Intrapulmonary Nodes Research Articles

Imaging Features and Clinical Decision Analysis of 110 Cases of Intrapulmonary Lymph Nodes.

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

Surgical Choice for Clinical Stage IA Non-Small Cell Lung Cancer: View From Regional Lymph Node Metastasis

We aimed to investigate the pattern of regional lymph node (LN) metastasis of early-stage non-small cell lung cancer (NSCLC) to provide novel rationale for surgical choice (lobectomy, segmentectomy, or wedge resection) for these patients. We retrospectively collected clinical data of patients undergoing lobectomy with systematic mediastinal LN dissection or sampling for cT1N0M0 peripheral NSCLC from January 2015 to December 2018. The regional LN metastasis pattern was analyzed based on tumor size. We included a total of 354 patients for analysis. The rate of hilar or intrapulmonary LN metastasis was 13.6%. When stratified by tumor size, NSCLC less than or equal to 1 cm had no hilar or intrapulmonary LN metastasis (0%) while NSCLC greater than 2 cm but less than or equal to 3 cm had a significantly high rate of hilar or intrapulmonary LN metastasis (18.4%) and the rates of hilar, interlobar, and peripheral LN metastasis were also relatively high (5.4%, 5.4%, and 12.2%, respectively). NSCLC greater than 1.5 cm but less than or equal to 2 cm also had relatively high rates of hilar (6.5%) and peripheral (18.3%) LN metastasis, while NSCLC greater than 1 cm but less than or equal to 1.5 cm had significantly low rates of hilar or intrapulmonary (2.5%) and peripheral (2.5%) LN metastasis. Radiographic feature and histology were found to be independent predictors of regional LN metastasis. The pattern of regional LN metastasis in clinical stage IA peripheral NSCLC was significantly influenced by tumor size, which may provide evidence on surgical choice (lobectomy, segmentectomy, or wedge resection) for these early-stage NSCLC patients based on tumor size.

The first case of gland inclusion in an intrapulmonary lymph node: a mimic of metastasis

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

WS05.04 Particularities of Lymphadenectomy in Malignant Pleural Mesothelioma

WS05.04 Particularities of Lymphadenectomy in Malignant Pleural Mesothelioma

P2.17-42 Surgical Choice for Clinical Stage IA Non-Small Cell Lung Cancer: Novel Rationale from Intrapulmonary Lymph Node Metastasis Pattern

