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Background The assumption that increased [18F] fluoro-2-deoxy-d-glucose (FDG) uptake in hilar nodes on PET/CT imaging is indicative of distant metastasis can result in palliative rather than curative care in patients with esophageal cancer. This study aims to determine the significance of increased FDG uptake in hilar nodes in patients with potentially curable, locally advanced disease at initial staging. Methods We included patients with biopsy-proven esophageal carcinoma who had pretreatment FDG-PET/CT at initial staging, and follow-up imaging >1 year. We excluded patients with distant hematogeneous metastases. Hilar nodes were considered concerning for metastatic disease when SUV max was >2.5 or FDG uptake was visually > mediastinal background were examined. Results We reviewed FDG-PET CT scans from 806 patients treated for esophageal cancer from 2010-2018 and identified 42 patients with FDG avid hilar adenopathy. Thirteen patients underwent histological assessment and 29 were followed with imaging. None of the 42 patients were found to have distant metastatic disease on initial work up and all were treated curatively. In follow up, 2/42 patients eventually manifested hilar nodal metastases after treatment; one who had a biopsy-negative hilar node at initial staging and another who did not have a biopsy of the hilar node. Conclusions Increased FDG uptake in hilar nodes in patients with localized esophageal cancer was not indicative of non-regional nodal metastasis. Patients in these situations should be approached with curative intent. The need for biopsy of FDG avid hilar nodes in this cohort should be carefully considered due to the low diagnostic utility.

A case of silicosis presenting as middle lobe syndrome is described in a middle-aged female. The diagnosis was confirmed by both bronchoscopy and demonstration of right middle lobe lumen narrowing and compression by calcified hilar lymph nodes on computerized tomographic scan. Simultaneous occurrence of endobronchial silicosis and bronchial stenosis by enlarged calcified peribronchial lymph nodes causing middle lobe syndrome has not been described previously as reported in this case.

Aim: EBUS TBNA is an important diagnostic procedure for the intrathoracic lymph nodes. 21 G, 22 G and 25 G needles are used for sampling. Better samples can be expected to be taken via 21 G needle, as the inner diameter of 21 G needle is larger. However, the results of the studies comparing 21 G and 22 G needles are controversial. Methods: The study population consists of patients with EBUS TBNA performed via 21 G needles (Group 1; n=40) and the patients for whom 22 G needles used (Group 2; n=40). The data of patients were retrospectively analyzed. ROSE was performed for all samples.Results: The sensitivity, specificity and diagnostic accuracy of the procedure with 21 G needle was 95%, 85%, 93%, respectively. The diagnostic accuracy of 21 G needle was found to be higher than that of 22 G needle (93% versus 80%). In the procedure performed with 21 G needle, fewer samples were sufficient for the diagnosis than 22 G needle (r = 0.03, p

Background Loco-regionally advanced lung cancer is typically treated with a combination of chemotherapy and radiation therapy, but overall survival and local control remain poor. Radio-enhancing nanoparticles such as NBTXR3 activated by radiotherapy results in increased cell death and potentially an anti-tumor immune response. The goal of this study was to assess the feasibility and safety of endobronchial ultrasound (EBUS)-guided injection of NBTXR3 into mediastinal and hilar lymph nodes (LN), as well as assess nanoparticle retention in the LN post-injection. Methods Animals underwent bronchoscopy under general anesthesia with EBUS-guided injection of NBTXR3 into hilar and mediastinal LN. LN and injection volumes were calculated based on pre-injection computed tomography (CT) scans. CT scans were repeated at 5 min, 30 min, and 8 days post-injection. Blood-draws were also obtained at baseline and post-injection. Animals were then housed, monitored, and sacrificed 8 days post-injection. Necropsy was then performed with gross and histologic analysis of LN. Results A total of 20 LN were injected in 5 pigs (4 LN per animal). Nanoparticles were retained in 100% of LN at 30 min, and 90% of LN at 8 days. Extravasation of nanoparticles was seen in 4 out of the 20 LN. There were no cases of nanoparticle embolization visible by CT in distant organs. Small air-bubbles were introduced in the targets and surrounding tissue in 3 out of 20 LN. Of note, at 8 days, none of these air-bubbles were present on CT scan. There were no intra-procedural or post-procedural complications in either CT scans or necropsy findings. Pigs remained clinically stable and neither laboratory values nor necropsy showed evidence of inflammation. Conclusions EBUS-guided injection of NBTXR3 radio-enhancing nanoparticles can be safely performed achieving a high rate of nanoparticle retention, low extravasation, and no visible nanoparticle embolization.

Sarcoidosis is achronic systemic granulomatous disease of unknown etiology. In more than 90% of patients with diagnosed sarcoidosis, mediastinal and hilar lymph nodes are affected. The objective of this paper is to discuss the most important chest imaging methods in pulmonary sarcoidosis. Achest X-ray remains the method of choice at both the diagnostic stage and during follow-up of the disease progress. High-resolution computed tomography allows for amore thorough description of lesions in terms of their location. Research demonstrates the superiority of FDG PET over both aforementioned techniques in the assessment of active inflammatory lesions. Magnetic resonance imaging is currently being used in diagnosing cardiac sarcoidosis. Although EBUS constitutes the basic diagnostic tool, the invasiveness of the method results in it not being used when monitoring the activity of the disease.

