ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;88:200-205. doi:10.1016/j.athoracsur.2009.04.005
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Marc Riquet
Emmanuel Brian
Claudia Vlas
Patrick Bagan
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Riquet, M.
Right arrow Articles by Le Pimpec Barthes, F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Riquet, M.
Right arrow Articles by Le Pimpec Barthes, F.
Related Collections
Right arrow Mediastinum
Right arrowRelated Article

Original Articles: General Thoracic

Intrathoracic Lymph Node Metastases From Extrathoracic Carcinoma: The Place for Surgery

Marc Riquet, MD*, Pascal Berna, MD, Emmanuel Brian, MD, Alain Badia, MD, Claudia Vlas, MD, Patrick Bagan, MD, Françoise Le Pimpec Barthes, PhD, MD

Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Thoracic Surgery Department, Georges Pompidou European Hospital, Paris, France

Accepted for publication April 1, 2009.

* Address correspondence to Dr Riquet, Thoracic Surgery Department, Georges Pompidou European Hospital, 20 rue Leblanc, Paris, 75015, France (Email: marc.riquet{at}egp.aphp.fr).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
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.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Intrathoracic hilar and mediastinal lymph node metastases (HMLNMs) are a usual mode of spread of lung or esophagus carcinomas. HMLNMs of extrathoracic carcinomas are infrequent but may be occasionally observed in patients with pulmonary metastases or other more distant metastases [1, 2]. Isolated HMLNMs are still more unusual. Giving the impression of orphan diseases, their treatment strategy is not established and their prognosis is poorly known [3]. However, their frequency is possibly underestimated: in effect, they are routinely diagnosed by cervical mediastinoscopy or more recently by endoscopic ultrasound with fine-needle aspiration (EUS-FNA) [4], and are usually considered as a metastatic disease not amenable to operation. Our attention was previously drawn to HMLNM with an unknown primary source, a still more uncommon entity, for which the best treatment results were achieved by surgical intervention in case of an isolated and completely resectable lesion [5]. Our purpose was to review the place of surgical intervention in the management of intrathoracic HMLNMs from extrathoracic carcinomas.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
From January 1996 to December 2007, 565 patients were referred to our department in view of diagnostic operations for hilar or mediastinal lymph node enlargement, without exhibiting intrathoracic manifestations such as lung nodules and pleural disease. Among them, 37 had a history of extrathoracic carcinoma. In 11 patients the lymph node disease was diffuse, mainly hilar and bilateral mediastinal and was unrelated to the extrathoracic malignancy. The diagnosis was obtained in all cases by cervical mediastinoscopy and consisted of lung cancer without a primary in 4, sarcoidosis or lymphoma in 3 each, and anthracosis in 1. The extrathoracic carcinoma was breast in 4, kidney or rectum in 2 each, and ovary, thyroid, and prostate in 1 each.

In the remaining 26 patients (15 men, 11 women), the mediastinal HMLNMs were from an extrathoracic malignancy and form the basis of our study. The patients were a mean age of 57.6 ± 15.3 years (range, 19 to 78 years). The HMLNMs were synchronous in 2 patients and metachronous in 24, and the mean interval between both events was 5.5 ± 5.7 years (range, 1 to 24 years).

Our Institutional Review Board approved this study and waived the requirement for patient consent. All medical charts were reviewed, and a thorough workup included bone scintigraphy, brain and abdominal computed tomography imaging, and more recently, positron-emission tomography tomodensitometric (PET-TDM) imaging, to rule out distant metastases or local recurrence, or both, of the previously resected extrathoracic carcinoma. Diagnostic and therapeutic surgical procedures were analyzed. The postoperative course was uneventful. Involved LN stations were classified according to Mountain and Dresler [6].

Follow-up information was obtained from the hospital case records, from a questionnaire completed by the local chest physician or general practitioner, or from death certificates. The main outcome was the overall survival, defined as the time interval between the date of operation and the date of death or the last follow-up visit for censored patients. No patient was lost to follow-up. Actuarial survival curves were estimated by the Kaplan-Meier method. Statistical comparisons between survival distributions were made using the log-rank test. The statistical software used for the analysis was SEM (Anticancer Centre Jean Perrin, Clermont-Ferrand, France) [7].


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Surgical intervention was performed to assess the diagnosis in 15 patients and to assess the diagnosis and for treatment in 11 (Table 1). The median survival was 34.6 months, and the global 10-year survival was 20.3%.


