Solitary Pulmonary Lesions Research Articles

Simultaneous thoracoscopic resection for coexisting pulmonary and thymic lesions.

The management of synchronous thymic and pulmonary lesions remains a challenge due to the lack of case series and surgical guidelines. This study aims to retrospectively review our preliminary experience and results of performing simultaneous thoracoscopic resection of coexisting diseases of the lung and thymus. Simultaneous thoracoscopic resection was performed to remove coexisting thymic and pulmonary lesions in nine patients from August 2008 to November 2013. Patient demographics, preoperative assessment, surgical procedures and postoperative course of these patients were reviewed. There were four female and five male patients between 43 and 70 years old (median age, 64 years). Each patient had thymic neoplasm and solitary pulmonary lesion on chest computed tomography (CT) scan. Four patients underwent thoracoscopic lobectomy and thymectomy. One patient had thoracoscopic bronchovascular sleeve lobectomy combined with thymic cyst resection (TCR). The other four patients received pulmonary wedge resection and thymectomy (n=3)/TCR (n=1). The operation lasted from 35-480 min (median, 110 min). Intra-operative blood loss was 20-380 mL (median, 120 mL). Two patients developed post-operative pneumonia without mortality. All the patients were discharged home within 9 days after surgery. Two patients died from metastatic lung cancer 14 months after surgery. Simultaneous thoracoscopic resection of coexisting pulmonary and thymic lesions is safe and feasible in selected patients.

The applications of corrected standardized uptake values in the diagnosis of peripheral lung lesions.

Fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging has been widely used to diagnose many types of tumors. However, many factors can affect the accuracy of standardized uptake values (SUVs). In this study, we aimed to explore the applications of corrected SUVs in the diagnosis of peripheral solitary pulmonary lesions.A retrospective study was undertaken in 69 patients with peripheral solitary pulmonary lesions. Whole-body PET/CT was acquired approximately 60 min after 18F-FDG injection. The lesions were found to be malignant in 57 cases and benign in 12 cases. Of the 69 cases, 68 were correctly diagnosed, and only 1 was misdiagnosed by the corrected SUVs. The diagnostic accuracy rate was 98.5%. The sensitivity, specificity, positive predictive value, and negative predictive value of the corrected SUV were 100%, 91.7%, 98.3%, and 100%, respectively.18F-FDG PET/CT with corrected SUVs is of great value for improving diagnostic accuracy in peripheral lung lesions.

Spontaneous pneumothorax after intensive chemotherapy in endometrial cancer: A rare complication

ObjectiveEndometrial cancer with hematogenous metastases can be treated with chemotherapy. We present a case of spontaneous pneumothorax that occurred when a solitary pulmonary endometrial metastatic lesion was treated with paclitaxel plus carboplatin. Case reportA 38-year-old female had stage II endometrial endometrioid adenocarcinoma. Solitary bilateral pulmonary metastases developed after primary treatment. Complete remission accompanied by a right spontaneous pneumothorax occurred during chemotherapy with paclitaxel plus carboplatin. ConclusionRapid shrinkage of a pulmonary space-occupying tumor sometimes causes rare but life-threatening spontaneous pneumothoraces. We report the first case of a spontaneous pneumothorax after using paclitaxel plus carboplatin in the treatment of endometrial cancer.

Accuracy of FDG PET/CT in the evaluation of solitary pulmonary lesions - own experience.

