Fine needle aspiration biopsy of tuberculous cervical lymphadenopathy

Fine needle aspiration biopsies of 42 histologically confirmed tuberculous cervical lesions were studied. Thirty-four patients had subsequent excision of cervical lymph nodes and eight had incision and drainage of cervical abscesses. All aspirates except two (which were inadequate) were satisfactory for diagnosis and contained inflammatory cells. Twenty-seven smears revealed cells typical of granulomatous lymphadenopathy, that is, epithelioid and multinucleated giant cells. Of all aspirates, 17 smears had bacteriological staining by Ziehl-Nielsen technique, nine of which (53%) were positive for acid-fast bacilli. An aspiration biopsy diagnosis of granulomatous or tuberculous cervical lymphadenopathy was made in 30 patients (71%). In regions where mycobacterial infection is common, the presence of granulomatous changes in lymph node aspirates is highly suggestive of tuberculosis. When the aspirates contain purulent material or when tuberculosis is suspected, staining and culture for mycobacteria should be performed. FNA biopsy is a sensitive, specific and cost-effective way to diagnose tuberculous cervical lymphadenopathy and is recommended.     

Tuberculous cervical abscess: comparing the results of total excision against simple incision and drainage

In 40 patients with tuberculous cervical abscesses a prospective study was undertaken to determine the results of surgical treatment by either total excision or incision and drainage, together with 6 months of chemotherapy in both groups. While both procedures were well tolerated, the results showed that 17/22 (77 per cent) of those having a simple drainage procedure required a second operation to excise the residual infected lymph glands because of persistent sinus discharge, recurrent abscesses or enlarging lymphadenopathy. In contrast, 17/18 (94 per cent) of those having total excision as the primary procedure had no local ward problem afterwards. Most of the patients remained asymptomatic after completion of the chemotherapy but small painless lymph nodes might still be palpable during follow-up at 2 years.     

Peripheral lymph node tuberculosis: a review of 80 cases

One hundred and ninety-two patients with peripheral lymphadenopathy were screened and 80 patients with tubercular lymphadenitis were studied. Their ages ranged from 1 to 65 years; most were younger than 30 years and there was a slight female preponderance (1.2:1). Seventy per cent of patients were of low socioeconomic status. Of the 80 patients, 56 had affected cervical nodes, seven had inguinal nodes, five had axillary nodes and 12 had multiple sites of lymph node involvement. All had enlarged nodes which were matted in 44 cases and discrete in 18 cases, while the rest had either an abscess or a discharging sinus. Fifty-nine cases (74 per cent) showed a positive Mantoux test and four cases (5 per cent) had associated pulmonary tuberculosis. Fine needle aspiration cytology gave a positive diagnosis in 66 cases (83 per cent). Fifty-two cases showed a positive culture for Mycobacterium tuberculosis of human type in Lowenstein-Jensen medium. Short-term chemotherapy (9 months) consisting of rifampicin, isoniazid and ethambutol gave an excellent result. Surgery was not required in any of the cases.     

Lymph node metastasis from melanoma with an unknown primary site

Twenty-six patients, treated surgically between 1961 and 1986 because of lymph node metastasis from melanoma with an unknown primary, were analysed. Six patients had a history of spontaneous regression of a skin lesion. Following node dissection, the overall actuarial disease-free survival rate was 49 per cent, after both 5 and 10 years. When considered as single factors, female (versus male), one lymph node involved (versus more than one node involved) and site of metastasis in the groin or axilla (versus the neck) were found to have significantly favourable effects on prognosis with 5-year survival rates of 82 per cent (25 per cent), 82 per cent (27 per cent) and 80 per cent (11 per cent) respectively. However, at multifactorial analysis only the site of cervical metastases maintained a significant influence on survival (P = 0.005). As survival in this series is comparable with, or even better than, that of adequately treated patients with lymph node metastasis from a known primary melanoma, a radical node dissection is essential also in these patients.     

Immunohistochemical demonstration of prostatic origin of metastases

An immunoperoxidase technique for prostate specific acid phosphatase was performed on 14 lymph node metastases of prostatic carcinoma and 13 cases of metastatic adenocarcinoma from other primary sites. Eleven metastatic prostate carcinomas showed diffuse strongly positive immunostain and one showed focal weak positivity. Two prostatic and all other metastatic carcinomas were negative. Thus, the method is found to be extremely specific (100 per cent) and to show a high degree of sensitivity (86 per cent) for the demonstration of the prostatic origin of lymph node metastases.     

