Normal radiological lymph node appearance in the thorax

What's in a node? The clinical and radiologic significance of Virchow's node

In 1848, Rudolf Ludwig Karl Virchow described an association of left supraclavicular lymphadenopathy with abdominal malignancy. The left supraclavicular lymph node later became commonly referred to as Virchow's node. Charles-Emile Troisier went on to describe the physical exam finding of an enlarged left supraclavicular lymph node, later termed Troisier's sign. Subsequent studies confirmed a predilection of abdominal and pelvic malignancies to preferentially metastasize to the left supraclavicular node. Identification of a pathologically enlarged left supraclavicular node raises the suspicion for abdominopelvic malignancy, particularly in the absence of right supraclavicular lymphadenopathy, and provides a safe and easy target for biopsy. Supraclavicular lymph nodes also represent a great target for diagnosis of metastatic thoracic malignancies, although thoracic malignancies can involve either right or left supraclavicular nodes and do not show a predilection for either. This article presents a review of the history, anatomy, pathophysiology, clinical significance, radiological appearance, and biopsy of Virchow's node. Key points are illustrated with relevant cases.

Mapping of Cervical and Upper Mediastinal Lymph Node Recurrence for Guiding Clinical Target Delineation of Postoperative Radiotherapy in Thoracic Esophageal Squamous Cell Carcinoma

Background

The lower neck and upper mediastinum are the major regions for postoperative radiotherapy (PORT) in thoracic esophageal squamous cell carcinoma (TESCC). However, there is no uniform standard regarding the delineation of nodal clinical target volume (CTVnd). This study aimed to map the recurrent lymph nodes in the cervical and upper mediastinal regions and explore a reasonable CTVnd for PORT in TESCC.

Methods

We retrospectively reviewed patients in our hospital with first cervical and/or upper mediastinal lymph node recurrence (LNR) after upfront esophagectomy. All of these recurrent lymph nodes were plotted on template computed tomography (CT) images with reference to surrounding structures. The recurrence frequency at different stations was investigated and the anatomic distribution of recurrent lymph nodes was analyzed.

Results

A total of 119 patients with 215 recurrent lymph nodes were identified. There were 47 (39.5%) patients with cervical LNR and 102 (85.7%) patients with upper mediastinal LNR. The high-risk regions were station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. LNR in the external group of station 104L/R was not common, and LNR was not found in the narrow spaces where the trachea was in close contact with the innominate artery, aortic arch and mediastinal pleura. LNR below the level of the cephalic margin of the superior vena cava was also not common for upper TESCC.

Conclusions

The CTVnd of PORT in the cervical and upper mediastinal regions should cover station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. Based on our results, we proposed a useful atlas for guiding the delineation of CTVnd in TESCC.

Endoscopic Submucosal Dissection for Upper Gastrointestinal Neoplasia-a North American Perspective

OBJECTIVES

Organ-sparing endoscopic submucosal dissection (ESD) is an acceptable treatment strategy for superficial neoplastic lesions of the esophagus and stomach. The adoption of this technique has lagged in North America compared with Asia, and we sought to report on our experiences with ESD for upper GI neoplasia.

METHODS

A prospectively entered database of all patients undergoing endoscopic resection of esophageal and gastric neoplasia at McGill University from 2009 to 2019 was queried for those who received ESD.

RESULTS

A total of 103 consecutive ESDs were identified from 2009 to 2019. Seventy-one (69%) patients were male and the median age was 72 (range: 38-90). Sixty-one (59%) cases were esophageal and 42 (41%) gastric. Forty-nine (48%) were performed in the endoscopy suite under local sedation only. Perforation occurred in 9 patients (7 esophageal and 2 stomach), of which 3 required operative repair. Histology was principally invasive carcinoma (79, 77%), with 17 (16%) dysplastic lesions (e.g., HGD), 1 (1%) neuroendocrine tumor, and 7 (7%) benign lesions. En bloc resection was achieved in 90 (87%), and the complete resection rate was 74 (72%), with 51 (50%) of procedures fulfilling the criteria for curative resection. At medium of 23-month (2-199) follow-up of these 51 curative resections, one case of recurrent carcinoma was found at follow-up and was managed with repeat endoscopic resection. Non-curative ESDs were found 45 (R1 resection = 29: risk of lymph node metastasis = 16), 21 had active surveillance, and 24 were resected.

CONCLUSION

ESD is a viable, effective, and safe therapeutic and staging modality for superficial lesions of the stomach and esophagus.