View this table:
[in this window]
[in a new window]

  		Table 1 Hilar and Mediastinal Lymph Node Metastases of Extrathoracic Carcinoma and Surgical Procedures
 
The diagnostic procedure consisted of cervical mediastinoscopy in 9, anterior mediastinotomy (Chamberlain procedure) in 2, and video-assisted thoracic surgery (VATS) in 4, with 1 conversion. Curative surgical intervention was ruled out in those patients because of synchronous extrathoracic malignancy in 2 (kidney in 1, bladder in 1) and synchronous brain metastasis and rectum in 1, and because of unresectability in the others due to diffuse and bilateral HMLNMs in 4 (breast in 2, kidney in 1, melanoma in 1) and to carcinomatosis mediastinitis in 6 (breast in 4, prostate in 2). The resection was attempted by VATS in 1 patient (larynx) but was incomplete because of postradiation upper mediastinum fibrosis. Cure was achieved by adjuvant chemotherapy in 1 patient with a multinodal mediastinal recurrence of a testicular seminoma; the patient is alive and disease-free at 7 years of follow-up. Median survival was 21 months for the entire group (Fig 1).


Figure 1
View larger version (12K):
[in this window]
[in a new window]

  		Fig 1. Long-term survival curves of resected (curve 1) or just biopsied (curve 2) hilar or mediastinal lymph node metastases.

 
Surgical intervention was performed in a curative attempt in 11 patients (Table 2). The LNs were the only recurring disease, were unilateral, and appeared resectable. The thoracic approach consisted in posterolateral thoracotomy in 6, muscle-sparing thoracotomy in 2, and VATS in 3. All the patients underwent a lymphadenectomy, and 17 involved LN stations were removed (Table 2). Three stations (10R, 7, 3A and 10R, 7, 12) were resected in 2 patients who previously underwent a nephrectomy for a clear cell carcinoma. One patient required a right upper lobectomy to remove the interlobar LN involvement. Three stations (10R, 9, and 7) were removed in a patient who was treated 7 years previously for a breast cancer. Two stations (5 and 6) were resected in a patient with a renal cancer and two stations (9 and 8) in a patient previously treated for a testis malignancy. Only one station was involved in the 6 other patients (Table 2).


View this table:
[in this window]
[in a new window]

  		Table 2 Characteristics of Patients Who Underwent Resection of the Mediastinal Lymph Nodes
 
Median survival was 45 months, and the overall 5-year survival rate was 41.6% (Fig 1) without other mediastinal recurrence, but this tendency to a better prognosis than in the other group was not significant (p = 0.19). Three patients are still alive more than 5 years after operation. One patient had previously been treated for breast cancer and 2 for testis malignancy having evolved into mature tissue. When breast and testis malignancy was excluded from groups with diagnosis and resection procedures, the results still appeared encouraging: median survival was 9 months (8 patients) and 21 months (8 patients), respectively (p = 0.04).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Intrathoracic LN metastases from extrathoracic carcinomas are infrequent. They were detected on chest roentgenograms in 25 of 1071 patients (2.3%) by McLoud and colleagues [1]. The primary malignancies included 8 tumors of the head and neck, 12 genitourinary malignancies, 3 carcinomas of the breast, and 2 malignant melanomas. The most frequently detected LN group was the right paratracheal 4R and 2R (60%).

Mahon and Libshitz [2] analyzed 50 mediastinal metastases of infradiaphragmatic malignancies on computed tomodensitography, a technique allowing a better visualization of all nodal groups in the mediastinum. None of the HMLNMs were isolated, and all were associated with other distant metastases, of which 29 (58%) were located in the lungs. Several LN stations were commonly involved, and one single station was involved in only 6%. Besides a majority of genitourinary malignancies (kidney, 25; testis, 7; prostate, 4; ovary, 3; bladder, 2), they also observed metastases from carcinoma of the colon or rectum in 6 and stomach in 3. However, Mahon and Libshitz [2] could not draw any conclusion about the frequency of mediastinal metastases among patients with gastrointestinal carcinomas. This information was provided by Libson and colleagues [8], who reported 12 cases in 1194 patients (1%) with carcinomas of the stomach, pancreas, colon, and rectum.

Mediastinal metastases from tumors of the head and neck are also infrequent. Of 779 patients with head and neck cancer, 96 (12.3%) were found clinically or at autopsy to have distant metastases, and mediastinal metastases were detected in 5 (0.6%) [9]. However, they are probably slightly more frequent in case of carcinoma of the nasopharynx [10] and may be observed in 2% to 9% of patients with thyroid carcinoma [11, 12].

