Ultrasound Pitfalls in a Complex Fetal Cardiac Malformation—Case Report of a New Arteriovenous Central Communication

Cardiac and cardiovascular malformations are of real interest in terms of definition, epidemiology, and means of early diagnosis by imaging. Although ultrasound examination reaches exceptional performance nowadays, unusual pathologies are still exposed to the risk of either incorrect acquired image or misinterpretation by the specialist in a routine scan. Herein, we present a case of a 20-week-old fetus (from an apparently low-risk pregnancy) with complex cardiac and vascular abnormalities, including an arteriovenous malformation along with ventricular septal defect, ductal coarctation of the aorta, aneurysm of a brachiocephalic vein, and dilation of the entire neck and upper mediastinum venous system, and the limitations that were encountered in the process of diagnosis and management of the case.

The Value of Paratracheal Lymphadenectomy in Esophagectomy for Adenocarcinoma of the Esophagus or Gastroesophageal Junction: A Systematic Review of the Literature

Background The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma. Methods A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival. Results A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive. Conclusions The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.

Synchronous Neck Melanoma and Papillary Thyroid Cancer: A Case Report

Introduction: The synchronous malignant melanoma of the neck and papillary thyroid cancer is rare but severe condition. Here, we describe the case of a patient with papillary thyroid cancer and melanoma invasivum cutis. Case report: A 49-year-old man had a change on the neck at the last 3-4 months that he accidentally noticed. He had hoarse voice, was afebrile, did not sweat more than usual and feel exhausted, without rash or itching. MR examination of the neck and upper mediastinum before the surgery indicated a hyperintense focal change in the left thyroid gland which dimensions was 19 x 15 mm and several hyperintense inhomogeneous lymph glands of the jugular chain, on the both sides, with different sizes. On the basis of the conducted analyzes, in addition to total thyroidectomy, two-sided functional dissection of the lymph nodes of the neck was performed. The pathohistological diagnosis of the left lobus was: Carcinoma papillary glandulae thyreoideae invasivum (G-I, nG-I, pT2, Lx, Vo). CT of head, neck and thorax were made, where it was noticed that the CT of the head and lungs were normal. PET/CT findings indicated that there was no rest or recurrence of the tumor. Conclusion: The message from this case report is that when diagnosing and treating thyroid cancer, the observed changes in the neck lymph nodes also indicate cancers of non-thyroid pathology such as malignant melanoma.

Long-Term Observation and Treatment of Epithelioid Haemangioendothelioma of the Mediastinum: A Case Report

Epithelioid haemangioendothelioma is a rare angiogenic tumour originating from vascular endothelial or pre-endothelial cells, and it can occur anywhere in the body, such as the liver, lung, bone, spleen, lymph nodes, parotid gland, and thyroid. In the fifth revision of the WHO classification, epithelioid haemangioendothelioma (EHE) was described as a malignant vascular neoplasm composed of epithelioid endothelial cells, distinct from epithelioid angiosarcoma. We, herein, report one patient with EHE of the left upper mediastinum who underwent resection and radiotherapy during the first therapeutic process. Multiple metastases occurred in the thoracic vertebrae 6 years later, and resection and multiple radiotherapies were performed. The condition of the patient remained stable at the last review in October 2020, and it has been more than 8 years since her first admission. The reasonable “take-away” lessons from the case are active treatment and prolonged surveillance.

221 THORACOSCOPIC ESOPHAGECTOMY WITH OR WITHOUT SMALL THORACOTOMY FOR ADVANCED THORACIC ESOPHAGEAL CARCINOMA IN THE LEFT LATERAL DECUBITUS POSITION

Standardized thoracoscopic esophagectomy for thoracic esophageal carcinoma in the left lateral decubitus position under artificial pneumothorax is slightly more difficult to dissect the middle and lower mediastinum than in prone position, but it is possible to operate the upper mediastinum with good visual field. In salvage surgery after definitive chemoradiotherapy, it is difficult to complete the operation only by throscopic surgery, and it is thought that sometimes small thoracotomy can be performed safely and reliably. Methods If this procedure is considered feasible, start with thoracoscopic surgery. If it is decided that the procedure cannot be completed, add a small thoracotomy of about 10–15 cm to allow one hand. Thoracoscopy not only reduced invasiveness, shared detailed anatomy, but also improved operability by taping the esophagus and ensured emergency safety. Results This standardized procedure is applied to salvage surgery after definitive chemoradiotherapy from January 2016 to March 2019. Thoracoscopic surgery was performed in 14 of the 27 cases (52%). Thoracoscopic surgery was completed in 10 cases and small thoracotomy was used in 4 cases. There are no serious complications such as bleeding. Conclusion Starting surgery with a thoracoscopy and adding small thoracotomy as appropriate can share the advantages of thoracotomy and throcoscopic surgery. This technique has the advantage that it can be easily converted to thoracotomy even in an emergency, and is considered to be superior to advanced cancer. Video https://www.dropbox.com/sh/47jcqu3palpsfvg/AAC4PvReWDP_WPBkJufxWU3da?dl=0.

