Bilateral Supraclavicular Nodes Research Articles

Successful long-term management for postoperative sternal infection with multiple disseminated lymphadenitis caused by Mycobacterium abscessus

BackgroundPostoperative sternal infection caused by Mycobacterium abscessus (M. abscessus) is rare, but associated with a high 2-year mortality rate of 40%. Decision-making around treatment strategy is challenging. Here, we present a successfully treated case of postoperative M. abscessus sternal infection with multiple disseminated lymphadenitis.Case presentationThe patient, an 80-year-old woman with anterior mediastinal tumor and myasthenia gravis, underwent extended thymectomy under median sternotomy. Redness appeared around the scar two months after the operation. Sternal wires were removed, debridement was performed, and the wound was kept open. Mycobacterium abscessus was isolated from the wound culture. The disseminated lesions in the right axillary, parasternal, and bilateral supraclavicular lymph nodes, rendered surgical options for infection control difficult; therefore, she was treated conservatively with antibiotics and negative pressure wound therapy (NPWT). The wound diminished but infectious granulation tissue remained after NPWT. Two disseminated lesions were percutaneously punctured and drained of pus, which resulted in negative cultures. Additional debridement and wound closure were performed. She was discharged after switching to oral antibiotics. No recurrence was observed five months after the antibiotics were completed (total sensitive antibiotics use: 366 days).ConclusionsRepeated culture assessment of disseminated lesions is recommended to facilitate the development of appropriate therapeutic strategies. Localized procedures may be an option for patients with controlled disseminated lesions evidenced by negative cultures.

Preliminary Evaluation of Postoperative Radiotherapy between Small T-Shaped Field and All Regional Lymph Nodes Field in Thoracic Esophageal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> The optimal extent of clinical target volume (CTV) for postoperative radiotherapy in complete resection thoracic esophageal squamous cell carcinoma (ESCC) patients remains controversial. This study aimed to evaluate the preliminary results of postoperative radiotherapy with standard all regional lymph nodes field and adjusted small T-shaped field. <h3>Materials/Methods</h3> A total of 75 thoracic ESCC patients were enrolled from April 2017 to March 2021, retrospectively. Among them were 63 males and 12 females, with an average age of 64.28 (range, 49-82) years. All patients received intensity-modulated radiotherapy (IMRT) at a dose of 45-50.4Gy/25-28F after radical resection of esophageal carcinoma, of which 39 cases were small T-shaped field (including bilateral supraclavicular lymph nodes, upper and middle mediastinal lymph nodes, small T group),36 cases were all regional lymph nodes field (including tumor bed, bilateral supraclavicular lymph nodes, all mediastinal lymph nodes, left gastric lymph nodes and celiac lymph nodes, control group). 24 cases (32%) received concurrent chemotherapy and 57 cases (76%) received adjuvant chemotherapy. The median follow-up period was 31(range, 15-57) months. <h3>Results</h3> At the end of follow-up period, 7 (17.9%) cases had locoregional recurrence (LRR) and 8(20.5%) had distant metastasis (DM) in small T group, while 9 (25%) cases had LRR and 9 (25%) had DM in control group. There was no significant difference in LRR rate (p=0.456) and DM rate (p=0.643) between the two groups. There was also no significant difference in the total OS rate between the two groups (p=0.146). In terms of radiotherapy parameters, in small T group, the median values of V5, V20 and average dose of the lungs were 37.31%, 16.43% and 8.11Gy, respectively. The median value of the maximum dose of spinal cord was 29.95Gy. For the heart, the median value of the average dose and V30 were 5.13Gy and 2.64%. And the median value of V40 of the stomach was 34.32%. In control group, the median values of V5, V20 and average dose of the lungs were 53.49%, 22.08% and 11.41Gy. The median value of the maximum dose of spinal cord was 36Gy. For the heart, the median value of the average dose and V30 were 27.52Gy and 37.39%. And the median value of V40 of the stomach was 63%. All of the above parameters in small T group were significantly lower than those in control group (p<0.05). In addition, we observed grade 2 radiation pneumonitis and grade 2 radiation esophagitis in both groups:9 cases of radiation pneumonia with grade 2 or above in control group and only 1 case in small T group (p<0.001). There were 15 cases of radiation esophagitis with grade 2 or above in control group and 6 cases in small T group (p=0.024). <h3>Conclusion</h3> In conclusion, radiotherapy with small T-shaped field might be a feasible and efficacious postoperative approach for ESCC patients.

