Left Supraclavicular Node Research Articles

Diffuse Pulmonary Infiltrates following Lymphography

A 27-year-old man was admitted to the hospital complaining of two days of increasing weakness, fatigue, and dyspnea, with a nonproductive cough and fever. Two months prior to admission he had been evaluated for fevers (39.4#{176}C)and left neck swelling. CT scans of the chest and abdomen showed cervical and supraclavicular adenopathy and a left axillary mass. No mediastinal or abdominal adenopathy was noted. Biopsy examination of a left supraclavicular lymph node revealed large cell lymphoma. He was subsequently evaluated at Stanford Hospital, and four days prior to admission had a lymphangiogram as part of a routine staging workup. The patient had no prior history of respiratory illness and had not traveled abroad. He had no risk factors for AIDS, but an HIV titer was performed on admission, which was subsequently returned as negative. On admission his temperature was 38.8#{176}C, and he was in moderate respiratory distress. He was orthostatic. His chest examination was significant for diffuse crackles with no wheezes. Palpable lymph nodes were present in both axilla and in the cervical and supraclavicular regions. Laboratory studies showed the following: WBCs, 15.4 x 10 /L, with 68 percent segmented forms, 19 percent band forms, 1 1 percent lymphocytes, and 2 percent monocytes; hematocrit, 32.7 percent; and hemoglobin, 10.9 g/dl. Four days prior to admission his hematocrit was 36 percent. Platelets were 551,000/mi, the PT, 13.9 s (control, 13 s); PTT, 33.9 s (control, 24 to 33 s). The BUN was 5 mg/dl and creatinine 0.6 mg/dl. The urinalysis was normal. Arterial blood gas while breathing with 2 L of supplemental 02 was pH 7.46; PC02, 36 mm Hg; and Po2, 106 mm Hg. Chest roentgenogram (Fig 1) showed diffuse patchy infiltrates throughout all lung fields. His therapy was begun with empiric trimethoprim/sulfamethoxazole and erythromycin. On the day following

A CASE OF GASTRIC CARCINOMA CONFINED TO THE MUCASAL LAYER ACCOMPANYING VIRCHOW'S NODE METASTASIS

A case of gastric carcinoma confined to the mucosal layer accompanying by Virchow's node metastasis, an extremely rare case, is reported. The patient, a 45-year-old woman, admitted to our hospital with a complaint of left supra-clavicular lymph node swelling. Endoscopic examinaiton revealed the finding of IIb+IIc type early gastric cancer in pyloric antrum. After closer examination, no non-curative factors were found except a wide-spread lymph node metastasis, accordingly distal partial gastrectomy and lymph node dissection as reduction surgery were performed. Pathological examination disclosed a diffuse proliferation of signet ring cells only in the mucosal layer. It seems important to take into consideration the possibility of wide-spread lymph node metastasis, though a carcinoma is limited in the gastric mucosal layer.

Peripheral ameloblastoma with metastatis

Peripheral ameloblastoma is an uncommon clinical entity, while ameloblastoma with distant metastasis is still more unusual. A case of peripheral ameloblastoma with left supraclavicular lymph node metastasis is presented here.

Ovarian sex cord tumor with annular tubules

A pathologic study was done on four cases of ovarian sex cord tumor with annular tubules. All four tumors occurred in young women (11-24 years of age) and were not associated with the Peutz-Jeghers syndrome. Two patients had evidence of hyperestrinism. One patient who had metastasis to the retroperitoneum, left supraclavicular lymph node, and liver confirmed the malignant potential of this tumor. Gross examination revealed tumors that were solid, yellowish, and unilateral, with varying degrees of cystic degeneration. Microscopic examination showed simple or complex annular tubules with prominent basement membranes. Many tumor cells contained lipid in the cytoplasm. Ultrastructural study showed Charcot-Bottcher filaments in all four cases, indicating Sertoli cell differentiation. True lumens and microvilli were identified in one case. The classification of the sex cord tumor with annular tubules as a Sertoli cell tumor, annular tubular type was proposed on the basis of ultrastructural findings.

