Intrapulmonary Nodes Research Articles

Gradual Progression of Intrapulmonary Lymph Nodes Associated with Usual Interstitial Pneumonia in Progressive Systemic Sclerosis on Chest Radiographs and CT

Progressive systemic sclerosis (PSS) is a chronic, multisystemic disease, which is characterized by vascular changes, fibrosis, and inflammation of the skin and visceral organs. Pulmonary involvement occurs frequently in patients with PSS and is now considered as the main cause of death among these patients (1). Lung abnormalities are often subtle, most frequently occurring at the lung bases, and progressively expanding to involve the lower two-thirds of the lungs (2). High resolution CT (HRCT) findings of interstitial fibrosis in PSS include fine reticular opacities, ground-glass opacity, consolidation, traction bronchiectasis, honeycombing, and coarse or irregular reticulations. The presence of faint parenchymal micronodules on CT scans is not unexpected, as focal lymphoid hyperplasia (follicular bronchiolitis) has been reported as a frequent histologic feature. Subpleural micronodules may reflect lung involvement at the pleural parenchymal interface, as small lymphoid aggregates adjacent to the pleura have been observed in lower lobe biopsies of patients with PSS (3). However, the radiologic detection of progressive intrapulmonary lymph nodes (IPLNs) with PSS has not yet been reported. In this review, we report the serial chest radiologic findings in one case of PSS with multiple growing lung nodules, which turned out to be IPLNs on video-assisted thoracoscopic lung biopsy (VATS).

Incomplete intrapulmonary lymph node retrieval with routine pathology evaluation of resected lung cancer.

Incomplete intrapulmonary lymph node retrieval with routine pathology evaluation of resected lung cancer.

Intrapulmonary-located Castleman’s Disease, Which Was Surgically Resected without Pulmonary Resection

Castleman's disease (CD) is a rare disease with unknown aetiology. It is characterised by benign lymph node hyperplasia that may involve all lymph nodes. The most common locations are the mediastinum and abdomen. CD arising from intrapulmonary lymph nodes has been reported in five cases, in the English language literature to date. Tumours in these patients are usually resected during lung surgery. An asymptomatic 29-year-old male patient was evaluated due to a mass lesion with a diameter of 55 mm located in the infrahilar region of the right lung with a high degree of contrast enhancement on thoracic computed tomography (CT). Vascularity of this central lesion was excluded by pulmonary angiography. Thoracotomy was performed due to the inability to obtain a diagnosis with percutaneous fine needle aspiration biopsies. A frozen section examination of the mass revealed a benign lesion, arising from the intrapulmonary lymph nodes and protruding to the lower-lobe parenchyma. The mass was then extracted from the parenchyma. After histopathological evaluation of the mass, CD involving the lymph nodes was diagnosed. CD rarely involves the intrapulmonary lymph nodes. Diagnosis is difficult in these patients, and thoracotomy may be required. After obtaining benign results by mass sampling, limited resection of these masses, while sparing the lung parenchyma, may be possible.

CT features of intrapulmonary lymph nodes confirmed by cytology

We retrospectively assessed the computed tomography features of intrapulmonary lymph nodes confirmed by cytology in 18 patients. The median size of the lymph nodes was 5.8 mm (range=3.3–8.5 mm). All were below the carina, and only one nodule, which was associated with an interlobar fissure, was over 20 mm from the chest wall. The nodules were oval, round, triangular, or trapezoidal; had sharply defined borders; were solid and homogenous; and were without calcification. Six nodules (33.3%) had a discrete thin tag extending to the pleura. Intrapulmonary lymph nodes can reliably be confirmed by fine needle aspiration with cytological diagnosis.

Castleman’s disease arising from an intrapulmonary lymph node

A 23-year-old woman was admitted to our hospital because of an intrapulmonary mass that had been observed for 7 years. Chest computed tomography revealed a 3.5-cm well-defined mass with enhancement in the left lower lobe. During the 7 years of observation, she had been asymptomatic and the tumor size was unchanged. She underwent surgical resection for diagnosis and treatment. Histological examination revealed Castleman's disease of the hyaline vascular type. We present this rare case of solitary Castleman's disease arising from an intrapulmonary lymph node.

