Thymic carcinoid tumor--report of 3 operative cases]

Three cases of thymic carcinoid were surgically treated in our hospital. All 3 cases belonged to stage IVb (Masaoka's classification) because of anterior lymph nodes metastasis. A 44-year-old male patient died of multiple metastasis of bone and liver in 94 months after the operation. A 45-year-old female patient who had undergone operation 4 years ago, was re-operated on for recurrent carcinoid tumor but complete resection of the tumor could not be performed because of the tumorous invasion to superior vena cava, pericardium and costal bone. After the operation she has been treated by radiotherapy and any re-growth of the tumor has never been detected for 1 year. Another 50-year-old male patient who had been operated and treated by chemo-radiotherapy for thymic carcinoid before 50 months was diagnosed as recurrent tumor at left interpectoral lymph node. Radiotherapy is now preparing for this patient. 160 cases of thymic carcinoid reports in Japan were reviewed. 37 cases were stage IVb and 36 cases had supraclavicular or mediastinal lymph nodes metastasis. Those cases which had been underwent complete resection followed by radiotherapy seemed to have better prognosis. We conclude that patients of thymic carcinoid should be treated with complete resection including supraclavicular and mediastinal lymph nodes dissection, followed by radiotherapy.     

Coexistence of sarcoidosis and thymic carcinoid

We report a case of coexistence of sarcoidosis and thymic carcinoid. A 57-year-old man was pointed out the anterior mediastinal tumor when his generator of pacemaker was exchanged. The tumor was diagnosed as atypical carcinoid by percutaneous needle biopsy. Chest computed tomography (CT) revealed the mediastinal and right hilar lymphadenopathy. Preoperative transbronchial aspiration cytology revealed no malignancy and extirpation of the anterior mediastinal tumor was carried out together with left diagraphmatic nerve and pericardium. The histopathological examination of the pretracheal lymph node was sarcoidosis. Postoperative radiation was performed because the thymic carcinoid invaded the pericardium. The right hilar lymph node was enlarged after the radiation. Five months later, follow-up chest CT showed reduction of the right lymph node. He has been alive without recurrence of the thymic carcinoid for 3 years. Simultaneous occurrence of sarcoidosis and thymic carcinoid is extremely rare. Assessment of mediastinal lymph node is difficult either preoperatively and postoperatively. Histological confirmation of the lymph node and careful follow-up are necessary.     

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.     

Thymic carcinoid tumor

In this report on 3 cases of thymic carcinoid, tumors recurred in 2 patients not undergoing lymph node dissection. We review 47 cases of this disease taken from the Japanese literature, and discuss surgical procedures for reducing recurrence. In 9 of 20 cases of recurrence in encapsulated thymic carcinoid, lymph nodes were not dissected in eight. Differential diagnosis of an anterior mediastinal tumor should include thymic carcinoid, for which lymph nodes should be routinely dissected, even when the tumor is encapsulated.     

Thymic carcinoid tumor

In this report on 3 cases of thymic carcinoid, tumors recurred in 2 patients not undergoing lymph node dissection. We review 47 cases of this disease taken from the Japanese literature, and discuss surgical procedures for reducing recurrence. In 9 of 20 cases of recurrence in encapsulated thymic carcinoid, lymph nodes were not dissected in eight. Differential diagnosis of an anterior mediastinal tumor should include thymic carcinoid, for which lymph nodes should be routinely dissected, even when the tumor is encapsulated.     

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.     

Clinical study of six thymic carcinomas including long-term survivors]

