胸部受累的巨淋巴结增生症10例临床分析

目的 提高对少见胸部受累的巨淋巴结增生症的认识,减少误诊,延长患者的生存期.方法 2000年1月至2006年5月对10例胸部受累的巨淋巴结增生症患者的临床表现、影像学、病理学、鉴别诊断、治疗及预后进行研究.结果 10例胸部受累的巨淋巴结增生症患者均为女性,其中5例多中心型患者的年龄为29～49岁,临床表现多样,外周淋巴结多处肿大伴多系统损害,影像学表现为间质性肺炎和纵隔淋巴结肿大,病理分型均为浆细胞型,给予糖皮质激素或化疗后4例部分缓解,1例死于心肺衰竭.5例局灶型患者的年龄为13～49岁,均无症状体征,实验室检查无异常,病灶均位于右侧纵隔,直径6～9 cm,病灶呈均匀显著强化,病理分型均为透明血管型,经手术切除肿块,5例随访均存活.结论 胸部受累的巨淋巴结增生症易误诊,有多发淋巴结肿大或局灶巨大淋巴结者应警惕该病的发生.诊断的关键在于早期多次、多部位淋巴结病理检查,与血管同步显著强化的影像学表现具有诊断价值.     

Successful Treatment of Chylothorax and Chylopericardium by Radiotherapy in Lung Cancer

A 58-year-old man was diagnosed with stage IVB lung adenocarcinoma in the right upper lobe and underwent systemic chemotherapy. Seven months after the diagnosis, large left pleural and pericardial effusion was detected. The patient developed both chylothorax and chylopericardium following superior vena cava (SVC) obstruction with mediastinal lymphadenopathy caused by lung carcinoma. Since conservative treatment of the chyle leakage was ineffective, we administered radiotherapy to treat the SVC obstruction and mediastinal lymphadenopathy. After radiotherapy, the chylothorax and chylopericardium gradually resolved, and no further chyle leaks were identified on follow-up computed tomography. This case indicates that radiotherapy can be used to ameliorate lung cancer-related chylothorax and chylopericardium.     

Mediastinal mass and hilar adenopathy. Rare thoracic manifestations of wegener's granulomatosis

Objective. To assess the frequency and characteristics of hilar and mediastinal involvement in patients with Wegener's granulomatosis (WG). Methods. A patient with WG presented with the unusual finding of a mediastinal mass, prompting a comprehensive review of 302 patient records from 2 WG registries to obtain evidence of hilar adenopathy or mediastinal masses. Clinic progress notes and findings of chest imaging studies (routine imaging and computed tomography) were reviewed for the presence of hilar lymphadenopathy, mediastinal masses, or mediastinal lymphadenopathy. All radiographs and surgical pathology specimens from these lesions were reviewed. Results. Six examples of mediastinal or hilar involvement (2.0%) were identified among 302 patients with WG. Three of these 6 patients had mediastinal masses. One patient with a mediastinal mass also had mediastinal lymphadenopathy. Two of the patients with mediastinal masses had lung parenchymal lesions. The remaining 3 patients had enlarged hilar lymph nodes in addition to pulmonary parenchymal lesions. All of the patients were treated with corticosteroids and cytotoxic drugs. Followup information was available on all patients. Two patients died. In the remaining 4 patients, the mediastinal mass or hilar lymphadenopathy decreased in size or resolved after 2 months of immunosuppressive therapy. Conclusion. In the past, hilar adenopathy and/or mediastinal mass have been considered unlikely features of WG, and their presence has prompted consideration of an alternative diagnosis. Although this caution remains valuable, the present retrospective review of data from 2 large WG registries illustrates that such findings may rarely be a part of the spectrum of WG chest disease. Because these findings are uncommon, they necessitate consideration of a primary or concurrent infection or malignancy in the diagnostic evaluation.     

Isolated primary oesophageal involvement by lymphoma: a rare cause of dysphagia: two case histories and a review of other published data.

