Hilar Metastasis Research Articles

Non–Small Cell Lung Cancer With N1 Involvement or Skip Metastases Presents the Same Survival Outcome: Results From a Multicentric Study

BackgroundThe prognostic difference among patients affected by NSCLC with hilar metastases only or mediastinal nodes metastases without hilar involvement (skip metastases) is still unclear. Aim of this study is to analyse if prognostic difference are present or if the two groups present the same survival outcome. Materials and MethodsData on NSCLC patients from 7 high volume centres (2004-2014) were collected and retrospectively reviewed. Histology different from adenocarcinoma(ADC) or squamous cell carcinoma(SCC), patients without data on lymphadenectomy, who underwent neoadjuvant treatment, with distant metastases or incomplete resection were excluded, selecting patients with hilar involvement or with skip metastases. Different prognostic factors such as Tstage, histology, pathological stage, nodal characteristics and adjuvant therapy administration were correlated to overall survival (OS) by the Kaplan–Meier product-limit method. The log-rank test was used to assess differences between subgroups. A multivariable Cox proportional hazard model was developed using stepwise regression to compare the prognostic power of different factors. ResultsThe final analysis was conducted on 480 adenocarcinoma/squamous cell carcinoma patients. Five-year OS (5YOS) resulted 53.9%. No significant differences in OS were detected comparing pN1 vs. pN2 patients or stage IIB vs. stage IIIA-B patients. Univariable confirmed as favourable prognostic factors young age (P<.001), T1-2 tumors (P=.030), number of resected nodes≥10 (P=.040), lymph node ratio (P=.026). Multivariable analysis confirmed as independent negative prognostic factors T≥3 (HR:1.385, 95%CI:1.037-1.851, P=.027) and age≥68 years (HR1.637, 95%CI:1.245-2.152). ConclusionPatients with N1 involvement or skip metastases present a similar prognosis, suggesting that N2 involvement in these cases may be related to a direct lymphatic drainage to the mediastinal stations.

Stereotactic Body Radiation Therapy (SBRT) for Oligorecurrent/Oligoprogressive Mediastinal and Hilar Lymph Node Metastasis: A Systematic Review.

Simple SummaryThis paper is a review of the literature on oligorecurrent/oligoprogressive mediastinal and hilar lymph node metastasis treated with SBRT. The use of mediastinal SBRT had historically been not feasible in view of the expected toxicity due to the proximity of critical structures such as the airways and esophagus. Despite the heterogeneity and lack of some data in the studies analyzed, this literature review is the first published and can be a valid guide for the radiotherapist in the management of oligometastatic/oligoprogressive patients, with particular regard to the radiotherapy doses, dose constraints for organs at risk, and clinical outcomes.Introduction: Mediastinal or hilar lymph node metastases are a challenging condition in patients affected by solid tumors. Stereotactic body radiation therapy (SBRT) could play a crucial role in the therapeutic management and in the so-called “no-fly zone”, delivering high doses of radiation in relatively few treatment fractions with excellent sparing of healthy surrounding tissues and low toxicity. The aim of this systematic review is to evaluate the feasibility and tolerability of SBRT in the treatment of mediastinal and hilar lesions with particular regard to the radiotherapy doses, dose constraints for organs at risk, and clinical outcomes. Materials and methods: Two blinded investigators performed a critical review of the Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA), starting from a specific question: What is the clinical impact of SBRT for the treatment of oligorecurrent/oligoprogressive mediastinal and hilar metastasis? All retrospective and prospective clinical trials published in English up to February 2022 were analyzed. Results: A total of 552 articles were identified and 12 of them were selected with a total number of 478 patients treated with SBRT for mediastinal or hilar node recurrence. All the studies are retrospective, published between 2015 and 2021 with a median follow-up ranging from 12 to 42.2 months. Studies following SBRT for lung lesions or retreatments after thorax radiotherapy for stage III lung cancer were also included. The studies showed extensive heterogeneity in terms of patient and treatment characteristics. Non-small cell lung cancer was the most frequently reported histology. Different dose schemes were used, with a higher prevalence of 4–8 Gy in 5 or 6 fractions, but dose escalation was also used up to 52 Gy in 4 fractions with dose constraints mainly derived from RTOG 0813 trial. The radiotherapy technique most frequently used was volumetric modulated arc therapy (VMAT) with a median PTV volume ranging from 7 to 25.7 cc. The clinical outcome seems to be very encouraging with 1-year local control (LC), overall survival (OS) and progression-free survival (PFS) rates ranging from 84 to 94%, 53 to 88% and 23 to 53.9%, respectively. Half of the studies did not report toxicity greater than G3 and only five cases of fatal toxicity were reported. CONCLUSIONS: From the present review, it is not possible to draw definitive conclusions because of the heterogeneity of the studies analyzed. However, SBRT appears to be a safe and effective option in the treatment of mediastinal and hilar lymph node recurrence, with a good toxicity profile. Its use in clinical practice is still limited, and there is extensive heterogeneity in patient selection and fractionation schedules. Good performance status, small PTV volume, absence of previous thoracic irradiation, and administration of a high biologically effective dose (BED) seem to be factors that correlate with greater local control and better survival rates. In the presence of symptoms related to the thoracic lymph nodes, SBRT determines a rapid control that lasts over time. We look forward to the prospective studies that are underway for definitive conclusions.

