A prediction model for lung metastases in patients with indeterminate pulmonary nodules in newly diagnosed colorectal cancer

INTRODUCTION

Multidisciplinary teams treating patients with newly diagnosed Colorectal Cancer (CRC) often encounter the appearance of Indeterminate Pulmonary Nodules (IPNs) that warrants follow-up with repetitive medical imaging and anxiety for patients. We determined the incidence of IPNs in patients with newly diagnosed CRC and developed and validated a model for individualized risk prediction of IPNs being lung metastases.

MATERIAL AND METHODS

Newly diagnosed CRC who underwent surgery between November 2011 to June 2014 were included to create the risk model, developed using both clinical experience and statistical selection. Discrimination and calibration slopes of the risk score were evaluated in an independent temporal validation sample. A nomogram is presented to assist clinicians in estimating an individual risk score.

RESULTS

Out of 2111 CRC patients staged with chest CT, 204 (9.6%) had IPNs and 54/204 (26%) had lung metastases. We identified 4 predictors: "location of primary tumour", "pathological nodal stage", "size of the largest nodule" and "extrapulmonary synchronous metastases at diagnosis". Discrimination of the final model in the validation sample was demonstrated by the difference in mean predicted risk between progressed cases en non-progressed cases (49% versus 21%, p = <0.001).

CONCLUSION

A prediction model with 4 clinical risk factors can be used to assist multidisciplinary teams in the prediction of individualized risk of lung metastases and imaging strategy in patients with IPNs and newly diagnosed colorectal cancer. The model performed well in new patients not included in the model development.

Near-infrared intraoperative imaging for minimally invasive pulmonary metastasectomy for sarcomas

BACKGROUND

Complete pulmonary metastasectomy for sarcoma metastases provides patients an opportunity for long-term survival and possible cure. Intraoperative localization of preoperatively identified metastases and identification of occult lesions can be challenging. In this trial, we evaluated the efficacy of near-infrared (NIR) intraoperative imaging using second window indocyanine green during metastasectomy to identify known metastases and to detect occult nodules.

METHODS

Thirty patients with pulmonary nodules suspicious for sarcoma metastases were enrolled in an open-label, feasibility study (NCT02280954). All patients received intravenous indocyanine green (5 mg/kg) 24 hours before metastasectomy. Patients 1 through 10 (cohort 1) underwent metastasectomy via thoracotomy to assess fluorescence patterns of nodules detected by traditional methods (preoperative imaging and intraoperative visualization/bimanual palpation). After confirming reliability within cohort 1, patients 11 through 30 (cohort 2) underwent video-assisted thoracic surgery metastasectomy with NIR imaging.

RESULTS

In cohort 1, 14 out of 16 preoperatively identified pulmonary metastases (87.5%) displayed tumor fluorescence. Nonfluorescent metastases were deeper than fluorescent metastases (2.1 cm vs 1.3 cm; P = .03). Five out of 5 metastases identified during thoracotomy displayed fluorescence. NIR imaging identified 3 additional occult lesions in this cohort. In cohort 2, 33 out of 37 known pulmonary metastases (89.1%) displayed fluorescence. Nonfluorescent tumors were deeper than 2.0 cm (P = .007). NIR imaging identified 24 additional occult lesions. Of 24 occult lesions, 21 (87.5%) were confirmed metastases and the remaining 3 nodules were lymphoid aggregates.

CONCLUSIONS

NIR intraoperative imaging with indocyanine green (5 mg/kg and 24 hours before surgery) localizes known sarcoma pulmonary metastases and identifies otherwise occult lesions. This approach may be a useful intraoperative adjunct to improve metastasectomy.

Management of pulmonary nodules in head and neck cancer patients - Our experience and interpretation of the British Thoracic Society Guidelines

BACKGROUND

and purpose of the study: The frequency of lung nodules in the head and neck cancer population is unknown, currently the only guidance available recommends following local policy. The aim of this study was to determine the incidence of pulmonary nodules in our head and neck cancer group and interpret the recently updated British Thoracic Society (BTS) Lung Nodule Guidelines in a head and neck cancer setting.

METHODS

100 patients were diagnosed with head and neck cancer between July 2013-March 2014, clinico-pathological, demographic and radiological data was extracted from the electronic records. Images with lung findings were re-reviewed by a single consultant radiologist for patients with lung pathology on the initial staging CT report.

RESULTS

Twenty patients (20%) had discreet pulmonary findings on CT. Eleven (11%) had lung nodules, 6 (6%) had lesions suspicious for metastasis and 3 (3%) had co-incidental bronchogenic primary cancers. These patients were re-imaged between 6 and 18 months and in 1 patient the previously identified 7 mm nodule had progressed to 16 mm at 1 year. There was no set follow up imaging protocol used.

CONCLUSION

The MDT in NHS Lothian has reviewed the BTS guidance and now has a local policy for the management of lung nodules in head and neck cancer patients. Lung Nodules in the head and neck cancer population are common >10%. Higher risk patients with larger nodules should be risk assessed with validated assessment tools. PET-CT has a place in the assessment of lung nodules when risk of malignancy is high.

A rare case of pulmonary sclerosing hemagioma with lymph node metastasis and review of the literature

Pulmonary sclerosing hemagioma (SH) is an uncommon tumor with malignance potential. Clinically this disease is regarded as benign but extremely rare cases can have lymph node metastasis. Up to date, there have been only very few reports concerning SH with lymph node metastasis. In this paper we reported one pulmonary SH case with lymph node metastasis and additionally overviewed the clinical and pathological features of SH. A young-aged female was found incidentally to have a nodule in the right upper lung. This patient presented no cough, no hemoptysis and chest pain. Computed tomography (CT) scan indicated a large mass in the right upper lung and enlarged lymph nodes in the right hilum. The patient underwent lobectomy of the right upper lung. Histologically, the tumor demonstrated typical features of SH and was consisted of angiomatoid areas, sclerosis, papillary structures lined with cuboidal cells and sheets of round to polygonal cells. Polygonal cells in some solid areas presented abnormal enlarged nuclei and increased karyoplasmic ratio; tumor giant cells were noted; whereas mitosis was not observed. One peribronchial lymph node was noted for SH metastasis and the metastatic tissue were consisted of polygonal cells. Immunohistochemistry (IHC) revealed that both surface-lining cuboidal and polygonal cells expressed EMA and thyroid transcription factor 1 (TTF-1), but were negative for CD34, VIII factor, CD68 and Claratinin. The polygonal cells showed relatively higher expression of Ki-67 and p53 than the surface-lining cells. Postoperatively, the patient received no chemotherapy or radiotherapy and no recurrence 2 years after surgery was noted.

