Document 3Qbma746y8RXerr5dNzDOjybx

PATHOLOGY OF SCALENE LYMPH NODES A n Analysis of 373 Biopsies BERNARDGONDOMS,.D., AND IRVINGM. REINGOLMD.D, ." As EARLY AS 1889, TROISIER~~ DESCRIBED 2.5 cm. I n our series 343 of 373 biopsies had `TadCnopathie" of the neck in diagnos- grossly detectable lymph nodes. ing metastatic cancer. He reported 27 cases of In 30 cases ( S X ) , no lymph nodes were intra-abdominal carcinoma detected by supra- found on gross examination. These specimens clavicular node extension. At the same time, were then serially sectioned and entirely reference was made to Virchow's earlier simi- blocked. Small nodes frequently were so well lar findings, which have been perpetuated by embedded in the fat tissue that they defied the term, "Virchow'snode." Rouvikre'sl5 clas- detection. Microscopic examination identified sical treatise of the anatomy of the lymphatic nodes in 28 of these 30 cases. Only 2 cases, less system in 1938 served to elucidate the path- than 1% of the series, were unsatisfactory be- ways of lymphatic dissemination of malignant cause of the absence of lymph nodes. tumors and particularly to indicate the drain- No attempt was made to determine the age of pulmonary lymphatics into scalene adequacy of the surgery, since several groups lymph nodes. It remained for Daniels3 in 1949 of surgeons over the 10-year period were in- to emphasize the usefulness of scalene lymph volved in removing the lymph nodes. T h e node biopsy as a diagnostic tool. Harken et al.5 experience of the surgeon and the scope of subsequently discussed the prognostic implica- the dissection undoubtedly affect the yield of tions of this procedure in cases of pulmonary positive nodes. carcinoma. Numerous reports have since ap- peared relating positive scalene biopsies in cases of extrapulmonary carcinoma,'!16 lym- RESULTS phoma,lq 297 tuberculosis,7~19 sarcoidosis,l*79 14, Table 1 indicates the numbers and per- 19 and other conditions. centages of positive diagnoses. Of the 373 biopsies, 113 (30.3%) received a specific diag- MATERIALASND METHODS nosis. This figure is comparable to other extended series.19 2, 7, 9-11, Variations in results A review of the Pathology Service of Long of scalene node biopsy studies appear to be Beach Veterans Administration Hospital for related to number of cases included, nature of a ten year period, 1954 to 1963, revealed a hospital population,7 surgical techniques, 8812 total of 373 scalene lymph node biopsies. Clini- and technique of study. cal records as well as autopsy and surgical Pulmonary carcinoma. Considering the en- pathology material were reviewed on all of tire group of patients with proven pulmonary these cases. carcinoma at surgery and/or autopsy, 40.0% The scalene tissue received in our labora- (70 of 175) of scalene biopsies were positive. tory generally consisted of a mass of fat, If the 48 additional cases of probable broncho- measuring on the average approximately genic carcinoma (tissue diagnosis unavailable) 4 ~ 3 x 2cm., within which lymph nodes were embedded. All lymph nodes were isolated and TABLE1 completely sectioned. In most instances, 2 to 8 lymph nodes were found in each specimen and RESULTS OF SCALENE LYMPH NODE BIOPSY they usually measured u p to 1.5 cm. T h e Number greatest number of nodes found in a single case was 15, and the largest node measured Diagnostic Bronchogenic carcinoma 113 (30%) 70 From the Laboratory Service, Veterans Administration Hospital, Long Beach, California 90804, and *The Department of Pathology, Univcrsity of California Medical School, Los Angeles, California 90024. Received for publication June 12, 1964. Extrapulmonary carcinoma Neuroblastoma Lymphoma Tuberculosis Coccidioidomycosis Sarcoid Non-Diagnostic TOTAL 17 1 6 84 No. 1 SCALENLEYMPHNODES Condos and Reingold 85 are included, the above figure becomes 31.4%. In 46 patients, initial tissue diagnosis was made on the basis of scalene node biopsy. As shown in Table 2, undifferentiated carci- nomas of the lung metastasized most often to the scalene nodes, 38 of 71 (53.579, and adenocarcinomas were next, 7 of 14 (50%). Squamous-cellcarcinomas of the lung metastasized to scalene nodes in only 24 of 83 cases (28.9%). Of 5 cases of bronchiolar carcinoma in which scalene fat pad was biopsied, 1 had spread to the nodes. Extrapulmonary carcinoma. Malignant tumor of primary extrapulmonary origin was found in 24 cases (6.4%) of this series. (Table 3). In cases of extrapulmonary carcinoma scalene biopsy was performed for one of several reasons: undiagnosed lymphadenopathy, suspected bronchogenic carcinoma, follow-up on previously diagnosed tumors. 