Background The main objective was to analyze the technical variability of EBUS-elastography in the differentiation of benign and malignant hilar and mediastinal lymph nodes. As a secondary objective, the results of the EBUS-elastography in said differentiation were analyzed, comparing them with the anatomopathological results. Methods Prospective and analytical study of lymph nodes in which EBUS-elastography was performed. Elastographic variables and their variability were analyzed. Results 24 patients and 38 lymph nodes were evaluated. Of these, 60.5 % had a history of neoplasia, 71 % of them were EBUS-elastography with diagnostic intention, 53 % were mediastinal staging of lung cancer. Both procedures were performed in 25 % of the patients. Lymph nodes were classified into elastographic colour patterns, red being characteristic of elastic tissues and blue of rigid tissues. The lymphadenopathies with apredominantly blue pattern were associated with an anatomopathological result of malignancy (86 % vs 14 %, OR 20.4 (3.1–245.1) p-value = .00015). Malignant lymph nodes presented less colour dispersion in the frequency histograms and a higher ratio of blue pixels and higher strain ratio. These variables showed a variability of 8.7 %, 9.9 % and 31.6 % respectively in repetitions in the same adenopathy. Finally, a 66 % of consistency was obtained in the event of colour pattern variability (p 0.0000). Conclusion EBUS-elastography is feasible during EBUS and may be helpful in predicting malignant lymph node infiltration. The quantitative elastographic data show low variability in repetitions in the same adenopathy. The strain ratio is the most variable elastographic parameter.

Introduction. Algorithms of the early detection of lung cancer remain a topic of discussion and the problem of timely assessment of the expansion of lung cancer remains unresolved.Objective – to determine if the combined use of contrast­enhanced MDCT and 99mTc­MAA SPECT and Gallium‐67 citrate SPECT is effective in assessing the expansion of lung cancer in the determination in the intervention tactics.Material and methods. In the study, radiologic examination was performed to 81 patients with lung cancer. Combined examinations included bolus contrast­enhanced computed tomography (n = 81 patients), 99mTc­MAA SPECT (n = 62 patients) and Gallium‐67 citrate SPECT (n = 9 patients).Results.According to MDCT data in most cases (n = 65 patients; 80 %) this method was able to diagnose the T­stage of the tumor; in some cases, the stage of malignancy was overestimated (n = 8 patients, 10 %), or underestimated (n = 8 patients, 10 %). According to the results of 99mТc­МАА SPECT, it was possible to reliably determine the microcirculation disorders that were observed in the whole group of patients, while in 12 cases the impaired blood flow was recorded only according to the results of 99mTc­MAA SPECT and in 50 cases the severity of changes in blood flow was more signifcant than according to MDCT. When analyzing Ga­67 citrate SPECT data, in all 9 cases whole­body Ga­67 citrate SPECT showed intense hot areas at the tumor region. It was also possible to show several mildly increased foci in the hilar lymph nodes in 6 cases, but in 3 cases the result was false positive.Conclusions. Bolus contrast­enhanced computed tomography in most cases allows to correctly determine the T­stage of lung cancer and show tumor invasion into the surrounding tissues and vessels. At the same time, an additional 99mTc­MAA SPECT study allows to clarify the degree of disturbance of the microvasculature in more detail. It is possible to supplement the assessment of regional metastasis by Gallium‐67 citrate SPECT, however, it is necessary to take into account the inflammatory nature of lymph node changes as a cause of false­positive data.

A 68-year-old man with interstitial pulmonary fibrosis underwent bilateral lung transplantation. Histopathologic examination of hilar lymph nodes in the explanted lungs showed effacement of normal nodal architecture by the proliferation of small lymphocytes, consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). Unexpectedly discovered malignancies at the time of lung transplantation is uncommon, especially in the lymph nodes. The clinical management was challenging because of attempts to balance treatment of CLL and immunosuppressive treatment to prevent graft rejection. Here, we report a case of incidentally detected CLL in hilar lymph nodes with explanted lungs and review the relevant literature.

Intrathoracic lymph node metastasis from extrathoracic neoplasms are rare. Primary malignancies that metastasize to mediastinal-hilar lymph nodes are head and neck , carcinoma breast ,and genitourinary. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)/endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the preferred modality for mediastinal lymph node sampling.Fifty seven patients with extrathoracic malignancies with maximum standardized uptake value (SUVmax) of mediastinal-hilar lymph nodes greater than or equal to 2.5 were taken up for EBUS-TBNA. The histo-cytopathological results obtained from EBUS-TBNA were compared with SUVmax value and short-axis diameter of a lymph node as noted on EBUS.Out of 74 sampled nodes, 49 (66.2%) were benign and 25 (33.8%) were malignant. The SUVmax range of benign nodes was 2.8-13 as compared to 3-18 of malignant nodes. The size range of malignant and benign nodes were 8-35 mm and 8-30 mm, respectively. The mean size of abnormal nodes (metastatic + granulomatous) was 17.5 (8-35 mm) and the mean SUVmax was 9.1 (3.4-18), and it was a statistically significant difference when compared to reactive (normal) nodes. At SUVmax cut-off 7.5, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were 78.5%, 81.2%, 84.6%, and 74.2%, respectively for detecting abnormal nodes. At 13 mm size cut-off, sensitivity, specificity, PPV, NPV were 75.5%, 65%, 75%, and 72%, respectively, for detecting abnormal nodes.The majority of mediastinal-hilar nodes with increased metabolic activity are benign in nature. Size and SUVmax are poor predictors of metastasis in tuberculosis endemic region. There should be a restrictive attitude toward invasive diagnostic testing for mediastinal-hilar nodes in extrathoracic malignancies.