Atypical bilateral ventilation/perfusion mismatches in an asymptomatic patient suffering from metastatic thyroid cancer

BackgroundPulmonary embolism is indicated by ventilation/perfusion (V/P) mismatches in ventilation/perfusion scintigraphy. However, other pathologies may also evoke segmental or lobar mismatches. Thus, diagnosis can be difficult in asymptomatic patients with equivocal clinical presentation.Case presentationWe present a case of multiple bilateral pulmonary ventilation/perfusion mismatches in a poorly differentiated thyroid cancer patient. Exact diagnosis was difficult, as the patient was asymptomatic and pulmonary embolism is commonly unilateral in tumour patients and not typical for thyroid cancer. External pulmonary artery compression by aortic aneurysm, multiple metastases or additional bronchopulmonary malignancies were considered as differential diagnosis. After unilateral pulmonary and hilar metastasectomy, perfusion normalised on the operated side. Pulmonary perfusion defects due to pulmonary artery compression by hilar metastases were finally diagnosed. Pulmonary embolism was deemed unlikely due to the left-sided post-operative normalisation, persistence of right-sided V/P mismatches, and the lack of clinical symptoms.ConclusionPulmonary artery compression may mimic pulmonary artery embolism in lung perfusion scintigraphy and should be considered in bronchopulmonary tumour patients with hilar metastases and unilateral ventilation/perfusion mismatches affecting a complete lobe or even lung. Following the presented case, also bilateral segmental and subsegmental mismatches in patients with hilar metastases from non-bronchopulmonary cancer entities should be carefully evaluated.

Recurrent follicular thyroid carcinoma metastatic to axillary lymph nodes mimicking pulmonary adenocarcinoma

Differentiated thyroid cancers generally have favorable prognoses, though follicular thyroid cancer is overall associated with a worse prognosis due in part to increased incidence of distant metastasis. We report a case of a 51-year-old woman with a history of widely invasive follicular thyroid carcinoma treated with a total thyroidectomy, radioactive iodine and external beam radiation. Five and a half years following her surgery, she was found to have an axillary lymph node mass, multiple lung masses, and a hilar mass in the setting of declining thyroglobulin (Tg) antibodies. Her metastases were initially thought to be due to a primary lung adenocarcinoma given a neoplastic cell immunophenotype that included an absence of Tg expression and co-expression of TTF-1 and Napsin A. However, PAX8 expression demonstrated that the axillary and hilar metastases were actually thyroid in origin rather than lung. Axillary metastases in differentiated thyroid carcinoma are exceedingly rare and previous reports have typically involved widely disseminated disease with extensive neck lymphadenopathy. With a decline in Tg antibodies levels in high-risk patients, one should consider progression and loss of differentiation of thyroid carcinoma rather than a response to treatment.Learning pointsAxillary metastases in differentiated thyroid carcinoma are uncommon.In patients with high-risk thyroid carcinomas, a decline in thyroglobulin antibody may not signal disease improvement, but rather a progression to a poorly differentiated form of cancer.PAX8 staining can be used to differentiate thyroid carcinomas from lung adenocarcinomas.

S1810 The Great Pretender: Painless Jaundice Caused by a Non-Hepatobiliary Source

