Surgical treatment for lung cancer with metastasis to mediastinal lymph nodes.

A series of cases of lung cancer were analyzed, with particular attention to the relationship between the presence of lymph node metastases and the prognosis for surgical intervention. The cases are classified into four clinical stages and a detailed classification of histologically proved lymph node metastasis and pleural involvement is presented. Results indicate that the presence of mediastinal lymph node metastasis, especially in cases with squamous-cell carcinoma and negative subcarinal lymph node, does not contraindicate surgical treatment.     

肺鳞癌、腺癌纵隔淋巴结转移的特点

目的 研究原发肺鳞癌及腺癌纵隔淋巴结转移特点,探讨临床意义.方法 对353例原发肺癌施行同侧纵隔淋巴结廓清术,病理检测淋巴结转移频度.结果 清除淋巴结2380组,平均每例6.74组.N2 淋巴结转移率16.2%.T1、T2、T3间淋巴结转移率差异有统计学意义(P<0.01).N2转移率在鳞癌、腺癌分别为30.1%、44.1%.64.2% 鳞癌N2转移为某一组淋巴结,腺癌3组以上转移者46.2%.上叶肺癌跨区域N2转移占15.1%,下叶(包括中叶)肺癌跨区域转移占53.1%.跳跃式转移占N2转移的53.7%.结论 肺鳞癌及腺癌纵隔淋巴结转移具有多发性、跳跃性及跨区域性特点.     

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.     

Mesangial proliferative glomerulonephritis with Legionnaires' disease. A case report

Although the clinical and biochemical features of renal involvement in Legionnaires' disease have been well described, only a few case reports detailed the histological changes. A patient with Legionnaires' disease who developed acute renal failure is described; a biopsy specimen revealed mesangial proliferative glomerulonephritis. The renal morphological changes in Legionnaires' disease are reviewed.     

Study of mediastinal lymph nodes in lung cancer using transesophageal ultrasonography]

Evaluation of mediastinal lymph nodes in patients with lung cancer is fundamental for their treatment and prognosis. Chest computed tomography (CT) is presently the most utilized diagnostic modality. In recent years endoscopic ultrasound (EUS) is being employed for this purpose. We retrospectively compared the results of CT and EUS staging of 35 selected patients with postsurgical stage. A total of 175 lymph node sites were examined. Results CT vs EUS were as follows: specificity 92% vs 98%, sensitivity 88% vs 84%, positive predicted accuracy 80% vs 96%, negative predicted accuracy 95% vs 94%, overall accuracy 92% vs 95%. The region most accessible by EUS evaluation were the paraesophageal lymph nodes; the most difficult were the right superior mediastinal nodes which cannot be imaged for anatomic reasons. EUS not only allows one to arrive at correct diagnosis with less false positive results, but also permits evaluation of lymph nodes which are not enlarged. We think that EUS, in combination with CT, is an appropriate modality for staging of mediastinal lymph nodes in patients with lung cancer.     

Imprint cytology for detecting metastasis of lung cancer in mediastinal lymph nodes

Background

Lymph node metastasis of lung cancer has been evaluated with histologic examination. We studied the usefulness of cytologic diagnosis for detecting metastasis of lung cancer in mediastinal nodes.

Methods

Five hundred twelve stations of mediastinal nodes in 157 patients with lung cancer were excised for staging of the disease through mediastinoscopy or thoracoscopy. Among them, 474 stations of mediastinal nodes in 151 patients were examined for metastasis both with imprint cytology and with hematoxylin-eosin histology independently. The final diagnostic decision was made by overall pathologic information, including cytology and histology. The diagnostic accuracies were compared between cytologic and histologic examinations.

Results

Cytologic examination identified 66 positive stations and 2 suspicious stations in 45 patients, whereas histologic examination identified 61 positive stations in 42 patients. The final pathologic diagnosis was 70 positive stations and 1 suspicious station in 45 patients. The sensitivity, accuracy, and negative predictive value of cytologic examination for node metastasis were 95.7%, 99.4%, and 99.3%, respectively, and those of histologic examination were 87.1%, 98.1%, and 97.7%, respectively. On a patient basis the sensitivity, accuracy, and negative predictive value of cytologic examination were 100%, 100%, and 100%, respectively, whereas those of histologic examination were 93.8%, 98.0%, and 97.2%, respectively. An additional 3 patients (2.0%) who had contralateral mediastinal node metastasis diagnosed only with cytology were identified with upstaged disease.

