Cases reported "Mediastinal Neoplasms"

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1/12. EUS and fine-needle aspiration in the evaluation of mediastinal masses superior to the aortic arch.

    BACKGROUND: Mediastinal lesions require a tissue diagnosis. This cannot be obtained with CT-guided biopsy or bronchoscopy in many patients. Co-morbid diseases increase the risk of mediastinoscopy in some of these patients. EUS with fine-needle aspiration (FNA) is frequently used to obtain tissue from the mediastinum, but there have been no case series published of FNA of lesions superior to the aortic arch. methods: This is the report of a case series of 4 patients with mediastinal masses superior to the aortic arch. EUS with a linear array echoendoscope and FNA were performed to evaluate each lesion. OBSERVATIONS: All 4 patients underwent the procedure without complication, and cytologic material obtained in 3 was diagnostic. One patient had a nondiagnostic aspirate and underwent mediastinoscopy. CONCLUSIONS: EUS with FNA is a safe and effective method for tissue diagnosis of mediastinal lesions. Heretofore, mediastinoscopy or transtracheal biopsy was required for diagnosis in patients with lesions superior to the aortic arch. However, for such lesions EUS with FNA appears to be an excellent alternative for establishing a diagnosis.
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2/12. Effective therapy of a vascular tumor of infancy with vincristine.

    Vascular tumors are common in infancy, affecting as many as 10% of children. These lesions often follow a benign course, with an initial proliferative phase followed by spontaneous involution, and require no therapy. Others manifest explosive early growth and Kasabach-Merritt phenomenon, requiring therapeutic intervention. Occasionally, some bulky tumors threaten life or vision because of mass effect, also mandating intervention. steroids are the mainstay of therapy, but often are ineffective. Interferon alpha (2a and 2b) has been used as second-line therapy in cases of steroid failure. However, interferon therapy has been associated with a significant incidence of spastic diplegia. The authors present the case of a 3-month-old girl in whom respiratory distress secondary to tracheal compression developed. magnetic resonance imaging and magnetic resonance angiography showed a large cervicothoracic lesion encasing the great vessels and displacing the airway. She did not display associated Kasabach-Merritt phenomenon. The lesion proved refractory to standard steroid therapy, but responded dramatically to 4 cycles of vincristine (0.05 mg/kg). Although this agent has been used in children with life-threatening Kasabach-Merritt phenomenon, this is the first time it has been described in the setting of compromised vital function. vinca alkaloids recently have been shown to have potent antiangiogenic activities in experimental models. Given the low predicted incidence of side effects at this dose, vincristine used as an antiangiogenic agent may prove an attractive alternative therapy for patients with life-threatening vascular tumors of infancy.
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3/12. Mediastinal pancreatic pseudocyst in a child. A thoracoscopic approach.

    Mediastinal pancreatic pseudocyst is a rare occurrence in children and may be difficult to diagnose. Internal drainage via a cystenterostomy and a simple external drainage are two of the treatment options that are currently employed. We describe the case of an 11-year-old boy with a mediastinal pseudocyst who was treated via a thoracoscopic approach using an original pulmonary exclusion. The pseudocyst disappeared in 15 days and there has been no recurrence. No adjuvant treatment was necessary. Endoscopic retrograde cholangiopancreatography (ERCP) was useful in establishing the etiology (pancreas divisum). We believe that the thoracoscopic approach is a reproducible, simple, and safe procedure for the treatment of mediastinal pseudocysts. The technique may represent a valid alternative to cystogastrostomy.
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4/12. Re-mediastinoscopy.

    In a series of 1,188 mediastinoscopies, six re-mediastinoscopies (0.5%) were made. The indications for repeated mediastinal exploration can be made more lenient since the adhesions between the innominate artery and the trachea need not always be extensive; if they are, an alternative paratracheal route can be used. Caution should be used, keeping possible vascular complications in mind, but we believe that an earlier mediastinoscopy does not contraindicate a repeated procedure.
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5/12. Transclavicular access as an adjunct to standard cervical incision in the treatment of mediastinal goitre.

    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 cervicomediastinal 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.
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6/12. Lineage alteration in precursor B cell acute lymphoblastic leukemia following T cell lymphoblastic lymphoma.