INTRODUCTION: Painless jaundice is a known sign of obstruction from pathologies within the hepatobiliary system. Proliferation of epithelial cells may form a rare tumor known as a cholangiocarcinoma. Colorectal cancer (CRC) may metastasize to the liver parenchyma but there is no prior report of a common bile duct (CBD) tumor leading to the discovery of CRC. We present a case of obstructive jaundice which was initially thought be cholangiocarcinoma based on Computerized Tomography (CT) imaging and Endoscopic retrograde cholangiopancreatography (ERCP), but found to be hilar metastasis from an undiscovered CRC. CASE DESCRIPTION/METHODS: A 61 year-old man with no known medical history presented with complaints of jaundice, nausea, vomiting, dark urine, and right upper abdominal pain for two weeks. He denied fever, itching, weight loss, constipation or diarrhea. He was a tobacco user and had four tattoos. He denied alcohol, intravenous or other drug use. He had no recent use of acetaminophen or herbal medicine. He had no recent travel, exposure to ill contacts, history of hepatitis or risky sexual practices. His vitals were normal on presentation. On general examination the patient was an elderly man with scleral icterus but other systems, including the abdomen, were unremarkable. CT Abdomen revealed a porta hepatis mass at the CBD, concerning for cholangiocarcinoma. There were also multiple focal areas of the liver, involving the right lobe extending into segment 4 worrisome for additional large areas of metastatic cholangiocarcinoma. He was admitted for further work up. ERCP was performed, revealing a tumor extruding from the CBD. The CBD mass and a hepatic mass were biopsied. A biliary stent was placed for symptomatic relief. Immunohistochemical staining of the biopsies were negative for CK7 but positive for CK20 and CDX2, in keeping with a colonic primary. There was no clinical evidence of primary CRC but subsequent colonoscopy revealed a colonic mass with histology showing adenocarcinoma. The patient was scheduled for oncology follow up. DISCUSSION: CRC remains one of the leading causes of cancer worldwide and this case highlights an exceptionally unusual way in which this disease presented. Though a rare presentation, clinicians should be aware that it is possible for a cholangiocarcinoma to not be of primary origin. To our knowledge, this is the first known case of painless jaundice from a bile duct tumor as the initial manifestation of a primary colon cancer.Figure 1.: ERCP image showing tumor extruding from CBD.Figure 2.: Standard H&E stain of a) common bile duct tumor and b) colon carcinoma.Figure 3.: Colonoscopy image showing colon carcinoma.

Outcomes of Real-Time MRI-guided Lung Stereotactic Body Radiation Therapy

Lung stereotactic body radiation therapy (SBRT) is an effective therapy that provides excellent local control for small primary and/or metastatic lung tumors. We report our experience using real-time MRI-guidance with respiratory breath hold gating for delivery of lung SBRT. Patients with primary or metastatic lung tumors ≤5cm were eligible for treatment with MRI-guided SBRT. Patients underwent simulation and treatment on a Cobalt-60 MRI-guided treatment planning system, with max inhale breath hold used to minimize normal lung dose. All patients underwent 4D-CT simulation as well. Gross tumor to PTV expansions were 3mm, with gross tumor tracked in real-time during treatment and the PTV, or similar numeric expansion, used as a boundary structure for gating. Thirteen of fifteen tumors were treated with 50 Gy in 5 fractions, with the remaining two treated with 45 Gy in 5 fractions and 40 Gy in 5 fractions. Constraints for radiation therapy were similar to RTOG 0813. For comparison, the 4D-CT was used to create an ITV, which was itself expanded 5mm to PTV as per institutional practice. The study population consisted of fourteen patients with a total of fifteen treated tumors. Eleven of fourteen patients had primary non-small cell lung cancer, while the remaining three had metastatic lung tumors (nasopharygeal adenoid cystic carcinoma, breast adenocarcinoma, and tonsil squamous cell carcinoma). Nine of the fourteen patients were female, with a median age of 69.5 years (range 60-79). The median follow-up at this time is 13.7 months (range 1.6-35.9 months). The median PTV volume using respiratory gating with MRI-guidance was 16.5cc (range 2.8-58.5cc), compared to a median PTV volume of 43.6cc (range 8.2-136.4cc, p= 0.01) when using an ITV to account for respiratory motion. Median Lung-PTV volume using respiratory gating with MRI-guidance was 4746.9cc (range 2742.5-6563.5cc) compared to 3967.8cc (range 2255.8-5190.0cc, p = 0.02) when using an ITV. Analysis of > 800 minutes of cine images shows patients were coached into repeatable tumor positioning (< 2 mm) for a median breathhold of 29 seconds, with a median duty cycle of 53%. No treatment-related toxicities were noted. Only one of the fifteen treated tumors, a right hilar metastasis from right tonsil primary, recurred at 5 months after treatment. This tumor was seen to have responded to therapy on initial post-treatment imaging; however, subsequent imaging identified local failure at the right hilum as well as progression of systemic disease elsewhere. Of note, this tumor was treated with 40 Gy in 5 fractions. MRI-guided SBRT to the lung is well-tolerated by patients and provides excellent local control similar to historic controls. Respiratory gating utilizing real-time tumor visualization allows for smaller PTV volumes and greater sparing of normal lung.

