Friday, November 11, 2005

Persistently Enlarged Mediastinal Lymph Nodes

Originally posted on Thursday 11/3/05. Now updated.

This patient is in his late 50s and presented with persistent hilar lymphadenopathy. This was incidentally discovered 1.5 years ago on a routine CXR for PNA (resolved). He had 6-month interval CT scans which did not reveal any change in the LAD. A PET scan performed after the most recent CT scan revealed mild-moderate FDG uptake of a right paratracheal node. There were no other FDG avid areas. He is referred to our instititution for further evaluation.
He is asymptomatic.

Significant history:
35 pk year current cmoker (1ppd)
7 years ago he had a RLL resection for bronchoalveolar CA. Margins were clean and all lymph nodes sampled were negative.
PPD positive 14 years ago, treated with INH for 6-9 months
DM2, Hyperchol, MI 12 years ago
CABG 12 years ago

Exam: Unremarkable except for evidence of prior surgeries noted above.

CT scan w IV contrast was performed at our institution for comparision with prior OSH films:

On the above CT scan, the radiologist noted stable LAD and new LUL GGO compared with prior films (1.5 years of f/u CT scans [3 total]).

Bronchoscopy was performed.
TBBX lingula: No granulomas or malignancy. Focal patchy interstitial fibrosis.
BAL: No orgs on stain. <10,000 Citrobacter Koseri
R. paratracheal TBNA: Benign epithelial cells and lymphocytes

He continued to be asymptomatic over the next two months. He an episode of RLL PNA for which he was treated. A CT scan was performed at the OSH that time. Comparison of these films with previous films did not reveal any significant changes in the adenopathy and LUL GGO.

He returned to our institution for CT scan that had been previously scheduled for surveillance:

He continues to be asymptomatic. What do you think this is?

9 comments - CLICK HERE to read & add your own!:

Baleeiro said...

Mike, has the GGO been there for 1.5 year? BAC can be multifocal and look like GGO and be quite indolent. It can also be PET- or low-FDG avid. The stability is very reassuring but I would consider at least a bronch: he is young, there are infectious conditions (NTMyc) that may cause persistent infiltrates/abnormalities and if he has recurrent BAC at some point there are receptor-based treatments that may be available to him. If the bronch is non-diagnostic though, it might be a hard sell to be more invasive with a Med in a stable patient...

Mendez said...

Sorry, that was unclear at the end of the post. The LAD is stable, and the LUL GGO opacity is new. I'll correct the post.

Mike L said...

This is a nice case.
I agree with CEOB (to not do so would be intellectual suicide).
He needs a bronch and a BAL of the airspace disease. Just out of curiosity, how many would TBBx the airspace disease? GGO's in patients with patients who smoke and with prior BAC is worrisome for new/recurrent BAC.
I still am unclear... have the lymph nodes ever become normal in size after the finding 1.5 years ago.
If not, have you gotten fungal precipitans?

Jeff H said...

I think I'd do a bronch. If negative, I'd strongly consider a mediasteinoscopy for biopsy of that right pretracheal node.

Arenberg said...

The PET+ lymph node and the GGO are separate problems, but both potentially important. I would not trust a bronch to tell me what either of them was unless you got cancer. If you bronch and find some pathogen, you could treat and follow-up, but I'd follow up sson with a CT and then biopsy whatever remains, up to and including taking out the lobe if he has the pulmonary reserve.

For what its worth, its very unlikely for true bronchoalveolar carcinoma to metastasize to the LNs. On the other hand, I once heard Adi Gazdar say that "bronchoalveolar" was the single most overused term by pathologists looking at lung cancers under the microscope.

Jennings said...

So I am clear; you are saying that the paratracheal node (the one you did FNA on and the one that is mildly PET+) has not changed in size in 1.5 years? I didn't see the rest of the mediastinum and hilum. Was there other sites of adenopathy and were they sampled as well? Did you get lymphocytes? Was 19 gauge used.
Nonetheless, with the intitial bronch negative for cytology and if the nodes have not chnaged, it sounds like a slow indolant granulomatous-type infectious process that warrants follow-up without intervention until chnage or onset of any symptoms.

Mendez said...

Jennings: Yes that node has not changed in size over 1.5 years. Films from OSH and our institution were compared by our radiologists.
There were other sites of adenopathy that could not be sampled by bronch - but had also been unchanged:
"smaller subcentimeter and borderline ( just
about 1 cm ) lymph nodes in the pre-vascular and AP window region"

Normal appearing lymphocytes were obtained on TBNA. I am not sure what gauge was used since I did not perform the bronchoscopy.

I posted follow-up images (CT scan) above. Now what do you think is going on?

Jennings said...

Um, I realize the CT slice is a bit lower, but those nodes sure look bigger to *me*....

Mendez said...

Right... a repeat bronchoscopy revealed Adenocarcinoma from TBNA of right paratracheal node.