Mediastinal Castleman disease associated with pulmonary carcinoma, mimicking N2 stage lung cancer.

A 67-year-old man presented at our hospital with suspected right lung cancer with mediastinal and hilar lymphadenopathy. Although swollen lymph nodes had first been noted 8 years previously, only minimal enlargement had occurred over the intervening period. Video-assisted thoracoscopic biopsy of the pulmonary lesion and the mediastinal and hilar lymph nodes was performed. Final histopathological diagnosis was a poorly differentiated adenocarcinoma of the lung staged as T1NOMO and a coexistent localized hyaline-vascular type of Castleman disease. Right upper lobectomy was performed and postoperative histological findings suggested that this was likely to be curative. This is a rare case of coexistence of lung cancer and Castleman disease, illustrating the difficulties in distinguishing lymph node metastasis from other pulmonary diseases.     

Mediastinal castleman disease associated with pulmonary carcinoma,Mimicking N2 stage lung cancer

A 67-year-old man presented at our hospital with suspected right lung cancer with mediastinal and hilar lymphadenopathy. Although swollen lymph nodes had first been noted 8 years previously, only minimal enlargement had occurred over the intervening period. Video-assisted thoracoscopic biopsy of the pulmonary lesion and the mediastinal and hilar lymph nodes was performed. Final histopathological diagnosis was a poorly differentiated adenocarcinoma of the lung staged as T1N0M0 and a coexistent localized hyaline-vascular type of Castleman disease. Right upper lobectomy was performed and postoperative histological findings suggested that this was likely to be curative. This is a rare case of coexistence of lung cancer and Castleman disease, illustrating the difficulties in distinguishing lymph node metastasis from other pulmonary diseases.     

Sarcoidosis development during induction chemotherapy for lung cancer mimicked progressive disease

We report a rare case of sarcoidosis that developed during induction chemotherapy for primary lung cancer, mimicking progressive disease. A 63-year-old man had an abnormal shadow in the right upper lung, and a bronchoscopic examination revealed a squamous cell carcinoma. Swelling of a pretracheal lymph node was also noted. Thus, we gave induction chemotherapy consisting of paclitaxel (days 1, 8) + carboplatin (days 1, 8) for two cycles under clinical staging of T2N2M0. After induction chemotherapy, ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed positive accumulation of FDG in mediastinal and bilateral hilar lymph nodes that had been negative in a previous FDG-PET examination, which led us to suspect disease progression. Transbronchial lymph node biopsy results showed sarcoid granulomas in the specimens. Following complete resection of the lung cancer, sarcoid granulomas were revealed in both nonneoplastic lung tissue and lymph nodes, which resulted in a diagnosis of lung cancer accompanied with sarcoidosis.     

肺癌跳跃式纵隔淋巴结转移的临床病理探讨

目的　探索肺癌跳跃式纵隔淋巴结转移的病理特点 ,为合理施行淋巴结清除术提供可靠的理论依据。方法　 1992年 10月至 1998年 6月 ,为 398例肺癌病人施行了根治性肺切除、规范淋巴结清除术 ,对其中 4 7例 ( 2 9 4 % )跳跃式纵隔转移淋巴结病例进行病理学研究。结果　各型或各叶肺癌中 ,跳跃式转移淋巴结分布最密集的部位依次是第 7、4、3、5组淋巴结 ,分别占 2 9 8%、2 4 5 %、14 9%与10 6 % ;就鳞癌与腺癌而言 ,肿瘤长径在 1cm以内者均无跳跃式淋巴结转移 ,跳跃式淋巴结转移率随长径增加而增加 ;低分化腺癌淋巴结转移率明显高于高分化者 (P <0 0 1) ;发生跳跃式淋巴结转移的肿瘤平均长径鳞癌与腺癌分别为 15 3mm与 9 1mm。结论　对肺癌淋巴结的廓清 ,切勿仅凭手触摸或靠肉眼观察淋巴结大小而盲目判定其是否转移或清除。除T1 中肿瘤长径 <1cm的鳞癌外 ,淋巴结的规范清除应重视其跳跃性 ,原则上必须包括同侧胸腔的肺门及上、下纵隔各组淋巴结 ,尤其要重视跳跃式淋巴结转移分布较密集区域 ,即右侧的第 3、4、7组与左侧的第 4、5、7组淋巴结     