P2.16-34 Visceral Pleural Invasion is Closely Associated with Nodal Spread in cStage IA Lung Adenocarcinoma

Survival outcomes of patients with clinical Stage IA (cIA) lung adenocarcinoma (LAD) are favorable after resections. In this decade, limited resection without lymphnodes dissections have been indicated for selected cases based on the radiological findings and intraoperative hilar explorations, while we sometimes experience occult lymphnodes metastases among them. These facts refer that limited resections could potentially induce underestimation of the disease, local failure and worsened patients’ prognoses. In the present study, we retrospectively investigate the clinicopathological and oncogenic factors in association with the occult nodal spread and skip metastases, and aim to identify population for standard resection in cIA LAD. We retrospectively investigated 287 patients with cIA LAD who underwent standard pulmonary resections with mediastinal dissections from January 2013 through December 2017. Clinicopathological factors including location of the tumor, radiological pleural invasion and oncogenic status (EGFR/KRAS/ALK/Triple Negative) were reviewed for outcomes of occult nodal spread and skip metastasis. According to the ROC curves analyses, cutoff values of total diameter (TD), solid diameter (SD), mediastinal window diameter (MD) in CT image and pathological invasive size (IS) were settled to diagnose nodal metastases and skip pN2, respectively. Among 287 patients with cIA LAD, 34 (11.8%) with lymph node metastases and 8 (2.8%) with pN2 without hilar metastases (skip pN2) were identified. Univariate analyses revealed that high serum CEA level, TD, MD, SUVmax, IS and pathological pleural invasion (pl) were predictive for nodal metastases. And multivariate analysis showed that pl was closely associated with nodal metastases (Odds Ratio: 3.3, p=0.007). Furthermore, multivariate analysis following the univariate analyses also showed that presence of pl was the factor closely associated with skip N2 metastases (Odds Ratio: 5.7, p=0.029), whereas radiological findings nor oncogenic status were not so. In the clinical valuables, serum CEA level, SD, MD, SUVmax were significantly associated with pl. In resected cIA LAD, pathological pleural invasion was closely associated with both occult nodal spread and skip pN2, while any other preoperative factors and oncogenic status were not. New diagnostic modalities for pl may provide the candidates for standard resections in cIA LAD.

Prognostic impact of splenic hilar lymph node metastasis in proximal gastric carcinoma: A retrospective analysis of 665 patients treated with D2 total gastrectomy.

11 Background: Standard D2 lymph node (LN) dissection for proximal gastric carcinoma includes removing splenic hilar LNs. However, patients with splenic hilar LN metastasis often show a poor prognosis even after curative surgery. This study aimed to investigate the prognostic impact of splenic hilar LN metastasis in proximal gastric carcinoma. Methods: We reviewed prospectively constructed data of 665 patients who underwent total gastrectomy with D2 LN dissection for proximal gastric carcinoma. Clinicopathological features and survivals were compared between patients with and without splenic hilar LN metastasis. The prognostic value of splenic hilar LN metastasis was examined using a multivariate Cox prognostic model. Results: Of 665 patients, 63 (9.5%) with stage III or IV disease had splenic hilar LN metastasis. Splenic hilar LN metastasis was associated with a larger tumor size, B4 gross type, undifferentiated histology, and lymphovascular invasion. The 5-year survival of patients with splenic hilar LN metastasis was significantly worse at each tumor stage (stage III = 45% vs. 66%, p = 0.044, stage IV = 12% vs. 32%, p = 0.017). The 5-year survival of patients with splenic hilar LN metastasis did not significantly differ from that of the distant metastasis group (26% vs. 31%, p = 0.484). Multivariate analysis revealed that splenic hilar LN metastasis is an independent poor prognostic factor when adjusting for tumor node metastasis stage and other prognostic factors. Conclusions: Patients with splenic hilar LN metastasis show a poor prognosis after surgery. More intensive adjuvant treatment and postoperative surveillance will be required for patients with splenic hilar LN metastasis.

The relationship between lymphatic metastasis and tumor volume in patients with non small cell lung cancer

