Humans ; Artificial Intelligence ; Lung Neoplasms/pathology* ; Mediastinum/pathology* ; Lymph Nodes/pathology* ; Neoplasm Staging ; Lymph Node Excision

BACKGROUND: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is well known as an important technique for diagnosis and staging of lung cancer. But a standard protocol to deal with patients who have a negative pathology result still needs to be defined. Herein, we describe the subsequent procedures of these patients in a single center. METHODS: A total of 1,412 patients with clinical suspected lung cancer and mediastinal metastasis who underwent EBUS-TBNA were collected between September 2010 and December 2016. Among them, 51 patients with nonspecific pathology result were included and retrospectively analyzed. RESULTS: The 51 patients were stratified into five groups by clinical characterize and follow-up procedures: (1) Diagnosed by other bronchoscopy procedures group (9 cases). Abnormalities of tracheobronchial tree were found during visual examination in the majority of patients (8 cases). Biopsy, endobronchial brushing, bronchoalveolar lavage, and transbronchial lung biopsy (TBLB) were used to get a specific diagnosis. (2) EBUS-TBNA re-biopsy group (11 cases). Patients in this group had normal mucosal appearance and airway lumen. Re-biopsy were performed on patients in this group. (3) Surgery group (6 cases). Patients underwent surgery after negative result of EBUS-TBNA. Five of them were confirmed with non-nodal metastasis after surgery. (4) Underwent other pathology diagnosis group (15 cases). patients in this group had other metastasis sites besides midiastinal lymph node. Computed tomography (CT)-guided fine-needle aspiration and lymph node biopsy were performed. (5) Follow-up group (10 cases). None invasive procedure was used in this group. The median follow up time was 38 months. One patient was diagnosed lymphoma during the follow up. CONCLUSIONS Diagnostic procedures should be chosen based on the clinical character in EBUS-TBNA negative patients with suspected lung cancer. Long time follow-up is very important in patients whose diagnosis is apparently unknown.
Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Female ; Humans ; Lung Neoplasms ; pathology ; Lymphatic Metastasis ; Male ; Mediastinum ; Middle Aged ; Retrospective Studies

A 65-year-old male was referred to our hospital for evaluation of a right pleural effusion. Thoracic computed tomography (CT) revealed a huge central mass with right hilar and subcarinal lymph node conglomerates. An endobronchial mass was incidentally found in the right upper lobe bronchus, and endobronchial ultrasound-guided transbronchial needle biopsy of the mediastinal lymph nodes was thus also performed at the time of bronchoscopy. The two biopsies revealed squamous cell carcinoma and diffuse large B-cell lymphoma (DLBCL), respectively. As the pathology of the mediastinal lymph nodes was unknown, the lung cancer could not be accurately staged. Thus, we treated the DLBCL; follow-up positron emission tomography/CT after two cycles of chemotherapy showed that the conglomerate mass had disappeared but the right upper lobe lesion remained. Lung cancer staging thus became more accurate and radical treatment could be considered. To the best of our knowledge, this is the first report of a co-existing squamous cell carcinoma of the lung and DLBCL of the intrapulmonary lymph nodes.
Aged ; B-Lymphocytes* ; Biopsy ; Biopsy, Needle ; Bronchi ; Bronchoscopy ; Carcinoma, Squamous Cell* ; Drug Therapy ; Electrons ; Epithelial Cells* ; Follow-Up Studies ; Humans ; Lung Neoplasms ; Lung* ; Lymph Nodes ; Lymphoma ; Lymphoma, B-Cell* ; Male ; Mediastinum ; Pathology ; Pleural Effusion

