Diagnosis of nasopharyngeal carcinoma metastatic to mediastinal lymph nodes by endoscopic ultrasonography-guided fine-needle aspiration biopsy

We report the case of a patient with nasopharyngeal carcinoma who was diagnosed as having metastasis in mediastinal lymph nodes and successfully underwent systemic chemotherapy without surgery. A 61-year-old male with a history of nasopharyngeal carcinoma presented with odynophagia. Examination revealed two palpable lymph nodes in the right neck. Pharyngoscopy showed a mass in the left inferior pharyngeal mucosa, and upper gastrointestinal endoscopy showed only chronic gastritis, with no sign of esophageal disease. Chest CT confirmed the presence of a non-enhancing 20-mm soft tissue mass in the paraesophageal area, with increased attenuation compared with the adjacent esophagus. To evaluate this lesion we applied endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA). Two passes were made with a 21-gauge fine needle and the patient tolerated the procedure well, without complications. Cytological findings were compatible with metastatic squamous cell carcinoma from a nasopharyngeal tumor, and the clinical stage was determined as T3N2bM1 (stage IVC) because of mediastinal lymph node metastasis. We thus determined the nodal status of a head and neck tumor by means of EUS-FNA. In conclusion, EUS-FNA is a safe and reliable technique for evaluation of mediastinal lymphadenopathy, and is especially valuable for head and neck tumors with suspected metastasis.     

Cutaneous squamous cell carcinoma metastatic to parotid-area lymph nodes

Introduction: Metastatic spread to parotid‐area lymph nodes (PALN) occurs in 1% to 3% of patients with cutaneous squamous cell carcinoma of the head and neck. Presented herein is the University of Florida experience using radiation therapy (RT) to treat patients with PALN metastases from a skin primary. Methods and Materials: From November 1969 to February 2005, 121 parotids in 117 patients received irradiation for nonmelanotic skin carcinoma metastatic to PALN. Patients were staged by the O'Brien staging system. Of the 121 parotids receiving RT, 17 (14%) were treated preoperatively, 87 (72%) postoperatively, and 17 with RT alone. Results: Five‐year actuarial probabilities of local (parotid) control, local‐regional control, disease‐free survival and overall survival were 78%, 74%, 70%, and 54%, respectively. When patients were separated by O'Brien P‐stage, statistically significant differences were seen among the groups for local (parotid) control, local‐regional control, and disease‐free survival. A statistically significant decrease in local control was seen in patients treated with positive surgical margins (92% vs. 76%) and in local‐regional control for patients treated with preoperative RT or RT alone when compared with postoperative RT (59% and 47% vs. 83%, respectively). The 5‐year actuarial probability of freedom from distant metastases was 92%. Three (2.6%) patients suffered severe complications. Conclusions: PALN metastases from a cutaneous head and neck primary site are best treated with surgery and postoperative RT. Our data support the hypothesis that the O'Brien staging system is superior to the American Joint Committee on Cancer system for the staging of cutaneous metastases to PALN. Positive surgical margins confer a worse prognosis in terms of local‐regional control and disease‐free survival. Patients treated with preoperative RT seem to have a worse prognosis than those treated postoperatively, likely a result of patient selection and the surgeon's inability to accurately assess viable tumor extent after preoperative RT. Severe complications are uncommon after surgery and RT for PALN metastases.     

甲状腺乳头状癌前上纵隔淋巴结转移临床病理特征初步分析

目的 探讨肿瘤位置、最大直径及甲状腺外浸等临床病理特征与甲状腺癌前上纵隔淋巴结转移的关系。 方法 研究分析初次手术治疗的60例甲状腺乳头状癌患者临床及病理资料,运用检验临床病理特征与前上纵隔淋巴结阳性率的相关性。 结果 肿块位置、最大直径、数量、腺体外侵、受累腺叶数及Ⅵ区淋巴结转移等特征,以及患者年龄等相关因素中,只有VI区淋巴结对前上纵隔淋巴结状态有影响;60例患者前上纵隔淋巴结转移率为10/60(16.67%)。相关因素的前上纵隔淋巴结转移率对比:≥55岁vs <55岁(20% vs 16.36%, P<0.05);肿块位于下极 vs 上极 vs 中极(P>0.05);最大直径≥1.5 cm vs 最大直径<1.5 cm(18.18% vs 15.79, P>0.05);单灶 vs 多灶(21.88% vs 10.71%, P>0.05);单叶 vs 多叶(17.5% vs 15%, P>0.05);男性vs女性(20% vs 15.55%, P>0.05); Ⅵ区淋巴结阳性vs 阴性(24.43% vs 3.57%, P<0.05); 结论 总体来说,甲状腺乳头状癌前上纵隔淋巴结转移率较低。本研究发现VI区淋巴结状态可能与前上纵隔淋巴结转移相关,未来仍需大样本前瞻性的研究验证。     

