Scalene Node Biopsy Research Articles

Pneumothorax Following "Trigger Point" Injection

To the Editor:— Antoni reviewed 226 cases of pneumothorax occurring in patients treated at the Henry Ford Hospital during the period 1955 to 1959, of which 76 were iatrongenically produced. 1 Techniques used by the surgeons, otolaryngologists, internists, gastroenterologists, and anesthesiologists could be complicated by pneumothorax and he urged that all physicians be cognizant of this complication. Iatrogenic causes included scalene node biopsy, arterial catheterization, pneumoperitoneum, tracheotomy, and radical neck dissection. Although Osler mentions the occurrence of pneumothorax as a result of exploration with needles, he does not indicate after which procedure or explorations this may occur. Pleural biopsy, now a widely accepted procedure, may be complicated by pneumothorax as well as intercostal nerve injury or hemorrhage. We recently encountered a case of traumatic pneumothorax as a result of injection of trigger-points on the neck with a local anesthetic. Report of a Case.— A 29-year-old white man was admitted to

Scalene Node Metastases In Prostatic Cancer

To the Editor.— In a medical news item, ( 212 :251, 1970) in regard to the rarity of supraclavicular lymph node metastases in prostatic cancer, James J. Butler, MD, reported two patients with metastatically enlarged supraclavicular nodes in 100 consecutive admissions with prostatic cancer. A study of routine bilateral scalene (supraclavicular) node biopsy in 194 patients with prostatic carcinoma ( J Urol 103 :458, 1970) investigated 128 consecutive (new) patients with stage 3 and 4 prostatic cancer over a period of 38 months, and 66 similar patients who had been under treatment for 6 months to five years, who also had a scalene node biopsy during the same period. In 41 patients with stage 4 prostatic carcinoma there were 8 with palpable supraclavicular nodes which were positive on biopsy, and 13 more with nonpalpable nodes but showing microscopic metastatic cancer deposits. This gave an incidence of 51%. In stage 3, there were

Cystoscopic Control of Hemorrhage via Gastrostomy

To the Editor.— In suitable cases gastric bleeding points may be effectively effulgurated, with satisfactory control of severe hemorrhage. Report of a Case.— A 63-year-old man was admitted on Feb 20,1966, with a history of increasing dysphagia and weight loss. Barium swallow, esophagoscopy, and scalene node biopsy confirmed the diagnosis of inoperable squamous cell carcinoma in the mid portion of the esophagus. Roentgenographic therapy was started after producing a feeding gastrostomy. Following administration of 4,035 rads in 31 days, the patient suddenly experienced massive gastrointestinal hemorrhage and the hemoglobin level fell to 4.1 gm/100 ml. Studies confirmed hemorrhage from the stomach, and a large ulceration of the lesser curvature. In spite of the usual procedures for control of gastric hemorrhage, persistent bleeding required transfusion of 8 units of blood over a 24-hour period. Examination of the stomach with a cystoscope passed through the gastrostomy, revealed a large ulcer of the

The definitive evaluation of sarcoidosis.

Thirty patients with clinical, roentgenographic, and histologic manifestations of sarcoidosis on biopsy of peripheral tissues were subjected to exhaustive diagnostic study in an attempt to establish a definitive diagnosis other than sarcoidosis. This was accomplished in 27 patients. The most rewarding diagnostic procedure was open lung biopsy, which proved to be the definitive diagnostic procedure in 16 patients. Additional diagnostic procedures included cultures of secretions and biopsied tissues, special staining techniques, chemical analysis of biopsy specimens, and immunologic studies. In the patient with suspected intrathoracic sarcoidosis, the diagnosis cannot be established without open thoracotomy unless preliminary cultures or biopsies of peripheral tissue reveal evidence of another pathologic process known to cause a granulomatous reaction. The presence of sarcoid in a patient with an abnormal chest film cannot be confirmed by scalene node biopsy, a Kveim test, or absence of bacteriologic eviden...

