Controversies in endobronchial ultrasound.

Endobronchial ultrasound (EBUS) is a minimally invasive highly accurate and safe endoscopic technique for the evaluation of mediastinal lymphadenopathy and mediastinal masses including centrally located lung tumors. The combination of transbronchial and transoesophageal tissue sampling has improved lung cancer staging, reducing the need for more invasive and surgical diagnostic procedures. Despite the high level of evidence regarding EBUS use in the aforementioned situations, there are still challenges and controversial issues such as follows: Should informed consent for EBUS and flexible bronchoscopy be different? Is EBUS able to replace standard bronchoscopy in patients with suspected lung cancer? Which is the best position, screen orientation, route of intubation, and sedation/anesthesia to perform EBUS? Is it advisable to use a balloon in all procedures? How should the operator acquire skills and how should competence be ensured? This Pro-Con article aims to address these open questions.

Advantages of robot-assisted resection of large mediastinal tumors: a single-center preliminary study.

Current study aims to assess the safety and efficacy of robot-assisted thoracoscopic surgery (RATS) for sizable mediastinal masses with a minimum diameter ≥6 cm, compared with video-assisted thoracoscopic surgery (VATS) and open surgery. This study enrolled 130 patients with mediastinal tumors with no less than 6 cm diameter in Zhongnan Hospital, Wuhan University, including 33 patients who underwent RATS, 52 patients who underwent VATS and 45 patients who underwent open surgery. After classifying based on mass size and whether it has invaded or not, we compared their clinical characteristics and perioperative outcomes. There was no significant difference in age, gender, mass size, myasthenia gravis, mass location, pathological types (p > 0.05) in three groups. Patients undergoing open surgery typically presenting at a more advanced stage (p < 0.05). No obvious difference was discovered in the average postoperative length of stay, operation duration, chest tube duration and average postoperative day 1 drainage output between RATS group and VATS group (p > 0.05), while intraoperative blood loss in RATS group was significantly lower than VATS group (p = 0.046). Moreover, the postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss in RATS group were significantly lower than open surgery group (p < 0.001). RATS is a secure and efficient approach for removing large mediastinal masses at early postoperative period. In comparison with VATS, RATS is associated with lower intraoperative blood loss. Compared with open surgery, RATS is also associated with shorter postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss.

The combination of maximum standardized uptake value and clinical parameters for improving the accuracy in distinguishing primary mediastinal lymphomas from thymic epithelial tumors.

Background: Anterior mediastinal masses are relatively uncommon, and mediastinal lymphomas are the malignancies most likely to be confused with thymic epithelial tumors (TETs). The aim of this study was to investigate whether the combination of 18fluorine-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) findings and clinical parameters is useful in differentiating lymphoma from TETs in anterior mediastinal masses. Methods: This retrospective study consecutively included 304 patients with anterior mediastinal masses (244 TETs and 60 lymphomas) who underwent 18F-FDG PET-CT 1 to 2 weeks before tumor resection or biopsy between August 2016 and March 2022. The correlations between the maximum standardized uptake value (SUVmax) of tumors and clinical parameters of patients with histology subtypes were analyzed. Receiver operating characteristic curve analysis was used to obtain the optimal cutoff values of age, lactate dehydrogenase (LDH), tumor size, and SUVmax to predict lymphoma. Logistic regression analysis was used to identify potential predictive factors for lymphoma. Results: Lymphoma was significantly associated with younger patient age, higher LDH level, larger tumor size, and higher SUVmax compared to TETs (P<0.001). In the modeling cohort, age ≤40.5 years, LDH level ≥197 U/L, tumor size ≥10.72 cm, and SUVmax ≥11.95 were identified as independent predictors for lymphoma with odds ratios of 20.14 [95% confidence interval (CI): 6.02-67.40; P<0.001], 4.89 (95% CI: 1.27-18.89; P=0.021), 8.82 (95% CI: 2.31-33.69; P=0.001), and 30.01 (95% CI: 6.59-136.72; P<0.001), respectively. The accuracy of age, LDH, tumor size, and SUVmax in predicting lymphoma was 84.8%, 67.8%, 85.2%, and 78.3% respectively. The combination of the four above parameters could improve the predictive accuracy to 89.1%, and in the validation cohort, this combination increased the predictive accuracy to 87.8%. Conclusions: SUVmax on 18F-FDG PET-CT has the potential ability to discriminate lymphomas from TETs in the diagnosis of anterior mediastinal masses, and the combination of SUVmax with clinical parameters can improve the diagnostic accuracy. This combination may therefore may be helpful in avoiding unnecessary operation in patients with anterior mediastinal lymphomas.