FNAC诊断甲状腺炎的临床评价

目的　评价甲状腺细针抽吸细胞学检查 (fine needleaspirationcytologyFNAC)在诊断亚急性甲状腺炎和桥本甲状腺炎中的作用。方法　对疑似甲状腺炎 12 0例采用血清T3 、T4、TSH检测加甲状腺核素扫描以及甲状腺FNAC两种方式检查 ,同时观察甲状腺针吸后的咽喉疼痛反应。结果　 12 0例甲状腺病变中 86例经FNAC确诊 ,其中亚急性甲状腺炎 4 0例、桥本甲状腺炎 4 2例、桥本甲亢 4例。甲状腺FNAC的敏感性、特异性和准确性分别为 95 .6 %、82 .6 %、92 .9%。甲状腺FNAC对甲状腺炎确诊数与同位素检查确诊数的差别有统计学意义(P <0 .0 1)。在疼痛组 4 5人和无痛组 75人中 ,针吸疼痛持续时间大于 4h的人数分别为 2 5例和 11例 ,两组针吸疼痛反应阳性人数的差别有统计学意义 (P <0 .0 1)。结论　甲状腺FNAC是诊断甲状腺炎的重要方法 ,但具有严重咽喉疼痛者不宜优先选择此法。     

Surgery and adjuvant radiotherapy in patients with cutaneous head and neck squamous cell carcinoma metastatic to lymph nodes: combined treatment should be considered best practice

OBJECTIVE: Patients with cutaneous squamous cell carcinoma (SCC) may develop metastatic SCC to nodes in the head and neck. Recent data support best outcome with the addition of adjuvant radiotherapy. This study aims to present further supportive evidence. STUDY DESIGN: Retrospective chart review. METHODS: Patients were identified with metastatic cutaneous SCC to nodes of the head and neck treated with surgery or surgery and adjuvant radiotherapy. Relapse and outcome were analyzed using Cox regression analysis. Disease-free survival and overall survival rates were calculated using Kaplan-Meier survival curves. RESULTS: Between 1980 to 2000, 167 patients were treated with curative intent at Westmead Hospital, Sydney. Median age was 67 years (range, 34-95) in 143 men and 24 women with a minimum follow-up of 24 months. Patients underwent surgery (21/167; 13%), or surgery and adjuvant radiotherapy (146/167; 87%). The majority (98/167; 59%) of metastatic nodes were located in the parotid and/or cervical nodes. The remaining 69 (41%) had metastatic cervical nodes (levels I-V). Forty-seven patients (28%) had recurrences, with the majority (35/47; 74%) as locoregional failures. On multivariate analysis, spread to multiple nodes and single-modality treatment significantly predicted worse survival. Patients undergoing combined treatment had a lower rate of locoregional recurrence (20% vs. 43%) and a significantly better 5-year disease-free survival rate (73% vs. 54%; P = .004) compared to surgery alone. CONCLUSIONS: In patients with metastatic cutaneous head and neck SCC, surgery and adjuvant radiotherapy provide the best chance of achieving locoregional control and should be considered best practice.     

Cutaneous head and neck squamous cell carcinoma metastatic to cervical lymph nodes (nonparotid): a better outcome with surgery and adjuvant radiotherapy

OBJECTIVE: The aim of this study is to report on the experience of treating cutaneous squamous cell carcinoma (SCC) metastatic to cervical (nonparotid) lymph nodes at the Head and Neck Unit, Westmead Hospital, Sydney, Australia. STUDY DESIGN: Retrospective chart review. METHODS: Patients diagnosed with previously untreated metastatic cutaneous SCC to cervical lymph nodes (levels I-V) and treated with radiotherapy, surgery, or surgery and adjuvant radiotherapy were identified. Relapse and outcome was analyzed using Cox regression analysis. RESULTS: Between 1980 and 2000, 74 patients were treated with curative intent. There were 59 males and 15 females, with a median age of 66 (range 37-93) years. Median duration of follow up was 48 (range 12-187) months. Fifty-two were treated with neck dissection and radiotherapy, 13 with neck dissection alone, and 9 with only radiotherapy. Most patients (85%) had an identifiable index lesion. Level I (38%) and II (36%) lymph nodes were the most often involved. In total, 25 (34%) patients developed recurrent disease, predominantly locoregional (22 of 25). Median time to recurrence was 5.2 (2-34.3) months. Increasing nodal size (> or =3 cm) (P =.01), metastatic spread to multiple nodes (P =.05), and the presence of extranodal spread (P =.01) all predicted for worse survival. Patients undergoing combined modality treatment had a lower relapse rate (15%) and a significantly better disease free survival (P =.001) compared with single modality treatment. CONCLUSION: Metastatic cutaneous SCC is uncommon but potentially lethal. Surgery and adjuvant radiotherapy remain the best practice and provide the best chance of achieving locoregional control.     