Indeterminate pulmonary nodules in colorectal cancer

AIM: To investigate the clinicopathologic parameters of pulmonary metastasis in colorectal cancer (CRC) patients after lung operation of indeterminate pulmonary nodules (IPNs).

METHODS: From a prospective database of CRC patients, 40 cases that underwent lung operation between November 2008 and December 2012 for suspicious metastatic pulmonary nodules on chest computed tomography (CT) were enrolled. The decision to perform a lung operation was made if the patient met the following criteria: (1) completely resected or resectable primary CRC; (2) completely resectable IPNs; (3) controlled or controllable extrapulmonary metastasis; and (4) adequate general condition and pulmonary function to tolerate pulmonary operation. Lung operation was performed by a thoracic surgeon without CT-guided biopsy for pathologic confirmation.

RESULTS: A total of 40 cases of lung resection was performed in 29 patients. Five patients underwent repeated lung resection. The final pathology result showed metastasis from the CRC in 30 cases (75%) and benign pathology in 10 cases (25%). The primary tumor site was the rectum in 26/30 (86.6%) cases with pulmonary metastasis, but only 3/10 (30%) cases in the benign group had a primary rectal cancer (P = 0.001). Positron emission tomography (PET)-CT was performed for 22/30 (73.4%) patients in the lung metastasis group and for 6/10 (60.0%) patients in the benign group. PET-CT revealed hot uptake of ¹⁸fluorine 2-fluoro-2-deoxy-D-glucose with all IPNs in both groups. The group with pulmonary metastasis had a higher incidence of primary rectal cancer (P = 0.001), a more advanced tumor stage (P = 0.011), and more frequent lymphatic invasion of tumor cells (P = 0.005). Six cases with previous liver metastasectomy were present in the lung metastasis group. Serum carcinoembryonic antigen levels before lung operation were not elevated in any of the patients.

CONCLUSION: The stage and location of the primary tumor and tumor cell infiltration of lymphatics provide useful indicators for deciding on lung resection of IPNs in CRC.

A case of basaloid carcinoma of the esophagus with a solitary lung metastasis for which thoracoscopic partial lung resection was performed

We experienced a case of basaloid carcinoma of the esophagus with a solitary lung metastasis for which thoracoscopic partial lung resection was performed. To the best of our knowledge, this is the first reported case of basaloid carcinoma of the esophagus with lung metastasis for which surgery was performed. There are no evidence-based treatment strategies for postoperative recurrence of basaloid carcinoma of the esophagus. Treatment strategies such as adjuvant therapy centered on chemotherapy and surgical indications should be established.

Squamous cell carcinoma presenting as a solitary growing cyst in lung: a diagnostic pitfall in daily clinical practice

Gradually growing cystic lesion of the lung is commonly encountered in daily clinical practice. Thin-walled cavitary lung cancer is a rare entity; however, it could be a pitfall in the diagnosis of such radiographically benign-looking lesions, especially without an obvious solid, nodular, or tumorous appearance in the lesion. We herein report a rare case of lung cancer successfully treated by surgical resection that appeared as a gradually growing cystic lesion mimicking benign emphysematous disease, with a review of the literature. A 68-year-old man with a 24-year history of hypothyroidism presented with an abnormal cystic shadow in the left lung on routine chest X-ray. Twelve months later, occasional bloody sputa had started and was gradually getting worse. The patient was then referred to our department for surgical intervention. He received clarithromycin by daily oral administration, and the bloody sputa soon disappeared. However, a malignancy was still suspected because the wall was slightly thickened unevenly in comparison with the previous chest X-ray and computed tomography findings. Thus we performed a left lower lobectomy followed by mediastinal dissection because a squamous cell carcinoma was diagnosed by intraoperative frozen section. The patient postoperatively received 4 courses of paclitaxel-carboplatin therapy. Twelve months after surgery, he survives without recurrence.

Das „benigne” metastasierende Leiomyom

We report two patients with pulmonary nodules detected by chance. Histopathology of biopsies retrieved by surgical videothoracoscopy revealed benign metastasizing leiomyoma (BML). The origin of this disease as well as its dignity are not fully understood. We discuss the origin of this disease and different therapeutic options - from oophorectomy to different hormon therapies. A standardized therapeutic recommendation cannot be given.

The role of surgery in the management of solitary pulmonary nodule in breast cancer patients

AIMS

To assess the role of surgery in the diagnosis and treatment of a solitary pulmonary nodule (SPN) in patients who had received previous surgery for breast cancer.

METHODS

A series of 79 consecutive patients who underwent surgery for an SPN between 1990 and 2003 after a curative resection for breast cancer were reviewed.

RESULTS

Surgical diagnosis was obtained by open procedure before 1996 (37 cases), and by video-assisted thoracoscopic surgery (VATS) after 1996 (33 out of 42 cases, 9 open procedures) and intraoperative evaluation. Histology of SPN was primary lung cancer in 38 patients, pulmonary metastasis of breast cancer in 27, and benign condition in 14. VATS was converted to open procedure for anatomical resection in primary lung cancer and for the palpation of the lung in metastatic disease. Average disease-free interval from the initial mastectomy was significantly longer in primary lung cancer than in metastatic patients (179+/-107 vs 51+/-27 moths). Manual palpation identified multiple pulmonary nodules in 3 out of 27 metastatic patients. Five-year survival rate after pulmonary metastasectomy was 38% and was significantly influenced by disease-free interval; 5-year survival rate after resection of primary lung cancer was 43% and was significantly influenced by the pathological stage.

CONCLUSIONS

VATS is a good procedure for diagnostic management of peripheral SPN. As SPN in breast cancer patients is primary lung cancer in half cases, it deserves confirmation of pathological diagnosis and appropriate surgical treatment. When breast cancer metastasis is demonstrated, open procedure must be performed to palpate the entire lung to exclude previously unknown nodules.

