直径≤3cm的周围型非小细胞肺癌纵隔淋巴结转移规律的初步研究

目的探讨直径≤3cm的周围型非小细胞肺癌(non-small cell lung cancer,NSCLC)纵隔淋巴结转移的情况,分析早期周围型NSCLC纵隔淋巴结转移的规律。方法 2000年1月1日～2008年12月31日治疗直径≤3cm的周围型NSCLC161例,男89例,女72例,年龄(63.4±10.7)岁,行肺叶切除或肺局限性切除加系统性纵隔淋巴结清扫术,分析其临床特征、病理特点及纵隔淋巴结转移规律。结果全组手术顺利,无死亡及严重并发症发生。肺叶切除153例,肺楔形切除7例,肺段切除1例。全组共清扫淋巴结2456枚,平均每例4.5±1.6组、13.1±7.3枚。术后病理:腺癌99例,鳞癌30例,肺泡细胞癌19例,其他类型肺癌13例。术后TNM分期:ⅠA期50例,ⅠB期62例,ⅡA期6例,ⅡB期10例,ⅢA期33例。N1组淋巴结转移率为23.6%(38/161),N2组转移率为20.5%(33/161),其中隆突下淋巴结转移率为8.1%(13/161),跳跃式纵隔转移率为6.8%(11/161),全组未发现下纵隔淋巴结转移。肺泡细胞癌及直径≤2cm的鳞癌、直径≤1cm的腺癌均无pN2转移。上肺癌发生pN2转移时上纵隔100%(19/19)受累,其中21.1%(4/19)同时伴有隆突下淋巴结转移;下肺癌则除主要转移至隆突下外(64.3%,9/14),还常直接单独转移至上纵隔(35.7%,5/14)。转移的纵隔淋巴结左肺癌主要分布在第5、6、7组,右肺癌主要分布在第3、4、7组。结论对于直径≤3cm的周围型NSCLC,肿瘤直径越大,其纵隔淋巴结转移率越高,肺泡细胞癌、直径≤2cm的鳞癌和≤1cm的腺癌其纵隔淋巴结转移率相对较低;上肺癌主要转移在上纵隔,下肺癌则隆突下及上纵隔均可转移;第5、6、7组淋巴结是左肺癌主要转移的位置,第3、4、7组是右肺癌主要转移的位置,术中应重点清扫。     

Peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes

A 61-year-old man was pointed out a small peripheral lung nodule and mediastinal lymph node swelling on the chest computed tomography (CT). At the operation, it was diagnosed squamous cell carcinoma and right upper lobectomy and nodal dissection were done. The tumor was 9 mm in size and diagnosed as well differentiated squamous cell carcinoma with metastasis to mediastinal lymph nodes. Postoperative radiotherapy was done (50 Gy). The patient is doing well without apparent recurrence 33 months after surgery. We reported a case of peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes.     

肺癌跳跃式纵隔淋巴结转移的临床病理探讨

目的　探索肺癌跳跃式纵隔淋巴结转移的病理特点 ,为合理施行淋巴结清除术提供可靠的理论依据。方法　 1992年 10月至 1998年 6月 ,为 398例肺癌病人施行了根治性肺切除、规范淋巴结清除术 ,对其中 4 7例 ( 2 9 4 % )跳跃式纵隔转移淋巴结病例进行病理学研究。结果　各型或各叶肺癌中 ,跳跃式转移淋巴结分布最密集的部位依次是第 7、4、3、5组淋巴结 ,分别占 2 9 8%、2 4 5 %、14 9%与10 6 % ;就鳞癌与腺癌而言 ,肿瘤长径在 1cm以内者均无跳跃式淋巴结转移 ,跳跃式淋巴结转移率随长径增加而增加 ;低分化腺癌淋巴结转移率明显高于高分化者 (P <0 0 1) ;发生跳跃式淋巴结转移的肿瘤平均长径鳞癌与腺癌分别为 15 3mm与 9 1mm。结论　对肺癌淋巴结的廓清 ,切勿仅凭手触摸或靠肉眼观察淋巴结大小而盲目判定其是否转移或清除。除T1 中肿瘤长径 <1cm的鳞癌外 ,淋巴结的规范清除应重视其跳跃性 ,原则上必须包括同侧胸腔的肺门及上、下纵隔各组淋巴结 ,尤其要重视跳跃式淋巴结转移分布较密集区域 ,即右侧的第 3、4、7组与左侧的第 4、5、7组淋巴结     

A case report of resected double primary lung cancers in the same one segment

A 68-year-old man with hypertension was admitted to the Shiga Kenritsu Seijinbyo Center for further examinations, because abnormal opacity in the right upper lung field was accidentally revealed by chest X-ray. Chest CT demonstrated two separate mass shadows, one 31 X 27 mm, the other 10 X 10 mm in size, both of which were located in the posterior segment of right lung. Specimens from transbronchial biopsy of the larger mass was histologically diagnosed as adenocarcinoma. He underwent right upper lobectomy with hilar and mediastinal lymph nodes resections. Postoperative patho-histological study showed the larger mass to be poorly differentiated adenocarcinoma, the smaller one, small cell carcinoma respectively, and no continuity between the two masses. Lymph nodes metastasis were negative. Any malignancy was not detected by brain CT, abdominal CT and any other gastro-intestinal examinations, and he was diagnosed to have double primary lung cancers in the same one segment. In this report, we discussed the diagnosis and treatment of double primary lung cancers, and reviewed the literatures.     

Lung cancer with both sarcoid reaction and metastasis in the mediastinal lymph nodes; report of a case

A 66-year-old man was admitted to our hospital for detailed investigation of an abnormal shadow on his chest X-ray. Chest radiography and computed tomography(CT) of the chest showed mediastinal lymphadenopathy and a tumor shadow in the left upper lobe. Biopsy of the mediastinal lymph nodes by mediastinoscopy showed that sarcoid nodules existed in all the biopsies nodes. Therefore, the lymphadenopathy was thought to be sarcoidosis or sarcoid reaction accompanied with lung cancer. Left upper lobectomy and dissection of hilar and mediastinal lymph nodes were performed. Although sarcoid nodules were seen in all the dissected lymph nodes, the cancer involved #5 and #14 lymph nodes. He died of brain metastasis 10 months after surgery.     

Adrenal metastasis of lung adenocarcinoma with unusual sites of lymph node metastasis and concomitant renal cell carcinoma: a case report

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.     

Prognosis of completely resected pN2 non-small cell lung carcinomas: What is the significant node that affects survival?

OBJECTIVE: We analyzed the effect of the station of mediastinal metastasis with regard to the location of the primary tumor on the prognosis in patients with non-small cell lung cancer. METHODS: Of 956 consecutive patients who underwent operation for primary lung carcinoma between 1986 and 1996, 760 patients (79.5%) were diagnosed as having non- small cell carcinoma and were subjected to complete removal of hilar and mediastinal lymph nodes together with the primary tumor. RESULTS: The status of lymph node involvement was N0 in 480 patients (63.2%), N1 in 139 patients (18.3%), and N2 in 141 patients (18.6%). The 5- and 10-year survival of patients with N2 disease were 26% and 17%, respectively. Neither cell type nor the extent of procedure was a significant survival determinant. Patients having involvement of subcarinal nodes from upper-lobe tumors had a significantly worse prognosis than those patients with metastases only to the upper mediastinal or aortic nodes (P =.003). Patients with nodal involvement of the upper mediastinum from lower-lobe tumors had a significantly worse survival than those patients with metastases limited to the lower mediastinum (P =.039). Furthermore, patients with involvement of the aortic nodes alone from left upper-lobe tumors had a significantly better survival than those patients with metastasis to the upper or lower mediastinum beyond the aortic region (P =.044). CONCLUSIONS: When mediastinal metastasis is limited to upper nodes from upper-lobe tumor, to lower nodes from lower-lobe tumor, or to aortic nodes from left upper-lobe tumor, acceptable survival could be expected after radical resection.     

A case of typical carcinoid accompanied with left atrium myxoma

A 78-year-old female was admitted to Shizuoka red cross hospital because of an abnormal shadow at the right upper lung field on chest X-ray film. A left atrium myxoma was detected at chest CT scan after admission. Though the lung tumor was well defined and hilar and mediastinal lymph nodes were not swollen at CT scan, the tumor was suspected a small cell carcinoma at the result of trans-bronchoscopic biopsy. Firstly we performed removal of the left atrium myxoma, and two months later, we performed thoracotomy and partial resection of the right upper lobe. The lung tumor was finally diagnosed as a typical carcinoid. We have followed the patient for about 32 months after the operation and there is no evidence of tumor recurrence.     

Consecutive left lower sleeve lobectomy and left S3 segmentectomy for a patient with node-negative double lung cancer

A 74-year-old-man visited our hospital because of a dry cough. A chest radiograph showed a nodular shadow measuring 2.0 cm diameter in the left S3 segment and a tumor shadow measuring 3.5 cm diameter in the left S6 segment; no mediastinal lymph node enlargement was observed. The bronchoscopic findings revealed direct invasion of the tumor into the spur of the left B6 branch, but no abnormal findings were found in the upper bronchus. An endobronchial biopsy revealed squamous cell carcinoma in a left B6 biopsy specimen and adenocarcinoma in the left S3 lung biopsy specimen. The patient's lung function was not good, and an arterial blood gas analysis was Po2 69.3mmHg and PCO2 48.5 mmHg. We performed left lower sleeve lobectomy and left S3 segmentectomy simultaneously. He was discharged uneventfully on the 14th day after the operation, and he has since been doing fine without lung caner recurrence for 3 years after surgery.     

A case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis

We report a rare surgically-treated case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis. A 65-year-old male was admitted to our hospital because of fever, anemia and epigastralgia. Chest X-ray examination and CT scanning revealed a round mass shadow (8 cm) in contact with the chest wall in the right upper lung field and metastasis to the mediastinal lymph nodes. Laboratory examination showed a WBC of 16,800/mm3, CRP of 11.6 mg/dl, and a serum G-CSF of 90 pg/ml. Upper gastrointestinal series and gastroscopy showed an ulcerating submucosal tumorous lesion in the pyloric antrum. The lung carcinoma was treated by right upper lobectomy with chest wall resection. After 1 month, gastrectomy was performed. After the operation, the WBC normalized, and the CRP and serum G-CSF levels decreased. Histopathological examination demonstrated a poorly differentiated large cell carcinoma in the lung and a metastatic lesion in the stomach. Immunohistochemical staining with anti-G-CSF mono-clonal antibody showed negative results in the lung but positive results in the stomach. He was discharged 3 weeks after gastrectomy but died of aggravation of the general condition associated with local recurrence in the chest wall 2 months after discharge.     

Long-term survival cases of lung cancer presented as solitary bone metastasis.

The prognosis of non-small cell lung carcinoma (NSCLC) with bone metastasis has been regarded as very poor. We report herein on two cases of NSCLC which presented as a solitary bone metastasis, were treated with surgical resection. Both these cases survived for over 5 years after their last operations. A 71-year-old-man was hospitalized with right crural pain. A diagnosis of squamous cell carcinoma of the left lower lobe with right fibula metastasis was made. A marginal resection of the right fibula was performed. After that, a left lower lobe lobectomy and systemic chemotherapy were carried out. He had a local recurrence in the right mediastinal lymph nodes eleven months after the operation. He received intraluminal and external radiation therapy and obtained complete remission. He has survived for 5 years without any other recurrence or metastasis. A 52-year-old-man was admitted to our hospital with left thigh pain. A diagnosis of adenocarcinoma of the right upper lobe with left thigh metastasis was made. A right upper lobe lobectomy and a resection of the left thigh tumor were performed. Three cycles of systemic chemotherapy were given after that. He has survived for 5 years since his last operation without any recurrence or metastasis.     

Combined large cell neuroendocrine carcinoma

We report a case of combined large cell neuroendocrine carcinoma. A 78-year-old man with vertigo was referred to our hospital where chest X-ray revealed a tumor shadow in the right lung. A transbronchial lung biopsy specimen verified a diagnosis of non-small cell lung carcinoma (cT1N0M0). Right lower lobectomy with mediastinal lymph node dissection (#7,8,9) was performed. A postoperative histological diagnosis was combined large cell neuroendocrine carcinoma of a component of squamous cell carcinoma [pT4 (pm) N2M0]. The patient received concurrent chemoradiotherapy due to upper mediastinal lymph node metastasis 4 months after surgery. The chemoradiotherapy well responded and the patient remains well 9 months after surgery.     

