Multislice spiral CT feature analysis of intrapulmonary lymph nodes

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.

A 48-year-old male was admitted for further examination of a coin lesion with a diameter of 8 mm seen on chest X-ray. The patient was a heavy smoker and his serum level of CEA was elevated to 29.8 ng/ml. Since the broncho-fiberscopic examination was not able to yield a definitive diagnosis, an operation was performed as lung cancer was suspected. According to the histological examination, the small nodule was diagnosed as an intrapulmonary lymph node with anthracosis and silicotic nodules. A review of the limited number of case reports shows that men are more prone to intrapulmonary lymph nodes, and that the patients were all smokers but not necessarily with occupational experience of exposure to silica.

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)

BackgroundLymph node inclusions are foci of ectopic tissue in lymph nodes, which were reported in different areas of the body. However, inclusions in the mediastinal lymph node are rare. Here, we report the first case of glandular inclusion within the parenchyma of the intrapulmonary lymph node in a patient with primary lung adenocarcinoma.Case presentationA computed tomography (CT) scan showed a solid pulmonary nodule in the right upper lobe in a 44-year-old man. After a fine needle aspiration biopsy diagnosis of adenocarcinoma, lobectomy and lymph dissection were performed. Histological sections of the lung demonstrated a papillary predominant adenocarcinoma and one intrapulmonary lymph node, which displayed glandular inclusion occupying the node parenchyma. The gland inclusion was very similar to metastasis, but was formed by two layers of epithelial cells, and the abluminal cells were positive for P63, P40, and CK5/6. The patient has remained alive without recurrence and metastasis at the last follow-up before publication.ConclusionsIt is very important to correctly diagnose a lymph node inclusion for proper clinical management.

The incidental pediatric pulmonary nodule: What to ignore, what to worry about.

Intrapulmonary Lymph Nodes: Clinical, Radiologic, and Pathologic Features

The objective of this study was to assess the prevalence of pathologically proven intrapulmonary lymph nodes and to evaluate their appearance on CT. Over a 15-year period (1980-1994), 184 patients underwent minithoracotomies for evaluation of CT-detected peripheral pulmonary abnormalities. Of these 184 patients, 96 had well-circumscribed peripheral pulmonary nodules. The size, position, and radiographic features of all pathologically proven intrapulmonary lymph nodes were independently assessed by two experienced radiologists. The nodules in 17 (18%) of the 96 patients with well-circumscribed peripheral pulmonary nodules were pathologically proven to be intrapulmonary lymph nodes. Two of the 17 patients had two nodules; the remaining patients had solitary nodules. The maximum diameter of the nodules varied from 7 to 12 mm. All the nodes were located within 20 mm of a visceral pleural surface. Twelve of the nodules were located in the lower lobes, and the remaining nodules were located in the right middle lobe. Although intrapulmonary lymph nodes are not a well-known entity, our results indicate that they are discovered in a significant number of patients who undergo minithoracotomies for the evaluation of CT-detected pulmonary nodules. Although these lymph nodes do not possess any specific CT appearance, they should be considered in the differential diagnosis of single (or multiple) parenchymal nodules, particularly those found in the lower lobes.

Malignant pleural mesothelioma has a poor prognosis and an average survival of 12–18 months despite treatment. One of the unique features of this malignancy is development of diffuse nodules inside the pleural cavity which lead to an irregular lymph node metastasis pattern in the chest cavity. Lymph node staging of mesothelioma was the same as Lung Cancer lymph node staging. It was recently revised to include unique intrathoracic involvement sites (internal mammary, peridiaphragmatic, pericardial fat pad and intercostal lymph nodes) in mesothelioma and ipsilateral mediastinal and intrapulmonary lymph nodes were grouped as N1. The preoperative invasive lymph node staging is inadequate and almost 40% are understaged in clinical N0 patients and 30% in N1 patients. Invasive mediastinal staging with cervical mediastinoscopy, endobronchial ultrasound or endoscopic ultrasound are used, however pericardial, posterior intercostal and internal mammary lymph nodes are inaccessible. Invasive preoperative mediastinal staging is important to stratify patients for appropriate treatment. The number and sites of potential lymph node involvement in mesothelioma is much higher and widespread than lung cancer. Thus, the technique and principles of lymphadenectomy or sampling in lung cancer is obviously not enough in mesothelioma. Long term survival difference is less than 10% in patients with bronchopulmonary or ipsilateral mediastinal and extrapleural lymph node involvement compared with those without lymph node involvement. The revised N staging system emphasizes the importance of preoperative invasive mediastinal staging, broadens surgical indications without dramatic improvements in survival.

