Spontaneous Regression of NSCLC After Lymph Node Biopsy
Spontaneous Regression of NSCLC After Lymph Node Biopsy
A 76-year-old Caucasian man with progressive dyspnea for the last two months was admitted to our hospital. A contrast-enhanced computed tomography (CT) scan of his chest disclosed an oval-shaped tumor mass in the upper lobe of his right lung, adjoining the pleura and 6 × 5 × 3cm in size (Fig. 1a). In addition, the CT scan showed enlarged mediastinal lymph nodes in the right paratracheal position. Our patient was an active smoker with a cumulative exposure of 50 pack-years and had a medical history of hypertension and hyperlipidemia. His actual medication consisted of an ACE inhibitor and a statin with no changes for the last 2 years. Physical and laboratory examinations revealed no abnormal findings. A mediastinoscopic biopsy of the mediastinal lymph nodes revealed metastatic cells of a poorly differentiated NSCLC in a paratracheal lymph node (4R) (Fig. 2). Immunohistochemical findings showed positive staining for cytokeratin (CK) 7 but no reactivity with antibodies against TTF1, CK5/6, p63 and napsin. Furthermore the cells were negative for CD56, chromogranin and synaptophysin. By these findings, the tumor was classified as large cell carcinoma. Further staging procedures including bone scintigraphy, abdominal CT and head magnetic resonance imaging (MRI) disclosed no distant metastases, so that our patient was diagnosed with clinical stage IIIA (T2bN2M0) NSCLC. Consequently, a neoadjuvant concept consisting of a combined chemoradiation was indicated.
(Enlarge Image)
Figure 1.
a Initial chest computed tomography scan showing the tumor in the upper lobe of the right lung and enlarged mediastinal lymph nodes in the paratracheal position. b Computed tomography scan after 2 months, c after 1 year
(Enlarge Image)
Figure 2.
a Tissue obtained by biopsy of a right paratracheal lymph node showing metastatic cells of large cell carcinoma. b Immunohistochemical staining showing cytokeratin positivity (KL-1) of tumorous cells within the lymphatic tissue
However, CT planning before starting therapy and 2 weeks after mediastinoscopy showed a decrease of both the tumor mass in the upper lobe of his right lung and the mediastinal lymph nodes. We conducted a CT-guided fine-needle biopsy of the tumor in the upper lobe of his right lung (Fig. 3). The histological examination showed extended necrosis but failed to prove malignant cells. In addition, the tissue obtained by mediastinoscopy was examined by a second pathologist, who confirmed the prior diagnosis of NSCLC. A repeated chest CT scan showed further regression of the tumor and the mediastinal lymphadenopathy (Fig. 1b). At this time we agreed with our patient to postpone chemoradiation and instead perform a routine follow-up by an annual chest CT scan. After 1 year, a CT scan revealed the almost complete disappearance of the tumor in the upper lobe of his right lung and a decrease of the mediastinal lymph nodes to normal size (Fig. 1c). Up to the present day, our patient has received no anticancer therapy. He remains in follow-up care in our hospital and after 7 years no relapse has been reported.
(Enlarge Image)
Figure 3.
Computed tomography-guided fine-needle biopsy of the tumor in the upper lobe of the right lung
Case Presentation
A 76-year-old Caucasian man with progressive dyspnea for the last two months was admitted to our hospital. A contrast-enhanced computed tomography (CT) scan of his chest disclosed an oval-shaped tumor mass in the upper lobe of his right lung, adjoining the pleura and 6 × 5 × 3cm in size (Fig. 1a). In addition, the CT scan showed enlarged mediastinal lymph nodes in the right paratracheal position. Our patient was an active smoker with a cumulative exposure of 50 pack-years and had a medical history of hypertension and hyperlipidemia. His actual medication consisted of an ACE inhibitor and a statin with no changes for the last 2 years. Physical and laboratory examinations revealed no abnormal findings. A mediastinoscopic biopsy of the mediastinal lymph nodes revealed metastatic cells of a poorly differentiated NSCLC in a paratracheal lymph node (4R) (Fig. 2). Immunohistochemical findings showed positive staining for cytokeratin (CK) 7 but no reactivity with antibodies against TTF1, CK5/6, p63 and napsin. Furthermore the cells were negative for CD56, chromogranin and synaptophysin. By these findings, the tumor was classified as large cell carcinoma. Further staging procedures including bone scintigraphy, abdominal CT and head magnetic resonance imaging (MRI) disclosed no distant metastases, so that our patient was diagnosed with clinical stage IIIA (T2bN2M0) NSCLC. Consequently, a neoadjuvant concept consisting of a combined chemoradiation was indicated.
(Enlarge Image)
Figure 1.
a Initial chest computed tomography scan showing the tumor in the upper lobe of the right lung and enlarged mediastinal lymph nodes in the paratracheal position. b Computed tomography scan after 2 months, c after 1 year
(Enlarge Image)
Figure 2.
a Tissue obtained by biopsy of a right paratracheal lymph node showing metastatic cells of large cell carcinoma. b Immunohistochemical staining showing cytokeratin positivity (KL-1) of tumorous cells within the lymphatic tissue
However, CT planning before starting therapy and 2 weeks after mediastinoscopy showed a decrease of both the tumor mass in the upper lobe of his right lung and the mediastinal lymph nodes. We conducted a CT-guided fine-needle biopsy of the tumor in the upper lobe of his right lung (Fig. 3). The histological examination showed extended necrosis but failed to prove malignant cells. In addition, the tissue obtained by mediastinoscopy was examined by a second pathologist, who confirmed the prior diagnosis of NSCLC. A repeated chest CT scan showed further regression of the tumor and the mediastinal lymphadenopathy (Fig. 1b). At this time we agreed with our patient to postpone chemoradiation and instead perform a routine follow-up by an annual chest CT scan. After 1 year, a CT scan revealed the almost complete disappearance of the tumor in the upper lobe of his right lung and a decrease of the mediastinal lymph nodes to normal size (Fig. 1c). Up to the present day, our patient has received no anticancer therapy. He remains in follow-up care in our hospital and after 7 years no relapse has been reported.
(Enlarge Image)
Figure 3.
Computed tomography-guided fine-needle biopsy of the tumor in the upper lobe of the right lung
Source...