17 of 30 (5701,) were positive, including 7 from the gastrointestinal tract and 5 from the genitourinary system. In most instances a diagnosis of "mucus-secreting adenocarcinoma" (Fig. l), "transitional-cell carcinoma," etc. was made and primary site was determined by appropriate studies. In one case, a definitive diagnosis of follicular carcinoma of the thyroid gland could be made (Fig. 2); the clinical diagnosis had been bronchogenic carcinoma on the basis of a left hilar mass. A thyroidectomy was thereupon performed, confirming the diagnosis; the patient expired 2 years later without necropsy being done. Two cases of squamous cell carcinoma of the esophagus had both been incorrectly diagnosed as bronchogenic carcinoma, one presenting with hemoptysis and the other with a TABLE3 EXTRAPULMONARY TUMORS IN SCALENE LYMPH NODES Previ- Initial Diagnosed ously Dx. by following To- diag- scalene scalene tal nosed Bx. Bx. Gastrointestinal 7 Esophagus 2 Stomach 2 Pancreas 2 Colon 1 Genitourinary 5 Bladder 2 Prostate 2 Testis 1 Lymphoma 6 Other 6 Thyroid 1 Mediastinal ganglioneuro- 1 1 6 1 2 2 2 1 1 2 blastoma 1 1 Breast 11 Primary unknown _ _3 _ -- TOTAL 24 3 8 10 hilar mass. Autopsies performed one week and three weeks following respective biopsies established the correct diagnoses. Of the other gastrointestinal tumors, all adenocarcinomas, two arising in the pancreas each produced death within six weeks, and two originating in the stomach terminated respectively in one and 10 months, the latter following total gastrectomy. A case of metastatic carcinoma of the descending colon was lost to follow-up. Two patients with metastatic transitional cell carcinoma of the urinary bladder expired 3 weeks and 3 months, respectively, fol- TABLE2 HISTOLOGIC CLASSIFICATION OF METASTATIC PULMONARY CANCER I N SCALENE LYMPH NODES Positive Negative Percent node node diagnostic Squan?ous cell carcinoma Adenocarcinoma Undifferentiated carcinoma Bronchiolar carcinoma Mesothelioma (Pleura) TOTAL 24 7 38 1 -- 70 59 7 33 4 -2 105 28.9 50.0 53.5 20.0 - __ 40,0 FIG. 1. Mucus secreting adenocarcinoma in left scalene lymph node metastatic from pancreas. (H. & E. XZOO.) 86 CANCERJanuary 1965 Vol. 18 FIG.2. Follicular adenocarcinoma of thyroid, metastatic to scalene lymph node. (H. & E.~ 1 0 0 . ) lowing positive scalene node biopsy. A 77- year-old male patient with a 6-month history of epigastric discomfort and a hard nodule in the left scalene area containing metastatic adenocarcinoma had a needle biopsy of the prostate gland showing similar tumor. Subsequent laparotomy revealed extensive pelvic lymph node metastases. The patient expired 15 months later with carcinomatosis. Scalene node biopsy of a 51-year-old male who had had previous orchiectomy indicated an embryonal carcinoma. He expired 6 months later and no autopsy was obtained. The scalene lymph nodes of the left side were the ones involved with extrapulmonary carcinomas, except in the case of sigmoid colon carcinoma and of the testis, both of which had palpable, enlarged right sided scalene lymph nodes. L y m p h o m a . Only 1 of 7 patients with a final diagnosis of lymphoma or leukemia had a negative node biopsy. However, in most cases, nodes were palpable and the disease was already fairly widespread; 3 patients with Hodgkin's disease survived 5, 6 and 18 months respectively following positive scalene biopsy, indicating the relatively poor prognosis in these circumstances. A patient