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.     

Two cases of multiple primary cancer involving the lung with old pulmonary tuberculosis]

We reported 2 relatively rare cases of multiple primary cancer including lung cancer accompanied by old pulmonary tuberculosis. Patient 1 was a 62-year-old man admitted to our hospital for further evaluation of an infiltrative shadow on chest X-ray films, and a cervical tumor noted 10 years earlier and thought to be thyroid cancer. A Transbronchial lung biopsy (TBLB) specimen disclosed poorly differentiated squamous cell carcinoma. A right upper lobectomy and thyroidectomy were performed. Histopathologic findings showed a neoplastic lesion adjacent to caseous necrosis with formation of granuloma consistent with tuberculosis. Also, the cervical tumor was considered to be a metastatic lymph node from thyroid papillary carcinoma. Patient 2 was a 73-year-old man with a 14-year history of treatment for transitional cell carcinoma of urinary bladder, who had been admitted to our hospital for further evaluation because of a nodular shadow observed on chest X-ray films. TBLB specimens disclosed adenocarcinoma. A right upper lobectomy was performed. Histopathologic findings revealed a neoplastic tumorlet in the same lobe. No detectable increases in serum TNF-alpha, IL-1 beta or IFN-gamma were observed in either patient. Phytohemagglutinin- and concanavalin-A-stimulated lymphocyte proliferation decreased in Patient 1. These findings suggested that the immunocompromised status of patients with cancer in addition to old pulmonary tuberculosis may contribute to the development of lung cancer.     

Primary neuroendocrine carcinoma of the hypopharynx: a case report

Primary neuroendocrine carcinoma of the hypopharynx is extremely rare. A 59‐year‐old man complaining of swollen right cervical lymph node was admitted to our hospital. Although computed tomography, upper endoscopy, and positron emission tomography scan were performed, the primary lesion was unknown. Bilateral neck lymph node dissection was performed and diagnosed as metastasis of neuroendocrine carcinoma. Sixteen months after the first operation, computed tomography scan revealed multiple liver metastases. There was no another metastatic lesion, and hepatectomy with negative margin was performed. Three months after the second operation, a small tumor of the hypopharynx was detected by upper endoscopy, and biopsy revealed neuroendocrine carcinoma. Concurrent chemotherapy (cisplatin + docetaxel) and radiotherapy (60 Gy) were carried out. This therapy was highly effective, and primary lesion disappeared. After the chemoradiotherapy, lung metastasis and bone metastasis emerged and treated by radiotherapy and chemotherapy (cisplatin + irinotecan). These therapies were also effective, but multiple liver metastases appeared. The patient died 39 months after the first surgery. Although neuroendocrine carcinoma is a high‐grade malignancy which metastasizes easily, combined treatment strategy may be useful for these patients. We have here reported, with bibliographic consideration, a case in which multimodal treatment was employed for primary hypopharyngeal neuroendocrine carcinoma with distant metastases.     

Pancreatic metastasis from lung cancer: report of an autopsy case]

A 69 year-old man with abnormal lung shadows in the right lung field was admitted to our hospital. A chest computed tomography (CT) scan showed a lung tumor with hilar and mediastinal lymph node swelling. A CT scan of the abdomen demonstrated a solitary pancreatic head tumor with a diameter of 3 cm. Pathological examination of a transbronchial biopsy specimen revealed squamous cell carcinoma (SCC) of the lung. Since obstructive jaundice had progressed rapidly, the patient received endoscopic nasobiliary drainage (ENBD) and stent-drainage therapy prior to chemotherapy using gemcitabine. However, he died 4 months later of respiratory failure and systemic candidiasis associated with progression of the cancer. An autopsy was performed, and microscopic and immunohistochemical examination revealed that the pancreatic tumor was a metastasis from lung cancer. To our knowledge, obstructive jaundice due to pancreatic metastasis from lung SCC, especially that preceding the advent of a clinical manifestation of primary lung cancer, has rarely been reported.     

Orbital metastasis as primary manifestation of thyroid carcinoma.

