Peripheral Intrapulmonary Lymph Node Metastases of Non-Small-Cell Lung Cancer

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pulmonary disease. In a number of these patients a postoperative CT scan is performed for diagnostic purposes.

It has been shown that a mass shadow on chest roentgenogram and CT scan in the lung can be caused by a reaction to foreign bodies such as nonabsorbable su- tures (eg, braided silk, braided polyester) [2, 3]. In these reported cases, patients had developed hemoptysis and proceeded to have surgery.

We have previously reported 3 patients who coughed up staples after LVRS [4]. This was thought to be due to a reaction to the bovine pericardial strips. It seems that this inflammatory reaction can also cause a mass lesion, although the histology in the second case did not specif- ically show foreign body inflammatory changes.

Surgical metal clips are known to cause artifacts on CT scans with streaks radiating from the clips. Titanium has been found to cause less artifact compared with stainless steel or tantalum [5]. In the first presented case, the suspected foreign body was reported to be 2 cm in diameter, and a rigid bronchoscopy was performed to exclude an intrabronchial foreign body. Perhaps the density was caused by a row of clips organized in a circle due to the surface of the lung being folded together.

It could be that the suspected foreign body was in fact calcification in an inflammatory mass. Glutaraldehyde used in the pretreatment of bovine pericardium is known to cause calcification. However, the first CT scan to show this mass was performed within 1 month postoperatively.

As previously mentioned, the histology of the first case revealed an aspergilloma. Perhaps the mass found post- operatively is related to the presence of an aspergilloma, even though a preoperative CT scan did not show an abnormal mass.

However, these patients, who have smoking related emphysema, are at risk of developing a malignant tumor.

Hazelrigg and colleagues [6] found a 6.4% overall inci- dence of malignancy in a group of 281 patients undergo- ing LVRS. Therefore, a mass lesion appearing after LVRS should be further investigated.

In conclusion, after LVRS, mass lesions may develop, which are pseudotumors related to the foreign material left on the lung surface. Nevertheless, these lesions do need to be investigated to exclude more serious conditions.

References

1. Lando Y, Boiselle P, Shade D, Travaline JM, Furukawa S, Criner GJ. Effect of lung volume reduction surgery on bony thorax configuration in severe COPD. Chest 1999;116:30 –9.

2. Baba K, Nagao K, Matsuda M, et al. An operative case of suture-granuloma which resulted from an intra-pulmonary treatment 10 years ago and manifested hemoptysis. Kyobu Geka 1996;49:1048 –51.

3. Nonaka M, Arai T, Inagaki K, Morita T, Yano M, Miyazawa H.

Intra-pulmonary suture abscess with hemoptysis after partial resection– concerning to the pathogenesis of the suture ab- scess. Nippon Kyobu Geka Gakkai Zasshi 1991;39:2088 –91.

4. Oey I, Waller DA. Metalloptysis: a late complication of lung volume reduction surgery. Ann Thorac Surg 2001;71:1694 –5.

5. Silverman PM, Spicer LD, McKinney R Jr, Feldman DB.

Computed tomographic evaluation of surgical clip artifact:

tissue phantom and experimental animal assessment. Com- put Radiol 1986;10:37–40.

6. Hazelrigg SR, Boley TM, Weber D, Magee MJ, Naunheim KS.

Incidence of lung nodules found in patients undergoing lung volume reduction. Ann Thor Surg 1997;64:303–6.

Peripheral Intrapulmonary Lymph Node Metastases of Non-Small-Cell Lung Cancer

Souheil Boubia, MD, Franc¸oise Lepimpec Barthes, MD, Claire Danel, MD, and Marc Riquet, MD, PhD

Departments of Thoracic Surgery and Pathology, Georges Pompidou European Hospital, Paris, France

Since the development and progress of computed tomo- graphic imaging, peripheral intrapulmonary lymph nodes (IPLNs) have become increasingly described and well-known entities. Intrapulmonary lymph nodes may appear as a solitary pulmonary nodular shadow mimick- ing a non-small-cell lung cancer (NSCLC) or as multiple nodules masquerading as carcinoma metastases. We de- scribe a case in which IPLNs presented as a clinical

“nodular” T4 N0 NSCLC that finally proved to be a pathologic T2 N1 NSCLC, thus raising new questions on this entity.

(Ann Thorac Surg 2004;77:1096 – 8)

Accepted for publication April 9, 2003.

Address reprint requests to Dr Riquet, Service de Chirurgie Thoracique, Hoˆpital Europe´en Georges Pompidou, 20-40 Rue Leblanc, 75015 Paris, France; e-mail: marc.riquet@hop.egp.ap-hop-paris.fr.