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of euvolemic hypo-osmotic hyponatremia. There are several etiologies of SIADH including neuroendocrine tumor, pulmonary disease, infection, trauma, and medications. Here, we report a case of SIADH associated with a schwannoma involving the mediastinum in a 75-year-old woman who presented with nausea, vomiting, and general weakness. Laboratory testing showed hypo-osmolar hyponatremia, with a serum sodium level of 102mmol/L, serum osmolality of 221mOsm/kg, urine osmolality of 382mOsm/kg, urine sodium of 55 mmol/L, and plasma antidiuretic hormone (ADH) of 4.40 pg/mL. Chest computed tomography identified a 1.5-cm-sized solid enhancing nodule in the right lower paratracheal area. A biopsy specimen was obtained by video-assisted thoracoscopic surgery, which was diagnosed on pathology as a schwannoma. The hyponatremia was completely resolved after schwannoma resection and plasma ADH level decreased from 4.40 pg/mL to 0.86 pg/mL. This case highlights the importance of suspecting and identifying the underlying cause of SIADH when faced with refractory or recurrent hyponatremia, and that on possibility is mediastinal schwannoma
Aged ; Biopsy ; Female ; Humans ; Hyponatremia ; Inappropriate ADH Syndrome ; Lung Diseases ; Mediastinum ; Nausea ; Neurilemmoma* ; Neuroendocrine Tumors ; Osmolar Concentration ; Pathology ; Plasma ; Sodium ; Thoracic Surgery, Video-Assisted ; Thorax ; Vomiting

OBJECTIVETo explore the application of mesoesophagus suspension technique to improve the upper mediastinal lymph node dissection during thoracoscopic esophagectomy in the treatment of esophageal cancer.

METHODSClinical data of 164 thoracic esophageal cancer patients who underwent combined thoracoscopic and laparoscopic esophagectomy with two-field lymph node dissection in the Union Hospital of Fujian Medical University between October 2012 and June 2015 were retrospectively analyzed. Among 164 patients, 80 cases underwent upper mediastinal lymph node dissection by traditional method (traditional group), and the remaining 84 cases underwent upper mediastinal lymph node dissection by mesoesophagus suspension technique (suspension group). The operation time, estimated blood loss, number of excised lymph nodes and postoperative complications were compared between the two groups.

RESULTSThere were no significant differences in gender, age, location of tumor and pathology stage between the two groups. The operation time in the two groups was similar. The suspension group had significantly less thoracic blood loss than traditional group [(85±5) ml vs.(140±7) ml, P=0.000]. The number of dissected lymph nodes of bilateral recurrent laryngeal nerve was more in suspension group [median (interquartile range): left: 3 (2 to 4) vs. 2 (1 to 3), P=0.013; right: 3(2 to 6) vs. 2(1 to 3), P=0.007]. There was no significant difference in metastatic rate of lymph node in different sites between the two groups. The highest metastatic rate of suspension and traditional group was found at paracardia lymph nodes[22.6%(19/84) and 22.5%(18/80)], the next was at right laryngeal nerve lymph nodes [17.9%(15/84) and 15.0%(12/80)] and left laryngeal nerve lymph nodes [16.7%(14/84) and 12.5%(10/80)]. There were no significant differences with regard to the incidence of major postoperative complications between two groups, including respiratory complication, anastomotic leakage, vocal cord palsy.

CONCLUSIONSUpper mediastinal bilateral recurrent laryngeal nerve lymph node is the predilection site of lymphatic metastasis of thoracic esophageal cancer. Application of mesoesophagus suspension technique in thoracoscopic esophagectomy can improve the clearance quality of bilateral recurrent laryngeal nerve lymph nodes.

Anastomotic Leak ; Blood Loss, Surgical ; Esophageal Neoplasms ; surgery ; Esophagectomy ; adverse effects ; methods ; Female ; Humans ; Laparoscopy ; Lymph Node Excision ; adverse effects ; methods ; Lymph Nodes ; anatomy & histology ; pathology ; surgery ; Lymphatic Metastasis ; physiopathology ; Male ; Mediastinum ; surgery ; Operative Time ; Postoperative Complications ; Recurrent Laryngeal Nerve ; physiopathology ; Retrospective Studies ; Treatment Outcome

OBJECTIVETo evaluate the patterns of recurrence and the related factors in patients with pT3N0M0 thoracic esophageal squamous cell carcinoma (ESCC) after two-field esophagectomy.

