An adult case of cervico-mediastinal lymph nodes tuberculosis followed by the development of pulmonary lesions during the treatment with antituberculous drugs

A 27-year-old man was admitted to our hospital due to a painful mass in the right neck and fever. Cervical and superior mediastinal computed tomography showed an enlargement of right supraclavicular lymph node and multiple swollen mediastinal lymph nodes, including low-density areas and contrast medium-enhanced septa and margins. Smears of the pus obtained from right supraclavicular lymph node showed acidfast bacilli identified as Mycobacterium tuberculosis by PCR method. He was treated with antituberculous drugs with INH, RFP, EB, and PZA. PZA was given for initial two months. Six months later, productive cough developed and chest X-ray films showed infiltrative shadow in the right upper lung field. One month after the onset of cough, bronchoscopy revealed a polypoid lesion with a white coating in the right main bronchus. Microscopic examination of the specimen obtained by transbrochial biopsy revealed many epithelioid cell granulomas, consistent with tuberculosis. From these findings, pulmonary lesion was suggested to be due to invasion of the mediastinal lymph node into the bronchus. After one year of antituberculous chemotherapy, the swelling of the cervical-mediastinal lymph nodes was reduced and the abnormal chest X-ray shadows disappeared.     

超声支气管镜引导下的经支气管针吸活检术的临床应用分析

目的研究超声支气管镜引导下的经支气管针吸活检术(EBUS-TBNA)在肺恶性肿瘤及纵隔肿物中的诊断价值及安全性。方法分析我科2013年10月至2015年10月经胸部CT发现肺门、纵隔淋巴结肿大或气管支气管旁肿物的94例患者行EBUS-TBNA检查结果。结果 94例患者中确诊肺恶性肿瘤80例;共穿刺150组淋巴结,每组平均穿刺2.4针,对肺恶性肿瘤的诊断敏感性为93.02%,特异性为100%,准确性为93.62%;4例患者临床诊断结节病;4例患者临床诊断淋巴结炎。结论 EBUS-TBNA在纵隔、肺门淋巴结和气管支气管旁肿物的诊断和肺恶性肿瘤的分期上有较高的敏感性、特异性、准确性和安全性,是经济有效的诊断方法。     

Gastrointestinal stromal tumor of the stomach with axillary lymph node metastasis: A case report

Gastrointestinal stromal tumors (GISTs) are the most common type of gastrointestinal mesenchymal tumors, although metastasis to the perigastric lymph nodes is relatively rare, compared with liver or peritoneal metastasis. In this report, we describe a case of stomach GIST with a solitary simultaneous metastasis in the left axillary lymph node. A 68-year-old man was diagnosed with a large upper-stomach GIST, and computed tomography and positron emission tomography revealed masses in the left axilla and right mediastinum. We did not detect evidence of metastases to the liver, or other sites including the perigastric lymph nodes, although findings from the surgically resected axillary lymph nodes were compatible with GIST metastasis. Treatment using imatinib markedly reduced the gastric and mediastinal lesions, and this response persisted for 3 years. The patient subsequently experienced rapid growth of the gastric lesion without mediastinal or axilla recurrence, which required palliative surgery. Despite continuing medical treatment(sunitinib and regorafenib), the patient died of liver metastases 23 mo after the surgery. Based on our findings, it appears that the axillary lymph nodes can be a potential metastatic site for GIST metastasis.     

Posterior mediastinal lymph node dissection using the pneumomediastinum method for esophageal cancer

Although posterior mediastinal lymph node metastases are often observed in patients with esophageal cancer, their complete resection via a right thoracic approach is difficult and carries a risk of complications. We have developed a novel procedure for en-bloc dissection of the posterior mediastinal lymph nodes using the pneumomediastinum method. The patient was a 48-year-old female with middle thoracic esophageal cancer. A computed tomography scan showed a posterior mediastinal lymph node 1?cm in diameter. After division of the gastrosplenic ligament by hand-assisted laparoscopic surgery, the esophageal hiatus was opened, and carbon dioxide was introduced into the mediastinum. The anterior and left sides of the distal esophagus were separated, and a swollen posterior mediastinal lymph node was detected. Subsequently, the adventitia of the thoracic aorta was exposed, and the posterior side of the lymph node was separated. While lifting these nodes like a membrane, we cut them along the border of the left mediastinal pleura. Histopathological examination revealed a single squamous cell carcinoma metastasis in the resected lymph node. A good surgical view was obtained in our surgical procedure, and en-bloc dissection of the posterior mediastinal lymph nodes was safely performed.     