Diagnostic Accuracy of Exfoliative Pulmonary Cytology

he increased incidence of bronchogenic carcinoma has brought with it diagnostic problems, especially in the evaluation of abT normal chest roentgenograms. In primary carcinoma of the lung, bronchial biopsy will reveal the diagnosis in about one-third of cases. Biopsy of scalene lymph nodes in the absence of palpable nodes will demonstrate the presence of metastatic carcinoma in about 10 to 20% of cases. An outcome of the development of exfoliative cytology during the last two decades has been the growing dependence of thoracic surgeons on cytological examination of respiratory secretions to diagnose lung cancer. It is not generally realized, however, that not only can cytological examination of sputum or bronchial aspirate be used to diagnose the presence of bronchogenic carcinoma; it also can be applied to the histological typing of the neoplasms. In our medical center the presence of malignant cells in sputum or bronchial aspirate is regarded as reliable evidence that a malignant neoplasm exists in the respiratory tract. A question has been raised, however, concerning the reliability of cytological examination in the typing of bronchogenic carcinomas. T o answer this question, we have reviewed our experience with 104 cases of bronchogenic carcinoma. In these cases a definite statement as to the type of carcinoma was arrived at by cytological examination, and there was histopathological material to confirm or refute the cytological typing.

Retrospective search for asbestos bodies in necropsies and biopsies on cases of primary malignant disease of the lung

Fifty-three histologically confirmed carcinomas of the lung, diagnosed between 1965 and 1967, were studied: 23 in a necropsy series, 15 in operation specimens, 5 of which in scalene node biopsy, and 15 in bronchial biopsy. All the tumours, with the exception of the 5 observed in scalene node biopsy, were re-examined for possible association with asbestos bodies. No asbestos bodies were found in any case. Other possible causative factors were investigated, but it was not possible to establish a definite association with the tumours. In the necropsy series, the average age was 63·3 years, there were 19 tumours in males and 4 in females and, histologically, the anaplastic type was the most frequent, 16 out of 23. In the operation specimen series the average age was 53·8 years, there were 10 tumours in males and 5 in females and 8 out of 15 were of anaplastic type. In the bronchial biopsy series the average age was 59·5 years, there were 13 tumours in males and 2 in females, the squamous type was the most frequent, 11 out of 15.

Metastatic neoplasm to the kidney. A report of four cases studied with angiography and nephrotomography.

Metastatic neoplasm to the kidney is not uncommon, but it is unusual for a metastasis to the kidney to present as a solitary renal mass lesion or to cause urinary tract symptoms. We have had the opportunity to radiographically study four such lesions with angiography and nephrotomography. In all instances the angiogram revealed an avascular or hypo-vascular lesion while nephrotomography (performed in three cases) clearly indicated that the lesion was not a simple benign cyst. The presentation of the clinical and radiographic features of these cases forms the basis of this report. Case I: A 59-year-old male was admitted to the Boston University Hospital complaining of shortness of breath of two to three months duration. He also complained of a nonproductive cough and a gradual weight loss of thirty pounds during this period. He had been smoking three packs of cigarets a day for forty-six years. Positive findings on physical examination included a left supraclavicular node and mild clubbing of the fingers. The admission chest radiograph showed a lobulated mass in the left hilar region. A scalene node biopsy as well as bronchoscopy revealed epidermoid carcinoma. A course of radiotherapy, cobalt 60, to the mediastinum and left chest was administered. The patient was discharged from the hospital and then was readmitted for a second time seven months later with a chief complaint of right hip pain. No definite lytic or blastic lesions could be identified on x-ray examination of the hip, and further work-up to evaluate possible metastatic disease to the retroperitoneal and epidural areas was instituted. Myelography revealed lumbar epidural metastases. Intravenous pyelography and inferior venacavography demonstrated retroperitoneal masses. A large intrarenal mass was also noted at the lower pole of the left kidney (Fig. 1, A). The left renal mass was evaluated by renal arteriography and nephrotomography. The lesion revealed no “tumor vessels” but demonstrated amputation and encasement of intrarenal arterial branches (Figs. 1, B and C). Nephrotomography confirmed the fact that the lesion was not a simple benign process (Fig. 1, D). A left renal exploration was decided upon so that the subsequent treatment could be planned on the basis of the histology of the kidney lesion. A left nephrectomy disclosed an 8-cm-in-diameter metastatic lesion (epidermoid carcinoma) to the kidney with the identical cell type as seen in the left supraclavicular node and bronchoscopic biopsy previously obtained (Fig. 1, E). Metastatic disease to the peritoneum, left para-aortic nodes, and muscular fascia was also present. The patient was given palliative radiotherapy to these areas. Case II: This 61-year-old male was admitted to the Boston University Hospital for the surgical removal of a mass in the soft tissues of the lower left leg. The mass was 15 × 5 × 5 cm and was firm but not attached to adjacent bone.