The deposition of particulate antigen into the dog lung induces a large accumulation of antigen-specific-forming cells in immunized lung lobes. The results of our previous studies with dogs indicate that these cells are recruited to the immunized lung lobes from the blood. The present study was designed to determine if the recruitment of immune cells to the lung is antigen-specific, or if changes occur in the lung after immunization that allow immune cells to enter the lung nonspecifically. Dogs were immunized in the left and right cardiac lung lobes with antigenically different particulate antigens. The number of lymphoid cells producing antibody to each antigen and the concentrations of antigen-specific antibody were measured in the immunized lung lobes and in a control lung lobe at 5 through 14 days after immunization. Similar numbers of antibody-forming cells and concentrations of antibody to both antigens were found in each immunized lung lobe, regardless of which antigen was used for immunization. These results indicate that antigen exposure alters the lung to allow a nonspecific recruitment of immune cells from the blood into the immunized lung lobes, regardless of antigen specificity. These data also provide further evidence that the antibody-forming cells found in the lung lavage fluid after localized immunization are produced in the thoracic lymph nodes or other systemic lymphoid tissues, rather than locally in lymphoid tissues in the deep lung.

Objective To explore the method and clinical value of sentinel lymph node biopsy for penile carcinoma guided by multispectral separate-merge guided surgery device(MGS). Methods The clinical data of 7 patients with sentinel lymph node biopsy of penile cancer guided by MGS from April 2017 to April 2018 were analyzed retrospectively at First Hospital of Shanxi Medical University. They were 62-78 years old, with an average age of 65 years. All of carcinoma was located in the glans or coronal sulcus, which diameter was 1.0-3.5 cm, with an average of 2.5 cm. Three cases of inguinal lymph nodes could be non-palpable and the others palpable. All patients were injected 0.25 ml (2.5 mg/ml) of indocyanine green solution with 1 ml syringe at 12, 4, 6 and 9 points in the proximal normal skin of penile tumors. Immediately, the imaging probe was aligned with the injection point to observe the dynamic changes of fluorescence image on MGS display. Results There were 14 sides of groin in 7 patients, except for 1 side without images, other 13 sides developed well. The images displayed by MGS include visible image, fluorescent image and merged image, and the merged image was green pseudo color. According to the dynamic changes of the image, it could be divided into five parts: injection point, penile body, pubic symphysis, inguinal region and sentinel lymph node. In 13 well-developed sides, fluorescence gradually disappeared in other parts about 15 minutes after injection, and the location of sentinel lymph nodes was determined in vitro by gradually consolidating and fixing the fluorescence images in the inguinal region. The lymph node-like tissue with strong fluorescence intensity was observed immediately after the skin incision. There was a clear boundary between the lymph node-like tissue and the surrounding tissue. Along this boundary, lymph nodes were separated, ligated, excised. No lymph nodes were found on the undetected side. Postoperative pathology confirmed that lymph nodes were located by fluorescence imaging in vitro and traced by fluorescence imaging in vivo, the coincidence rate was 100%. There were residual fluorescent tissues on three sides and lymphatic vessels were removed. Conclusions MGS-assisted intraoperative fluorescence imaging could improve the doctor's visual depth so that physicians can real-time, dynamic, accurate in vitro location and in vivo tracking of sentinel lymph nodes of penile cancer. Key words: Penile carcinoma; Sentinel lymph node biopsy; Fluorescence image; Indocyanine green; Image guided