Current available surgical resection methods for early-stage NSCLC mainly consisted of lobectomy and sublobar resection (including segmentectomy and wedge resection) with lobectomy being the preferred option, which was established by the only completed RCT study finding that sublobar resection yielded a significantly higher recurrence rate and a trend toward worse survival than lobectomy. However, there are growing interest in observational studies and systematic reviews exploring the efficacy of sublobar resection in treating early-stage NSCLC, aiming to justify for applying sublobar resection as an alternative to lobectomy for treating these patients but with conflicting conclusions. We aimed to investigate the pattern of intrapulmonary lymph node (LN) metastasis of clinical T1N0M0 peripheral non-small cell lung cancer (NSCLC) to provide novel rationale for surgical choice (lobectomy, segmentectomy, or wedge resection) for these patients. We retrospectively collected clinical data of patients undergoing lobectomy with systematic mediastinal LN dissection or sampling for early-stage NSCLC from January 2015 to December 2018. The intrapulmonary LN metastasis pattern was analyzed by tumor size. We included a total of 354 patients for final analysis. The rate of intrapulmonary LN metastasis was 13.6% (Table 1). When stratified by tumor size, NSCLC ≤1cm had no hilar/intrapulmonary LN metastasis while NSCLC >2 but ≤3cm had significantly high rates of hilar/intrapulmonary LN metastasis (18.4%) and the rates of hilar, interlobar and peripheral LN metastasis were relatively high (5.4%, 5.4% and 12.2%, respectively). NSCLC >1.5cm but ≤2cm also had a relatively high rate of hilar (6.5%) and peripheral (18.3%) LN metastasis while NSCLC >1cm but ≤1.5cm had a significantly low rate of hillar/intrapulmonary (2.5%) and peripheral (2.5%) LN metastasis.Table 1Intrapulmonary lymph node metastasis pattern among clinical stage IA (cT1N0M0) peripheral non-small cell lung cancers with different tumor size.CharacteristicsTotal (N=354)Tumor size groupP value≤1cm (N=35)>1cm but ≤2cm (N=172)>2cm but ≤3cm (N=147)Total dissected N1 LN number (Mean±SD)5.6±3.03.6±1.95.4±2.76.3±3.3<0.001Total dissected N2 LN number (Mean±SD)8.1±4.07.0±3.47.6±3.68.8±4.40.008Lymph node metastasis rate16.9% (60/354)0 (0/35)14.5% (25/172)23.8% (35/147)0.002N1 LN metastasis rate (10-14#)13.6%(48/354)0(0/35)12.2%(21/172)18.4%(27/147)0.013Hilar LN metastasis rate (10#)4.2%(15/354)0(0/35)4.1%(7/172)5.4%(8/147)0.348Interlobar LN metastasis rate (11#)3.4%(12/354)0(0/35)2.3%(4/172)5.4%(8/147)0.263*Peripheral LN metastasis rate (12-14#)10.5%(37/354)0(0/35)11.0%(19/172)12.2%(18/147)0.092N2 LN metastasis rate (1-9#)8.8%(31/354)0(0/35)8.1%(14/172)11.6%(17/147)0.088Note: LN=lymph node; SD=standard deviation. *Fisher’s exact test Open table in a new tab Note: LN=lymph node; SD=standard deviation. *Fisher’s exact test Based on the pattern of intrapulmonary LN metastasis, our study provided novel perspectives on surgical choice of lobectomy, segmentectomy, or wedge resection for clinical stage IA peripheral NSCLC: for NSCLC ≤1cm both segmentecotmy and wedge resection could be utilized, and for NSCLC >1cm but ≤1.5cm segmentecotmy could be utilized provided that sufficient resection margin could be achieved; while for NSCLC >1.5cm lobectomy should be the preferred surgical option.

MS06.04 Approaches to Overcoming the Nodal Staging Quality Gap

MS06.04 Approaches to Overcoming the Nodal Staging Quality Gap

1301P - Deep learning radiomics distinguishes intrapulmonary disease from metastases in immunotherapy-treated melanoma patients

BackgroundMelanoma patients have shown sarcoid-like lesions as an immune-related adverse event to anti-PD-1 immunotherapy. Proper discrimination is essential for accurate treatment decision. Aim of the study is to distinguish granulomatous disease (GD) from pulmonary metastases (MET) and enlarged intrapulmonary lymph nodes (LN) in melanoma patients treated with immune checkpoint blockade by using deep learning. MethodsRetrospective (2012-2018) analysis of 165 melanoma patients treated with anti-PD-1 immunotherapy. All patients underwent standardized imaging-based tumor response assessment with contrast enhanced computed tomography (CT) (follow up interval 8-10 weeks) during treatment. Only patients with intrapulmonary lesions were included (n=132, f=72, median age 63 (IQR 55-74ys). All lesions were clustered in 4 different classes: (1) MET, (2) LN, (3) GD, and (4) small (2-5mm) indeterminate calcified granulomas (GC). GD was histologically proven (guided biopsy or operative excision). All LNs and GCs were identified in CT examinations (1-6 years) prior to diagnosis. For all lesions, a labeled region of interest was extracted by an experienced radiologist (11 years). Automatic classification of intrapulmonary lesions was performed by deep learning (VGG-like model). ResultsIn total, 4409 lesions were labeled (2746 METs (62.3 %), 1143 LNs (25.9%), 328 GC (7.4%), 192 GD (4.4%)). The model predicted instances of these classes for GD, GC or LN with a significant area under the receiver operating curve (ROC) of 0.66, 0.70 and 0.68, respectively (p-value <0.001). The performance of the algorithm was independent of imaging protocol (e.g. contrast enhancement, slice thickness, and reconstructed imaging kernel (soft versus sharp)) with AUC 0.65 for all. ConclusionsDeep learning can help to discriminate between intrapulmonary granulomatous disease, indeterminate calcified granulomas and intrapulmonary lymph nodes in anti-PD-1 treated melanoma patients. Further model development is needed to overcome the imbalanced “real clinical scenario” data to classify granulomatous disease in melanoma patients treated with anti-PD-1 immune checkpoint inhibitor blockade for implementation in the clinical workflow. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