Restrictive cardiomyopathy as the presenting feature of reticulum cell sarcoma

A case of reticulum cell sarcoma with restrictive cardiomyopathy is reported. The patient was examined because of increasing dyspnea and fatigue. Cardiac evaluation, including cardiac catheterization, demonstrated that a restrictive cardiac process was present. The patient initially responded to digitalis, but eventually developed cardiac enlargement, third degree A-V block, and more severe cardiac failure. Superior vena caval obstruction developed as a result of right superior mediastinal lymphadenopathy. Scalene node biopsy initially showed atypical lymphoid hyperplasia. After a course of radiation therapy the caval obstruction was relieved, the heart block disappeared, and the symptoms and signs of cardiac failure regressed. A subsequent biopsy of a cervical lymph node showed anaplastic reticulum cell sarcoma. Repeat cardiac catheterization one year after radiation therapy demonstrated substantial resolution of the restrictive process. Up to the time of writing, i.e., 18 months after therapy, she continues to feel well, and she is able to do all of her housework.

Diagnosis of Lung Cancer by the Transbronchial Brush Biopsy Technique

The problem of diagnosis of cancer of the lung has yielded partially to the diagnostic triad of bronchoscopy, sputum cytology, and scalene-node biopsy. There still remains a considerable number of cases in which open-lung biopsy is the only means of arriving at a diagnosis, especially with the small, peripheral lesions. The development of brush biopsy technique by Hattori et al¹and modifications made by Fennessey²make it possible to diagnose peripheral lung cancer nonsurgically in a majority of cases.³ We first applied this technique in January 1967 in problem cases and have found the method very useful, easy to learn, and safe to use. We therefore present our experiences in the hope that this will encourage others to utilize the method for the benefit of their patients. <h3>Material, Equipment, and Technique</h3> The brushes used in this technique are nylon mounted on a 36.5-inch stainless steel wire. They

Diagnostic value of scalene node biopsy in pulmonary tuberculosis

Summary In 288 cases patients proved to have pulmonary tuberculosis were subjected to scalene node biopsy in an attempt to assess the diagnostic value of the procedure. Tuberculous histopathology in the scalene nodes was obtained in 72 cases (26%) out of a total of 276 in which glands were obtained. Even when acid-fast bacilli were absent in sputum (smear examination) the scalene nodes confirmed the diagnosis in 23% of cases. The corresponding figure for those with acid-fast bacilli in the sputum was 30%. Previous chemotherapy did not appear to affect the diagnostic value of the procedure, nor did the extent of involvement of the lung parenchyma. ‘Sinus catarrh’ in 84 instances were taken to be diagnostically inconclusive. In no instances did the scalene nodes suggest a tuberculosis. We suggest that scalene node biopsy may be helpful in some patients when the diagnosis of pulmonary tuberculosis is in doubt.

Clinical and Pathological Study of Scalene Node Biopsy and Mediastinoscopy in Pulmonary Diseases, Especially Cancer of the Lung

The study is to evaluate the validity of scalene node biopsy and mediastinoscopy as methods of clinical examination on various pulmonary disabilities and to discuss the possible route of lymph node metastasis of cancer of the lung.In a 4 year duration til June, 1966, 111 patients were examined and those included 45 patients of cancer the lung, 17 mediastinal tumor, 10 pulmonary tuberculosis, 8 sarcoidosis, 6 metastatic tumer of the lung and others. In general, scalene node biopsy and mediastinoscopy were infrequently positive in patients with pulmonary diseases unless the mediastinum were involved by the disease or the patients had sarcoidosis.From the study of cervical lymph node and mediastinal metastases of cancer of the lung based on both examinations of biopsy and mediastinoscopy, an obvious route of metastasis was determined in none of each case and it was considered that metastases were produced via the much complicated route of lymphatic system. Considering the validity of scalene node biopsy and mediastinoscopy, as methods of pre-operative examination, it was assured that scalene node biopsy, as biopsy of distant lymph node from the lung, is an useful method fo- determination of indication of surgery, and mediastinoscopy as a good tool of examination of the mediastinum is useful to determine operability of the lesion of the lung.

Postirradiation costal osteochondritis simulating metastatic cancer.