Tuberculosis presenting as immune thrombocytopenia

A 19-year-old male presented with chief complaints of generalised weakness and unintentional weight loss from 50 Kg to 45 Kg within a span of 1 month. He complained of fever for 15 days and had developed petechiae over bilateral upper limbs and bilateral subconjunctival haemorrhage. Laboratory investigations done elsewhere showed platelet count of 10,000/mm3. On further investigation, Widal test, dengue serology, and smear examination for malarial parasite, antinuclear antibodies, and viral markers were negative. Abdominal ultrasonography showed multiple conglomerative enlarged lymph nodes in peripancreatic, peripatetic and paracaval, with few of them showing necrosis and loss of hilum and minimal ascites. Bone marrow examination showed megakaryocytic hyperplasia features, suggestive of immune thrombocytopenic purpura (ITP). No improvement in the platelet count was noted with intravenous methylprednisolone. On examination, the patient had ecchymotic patches over bilateral upper limbs and bilateral subconjunctival haemorrhages. Bilateral supraclavicular lymph nodes were palpable, non-tender, mobile, measuring 3 cm × 3 cm in the right side and 2 cm × 2 cm in the left side and firm in consistency. Cervical lymph node biopsy showed caseous necrotising granulomatous inflammation. Contrast-enhanced computed tomography neck, chest and abdomen showed multiple enlarged conglomerated heterogeneous enhancing lymph nodes with central non-enhancing areas s/o necrosis noted in the neck, mediastinum and abdomen. Tuberculin skin test (Mantoux test) revealed induration of 20 mm. The patient was started on eltrombopag, and four doses of intravenous immunoglobulin were given without improvement. The patient was started on liver-friendly anti-tuberculosis treatment in view of deranged liver function tests with isoniazid, rifampicin, ethambutol and levofloxacin and later pyrazinamide was added. The platelet count increased after 1 month of ATT to 40,000, and after 2 months, the count was 100,000/mm3.

Effect and Toxicity of Bilateral Supraclavicular Lymph Node Irradiation on Stage III Lower Thoracic Esophageal Cancer After Radical Surgery

Surgery is the most important treatment for patients with lower thoracic esophageal squamous cell carcinoma (LTEC). Treatment failures, especially loco-regional recurrence involving mediastinal, abdominal, and supraclavicular lymph nodes area, are common after radical esophagectomy. Post-operative radiotherapy (PORT) has been demonstrated to benefit patients with stage III disease. However, whether bilateral supraclavicular lymph node radiotherapy should be included in the clinical target volume (CTV) remains unclear for those patients with lower thoracic esophageal cancer. So, we aim to explore whether PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node, prolong overall survival and control distant metastasis in patients with stage III LTEC. We retrospectively analyzed 79 patients with stage III LTEC who had undergone radical surgery and PORT between 2010 and 2014. Among these patients, 51 patients received PORT which CTV excluding the bilateral supraclavicular lymph node region (Group A), and the remaining 28 patients received PORT which CTV including the supraclavicular region (Group B). Clinical outcomes (including local control, survival time, side-effects and prognostic factors) were analyzed with SPSS 25.0. Follow-up to August 2016, the 1-, 2-, and 3-year supraclavicular lymph nodes metastasis rates were 15.7%, 41.2%, 45.1% in Group A, 10.7%, 10.7%, 10.7% in Group B. The median overall survival (OS) of Group A and Group B were 25 and 24.5 months respectively. Univariate and multivariate analysis indicated that radiotherapy to the supraclavicular region decreased supraclavicular lymph node recurrence (p = 0.007/0.016, respectively) but did not prolong OS (p = 0.273/0.324) or control distant metastasis (p = 0.760/0.804). Our data also indicated that PORT including the supraclavicular region was not associated with the increase of radiotherapy-related complications (all p > 0.05). PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node in patients with stage III LTEC without increase of treatment-related toxicities. However, PORT including bilateral supraclavicular region failed to prolong OS or control distant metastasis. Further prospective studies are warranted.