P1.17-36 Analyses of Segmental and Intrapulmonary Lymph Node Metastases of Small-Sized Peripheral Solid Predominant Non-Small Cell Lung Cancer (NSCLC)

P1.17-36 Analyses of Segmental and Intrapulmonary Lymph Node Metastases of Small-Sized Peripheral Solid Predominant Non-Small Cell Lung Cancer (NSCLC)

Perinodular Vascularity Distinguishes Benign Intrapulmonary Lymph Nodes From Lung Cancer on Computed Tomography.

A common diagnostic dilemma in the assessment of small pulmonary nodules on computed tomography (CT) is in distinguishing benign intrapulmonary lymph nodes (IPLNs) from small primary pulmonary malignancies. Several CT features have been described of IPLNs, including attachment to a pleural surface. We had observed that IPLNs were often connected to a pulmonary vein and sought to evaluate the utility of this sign in discriminating IPLNs from lung adenocarcinomas. The frequency of other previously described CT signs of IPLNs was also compared with lung adenocarcinomas. We retrospectively identified histopathologically proven benign IPLNs (n=62) and small (<15 mm) adenocarcinomas (n=61). CTs were reviewed to assess the number and type of pulmonary blood vessels arising from, or terminating within, these nodules, as well as other CT features of IPLNs (shape, location, and outline). The termination of a pulmonary artery within a nodule was strongly associated with primary lung adenocarcinoma (55.7%), and this was never seen in isolation in IPLNs (0%) (P<0.001). IPLNs were more frequently associated with pulmonary venous connections (93.5%) compared with lung adenocarcinomas (21.3%) (P<0.001). The connection to a pleural surface was observed in both IPLNs (38.7%) and lung adenocarcinomas (37.7%) (P=1.0). We describe a novel imaging marker that can help to differentiate between benign and malignant pulmonary nodules. However, attachment of a nodule to a pleural surface should not be used in isolation to distinguish IPLNs from lung malignancy.

Clinicopathologic features and lymph node metastatic characteristics in patients with adenocarcinoma manifesting as part-solid nodule exceeding 3 cm in diameter

PurposeThe purpose of this study was to elucidate the clinicopathologic and lymph node metastatic characteristics in patients with adenocarcinoma manifested as persistent ground glass mass (GGM, ground glass opacity [GGO] exceeding 3 cm in diameter). Materials and Methods304 patients with adenocarcinoma manifested as persistent GGM > 3 cm, who underwent complete surgical resection between November 2013 and December 2017 were included in this study. We elucidated the lymph node metastatic incidence and characteristics according to the primary tumor lobe location and extracted the associated clinicopathological factors, especially thin-section computed tomographic findings, with lymph node involvement. ResultsAll of the GGMs were invasive adenocarcinoma in histopathology. The total incidence of lymph node metastasis was 2.0% (6/304). All of the 6 cases with hilar or mediastinal lymph node metastasis were manifested as solid-predominant GGM > 3 cm and no cases with lymph node metastasis were identified in GGO-predominant GGM > 3 cm. Lymph node metastases were more likely to present in younger patients (p = 0.032), tumors with solid size >2.0 cm (p = 0.000), more advanced clinical T stage (p = 0.000), radiological solid-predominant tumors (p = 0.002) and acinar-predominant or papillary-predominant adenocarcinoma (p = 0.002). As for solid-predominant GGMs >3 cm, lymph node metastases were more likely to be found in tumors with solid size >2.0 cm (p = 0.026), more advanced clinical T stage(p = 0.026), acinar-predominant or papillary-predominant adenocarcinoma (p = 0.029). Whole tumor size was not associated with the presence of lymph node metastases. There were 2 right upper-lobe cases with upper mediastinal lymph nodes skip metastasis without intrapulmonary, interlobar, and hilar lymph node metastasis. ConclusionAll of the GGMs >3 cm were invasive adenocarcinoma. The incidence of lymph node metastasis in GGO-predominant GGMs >3 cm was extremely low. Solid size would be a better predictor of lymph node metastasis than whole tumor size in sold-predominant GGMs >3 cm.