Transdiaphragmatic approach to the thorax using mini-invasive devices

Operative management of synchronous abdominal and thoracic pathology has traditionally used 2 separate incisions. The introduction of laparoscopic devices has allowed the development of new techniques. The feasibility of a laparotomy and transdiaphragmatic access to the pleural cavity using mini-invasive instruments is presented. Three patients underwent combined thoracic and abdominal procedure through a laparotomy and transdiaphragmatic access using mini-invasive devices. The procedure was proposed for both elective and emergency procedures: the first to achieve histologic diagnosis and to perform resection of synchronous metastases, the latter in a trauma setting for control bleeding. The access was provided by a circumferential incision of 5 cm length at the periphery of the diaphragm, starting close to the esophageal hiatus and carried from behind forward 2.5 cm away from the lateral insertions of the diaphragm to the chest wall. After deflation of the lung a 30-degree-angled telescope, stapling instruments, and other devices were introduced through the diaphragm incision. We obtained good intraoperative view of the pleural cavity, safe removal of abdominal and pulmonary pathology at the same time, and early repair of the injured pleura with control of hemostasis. We had no associated mortality or postoperative complications. In the first 2 patients, histology confirmed complete removal of the lesion. No case of insufficient tissue for primary diaphragmatic closure was documented and none prosthetic material was required. The interesting aspect of this report lies in the combined management of abdominal and thoracic lesion through a laparotomy and transdiaphragm approach of the pleura using mini-invasive devices. Our series indicate that simultaneous thoracic and abdominal surgery is feasible and safe in selected patients. We feel that there is a considerable learning curve with this technique and future studies will have to prove the feasibility of this procedure.

Percutaneous localization of pulmonary nodules prior to thoracoscopic surgery by CT-guided hook-wire

BACKGROUND

When performing thoracoscopic surgery in patients with small pulmonary nodules, intraoperative localization can be difficult and time-consuming. The percutaneous localization of suspicious intrapulmonary lesions was evaluated pre-operatively to facilitate the resection of the lesion and to avoid thoracotomy.

MATERIALS AND METHODS

Thoracoscopies were performed in 13 patients with intrapulmonary nodules previously localized by CT-scan and flagged percutaneously with a hook-wire. Immediately after the procedure, the patient was transferred to the operating room and thoracoscopic pulmonary wedge resection was performed.

RESULTS

All the nodules were properly identified. The time to position the wire was 20-30 min and thoracotomy could be avoided in all patients. The nodules were 0.5 cm - 6 cm in size and situated 1 cm - 4 cm subpleurally.

CONCLUSION

Guide-wire identification of an intrapulmonary nodule is a safe, elegant, time-saving and reliable method. The lack of manual examination of pulmonary parenchyma in thoracoscopy is compensated for by precise pre-operative localization.

Solitary pulmonary nodules: association between signal characteristics in dynamic contrast enhanced MRI and tumor angiogenesis

PURPOSE

To estimate the association between signal characteristic of dynamic enhanced MRI using curve types and angiogenesis in solitary pulmonary nodules.

MATERIALS AND METHODS

Thirty-six patients with a solitary pulmonary nodule (SPN) ranging in size from 6 to 37 mm (median 17 mm) underwent dynamic contrast enhanced MRI with a time interval of 10 s over a total period of 4 min. Resulting from the time-intensity curves four different enhancement curve profiles (A-D) were defined: type A with strong increase followed by early washout, type B with strong increase without washout, type C with slow increase and type D without relevant increase. Maximum peak (Pmax), slope of the first bolus transit (slope) and washout were calculated. Microvessel densities (MVD) were counted at the margins and at the center of the nodules. The mean MVD of each nodule was calculated. Enhancement characteristics were correlated with MVD grouped by diagnosis and by curve types. Curve types were correlated with the score of vascular endothelial growth factor (VEGF).

RESULTS

The frequency of malignancy was 55% (20/36). Using curve types for differentiation between malignant and benign SPN, the sensitivity, specificity and accuracy were 100%, 75% and 89%, respectively. The correlation between Pmax and MVD(mean) for all nodules was moderate (r(s)=0.4, P=0.02). A relevant correlation was found between Pmax and MVD(margin) in curve type A (r(s)=0.63; P=0.04) and Pmax and MVD(mean) in curve type C (r(s)=0.86; P=0.006). No positive correlation was found between Pmax and MVD (mean, center and margin) in curve type B. No significant correlation was found for slope and washout. VEGF score correlated positively with curve types (r(s)=0.67; P<0.001).

CONCLUSION

A relevant association between perfusion curve profiles and angiogenesis was found in malignant nodules having early washout and in benign lesion with a slow increase of enhancement. In cases of strong signal increase without washout additional factors for enhancement must be considered. The use of curve profiles could allow for the estimation of the extent of VEGF.

[Managing small pulmonary nodules in head and neck malignant tumors]

The recent increase in the use of helical CT has produced a higher detection rate of small pulmonary nodules than in conventional CT application, and has presented a serious problem in their treatment. We carried out a retrospective study to identify a clinical standard in the management of those nodules in head and neck malignant tumors. The subjects were 108 in-and out patients (87 men and 21 women) with head and neck malignant tumors who received radiation therapy in our university hospital between 2003 and 2004 (ages ranging from 25 to 93 years; mean, 66 years). Helical CT of the chest was applied to 92 patients of the 108 (85%). We determined small pulmonary nodules as round nodules 5 mm or more and less than 1 cm in diameter, and observed them in 14 of the 92 (15%). Firstly, we compared nodule growth by dividing the patients into 2 groups. The nodules grew in 2 of 7 patients of Group I, where chemotherapy was not done or where chemotherapy was not effective on the primary tumor, and in 3 of 7 patients of Group II, where chemotherapy was effective on the primary tumor. Secondly, disregarding the effects of chemotherapy, we analyzed nodule growth: the nodules grew in 5 of the 14 patients (36%). Those small pulmonary nodules were all pulmonary metastases. When small pulmonary nodules are detected by helical CT, accompanying malignant tumors of the head and neck, and bearing in mind the probability of their growth of at least 36%, we should therefore follow them up carefully.