Unusual local and distant metastases after complete resection of roentgenographically occult squamous cell carcinoma.

Roentgenographically occult squamous cell carcinoma (ROSCC) was reported to have been cured after complete resection. We experienced unusual local and distant metastases after complete resection of a ROSCC of left B6 bronchus. During the operation due to the proximal bronchial stump being positive for squamous cell carcinoma (SCC), a left lower sleeve lobectomy was performed. Six years after the operation, a chest CT showed no abnormal shadows. 6months later a PET-CT showed metastases on bilateral supraclavicular lymph nodes, mediastinal lymph nodes, and the right adrenal glands. A biopsy of the right supraclavicular lymph node revealed that it was a metastatic SCC. The possibility of recurrence from a second pulmonary SCC might still remain. A prolonged follow-up over many years is desirable for a heavy smoker with a ROSCC.

Role of fine needle aspiration cytology in the management of supraclavicular lymph node metastasis: Review of our experience.

In the 19th century Virchow described that metastasis to left supraclavicular lymph nodes (SLN) could originate in neoplasms located under the diaphragm. In the same way, right SLN metastasis are usually thought to arise from thoracic neoplasms. Our aims are to review our experience with metastatic SLN diagnosed by fine-needle aspiration cytology (FNAC) and to discuss the location of the primary in these cases. We have reviewed all lymph node FNACs diagnosed in a single tertiary hospital between 2010 and 2017 and we have included all cases of metastatic SLN. We have found 57 cases of SLN FNAC with a diagnosis of malignancy, 39 of which had no previous diagnosis (17 left, 20 right and 2 bilateral SLN). The most frequent diagnosis were adenocarcinoma, squamous cell carcinoma and small cell carcinoma. Right and bilateral SLN showed mainly lung metastasis. Left lesions were more widely distributed, with 11 originating in the lung, followed by the breast, gastroesophageal junction and prostate gland. In two cases, the primary origin was not identified. In SLN with metastasis of a known origin, the main source of the tumor was again the lung and only one case originated in the stomach (left SLN metastasis). The origin of SLN metastasis seems to be dependent on both the frequency of tumor types in each geographic area and tumor location. Left SLN are more frequently involved by infradiaphragmatic primary tumors, while right SLN are exclusively involved by supradiaphragmatic neoplasms.

Effect of bilateral supraclavicular lymph nodes irradiation in stage III lower thoracic esophageal squamous cell carcinoma after radical surgery.

e15555 Background: Surgery is the most important treatment for patients with lower thoracic esophageal squamous cell carcinoma (LT-ESCC) at stage III, but the locoregional failure is common, especially mediastinal and supraclavicular lymph nodes metastases. Postopearative radiotherapy (PORT) is benefit for those patients. However, the clinic target volume (CTV) remains controversial, especially whether or not including bilateral supraclavicular lymph nodes radiotherapy. Methods:79 patients of lower LT-ESCC at stage III who had undergone radical surgery and PORT were enrolled. 51 patients received the PORT CTV without bilateral suparclavicular lymph nodes region (group A), while 28 patients received the CTV with suparclavicular region (group B). Results: Totally, 26 patients had the tumor recurrences of supraclavicular lymph nodes. Among them, 23(45.1%) patients had the metastasis in group A, 3(10.7%) patients had the metastasis in group B. Univariate analysis showed the bilateral supraclavicular region RT can decrease of supraclavicular lymph nodes recurrence (p = 0.007). However, it could not prolong the overall survival (p = 0.273) or control the distant metastasis (p = 0.760).The Cox analysis revealed it was independent factor to control supraclavicular lymph node recurrence (HR = 0.027; 95 % CI 0.068-0.757; p = 0.016). PORT includingsupraclavicular region didn’t increase the radiotherapy complications, such as radiation pneumonia (p = 0.354), radiation esophagitis (p = 0.456), gastrointestinal reaction (p = 0.809), neutropenia (p = 0.470), thrombocytopenia (p = 0.137) and anemia (p = 0.642). Conclusions:PORT including bilateral supraclavicular region can reduce the metastasis of supraclavicular lymph nodes in LT-ESCC at stage III, and it does not increase radiotherapy complications. However, it can’t prolong OS or control the distant metastasis. Chemotherapy is essential to control distant metastasis and prolong OS.