From Individual Lymph Nodes to Stations and Zones: East and West Reconciled?

When there are no distant metastases prognosis of a bronchogenic carcinoma depends on specific lymph node involvement, patients with preoperatively identified mediastinal nodal metastases having a poor prognosis. In this way, characterization of individual lymph nodes and their grouping is of paramount importance. Unfortunately, until now no lymph node map has been available that is universally accepted and agreed upon. Most commonly used are the Naruke map advocated by the Japan Lung Cancer Society and the so-called Mountain-Dresler modification of the American Thoracic Society map which was adopted by the Union Internationale Contre le Cancer and depicted in the American Joint Commission on Cancer staging manual. 1,2 The Naruke map especially relies on precise surgical landmarks and the American Thoracic Society map more on radiologic reference points. However, important differences exist between these two nodal charts rendering nodal mapping the Achilles heel of the current tumor node metastasis classification. 3 In preparation for the 7th tumor node metastasis classification due in May 2009, the International Association for the Study of Lung Cancer initiated the Lung Cancer Staging Project and proposals for the revision of the N descriptors were published in July 2007. 4 In this article the new concept of anatomic lymph node “zones” is introduced. Six zones are defined: regarding N1 nodes, a peripheral and hilar zone, and for N2 nodes, an upper and lower mediastinal, aortopulmonary, and subcarinal zone. However, a definite chart was not yet proposed and this was the subject of a subsequent manuscript which is now published. 5 Why are the lymph nodes in lung cancer so difficult to assess and characterize? For a long time the discussion has centered around the anatomic borders of the mediastinal lymph node stations and the demarcation between N1 and N2 involvement, but much less on the hilar and intrapulmonary lymph nodes. This was already recognized during the International Workshop on Intrathoracic Staging held in London in October 1996. 6 Over the last year, highly dedicated and renowned thoracic surgeons from different continents have gathered to create a new international nodal map. 5 They are to be commended for reconciling the “best of both worlds,” not only uniting East and West, but also surgical and radiologic landmarks. Specific definitions are provided for each lymph node station which are now grouped into seven “zones,” the supraclavicular being added to the six previously described. Detailed radiologic images are added clearly defining the border of each station. Although at first sight changes seem to be minimal, this new map will have profound implications for all physicians dealing with lung cancer, not in the least for thoracic surgeons. In the new proposal the pleural reflection which is not visible to thoracic radiologists, is no longer considered to represent the border between N1 and N2 disease. Specific radiologic and surgical landmarks now delineate each lymph node station. However, some of these margins are more difficult to identify for a thoracic surgeon; e.g., the lower border of #2R and the upper border of #4R consist of the intersection of the caudal margin of the innominate vein with the trachea, which is difficult to visualize during a classic cervical

Complete mediastinal lymphadenectomy: the core component of the multidisciplinary therapy in resectable non-small cell lung cancer

There is a great deal of concern about metastasis of lung cancer to regional lymph nodes, due partly to the work of groups of thoracic surgeons in Japan and North America beginning in the 1970s. The classification of regional lymph node stations for lung cancer staging published by Mountain and Dresler has been widely adopted for more than ten years. Anatomic landmarks for 14 levels of intrapulmonary, hilar, and mediastinal lymph nodes stations are designated. Skip transfer and occult lymph node metastasis, confirmed by studies regarding the mode of spread of intrathoracic lymphatic metastasis, are two theoretical bases for complete mediastinal lymphadenectomy of lung cancer. However, whether or not the degree of the dissection influences prognosis, the role of systematic nodal dissection (SND) vs mediastinal lymph node sampling (MLD) in resectable non-small cell lung cancer (NSCLC) remains controversial. A systematic literature search was performed to identify relevant reports, making full use of the 'Cited by,' 'Related Records,' 'References,' and 'Author Index' functions in the PubMed and ISI Web of Science databases. This paper presents a review of the role of mediastinal lymph node distribution and methods of determining suitability for hilar and mediastinal lymphadenectomy based on the four subsets of stage IIIA-N2, balancing the cost vs effect of mediastinal lymph node dissection in resectable NSCLC, focusing on the stage migration bias in clinical trials comparing SND and MLS, recommending a reasonable node dissection sequence, improving the prospects for the perioperative anti-tumor therapy based on mediastinal lymphadenectomy, and evaluating the various preoperative staging techniques. Finally, we believe that, besides the role of complete resection and accurate staging, the complete mediastinal lymphadenectomy is the core component of the lung cancer multidisciplinary therapy, and suggest that the values of lymphadenectomy should be further assessed using decision-tree analysis based on large-scale prospective randomized trials and pooled analysis to evaluate the costs vs effects.