Primary oesophageal involvement by lymphoma in two patients, one with Hodgkin's disease and one with non-Hodgkin's lymphoma is reported. In both, there were no manifestations of the disease outside the oesophagus, which is exceptionally rare. In the patient with non-Hodgkin's lymphoma, the oesophageal tumour was the first manifestation of lymphoma. Shortly after admission he developed a tracheo-oesophageal fistula from which he died before treatment could be started. In the patient with Hodgkin's disease, isolated oesophageal lymphoma was the first relapse after a 13 year interval free of disease. As he had previously received mediastinal irradiation he was treated with combination chemotherapy that resulted in long term survival (> five years). Several other long term survivors have been described but only after radiotherapy or surgery. These findings suggest that systemic chemotherapy may be equally successful in treating isolated primary oesophageal lymphoma, thus offering an alternative for those patients in whom local treatment is contraindicated.     

Endoscopic ultrasound‐guided fine‐needle aspiration when combined with positron emission tomography improves specificity and overall diagnostic accuracy in unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer

Background: The aim of this study was to assess the incremental value of endoscopic ultrasound (EUS)‐guided fine‐needle aspiration (FNA) to positron emission tomography (PET) in the diagnosis of unexplained mediastinal lymphadenopathy and staging of non‐small‐cell lung cancer (NSCLC). Methods: Patients who had both EUS‐guided FNA and PET were retrospectively identified from an EUS database at a tertiary hospital. All EUS‐guided FNA were carried out by one endoscopist between August 2002 and April 2005, either for the diagnosis of unexplained mediastinal lymphadenopathy or for the staging of NSCLC. Results of PET and EUS were compared with histology. A true histological positive result was defined as histological involvement in either surgery (mediastinoscopy or resection) or EUS‐guided FNA. A true histological negative result was defined as negative involvement at surgery (mediastinoscopy or resection). Results: Forty‐nine patients who had both PET scanning and EUS‐guided FNA for diagnosis of unexplained mediastinal lymphadenopathy or staging of NSCLC were identified. Of these, 33 (73% males, n = 24, age range = 44–78 years, mean = 62 years) had surgical confirmation of mediastinal lymph node pathology. In these patients, PET alone showed sensitivity, 95%; specificity, 90%; positive predictive value, 87%; negative predictive value, 90% and accuracy, 88%; whereas the addition of EUS‐guided FNA increased the overall specificity and positive predictive value to 100%, with an overall accuracy of 97%. Conclusions: This study suggests that EUS‐guided FNA complements PET by improving the overall specificity and thereby the accuracy for diagnosis of unexplained mediastinal lymphadenopathy. It provides a minimally invasive technique to assess the mediastinum in patients with NSCLC and is particularly valuable in cases in which PET findings are equivocal.     

An unusual presentation of oesophageal tuberculosis.

Oesophageal tuberculosis secondary to tuberculous mediastinal lymphadenopathy is a very unusual presentation of adult tuberculosis. We report a young patient who presented with anorexia and weight loss. The chest radiograph and CT scan revealed mediastinal lymphadenopathy causing extrinsic oesophageal compression on the barium swallow. This was confirmed by upper gastrointestinal endoscopy. Four weeks later, because of spontaneous partial relief in dysphagia, upper gastrointestinal endoscopy was repeated and revealed an ulcerated lesion with nodular margins at the mid-oesophagus. Biopsy from the ulcer margin revealed non-caseating granulomas. The patient had complete relief of dysphagia and other symptoms within 3 weeks of start of antituberculosis therapy.     