Metastatic characteristics of lymph node in supraclavicular zone and radiotherapy target volume for limited-stage small cell lung cancer

To explore the reasonable radiotherapy range by analyzing the characteristics of supraclavicular lymph node metastasis in limited-stage small cell lung cancer (LS-SCLC). From January 2005 to December 2011, patients of LS-SCLC were reviewed. Supraclavicular zone was further divided into five subgroups including para-recurrent laryngeal nerve (region I and region II ), para-internal jugular vein (region III ), supraclavicular region (region IV), as well as the other regions except for the mentioned above (region V). The characteristics of the lymph nodes in each region were analyzed. The supraclavicular lymph node metastasis was found in 60 patients, with a positive rate of 34.5%. In multivariate Logistic regression analysis,intra-thoracic lymph node metastasis in the lymph node stations of level 2 and 3 were found to be the risk factors of supraclavicular lymph node metastasis (P = 0.006,P = 0.000). Our data suggests that the frequencies of metastasis in region I and III were much higher than those in the other areas.Among the sixty patients with supraclavicular lymph node metastasis, 95.0% were found at region I or III while the incidence of skip metastasis was only 5.0%. It is advisable to contain the bilateral supraclavicular nodes in patients with mediastinal lymph nodes metastasis to the level 2 or 3 for elective radiation target volume.The clinical target volume (CTV) exterior margin containing the outer margin of internal jugular vein may be suitable.

Lung cancer: a 6-field technique using lateral beams in conformal radiotherapy for bilateral supraclavicular lymph node metastases.

A 6-field technique using lateral beams in conformal radiotherapy was developed for patients with bilateral supraclavicular lymph node metastasis of lung cancer. The possibility of using this technique in practice was evaluated. Six fields with the same isocenter point (IP) were arranged. Two fields using anterior-posterior opposed beams involved all of the planning target volume (PTV). The next 2 fields using off-cord oblique beams involved the PTV inferior to the IP. The remaining 2 fields using lateral opposed beams, that shielded the spinal cord, involved the PTV superior to the IP. The oblique 2 fields and lateral 2 fields were connected using a half-beam technique. In 6 patients with non-small-cell lung cancer (NSCLC, n = 4) or small-cell lung cancer (SCLC, n = 2), treatment re-planning based on this technique was performed. This technique was applicable in 4 patients with NSCLC, in whom the general criteria of radiotherapy for lung cancer were met. In 2 patients with SCLC, the cumulative volume of lung that received more than 20 Gy exceeded 37% of the total lung volume. This technique was usable in 67% of the patients and was not necessarily contraindicated in the other 33%.Electronic supplementary materialThe online version of this article (doi:10.1186/2193-1801-3-733) contains supplementary material, which is available to authorized users.

Fluid biopsy for circulating tumor cells in an occult ovarian cancer patient exhibiting bilateral supraclavicular lymph node metastases: A case report

Metastases to the supraclavicular region usually originate from the head and neck or from infraclavicular tumors. Ovarian primaries of supraclavicular metastases are extremely rare. The present study reports the case of a 60-year-old patient with a bilateral supraclavicular mass that was diagnosed as a poorly-differentiated squamous cell carcinoma of unknown primary, following a fine-needle aspiration biopsy (FNAB) and comprehensive clinical investigation. The analysis of a peripheral blood sample using the CellSearch system revealed the presence of circulating tumor cells (CTCs) that were positive for epithelial cell adhesion molecule (EpCAM) and cytokeratin (CK) expression. Since EpCAM is usually expressed in adenocarcinoma, an excisional biopsy of the right supraclavicular lymph node was performed. The patient was diagnosed with occult ovarian low-grade serous carcinoma by immunohistochemistry. To the best of our knowledge, this is the first report to demonstrate that CTCs may be detected in the peripheral blood of a patient with cancer of unknown primary (CUP) by using the CellSearch system. A literature review was performed to analyze the diagnostic procedures of CUP metastatic to the cervical lymph nodes and the clinical features of CTCs.