Internal Jugular Venous Thrombosis With Superior Vena Cava Syndrome: A Rare First Presentation of Gray Zone Lymphoma.

Gray zone lymphoma (GZL) is defined as a B-cell lymphoma with intermediate features between both diffuse large B-cell lymphoma (DLBCL) and classical Hodgkin lymphoma (CHL). GZL is an aggressive disease, which in addition to the B-symptoms, can present as shortness of breath and neck swelling from underlying superior vena cava (SVC) syndrome. Thrombosis of the internal jugular vein (IJVT) is rare and usually associated with head and neck infection, intravenous (IV) drug abuse, and central venous catheter placement. GZL's initial presentation as IJVT with SVC syndrome is very uncommon. We report the case of a 47-year-old female presenting with neck swelling and shortness of breath. Initial investigations were oriented at the thyroid gland. A computerized tomography (CT) scan of the chest, neck, and head showed a large anterior/superior mediastinal soft tissue mass with left IJVT. An excisional biopsy of the left axillary lymph node confirmed the diagnosis of GZL. The mediastinal lymphoma can compress the internal jugular vein and also release thrombogenic substances that can cause IJVT. The compression of the SVC by the lymphoma and the IJVT formation can cause SVC syndrome. Both of these conditions can be life-threatening and should be identified in the early stages to prevent complications.

Creeping mediastinal lymphangioma transgressing anatomical compartments: A rare case in an adult female patient.

Lymphangiomas, also known as lymphatic malformations, are rare non-neoplastic lesions of vascular origin showing lymphatic differentiation. These are most commonly reported in children within the neck and axillary region; however, mediastinum remains the commonest site in adults whereby diagnosis is usually incidental on imaging done for non-specific symptoms. Radiologically, these lesions are well-defined multicystic non-enhancing masses, with CT attenuation values ranging from simple to complex fluid and fat. Being benign, these mostly present clinically either due to mass effect exerted on structures, secondarily infected or developing intra lesion haemorrhage. We present a rare case of mediastinal lymphangioma with secondary hilar and intrapulmonary extension in a middle-aged female presenting with occasional haemoptysis and shortness of breath. The patient underwent thoracotomy with complete dissection of the mediastinal tumour, per operative Bleomycin administration in pulmonary component, and made subsequent uneventful post-operative recovery.

Diagnostic approach for mediastinal masses with radiopathological correlation.

PURPOSE: Mediastinal masses have various histopathological and radiological findings. Although lymphoma is the most common type of tumor, thymic epithelial and neurogenic tumors are common in adults and children, respectively, but several other types are difficult to distinguish. No previous review has simply and clearly shown how to differentiate mediastinal masses. METHOD: We conducted a review of the latest mediastinal classifications and mass differentiation methods, with a focus on neoplastic lesions. Both older and recent studies were searched, and imaging and histopathological findings of mediastinal masses were reviewed. Original simple-to-use differentiation flowcharts are presented. RESULTS: Assessing localizations and internal characteristics is very important for mediastinal mass differentiation. The mass location and affected organ/tissue should be accurately assessed first, followed by more qualitative diagnosis, and optimization of the treatment strategy. In 2014, the International Thymic Malignancy Interest Group presented a new mediastinal clinical classification. In this classification, mediastinal masses are categorized into three groups according to location: prevascular (anterior)-, visceral (middle)-, and paravertebral (posterior)-compartment masses. Then, the internal characteristics and functional images are evaluated. CONCLUSIONS: Differentiation of mediastinal masses is very difficult. However, if typical imaging findings and clinical characteristics are combined, reasonable differentiation is possible. In each patient, proper differential diagnosis may contribute to better treatment selection.

Diagnostic difficulties of antero-superior mediastinal masses with cardiac infiltration. Endovascular bioptic alternative approach.