Radiation injuries to subcutaneous tissues and underlying bones can create difficulty in differential diagnosis because their appearance may simulate metastasis or local recurrent cancer. Their recognition is important in order to avoid unnecessary surgical procedures, chemotherapy, or even reirradiation. This report will describe three cases of postirradiation osteochondritis involving the costochondral and sternoclavicular joints, simulating chest wall recurrences. Case I: A 65-year-old male, complaining of hemoptysis, was admitted to The University of California San Francisco Medical Center. A diagnosis was made of inoperable bronchogenic carcinoma, on the basis of a large right hilar mass and Class V sputum cytology. Palliative x-ray therapy, utilizing a cobalt-60 unit, was administered. In November 1964, 1,000 R was given on three consecutive days through a 9 × 7 cm right anterior field over the right hilus. After four weeks, another course of 3 times 1,000 R was given in three days to the same area. Thus, a total given dose of 6,000 R was administered in 6 treatments over a period of five weeks. In September 1965, nine months after completion of x-ray therapy, the patient was admitted to the emergency room for acute pain in the right chest and shoulder. A painful mass was felt over the irradiated right parasternal region (Fig. 1). The skin adherent to the mass was woody, wrinkled, and erythematous. X-ray films of the rib cage showed a soft-tissue mass associated with the involved costochondral joint. Although no bony destruction was evident even in the tomograms, the problem was diagnosed clinically as a metastasis. Since further x-ray therapy was contraindicated, the patient was discharged on Darvon compound. After three months, the lesion became asymptomatic; the mass did not disappear, but the skin discoloration faded. The patient was last seen on Nov. 1, 1966, free of disease. Case II: A 40-year-old female, on the basis of chest x-ray films taken in April 1965, was found to have an anterior mediastinal mass. Complete gastrointestinal studies, intravenous pyelography, mammography, and thyroid scan were reported normal. A right scalene node biopsy on May 11, 1965, revealed metastatic adenocarcinoma. At the University of California San Francisco Medical Center, initial chemotherapy was ineffective, and the patient was referred for radiation therapy in July 1965. The patient was seen by a radiotherapist in August and found to have pulmonary osteoarthropathy, as evidenced by clubbing of the fingers and swelling and pain in the left ankle and shoulder. In addition to the mediastinal mass, which had not regressed after chemotherapy, there were several metastatic subcutaneous masses. Through a single 10 × 9 cm anterior field with the cobalt-60 unit, the superior mediastinum and the left hilus were covered; doses of 1,000 R were delivered daily from Sept. 27 to 29, 1965.

A comparison of mediatinoscopy and scalene node biopsy.

A comparison of mediatinoscopy and scalene node biopsy.

Present Diagnostic Approach to Sarcoidosis in Japan

Sarcoidosis is a rare disease in Japan. Bilateral hilar adenopathy is suggestive of malignant tumor rather than sarcoidosis. Hematology and plasma chemistry offer no clues to the diagnosis of sarcoidosis. The Kveim test is still poor in reliability even in biopsy-confirmed patients in this country. One-third of patients with bilateral hilar node swelling or pulmonic mottled silhouette alone are left undiagnosed even after Daniels' scalene lymph node biopsy. Sarcoidosis was discovered in 18 patients among those who underwent thoracotomy biopsy to exclude definitely the possibility of malignancy.

Aspiration biopsy of thoracic lesions

We have performed percutaneous needle aspiration biopsy of intrathoracic lesions under fluoroscopic control on 50 patients. Lesions as small as 1 to 1·5 cm. in diameter were aspirated. Thirty of the 36 cases of malignant neoplasm were diagnosed by this method. Of the 14 non-neoplastic cases, granuloma was diagnosed in two, and in eight of the remaining 12 the clinical diagnosis was supported by the nature of the aspirated material. Pneumothoraces are to be expected as a complication of the method. Most will be asymptomatic; a small proportion will require treatment. There will also be the occasional haemoptysis. The procedure can be quickly performed and it is well tolerated by the patient. It causes less discomfort than bronchoscopy or scalene lymph node biopsy. The interpretation of the cytological material presents no undue difficulty to the pathologist experienced in conventional pulmonary exfoliative cytology.

Scalene Node Biopsy in Pulmonary Diseases: Report of 110 Cases

An analysis of 110 cases of scalene node biopsy in pulmonary disease is presented. A positive diagnosis was obtained in 85 per cent of 20 cases with clinically palpable nodes, and in 28.9 per cent of 90 cases with clinically non-palpable nodes. Sarcoidosis and malignancy gave the highest percentage of positive histologic diagnosis. The procedure was found to be of no value in the diagnosis of pulmonary fibrosis. Occasionally, carcinoma and tuberculosis may coexist, but scalene node biopsy may be positive for tuberculosis alone. There has been evidence of spread of malignancy to the contralateral side. Positive diagnosis can, in some cases, be made from histologic examination of the scalene fat pad, though the lymph nodes may not show any involvement. The bacteriologic studies were not of much help in making a diagnosis. We feel that scalene node biopsy should be a part of the various investigations for establishing the diagnosis of pulmonary disease. Through its frequent use and proper interpretation, thoracotomy may be avoided in a number of cases with primary or metastatic pulmonary malignancy.