METHODSFrom Jan 2008 to Dec 2009, 208 patients with stage pT3N0M0(2002, UICC) thoracic ESCC were treated with two-field esophagectomy in our hospital. There were 138 males and 70 females, and the median age was 60 years old (range 33-78). There were 33 patients in the upper-, 134 in the middle-, and 41 in the lower-thoracic esophagus, with a median length of lesion of 5 cm. There were 32 patients with no-, 78 with mild- and 98 patients with severe adhesions at surgery. The median number of dissected lymph nodes was 9 (range 1-27). 98 patients were treated with surgery alone and 110 with postoperative adjuvant chemotherapy. The statistical analysis was conducted using SPSS 13.0 software.

RESULTSThe follow-up was ended on July 2013. In the total group of 208 patients, the total recurrence rate was 41.8% (87/208). Among them, 52 patients had locoregional recurrence (LR), 15 had distant metastasis (DM) and 20 patients had both local recurrence and distant metastasis. 40.2% (35/87) of all recurrences were found within one year after operation, 67.8% (59/87) within 2 years, 86.2% (75/87) within 3 years, and 100% (87/87) within 4 years. The 1-, 3-, and 5-year progression-free survival (PFS) rate was 83.0%, 62.8% and 56.3%, respectively. The overall locoregional recurrence rate was 34.6% (72/208), among them, 9 cases had recurrence in the cervix (all were supraclavicular lymph node metastasis), 66 cases in the mediastinum and 4 cases had para-aortic lymph node metastasis. 83.3% (60/72) of the locoregional recurrence was located in the carinal region or upper area. The 1-, 3-, 5-year locoregional recurrence rate was 15.6%, 32.2%, and 36.8%, respectively, and the median time of recurrence was 15.5 months. The overall distant metastasis (DM) rate was 16.8% (35/208). The 1-, 3-, and 5-year DM rate was 4.4%, 15.3%, and 20.1%, respectively, and the median time of DM was 24 months. The most common site of DM was the lung and bone. The univariate analysis showed that age and tumor site were associated with PFS, tumor site and small lymph node in the mediastinum (diamter <1 cm) before surgery were related with LR (P<0.05 for all), and tumor site, histological differentiation and LR were related with distant metastasis after surgery (P<0.05). Multivariate analysis showed that the tumor site was an independent prognostic factor affecting the progression-free survival and locoregional recurrence (P<0.05), and histological differentiation and LR were independent factors associated with distant metastasis (P<0.05 for all).

CONCLUSIONSThe recurrence rate is very high in patients with pT3N0M0 thoracic ESCC after surgery, and most of them occur within 3 years after operation. Locoregional recurrence occurs more frequently and shortly than distant metastasis, and most of LR is located in the carinal region or upper-mediastinum. LR rate in upper-thoracic ESCC is very high, therefore, postoperative radiotherapy (PORT) is strongly suggested. LR rate in middle thoracic ESCC is also rather high and PORT is suggested. LR occur much less in the lower-thoracic ESCC, thus, PORT is not suggested routinely. Patients with poorly differentiated ESCC and LR have a high rate of distant metastasis.

Adult ; Aged ; Carcinoma, Squamous Cell ; drug therapy ; pathology ; surgery ; Chemotherapy, Adjuvant ; Disease-Free Survival ; Esophageal Neoplasms ; drug therapy ; pathology ; surgery ; Esophagectomy ; methods ; Female ; Humans ; Lymph Node Excision ; Lymph Nodes ; Lymphatic Metastasis ; Male ; Mediastinum ; Middle Aged ; Multivariate Analysis ; Neck ; Neoplasm Recurrence, Local ; pathology ; Neoplasm Staging ; Postoperative Period