P3-257: Comparison of 5-year survival rate in surgically treated IB and IIA NSCLC patients

The group of patients operated on for N1 NSCLC is considered very heterogeneous in terms of 5-year survival rates. Therefore we have decided to compare 5-year survival rates operated on at our institution for NSCLC in pathological stage of T2N0 and T1N1. We reviewed retrospectively the data of 696 patients who underwent the lung resection for NSCLC in our institution between January 1998 and December 2000. In all of them the complete lymphadenectomy (hilar and mediastinal) was performed along with lung resec-tion. The stage of the disease was estimated as IB in 181 pts (26,6%) and as IIA in 44 pts (6,3%). (N1 was confirmed in 221pts out of 696 oper-ated on). 5-year survival rate in IB and IIA groups was 61% and 54,5% respectively. We accepted the p value < 0,001 in log rank test as the statistically significant. We have found no statistically significant influence of age (59,4% in <50 year old pts and 59,4% in >70y old pts, p<0.55), type of resection (63,8% in lobectomy, 56,3% in pneumonectomy, p<0.69), histology (59,7% in adenocarcinoma, 61,3% in squamous cell, p=0,93), T value (p=0.66), presence of neoplastic tromboli in lymphatic vessels (50% of positive, 61,1% if negative, p< 0,34) or infiltration of nerves (61% if negative, 47,1% if positive, p<0,28) on 5-year survival rate. Among patient with N1 there was no statistically significant difference between hilar and intrapulmonary lymphatic spread - the 5-year sur-vival rate was 60,9% and 52,7% respectively (p<0,32). Each of these two groups of hilar lymphnodes were divided into two subgroups. There was also no statistically significant difference within both of them. In hilar lymphnodes - groups 10 and 11 - the 5-year survival rate was 60.9% and 52.7% (p < 0.32) respectively and in intrapulmonary lymphnodes - groups 12 and 13 - 5-year survival rate was 51.5% and 48.3% (p<0.56) respectively. Marginal statistically significant influence on 5-year survival rate we found comparing the sex of patients (M -55,1%, F - 61,1,%, p < 0,01) and presence of neoplastic emboli in blood vessels (52,6% if positive and 64,4% if negative, p < 0.08). The lack of statistically significant differences between these two groups of patients let us suggest combining them into one group.

Ultrasmall Intrapulmonary Lymph Node

To clarify high-resolution computed tomographic findings of ultrasmall intrapulmonary lymph node (IPLN) with histopathologic correlation. Fourteen IPLNs 3 to 6 mm in diameter were identified in 7 lobectomy specimens. Preoperative multidetector-row, high-resolution computed tomography covering the whole lobe was evaluated and compared with histopathologic findings. Thirteen of 14 nodules appeared as well-defined solid nodules. The shape was polygonal or angular in 11 and round or oval in 3. Thirteen of 14 nodules were located within 15 mm of pleura. All 11 nodules apart from pleura were accompanied with linear opacity contiguous with pleura. Ten of 14 nodules were adjacent to peripheral pulmonary veins, and 4 were adjacent to linear opacity from pulmonary veins. These findings were confirmed pathologically, and linear opacities were consistent with thickened or normal interlobular septa. Ultrasmall IPLN has usual high-resolution computed tomographic findings reflecting histopathologic findings.