Bilateral pleural effusions in a 23-year-old man: a clinical puzzle

A 23-year-old man presented with progressive swelling in the left supraclavicular area and worsening dyspnea of 7 days duration. Histories of fever, chills, night sweats, cough or weight loss was denied. Medical and family histories were unremarkable. Physical examination revealed usage of accessory muscles of respiration, facial plethora, acne, multiple dilated veins on chest wall, firm non-tender bilateral supraclavicular lymph nodes and decreased air entry and dullness in both lung bases. Chest X-ray revealed bilateral pleural effusions (Figure 1A). Computed tomography (CT) scan of the neck and chest demonstrated thrombotic occlusion of the superior vena cava, right subclavian, innominate and internal jugular veins, mediastinal fibrosis, subcentimeter mediastinal adenopathy and a mass on the left cardiac atrioventricular wall (Figure 1B and C). Pleural fluid revealed a triglyceride concentration of 799 mg/dl and lactate dehydrogenase (LDH) of 947 U/l with negative cultures and cytology. Lymph node and pleural biopsies were benign. Cardiac magnetic …

Dyspnea and Hemoptysis in a 53-Year-Old Woman With a History of Breast Cancer

A 53-year-old woman presented to her primary physician with the complaint of a new, progressive cough accompanied by wheezing and dyspnea over a period of 1 month. She had a history of stage 1 breast adenocarcinoma diagnosed 13 years earlier, treated with a right modified radical mastectomy and 7 months of adjuvant chemotherapy. Ten years later, she had a recurrence of her cancer in the bilateral supraclavicular lymph nodes, and she was treated with three courses of chemotherapy and radiation with complete remission.

The right upper lobe pulmonary resection performed through the transcervical approach

Preliminary report: presentation of the new technique of transcervical right upper lobectomy with transcervical extended mediastinal lymphadenectomy (TEMLA) for NSCLC. Two patients underwent the operation that was performed through the collar incision, with elevation of the sternal manubrium with the mechanical sternal retractor. TEMLA and bilateral mediastinal lymph node excision (stations 1, 2R, 4R, 2L, 4L, 3A, 3P, 7 and 8) and bilateral supraclavicular lymph node excision were performed (frozen section analysis: all nodes negative). The mediastinal pleura was opened and the following structures were dissected in the open fashion with standard surgical instruments and divided with the use of endostaplers: the azygos vein, the upper trunk of the right pulmonary artery, the branch of the superior pulmonary vein to the upper lobe, the upper lobe bronchus, the segment 2 artery, the posterior part of the oblique fissure and the horizontal fissure. The operation was performed with the use of one videothoracoscopic (VTS) port for insertion of 5mm, 30 degree VTS camera for intraoperative control and for single thoracic drain for the postoperative period. The operative times were 250 and 270 min, respectively; intraoperative blood loss was 110 and 100ml, respectively. There were no intraoperative complications. The postoperative course was remarkably smooth. The final pathologic report: large cell carcinoma pT2N0M0 and squamous cell carcinoma pT2N0M0, no metastatic changes of 51 and 41 mediastinal and intrapulmonary (stations 10, 11 and 12) and supraclavicular nodes, respectively. This preliminary report indicates possible advantages of the transcervical right upper lobe pulmonary resection including: (1) extremely radical, minimal invasive procedure with no need for utility thoracotomy; (2) dissection performed with standard surgical instruments in the open fashion.

