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.     

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.     

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.     

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.     

A case of mesenteric lymphadenitis with long-acting symptom, showing marked response to corticosteroid.

A 17-year-old girl who had right lower abdominal pain with multiple swelling of lymph nodes in the ileocecal region and she was admitted to a neighboring hospital. Since there was no improvement of condition with antibiotic resistance, we were consulted. Lymph node biopsy under laparoscopy demonstrated nonspecific findings. She then developed erythema nodosum, suggesting the presence of autoimmune etiology. Treatment with systemic corticosteroid resulted in symptomatic improvement. Mesenteric lymphadenitis like this case is rare.     

An adult case of cervico-mediastinal tuberculous lymphadenitis]

We reported a case of cervico-mediastinal tuberculous lymphadenitis followed by the development of pulmonary lesions and recurrent laryngeal nerve palsy. A 48-year-old man was admitted to our hospital due to fever, dry cough, and loss of body weight. He had no medical history of tuberculosis or other significant diseases. On admission, a right cervical tumor was palpable and chest X-ray films revealed widened superior mediastinum. Chest computed tomography showed multiple swollen mediastinal lymph nodes, including multiple low-density areas and contrast medium-enhanced septa and margins. Gallium-67 scintigraphy demonstrated abnormal uptake in the right cervix and mediastinum. A PPD skin test was strongly positive and ribosomal RNA of tubercle bacilli was detected in aspirated gastric juice. Although anti-tuberculous chemotherapy was initiated, fever and cough persisted, and hoarseness due to left recurrent laryngeal nerve palsy developed. One month later, chest X-ray films showed abnormal infiltration in the left upper lung field. The patient was sero-negative for HIV. To confirm the diagnosis, right supraclavicular lymph node biopsy was performed. Microscopic examination of the biopsy specimen revealed acid-fast bacilli and granuloma with central caseous necrosis surrounded by Langhans' giant cells and epithelioid cells. After 9 months of extended anti-tuberculous chemotherapy, the cervical and mediastinal masses receded and the abnormal chest X-ray shadows disappeared. Because the incidence of tuberculosis in Japan is gradually increasing among young people as well as the elderly, the differential diagnosis of this disease will become more necessary.     

Four cases of the tuberculous adenitis

We report four cases of tuberuculosis with the lymph nodes swelling in the porta hepatis. Case 1 is 52 years-old man, who was admitted to our hospital because of anorexia. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. At the time of hospitalization, patient's conjunctiva is icteric on physical examination. The serum T-Bil was 3.21 mg/dL and D-Bil was 2.54 mg/dL. The enhanced CT showed compression of the extrahepatic common bile duct which was caused by enlarged lymph nodes secondary to tuberculous adenitis. Case 2 is 25 years-old man, who was admitted to our hospital because of low grade fever and lower abdominal pain. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. An enhanced CT showed the swelling of the lymph nodes in the porta hepatis. Case 3 is 21 years-old woman, who visited the outpatient clinic bacause of neck lymph node swelling. And she was diagnosed as tuberculous adenitis of the cervical lymph-nodes by the neck lymph node biopsy. The patient complained of upper abdominal pain during the clinical course. The enhanced CT showed the swelling of the lymph nodes in the porta hepatis. A Case 4 is 31 years-old man, who visited to outpatient clinic bacause of fever. The chest X-ray film showed mediastinal lymphadenopathy, and he was diagnosed as tuberculosis by the thoracoscopic biopsy. The enhanced abdominal CT showed lymph nodes swelling in the porta hepatis. All of lymph nodes swelling found in our four cases markedly reduced in size on abdominal enhanced CT or ultrasonography after the initiation of anti-tuberculous standard chemotherapy. Symptom of all cases got better as well. In these clinical circumstances, it was clinically important to rule out malignant lymphoma and lymphadenopathy caused by cancer. The enhanced abdominal CT were useful for diagnosis and follow-up as tuberculous adenitis.     

A suspected case of perforation of a lymph node into the bronchus during the treatment of adult hilar lymph node tuberculosis]

A 27-year old patient was diagnosed as having post-primary hilar lymph node tuberculosis. First being admitted to the hospital with a high fever, a chest x-ray examination revealed a swelling of the left hilar lymph nodes and a sputum smear tested positive for acid-fast bacilli. Neither regular clinical examination or investigation had reported abnormality. The acid-fast bacilli was successfully treated through treatment using INH RFP SM. However, after two months, swelling was observed in the right para-tracheal lymph nodes, Further, a bronchoscopic examination revealed polyp-like tumors at the left upper and lower bifurcation. The swelling of the para-tracheal lymph nodes was considerably reduced and the tumors non-existent after five months. These lymph node reactions could have likely been a part of the so called early exacerbation. The polyp-like tumors were not found during the bronchoscopy performed during admission to the hospital. It is therefore suspected that the cause was perforation of the hilar lymph node into the bronchus.     