The diagnosis of mediastinal masses is challenging due to the variety of possiblepathologies , and its definitive diagnosis is mainly confirmed by histological evaluation. Sometimes some lesions may have a greater intravascular rather than mediastinal development and the collection of a biopsy sample becomes even more complex. In these cases endovascular catheter biopsy is helpful in the collection of the necessary biological material, having to adapt to the type of surface and consistency of the mass to be analyzed. Endovascular catheter biopsy was performed with a biliary forceps to sample a mediastinal mass with greater endovascular and cardiac development, with a hard and difficult to sample surface. The histological result was diagnosed with non-hodgkins lymphoma.

Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma.

OBJECTIVE: Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision. METHODS: A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma. RESULTS: There was no association between tumor type and age group (P = .183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P < .001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P < .001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma. CONCLUSIONS: Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

An Unusual Clinical Outcome and Surgical Intervention for Mediastinal Histoplasmosis.

Histoplasma capsulatum, an endemic mycosis in the United States, can result in a variety of clinical manifestations. When encountering histoplasmosis sequelae, such as mediastinal adenitis, granulomas, and fibrosing mediastinitis, surgical management may be an unexpected but necessary treatment. Due to the complexity of the mediastinum, it is imperative to have optimal operative planning. In this report, we present an unusual case of an inflammatory mediastinal mass in the setting of acute histoplasmosis resulting in left atrium compression and arrhythmias.

An asymptomatic giant AB thymoma in a patient with Down syndrome: a case report.

Background: Mediastinal mass management may represent a real challenge for all the physicians who deal with it. Mediastinum, in fact, contains different vital structures which are often involved by growing neoplasms with increasing severity. Therefore, up to 60% of the patients with mediastinal mass are symptomatic, according to the structure involved. Different neoplasms may arise essentially from all mediastinal organs, whereas thymic epithelial tumors and lymphomas represent more than 90% of mediastinal tumors. Case Description: We report the first case described of a giant asymptomatic mediastinal mass in a 43-year-old male affected by Down syndrome (DS), turned out to be a thymoma, treated exclusively and successfully with radical surgery. Despite the absence of any symptoms, the giant thymoma infiltrated the diaphragm, the pericardium, the upper lobe of the left lung together with the left phrenic nerve resulting in the compression of heart and great vessels. Conclusions: To date, this is the first description of a thymic malignancy in a patient with DS, that usually is characterized by a low-incidence of solid tumor except for germ-cells ones. Surgery has been extremely challenging, due the clinical condition of the patient together with the tumor features; nevertheless, oncological radicality criteria were completely fulfilled. After four years from surgery, the patient is alive and still disease-free, highlighting the importance of radical surgery.

Transesophageal Endoscopic Ultrasound Fine Needle Biopsy for the Diagnosis of Mediastinal Masses: A Retrospective Real-World Analysis.

Background: Endoscopic ultrasound (EUS) plays an important role in the diagnosis and staging of thoracic disease. Our report studies the diagnostic performance and clinical impact of EUS fine needle aspiration (FNA) in a homogenous cohort of patients according to the distribution of the enlarged MLNs or pulmonary masses. Methods: We retrospectively reviewed the diagnostic performance of 211 EUS-FNA in 200 consecutive patients with enlarged or PET-positive MLNs and para-mediastinal masses who were referred to our oncological center between January 2019 and May 2020. Results: The overall sensitivity of EUS-FNA was 85% with a corresponding negative predictive value (NPV) of 56% and an accuracy of 87.5%. The sensitivity and accuracy in patients with abnormal MLNs were 81.1% and 84.4%, respectively. In those with para-mediastinal masses, sensitivity and accuracy were 96.4% and 96.8%. The accuracy for both masses and lymph nodes was 100%, and in the LAG (left adrenal gland), it was 66.6%. Conclusions: Our results show that, in patients with suspected mediastinal masses, EUS-FNA is an accurate technique to evaluate all reachable mediastinal nodal stations, including station 5.

An Incidental Finding of a Large Pericardial Cyst.