Objective To discuss the relationship between the incidence of lymph node metastasis and tumor size in patients with non small cell lung cancer, and to provide evidence for clinical operation and follow-up treatment. Methods 180 patients with non small cell lung cancer who were hospitalized and recieived Lobectomy operation were selected, the clinical data of patients and resection of tumor size, lymph node metastasis were retrospectively analyzed, and then the relationship between the lymph node metastasis and tumor volume was investigated. Results 180 cases of patients with lymph node metastasis rate was 37.20%, in which hilar lymph node metastasis rate was 11.02 percent and mediastinal lymph node metastasis rate was 10.95%.Lung lymph node metastasis rates in lymph node metastasis, hilar and mediastinal lymph node metastasis of T1a were 13.21%, 15.09% and 13.21%; those of T1b period were 38.09%, 35.71% and 28.57%; of T2a period were 44.44%, 37.78% and 31.11%; of T2b period were 64.26%, 57.14% and 53.57%; and those of T3 period were 58.33%, 66.67% and41.67%.Lymph node metastasis, hilar and mediastinal lymph node metastasis in lung lymph nodes transfer rate with patients of T1a had significantly differences compared with patients of T1b, T2a, T2b and T3 stage.(χ2=5.363, 6.175, 4.372, 8.778, 5.363, 9.631, 7.936, 9.631, 20.463, 7.521, 6.175, 4.387, all P<0.05). Hilar lymph node metastasis and lung metastases of T1b and T2b had a significant difference (χ2=12.353, 4.585, all P<0.05). Conclusion For non-small cell lung cancer, tumor size is positively correlated with lymph node metastasis and the greater the tumor size, the greater the likelihood of lymph node metastasis. Key words: Tumor volume; Tumor metastasis; Lymph nodes; Carcinoma, non small cell lung

Clinicopathological characteristics and imaging features of pulmonary adenocarcinoma with micropapillary pattern

To explore the clinicopathological characteristics and imaging features of lung adenocarcinoma with a micropapillary pattern (MPP). Eighty cases of pulmonary adenocarcinoma with a micropapillary pattern treated in our hospital from July 2011 to December 2012 were selected to retrospectively analyze their clinicopathological characteristics and imaging features. Among the 80 cases of lung adenocarcinoma with MPP, there were 38 cases of stage I (47.5%), 12 cases of stage II (15.0%), 25 cases of stage III (31.3%) and 5 cases of stage IV (6.2%). There were 14 cases of moderately differentiated (17.5%) and moderately/poorly differentiated (82.5%) tumors. Sixty-three cases had pleural involvement, vascular invasion, involving the bronchial wall, invasion of large vessels, nerve invasion, and lymph node metastasis (at least one of them) (78.8%). Immunohistochemical staining revealed that both positive rates of TTF-1 and CK7 were 100%, and that of pulmonary surfactant apolipoprotein-A (SPA) was 84.0%. Imaging examination revealed hilar or mediastinal lymph node enlargement in 15 cases (18.8%). but the pathology confirmed hilar or mediastinal lymph node metastasis in 36 cases (45.0%). Lung CT imaging showed that the majority of the cases were peripheral type, and only a few of central type, and most cases were solid lesions, with lobulation, spiculation, pleural indentation, and vascular convergence sign, while there were few ground-glass opacity sign and vacuole sign. Lung adenocarcinoma with MPP component often presents with early invasions of pleura, blood vessels, lymphatic vessels, and lymph nodes. Imaging manifestation of this cancer mainly shows as peripheral and solid lesions, often with lobulation, spiculation, pleural indentation, vascular convergence sign, but GGO and vacuole signs are unusual. Overexpression of TTF-1, CK7 and SPA, and elevated CEA level are associated with clinical staging of the disease.

A rare and unusual case of acinic cell carcinoma of parotid gland evaluated by F-18 FDG PET/CT

Acinic Cell Carcinoma (ACC) is a rare parotid gland tumour. In this case, we present F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) images of a 75 year old male with a history of metastatic ACC. The patient was iniatially diagnosed in 2009 after he received multiple surgeries secondary to local recurrences. The patient was also treated with chemoradiation. PET/CT was performed as part of the treatment strategy evaluation. PET/CT demonstrated brain metastasis, multiple pulmonary metast a tic nodules, multiple hepatic metastasis, hilar, pleural and mesenteric masses and multiple osseous metastasis. Although ACC is a low grade malignancy, it has a tendency to recur and metastasize. In this case, we report diffuse metastatic disease of ACC. Hence, we conclude PET/CT could be a very valuble tool managing the disease.

