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and reduced costs&#44; deserve mention&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> We aimed to assess the feasibility&#44; diagnostic success&#44; and safety of US-NAB of isolated anterior mediastinal masses &#40;AMM&#41; in the hands of pulmonologists&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">We reviewed the US-NABs performed by pulmonologists for the diagnosis of isolated AMM during a 2-year period &#40;2020-2021&#41; at the Interventional Pulmonology Division of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS&#46; The Institutional Review Board approved the research &#40;ID 5037&#41;&#44; and patients signed a written informed consent&#46; Patients were eligible if they were 18 old and had indications for a tissue diagnosis of an isolated anterior mediastinal mass&#46; Exclusion criteria were&#58; i&#41; unwillingness to consent&#59; ii&#41; platelet count &#60;50&#46;000 per &#956;L&#59; and iii&#41; inability to stop anticoagulant or antiplatelet therapy before the procedure &#40;except acetylsalicylic acid 100 mg&#47;day&#41;&#46; Demographic&#44; clinical&#44; imaging and pathological data were retrieved for each case&#46; US-NABs were performed using a parasternal approach without any biopsy guide system &#40;&#8220;free hand technique&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> B-mode and color-doppler ultrasound study of the chest aimed at localizing the lesion and identifying a safe path for needle placement were always performed with both linear and convex probes before sampling&#46; A 16G or 18G cutting needle needles &#40;Biomol biopsy set&#44; Hospital Service SPA&#44; Rome&#44; Italy&#41; was used &#40;Supplemental videos 1 and 2&#41;&#46; After the procedure&#44; all patients underwent an ultrasound examination to rule out pneumothorax and were observed for 2 hours prior to discharge&#46; The primary endpoint was the diagnostic yield&#44; whereas the secondary endpoints were feasibility of lesion sampling&#44; and safety&#46; Clinical and pathologic results are presented as standard descriptive statistics&#46; Continuous variables are reported as mean &#177; standard deviation &#40;SD&#41;&#44; whereas categorical variables are given as percentages&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">During the study period&#44; 11 patients were evaluated and in 10 a US-NAB was attempted &#40;91&#37; feasibility&#41;&#59; in the remaining patient the US evaluation did not show a safe path to the mass due to the interposition of the mammary vessels&#46; <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a> shows the main characteristics of patients and lesions&#46; Patients were predominantly male &#40;6&#47;10&#41; and middle-aged &#40;mean &#177; SD&#61; 47&#46;7 &#177; 18&#41;&#46; The lesion size was large both in short &#40;median &#40;IQR&#41; mm&#8239;&#61;&#8239;61 &#40;46&#46;3-108&#46;8&#41;&#41; and in long axis &#40;median &#40;IQR&#41; mm&#8239;&#61;&#8239;108&#46;5 &#40;92-135&#46;3&#41;&#41;&#46; A definitive diagnosis was obtained in 8&#47;10 patients &#40;80&#37; diagnostic yield&#41; in which US-NAB was attempted&#44; lymphoma being the most common etiology by far &#40;6&#47;10&#44; 60&#37;&#41;&#46; Of the 2 patients with a non-diagnostic procedure&#44; one had a thymic carcinoma diagnosed with a surgical biopsy&#46; In the other patient&#44; US-NAB was used to diagnose an undifferentiated epithelial malignancy &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>G-I&#41;&#59; the patient then underwent an anterior mediastinotomy&#44; but even on the surgical specimen&#44; which contained a vast necrotic component&#44; a more specific diagnosis could not be obtained despite a very large immunohistochemistry panel&#46; No patient in the present cohort developed complications after the US-NAB&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0006" class="elsevierStylePara elsevierViewall">This study suggests that US-NAB of isolated AMMs can be performed safely and successfully by pulmonologists&#46; In a literature review&#44; we found only a handful of studies in which pulmonologists carried out US-NABs of AMMs&#44; and in none was the inclusion limited to patients with isolated AMMs&#46; In the landmark study&#44; Saito et al&#46; were able to obtain a definitive diagnosis in 69&#37; of the patients&#44; of whom 60&#37; had a benign AMM&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Koegelenberg et al&#46; achieved an excellent 93&#37; diagnostic yield in a study cohort in which 62&#37; of the patients had an anterior mediastinal metastasis from lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> A few more recent studies in which pulmonologists were likely to have been involved in the US-NAB procedure tend to confirm both feasibility and satisfactory success rate in the setting of AMMs of different etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">The diagnosis of primary tumors of the anterior mediastinum with US-NAB pose challenges both from a technical and a pathological standpoint&#46; From a technical perspective&#44; the acoustic window between sternum and adjacent ribs needed to safely sample the mass is often minimal compared with the overall lesion size&#44; and is partly occupied by