Skip Navigation


Japanese Journal of Clinical Oncology Advance Access originally published online on February 1, 2007
Japanese Journal of Clinical Oncology 2007 37(2):90-95; doi:10.1093/jjco/hyl141
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
37/2/90    most recent
hyl141v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Tomimaru, Y.
Right arrow Articles by Tsukamoto, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tomimaru, Y.
Right arrow Articles by Tsukamoto, Y.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?


© 2007 Foundation for Promotion of Cancer Research

Surgical Results of Lung Cancer with Sarcoid Reaction in Regional Lymph Nodes

Yoshito Tomimaru1, Masahiko Higashiyama1,, Jiro Okami1, Kazuyuki Oda1, Koji Takami1, Ken Kodama1 and Yoshitane Tsukamoto2

1 Department of Thoracic Surgery
2 Department of Pathology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan

For reprints and all correspondence: Masahiko Higashiyama, Department of Thoracic Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan. E-mail: higasiyama-ma{at}mc.pref.osaka.jp

Received June 8, 2006; accepted October 7, 2006


   Abstract
TOP
 Abstract
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
 References
 
Background: There have been few reports of sarcoid reaction in the regional lymph nodes associated with lung cancer. The purpose of this study was to analyze the surgical results of lung cancer with sarcoid reaction.

Methods: Of 1733 lung cancer patients undergoing surgical treatment in our institute from 1990 to 2004, we reviewed 22 patients (1.3%) with sarcoid reaction in the regional lymph nodes of lung cancer.

Results: On pre-operative computed tomography (CT), mediastinal lymph node swelling was detected in 19 patients (86%) as clinical N3 disease (c-N3) in six or as c-N2 in 13, while three patients were classified as c-N0. To these 19 patients, lymph node status was histologically checked by mediastinoscopy in four patients, sternotomy approach in two and open mini-thoracotomy in 13. Because the sampling-biopsy nodes showed no tumor metastasis, radical surgery was promptly performed. However, four patients (18%) were finally judged to have pathological lymph node positive disease. Five patients were in pathological stage (p-stage) IA, nine in p-stage IB, five in p-stage IIB, two in p-stage IIIA, and one in stage IIIB. The overall 3-, and 5-year survival rates of these patients were 85.2 and 77.7%, respectively, with no significant difference compared to those of the remaining patients without sarcoid reaction.

Conclusions: Because lung cancer patients with sarcoid reaction in the regional lymph nodes frequently show mediastinal lymph node swelling on CT, radical resection should be performed after confirming the node status by appropriate sampling biopsy. It seems that surgical results of lung cancers with sarcoid reaction in the regional nodes are not prognostically different from those without sarcoid reaction.

Key Words: sarcoid reaction • lymph nodes • lung cancer • immunologic disorder


   INTRODUCTION
TOP
 Abstract
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
 References
 
Sarcoidosis is a common systemic disorder of unknown etiology, which is characterized by the formation of non-caseating epithelioid cell granulomas. Besides systemic sarcoidosis, these gnanulomas have also been observed not only in various parenchymas, but also in the lymph nodes associated with other granulomatous diseases. They are caused by infections, environmental exposure to chemical substances, autoimmune disorders and malignant diseases, which have been termed ‘sarcoid reactions’ or ‘sacoid-like reactions’ (1–3). However, there have been few reports of this disease associated with lung cancer. To date, we have surgically treated 22 patients in whom a sarcoid reaction was histologically observed in the resected regional lymph nodes of lung cancer. In this report, reviewing the surgical data of such patients, we discuss the clinocopathological features and problems of this disease combined with lung cancer.


   PATIENTS AND METHODS
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
 References
 
During the 15 years between January 1990 and December 2004, 1733 patients with primary lung cancer underwent radical surgical resection in Osaka Medical Center for Cancer and Cardiovascular Diseases. Their resected primary lung cancers and regional lymph nodes were histologically reviewed, and in 22 patients (1.3%), non-caseating epithelioid cell granulomas were typically observed limitedly in the regional lymph nodes. These patients showed no signs of systemic sarcoidosis and they had no granulomatous diseases, such as tuberculosis and leprosy, and no history of exposure to chemical materials such as beryllium. Therefore, these lesions in the lymph nodes were diagnosed as sarcoid reaction associated with lung cancer. T and N categories in this report were assessed according to the TNM staging system of the Japan Lung Cancer Society (4). Location number (#) of lymph node was indicated by Naruke's node mapping classification (5). Clinicopathological and post-operative follow-up data were also retrospectively collected from the ongoing database in our center. Median post-operative follow-up period of all the patients was 53 months (range: 12–186 months). The post-operative survival rates were calculated by the Kaplan–Meier method and compared using the log-rank test. The significance of differences in each group was analyzed by the {chi}2 test, Fisher's exact test or the Mann–Whitney U test. Statistical analysis was performed using Statview (Version 5.0, SAS Institute Inc., Cary, NC, USA). A P value of < 0.05 was considered statistically significant. This study was approved by the Human Ethics Review Committee of Osaka Medical Center for Cancer and Cardiovascular Diseases and a signed consent form was obtained from each patient.