A 68-year-old man with sarcoidosis showed high 18F-FDG uptake in the mediastinal and hilar lymph nodes on 18F-FDG PET, suggesting active inflammation. 18F-fluoro-boronophenylalanine (FBPA) PET showed no significant uptake in the mediastinal and hilar lymph nodes, suggesting its cancer specificity as a substrate of l-type amino acid transporter 1. 18F-fluoro-boronophenylalanine PET can be used for precise evaluation in oncology when the differentiation between inflammation and metastasis is inconclusive on 18F-FDG PET.

Background: Endobronchial ultrasound elastography that provides information on tissue stiffness may help distinguish malignant from benign mediastinal and hilar lymph nodes. Objectives: In this prospective trial, we assessed the diagnostic value of elastographic images and the interobserver agreement in its evaluation. Method: Elastographic images from 77 lymph nodes in 65 patients were reviewed by 3 pneumologists. The elastographic image was classified based on the predominant colour: predominantly green, intermediary, and predominantly blue. With 2 or 3 interobserver matches, the corresponding elastographic image was correlated with the pathological result obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and/or other invasive procedures. Results: All 3 reviewers had agreement in classifying elastographic images in 45% (35/77). Overall, the interobserver agreement among the 3 readers for classifying elastographic pattern was found to be moderate (Fleiss Kappa index = 0.519; 95% CI = [0.427; 0.611]). On cytological/histological evaluation, 55 lymph nodes were malignant and 22 were benign. In classifying “green” as benign and “blue” as malignant, the sensitivity and specificity were 71% (95% CI = [54%; 85%]) and 67% (95%-CI = [35%; 90%]), respectively. Conclusions: Elastography will not replace invasive EBUS-TBNA due to a moderate interobserver agreement and insufficient sensitivity and specificity. However, elastography will, maybe, present an additional feature to identify malignant lymph nodes in the context of clinical, radiological, and cytological results.

Objectives: In countries with a high prevalence of tuberculosis, such as Iran, the differentiation of malignant from non-malignant tumors is crucial. We attempted to find a reliable model in determining malignant nodes by investigating the sonographic characteristics of lymph nodes (LNs). Methods: In this prospective study, the morphologic characteristics of LNs, including size, shape, vascular pattern, echogenicity, margin, coagulation necrosis sign, calcification, and central hilar structure, which had been obtained during endobronchial ultrasound-guided transbronchial needle aspiration, were compared with the final pathology results. Results: We examined 253 LNs from 93 patients. Round shape, non-hilar vascular pattern, heterogeneous echogenicity, hyperechogenicity, distinct margin, and the existence of necrosis signs were significantly higher in malignant nodes. On the other hand, the existence of calcification, as well as the presence of central hilar structure, were highly suggestive of benign nodes (p < 0.050). Multivariate logistic regression revealed that size > 1 cm, heterogeneous echogenicity, hyperechogenicity, the existence of necrosis signs, and the lack of central hilar structure are independent predictive factors for malignancy. The accuracy of each of the aforementioned characteristics are 42.3%, 71.5%, 71.9%, 73.5%, and 65.6%, respectively. Of 74 malignant LNs, 100% had at least one of these independent factors. Conclusions: The morphological features of LNs based on endobronchial ultrasound-guided transbronchial needle aspiration can play a role in predicting malignancy.

The role of positive lymph node location in non-small-cell lung cancer (NSCLC) patients and effects on survival was assessed. A total of 88 operated patients with unsuspected N2 disease or station 10 lymph nodes were included. No difference was found in survival between inferior positive mediastinal N2 node patients compared to multilevel N2 disease patients. The survival of patients with positive hilar disease was similar to the inferior mediastinal positive N2 group. Background: The role of surgery in the treatment of non-small-cell lung cancer that has spread to ipsilateral mediastinal or hilar lymph nodes (LNs) is controversial. We examined whether the location of LNs positive for non-small-cell lung cancer in mediastinum or hilum influences the survival of these patients. Patients and Methods: We reviewed data from 881 patients and analyzed those with unsuspected N2 disease or hilar (station 10) LNs. The patients were stratified into the following groups: group A, positive hilar Naruke 10; group B, superior mediastinal and aortic nodes (Naruke 1, 2, 3, 4, 5, and 6); group C, inferior mediastinal nodes (Naruke 7, 8, and 9), and multilevel group D (2 or more positive N2 levels). Results: A total of 69 pN2 and 19 pN1 patients were included. Progression-free survival (PFS) was statistically significant better in group B versus group C (P = .044) and group B versus group D (P = .0086). The overall survival (OS) of group A did not differ from that of group C. A statistically significant better OS was found between groups B and D (P= .051). Conclusion: Inferior positive mediastinal N2 node patients seem to have an OS and PFS as poor as multilevel N2 disease patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Superior positive mediastinal N2 node patients have better OS and PFS than the inferior mediastinal positive N2 group. (C) 2018 Elsevier Inc. All rights reserved.