Recurrence of Thymoma with Appearance of Myasthenia Gravis 18 Years after Surgery: A Case Report

A 59-year-old woman was admitted to the hospital because of recurrence of thymoma with appearance of myasthenia gravis 18 years after excision of an invasive thymoma. Recurrence was observed in the anterior mediastinum, right pleura, pericardium and left supraclavicular lymph node. Hashimoto's thyroiditis, vitiligo vulgaris and leukopenia were also seen. After creation of a pericardial window for pericardial effusion, she received vincristine, then carbazilquinone intravenously as single chemotherapeutic agents based on the chemosensitivity by clonogenic assay of the supraclavicular tumor, but response was not achieved. At one and a half years after radiotherapy to the mediastinum, she is now doing well without symptoms and is receiving a fairly low dose of anticholinesterase medication.

Opisthorchis viverrini infection and cholangiocarcinoma: A prospective, case-controlled study

During a prospective, 24-mo case-controlled study, 551 patients from northeastern Thailand were independently evaluated for Opisthorchis viverrini infection, hepatobiliary tract disease, and hepatic carcinoma to determine whether there was any association between hepatic carcinoma and O. viverrini infectjpn. Stool examination by the formalinether concentration method revealed O. viverrini ova in 389 (70.6%) patients. Of the 551 patients, 72 (13.1%) had both clinical and laboratory evidence of hepatobiliary tract disease, chronic liver disease, or hepatic carcinoma, alone or in combination. Of these 72 patients, 28 (38.9%) had a liver biopsy that revealed cholangiocarcinoma in 7 patients with O. viverrini ova in their stools, and in 4 patients without. In another patient with ova in the stool combined hepatocellular carcinoma and cholangiocarcinoma was found. In the 4 patients with cholangiocarcinoma who had no O. viverrini ova in their stools, ova were detected in the bile fluid aspirated from the intrahepatic biliary tree during exploratory laparotomy. An additional patient with clinically suspected cholangiocarcinoma and O. viverrini ova in stool had a left supraclavicular lymph node biopsy specimen taken that revealed metastatic adenocarcinoma; this adenocarcinoma was interpreted as compatible with cholangiocarcinoma. Cholangiocarcinoma, therefore, was found only in patients with O. viverrini ova in stool or in the intrahepatic biliary tree. Statistical analysis revealed that patients with known O. viverrini infection had a higher incidence of cholangiocarcinoma than did patients without such infection (x2 test, p < 0.05).

A Case of Neuroblastoma Presenting with Sudden Blindness

Neuroblastoma is the most common extracranial solid tumor of childhood which presents various clinical symptoms depending on the primary and metastatic sites. However, it has been rarely reported that sudden onset of blindness was the chief complaint of neuroblastoma. A four years old boy was admitted to the Yeungnam University Hospital with the chief complaint of a sudden onset of blindness due to a distant metastasis of abdominal neuroblastoma to the sphenoid sinus. On admission, both side pupils were dilated without light reflex, fundoscopy showed pale optic disk, electroretinogram was subnormal and visual evoked potential showed no response. The liver was palpable in finger breadth from the right costal margin and adult fist sized mass was palpable in the right flank. Skull X-ray showed destructed sphenoid bone and clinoid process and brain CT scan showed tumor mass in the sphenoid sinus and left orbit. Ultrasonogram and CT scan of the abdomen showed large tumor masses around the right kidney and para-aortic and retropancreatic lymph node. IVP showed displaced right calyceal system with preserved contour. Left supraclavicular lymph node which appeared after admission was biopsied and it showed poorly differentiated neuroblasts. He was treated according to the multiagent chemotherapy schedule for stage IV neuroblastoma patient of children's cancer study group. Abdominal tumor masses and sphenoid sinus mass were markedly reduced after 2 courses of the combination chemotherapy of cyclophosphamide, vincristine, DTIC, adriamycin and VM-26. Eventhough the blindness was not improved, the patient has been in good clinical condition.