A case of diffuse endobronchial infiltration in a patient with non-Hodgkin's lymphoma]

A 38-year-old man with diffuse endobronchial infiltration with non-Hodgkin's lymphoma (NHL) is reported. He was admitted to our hospital on November 1990 because of lymph node swelling. Physical examination on admission revealed left axillary, bilateral cervical and inguinal lymph node swelling. Chest and abdominal CT scan showed para-aorta lymph node swelling, mild splenomegaly and heterogeneous density of the liver, although hilar and mediastinal lymphadenopathy were not found. Microscopic examination of the biopsy specimen obtained from the right inguinal lymph node and liver revealed NHL (B cell lymphoma, diffuse, mixed type). After two courses of chemotherapy, a chest roentgenogram showed bilateral hilar lymphadenopathy and reticular shadows. CT scan demonstrated a thickening of the left main bronchus. Bronchoscopic examination revealed a small submucosal nodule in the left main bronchus on February 1991, from which the biopsy specimen revealed NHL infiltration similar to that of the lymph node. At follow-up bronchoscopic examination, in spite of chemotherapy, scattered NHL infiltration was found in the submucosal space of the left vocal cord, carina and the bifurcation between left upper and lower bronchi. In patients with NHL, endobronchial involvement is rare. In this case, diffuse endobronchial infiltration was not thought to be direct invasion from the lymph node but hematogenous or lymphatic spread to the bronchi.     

Three cases of small intrapulmonary lymph nodes coincidental with primary lung cancer]

We report three cases of intrapulmonary lymph nodes coincidental with primary lung cancers. In the first case, a 56-year-old man had a small subpleural nodule in the right lower lobe associated with adenocarcinoma of the right upper lobe. The small nodule was 10 mm in diameter and was difficult to differentiate radiologically from intrapulmonary metastasis. Wedge resection of this small nodule was performed. Histologic examination of the nodule revealed an intrapulmonary lymph node with anthracotic pigmentation. A right upper lobectomy for adenocarcinoma was performed, and was completely curative. The second patient, a 77-year-old woman, had adenocarcinoma in the right lower lobe diagnosed by transbronchial biopsy. Computed tomography (CT) revealed a small nodule 5 mm in diameter in the right upper lobe. Histologic examination of the small wedge-resected nodule revealed a lymph node. Lower lobectomy was performed with completely curative results. In the third case, a 63-year-old man was admitted for investigation of a mass shadow in the right upper lobe. CT showed a small nodular shadow in the right middle lobe, confirmed histologically to be lymphoid tissue, in addition to the original mass, which was diagnosed by transbronchial biopsy as squamous cell carcinoma. Upper lobectomy was performed and proved to be curative. Small intrapulmonary lymph nodes are very difficult to diagnose by methods other than surgical resection. When a small intrapulmonary nodule is detected in a patient with primary lung cancer, the presence of an intrapulmonary lymph node must be considered. If radiological characters compatible with an intrapulmonary lymph node are found and there is no other metastasis indicating poor prognosis, it should be considered as a possible indication for surgical resection.     

Endoscopic ultrasound examination for mediastinal lymph node metastases of lung cancer

Among patients with primary lung cancer who were admitted to the National Cancer Center Hospital from July 1987 to April 1988 for surgical treatments, 132 underwent preoperative transesophageal endoscopic ultrasound examination (EUS) on mediastinal lymph nodes. Of the 132 patients, 101 were pathologically evaluated and studied in this article. A GF-UM2 radial scanner with 7.5-MHz (Olympus Co Ltd) was used for image examination. The lymph nodes were diagnosed as positive for metastasis when they had thickened images, clear contours, and low echoing images of fusion or lobulation. The results obtained from 509 sites were as follows: sensitivity, 53.6 percent; specificity, 97.5 percent; positive predictive accuracy, 77.1 percent; negative predictive accuracy, 93.1 percent; and overall accuracy, 91.6 percent. The sensitivity rate was 80.6 percent excluding the result of the right superior mediastinal lymph nodes that were difficult to examine for anatomic reasons. Although EUS was considered to be an excellent method in diagnosing lymph node metastases, it had a blind angle in the field. More accurate diagnoses of mediastinal lymph node metastases could be achieved by using EUS and computed tomography (CT) together.     