In recent years, positron emission tomography (PET) has been increasingly applied in the diagnosis of neoplastic lung diseases. In contrast to conventional imaging studies, PET-CT enables the visualisation of not only the morphology of the suspicious lesion, but also its metabolism. The aim of the present study was to investigate the role of PET-CT in the initial assessment of patients with indeterminate solitary pulmonary lesions. The study was conducted on a group of 82 patients with indeterminate lung nodule diagnosed at the National Institute of Tuberculosis and Lung Diseases in the period from January 2008 to May 2011. CT and PET-CT were performed in all of the patients. Histological or cytological examination of the biopsy specimens obtained from bronchoscopy, mediastinoscopy and intraoperatively were the reference tests. Malignancy was documented in 40 patients (48.8%). Histopathological analysis of all tumours revealed 12 cases of squamous cell carcinoma, 18 cases of adenocarcinoma and 1 case of carcinoid, whereas in 9 patients the diagnosis of "non-small cell cancer not otherwise specified" was made. All lesions except one were of solid character on chest CT. SUV(max) values exceeding 2.5 were found in 38 cancer patients (true positives, TP). The mean value of SUV(max) was 9.1 (1-26.8). Forty-two lesions were documented as benign (51.2%). SUV(max) values equal to or less than 2.5 were found in 37 patients (true negatives, TN). The mean value of SUV(max) in this group was 1.9 (0.5-8.6). The diagnostic value of PET-CT SUV(max) exceeding 2.5 in the prediction of neoplastic origin of solitary pulmonary lesions was: sensitivity - 95% (95% CI 84-99%), specificity - 88% (95% CI 75-95%) and accuracy - 91.5% (95% CI 83-96%). Positive predictive value (PPV) was 88.4% (95% CI 76-95%), and negative predictive value (NPV) was 94.8% (95% CI 83-99%). False negative results concerned two patients, with final diagnosis of carcinoid and adenocarcinoma; false positive results were obtained in 5 patients with various inflammatory lesions. In the present study, PET-CT appeared to have high sensitivity (95%), but lower specificity (88%) for predicting the malignant character of solitary pulmonary lesions. Overall diagnostic value of PET-CT SUV(max) > 2.5 was high - PPV was 88.4%, NPV was 94.8%. In the authors' opinion, the PET-CT value may increase when clinical data as well as other radiological documentation (with retrospective assessment) are taken into consideration.

The role of FDG-PET/CT in detecting unsuspected and unknown distant metastasis in the initial staging of NSCLC.

Our purpose in this retrospective study was to determine the ratio of unexpected [metastases within the coverage area of thorax computed tomography (CT)] and unknown (metastases out of the coverage area of thorax CT) metastases by positron emission tomography/CT (PET/CT) in patients with newly diagnosed non-small cell lung cancer (NSCLC) who had no defined metastatic lesion, and to investigate the contribution of fludeoxyglucose (FDG)-PET/CT in metastasis staging. A total of 567 patients (489 males and 78 females, mean age 60.9 ± 10.7 years) were enrolled in this study. Among the 567 patients, a total of 156 patients who underwent PET/CT for metabolic characterization (group 1) and had solitary pulmonary nodules (group la, n = 39) or solitary pulmonary masses (group lb, n = 117) and the remaining 411 patients (group 2) with NSCLC who had PET/CT performed for staging formed the basis of this study In group 1, 5/39 (12.8%) patients with a solitary pulmonary nodule and 29/117 (24.8%) patients with a solitary pulmonary mass had distant metastases. In group 2, 129 patients of 411 (31.4%) had distant metastasis. FDG-PET/CT is proven to be an effective method in detection of unsuspected-unknown metastasis, either in patients with solitary pulmonary lesion or in the initial staging of patients with NSCLC.

Characterisation of solitary pulmonary lesions combining visual perfusion and quantitative diffusion MR imaging

To evaluate the diagnostic accuracy of dynamic contrast-enhanced (DCE) magnetic resonance (MR) and diffusion-weighted imaging (DWI) sequences for defining benignity or malignancy of solitary pulmonary lesions (SPL). First, 54 consecutive patients with SPL, clinically staged (CT and PET or integrated PET-CT) as N0M0, were included in this prospective study. An additional 3-Tesla MR examination including DCE and DWI was performed 1 day before the surgical procedure. Histopathology of the surgical specimen served as the standard of reference. Subsequently, this functional method of SPL characterisation was validated with a second cohort of 54 patients. In the feasibility group, 11 benign and 43 malignant SPL were included. Using the combination of conventional MR sequences with visual interpretation of DCE-MR curves resulted in a sensitivity, specificity and accuracy of 100%, 55% and 91%, respectively. These results can be improved by DWI (with a cut-off value of 1.52 × 10(-3) mm(2)/s for ADChigh) leading to a sensitivity, specificity and accuracy of 98%, 82% and 94%, respectively. In the validation group these results were confirmed. Visual DCE-MR-based curve interpretation can be used for initial differentiation of benign from malignant SPL, while additional quantitative DWI-based interpretation can further improve the specificity. • Magnetic resonance imaging is increasingly being used to help differentiate lung lesions. • Solitary pulmonary lesions (SPL) are accurately characterised by combining DCE-MRI and DWI. • Visual DCE-MRI assessment facilitates the diagnostic throughput in patients with SPL. • DWI provides additional information in inconclusive DCE-MRI (type B pattern).