A 59-year-old woman with unknown primary tumor developed progressive painless left upper eyelid swelling and exophthalmos. Computed tomography (CT) showed a well-circumscribed left orbital mass producing bone lysis. Immunohistologic staining of the incisional biopsy specimen was positive for thyroglobulin, suggesting an orbital metastasis from thyroid carcinoma. At this time, thyroglobulin was high (1400 ng/dL). Total thyroidectomy with lymph node dissection disclosed a follicular carcinoma with microscopic foci of papillary variant follicular carcinoma. Two months after radioiodine treatment, the CT showed a regression of the orbital tumor mass with concomitant decrease in thyroglobulin (428 ng/dL). Although orbital metastases of thyroid carcinoma are uncommon, thyroid carcinoma has to be considered as a potential primary tumor in a patient with an orbital metastasis.     

A case of subacute necrotizing lymphadenitis with localized interstitial pneumonia

A 16-year-old male was admitted with a history of cervical lymph node swelling, high fever, cough and hemosputum. On admission, bilateral cervical lymph nodes swelling and fine crackles in the right lower lung field were noted. A chest X-ray film showed an infiltrative shadow in the right lower lung field and right hilar enlargement. Cervical lymph node biopsy specimens revealed wide areas of necrosis with nuclear debris. Transbronchial lung biopsy showed infiltration of lymphocytes in the interstitium and bronchoalveolar lavage fluid showed increased T-lymphocytes and a decreased T4/T8 ratio. The patient was diagnosed to have subacute necrotizing lymphadenitis with T-lymphocyte alveolitis. Additionally, antinuclear antibodies were positive, and anti HTLV-I antibody was false positive. These findings suggested an immunological abnormality in this case. His cervical lymph node swelling and infiltrative shadow on chest X-ray film improved with steroid therapy. Our case may be the first case of subacute necrotizing lymphadenitis with T-lymphocyte alveolitis.     

Four cases of cancer of unknown primary site that manifested as mediastinal metastatic lesions]

We encountered 4 patients with cancers of unknown primary sites that were manifested by mediastinal lesions. Patient 1 was a 58-year-old man with enlarged superior mediastinal lymph nodes. An exploratory thoracotomy yielded a diagnosis of lymph node metastasis of poorly differentiated adenocarcinoma. The patient was treated with chemotherapy and radiation therapy. Patient 2 was a 68-year-old man with a tumor in the right superior mediastinum. A total resection of the tumor was performed through a thoracotomy. The diagnosis was lymph node metastasis of squamous cell carcinoma, and treatment consisted of irradiation. A tumor shadow in the right upper lobe appeared 14 months after the thoracotomy, and was considered to be a primary lesion requiring a right pneumonectomy. The patient died of hepatic metastasis 6 months after the second operation. Patient 3 was a 59-year-old man with mediastinal and hilar lymph node swelling. Mediastinoscopic findings resulted in a diagnosis of squamous cell carcinoma. Because of the patient's insistence, only radiation therapy was performed. Patient 4 was a 65-year-old woman with a tumor in the right superior mediastinum who underwent a median sternotomy for total resection of the tumor. The pathological findings were strongly suggestive of metastasis of clear cell carcinoma. Patients 1, 3, and 4 were alive 33, 24, and 51 months, respectively, after their initial operation, without detectable primary sites. Patient 2 was considered to have had T 0 N 2 lung cancer.     

Colonic metastasis after resection of primary squamous cell carcinoma of the lung:A case report and literature review

Lung cancer is a common malignancy in the world;however symptomatic colonic metastasis from primary lung cancer is rare.A 64-year-old man was originally found poorly differentiated squamous cell carcinoma of right lung and received right lower lobectomy and lymph node dissection.Three years later,the patient presented to our emergency room with the symptom of upper abdominal pain and weight loss.Abdominal palpation and computed tomography scan of the abdomen revealed a large mass measuring 7.6 cm×8.5 cm in the ascending colon.Colonoscopy and biopsy revealed poorly differentiated squamous cell carcinoma with similar morphological pattern to that of the previous lung cancer.Chemotherapy was given and the patient died 5mo later.Lung cancer metastatic to the colon confers a poor prognosis:overall survival ranged from 5 wk to 1year,with a median survival of 3 mo after the diagnosis of the colonic metastasis.     

