Mediastinal lymph node metastases from gastrointestinal carcinoma

Solitary metastasis to a superior mediastinal lymph node after distal gastrectomy for gastric cancer: a case report

Background

Mediastinal lymph node metastases occasionally occur in patients of advanced gastric cancer of the cardia with esophageal invasion, but they rarely occur in patients with gastric cancer of other sites. This report describes a case of a solitary metastasis to t a superior mediastinal lymph node after distal gastrectomy for gastric cancer of the antrum.

Case presentation

A 70-year-old man underwent curative distal gastrectomy for advanced gastric cancer of the antrum (pT2pN2M0, stage IIB). Postoperatively, he underwent adjuvant chemotherapy with S-1 (100 mg/day). Although the serum levels of his tumor markers increased after surgery, computed tomography scans did not detect evidence of early recurrence in the superior mediastinum. However, a ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed accumulation of fluorodeoxyglucose in the upper mediastinum with no evidence of recurrence elsewhere. Therefore, a solitary superior mediastinal lymph node was suspected to have a metastatic lesion derived from the gastric cancer. The patient underwent tumor resection right mini-thoracotomy two years and three months following gastrectomy. A pathological examination demonstrated moderately differentiated adenocarcinoma, confirming that it was a metastatic adenocarcinoma from the gastric cancer. The patient developed recurrences in the superior mediastinum and several right costa six months following the second surgery. He was treated with chemotherapy, but he died 18 months after the second operation.

Conclusion

We present a rare case of a solitary metastasis to a superior mediastinal lymph node after distal gastrectomy for gastric cancer. An FDG-PET scan is useful for the diagnosis of mediastinal lymph node metastasis in gastric cancer. Metastasis to the superior mediastinal lymph nodes from gastric cancer in sites other than the cardia suggests systemic expansion of gastric cancer, and therefore, even a solitary metastasis may be related to a poor prognosis.

[Metastatic thoracic lymph node carcinoma from extra-thoracic malignancy or from unknown primary site]

Malignant mediastinal lymph nodes without pulmonary disease may be lymphomatous or the metastases from thoracic or extrathoracic malignancy. More rarely, metastatic lymph nodes are without primary site. Surgery is generally diagnostic, restricted to confirming the metastatic process, because of too numerous and disseminated or unresectable lymph nodes. Radical surgery consisting in lymphadenectomy can be effective in case of mediastinal lymph node malignancy without other extra- and intrathoracic disease. We observed in our experience and in several case reports long-term good results in such cases. We suggest that including surgery in the multimodality treatment of mediastinal metastatic lymph nodes may be advisable in selected patients.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal and hilar lymph node metastases in patients with extrapulmonary malignancy

OBJECTIVE

The determination of mediastinal lymphadenopathy is important in the management of extrapulmonary malignancy. The purpose of this study was to determine the diagnostic performance of EBUS-TBNA in the diagnosis of mediastinal and hilar lymphadenopathy in patients with proven or suspicious extrapulmonary malignancy.

PATIENTS AND METHODS

Retrospective analysis was performed in 57 patients (81 lesions) with proven (n=51) or suspicious (n=6) extrapulmonary malignancies who underwent EBUS-TBNA between May 2009 and January 2011.

RESULTS

There were 37 male and 20 female patients, with a median age of 64 years. Thirty-five (61.4%) patients were confirmed as malignancy (34 extrapulmonary malignancy and 1 primary lung cancer) and 22 (38.6%) patients were confirmed as benign. EBUS-TBNA identified malignancy in 30 patients. One patient who was diagnosed as primary lung cancer was excluded from diagnostic performance analysis. Overall cancer prevalence was 61% in 56 study patients. The diagnostic sensitivity, accuracy, and negative predictive value of EBUS-TBNA per patient were 88%, 93%, and 85%. The diagnostic sensitivity, accuracy, and negative predictive value of PET/CT scan per patient were 81%, 82%, and 71%, respectively. There were no serious complications related to EBUS-TBNA.

CONCLUSION

Since mediastinal and hilar lymphadenopathy do not always result from metastases in patients with extrapulmonary malignancy, histopathologic confirmation is mandatory. EBUS-TBNA is a sensitive modality and can be considered as the initial test for the histopathological diagnosis of mediastinal and hilar lymphadenopathy in patients with extrapulmonary malignancy.

[Isolated malignant mediastinal lymphadenopathy]

Mediastinal adenopathies without pulmonary disease may be benign, lymphomatous or the metastases from intra- or extrathoracic malignancy or more rarely metastases with unknown primary site. We observed 507 patients with isolated mediastinal adenopathies: benign, lymphomatous and metastatic disease represented 41.4% (210/507), 26.8% (136/507), 31.8% (161/507) of them, respectively. Management of the latter was the most challenging. Surgery was generally diagnostic, restricted to confirming the metastatic process, because of too numerous and disseminated or unresectable lymph nodes in 84% of patients (135/161). However, radical surgery consisting in lymphadenectomy proved effective in case of mediastinal lymph node malignancy without other extra- and intrathoracic disease. We observed long-term good results in such cases, which also was demonstrated by case reports in the literature. We suggest that including surgery in the multimodality treatment of mediastinal metastatic lymph nodes may be advisable in selected patients.

Intrathoracic lymph node metastases from extrathoracic carcinoma: the place for surgery

BACKGROUND

Intrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management.

METHODS

Among 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed.

RESULTS

Diagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months).

CONCLUSIONS

HMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

Mediastinal metastases of infradiaphragmatic malignancies

Mediastinal lymph node metastases from infradiaphragmatic malignancies are reported to be a rare occurrence. The results of previous studies have been based on the evaluation of chest radiographs. In this study we retrospectively reviewed the chest and abdominal computed tomography examinations of 50 such patients. Of these, 25 had renal cell carcinoma and the remainder, other genitourinary or gastrointestinal carcinomas. The major nodal groups involved in the mediastinum were the right paratracheal in 41 cases, subcarinal in 31, paraesophageal in 26, and aortopulmonary in 25. Hilar nodes were involved in 21 cases. In the abdomen, para-aortic and or retrocrural adenopathy was present in 29 cases. Of 21 patients with pulmonary metastases, only 12 cases were associated with ipsilateral hilar lymphadenopathy. Supraclavicular lymphadenopathy occurred in only 8 patients. These results suggest that spread of infradiaphragmatic malignancies to the mediastinum occurs primarily by extension from the retrocrural and para-aortic nodes into the thoracic duct and then by antegrade flow in the thoracic duct and its collaterals, with retrograde flow from these channels to the mediastinal nodes.