Fig 3. Chest roentgenogram after lung volume reduction surgery showing a mass in the upper zone of the right lung.

1096 CASE REPORT BOUBIA ET AL Ann Thorac Surg

INTRAPULMONARY LYMPH NODE METASTASES OF NSCLC 2004;77:1096 – 8

Published by Elsevier Inc doi:10.1016/S0003-4975(03)01275-X

CASEREPORTS

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Intrapulmonary lymph nodes (IPLNs) are located distal to the fourth-order bronchi. Trapnell [1] demon- strated IPLNs in 7% of postmortem lungs by injecting contrast medium into pleural lymphatic vessels, which were detected by plain radiography in less than 1% of cases. The increasing availability of sensitive radio- graphic techniques has increased the frequency of detec- tion of these nodes. Intrapulmonary lymph nodes may appear as a solitary pulmonary nodular shadow mimick- ing a non-small-cell lung cancer (NSCLC) [2] or as multiple nodules masquerading as carcinoma metastases [3, 4]. We observed a case presenting as a clinical “nod- ular” T4 N0 NSCLC [5] that proved to be a pathologic T2N1 NSCLC. Such a presentation of IPLNs raises ques- tions on the role this entity may play in NSCLC lym- phatic spread.

A 51-year-old woman who was a heavy smoker with a past medical history of tuberculosis primoinfection un- derwent a chest roentgenogram demonstrating an exca- vated opacity of the right lower lobe (RLL) with a satellite nodule. Bronchoscopy demonstrated hypervasculariza- tion of the RLL apical bronchus suggestive of sequelae of tuberculosis. Distal biopsy results were negative, and aspiration results were positive for carcinomatous cells suggestive of squamous cell carcinoma.

A chest computed tomographic (CT) scan demon- strated a necrosed tumor with two satellite nodules (Fig 1) and no lymph node involvement (clinical T4 N0).

Extension assessment was negative and surgical treat- ment was scheduled. A right lower lobectomy with me- diastinal lymph node dissection was performed.

A histologic examination of the resected material dem- onstrated the main lesion to be a squamous cell carci-

noma. The first nodule, distant by about 1 cm from the main lesion, appeared as a metastasis (Fig 2). The second nodule was approximately 2 cm from the main lesion and corresponded to an IPLN with carcinoma metastasis (Fig 3a). The first nodule was reexamined and was in fact also a metastasis developed in an IPLN, with the destruction of the lymph node architecture, capsular effraction, and lymphatic carcinomatous emboli (Fig 3b); remnants of the lymph nodes had escaped the first examination, and the NSCLC was reclassified as T2 N1.

Comment

The existence of satellite nodules within the ipsilateral primary lobe of the lung is classified as T4, and thus the NSCLC is stage IIIB [5]. Stage IIIB NSCLCs are poor candidates for surgical intervention. The treatment of Fig 1. Chest tomodensitometry. (a) Posterior bilobar tumor and

shadow of an anterior satellite nodule. (b) Neighboring slide demon- strating the two nearby satellite nodules.

Fig 2. Metastatic satellite nodule with carcinomatous lymphangitis (asterisks) (hematoxylin & eosin stain, magnification⫻200).

Fig 3. (a) Intrapulmonary lymph node with microscopic metastasis (asterisks) among lymphoid follicles (hematoxylin & eosin stain, magnification⫻100). (b) On the new section, malignant cells appear to have developed within another intrapulmonary lymph node (he- matoxylin & eosin stain, magnification⫻200).

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patients with multiple intrapulmonary lesions remains controversial; one lesion may be a metastasis of the other, or either lesion may be benign or malignant [6]. How- ever, it has been demonstrated that the existence of a solitary intrapulmonary sublesion should not preclude surgical treatment, unless surgical intervention is contra- indicated because of other clinical or radiologic findings [6], which was the case in our observation, initially classified as a T4 N0 NSCLC.

Intrapulmonary lymph nodes may represent the pathologic diagnosis in up to 46.2% of small pulmonary nodules demonstrated by chest CT scans [2]. Most IPLNs may be considered to be acquired, highly organized lymphoid nodules formed along interlobular lymphatic drainage routes [7]. Seventy-two percent are located in the lower-lobes [2]. Thirty-five percent are multiple nodes [7].

In our patient, the lower-lobe location of two IPLNs was therefore not surprising. The originality of this case is that both IPLNs were metastatic. In 1965, Greenfield and Jelaso [8] reported two peripheral left lower-lobe nodules that at surgical intervention appeared to be IPLNs, and microscopic study revealed undifferentiated squamous cell carcinoma in one. Five enlarged lymph nodes were palpated in the left mediastinum, and one of these examined by frozen section also showed metastatic squamous cell carcinoma. However, no primary lung cancer was found in the left lung of the patient.