肺癌手术中淋巴结清扫的现状与进展

淋巴结转移是肺癌主要而常见的转移途径,也是术后癌残留而导致复发和转移的主要因素,肺癌手术中纵隔、肺门淋巴结清扫至关重要。但目前淋巴结的清扫方式尚不统一,有系统淋巴结清扫术（CMLND）、根治性淋巴结清扫术、淋巴结采样、系统淋巴结采样以及前哨淋巴结技术导航切除,并且随着微创外科的发展,胸腔镜下淋巴结清扫也日趋成熟。而寻求一个更规范、更完善的淋巴结清扫方式甚有必要。现就目前肺癌手术中纵隔、肺门淋巴结清扫的临床意义、清扫方式、清扫范围以及胸腔镜下淋巴结清扫的现状以及展望进行综述。     

Indication of limited pulmonary resection for small-sized lung cancer based on preoperative clinical data

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.     

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.     

Pulmonary T2N0 adenocarcinoma with metastasis to a lymph node in the thoracic wall.

We experienced a rare case of lung cancer without hilar/mediastinal nodal involvement or direct invasion to the thoracic wall, but with metastasis to a lymph node in the thoracic wall. A 72-year-old woman with lung cancer was admitted to our hospital for the surgical therapy. She had suffered from right pleuritis in her childhood. During the dissection of the pleural adhesion around the whole lung, one small black lymph node was found in the thoracic wall and resected. Then, right middle and lower lobectomy and systematic nodal dissection were performed. The postoperative pathological examination revealed that nodal involvement was not observed in all samples except in the lymph node in the thoracic wall. In lung cancer patients with broad pleural adhesion, we should pay attention to lymph nodes in the thoracic wall. If we find them, the nodes should be resected for accurate staging.     

Pulmonary T2N0 adenocarcinoma with metastasis to a lymph node in the thoracic wall

We experienced a rare case of lung cancer without hilar/mediastinal nodal involvement or direct invasion to the thoracic wall, but with metastasis to a lymph node in the thoracic wall. A 72-year-old woman with lung cancer was admitted to our hospital for the surgical therapy. She had suffered from right pleuritis in her childhood. During the dissection of the pleural adhesion around the whole lung, one small black lymph node was found in the thoracic wall and resected. Then, right middle and lower lobectomy and systematic nodal dissection were performed. The postoperative pathological examination revealed that nodal involvement was not observed in all samples except in the lymph node in the thoracic wall. In lung cancer patients with broad pleural adhesion, we should pay attention to lymph nodes in the thoracic wall. If we find them, the nodes should be resected for accurate staging.     

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。     

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.     

肺叶、肺段淋巴结引流的解剖学特征

目的探讨肺叶、肺段淋巴结引流的解剖学特征。 方法对9具成人尸体采用解剖乳胶填充剂行胸部淋巴结灌注,然后游离标本的纵隔前、纵隔后及中纵隔淋巴结,同时游离并清扫右肺上、中、下肺叶和各个肺段,以及左肺上、下肺叶和各个肺段的肺内淋巴结、肺门淋巴结;观察淋巴结的分布、数目和淋巴回流状况。 结果在标本上共观察到212个纵隔淋巴结,平均每例23.5个;各区淋巴结的数目以隆突下淋巴结7区和右下气管旁4R最多,其次为右气管支气管旁(10R)、左支气管旁(10L)和主-肺动脉窗区(5区)淋巴结;纵隔各区以隆突下区(7区)淋巴结最大,其次是右气管支气管旁(10R)淋巴结,气管旁淋巴结自上而下直至隆突下淋巴结逐渐增大,并且右侧大于左侧,即下大于上,右大于左。左肺和右肺的肺内淋巴结一般按照亚段淋巴结→段淋巴结→叶淋巴结→叶间淋巴结/肺门淋巴结;右肺上叶、中叶及肺门淋巴结通常回流至上纵隔淋巴结及隆突下淋巴结,下叶回流至下纵隔淋巴结。而左肺上叶一般引流至主—肺动脉窗区淋巴结及隆突下淋巴结,下叶也引流至下纵隔淋巴结。 结论肺叶及纵隔淋巴回流具有一定的规律性,从而为肺叶特异性/系统性淋巴结清扫方式的选择提供了解剖学依据。     

