- Email: [email protected]
Computed tomography in the management of cervical lymph node pathology
1244
Correspondence and communications
7. Carter JJ, Kaur MR, Hargitai B, et al. Congenital desmoplastic trichoepithelioma. Clin Exp Dermatol 2007;32:522e4.
C.B. Chuo R. Slator Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Birmingham, West Midlands B29 6JD, UK E-mail address: [email protected] R.M. Brown Department of Histopathology, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, West Midlands B4 6NH, UK K.D. Anderson Department of Plastic Surgery, Whiston Hospital, Warrington Road, Prescot, L35 5DR, UK ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Figure 1 Specimen photograph (scale 10:1) of a degenerative transparent lymph node, with contrast-filled (lead oxide mixture) afferent lymphatics demonstrated (arrows).
doi:10.1016/j.bjps.2007.12.054
Computed tomography in the management of cervical lymph node pathology We would like to congratulate Sonmez et al. on their paper ‘Computed tomography in the management of cervical lymph node pathology’.1 This paper is a useful guide to the CT evaluation of lymph node pathology, and provides guidelines for the importance of specific CT findings. We would like to share our experience with cadaveric head and neck lymph node anatomical dissection that may contribute to and assist in the interpretation of the CT findings of Sonmez et al. The use of preoperative computed tomography (CT) scanning for head and neck tumours is frequently used to identify the presence or absence of cervical metastases. In addition to the size and architecture of nodal basins, the presence of central lymph node necrosis has been widely described as a sensitive tool for the presence of metastases on CT scan, with this importance emphasised by Sonmez et al. However, it is noteworthy that all of the studies referenced by Sonmez et al. have shown false positive CT findings for the presence of lymph node metastases.2e6 Other imaging techniques, including MRI, have also demonstrated false positive findings for the presence of metastases, whether size or central necrosis is used as the diagnostic feature on imaging.5 The paper by Sonmez et al. did not describe the accuracy of their imaging based on the CT criterion of central necrosis, a result that would be interesting in the context of these previous studies. As such, we would like to share some of our microanatomical findings in our series of fresh cadaveric dissections that may demonstrate a cause for false positive CT evaluation of cervical nodes with central necrosis. We have performed dissection studies in seven fresh cadavers, evaluating 161 lymph nodes of the head and neck. Using microsurgical techniques, we have identified the afferent lymphatic pathways of the superficial and deep tissues, and
cannulated the lymphatics for injection with contrast media that allows the combination of dissection and lymphangiography for analysis of the lymphatic pathways and lymph nodes. These cadaveric studies have identified the presence of 123 unique lymph nodes that we have labelled ‘transparent’ lymph nodes (see Figure 1). These lymph nodes demonstrate a graded degree of central lymph node necrosis both macroscopically and microscopically, with many of these nodes demonstrating extensive central necrosis, as shown in Figure 2. Despite these necrotic changes, these nodes maintain normal capsular formation, lymphatic communications and other architectural features radiographically (see Figure 3).
Figure 2 Haematoxylin and eosin stained transparent lymph node (scale 40:1), with contrast-filled (lead oxide mixture) lymphatics (arrows). Central necrosis is evident, with multiple small and large degenerative vacuoles seen.
Correspondence and communications
1245 Wei-Ren Pan Hiroo Suami Warren Matthew Rozen G. Ian Taylor Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Room E533, Department of Anatomy and Cell Biology, The University of Melbourne, Parkville, Victoria 3050, Australia E-mail address: [email protected] Crown Copyright ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2008.01.023
‘Teenage BCC: to tan or not to tan?’
Figure 3 Plain radiograph of contrast-filled (lead oxide mixture) lymphatics of the head and neck, demonstrating the radiographic appearance of contrast-filled lymph nodes (arrows).
These necrotic lymph nodes do not contain tumours. Furthermore, all of these lymph nodes were identified in patients without known head and neck malignancy or previous surgery. As such, it is likely that they represent degenerative changes associated with aging. Our findings suggest that the presence of central necrosis in lymph nodes, although a marker for malignancy, can have other causes. Although CT remains a highly sensitive tool, the potential for false positives remains a limiting feature.
