Scalene Node Biopsy Research Articles

Malignant Superior Vena Cava Obstruction Reconsidered: The Role of Diagnostic Surgical Intervention

The cases of 42 patients with malignant superior vena cava (SVC) obstruction were reviewed to evaluate clinical dogmas of prohibitive risk for invasive diagnostic procedures and need for urgent radiotherapy. Thirty-nine had carcinoma (35, bronchogenic and 4, other), and 3 had lymphoma. Lung cancer histology was squamous cell in 11, adenomatous in 10, large cell in 7, and small cell in 7. The SVC obstruction was always symptomatic, usually causing facial or cervical swelling, but there was no instance of SVC obstruction causing life-threatening problems such as cerebral or laryngeal edema. Twenty-two patients underwent bronchoscopy (11 flexible and 11 rigid) prior to radiotherapy without respiratory complications, and diagnostic tissue was obtained in 8. Also prior to radiotherapy, 29 invasive diagnostic procedures were performed: thoracotomy (1), mediastinotomy or mediastinoscopy (11), supraclavicular or scalene node biopsy (15), and percutaneous lung needle biopsy (2). Neither excessive blood loss nor serious complications occurred, and diagnostic tissue was obtained in 22 patients who received individualized therapy. Eight patients had urgent radiotherapy, which delayed diagnosis and specific therapy for two weeks to 6 months. For the 33 patients who underwent radiotherapy after development of the SVC obstruction, the obstruction clinically resolved spontaneously within fourteen days, independently of whether radiotherapy was begun immediately or was delayed. Median survival was 5.0 months and was not influenced by the dose or timing (early or late) of radiotherapy. We reached the following conclusions. First, although a grim prognostic sign, SVC obstruction is rarely life-threatening and typically resolves spontaneously, probably by development of venous collaterals. Second, malignant SVC obstruction is caused by all types of lung carcinoma and lymphoma; specific therapy may not include radiotherapy. Finally, diagnostic surgical intervention can be performed with low morbidity prior to treatment, and results allow specific, maximally effective therapy.

Effectiveness of scalene node biopsy for staging of lung cancer in the absence of palpable adenopathy.

Scalene node biopsy (SNB) has been performed in patients with lung cancer at the Saint Francis Hospital and Medical Center if any of the following criteria has been present: (1) potentially resectable central lesion by chest radiograph, or (2) significant cardiac or pulmonary dysfunction, thereby placing the patient at increased risk for thoracotomy, or (3) a diagnosis of adenocarcinoma prior to SNB. Within these guidelines, a retrospective study was undertaken to determine the benefit of routine SNB in the absence of clinically palpable scalene nodes. In a 2-year period beginning April 1981, 56 patients (37 males) presented with radiographic evidence of lung carcinoma without clinical evidence of scalene adenopathy. Approximately half of the lesions were of a central position. While the majority had symptoms of cough, hemoptysis, or chest pain, the primary lung lesion was identified on routine chest radiograph in 15 (27%). In only three was there no history of smoking, the remainder having at least a 20-pack-year history of cigarette use. Following a routine evaluation, 57 SNBs were performed alone or in concert with other surgical procedures (mediastinoscopy, bronchoscopy). Of these, only two (3.5%) were diagnostic and indicative of unresectable disease. While in one patient no additional procedure was performed, a simultaneous Chamberlain procedure in the other confirmed that the patient was unresectable for cure. In the remaining patients, tissue diagnosis of cancer was obtained through other maneuvers. Because of the low probability that SNB in the absence of clinically palpable nodes altered the management of lung cancer, we do not believe it to be of benefit in the diagnosis or staging of this disease.