Bone 'Flare,' Hypercalcemia, and Jaundice After Tamoxifen Therapy

<h3>To the Editor.</h3> —The antiestrogen tamoxifen citrate frequently is used in the treatment of metastatic breast carcinoma and has been associated with remarkably few clinical side effects. Herein is a case of bone "flare," hypercalcemia, and jaundice after tamoxifen therapy. <h3>Report of a Case.</h3> —A 59-year-old woman, after having had a left radical mastectomy in 1974 for breast adenocarcinoma, had multiple bony metastases develop in September 1977. Fluoxymesterone therapy, 10 mg three times daily, was started. This seemed to stabilize her disease until May 1978, when she had left supraclavicular lymph node metastases develop. Fluoxymesterone therapy was discontinued. Chemotherapy with cyclophosphamide, methotrexate, and fluorouracil was given to her until October 1979. This therapy was then discontinued at the patient's request, although chemotherapy kept her disease stable. Two months after discontinuation of chemotherapy, tamoxifen citrate therapy, 10 mg two times daily, was started. After two weeks of therapy, she was admitted

Fine needle aspiration cytology of supraclavicular lymph nodes in gynecologic malignancies

Eight cases of fine needle aspiration (FNA) of supraclavicular lymph nodes are presented. Clinical and pathologic data and the route of spread to the left supraclavicular node (Vir-chow's node) are discussed. FNA has proven to be an accurate, inexpensive, and easily learned skill in the evaluation of distant metastatic disease. Careful palpation of the supraclavicular nodes in all patients with known or suspected pelvic malignancy may influence stage and therapy if positive nodes are identified.

Generalized Lipodystrophy, Scleroderma, and Hodgkin's Disease

<h3>To the Editor.—</h3> Recent reports of Sjögren's (sicca) syndrome associated with total and partial lipodystrophy^1,2prompted us to report the case of a patient with total lipodystrophy and scleroderma who has developed Hodgkin's disease. <h3>Report of a Case.—</h3> A 22-year-old black female was noted at 3 months of age to lack subcutaneous fat. One month later subcutaneous nodules developed on the extremities. At age 8, chronic skin changes were seen, and results of multiple skin biopsies were consistent with scleroderma (Fig 1 and 2). Recently, palpable left supraclavicular and left inguinal lymph nodes were found. Hilar and mediastinal adenopathy were seen on chest x-ray film. Esophageal abnormalities that were compatible with scleroderma were seen on barium swallow film, and old healed bone infarcts with periarticular calcifications were identified in the left ulna. Results of routine blood chemistry studies were normal. Total serum protein levels were elevated, and electrophoresis demonstrated

Abnormal Cardiac Silhouette in a Patient With Hodgkin's Disease

History Hodgkin's disease, mixed cell type, was diagnosed in a 38-year-old woman after biopsy of an enlarged left supraclavicular lymph node in May 1975. Chest roentgenogram showed right and left paratracheal masses (Fig 1), and her lymphoma was subsequently staged as IIIA after splenic involvement was found at laparotomy. She received external beam irradiation with 4,500 rads to a standard thoracic mantle and 4,000 rads to inverted Y and right and left inguinal fields. The paratracheal adenopathy disappeared after irradiation, but the cardiac silhouette was noted to be abnormal in August 1977 (Fig 2). Diagnosis Recurrent Hodgkin's disease involving the paracardiac lymph nodes at the cardiac apex. Comment Figure 2 shows a mass in the left cardiophrenic angle that was not present on the earlier film. Histological proof of Hodgkin's disease was obtained by a fluoroscopically guided transcutaneous fine-needle aspiration biopsy. Mediastinal lymph node involvement is common in Hodgkin's disease,

Enlargement of the supraclavicular lymph nodes as the initial sign of prostatic carcinoma.

During the past 12 years, 19 patients have presented themselves with enlargement of the supraclavicular lymph nodes as the initial manifestation of previously unrecognized prostatic carcinoma. Of the 19 patients, 18 had enlargement of the left supraclavicular lymph nodes, and one had enlargement of those on the right side. This study group was compared with a control group of 100 consecutive previously untreated patients exhibiting the typical signs and symptoms of prostatic carcinoma. The histologic picture in both the lymph nodes and prostate gland of the study group was that of a less well-differentiated carcinoma than was usually observed in the control group. The disease should, therefore, be considered when metastatic adenocarcinoma is discovered in the supraclavicular lymph nodes, usually those on the left, of men over 45 years of age. Prostatic carcinoma appearing initially as metastases in supraclavicular lymph nodes does not differ significantly in its response to therapy or survival from prostatic carcinoma manifested by the typical clinical features.