Node dissection for solitary interlobar node metastasis from renal cell carcinoma by VATS

We present an unusual case of a patient with a right pulmonary interlobar node metastasis from renal cell carcinoma following nephrectomy. She underwent interlobar node dissection (ND) by video-assisted thoracoscopic surgery (VATS). Interlobar ND without lobectomy by VATS has not been reported until now in English literature. The retraction of the right intermediate bronchus is a useful technique during this procedure.

Simultaneous thoracoscopic wedge resection of a solitary lung nodule and laparoscopic partial nephrectomy for a renal mass

Approximately 33% of patients with renal cell carcinoma will present with metastases. Patients have a reported 35% 5-year survival rate in instances in which nephrectomy and surgical resection of a solitary metastasis have been performed. Laparoscopic partial nephrectomy has become an increasingly viable option in the treatment of some renal cancers. We report a case in which a patient had a solitary lung nodule in the workup for a renal mass. This patient underwent combined thoracoscopic and laparoscopic resection of both the lung nodule and the renal mass in the same setting.

Solitary pulmonary nodules: dynamic contrast-enhanced MR imaging--perfusion differences in malignant and benign lesions

PURPOSE

To determine whether dynamic contrast material-enhanced magnetic resonance (MR) imaging with use of kinetic and morphologic parameters reveals statistically significant differences between malignant and benign solitary pulmonary nodules.

MATERIALS AND METHODS

Fifty-eight patients met the inclusion criteria of a solitary 5-40-mm pulmonary nodule without calcification or fat at computed tomography. Fifty-one patients were examined successfully; 46 received a histologic diagnosis, and five received a diagnosis by means of observation over 2 years. Dynamic MR images were acquired every 10 seconds for a total of 4 minutes. Diagnostic characteristics for differentiation were examined by using threshold values for maximum peak enhancement, slope of enhancement, and washout. Receiver operating characteristic curves were calculated to test the usefulness of these parameters. The diagnostic performance of a combination of curve profiles and morphologic contrast material distribution were tested by using a decision tree.

RESULTS

Frequency of malignancy was 53% (27 of 51 nodules). Malignant nodules showed stronger enhancement with a higher maximum peak and a faster slope (P <.001). Significant washout (>0.1% increase in signal intensity per second) was found only in malignant lesions (14 of 27 lesions). Sensitivity, specificity, and accuracy were 96%, 88%, and 92%, respectively, for maximum peak; 96%, 75%, and 86% for slope; and 52%, 100%, and 75% for washout. When curve profiles and morphologic enhancement patterns were combined, sensitivity increased to 100%.

CONCLUSION

Dynamic MR imaging delineates significant kinetic and morphologic differences in vascularity and perfusion between malignant and benign solitary pulmonary nodules. Washout seems to be highly specific for malignancy.

Use of FDG-microPET for detection of small nodules in a rabbit model of pulmonary metastatic cancer

OBJECTIVE

The performance of microPET using 18F-FDG was evaluated in a rabbit model of hematogenous pulmonary metastatic cancer.

METHODS

A total of 15 Japanese white rabbits and VX-2 carcinoma were used in this study. In the microPET study, tumor-bearing rabbits were administered intravenously 74 MBq of 18F-FDG, and 30 min later, the emission data were acquired for 60 min. The transmission scans were performed with a 68Ge/68Ga external point source. To augment the anatomical information, we performed multi-detector row computed tomography (MDCT) in the combination with MDCT and microPET on 10 rabbits. The other 5 rabbits were followed once a week for 5 weeks only by microPET. Tumor/muscle (T/M) ratios were used for quantitative evaluation in this study.

RESULTS

Multiple pulmonary nodules were detected by MDCT and microPET starting 14 days after the tumor injection. The high-uptake lesions in the lung detected by microPET corresponded well to the tumors detected by MDCT. The smallest nodule detected by microPET was ca. 1.5 mm in diameter. Overall, 87 nodules were detected by MDCT and the ratios of lesions detected by microPET to those by MDCT were 35.3%, 77.5%, and 90% for tumors equal to or smaller than 2 mm, 2-4 mm, and 4-6 mm in diameter, respectively. The respective T/M ratios were 2.41 +/- 0.41, 2.93 +/- 0.55, and 3.34 +/- 0.71. The T/M ratio increased with tumor size, but it was similar in each tumor size category. In the 35-day follow-up protocol, it was possible to follow sequentially the same tumor by the microPET.

CONCLUSIONS

By FDG-microPET, it is possible to evaluate tumors larger than 2 mm in diameter and to follow the growth of individual tumors. Our results also suggest that the rabbit model of VX-2 pulmonary metastasis is a stable experimental model for evaluation using FDG. Monitoring of the therapeutic effects of anticancer drugs and radiation therapy could be tried by using this model and microPET.

Endothoracic nodules in patients who under-went nephrectomy for renal cell carcinoma. Results of surgical resection

AIM

A review of our experience with surgical resection of endothoracic nodules in patients who underwent nephrectomy for renal cell carcinoma (RCC) is presented, to evaluate the incidence of metastases in our series and the effectiveness and the opportunity of surgical treatment in this sort of patients.

METHODS

Between January 1988 and January 2002, 41 consecutive patients (33 men, 8 women) underwent resection for suspected endothoracic metastases from RCC; 1 more male patient for metastases from an occult renal cancer. Mean age was 62 y (range: 43-80 y). Mean time between nephrectomy and 1st pulmonary resection in 41 patients was 29 mo (range: 0-120 mo). Nineteen patients had solitary lesions, 11 multiple unilateral and 12 bilateral. Antero-lateral thoracotomy was performed in 37 patients, median sternotomy in 1, simultaneous bilateral thoracotomy (clam-shell) in 2, sterno-laparotomy in 1, thoracofrenolaparotomy in 1. Wedge excision was performed in 36 patients, lobectomy with lymphadenectomy in 5, mediastinal limphadenectomy in 1. Six patients had repeat resection for recurrent metastases.

RESULTS

Only 24 patients (57%) had histologic diagnosis of pulmonary metastases from RCC; 11 (26%) had benign lesions; 7 (17%) primary lung cancer. Mean follow-up was 25 mo (range: 1-91 mo). Overall, 4-y survival was 50%. Patients with solitary metastasis had a lower survival than those with 4 and more lesions.

