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一项新研究结果显示，中膈淋巴结（MLN）肉芽肿发炎，不论是透过中膈腔镜切除或是切片，都需要以微生物染色才能完全看到，即使一开始被诊断为类肉瘤。
发表者德州休士顿Baylor医学院的博士后研究员Hanan Abdel Monem医师在一项与Medscape病理学的访谈中谈到，我们发现70%肺癌患者与肉芽肿有关；Monem医师表示，有趣的是，这其中仅有少数人有淋巴结病变。
肺肿瘤的分期与诊断淋巴结肿大原因需要胸膈镜导引的MLN外科切除或是切片。
主要作者、Michael E. DeBakey VA医疗中心与Baylor医学院的病理学教授Linda K. Green医师在一项与Medscape的访谈中说道，越来越多人依赖PET（正子摄影）作为癌症分期的工具。
Green医师表示，部份罹患肉芽肿疾病的病患在PET扫描上会有阳性结果，而因此可能被诊断为罹患较后期的癌症（例如若是医师依靠PET扫描，他们可能被认为不适合接受手术）。
Green医师的结论是，我们发现，相较于PET扫描，胸膈镜对于可以切除的肺肿瘤仍然是诊断的黄金标准，因为恶性肿瘤可能诱发胸膈肉芽肿疾病，且与胸膈转移没有关系。
这项研究发现发表于2008年美国临床病理学会年会上。
研究团队想要确认胸膈肉芽肿发炎疾病的常见与罕见病因。
他们回顾到1992年的病例，并分析76位病患的临床、放射学、病理学以及培养数据和临床病程，其中71位为男性，5位为女性，年龄介于29至80岁。
总共有38位病患有恶性肿瘤，其中35位是肺癌，黑色素瘤、食道癌、肾脏癌症各有1位，这些病患中，大部分（共29位）没有MLN转移，其余病患有MLN转移（共有6位）或是组织浆菌（Histoplasma capsulatum）或分支杆菌（Mycobacterium avium intracellulare），1位感染放线菌，1位感染莫拉克氏菌。
作者们在他们的壁报发表中表示，感染会合并坏死或干酪性坏死肉芽肿发炎，包括分支杆菌与霉菌感染，有或是没有并存肺肿块。
Green医师指出这项研究的主要临床重要性，在退伍军人事务（VA），我们的族群经常是老年男性病患，且有许多有并发感染的问题，例如肺结核或是组织浆菌，这些可能是潜伏的，但在PET扫描上仍呈阳性。
密西根州安纳堡圣约瑟芬基督教医院的血液病理学科主任Daniel D. Mais医师向Medscape病理学表示，这是一般病理学家希望看到的研究类型，非常实际且谈到我们几乎每天都会面对到的问题；Mais医师并未参与这项研究。
Mais医师继续说道，重点在于，当我们第一次在样本切片中找到它们，我们要对这些肉芽肿做多少检验，不同专家的执业之间是有差异的，部份专家每次在看到一个肉芽肿时，他们就会做一次染色，其他则认为这是类肉瘤肉芽肿，并不需要进一步确认。
Mais医师附带表示，这样的研究协助再次强调进行所有微生物染色的重要性；Mais医师做出这样的结论，经常，如果你给病患一个类肉瘤的诊断，举例来说，是你看到肉芽肿时所做出的诊断，而你并没有发现任何微生物，这位病患可能得到类肉瘤，类固醇则是感染这些细菌病患所不需要的。
这项研究并未接受商业赞助。Green医师，Monem医师与Mais医师表示无相关资金上的往来。
Mediastinoscopy More Reliable Than PET for Characterizing Granulomatous Inflammation in Lymph Nodes
By Crina Frincu-Mallos, PhD
Medscape Medical News
Granulomatous inflammation in mediastinal lymph nodes (MLN) that were either excised or biopsied at mediastinoscopy needs full characterization through microbial stains, even when it is initially diagnosed as sarcoidosis, a new study shows.
"We found that 70% of the patients had lung cancer associated with granulomatous inflammation," presenter Hanan Abdel Monem, MD, postdoctoral fellow at Baylor College of Medicine, in Houston, Texas, said in an interview with Medscape Pathology. Interestingly, "only some of them had lymphadenopathy," added Dr. Monem.
Mediastinoscopy-guided surgical resection or biopsy of MLN is needed to stage lung neoplasms and diagnose causes of lymphadenopathy.
"There are more and more people relying on PET [positron emission tomography] scans as a staging mechanism," lead author Linda K. Green, MD, professor of pathology at Michael E. DeBakey VA Medical Center and Baylor College of Medicine, told Medscape Pathology in an exclusive interview.
"Some of the patients with granulomatous disease will show PET-scan positivity and therefore they may be upstaged" (i.e., not be considered surgical candidates if their doctor relies on a PET scan), noted Dr. Green.
"We have found that mediastinoscopy in resectable lung tumor is still the gold standard, compared with PET scans, because of the very nature of the fact that malignancies can induce granulomatous disease in the mediastinum yet not be associated with metastases in the mediastinum," concluded Dr. Green.
The findings were reported here at the American Society for Clinical Pathology 2008 Annual Meeting.
The investigators sought to determine common and unusual causes of granulomatous inflammatory disease in the mediastinum.
They reviewed their files going back to 1992 and analyzed the clinical, radiography, histology, and culture data and the clinical course of 76 patients, 71 males and 5 females, ranging in age from 29 to 80 years.
A total of 38 patients had malignancies: 35 had lung cancer, 1 had melanoma, 1 had esophageal cancer, and 1 had renal cancer. Of these patients, the majority (n?= 29) presented no MLN metastases. The rest of the patients had MLN with metastases (n?= 6) or infections with Histoplasmosis (n?= 1) or Cryptococcus (n?= 2).
A total of 21 non-caseating granuloma inflammations were diagnosed as sarcoidosis. In addition, there were 13 primary infectious causes: 5 had tuberculosis, 4 had Histoplasma capsulatum, 2 had Mycobacterium avium intracellulare, 1 had Actinomyces, and 1 had Moraxcella.
"Necrotizing or caseating granulomatous inflammation is seen with infections, including mycobacteria and fungal infections, with or without a concurrent lung mass," the authors stated in their poster presentation.
Dr. Green pointed to the primary clinical importance of this study: "In the VA [Veterans Affairs], we have an older male population, and there are lots of concomitant infections, such as tuberculosis or histoplasmosis, which could be dormant but still show positive in a PET scan."
"This is the kind of study the general pathologist would like to see more of — very practical, and addressing a problem that we deal with almost every day," Daniel D. Mais, MD, FASCP, medical director of Hematopathology at St. Joseph's Mercy Hospital, in Ann Harbor, Michigan, told Medscape Pathology. Dr. Mais was not involved in the study.
"The issue is: How much do we need to work up these granulomas when we first find them in sample biopsies?" continued Dr. Mais. "There are differences between specialists' practices. Some will do all of the microbial stains every time they see a granuloma, others think that if it looks like a sarcoidal granuloma, there is no need for further characterization."
"This kind of study helps reinforce the need to do all the microbial stains," added Dr. Mais. "Often, if you give the patient a diagnosis of sarcoidosis, for example — which is the diagnosis you would give if you see a granuloma and you did not find any organisms — the patient may get steroids, and steroids are exactly the opposite of what people with these infections need," concluded Dr. Mais.
The study did not receive commercial support. Drs. Green, Monem, and Mais have disclosed no relevant financial relationships.
American Society for Clinical Pathology (ASCP) 2008 Annual Meeting: Poster 29. Presented October 17, 2008.