Regression of Lymph Node Metastases by Immunotherapy Using Autologous Breast Tumor-Lysate Pulsed Dendritic Cells: Report of a Case

A 50-year-old woman was diagnosed as having stage IV breast cancer with bilateral supraclavicular lymph node metastasis resistant to CAF therapy. She received immunotherapy using autologous tumor lysate-pulsed dendritic cells (DCs). Four cycles of DC injection into the right supraclavicular lymph nodes resulted in regression of bilateral supraclavicular lymphogenous metastasis. Histological studies revealed an accumulation of CD45+ T lymphcytes in the regressive lymph nodes. This case suggests that immunotherapy with DCs may be a safe and promising approach for the treatment of advanced breast cancer.

Induction chemotherapy plus high-dose radiotherapy versus radiotherapy alone in locally advanced unresectable non-small-cell lung cancer

High-dose radiation therapy is generally recommended as standard treatment in regionally advanced unresectable non-small-cell lung cancer (NSCLC), but median- and long-term survival remain poor. Some reports have recently shown an improvement of results in advanced NSCLC when cisplatin was included in the chemotherapy regimens. Therefore, we designed a randomized trial to determine whether induction chemotherapy before high-dose radiotherapy improves response rate and survival in stage III NSCLC over that achieved with radiotherapy alone. From March, 1984 to December, 1988, 66 consecutive patients with stage III unresectable NSCLC were randomized to one of two treatment arms; 61 were evaluable for survival and 58 for response and toxicity. Patients randomly assigned to arm A received cisplatin (CDDP 100 mg/m2 on day 1) and etoposide (VP 16 120 mg/m2 on days 1, 2, 3) every 3 wks for 3 courses followed by radiotherapy 56 Gy on pre-treatment tumor volume and 40 Gy on mediastinum and bilateral supraclavicular nodes. Patients assigned to arm B received only the same radiotherapy. The 61 eligible patients were comparable in terms of age, performance status, histology and treatment. Response rate was 53% in arm A and 32% in arm B. The median survival was 52 wks for the combined treatment arm and 36 wks for the radiation therapy arm. At six years of follow-up all the patients were dead. Toxicity was mild and no treatment-related deaths were recorded. Induction chemotherapy produced a better response rate and a trend of improved survival (4 months) but a significant survival advantage was not achieved (p < 0.11), probably because of the small number of patients enrolled in the trial.

Fine needle aspiration cytology of palpable supraclavicular lymph nodes

Background: Fine needle aspiration cytology as a first line of investigation has assumed importance in diagnosing a variety of disease process. The aim of this study was to assess the diagnostic value of fine needle aspiration cytology in the evaluation of palpable supraclavicular lymph nodes. Materials and methods: This was a retrospective study of fine needle aspiration cytology of palpable supraclavicular lymph node done between January 1, 2007 and December 31, 2009. Fine needle aspiration cytology was performed on 149 patients (49 cases at Om Hospital &amp; Research Centre and 100 cases at Tribhuvan University Teaching Hospital). Results: The right supraclavicular lymph node was enlarged in 55% cases, while the left supraclavicular lymph node alone was palpable in 40.3% cases and in 7 of 149 (4.7%) cases, bilateral supraclavicular lymph nodes were palpable. Cytological diagnoses were categorized as reactive (8.7%), tuberculosis (41.6%), lymphoma (4.8%) and metastasis (44.9%). Of a total of 74 cases of malignancy, 90.5% were non-lymphoid and 9.5% were lymphoid (5 Non-Hodgkin lymphoma and 2 Hodgkin lymphoma). Of the 67 cases of metastatic disease, three major types of malignancy found in supraclavicular lymph nodes were Squamous cell carcinoma (28 cases), adenocarcinoma (21 cases) and others (small cell carcinoma, papillary thyroid carcinoma etc). Adenocarcinoma tended to metastasize to the left supraclavicular lymph node. Lung was the most common primary site (43.3%), followed by stomach, ovary, breast and larynx. However, in 28.4% cases, no primary site was found. Conclusion: The fine needle aspiration cytology can be used as a first line investigation in the evaluation of supraclavicular lymphadenopathy due to its low cost, simplicity and minimal invasiveness. Keywords: Supraclavicular lymph node; Fine needle aspiration cytology; Metastasis DOI: 10.3126/jpn.v1i1.4441 Journal of Pathology of Nepal (2011) Vol.1, 8-12