Efficacy of routine preoperative computed tomography scans in colon cancer

A retrospective review of 180 patients who underwent surgery for primary colon carcinoma from August 1989 to August 1994 was performed to evaluate the necessity of preoperative CT scans in patients with known colon cancer. Sixty-seven patients had preoperative CT scans. Data were collected to evaluate the ability of the scan to detect hepatic metastases, lymph node involvement, and incidental findings that would possibly alter the planned surgical approach. In this study, CT had a sensitivity and specificity of 75 per cent and 88 per cent, respectively, in detecting hepatic metastases. Only 19 per cent of patients with lymph node involvement were correctly staged with CT scans as having lymphadenopathy. Only 3 of 67 patients had incidental findings on CT scans that ultimately changed the surgical approach. It is apparent that because CT scans detect only 75 per cent of hepatic and 19 per cent of hepatic and lymph node involvement and does not seem to alter the planned approach, it is not justified for routine preoperative evaluation of all patients. We, therefore, recommend a more selective approach to patients suspected of having advanced disease if the surgeon suspects that the information may alter the surgical approach.     

Correlation between prognosis and degree of lymph node involvement in carcinoma of the oral cavity

Accurate histologic determination of lymph node metastasis is most important in predicting prognosis in patients who undergo radical neck dissection. In this study of 340 determinate patients, the five year survival was 75 per cent when lymph nodes were histologically negative, 49 per cent when one lymph node was positive, 30 per cent when two lymph nodes were positive, and 13 per cent when three or more nodes were positive.     

Axillary lymph node dissection in breast cancer: an evolving question?

Axillary lymph node dissection (ALND) is performed for staging purposes. Sentinel lymph node biopsy may decrease the cost and morbidity of ALND. Are there patients that the procedure is not indicated avoiding cost and morbidity? We retrospectively studied the incidence of lymph node metastasis in 423 patients with T1 breast cancer. Thirty-one T1a, 146 T1b, and 246 T1c tumors were seen. The mean age was 61 years. Ten per cent were premenopausal, and 84 per cent were postmenopausal. Tumor size averaged 1.29 cm. Eighty-one per cent of the tumors were node negative and 19 per cent were node positive. One T1a patient (3 per cent) had an axillary metastasis, 19 T1b patients (13%), and 61 T1c patients (25%) were node positive, respectively. Seventy-three per cent were ER positive. Thirty-three patients (8%) died from cancer. Eighty-seven per cent received surgery with axillary lymph node dissection (ALND), and three per cent had surgery without ALND. Younger age, increased tumor size, premenopausal status, and ER negativity affected node positivity rates (P < 0.05). Death from breast cancer was more common among node-positive patients (P < 0.05). No difference was found regarding the performance of ALND and survival (P > 0.05). We feel that ALND can be safely omitted in T1a to reduce the morbidity and the expense of breast cancer treatment. In T1b and T1c tumors, the use of ALND is necessary, but morbidity and cost can be reduced by the use of sentinel lymph node biopsy.     

Radical mastectomy with parasternal node dissection or radiation to the parasternal region for breast cancer of medial or central location

In order to establish a therapeutic approach for primary breast cancer of medial and central origin, we reviewed 183 patients who had been treated by one of the following three modalities at the Second Department of Surgery, Osaka University Medical School between January, 1965 and December, 1980. Group A (n=70): standard radical mastectomy alone; Group B (n=34): standard radical mastectomy followed by postoperative irradiation to the parasternal and supraclavicular regions, and; Group C (n=62): extended radical mastectomy that included removal of the parasternal lymph nodes. The background factors of the three groups were not significantly different. The overall survival five and ten years following surgery in the three groups were 91 per cent and 79 per cent in group A, 82 per cent and 67 per cent in group B, and 82 per cent and 70 per cent in group C, respectively, showing no significant difference in overall survival among the three groups. When the patients were classified according to the extent of axillary lymph node involvement, there was no difference in survival among the three treatments in patients who had less than three lymph node metastases in the axilla. However, treatment of the parasternal lymph nodes improved survival in the patients who had more than four lymph node metastases in the axilla. Parasternal lymph node involvement definitely worsened the prognosis, showing it to be a good prognostic factor. Thus, extended radical mastectomy should be considered for patients with breast cancer of medial or central location, when extended axillary lymph node involvement is found.     