CONCLUSION

The evidence of pulmonary nodules in patients submitted to nephrectomy for RCC is not necessarily indicative of metastatic disease. Pulmonary resection for RCC metastases, even bilateral and recurrent, may help prolong survival in selected patients.

Long term survival of thoracoscopic metastasectomy vs metastasectomy by thoracotomy in patients with a solitary pulmonary lesion

AIMS

The aim of this study was to compare long term survival after resection of solitary pulmonary metastasis on CT scan performed by either thoracoscopy or through a standard thoracotomy.

METHODS

Patients with a solitary, CT scan confirmed, peripherally located lesion suspected for metastasis, less than 3cm in diameter were included. End points were: postoperative complication rate, disease free and overall survival and location of recurrence in the lung.

RESULTS

Thirty-five patients who underwent a thoracoscopic metastasectomy with (n=19) or without (n=16) confirmatory thoracotomy were included in this study. Patients experienced more complications following a thoracotomy (n=5) compared to those who had a thoracoscopy (n=0) (P=0.049). Two patients appeared to have further disease at thoracotomy besides the CT scan identified lesion, and some at thoracoscopy. At definitive histology, seven lesions were benign and eight appeared to be a second primary. Analysis of 20 patients with histological confirmed metastasis demonstrated a 2-year disease free and overall survival rate of 50% and 67% respectively following thoracoscopic metastasectomy (n=8) compared to 42% and 70% respectively following confirmatory thoracotomy (n=12). Recurrence occurred in three of the patients after thoracoscopic metastasectomy and in five patients after thoracotomy.

CONCLUSION

Our results suggest that thoracoscopic resection of solitary peripherally located metastasis is a safe and potentially curative procedure with a long term outcome that is comparable with that after resection by thoracotomy.

Thyroid carcinoma: iodine-131-negative whole-body scan reverses to positive after a combination of thyrogen stimulation and withdrawal

PURPOSE

Reports state that scan results for as many as 25% of patients with differentiated thyroid carcinoma will convert to iodine-131 (I-131) negative over time with positive thyroglobulin levels. Tl-201, positron emission tomography (PET), and sestamibi or tetrofosmin have all helped to identify I-131-negative thyroid carcinomas. The authors have identified a case of reversal of I-131 findings from negative to positive after short-term thyroxine withdrawal combined with treatment with recombinant human thyroid-stimulating hormone (rhTSH).

MATERIALS AND METHODS

The authors obtained multiple I-131 whole-body scans with 4-week thyroid hormone withdrawal, post-I-131 therapy scans, nonthyroid withdrawal Tl-201 chloride whole-body tumor images, and finally combined 2.5-week thyroid hormone withdrawal and rhTSH-stimulation I-131 whole-body scans before and after therapy.

RESULTS

The authors examined one patient during a period of 9 years whose I-131 whole-body scan results were at first positive and then became negative. After a combination of rhTSH stimulation and thyroid hormone withdrawal, the results changed again to I-131 positive.

CONCLUSIONS

This is the first known case in which I-131 findings changed from negative to positive. A combination of rhTSH stimulation and nearly adequate withdrawal may help convert more I-131-negative whole-body scans to positive.

Amelanotic malignant melanomas of the oral mucosa

Oral amelanotic melanomas are rare and the prognosis is poorer than that of pigmented melanomas because of delays in establishing the correct diagnosis and in the initiation of treatment. Amelanotic forms are also thought to be biologically more aggressive than pigmented melanomas. We have seen three cases of oral amelanotic melanomas since 1970, in two of whom the diagnosis was long delayed. Two lesions were not pigmented but one had slight pigmentation. One patient simultaneously had both an amelanotic and a pigmented melanoma in the oral cavity. Lymph node metastases and distant metastases developed in all patients, two of whom eventually died of the disease. Early diagnosis by histological examination together with immunostaining with S100 and HMB-45 are the keys to improve survival for patients with amelanotic melanoma.

Solitary pulmonary nodules in patients with extrapulmonary neoplasms

PURPOSE

To determine the frequency of single lung metastasis, primary lung cancer, and benign lesions in patients with a solitary lung nodule and a primary extrapulmonary neoplasm.

MATERIALS AND METHODS

The authors evaluated the electronic charts of 149 patients with an extrapulmonary malignant neoplasm and a solitary pulmonary nodule. The histologic characteristics of the nodule were correlated with those of the extrapulmonary neoplasm and with patient age and smoking history.

RESULTS

Patients with carcinomas of the head and neck, bladder, breast, cervix, bile ducts, esophagus, ovary, prostate, or stomach were more likely to have primary bronchogenic carcinoma than lung metastasis (ratio, 25:3 for patients with head and neck cancers; 26:8 for patients with other types of cancer combined). Patients with carcinomas of the salivary glands, adrenal gland, colon, parotid gland, kidney, thyroid gland, thymus, or uterus had fairly even odds (ratio, 13:16). Patients with melanoma, sarcoma, or testicular carcinoma were more likely to have a solitary metastasis than a bronchogenic carcinoma (ratio, 23:9). Thirty patients had a benign nodule. There was substantial overlap in age distribution among the patients with benign disease, lung cancer, and metastasis, although no patient younger than 44 years had a lung cancer. Smokers had a 3.5-fold higher chance of developing lung cancer compared with nonsmokers.

CONCLUSION

The likelihood of a primary lung cancer versus a metastasis depends on the histologic characteristics of the extrapulmonary neoplasm and the patient's smoking history.

[Solitary pulmonary nodule in a patient with treated carcinoma of the renal pelvis: metastatic disease?]

OBJECTIVE

To describe a case of a solitary pulmonary nodule in a patient that had been treated for carcinoma of the renal pelvis.

METHODS

A solitary pulmonary nodule was detected on the chest film of a patient that had been treated for carcinoma of the renal pelvis. The characteristics of the nodule are described and its diagnosis, with special reference to metastasis and primary pulmonary carcinoma, is discussed.

RESULTS

The anatomopathological study demonstrated a chondroid hamartoma.

CONCLUSIONS

A metastatic or a primary tumor is suspected when a solitary pulmonary nodule is detected in a patient that has been previously treated for urothelial carcinoma. However, other types of lesions with a more favourable outcome cannot be discarded, such as chondroid hamartoma as in the case described herein.