Prognostic value of scalene node biopsy in cervical cancer

Prognostic value of scalene node biopsy in cervical cancer

CLINICAL REAPPRAISAL OF SCALEN NODE BIOPY WITH VARIOUS INTRATHORACIC DISEASES

Scalene node biopsy (SNB) has been utilized for diagnostic and/or staging purposes in various primary and metastatic chest diseases. In this clinicopathological study, SNB was reassessed with regard to its indication and diagnosis. During the period between 1961 and 1983, 99 patients with chest diseases received SNB at our institution. The diagnosis prior to SNB consisted of 84 cases of primary lung cancer, 4 cases of metastatic lung cancer, 3 cases of mediastinal tumor and 8 cases of sarcoidosis. Satisfactory specimens were obtained from 94% of these patients and the complication rate was only 2%. Among benign thoracic lesions, sarcoidosis is best indicated for SNB. It can be diagnosed 100% accurately if adequate specimens are provided, preferably from the right side. It was diagnostic in 35% of the primary lung cancer cases. The accuracy rates were 65% for adenocarcinoma, 12% for squamous cell carcinoma and 50% for small cell carcinoma, respectively. Palpable scalene turned out to be 100% positive for metastases, while only 16% of nonpalpable nodes were proved to contain carcinoma. This study suggests that indication of SNB should be individualized.

Scalene node biopsy in diagnosis of intrathoracic diseases. Clinical notes.

Scalene node biopsy (SNB) still represents a useful diagnostic method in the difficult interpretation of hilar-mediastinal adenopathies. Of 858 sample cases of intrathoracic pathologies of various etiology, SNB indicated a high histological degree of positivity in sarcoidosis in stages I and I + II (86%) and in malignant lymphomas (91%). As a result, the authors believe that when faced with a process of localization prevailing in the hilar-mediastinal lymphatic system, the SNB is a preferable treatment and should be performed before a mediastinoscopy.

Scalene Node Biopsy in Advanced Carcinoma of the Cervix Uteri

To determine the incidence of scalene node metastasis from carcinoma of the cervix uteri, all patients with advanced carcinoma of the cervix who underwent scalene node biopsy as part of a pretreatment evaluation at the University of Iowa Hospitals and Clinics have been reviewed. In 40 patients, left scalene node biopsy was indicated because of (1) metastatic para-aortic nodes (25); (2) palpable scalene nodes (2); and (3) other evidence of metastasis or unresectability. Of the 25 patients with metastasis to para-aortic nodes, seven (28%) had metastasis to the scalene node. None of these was palpable preoperatively. Because scalene node involvement indicates that the disease is beyond the scope of both surgical and radiation treatment, routine scalene node biopsy is recommended in those patients with para-aortic node metastasis.

Scalene node biopsy in advanced carcinoma of the cervix uteri.

To determine the incidence of scalene node metastasis from carcinoma of the cervix uteri, all patients with advanced carcinoma of the cervix who underwent scalene node biopsy as part of a pretreatment evaluation at the University of Iowa Hospitals and Clinics have been reviewed. In 40 patients, left scalene node biopsy was indicated because of (1) metastatic para-aortic nodes (25); (2) palpable scalene nodes (2); and (3) other evidence of metastasis or unresectability. Of the 25 patients with metastasis to para-aortic nodes, seven (28%) had metastasis to the scalene node. None of these was palpable preoperatively. Because scalene node involvement indicates that the disease is beyond the scope of both surgical and radiation treatment, routine scalene node biopsy is recommended in those patients with para-aortic node metastasis.