Fine needle aspiration cytology of palpable supraclavicular lymph nodes

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

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

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

Lymphography in lymphatic obstruction.

Lymphography has added a new dimension to our understanding of the anatomy, physiology, and pathology of the lymphatic system. One application of the method is the evaluation of altered lymphatic flow dynamics in obstruction (1, 2, 7, 12, 17, 20, 33). The technic used by the majority of current investigators does not allow a completely physiological observation of the lymphatic flow dynamics. The volume and pressure added to the lymphatic flow by injection of contrast material, while transient, tend to enhance an abnormal feature. The world literature abounds with reports of lymphography in the study of lymphatic obstruction from various causes (3, 5, 7, 11, 19, 20, 21, 24, 27, 32–34). While experienced lymphographers easily recognize the classical signs of obstruction, other less frequently seen features are not adequately emphasized in the literature. The radiographic signs of lymphatic obstruction can be summarized and classified as follows: 1. Stasis and nonvisualization 2. Backflow 3. Dilatation 4. Extravasation 5. Collateral formation 6. Fistula formation 7. Absent or decreased lymphatic channels. In any given case of lymphatic obstruction, the abnormal lymphographic manifestations are usually a combination of two or more of these signs. Illustrative Cases Illustrative cases are shown in Figures 1-10, with the case reports themselves incorporated into the legends. Figure 1 shows regeneration, formation of collaterals and lymphocysts (dilatation and/or extravasation) following surgical interruption of peripheral lymphatic vessels. Figure 2 also demonstrates collateral formation, this time with backflow, subsequent to the surgical interruption of the central lymphatic channel (obstruction of the last segment of the thoracic duct secondary to left supraclavicular lymph node biopsy). Cases III–VI are a few representative cases of primary lymphedema of the lower extremities: Case III, of the right lower extremity twenty-four hours after the injection of contrast material; Case IV, of both lower extremities with reduction in the number of lymph vessels on the right side; Case V, with lymphatic varicosity; and Case VI with atretic subcutaneous lymphatic vessels. Other conditions depicted are of cutaneous lymphorrhea probably secondary to suprapelvic retroperitoneal lymphatic obstruction (Case VII); obstruction of the retroperitoneal (lumbar) lymphatic channels by tumor invasion (Case VIII); right unilateral chyluria from obstruction of the lowest segment of the thoracic duct (Case IX); and spontaneous chylothorax and cavernous lymphangioma of the left neck (Case X). Discussion In analyzing the lymphographic manifestations of obstruction, one must consider its two major categories: anatomical and functional. It must be realized that obstruction of lymphatics with resultant lymphographic manifestations may occur without gross clinical signs because of regeneration of lymph vessels or development of collateral pathways for the lymphatic flow.

Mediastinal lymph node visualization in the absence of intrathoracic disease.