Whatever the primary cancer, nodal or systemic metastases are common at distant sites by the time the spread to the mediastinum is apparent clinically [1, 2, 8, 10], and mediastinal involvement indicates an advanced stage of the disease, commonly ruling out surgical resection in view of a cure. For that reason, the rare isolated HMLNMs are considered to share the same poor prognostic value and their possible resectability is all the more overlooked because the procedure seems aggressive. Furthermore, the diagnosis is commonly assessed by cervical mediastinoscopy in case of mediastinal lymphadenopathy, and metastases from extrathoracic malignancies represent less than 2% of the patients (11 of 700) [13]. In our series, the 37 patients accounted for only 6% of the patients who underwent a diagnostic surgical procedure for isolated mediastinal LN during the same period of time in our department.

Nowadays, surgical intervention is progressively being replaced by EUS-FNA-based differential cytodiagnostics for establishing the diagnosis of mediastinal LN disease. In a series of 153 patients, 52 had a history of cancer that was extrathoracic in 37 patients, and a mediastinal recurrence was observed in 12 (32.4%) [4]. Our series had a similar number of patients and recurrence was diagnosed in 26 (70.3%), which is twice as frequent. This frequency could have been biased by the specificity of our department, but the mediastinal recurrence rate was 55% in another series of 20 patients [14]: EUS-FNA was negative in 8 patients and surgical intervention disclosed 5 more positive cases, which raises the rate of recurrences to 80%. Those results led to the conclusion that surgical intervention, a procedure with substantial risk of complications and limited therapeutic benefits, may be avoided in 60% of patients [14].

The extrathoracic malignancies harboring HMLNMs may be numerous and various. Because policy is to perform a lymphadenectomy when HMLNMs are isolated and deemed resectable, we were able to document 11 patients with 6 different extrathoracic primary cancers, confirming the safety and the effectiveness of the procedure and the place of surgical intervention for HMLNMs.

The HMLNMs from genitourinary malignancies appeared the most frequent, as reported in the literature [1, 2]. Hilar LN metastasis presenting as a recurrence after nephrectomy for cancer was first reported in 1976 [15]. Among a few more HMLNMs cases reported thereafter, 3 were treated by resection [16–18], and 1 patient is known to have survived 3 years [16]. One of our patients survived 45 months (Table 2). A recent series of 9 patients demonstrated a median survival of 3.2 years after resection, significantly extending survival compared with survival of other patients with stage IV disease from the same institution [19]. Those results are encouraging and support that resection should be considered an important component of treating patients with renal cell carcinoma who have asynchronous HMLNMs [19].

Nonseminatous germ cell tumors of testicular origin metastasize to the retroperitoneum LN. They may subsequently metastasize to contiguous mediastinal lymphatics. Cisplatin-based chemotherapy alone suffices for a cure for most patients with supradiaphragmatic metastases. In 10% to 20% of testicular nonseminatous germ cell tumors with presentation or subsequent development of supradiaphragmatic metastases, at least one thoracic surgical procedure, in the form of either of mediastinal dissection or pulmonary metastasectomy, was required to remove persistent radiographic abnormalities after chemotherapy [20].

Kesler and colleagues [20] reviewed 268 patients who required at least one procedure to remove residual mediastinal disease, and 98 (36.6%) manifested mediastinal disease during or after chemotherapy. Retroperitoneal LN dissection was performed in 89.2% of patients and was in conjunction with thoracic surgical procedures in 31.9%. Long-term survival was good to excellent. The rate of isolated HMLNM was not furnished, and all metastases were observed during the immediate follow-up of the patients. Late disease occurrence such as we observed is rare and also requires removal not only to assess the diagnosis but also to ensure a cure and to prevent the evolution toward a mediastinal growing teratoma syndrome, a phenomenon whereby germ cell tumors enlarge after chemotherapy [21].