A case of lung cancer with hyperthyroidism]

We here report a case of metastasis from lung cancer to the thyroid. On presentation, this patient showed painful anterior cervical swelling and right supraclavicular lymph node swelling. Laboratory data showed primary hyperthyroidism. Although subacute thyroiditis was suspected, echo-guided needle aspiration biopsy and lymph node biopsy revealed poorly differentiated squamous cell carcinoma. As a result, primary lung cancer with thyroid metastasis was diagnosed based on mediastinal enlargement on chest X ray films and normal findings in organs other than the lung and thyroid. Chemotherapy for lung cancer induced a decrease in the size of tumor and the normalization of thyroid function. However, 2 months after the normalization, cervical swelling enlarged and a lung mass in right upper lobe and skin tumor appeared. Despite treatment with chemotherapy, she died. Postmortem revealed that the right upper lung carcinoma was the primary lesion and immunohistochemical staining for surfactant protein was positive in the thyroid, skin tumor and lymph node, which revealed these carcinomas had metastasized from lung cancer. To the best of our knowledge, thyrotoxicosis induced by thyroid metastasis of lung cancer is an uncommon case.     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

A case of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall

A 61-year-old woman with schizophrenia that had been treated in a psychiatric hospital was admitted to our hospital because of subileus and back pain. Though subileus was improved, she had a sudden attack of fever 7 days later and developed right pleural effusion, a cold abscess in the anterior chest wall and swelling of a thumb-sized right cervical lymph node which broke through the skin. We made a diagnosis of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall due to the biopsy findings of the specimen taken from the cervical lymph node, examination of pleural effusion, chest CT, bacteriological examination of the cold abscess and spinal MRI. We started chemotherapy with the antituberculous drugs (HRSZ) and symptoms except back pain improved. She complained of paresis of the both lower extremities, which completely paralyzed 8 months later in spite of continued chemotherapy. Thereafter her paralysis was gradually improved and she was able to walk by herself after 12 months chemotherapy.     

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 remarkable effect of alpha-interferon in a case of angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) refractory to steroids and combination chemotherapies

We experienced a remarkable effect of recombinant interferon alpha 2a (alpha-IFN) in a case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) which was refractory to steroids and combination chemotherapies. A 62 year-old woman was admitted because of high grade fever and extreme swelling of cervical lymph nodes. Poly-clonal hypergammaglobulinemia and plasma cell-like atypical lymphocytosis in the peripheral blood were demonstrated. Cervical lymph node biopsy disclosed histology of AILD. She initially responded well to prednisolone. Three months later, AILD relapsed in spite of prednisolone treatment. She received combination chemotherapies and responded well again. Seven months later, she became refractory to these combination chemotherapies. Consequently, we tried alpha-IFN (3 million units/day given intramuscularly). She became afebrile on the next day, and lymph nodes swelling gradually disappeared. She has been free from the disease for more than three months.     

Case of liver tuberculosis requiring differentiation from liver metastasis of cancer

A 79-year-old woman was admitted to our hospital because of general fatigue. Chest radiograph and computed tomograph showed bronchiectasis and centrilobular nodules in the right middle lobe and lingula, which had not changed from previous examination. Intrahepatic nodular lesions and swelling of the left cervical lymph nodes, supraclavicular lymph node, abdominal paraaortic lymph nodes and inguinal lymph nodes was observed. Biopsy specimen of the liver lesion demonstrated epithelioid cell granulomas. Biopsy of the right inguinal lymph node demonstrated epithelioid cell granulomas with caseous necrosis and culture of the specimen showed Mycobacterium tuberculosis. The patient was diagnosed as having liver tuberculosis and multiple tuberculous lymphadenitis. Antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide were started and continued for 6 months. All lesions improved after treatment. This was a rare case of liver tuberculosis that was difficult to distinguish from liver metastasis of cancer.     

A case of sarcoidosis who showed rapid swelling of mediastinal and abdominal lymph nodes]

A 49-year-old woman noticed hoarseness and facial palsey three months prior to her visit to our hospital. Chest radiograph and CT scanning revealed bilateral mediastinal and hilar lymphadenopathy. Bronchofiberoptic biopsy showed sarcoidosis. Her symptoms improved under no treatment. However, she showed rapid increase of mediastinal and abdominal lymph nodes swelling and elevation of serum level of sIL-2R during observation. Therefore, we must discriminate sarcoidosis-lymphoma syndrome from exacerbation of sarcoidosis. Mediastinoscopic biopsy was conducted for diagnosis, and it revealed exacerbation of sarcoidosis. We reported this rare case of rapid increase of mediastinal and abdominal lymph node swelling due to sarcoidosis.     