Bronchioloalveolar carcinoma as a second malignancy in a pediatric osteosarcoma survivor: case report

BackgroundPrimary lung cancer is extremely rare in children, while secondary malignancies reportedly develop in 2% to 3% of pediatric osteosarcoma survivors.Case presentationA 14-year-old girl was found to have two pulmonary lesions on computed tomography. These tumors had developed 1 year after osteosarcoma surgery. Segmentectomy of right segment 1 and wedge resection of right segment 9 were performed. Both lesions were completely resected and postoperative histopathological examination revealed metastasis of osteosarcoma and bronchioloalveolar carcinoma, respectively.ConclusionBronchioloalveolar carcinoma may present as a solitary pulmonary lesion indistinguishable from a metastatic lesion and should be included in the differential diagnosis of pulmonary lesions in survivors of pediatric cancer. Thus, pulmonary lesions identified in these patients should be biopsied or resected to establish a histological diagnosis.

FDG PET/CT evaluation of pathologically proven pulmonary lesions in an area of high endemic granulomatous disease

PurposeThe goal of this study is to assess how reliable the threshold maximum standardized uptake value (maxSUV) of 2.5 on positron emission tomography–computed tomography (PET/CT) is for evaluation of solitary pulmonary lesions in an area of endemic granulomatous disease and to consider other imaging findings that may increase the accuracy of PET/CT.Materials and methodsThe staging PET/CT of 72 subjects with solitary pulmonary lesions (nodules (less than 3 cm) or masses (greater than 3 cm)) were retrospectively reviewed. Pathology proven diagnosis from tissue samples was used as the gold standard. Logistic regression was used to assess whether the subject’s age, maxSUV, size of lesion, presence of emphysema, or evidence of granulomatous disease was predictive of malignancy.ResultsMalignant lesions were identified in 84.7 % (61/72) of the 72 subjects. A threshold maxSUV of 2.5 had a sensitivity of 95.1 % (58/61), specificity of 45.5 % (5/11), positive predictive value of 90.6 % (58/64), negative predictive value of 62.5 % (5/8) and an accuracy of 87.5 % (63/72). The false negative rate was 4.9 %, and the false positive rate was 54.5 %. All 3 false negatives were less than or equal to 1.0 cm; however, false positives ranged from 1.1 to 5.6 cm. The false negatives had a mean (SD) maxSUV of 2.0 (0.4), whereas the false positives had a mean (SD) maxSUV of 5.6 (3.0). Emphysema was associated with 1.1 higher odds of malignancy, and evidence of granulomatous disease was associated with 0.34 lower odds of benign disease, however, neither was statistically significant (p = 0.92 and p = 0.31, respectively). Higher maxSUV was significantly associated with increased risk of malignancy (p = 8.3 × 10−3). Older age and larger size of lesion were borderline associated with increased risk of malignancy (p = 0.05 and p = 0.07, respectively).ConclusionIn an area of high endemic granulomatous disease, the PET/CT threshold maxSUV of 2.5 retains a high sensitivity (95.1 %) and positive predictive value (90.6 %) for differentiating benign from malignant pulmonary lesions; however, the specificity (45.5) and negative predictive value (62.5) decrease due to increased false positives. The presence of emphysema and absence of evidence of granulomatous disease increases the probability that a pulmonary lesion is malignant; however, these were not statistically significant.

Growing Peripheral Pulmonary Lipoma: A Case Report

Intrathoracic lipomas can be divided into five categories, depending on their location: endobronchial lipomas, pulmonary parenchymal lipomas, pleural lipomas, mediastinal lipomas, and cardiac lipomas (1). Among them, endobronchial lipomas are relatively common, while pulmonary parenchymal lipomas are extremely rare (2). In a differential diagnosis of solitary pulmonary lesions, pulmonary parenchymal lipomas should be considered, despite their rarity.