Background Endobronchial ultrasound (EBUS) has become a powerful tool for the diagnosis of mediastinal and hilar lymph nodes (LNs). Elastography has been introduced recently to provide more accurate data about the lesions seen during EBUS. Aim The aim of this study was to evaluate the role of elastography during EBUS for the diagnosis of hilar and mediastinal LN. Patients and methods We carried out a prospective, cross-sectional study. Patients with hilar/mediastinal LN enlargement on computed tomography examination were included. Convex probe EBUS was performed using conventional B-mode and elastography with transbronchial needle aspiration from the examined LN. All data are presented as mean±SD. Receiver operating characteristic analysis was carried out to find the relative sensitivity and specificity of EBUS elastography and to compare the results with other B-mode findings such as mediastinal LNs. Results A total of 147 LNs from 56 patients were examined. Malignancy was found in 111 of them. The strain ratio was found to be more accurate when compared with other findings of B-mode when comparing malignant and benign LNs with a cut-off value of 7.5, giving a sensitivity of 95.5% and a specificity of 91.67%. About 63% of malignant LNs were diagnosed from the first pass with the help of elastography. Conclusion Elastography is a very helpful tool for diagnosing mediastinal LNs with a strain ratio above 7.5, having a strong suggestion of malignancy. Elastography can help in directing the needle during EBUS-transbronchial needle aspiration to reach the final diagnosis with the least possible number of passes and avoiding unnecessary punctures (ClinicalTrials. gov Identifier: NCT02724059).

// Ye Gu 1,* , Hong Shi 2,* , Chunxia Su 3 , Xiaoxia Chen 3 , Shijia Zhang 3 , Wei Li 3 , Fengying Wu 3 , Guanghui Gao 3 , Hao Wang 1 , Haiqing Chu 4 , Caicun Zhou 3 , Fei Zhou 3 and Shengxiang Ren 3 1 Department of Endoscopy, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China 2 Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China 3 Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine & Tongji University School of Medicine Thoracic Cancer Institute, Shanghai, China 4 Department of Respirology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China * These authors have contributed equally to this work Correspondence to: Shengxiang Ren, email: // Fei Zhou, email: // Keywords : elastography, EBUS-TBNA, diagnosis, lung cancer, lymph nodes Received : October 19, 2016 Accepted : March 15, 2017 Published : July 06, 2017 Abstract Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been widely used for diagnosis and mediastinal lymph nodes staging in patients with suspicious lung cancer. Ultrasound elastography is a novel sonographical technique that can evaluate tissue compressibility. The aim of the present study was to investigate the diagnostic yield of elastography for differentiating malignant and benign mediastinal lymph nodes. Conventional EBUS B-mode features, including size, shape, border distinction, echogenicity, central hilar structure with central blood vessel and coagulation necrosis were also evaluated. The ultrasonic features were compared with the pathological results from EBUS-TBNA. 133 lymph nodes in 60 patients were assessed. Elastography displayed the highest area under the curve (AUC) (type 3 versus type 1: AUC, 0.825; 95% confidence interval [CI], 0.707-0.910) with an impressive sensitivity (100%) and an acceptable specificity (65%). The combined model covering the four positive criteria (elastography, heterogeneity, size, and shape) showed that the odds ratio for malignance is 9.44 with a 95% CI of 3.99 to 22.32 ( p

IgG4-related disease is a relatively newly described entity with findings that historically have been confused with a variety of other diseases with markedly different treatments and prognoses, including Sjogren's syndrome and MALT lymphoma. We present a case of IgG4-related disease of the salivary glands and review the literature on sonographic findings of IgG4-related disease. By connecting sonographic features of IgG4 disease with common ancillary features of IgG4 disease in other sites (pancreas, hilar lymph nodes, biliary tree, thyroid, and retroperitoneum), radiologists can play a pivotal role in the early diagnosis and identification of IgG4-related disease. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:73-77, 2018.

Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a very useful diagnostic tool for the assessment of enlarged mediastinal and hilar lymph nodes. It is a safe procedure with a low risk of complications. Case Description We report a case of bronchial fistula and pneumomediastinum after EBUS-TBNA, which was performed shortly after a mediastinoscopy. Due to the extent of the bronchial lesion, a surgical closure of the bronchial fistula was necessary. The patient recovered completely. Conclusion The performance of EBUS-TBNA shortly after a mediastinoscopy should not be recommended to avoid possible procedure-related complications.

Hepatic lymphoma can be divided into its primary and secondary forms. To be classified as primary hepatic lymphoma, the disease should be limited to the liver and hilar lymph nodes, with no distant involvement (to the bone marrow or other sites). Primary hepatic lymphoma is quite rare, accounting for less than 1% of all cases of non-Hodgkin lymphoma, whereas secondary hepatic lymphoma affects nearly half of such cases. Familiarity with the imaging features of hepatic lymphoma is important for its early diagnosis and appropriate management. In this essay, we aim to review the roles of computed tomography and magnetic resonance imaging in identifying and monitoring hepatic lymphomas, using sample cases to describe and illustrate the wide spectrum of imaging findings in the primary and secondary forms of this disorder.O linfoma hepático pode ser dividido em primário e secundário. Para ser classificada como linfoma hepático primário, a doença deve estar limitada ao fígado e linfonodos hilares, sem acometimento de outros órgãos (incluindo a medula óssea). O linfoma hepático primário é muito raro, correspondendo a menos de 1% de todos os linfomas não Hodgkin. Já o envolvimento secundário do fígado ocorre em quase metade dos casos de linfoma não Hodgkin. O conhecimento dos aspectos de imagem do linfoma hepático é importante para o diagnóstico precoce e manejo adequado do paciente. Com base em imagens de casos, nosso objetivo é revisar o papel da imagem por tomografia computadorizada e ressonância magnética na identificação e segmento do linfoma hepático, ilustrando e descrevendo o amplo espectro de achados de imagem observados nas formas primária e secundária da doença.