Surgical biopsy for persistent generalized lymphadenopathy

Lymph node biopsy was performed in 39 homosexual men with unexplained persistent generalized lymphadenopathy (PGL). Thirty-seven (95 per cent) of these patients had antibodies to human T-lymphotropic virus type III (HTLV-III), at the time of biopsy. Histology in all but one showed only follicular hyperplasia, the exception showed caseating granulomata typical of tuberculosis. Clinical differentiation between lymphadenopathy associated with HTLV-III and other causes of generalized lymphadenopathy is difficult; however, the presence of antibodies to HTLV-III probably identifies patients in whom surgical biopsy will only occasionally reveal a specific histological diagnosis. It is suggested that the presence of antibodies to HTLV-III in patients with PGL justifies a more selective approach to lymph node biopsy.     

Correlation of serum tumor markers and lymphangiography with degrees of nodal involvement in surgical stage II testis cancer

There were 60 patients at our cancer center who underwent serum tumor marker studies (beta subunit of human chorionic gonadotropins and alpha-fetoprotein) and pedal lymphangiography before retroperitoneal lymph node dissection. Surgical stage II cases were divided according to tumor, node and metastasis staging. Beta-human chorionic gonadotropin and/or alpha-fetoprotein was elevated in 9 per cent (1 of 11) and the N1 cases, 36 per cent (5 of 14) of the N2A cases, 50 per cent (13 of 26) of the N2B cases and 89 per cent (8 of 9) of the N3 cases. Lymphangiography was positive or suspicious in 9 per cent (1 of 11) of the N1 cases, 36 per cent (5 of 14) of the N2A cases, 46 per cent (12 of 26) of the N2B cases and 56 per cent (5 of 9) of the N3 cases. Serum tumor markers and lymphangiography combined suggested lymph node metastases in 18 per cent (2 of 11) of the N1 cases, 50 per cent (7 of 14) of the N2A cases, 73 per cent (19 of 26) of the N2B cases and 100 per cent (9 of 9) of the N3 cases. We conclude that tumor markers and lymphangiography measurements are equally effective in the diagnosis of retroperitoneal lymph node metastases and that diagnostic accuracy is enhanced significantly by combining these 2 modalities. Retroperitoneal lymph node dissection remains the most reliable staging procedure. Reports of the accuracy of clinical staging should be correlated with subcategories of stage II disease.     

Diagnosis and treatment of isolated tuberculous mediastinal lymphadenopathy in adults.

OBJECTIVE: To evaluate the diagnostic yield of bronchoscopy and mediastinoscopy in adults with isolated mediastinal tuberculous lymphadenitis and to assess the effect of antituberculous treatment. DESIGN: Prospective longitudinal cohort study of 34 patients with mediastinal tuberculous lymphadenitis followed for 6 to 19 months after completion of treatment. SETTING: Tertiary care hospital, Kuwait. PATIENTS: 34 consecutive patients who presented with isolated mediastinal lymphadenopathy from 1996 to 1998. INTERVENTIONS: Bronchoscopy and cervical mediastinoscopy for all patients. MAIN OUTCOME MEASURES: Diagnostic yield of bronchoscopy and mediastinoscopy, and the outcome of treatment in patients with tuberculous lymphadenopathy. RESULTS: The mean age was 35 years (range 15-58). The most common symptoms were cough, fever, and weight loss. The chest radiographs and computed tomograms showed abnormal mediastinal shadows with no evidence of parenchymal disease. All patients had right sided paratracheal lymphadenopathy. Tuberculin skin test gave a weal of >15 mm in 17 patients (50%). Sputum smears and cultures failed to grow acid-fast bacilli in any patient. Seven patients had an endobronchial abnormality and samples taken at bronchoscopy gave a definite diagnosis in 3 (9%). Paratracheal lymph node biopsy and culture by mediastinoscopy diagnosed tuberculosis in all cases. All patients were treated by a six month course of rifampicin and isoniazid supplemented initially by pyrazinamide for two months. Twenty-eight patients had a good response and the remaining patients were treated for a further 3 months. CONCLUSIONS: Bronchoscopy has a low diagnostic yield in mediastinal tuberculous lymphadenopathy in the absence of a parenchymal lesion. Mediastinoscopy is a safe but invasive procedure and provides a tissue diagnosis in most cases. Six months treatment with rifampicin and isoniazid supplemented initially by pyrazinamide is adequate treatment for most adults with tuberculous mediastinal lymphadenopathy.     