References 1. Sonmez A, Ozturk N, Ersoy B, et al. Computed tomography in the management of cervical lymph node pathology. J Plast Reconstr Aesthet Surg 2008;61:61e4. 2. Mancuso AA, Harnsberger HR, Muraki AS, et al. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of normal, and applications in staging head and neck cancer. Part II pathology. Radiology 1983;148: 715e23. 3. Friedman M, Shelton VK, Mafee M, et al. Metastatic neck disease. Evaluation by computed tomography. Arch Otolaryngol 1984;110:443e7. 4. Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumors of unknown origin: role of CT. Radiology 1984;152:749e53. 5. Yousem DM, Som PM, Hackney DB, et al. Central nodal necrosis and extracapsular neoplastic spread in cervical lymph nodes: MR imaging versus CT. Radiology 1992;182:753e9. 6. Friedman M, Roberts N, Kirshenbaum GL, et al. Nodal size of metastatic squamous cell carcinoma of the neck. Laryngoscope 1993;103:854e6.
Basal cell carcinoma (BCC) is the most common cancer in Caucasians, typically associated with increasing age, exposure to ultraviolet radiation and family history. Non-melanomatous skin cancer (NMSC) incidence is increasing by up to 10% per year globally and has been observed with increasing regularity in younger, and in particular, female populations.1,2 A 19 year old woman was referred to our clinic with an eight month history of a slow growing lesion, 10 6 mm, on the right inner canthus. (Figure 1) The patient was UK born, had no significant past medical history, family history or pre-malignant skin condition. Of note, she had suffered an extremely severe episode of blistering sunburn four years previously in Tenerife. There was no other significant episode of sunburn or sun-bed exposure. Punch biopsy revealed invasive nodular basal cell carcinoma. The lesion was completely excised, primarily closed (Figure 2) and the diagnosis histologically confirmed. The increasing incidence of BCC in younger age groups has been reported by several studies over the last 10 to 20 years1e3 but a de-novo case in a teenager has not previously been reported to our knowledge. Bath-Hextall et al.3 describe the recent trends in incidence across age groups in the UK from 1996 to 2003, revealing an increase in incidence
Figure 1
Clinical appearance of BCC at Right medial canthus.
Correspondence and communications
7. Carter JJ, Kaur MR, Hargitai B, et al. Congenital desmoplastic trichoepithelioma. Clin Exp Dermatol 2007;32:522e4.
C.B. Chuo R. Slator Department of Plastic Surgery, Selly Oak Hospital, Raddlebarn Road, Birmingham, West Midlands B29 6JD, UK E-mail address: [email protected] R.M. Brown Department of Histopathology, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, West Midlands B4 6NH, UK K.D. Anderson Department of Plastic Surgery, Whiston Hospital, Warrington Road, Prescot, L35 5DR, UK ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Figure 1 Specimen photograph (scale 10:1) of a degenerative transparent lymph node, with contrast-filled (lead oxide mixture) afferent lymphatics demonstrated (arrows).
doi:10.1016/j.bjps.2007.12.054
Computed tomography in the management of cervical lymph node pathology We would like to congratulate Sonmez et al. on their paper ‘Computed tomography in the management of cervical lymph node pathology’.1 This paper is a useful guide to the CT evaluation of lymph node pathology, and provides guidelines for the importance of specific CT findings. We would like to share our experience with cadaveric head and neck lymph node anatomical dissection that may contribute to and assist in the interpretation of the CT findings of Sonmez et al. The use of preoperative computed tomography (CT) scanning for head and neck tumours is frequently used to identify the presence or absence of cervical metastases. In addition to the size and architecture of nodal basins, the presence of central lymph node necrosis has been widely described as a sensitive tool for the presence of metastases on CT scan, with this importance emphasised by Sonmez et al. However, it is noteworthy that all of the studies referenced by Sonmez et al. have shown false positive CT findings for the presence of lymph node metastases.2e6 Other imaging techniques, including MRI, have also demonstrated false positive findings for the presence of metastases, whether size or central necrosis is used as the diagnostic feature on imaging.5 The paper by Sonmez et al. did not describe the accuracy of their imaging based on the CT criterion of central necrosis, a result that would be interesting in the context of these previous studies. As such, we would like to share some of our microanatomical findings in our series of fresh cadaveric dissections that may demonstrate a cause for false positive CT evaluation of cervical nodes with central necrosis. We have performed dissection studies in seven fresh cadavers, evaluating 161 lymph nodes of the head and neck. Using microsurgical techniques, we have identified the afferent lymphatic pathways of the superficial and deep tissues, and
cannulated the lymphatics for injection with contrast media that allows the combination of dissection and lymphangiography for analysis of the lymphatic pathways and lymph nodes. These cadaveric studies have identified the presence of 123 unique lymph nodes that we have labelled ‘transparent’ lymph nodes (see Figure 1). These lymph nodes demonstrate a graded degree of central lymph node necrosis both macroscopically and microscopically, with many of these nodes demonstrating extensive central necrosis, as shown in Figure 2. Despite these necrotic changes, these nodes maintain normal capsular formation, lymphatic communications and other architectural features radiographically (see Figure 3).