Background: Bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides reliable access to cytologic specimens from the mediastinal and hilar lymph nodes. The aim of our study was to compare the accuracy and diagnostic value between EBUS-TBNA pathologic samples using needle suction versus no suction. Method: This clinical trial study carried out on 93 patients with mediastinal or hilar lymphadenopathy or lung cancer patients who underwent EBUS-TBNA procedures using suction and no suction at Masih Daneshvari hospital. Result: A total of 93 patients and 245 LNs were studied. The numbers of malignant and non-malignant nodules using suction were 40 and 80 respectively. There were no significant differences between Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration with and without performing suction regarding diagnostic yield (p=0.16) and tumor size (1.6±0.58 vs 1.74±0.76 p=0.477). Conclusion: There were no differences in adequacy and diagnosis between samples obtained using EBUS-TBNA and those obtained using EBUS-TBNCS. According to this study, there is no advantage in using suction or no suction to EBUS-guided biopsies.

INTRODUCTION Adhesions between the hilar lymph nodes (HLN) and pulmonary artery are challenging during thoracoscopic surgery. Preoperative assessment of appropriate surgical access and feasibility of thoracoscopic surgery for lobectomy are crucial. However, there have been only a few reports of this issue. We investigated the association between the radiological features and the presence of HLN adhesions and validated the possibility of preoperatively predicting their presence. The types of adhesions were classified, and surgical strategies for each category were summarized. METHODS We retrospectively identified 19 patients with adherent HLN (group A) from 1134 patients who had undergone thoracoscopic surgery for lobectomy between January 2008 and December 2017. One case in group A was matched to two cases with normal HLN (group N) by propensity score matching. We compared the radiological features of HLN between the two groups on preoperative CT scans. For group A, we assessed the recurrence of regional lymph nodes (RLNs) and classified the types of adhesions. RESULTS Adherent HLN were larger and had higher CT values than normal HLN. Calcification in the RLNs indicated the possibility of adhesions in HLN. Group A had adhesions due to inflammation but no postoperative recurrence of RLNs. CONCLUSIONS Adhesion of HLN to the pulmonary artery may be predicted to some extent by using preoperative CT scans. Our findings may contribute to improving the safety of thoracoscopic surgery.

Volumetric parameters based on 3-dimensional reconstruction have recently been introduced for cancer staging. We aimed to improve the ability to diagnose hilar lymph node metastasis in patients with non-small cell lung cancer.We evaluated 142 patients with non-small cell lung cancer who underwent right upper lobectomy and radical lymph node dissection. Metastatic involvement of right upper lobar lymph nodes was assessed using high-resolution computed tomography (HRCT) and 18F-2-floro-2-deoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT).On receiver operating characteristic (ROC) curve analysis, the area under the curves (AUC) for short axis, maximum of standardized uptake value (SUVModified TLG is a good parameter to diagnose metastatic right upper lobar lymph nodes. Micrometastasis in the lymph node is difficult to predict using the current diagnostic method. However, more careful evaluation is required in patients with symmetric FDG accumulation at hilar region because hilar lymph nodes respond to various causes such as benign pulmonary diseases.

The sarcoid-like reaction represents an autoinflammatory cause of mediastinal and hilar lymphadenopathy but may also involve other lymph node regions and organs. This rare phenomenon has mainly been reported in patients with Hodgkin’s lymphoma (HL) or solid tumors (particularly melanoma) undergoing immunotherapy and chemotherapy. Cases in non-Hodgkin’s lymphoma (NHL) are very uncommon. We present an uncommon case of a patient with primarily mediastinal diffuse large B-cell lymphoma (DLBCL) who showed a CT-based partial response in interim staging, whereas at end-of-treatment multiple newly enlarged and hypermetabolic mediastinal and bilateral hilar lymph nodes were detected by 18F-FDG PET/CT imaging. A subsequent histological workup determined a sarcoid-like reaction without any lymphomatous tissue. Therefore, sarcoid-like reactions should be considered as a potential pitfall in Deauville staging with 18F-FDG PET/CT imaging for patients with NHL.