Six cases of thymic carcinoma (mean age 48.5 years old, one male and 5 females) were treated in our hospital from September 1990 to September 1998. The histological subtypes of thymic carcinoma were squamous cell in 4, undifferentiated in one, and small cell in one. All cases underwent midsternal thoracotomy, 4 had total resection of the tumor and 2 had exploratory thoracotomy due to tumor invasion of the aorta and the main pulmonary artery. Within 2 years after operation, 2 cases without radiation therapy were died of the carcinoma and one case was died of asthma. However, two cases of squamous cell carcinoma have been alive and disease free for 3 and 5 years since the operation followed by mediastinal irradiation. We think that radiation therapy is very effective to control the disease because one of them underwent only exploratory operation prior to irradiation. Another one case who survives 5 years after total resection of the tumor following irradiation revealed swelling of numerous mediastinal lymph nodes, pathologically consisted of non-caseating epithelioid cell granulomas without metastasis of carcinoma, at the time of operation. These lymph nodes were diagnosed as "sarcoid-like reaction" because there was no clinical evidence of generalized sarcoidosis. The "sarcoid-like reaction" may contribute to the 5-year survival of the patient because it is thought to be a local immune response against the cancer cells. A remaining patient, alive 6 months after total resection of the thymic small cell carcinoma following irradiation, received preoperatively three cycles of the intra-arterial administration using CBDCA via bilateral internal mammary arteries. This induction chemotherapy had no response of the tumor size, but it was considered to have a possibility of reducing the size of thymic carcinoma by the use of other agents (CDDP, VDS etc.) because the tumor was fed mainly by the highly developed internal mammary arteries.     

Recurrent thymic carcinoid tumor--report of a case

A previously operated 62-year-old male with recurrent thymic carcinoid tumor was reported. This patient underwent resection of the thymic carcinoid tumor through left thoracotomy 7 years ago. Although the postoperative clinical course was uneventful, an anterior mediastinal tumor on the patient's chest was discovered after an X-ray examination due to a traffic accident in July, 1989. With the diagnosis of recurrent thymic carcinoid tumor, he underwent an excision of the anterior mediastinal tumor and residual thymus. He also underwent partial resection of the pericardium, mediastinal pleura, and left upper lobe of the lung. 42 cases with thymic carcinoid tumor that have been reported in the Japanese literature were reviewed. A perusal in the relevant literature suggested that total thymectomy was advisable because partial thymectomy was associated with a high risk of local recurrence and metastases.     

A case report of ruptured thymic carcinoid

A scarce case of a rupture of thymic carcinoid followed by hemothorax and mediastinal enlargement was reported. And the mechanism of rupture of thymic carcinoid was discussed comparing to 38 thymic carcinoid cases reported in Japan. A 61-year-old male who had been pointed out mediastinal tumor by chance in a chest X-ray developed a sudden onset of chest pain and dyspnea during an aortography in a hospital transferred to our center because the rupture of the tumor was suspected. Emergency median sternotomy revealed a rupture of a solid tumor with a lot of clot which originally located in the anterior mediastinum but perforated into the right pleural space. This may be the first report of the ruptured thymic carcinoid, so far as we know in Japan. Reviewing the reported cases, the tumor of carcinoid is generally large in size and poorly differentiated in histological study. In more than half of the cases, it is reported that intraparenchymal necrosis or hemorrhage is found. Therefore, it is considered that a thymic carcinoid is a tumor which may result in the rupture, and it should be emphasized that the rupture of the thymic carcinoid which require an emergency treatment is one of the severe complications of the tumor.     

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.     

18FDG-PET诊断非小细胞肺癌纵隔淋巴结转移的初步临床研究

目的：初步探讨^18FDG-PET对非小细胞肺癌(NSCIC)纵隔淋巴结转移的诊断价值和影响SUV值(standard uptake value)的可能相关因素。方法回顾性分析作了完全性切除的31例NSCLC患者。比较CT和^18FDG-PET对纵隔淋巴结转移的诊断作用。对可能影响原发癌灶和纵隔淋巴结SUV值的各种因素作单因素和多重回归与相关分析。结果：^18FDG-PET的敏感性优于CT；但两者的特异性无显著性差异。NSCLC原发癌灶最大SUV值仅与原发癌灶大小相关，而未发现纵隔淋巴结最大SUV值与纵隔淋巴结大小或其它因素相关。结论：^18FDG-PET在诊断NSCLC纵隔淋巴结转移方面敏感性明显高于CT。NSCLC原发癌灶最大SUV值仅与原发癌灶大小相关。     

Metachronous mediastinal lymph node metastasis from ascending colon cancer: A case report and literature review