    A 10-year-old girl was diagnosed with lymphoblastic lymphoma; staging evaluation revealed a large mediastinal mass and normal peripheral blood and bone marrow morphology. Tumor cell immunologic marker analysis and Southern blot gene rearrangement studies demonstrated a T-cell lineage. She achieved a complete remission following multi-agent chemotherapy; however, 19 months following initial diagnosis while on maintenance therapy, she presented with typical acute lymphoblastic leukemia (ALL). The bone marrow was replaced by lymphoblasts, though the mediastinum was normal and there was no peripheral lymphadenopathy. Repeat immunophenotypic and genotypic studies demonstrated a precursor B-cell ALL lineage without expression of the T-cell surface antigens present on the original neoplasm. Repeat genotypic analysis showed immunoglobulin heavy and light chain gene rearrangements without the T-cell receptor gamma and beta gene rearrangements noted in the original lymphoblastic lymphoma. The complete alteration of lineage in these lymphoblastic processes suggests the de novo occurrence of a second neoplasm or, alternatively, an ALL relapse from a lineage-uncommitted neoplastic lymphoid progenitor cell.
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7/12. Fine needle aspiration biopsy in the diagnosis of mediastinal lesions.

    In the presence of a mediastinal mass, fine needle aspiration biopsy is an alternative to other time-consuming and expensive diagnostic procedures. We have performed a total of 25 fine needle aspiration biopsies of mediastinal lesions in 18 patients. Although our material is too limited to reach definite conclusions as to risks, we have found the technique enables a high percentage of positive diagnoses and is well tolerated by the patient.
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8/12. Evidence for neoplastic cell differentiation in mediastinal T lymphoblastic lymphoma.

    Immunostaining of frozen sections from a mediastinal T lymphoblastic lymphoma (T-LL) revealed the existence of two neoplastic cell populations characterized by different degrees of maturation. Several large nodules of 3A1 /T11 /T9 T6-/T4-/T8-/T3- lymphoid cells, resembling normal early thymocytes, were surrounded by 3A1 /T11 /T9 /T6 /T4 /T8 /T3- cells resembling normal cortical thymocytes. The junctional area between early and cortical lymphocytes was occupied by numerous Leu-M3 /PAM-1 /DR reticular macrophages which were also characterized by J5 reactivity. Cytokeratin /keratin epithelial cells were absent. Immunostaining of paraffin sections and of cytocentrifuge smears obtained from tumour cell suspensions revealed that a consistent percentage (8%) of neoplastic lymphoblasts were S-100 . Our findings are consistent with a cortical T-LL presenting areas of dedifferentiated cells or, alternatively, with an early T-LL whose cells were able to differentiate into cortical thymocytes, perhaps through the interaction with a specialized subset of J5 macrophages.
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9/12. The usefulness of percutaneous fine-needle aspiration biopsy in infants and children.

    During the past 2 years percutaneous fine-needle aspiration biopsy has been employed to help establish or confirm diagnosis in 32 infants and children. A 22-gauge needle is used to aspirate the site of suspected disease. For lesions inside the chest or abdomen, the needle is guided with the help of fluoroscopy, ultrasound, or computed tomography (CT) scan. Nineteen of the 32 patients had malignant disease, including lymphoma, neuroblastoma, rhabdomyosarcoma, Ewing's sarcoma, osteosarcoma, and leukemia. In all patients with solid tumors, tissue obtained at operation confirmed the accuracy of the diagnosis. In seven children with suspiciously enlarged lymph nodes, an open biopsy was avoided when the needle aspirate was clearly benign. In four children, the early appearance of metastatic or recurrent malignancy was confirmed without the need for open biopsy. In this small series, there were no false-negative or false-positive needle aspirates, and no complications directly related to the procedure. The skill and experience of the cytopathologist is essential to the success of this technique. Percutaneous fine-needle aspiration biopsy is a safe and reliable alternative method of establishing a diagnosis in infants and children with suspected malignant disease.
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10/12. Intrapleural analgesia in a child with a mediastinal tumour.

    A case is presented of an eight-year-old child with a mediastinal tumour, who had developed acute renal failure following the institution of steroid therapy. Intrapleural analgesia was successfully used for the insertion of a peritoneal dialysis catheter so that the considerable risks of general anaesthesia were avoided. Subsequent dialysis allowed chemotherapy to commence and, as a result of the shrinkage in tumour size, general anaesthesia was administered safely two days later. The purpose of this report is to highlight the use of intrapleural analgesia in children as an alternative to general anaesthesia, when the latter is contraindicated. The mechanism of action of intrapleural analgesia and the risks of anaesthesia in the presence of a mediastinal tumour are discussed.
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