   RESULTS
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
 References
 
Pre-operative, Operative and Pathological Profiles of the Lung Cancer Patients
The clinicopathological features of the 22 patients who had primary lung cancer with sarcoid reactions is shown in Table 1. The patients consisted of 17 males and five females. Their average age was 66 years (range: 37–82 years). The lung cancer was located in the right upper lobe in seven patients, right lower lobe in eight, left upper lobe in four and left lower lobe in three. Among the 22 patients, while only two were pre-operatively in clinical stage IA (c-stage IA), and one in c-stage IB, 13 patients were classified in c-stage IIIA and six in c-stage IIIB, respectively. Notably, six patients were pre-operatively diagnosed as clinical N3 (c-N3) and 13 were diagnosed as c-N2 because of mediastinal lymph node swelling on pre-operative computed tomography (CT) images (Fig. 1). The distribution and maximum minor axis of swollen lymph nodes on pre-operative CT were also shown in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1. Clinicopathological features of lung cancer patients with sarcoid reaction in regional lymph nodes

 

Figure 1
View larger version (71K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1. Computed tomography (CT) of the chest of a representative case, showing a tumor at the right B9 + 10 with mucoid impaction and mediastinal and bilateral hilar lymph node swelling.

 
Therefore, to examine histologically the status of the swollen mediastinal lymph nodes, mediastinoscopy before radical surgery was performed in four patients. Also, a sternotomy approach was conducted in two patients to obtain biopsy samples of swollen mediastinal lymph nodes of the opposite side. In such patients, because no tumor metastasis in the resected mediastinal lymph nodes for sampling was demonstrated, radical surgery was promptly performed. In the remaining 13 patients diagnosed pre-operatively as c-N2 or c-N3, in order to estimate complete intra-operative curability, node sampling or node dissection was first performed principally under open mini-thoracotomy. However, in the remaining three patients diagnosed as c-N0, standard thoracotomy was performed. Finally, lobectomy was performed in 19 patients and pneumonectomy in three, respectively, with mediastino-hilar lymph node dissection (ND2a).

Based on the pathological examination, although no nodal involvement was shown in 18 patients, the remaining four patients were judged to have pathological N1 (p-N1) or p-N2 disease. As for pathological stage (p-stage), five patients were in T1N0M0 (p-stage IA), nine in T2N0M0 (p-stage IB), five in T3N0M0 (p-stage IIB), two in T2N2M0 (p-stage IIIA) and one in T4N2M0 (p-stage IIIB, T4 owing to pleural dissemination). The histological type and grades of the tumors were as follows: adenocarcinoma in 11 patients, squamous cell carcinoma in nine and adenosquamous cell carcinoma in two. Tumors were well differentiated in five patients, moderately differentiated in eight, poorly differentiated in seven and not evaluated in two, respectively.

As for pre-operative complications, it was noted that eight patients (36%) had suffered from severe or moderate non-infectious immunologic disorders before radical surgery: severe multi-drug allergy (two or more drugs such as pyrine and antibiotics, for example) in five patients, bronchial asthma in two, rheumatoid arthritis in one and Hashimoto's thyroiditis in one, respectively. One of these patients (Case No. 20) had suffered from rheumatoid arthritis and severe multi-drug allergy.

Clinicopathological Features and Nodal Status: Sarcoid Reaction and Metastasis
In the 22 patients examined, sarcoid reactions were observed histologically in the lymph nodes, in which round granulomas markedly contained large, uniform epitheloid and often multi-nucleated giant cells of Langerhans (Fig. 2). As described in Patients and Methods, such well-developed granulomatous reactions were found in the resected regional lymph nodes, but not in the primary tumor. In 21 patients, sarcoid reactions were typically observed in all the resected mediastino-hilar lymph nodes, although in the remaining patient (Case No. 16), the reactions were seen only in the resected mediastinal lymph nodes and not in the hilar lymph nodes.


Figure 2
View larger version (103K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2. Histology of a representative case, showing sarcoid reactions in the regional lymph node.

 
In four of these patients, tumor metastatic foci were microscopically detected in several mediastino-hilar nodes: #4 and #11 nodes in one patient (Case No. 9), #7 and #13 nodes in another (Case No. 11), #3 and #11 nodes in another (Case No. 16), and #10 and #11 nodes in the other (Case No. 22), respectively. Thus, one patient was diagnosed with p-N1 disease and the remaining three were diagnosed with p-N2.


   SURGICAL OUTCOME
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
DISCUSSION
 Conflict of interest statement
 References
 
Under the average follow-up periods of 52.6 months after radical surgery (range: 5–156 months), tumors recurred in five patients, including two in p-stage IB, two in p-stage IIIA and one in p-stage IIIB. Nine patients died, four suffered tumor recurrence and five from other diseases with no evidence of recurrence, respectively.