Scalene node biopsy in primary and recurrent invasive carcinoma of the cervix

Since June 1971, it has been the policy of the Walter Reed Army Medical Center's Gynecologic Oncology Service to biopsy the left scalene fat pad in two groups of patients presenting with carcinoma of the cervix: (1) primary cases with biopsy-proven metastatic involvement to high common iliac or paraaortic lymph nodes, and (2) all recurrent cases being considered for pelvic exenteration. From June 1971 through June 1979, 43 patients met these criteria for left scalene biopsy. Ten patients had primary disease and 33 had recurrent pelvic carcinoma. Three of ten patients, or 30%, with primary cervical carcinoma had positive left scalene biopsies. All 10 patients had clinically negative supraclavicular examinations. The 3 patients with positive scalene biopsy also had positive paraaortic lymph nodes. However, 4 patients with negative scalene biopsies also had positive aortic lymph nodes. Fourteen of the thirty-three patients with recurrent pelvic carcinoma had positive left scalene node biopsies. Eight of these fourteen were clinically positive, but the other 6 were clinically negative. Therefore, 6 of 25 patients, or 24%, with recurrent cervical carcinoma and clinically negative supraclavicular areas, had metastatic tumor present in the left scalene lymph nodes. In order that patients with widespread carcinoma of the cervix do not receive inappropriate treatment, we recommend scalene node biopsies for the following groups of patients: (1) all primary diagnosed patients with biopsy-proven positive paraaortic lymph nodes; (2) all patients with recurrent carcinoma who are being considered for a pelvic exenteration; and (3) all patients with primary or recurrent disease who have palpable supraclavicular masses.

Scalene Node Biopsy in Pulmonary Carcinoma: When Is It Indicated?

While there is universal agreement that palpable scalene lymph nodes should be biopsied in the preoperative evaluation of patients with carcinoma of the lung, the role of biopsy of nonpalpable scalene nodes remains unclear. This report evaluates the results of biopsy of nonpalpable scalene lymph nodes in 101 consecutive patients with bronchogenic carcinoma otherwise deemed candidates for pulmonary resection. The overall incidence of biopsy positive for metastatic disease was 8.9%. No patient with a peripheral primary lesion, regardless of size or cell type, had metastasis to scalene nodes. Six of 15 patients with centrally located adenocarcinomas showed scalene node metastasis, while only 1 of 40 patients with central squamous cell carcinomas had a positive scalene biopsy. Bilateral biopsy was no more likely to yield positive information than ipsilateral biopsy alone. We now recommend preoperative biopsy of nonpalpable scalene nodes only in patients with central lesions in whom the cell type is adenocarcinoma or unknown.

Muscle Involvement in Sarcoidosis

In 22 patients with sarcoidosis, symptoms and signs of muscle involvement were scanty, but muscle biopsy showed epithelioid cell granulomas consistent with sarcoidosis in 11 patients (50%). Serial sectioning of the muscle biopsies increased the diagnostic yield. The incidence of muscle involvement was highest among patients with both acute sarcoidosis and erythema nodosum. Involvement of other organs was common in patients with muscle sarcoidosis. In two patients with negative scalene node biopsy and negative bronchial and transbronchial biopsies, muscle biopsy showed histological evidence of sarcoidosis. Muscle involvement is common in patients with sarcoidosis, but in many cases there are few or no symptoms. In patients with both acute sarcoidosis and erythema nodosum, muscle biopsy frequently provides histological evidence of the disease. Good cooperation with the pathologist and serial sectioning of the biopsies are necessary if muscle biopsy is to be used as a routine in the diagnosis of sarcoidosis.

Scalene Node Biopsy in Sarcoidosis

Scalene node biopsy was performed by a trained surgeon in 39 patients with established sarcoidosis. The diagnostic yield in this group was compared wtih the results in 43 patients with established sarcoidosis who had been subjected to routine scalene node biopsies at the same clinic. Sarcoid tissue was found in 82% of the patients operated on by the trained surgeon compared with 47% in the other group. It is concluded that, in the hand of a trained surgeon with a good operating technique. scalene node biopsy is a good alternative for obtaining tissue from sarcoidosis patients for histopathological examination.

Supraclavicular Node Biopsy in Staging Testis Tumors

Supraclavicular node biopsy has been advocated previously as a routine staging procedure for patients with testicular tumors. Of 73 patients with testis tumors the scalene node biopsy revealed metastasis in only 3 of 61 patients with non-seminomatous tumors and in 1 of 12 patients with seminoma. Furthermore, all 4 patients were known to have other metastases; in 3 of the 4 patients a palpable supraclavicular mass was noted as well. The low yield of this procedure, in conjunction with a complication rate of 8 per cent, mitigates against the routine use of supraclavicular node biopsy in patients without a palpable supraclavicular mass.