Surgeon-performed ultrasound in the management of thyroid malignancy

Surgeon-controlled real-time ultrasound (US) is a new adjunct in the management of patients with thyroid malignancy. The introduction of US as a routine evaluation tool has increased the recognition of nonpalpable thyroid cancers and cervical lymph node metastases. We report our experience and the change in management of patients with thyroid cancer due to the use of US. We reviewed the records of all patients undergoing neck operations for thyroid cancer since 2002. US was performed by a surgeon preoperatively in all patients and intraoperatively when non-palpable cervical lymph nodes were present. Suspicious nonpalpable thyroid nodules underwent US-guided fine-needle aspiration (FNA) for cytology. Seventy-two patients underwent operations for thyroid cancer. US influenced the management in 57 per cent (41/72) of patients. US was useful in 1) identification and guidance for the FNA of nonpalpable cancers in 28 per cent (20/72), 2) identification of nonpalpable nodules in the contralateral lobe in 38 per cent (27/72), 3) preoperative diagnosis of nonpalpable metastatic lymph nodes in 24 per cent (17/72), and intraoperative guidance for their excision. Surgeon-performed US changed and enhanced the pre- and intraoperative management in more than half the patients with thyroid cancer.     

Multiple sectioning and immunohistochemical staining of sentinel nodes in patients with breast cancer

BACKGROUND: The aim of the present study was to investigate whether focused analysis of sentinel nodes is more useful than routine haematoxylin and eosin examination of axillary lymph nodes obtained by axillary lymph node dissection. METHODS: One hundred and fifty-two patients with breast cancer with clinically negative axillary nodes underwent successful sentinel node biopsy using a combination of dye and radioisotope, followed immediately by standard level I and II axillary lymph node dissection. Multiple sectioning, with haematoxylin and eosin and immunohistochemical analysis of sentinel nodes using cytokeratin antibody, was compared with single section and haematoxylin and eosin analysis of sentinel and non-sentinel nodes (routine examination). RESULTS: A mean of 1.9 (range 1-12) sentinel nodes and 11.2 (range 4-24) non-sentinel nodes were excised per patient. Metastases were detected in 44 patients (29 per cent) by single section and haematoxylin and eosin analysis of sentinel and non-sentinel nodes. An additional five patients (3 per cent) with metastases were detected by multiple sectioning and haematoxylin and eosin analysis of sentinel nodes. A further 20 patients (13 per cent) with metastases were identified by multiple sectioning and immunohistochemical analysis of sentinel nodes. Both haematoxylin and eosin and immunohistochemical analysis of sentinel nodes missed one patient with node metastases, which led to a false-negative rate of 1 per cent. CONCLUSION: Multiple sectioning and immunohistochemical staining of sentinel nodes identified 16 per cent more patients with positive axillary lymph nodes than routine haematoxylin and eosin examination.     

Stage II nonseminomatous germ cell tumors of the testis: an analysis of treatment options in patients with low volume retroperitoneal disease

The management of patients with nonseminomatous germ cell tumors of the testis and low volume retroperitoneal disease remains controversial. We analyzed the treatment modalities of 56 patients divided into 3 groups: group I--18 clinical stage I cancer patients who had pathological stage II disease after retroperitoneal lymph node dissection, group II--31 patients with abdominopelvic computerized tomography abnormalities of 5 cm. or less with or without positive biological markers and group III--7 patients with persistently positive biological markers after orchiectomy with normal abdominopelvic computerized tomography scans. In group I 4 of 18 patients received chemotherapy after retroperitoneal lymph node dissection. Two patients met criteria for post-dissection chemotherapy, but they did not receive it and subsequently had relapse. Of the remaining 12 patients who were observed after dissection only 1 (8 per cent) had relapse. In group II 19 of 31 patients were treated with initial chemotherapy: 13 (68 per cent) achieved a complete response, while 6 required retroperitoneal lymph node dissection after chemotherapy. Of 31 patients 12 were treated with initial retroperitoneal lymph node dissection and 9 (75 per cent) received post-dissection chemotherapy. In group III 5 of 7 patients were treated with initial retroperitoneal lymph node dissection and 3 of the 5 subsequently required chemotherapy. Of the 7 patients 2 received initial chemotherapy and achieved a complete response. All 56 patients are without disease at 4+ to 106+ months (median 28 months). We conclude that patients with the characteristics of groups II and III should be managed initially with chemotherapy, with retroperitoneal lymph node dissection reserved for patients who fail to achieve a complete response. In group I retroperitoneal lymph node dissection is sufficient initial treatment if pathological evaluation of the retroperitoneal lymph nodes does not meet our criteria for post-dissection adjuvant chemotherapy.     

Cytoreductive surgery in disseminated non-seminomatous germ cell tumours of testis.