The value of roentgenographic and fiberbronchoscopic findings in predicting outcome of adults with lower lung field tuberculosis

Proper antituberculosis chemotherapy may not prevent occurrence or progression of endobronchial involvement in patients with pulmonary tuberculosis. We previously reported a higher incidence of endobronchial involvement in adults with lower lung field tuberculosis (LLFTB). We evaluated the value of roentgenographic and fiberbronchoscopic findings in predicting the outcome of adults with LLFTB after 9 months of antituberculosis chemotherapy. The most common change on chest roentgenograms among 101 patients with LLFTB was consolidation, followed by cavitary lesion, lung collapse, and solitary mass. Intrathoracic lymphadenopathy (hilar and/or mediastinal lymphadenopathy) was found in 12 cases. Sputum smear for acid-fast bacilli was positive in 64 patients, and sputum culture for tuberculous bacilli was positive in 37 of 50 patients. Endobronchial involvement was found in 45 of 63 patients who underwent fiberbronchoscopic examination. Of these 45, 18 had ulcerative granuloma, 12 had fibrostenosis, eight had submucosal infiltration, and seven had mucosal redness and swelling. A higher incidence of endobronchial involvement was found in the patients with LLFTB when they presented with roentgenographic findings of pulmonary consolidation, lung collapse, or associated intrathoracic lymphadenopathy. The outcome seemed unfavorable in the patients with LLFTB who presented with roentgenographic findings of lung collapse or pulmonary consolidation, or in those who presented with fiberbronchoscopic findings of fibrostenosis or ulcerative granuloma. Our results show that roentgenographic and fiberbronchoscopic findings are of value in predicting outcome of patients with LLFTB. With proper antituberculosis chemotherapy and close follow-up, fiberbronchoscopy may be clinically indicated in patients with LLFTB to assess the presence and severity of endobronchial involvement. Early surgical intervention can be considered in those with severe endobronchial involvement before serious sequelae occur.     

Clinical role of bronchoscopy in adults with intrathoracic tuberculous lymphadenopathy

Twenty-five adult tuberculosis patients with intrathoracic lymphadenopathy were studied. Intrathoracic tuberculous lymphadenopathy seems rare in Chinese and affects more older and female subjects. The most common symptoms were cough, followed by chills, fever and the most common physical finding was peripheral lymph node enlargement. The roentgenographic appearance of mediastinal lesions varied but often included right paratracheal involvement. Nine patients had clear lungs. Tuberculous involvement was limited to the lower lung field in seven out of 16 patients with concomitant parenchymal lesions. The remaining nine patients had pulmonary tuberculosis involving the upper lobes. Consolidation was the most common form of pulmonary lesion. A diagnosis was made on the basis of sputum examination in nine patients; however, peripheral lymph node examination yielded a higher diagnostic rate (90 percent). Endobronchial involvement was proved by bronchoscopy in 12 of 16 patients. In three instances, the final diagnosis could be documented after mediastinoscopy or exploratory thoracotomy.     

经支气管针吸活检在纵隔及肺门淋巴结结核诊断中的作用

目的 探讨经支气管针吸活检术（TBNA）在纵隔及肺门淋巴结结核诊断中的作用和临床意义。方法 在常规气管镜检查过程中，对CT检查提示纵隔及肺门淋巴结肿大、肺部及气道腔内无异常表现的24例患者予以TBNA术，在用细胞学穿刺针活检的基础上，选择性地应用组织学穿刺活检针，对所获标本进行细胞学、组织学切片及涂片找抗酸杆菌等检查。结果 24例患者中，18例获得明确的组织学诊断，5例涂片中找到抗酸杆菌，所有患者均无明显的并发症。结论 TBNA操作方便、安全，有较高的诊断率，可作为诊断纵隔及肺门淋巴结结核的首选方法和技术。     

Accuracy of TB-PCR using endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS-TBNA) samples in mediastinal granulomatous lymphadenopathy

