo) 8 años antes de la intervención actual. Tres años más tarde fue intervenido de urgencia por perforación intestinal, acción durante la cual le extrajeron 2 alambres y el bolígrafo. Posteriormente ingirió un nuevo cuerpo extraño que también fue extraído quirúrgicamente. En la actualidad el motivo de consulta fue una fístula en la región lumbar derecha en relación con un cuerpo extraño (alambre) localizado desde el mediastino posterior e inferior hasta el retroperitoneo. Se comentan los resultados de los estudios imaginológicos y algunas manifestaciones inusuales en este caso. Por último, se describen los hallazgos quirúrgicos y la evolución posoperatoria(AU)

The intentional ingestion of foreign bodies occurs in patients presenting psychiatric disorders and in subjects from some population imprisoned groups. This patient aged 36 had psychiatric disorders (paranoid psychosis) ingested some foreign bodies (three wires and a Biro) eight years before present intervention. Three years later he was operated on urgently due intestinal perforation, action where three wires and the Biro were extracted. Subsequently he ingested a new foreign body surgically recuperated. At present time the consultation reason was a fistula in right lumbar region related to a foreign body (wire) located from the posterior and inferior mediastinum up to the retroperitoneum. Results of the imaging studies are approached and some unusual manifestations in this case. Finally, the surgical findings and the postoperative evolution were described(AU)

Mediastinal Ga-67 uptake in patients with lymphoma following chemotherapy

Scintigraphic imaging with [67]Ga remains an important tool in evaluating the response of lymphoma to therapy. Scintigraphic characteristics of lung hilar Ga-67 uptake [HU] and their relationship with the etiology [benign vs. malignant] of the hilar lesions in lymphoma patients following chemotherapy were retrospectively investigated. A total of 161 lymphoma patients were included in the study. The presence/absence of HU and if present, symmetry/asymmetry and intensity of HU [on the basis of a 3 scale grading system] were visually and semi-quantitatively assessed on transaxial sections of thorax Ga-67 SPECT. By drawing ROIs over right and left hilum, asymmetry index [AI%] was also calculated. HU was categorized as benign or malignant depending on the radiological correlation and clinical follow-up. In the malignant group, the majority of patients [85.7%] had grade 2 or grade 3 uptake and all had asymmetric pattern. However, in the benign group, grade 1 uptake was more common [66%] and was mainly symmetric [94.6%] in appearance. AI% in the malignant group [73.7 +/- 36.6] was significantly higher than in the benign group [5.7 +/- 4.9] confirming the marked asymmetry in malignant patients. Lung HU is a common finding in patients with lymphoma following chemotherapy and frequently benign in origin, particularly if HU is symmetric and its intensity is less than that of sternum. Asymmetry index [AI%] as proposed in the present study can be used when visual assessment for the symmetry of HU is inconclusive

Traumatic pseudoaneurysm from the aorta to the left common carotid artery presenting as widened mediastinum

Diagnosis of pseudoaneurysm of the aorta or its main branches is a challenge in patients with blunt chest trauma. Computed tomography helps to demonstrate intrathoracic hemorrhage and suspected great vascular injury when a chest radiograph reveals widening of the mediastinum. Aortic angiography remains the gold standard in the determination of the site, and severity of vascular injury for definitive surgical intervention. Timing of surgical repair is controversial. Delayed repair of traumatic pseudoaneurysm of the aorta after primary control of associate injuries decreases mortality significantly, thus improving prognosis. We report a case of successful repair of a traumatic pseudoaneurysm of the aortic arch with extension to the left common carotid artery in an 18-year-old female patient. The diagnosis, surgical approaches, and timing of operation are discussed along with case presentation

CT findings of extramedullary hematopoiesis in the thorax, liver and kidneys, in a patient with idiopathic myelofibrosis

Extramedullary hematopoiesis occurring in multiple organs such as thorax, liver and both kidneys is an unusual condition. We report the CT findings of this condition with review of literature. The lesions consisted of intrathoracic paravertebral masses, focal intrahepatic mass and masses of both pelvocalyceal systems on CT scans.

CT findings of extramedullary hematopoiesis in the thorax, liver and kidneys, in a patient with idiopathic myelofibrosis

Extramedullary hematopoiesis occurring in multiple organs such as thorax, liver and both kidneys is an unusual condition. We report the CT findings of this condition with review of literature. The lesions consisted of intrathoracic paravertebral masses, focal intrahepatic mass and masses of both pelvocalyceal systems on CT scans.