Biphasic synovial sarcoma with a striking morphological divergence from the main mass to lymph node metastasis: A case report

Rationale:Synovial sarcoma accounts for 5% to 10% of all soft tissue sarcomas and involves almost any anatomic site, particularly the deep soft tissue of the extremities of young adults. The incidence rate of lymph node metastases in synovial sarcoma is 3% to 7%, but the detailed morphological features of the metastatic tumors in the lymph node have not been documented.Patient concerns:A 64-year-old Korean man presented with a huge mass in the left lower thorax and multiple hypermetabolic lymph nodes along the mediastinal, supraclavicular, internal mammary, and retrocrural regions.Diagnoses:The patient was diagnosed with primary pleuropulmonary biphasic synovial sarcoma with lymph node metastases, where the main mass mostly comprised spindle cells (>95%) and the metastatic lymph nodes comprised only epithelial cells.Interventions:Left lower lobe lobectomy with the resection of the chest wall (including left ribs 8-10) and diaphragm and mediastinal lymph node dissection were performed.Outcomes:In the 2-month follow-up period, there have been no complications so far, and the attending physician is currently planning for the adjuvant chemotherapy.Lessons:The main mass and the metastatic lesion can be clearly different morphologically. In tumors with biphasic differentiation, such as synovial sarcoma, cells that constitute only a small fraction of the main mass may appear as the dominant cells in metastatic lesions.     

Micrometastases in the cervical lymph nodes in esophageal squamous cell carcinoma

Few studies have investigated the presence of lymph node micrometastases (MM) in the cervical region of patients with esophageal squamous cell cancer. The present study examines the presence of cervical MM and attempts to determine a way to predict the occurrence and site of such micrometastases. A total of 2203 cervical lymph nodes and 118 mediastinal recurrent nerve nodes obtained from 86 patients with esophageal carcinoma were examined immunohistochemically using cytokeratins. Cervical lymph nodes and mediastinal recurrent nerve nodes metastases were detected histologically in 33 and 41 of the 86 patients respectively. Cervical lymph node and mediastinal recurrent nerve node MM were immunohistochemically detected in 16 (18.6%) and 6 (7.0%) patients respectively. Of these 16 patients with cervical MM, seven were found to have lymph node metastases in different cervical regions, whereas cervical MM only were detected in nine patients. Among the former group of patients, five were diagnosed by ultrasound examination as having cervical lymph node metastases. Mediastinal recurrent nerve node metastases and MM correlated with the presence of cervical MM in all but one patient. Cervical lymph node metastasis, including micrometastasis, can be predicted by preoperative ultrasonography and the routine histologic examination of mediastinal recurrent nerve nodes.     

Port site and distant metastases of gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography

We report port site and distant metastases of unsuspected gallbladder cancer after laparoscopic cholecystectomy diagnosed by positron emission tomography （PET） in two patients. Patient 1, a 72-yearold woman was diagnosed as cholelithiasis and cholecystitis and received laparoscopic cholecystectomy. Unsuspected gallbladder cancer was discovered with histological result of well-differentiated squamous cell carcinoma of the gallbladder infiltrating the entire wall. A PET scan using F-18-fluorodeoxyglucose （FDG- PET） before radical resection revealed residual tumor in the gallbladder fossa and recurrence at port site and metastases in bilateral hilar lymph nodes. Patient 2, a 69-year-old woman underwent laparoscopic cholecystectomy more than one year ago with pathologically confirmed unsuspected adenosquamous carcinoma of stage pTlb. At 7-mo follow-up after surgery, the patient presented with nodules in the periumbilical incision. Excisional biopsy of the nodule revealed adenosquamous carcinoma. The patient was examined by FDG-PET, demonstrating increased FDG uptake in the right lobe of the liver and mediastinal lymph nodes consistent with metastatic disease. This report is followed by a discussion about the utility of FDG-PET in the gallbladder cancer.     

