Prevalence of Pathologically Proven Intrapulmonary Lymph Nodes ...

4 downloads 0 Views 377KB Size Report
The objective of this study was to assess the prevalence of pathologically proven intrapulmonary lymph nodes and to evaluate their appearance on CT.
Prevalence of Pathologically Proven Intrapulmonary Lymph Nodes and Their Appearance on CT Mark S. Bankoff1 Niall J. McEniff1 Rafeeque A. Bhadelia Maria Garcia-Moliner2 Benedict

The objective

OBJECTIVE. proven

intrapulmonary

MATERIALS

1

underwent

D. T. Daly3

AND

Of

size,

position.

these

I 84

were

independently

diameter

he

study

logically

0361-803X/96/1 © American

Roentgen

AJR:167, September

1996

with

the

patients

7 to 1 2 mm.

had

were

periph-

lymph

solitary

All the nodes

of the nodules

evaluation any

existence

nodes.

Two

The

maxi-

nodules. were

located

been

previously

on CT have never series.

is to assess

the

with

well-circumscribed

and

evalu-

objective

prevalence

intrapulmonaiy

nodules

been

The

of

of patho-

lymph

nodes

peripheral

to

they

parenchymal

intrapulmonary

has

pulmonary

CT appearance,

(or multiple)

of

nodes

of CT-detected

specific

evaluate

their

located

within

in the lower

should

nodules.

3-mm

tional

Materials

were

1980

and

went

a minithoracotomy

uation

of peripheral

ered

1994. pulmonary

needle

aspiration

technically

patients

of

CT-guided

per-

had for

well-circumscribed

a known

was

inappropriate.

attempted.

nodules.

underfor eval-

abnornialities biopsy

difficult,

unsuccessfully 96

184

at our institution

In these patients.

cause.

investigated

in the study.

and Methods

Between

cutaneous

included

These

patients

underlying

Of

these

nodule

disease

two

thick

slices

to he resected a barium

were

was

marker

the

radiologists

no knowledge ules’

or

had

pleura

I 84

pleura

(such

those

found

in

obtained

through

the

localized

on full inspira-

placed

on the skin over

was

was performed to (Fig. I ). The barium marker was then replaced by an indelible skin marker. All nodules were successfully identified and excised during surgery. The resected nodules were itiimediately sent for pathologic analysis. All CT scans were reviewed independently by

consid-

peripheral were being

these

in the dii’-

nodules. The technique of minithoracotomy has been described in detail previously 131. Patients were positioned in the gantry of the CT scanner in the position selected for operative exposure. The

surface

nary abnormalities

entity, undergo

as primary tunior, infective process. collagen ascular disease) or for investigation of an abnormality seen on a chest radiograph. CT scans of the chest were obtained for each of these patients at I cm intervals with a I-cm slice thickness. Addi-

and a repeat

pulmo-

and

Although

particularly

20

lobes.

be considered

the nodule.

of peripheral

The lymph

well-circumscribed

intrapulmonary

conIirii

pulmonary Ray Society

to he

15 years for evaluation

patients.

673-629

from

Twelve

nodules.

intrapulmonary

tion,

been

AJR 1996:167:629-630

proven

appearance on CT. All patients who underwent minithoracotomy at our institution over the past

unknown 3Department ofThoracic Surgery, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111.

varied

surface.

proven

pulmonary

2Department of Pathology, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111.

the remaining

abnormal-

pulmonary

radiologists.

proven

documented [ 1 , 2]. However, to our the prevalence of these nodes and

in patients

Tufts University School of Medicine, Division of Computed Tomography, 750 Washington St., NEMC #180, Boston, MA 02111. Address correspondence to M. S. Bankoff.

by two experienced

nodules:

of single

in a consecutive

this

Center,

peripheral

pathologically

184 patients

pulmonary

nodules.

ated

New England Medical

all

pathologically

two

for

their appearance

of Radiology,

were

nodes do not possess

knowledge

1 Department

of

( 1980-1994),

peripheral

minithoracotomies

lymph

Roent-

period

of pathologically

on CT.

not a well-known of patients who

T

Presented at the annual meeting of the American gen Ray Society, San Diego, CA, May 1996.

a 15-year

in 17 ( 18%) of the 96 patients

ol’ the nodules

ferential diagnosis the lower lobes.

after revision

the prevalence appearance

the remaining nodules were located in the right middle lobe. CONCLUSION. Although intrapulmonary lymph nodes are our results indicate that they are discovered in a significant number lymph

26, 1995; accepted

their

well-circumscribed

assessed

pleural

to assess

of CT-detected

features

The nodules

of a visceral

had

radiographic

pulmonary nodules of the 17 patients had

Received December March 26, 1996.