All the other genitourinary malignancies can metastasize to the hilar or mediastinal LNs, and primary cancers from the bladder [1, 2, 4, 14], cervix and corpus uteri [1, 4, 14], ovary [1, 2], breast [1, 4, 13], and prostate [22] have been reported. However, the HMLNMs presentation rarely offers an opportunity for resection. Thoracic metastases from breast cancer do not usually present as isolated HMLNM [23, 24], or are unresectable, as we observed in 6 patients; however, the selected patient we had the opportunity to treat by resection is still disease-free 5 years later, thus supporting the idea of resection. Cancers of the uterus may recur as isolated HMLNMs. Kawaguchi and colleagues [3] reported a patient who underwent a radical hysterectomy for a cervical cancer of the uterus, a left hilar and mediastinal lymphadenectomy for intrathoracic recurrence 26 months later, and again a right hilar lymphadenectomy 25 months after that. She eventually died of the disease 8 months after the second thoracotomy because of retroperitoneal recurrence, almost a 5-year survival.

The infradiaphragmatic malignancies that do not involve the genitourinary tract are not so frequently responsible for HMLNMs [1, 2]. The small-intestine neuroendocrine tumor of which we operated on as a HMLNM was of low-grade malignancy. The most frequently concerned gastrointestinal carcinomas are the colon carcinomas [8], and 2 patients treated by HMLNMs resection were reported [3, 25]. Both patients also underwent intervention for liver metastases, and it is worth stressing that 1 patient was disease-free 3 years after the thoracotomy [3].

We performed three procedures for isolated HMLNM from head and neck cancers. In 2 patients the resection was after a previous laryngectomy. The resection was incomplete in 1 patient because postradiation fibrosis rendered further dissection impossible, and the mediastinal LN capsula was ruptured in the other patient. In fact, previous radiation therapy that precluded new irradiation was one of the main reasons prompting the surgical resection in these 3 patients. The third patient, with former nasopharynx cancer, is still alive disease-free more than 1 year after complete resection.

Mediastinal dissection is rather uncommon in case of thyroid carcinoma but may be performed in four circumstances: at the time of thyroidectomy and conservative bilateral neck dissection [11], on the occasion of revision of the initial dissection for a recurrence [11], in association with lung metastasectomy [26], and more rarely as isolated HMLNM, as we performed twice. Macroscopic locoregional LN metastases from thyroid cancer should be first dealt with surgically, if technically feasible, because their extirpation can be occasionally curative [27] or can render subsequent radioactive iodine administrations for residual disease more efficacious [26]. However, the prognosis is generally poor at this stage of the disease.

The route and mechanism of extension of LN metastases into the thorax from extrathoracic malignancies is not completely understood. The metastases from primary sites in the head and neck are postulated to result from spread from the neck to mediastinal LNs along lymphatic vessels described by Rouvière [28], the anterior or jugular lymphatic chain communicating with the anterior mediastinal LN [1]. In differentiated thyroid carcinoma, HMLNM is significantly correlated with contralateral cervical LN metastases, but metastasis to the mediastinal region directly from the primary tumor was also demonstrated [29]. In medullary thyroid carcinoma, extrathyroidal extension, and not involvement of contralateral cervicolateral LN, is a predictor of HMLNM [12]. In laryngeal carcinoma, mediastinal LN involvement more often accompanies stomal recurrence [30], which was not the case in both our patients.

In case of infradiaphragmatic malignancy, the spread to the mediastinum occurs from the thoracic duct. In effect, the lymphatics from the pelvis and abdomen drain into the thoracic duct, which also receives tributaries from the intrathoracic organs and their regional LN basins within the mediastinum [31]. Retrograde flow from the thoracic duct into the paratracheal and bronchopulmonary LN may ensue through a lymphatic vessel with incompetent valves, a dysfunction reported to occur in 5% to 14% of lymphatic vessels by McLoud and colleagues [1].

In genitourinary carcinomas, the demonstration is easily available. The renal lymphatics drain into the paraaortic LN groups, and, further on, consistently terminate into the thoracic duct, sometimes directly without crossing through any LN [32]. They mainly contribute to the thoracic duct origin because of this particular anatomy and of the large quantity of lymph they generate [32]. The lymphatics from the pelvis and other genitourinary neoplasms connect to the same paraaortic LN [1, 2, 28] and thus follow the same route [8], but the quantity of lymph is smaller. However, this special layout probably explains the reason why HMLNMs from those organs are the most frequent. In instances of gastrointestinal carcinomas, the lymphatic drainage also ultimately connects to the paraaortic nodes, but the juxtaorgans mesenteric LN amount is longer acting as a dam reservoir.