Background and Objectives: Endobronchial ultrasound elastography is a new technique for describing the stiffness of tissue during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The aims of this study were to investigate the diagnostic value of Endobronchial ultrasound (EBUS) elastography for distinguishing the difference between benign and malignant lymph nodes among mediastinal and hilar lymph nodes. Materials and Methods: From June 2015 to August 2015, 47 patients confirmed of mediastinal and hilar lymph node enlargement through examination of Computed tomography (CT) were enrolled, and a total of 78 lymph nodes were evaluated by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). EBUS-guided elastography of lymph nodes was performed prior to EBUS-TBNA. A convex probe EBUS was used with a new EBUS processor to assess elastographic patterns that were classified based on color distribution as follows: Type 1, predominantly non-blue (green, yellow and red); Type 2, part blue, part non-blue (green, yellow and red); Type 3, predominantly blue. Pathological determination of malignant or benign lymph nodes was used as the gold standard for this study. The elastographic patterns were compared with the final pathologic results from EBUS-TBNA. Results: On pathological evaluation of the lymph nodes, 45 were benign and 33 were malignant. The lymph nodes that were classified as Type 1 on endobronchial ultrasound elastography were benign in 26/27 (96.3%) and malignant in 1/27 (3.7%); for Type 2 lymph nodes, 15/20 (75.0%) were benign and 5/20 (25.0%) were malignant; Type 3 lymph nodes were benign in 4/31 (12.9%) and malignant in 27/31 (87.1%). In classifying Type 1 as 'benign' and Type 3 as 'malignant,' the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates were 96.43%, 86.67%, 87.10%, 96.30%, 91.38%, respectively. Conclusion: EBUS elastography of mediastinal and hilar lymph nodes is a noninvasive technique that can be performed reliably and may be helpful in the prediction of benign and malignant lymph nodes among mediastinal and hilar lymph node during EBUS-TBNA.

The efficacy of low-dose computed tomography screening is likely to increase the number of early-stage lung cancers identified. The aging population, as well as increase in number of patients with multiple comorbidities, suggests that nonsurgical techniques such as stereotactic body radiotherapy will be vital in treating such malignancies. Convex probe endobronchial ultrasound facilitates the identification of mediastinal and hilar lymph nodes, in addition to central lung tumors. Using a simple modification of the transbronchial needle aspiration technique, we describe a method for placing fiducial markers into isolated central tumors that ensures appropriate localization for definitive radiotherapy.

Pneumonia is an infectious disease of the lung causing mortality. Mycoplasma pneumonia (MP) is an atypical bacterial pneumonia that damages several organs. Lung computed tomography (CT) has been utilized in its identification. The aim of the present study was to examine the value of computed tomography diagnosis for pediatric MP. The present study prospectively analyzed the clinical and imaging data of 1,280 cases of pediatric MP in the out- and inpatient departments from March, 2010 to March, 2014; analyzed the morphology and distribution of the pneumonic lesion in the lungs; and summarized the value of CT diagnosis for pediatric MP. In the included children, there were 688 cases of lesions in the unilateral lobe, 592 cases of lesions in the bilateral lobes, 1,101 cases of extensive patchy opacity, 496 cases of mottled opacity, 432 cases of increased lung marking, 256 cases of streak opacity, 192 cases of ground-glass opacity, 992 cases of thickened bronchial wall in the lesions, 128 cases of lymphadenopathy in the hilar lymph nodes and mediastinal lymph nodes, and the lung CT showed 32 cases of pulmonary cavity and 144 cases of pleural effusion. In conclusion, the CT signals of pediatric MP had several types with some children exhibiting complicated changes. The child's clinical manifestation and symptoms should thus be considered in the diagnosis to improve the diagnostic rate.

We report findings for a patient that underwent endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) for diagnostic purposes after an abnormal chest CT. The patient initially presented with cough and shortness of breath. Chest CT revealed a 6 cm soft tissue mass with mildly enlarged right hilar lymph nodes (LNs) and a small right sided pleural effusion. Based on these radiologic findings, the patient underwent an EBUS guided FNA of the mass. To our surprise, the mass was hypoechoic by EBUS and on aspiration, the syringe filled with yellow fluid. This finding in combination with a re-review of the CT scans with a special focus on the Hounsfield Units of the lesion confirmed the diagnosis of a mediastinal bronchogenic cyst. This case demonstrates the role of Hounsfield units in analyzing mediastinal masses and highlights the effectiveness of EBUS guided TBNA in diagnosis and treatment of bronchogenic cysts. Keywords: Bronchogenic cysts, Endobronchial ultrasound, Hounsfield units

359 Background: Splenectomy for dissecting splenic hilar nodes (#10) should be avoided for most gastric cancer considering high morbidity and no survival benefit, while that is often selected in scirrhous type of gastric cancer because this special type frequently invades the whole stomach and the #10 nodes. Splenectomy is necessary for dissecting #10, however, survival benefit of dissecting #10 is unclear. Methods: Patients who had scirrhous gastric cancer and underwent D2 total gastrectomy with splenectomy in National Cancer Center Hospital, Japan, between 2000 to 2011 were retrospectively analyzed. The therapeutic value index was calculated by multiplying the metastatic rate of each nodal station and the 5-year survival of patients who had metastasis to each node. Results: In total, 144 patients were eligible for the present study. The most frequent metastatic site was the nodes along the lessar curvature (#3, 57%), followed by the nodes along the right gastro-epiploic artery (#4d, 45%), the right nodes located at the cardia (#1, 34%), the nodes along the left gastro-epiploic artery (#4sb, 23%), the inferior nodes at the pyloric ring (#6, 22%), the nodes along the left gastric artery (#7, 21%), the nodes along the short gastric artery (#4sa, 18%), the nodes along the cardiac branched artery (#2, 15%), the nodes around the spleen (#10, 15%), the distal nodes along the splenic artery (#11d, 15%), the proximal nodes along the splenic artery (#11p, 13%), the nodes around the celiac artery (#9, 13%), and the nodes along the common hepatic artery (#8a, 10%). These lymph nodes had a metastatic rate of more than 10%. The node with the highest index was #3(18), followed by #4d(13.4), #1(9.59), #4sa(5.85), #4sb(5.75), #10(4.86), #7(4.16), #11d(4.16), #11p(3.87), #2(3.07), #8a(2.08), and #9(1.39). The index of #10 was exceeded that of #2, #7, #8a, and #9 which are the key nodes dissected in D2. Conclusions: The metastatic rate of splenic hilar nodes was relatively high, and the therapeutic index was the sixth highest in the fifteen regional lymph nodes included in D2 dissection. Splenectomy for dissecting splenic hilar nodes would be justified in scirrhous type of gastric cancer considering its survival benefit.