with multiple TABLE4 RESULTS OF SCALENE NODE BIOPSIES IN GRANULOMAS Total Positive Per cent Sarcoidosis Tuberculosis Coccidioidomycosis 18 12 -3 33 15 3 -1 19 83 25 3-3 58 myeloma involving scalene nodes expired one month after biopsy with generalized myelomatosis. A patient with chronic lymphatic leukemia and another with lymphosarcoma died within a few months after positive scalene nodes were identified. Granuloma. Scalene lymph node biopsy in non-neoplastic pulmonary diseases is of greatest value in cases of sarcoidosis, and is much less profitable in those of tuberculosis, the mycoses and pneumoconiosis16,19 (Table 4). I n the present series 15 of 18 (83%) cases of sarcoidosis were correctly diagnosed by scalene node biopsy. All 15 were clinically and histologically confirmed. 3 of 12 cases of pul- monary tuberculosis were detected, only 2 in non-palpable nodes. One of 3 cases of coccidioidomycosis was positive (Fig. 3). T w o cases of silicosis had negative scalene lymph node biopsies. Unusual Cases. Two cases of particularly unusual interest merit brief reports. The first was a 60-year-oldwhite male who had tarry stools, anemia and albuminuria. Two lymph nodes, measuring 1.5 cm. and 0.5 cm.,respectively were felt in the left supraclavicular area. Biopsy showed replacement of the nodal architecture by varying sheets of plasma cells in a manner consistent with plasma cell myeloma. Bone marrow and electrophoretic studies confirmed this diagnosis, which was further substantiated at autopsy. The second case was that of a 66-year-old Negro male who had an enlarging posterior mediastinal mass and symptoms of back pain and weight loss. A left scalene node biopsy showed infiltration by large nests and sheets of small round cells embedded in a loose fibrillar matrix of neurogenic appearance. This was diagnosed as "metastatic malignant tumor of neural origin." At autopsy, a mediastinal ganglioneuroblastoma was found with metastases to the brain, liver, left kidney, para- TABLE5 PALPABILITY OF SCALENE LYMPH NODES IN BRONCHOGENIC CARCINOMA Nodes palpable ~~ Nodes non- % palpable % Total cases 175 44 25.1 131 74.9 Positivenodes 70 37 Non-diagnostic 52.9 33 47.1 nodes Percent 105 7 6.6 98 93.4 positive 40.0 84.1 25.2 -No. 1 SCALENELYMPHNODES Gondos and Reingold 57 aortic, supraclavicular and pelvic lymph nodes.4 Each of these cases concerns a tumor in which lymph node involvement is not generally well known. Node Palpability and Nonpalpability. The advisability of performing routine diagnostic scalene biopsies on patients without palpable nodes had been disputed by several authors.6913316 I n order to determine the value of random sampling of non-palpable scalene nodes when clinically indicated, we divided all of our cases into 2 groups, those with palpable lymph nodes, and those without palpable nodes, depending on the clinical examiner's description. I n general, palpable lymph nodes were usually greater than 1.5 cm. in size. As can be seen in Table 5, i n 33 of the 70 cases (47.1%), nodes containing metastatic bronchogenic carcinoma were not clinically palpable. This represented 2501, of the total of cases with non-palpable nodes in this series, figures considerably higher than those of Hellwig et a1.6 who reported 3 of 20 positive nonpalpable nodes. Thus, in almost half of the cases of bronchogenic carcinoma involving scalene lymph nodes, the nodes were not clinically palpable. Three cases of extrapulmonary carcinoma were discovered by biopsy of the scalene fat pad in the absence of clinical lymphadenopathy (Table 6.) I n one, previously referred to above, a 46-year-old Negro male presented with a Horner's syndrome and left hilar mass, and was thought to have a bronchogenic carci- FIG. 3. Coccidioidomycosis involving scalene lymph node. (H. & E. x300.) noma. Biopsy showed follicular adenocarcinoma metastatic from the thyroid gland. Another, a 75-year-old white male with hemoptysis and dysphagia, proved at autopsy to have a squamous cell carcinoma of the esophagus. 