Other anecdotal and marginal explanations have been provided. Rino and colleagues [33] incidentally demonstrated a route from the paraaortic LN through the diaphragm, visible on a lymphangiogram performed during a gastrectomy in a patient with a gastric cancer, but without nodal involvement. In the colonic cases of Libson and colleagues [8], mediastinal metastases were seen after, or coincidentally with, the appearance of liver metastases. The authors reported two main lymph streams from the liver, one through the celiac nodes and the other through the thorax to the mediastinal nodes of both sides: metastatic spread to the liver could, in this manner, be followed by antegrade seeding to the mediastinal LNs [8].

To conclude, HMLNM from an extrathoracic carcinoma is infrequent but may present in isolated patients, probably in the context of a particular lymphatic mode of spread. In our experience, corroborating some sparse results reported in the literature, resection could be done safely and proved useful to achieve local control of the disease as well as beneficial to some selected patients. We therefore suggest that surgical intervention should not only be considered for diagnosis in all patients but also more ambitiously discussed in cases of isolated and resectable HMLNMs.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. McLoud TC, Kalisher S, Stark P, Greene R. Intrathoracic lymph node metastases from extrathoracic neoplasms Am J Roentgenol 1978;131:403-407.[Abstract]
  2. Mahon TG, Libschitz H. Mediastinal metastases of infradiaphragmatic malignancies Eur J Radiol 1992;15:130-134.[Medline]
  3. Kawaguchi T, Kushibe K, Kimura M, et al. Outcome of surgical intervention for isolated intrathoracic lymph node metastasis from infradiaphragmatic malignancy: report of two cases. Ann Thorac Ccardiovasc Surg 20006;12:358–61.
  4. Fritscher-Ravens A, Sriram PVJ, Bobrowski C, et al. Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients Am J Gastroenterol 2000;95:2278-2284.[Medline]
  5. Riquet M, Badoual C, Le Pimpec Barthes F, Dujon A, Danel C. Metastatic thoracic lymph node carcinoma with unknown primary site Ann Thorac Surg 2003;75:244-249.[Abstract/Free Full Text]
  6. Mountain C, Dresler CM. Regional lymph node classification for lung cancer staging Chest 1997;111:1718-1723.[Abstract/Free Full Text]
  7. Kwiatkowski F. SEM (Statistiques, Epidémiologie, Médecine): un outil de gestion informatique et statistique adapté à la recherche en cancérologie Bull Cancer 2000;87:715-721.[Medline]
  8. Libson E, Bloom RA, Halperin I, Peretz T, Husband JE. Mediastinal lymph node metastases from gastrointestinal carcinoma Cancer 1987;59:1490-1493.[Medline]
  9. Probert JC, Thompson RW, Bagshaw MA. Patterns of spread of distant metastases in head and neck cancer Cancer 1974;33:127-133.[Medline]
  10. Daly BD, Leung SF, Cheung H, Metreweli C. Thoracic metastases from carcinoma of the nasopharynx: high frequency of hilar and mediastinal lymphadenopathy Am J Roentgenol 1993;160:241-244.[Abstract/Free Full Text]
  11. Sarrazin R, Brichon PY, Chaffanjon P. Les métastases médiastinales des cancers différenciés de la thyroïde. Traitement par curage médiastinal total sur 9 cas. Ann Endocrinol (Paris) 1997;58242–24.
  12. Machens A, Holzhausen HJ, Dralle H. Prediction of mediastinal lymph node metastasis in medullary thyroid carcinoma Brit J Surg 2001;91:709-712.
  13. Heinemann M, Wacha H, Rosenthal R. Mediastinale Metastasen extrathorakaler Tumoren-wichtige Befunde bei der Mediastinoskopie Chirurg 1986;57:560-564.[Medline]
  14. Kramer H, Koëter GH, Sleijfer DT, van Putten JWG, Groen HJM. Endoscopic ultrasound-guided fine-needle aspiration in patients with mediastinal abnormalities and previous extrathoracic malignancy Eur J Cancer 2004;40:559-562.[Medline]
  15. Reinke RT, Higgins CB, Niwayama G, Harris RH, Friedman PJ. Bilateral pulmonary hilar lymphadenopathy. An unusual manifestation of metastatic renal cell carcinoma. Radiology 1976;121:49-53.[Abstract/Free Full Text]