A pericardial cyst is a rare and benign cause of a mediastinal mass. They are frequently asymptomatic and are usually incidental findings on imaging. Symptoms may include persistent cough, atypical chest pain, dysphagia, and dyspnea. Diagnosis is usually established with the aid of imaging, including a chest x-ray, a computed tomography (CT) scan, and magnetic resonance imaging (MRI). Therapeutic options include surgical resection or aspiration for large and/or symptomatic cysts, whereas conservative management with routine follow-up is advised for small or asymptomatic cysts. We herein describe the case of a 48-year-old lady, who presented with clinical features suggestive of acute cholecystitis, with an incidental finding of a pericardial cyst, measuring approximately 10.1 cm x 8.7 cm x 10.7 cm. The patient underwent video-assisted thoracoscopic surgery (VATS) for excision of the pericardial cyst. She had an uneventful recovery and was discharged on the second post-operative day. At six months, there was no evidence of disease recurrence.

The Key Role of Lung Ultrasound in the Diagnosis of a Mature Cystic Teratoma in a Child with Suspected Difficult to Treat Pneumonia: A Case Report.

To date, the diagnosis of mediastinal teratoma and mediastinal masses relies on the use of chest X-ray and CT. Lung and thoracic ultrasound is becoming increasingly used in the diagnosis and follow-up of many lung and thoracic diseases. Here, we report the case of a mature cystic teratoma in which the performance of lung ultrasound allowed to speed up the diagnostic workup and to provide the indication for the execution of CT of the thorax allowing the diagnosis.

Think outside the coronary artery: Extremely rare case of STEMI in young man.

Acute myocardial infarction caused by a bronchogenic cyst is a very rare pathology. It occurs as a result of external compression of the coronary artery by the cyst, leading to myocardial ischemia. The present case illustrates that a bronchogenic cyst, which is generally considered to be a chronic disease entity with gradual onset of symptoms, can manifest acutely as a life-threatening condition. Timely invasive coronary intervention is critical in the acute management of this complication while multimodality imaging assessment is essential in the subsequent management of the underlying etiology.

Utility of cine MRI in evaluation of cardiovascular invasion by mediastinal masses.

BACKGROUND: Accurate imaging assessment of cardiovascular invasion by mediastinal masses is essential for determining surgical feasibility. This can sometimes be difficult on CT owing to limited space available in the mediastinum, resulting in mediastinal masses abutting and indenting adjacent cardiovascular structures. Cine MRI may aid in such situations by demonstrating differential mobility. AIMS AND OBJECTIVES: To evaluate the role of cine MRI in assessing cardiovascular invasion by mediastinal masses, by evaluating sliding motion and the presence of chemical shift artifact between the mediastinal mass and apposing structures. MATERIAL AND METHODS: Retrospective study of 44 patients with mediastinal masses, with equivocal involvement of 162 cardiovascular structures on CT scan, in whom cine MRI was done. Involvement on CT was considered equivocal when there was a loss of intervening fat plane and broad surface (>3 cm) or angle (>90°) of contact between the mediastinal mass and cardiovascular structure. The presence of either sliding movement or type 2 chemical shift artifact or both between mass and the cardiovascular structure was considered as no adherence or invasion. The absence of both the parameters was considered as the presence of invasion or adhesion. Imaging findings were correlated with intraoperative findings. RESULTS: After excluding 25 cardiovascular structures in 7 patients, 137 cardiovascular structures whose involvement was suspected on CT were evaluated in 37 patients with mediastinal masses. In all, 31 cardiovascular structures showed invasion on MRI out of which 28 structures were invaded or adhered intraoperatively and 106 cardiovascular structures showed no invasion on MRI out of which 97 structures were intraoperatively not invaded/adhered. The sensitivity, specificity and accuracy of our study are 75.7%, 97% and 91.2%, respectively. CONCLUSION: Cine MRI can be used as an effective tool in patients with equivocal cardiovascular invasion by mediastinal masses on CT scans.

Flow Cytometric Analysis of Mediastinal Masses in Cats: A Retrospective Study.