The lymphatic drainage of the pericardial space in the dog

The purpose of this study was to characterize definitively the lymphatic drainage system of the pericardial space in the dog. The reports on this subject, based on dissection experiments and acute dye injections, remain controversial, and our own previous studies have been incomplete. Seventeen dogs were studied using a radiographic technique. Micropulverized barium sulfate instilled into the pericardial sac was followed with serial chest x-rays in seven dogs with intact cardiac lymphatics, in seven dogs after section of the cardiac lymphatic drainage node (the cardiac lymph node) in the right upper mediastinum, and in three dogs after resection of cardiac drainage lymphatic nodes in the left upper mediastinum. These studies revealed that the lymphatic drainage of the pericardial space is via (a) the principal coronary lymphatic which drains from the left ventricular muscle and passes to the right upper mediastinum via the cardiac lymph node, (b) the lesser coronary lymphatic which drains the right ventricular muscle and passes to the left upper mediastinum, and (c) bilateral internal mammary (parasternal) lymphatic chains. These observations are important in planning experimental approaches to the effects of impairment of lymph drainage from the pericardial space. An understanding of the lymph drainage from the pericardial space may prove significant to understanding fibrotic reactions within it and the pathologic mechanisms of such entities as constrictive pericarditis.     

Topographical distribution of lymph node metastasis in adenocarcinoma of the gastroesophageal junction

BACKGROUND/AIMS: The current discussion concerning the extent of resection in patients with adenocarcinoma of the gastroesophageal junction is focused beside the luminal extent of resection primarily on the value of lymphadenectomy. METHODOLOGY: In order to clarify whether spread of lymph node metastasis shows different pathways in adenocarcinomas of the gastroesophageal junction, a prospective, morphological study of the topographical distribution of lymph node metastasis was performed. Transthoracic en bloc esophagectomy with two-field lymphadenectomy (n = 13) or transhiatal esophagectomy with lymphadenectomy of the lower mediastinum and compartment I (lymph node No. 1-3) as well as II (n = 4) was performed in type I carcinoma and transhiatally extended gastrectomy with D2-lymphadenectomy and lymphadenectomy of the lower mediastinum in type II and III carcinoma (n = 33). RESULTS: In 50 specimens, 1730 lymph nodes were evaluated with regard to metastatic infiltration. We found metastases in the lymph nodes of the lower mediastinum in 24% of type I carcinoma, in 11% of type II carcinoma and in 13% of type III carcinoma, whereas the lymph nodes of the upper mediastinum were tumor free in all patients with transthoracic en bloc resection and 2-field lymphadenectomy (n = 13). In all cases with lymph node metastasis abdominal lymph nodes were affected independently from the localization of the primary tumor. CONCLUSIONS: The main direction of lymph node spread in adenocarcinoma of the gastroesophageal junction is towards the abdomen and the lower mediastinum. For precise tumor staging standardized lymphadenectomy of the lower mediastinum and the abdominal compartments I and II is essential.     

A case of massive true thymic hyperplasia with non-Hodgkin's lymphoma

A case of massive true thymic hyperplasia with non-Hodgkin's lymphoma of the mediastinum is reported in a 14-year-old boy. Computed tomographic scan of the chest showed a mass of the anterior mediastinum and conspicuous swelling of the lymph nodes in the upper and lower mediastinum. They were grossly resected. The tumor of the anterior mediastinum was histologically diagnosed as true thymic hyperplasia. All of the mediastinal lymph nodes were diagnosed as non-Hodgkin's lymphoma, diffuse, mixed small and large cell type.     

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.     

The role of lymphatic drainage of the liver in gallbladder cancer: a case report.

We report a case of a patient with a unique lymph node relapse after right hepatectomy and aggressive lymph node dissection for gallbladder cancer. There was extensive involvement of the hepatic parenchyma from the primary tumor, but no extension to the lymph nodes or other adjacent organs. Seventeen months later, the patient underwent re-dissection of the retroperitoneal lymph nodes with right nephrectomy and partial resection of the vena cava because of lymph node recurrence at the hilum of the right kidney. This pattern of lymph node metastasis to the right side of the vena cava from gallbladder cancer invading the liver is probably due to the distinct lymphatic drainage of the liver.