Complete mediastinal lymphadenectomy: the core component of the multidisciplinary therapy in resectable non-small cell lung cancer.

There is a great deal of concern about metastasis of lung cancer to regional lymph nodes, due partly to the work of groups of thoracic surgeons in Japan and North America beginning in the 1970s. The classification of regional lymph node stations for lung cancer staging published by Mountain and Dresler has been widely adopted for more than ten years. Anatomic landmarks for 14 levels of intrapulmonary, hilar, and mediastinal lymph nodes stations are designated. Skip transfer and occult lymph node metastasis, confirmed by studies regarding the mode of spread of intrathoracic lymphatic metastasis, are two theoretical bases for complete mediastinal lymphadenectomy of lung cancer. However, whether or not the degree of the dissection influences prognosis, the role of systematic nodal dissection (SND) vs mediastinal lymph node sampling (MLD) in resectable non-small cell lung cancer (NSCLC) remains controversial. A systematic literature search was performed to identify relevant reports, making full use of the 'Cited by,' 'Related Records,' 'References,' and 'Author Index' functions in the PubMed and ISI Web of Science databases. This paper presents a review of the role of mediastinal lymph node distribution and methods of determining suitability for hilar and mediastinal lymphadenectomy based on the four subsets of stage IIIA-N2, balancing the cost vs effect of mediastinal lymph node dissection in resectable NSCLC, focusing on the stage migration bias in clinical trials comparing SND and MLS, recommending a reasonable node dissection sequence, improving the prospects for the perioperative anti-tumor therapy based on mediastinal lymphadenectomy, and evaluating the various preoperative staging techniques. Finally, we believe that, besides the role of complete resection and accurate staging, the complete mediastinal lymphadenectomy is the core component of the lung cancer multidisciplinary therapy, and suggest that the values of lymphadenectomy should be further assessed using decision-tree analysis based on large-scale prospective randomized trials and pooled analysis to evaluate the costs vs effects.     

Mediastinal lymph nodes: Ignore? Sample? Dissect? The role of mediastinal node dissection in the surgical management of primary lung cancer

The role of mediastinal lymph node dissection (MLND) during the resection of non-small-cell lung cancer is still unclear although most surgeons agree that a minimum of hilar and mediastinal nodes must be examined for appropriate pathological staging. Current surgical practices vary from visual inspection of the mediastinum with biopsy of only abnormal looking nodes to systematic mediastinal node sampling which is to the biopsy of lymph nodes from multiple levels whether they appear abnormal or not to MLND which involves the systematic removal of all lymph node bearing tissue from multiple sites unilaterally or bilaterally within the mediastinum. This review article looks at the evidence and arguments in favour of lymphadenectomy, including improved pathological staging, better locoregional control, and ultimately longer disease-free survival and those against which are longer operating time, increased operative morbidity, and lack of evidence for survival benefit.     

Mediastinal sarcoidosis: An easily forgotten diagnosis

Sarcoidosis is rarely diagnosed and reported in Hong Kong. We report a 58‐year‐old woman with incidental findings of right hilar adenopathy on chest X‐ray and subsequent computed tomography showed bilateral hilar and paratracheal lymphadenopathy. A biopsy of the paratracheal lymph node was carried out by mediastinoscopy and pathology confirmed sarcoidosis. We acknowledged that sarcoidosis was probably an underdiagnosed condition in our locality and clinicians should be reminded to include sarcoidosis as a differential diagnosis when dealing with patients with hilar lymphadenopathy. Surgical biopsy by mediastinoscopy is a minimally invasive option for accessing mediastinal pathology.     