Mediastinal masses occur in dogs and cats and are often investigated with cytology. However, discrimination between the two most common lesions (thymoma and lymphoma) may be challenging, especially when small/medium lymphocytes represent the prevalent population. The aim of the present study is to describe the flow cytometric aspects of mediastinal masses in cats and to assess the ability of flow cytometry (FC) to differentiate lymphoma from non-lymphomatous lesions. We retrospectively describe FC features of fine needle aspiration cytology from cats with mediastinal masses. Cases were grouped in lymphoma and non-lymphoma based on results of cytology, histopathology, PCR for antigen receptor rearrangement (PARR), clinical presentation, and follow-up. Scatter properties, positivities to CD5, CD4, CD8, CD21, CD18, and their co-expressions were recorded using a multicolour approach. Twenty cats were included, 12 lymphomas and eight non-lymphomatous cases. Forward scatter (FSC) of lymphoid cells was higher in the lymphoma group. Double positive CD4+CD8+ T-cells were the dominant population in eight out of 12 lymphomas, whereas non-lymphomatous lesions showed no dominant lymphoid population in five out of eight cases. Unlike dogs, the high prevalence of CD4+CD8+ lymphomas in cats it makes difficult to differentiate lymphoma from non-lymphomatous lesions using FC alone. FC may add interesting information to refine diagnosis in some cases, but PARR and histopathology remain mandatory to solve differential in case of expansion of small-medium sized double positive lymphoid cells.

Rarity among the rare-large and invasive thymoma, a case report and review.

Thymomas are rare tumors of the thymic epithelium with an incidence of 1.5 cases in a million, with a wide spectrum of morphological, pathologic characteristics, and clinical presentations. Despite its benign histological appearance, it can invade nearby structures or metastasize hence clinicians need to have a high index of suspicion for early diagnosis. The natural history of the disease is seldom predictable and ranges anywhere from indolent to aggressive malignant course. In this review, we report a case of invasive thymoma in a patient whose presenting complaint was intermittent chest pain x 2 years that had gone undiagnosed. Complete surgical resection is the cornerstone of treatment in early presentation, but with the case of our patient who presented with a locally advanced thymoma treatment, her treatment options were challenging and had to be a multimodal approach with a combination of surgery, chemotherapy and radiation therapy to reduce the chances of recurrence and improve survival. Given the rarity of this presentation, the clinicopathological characteristics that influence the survival of patients with these tumors are still under debate, and guidelines for management for advanced disease are yet to be defined hence warranting our review on this discussion.

Evaluation of surgical procedures in primary mediastinal cysts and tumors: single-center experience.

AIM: In this study, we aimed to evaluate the results of our patients with a primary mediastinal mass and the surgical techniques applied in our clinic retrospectively. MATERIAL AND METHODS: Between March 2015 and March 2019, the results and treatment protocols of 32 patients with a primary mediastinal mass or cysts who were followed up and treated in our clinic were evaluated retrospectively. Twenty-six patients who underwent surgery for biopsy or resection were included in the study. RESULTS: Sixteen of our patients were male and 10 were female. The mean age was 39 years. 80.2% of our patients were symptomatic and 19.2% were asymptomatic and a mediastinal mass was incidentally detected in these asymptomatic patients. The most common symptom was dyspnea with frequency of 38.4%. In terms of localization, the mass was lateralized on the right side in 7 patients, on the left side in 5 patients. In 13 patients, the tumor was located in the posterior mediastinum. 8 patients underwent anterior mediastinotomy and 1 patient underwent biopsy with video-assisted thoracoscopic surgery (VATS). Most commonly a thymus-derived mass was seen. Fifteen patients underwent excision with VATS, 3 thoracotomy, 2 sternotomy and in 1 patient VATS assisted anterior minithoracotomy was performed. CONCLUSIONS: Mediastinal tumors and cysts have different histopathological features. Robotic surgery and VATS-assisted surgery are increasingly used in surgical excision.

Pericardial Cysts: a Contemporary Comprehensive Review.

PURPOSE OF REVIEW: This is an in-depth review on the etiology, clinical manifestation, differential diagnosis, diagnostic modalities, complications, and management of pericardial cysts (PCs). RECENT FINDINGS: PCs are the third most common type of mediastinal masses and are usually identified incidentally by chest x-ray (CXR) or transthoracic echocardiography (TTE). Although most PCs are asymptomatic, they might lead to serious complications such as cardiac tamponade. Diagnosis is confirmed by cardiac computed tomography or cardiac magnetic resonance. Cysts need to be followed by imaging every 1 to 2 years; however, a recent report suggested less frequent follow-up. Most cases resolve spontaneously, but if needed, aspiration or surgical resection can be done. PCs are rare entities and are usually detected incidentally after CXR or TTE. Providers should be aware of this condition since it could potentially lead to serious complications.