非典型结节病21例临床分析

目的　提高对非典型结节病的认识。方法　回顾性分析了２１ 例非典型结节病的临床资料,所有病例均经病理检查证实。结果　不典型结节病影像学可表现为：（１）肺内病变：有孤立结节影,肺不张,单侧、双侧肺实变,双肺栗粒样结节。（２） 单纯纵隔淋巴结病变：有纵隔肿物,纵隔淋巴结肿大和单侧肺门淋巴结肿大,纵隔单纯淋巴结肿大。（３） 胸膜病变：有液、气胸,胸膜增厚。（４） 肺门病变：有单侧肺门淋巴结肿大和纵隔淋巴结肿大,双侧肺门淋巴结非对称性肿大, 单侧肺门淋巴结肿大钙化。结论　不典型结节病临床表现多种多样,影像学检查难以满足诊断需要。只有对结节病有足够认识,辅以其他检查,其诊断并不困难。     

非黄型结节病21例临床分析

目的 提高对非典型结节病的认识,方法 回顾性分析了２１例非典型结节病的临床资料,所有病例以病理检查证实。结果 不典型结节病影像学可表现为：１）肺内病变;有孤立结节影,肺不张,单侧,双侧肺实变,双肺栗粒样结节。（２）单纯纵隔淋巴结变;有纵隔肿物,纵隔淋巴结肿大和单侧肺门淋巴结肿大,纵隔单纯淋巴结肿大。（３）胸膜病变;有液,气胸,胸膜增厚。（４）肺门病变：有单侧肺门淋巴 肿大和纵隔淋巴 肿大,双侧肺门     

Azygos lymph node enlargement as initial manifestation of underlying disease

Azygos lymph node enlargement is usually an indication of advanced bronchogenic carcinoma, although it may occur in benign pulmonary disease. Often it is found in conjunction with enlargement of hilar and other mediastinal lymph nodes. Isolated azygos lymph node enlargement is unusual and demands tissue diagnosis. Four patients without other evidence of underlying disease were evaluated because of roentgenographic finding of azygos lymph node enlargement. Three had malignant disease and one reactive lymphoid hyperplasia. Current concepts of mediastinal lymphatic drainage are presented. Because of the likelihood of underlying malignancy, biopsy examination of an enlarged azygos node by cervical mediastinoscopy is indicated.     

Thoracic computed tomography in the preoperative evaluation of primary bronchogenic carcinoma

One hundred seventy-four patients with bronchogenic carcinoma underwent computed tomography (CT) as part of their preoperative evaluation. Overall, CT had a sensitivity of 86%, a specificity of 78%, and an accuracy of 81% in identifying mediastinal lymph node metastases. In patients with a central tumor, the sensitivity was 93%, the specificity 74%, and the accuracy 83%. In patients with a peripheral tumor, the respective percentages were 55%, 82%, and 77%. Only 11 of 66 patients with a peripheral tumor had mediastinal metastases, and five of these patients had a normal CT scan. Conversely, 43 of 64 patients with a central tumor and mediastinal lymph node enlargement on the CT scan had unresectable disease, compared with only one of 44 patients without such enlargement. We conclude that CT is not useful in the evaluation of patients with a peripheral tumor; however, it is useful in determining which patients with a central tumor do not require a surgical staging procedure prior to thoracotomy.     

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.     

Thyroid tuberculosis associated with mediastinal lymphadenitis

A 25-year-old man developed thyroid tuberculosis associated with mediastinal lymph node enlargement. He was treated by antituberculosis chemotherapy and hemithyroidectomy.     

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.     

Thoracoscopic resection of Castleman disease: case report and review

Castleman disease is an uncommon entity, most often occurring in patients presenting with localized mediastinal lymph node enlargement. While surgical resection is the preferred treatment, there are concerns about approaching this highly vascular tumor with thoracoscopy. We present the second reported case of thoracoscopic resection of a patient with Castleman disease and review the literature.     

Solitary recurrence of hilar cholangiocarcinoma in a mediastinai lymph node two years after curative resection

We recently encountered an unusual case of hilar cholangiocarcinoma in which a solitary recurrence in a mediastinal lymph node occurred two years after curative resection of the primary tumor. A 64-year old woman was admitted to our hospital with a complaint of right hypochondrial discomfort. After imaging studies demonstrated a hilar cholangiocarcinoma in the left hepatic duct, a curative resection of the tumor was performed, consisting of a left hepatic lobectomy along with caudate lobectomy, regional lymph node dissection, and resection of the extrahepatic bile duct. No nodal metastasis was observed histologically. Two years after surgery, the patient was found to have a nodule in the posterior mediastinum, which was thoracoscopically resected. No other swollen lymph nodes, local recurrence, or distant metastasis were noted. Histologically, the nodule proved to be a metastatic lymph node, and adjuvant chemoradiation therapy was initiated. The patient remained well for the four years following her first operation and had no evidence of disease recurrence 28 mo after her second operation. To our knowledge, this case is the first report of solitary recurrence in a mediastinal lymph node after curative resection of hilar cholangiocarcinoma.     