Atypical presentation of invasive pulmonary aspergillosis in a liver transplant recipient

Invasive pulmonary aspergillosis (IPA) occurs in 1% to 8% of liver transplant recipients. It is one of the most frequent life-threatening fungal infections in immunocompromised patients, with a reported mortality rate of approximately 60%. We present the case of an 18-year-old man who underwent liver transplantation (LT) in January 2004 due to multifocal hepatoblastoma (HBL) and was diagnosed with IPA 3 years after LT. Because of a single pulmonary nodule of the left lung found in chest computed tomography (CT) 4 weeks after LT, the patient received adjuvant chemotherapy. A control chest CT performed in September 2004 did not reveal any pathological changes. A subsequent examination in May 2006 demonstrated a pulmonary lesion situated in the 10th segment of the left lung, which was confirmed by PET in October 2006. In March 2007 the patient underwent videothoracoscopic complete resection of the lesion. Histopathological examination revealed IPA and subsequent 3-month antifungal treatment with voriconazole resulted in 5 years of recurrence-free survival. We conclude that any stable solitary pulmonary lesion in a transplant recipient needs to be resected in order to allow a definitive diagnosis and prevent disease dissemination such as IPA in our patient.

Pulmonary metastasectomy for gastric cancer: a 13-year single-institution experience

Pulmonary metastases from gastric cancer are rare, and the role of surgery is unclear. The purpose of this study was to determine which patients with metachronous metastatic gastric cancer (MGC) might benefit from pulmonary resection. Between 1998 and 2011, 12 patients underwent 14 pulmonary resections for MGC. We reviewed their clinical courses and evaluated their radiological findings. Solitary pulmonary lesions were identified for 11 metastases, and the remaining three showed multiple pulmonary lesions. Six patients received treatment for the metastases before pulmonary resection. Lobectomy was performed for five lesions and wedge resection was performed for the remaining nine lesions. At the median follow-up time of 23.0 months, four patients were alive without disease, and the median DFS following pulmonary resection was 6.6 months. The overall 5-year survival rate following pulmonary resection was 58.4 %. In a univariate analysis, the number of lesions and the tumor doubling time (TDT) were significant predictors of the DFS, although prior treatment was not a significant predictor of the DFS. Pulmonary resection for MGC might be an effective therapeutic option when there is a solitary metastatic lesion that has a long TDT, even if the patient has been previously treated for metastases.

Simultaneous Computed Tomography-Guided Biopsy and Radiofrequency Ablation of Solitary Pulmonary Malignancy in High-Risk Patients

Background: In recent years experience has been accumulated in percutaneous radiofrequency ablation (RFA) of lung malignancies in nonsurgical patients. Objectives: In this study, we retrospectively evaluated a simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions. Methods: CT-guided transthoracic core needle biopsy of solitary pulmonary lesions suspicious for malignancy was performed and histology was proven based on immediate frozen sections. RFA probes were placed into the pulmonary tumors under CT guidance and the ablation was performed subsequently. The procedure-related morbidity was analyzed. Follow-up included a CT scan and pulmonary function parameters. Results: A total of 33 CT-guided biopsies and subsequent RFA within a single procedure were performed. Morbidity of CT-guided biopsy included pulmonary hemorrhage (24%) and a mild pneumothorax (12%) without need for further interventions. The RFA procedure was not aggravated by the previous biopsy. The rate of pneumothorax requiring chest tube following RFA was 21%. Local tumor control was achieved in 77% with a median follow-up of 12 months. The morbidity of the CT-guided biopsy had no statistical impact on the local recurrence rate. Conclusions: The simultaneous diagnostic and therapeutic approach including CT-guided biopsy followed immediately by RFA of solitary malignant pulmonary lesions is a safe procedure. The potential of this combined approach is to avoid unnecessary therapies and to perform adequate therapies based on histology. Taking the local control rate into account, this approach should only be performed in those patients who are unable to undergo or who refuse surgery.