2 of the 3 cases of tuberculosis, 8 of the 15 cases of Boeck's sarcoid and the case of coccidioidomycosis did not have palpable nodes. SUMMARY T h e present report analyzes 373 patients who had scalene lymph node biopsies, collected and studied over a 10-year period. Consideration was given to biopsy examination, analysis of surgical and autopsy controlled data, unusual diagnosis, and relationship of TABLE6 PALPABILITY OF SCALENE LYMPH NODES IN OTHER CONDITIONS Total Nodes palpable Nodcs nonpalpable Extra.pulrnonary carcinoma Pos. Scalene node Non-diagnostic node Lymphoma Pos. scalene node Non-diagnostic node Tuberculosis Pas. scalene node Non-diagnostic node Sarcoid Pos. scalene node Non-diagnostic node Coccidioidomycosis POS.scalene node Non-diagnostic node 30 17 13 7 6 1 12 3 9 18 15 3 3 1 2 17 14 3 4 4 0 1 1 0 7 7 0 0 0 0 13 3 10 3 2 1 11 2 9 11 8 3 3 1 2 node palpability to pathologic findings. Scalene lymph nodes were positive in 70 of 175 patients who had bronchogenic carcinoma, in 19 of 33 patients who had pulmonary granulomatous diseases, and in 24 patients who had extrapulmonary malignancies. T h e scalene lymph node biopsy is important as a method of avoiding needless thoracotomy in bronchogenic carcinoma, since a positive scalene node indicates non-resectability of the tumor. It is a method of diagnosing many pulmonary granulomatous diseases, especially sarcoidosis, and many unsuspected extrapulmonary malignancies, including lymphomas, gastro-intestinal carcinomas, and genitourinary carcinomas. 88 CANCERJanuary 1965 Vol. 18 REFERENCES 1. BENNETTW, . A., and CARR,D. T.: Scalene lymphadenopathy; post-mortem study. A m . Rev. TziDerc. 76: 503-505, 1957. 2. CONNARR, . G.: Prescalene and deep cervical lymph node biopsy. Surg. GYnec. O h t . 101: 732743, 1955. 3. DANIELSA,. C.: Method of biopsy useful in diagnosing certain intrathoracic diseases. Dis. Chest lG: 360-366, 1949. 4. GONDOS,B., and REINCOLDI,. M.: Mediastinal ganglioneuroblastoma metastasizing to scalcne lymph nodes in adult; report of case and review of literature. J. Thoracic Surg. 47: 430-437, 1964. 5. HARKEND, . E.; BLACKH, .; CLAUSSR, ., and FARRAND, R. E.: Simple cerviiomediastinal exploration for tissue diagnosis of intrathoracic disease, with comments on recognition of inopcrablc carcinoma of lung. New England 1.M e d . 251: 1041-1044,1954. 6. HELLWIGC., A.: DREESE,W. C.; WELCH,J. W., and MCCUSKERE,. N.: How useful is biopsy of supraclavicular lymph nodes? Surgery 51: 592-596, 1962. 7. HIGGINGS., A., and BROWNLEEW, . E.: Prescakne fat pad biopsy; analysis of 362 cases. J. Thoracic Sztrg. 38: 402-407, 1959. 8. HOLMAN, C. W.: Scalene node biopsy for determining operability of lung carcinoma. Surgery 53: 319-321, 1963. 9. LAL,S., and POOLE,G. W.: Scalene node biopsies. Lancet 2 : 112-113, 1963. 10. LILLINCTONG,. A,, and JAMPLIS,R. W.: Scalene node biopsy. Ann. Znt. M e d . 59: 101-110,1963. 11. LULUD, . J., and LAWSONL,. J.: Carcinoma of the lung; review of 321 cases. Arch. Surg. 88: 213-217, 1964. 12. MALONEYJ,. V., JR.; FRANKS,R.; MAKOFF,D., and SHERMANP,. H.: Biopsy of scalene lymph nodes and right thoracic duct lymph node for diagnosis of pulmonary disease. J. Thoracic Surg. 47: 438-445, 1964. 13. MORGANS,. W., and ScoTr, S. M.: Critical reappraisal of scalene fat pad biopsies. J. Thoracic Surg. 43: 548-551, 1962. 14. PALUMBOL,. T., and SHARPEW, . S.: Evaluation of scalene node biopsy. Surgery 53: 639-643, 1963. 15. ROUVI~REH, .: Anatomy of human lymphatic system. pransl.by M. J. Tobias.) Arbor, Mich. Edwards B ~ ~I ~~ ~.19,.38, . 16. SKINNERD, . B.: Scalene-lymph-node biopsy; re- appraisal of risks and indications. New England J . &fed.268: 1324-1329, 1963. c,17. TARNOWSKI, E,: One hundred consecutive lymph gland biopsies by Daniels' method in cases of obscure pulmonary disease. Actn tuberc. scundinnv. 41: 192-198, 1962. 18. TROISIERE, .: L'adenopathie sus-claviculaire dans les cancers de I'abdomen. Arch. gen. m t d . 1: 129-138, 297-309, 1889. 19. WILLIAMST, . K., and WEBB,W. R.: Prescalene node biopsy; evaluation. Arch. Surg. 84: 261-264, 1962.