Intrapulmonary lymph nodes in South African miners—an autopsy survey

Knowledge on intrapulmonary lymph nodes (IPLNs) is still limited. Progress in imaging techniques has enabled easier, more frequent visualization of IPLNs so that a more comprehensive understanding of these nodes is necessary. Microscopic slides of lung tissue from 2,337 dust-exposed South African miners autopsied in 1975 were reviewed to identify IPLNs. The prevalence of IPLNs was calculated and histopathological changes in IPLNs and the surrounding lung parenchyma were described. Pathological changes of IPLNs were correlated with those of the surrounding pulmonary parenchyma. IPLNs were found in 86 of the miners (3.7%). Silicotic nodules were seen in IPLNs in 32 of the 86 cases (37.2%), in the majority of which (21/32; 65.6%) the surrounding lung parenchyma was almost normal. IPLNs are not uncommon among dust-exposed individuals. Silicotic fibrosis of IPLNs appears to precede pulmonary parenchymal disease.

E(B)US-Guided Pulmonary Interventions

Transesophageal ultrasound-guided fine needle aspiration (EUS-FNA) enables minimally invasive tissue sampling of mediastinal lymph nodes. There is convincing evidence that EUS-FNA is an accurate method for mediastinal staging of patients with non small cell lung cancer (NSCLC), and therefore EUS-FNA provides an alternative for surgical evaluation of the mediastinum. Due to the complementary reach in analyzing different mediastinal regions, additional staging by EUS-FNA to mediastinoscopy improves preoperative staging of NSCLC and therefore reduces the number of futile thoracotomies. Preliminary data suggest an important role for EUS-FNA in the assessment of mediastinal tumor invasion as well as mediastinal restaging after prior chemo (radiation) therapy. For interstitial lung diseases, EUS-FNA has been demonstrated to be an accurate method in diagnosing sarcoidosis. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a novel diagnostic method by which mediastinal, hilar, and intrapulmonary nodes can be aspirated under real-time ultrasound control from the trachea or main bronchi. EBUS-TBNA can be performed in an ambulatory setting and has been proven to be accurate in mediastinal staging of patients with NSCLC. Like EUS-FNA, EBUS-TBNA is an alternative for mediastinoscopy. EUS-FNA and EBUS-TBNA have a complementary reach for various mediastinal nodal stations, and recent studies indicate that complete and accurate locoregional staging of NSCLC can be achieved by the combination of EUS-FNA and EBUS-TBNA.

Intrapulmonary lymph node metastasis and renal cell carcinoma

Intrapulmonary lymph node metastasis occuring after nephrectomy for renal cell carcinoma is a particular recurrence modality. Authors report two male patients presenting with this recurrence 2 and 4 years after treatment of the primary and who underwent surgery. Surgery confirmed the diagnosis and demonstrated station 7 minimal metastases and positive pleural lavage cytology in both patients. The first patient survived 2 years and the second was alive disease free at 33 months follow-up. Such metastases probably originate from the thoracic duct. Resection confirms the diagnosis and may be part of the treatment.

The solitary pulmonary nodule: not always bronchogenic carcinoma

A solitary lung nodule (SLN) is seen in 1 in 500 chest radiographs. Benign causes include infectious granulomas and hamartomas, and less commonly, rheumatoid nodules, intrapulmonary lymph nodes and sarcoidosis. Bronchogenic carcinoma and solitary pulmonary metastases are found in 35% and 23% of SLN's respectively. Primary pulmonary non-Hodgkins lymphoma is a rare disease, constituting 0.4% of all lymphomas. We present a case of primary pulmonary non-Hodgkins lymphoma which presented as a SLN in an 87-year old lady with a smoking history of 50 pack years.