An unusual mediastinal mass due to metastasis.

During childhood the common anterior middle mediastinal masses are either lymph node enlargement or teratomas/dermoids. A case of ossific mediastinal metastasis and pleural metastases from osteosarcoma, presenting three years after the primary disease (late metastasis) is reported for its rarity.     

Solitary recurrence of hilar cholangiocarcinoma in a mediastinal lymph node two years after curative resection

We recently encountered an unusual case of hilar cholangiocarcinoma in which a solitary recurrence in a mediastinal lymph node occurred two years after curative resection of the primary tumor. A 64-year old woman was admitted to our hospital with a complaint of right hypochondrial discomfort. After imaging studies demonstrated a hilar cholangiocarcinoma in the left hepatic duct, a curative resection of the tumor was performed, consisting of a left hepatic lobectomy along with caudate lobectomy, regional lymph node dissection, and resection of the extrahepatic bile duct. No nodal metastasis was observed histologically. Two years after surgery, the patient was found to have a nodule in the posterior mediastinum, which was thoracoscopically resected. No other swollen lymph nodes, local recurrence, or distant metastasis were noted. Histologically, the nodule proved to be a metastatic lymph node, and adjuvant chemoradiation therapy was initiated. The patient remained well for the four years following her first operation and had no evidence of disease recurrence 28 mo after her second operation. To our knowledge, this case is the first report of solitary recurrence in a mediastinal lymph node after curative resection of hilar cholangiocarcinoma.     

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.     

非小细胞肺癌淋巴结转移时间对患者生存率影响分析

目的评价非小细胞肺癌患者淋巴结转移出现于初诊前或治疗中对患者生存率的影响。方法 80例未手术非小细胞肺癌（NSCLC）患者,卡氏评分≥70分,按初诊时有无淋巴结转移分为两组,初诊有淋巴结转移40例,归为同步淋巴结转移组,中位年龄50岁;治疗中或治疗后出现淋巴结转移40例,归为非同步淋巴结转移组,中位年龄55岁。两组患者皆行序贯放化疗,放疗范围包括病灶、纵隔及出现转移的颈部淋巴结区,总剂量Dt5000～6400cGy（中位剂量6000cGy）,常规分割,预防性照射病侧锁骨上淋巴结区,单侧锁骨上淋巴结区转移者预防性照射对侧锁骨上淋巴结区。化疗方案采用NP和（或）TP方案。放疗后均继续化疗直至完成至少4个周期的化疗。结果同步淋巴结转移组平均生存时间为13月,非同步组平均生存时间为16月（P=0.020）。非同步组出现淋巴结转移至死亡的平均时间为7月（P〈0.01）。结论对于未手术的NSCLC患者来说,发生淋巴结转移,从出现淋巴结转移至死亡的生存时间同步较非同步者长。     

Radiologic staging of lung cancer.

Preoperative tumor staging in patients with known or suspected non-small cell lung cancer is generally performed using contrast enhanced chest computed tomography (CT) (including the adrenal glands). Abdominal CT is generally unnecessary, given the low frequency of isolated liver metastases. The role of MRI is limited, and it is used mainly as a problem solving tool in certain specific situations. A CT showing no mediastinal lymph node enlargement usually oviates preoperative mediastinal lymph node sampling, with certain exceptions. If enlarged mediastinal lymph nodes are demonstrated at CT, then CT may be used to direct preoperative lymph node sampling via transbronchoscopic Wang needle biopsy, mediastinoscopy, mediastinotomy, or video assisted thoracoscopy.     

经气管镜超声引导针吸活检术在定性诊断不明原因肺门及纵隔肿块、纵隔淋巴结肿大中的应用价值

背景 不明原因肺门及纵隔肿块、纵隔淋巴结肿大是胸外科常见的一种疾病,尽管纵隔镜或胸腔镜检查是临床诊断纵隔病变良恶性的"金标准",但因对机体损伤较大、检查费用高昂、可重复性差等导致其临床应用受限,故寻找一种安全、有效的诊断方法一直是临床医师面对的难题.目的 探讨经气管镜超声引导针吸活检术(EBUS-TBNA)在定性诊断不...     