OBJECTIVE: To assess the value of endobronchial ultrasound elastography in the diagnosis of mediastinal and hilar lymph node metastasis in lung cancer. 
 METHODS: A total of 40 patients with lung cancer underwent ultrasonic bronchoscope examination before operation. Elastography and standard endobronchial ultrasound (EBUS) of lymph nodes were performed before EBUS-guided transbronchial needle aspiration (EBUS-TBNA). The elastography characteristics was compared between benign and malignant lymph nodes. The diagnosis accuracy in malignant lymph nodes was also compared between the elastography and the standard EBUS. The value of the elastography was assessed in distinguishing the benign and malignant lymph nodes.
 RESULTS: 1) The significant indicators of standard EBUS in diagnosis of malignant lymph nodes were hypoechonic nodes, uneven echo, distinct boundary and short diameter greater than 1 cm (all P<0.01). 2) There was significant difference in the elastosonography grading score between benign and malignant lymph nodes (P<0.01). 3) The elastography grading score was more sensitive and specific in determining the malignant lymph node than the standard EBUS criteria. The area under the receiver operating characteristic curve (AUC) was maximal when the elastography grading score was ≥2.5. The specificity, sensitivity, positive predictive value, negative predictive value of elastography grading score was 76.9%, 85.7%, 85.7% and 76.9% in distinguishing malignant and benign nodes. The overall accuracy of elastography grading score was 82.3%. The combination of elastography grading score, low echo, distinct boundary and short diameter greater than 1 cm showed the best diagnostic efficiency value. The AUC was 0.911. In distinguishing malignant and benign nodes, the specificity, sensitivity, positive predictive value, negative predictive value and accuracy of the combined indexes was 84.6%, 88.1%, 90.2%, and 81.5% respectively. The overall accuracy was 86.8%.
 CONCLUSION The endobronchial ultrasound elastography can effectively distinguish the mediastinal and hilar lymph node metastasis in lung cancer. The diagnosis accuracy of elastography in malignant lymph node is higher than that of standard EBUS criteria. The combination of elastosonography grading score and standard EBUS criteria can improve the diagnostic efficiency.
Bronchoscopes ; Elasticity Imaging Techniques ; Humans ; Lung Neoplasms ; pathology ; Lymph Nodes ; pathology ; Lymphatic Metastasis ; diagnostic imaging ; Mediastinum ; pathology ; Retrospective Studies ; Sensitivity and Specificity

Neurogenic tumors located in the posterior mediastinum, generally require surgery which be confronted with greater risk,therefore, to design the best surgical approach and surgical methods is essential. A 67-year-old female patient had pharyngeal foreign body sensation and dysphagia. Thyroid ultrasound showed the right thyroid had a little nodule, and the left thyroid had a hypoechoic lumps. Neck enhanced CT showd mediastinal mass, esophageal tumor origin or stromal tumor? We used the jugular approach to resect the tumor which eventually diagnosed as schwannoma. The meditational benign tumor with an envelope easy to peel can employ the jugular approach to resect it completely.
Aged ; Female ; Humans ; Jugular Veins ; Mediastinal Neoplasms ; surgery ; Mediastinum ; pathology ; Neck ; surgery ; Neurilemmoma ; surgery

OBJECTIVETo explore the patterns and influencing factors of lymph node metastasis in limited esophageal small cell carcinoma (PESCC).

METHODSA total of 98 limited stage PESCC patients who underwent surgery were selected for this study. The lymph node metastasis ratio at different sites, depth of invasion, tumor length and other factors were analyzed to assess their influence on lymph node metastasis.