An autopsy case of adenocarcinoma of the lung with signet ring cells, manifesting with aphasia and hemiparesis due to nonbacterial thrombotic endocarditis

A 42-year-old male was admitted to Tokyo University Hospital because of confusion, aphasia and right hemiparesis. Cranial computed tomography and cerebral angiography demonstrated cerebral infarction due to occlusion of the left middle cerebral artery, while chest roentgenography disclosed a nodular shadow in the right upper lobe and swelling of right hilar and paratracheal lymph nodes. These findings suggested carcinoma of pulmonary origin and tumor-associated cerebral thrombosis, but a possibility of gastric cancer was raised by the finding of cervical lymph node biopsy which revealed signet ring cells in metastatic adenocarcinoma. He developed disseminated intravascular coagulation syndrome and died on the 83rd hospital day. Autopsy revealed adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis which appeared to be responsible for the cerebral infarction. The relationship between adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis was discussed.     

A case of primary lung cancer with cervical tuberculous lymphadenitis]

A 66-year-old woman was admitted due to right cervical lymphadenopathy and an abnormal chest radiograph. Acid-fast bacilli smear of fine needle aspiration from a right cervical lymph node was positive. Histopathological examination of the specimen obtained by percutaneous right cervical lymph node biopsy showed necrotizing epithelioid granulomas and no malignant cells. Therefore, right cervical tuberculous lymphadenitis was diagnosed. Partial lung resection of the right S4 was carried out by video-assisted thoracoscopic surgery and primary lung cancer was diagnosed. To our knowledge, there has been no previous report of both primary lung cancer and cervical tuberculous lymphadenitis being present at the time of the first examination. We report this very rare case.     

A case of occult thyroid cancer detected as a solitary nodular lung metastasis

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.     

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.     

Pancreatic metastasis of papillary thyroid carcinoma preoperatively diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy: a case report with review of literatures

Pancreatic metastatic tumors from thyroid carcinoma are extremely rare. We report a case of an 80-year-old female with a pancreatic metastatic tumor derived from papillary thyroid carcinoma which was initially resected 158 months prior to detection of the metastatic pancreatic tumor. The patient has encountered cervical lymph-node metastasis on three occasions following the initial operation. Metastatic pancreatic lesions and cervical lymph nodes were first detected using 18-fluorodeoxyglucose positron-emission tomography/computed tomography, and she was preoperatively diagnosed using endoscopic ultrasound-guided fine-needle aspiration biopsy. A coin lesion, 10 mm in size, was detected in the left lung by chest computed tomography with no abnormal uptake in 18-fluorodeoxyglucose positron-emission tomography/computed tomography. Distal pancreatectomy and cervical lymph-node dissection were performed. Adjuvant chemotherapy with weekly paclitaxel was administered because anaplastic transformation had been detected in one of the cervical lymph nodes. The patient eventually died from multiple lung metastases 11 months after removing the metastatic pancreatic lesion. We reported a rare case of a pancreatic metastatic tumor from thyroid carcinoma, and found that 18-fluorodeoxyglucose positron-emission tomography/computed tomography and endoscopic ultrasound-guided fine-needle aspiration biopsy are useful for preoperatively diagnosing tumors.     

Tongue metastasis as an initial presentation of a lung cancer

Metastasis to the tongue seldom occurs, and lingual metastasis as an initial sign of cancer occurs even less frequently. We report a case of lung cancer in which the patient's initial symptom was related to the tongue metastasis. A 63-year-old man had a submucosal tumor on the left posterolateral aspect of the tongue and a biopsy specimen of the tongue tumor showed poorly differentiated squamous cell carcinoma. A chest X-ray showed a mass in the right lung and cytological examination of the specimen obtained by bronchial brushing showed poorly differentiated squamous cell carcinoma, whose appearance was similar to that of the tongue. Based on these findings, the tongue lesion was diagnosed a metastatic tumor from the lung cancer. The patient received radiation therapy combined with systemic chemotherapy, however, he died 5 months after the diagnosis of lung cancer. An autopsy revealed a lung cancer in the right lower lobe with metastatic tumors in the tongue, right middle lobe, left upper lobe, liver, adrenal gland, pericardium, heart, and subcutaneous tissues. No other possible primary cancer that may have been the cause of the metastases was identified.     