Analysis of risk factors for skip lymphatic metastasis and their prognostic value in operated N2 non-small-cell lung carcinoma

Background The aim of this study is to report a series and to analyze risk factors for skip lymphatic metastasis an their prognostic value in operated N2 non-small-cell lung carcinoma. Methods From 1997 to 2002, 142 patients classified pN2 were included in the study. Tumours were classified according to the TNM classification. Skips metastases were defined by the cases of N2 disease without lobar and interlobar and hilar lymph node involvement. A skip (+) and a skip (−) group were defined. Characteristics of tumours, ganglionar involvement and survival were analysed in both groups. Results Forty-two patients fulfilled the criteria for skip metastasis. The average number of mediastinal lymph nodes resected by patient was similar in both groups, whereas more intrapulmonary nodes were dissected in the skip (−) group (4.7±3 vs 3±3; p<0.002). The ratio of involved to resected lymph nodes was 0.47±0.27 in the skip (−) group vs 0.23±0.20 in the skip (+) group ( p<0.0001). In the skip (+) group, 85% of the patients presenting with a right upper lobe tumour had involvement of the superior mediastinal lymph nodes against 40% in the skip (−) group. The 5-year survival rate was 48% in the skip (−) group vs 37% in the skip (+) group ( p=0.49). In multivariate analysis, incomplete resection, tumour size, extended resection and pT were significant prognostic factors. Conclusions Skip metastasis are frequent in non-small-cell lung cancer and complete dissection of hilar and mediastinal lymph nodes should remain the surgical standard procedure for this disease. However, skip metastasis are not an independent prognostic factor in survival.

Sleeve Lobectomy Versus Pneumonectomy: Tumor Characteristics and Comparative Analysis of Feasibility and Results

Sleeve lobectomy (SL) seems to have better results than pneumonectomy. Some authors propose to extend its indications. The aim of this study was to compare postoperative results, locoregional recurrence, and survival after sleeve lobectomy and pneumonectomy in focusing on right upper lobe cancer. From 1984 to 2002, 973 lung resections were performed for T1, T2, and bronchial T3 right upper lobe non-small cell lung cancer. There were 756 lobectomies (L group), 151 pneumonectomies (RP group), and 66 sleeve lobectomies (SL group). The RP group was further divided with regard to intrapulmonary lymph node involvement. Pneumonectomy 1 (RP1) was a group of N0, intralobar N1, and skip metastasis involvement (N0-N2). Pneumonectomy 2 (RP2) was a group of extralobar N1 and nonskip metastasis involvement (N1-N2). Postoperative results were compared among SL, L, and RP groups. Survival was compared between the two homogeneous groups for oncologic characteristics (SL, RP1). Statistical comparison of 5-year actuarial survival showed a significant difference favoring SL (SL: 72.5%/ RP1: 53.2%; p = 0.0025). Postoperative mortality was higher after RP (L: 2.9% / SL: 4.5%/ RP: 12.6 %). Significant factors limiting SL were tumor size, extralobar N1, and main bronchus involvement (p = 0.000026, 0.0002, and 0.005, respectively). Immediate and long-term survival appears better after sleeve lobectomy than right pneumonectomy for comparable stages of right upper lobe cancer. For frequency to increase by systematic attempt at SL, limited by large tumors and extralobar N1 involvement, the only way should be after favorable response to induction chemotherapy.

Ultrasmall Pulmonary Opacities on Multidetector-Row High-Resolution Computed Tomography

To clarify the pathologic findings of ultrasmall pulmonary opacities (5 mm or smaller in diameter) found on multidetector-row high-resolution computed tomography (MD-HRCT). Ten lobes in 10 patients were included in this study. Each lobe had a primary lung tumor and was removed surgically. Two thoracic radiologists noted any tiny nonlinear opacity on preoperative MD-HRCT films (1.25-mm thickness) covering the whole lobe. Pathologic findings of detected opacities were evaluated macroscopically and microscopically. Among 139 ultrasmall opacities 5 mm or smaller in diameter, 94 corresponded to normal anatomic structures (partial volume averaging or motion artifact), 36 corresponded to pathologic abnormalities, and 9 were unidentified. Histologic diagnoses of 36 pathologic abnormalities were inflammatory lesions (n = 16), intrapulmonary lymph nodes (IPLN; n = 7), atypical adenomatous hyperplasia (AAH; n = 7), bronchioloalveolar carcinoma (BAC; n = 5), and another neoplastic lesion (n = 1). Tiny pulmonary lesions, such as AAHs, BACs, and IPLNs, were identified among ultrasmall opacities found on MD-HRCT.

