Lymph node: Metastases from SCC of lung

A 45 yr old Malay man complained of a swelling on the left side of his neck for 1 month.  He had coughed out fress blood several times last week.  Smoked 20 cigarettes a day since the age of 20.  Physical examination showed a painless, 2 cm diameter swelling at the left side of his neck.  There were no chest signs.  Chest X-ray revealed a left lung shadow.

1.    What is the differential diagnosis?

        Differentials include:

              Primary lymph node disorders

              Metastasis carcinoma

              Reactive hyperplasia

              Inflammation / infections

              Lipid storage diseases

              Endocrine diseases - hyperthyroidism

2.    What sort of biopsy would you recommend?

Bronchial biopsy, fine needle aspiration of lung

Mediastinal lymph nodes biopsy

3.    How would you confirm a possible infective aetiology?

Ziehl-Neelsen stain for acid fast bacilli � pink bacilli

4.    List the histopathological features of the 2 conditions.

Tuberculosis:

Central caseating necrosis surrounded by a rim of epitheloid macrophages followed by a rim of lymphocytes and fibroblasts.

Langhan giant cells may be present. (nuclei of these cells are arranged in a peripheral horseshoe pattern)

Effacement of lymph node architecture.

Metastases from lung cancer:

Broad sheets/ nests of squamous epithelial cells

Presence of keratin pearls (lamellated pink stained masses)

Effacement of lymph node architecture

5.    Name a simple test to ascertain the nature of the lung lesion.

Microscopic examination of a bronchial biopsy and use Z-N stain for AFB.

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Copyright � Joseph Ong 2003