Systemic dissemination of chronic necrotizing pulmonary aspergillosis in an elderly woman without comorbidity: a case report

IntroductionChronic necrotizing pulmonary aspergillosis usually occurs in mildly immune-compromised hosts or those with underlying pulmonary disease. The radiographic pattern of chronic necrotizing pulmonary aspergillosis is typically a progressive upper lobe cavitary infiltrate with pleural thickening. We report here an atypical case of chronic necrotizing pulmonary aspergillosis mimicking lung cancer, which developed into a disseminated fatal disease in an older woman with no comorbidity.Case presentationAn 80-year-old Japanese woman was referred to our hospital for a chest roentgenogram abnormality. Repeated fiber-optic bronchoscopy could not confirm any definite diagnosis, and she refused further examinations. Considering the roentgenogram findings and her age, she was followed-up as a suspected case of lung cancer without any treatment. Then, 10 months later, she complained of visual disturbance and was admitted to our department of ophthalmology. She was diagnosed as having endophthalmitis. After treatment with corticosteroids for 20 days, she developed acute encephalitis and died four weeks later. Autopsy revealed dissemination of Aspergillus hyphae throughout her body, including her brain.ConclusionsIn older patients, even if they do not have any comorbidity, chronic necrotizing pulmonary aspergillosis should be added to the differential diagnosis of solitary pulmonary lesions in a chest roentgenogram.

Only Surgical Resection Can Identify the Second Primary Lung Cancer out of the Metastasis after Gastric Cancer Surgery

Solitary pulmonary lesions (SPLs) in patients with a history of malignancy require not only the distinction between benign and malignant, but also that between metastatic and primary lesions. We aim to establish the clinical strategy for the treatment of a solitary pulmonary lesion that is detected during the postoperative surveillance for gastric cancer. We retrospectively examined the clinical records of the patients who underwent curative resection for gastric cancer between January 1999 and December 2009. Patients who were diagnosed with solitary pulmonary lesion during the postoperative surveillance underwent pulmonary resection, and were reviewed with regard to their histological diagnosis and prognosis. Out of a total of 1017 patients who underwent gastric resections during this period, 13 patients with solitary pulmonary lesion underwent pulmonary resection. These tumors were shown to be eight primary lung cancers, four metastatic tumors (three from gastric cancer) and one benign nodule. Of the eight patients with primary lung cancer, seven remained alive after pulmonary resection, including one liver metastasis case, and the other died without recurrence. In contrast, the other three patients with metastasis from gastric cancer died with distant metastasis, despite undergoing curative pulmonary resection. One of these three metastatic patients was misdiagnosed as primary lung cancer by transbronchial biopsy before surgery. Solitary pulmonary lesions detected during postoperative gastric cancer surveillance should undergo surgical resection to distinguish between primary and metastatic disease because of the quite different prognosis of these two entities.

Diagnostic value of 18F-FDG PET/CT in solitary pulmonary lesions and analysis on the causes of misdiagnosis

Objective To evaluate the diagnostic value of 18F-FDG PET/CT in solitary pulmonary lesions and to analyze the causes of misdiagnosis.Methods Thirty-two patients with solitary pulmonary lesions detected by 18F-FDG PET/CT were enrolled into this study and reviewed retrospectively.All the lesions were confirmed by histopathology.The possible causes for wrong-interpretation based on 18F-FDG PET/CT findings were investigated.Statistical analysis was performed using SPSS 16.0.The correlations between the SUVmax of early phase ( SUVmax,early) or the percentage change in SUVmax between early and delayed phases( ASUVmax ) and the lesion size were tested by Pearson analysis,respectively.Results 18F-FDG PET/CT had a detection accuracy of 68.75％ (22/32) for solitary pulmonary lesions.Among 32 cases,there were 5 false negatives and 5 false positives based on 18F-FDG PET/CT.The SUVmax,early was less than 2.5 in 6 of 22 malignant pulmonary lesions.The SUVmax,early in 2 of 10 benign pulmonary lesions was ≥2.5.The △SUVmax was less than 15％ in 5 of 22 malignant pulmonary lesions.As for the 10 benign pulmonary lesions,△SUVmax was ≥15％ in 4 cases.The average size (largest dimension) of 32 pulmonary lesions was ( 1.98 ± 1.08) cm,with 26 lesions smaller than or equal to 3 cm and 6 lesions larger than 3 cm.The SUVmax was positively correlated with the lesion size ( r =0.690,P ＜ 0.01 ),but there was no correlation between △SUVmax and the lesion size (r =- 0.081,P ＞ 0.05).Conclusions 18F-FDG PET/CT plays an important role in the diagnosis of solitary pulmonary lesion.However,SUVmax alone has its limitations; it is best to combine measurements with CT and other diagnostic parameters. Key words: Lung neoplasms; Lung diseases ; Tomography,emission-computed ; Tomography,X-ray computed; Deoxyglucose