IntroductionMediastinal granulomatous lymphadenopathies, such as tuberculous lymphadenitis, sarcoidosis, are frequently encountered by respiratory physicians, and their diagnosis is based on histological and microbiological tests. Endobronchial ultrasound-guided Trans bronchial needle aspiration (EBUS-TBNA) is widely used to perform mediastinal lymph node sampling. However, very limited data is available on the yield of polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) using EBUS-TBNA samples in patients with mediastinal granulomatous lymphadenopathy.Materials and methodsA retrospective study using a prospectively collected database was performed from January 1, 2018 to December 31, 2018, to evaluate the efficacy of the TB-PCR test using EBUS-TBNA samples in patients with benign mediastinal lymphadenopathy which included both granulomatous lymphadenopathy and reactive lymphadenopathy. The cohort with reactive lymphadenopathy acted as the control group of the study population. The patients with mediastinal lymphadenopathy who were awaiting EBUS-TBNA either for diagnostic evaluation of primary disease or for staging of a known malignancy were included in the study. The patients were then followed up for 1 year post procedure with clinical and radiological evaluation.ResultsOf the 310 patients with mediastinal lymphadenopathy who underwent EBUS-TBNA, 190 cases had a benign pathology with granulomatous lymphadenopathy in 120 and reactive lymphadenopathy in 70 patients. The sensitivity, specificity, the positive predictive value and the negative predictive value of TB-PCR was at 90%, 97.14%, 98.18%, and 85% respectively. The accuracy of TB-PCR is 92.63%.ConclusionTB-PCR using EBUS-TBNA samples is an effective tool for diagnosing mediastinal granulomatous lymphadenopathy. This technique can prevent further invasive interventions like mediastinoscopy in patients whose histological and microbiological tests are non-diagnostic. It should always be performed when tuberculosis is in the differential diagnosis of a patient with mediastinal lymphadenopathy.     

A case of prostatic adenocarcinoma clinically presenting as supraclavicular and mediastinal lymphadenopathy]

We report a 70-year-old man with prostatic carcinoma presenting as supraclaviculer and mediastinal lymphadenopathy. He had no urinary tract symptoms, and computed tomography and FDG-PET showed no abnormality in the prostate or pelvic lymph nodes. Metastatic prostatic adenocarcinoma was finally diagnosed from the results of immunohistochemical staining for PSA of a biopsy specimen of the mediastinal lymph node, and he was treated by hormonal therapy. There are fears that some other similar cases might be treated with chemotherapy as lung cancer without immunohistochemical staining. Prostatic carcinoma should always be considered in the differential diagnosis of elderly men with supraclaviculer or mediastinal lymph node metastases, since appropriate treatment will lead to a prolonged survival.     

Neuroendocrine sarcoidosis: a case

The authors report a case of neuro-endocrine sarcoidosis, associating panhypopituitarism , diabetes insipidus, and involvement of the optic chiasma with behavioural changes, chronic meningitis and a diffuse pyramidal syndrome. The diagnosis was suggested by the presence of mediastinal lymphadenopathy and confirmed during a surgical procedure to conserve the optic nerves. The clinical course on corticosteroids was unfavourable because of iatrogenic cushing' syndrome and steroid dependence . It was not possible to withdraw steroids, even with the use of immunosuppressors (Methotrexate).     

Impact of EUS-guided FNA of enlarged mediastinal lymph nodes on subsequent thoracic surgery rates

BACKGROUND: A histopathologic diagnosis of metastasis in enlarged mediastinal lymph nodes usually results in non-surgical management. Cytologic specimens obtained by EUS-guided FNA can be used to detect malignancy in posterior mediastinal lymph nodes. The purpose of this study was to determine the rate of thoracic surgery after EUS-guided FNA of enlarged mediastinal lymph nodes. METHODS: A prospective observational study of patients with enlarged posterior mediastinal lymphadenopathy who were referred for EUS-guided FNA. All patients were candidates for mediastinoscopy. Patients were followed for 12 months to determine the subsequent rate of mediastinoscopy or thoracotomy and the diagnostic accuracy of EUS-guided FNA. RESULTS: Evaluation of cytologic specimens obtained by EUS-guided FNA revealed malignancy in 23 of 59 (39%) patients. The overall rate of surgery was 22% (13/59): 95% CI[0.12, 0.35]. The surgery rate for patients with a positive cytologic result was 4% (1/23) compared with 33% (12/36) for those with a negative result (p=0.009). Of patients with CT findings of a peripheral lung mass plus mediastinal lymphadenopathy, 22 of 26 (42%) underwent surgery after EUS-guided FNA, compared with two of 33 (6%) of those with mediastinal lymphadenopathy alone (p=0.0009). For cytologic evaluation of specimens obtained by EUS-guided FNA, the overall sensitivity, specificity, and accuracy for the diagnosis of malignant lymphadenopathy were 96%, 100%, and 98%, respectively. CONCLUSIONS: Few patients who undergo EUS-guided FNA of enlarged posterior mediastinal lymph nodes require subsequent thoracic surgery.     

