The Value of a Systematic Protocol Using Endobronchial Ultrasound and Endoscopic Ultrasound in Staging of Lung Cancer for Patients with Imaging iN0–N1 Disease

<b><i>Introduction:</i></b> We hypothesize that systematic, combined, and multidisciplinary study of the mediastinum (endobronchial ultrasound [EBUS] and endoscopic ultrasound [EUS]) in patients with NSCLC with radiologically normal mediastinum improves the results of mediastinal staging obtained with EBUS alone. <b><i>Material and Methods:</i></b> A retrospective study of the prospective database collected on the patients with NSCLC with a radiologically normal mediastinum and an indication for systematic staging with EBUS and EUS. EBUS staging was followed by EUS in patients in which the results from the pathological analysis of EBUS were negative. <b><i>Results:</i></b> Forty-five patients were included in the analysis. The combination of EBUS followed by EUS provided better results than EBUS alone: sensitivity (S) 95% versus 80%, negative predictive value (NPV) 96.15% versus 86.21%, negative likelihood ratio 0.05 versus 0.20, and post-test probability 3.8% versus 13.8%. This represents an increase in S (15%), the validity index (6.6%), and NPV (9.9%) compared to EBUS alone. There were 4 false negatives (FNs) (8.8%) with the EBUS test alone. After adding EUS, 3 more cases were positive (6.6%) and only 1 FN (2.2%). <b><i>Conclusions:</i></b> In patients with NSCLC and a radiographically normal mediastinum, a systematic and combined staging with EBUS and EUS show higher sensitivity in the detection of mediastinal metastasis than with the use of EBUS alone. The high accuracy of the test means that the use of mediastinoscopy is not necessary to confirm the results in these patients. Since the availability of EUS is low, it may be advisable for the interventional pulmonologist to receive training in EUS-b.

Chronic Granulomatous Disease with Associated IgG4-Related Disease: A Case Report and Review of the Literature

BackgroundIgG4-related disease (IgG4RD) may initially present with pulmonary pseudotumor, making the diagnosis challenging particularly in patients prone to granulomatous inflammation. Here, we describe the first case of chronic granulomatous disease (CGD) with associated IgG4RD.Case presentationAn 8.5-year-old male was hospitalized two years ago with exertional dyspnea, mild cough, chest pain, and nocturnal sweating and was found to have a tumor-like mass in the right lung. The histopathologic findings were consistent with non-necrotizing granulomatous inflammation, central neutrophilic micro-abscess, and extensive peripheral fibrosis without any evidence for acid-fast bacilli or fungal elements. Treatment with prednisolone resulted in considerable symptom resolution. After 15 months, following the discontinuation of prednisolone by the patient, symptoms recurred, gradually exacerbated, and he developed anorexia and weight loss. The next chest spiral computed tomography (CT) scan showed a larger mass in the right lung, right lung collapse, and mediastinal metastasis. The abdominal ultrasound and CT scan were normal. In laboratory evaluation, low counts of B and T cells, normal natural killer (NK) cells, high levels of IgG4, and high inflammatory markers were detected. The nitro blue tetrazolium (NBT) test was zero in two consecutive evaluations. In virtue of high IgG4 level, the immunostaining of lung specimen was performed which was inconclusive for IgG4+cells, and staining for CD138 was not available. He was diagnosed with concurrent CGD and IgG4RD, but progressed to respiratory failure and died despite the reinstitution of steroid therapy.ConclusionsThe overlap between inborn errors of immunity (IEIs) and IgG4RD is not common. Further studies to investigate IgG subsets among IEI patients can help elucidate clinicopathological correlations between these two immune-mediated disorders.

Mediastinal Goiter Operated as Trans Clavicular Access as Adjunct to Cervical Incision

There are cases in which resection of cervico-mediastinal goitres requires additional thoracic access as an adjunct to standard transverse cervicotomy, and typically this takes the form of sternotomy or thoracotomy. The authors propose transclavicular access as an alternative to thoracotomy or sternotomy access for the removal of such goitres. This technical variant is performed by means of resection of the middle third of the clavicle and extraperiosteal disarticulation. They report a case of cervico mediastinal or “plunged” goitre associated with mediastinal metastasis from a follicular thyroid carcinoma in a 77-year-old woman, in whom this technical variant was used. They conclude by stressing the greater effectiveness, ease of execution and relatively limited “aggressiveness” of the technique in comparison with other ways of reaching the mediastinum. The variant proves effective in solving a number of technical, functional and aesthetic problems.

Bulky Mediastinal Metastasis in Neglected Follicular Thyroid Carcinoma: A Case Report

Follicular carcinoma of thyroid usually behaves in an indolent manner with low metastatic potential. Distant metastases as initial presentation are rare in follicular carcinoma, especially in young patients. Blood borne metastasis is common with spread to lung, bone and other solid organs. However, metastatic mediastinal tumors are rare. Here, a neglected case of follicular carcinoma of thyroid (FTC) is reported. The patient is a 43 year old female who was referred to the Thyroid Division of NINMAS for radioiodine therapy for an inoperable metastatic FTC. She was presented with fever, shortness of breath and chest discomfort. 99mTc scan showed concentration of most of the isotope in the big metastatic mediastinal mass. Because of the sheer volume of the mass, a plan was undertaken to first reduce her tumor burden with external beam radiation therapy (EBRT) and then considered adjuvant therapy with radioiodine after manageable regression in size of the metastatic tumor. She had a history of thyroidectomy for FTC 14years back without radio iodine ablation. Negligence about proper management for FTC may result in poor outcome like huge mediastinal mass as in this reported case. Radioiodine therapy is usually the first line approach for functional metastasis, but in exceptional cases when the tumor size is very big, EBRT may be considered first. Radiotherapy (RT) is effective in relieving compression symptoms and may improve the quality of life in these patients. Bangladesh J. Nuclear Med. 22(2): 141-145, Jul 2019