Clinical analysis of intrapulmonary lymph nodes]

We encountered 12 cases (9 men, 3 women) of intrapulmonary lymph nodes, discovered by chest radiography or chest CT and identified by thoracoscopic lung biopsy (in 10 cases), open lung biopsy (1 case) or lobectomy (1 case). We also studied the literature related to intrapulmonary lymph nodes in Japanese. Many intrapulmonary lymph nodes were found in the lower lung field, few in the upper lung field. All intrapulmonary lymph nodes were spherical and were located under the pleura, but we were not able in some cases to differentiate them from malignancies by the CT scanfindings. We could not diagnose them or rule out malignancy before surgery. Pathological findings revealed that all of them showed anthracosis. Silicotic changes were found in three cases. We consider that thoracoscopy is useful in making a definite diagnosis if peripheral pulmonary lesions cannot be diagnosed. We emphasize that intrapulmonary lymph nodes should be taken into consideration in differential diagnoses of small nodular lesions in the lung.     

Three cases of small intrapulmonary lymph nodes coincidental with primary lung cancer]

We report three cases of intrapulmonary lymph nodes coincidental with primary lung cancers. In the first case, a 56-year-old man had a small subpleural nodule in the right lower lobe associated with adenocarcinoma of the right upper lobe. The small nodule was 10 mm in diameter and was difficult to differentiate radiologically from intrapulmonary metastasis. Wedge resection of this small nodule was performed. Histologic examination of the nodule revealed an intrapulmonary lymph node with anthracotic pigmentation. A right upper lobectomy for adenocarcinoma was performed, and was completely curative. The second patient, a 77-year-old woman, had adenocarcinoma in the right lower lobe diagnosed by transbronchial biopsy. Computed tomography (CT) revealed a small nodule 5 mm in diameter in the right upper lobe. Histologic examination of the small wedge-resected nodule revealed a lymph node. Lower lobectomy was performed with completely curative results. In the third case, a 63-year-old man was admitted for investigation of a mass shadow in the right upper lobe. CT showed a small nodular shadow in the right middle lobe, confirmed histologically to be lymphoid tissue, in addition to the original mass, which was diagnosed by transbronchial biopsy as squamous cell carcinoma. Upper lobectomy was performed and proved to be curative. Small intrapulmonary lymph nodes are very difficult to diagnose by methods other than surgical resection. When a small intrapulmonary nodule is detected in a patient with primary lung cancer, the presence of an intrapulmonary lymph node must be considered. If radiological characters compatible with an intrapulmonary lymph node are found and there is no other metastasis indicating poor prognosis, it should be considered as a possible indication for surgical resection.     

Five patients with intrapulmonary lymph nodes indistinguishable from small peripheral carcinoma of the lung]

We encountered 5 patients with subpleural intrapulmonary lymph nodes. In all 5 patients, computed tomographic (CT) scans demonstrated subpleural small nodules in the middle or lower lung lobes. Because lung cancer could not be ruled out, biopsies by video-assisted thoracic surgery (VATS) were performed, yielding a diagnosis of intrapulmonary lymph nodes in all 5 cases. Two of the patients were women and nonsmokers. Sharply defined borders and subpleural locations were the characteristic CT findings for the intrapulmonary lymph nodes. However the borders of some of the nodules were irregular. Small peripheral lung cancer is also sometimes characterized by sharply defined borders and subpleural locations. For this reason, it is difficult to differentiate between intrapulmonary lymph nodes and small peripheral lung cancer on the basis of CT findings alone. VATS should be readily employed for diagnostic purposes in such cases.     

Churg-Strauss syndrome with pulmonary eosinophilia and intrapulmonary lymph nodes 2 years before the onset of vasculitis]

We report a case of a 55-year-old man who had been treated for bronchial asthma diagnosed at the age of 51. One year following diagnosis, chest X-ray films disclosed nodular shadows. Biopsy specimens obtained by video-assisted thoracoscopic surgery were histopathologically identified as intrapulmonary lymph nodes. Three years after the initial diagnosis, the patient experienced sensory disturbance of the lower extremities, low-grade fever, and weight loss. At this point he was admitted to our hospital. On admission, physical examination and clinical investigations showed peripheral eosinophilia and signs of vasculitis. Specimens obtained by transbronchial lung biopsy and bronchoalveolar lavage showed strong evidence of tissue damage with infiltration of eosinophils but no evidence of necrotizing vasculitis or extra-vascular granuloma. Churg-Strauss syndrome (CSS) was diagnosed, and treatment was initiated with prednisolone at a dose of 60 mg/day. Except for the sensory disturbances in the lower extremities, after a few days of treatment the patient's symptoms subsided and his clinical data improved. This case was clinically important because pulmonary eosinophilic infiltration into vessel walls was confirmed a year after the diagnosis of bronchial asthma, and 2 years before the patient demonstrated signs of vasculitis. Further, it was a very rare case of CSS in which intrapulmonary lymph nodes had developed beneath the visceral pleura despite the absence of a history of heavy smoking, thus suggesting continuous stimulation by some as yet unknown antigen.     

