Intrapulmonary Lymph Nodes: Clinical, Radiologic, and Pathologic Features

A 59-year-old man came to our hospital for further examination of multiple small nodular lesions in both lungs. Chest CT scan revealed multiple nodular lesions in rt-S6, It-S5, and It-S9 (two lesions). All of these nodules measured about 10 mm or less and those in It-S9 had spicula. Bronchoscopic examination did not yield a definitive diagnosis, so open lung biopsy was done. The open lung biopsy specimen revealed intra-pulmonary lymph nodes with anthracosis and pulmonary emphysema. Intrapulmonary lymph nodes are very difficult to distinguish from small lung tumors by radiographic examination alone, so the possibility that small nodules in the lungs may be intra-pulmonary lymph nodes should be kept in mind.

Through the summary and analysis of large samples, the characteristic imaging manifestations of intrapulmonary lymph nodes (IPLNs) were quantified, and two corresponding rating tables were developed. These rating tables could be used to distinguish the IPLNs from primary lung cancer, so as to improve the diagnostic accuracy and help clinicians make correct judgments and decisions. A total of 82 patients with 110 IPLNs and 35 patients with primary lung cancer lesions were collected from June 2017 to December 2018. All lesions were solid nodules of less than 12 mm in diameter, which were confirmed by pathology. Observation indicators included location, size, shape, density, border and internal vacuoles of nodules, linear high-density shadow around the nodules, distance from the pleura, pleural indentation, and so on. There were statistically significant differences in the location, size, shape, internal vacuole of the nodules, and distance from the pleura (p < 0.05). The diagnostic scoring table of the nature of solid nodules and the malignant risk table were drawn. The nodule corresponding to Level A was most likely the primary lung cancer, and surgical resection was recommended. The nodule corresponding to Level C was most likely IPLNs, and it was better to receive no treatment currently. The positive predictive value was 81% (23/28), the negative predictive value was 97% (89/92), the sensitivity was 63% (23/35), and the specificity was 81% (89/110). For the pulmonary solid nodules of less than 12 mm in diameter and unknown nature, the evaluation in accordance with the Score Table and the Risk Level Table of this study can be more accurate and faster than the original judgment, which will help clinicians in diagnosis and treatment decisions.

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is an uncommon idiopathic, self-limiting disease characterized by cervical lymphadenopathy. Patients with KFD may present with a wide variety of nonspecific symptoms, including fever, night sweats, and weight loss. Although KFD can affect all lymph nodes of the body, involvement of the intrathoracic lymph nodes is relatively rare. In particular, isolated involvement of the intrapulmonary lymph nodes is extremely unusual. We herein report a case involving a 45-year-old man who presented with symptoms of myalgia, fatigue, and fever. Computed tomography performed during follow-up showed a slowly growing nodule in the upper lobe of the left lung. Results of laboratory tests did not reveal any evidence of infection or autoimmune disease, including systemic lupus erythematosus. Results of excisional biopsy by video-assisted thoracoscopic surgery revealed KFD in an intrapulmonary lymph node. His symptoms improved after a trial of nonsteroidal anti-inflammatory drugs. (Korean J Med 2015;89:220-224)

BackgroundPreoperative localization of lung tumor mainly consisted of two methods: CT-guided percutaneous localization and electromagnetic navigation bronchoscopy-guided localization. However, these invasive methods could result in serious complications. In order to avoid the adverse effects of preoperative invasive localization, we propose a method of intraoperative noninvasive localization for lung tumors: clock dial integrated positioning (CDIP).MethodsTo retrospectively analyze the clinic data about the application of CDIP for 127 lung tumour patients in single utility port video-assisted thoracoscopic surgery (SUPVATS) between June 2017 and October 2017.ResultsOne hundred and twenty-four cases (97.64%) underwent thoracoscopic surgery, which including 14 lobectomy, 107 partial resection, 2 lobectomy plus partial resection and 1 left pneumonectomy. Three cases (2.36%) underwent thoracoscopic biopsy. The mean operation time and intraoperative bleeding were 47.9±22.1 min and 70.1±40.3 mL, respectively. The mean postoperative hospital stay and chest drain duration were 3.9±2.2 and 3.6±1.8 days, respectively. There were 118 cases of malignant tumors, including adenocarcinoma (n=101), squamous cell carcinoma (n=9), large cell carcinoma (n=2), small cell lung carcinoma (n=3), and metastatic lung carcinoma (n=3). The remaining nine cases were benign tumors, including granuloma (n=3), intrapulmonary lymph node (n=2), sclerosing hemangioma (n=2), and hamartoma (n=2). The incidence of postoperative complications was 10.2%. There was no mortality, secondary operation, or conversion to open procedure due to massive intraoperative bleeding.ConclusionsCDIP combined with SUPVATS is a safe, feasible, and effective method for the localization of lung tumors. This novel method can provide a reliable alternative technique when the marker is dislocated.