A Preliminary Study to Evaluate the Efficacy and Safety of A Optimized Computed Tomography-guided Pulmonary Nodule Microcoil Localization Technique

背景与目的肺内小结节微弹簧圈穿刺定位是微创手术切除肺内小结节常用的术前定位方法，然而该方法仍有操作复杂、轻微并发症多等不足之处，我们将原有方法进行了优化。本研究旨在探讨优化后的预充式计算机断层扫描（computed tomography, CT）引导下肺内小结节微弹簧圈穿刺定位法在临床中的应用价值。方法对2018年9月-2019年1月间31例患者的35枚肺结节，于术前采用预充式CT引导下肺内小结节微弹簧圈穿刺定位，然后施行胸腔镜下（video-assisted thoracoscopic surgery, VATS）手术。统计分析定位操作相关数据、成功率、并发症、病理结果等。结果定位成功率97.1%，VATS切除成功率100%。CT定位时间平均10.1 min（5 min-31 min），微创切除病灶所需时间平均38.2 min（10 min-100 min）。术中发现微弹簧圈脱位回缩至胸壁内1例，通过充气膨肺状态下自胸壁穿刺点刺入穿刺针，成功定位肺内结节并予以切除。3例患者定位后发生微量气胸，但无需闭式引流处理。3例患者出现肺内血肿。35枚肺结节术后病理结果为：高分化腺癌15例，原位癌7例，微浸润腺癌5例，非典型腺瘤样增生4例，肺内淋巴结增生、炎性结节各2例。结论采用预充式微弹簧圈定位肺内小结节简便、安全、有效，值得推广。

Identification of Nonaggressive Pulmonary Nodules Using an Optimized Scoring System.

The purpose of this study was to define the optimal scoring method for identifying benign intrapulmonary lymph nodes. Subjects for this study were selected from the COPDGene study, a large multicenter longitudinal observational cohort study. A retrospective case-control analysis was performed using identified nodules on a subset of 377 patients who demonstrated 765 pulmonary nodules on their baseline computed tomography (CT) study. Nodule characteristics of 636 benign nodules (which resolved or showed <20% growth rate at 5 y follow-up) were compared with 51 nodules that occurred in the same lobe as a reported malignancy. Two radiologists scored each pulmonary nodule on the basis of intrapulmonary lymph node characteristics. A simple scoring strategy weighing all characteristics equally was compared with an optimized scoring strategy that weighed characteristics on the basis of their relative importance in identifying benign pulmonary nodules. A total of 479 of 636 benign pulmonary nodules had the majority of lymph node characteristics, whereas only 1 subpleural nodule with the majority of lymph node characteristics appeared to be malignant. Only 279 of 479 (58%) of benign pulmonary nodules with the majority of lymph node characteristics were intrafissural or subpleural. The optimized scoring strategy showed improved performance compared with the simple scoring strategy with average area under the curve of 0.80 versus 0.55. Optimized cutoff scores showed negative likelihood values for both readers of <0.2. A simulation showed a potential reduction in CT utilization of up to 36% for Fleischner criteria and up to 5% for LUNG-RADS. Nodules with the majority of lymph node characteristics, regardless of location, are likely benign, and weighing certain lymph node characteristics greater than others can improve overall performance. Given the potential to reduce CT utilization, lymph node characteristics should be considered when recommending appropriate follow-up.