经支气管镜针吸活检术在肺部及纵隔疾病中的应用价值

目的探讨经支气管镜针吸活检术(TBNA)在肺部及纵隔疾病中的临床应用价值。方法对42例肺部及纵隔病变进行针吸活检,观察阳性率。结果 42例均针吸或活检成功,确诊率76.2%,无严重并发症。结论 TBNA对肺部及纵隔疾病诊断率高,并发症少。     

经气管镜超声引导针吸活检术在定性诊断不明原因肺门及纵隔肿块、纵隔淋巴结肿大中的应用价值

背景 不明原因肺门及纵隔肿块、纵隔淋巴结肿大是胸外科常见的一种疾病,尽管纵隔镜或胸腔镜检查是临床诊断纵隔病变良恶性的"金标准",但因对机体损伤较大、检查费用高昂、可重复性差等导致其临床应用受限,故寻找一种安全、有效的诊断方法一直是临床医师面对的难题.目的 探讨经气管镜超声引导针吸活检术(EBUS-TBNA)在定性诊断不...     

应用纵隔镜检查术诊断纵隔淋巴结结核和结节病

目的寻找和探索一种区分良恶性纵隔淋巴结肿大,确诊纵隔淋巴结结核和结节病的有效方法。方法应用纵隔镜检查术对胸部ＣＴ或ＭＲＩ检查发现的纵隔淋巴结肿大、临床诊断不清疑为淋巴结结核或结节病者实施此检查,获取病理组织,做出明确诊断,以指导治疗。结果本组２５例患者接受纵隔镜检查,其中１６例被病理诊断为纵隔淋巴结结核,占６４％（其中增殖性结核１４例,占８８％;干酪性结核２例,占１２％）;８例诊为结节病,占３２％;１例难于确定为淋巴结结核或结节病,占４％。非典型的纵隔淋巴结结核与结节病在影像诊断上难于区别,而且在显微镜下也极易混淆。这两种疾病常与其他原因引起的纵隔淋巴结肿大（如恶性淋巴瘤、淋巴结转移性癌等）在影像检查中不易区分,极易误诊,造成误治。本组病例术前影像诊断及临床诊断大多考虑为恶性疾病,其中第一诊断为恶性疾病的占８４％（２１／２５）,有２例已在外院接受化疗。结论对于纵隔区域发现的肿大淋巴结,纵隔镜检查术是一种很有价值的确诊手段,治疗前应尽一切可能获取明确的病理诊断     

Prognostic Significance of Large Mediastinal Involvement in Hodgkin's Disease

Relapse rates of 75 patients with previously untreated Hodgkin's disease with stages I and II nodular sclerosis were analyzed according to the mediastinal involvement. The overall relapse rate was 22.6%. The probability of relapse was much greater for patients with large mediastinal involvement (66.6%) compared with 17% for patients with small mass, and 11.7% of patients without mediastinal involvement (P < 0.001). There was no significant difference in recurrence rates between patients without mediastinal mass and patients with a small mass, and in these patients adjuvant chemotherapy MOPP after radiotherapy showed an evident benefit in reducing the relapse rate. On the other hand, no benefical effect of adjuvant chemotherapy was observed in patients with large mediastinal involvement. Finally, in the 17 relapsing patients, ‘salvage’ chemotherapy was less effective in patients with large mediastinal mass than in those with small or no mediastinal involvement.     

The accuracy of EUS-FNA in assessing mediastinal lymphadenopathy and staging patients with NSCLC.