A 21-year-old man presented to our hospital on June 7, 1990, asymptomatic but with an abnormal shadow in his chest roentgenogram. A well-demarcated tumorous shadow was seen in the left hilum of the lung in the frontal view of the chest X-ray, and adjacent to the posterior chest wall in the lateral view. A percutaneous needle biopsy was performed, and since there were no malignant findings, the tumor was left untreated for future examinations. However, since the tumor was observed to be enlarging gradually in subsequent chest X-rays, it was resected surgically on June 18, 1991. The tumor was fist-sized and its surface smooth, and was protruding into the thoracic cavity. At surgery, the tumor was separated from the chest wall. The tumor, weighing 170 grams, was diagnosed pathologically as a liposarcoma (myxoid type). It was confirmed that there was no infiltration into the surrounding tissue and that total resection had been performed. There are few reports of liposarcomas within the thoracic cavity developing in the extra-mediastinal chest wall. As our case is the second in Japan occurring in a young patient, we present it here together with a review of the literature.

Role of percutaneous transpedicular biopsy in diagnosis of spinal tuberculosis and its correlation with the clinico-radiological features

Epidemiology of Canine Mammary Gland Tumours in Espírito Santo, Brazil

Sarcoidosis is a multisystemic disease that may involve the breast parenchyma and can be confused with benign or malignant tumors. A recent case of sarcoidosis of the breast treated in our institution prompted us to review the world literature on the topic. From 1921 to 1997, 45 cases relating to sarcoidosis of the breast were reported; 10 of these cases were excluded from our review because of the lack of histological proof of sarcoidosis. The data were organized according to clinical presentation, diagnostic studies, treatment plan, and follow-up care. The mean age at presentation was 47 years (range 20-72 years) and all patients were female. Seven patients (20%) had a breast mass as primary presentation of sarcoidosis without any clinical evidence of systemic sarcoidosis. Thirty-one patients (89%) presented with a self-detected mass and three patients (8%) demonstrated skin dimpling and peau d'orange appearance mimicking cancer. The size of the breast lesions ranged from 0.25 to 5 cm in diameter. One patient presented with bilateral breast lesions and one with more than one lesion in the same affected breast. A single breast mass was found in the rest of the patients. Of the seven patients evaluated by mammography, only one revealed changes suspicious for malignancy. Fine-needle aspiration was used only in four cases; the results of two were compatible with sarcoidosis and two required an excisional biopsy as a result of inconclusive results. Seventeen cases reported excisional biopsy as the diagnostic procedure. In 11 patients the type of biopsy was not stated. In two cases of radical mastectomies for breast adenocarcinoma, sarcoidosis was an incidental finding, either in the remaining breast tissue or in the axillary nodes. One patient underwent a partial mastectomy revealing sarcoidosis as the definitive diagnosis. Ultrasound was used in two cases; one revealed a suspicious lesion and one was inconclusive. Although sarcoidosis of the breast constitutes a rare entity it should be considered in the differential diagnosis of breast cancer even in patients without clinical evidence of systemic sarcoidosis. These patients should undergo a biopsy to rule out malignancy because clinical findings, mammography, and ultrasound results can be misleading or inconclusive.

It is very rare or almost impossible that an event can be negative from all points of view -Dalai Lama XIV C ardiac masses and tumors have always fascinated pathologists and cardiovascular physicians/surgeons alike. Before the mid-1950s, primary cardiac tumors were usually reported at autopsies. With the development of echocardiography, the imaging and diagnosis of tumors like myxoma became a possibility. With advancements in cardiopulmonary bypass, their resection and thus a cure became an exciting reality. Further developments in imaging, particularly echocardiography, 3-dimensional echocardiography, multidetector cardiac computed tomography (MDCT), and cardiac magnetic resonance imaging (CMR), have facilitated antemortem diagnosis of cardiac tumors.

ENZYMOLOGICAL DIAGNOSIS OF PRIMARY HYPEROXALURIA TYPE 1 BY MEASUREMENT OF HEPATIC ALANINE: GLYOXYLATE AMINOTRANSFERASE ACTIVITY