Endobronchial ultrasonography for mediastinal and hilar lymph node metastases of lung cancer

STUDY OBJECTIVES: Conventional radiologic procedures are frequently unreliable in the diagnosis of mediastinal and hilar lymph node metastases of lung cancer. In order to improve diagnostic accuracy, we performed endobronchial ultrasonography (EBUS) during bronchofiberscopic examinations of patients with lung cancer. METHODS AND PATIENTS: To evaluate mediastinal and hilar lymph node metastases, EBUS was performed prospectively using a radial scanning probe of 20 MHz through a bronchofiberscope. RESULTS: We observed hilar lymph nodes (10R, 11R superior, 11R inferior, 12R, 10L, 11L, 12L) in 20 of 37 patients who underwent EBUS, and we could clearly identify whether direct invasion of the pulmonary artery by a lymph node had occurred. Of the 27 patients who showed no hilar lymph nodes on chest CT scan, lymph node swellings < 10 mm or > or = 10 mm in diameter were identified by EBUS in 9 patients and 2 patients, respectively. Interestingly, EBUS also revealed that the pulmonary artery was directly invaded by an interlobar lymph node < 10 mm in diameter in one patient. In most patients, lymph node 7 was easily identified and was clearly differentiated from the surrounding esophagus, vessels, and mediastinal fat tissue by EBUS. However, fused lymph nodes or lymph nodes with low central density when visualized by chest CT scan were occasionally observed as independent lymph nodes by EBUS. When compared with the pathologic diagnosis of lymph node metastasis in 16 patients who underwent surgery, the most specific and sensitive method for identifying lymph node metastases were EBUS alone (92%) and EBUS in combination with CT scan (100%), respectively. The overall accuracy of EBUS was 94% for the diagnosis of direct invasion of the pulmonary arteries by a hilar lymph node. CONCLUSIONS: EBUS in combination with conventional radiologic tools may contribute to improved staging, especially in surgical cases with hilar lymph node metastases.     

Frequency of mediastinal lymph node metastases in patients undergoing EUS evaluation of pancreaticobiliary masses

BACKGROUND: Mediastinal lymph node metastases have rarely been reported in patients with pancreatic cancer. Our aim was to determine the frequency of mediastinal lymph node metastases in patients with pancreaticobiliary masses by using EUS-guided fine needle aspiration. METHODS: Sixty-six consecutive patients with pancreatobiliary masses were evaluated on EUS for the presence of mediastinal lymph node metastases. All masses were staged by commonly used EUS criteria by using sector scanning echoendoscopes. Mediastinal lymph nodes with EUS features that suggested malignancy were aspirated. RESULTS: Of the 66 patients (mean age 65.6 years; 38 men), 4 had biliary masses, 5 had lesions of the major duodenal papilla, and 57 had pancreatic masses. Eleven patients (10 pancreatic masses, 1 biliary mass) had enlarged mediastinal lymph node (12-30 mm) on EUS; in 2 patients these had a benign appearance and were not aspirated. Nine patients underwent EUS-guided fine needle aspiration: in 1 the cytology was inconclusive (patient subsequently had a negative Whipple resection); in 4 the mediastinal lymph node cytology was benign; the remaining 4 patients had adenocarcinoma cells in the aspirate from mediastinal lymph node. These 4 pancreatic tumors were staged by EUS as T2N1M1 (1), as T4N0M1 (2, one later found to also have a lung mass), and T4N1M1 (1). CONCLUSION: Enlarged mediastinal lymph nodes were found on EUS in 16.6% (95% CI [7.7%, 25.6%]) of patients with pancreatobiliary masses and in 17.5% (95% CI [7.6%, 27.4%]) of patients with pancreatic masses. The frequency of mediastinal lymph node metastases in pancreatobiliary masses was 6.1% (95% CI [0.34%, 11.9%]) and in pancreatic masses 7.0% (95% CI [0.4%, 13.6%]). Routine EUS evaluation of the mediastinum in patients with pancreatic masses is warranted.     