Intrapulmonary lymph node mimicking a pulmonary metastasis associated with adenocarcinoma on high resolution computed tomography (HR-CT) findings

The widespread use of chest CT has increased the detection of small nodules in lung, and intrapulmonary lymph nodes are identified frequently among them. We report a case of intrapulmonary lymph node mimicking a pulmonary metastasis associated with adenocarcinoma. The patient was a 60-year old woman with a small nodule that was round shaped and existed subpleural portion of left upper lobe distant from primary adenocarcinoma. She underwent surgery, and histological examination of resected material revealed that the small nodule was composed of lymph node without malignant cell. Intrapulmonary lymph nodes (IPLN) should be included in the differential diagnosis of small nodules in the peripheral lung field.

Entirely thoracoscopic pneumonectomy using the prone position: a new technique

Reports on video-assisted pneumonectomy have remained scarce, despite early demonstration of its technical feasibility. A totally videothoracoscopic pneumonectomy was first reported by Conlan and Sandor. The patient in this report was positioned in the full lateral position. In this video, we report a totally videothoracoscopic left-side pneumonectomy with the patient in prone position. A 49-year-old man was admitted to our hospital for a bifocal cancer of the left lower lung lobe (LLL) and the cervical esophagus. The preoperative workup included a chest computed tomography (CT) scan showing a 3-cm mass of the laterobasal segment of the LLL, with retrotumoral atelectasis, lymph nodes smaller than 1 cm in diameter at the aortopulmonary window and under the carena, and finally posterolateral adherences between the parietal and the visceral pleura. Flexible bronchoscopy confirmed the presence of a bronchial tumor at the offspring of the apical bronchus of the LLL. Biopsy showed invasive adenocarcinoma, and a CT scan of the neck and head was significant for tumoral infiltration of the cervical esophagus and retropharyngeal space. Gastroscopy showed a stenosis of the cervical esophagus and hypopharynx. Biopsy showed spinocellular epithelioma, but CT scan of the abdomen and bone scintigraphy did not show metastatic disease. A position emission tomography (PET) scan confirmed the findings of the CT scan. Pneumonectomy and esophagectomy by thoracoscopy, laparoscopy, and cervicotomy were proposed. The purpose of this video is to show the details of the thoracoscopic technique with the patient in the prone position. After induction of general anesthesia, a double-lumen endotracheal tube was placed. The patient was subsequently placed and strapped in a prone position. The surgical team was placed to the left of the patient. A 10-mm trocar was placed in the seventh intercostal space on the posterior axillary line, and a 30 degrees angled videoscope was introduced. Three additional 5-mm trocars were placed at the same level in the 5th, 9th, and 11th intercostal spaces on the posterior axillary line. The mediastinal pleura was opened just ventral to the aorta. The first structure identified was the left main bronchus, which was dissected free and transected with a linear stapler (blue load). The aortopulmonary window became immediately visible. Clearance of this window's lymphoglandular tissue showed, bottom to top, the inferior pulmonary vein, the superior pulmonary vein, and the pulmonary artery. These vascular structures were carefully dissected free with the cautery hook and transected with a vascular linear stapler (white load). The lung was freed entirely tend placed in a retrieval bag for later transhiatal extraction during the laparoscopic phase of the esophagectomy. The intraoperative time for the pneumonectomy was 146 min, and intraoperative blood loss was 30 ml. The pathology report confirmed the presence of invasive, poorly differentiated adenocarcinoma. The bronchial section was free of tumor. One intrapulmonary lymphnode (N1) was positive, whereas all 10 N2 and N3 nodes harvested were free of disease. The tumor was thus staged as IIB (pT2N1Mx). The esophagetomy specimen showed fairly wide differentiated keratinizing of the spinocellular epithelioma with invasion of both pyriform sinuses and both sides of the glottis. First described by Cuschieri et al. in 1992, the prone position for thoracoscopy allows for a more direct approach to the aortopulmonary window under excellent visual and ergonomic circumstances. Dissection of the hilar larger vessels and performance of lymphnode sampling appear more straightforward because with this technique, the lung is kept out of harm's way, thanks to gravity.