RESULTSAmong the 98 PESCC cases, 46 cases had lymph node metastasis (46.9%). 100 out of 833 lymph nodes had metastasis, with a metastasis ratio of 12.0%. For upper thoracic esophageal small cell carcinomas, lymph node metastasis ratios were 42.9%, 12.5%, 0 and 0 in the superior mediastinum, middle mediastinum, inferior mediastinum and abdominal cavity, respectively. In the middle thoracic PESCCs, the lymph node metastasis ratios were 18.8%, 7.7%, 15.7%, and 15.3%, respectively. In the lower thoracic PESCCs, the lymph node metastasis ratios were 0, 0, 27.3% and 23.5%, respectively. Lymph node metastasis rates in PESCCs at stages T1, T2, T3, T4 were 15.4%, 42.3%, 63.9%, and 80.0%, respectively. The lymph node metastasis ratios in PESCCs at stages T1, T2, T3, T4 were 2.0%, 8.3%, 17.8% and 25.0%, respectively. Lymph node metastasis rate and lymph node metastasis ratio at different T stages were of significant difference (P<0.05 for all). Lymph node metastasis rates in patients with tumor <3 cm, 3-5 cm, and >5 cm were 30.6%, 46.9% and 66.7%, respectively, and lymph node metastasis ratios were 5.4%, 11.0% and 21.1%, respectively. Lymph node metastasis rate and lymph node metastasis ratio in patients with different tumor length had significant differences (P<0.05 for all). Lymph node metastasis ratio was 11.6% in the Chr-A negative and weak positive group, much higher than 4.3% in the Chr-A positive group (P=0.013). There was a tendency that lymph node metastasis ratio of NSE-positive group was higher than that of NSE-negative and weak positive group (P=0.069). The logistic univariate analysis did not find high risk factors of distant lymph node metastasis (all P>0.05). Logistic multivariate analysis found that only depth of invasion was a risk factor of lymph node metastasis in limited PESCC (P=0.002).

CONCLUSIONSEsophagus small cell carcinomas sometimes have early lymph node metastases in many sites and distant range. The middle thoracic PESCCs tend to have extensive metastasis quite common in the upper mediastinal lymph nodes. Lower mediastinal and abdominal lymph node metastases are often seen in lower thoracic PESCCs. The depth of invasion and tumor length are main factors influencing mediastinal lymph node metastasis. The depth of invasion is an independent risk factor for lymph node metastasis.

Abdominal Cavity ; Carcinoma, Small Cell ; pathology ; secondary ; Esophageal Neoplasms ; pathology ; Humans ; Lymph Nodes ; pathology ; Lymphatic Metastasis ; Mediastinum ; Multivariate Analysis ; Neoplasm Invasiveness ; Risk Factors

BACKGROUNDPathophysiological processes, such as malignancy, can lead to the formation of stiffer tissue in lung cancers. Endobronchial ultrasound (EBUS) elastography is a novel technique for measuring tissue stiffness during EBUS-guided transbronchial needle aspiration (EBUS-TBNA). The current study was conducted to investigate the diagnostic value of EBUS elastography for mediastinal and hilar lymph node metastasis in lung cancers.

METHODSFrom January 2014 to January 2015, 40 patients suspected of lung cancer were enrolled, and a total of 68 lymph nodes were evaluated by EBUS-TBNA. EBUS-guided elastography of lymph nodes was performed prior to EBUS-TBNA. Standard EBUS characteristics were also described. Pathological determination of malignant or benign lymph nodes was used as the gold standard for this study. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were referred for a surgical procedure. Comparisons of elastography and standard EBUS characteristics were made between benign and malignant lymph nodes.

RESULTSElastography grading scores and strain ratios showed significant differences between benign and malignant lymph nodes (P = 0.000). The elastography strain ratio was more sensitive and specific for determining malignant lymph nodes than elastography grading score or standard EBUS criteria. The receiver operating characteristic curve for the elastography strain ratio showed an area under the curve of 0.933. The best cut-off point of the strain ratio for differentiating malignant from benign lymph nodes was 32.07. The elastography strain ratio had a sensitivity of 88.1%, the specificity of 80.8%, positive predictive value of 88.1%, and negative predictive value of 80.8% for distinguishing malignant from benign nodes. The overall accuracy of elastography strain ratio was 85.3%. The strain ratio of malignant and benign lymph nodes positively correlated with the elastography grading score (r = 0.561, P = 0.000).

CONCLUSIONSEBUS elastography can be effectively used to predict mediastinal and hilar lymph node metastases in lung cancer. This noninvasive technique may thus complement standard EBUS and help guide EBUS-TBNA procedures.

Aged ; Elasticity Imaging Techniques ; methods ; Endosonography ; methods ; Female ; Humans ; Lung Neoplasms ; diagnosis ; Lymph Nodes ; pathology ; Male ; Mediastinum ; pathology ; Middle Aged