Mediastinal and hilar lymph node of cancer unknown origin: 3 case reports]

We encountered three rare cases of cancer of unknown origin affecting the mediastinal and hilar lymph nodes. Patient 1 was a 63 year-old man. Chest X-ray and CT films revealed an enlarged right hilar lymph node. A right mediastinal and hilar lymphadenectomy was performed. The histological diagnosis was metastatic squamous cell carcinoma (SCC). SCC of the right upper lobe appeared 34 months after the operation, requiring a right pneumonectomy. Patient 1 was alive 43 months after his first operation. Patient 2 was a 73 year-old man in whom left mediastinal and hilar lymph node swelling had been detected. A mediastinoscopy and lymph node biopsy were performed. The histological findings resulted in a diagnosis of metastatic small cell carcinoma. Chemotherapy was initiated, and the patient was alive 5 months after the biopsy procedure, Patient 3 was a 57 year-old man in whom right mediastinal and hilar lymph node swelling had been disclosed by chest CT scans. We performed a medianosternotomy and mediastinal and right hilar lymphadenectomy. Histologically, the diagnosis was metastatic adenocarcinoma. After the operation, radiation therapy was performed on the patient's mediastinum. Patient 3 was alive 5 months after the initial operation. The patients were given diagnoses of T0N1 or T0N2 lung cancer.     

Metastatic squamous cell carcinoma of hilar lymph node with unknown primary site]

An abnormal shadow was observed on chest X-ray films of a 63-year-old man presenting with cough and sputum. Chest computed tomographic scans disclosed enlargement of the right hilar lymph nodes, but no obvious primary lesion was found in the lung field. Bronchoscopic examination revealed a slightly widened second carina, but no malignant cells were detected by transbronchial aspiration cytology. At surgery, a tumor was found between the truncus superior and the truncus intermedius. The pathologic diagnosis was a metastatic lymph node of poorly differentiated squamous cell carcinoma. Because the tumor severely adhered to the bronchus and pulmonary arteries, we performed a right pneumonectomy with mediastinal node dissection. Pre- and postoperative examinations did not detect the primary lesion, and no recurrence had been observed 76 months after surgery. This was thought to be a very rare case of T0 N1 M0 lung cancer. In general, the prognosis is poor for patients with metastatic carcinoma of unknown primary site. However, patients with T 0 lung cancer, as in this case, might enjoy a better prognosis if complete resection and dissection of metastatic lymph nodes are performed.     

Adenoendocrine cell carcinoma of the gallbladder producing a high level of alpha-fetoprotein

We present the case of a 78-year-old Japanese woman with adenoendocrine cell carcinoma of the gallbladder accompanied by a high serum alpha-fetoprotein level. The patient visited our hospital with a complaint of a large mass in the right hypochondrium. Ultrasonography and computed tomography revealed multiple large hepatic tumors, swelling of lymph nodes in the hepatic hilum and para-aortic regions, and a slightly irregular gallbladder wall. The serum alpha-fetoprotein level was 157,428?ng/mL. We initially suspected scirrhous hepatocellular carcinoma, sarcomatous hepatocellular carcinoma, biliary tract cancer, or pancreatic cancer. However, the hepatic tumor biopsy was histologically diagnosed as undifferentiated adenocarcinoma. Immunohistochemical analysis demonstrated that the tumor was positive for cytokeratin 19, focally positive for cytokeratin 7, but negative for hepatocyte paraffin 1 and cytokeratin 20, suggestive of biliary tract carcinoma. Although the patient received a course of hepatic arterial infusion chemotherapy with cisplatin, she died 2?months after admission. Histopathological examination at autopsy revealed that the hepatic tumor was adenoendocrine cell carcinoma of the gallbladder, which was positive for cytokeratin 19, focally positive for cytokeratin 7, chromogranin A, synaptophysin, and weakly positive for alpha-fetoprotein. Labeling index of Ki-67 was 28?%. Interestingly, this was the first case report of adenoendocrine cell carcinoma of the gallbladder that produced a high level of alpha-fetoprotein, which hampered correct diagnosis before autopsy.     