Early gastric cancer with Krukenberg tumor and review of cases of intramucosal gastric cancers with Krukenberg tumor

A 47-year-old woman was admitted because of hypermenorrhea. Transvaginal ultrasonography revealed an ovarian tumor and myoma uteri, and total hysterectomy with bilateral salpingo-oophorectomy was performed. Histology revealed signet-ring cell carcinoma in the right ovary. In order to find out the primary site of this tumor, gastroendoscopy was performed after the operation, and showed a IIc lesion in the lower body of the stomach; biopsy specimens showed signet-ring cell carcinoma similar to that in the right ovary. Total gastrectomy revealed that the lesion was an early gastric cancer confined to the mucosa, but there was lymphatic invasion slightly beneath the muscularis mucosa, with regional lymph node metastasis. In the light of a review of the seven cases of early gastric cancer with Krukenberg tumor previously reported, lymphatic metastasis seemed to be the most likely pathway of ovarian metastasis in early gastric cancers.     

A case report of small cell lung cancer with extrahepatic biliary obstruction and intramedullary spinal cord metastasis

A 62-year-old man was admitted to our hospital because of high serum amylase and neck swelling. His chest radiography revealed a mass lesion in the right upper lung. Open lung biopsy specimen established the pathological diagnosis as intermediate type small cell lung cancer. In his clinical course, obstructive jaundice recurred several times with response to combination chemotherapy. The findings of abdominal echogram, computed tomography and endoscopic retrograde cholangiopancreatography suggested that the jaundice was caused by extrahepatic biliary obstruction with parapancreatic lymph node metastasis. He died of spinal bleeding which spread from the medulla oblongata to the thoracic spinal cord. Bleeding was caused by intramedullary spinal cord metastasis. Both extrahepatic biliary obstruction and intramedullary spinal cord metastasis are rare and their symptoms were more prominent than those of the pulmonary lesion.     

A patient with gallbladder cancer with paraaortic lymph node and hepatic metastases who has survived for more than 13 years after the primary extended radical operation

Gallbladder cancer is a disease with poor prognosis, especially when it is associated with distant metastasis. Here we report a rare case of a patient with gallbladder cancer with extensive local and distant lymph node metastases and multiple liver metastases who has survived for more than 13 years through aggressive treatments. A 54-year-old woman developed right upper quadrant pain. Computed tomography (CT) revealed a papillary tumor in the gallbladder. Low-density tumors in segments 4, 5, and 8 of the liver and extensive paraaortic lymph node swelling were observed. She underwent central hepatic bisectionectomy and paraaortic lymphadenectomy. Two months later, hepatic metastases were found in segments 2, 3, 6, and 7, and percutaneous ethanol injection and transcatheter arterial chemoembolization were performed. Twelve months after the first surgery, CT revealed lymph node swelling around the right external iliac artery and behind the left renal vein. Metastatic lymph node dissection and resection and reconstruction of the right external iliac artery and vein with artificial graft replacements were performed. Two months later, CT revealed a paraesophageal lymph node swelling, which was treated by radiotherapy. At present, 13 years after the first surgery, and 11 years after the last radiotherapy, she is alive without any sign of recurrence.     

A case of papillary carcinoma of the thyroid with more than 30 years long-term asymptomatic pulmonary metastases

This is a case report of a patient with thyroid cancer with asymptomatic pulmonary metastases, and without obvious progression over 34 years. The patient, a 47-year-old male, was shown to have miliary shadows on chest radiographs from the age of 13; indeed, he was temporarily treated for pulmonary tuberculosis without success. A tumour appeared in the right neck in December 1988 (at age 47). A diagnosis of lymph node metastasis of papillary carcinoma of the thyroid was made by biopsy; he then underwent total thyroidectomy with radical dissection of the neck (April 1989). However, the bilateral metastatic lymph nodes in the neck had invaded the vasculature, preventing complete dissection. Post-operative whole body ¹³¹I scintigraphy revealed diffuse intensive uptake in the bilateral lung fields, demonstrating for the first time that the pulmonary lesions were metastases of the thyroid cancer. He remains under periodic effective treatment with ¹³¹I.