IntroductionMetachronous mediastinal lymph node metastasis without pulmonary metastasis is extremely rare in colorectal cancer, which makes the clinical diagnosis difficult and treatment strategy unclear.Prsentation of caseA case was a 59-year-old man, who had undergone right hemicolectomy for ascending colon cancer 2 years and 8 months previously, presented with enlarged mediastinal lymph nodes. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography revealed FDG was accumulated only into the mediastinal lymph nodes. Serum carcinoembryonic antigen (CEA) level was within the normal range. Six months later, the size and FDG uptake of the mediastinal lymph nodes had increased. We assumed a possibility that the mediastinal lymph nodes were metastasized from ascending colon cancer and so performed thoracoscopic-assisted resection of the mediastinal lymph nodes. Histopathological analysis revealed the resected lymph nodes were filled with moderately differentiated adenocarcinoma and a diagnosis of mediastinal lymph nodes metastasis from previously-resected ascending colon cancer was made. The patient was postoperatively followed for more than 1 year and 8 months without any sign of recurrence.DiscussionOnly 7 cases of metachronous mediastinal lymph node metastasis from colorectal cancer, including our case, have been reported in the English literature. It is difficult to clinically diagnose mediastinal lymph node metastasis.ConclusionWe report a rare case of metachronous mediastinal lymph node metastasis from ascending colon cancer with literature review. If the mediastinal lymph nodes are enlarged after colorectal cancer resection, we need to make a treatment strategy as well as a diagnostic approach considering the possibility of mediastinal lymph node metastasis.     

Role of flourine-18 fluorodeoxyglucose positron emission tomography in thymic pathology.

OBJECTIVE: To evaluate the utilization of positron emission tomography (PET) scan with fluorine-18 fluorodeoxyglucose (FDG) in thymic pathology. METHODS: Twenty-five consecutive patients with thymic pathology underwent FDG-PET after being evaluated by computed tomography (CT). The indication for CT was myasthenia gravis in 10, anterior mediastinal mass in 7, and recurrent thymic tumor after surgical excision in 8 patients. The results of PET were compared with results obtained by CT, and histopathologic examination of the surgical specimens. RESULTS: All mediastinal abnormal thymic tissue showed FDG uptakes. FDG-PET managed to differentiate between thymic hyperplasia and thymoma in myasthenia gravis group (n=10) in which CT images were questionable in two patients. There was one case of ectopic thymic tissue which was not diagnosed preoperatively. There were no false-negative results for both CT and FDG-PET in seven patients with thymoma presented as anterior mediastinal mass. However, PET scan predicted thymic carcinoma in one patient. PET was superior to CT scan in localization of recurrent thymoma in two patients, and equal to CT in detecting metastatic lesions in six patients during the follow-up after thymoma excision. CONCLUSIONS: In myasthenia gravis, selective use of FDG-PET is useful in differentiating thymoma from hyperplasia, especially when CT scan is controversial, but fails to recognize ectopic thymic tissue. FDG-PET may differentiate thymoma from thymic carcinoma. FDG-PET is also useful in follow-up patients, who underwent thymoma excision, when there is suspicion of recurrence or metastasis.     

Two cases of thymic carcinoid

Two cases of thymic carcinoid tumor were reported. Case 1 was 64-year-old male who was admitted to our hospital with a complaint of dyspnea. He was proved to have a huge anterior mediastinal tumor by chest X-ray and chest CT. After radiation therapy, the tumor was resected on February 5, 1981. Pericardium was partially resected and showed tumor invasion. Sixty-four days after operation, he died due to respiratory insufficiency. Case 2 was 71-year-old male who was pointed out to have an abnormal shadow by X-ray mass screening and was admitted to our hospital. Chest X-ray and chest CT revealed the presence of an anterior mediastinal tumor. Resection of the tumor was done on February 13, 1986. Although the tumor showed mediastinal lymph node metastasis and invaded to the pericardium and the right lung, it was resected completely. Cytological examination of pericardial effusion showed tumor cells at the time of resection. He is now quite well and without any evidence of recurrence 3 year and 1 months after operation. Histopathologically, the tumors of two cases consisted of relatively uniform cells with abundant clear or slightly eosinophilic cytoplasm and regularly and centrally located nuclei. Mitotic figures were occasionally seen in both cases. Many tumor cells were positively to Grimelius stain. On the other hand, Fontana-masson stain was negative. Immunohistochemically, the tumor cells were positively stained with anti-NSE and anti-GRP antibodies in Case 1 and with anti-NSE antibody in Case 2.(ABSTRACT TRUNCATED AT 250 WORDS)     