Mo2032 Small Cell Carcinoma of the Ampulla of Vater

[Background/Aim] An extensive hepatic resection is required in cases of malignant hepatic and biliary tract tumor. The prognosis is influenced by a shortage of functional capacity of the remnant liver. Since preoperative portal vein embolization (PVE) was first reported, this technique has become widely used in such cases. However, the indication for PVE and its outcome are unclear. In the present study, we retrospectively analyzed preoperative PVE patients. [Patients] From January 2002 to December 2011, 58 patients underwent preoperative PVE at our institute. In this study, we analyzed 46 patients (29 cases of hilar bile duct cancer [no liver damage group] and 17 colorectal liver metastatic tumor cases after chemotherapy [liver damage group]). In cases of hilar bile duct cancer or colorectal hepatic metastasis, we compared the resection rate and prognosis of these patients before and after PVE introduction. [Results] Two of 46 patients had complications caused by preoperative PVE (minimal bleeding into the biliary tract). Four cases in the group without liver damage (13.8%) could not undergo hepatectomy (3 cases, progressive disease; 1 case, no hypertrophy of the remnant liver). Five cases in the liver damage group (29.4%) could not undergo hepatectomy (1 case, severe steatohepatitis; 4 cases, no hypertrophy of the remnant liver). The median rates of hypertrophy of the remnant liver in the group without liver damage and the liver damage group were 9.4% and 7.5%, respectively (no statistical difference). The median maximum total bilirubin levels after hepatectomy in the group without liver damage and the liver damage group were 4.3 and 1.9 mg/dL, respectively (no statistical difference). In cases of hilar bile duct cancer and colorectal hepatic metastasis, the resection rate and the prognosis improved significantly after PVE introduction (resection rate: 56.7% vs. 90.2% and 30.0% vs. 58.2%, respectively; 3-year survival rate: 35.2% vs. 70.2% and 35.2% vs. 45.2%, respectively). [Conclusion] In the present study, no statistical difference was noted between the liver damage group and the group without liver damage in the rate of hypertrophy of the remnant liver after PVE and postoperative complications. However, the incidence of unresectability because of lack of hypertrophy of the remnant liver was higher in the liver damage group than in the group without liver damage. Thus, we believe that PVE has potential benefits for hilar bile duct cancer patients and colorectal liver metastasis patients because of the associated improved resection rate and prognosis.

Magnetic resonance imaging diagnosis of hilar cholangiocarcinoma

Hilar cholangiocarcinoma (HCCA) or Klatskin tumor is a scirrhous adenocarcinoma that arises from the conjunction of bile duct and hepatic ducts.Hepatic magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) are important methods for the diagnosis of HCCA.In this article,the clinical data of 42 patients in the Changhai Hospital and 18 patients in the Eastern Hepatobiliary Surgery Hospital who received MRI and MRCP examination from October 2010 to October 2012 were retrospectively analyzed.According to the pathological features,HCCA could be divided into mass-forming type,infiltrating type and intraductal type.Based on the results of imaging examination and intra-and postoperative pathological examination,Bismuth-Corlette types were decided pre-and postoperatively.The coincidence rate of pre-and postoperative Bismuth-Corlette types was 89.7％ (35/39).Infiltration of liver parenchyma was both detected pre-and postoperatively in 19 patients (16 patients were detected by MRI preoperatively),and the sensitivity of MRI was 84.2％ ; vascular invasion was both detected pre-and postoperatively in 10 patients (12 patients were detected by MRI preoperatively),and the sensitivity of MRI was 83.3％ ; hilar and retroperitoneal lymph node metastasis was both detected pre-and postoperatively in 6 patients (4 patients were detected by MRI preoperatively),and the sensitivity of MRI was 66.7％.Combined application of different sequences and techniques of MRI is helpful in the diagnosis,staging and treatment of HCCA. Key words: Cholangiocarcinoma, hilar; Imaging diagnosis ; Magnetic resonance imaging; Magnetic resonance cholangiopancreatography

Isolated Mediastinal Lymph Node False Positivity of [18F]-Fluorodeoxyglucose–Positron Emission Tomography/Computed Tomography in Patients With Cervical Cancer

This study aimed to evaluate the degree of mediastinal involvement in patients with cervical cancer with isolated mediastinal [F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) positivity as verified by histopathologic examination. Two hundred twenty-eight patients with newly diagnosed cervical cancer and who underwent FDG-PET imaging were analyzed. Twenty-nine patients (17%) had disseminated disease detected with PET/computed tomography (CT). Only 10 patients (4%) had increased FDG uptake in mediastinal lymph nodes alone. Of the 10 patients with mediastinal disease, 2 refused surgical mediastinal lymph node biopsy and did not receive any treatment. Patients with suspected paratracheal or subcarinal lymph node metastasis detected on PET/CT underwent mediastinoscopy, and those with hilar metastasis had video-assisted mediastinal lymphadenectomy. Treatment was delivered according to final staging based on histopathologic confirmation of mediastinal lymph node involvement. The mean (SD) maximum standardized uptake values for primary cervical tumor and mediastinal lymph nodes were 19.7 (10.3) and 7.5 (1.6), respectively. Of 8 patients who underwent mediastinal lymph node confirmation, 6 (75%) were tumor free, demonstrating granulomatous changes, and were treated curatively. No patients had residual or recurrent disease at the primary site, and all but 1 were alive without disease. Two patients with confirmed mediastinal lymph node metastasis were treated palliatively and died between 9 and 11 months after diagnosis. Positron emission tomography/CT is an important tool for lymphatic staging and evaluation of distant metastases in cervical cancer. However, PET/CT should be interpreted cautiously for isolated mediastinal involvement; surgical evaluation is required for accurate staging and appropriate treatment decisions to achieve better outcomes.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A study in a tuberculosis-endemic country