[Thoracoscopic surgery for pulmonary nodules in patients with previous malignant tumor]

We evaluated the clinico-pathological characteristics of thirty-four cases with previous malignant tumor who was operated under thoracoscopy for pulmonary nodules. In twenty-three cases (67.6%), including 20 cases suspected metastatic pulmonary tumor before operation, thoracoscopic surgery was performed without doing the preoperative examinations for the definite diagnosis. The mean diameter of resected tumors was 13.5 mm and the definite diagnosis was determined in all cases by the intraoperative pathological diagnosis. There were 26(76.5%) cases of malignancy, including 20 cases(58.8%) of metastatic pulmonary tumor and 6 cases (17.7%) of primary lung cancer. Accuracy rate of predictive diagnosis before operation was 67.6%. From the analysis of difference between pre- and post-operative diagnoses, inflammatory nodules or tuberculoma in the solitary nodule and intrapulmonary lymph nodes or silicotic nodules in the multiple nodules should have been considered with more carefully attention. Univariate and multivariate analysis showed that patients with metastatic tumor previously was only a predictive factor for metastatic tumor. Age, gender, CT findings, the number of nodules, disease free interval and tumor markers were unreliable factors in this study. In conclusion, there were a lot of cases with previous malignant tumor in which thoracoscopic surgery could become a first choice of modalities for the diagnosis of pulmonary nodules. Early thoracoscopic procedure will be recommended for such patients to perform the immediate treatment.

Significance and management of computed tomography detected pulmonary nodules: a report from the National Wilms Tumor Study Group

PURPOSE

To define the optimal treatment for children with Wilms tumor who have pulmonary nodules identified on chest computed tomography (CT) scan, but have a negative chest radiograph, we evaluated the outcome of all such patients randomized or followed on National Wilms Tumor Study (NWTS)-3 and -4.

PATIENTS AND METHODS

We estimated the event-free and overall survival percentages of 53 patients with favorable histology tumors and pulmonary densities identified only by CT scan (CT-only) who were treated as Stage IV with intensive doxorubicin-containing chemotherapy and whole-lung irradiation, and compared these to the event-free and overall survival percentages of 37 CT-only patients who were treated less aggressively based on the extent of locoregional disease with 2 or 3 drugs, and without whole-lung irradiation.

RESULTS

The 4-year event-free and overall survival percentages of the 53 patients with CT-only nodules and favorable histology Wilms tumor who were treated as Stage IV were 89% and 91%, respectively. The 4-year event-free and overall survival percentages for the 37 patients with CT-only nodules and favorable histology who were treated according to the extent of locoregional disease were 80% and 85%, respectively. The differences observed between the 2 groups were not statistically significant. Among the patients who received whole-lung irradiation, there were fewer pulmonary relapses, but more deaths attributable to lung toxicity.

CONCLUSIONS

The current data raise the possibility that children with Wilms tumor and CT-only pulmonary nodules who receive whole lung irradiation have fewer pulmonary relapses, but a greater number of deaths due to treatment toxicity. The role of whole lung irradiation in the treatment of this group of patients cannot be definitively determined based on the present data. Prolonged follow-up of this group of patients is necessary to accurately estimate the frequency of late, treatment-related mortality.

Helical CT of pulmonary nodules in patients with extrathoracic malignancy: CT-surgical correlation

OBJECTIVE

Our aim was to assess the sensitivity of helical CT for revealing pulmonary nodules. Thoracotomy with palpation of the deflated lung, resection, and histologic examination of palpable nodules was used as the gold standard.

SUBJECTS AND METHODS

Thirteen patients underwent helical CT (slice thickness, 5 mm; reconstruction intervals, 3 mm and 5 mm; interpreted by two independent observers). Subsequently, patients underwent unilateral (n = 6) or bilateral (n = 7) surgical exploration, and CT-surgical correlation of 20 lungs was performed.

RESULTS

Ninety nodules were resected (61 were smaller than 6 mm; 13 were 6-10 mm; 11 were larger than 10 mm; in five nodules, the size was not recorded at surgery). Sixty-nine nodules were located in the pulmonary parenchyma and 21 in the visceral pleura. Of the 90 lesions, 43 (48%) were found on histology to represent metastases. For lesions detected by at least one observer, the sensitivity of helical CT was 69% for intrapulmonary nodules smaller than 6 mm, 95% for intrapulmonary nodules larger than or equal to 6 mm, and 100% for histologically proven intrapulmonary metastases larger than or equal to 6 mm. For lesions smaller than or equal to 10 mm, sensitivity was better using a reconstruction interval of 3 mm rather than of 5 mm.

CONCLUSION

In this study, the sensitivity of helical CT exceeded the sensitivity of conventional CT in previous reports. However, because of limitations in the detection of intrapulmonary nodules smaller than 6 mm and of pleural lesions, complete surgical exploration should remain the procedure of choice in patients undergoing pulmonary metastasectomy. Preoperative helical CT should be used to guide the surgeon to lesions that are difficult to palpate.

Pulmonary nodules in patients with esophageal carcinoma

The clinical significance of lung nodules in patients with esophageal carcinoma has received little attention. Therefore, we carried out a retrospective detailed review of 116 consecutive cases of esophageal carcinoma, including 98 squamous cell cancers, seen at the Philadelphia Veterans Affairs Medical Center between 1984 and 1997. Seventy-four percent of our patients were black; it was not surprising therefore that 84% of our patients in this series had squamous cell cancers. Initially, chest radiographs, computed tomography (CT) scans, or thoracotomy showed solitary pulmonary nodules in 22 (19%) patients. A definitive diagnosis was established in 19 patients, including 15 (68%) benign nodules and 4 (18%) new primary lung carcinomas. Three (14%) nodules were indeterminate, but in no case could a solitary lung metastasis be identified. Radiographic evidence of multiple lung metastases was present, however, in 4 (3%) of 116 patients at diagnosis. Autopsies of six patients were later performed, and three showed multiple lung metastases; two of these patients had negative chest radiographs shortly before death. Our experience suggests that for a cohort of mostly squamous cell esophageal cancers, a solitary lung metastasis is rare at diagnosis; a solitary pulmonary nodule at this time likely represents a benign abnormality or primary lung cancer. Multiple pulmonary metastases are also very unusual at diagnosis, probably become increasingly common during the terminal phases of disease, and may be radiographically occult.