Mediastinal and subglottic hemangioma in an infant: a case report and literature review

We performed a retrospective analysis of the clinical manifestations, laboratory and imaging examinations, treatment, and prognosis of a male infant who was diagnosed with mediastinal and subglottic hemangioma in our hospital. The clinical features of this patient were coughing, wheezing, and dyspnea. Enhanced computed tomography of the neck and chest showed a diffuse abnormality in the right-upper mediastinum. He was diagnosed with a hemangioma after a physical examination combined with bronchoscopy. The clinical symptoms were relieved by oral propranolol. We also investigated the clinical characteristics, treatment, and prognosis of mediastinal and subglottic hemangioma in infants in the previous literature, and searched for case reports of this disease in China and in other countries. We only identified three previous cases of mediastinal and subglottic hemangioma in infants, indicating that this condition is rare. In the proliferative stage, surrounding organs and tissues are compressed, which can be life-threatening. Most of these children develop wheezing, shortness of breath, dyspnea, cyanosis, and other symptoms within 2 months. Enhanced computed tomography and magnetic resonance imaging combined with soft bronchoscopy can confirm the diagnosis of this disease, and oral propranolol achieves a favorable effect.

Giant dissected aortic aneurysm presenting as a superior vena cava syndrome

A 47-year-old man, with a history of aortic valve replacement 28 years earlier, was admitted to the emergency department with a right cervical mass and a superior vena cava syndrome. Thoracic angio-CT revealed a giant ascending aorta aneurysm, with an intramural thrombus and dissection flap, compressing the superior vena cava. Emergency surgery was performed, confirming those findings. The dissection had ruptured but was contained by surrounding structures, creating a false-aneurysm that compressed the superior vena cava. The aneurysm was excluded and the aorta was replaced by a Dacron conduit, thereby decompressing the upper mediastinum. The patient made an uneventful recovery.

Case Report: Prenatal and Postnatal Management for Fetal Bronchogenic Cysts During the COVID-19 Pandemic

Background: A fetal bronchogenic cyst (BC) is a rare congenital anomaly with an incidence of 0.147–0.238‰. The coronavirus disease 2019 (COVID-19) pandemic, as a particular situation, hindered pregnant women from receiving periodic prenatal checkups.Case Description: Until 34+6 weeks of gestation, a fetal case of the intrathoracic cyst was found by ultrasound examination. Further, MRI examination confirmed the diagnosis of the congenital mediastinal cystic lesion, probably a BC. Genetic testing was not conducted due to the COVID-19 pandemic. At 38+5 weeks of gestation with maternal COVID-19 testing negative, a live girl was delivered by cesarean section. Five months later, the child underwent bronchocystectomy, and the postoperative pathological lesions confirmed a (right upper mediastinum) BC.Conclusion: Herein, we reported the prenatal and postnatal management for a rare case of the congenital BC by multidisciplinary approaches during the COVID-19 pandemic. Fetal MRI and screening for fetal chromosomal abnormalities are especially recommended. This case contributes to the awareness that the COVID-19 pandemic interferes with regular follow-up schedules during pregnancy and may interfere with timely performed additional tests; which leads to more accurate genetic counseling. A combination of multidisciplinary approaches, including radiology, infection control, genetic counseling, obstetrics, and pediatric surgery, is pivotal for managing fetal BC during the COVID-19 pandemic.

Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Background Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum. Case presentation A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma. Conclusions RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

A Literature Review of Localized Mediastinal Mesothelioma and a Rare Case Report

Background: Primary localized mediastinal mesothelioma is a rare tumour which accounts for about 0.7% of all mesotheliomas. The mesothelial cells lining of the pericardium are suggested as the most probable cells of origin. Mediastinal pleural mesothelioma are distinctly uncommon, which has only been reported in a single case. Case presentation: We report a case of a 57 years old man with primary mediastinal pleural mesothelioma involving middle and posterior upper mediastinum, one months following surgery, the patient is alive with good performance status. Chest plain scan and contrast-enhanced computer tomography（CT）scan showed a 43 mm×36 mm×36 mm tumor，with a CT value of about 41.5 HU, an arterial phase CT value of about 59.8HU and a venous phase CT value of about 77.5HU during the contrast-contrast-enhanced scan.Patients underwent thoracotomy.The pathological diagnosis was derived from malignant pleural mesothelioma(MPM) growing from the chest wall into the mediastinum. Conclusions Imaging manifestations of tumors have rarely been described in the literature. A short review of literature on MPM is given and summarize the imaging characteristics.