Background The optimal procedure for maximizing the diagnostic yield and minimizing the procedural complexity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is controversial. We conducted a prospective randomized controlled trial to determine the optimal procedure of EBUS-TBNA for mediastinal and hilar lymphadenopathy, with a particular focus on the roles of the inner-stylet and suction. Methods Consecutive patients with enlarged mediastinal and hilar lymph nodes (LNs), detected by computed tomography (CT) or positron emission tomography-CT (PET-CT), who underwent EBUS-TBNA were included. Each LN was sampled with three needle passes using suction–stylet, suction–no stylet, and stylet–no suction procedures. The samples were smeared onto glass slides for cytological evaluation. A single, blinded cytopathologist evaluated each set of slides. The primary outcomes were cytological specimen adequacy rate and diagnostic yield of malignant LNs. The secondary outcomes were tissue-core acquisition rate, procedural time, and the amount of bleeding. Results This study evaluated 97 patients with a total of 255 LNs. The final LN diagnosis was benign in 144, malignant in 104, and inadequate in 7 cases. There were no significant differences among the suction–stylet, suction–no stylet, and stylet–no suction groups in specimen adequacy rate (87.1, 88.2, 85.9%, respectively) or diagnostic yield of malignancy (32.2, 31.8, 31.0%, respectively). However, the use of suction was associated with an increase in tissue-core acquisition rate (P

Background: Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is widely utilized as a minimally invasive technique for sampling of mediastinal and/or hilar lymphadenopathy (MHL). Its value on small lymph nodes (LN) of Objectives: The aim of our study is to identify the value of EBUS-TBNA sampling of MHL of Methods: We retrospectively studied all patients who underwent EBUS-TBNA from February 2016 to August 2017. All LN samples were categorised into three groups according to the size and subsequently assessed for their histological diagnosis. Results: Out of 146 patients who underwent EBUS-TBNA, 62 patients had MHL

The paper presents an integrated methodology that combines experimental and modeling techniques and links exposure to airborne particulate matter (PM) with internal dose in the respiratory system and burden in adjacent tissues over a period of time. The methodology is used to estimate doses in the respiratory systems of elders that reside in 10 elderly care centers (ECCs) in the metropolitan area of Lisbon. Measurements of PM were performed in the ECCs and combined with a time-budget survey for the occupants. This information served as input to the first model that estimated particle doses in the different regions of the respiratory tract of the elderly, and then a second model was used to calculate particle build-up in the alveolar region, the interstitium and the hilar lymph nodes of the elders over a 5-year exposure period. It was found that in 5 years of continuous exposure to the average particle concentration measured over all ECCs, 258 mg of all particles are deposited on the surface of the alveoli of which 79.6% are cleared, 18.8% are retained in the alveolar region, 1.5% translocate to the hilar lymph nodes, and 0.1% are transferred to the interstitium.

Background The next-generation convex probe endobronchial ultrasound (CP-EBUS) was developed to improve the ease of operation and the acquisition of EBUS skills for new trainees. The aim of this study was to evaluate the changes in the prototype next-generation CP-EBUS compared with the current CP-EBUS. Methods The prototype next-generation CP-EBUS, with a decreased forward oblique view, more flexible angulation range, smaller ultrasound probe, and sharper needle angle, was compared with the current CP-EBUS. The operability, which was evaluated by using a 5-level Likert-type scale, and safety were evaluated in 2 live pigs, a cadaveric lung, and 10 ex vivo human lungs by 9 bronchoscopists. The time required to access the upper lobe bronchus and the time required to detect prespecified lymph node stations by 7 novice bronchoscopists with both CP-EBUS were compared with assess the operability difference for new trainees. Results In all evaluated models, operability (eg, maneuverability, endoscopic visibility, bronchial trees selectivity, insertability to the upper airway) was scored 5 (significantly improved). All trainee bronchoscopists were able to access the upper lobe bronchi and detect each lymph node except 4R significantly faster than with the current CP-EBUS without any airway damage. Conclusions The next-generation CP-EBUS has improved operability, which resulted in better access to each lobar bronchus and more prompt detection of mediastinal or hilar lymph nodes. These improvements may allow more precise lymph node staging and diagnosis, as well as improve EBUS procedural skill acquisition, once introduced to clinical practice.