Conclusions

Imprint cytology for detecting metastasis of lung cancer in mediastinal nodes has high sensitivity and accuracy and is no less useful than histologic examination.     

Pathological assessment of mediastinal lymph nodes in lung cancer: implications for non-invasive mediastinal staging.

BACKGROUND: The use of computed tomography in mediastinal staging of lung cancer relies on the premiss that malignant lymph nodes are larger than benign ones. This hypothesis was tested by linking node size and presence or absence of malignancy and looking at factors possibly influencing the size of benign nodes. METHODS: All accessible mediastinal lymph nodes were taken from 56 consecutive patients with lung cancer who underwent thoracotomy. Nodes were measured and histologically examined. Resected cancer bearing lung from 44 of these patients was assessed for degree of acute and chronic inflammation. RESULTS: Lymph node size was not significantly related to the presence of metastatic disease, 58% of malignant and 43% of benign lymph nodes measuring over 15 mm. Similarly, there was no statistically significant relation between size of lymph nodes and the likelihood of malignancy, 20% of lymph nodes of 10 mm or more but also 15% of those less than 10 mm being malignant. Thresholds of 15 and 20 mm showed similar results. The maximum size of benign lymph nodes was significantly greater in those patients with histological evidence of acute pulmonary inflammation than in those without. CONCLUSIONS: The study shows that in patients with lung cancer (1) malignant mediastinal lymph nodes are not larger than benign nodes; (2) small mediastinal lymph nodes are not infrequently malignant; and (3) benign adenopathy is more common in patients with acute pulmonary inflammation.     

Tuberculoma of the mediastinal lymph nodes with spinal caries

A 65-year-old male presented with a chief complaint of back pain. Chest computed tomography (CT) demonstrated partially calcified enlargements of the anterior mediastinal lymph nodes and pleural effusion in both lungs. His spondylous lesion rapidly progressed and developed into quadriparesis approximately 2 months after he noticed the back pain. We could not determine whether the lesion was an invasion of the spinal cord by a carcinoma of unknown primary or malignant lymphomas. Therefore, we performed a lymph node biopsy using a thoracoscope for a definitive diagnosis. Histopathology showed tuberculoma with epithelioid cell growth and images of previous scars. However, the staining method for tubercle bacillus did not reveal the presence of tubercle bacillus. As in this case, not all cases of tuberculoma present tubercle bacillus. Therefore, even with poor, suspicious findings for tuberculosis, we should always consider tuberculosis. Old tuberculoma may relapse and rapidly progress. Therefore, we concluded that a biopsy should be performed when tuberculoma is suspected.     

A case of an anaplastic meningioma metastasizing to the mediastinal lymph nodes

Context: Grade II and III (World Health Organization classification) meningiomas rarely develop in the spinal cord. However, we experienced a case with an anaplastic meningioma that developed in the spinal cord at the cervicothoracic junction and metastasized to the mediastinal lymph nodes. No such cases have previously been reported.

Findings: The patient was a 68-year-old man who developed back pain that did not affect his daily living. He developed left lower limb paralysis, and was admitted after magnetic resonance imaging (MRI) revealed an intramedullary tumor at the level of cervical vertebra 7 and thoracic vertebra 1. Positron emission tomography revealed tracer uptake in the intramedullary tumor and the mediastinal lymph nodes, suggesting a metastatic spinal cord tumor or malignant lymphoma. A lymph node biopsy was then performed. Although the tumor was highly malignant, its primary site was not identified. Detailed examinations by several other departments revealed no abnormalities. On hospital day 30, his left lower limb paralysis deteriorated, and MRI revealed that the tumor had grown. Thus, laminaplasty, laminectomy, and tumor resection were performed. The tumor was an anaplastic meningioma that resembled mediastinal lymph node tissue, and other tumor lesions were not found. These findings suggested that an anaplastic meningioma had metastasized to the mediastinal lymph nodes. The patient did not respond to radiotherapy, and he was transferred to another hospital.

Conclusion: In cases of intramedullary spinal tumors with metastasis without other potential primary tumor lesions, early diagnosis and treatment should be performed while considering anaplastic meningioma.     