Bacteriology of normal and diseased tonsils assessed by fine-needle aspiration: Haemophilus inf luenzae and the pathogenesis of recurrent acute tonsillitis

The pathogenesis of recurrent tonsillitis is largely unknown. Selection of appropriate antibiotic therapy for patients with recurrent tonsillitis is difficult because of the limitations of traditional methods of sampling tonsillar microflora and the increasing incidence of β-lactamase producing bacteria in the tonsil. In addition, little attention has been paid to the bacteriology of normal tonsils. The tonsil core bacteria was assessed in 124 patients with recurrent acute tonsillitis. Fifty-five of these patients were randomly selected for fine-needle aspiration which revealed a similar profile of bacteria in 85%. Fine-needle aspiration of 10 normal tonsils found few pathogens; the predominant organisms being normal flora. No Haemophilus influenzae were detected in this control group. This study demonstrates the accuracy of fine-needle aspiration in identifying tonsil core bacteriology and its suitability in the clinical setting. It reports on the flora of normal healthy tonsils and it highlights the association between H. influenzae and recurrent acute tonsillitis.     

Fine-needle aspiration biopsy findings suspicious for papillary thyroid carcinoma: a review of cytopathological criteria

OBJECTIVES/HYPOTHESIS: The objective was to evaluate the usefulness of standard suspect cytological features on fine-needle aspiration biopsy (FNAB) in predicting papillary thyroid carcinoma. STUDY DESIGN: Retrospective chart review of consecutive fine-needle biopsies of the thyroid. METHODS: The study was a retrospective review of consecutive patients presenting with a diagnosis of suspected (group 1) or positive papillary thyroid carcinoma (group 2). The frequency of standard cytological features (i.e., papillary architecture, multinucleated giant cell, nuclear pseudo-inclusions, nuclear grooves, micronucleoli, powdery chromatin, and psammoma bodies) were recorded for each group. These were compared using chi test. Sensitivity and specificity for both individual and a combination of features were calculated for patients in group 1. RESULTS: One hundred eight patients were eligible for the study (group 1, n = 57; group 2, n = 51). Fifty-one patients (89%) in group 1 and all patients in group 2 had a histopathological diagnosis of papillary thyroid carcinoma. Respectively, the most frequent features present on fine-needle aspiration biopsy in group 1 versus group 2 were nuclear grooves (79% vs. 88%), micronucleoli (74% vs. 86%), pseudo-inclusions (58% vs. 88%), and powdery chromatin (47% vs. 59%); P values for these features were P > .05, P > .05, P < .05, and P > .05, respectively. In group 1, the sensitivities of nuclear grooves and micronucleoli were 80% and 71%, respectively. The presence of psammoma bodies was associated with a specificity of 100%. A combination of nuclear grooves, micronucleoli, pseudo-inclusions, powdery chromatin, and multinucleated giant cells was 100% specific in detecting papillary thyroid carcinoma. CONCLUSION: In choosing the most appropriate management of a finding suspect for papillary thyroid carcinoma on fine-needle aspiration biopsy, the surgeon must be aware of the diagnostic importance of certain cytopathological features. The presence of a combination of these factors may allow a more confident surgical approach.     

Risk factors and distribution features of level IB lymph nodes metastasis in nasopharyngeal carcinoma

Objective

The objective of this study is to investigate the risk factors and distribution features for level IB metastasis in nasopharyngeal carcinoma (NPC) and provide clinical evidence for defining the indications and clinical target volume (CTV) of prophylactic level IB irradiation.

