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Thorax: first published as 10.1136/thx.11.3.172 on 1 September 1956. Downloaded from Thorax (1956), 11, 172. AN INVESTIGATION INTO THE LYMPHATIC AND VASCULAR SPREAD OF CARCINOMA OF THE BRONCHUS * BY H. C. NOHL From the London Chest Hospital (RECEIVED FOR PUBLICATION JANUARY 28, 1956) The present investigation was carried out be- Each spezimen while still fresh and unfixed was cause little work has been done to elucidate the carefully cleared of all the visible lymph nodes, and problems concerning the lymphatic spread of their relationship to the nearest bronchus was noted bronchogenic carcinoma. The question, whether and charted on a diagram (Fig. 1). the treatment of carcinoma of the bronchus by Vascular involvement was also looked for and lobectomy rather than by pneumonectomy is p.eces of pulmonary vein were sent for histological examination where invasion seemed most likely. based on sound pathological principles, needed Visceral or parietal pleural infiltration was noted and clarification. It was also felt that the establish- again microscopic confirmation was sought. And, ment of a surgical-pathological classification for lastly, the situation and extent of the growth were the purpose of prognosis and assessment of various carefully recorded. forms of treatment, as has been donz for cancer Each lymph node was then sectioned after fixation copyright. at other sites, was long overdue. Furthermore, and two slides were made of each gland. A serial the anatomy of the intrapulmonary lymphatic section of each lymph node was not done, as it would pathways described in the past are no longer have entailed an insurmountable amount of work. tenable in the light of our present knowledge of In all, 753 lymph nodes were histologically the bronchial and segmental anatomy of the lungs. examined, which means an average of 7.5 lymph Rouviere (1932), in his classic Anatomie des nodes per specimen. Borrie, who undertook a similar http://thorax.bmj.com/ Lymphatiques de l'Homme, gives an excellent investigation, found five lymph nodes per specimen. description of the mediastinal lymphatic path- The growth itself was also examined and was de- ways and nodes, but that of the interlobar and scribed as being one of four types (Table I). intrapulmonary nodes is inaccurate and his work TABLE I does not divide the lymph flow into lobar or seg- HISTOLOGICAL CLASSIFICATION OF CASES EXAMINED mental distribution. Since that time few contri- Squamous cell carcinoma ..59 butions have been made in this field; papers by Undifferentiated .28 McCort and Robbins (1951), Weinberg (1951), Adenocarcinoma. 8 on September 23, 2021 by guest. Protected Adeno- and squamous cell carcinoma .. Borrie (1952), and that by Brock and Whytehead ,, ,, undifferentiated cell carcinoma .. (1955) have touched on this subject. But all of Oat celIcarcinoma. 3 these authors, with the exception of Borrie, Total .. .. 100 reiterate, on the whole, Rouviere's statements on either the lymphatic anatomy or the drainage of the lungs. INCIDENCE OF LYMPH NODE INVOLVEMENT The incidence of lymph node involvement where METHOD OF INVESTIGATION pneumonectomies had been carried out was 88.8 %, One hundred specimens of lung resected for while the incidence after lobectomy was only bronchogenic carcinoma were examined. Of these 71 41.4%. The overall incidence of lymph node were pneumonectomies and 29 were lobectomies. involvement in the 100 resected specimens was They constitute a continuous series, except for three than cases which were not investigated, as a growth was not thus 75%. This percentage is higher the suspected at the time of the operation. usual figures quoted (Table IL). In this series 7.5 lymph nodes per specimen were found, while * An enlarged version of a paper read to the Thoracic Society in London in March, 1955. in that of Brock and Whytehead, where " radical Thorax: first published as 10.1136/thx.11.3.172 on 1 September 1956. Downloaded from LYMPHATIC AND VASCULAR SPREAD OF BRONCHIAL CARCINOMA 173 J~~~~~~~* Name: Mr. H. L. Reg. No.. 44495 Type of growth Squamous cell carcinoma Situation of growth : Distal branch of anterior segmental bocu involvement : None TraheaPleuralscular involvement: Infiltration of superior vena cava, part of which lperioP,tnorr Va}/ \\- 1 wii1 Trachca \Iwas excised (perivascular). No pulmonary vein involved i caval- 2-Oesophagusl copyright. I -Vena Posterior http://thorax.bmj.com/ 'rior ]1 11 A'bronchus6 s ntal I Pretracheal in superiorLymphmediastinumNodes ionary 2 Pretracheal attached firmly to superior vena cava, part of whichwasexcised. Mediallyextendingtoarchofaorta 1Apical lower3 lobe bronchus1bronchus 4 Medial to (R) main bronchus on September 23, 2021 by guest. Protected 'ulmonary, <; -51/ Posterior to (R) main bronchus lower part 6 Lateral to (R) main bronchus pulmonairy 1 diddle lobe. 1 v nvein /umnr 7 Inferior to anterior segmental bronchus of R.U.L. bronchus \f // 8 Superior to middle lobe bronchus 2 }| Pulmonary Malignant 9 Medial to lower lobe bronchus Infiltration ~~~lobcligament' 10 Lateral to and medial to middle lobe bronchus Classification: A3 11 At the top of pulmonary ligarment FIG. 1.