Intrapulmonary lymph node metastasis is common in clinically staged IA adenocarcinoma of the lung

BackgroundIntrapulmonary lymph nodes (LNs, stations 11–14) are usually omitted in postoperative pathological examination. Some non‐small cell lung cancer (NSCLC) patients with intrapulmonary LN metastasis are incorrectly diagnosed as N0 cases. Furthermore, underestimation of intrapulmonary LN involvement in clinically early stage NSCLC may lead to the incorrect choice of surgical procedure: lobectomy or sublobar resection. This study was conducted to determine the status of intrapulmonary LN involvement in clinically staged IA (c‐T1N0M0) peripheral adenocarcinoma of the lung.MethodsSeventy‐five lobectomy specimens of c‐T1N0M0 peripheral adenocarcinoma of the lung were carefully dissected to find intrapulmonary LNs. The longest diameter of each intrapulmonary LN was measured and sent for pathological examination, together with hilar and mediastinal LNs, to investigate the relationship between LN metastasis and primary tumor size.ResultsIntrapulmonary LN metastasis was detected in 22.7%(17/75) of patients. Positive LNs were detected in 21.7% (10/46) of T1b patients and 45% (11/24) of T1c patients, while no metastasis (0/5) was observed in T1a patients (P = 0.036). The mean longest diameter of the 17 involved intrapulmonary LNs was only 6.5 ± 2.1 mm, which was not significantly different to the size of negative intrapulmonary LNs (5.2 ± 1.4 mm).ConclusionsIntrapulmonary LN metastasis is common in clinically staged IA peripheral adenocarcinoma of the lung. LN metastasis is related to tumor size, and this should be taken into account to determine appropriate surgical procedures and postoperative treatment. Computed tomography is not a reliable method to judge LN metastasis, particularly intrapulmonary LN metastasis.

Clinical and pathological characteristics of surgically resected intrapulmonary lymph nodes: Can they be differentiated from other malignant nodules?

Intrapulmonary lymph nodes (IPLNs) are often recognized as sub-centimeter solid pulmonary nodules (SCPNs). The present study investigated their clinical and pathological characteristics to allow clinicians to distinguish them from malignant nodules. Among 194 SCPNs surgically resected between 2006 and 2016, 26 IPLNs were investigated histopathologically. In addition, 145 resected malignant SCPNs were compared radiographically with the 26 IPLNs. Radiographically, most IPLNs were in a middle or lower lobe, and all lesions were within 20 mm of the visceral pleura. Enlargement was seen in one lesion. Three lesions demonstrated linear density contiguous to pleura (LD), and 13 lesions were adjacent to the peripheral pulmonary vein (APV). Microscopically, all IPLNs showed adjacency to pulmonary veins, 23 showed interlobular septa extending from the IPLN, and 18 were surrounded by a dilatated lymphoid channel. Radiographical findings of LD and APV were also seen in malignant SCPNs (LD, 12/145; APV, 25/145). Comparative analysis revealed that enlargement and APV were significant predictors differentiating IPLNs from malignant SCPNs. The sensitivity/specificity of enlargement and APV were 92%/92% and 17%/50%, respectively. IPLNs show typical high-resolution computed tomography findings that reflect their histopathological characteristics. Such findings help identify IPLNs prior to surgery. Specifically, enlargement and APV may differentiate IPLNs from malignant SCPNs. However, atypical cases are also possible, and radiological findings are not specific for differentiating IPLNs from malignant lesions. Thus, clinicians should consider surgical exploration when diagnosing SCPNs.

P3.16-36 Adjuvant Chemotherapy May Improve the Outcome of Patients with Non-Small-Cell Lung Cancer with Metastasis of Intrapulmonary Lymph Nodes.