Mediastinal lymphadenopathy in patients with malignancy is a common clinical problem in tuberculosis-endemic countries. The recently developed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedure enables direct and real-time aspiration of mediastinal and hilar lymph nodes. The aim of the study was to determine the efficacy of EBUS-TBNA results in the evaluation of mediastinal lymph nodes in patients with extrathoracic malignancy. Retrospective analysis was performed in 40 patients with proven (n = 38) or suspected metastasis of unknown origin (n = 2) who underwent EBUS-TBNA between July 2007 and August 2011. All 40 patients successfully underwent EBUS-TBNA and no complications were observed. EBUS-TBNA diagnosed metastasis from extrathoracic malignancy in 16 (40%) patients, new lung cancer in 2 (5%), reactive lymph node in 9 (22.5%), sarcoidosis in 5 (12.5%), anthracosis in 5 (12.5%) and tuberculosis in 3 (7.5%). The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EBUS-TBNA based on the number of patients were 90.0%, 100%, 100%, 90.9% and 95.0%, respectively. In 33 patients with available data of fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) scans, the diagnostic sensitivity, specificity, PPV, NPV and accuracy of PET/CT scan based on the number of patients were 94.7%, 35.7%, 66.6%, 83.3%, and 69.6%, respectively. The association between larger lymph node size on EBUS and malignancy of lymph node sample on pathological examination was statistically significant (P = 0.018). EBUS-TBNA is a sensitive, specific, minimally invasive and a safe procedure for the diagnosis of mediastinal and hilar metastasis from extrapulmonary malignancy in a tuberculosis-endemic country.

Cutaneous metastasis as the presenting sign of papillary thyroid carcinoma

Cutaneous metastasis of visceral tumors accounts for 2% of skin tumors. We report the case of a 71-year-old male with a smoking history who presented to dermatology department with a violaceous nodule of the right sideburn skin. The lesion was interpreted as an adenocarcinoma that was completely excised and was suspicious for a metastasis. There was a recommendation for additional work-up. At a different institution, a positron emission tomography scan showed a left hilar mass and uptake in the right thyroid. He was then referred to our hospital for tissue diagnosis. Mediastinoscopy with biopsy of the left hilar mass showed metastatic follicular thyroid carcinoma. Subsequently, a thyroid fine needle aspirate showed suspicion for malignancy with similar morphology. Thyroidectomy and central neck dissection showed right thyroid papillary carcinoma extending to one margin and involving the lymph nodes. The left hilar metastasis mass resection showed similar lymph node findings. A re-review of the sideburn excision revealed similar histopathology to the thyroid and mediastinal resection. This case illustrates the opportunity of considering metastatic thyroid carcinoma to skin even in cases which lack the classic cytologic and architectural features of papillary thyroid carcinoma follicular variant.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Intrathoracic Lymphadenopathy in Patients with Extrathoracic Malignancy: A Multicenter Study

Mediastinal lymphadenopathy in patients with an extrathoracic malignancy is a common clinical scenario. Invasive sampling of intrathoracic lymph nodes may be performed by mediastinoscopy or endoscopic ultrasound-guided fine needle aspiration. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an alternative to mediastinoscopy and endoscopic ultrasound in patients with lung cancer and sarcoidosis. The utility of EBUS-TBNA in patients with extrathoracic malignancy was evaluated. Consecutive patients who were suspected to have intrathoracic lymph node metastases from an extrathoracic malignancy underwent EBUS-TBNA. When EBUS-TBNA did not provide a specific diagnosis, patients underwent mediastinoscopy or clinical follow-up of at least 6 months duration. One hundred sixty-one patients meeting the inclusion criteria underwent EBUS-TBNA in five UK centers over a 3-year period. EBUS-TBNA diagnosed mediastinal or hilar metastases in 71 (44%) patients, new lung cancer in 20 (12%) patients, and sarcoidosis in 14 (9%) patients. The sensitivity, negative predictive value for malignancy, and overall accuracy for EBUS-TBNA were 87%, 73% and 88%, respectively. One hundred ten (68%) patients in the study had a final diagnosis of malignant intrathoracic lymphadenopathy. Because of the high prevalence of alternative diagnoses, pathological evaluation is important in patients with extrathoracic malignancy and suspected mediastinal or hilar lymph node metastases. EBUS-TBNA is a safe and sensitive technique and may be considered a first-line investigation in these patients.