To retrospectively evaluate the diagnostic performance and complications of C-arm cone-beam computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) in 1108 patients. This retrospective study was approved by the institutional review board with waiver of patient informed consent. From January 2009 to December 2011, 1108 patients (633 male, 475 female; mean age, 62.4 years ± 12.3 [standard deviation]) with 1116 pulmonary lesions (mean size, 2.7 cm ± 1.7) underwent 1153 cone-beam CT-guided PTNBs. A coaxial system with 18-gauge cutting needles was used. Diagnostic performance, complication rate, influencing factors, and patient radiation exposure were investigated. Variables influencing diagnostic performance and complications were assessed by using uni- and multivariate logistic regression analyses. Among 1153 PTNBs, pathologic analysis showed 1148 (99.6%) were technically successful (766 malignant [66.4%], 323 benign [28.0%], and 59 [5.1%] indeterminate). Sensitivity, specificity, and accuracy for diagnosis of malignancy were 95.7% (733 of 766), 100% (323 of 323), and 97.0% (1056 of 1089), respectively. In regard to diagnostic failures (five technical failures, 33 false-negative findings), lesions 1 cm in diameter or smaller and lesions in the lower lobe were significant risk factors (P = .028 and P = .034, respectively). As for complications, pneumothorax and hemoptysis occurred in 196 (17.0%) and 80 (6.9%) procedures, respectively. Multivariate analysis revealed two or more pleural passages and emphysema along the needle pathway were the two most significant risk factors for pneumothorax, and ground-glass nodules were the most significant risk factor for hemoptysis (P < .001 for all). Virtual guidance was a significant protective factor for both pneumothorax and hemoptysis (P < .001 for both). Mean estimated effective radiation dose through cone-beam CT-guided PTNBs was 7.3 mSv ± 4.1. Cone-beam CT-guided PTNB is a highly accurate and safe technique with which to diagnose pulmonary lesions with reasonable radiation exposure.

Eighty-six patients with focal liver disease underwent sonography-guided percutaneous fine needle biopsy for definitive diagnosis. Twenty-five out of twenty-six neoplastic liver tumors were correctly recognized as malignant. A sensitivity of 96% and a specificity of 98% (25 true positives, 60 true negatives, 1 false negative) was obtained. The high accuracy rate of this diagnostic procedure is explained by the precision of sonographic guidance and the copious excision of tissue material. In 57% of the malignant tumors, small tissue cylinders were obtained besides cytological material, which allowed a definitive tumor diagnosis in 11 out of 15 cases by histologic examination. In addition, the histologic evaluation of tissue fragments enables the differentation between primary and secondary hepatic malignomas. Because of the higher specificity of histological diagnosis, fine needle puncture of solid liver tumors should always provide tiny tissue cylinders for histologic examination.

Background: Percutaneous needle biopsy (PNB) and bronchoscopic biopsy (BB) are widely used in the preoperative diagnosis of pulmonary nodules, but whether PNB or BB may cause tumor spread through air spaces (STAS) has not been reported. Methods: 433 postoperative patients with pathological stage I non-small cell lung cancer (NSCLC) from January 2015 to December 2018 at our hospital were enrolled and divided into PNB group (n = 40), BB group (n = 48) and non-biopsy group (n = 345). The PNB and BB groups were matched using propensity score matched (PSM) separately from the non-biopsy group, after which the effects of PNB and BB on STAS, recurrence-free survival (RFS) and overall survival (OS) were assessed. Results: After PSM for 9 confounding factors (gender, age, smoking history, tumor site, scope of surgery, pathology type, stage, maximum tumor diameter and postoperative treatment), 38 cases in the PNB group were successfully matched with 38 cases in the non-biopsy group and 28 cases in the BB group were successfully matched with 28 cases in the non-biopsy group. After PSM, there was no significant difference in the incidence of STAS between the PNB and non-biopsy groups (42.1% vs. 34.2%, P > 0.05) and between the BB and non-biopsy groups (42.9% vs. 46.4%, P > 0.05). The results after PSM showed no significant effect of both PNB and BB on RFS and OS after radical surgery (P > 0.05). Conclusion: Preoperative biopsy in patients with stage I NSCLC has not been shown to increase the occurrence of STAS, nor postoperative recurrence and death.

Investigation of the Safety and Usefulness of Computed Tomography-Guided Percutaneous Needle Biopsy of Paraaortic Lymph Nodes.

A 48-year-old woman, showing a huge tumor shadow on the right side of the chest by roentgenogram, was admitted to our hospital. CT-scan showed that the tumor, 20cm in diameter, ocuppied the lower half of the right thoracic cavity, and expanded to the liver. MRI suggested, direct invasion of the liver by the lung tumor through the diaphragma. From angiographic examination, the main vessels of the tumor arose from the right inferior phrenic artery. The inferior vena cava, the right inferior pulmonary artery and vein, and the right hepatic vein were intact. The pathologic diagnosis of the specimen obtained by percutaneous needle biopsy was a fibrous tumor of the pleura. An operation was performed using a midsternal and right subcostal incision to resect the tumor completely. The tumor was 19.5×16.5cm in size and 2056g in weight. Pathological features were compatible with fibrous tumor of the pleura, and results of immuno-pathological examination was Desmin & cytokeratin negative, but vimentin & CD34 positive.