Comparative efficacy of positron emission tomography with fluorodeoxyglucose in evaluation of small (<1 cm), intermediate (1 to 3 cm), and large (>3 cm) lymph node lesions

PURPOSE: Our objective was to determine if positron emission tomography (PET) with fluorodeoxyglucose (FDG; PET-FDG) imaging is equally efficacious in detection of metastases in small and large mediastinal lymph nodes as compared to CT scanning. MATERIALS AND METHODS: PET-FDG imaging, CT scanning, and histology results of sampled mediastinal lymph nodes were compared in 54 patients of total 118 patients studied. Efficacy of PET and CT was determined and compared in small (< 1 cm), intermediate (1 to 3 cm), and large (> 3 cm) mediastinal lesions. RESULTS: PET was accurate in 94% of patients in characterizing "N" disease as compared to 61% with CT. Overall, sensitivity, specificity, and accuracy of PET for staging mediastinal lymph nodes (n = 168 in 54 patients) was 96, 93, and 94%, as compared to 68, 65, and 66% with CT. Positive and negative predictive value of PET in detecting mediastinal adenopathy was 86% and 98%, as compared to 47% and 82% with CT, respectively. PET was also highly reliable and accurate for detecting lymph nodes < 1 cm, 1 to 3 cm, and > 3 cm in size with superior efficacy than CT. Sensitivity, specificity, and accuracy of PET for detecting malignancy in lymph node lesions < 1 cm in size was 97, 82, and 95%, respectively. CONCLUSION: PET-FDG imaging is equally reliable and accurate for detecting disease in small and large lymph node lesions in patients with suspected or proven lung cancer with better efficacy than CT.     

Analysis of lobar lymph node metastases around the bronchi of primary and nonprimary lobes in lung cancer: risk of remnant tumor at the root of the nonprimary lobes.

STUDY OBJECTIVE: The details of lobar lymph node metastases at the root of nonprimary lobes (NPLs) in patients with lung cancer are still unclear. DESIGN: A prospective study from February 1989 to November 2000. Lobar lymph nodes in primary lobes (PLs) and NPLs were evaluated regardless of the location of the primary tumor. PATIENTS: Two hundred forty-eight patients who underwent surgery and had no involvement of the adjacent lobe by primary tumor were enrolled in this study. MEASUREMENTS AND RESULTS: Lobar lymph node metastases were observed in 53 patients (21.4%), with frequencies not different among the primary sites. Thirty-seven patients had lobar lymph node metastases limited to the PL, and 16 patients had metastases in the NPLs. The frequencies of lobar lymph node metastases in NPLs were not affected by histologic type or T classification, but they were dependent on laterality and proximal lymph node metastases. On the right side, lobar lymph node metastases in NPLs were observed in 9.0% of all 155 patients, in 45.2% of 31 patients with lobar lymph node metastases, and in 34.3% of 35 patients with mediastinal lymph node metastases. They were significantly higher in the patients with interlobar/hilar lymph node metastases (12 of 28 patients) or with mediastinal metastases (12 of 35 patients) than in those without metastases on the right (p < 0.0001, respectively). CONCLUSIONS: Lobar lymph node metastases in NPLs were frequent on the right side and became more frequent according to the prevalence of the proximal lymph node metastases, rather than the clinicopathologic properties of the primary tumor itself.     

A case of prostatic adenocarcinoma clinically presenting as supraclavicular and mediastinal lymphadenopathy]

We report a 70-year-old man with prostatic carcinoma presenting as supraclaviculer and mediastinal lymphadenopathy. He had no urinary tract symptoms, and computed tomography and FDG-PET showed no abnormality in the prostate or pelvic lymph nodes. Metastatic prostatic adenocarcinoma was finally diagnosed from the results of immunohistochemical staining for PSA of a biopsy specimen of the mediastinal lymph node, and he was treated by hormonal therapy. There are fears that some other similar cases might be treated with chemotherapy as lung cancer without immunohistochemical staining. Prostatic carcinoma should always be considered in the differential diagnosis of elderly men with supraclaviculer or mediastinal lymph node metastases, since appropriate treatment will lead to a prolonged survival.     

Signet ring cell carcinoma of the stomach--a case of diagnostic dilemma

Inguinal lymphonodal metastases of an adenocarcinoma were diagnosed in a 40-year-old patient by ultrasound guided puncture. The leading symptom was elephantiasis preferentially of the right lower extremity. In addition, atypical mycobacteriosis was detected later on. The causal gastric cancer had not been identified during two years until the fourth gastroscopy assisted by endoscopic ultrasonography revealed the lesion. No regional lymph node metastases were found while distant metastases in terms of inguinal lymph nodes were already present.