the mammary vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41;&#46; From a pathological standpoint&#44; these tumors are histologically complex&#44; often contain a massive necrotic component &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>G and <a class="elsevierStyleCrossRef" href="#fig0001">1</a>L&#41; and are more reliably diagnosed and subtyped -especially lymphomas and thymomas- when large biopsy samples are available&#46; As a consequence&#44; large cutting biopsy needles need to be used to achieve a satisfactory diagnostic success&#46; A few of these lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>A and <a class="elsevierStyleCrossRef" href="#fig0001">1</a>D&#41; might have been theoretically reached with a convex EBUS procedure&#44; but the tissue cores obtained with EBUS-TBNA are often insufficient for the diagnosis of primary tumors of the anterior mediastinum&#46; As for lymphomas&#44; in particular&#44; only 24&#37; of subjects with <span class="elsevierStyleItalic">de novo</span> lymphoma were able to be appropriately subtyped using endosonographic specimens in one of the largest studies available in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> Taking into account the technical and pathological challenges&#44; we started our diagnostic invasive ultrasound-guided biopsy program for AMMs after an extensive experience with less complex US-NABs&#44; such as those of pulmonary masses and &#8220;superficial&#8221; metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> In the last decade&#44; different scientific societies have made recommendations about which topics to include in a structured thoracic ultrasound training curriculum&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> Several theoretical and practical training courses exist&#44; but they rarely involve ultrasound-guided interventions and present major challenges to education such as variable caseload&#44; limited availability of expert supervision and different learning paces among trainees&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> It is therefore unsurprising that studies have clearly demonstrated a lack of uniform&#44; competency-based training programs and assessment tools in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">In conclusion&#44; our pilot experience suggests that properly trained pulmonologists can safely and successfully diagnose isolated AMMs with US-NAB despite the technical challenges of the procedure and the pathological complexity of these lesions&#44; that are usually expression of primary tumors&#46; This would offer&#44; whenever possible and safe&#44; a less invasive and costly diagnostic alternative to procedures &#40;anterior mediastinoscopy and CT-guided biopsy&#41; currently used in this setting&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-08-22"
    "fechaAceptado" => "2022-10-13"
    "NotaPie" => array:1 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="notep0001"><span class="elsevierStyleBold">Funding&#58;</span> This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="para0009a" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="ecom0001"></elsevierMultimedia><elsevierMultimedia ident="ecom0002"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix"
            "titulo" => "Supplementary materials"
            "identificador" => "sec0002"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0001"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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        "detalles" => array:1 [
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            "rol" => "short"
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Computed tomography&#44; ultrasound image and corresponding histology of 4 cases of US-NAB of anterior mediastinal masses expression of diffuse large B-cell lymphoma &#40;panels A-C and D-F&#41;&#44; undifferentiated epithelial malignancy with massive necrotic component &#40;panels G-I&#41; and primary thymic neuroendocrine tumor &#40;panels L-N&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0001"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0002"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Lesion size short axis &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Lesion size long axis &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0007"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Needle size &#40;gauge&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0008"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Final diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">140&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Former&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Epithelial malignancy NOS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">350&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Pulmonary adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Letter to the Editor
Ultrasound-guided needle aspiration biopsy of isolated anterior mediastinal masses
M. Viscusoa, V. Livib, A. Cancellieric, D. Paiolib, D. Magninib, F. Leoncinib, L. Richeldia,d, R. Trisolinib,d,
Corresponding author
rocco.trisolini@policlinicogemelli.it

Corresponding author at: Interventional Pulmonology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Roma, Italy.
a Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
b Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
c Pathology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
d Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Hearth, Rome, Italy
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Computed tomography&#44; ultrasound image and corresponding histology of 4 cases of US-NAB of anterior mediastinal masses expression of diffuse large B-cell lymphoma &#40;panels A-C and D-F&#41;&#44; undifferentiated epithelial malignancy with massive necrotic component &#40;panels G-I&#41; and primary thymic neuroendocrine tumor &#40;panels L-N&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0003" class="elsevierStylePara elsevierViewall">Isolated masses of the anterior mediastinum are most commonly expression of primary tumors such as lymphomas&#44; thymomas&#44; germ cell neoplasms&#44; neurogenic tumors&#44; and thyroid lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> Due to the histological complexity of the above disorders&#44; they have been traditionally diagnosed with CT-guided biopsy performed by interventional radiologists or with surgical procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> However&#44; when feasible&#44; ultrasound-guided needle aspiration biopsy &#40;US-NAB&#41; offers several potential advantages among which real-time guidance&#44; availability of oblique needle paths&#44; possibility of carrying out the procedure at the bedside of critically ill patients who cannot tolerate the supine position&#44; and reduced costs&#44; deserve mention&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> We aimed to assess the feasibility&#44; diagnostic success&#44; and safety of US-NAB of isolated anterior mediastinal masses &#40;AMM&#41; in the hands of pulmonologists&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">We reviewed the US-NABs performed by pulmonologists for the diagnosis of isolated AMM during a 2-year period &#40;2020-2021&#41; at the Interventional Pulmonology Division of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS&#46; The Institutional Review Board approved the research &#40;ID 5037&#41;&#44; and patients signed a written informed consent&#46; Patients were eligible if they were 18 old and had indications for a tissue diagnosis of an isolated anterior mediastinal mass&#46; Exclusion criteria were&#58; i&#41; unwillingness to consent&#59; ii&#41; platelet count &#60;50&#46;000 per &#956;L&#59; and iii&#41; inability to stop anticoagulant or antiplatelet therapy before the procedure &#40;except acetylsalicylic acid 100 mg&#47;day&#41;&#46; Demographic&#44; clinical&#44; imaging and pathological data were retrieved for each case&#46; US-NABs were performed using a parasternal approach without any biopsy guide system &#40;&#8220;free hand technique&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> B-mode and color-doppler ultrasound study of the chest aimed at localizing the lesion and identifying a safe path for needle placement were always performed with both linear and convex probes before sampling&#46; A 16G or 18G cutting needle needles &#40;Biomol biopsy set&#44; Hospital Service SPA&#44; Rome&#44; Italy&#41; was used &#40;Supplemental videos 1 and 2&#41;&#46; After the procedure&#44; all patients underwent an ultrasound examination to rule out pneumothorax and were observed for 2 hours prior to discharge&#46; The primary endpoint was the diagnostic yield&#44; whereas the secondary endpoints were feasibility of lesion sampling&#44; and safety&#46; Clinical and pathologic results are presented as standard descriptive statistics&#46; Continuous variables are reported as mean &#177; standard deviation &#40;SD&#41;&#44; whereas categorical variables are given as percentages&#46;</p><p id="para0005" class="elsevierStylePara elsevierViewall">During the study period&#44; 11 patients were evaluated and in 10 a US-NAB was attempted &#40;91&#37; feasibility&#41;&#59; in the remaining patient the US evaluation did not show a safe path to the mass due to the interposition of the mammary vessels&#46; <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a> shows the main characteristics of patients and lesions&#46; Patients were predominantly male &#40;6&#47;10&#41; and middle-aged &#40;mean &#177; SD&#61; 47&#46;7 &#177; 18&#41;&#46; The lesion size was large both in short &#40;median &#40;IQR&#41; mm&#8239;&#61;&#8239;61 &#40;46&#46;3-108&#46;8&#41;&#41; and in long axis &#40;median &#40;IQR&#41; mm&#8239;&#61;&#8239;108&#46;5 &#40;92-135&#46;3&#41;&#41;&#46; A definitive diagnosis was obtained in 8&#47;10 patients &#40;80&#37; diagnostic yield&#41; in which US-NAB was attempted&#44; lymphoma being the most common etiology by far &#40;6&#47;10&#44; 60&#37;&#41;&#46; Of the 2 patients with a non-diagnostic procedure&#44; one had a thymic carcinoma diagnosed with a surgical biopsy&#46; In the other patient&#44; US-NAB was used to diagnose an undifferentiated epithelial malignancy &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>G-I&#41;&#59; the patient then underwent an anterior mediastinotomy&#44; but even on the surgical specimen&#44; which contained a vast necrotic component&#44; a more specific diagnosis could not be obtained despite a very large immunohistochemistry panel&#46; No patient in the present cohort developed complications after the US-NAB&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0006" class="elsevierStylePara elsevierViewall">This study suggests that US-NAB of isolated AMMs can be performed safely and successfully by pulmonologists&#46; In a literature review&#44; we found only a handful of studies in which pulmonologists carried out US-NABs of AMMs&#44; and in none was the inclusion limited to patients with isolated AMMs&#46; In the landmark study&#44; Saito et al&#46; were able to obtain a definitive diagnosis in 69&#37; of the patients&#44; of whom 60&#37; had a benign AMM&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Koegelenberg et al&#46; achieved an excellent 93&#37; diagnostic yield in a study cohort in which 62&#37; of the patients had an anterior mediastinal metastasis from lung cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> A few more recent studies