  16. Wright FW. Enlarged hilar and mediastinal nodes (and especially lower right hilar node enlargement) as a sign of metastasis of a renal tumour Clin Radiol 1977;28:431-436.[Medline]
  17. Yamashita K, Yamamoto M, Nishimura H, Akiyama H, Tsuchiya E, Tanaka S. Hilar lymph node metastasis in renal cell carcinoma Jap J Thorac Cardiovasc Surg 2000;48:194-197.[Medline]
  18. Niikura S, Hirata A, Kunimi K, et al. Renal cell carcinoma recurrence in the mediastinum lymph node 19 years after nephrectomy: a case report Hinyokika Kiyo 1999;45:419-421.[Medline]
  19. Whitson BA, Groth SS, Andrade RS, et al. Extension of survival by resection of asynchronous renal cell carcinoma metastases to mediastinal lymph nodes J Thorac Cardiovasc Surg 2008;135:1022-1028.[Abstract/Free Full Text]
  20. Kesler KA, Brooks JA, Rieger KM, Fineberg NS, Einhorn LH, Brown JW. Mediastinal metastases from testicular nonseminomatous germ cell tumors: patterns of dissemination and predictors of long-term survival with surgery J Thorac Cardiovasc Surg 2003;125:913-923.[Abstract/Free Full Text]
  21. Afifi HY, Bosl GJ, Burt ME. Mediastinal growing teratoma syndrome Ann Thorac Surg 1997;64:359-362.[Abstract/Free Full Text]
  22. Lindell MM, Doubleday LC, von Eschenbach AC, Libshitz HI. Mediastinal metastases from prostatic carcinoma J Urol 1982;128:331-334.[Medline]
  23. Kreisman H, Wolkove N, Schwartz Finkelstein H, Cohen C, Margolese R, Frank H. Breast cancer and thoracic metastases: review of 119 patients Thorax 1983;38:175-179.[Abstract/Free Full Text]
  24. Ampil FL, Burton GV, Li BDL, Chu Q, Krishnamsetty RM, Caldito G. Thoracic metastases from breast cancer: a single-institution's experience Eur J Gynaecol Oncol 2005;26:155-157.[Medline]
  25. Kuba H, Sato N, Uchiyama A, et al. Mediastinal lymph node metastasis of colon cancer: report of a case Surg Today 1999;29:375-377.[Medline]
  26. Pak H, Gourgiotis L, Chang WI, et al. Role of metastasectomy in the management of thyroid carcinoma: the INH experience J Surg Oncol 2003;82:10-18.[Medline]
  27. McHenry CR, Rosen IB, Walfish PG. Prospective management of nodal metastases in differentiated thyroid cancer Am J Surg 1991;162:353-356.[Medline]
  28. Rouvière H. Anatomy of the human lymphatic systemTranslated by Tobias MJAnn Arbor, MI: Edwards Brothers; 1938. pp. 245.
  29. Ito Y, Miyauchi A. Lateral and mediastinal lymph node dissection in differentiated thyroid carcinoma: indications, benefits, and risks World J Surg 2007;31:905-915.[Medline]
  30. Sisson GA, Straekley CJ, Johnson NE. Mediastinal dissection of recurrent cancer after laryngectomy Laryngoscopy 1962;72:1064-1077.
  31. Riquet M, Le Pimpec Barthes F, Souilamas R, Hidden G. Thoracic duct tributaries from intrathoracic organs Ann Thorac Surg 2002;73:892-898discussion 898–9.[Abstract/Free Full Text]
  32. Assouad J, Riquet M, Foucault C, Hidden G, Delmas V. Renal lymphatic drainage and thoracic duct connections: implications for cancer spread Lymphology 2006;39:26-32.[Medline]
  33. Rino Y, Imada T, Takanashi Y, Kobayashi O, Sairenji M, Motohashi H. Route from the paraaortic lymphatic system to the tracheobronchial lymph nodes evidenced on lymphangiogram in a patient with gastric cancer Gastric Cancer 2004;7:176-177.[Medline]

Related Article

Invited Commentary
Eddie Hoover
Ann. Thorac. Surg. 2009 88: 205. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
A. Sano, T. Murakawa, T. Morota, and J. Nakajima
Resection of a Posterior Mediastinal Metastasis of Colon Cancer
Ann. Thorac. Surg., July 1, 2011; 92(1): 353 - 354.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
E. Hoover
Invited Commentary
Ann. Thorac. Surg., July 1, 2009; 88(1): 205 - 205.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Marc Riquet
Emmanuel Brian
Claudia Vlas
Patrick Bagan
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Riquet, M.
Right arrow Articles by Le Pimpec Barthes, F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Riquet, M.
Right arrow Articles by Le Pimpec Barthes, F.
Related Collections
Right arrow Mediastinum
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS