Squamous cell carcinoma of the thymus. An analysis of eight cases

Eight cases of squamous cell carcinoma of the anterior mediastinum, most likely derived from the thymus, are presented. Seven were male and one female ranging in age from 39 to 65 years; the average was 55.5 years. There were no cases associated with any paraneoplastic syndromes. They possessed common morphological characteristics. Grossly, the tumors resembled malignant thymoma. Invasion of the lung and metastases to regional lymph nodes were frequent. Often observed microscopically were foci of sharply defined keratinization resembling Hassall's corpuscles, no radial arrangement of tumor cells at the periphery of nests, and broad, fibrotic, or hyalinized stroma. Admixture of a few lymphoid cells and some features transitional to thymoma were also observed in some parts of tumors. However, undoubtedly carcinomatous areas were present in some or large parts of all the tumors, where individual cells possessed a vesicular nucleus and a prominent round nucleolus. These features were distinct from those of bronchogenic squamous cell carcinoma and other thymic tumors, although they appeared to be related to thymoma. Treatment of choice is radical surgery and postoperative radiotherapy, because of relatively high radiosensitivity. Prognosis of patients was relatively good. From analyses of cases it is concluded that squamous cell carcinoma of the thymus should be separated from ordinary thymoma of the epithelial type, and that squamous cell carcinoma involving both the thymus and lungs should be carefully examined for the primary site of growth.     

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。     

A case of thymic carcinoma

A 41-year-old male visited with chief complaints of chest pain and cough. The patient was operated on under a diagnosis of invasive thymoma. The tumor was located in the left lobe of the thymus and measured 6 X 9 cm. Since the tumor invaded the left innominate vein, pericardium, and the upper lobe of the left lung, we resected it with adjacent structures. Postoperative pathological examination indicated squamous cell carcinoma of the thymus. Because the tumor metastasized also to the mediastinal lymph nodes, the patient was treated postoperatively by radiation therapy and adjuvant chemotherapy mainly with CDDP. The patient is well presently 2 years after operation without signs of recurrence.     

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.     

Thymic metastasis of laryngeal cancer

A 70-year-old man visited the Department of Head and Neck Surgery with a chief complaint of dysphagia. A tumor was observed in the epiglottis and vocal cord, and was diagnosed as squamous cell carcinoma by biopsy. Computed tomography (CT) showed a tumor mainly in the vocal cord. CT scans revealed a tumor centered on the vocal cord, with bilateral cervical lymph node metastases and a well-circumscribed 20-mm tumor in the anterior mediastinum. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed uptake in the primary lesion, left cervical lymph nodes, and anterior mediastinal tumor, which suggested a lymph node metastasis but did not exclude thymoma. The patient underwent video-assisted thoracic surgery (VATS) resection of the anterior mediastinal tumor with total laryngectomy, total thyroidectomy, and bilateral cervical lymph node dissection. The final pathological diagnosis was laryngeal cancer (glottic cancer, pT4aN2M1, pStage IVC) with thymic metastasis (presenting as an anterior mediastinal tumor). Thymic metastasis of laryngeal cancer is rare, and appears difficult to preoperatively differentiate from other mediastinal tumors.     

Two cases of thymic carcinoma effectively treated by preoperative chemotherapy

A 67-year-old man was admitted with left pleural effusion on chest X-ray film. Chest CT scans showed an anterior mediastinal tumor, left pleural dissemination and pleural effusion. Percutaneous needle biopsy yielded a diagnosis of epitherial carcinoma. The patient underwent 3 courses of systemic chemotherapy (CDDP + ADM + VCR + CPA). At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. A 49-year-old woman was admitted our hospital with supraclavicular lymph nodes swelling. Chest CT scans showed an large mediastinal tumor. Percutaneous needle biopsy yielded a diagnosis of squamous cell carcinoma of thymus. The patient underwent 3 courses of systemic chemotherapy. At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. These cases indicate the usefulness of preoperative chemotherapy for advanced thymic carcinoma to reduce tumor size and to control local invasion, distant metastasis before operation.     

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.     

Radiation-induced squamous cell carcinoma of the chest wall seven years after adjuvant radiotherapy following the surgery of breast cancer: a case report

A 54-year-old woman, who had underwent an adjuvant radiotherapy following the modified radical mastectomy in the left primary breast cancer in June 1988. She underwent second surgery and adjuvant radiotherapy (electronic radiotherapy) for recurrent breast cancer in the major pectoral muscle and received chemoimmunotherapy in May 1989. In May 1996 she complained of two ulcers of the chest wall. The ulcer biopsy findings was squamous cell carcinoma, and we diagnosed she fell the radiation-induced skin cancer. She underwent chest wall resection and reconstruction with vertical rectal abdominal musculocutaneous flap (VRAM). However two months later her chest wall resection, she again got the recurrent squamous cell carcinoma in the right axillary lymph nodes and left pleura. The third radiotherapy and the chemotherapy with pepleomycin were uneffective on her recurrent cancer. And she died in March 1997.     

Squamous inclusion cyst in a sentinel axillary lymph node associated with breast malignancy

Axillary intranodal squamous inclusion cyst is a rare benign histological finding that may be confused with malignant diseases. A 52 years old female presented with a painless lump in the left breast for one and a half month. The mammogram was reported as being suspicious of carcinoma. Left breast lumpectomy and histology revealed infiltrating ductal carcinoma. After a month, modified radical mastectomy was done. Frozen section of axillary sentinel lymph nodes revealed benign histology with squamous inclusion cyst in one of the nodes. All lymph nodes recovered from mastectomy specimen were also benign.     

Concomitant surgery of a left atrial myxoma and a pulmonary carcinoma

We report the first successful outcome of a patient undergoing concomitant surgery for a left atrial myxoma and a squamous cell carcinoma of the lung. Preoperative evaluations revealed lung cancer and a left atrial tumor of undetermined origin. An operation to excise both cardiac and pulmonary tumors was performed. The cardiac tumor was first resected with the aid of cardiopulmonary bypass. The histopathological diagnosis was myxoma. Resection of the left upper pulmonary lobe and mediastinal lymph nodes followed. The postoperative course was uneventful, and the patient is well without evidence of recurrence 7 years after the operation.     

A case of pure red cell aplasia appearing after thymectomy]

We present a case of pure red cell aplasia appearing four months after thymectomy for an invasive thymoma. A 61-year-old female whose chest X-ray demonstrated an anterior mediastinal mass was admitted to our hospital. Preoperative examination revealed neither anemia nor myasthenia gravis. During surgery, as it was found that the thymoma had invaded the upper left lobe of the lung and the left diaphragmatic nerve, these tissues were partially resected along with the thymus and the parathymic adipose tissue. Histologically the epithelial cells of the thymoma had round-oval nuclei with predominant lymphatic infiltration. There were some clusters of epithelial cells in the adjacent involuted thymic tissues. After postoperative radiotherapy of 40 Gy, the patient was discharged. About four months after the operation, she was readmitted because of anemia. Bone marrow aspiration demonstrated few erythroblasts but normal findings of granulopoiesis. Chest CT and radioisotopic examination revealed neither metastases nor recurrence of thymoma. Her anemia showed marked improvement by steroid therapy. After she was discharged, her condition has been uneventful in spite of tapering the steroid dose for seven months.     

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。     

An assessment of the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination as a dissecting measure in the surgical treatment of lung cancer]

The availability of the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination as a dissecting measure was analyzed according to prognosis retrospectively because mediastinal lymph nodes dissection is made with ease and certainty after the examination. The separation by mediastinoscopic examination did not have an impact on the mediastinal lymph nodes dissection for carcinoma of the left lung and superior mediastinal lymph nodes metastases (# 1-4), but an influence on the dissection for carcinoma of the right lung and middle and lower mediastinal lymph nodes metastases (# 5-9). This result showed the existence of occult metastases and the good effects caused by the separation of mediastinal lymph nodes. In the histological type, the effects were present in squamous cell carcinoma and p-N0 adenocarcinoma, but it was concluded that the prognosis in adenocarcinoma was associated with other factors rather than lymph node metastasis. Therefore, it can be seen that the separation of mediastinal lymph nodes by preoperative mediastinoscopic examination is available as a dissecting measure.     

Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases

IntroductionThe incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position.Case presentationCase 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case 2: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery.ConclusionBilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.     

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

Primary thymic adenocarcinoma coexisting with type AB thymoma: a rare case with long-term survival

Thymic carcinoma is a rare tumor. The most common histological subtype is squamous cell carcinoma, and only a few cases of thymic adenocarcinoma have been reported. A case of papillary adenocarcinoma of thymic origin that coexisted with type AB thymoma as a separate nodule is presented herein. The patient was found to have an abnormal mediastinal shadow on chest X-ray. A computed tomography scan revealed a round, 6.5-cm-diameter mass in the right anterior mediastinum. The preoperative diagnosis was thymoma, and thymothymectomy was performed. On pathological examination, two tumors, which were diagnosed as papillary adenocarcinoma and type AB thymoma, respectively, were present in the thymus without any connection with each other. The patient has been alive without any signs of recurrence for 11 years after surgery. We diagnosed the adenocarcinoma in this case was a primary thymic carcinoma.     

Lymphogenous and hematogenous metastasis of thymic epithelial tumors

BACKGROUND: A TNM classification has been established for various tumors. However, the TNM classification of thymic epithelial tumor has not been established yet. METHODS: We received replies to a questionnaire on thymic epithelial tumors from 115 institutes. We compiled a database of 1,320 patients with thymic epithelial tumor (1,093 thymomas, 186 thymic carcinomas, and 41 thymic carcinoids) who were treated between 1990 and 1994. We used a tentative TNM classification of thymoma presented by Yamakawa and associates in 1991. The regional lymph nodes of the thymus were classified into three groups: anterior mediastinal lymph nodes (N1), intrathoracic lymph nodes (N2), and extrathoracic lymph nodes (N3). RESULTS: The rate of lymphogenous metastasis in thymoma, thymic carcinoma, and thymic carcinoid was 1.8%, 27%, and 28%, respectively. Most tumors with lymph node metastasis metastasized to N1 (thymoma, 90%; thymic carcinoma, 69%; thymic carcinoid, 91%). The 5-year survival rates of N0, N1, and N2 thymoma were 96%, 62%, and 20%, respectively. The 5-year survival rates of N0, N1(,) N2, and N3 thymic carcinoma were 56%, 42%, 29%, and 19%, respectively. The 5-year survival rates of M0 and M1 thymoma were 95% and 57%. The 5-year survival rates of M0 and M1 thymic carcinoma were 51% and 35%. Multivariate analysis demonstrated that survival of patients with thymoma was dependent on the clinical stage of Masaoka and complete resection. In thymic carcinoma, survival was dependent on lymph node metastasis and complete resection. CONCLUSIONS: The N factor was one of the predictors of survival in thymoma and thymic carcinoma. However, M factor showed less influence on survival than T or N factors.     

Sudden death from metastatic esophageal cancer to the ventricular septum

A 67-year-old man was admitted to our hospital due to esophageal cancer. Cancer existed at the lower esophagus and subtotal esophagectomy and lymphadenectomy was performed. The postoperative course was uneventful. Pathological findings revealed moderately differentiated squamous cell carcinoma that metastasized to the abdominal lymph nodes which include the paraaortic lymph nodes. He complained of anorexia three months after the operation and was found to have multiple liver and mediastinal lymph node metastases. He was admitted for chemotherapy. Before starting chemotherapy, he suddenly died without any sign of hemorrhage or respiratory disorder. Autopsy showed metastatic lesions to the heart and mediastinal lymph nodes, liver, thoracic vertebrae, kidney, adrenal gland and heart. Metastatic nodules in the heart were on the ventricular septum where the conducting system exists. No direct invasion from the pericardium was observed. Blockade of the conducting system of the heart was considered to have caused the severe arrhythmia and sudden cardiac arrest.     

Esophagectomy via left thoracotomy for esophageal cancer with situs inversus totalis: Report of a case

We report a case of successful esophagectomy via a left thoracotomy for esophageal cancer in a 57-year-old Japanese man with situs inversus totalis. An upper gastrointestinal endoscopy, performed to investigate the cause of dysphagia, revealed a 7-cm irregular shaped mass occupying more than half of the circumference of the middle-third of the esophagus. Computed tomography (CT) showed enlarged mediastinal lymph nodes and situs inversus totalis. Histological examination of a biopsy specimen revealed squamous cell carcinoma of the esophagus. Although esophagectomy is usually performed through a right thoracotomy because of the left position of the aortic arch, we performed successful subtotal esophagectomy with radical lymph node dissection through a left thoracotomy. During surgery, we modifi ed the standard surgical technique in a mirrorimage fashion to complete the esophagectomy safely. The patient had an uneventful postoperative course.     

Sudden death from metastatic esophageal cancer to the ventricular septum.

A 67-year-old man was admitted to our hospital due to esophageal cancer. Cancer existed at the lower esophagus and subtotal esophagectomy and lymphadenectomy was performed. The postoperative course was uneventful. Pathological findings revealed moderately differentiated squamous cell carcinoma that metastasized to the abdominal lymph nodes which include the paraaortic lymph nodes. He complained of anorexia three months after the operation and was found to have multiple liver and mediastinal lymph node metastases. He was admitted for chemotherapy. Before starting chemotherapy, he suddenly died without any sign of hemorrhage or respiratory disorder. Autopsy showed metastatic lesions to the heart and mediastinal lymph nodes, liver, thoracic vertebrae, kidney, adrenal gland and heart. Metastatic nodules in the heart were on the ventricular septum where the conducting system exists. No direct invasion from the pericardium was observed. Blockade of the conducting system of the heart was considered to have caused the severe arrhythmia and sudden cardiac arrest.