Esophageal Compression in Association with Silicosis and Mycobacterium Intracellulare

An enameler with dysphagia was found to have extrinsic compression of the esophagus by enlarged mediastinal lymph nodes. Scalene lymph node biopsy revealed silicosis, and tissue cultures grew Mycobacterium intracellulare. We believe our patient is the first reported to have dysphagia due to silicotic adenopathy complicated by an atypical mycobacteriosis.

Thoracoscopy: A Useful Tool in the Diagnosis of Thoracic Disease

During a 12-month period, 11 patients underwent diagnostic thoracoscopy for previously undiagnosed thoracic disease. In all patients, the diagnosis had been unobtainable by the usual diagnostic modalities of bronchoscopy, scalene node biopsy, mediastinoscopy, thoracentesis, or closed pleural biopsy. Thoracoscopy was diagnostic in 10 of the 11 patients. There was no morbidity or mortality. In all patients the indication for thoracoscopy was suspected malignancy. The majority of patients had recurrent pleural effusions in which routine cytological studies and tissue biopsies had been nondiagnostic. Pathological findings were mesothelioma in 3 patients, primary carcinoma of the lung in 4, congestive heart failure with pleural effusion in 1, metastatic carcinoma in 2, and inflammatory disease in 1 patient. Indications, techniques, and results are discussed. Thoracoscopy is a valuable tool in the diagnosis of thoracic disease; with it, unnecessary thoracotomy can often be avoided.

Bronchoscopy in the community hospital.

A new Pulmonary Medicine-Thoracic Surgery service was established in a community hospital in July 1974. This report details the experience of 409 bronchoscopies performed from July 1, 1974 through Dec 31, 1976. There were no deaths and four complications--one aspiration and three pneumothoraces resulting from transbronchial lung biopsy. Final diagnoses for which bronchoscopy was done were as follows: cancer--141; infectious disease--97; interstitial disease--33; obstructive lung disease--58; hemoptysis--35; miscellaneous--45. In the cancer group, a cytohistologic diagnosis was made in 82 patients by bronchoscopy alone, 31 additional diagnoses were made by scalene node biopsy or mediastinoscopy, and the remainder by surgical exploration and/or resection. In 268 patients with benign disease, bronchoscopy established the diagnosis in 87% of the cases. Pulmonary Medicine tended not to repeat nondiagnostic bronchoscopy but rather to refer immediately for a definitive surgical procedure. Thoracic Surgery tended not to reduplicate bronchoscopy for the purpose of "confirmation." A conjoint medical-surgical approach to bronchial disease, at the community level and based on a mutual understanding of capability and limitation, is feasible, productive, and economical.

Diagnostic scalene node biopsy in the preoperative evaluation of the surgical cancer patient: Five-year experience with 108 cases and literature review.

Records were reviewed of 108 consecutive patients with a variety of surgically approachable malignancies undergoing scalene node biopsy as part of a preoperative staging evaluation. Metastases to the scalene nodes were detected in 12 patients (11.1%). In six patients the scalene nodes were clinically suspicious before biopsy, but in six with nonpalpable nodes the scalene metastases were occult clinically. Four of the patients with clinically benign, but pathologically positive, scalene biopsies were found among the group of 62 patients with epidermoid carcinoma of the cervix. It was concluded that routine scalene biopsies are justified in the properative evaluation of cancer patients only if the nodes are clinically suspicious, except for in patients with advanced pelvic cancers, in whom the incidence of completely occult scalene metastases is 6% or more.

Lipoid Granulomata in Scalene Node

Excerpt To the editor: Varkey and Kutty (1) suggest that the finding of mineral oil in a scalene node biopsy may aid in the diagnosis of lipoid pneumonia. Although aspirated mineral oil may well re...