Completely thoracoscopic right upper lobectomy and mediastinal lymph node dissection

Video-assisted thoracoscopic surgery (VATS) has been constantly used in the diagnosis and treatment of intrathoracic disease. The focus of VATS is primarily concerned with the completeness of mediastinal lymph node dissection for lung cancer and the safety of surgery. Here we discuss the feasibility of VATS right upper lobectomy and systematic lymph node dissection, for a 60-year-old woman who was admitted for tumor of the right upper lobe, and describe this treatment method and the major indications. The technique of single-direction lobectomy and mediastinal lymph node dissection is a safe and feasible completely thoracoscopic lobectomy in minimally invasive approach. Single-direction lobectomy can shorten the operation time and reduce the difficulty and complexity of the procedure. The video demonstrates the manipulation of arterial and venous bleeding in thoracoscopic surgery and the skill of single-direction operation.KEYWORDS : Video-assisted thoracoscopic surgery (VATS), right upper lobectomy, systematic lymph node dissection     

Development of IgG4-related disease 10 years after chemotherapy for diffuse large B cell lymphoma and longstanding bronchial asthma

Reported is a rare case IgG4-related disease that developed 10 years after combination chemotherapy for non-Hodgkin lymphoma. A 59-year-old Japanese man with longstanding bronchial asthma was referred to our hospital for bilateral hilar lymph node enlargement. The initial diagnosis was diffuse large B cell lymphoma (DLBCL) by supraclavicular lymph node biopsy. Serum IgG was high (4550 mg/dL) at diagnosis. The patient achieved complete response following six cycles of combination chemotherapy. Ten years later, bilateral submaxillary gland swelling was observed. Serum IgG and IgG4 were 2909 and 1470 mg/dL, respectively. The patient was diagnosed with IgG4-related disease by submandibular lymph node biopsy. Due to the difficulty in distinguishing IgG4-related disease from DLBCL through imaging findings alone, pathological confirmation of such lesions by biopsy is mandatory before proceeding to treatment.     

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.     

Metastatic squamous cell carcinoma of hilar lymph node with unknown primary site]

An abnormal shadow was observed on chest X-ray films of a 63-year-old man presenting with cough and sputum. Chest computed tomographic scans disclosed enlargement of the right hilar lymph nodes, but no obvious primary lesion was found in the lung field. Bronchoscopic examination revealed a slightly widened second carina, but no malignant cells were detected by transbronchial aspiration cytology. At surgery, a tumor was found between the truncus superior and the truncus intermedius. The pathologic diagnosis was a metastatic lymph node of poorly differentiated squamous cell carcinoma. Because the tumor severely adhered to the bronchus and pulmonary arteries, we performed a right pneumonectomy with mediastinal node dissection. Pre- and postoperative examinations did not detect the primary lesion, and no recurrence had been observed 76 months after surgery. This was thought to be a very rare case of T0 N1 M0 lung cancer. In general, the prognosis is poor for patients with metastatic carcinoma of unknown primary site. However, patients with T 0 lung cancer, as in this case, might enjoy a better prognosis if complete resection and dissection of metastatic lymph nodes are performed.     

Current status and clinical applicability of endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has played a key role in the diagnosis of mediastinal, paratracheal, and peribronchial lesions, as well as in lymph node staging for lung cancer. Despite its minimally invasive character, EBUS-TBNA has demonstrated a diagnostic yield comparable with that of established surgical methods. It has therefore gained credibility and has become a routine procedure at various referral centers. A successful EBUS-TBNA procedure requires careful planning, which includes a thorough review of the radiological imaging and special care during specimen collection and preparation, as well as technical expertise, experience with the procedure itself, and knowledge of the potential complications inherent to the procedure. The most common indications for EBUS-TBNA include lymph node staging for lung cancer and the diagnostic investigation of mediastinal/hilar masses and lymph node enlargement. Recently, tumor biomarkers in malignant samples collected during the EBUS-TBNA procedure have begun to be identified, and this molecular analysis has proven to be absolutely feasible. The EBUS-TBNA procedure has yet to be included on the Brazilian Medical Association list of medical procedures approved for reimbursement. The EBUS-TBNA procedure has shown to be a safe and accurate tool for lung cancer staging/restaging, as well as for the diagnosis of mediastinal, paratracheal, and peribronchial lesions/lymph node enlargement