in which pulmonologists were likely to have been involved in the US-NAB procedure tend to confirm both feasibility and satisfactory success rate in the setting of AMMs of different etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">The diagnosis of primary tumors of the anterior mediastinum with US-NAB pose challenges both from a technical and a pathological standpoint&#46; From a technical perspective&#44; the acoustic window between sternum and adjacent ribs needed to safely sample the mass is often minimal compared with the overall lesion size&#44; and is partly occupied by the mammary vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41;&#46; From a pathological standpoint&#44; these tumors are histologically complex&#44; often contain a massive necrotic component &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>G and <a class="elsevierStyleCrossRef" href="#fig0001">1</a>L&#41; and are more reliably diagnosed and subtyped -especially lymphomas and thymomas- when large biopsy samples are available&#46; As a consequence&#44; large cutting biopsy needles need to be used to achieve a satisfactory diagnostic success&#46; A few of these lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>A and <a class="elsevierStyleCrossRef" href="#fig0001">1</a>D&#41; might have been theoretically reached with a convex EBUS procedure&#44; but the tissue cores obtained with EBUS-TBNA are often insufficient for the diagnosis of primary tumors of the anterior mediastinum&#46; As for lymphomas&#44; in particular&#44; only 24&#37; of subjects with <span class="elsevierStyleItalic">de novo</span> lymphoma were able to be appropriately subtyped using endosonographic specimens in one of the largest studies available in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> Taking into account the technical and pathological challenges&#44; we started our diagnostic invasive ultrasound-guided biopsy program for AMMs after an extensive experience with less complex US-NABs&#44; such as those of pulmonary masses and &#8220;superficial&#8221; metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> In the last decade&#44; different scientific societies have made recommendations about which topics to include in a structured thoracic ultrasound training curriculum&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> Several theoretical and practical training courses exist&#44; but they rarely involve ultrasound-guided interventions and present major challenges to education such as variable caseload&#44; limited availability of expert supervision and different learning paces among trainees&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> It is therefore unsurprising that studies have clearly demonstrated a lack of uniform&#44; competency-based training programs and assessment tools in this setting&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">In conclusion&#44; our pilot experience suggests that properly trained pulmonologists can safely and successfully diagnose isolated AMMs with US-NAB despite the technical challenges of the procedure and the pathological complexity of these lesions&#44; that are usually expression of primary tumors&#46; This would offer&#44; whenever possible and safe&#44; a less invasive and costly diagnostic alternative to procedures &#40;anterior mediastinoscopy and CT-guided biopsy&#41; currently used in this setting&#46;</p></span>"
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-08-22"
    "fechaAceptado" => "2022-10-13"
    "NotaPie" => array:1 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="notep0001"><span class="elsevierStyleBold">Funding&#58;</span> This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="para0009a" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="ecom0001"></elsevierMultimedia><elsevierMultimedia ident="ecom0002"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix"
            "titulo" => "Supplementary materials"
            "identificador" => "sec0002"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0001"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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        "detalles" => array:1 [
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            "identificador" => "alt0001"
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            "rol" => "short"
          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Computed tomography&#44; ultrasound image and corresponding histology of 4 cases of US-NAB of anterior mediastinal masses expression of diffuse large B-cell lymphoma &#40;panels A-C and D-F&#41;&#44; undifferentiated epithelial malignancy with massive necrotic component &#40;panels G-I&#41; and primary thymic neuroendocrine tumor &#40;panels L-N&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0001"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0002"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0005"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Lesion size short axis &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0006"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Lesion size long axis &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0007"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Needle size &#40;gauge&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0008"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Final diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">140&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Former&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">121&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Epithelial malignancy NOS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Diffuse large B-cell lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Current&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">350&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Pulmonary adenocarcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Never&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Small lymphocytic lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#35;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Clear cell thymic carcinoma&nbsp;\t\t\t\t\t\t\n
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