The density of metastatic lymph node as prognostic factor in squamous cell carcinoma of the tongue and floor of the mouth

The presence of metastatic lymph nodes is a relevant prognostic factor in oral cancer.ObjectiveThis paper aims to assess metastatic lymph node density (pN+) in patients with tongue and floor-of-mouth squamous cell carcinoma (SCC) and the association of this parameter with disease-free survival (DFS).Materials and MethodsA group of 182 patients seen between 1985 and 2007 was included, 169 of which were males. Five were on stage I, 35 on stage II, 56 on stage III, and 85 on stage IV. Median values were considered in lymph node density assessment, and the Kaplan-Meier curve was used to evaluate DFS; survival differences within the group were elicited through the log-rank test.ResultsAn average 3.2 metastatic lymph nodes were excised from the patients in the group. Density ranged from 0.009 to 0.4, with a mean value of 0.09. Five-year DFS rates were of 44% and 28% for the groups with lymph node densities below and above the median respectively (p = 0.006). Two-year local/regional control was achieved for 71% and 49% for the patients below and above the median density respectively (p = 0.01). In terms of pN staging, local/ regional control was achieved in 70% and 54% of pN1 and pN2 patients respectively, albeit without statistical significance (0.20%).ConclusionLymph node density may be used as a prognostic indicator for tongue and floor-of-mouth SCC.     

不同浓度和剂量3种示踪剂应用于甲状腺前哨淋巴结活检的实验研究

目的:通过应用不同浓度和剂量的异硫蓝(IB)、专利蓝(PB)及美蓝(MB)于兔甲状腺,观察其在兔甲状腺前哨淋巴结(SLN)活检中的作用,为甲状腺癌患者SLN活检示踪剂的选择提供实验依据。方法:36只成年兔随机分为9组,每组4只。分别将1%-0.01ml,1%-0.02ml,2%-0.02ml的IB、PB、MB注入各组兔甲状腺左右叶,观察SLN的染色枚数,显色时间及明显、完全褪色时间。结果:9组实验中每侧兔颈部检出的SLN在1～3枚之间,9组间差异无统计学意义。9组实验中,SLN平均显色时间最短为2%MB0.02ml组,6.3s;平均明显褪色时间最长为2%MB0.02ml组,28.2min;1%MB0.02ml组与2%MB0.02ml组观察至40min后染色SLN仍可辨别。结论:2%MB0.02ml注射时,SLN染色较深,显色较快,褪色时间较长,为甲状腺SLN活检应用较佳的示踪剂。     

A retrospective study of dual-energy CT for clinical detecting of metastatic cervical lymph nodes in laryngeal and hypopharyngeal squamous cell carcinoma

Conclusion: After the reconstruction of imaging in dual-energy CT gemstone spectral imaging, the ratio of the two slopes curves, the target lymph node and primary lesion, respectively, might contribute to the clinical diagnosis of cervical lymph nodes in laryngeal and hypopharyngeal squamous carcinoma. Objective: To investigate the value of the dual-energy CT gemstone spectral imaging for clinical detecting of metastatic cervical lymph nodes in laryngeal and hypopharyngeal squamous carcinoma. Methods: Forty-seven cases who were suffering from laryngeal or hypopharyngeal squamous carcinoma and had complete clinical and pathological data were included, and 79 cervical lymph nodes were studied retrospectively (including 31 metastatic nodes and 48 non-metastatic nodes). Contrast-enhanced energy spectral imaging and reconstruction were performed. After the reconstruction, the slope of the curve in the target lymph node and the lesion were calculated. The ratio of the two slopes was studied. The pathological data of cervical lymph node and primary lesion were also collected. Results: The ratios were 1.20 ± 0.09 and 0.82 ± 0.12 in metastatic and non-metastatic lymph nodes, respectively. The difference was statistically significant (p < 0.05). The ratio was positively correlated to the stasis of lymph nodes only, rather than their morphological appearance, the pathological classification, or the individual difference (p < 0.05).     

荧光探测法探测兔甲状腺前哨淋巴结

目的 通过将荧光示踪剂吲哚花青绿(indocyanine green,ICG)及其与小牛血清白蛋白( calf serum albumin,CSA)的复合体ICG:CSA注射入兔甲状腺中,观察其探测兔甲状腺前哨淋巴结的效果,为使用荧光探测法探测甲状腺癌患者的前哨淋巴结提供动物实验依据.方法 将35 nmol/L的ICG 1 ml和35 nmol/L的ICG:CSA 1 ml进行荧光成像,记录两者的荧光总量.20只实验兔单纯随机抽样方法分为两组,每组各10只实验兔,分别注射100 nmol/L ICG和35 nmol/L ICG:CSA 0.02 ml于兔单侧甲状腺组织内.再对该20只实验兔同侧甲状腺内注射美蓝0.02 ml.观察注射ICG、ICG:CSA和美蓝后前哨淋巴结的检出情况.结果 同等浓度和剂量的ICG:CSA溶液的荧光总量为ICG溶液的3倍.注射ICG和ICG:CSA的20只实验兔均有前哨淋巴结被检出,注射美蓝后有16只实验兔前哨淋巴结被检出.荧光探测法和美蓝探测法的准确率分别为95.8％和79.2％.结论 ICG和ICG:CSA作为荧光示踪剂探测兔甲状腺的前哨淋巴结具有满意的检出率.荧光探测法探测甲状腺前哨淋巴结具备在未来应用于临床的可能.     