CT features of intrapulmonary lymph nodes:a comparative study with pathology

正Objective To explore the CT features and pathology of intrapulmonary lymph nodes (IPLNs), so as to improve the understanding and diagnosis of IPLNs.Meth-o dsA total of 38 patients (49 IPLNs) confirmed by the surgery and pathology were retrospectively analyzed, including 21 males and 17 females with a mean age of(56±8) years. All the patients underwent MSCT scan and 1. 0 mm thin layer reconstruction before surgery.Double-blind method was used to analyze CT signs and the corresponding histopathological changes were compared.Results(1) Location:all IPLNs were located     

Peripheral subpleural intrapulmonary lymph nodes. Apropos of a clinical case and an anatomical case

The authors report the case of a round, peripheral radiographic opacity ("coin lesion" of English-language authors) which after surgical excision was found to be an intrapulmonary lymph node. In an anatomical study on the lymphatic drainage of pulmonary segments in adults, a similar lesion was found among 483 injected segments. A review of the literature yielded 27 similar cases which are described in detail. These lymph nodes are probably more frequent than is generally believed, as shown by an experimental radiolymphographic study. Such clinical findings will no doubt be rendered more numerous by the improved sensitivity of new medical imaging techniques. Despite hypotheses put forward by the authors, the presence of these lymph nodes, which seem to be acquired by the adult lung, has not yet been explained.     

Diffuse large cell lymphoma with spontaneous regression in the lung and lymph nodes. Case report]

An 84-year-old woman was admitted to our hospital because of swelling of the cervical lymph nodes and multiple tumorous lesions observed on radiographic studies. Transcutaneous lung biopsy was performed, but necrosis of the tissue was too marked to make a diagnosis. The diagnosis of diffuse large-cell lymphoma was made based on a biopsy of the pretracheal lymph node. During the first two months after admission, the left cervical lymph nodes and most of the pulmonary lesions regressed not withstanding of special treatment for lymphoma. The patient eventually died of generalized peritonitis. At autopsy, metastasis of systemic organs by malignant lymphoma was observed. Most of the lung regions were cicatrized, but clusters of atypical lymphocytes were observed in the necrotic tissue. The tumor in the mucosa of the small intestine showed necrosis, which accounted for the intestinal perforation. The total clinical course after admission was about six months. Spontaneous regression of diffuse large cell lymphoma is rare, and this is the second reported case in Japan.     

Case of autoimmune hepatitis with markedly enlarged hepatoduodenal ligament lymph nodes

Autoimmune hepatitis(AIH) is a necroinflammatory liver disease of unknown etiology.The disease is characterized histologically by interface hepatitis,biochemically by increased aspartate aminotransferase and alanine aminotransferase levels,and serologically by increased autoantibodies and immunoglobulin G levels.Here we discuss AIH in a previously healthy 37-year-old male with highly elevated serum levels of soluble interleukin-2 receptor and markedly enlarged hepatoduodenal ligament lymph nodes(HLLNs,diameter,50 mm).Based on these observations,the differential diagnoses were AIH,lymphoma,or Castleman’s disease.Liver biopsy revealed the features of interface hepatitis without bridging fibrosis along with plasma cell infiltration which is the typical characteristics of acute AIH.Lymph node biopsy revealed lymphoid follicles with inflammatory lymphocytic infiltration;immunohistochemical examination excluded the presence of lymphoma cells.Thereafter,he was administered corticosteroid therapy:after 2 mo,the enlarged liver reached an almost normal size and the enlarged HLLNs reduced in size.We could not find AIH cases with such enlarged lymph nodes(diameter,50 mm) in our literature review.Hence,we speculate that markedly enlarged lymph nodes observed in our patient may be caused by a highly activated,humoral immune response in AIH.     