Survival benefit of adjuvant chemotherapy (AC) of patients with intrapulmonary lymph node (IPLN) metastasis (level 12–14) needs investigation. We evaluated the impact of AC on patients whose metastatic nodes were limited to intrapulmonary levels after systematic dissection of N1 nodes. First, 155 consective cases of lung cancer confirmed as pathologic N1 were collected and evaluated. Patients received systematic dissection of N2 and N1 nodes. For patients with IPLN metastasis, survival outcomes were compared between those receiving AC and those not receiving AC. In this group, 112 cases (72.3%) had IPLN metastasis and 55 cases (35.5%) had N1 involvement limited to level 13–14 without further disease spread to higher levels. Patients with IPLN involvement had a better prognosis than that of patients with hilar–interlobar involvement. For the intrapulmonary N1 group (level 12–14-positive, level 10–11-negative or unknown, n = 112), no survival benefit was found between the AC group and non-AC group (5-year overall survival (54.6±1.6 vs. 50.4±2.4 months, p = 0.177, Figure 1A). However, 76 of 112 cases for whom harvesting of level-10 and level-11 nodes was done did not show cancer involvement in pathology reports (level 12–14-positive, level 10–11 both negative), oncologic outcome in this group was better for patients receiving AC than those not receiving AC (5-year OS: 57.3±1.5 vs. 47.1±3.2 months, p = 0.002, Figure 1B). Similarly, survival benefit of AC didn’t exist in patients with lymph node metastasis to level 13–14 (level 13–14-positive, 10-12-negative or unknown, n=55, Figure 1C), but was found in 38 patients with complete examination of N1 nodes (58.3±1.7 vs. 51.0±4.2 months, p = 0.048, Figure 1D). Oncologic outcome may be improved by AC for patients with involvement of N1 nodes limited to intrapulmonary levels after complete examination of N1 nodes.

MS27.01 Staging of Lymph Nodes in Early Stage NSCLC: Therapeutic Implications

MS27.01 Staging of Lymph Nodes in Early Stage NSCLC: Therapeutic Implications

CT features of intrapulmonary lymph nodes: a comparative study with pathology

Objective To explore the CT features and pathology of intrapulmonary lymph nodes (IPLNs), so as to improve the understanding and diagnosis of IPLNs. Methods A total of 38 patients (49 IPLNs) who were confirmed by the surgery and pathology were retrospectively analyzed, including 21 males and 17 females with a mean age of (56±8) years. All the patients underwent MSCT scan and 1.0 mm thin layer reconstruction before surgery. Double-blind method was used to analyze CT signs and the corresponding histopathological changes were compared. Results (1) Location: all IPLNs were located below the level of tracheal carina with 17 were on the left lung, and 32 were on the right lung. (2) Shape: 34 IPLNs were round, 15 were triangular or prism and so on. (3) Size: the maximum diameter of IPLNs ranged from 0.26 to 1.28 cm (0.66±0.23 cm), of which 45 cases were ≤ 1.0 cm. (4) Quantity: 28 IPLNs were solitary and 10 were multiple. (5) Density: All 48 IPLNs were solid nodules with a median CT value of 43 HU (range from 19 to 106 HU), and there were no calcification, vacuoles and air bronchial signs were showed. (6) Margin and pleura: all the 48 IPLNs boundaries were clear and smooth, and 45 pieces were less than 1.0 cm from the pleura, of which 20 were close to the pleura or inter-lobar fissure. (7) Other: no satellite focal , pleural depression syndrome, and vascular bundle sign were showed;22 peripheral fine lines of IPLNs were visible. (8) Pathology: IPLNs were dark brown or gray-black nodules with well-defined borders, coated, tough, hard, and carbon deposition could be seen in most cases. Conclusion IPLNs are benign nodules in the lung, which have certain CT features and typical pathological changes. Based on the CT performance and characteristics, it is helpful to make correct diagnosis of IPLNs before operation. Key words: Intrapulmonary lymph nodes; Tomography, X-ray computed; Pathology

Perspective and clinical relevance of intrapulmonary lymph node retrieval: response to the editorial by Tantraworasin and colleagues and the editorial by Marc Riquet and colleagues.