Ever since Kinmonth (1) established a practical method for visualizing lymph nodes in man, numerous articles have been published, but few references have been made to the opacification of thoracic nodes by means of peripheral lymphography. In each published instance (5, 9, 11), the authors assumed that the occurrence was due to some pathologic process or to an anatomical abnormality. This paper presents three cases in which opacification of the thoracic nodes was not due to pathology. One of the limitations of peripheral lymphography is the failure to demonstrate certain node groups. For the investigation, staging, and treatment of many malignant tumors, evaluation of the thoracic nodes would be extremely valuable if a simple method of doing so could be devised. The study of normal and abnormal cases in which this has occurred incidentally may provide information of value in this regard. In our routine technic of lymphography, the inguinal, iliac, and para-aortic nodes are visualized with ease. These, however, drain into the thoracic duct, which in most cases arises at the level of L1 or L2, and from there until termination of the duct very little information can be obtained as to the condition of the thoracic lymph nodes. In reviewing our own cases, we observed that in most instances the thoracic duct could be demonstrated whenever the study was technically satisfactory and whenever no major replacement of nodes had occurred. Some authors feel that the visualization of the thoracic duct should be a warning of a too high injection rate (4), but in our experience this has not been a source of complications. It was also noted that not infrequently there was opacification of the left supraclavicular nodes. This last observation is of some importance in the discussion of our three cases. Anatomy The lymphatics from the lower limbs, pelvis, and abdomen, as well as those from the gut, drain into the thoracic duct. The thoracic duct arises at the level of the second lumbar vertebra and extends to the root of the neck, where it usually terminates at the junction of the left sub-clavian and jugular veins. Its origin in the abdomen is from a triangular dilatation called the cisterna chyli, which lies anterior to the vertebral body and to the right side of and posterior to the aorta. Within the thorax, it is located to the right of the aorta and anterior to the vertebral column; later it passes behind the aortic arch and the thoracic part of the left sub-clavian artery, entering the neck, where it arches laterally about 3 to 4 cm above the clavicle, crossing anteriorly to the left subclavian artery and then going on to its termination (6). The thoracic duct usually has only two valves, one at its origin and one at the junction of the left subclavian and jugular veins. During its passage through the mediastinum, the thoracic duct receives tributaries from the intercostal nodes.

POSSIBLE TERATOGENIC EFFECT OF CHLORAMBUCIL ON A HUMAN FETUS.

THE EFFECTS OF SODIUM AMINOPTERIN, 1 and more recently, of thalidomide, 2 on the human fetus, when administered to the mother during early pregnancy, have stressed the necessity of carefully checking all drugs for teratogenic properties. Since it is desirable that any suspicions of this nature should be reported, the following case is felt worthy of mention. It concerns the possible teratogenic effect of chlorambucil on a human fetus removed from a mother receiving this drug for the treatment of Hodgkin's diseae. Report of a Case A 27-year-old married white woman was diagnosed as suffering from Hodgkin's paragranuloma after a biopsy of a left supraclavicular lymph node in the Lynchburg General Hospital in February, 1958. Since then her illness has been characterized by fever, generalized adenopathy, pulmonary infiltration, hepatosplenomegaly, anemia, lymphopenia, and weight loss, although the degree of each of these symptoms has varied from time to time. She was

The value of scalene node biopsy in intrathoracic disease

Summary The value of scalene node biopsy as a diagnostic procedure in intrathoracic disease is established beyond doubt. The percentage of positive biopsies depends on the thoroughness with which the operation is carried out and is especially high in cases of sarcoidosis. The results of the present study bear out the author's previously published views on the lymphatic drainage of the lungs and give a guide to the question of which side should be explored. Right-sided lesions always give rise to pathological changes on the right. In cases where no lymph nodes are palpable, the right supraclavicular region should be explored irrespective of whether the lesion in the chest is on the left or right. Similarly, in bilateral lesions a right scalene node biopsy is advised. Only when the left supraclavicular nodes are palpable should this side be operated upon. A bilateral exploration is only justifiable where a right scalene node biopsy is negative and the case cannot be diagnosed by any other means.

HODGKIN'S DISEASE OF THE NECK AND MEDIASTINUM

On Oct. 18, 1910, I examined a woman, aged 24, who complained of a lump which she had discovered two days previously above her left collar bone. She had measles, scarlatina and diphtheria in childhood and had been somewhat anemic between the ages of 16 and 18, but otherwise had been in good health. Her family history was without importance. The results of the general examination were negative, and glandular enlargement was found only in the left supraclavicular nodes. My diagnosis was enlarged lymph nodes, probably tuberculous. On October 20, I removed a mass of enlarged nodes from the supraclavicular space, through an incision above the clavicle. The pathologic report was: lymphoma, probably Hodgkin's disease (fig. 1). The patient was instructed to report for observation, but she did not appear until six months later, when the condition recurred in the same region. On April 17, 1911, an incision 15 cm.