Multiple surgical radical treatment in axillary lymph nodes: A case report

Abstract

Lymph node tuberculosis is a common clinical bacterial infectious disease. Regional lymph node tuberculosis is often difficult to cure by surgically radical resection. In addition, its recurrence rate is higher, and it can easily cause lymphatic leakage. This case was considered to have left axillary lymph node tuberculosis. A combination of clinical examination, ultrasound, and magnetic resonance imaging examinations were performed before surgery. The surgical procedure performed was left axillary lymph node excision. Postoperative pathology confirmed the lymph node tuberculosis. The patient was given anti-tuberculosis drug treatment with no recurrence after 6 months follow-up. This provides new ideas and methods for the clinical treatment of regional lymph node tuberculosis.

Introduction

A 40-year-old female patient was admitted to the Department of General Surgery in Dongzhimen Hospital, Beijing University of Chinese Medicine (Beijing, China), mainly due to left armpit tumor for 2 years. The tumor slowly increased. The patient had an obvious local oppressive feeling. The tumor was visible on the surface contour and affected left upper limb activity. She never had any other discomfort. Past history was not special. Stable vital signs when she was admitted to hospital. The left axillary lymph nodes could be felt, which was larger by approximately 6 × 5 cm² and located in the 2–4 intercostal of the left anterior front line. The swollen lymph node had a tough texture, smooth surface, clear boundaries, movable, slightly adhered with the surrounding tissue, and had no tenderness. Furthermore, the breasts and right armpit lymph nodes were not abnormal. Chest magnetic resonance imaging (MRI) revealed multiple lymph nodes with the larger diameter of approximately 10.88 cm (Figure 1). Superficial ultrasound revealed multiple hypoechoic nodules which were larger (5.4 × 2.1 cm²) and continued to have a clear boundary. To clarify the nature of lymph nodes, we decided to surgically explore the tumors and perform a lymphadenectomy. We carried out axillary lymph node dissection to remove the visible and palpable masses (a total nine) after dissecting visible caseous necrosis (Figure 2). Pathological diagnosis was axillary lymph node tuberculosis (TB) (Figure 3). FB stain and mycobacterium TB-specific cellular immune test were both positive. She was given isoniazid, rifampicin, and streptomycin triple therapy from Ditan Hospital and did not show signs of lymph node TB recurrence.

Figure 1.

Preoperative chest MR scan.

Figure 2.

Postoperative tumor longitudinal section by overlook.

Figure 3.

Pathological HE staining—Granuloma center was caseous necrosis surrounding Langerhans giant cells, epithelioid cells, and lymphocytes: (a)10x electron microscope and Part (b) 20x electron microscope.

Discussion

Axillary swollen lymph nodes generally are caused by infections, tumors, reactive hyperplasia, histiocytosis, and metabolic disorders. In the clinic, the setting of suspected or confirmed lymph node TB or malignant lymphoma should always be considered. ¹ Since the 1990s, the incidence of TB and extrapulmonary TB in China has also increased significantly. ² There were clinical reports that mentioned that the axillary lymph node involved was second only to the first cervical lymph nodes by 15%. Pathological staging is mainly nodular, cheese, and mixed. ³

The onset of lymph node TB is often occult. This patient had no further examination and treatment. And axillary lymphadenopathy with concomitant diseases can also have metastatic occult breast cancer, cat scratching, and chronic lymphadenitis. Clinical examination is difficult to identify. Further correct diagnosis needs to be in conjunction with other physical and chemical examinations such as positron emission tomography (PET) and computed tomography (CT) imaging. Furthermore, laparoscopy with biopsies is helpful for correct diagnosis and appropriate management. ⁴ In developing countries, ultrasound is considered a potential public health benefit in terms of a more rapid diagnosis of TB. ⁵

In conclusion, this case report has the following characteristics:

1. The patient developed slow axillary lymph node TB within 2 years.

2. Surgical treatment of lymph node TB has advantages.

3. Surgery to replace anti-TB treatment of lymph node TB deserves further study.