Computed tomography for evaluation of mediastinal lymph nodes in lung cancer: correlation with surgical staging

Computed tomography (CT) of the chest (late model) was done preoperatively in 56 candidates for resection of lung cancer. Precise borders for each node region were defined by the American Thoracic Society modification of the classification of the American Joint Committee for Cancer Staging and were used to "map" nodes seen on CT and nodes removed surgically. Metastatic involvement of mediastinal nodes was proven by mediastinoscopy in 11 patients; nodes were removed from multiple regions at thoracotomy in 45 patients. The mediastinum was clearly delineated by CT in 46 patients with determinate scans and was judged normal in 32 (CT-negative scans) and abnormal in 14 (CT-positive scans). A node was considered metastatically involved if it measured greater than 1.5 cm in diameter. Positive nodes were found at surgical staging in 3 of 32 patients with CT-negative scans and in all patients with CT-positive scans. Thus, for the 46 patients with determinate scans, sensitivity was 82%, specificity was 100%, and accuracy (true positive and true negative) was 93%. The high accuracy of CT in these patients suggests that mediastinoscopy is not necessary before thoracotomy in the patient with a CT-negative scan, but that for the patient with a CT-positive or CT-indeterminate scan, the indications for mediastinoscopy remain the same.     

Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer

Mediastinal lymph node status has important prognostic and therapeutic implications for nonsmall cell lung cancer patients. Consequently, an accurate pathologic assessment of mediastinal lymph nodes for metastasis is essential. Despite the significance of nodal assessment, practice patterns among surgeons vary widely. Therefore we reviewed the literature to provide evidence-based recommendations regarding the ideal means and extent of preoperative and intraoperative pathologic mediastinal lymph node staging in non-small cell lung cancer patients. We found that the most sensitive and accurate intraoperative method is a complete mediastinal lymph node dissection. Pathologic evaluation of at least 10 mediastinal lymph node from at least three stations should be performed at the time of surgery.     

Peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes

A 61-year-old man was pointed out a small peripheral lung nodule and mediastinal lymph node swelling on the chest computed tomography (CT). At the operation, it was diagnosed squamous cell carcinoma and right upper lobectomy and nodal dissection were done. The tumor was 9 mm in size and diagnosed as well differentiated squamous cell carcinoma with metastasis to mediastinal lymph nodes. Postoperative radiotherapy was done (50 Gy). The patient is doing well without apparent recurrence 33 months after surgery. We reported a case of peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes.     

Pulmonary hemangiopericytoma preoperatively diagnosed as mediastinal tumor; report of a case

An asymptomatic 67-year-old female was admitted because of an abnormal shadow on chest X-ray. Computed tomography (CT) revealed that a well-marginated round mass with low density, about 4 cm in diameter, was located in the right hilum. The border was enhanced at contrast material-enhanced CT. Magnetic resonance imaging (MRI) [T2-weighted] showed the lesion as a high intensity tumor. Because of the extra-pleural sign on CT and normal results of broncho-fiberscopic (BFS) examination, mediastinal tumor was suspected. We performed thoracoscopic surgery and revealed that the tumor was in lung, not in mediastinum. Biopsy of the easy-bleeding tumor was performed. The histopathological diagnosis was hemangiopericytoma. There was no remarkable change for 1 years. Hemangiopericytomas should be considered in the differential diagnosis of well-marginated masses. Thoracoscopic surgery is the useful methods to diagnose the hemangiopericytoma.     

Metastases to the mediastinal lymph nodes in a series of two-hundred-consecutive operations for primary lung cancer

We examined the characteristics of lymph nodes metastases to the mediastinum on cases of two-hundred-consecutive operations for primary lung cancer from October of 1987 to May of 1990, comparing the intraoperative macroscopic diagnosis of lymph nodes to the histologic reports. The purpose of this study is to know how important the mediastinal dissection is and how many cases resulting in vain are hidden behind it. Thirty three cases were excluded because of limited operation or other reasons. Remaining a hundred sixty seven cases were divided on the basis of lymph node metastasis into following 5 groups. Forty three cases (26%), of which N2 disease was correctly diagnosed macroscopically, true positive for N2, were classified into group A. Sixteen cases (10%), group B, in which we failed to detect N2 positive from dissected specimens during operation, was considered to be false negative for N2, thirty one cases of N1 disease (18%), were classified into group C and thirteen cases of N0 disease (8%) into group D with false positive of lymph node prediction for metastasis. Sixty four cases of N0 disease (40%) were classified into group E, true negative for N0 prediction, which were correctly detected by macroscopic appearance of lymph nodes. Nine cases had only mediastinal lymph nodes metastases without hilar and lobar lymph node. Almost of them with this skip phenomenon occurred in the patients with adenocarcinoma in the upper lobe. It could be concluded that we dissected the mediastinal lymph nodes in this series, salvaging one N2 disease of ten cases and wasting our efforts four cases of those cases, in vain.