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.     

Adrenal metastasis of lung adenocarcinoma with unusual sites of lymph node metastasis and concomitant renal cell carcinoma: a case report

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.     

21-year-old man with squamous cell carcinoma of the lung

Lung cancer among people in their twenties is rare and accounts for only 0.1-0.4% of all cases. We describe a case of squamous cell carcinoma of the lung in a 21-year-old man. The otherwise healthy patient presented with a 1 month history of cough. Chest radiography showed a well-defined round mass 5 cm in size in the right lower lobe. Computed tomography also showed a 3 cm hilar lymph node. Bronchoscopy revealed a white polypoid mass obstructing the right basal bronchus. Transbronchial biopsy revealed poorly differentiated squamous cell carcinoma of the lung. Clinical diagnosis was T2N1M0, stage IIB lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed. Lymph node metastases were proven histologically in the pretracheal, subcarinal, hilar, and intrapulmonary regions. Pathological diagnosis was T2N2M0, stage IIIA lung cancer. Endobronchial and mediastinal lymph node metastases were found 2 months after surgery. He received 3 rounds of chemotherapy with cisplatin and docetaxel and irradiation to the right hilum and mediastinum at a total dose of 60 Gy in 30 fractions. He is alive 6 months after surgery.     

Systemic mediastinal lymph node dissection of right lung cancer: surgical quality control and analysis of mediastinal lymph node metastatic patterns

Standardization of systemic mediastinal lymph node dissection (SMLD) of lung cancer requires further investigation. A consecutive 124 right lung cancer patients were recruited for pulmonary resection plus SMLD. Three mediastinal lymph node compartments, (i) the upper compartment (station 1-4), (ii) the middle compartment (station 7-8) and (iii) the lower compartment (station 9), were en bloc collected to achieve surgical quality control and to analyze mediastinal lymph node metastatic patterns. The number of total harvested lymph nodes, N1 nodes and N2 nodes were 21.9+/-8.7, 9.2+/-4.7 and 12.8+/-6.7, respectively. Tumor location (peripheral or central) (P=0.023) and status of blood vessel invasion (P=0.002) were identified as risk factors for nodal involvement. Right upper lobe (RUL) cancer with N2 disease primarily metastasized to the upper compartment (27.3%) (P=0.001). For right lower lobe (RLL) cancer, lymph node metastasis most commonly detected in the middle compartment (48.8%) (P=0.001). Single mediastinal compartment metastasis occurred in 64.7% (11/17) of adenocarcinomas from RUL and RML, whereas multiple compartments metastasis occurred in all adenocarcinoma cases (12/12) from RLL (P=0.001). SMLD needs to standardize the extent of lymphadenectomy and number of removed lymph nodes for surgical quality control. Simplifying mediastinal lymph node stations to three compartments may benefit surgical excision.     

Lung Cancer Associated with Sarcoidosis - A case report -

Sarcoidosis is a somewhat common pulmonary disease, but the concurrence of lung cancer and sarcoidosis in the same patient is very rare. Because sarcoidosis usually presents as mediastinal lymphadenopathies, this concurrence in a lung cancer patient detected radiologically is apt to be misunderstood to be mediastinal metastases, and it is thus considered to be an unresectable disease. We report a case of lung cancer associated with sarcoidosis that developed in a 65-year-old woman who underwent surgery. Radiological studies revealed a 1.9×1.7 cm mass in the left upper lobe with multiple enlarged bilateral mediastinal lymph nodes (2R, 3a, 4R, 4L, 5, 6, 7, 8R). Pathologic findings showed that the mass was a well-differentiated adenocarcinoma and all of the enlarged mediastinal lymph nodes were granulomas without cancer metastasis. We report this case with a review of the literature.