96

was

Over

for evaluation

eral

mum

study

and to evaluate

METHODS.

patients,

and

RESULTS.

mm

nodes

minithoracotomies

ities.

nodes

of this

lymph

position.

were was

the nodule. presence

of

lung-nodule

scan

localization

experienced

in the

of the pathologic size.

number,

recorded. measured

field

findings. and distance

The from

distance the deepest

Each nodule was also evaluated calcification and for character

who

had

The nodfrom the from the aspect of for the of the

interface.

629

Bankoff

et al.

Fig. 1.-CT

scan through lower lobes of 58-year-old woman in right lateral decubitus position shows nodule to be resected (short arrow) that was localized on full inspiration. Note barium marker (long arrow) that was placed on skin over nodule for surface localization. Nodule in this patient measured 1.5 cm from adjacent pleural surface.

Fig.2.-Magnified

CT scan of right lower

lung in 69-year-old man in leftlateraldecubitus position shows intraparenchymal lymph node (straight arrow) in right middle lobe close to pleura. No distinct imaging features were recognized to permit diagnosis before surgery. However, note nonspecific peripheral opacity located posteriorly in right lower lobe (curved arrow) that was thought to be caused by scarring; its cause was not confirmed surgically.

Results Of guided

has been done using the

96

who

patients

for

minithoracotomies

of well-circumscribed nodules,

were

proven

lymph

nodes.

known

primary

of these

able occupational The patients

intrapulmonary

dominantly

I 7 patients

middle

distribution

Lymph

a

10 men and seven

The

with

a mean

of 8 mm.

lymph

nodes

were

found

lower

lobes.

Five

lymph

nodes

lower

lobe

and seven

predominantly

lobe. The remaining in the right middle

The in the

were

located

in the left

five patients had lobe. All nodules

the level of the carina.

We

no nodes in the upper lobes. All the were located within 20 mm of a vis-

ceral pleural

surface.

Distances

ranged

from

5

to 20 mm (mean, 1 1 mm) (Fig. 2). None of the lymph nodes was calcified. The lung-nodule interface

was usually

these features preoperative

were not helpful differentiation of

lymph

nodes

from

ondary) found

or inflammatory more frequently

among scribed

our

96

peripheral

smooth.

neoplastic

However,

in confident these benign

(primary

or see-

lesions, which were than lymph nodes

patients pulmonary

with

nodes

in the lung

lymph

nodes in the lower

half

of the lungs may be explained both by the larger

had two

15 had solitary in size from 4 to

diameter

is not clear.

well-circumnodules.

ventilation

and by the lymphatic

in the lower upper

lungs when

lungs

fluid production

compared

[1 1, 12]. The pathologic

all the specimens were reviewed. were anthracotic in cases. We

who

on

have also CT had

observed nodules

within

the

proved

to be intrapulmonary

adjacent

pulmonary

to a fissure.

in these patients a thoracotomy; not considered

with

the

analyses

of

The

nodes

patients deep

parenchyma lymph

middle

lymph

of

benign

nodes is still a pathologic

nodes

discovered

at

intrapulmonary

to

be

benign

diagnosis.

intrapulmonary

lobes

4.

How-

lymph

Ann

Thorac

C, Hamada

Yoshii

monary with

lymph

node

with

Gakkai

roe

Cardiovasc

lesion.

node Dis

1967;5

diagnosis

Dis

C/zest

9. Benisch

RL,

presenting

Spirn

PW,

f’/zest

multiple)

peripheral

630

lymph nodes [1, 2, no extensive study

larly

those

found

pulmonary

in the lower

nodules, lobes.

particu-

toplasmosis

the lung.

roentgen-

lymph

nodes.

lesion

of

Mark

and

El.