Possible mechanism of metastasis in lung adenocarcinomas with a micropapillary pattern

Micropapillary differentiation in adenocarcinomas has recently been associated with poor prognosis because these tumors are more likely to metastasize. However, no clear explanation exists as to why the presence of a micropapillary pattern is associated with metastasis. A case of primary lung adenocarcinoma with a prominent micropapillary pattern is presented here, with special reference to the immunohistochemical expression of the E-cadherin-mediated system and IQGAP1. Histologically, the tumor was diagnosed as a moderately differentiated papillary adenocarcinoma, showing an extensive micropapillary pattern, with intrapulmonary metastases, pulmonary disseminations, lymphovascular invasions, and lymph node metastases. Immunohistochemically, positive staining for the adhesion molecules E-cadherin, alpha-catenin, and beta-catenin was detected in both the micropapillary and non-micropapillary areas, whereas IQGAP1 was detected in the micropapillary, but not in the non-micropapillary, area. The adhesive function of E-cadherin depends on the integrity of the entire cadherin-catenin-actin network, and thus the expression of IQGAP1 may lead to adherens junction disassembly, and consequently, the release of carcinoma cells organizing in a micropapillary pattern. This is the first report to suggest correlation between adenocarcinoma with a micropapillary pattern and the presence of adhesion molecules, and offers an intriguing first glimpse on the role of the micropapillary pattern in the process of metastasis.

Hypercalcemia as a result of sarcoidosis with normal serum concentrations of vitamin D

A 68 yo man with a h/o aortic valve repair in 1995, BPH, and mild renal insufficiency (crea 153 mcmol, nl: 59–104)) developed painful paresthesias in the lower extremities, polyuria, and fatigue. Meds: furosemide, falithromb. No h/o Tbc. On admission, crea 274 mcmol, Ca 3.11 mmol. Physical examination: crackles. Laboratory: serum phos 1.1 mmol (0.84–1.45), intact PTH 0.76 pmol (1.06–6.89), PTHrP <0.5 pmol, nl serum and urinary immunelectrophoresis, ACE 1110 nkat (133–866), IL-2R 2216 U (<710), Neopterin 47 nmol (0–10), 25-OH VitD 34 ng (9–45), 1,25-OH VitD 38 pg (20–46), and 24h urinary Ca 6.86 mmol (<7.5). Prim HPT was excluded. Bone marrow bx was neg for mult myeloma. Abd US: right kidney stones. An x-ray revealed a mass at the lower right hilus. Chest CT demonstrated multiple pleural and intrapulmonary calcifications and lymph node enlargement of approx 3cm size. To further clarify whether a granulomatous disease, malignant lymphoproliferative disorder, or cancer were responsible for this patient's hypercalcemia, we performed a bronchoscopy with lavage and a subcarinal transbronchial bx of pulmonary segment VIII. The CD4/CD8-ratio was elevated with 10.7 (1.1–3.5) and findings suggestive of an early stage of sarcoidosis. TTE showed no evidence for pulmonary hypertension. Pulmonary function tests revealed mild obstruction but no restriction. An empiric trial with prednisolone 40mg/die was initiated while the patient was carefully hydrated. Within 7 days, serum Ca dropped to 2.7 mmol, 1,25-OH VitD to 13.4 ng, and crea to 257 mcmol. For persisting paresthesias, carbamazepine and amitryptiline were given. After 6 weeks of prednisolone therapy, the patient's well being improved. Laboratory: Serum Ca 2.41 mmol, intact PTH 6.26 pmol, 1,25-OH vitD 6 (low), 25-OH VitD 22, ACE 226, IL-2R 1052, and crea 153. On CT, the thoracic mass had shrunken. This case illustrates that hypercalcemia can occur in sarcoidosis with normal 1,25 VitD levels. Contributing factors may include increased uptake of oral Ca or decreased excretion, especially in mild renal insufficiency.