Objective To investigate the patterns of lymph node metastases from nasopharyngeal carcinoma (NPC) based on magnetic resonance imaging (MRI) and to provide a basis for neck irradiation field in intensity-modulated radiation therapy.Methods From 2010 to 2013,3 100 patients newly diagnosed with NPC who underwent MRI were analyzed.All images were evaluated by the multi-disciplinary treatment group for NPC to analyze lymph node metastases.The locations of lymph nodes were determined by the RTOG consensus guidelines published in 2003.Results Of 3100 patients,2 679 (86.42％) had lymph node metastases; the detailed distribution was as follows:lateral retropharyngeal region (2012 patients,64.90％ ;6 patients were also in the medial group),level Ⅱ b(2341 patients,75.52％ ;492 had the upper border reaching half of C1 vertebra and 115 had the upper border reaching the skull base),level Ⅱ a(1798 patients,58.00％),level Ⅲ (1 184 patients,38.19％),level Ⅳ (350 patients,11.29％ ;28 had the lower border beyond the RTOG recommended boundary),level Ⅴ (995 patients,32.10％ ;91 had the lymph nodes beyond the RTOG recommended boundary),level Ⅰ b (115 patients,3.71％),and parotid region (40 patients,1.29％).Extensive ipsilateral lymph node metastases were seen in patients with lymph nodes metastases in levels Ⅳ and Ⅴ,and the total numbers of involved nodes were ≥ 6 and 7.Skip metastasis occurred in 6 patients (0.19％).Conclusions Metastases to retropharyngeal lymph nodes are seen mainly in the lateral group but rarely in the medial group.The upper border of level Ⅱ lymph nodes should be the skull base.Lymph node metastases from NPC are in an orderly manner,and skip metastasis is rarely seen.When level Ⅳ/Ⅴ lymph nodes are involved,there might exist metastases beyond the RTOG recommended boundary.In case of extensive ipsilateral lymph node metastases,the parotid region might be involved. Key words: Nasopharyngeal carcinoma; Magnetic resonance imaging; Lymph node metastasis; Lymph node subregion

To investigate the feasibility of differentiation of lymphoma, metastatic lymph nodes of squamous cell carcinoma (SCC) and papillary thyroid carcinoma (PTC) in the head and neck by single-source dual-energy spectral CT. 25 cases of non-Hodgkin lymphoma (NHL) with 236 lymph nodes, 3 cases of Hodgkin's lymphoma (HL) with 32 lymph nodes, 21 cases of SCC with 86 lymph nodes and 19 cases of PTC with 92 lymph nodes were evaluated by enhanced GSI. CT attenuation of lymph nodes in the monochromatic images at different keV levels and the iodine and water contents of these lymph nodes were measured. The slope of spectral curve was calculated using CT value at 40 keVand 90 keV. All results were analyzed with ANOVA and t test. 70 keV had the best single energy images. Normalized Hounsfield unit (NHU) of diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), T lymphoblastic lymphoma (T-LBL), HL, PTC and SCC was 0.32 ± 0.10, 0.46 ± 0.08, 0.41 ± 0.11, 0.41 ± 0.11, 0.56 ± 0.15 and 0.34 ± 0.16, respectively. Normalized iodine concentration (NIC) of them was 0.20 ± 0.08, 0.32 ± 0.08, 0.25 ± 0.09, 0.30 ± 0.12, 0.49 ± 0.18 and 0.23 ± 0.18, respectively. The slope of spectral curve (k) of them was -1.92 ± 0.55, -2.45 ± 0.60, -1.82 ± 0.57, -2.57 ± 0.54, -5.44 ± 2.41 and -1.97 ± 0.81, respectively. Compared with the NHU, there was a statistically significant difference in each pair except DLBCL and SCC, and T-LBL and HL. Compared with the NIC, there was a statistically significant difference in each pair except DLBCL and SCC, FL and HL, T-LBL and SCC, and T-LBL and HL. Compared with the slope of spectral curve, there was statistically significant difference in each pair except DLBCL and T-LBL, DLBCL and SCC, FL and HL, and T-LBL and SCC. Malignant lymph nodes of different types of diseases have certain different values of quantitative parameters in spectral CT imaging. By using CT attenuation, the shape and slope of spectral curve and the iodine content, single-source dual-energy CT may potentially provide a quantitative analysis tool for the diagnosis and differential diagnosis of lymph node alterations.