Intrapulmonary

1985;87:662-667 tumors.

In: Dail DH,

pat/wlog,

2nd

ed.

1994:1357-1359 M. Apical localization

tuberculosis, C/zest

A. An intrapulmoas a coin

1979;76:336-337

C/zest

nodes.

pulmonary

OF. The

B, Osborne

node

of benign intrapulmonary 4-10]. To our knowledge,

be

nodule.

1967:51:621-624

in the differential

(or

lymph

pulmonary

G. Gabriele

included

should

Intrapulmonary

intrapulmonary

B, Peison

10. Kradin

JG.

1:336-337 of

lymph

the lung.

i Tho-

BJ, Fred HL. Benign node presenting as coin

as a solitary

R. Wilson

ray

lymph

Weg

presenting Chest

nodule.

J 1974:67:1216-1218

Med

DS,

Shapiro

nary

Blumenthal lymph

South

7. Rosenthal

Kyobu

: I 17-122

1963;46:21-39

Surg

6. Blakely RW, intrapulmonary

in a patient

Nippon

5. Steele JD. The solitary pulmonary

aware of this diagnostic

ofsingle

nodules

pneumonia.

1993;31

Zasshi

Over the past 30 years, there have been many case reports and small series reported

which

of intra-

1991:51:465-469 et al. A case of intrapul-

silicotic

interstitial

idiopathic

S/zikkan

Surg

M, TaoY,

York: Springer-Verlag, 12. Goodwin RA, DesPrez

diagnosis

and

and in the right

pulmonary lymph nodes. Thorax 1964:19:44-50 3. Daly DBT. Faling U, Diehl JT, Bankoff MS. Gale ME. Computed tomography-guided minithoracotorny for the resection ofsmall peripheral pulmonary

I I . Dail DH. Uncommon mer SP, eds. Pulmonary

entity,

our

lobe.

nodes at percutaneous biopsy or at surgery. Therefore, it is important for radiologists to be

Discussion

in

case report.AiR 1969;l06:601-603 2. Trapnell DH. Recognition and incidence

8.

ever, with improvement in the image quality of Cr, more pulmonary nodules are likely to be identified and a higher proportion of these small peripherally placed nodules may ultimately be proven

nodules

pulmonary

are

of the periph-

I . Fellows KE Jr. Abell MR. Martel W. Intrapulmonary lymph node detected roentgenologically:

that

therefore, these nodes were in this study. Although at first

diagnosis

18%

that

nodes

References

appraisal these nodes appeared to be deep, they were in fact close to a pleural surface. The

for

in the lower

occurred

of the nodes

was generally

shown

patients who underwent minithoracotomies. The nodes were predominantly single

nodules.

several apparently

The nature

placed

has

lymph

for this

develop in response to antigenic stimuli, usually from inhaled dust. The predominant occurrence of intrapulmonary

ages of 63 and S I years,

below

study (10

[10]. The reason

12 mm,

found nodes

lobes and in the right

in the lower

lobe. In the only other sizable

study

accounting

erally

pre-

the level of the canna

the remaining nodes ranged

were located

nodule

patients), the lymph nodes were also seen below

of the 17 patients

Two

as a solitary

our

intrapulmonary

common,

had an identifi-

and The

lower nodes

had

nodes. of the intrapulmonaiy

occtared

nodes

In conclusion, benign

of them

nodules, nodules.

in the right

lymph

patho-

risk factor. were 30 to 70 years old, with

mean

proven

I 3 had a history

mean age of 57 years. had

the prey-

and

tumors None

CT to evaluate of pathologically

intrapulmonary lymph In our study, most

pulmonary to have

benign

Five

of smoking.

respectively.

found

and features

alence

CT-

the resection

peripheral

17 (18%)

logically

women

underwent

chronic

progressive

pulmonary

massive

fibrosis

HamNew

of hisof

1983:83:801-805

AJR:167, September

1996