Figure 2 Haematoxylin and eosin stained transparent lymph node (scale 40:1), with contrast-filled (lead oxide mixture) lymphatics (arrows). Central necrosis is evident, with multiple small and large degenerative vacuoles seen.
Correspondence and communications
1245 Wei-Ren Pan Hiroo Suami Warren Matthew Rozen G. Ian Taylor Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Room E533, Department of Anatomy and Cell Biology, The University of Melbourne, Parkville, Victoria 3050, Australia E-mail address: [email protected] Crown Copyright ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2008.01.023
‘Teenage BCC: to tan or not to tan?’
Figure 3 Plain radiograph of contrast-filled (lead oxide mixture) lymphatics of the head and neck, demonstrating the radiographic appearance of contrast-filled lymph nodes (arrows).
These necrotic lymph nodes do not contain tumours. Furthermore, all of these lymph nodes were identified in patients without known head and neck malignancy or previous surgery. As such, it is likely that they represent degenerative changes associated with aging. Our findings suggest that the presence of central necrosis in lymph nodes, although a marker for malignancy, can have other causes. Although CT remains a highly sensitive tool, the potential for false positives remains a limiting feature.
References 1. Sonmez A, Ozturk N, Ersoy B, et al. Computed tomography in the management of cervical lymph node pathology. J Plast Reconstr Aesthet Surg 2008;61:61e4. 2. Mancuso AA, Harnsberger HR, Muraki AS, et al. Computed tomography of cervical and retropharyngeal lymph nodes: normal anatomy, variants of normal, and applications in staging head and neck cancer. Part II pathology. Radiology 1983;148: 715e23. 3. Friedman M, Shelton VK, Mafee M, et al. Metastatic neck disease. Evaluation by computed tomography. Arch Otolaryngol 1984;110:443e7. 4. Muraki AS, Mancuso AA, Harnsberger HR. Metastatic cervical adenopathy from tumors of unknown origin: role of CT. Radiology 1984;152:749e53. 5. Yousem DM, Som PM, Hackney DB, et al. Central nodal necrosis and extracapsular neoplastic spread in cervical lymph nodes: MR imaging versus CT. Radiology 1992;182:753e9. 6. Friedman M, Roberts N, Kirshenbaum GL, et al. Nodal size of metastatic squamous cell carcinoma of the neck. Laryngoscope 1993;103:854e6.
Basal cell carcinoma (BCC) is the most common cancer in Caucasians, typically associated with increasing age, exposure to ultraviolet radiation and family history. Non-melanomatous skin cancer (NMSC) incidence is increasing by up to 10% per year globally and has been observed with increasing regularity in younger, and in particular, female populations.1,2 A 19 year old woman was referred to our clinic with an eight month history of a slow growing lesion, 10 6 mm, on the right inner canthus. (Figure 1) The patient was UK born, had no significant past medical history, family history or pre-malignant skin condition. Of note, she had suffered an extremely severe episode of blistering sunburn four years previously in Tenerife. There was no other significant episode of sunburn or sun-bed exposure. Punch biopsy revealed invasive nodular basal cell carcinoma. The lesion was completely excised, primarily closed (Figure 2) and the diagnosis histologically confirmed. The increasing incidence of BCC in younger age groups has been reported by several studies over the last 10 to 20 years1e3 but a de-novo case in a teenager has not previously been reported to our knowledge. Bath-Hextall et al.3 describe the recent trends in incidence across age groups in the UK from 1996 to 2003, revealing an increase in incidence
Figure 1
Clinical appearance of BCC at Right medial canthus.