To explore the feasibility of sentinel lymph node biopsy in peri-neoadjuvant chemotherapy for breast cancer patients. A total of 252 breast cancer patients underwent sentinel lymph node biopsy and axillary lymph node dissection from January 2005 to November 2011, including 150 patients in pre-neoadjuvant chemotherapy group and 102 in post-neoadjuvant chemotherapy group. The feasibility of sentinel lymph node biopsy under different clinical states of axillary lymph node was compared. No significant difference was found in the detection rate (98.5% vs 92.8%), false negative rate (6.7% vs 7.9%), accuracy (98.4% vs 91.9%) and negative sensitivity (97.9% vs 88.0%) of sentinel lymph node biopsy before neoadjuvant chemotherapy whether the axillary lymph node was negative or positive. However, the transfer rate of sentinel lymph node in the positive group was significantly higher than the negative group (28.8% vs 67.5%, P = 0.000). False negative rate of sentinel lymph node in biopsy was significantly higher in the post-neoadjuvant chemotherapy group than the pre-neoadjuvant chemotherapy group (7.5% vs 23.9%, P = 0.024) and the accuracy/negative sensitivity decreased significantly (95.1% vs 83.5%, P = 0.005/94.4% vs 75.0%, P = 0.003). No statistical difference existed in the detection rate, false negative rate, accuracy, negative sensitivity of sentinel lymph node in biopsy before and after neoadjuvant chemotherapy in patients with negative axillary lymph node for a preliminary diagnosis. The accuracy of sentinel lymph node decreased significantly in biopsy after neoadjuvant chemotherapy in patients with positive axillary lymph node confirmed pathologically for a preliminary diagnosis compared with before (98.4/83.7%, P = 0.010), the transfer rate of sentinel lymph node increased significantly (28.8/53.7%, P = 0.005) and negative sensitivity reduced significantly (97.9/68.0%, P = 0.007); Compared with pre-neoadjuvant chemotherapy, the negative sensitivity decreased significantly in patients with axillary lymph node positive confirmed pathologically and then turned negative (94.4% vs 57.1%, P = 0.005) while the transfer rate of sentinel lymph node increased significantly (28.8%/65.0%, P = 0.003). Sentinel lymph node before neoadjuvant chemotherapy may accurately predict axillary lymph node metastasis. The detection rate, false negative rate, accuracy, negative sensitivity of sentinel lymph node in biopsy after neoadjuvant chemotherapy in patients with negative axillary lymph node for preliminary diagnosis are the same before neoadjuvant chemotherapy. Patients with positive axillary lymph node for a preliminary diagnosis are unsuitable for sentinel lymph node biopsy whether axillary lymph node turns negative or not after neoadjuvant chemotherapy.

Objective To discuss the correlation between molecular subtypes of early stage breast cancer patients with positive sentinel lymph nodes and the metastasis of non-sentinel lymph nodes, and find out the factors predicting the metastasis of non-sentinel lymph nodes. Methods The clinical data of 124 female breast cancer patients with sentinel lymph node positive were retrospectively analyzed, and the patients were treated with axillary lymph node dissection. And the correlations were analyzed by single factor analysis and multiple factor Logistic regression analysis. Results Among the 124 patients, non-sentinel lymph node metastasis was in 45 cases (36.3%), and only sentinel lymph node positive was in 79 cases (63.7%). The single factor analysis result showed that the age ≤ 35 years, number of sentinel lymph node positive ≥ 2, macrometastasis of sentinel lymph node had correlation with the metastasis of non-sentinel lymph node (P 0.05). The multiple factor Logistic regression analysis result showed that the number of sentinel lymph node positive and circumstance of sentinel lymph node positive lesions were the independent risk factors of the non-sentinel lymph node metastasis in patients with sentinel lymph node positive (OR= 4.589 and 2.948; P<0.01 or<0.05). Conclusions The circumstance of sentinel lymph node positive lesions and number of sentinel lymph node positive are the independent risk factors of the non-sentinel lymph node metastasis, but the molecular type is not correlated with the metastasis of non-sentinel lymph node. Predicting non-sentinel lymph node metastasis should be combined with clinical and pathological factors. Key words: Breast neoplasms; Lymphatic metastasis; Early diagnosis; Molecular typing; Retrospective studies