This study aimed to semi-quantitatively evaluate the elastographic imaging color distribution of mediastinal and hilar lymph nodes (LNs), and explored its utility in helping define malignant and benign LNs for lung cancer patients. We prospectively collected patients who underwent preoperative mediastinal staging of suspected lung cancer by EBUS-TBNA. We analyzed the elastography color distribution of each LN and calculated the blue color proportion (BCP). The LN elastographic patterns were compared with the final EBUS-TBNA pathological results. A receiver operating characteristic (ROC) curve was constructed to evaluate the diagnostic value of BCP. We sampled and analyzed 79 LNs from 60 patients. The average BCP in malignant LNs was remarkably higher than that in benign LNs (57.1% versus 30.8%, P

Objective: To present chest radiographs, CT and pathological fndings of pulmonary sclerosing hemangioma with concurrent sarcoidosis. To review the literatures regarding lung cancer and associated sarcoidosis and/or sclerosing hemangioma.Materials and Methods: A 50 year-old female patient was screened for health at human dock at Preventive Medicine Research Center of our institution, and a rounded nodule, measuring about 15 mm in diameter, was found in the left lower lung feld medially. Non-enhanced CT showed a round nodule at the left cardiac border. The patient was sent to a clinic of our institution.Results: The patient was further studied by contrast enhanced CT (CECT), which showed marked increase of CT value to 91.8 HU from 50.1 HU on non-enhanced CT. It was difcult to di?erentiate a benign lesion from malignant lesion. CECT also showed enlarged hilar and mediastinal lymph nodes. Cytology at the time of bronchoscopy revealed Class 3 at the left B5b bronchus. Partial resection of the lingual was carried out by video-assisted thoracoscopic surgery. Biopsy of the left hilar nodes (#10, #11) at the same time revealed sarcoidosis.Conclusion: A rare case of pulmonary screlosing hemangioma and concurrent sarcoidosis was reported with imaging results and pathological proof.

A 52-year-old man presented with chest distress and low back pain for 1 month. CT examination displayed a thymic tumor with the metastases to bilateral lungs as well as mediastinal and bilateral hilar lymph nodes. To evaluate the involved extent of the disease, F-FDG PET/CT scan was carried out, which showed that in addition to the thymic mass, multiple foci of abnormally increased FDG activity in the bilateral lungs, neck and chest lymph nodes, and bones were observed. Finally, the biopsy of the mass confirmed the diagnosis of thymic small cell neuroendocrine carcinoma.

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BACKGROUND: Transbronchial needle aspiration (TBNA), serving as a remarkably invaluable and minimally invasive technique, has been widely used for the diagnosis and staging of mediastinal adenopathy and masses. To date, the International Association for the Study of Lung Cancer (IASLC) and Wang's nodal map are two well-documented intrathoracic lymph node guidelines for the TBNA procedure. METHOD: We characterized IASLC's and Wang's map, and interpreted the correlation of the two maps station by station. RESULTS: The pivotal role of IASLC map is to determine N descriptor in the tumor node metastasis (TNM) staging system of lung cancer, whilst Wang's map is employed to facilitate the localization of biopsy sites for bronchoscopists during TBNA performance. Furthermore, stations 1, 3 and 5 in Wang' map are equivalent to 4R station in IASLC' system, while stations 4 and 6 in Wang's account for IASLC station 4L as N2 stations. In addition, Wang's stations 2, 8 and 10 are correlated with station 7 in IASLC's. Wang's stations 7 and 9 are responsible for station 11R in IASLC's map. CONCLUSION: Given their unique benefits and limitations, and the practical links between the two maps, it appears reasonable to highlight the significance of their complementary utilization upon TBNA performance and lung cancer staging.

Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) facilitates diagnosis of hilar and mediastinal lymphadenopathy. The procedure usually requires two operators; one guiding the bronchoscope and other undertaking needling for biopsy. British Thoracic Society Quality Standards recommend a diagnostic yield of 88%. Increased training and experience has been shown to improve diagnostic yield over time.1 Services face a potential conflict between delivering a high quality service, as evidenced by high diagnostic yield, and training specialty registrars. Our EBUS-TBNA trainers have trained 35 trainees since 2011. We evaluated EBUS diagnostic yield at a tertiary centre with procedures carried out by trainer and trainee operators. Methods Retrospective analysis of two operator EBUS-TBNA procedures from March 2011 to December 2016 was carried out. Data was collected on gender, age, procedure date and clinicians involved in the procedure. Overall diagnostic yields were calculated for trainers compared to trainees for both manoeuvring the bronchoscope and needling. Diagnostic rates according to year of EBUS-TBNA for trainers vs trainees were also calculated. Mann-Whitney U test was used to check for differences in hit-rates for trainers vs trainees between the two components of the procedure, whilst Kruskal Wallis test was used to assess difference in diagnostic yield between 2011–2016. Results 1083 patients underwent EBUS-TBNA with mean age 61 years (SD +/-14), 464 (43%) were female. The overall diagnostic rate was 88%, with 479 (44%) malignant, 212 (20%) granulomatous, 262 (24%) benign and 130 (12%) non-diagnostic. Trainees manoeuvred the bronchoscope for 577 (53%) and needled for 461 (43%) patients. There were no differences in diagnostic yields between trainers compared to trainees for manoeuvring [88% vs 88% (p=0.81)] nor for needling [88% vs 88% (p=0.84). There were also no significant differences in diagnostic yield between years (figure1). Conclusion In our institution we can teach multiple trainees whilst maintaining high diagnostic yield in two operator EBUS-TBNA for both manoeuvring the bronchoscope and needling when one operator is fully trained. Reference Fuso, et al. Influence of the learning effect on the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Journal of Bronchology & Interventional Pulmonology 2017;24(3):193–199.