Academic discussion about clinical relevance of intrapulmonary lymph node retrieval will help the community to increase the awareness of this easy-to-be-neglected area in our practice. Dr. Tantraworasin et al . (1) and Dr. Riquet et al . (2) both contribute their thoughts on this important topic. As they mentioned in the editorials, these lymph nodes deserve special attention because they occupy a unique place not only with regard to the prognosis of the NSCLCs when they are metastatic but also because of their anatomical and pathogenic characteristics (2). These comments will surely encourage more and more investigation around this topic.

The impact of reconstruction techniques on observer performance for the detection and characterization of small pulmonary nodules in chest CT of children under 13 years

ObjectiveTo compare three different reconstruction techniques of CT data for the detection of pulmonary nodules in children under 13 years. Secondly to assess the prevalence of perifissural nodular opacities. Materials and methodsThe study consisted of chest CTs of 31 children (median age 6.9 years, range 2.1–12.7), of whom 17 had known extra-thoracic malignancies. Four observers assessed three techniques for the presence of nodules: axial 5 mm maximum intensity projections (MIPs) used in conjunction with 1 mm slices (mode A), 1 mm slices alone (mode B) and 3 mm slices (mode C). All modes were available in 3D. Per mode sensitivities were determined above a certain threshold of reader agreement. Confidence level and reader agreement for identification of an opacity as nodule served as surrogate for quality of nodule characterization. Results103 nodules (median size 2.0 mm) were detected. Mode A yielded the highest interreader agreement (κ 0.336) and a superior sensitivity (71%, p = 0.003) compared to mode B and C (κ 0.218, sensitivity 57% and κ 0.247, sensitivity 56%, respectively). Mode B provided the highest confidence level and interreader agreement with respect to nodule identification (mean 4.3/5, κw 0.508). Double reading improved and evened interreader agreement for all modes (κ 0.450), mode A maintained the highest sensitivity (89.1%, p = 0.05–0.08). A median of 1 intrapulmonary lymph node/patient was seen in children with and without malignancy. ConclusionMIP improves the detection of pulmonary nodules in chest CTs of children, but overall interreader agreement is only fair. Double reading represents a powerful tool to increase diagnostic reliability in chest CTs of children with a malignancy. Nodule characterization is best with 1 mm slices. Intrapulmonary lymph nodes occur in children with and without malignancy.

Adjuvant chemotherapy may improve outcome of patients with non-small-cell lung cancer with metastasis of intrapulmonary lymph nodes after systematic dissection of N1 nodes.

ObjectiveSurvival benefit of adjuvant chemotherapy (AC) of patients with intrapulmonary lymph node (IPLN) metastasis (level 12−14) needs investigation. We evaluated the impact of AC on patients whose metastatic nodes were limited to intrapulmonary levels after systematic dissection of N1 nodes.MethodsFirst, 155 consective cases of lung cancer confirmed as pathologic N1 were collected and evaluated. Patients received systematic dissection of N2 and N1 nodes. For patients with IPLN metastasis, survival outcomes were compared between those receiving AC and those not receiving AC.ResultsIn this group, 112 cases (72.3%) had IPLN metastasis and 55 cases (35.5%) had N1 involvement limited to level 13−14 without further disease spread to higher levels. Patients with IPLN involvement had a better prognosis than that of patients with hilar-interlobar involvement. For the intrapulmonary N1 group (level 12−14-positive, level 10−11-negative or unknown, n=112), no survival benefit was found between the AC group and non-AC group [5-year overall survival (OS): 54.6±1.6vs. 50.4±2.4 months, P=0.177]. However, 76 of 112 cases for whom harvesting of level-10 and level-11 nodes was done did not show cancer involvement in pathology reports (level 12−14-positive, level 10−11 both negative), oncologic outcome was better for patients receiving AC than those not receiving AC in this subgroup (5-year OS: 57.3±1.5vs. 47.1±3.2 months, P=0.002). ConclusionsOncologic outcome may be improved by AC for patients with involvement of N1 nodes limited to intrapulmonary levels after complete examination of N1 nodes.