Between 1977 and 1988, 67 patients underwent surgical removal of residual metastatic deposits following an aggressive chemotherapy regimen (cisplatin, vincristine, methotrexate and bleomycin alternating with etoposide, actinomycin D and cyclophosphamide) for disseminated germ cell tumours of the testis (stage IIB or above). Ninety-one surgical procedures were performed. There were 63 (69 per cent) retroperitoneal lymph node dissections, 16 (18 per cent) thoracotomies, three (3 per cent) hepatic resections, three (3 per cent) craniotomies, five (5 per cent) delayed orchidectomies and one anterolateral decompression of the vertebral column. Nine (13 per cent) patients required a repeat retroperitoneal node dissection and one patient needed a repeat thoracotomy to remove recurrent metastatic deposits during the period of follow-up. Multivisceral resections and vascular reconstruction procedures were required in 20 (30 per cent) patients undergoing retroperitoneal node dissection. Fifty-five (82 per cent) patients remain in complete remission with a mean follow-up period of 49.6 months (range 2-121 months). Nine (13 per cent) patients died with metastatic disease between 2 months to 4 years after operation. There were three deaths in the perioperative period (4 per cent). The histology of the resected metastases revealed undifferentiated active tumour in 20 (30 per cent) patients, differentiated mature teratoma in 29 (43 per cent) patients and fibrosis/necrosis in 18 (27 per cent) patients. Twelve (60 per cent) patients with undifferentiated elements and 15 patients (60 per cent) with raised preoperative tumour markers (poor prognostic categories) are in complete remission. Cytoreductive surgery in patients with metastatic germ cell tumours offers the best chance of remission following chemotherapy even in poor prognostic group categories.     

Prediction of mediastinal lymph node metastasis in medullary thyroid carcinoma

BACKGROUND: Mediastinal lymph node metastases can be life threatening owing to their proximity to vital organs. Reliable identification of mediastinal metastasis is of utmost importance for timely mediastinal lymph node dissection, although suitable clinicopathological variables for their detection in patients with thyroid cancer have yet to be identified. METHODS: This was an analysis of 83 consecutive patients with radiological suspicion of mediastinal metastasis who underwent trans-sternal mediastinal lymph node dissection for node-positive medullary thyroid carcinoma between November 1994 and March 2003. RESULTS: Univariate analysis revealed that extrathyroidal extension (P < 0.001), distant metastasis (P = 0.001), the preoperative serum calcitonin level (P = 0.001), operation type (P = 0.004), contralateral cervicolateral metastasis (P = 0.016) and bilateral nodal metastasis (P = 0.031) were significantly associated with mediastinal involvement. Only extrathyroidal extension remained significant in a multivariate logistic regression analysis of mediastinal lymph node metastasis. Prediction of mediastinal metastasis by extrathyroidal extension was best at reoperation, with a specificity of 97 per cent and a positive predictive value of 88 per cent. CONCLUSION: Mediastinal lymph node dissection should be considered in patients undergoing reoperation for node-positive medullary thyroid carcinoma who have extrathyroidal extension and cervical lymph node metastases.     

Abdominal aneurysms in a black population: clinicopathological study

With exclusion of vascular trauma 2182 patients (1302 black and 880 white) have been treated in our Vascular Service over a period of 3 years. Sixty black patients (4.6 per cent) and 260 white patients (29.5 per cent) presented with aneurysms of the aorta and its abdominal branches. The aneurysms in the black group were distributed as follows: 50 aortic (9 suprarenal, 41 infrarenal), 6 common iliac artery, 2 superior mesenteric and 2 renal artery aneurysms. None of the 260 aneurysms seen in white patients involved arteries other than the aorta (16 suprarenal, 244 infrarenal). In the black group there was an almost equal distribution among sexes, whereas in the white group there was a male to female ratio of 2:1. The mean age was 49.4 years among the black patients, and 67.1 years among the white patients. Surgery was performed on 47 black patients and 245 white patients. Among the black patients 16 aneurysms were atherosclerotic (34 per cent), 22 were of non-atherosclerotic origin (47 per cent) and 9 were of uncertain nature (19 per cent). Of the 22 non-atherosclerotic aneurysms 14 were due to non-specific aorto-arteritis, 4 were due to tuberculous arteritis, 2 were due to intimomedial mucoid degeneration, 1 was due to syphilitic aortitis and 1 was a mycotic aneurysm. In the white group 243 aneurysms were atherosclerotic and 2 had changes of intimomedial mucoid degeneration. All aneurysms were treated along standard surgical lines, antituberculous treatment was initiated when appropriate. It was concluded that abdominal aneurysm is an uncommon disease in black patients. When it occurs a more heterogeneous pathology can be expected with an unusually high prevalence of aorto-arteritis compared with the white population.