In our patient, a primary NSCLC was present. The IPLN in proximity to the tumor was initially interpreted as a satellite nodule. In fact, a metastatic IPLN due to the bulky involvement of its structure may be misinterpreted as a satellite nodule, suggesting the need for careful evaluation and interpretation of all satellite nodules in the area. For improved patient staging, we suggest that when a nodule is present in the lobe affected by cancer, one should rule out possible metastatic IPLNs.

References

1. Trapnell DH. Recognition and incidence of intrapulmonary lymph nodes. Thorax 1964;19:44 –50.

2. Yokomise H, Mizuno H, Ike O, Wada H, Hitomi S, Itoh H.

Importance of intrapulmonary lymph nodes in the differential diagnosis of small pulmonary nodular shadows. Chest 1998;

113:703–6.

3. Kolosseus RC, Temes RT, Feddersen RM, Williamson M, Smith AY. Intrapulmonary lymph nodes masquerading as renal cell carcinoma metastases. Urology 1995;46:249 –50.

4. Nagashiro I, Andou A, Aoe M, Date H, Shimizu N. Intrapul- monary lymph nodes enlarged after lobectomy for lung cancer. Ann Thorac Surg 2001;72:2115–7.

5. Mountain CF. Revisions in the international system for stag- ing lung cancer. Chest 1997;111:1710 –7.

6. Kunitoh H, Eguchi K, Yamada K, et al. Intrapulmonary sublesions detected before surgery in patients with lung cancer. Cancer 1992;70:1876 –9.

7. Kradin RL, Spirn PW, Mark EJ. Intrapulmonary lymph nodes:

clinical, radiologic, and pathologic features. Chest 1985;87:

662–7.

8. Greenfield H, Jelaso DV. Peripheral intrapulmonary lymph node metastasis. Br J Radiol 1965;38:955–6.

Superimposed Spontaneous Esophageal Perforation in

Congenital Esophageal Stenosis

J. Andres Gonzalez, MD, Christopher M. Craft, MD, T. Theron Knight, MD, and

William H. Messerschmidt, MD

Department of Surgery, Quillen College of Medicine, Johnson City, Tennessee

Congenital esophageal stenosis (CES) is a very rare embryologic anomaly of tracheoesophageal development that requires lifelong management, usually with fre- quent esophageal dilations and dietary precautions. We present a patient with spontaneous thoracic esopahgeal perforation in a setting of CES. The patient, a 27-year-old male, recovered uneventfully following open primary esophageal closure. A brief but comprehensive discus- sion of CES follows the case report.

(Ann Thorac Surg 2004;77:1098 –1100)

Congenital esophageal stenosis (CES) is an often un- recognized cause of childhood and adult dysphagia.

Only 500 patients have been reported [1]. Its frequency is thought to be 1 patient in 25,000 to 50,000 live births [2, 3].

Three forms of the anomaly are described: membranous diaphragm, submucosal and muscularis propia fibrosis, and esophageal wall tracheobronchial remnants [4].

Frank T-E fistula may be present in newborns. Symptoms are multiple ringed esophagus and multiple webbed esophagus, accouunting for its description on imaging studies and endoscopy [2]. CES may involve any portion of the thoracic esophagus, but involves the middle third in 80% of the patients. CES exhibits male predominance and typically presents in childhood with progressive dysphagia [2]. The stenotic segment usually contains tracheobronchial elements or maldeveloped muscular tissue, and may be associated with esophageal atresia or tracheoesophageal fistula. Intrauterine stress or anoxia predisposes esophageal lumen canalization defects and stenosis [4]. Most patients can be managed with intermit- tent dilations and dietary precautions, however surgical intervention is occasionally necessary [1]. Esophageal perforation is a potentially lethal complication of CES with treatment based upon clinical findings. Delayed diagnosis substantially worsens the prognosis [5].

A 27-year-old male, known to have CES, presented with 18 hours of unrelenting, severe substernal pain radiating

Accepted for publication May 14, 2003.

Address reprint requests to Dr Messerschmidt, Department of Surgery, ETSU, Quillen College of Medicine, Johnson City, TN 37614-0575;

e-mail: billm1@chartertn.net.

1098 CASE REPORT GONZALEZ ET AL Ann Thorac Surg

SUPERIMPOSED SPONTANEOUS ESOPHAGEAL PERFORATION 2004;77:1098 –1100

Published by Elsevier Inc doi:10.1016/S0003-4975(03)00890-7

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