Use of low-dose technetium Tc 99m sulfur colloid to locate sentinel lymph nodes in melanoma of the head and neck: preliminary study

OBJECTIVES/HYPOTHESIS: Because sentinel lymph nodes are the first lymph nodes that drain a primary cancer site, results of sentinel lymph node (SLN) biopsy indicate status of the regional lymph nodes. Preoperative lymphoscintigraphy and intraoperative combined application of the handheld gamma probe and blue-dye technique (i.e., the "combined technique") was used previously to accurately identify the SLN, mostly in melanoma of the extremities and trunk and, sometimes, in melanoma of the head or neck, which is anatomically complex. Because of this complexity, melanoma in the head or neck is inherently problematic to treat: Localization of the SLN can be difficult or impossible because the primary cancer site can be near or overlapping the nodal basin. The objective of the present study was to determine the technical modifications and other considerations that can make SLN localization feasible in cases of melanoma occurring near or overlapping the nodal basin in the head or neck. STUDY DESIGN/METHODS: In a retrospective study of clinical records containing our database of melanoma diagnoses made between January 1996 and December 1999, we identified 27 patients diagnosed with stage I or II primary melanoma of the head or neck with clinically negative neck nodes who also had had preoperative lymphoscintigraphy. Of the 27 patients (17 male and 10 female patients; mean age, 54 y), 24 had SLN biopsy by intraoperative localization using both the handheld gamma probe and the blue-dye technique. RESULTS: Among the 27 patients who had SLN mapping, a median Breslow thickness of 1.8 mm was noted. Sentinel lymph node was noted at preoperative lymphoscintigraphy in 26 (96%) of the 27 patients. Activity of technetium Tc 99m (Tc-99m) sulfur colloid injected ranged from 10 to 1000 microCi (0.37 to 37 megabecquerel [MBq]). Intraoperative use of the combined technique for sentinel lymphadenectomy was successful in 92% of patients. Sentinel lymph nodes were identified in all 14 patients who received Tc-99m sulfur colloid at an activity level less than 60 microCi (2.2 MBq); mean activity level of injected TC-99m sulfur colloid was 28 microCi (1.04 MBq). Sentinel lymph nodes were identified in 8 (80%) of 10 patients who received Tc-99m sulfur colloid at an activity level greater than 100 microCi (3.7 MBq); mean activity of injected Tc-99m sulfur colloid in these patients was 482 microCi (17.8 MBq). A mean number of 1.4 sentinel lymph nodes per patient was identified at preoperative lymphoscintigraphy, and a mean number of 3 sentinel lymph nodes per patient was identified intraoperatively using the combined technique. Tumor recurrence was seen in 2 (10%) of the 19 patients who had cancer-free SLN at mean follow-up of 18 months (range, 1 to 47 mo). Sentinel lymphadenectomy of the parotid region did not injure the facial nerve in any patients. CONCLUSIONS: For patients with primary melanoma that is near or overlaps the nodal basin in the head or neck, SLN biopsy can be accurately performed using Tc-99m sulfur colloid at low activity levels (10 microCi to 60 microCi [0.37 to 2.2 MBq]. However, background radiation from the primary injection site can incorporate the SLN, making localization at preoperative lymphoscintigraphy difficult if not impossible; therefore, the high doses commonly used for melanoma of the extremities and trunk (500 to 2000 microCi [18.5 to 74 MBq]) should not be used for melanoma of the head or neck if the primary site is near or overlaps the nodal basin. In addition, absorption of Tc-99m sulfur colloid by salivary glands increases background radiation in the nodal basin; therefore, use of the handheld gamma probe for intraoperative localization of SLN can be problematic in regions where lymph nodes are adjacent to or within the substance of the salivary gland (i.e., the submandibular and parotid glands).     

Parapharyngeal metastasis from papillary thyroid carcinoma: a case diagnosed by thyroglobulin measurement in peroral fine-needle aspiration of a cystic metastatic lymph node

We report a case of a parapharyngeal cystic metastatic lymph node arising from papillary thyroid carcinoma (PTC). Parapharyngeal metastases arising from PTC are rare and correct diagnosis of the parapharyngeal mass before surgery is difficult. In this case, the diagnosis of a parapharyngeal mass was made pre-operatively by thyroglobulin measurement in peroral fine-needle aspiration with negative cytology.