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。     

Diagnosis of esophageal cancer using positron emission tomography

Fluorodeoxyglucose positron emission tomography (FDG-PET) is more accurate than computed tomography (CT) for evaluating lymph node metastases and for N staging, but less accurate than combined CT and endoscopic ultrasonography (EUS). Lymph nodes located adjacent to the primary lesion tend to be false negatives. We consider that combined FDG-PET and EUS is the most accurate for the detection of lymph node metastasis in esophageal cancer. FDG-PET is also more accurate than CT for detecting distant metastases and improves the detection of stage IV disease compared with the conventional staging modalities. For the diagnosis of recurrence except for perianastomotic recurrence, FDG-PET provides additional information and is more sensitive than conventional work-ups. FDGPET is a valuable tool for the noninvasive assessment of tumor response after neoadjuvant therapy. 11C-methionine (MET) is another tracer for PET that can be used to assess the metabolism of amino acids, since MET accumulates in esophageal malignant tumors. Choline-PET is more accurate than FDG-PET for the detection of mediastinal lymph node metastases.     

Association of Carcinoid Tumor and Sarcoidosis

The association of systemic sarcoidosis with malignant neoplasms has been reported by several publications although there is controversy as to whether sarcoidosis predisposes patients to certain types of tumors or whether it is the tumors that cause a sarcoid reaction. The relationship between endobronchial carcinoid tumor and sarcoidosis is uncommon. We report the case of a 43-year-old male who was hospitalized due to hemoptysis. Thoracic CT revealed a pulmonary mass in the right upper lobe (RUL) as well as hypermetabolic lymphadenopathies seen with PET-CT. The endobronchial biopsies were compatible with carcinoid tumor. The patient underwent lobectomy of the RUL with mediastinal lymphadenectomy. Histology demonstrated type I endobronchial carcinoid tumor and sarcoid granulomas, both in the RUL surgical piece as well as in the mediastinal lymph nodes.     

False positive accumulation in 18F fluorodeoxyglucose positron emission tomography scan due to sarcoid reaction following induction chemotherapy for lung cancer

We present a case of lung cancer that showed false positive accumulation in an ¹⁸F fluorodeoxyglucose positron emission tomography (FDG-PET) scan following induction chemotherapy for suspected metastasis and progression of malignancy. A 66-year-old man was diagnosed with squamous cell carcinoma in the lung, classified as clinical stage IIIA (T2N2M0), and underwent induction chemotherapy. An FDG-PET scan prior to chemotherapy demonstrated accumulation only in the tumor, whereas following treatment it revealed a strong accumulation not only in the tumor, but also in the supraclavicular lymph nodes, which indicated lymph node metastasis. The patient underwent a biopsy of the right supraclavicular lymph node and mediastinoscopy, after which all dissected lymph nodes showed sarcoid reactions and no tumor cells were found pathologically. We concluded that when evaluating the effect of induction chemotherapy for malignancy, a sarcoid reaction might lead to the false positive accumulation of FDG.     

Induction chemoradiotherapy in small adenocarcinoma of the lung with bulky mediatinal lymph node metastasis

A 56-year-old man, who visited our hospital due to chest pain, was pointed out a large tumor, 60 mm in diameter, on the left superior mediastinum on the chest computed tomography (CT) scan. He was diagnosed as having mediastinal lymph nodes metastasis of adenocarcinoma through video-assisted thoracoscopic surgery (VATS) biopsy. He received induction chemoradiotherapy: cisplatin and paclitaxel were administered once per week for 2 weeks, and radiotherapy was simultaneously performed. No serious adverse reactions were noted. The ipsilateral mediastinal lymph nodes dissection was performed. Intraoperative frozen section analysis showed a small nodule in the left upper lobe, 5 mm in diameter, was adenocarcinoma. He was finally diagnosed as having mediastinal lymph nodes metastasis from the small adenocarcinoma of the lung, and left upper lobectomy was performed. Histopathological examination of the mediastinal lymph nodes showed no evidence of viable maligmant cell. Induction chemoradiotherapy with cisplatin and paclitaxel might be effective treatment for locally advanced non-small cell lung cancer.     

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.