Giant Cell Tumor Pulmonary Metastases Mimic Primary Malignant Pulmonary Nodules on 18F-FDG PET/CT

A 59-year-old man with a 30-year history of multiple recurrences of a giant cell tumor (GCT) of the left knee was referred for an (18)F-FDG PET/CT to evaluate a solitary pulmonary nodule. The nodule was mildly FDG-avid, raising suspicion of malignancy. It was excised and histologically proven to be a GCT pulmonary metastasis. A follow-up PET/CT done 2years later revealed a new, larger lung mass that was more intensely FDG-avid, but of the same histology. This rare report highlights a pitfall in the evaluation of solitary pulmonary lesions by (18)F-FDG PET/CT in patients with GCT of the bone.

Deaths and complications associated with respiratory endoscopy: A survey by the Japan Society for Respiratory Endoscopy in 2010

In order to survey the current status of the use and complications associated with respiratory endoscopy, the Japan Society for Respiratory Endoscopy conducted a nationwide postal questionnaire survey. The survey was mailed to all 538 facilities certified by the society. The subjects were patients who underwent respiratory endoscopy in 2010. The numbers of procedures, and associated complications and deaths were investigated according to lesion and procedure using a specific inventory. The inventory was completed by 483 facilities (89.8%). The total number of diagnostic flexible bronchoscopy procedures performed was 103 978, and four patients died (0.004%). The complication rate according to lesion ranged from 0.51% to 2.06%, with the highest rate being observed in patients with diffuse lesions. The complication rate according to procedure ranged from 0.17% to 1.93%, with the highest rate being observed in patients who underwent forceps biopsy. The complication rate after forceps biopsy of solitary peripheral pulmonary lesions was 1.79% (haemorrhage: 0.73%, pneumothorax: 0.63%), and that after endobronchial ultrasound-guided transbronchial needle aspiration of hilar and/or mediastinal lymph node lesions was 0.46%. Therapeutic bronchoscopy was performed in 3020 patients; one patient (0.03%) died due to haemorrhage induced by insertion of an expandable metallic stent. The complication rate according to procedure was highest for foreign body removal (2.2%). Medical pleuroscopy was performed in 1563 patients. The highest complication rate was for biopsy without electrocautery (1.86%). A total of 228 facilities (47.2%) experienced breakage of bronchoscopes and/or devices. Respiratory endoscopy was performed safely, but education regarding complications caused by new techniques is necessary.

Electromagnetic navigation bronchoscopy (ENB): Increasing diagnostic yield

To determine factors associated with diagnostic yield of ENB. In 112 consecutive patients referred to our department between March 2010 and December 2010 the diagnostic work-up for solitary pulmonary lesions included a FDG-PET-CT scan, and ENB in combination with ROSE. The final diagnosis was confirmed by histopathological evaluation of specimen obtained either by ENB, or - if ENB was not diagnostic - by CT-guided fine needle aspiration or surgery. Thirty-seven (33%) subjects were female, mean age was 66.7 (±1.04) years. The mean diameter of lesions was 27mm (range: 6-46mm). In 83.9% the combination of PET-CT, ENB, and ROSE established a correct diagnosis, as defined by the definite histopathological result. 15.2% (17/112) of lesions were benign, and 84.8% (95/112) were malignant. For 112 procedures we observed a steep learning curve with a diagnostic yield of 80% and 87.5% for the first 30 and last 30 procedures, respectively. The diagnostic yield in lesions ≤20mm and >20mm in diameter was 75.6% and 89.6% (p=0.06), respectively. No significant difference in diagnostic yield was seen depending on lung function, and the localization of the lesions. Two cases (1.8%) of pneumothorax were seen during and up to 24h after bronchoscopy, none of them required a chest tube. Diagnostic yield increased with experience but was independent from the size of the lesion, the localisation in the lungs, and lung function. The diagnostic yield of ENB can be as high as for CT-guided transthoracic biopsies but carries a significantly lower complication rate.