Thoracoscopic right upper mediastinal dissection for left lung cancer

OBJECTIVE: In left lung cancer, left and right mediastinum lymphatic spread occur equally frequently. We evaluated the safety and effectiveness of thoracoscopic right upper mediastinal dissection, implemented prior to left lung resection for left lung cancer. METHODS: Between January 1999 and May 2000, 17 patients with left lung cancer underwent thoracoscopic right upper mediastinal dissection prior to resection of the left lung and left mediastinal dissection for left lung cancer. These patients had either enlarged left hilar or bilateral mediastinal nodes, or either a tumor at least 3 cm in diameter or tumor extension to the hilum, mediastinum, or chest wall. Tumor and lymph nodes were examined with hematoxylin and eosin and immunohistochemical staining of cytokeratin for micrometastasis. RESULTS: In 3 patients (17.6%), metastasis occurred in right paratracheal nodes. The 30-day mortality was 0% and morbidity 35.3% (6/17). Postoperative complications occurred in 3 of 4 patients (75%) undergoing induction chemotherapy, but none were lethal. CONCLUSION: Thoracoscopic right upper mediastinal dissection is safe and feasible in treating advanced left lung cancer.     

A clinical study of small advanced lung cancer with metastasis to mediastinal lymph node

From January 1981 through December 1989, 15 patients with small advanced lung cancer were treated surgically at the Tenri Hospital. In these cases, the diameter of peripheral lung cancer did not exceed 3.0 cm (T1) and mediastinal lymph nodes were proved to be N2 postoperatively by lymph node dissection or sampling. The histological types were as follows: 8 adenocarcinoma, 4 large cell carcinoma, 1 squamous cell carcinoma, 1 small cell carcinoma, and 1 adenosquamous carcinoma. All but one patient were received postoperative chemotherapy and/or radiotherapy. The survival rate was 44.5% at 3 years, and median survival time was 36 months. The mediastinal lymph node metastasis with small peripheral lung cancer (T1N2) was ominous, and it should be said that complete mediastinal lymph node dissection and adjuvant therapy were indispensable to small advanced adenocarcinoma of lung.     

Successful lingular segmentectomy using bronchoplasty in a patient with early hilar second primary lung carcinoma

A 71-year-old man was admitted to our hospital with a small protrusive lesion at the lingular orifice of the left upper bronchus. He had undergone a right lower lobectomy and mediastinal dissection for lung carcinoma (large cell carcinoma, pT1N0M0) 14 months earlier. Early hilar squamous cell carcinoma was diagnosed by chest radiograph, CT and transbronchial biopsy. We performed a lingular segmentectomy with wedge resection of the left upper bronchus and N 1 lymph node dissection. The tumor was histopathologically diagnosed as early hilar second primary lung carcinoma. The patient's postoperative course was uncomplicated. At present, he is alive with good respiratory condition and without any evidence of recurrence. Segmentectomy is appropriate for a patient with contralateral second primary lung carcinoma as well as a patient with early hilar lung carcinoma. Bronchoplasty seems to increase the likelihood that such a patient will be a candidate for segmentectomy.     

The adequate diagnostic criterion of mediastinal lymph node size for detection of metastasis in primary lung cancer

The size of lymph node is one of the most important factor in evaluation of lymph node metastasis in lung cancer. The most appropriate size for detecting lung cancer lymph node metastasis was studied by 2403 dissected lymph nodes in 75 operated cases of lung cancer. From the result of Receiver Operating Characteristic (ROC) curve analysis, long-axis diameter of the lymph node showed higher accuracy of diagnosis of metastasis than short-axis diameter. Metastasis of squamous cell carcinoma was diagnosed more accurately than that of adenocarcinoma. The most adequate threshold for detection of metastasis in squamous cell carcinoma was 10 mm in long-axis diameter with sensitivity of 73.8% and specificity of 78%. On the other hand, that of adenocarcinoma was 7 mm in long-axis diameter with sensitivity of 65.7% and specificity of 55.9%. That threshold value of adenocarcinoma was approximate to the value of normal lymph node size in the mediastinum. It was suggested that the size for detection of lymph node metastasis was depended upon histological type, and detection of lymph node metastasis in adenocarcinoma was extremely difficult.     

Large cell neuroendocrine carcinoma of the lung; report of a case

Large cell neuroendocrine carcinoma (LCNEC) is a rare type of lung cancer and it has the least favorable prognosis. We describe our experience with a patient in whom LCNEC was diagnosed. A 65-year-old man who was pointed out abnormal shadow on a chest X-ray film in the health screening was admitted to the hospital. Chest X-ray film and computed tomography (CT) scan showed a 4 x 3 cm mass in the left-S2. Poorly differentiated adenocarcinoma of the left lung was suspected based on CT guided cytology. An upper lobectomy of the left lung and dessection of the mediastinal lymph nodes were performed. This tumor showed light microscopic and immunohistochemical evidences of neuroendocrine differentiation. Further it showed positive responses in neuronspecific enolase (NSE), synaptophysin, and chromogranin-A stainings. Pathological diagnosis was stage IB (pT2N0M0) LCNEC. There have been no findings of tumor recurrence 22 months after the operation.     

Primary lung adenocarcinoma with heterotopic bone formation

A 46-year-old man was referred to our hospital for the treatment of lung cancer. Computed tomography showed a well-defined tumor mass that was 50×45 mm in size and contained a trabecular pattern of calcification. Since he was diagnosed as having a primary lung adenocarcinoma (clinical stage IB), a left upper lobectomy with mediastinal lymph node dissection was performed. Histologically, the tumor was a poorly differentiated adenocarcinoma with rich fibrous stroma, in which there were island-shaped bone formation lesions. An immunohistochemical examination showed the expression of bone morphogenic protein-2 within tumor cells, which induce and stimulate bone formation. This finding may elucidate a possible mechanism of heterotopic bone formation.     

Video-assisted thoracic surgery for left lung cancer in a patient with a right aortic arch

We report a rare case of left lung cancer in a patient with a right aortic arch. A 65-year-old woman was diagnosed to have an adenocarcinoma in the left upper lobe (S3) in addition to a right aortic arch (type II), with the left subclavian artery originating from the descending aorta. Left upper lobectomy and lymph node dissection was performed by video-assisted thoracic surgery (VATS). For the mediastinal dissection, the upper mediastinal lymph nodes were easily resected after verifying the location of the arterial ligament and the recurrent laryngeal nerve (RLN). This is the first report of using VATS to remove a lung cancer from a patient with a right aortic arch.     

电视纵隔镜手术128例

目的探讨电视纵隔镜检查术（video-mediastinoscopy，VM）在肺癌术前分期、纵隔肿物诊断和恶性胸腔积液诊治中的价值。方法采用全麻单腔螺纹气管插管，48例行颈部纵隔镜术，33例行胸骨旁纵隔镜检查术，47例行经肋间纵隔镜术。结果125例经电视纵隔镜术后确诊：肺腺癌38例，肺转移性低分化鳞癌33例，结核9例，淋巴结炎症8例，肺小细胞癌7例，胸腺鳞状细胞癌6例，非霍奇金淋巴瘤5例，纵隔神经母细胞瘤4例，胸腺瘤4例，胸膜间皮瘤3例，霍奇金淋巴瘤2例，后纵隔神经鞘瘤2例，结节病1例，胸腺增生1例，类癌1例，中纵隔原始神经外胚叶肿瘤1例。1例电视纵隔镜检查纵隔淋巴结为反应性增生，行左下肺叶切除，病理为鳞癌。2例术前纤维支气管镜病理确诊左下肺鳞癌，电视纵隔镜检查右气管旁淋巴结转移。术中发生气胸1例、出血1例、喉返神经麻痹和切口感染各2例。结论电视纵隔镜术不但是肺癌术前病理分期、纵隔疾病的重要检查方法，而且也是诊治恶性胸腔积液的简便方法。