Detection of Covert Myocardial Sarcoidosis by Scalene Node Biopsy

The antemortem diagnosis of myocardial sarcoidosis is rare in patients without overt signs of the disease. Two patients are presented to alert physicians to the value of early scalene node biopsy when sarcoidosis could be the cause of marked disturbances in cardiac conduction. The first patient, aged 29 years, had first, second, and third degree atrioventricular block and intermittent left and right bundle-branch block; the second, aged 59 years, had second degree atrioventricular block and complete right bundle-branch block. Both had diagnoses of sarcoidosis based on scalene node biopsy. The cardiac conductive disturbance improved, and the symptoms disappeared with steroid therapy.

Scalene node biopsy in the pretreatment staging of carcinoma of the cervix uteri

This study reports the experience at the Ellis Fischel State Cancer Hospital with the use of scalene node biopsy for the pretreatment evaluation of patients with carcinoma of the cervix uteri. The study was stimulated by a report from the National Cancer Institutes which stated that impalpable scalene nodes contained metastatic cancer in 13 per cent of a series of 84 cases. By a meticulous biopsy technique, we were unable to confirm this high incidence. In a series of 73 cases, no impalpable lymph nodes were found to contain metastatic cancer regardless of the clinical stage of the cancer. Consequently, we have terminated the use of scalene lymph node biopsies in the staging of cervical cancer for primary treatment. The study is still in progress to evaluate patients with recurrent cervical cancer who may possibly require pelvic exenteration. Also, the procedure will be continued in patients referred for further treatment in whom carcinoma was first diagnosed as an unsuspected finding in a hysterectomy specimen.

Mediastinoscopy and bronchial carcinoma: experience with 600 mediastinoscopies.

Of 600 mediastinoscopies carried out from 1966 to 1973, 479 were performed to assess the operability of a pulmonary carcinoma. Of these, 206 (43%) were positive and 273 (57%) were negative. Of the 161 patients found positive during an initial period, 147 were refused operation; the remaining 14 were considered suitable candidates for operation, either because only one homolateral lymph node site was involved or because there was a concomitant osteoarthropathy. The tumour was irresectable in one of these 14 patients who died after 3-5 months; curative resection was possible in one and palliative resection in 12 patients. These 12 patients all died within a year. Of the 184 patients found negative during an initial period, 149 were treated by operation. The tumour proved irresectable in seven (5%), while curative resection was possible in 113 (76%) and palliative resection in 29 (19%) patients. Comparison with the period 1957-63, when in the same hospital resection was performed after a negative Daniels' (scalene node) biopsy, shows that the tumour was irresectable in 25 (20%) of the 124 patients with a negative biopsy, while curative resection was possible in 43 (35%) and palliative resection in 56 (45%) patients. During a second period, patients with a positive mediastinoscopy were in principle refused operation. Of 89 negative patients, 81 were treated by operation. No tumour was found to be irresectable; curative resection was possible in 63 (78%) and palliative resection in 18 (22%) patients. An operation for bronchial carcinoma was performed on 167 patients between September 1970 and September 1973 after a negative mediastinoscopy in 95, and without mediastinoscopy in 71 patients, either because of a peripheral tumour (70) or because of a tumour relapse after two years (1). The resection was palliative in 11% of the 71 cases, but in only one patient with a peripheral tumour could a mediastinoscopy have been positive. Finally, an operation was performed on one patient with a positive mediastinoscopy and a tumour relapse after six years. A survival study was made of the first 100 patients with pulmonary carcinoma, operated on between September 1970 and March 1972 and with a follow-up from a minumum of two years to a maximum of 3-5 years. The early mortality averaged 10% and was higher after pneumonectomy than after lobectomy. The late mortality was 16% after curative lobectomy, 38% after curative pneumonectomy, and 83% after palliative pneumonectomy. The survival after 2 to 3-5 years was 63%.