-Chart which is used to record the site of the nodes dissected and examined histologically. It shows the nrediastiral aspect of the resected lung,->with thetmediastinal~~Inferiorstructures superimposed. The diagram, therefore, presents the mirror image of the orthodox view. Thorax: first published as 10.1136/thx.11.3.172 on 1 September 1956. Downloaded from 174 H. C. NOHL TABLE II Table III shows the location of the various INCIDENCE OF LYMPH NODE INVOLVEMENT lymph nodes on the right side of the chest and ACCORDING TO VARIOUS AUTHORS also indicates the site of the growth of each par- Ochsner, Dixon, and DeBakey (1945) 58 resected ticular lymph node. cases . 56-9% 2 and 3 indicate diagrammatically the Rienhoff (1947) 112 pneumonectomies 70.00% Figs. Wiklund (1951) 100 resected cases 540°/ anatomical position of the more important lymph Borrie (1952) 200 resected cases 48-0%; Salzer and others (1952) 160 resected cases 31 0%. nodes. Higginson (1953) 62 pneumonectomies 60-6% Three hundred and forty-seven lymph nodes Brock and Whytehead (1955) 109 " radical" pneumonectomies 38-0% were examined, of which 108 showed metastatic London Chest Hospital (1954-55) 100 resected deposits, giving an invasion rate of 31%. (The cases 75-0% invasion rates for the various lobes are given in Table V.) pneumonectomies" were performed, it is stated On analysing Table III the following features that 30-40 lymph nodes per specimen were become apparent. examined, and the percentage of cases showing TABLE III lymph node involvement was 38% in the 109 cases LYMPH NODES OF THE RIGHT LUNG where the state of glands is mentioned. In necropsy series the incidence is, of course, very Site of Growth much higher and ranges from 75% (Simpson, 1929) to 94% (Willis, 1953). It was often difficult Site of Lymph Nodes to forecast from macroscopic appearances whether 00 a lymph node was malignant or not. Often large firm nodes were free from growth, while small, Mediastinal innocent-looking ones showed a secondary. Micro- Pre-, para-, or retro- Not invaded 7 1 3 tracheal Invaded 9 1 1 133 found copyright. scopic metastases are most likely to be Subcarinal Not invaded 10 1 2 1 16 under the capsule of the node where the afferent Invaded I15l li21;43 1~ 6 Para-oesophageal Not invaded 2 4 lymphatic vessels open into the peripheral sinuses. Invaded Pericardial or para- Not invaded 11 phrenic Invaded 1 ~~~13 THE MACROSCOPIC ANATOMY OF THE LYMPHATIC In relation to upper part Not invaded 10 1 1 1 4 PATHWAYS OF THE LUNGS AS DEMONSTRATED BY ofright main bronchus Invaded 2 1 2 In relation to upper lobe Not invaded 5 1 6 LYMPHATIC METASTASES bronchus Invaded 11 In relation to upper lobe Not invaded 8 10 1 http://thorax.bmj.com/ As previously stated, not much research has epampntal hronrhi Invaded 61 2 1 1 been done in recent years on the lymphatic path- In relation to lower part Not invaded 251 41 3 1 25 ofright main bronchusj Invaded ways by which metastases from growths in various 10 1 1 117 In relation to middle lobe Not invaded 15 1 2 2 segments and lobes spread towards the hilar and bronchus Invaded 176 In relation to lower lobe Not invaded 13 1 3 13 mediastinal lymph nodes. For this reason the con- bronchus and segmen- Invaded 1 3 7 clusions drawn from the dissections done on the tal branches Pulmonary ligament .. Not invaded 2 1 4 100 cases in this series are described in this sec- Invaded 3 tion. However, in view of the fact that in the majority of cases the growth has involved more Total, 347. Invaded, 108. Invasion rate, 31%. on September 23, 2021 by guest. Protected than one segment, it is only possible to describe the lobar drainage with definite certainty. Lower lobe growths metastasize upwards, even occasionally into the lymph nodes around the RIGHT LUNG.-There was a total of 47 right- segmental bronchi of the upper lobe. The sub- sided growths. carinal and the para-oesophageal glands are often involved, while this seems to be a very infrequent Of these 19 growths were involving the upper lobe event with upper lobe growths. 18 growths 9.. ,, lower lobe The most important lymph nodes from the sur- 2 growths ,. ,, middle gical point of view seem to be those in relation to lobe the lower part of the right main bronchus, i.e., the 5 growths , . ,, upper and lobe bronchus lower lobes area which lies between the upper and the middle and apical lower lobe bronchi. 2 growths , . middle and his lower lobes This area was referred to by Borrie in Hunterian Lecture as the "lymphatic sump" of and 1 growth ,,9 ,, upper and middle lobes the right lung.
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