Prognostic factors of curatively resected esophageal carcinoma associated with multiple metastatic lymph nodes

BACKGROUND/AIMS: Prognosis of esophageal carcinoma with multiple metastatic lymph nodes is dismal despite radical operation and adjuvant therapy. We investigated prognostic factors for curatively resected esophageal carcinoma with multiple positive nodes. METHODOLOGY: From January 1983 to December 2002, 343 patients with thoracic esophageal carcinoma underwent an esophagectomy with curative intent. Of these patients, 82 patients were associated with 4 or more histopathologically positive nodes. Of these patients, 59 patients underwent a curative resection. Of these 59 patients, 7 patients who died of postoperative complications during the hospital stay were excluded. Therefore, 52 patients were enrolled in this study. Survival curves were compared after stratifications according to 14 clinicopathologic variables. Independent prognostic factors were detected using a multivariate Cox proportional hazard model. RESULTS: The cumulative 5-year survival rate for the subjects was 10.6%. The factors affecting cumulative survival rate by a univariate analysis were intramural metastasis (absence vs. presence) (p=0.03), and postoperative therapy (performed vs. not performed) (p=0.02). A multivariate analysis detected the performance of postoperative therapy (Hazard Ratio= 0.390, p= 0.002) and the absence of intramural metastasis (Hazard ratio=0.429, p=0.01) as positive prognostic factors. CONCLUSIONS: The positive prognostic factors for esophageal carcinoma with multiple lymph node metastases were the absence of intramural metastasis and the performance of adjuvant therapy.     

Anterior diaphragmatic lymph nodes

In evaluating patients for malignant disease, involved or uninvolved anterior diaphragmatic lymph nodes (ADLNs) may be observed at computed tomography (CT) evaluation of either the chest or abdomen. While ADLNs have been described on both chest radiography and CT, lymph nodes lateral to the cardiophrenic angles have not been as well illustrated. In this review, we examine the anatomy of the entire group of ADLNs and emphasize the importance of the more laterally placed ADLNs. ADLNs were identified at CT in 125 patients. Lymphoma (41%) was the malignancy most commonly associated with enlarged ADLNs followed by breast cancer (12%), colon cancer (10%) and lung cancer (6%). Twenty other malignancies accounted for 30% of the series. ADLNs lateral to the cardiophrenic angles were half as common as the other ADLNs. Right-sided nodes were more common than left-sided ones. Of 71 patients with two or more CT scans, 53 showed change in size of the nodes on follow-up examination. Our data do not support prior reports that suggest that a particular site of origin of malignancy exclusively involves one side or other of the ADLNs. In our experience, knowledge of the location and appearance of the entire group of ADLNs, including those nodes lateral to the cardiophrenic angles, has been useful in planning radiotherapy portals in Hodgkin disease, as well as staging and follow-up of other malignancies.     

Endosonography of pararectal lymph nodes

One hundred thirteen patients with carcinoma of the rectum were evaluated for lymph node metastases by endorectal ultrasound. With the use of 7.5 MHz and based on different echo patterns, two main groups of lymph nodes can be differentiated: hypoechoic and hyperechoic lymph nodes. Compared with pathologic findings, hypoechoic lymph nodes represent metastases, whereas hyperechoic lymph nodes are visualized due to unspecific inflammation. Lymph node metastases can be predicted with a sensitivity of 72 percent and inflammatory lymph nodes with a specificity of 83 percent. The physical basis of the differentiation of lymph nodes was assessed in vitro by the determination of ultrasound parameters (speed of sound, acoustic impedance, attenuation, and backscattered amplitude). The attenuation coefficient of benign lymph nodes [2.5 dB/(MHz×cm)] is significantly higher than the mean value of lymph node metastases [1.3 db/(MHz×cm)]. The results demonstrate that involved nodes can principally be differentiated from not involved nodes. Micrometastases, mixed lymph nodes, and changing echo patterns within inflammatory nodes explain the accuracy rate of 78 percent.Supported by a grant from the Deutsche Forschungsgemeinschaft Hi 385/1-1     

Inflammatory pseudotumor of lymph nodes

A case of inflammatory pseudotumor in a 22-Year-old man is described. Symptoms and signs showed high fever and prominent cervical lymphadenopathy; laboratory findings were consistent with an acute inflammatory process. Diagnosis was reached through a lymph node biopsy which allowed a definitive diagnosis and ruled out several mimicking pathological processes such as malignant lymphoma, infectious diseases and autoimmune disorders. Inflammatory pseudotumor should be included in the differential diagnosis of patients with persistent fever and lymph node enlargement.