Pulmonary lymphatic drainage to the mediastinum based on computed tomographic observations of the primary complex of pulmonary histoplasmosis

In the primary infection of pulmonary histoplasmosis, pulmonary lesions are commonly solitary and associated with hilar and/or mediastinal nodal diseases, which spontaneously resolve, resulting in calcifications in individuals with normal cellular immunity. To assess the lymphatic drainage to the mediastinum from each pulmonary segment and lobe using computed tomographic (CT) observations of a calcified primary complex pulmonary histoplasmosis and predict which patients with N2 disease that would benefit from surgery. We collected 585 CT studies of patients with primary complex histoplasmosis consisting of solitary calcified pulmonary lesions and calcified hilar and/or mediastinal nodal disease. Using the N stage criteria of non-small cell lung cancer, we assessed the distribution of the involved hilar and mediastinal nodes depending on the pulmonary segment of the lesion, with a focus on skip involvement. We also assessed the correlation between the incidence of N1 and skip N2 involvement and the mean number of involved mediastinal nodal stations in the non-skip N2 and skip N2 groups. Skip involvement was common in the apical segment (9/45, 20.0%), posterior segment (7/31, 22.6%), and mediolbasal segment (13/20, 65.0%) in the right lung, and in the apicoposterior segment (7/55, 12.7%), lateral basal segment (6/26, 23.1%), and posterobasal segment (16/47, 34.0%) in the left lung. The incidence of skip involvement in each segment showed a significant inverse correlation with that of N1 involvement (r = -0.51, P <0.05) in both lungs. The mean number of involved mediastinal nodal stations in the non-skip N2 and skip N2 groups in all segments of both lungs were 1.4 (434/301) and 1.2 (93/77), and the former was significantly greater than the latter (P <0.01). Our data showed a predictable pattern of segmental and lobar lymphatic drainage to the mediastinum and suggested that skip involvement could represent the initial mediastinal node involvement via direct lymphatic drainage.

A case of long-term survival after pulmonary resection for metachronous pulmonary metastasis of basaloid squamous cell carcinoma of the esophagus

INTRODUCTIONBasaloid squamous cell carcinoma of the esophagus (BSCE) is a rare malignancy among esophageal cancers. We reported a case of 63-year-old woman with metachronous pulmonary metastasis of BSCE, successfully treated by metastasectomy of the left lung. PRESENTATION OF CASEBiopsy specimens of upper gastrointestinal fiberscopy led to diagnosis of poorly differentiated squamous cell carcinoma of the esophagus. Computed tomography revealed metastatic lymph nodes surrounding the bilateral recurrent laryngeal nerve and no evidence of metastasis to distant organs. Curative esophagectomy with three-field lymph node dissection was performed through thoracoscopic approach. Pathological examination of the resected specimens led to diagnosis of BSCE with invasion into the submucosal layer of the esophageal wall. Two years later, a solitary oval-shaped pulmonary lesion of approximately 10mm was detected in the left lung. Wedge resection of the left upper lobe was performed via thoracoscopic approach. The postoperative course was uneventful. Histologically, the pulmonary lesion was diagnosed as metastatic BSCE. Follow-up indicated no recurrence 9 years after the initial surgery. DISCUSSIONSurgical intervention was acceptable on this case of solitary pulmonary metastasis. However, data are lacking about the efficacy of pulmonary resection for metachronous pulmonary metastasis of BSCE because the postoperative outcome is usually poor. The efficacy of surgical intervention for metastatic lesions of BSCE is debatable and requires further examination. CONCLUSIONAlthough the usefulness of surgical intervention for metastatic lesions from BSCE is controversial, the patients with metachronous solitary metastasis to the lung and without extrapulmonary metastasis would be good candidate for pulmonary resection.