Detection of pulmonary nodules with helical CT: comparison of cine and film-based viewing

OBJECTIVE

The purpose of our study was to determine whether cine viewing of helical CT scans of the chest improves the detection of pulmonary nodules in patients with known extrathoracic malignancy.

SUBJECTS AND METHODS

Identical helical CT studies of the chest of 60 patients with known extrathoracic malignancy were reviewed for detection of pulmonary nodules. Four radiologists interpreted the helical CT studies. Pulmonary nodules were divided into four groups according to maximum diameter: group 1, nodules smaller than or equal to 5 mm; group 2, nodules larger than 5 mm but smaller than or equal to 10 mm; group 3, nodules larger than 10 mm but smaller than or equal to 20 mm; group 4, nodules larger than 20 mm. Interpreters also assigned a lesion conspicuity score of pulmonary nodules based on a four-point scale: one point for poor visibility, two points for adequate visibility, three points for good visibility, and four points for excellent visibility. Static film-based images printed on a laser printer were viewed on a light box. Cine viewing of helical CT scans from the same examinations was done on a commercially available workstation. The number, diameter, and conspicuity scores of pulmonary nodules detected at lung window settings were documented.

RESULTS

Interpreters saw 266 nodules on cine viewing, whereas 237 nodules were seen with static film-based viewing. A significantly higher percentage of nodules that were smaller than or equal to 5 mm in diameter was found with cine viewing (n = 106) than with static film-based viewing (n = 81) (p < .05). Cine viewing (n = 105) also allowed a slightly but not significantly higher detection rate of nodules that were larger than 5 mm but smaller than or equal to 10 mm in diameter than did static film-based viewing (n = 101). We found no differences between cine (n = 55) and static film-based viewing (n = 55) in the detection of pulmonary nodules that were larger than 10 mm in diameter. The mean conspicuity score of nodules was significantly higher with cine viewing (2.9 +/- 0.2) than with film-based viewing (2.4 +/- 0.2) (p < .05).

CONCLUSION

Cine viewing of helical CT scans significantly increases the detection rate of pulmonary nodules that are smaller than or equal to 5 mm in diameter. However, we found no significant difference between cine and film-based viewing in the detection rate of pulmonary nodules that were larger than 5 mm in diameter. The advantages of cine viewing may be attributed to both the larger image size and the ability to scroll through images for improved differentiation between vessels and nodules.

A case of malignant fibrous histiocytoma of the lung arising as a third primary tumor

A case of primary malignant myxoid fibrous histiocytoma of the lung presenting as a solitary lung nodule in a 61-year-old man is presented. This tumor arose in a patient with a transitional-cell carcinoma of the urinary bladder and a well differentiated squamous-cell carcinoma of the larynx. The differential diagnosis between a primary lung tumor, versus a solitary metastasis is difficult and was supported by histological features and the lack of epithelial properties proved by immunohistochemistry. Tobacco was the only etiologic factor known in the patient.

A case of extragonadal germ cell tumor with elevated postchemotherapy HCG successfully treated by resection of a solitary metastasis and chronic oral etoposide

We report a 39 year-old man with disseminated extragonadal germ cell tumor (GCT), whose serum level of human chorionic gonadotropin (HCG) increased again after platinum-based combination chemotherapy, high-dose chemotherapy with autologous bone marrow rescue and radical adjunctive surgery. The increase in the HCG level was progressive in spite of multiple chemotherapy, and after a while, a coin lesion in the right lung was identified by chest roentgenography. The pulmonary lesion was refractory to additional chemotherapy. After a systemic survey to confirm that the lesion was solitary, video-assisted thoracoscopic wedge resection of the right lower lobe was performed. Because the resected tumor included viable tumor cells and the serum HCG level remained slightly high one month after the operation, oral low-dose etoposide was begun. In a short time, the level of the serum tumor marker decreased and remained normal during the subsequent 7 months of therapy and thereafter. The patient remains in complete remission 13 months after completion of the final therapy and 3 years after the initial diagnosis. Even if the level of a serum tumor marker is high, salvage resection can be a promising therapeutic option for operable tumors that are refractory to chemotherapy. The usefulness of chronic oral etoposide for patients with GCT should be examined by further clinical trials.

Isolated late metastasis of a renal cell cancer treated by radical distal pancreatectomy

A 53-year-old man underwent right nephrectomy for a locally renal cell carcinoma with concomitant resection of a solitary metastasis in the right lung. Ten years later, he presented with haematochezia caused by a tumour in the tail of pancreas, invading the transverse colon and the greater curvature of the stomach. The tumour was radically resected, and histological examination revealed a solitary metastasis of the previous renal cell carcinoma. This case illustrates a rare indication for pancreatic resection because of pancreatic metastasis.

Metastatic breast carcinoma to the os calcis presenting as heel pain

A 47-year-old woman who had been treated for breast carcinoma 11 years previously developed significant heel pain of unclear etiology, which ultimately proved to be metastatic adenocarcinoma. A low index of suspicion and falsely negative plain radiographs contributed to a delay in diagnosis. No other osseous metastases besides those to the foot were identifiable at the time of diagnosis. Breast carcinoma is one of the most common malignancies and frequently metastasizes to bone. Despite this, metastases to the hands or feet (acrometastases) have been identified in only a few cases. It is likely that acrometastases are more common than reported but unrecognized.