Survival benefits from splenic hilar lymph node dissection by splenectomy in gastric cancer patients: relative comparison of the benefits in subgroups of patients

The present study estimated survival benefits from lymph node dissection at the splenic hilus in advanced proximal gastric cancer patients who underwent total gastrectomy with simultaneous splenectomy, and then determined patient subgroups that received relatively high survival benefits from splenectomy. A total of 280 patients with advanced proximal gastric cancer who underwent curative total gastrectomy with simultaneous splenectomy were retrospectively analyzed. Patients with primary tumors directly invading the spleen or pancreas and those with gross metastases to the para-aortic nodes, as determined by intraoperative diagnosis, were excluded from analyses. The index of estimated benefit from lymph node dissection at the splenic hilus by splenectomy was calculated for each clinicopathological factor by multiplying the incidence of splenic hilar metastasis by the 5-year survival rate of patients with metastasis to that nodal station. Thirty patients (10.7%) showed lymph node metastasis at the splenic hilus, and the 5-year survival rate of these patients was 51.3% (overall index 5.49). The index was relatively high in patient subgroups with tumors localized on the greater curvature (19.4) and Borrmann type 4 cancers (12.9), while relatively low in subgroups with encircling tumors (1.62) and tumors invading adjacent organs other than the spleen and pancreas (0). Patients with tumors localized on the greater curvature and Borrmann type 4 cancers might obtain relatively high survival benefits from lymph node dissection at the splenic hilus by splenectomy.

Analysis of patients with resected small-size (less than or equal to 2 cm in diameter) peripheral type lung cancer lesions

From 1953 to 1985, a total of 1289 patients with primary carcinoma of the lung underwent surgical treatment. Of these 116 (8.9%) had small-sized (less than or equal to 2 cm in diameter) peripheral type lung cancer lesions. This study had three purposes: 1) to analyse how small-sized lung cancer lesions were detected; 2) to evaluate the reliability of diagnosis of small-sized cancer lesions; and 3) to evaluate pre- and post-prognostic factors of such patients compared with patients with peripheral type lung cancer lesions 2.1-3 cm in diameter. Of the 115 patients with small-sized lung cancer lesions were detected in the course of mass surveys. Cytopathological diagnosis in 75% of the patients resulted from transbronchial brushing cytology. The 5-year survival rate of patients who underwent resection of small-sized peripheral type lung cancer lesions was 70% (2.1-3 cm; 52%). Various factors such as histologic type, nodal involvement, pleural involvement, pathological stage, and success of the operation were shown to significantly affect survival. A comparison of two groups, i.e., those with lesions smaller than 2 cm in diameter and those with lesions 2.1-3 cm in diameter, showed the rate of lymph node metastasis to be significantly different. Of the patients with peripheral lung cancer lesions smaller than 2 cm who underwent surgery, 21% had peribronchial, hilar, or mediastinal lymph node metastasis. On the other hand, lymph node metastasis was seen in 43% of cases with peripheral lung cancer lesions 2.1-3 cm in diameter who underwent surgery.

Imaging findings of primary synodal sarcoma of the lung

Objective To evaluate the imaging characteristics of primary pulmonary synovial sarcoma and improve its diagnosis and differential diagnosis. Methods The clinical, imaging and pathology findings of 5 patients were retrospectively analyzed. All 5 patients received X-ray and CT scan, 1 case had MRI and PET-CT examination. SYT-SSX fusion gene was analyzed in 4 patients using reverse transcriptase-polymerase chain reaction (RT-PCR). Results All the 5 patients had solid mass in the lungs and their diameter were 5. 3 to 15.7 cm.One was associated with pneumothorax and the others were with moderate pleural effusion. Peripheral minors, which showed clear margin partly with inhomogeneous density, was found in CT scan. On the contrast-enhanced CT scan, 3 cases were inhomogeneons enhancement and 2 were circular enhancement. Pleural invasion or conglutination was detected in 5 patients. No hilar or mediastinal lymph nodes metastasis were seen in all cases. MRI showed intermediate signal on T1 WI and heterogeneous on T1WI of one case with right upper lobe lesion and showed thick mural enhancement after Gadolinium enhancement. The adjacent chest wall, rib thoracic vertebra, vertebral canal and thoracic cord were invaded. PET-CT showed increased uptake of FDG (SUV=12. 3) in tumors. The immunohistochemical examination of Vim, CK and EMA were positive and SYT-SSX gene was detected in 4 patients. Conclusions There are some relatively specific imaging findings of primary pulmonary synovial sarcoma-However it is necessary for diagnosing the disease to combine pathology, immunohistochemistry and SYT-SSX gene detection. Key words: Lung neoplasms; Sarcoma; synovial; Tomography; X-ray computed; Pathology