Optimal management of nonsmall cell lung cancer (NSCLC) depends on tissue diagnosis and accurate staging. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is minimally invasive and provides cytological confirmation of malignant mediastinal disease. The aim was to assess the accuracy of EUS-FNA in cases of enlarged mediastinal lymphadenopathy (LN) of unknown aetiology and in the staging of NSCLC. A total of 52 consecutive patients with stage I-IIIb NSCLC or enlarged mediastinal LN of unknown aetiology underwent EUS-FNA. Negative results were confirmed with a surgical procedure: mediastinoscopy, video-assisted thoracic surgery (VATS) or lobectomy with systematic mediastinal lymph node dissection. In total, 34 patients had EUS-FNA performed for diagnosis, whilst the remaining 18 had EUS-FNA for staging. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% confidence interval) were 93% (77-99), 100% (78-100), 100% (87-100), 88% (63-99) and 95% (84-99), respectively. When EUS-FNA was used in patients with NSCLC, the sensitivity, specificity, PPV, NPV and accuracy were 92% (73-99), 100% (69-100), 100% (85-100), 83% (51-98) and 94% (80-99), respectively. For mediastinal LN of unknown aetiology, no malignant disease was missed. Endoscopic ultrasound-guided fine-needle aspiration is an accurate tool for assessing mediastinal lymph node involvement in nonsmall cell lung cancer and in the diagnosis of unexplained mediastinal lymphadenopathy. Endoscopic ultrasound-guided fine-needle aspiration is a minimally invasive procedure that can be used as an adjunct or alternative to mediastinoscopy.     

Diagnosis of tuberculous uveitis: clinical application of an interferon-gamma release assay

M. tuberculosis is a possible cause of uveitis; the diagnosis is often difficult. The aim of this study is to evaluate, in this context, the application of an interferon gamma assay, the SpotTB?. The prospective study, in patients presenting with uveitis without obvious cause and not resolving with local treatment, compared the therapeutic approach (giving antituberculous treatment or not) with and without the result of the SpotTB?. The analyses included 23 patients: 78% had received BCG; 78% had isolated ocular involvement; 22% had associated mediastinal lymphadenopathy. The results of the IDR and the SpotTB? were concordant in 61%, discordant in 22% and non-evaluable in 17% of cases. In the patients with isolated ocular involvement the SpotTB? avoided treatment in five and reinforced the decision not to treat in 13 others. In the patients with mediastinal lymphadenopathy, the SpotTB? reinforced the diagnosis of sarcoidosis in four cases (one lost from view). In conclusion, when infection with M. tuberculosis is considered in the aetiology of uveitis the SpotTB? allows, in a significant number of cases, the avoidance of antituberculous treatment.     

Cardiac sarcoidosis underlies idiopathic dilated cardiomyopathy: importance of mediastinal lymphadenopathy in differential diagnosis.

BACKGROUND: Cardiac sarcoidosis is frequently overlooked or misdiagnosed as idiopathic dilated cardiomyopathy (DCM), primarily because of difficulties in its diagnosis. This is a crucial issue because appropriate therapy with immunosuppressive agents can be initiated if early diagnosis is achieved. METHODS AND RESULTS: Thoracic computed tomography (CT) was retrospectively analyzed in detail with special reference to lymph node swelling (LNS) in the mediastinum of 8 patients diagnosed with idiopathic DCM who underwent left ventriculoplasty (LVP), and were later proven to have active cardiac sarcoidosis by histological evaluation of the resected myocardium. Twenty age-matched patients with idiopathic DCM who also underwent LVP served as controls. On conventional chest radiographs, none of the cardiac sarcoidosis patients exhibited lymph node involvement, including bilateral hilar lymphadenopathy. However, CT demonstrated significant mediastinal LNS in 7 (88%) of them and in only 1 (5%) of the 20 controls. There was a significant difference in the incidence of LNS in the 2 groups (p=0.00005). CONCLUSION: Evaluation of mediastinal lymphadenopathy by CT is an easy and valuable initial screening method for distinguishing cardiac sarcoidosis from idiopathic DCM.