Role of videoendoscopy in pulmonary surgery: present experience

Videothoracoscopic techniques were utilized in managing 88 consecutive patients. The series was composed of 36 patients with pneumothorax, 44 cases of single and 9 of multiple pulmonary nodules and 1 patient with diffuse lung disease. In 14 cases (15.9%) conversion to open thoracotomy was necessary while in the remaining 74 patients the procedure (30 blebectomies, 2 bullectomies, 37 wedge resections, 6 lobectomies and one multiple biopsies) were carried out as planned. In each lobectomy and in six wedge resections an accessory small incision was necessary; we consider only this video-assisted thoracic surgery (VATS). Benign disease, aside from the blebs and bullae, was found in 12 cases of solitary pulmonary nodules and in 1 case of multiple lesions, while malignant lesions were detected in 31 patients. Primary carcinoma was diagnosed in nine cases after a wedge resection had been performed on a suspicious solitary nodule. In two of these wedge resection had to suffice because of poor lung function, while in the remaining seven cases, a lobectomy was carried out through an open thoracotomy in two patients, and in five cases VATS was attempted successfully in four, while in one case a formal thoracotomy was necessary due to bleeding. Solitary metastases were found in 14 patients and were managed by 12 wedge resections and 2 lobectomies. Seventy-one patients (97.3%) had an uneventful postoperative course while 2 (2.7%) had only minor complications. No recurrences were observed, however follow-up is limited. Videothoracoscopy techniques are very useful and are good alternatives to conventional thoracotomy in managing cases of pneumothorax, benign pulmonary lesions and in taking biopsies.(ABSTRACT TRUNCATED AT 250 WORDS)

CT-guided localizations of pulmonary nodules with methylene blue injections for thoracoscopic resections

As only peripheral subpleural lesions can be visualized at thoracoscopy, deep nonpalpable pulmonary nodules have to be identified before performing wedge resections. We evaluate the efficiency of computed tomographic (CT) guided methylene blue injections to localize these nodules before their thoracoscopic resection. Twenty-three nodules in 21 patients were preoperatively localized under CT guidance and marked with methylene blue injections. The localizations under CT guidance of the 23 nodules were successful in all cases. The surgeon confirmed accurate localization of 22 nodules. In one case, the injected methylene blue could not be identified during thoracoscopy. Complications of this technique included six cases of asymptomatic pneumothorax, four cases of local and asymptomatic pulmonary hemorrhage, and two cases of fit of coughing. Because of this technique, 22 thoracotomies could be avoided and the duration of the hospital stay was then reduced. Computed tomographic-guided localization with methylene blue injection is a simple, effective, and rapid technique enabling good thoracoscopic surgery results.

Crystalloids in metastatic prostatic adenocarcinoma

The authors report a case of metastatic prostate cancer masquerading as a primary lung tumor. Histologically, the lung tumor displayed eosinophilic crystalloids in the malignant glands typical of those previously described in prostatic adenocarcinoma. Review of histologic material from 30 additional patients with metastatic prostate cancer failed to reveal crystalloids in the metastases. Seven patients with histologic material from locally advanced prostatic adenocarcinoma, defined as spread to the rectum, bladder, or nonnodal pelvic soft tissue, were also reviewed. One of these patients demonstrated crystalloids in the bladder extension of locally advanced prostatic adenocarcinoma. Although rare, the presence of crystalloids may be used as strong evidence for the prostatic origin of an adenocarcinoma of uncertain origin.

Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule

Traditional nonoperative diagnostic approaches to the indeterminate solitary pulmonary nodule include bronchoscopy and percutaneous needle biopsy. Although both methods are minimally invasive, the diagnosis of the small, peripheral nodule may remain elusive. Open thoracotomy is often required when these methods fail to obtain a diagnosis. Between January 1991 and June 1992, 242 patients with indeterminate solitary lung nodules underwent thoracoscopic excisional biopsy as the primary diagnostic method. Wedge excisions of the nodules were all performed by thoracoscopic techniques using an endoscopic stapler alone (72%), neodymium:yttrium-aluminum garnet laser (18%), or both (10%). A definite diagnosis was obtained in all patients. Two patients required conversion to thoracotomy to locate the nodule (both malignant). A benign diagnosis was obtained in 127 patients (52%) and a malignant diagnosis in 115 (48%). Of the malignant nodules, 51 (44%) were primary lung cancer and 64 (56%) were metastases. All patients diagnosed with primary lung cancer having adequate pulmonary reserve (n = 29) underwent formal open lung resection during the same procedure. There was no mortality, and significant morbidity was limited to atelectasis in 3 patients (1.2%), pneumonia in 2 patients (0.8%), and prolonged air leak more than 7 days in 4 patients (1.6%). Average hospital stay for patients having thoracoscopy only (n = 213) was 2.4 days (range, 1 to 12 days). Thoracoscopy offers a minimally invasive approach for the diagnosis of the indeterminate solitary nodule. It has advantages over traditional diagnostic methods of being virtually 100% sensitive and 100% specific with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Solitary coin lesion in patients with malignant melanoma: an indication for thoracotomy?

In five patients solitary pulmonary lesions were detected radiographically during routine follow up after malignant melanoma. Surgical removal was done in each case under the tentative diagnosis of metastases. Histologically, two lesions turned out as benign chondroma, one as organized pulmonary infarction and one as bronchogenic carcinoma. Only in one patient was a melanoma metastasis present. The findings underline the usefulness also in malignant melanoma of a surgical approach in suspected solitary pulmonary metastases.

Pulmonary metastatic disease: radiologic-surgical correlation

Radiologic-surgical correlative studies were performed for new pulmonary parenchymal nodules in 100 lungs of 84 patients with previously treated extrathoracic malignancies. Ten patients with radiographically typical bronchogenic carcinomas were excluded from analysis. Of 237 nodules resected, 173 (73%) were identified with computed tomography (CT) and 64 (27%) were not. Two hundred seven (87%) were of metastatic origin, 21 (9%) were benign, and nine (4%) were bronchogenic carcinomas. Of those nodules seen with CT and not with radiography of the chest, 84% were of metastatic origin. Between patients with carcinoma and those with sarcoma or melanoma, there was little difference in the percentage of nodules found with CT. More resected nodules were metastases in the sarcoma-melanoma group (93%) than in the carcinoma group (77%). New bronchogenic carcinomas and benign lesions were more common in the carcinoma group. Chest radiography disclosed all nodules resected in 44% of cases, whereas CT disclosed 78%. Of 65 nodules detected as solitary nodules with chest radiography, only 35 (54%) proved to be truly solitary, whereas 35 of 44 (80%) detected with CT were truly solitary.

[The solitary pulmonary nodule. A radiologic and clinical approach (author's transl)]

The cases of pulmonary coin lesions operated at the National Cancer Institute of Milan during the last ten years are presented. Both the disadvantages of early thoracotomy as well as watchful waiting are discussed. Therefore different parameters with the aim to select the patients with the highest probability of cancer are analysed. Finally we tried to identify a diagnostic-therapeutic approach to reduce the complications and risks of thoracotomy in non-oncologic patients.