Mediastinoscopy in a Community Hospital

Mediastinoscopy is being used as a diagnostic tool with increasing frequency in this country. In the absence of peripheral nodes, it is a more rewarding procedure than scalene node biopsy in the diagnosis of sarcoidosis. Mediastinoscopy is a better method of detecting lymphatic extension of bronchogenic carcinoma than scalene node biopsy. This technique is useful in the determination of the operability of lung carcinoma. The procedure is usually accomplished with minimal complications.

Air Embolism following Mediastinoscopy and Scalene Node Biopsy: Report of a Case

Air Embolism following Mediastinoscopy and Scalene Node Biopsy: Report of a Case

Combined superior vena cavography and azygography in patients with suspected lung carcinoma.

Intraosseous costal or spinous process azygography has occasionally been used for visualization of the thoracic venous system in the preoperative assessment of carcinoma of the lung (2, 7). Obstruction of the superior vena cava or extrinsic compression or invasion of its lumen is a relatively frequent finding in the natural history of pulmonary carcinoma, especially when the lesion originates in the right lung (3). In 85 per cent of 33 cases coming to autopsy in one series, cancer was the etio-logic agent producing superior vena caval obstruction (1). To our knowledge, the combined use of superior vena cavography and azygography as part of the preoperative assessment of pulmonary carcinoma has not been previously reported. Our experience with 63 consecutive patients who have been evaluated for suspected primary lung carcinoma by the use of superior vena cavography and azygography forms the basis of this report. The roentgenographic patterns of abnormality are evaluated and presented. The importance of proper technic is discussed. Assessment of each study separately and in combination is made to determine its value in defining resectability. Materials and Technic Sixty-three patients with suspected primary pulmonary cancer were evaluated by a diagnostic work-up which included pos-tero-anterior and lateral chest roentgenograms, transtracheal bronchography (6), azygography and superior vena cavography, scalene node biopsy, bronchoscopy, sputum cytology, and pulmonary function studies. The clinical records of each patient were reviewed, and the significance of the findings from azygography and superior vena cavography was correlated with the operative and pathological findings. Azygography and superior vena cavography were performed at the same time in all cases. Each patient was premedicated with 50 mg meperidine (Demerol), 100 mg secobarbital (Seconal), and 25 mg Phener-gan thirty minutes before the start of the procedure. A rapid-sequence film-changer should be used for both azygography and superior vena cavography if really meaningful results are to be obtained. False-negative examinations are greatly minimized (Fig.1). False-positive examinations due to spurious physiologic obstruction from the Valsalva maneuver or tightening of neck and shoulder musculature are eliminated by using serial exposures and by cautioning the patient to remain relaxed and to continue breathing normally throughout the injection and exposure times (Fig. 2, A and B). The equipment for superior vena cavography includes two 30 cc syringes, each containing 25 cc of 50 per cent Hypaque and No. 16 gauge needles with plastic connecting tubing. The basilic veins in both antecubital fossae are injected simultaneously by hand to give complete visualization of the innominate veins as well as of the superior vena cava. The total injection time is between two and three seconds.

Significance of mediastinoscopy in carcinoma of the lung.

EXPLORATION of the mediastinum for the purpose of obtaining the diagnosis of intrathoracic pathology was stimulated by Daniels¹in 1949 when he reported the first series of supraclavicular node biopsies. The quest for diagnoses was pursued further by Harkins and associates²when they proposed exploring behind the clavicle with a laryngoscope at the time of scalene node biopsy. In 1959 Carlens³was able to report 100 cases in which he had biopsied hilar and subcarinal lymph nodes from a supraclavicular incision during a procedure he called mediastinoscopy. These steps in the development of mediastinoscopy have a definite anatomic basis in the work done by Rouviere⁴and confirmed by Palva,⁵when they demonstrated that the lung lymphatics drained to subcarinal and paratracheal areas and then up along the sides of the trachea of the supraclavicular areas. Each advance in the evolution of mediastinoscopy has brought the