The overall 3- and 5-year survival rates of the 22 patients with sarcoid reaction after radical surgery were 85.2 and 77.7%, respectively (Fig. 3). Compared with the remaining 1711 patients without sarcoid reactions (the overall 3- and 5-year survival rates: 82.1 and 75.2%), no statistically significant difference in the overall survival was found in those with sarcoid reactions (P = 0.8227). Especially, among p-stage IA and IB patients with sarcoid reaction, the overall 3-, and 5-year survival rates were 91.7 and 82.5% (Fig. 4). Compared with the remaining 905 p-stage IA and IB patients without sarcoid reactions (the overall 3- and 5-year survival rates: 90.4 and 86.8%), no statistically significant difference in the overall survival was also found in those with sarcoid reactions (P = 0.7853).


Figure 3
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3. Survival curves after pulmonary resection for lung cancer of patients with sarcoid reactions (n = 22) and those without sarcoid reactions (n = 1,711). The thick line indicates patients with sarcoid reactions and the dotted line those without sarcoid reactions (P = 0.8227). N.S., not significant.

 

Figure 4
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4. Survival curves after pulmonary resection for lung cancer of patients staged IA or IB with sarcoid reactions (n = 14) and those staged IA or IB without sarcoid reactions (n = 905). The thick line indicates patients with sarcoid reactions and the dotted line those without sarcoid reactions (P = 07853). N.S., not significant.

 

   DISCUSSION
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
 DISCUSSION
Conflict of interest statement
 References
 
Sarcoid reactions have been observed in a variety of malignant tumors. Their incidence has been reported to be as high as 4.4–7.9%, not only in the tumor tissues but also in the regional lymph nodes (1,2,6). For example, the incidence of sarcoid reaction was reported to be 0.93% in patients with Hodgkin's disease by Brincker et al. and 2.2% in patients with breast cancer by Giunti et al. (7,8). However, the incidence of this disease associated with lung cancer was reported to be 2.2–3.2% (9,10). In this study reviewing 1733 lung cancer patients, the incidence was 1.3%. This incidence seemed slightly lower, but this might be due to the fact that the subjects analysed were only patients with sarcoid reactions in the resected mediastinal and hilar lymph nodes of lung cancer, while those with this disease in the primary lesions were excluded. While Kamiyoshihara et al. reported that younger patients tended to suffer from lung cancer with sarcoid reactions, the average age in this study seemed to be similar to that of the overall patients undergoing surgery for lung cancer in our institute (6).

Lauberg et al. mentioned that this disease associated with lung cancer was histologically common (15 out of 20, 75%) in the squamous cell carcinoma type because this type of cancer grew more slowly than other types and its regional lymph nodes were exposed to lymphatic flow from the primary lesion for a longer period (9). However, several authors reported that among lung cancer patients this disease was not associated with any histological type, while others reported the adenocarcinoma type was more frequent. Kamiyoshihara et al. reported that the relative incidence of the various histological types varied greatly between countries or races even in cases of small cell lung cancer with sarcoid reactions (10). In our series where various histological types of lung cancer were observed, it was suggested that no histological type is etiologically associated. In addition, considering the findings in our series, histological grade did not seem to be so important for this condition.

Since lymphadenopathy caused by a sarcoid reaction often mimics metastatic lymph nodes, the differential diagnosis may be very important clinically. In fact, 19 patients (86%) in our series showed regional lymph node enlargement on pre-operative CT scans. In general, surgical resection has been the mainstay of treatment for primary lung cancer. However, the surgical procedures of pulmonary resection may cause substantial mortality and morbidity, and therefore be inappropriate if the disease burden of the patient is so extensive as to be non-resectable (11). Moreover, the number of p-N2 stations was reported to be a useful prognostic factor (12). Asamura et al. mentioned that patients with single-station and single-node metastases had a significantly better prognosis than those with more extensive metastases (13). Accordingly, when surgical treatment is considered for lung cancer with mediastino-hilar lymph node swelling, we should assess the appropriate treatment required by using lymph node biopsy via mediastinoscopy or (mini-)thoracotomy. Only after the histological examination of the lymph node specimen, should we be able to select the most appropriate treatment mode. Recently, positron emission tomography (PET) and PET-CT have been reported to be useful in the diagnosis of lymph node metastasis with lung cancer. Nevertheless, as seen in a patient in our series (Case No. 22), PET and PET-CT are also reported to show false positives in tuberculosis, sarcoidosis and other granulomatous or inflammatory processes (14–17). There is no useful examination, except the histopathological one, for distinguishing lymphadenopathy caused by a sarcoid reaction from metastatic lymph nodes. Thus, after pre-operative assessment of swollen lymph nodes, we should perform radical surgery after histological confirmation of sarcoid reaction in the swollen lymph nodes by appropriate sampling biopsy. This presupposes, of course, general considerations of factors such as the size and distribution of the swollen lymph nodes, tumor markers and the findings of biopsy specimens in addition to the findings of PET and PET-CT. Only on this basis should we be able to determine the treatment strategy for such patients with regional lymph node enlargement on pre-operative CT scans.

The mechanism of tumor-associated sarcoid reaction in the regional nodes has not yet been elucidated. Some authors suggested a relationship between malignant tumors and sarcoid reactions as follows: (i) a localized defense reaction to tumor cells themselves; (ii) a simple tissue reaction to a tumor embolism in the lymphatic system or capillaries; and (iii) an immunological reaction to substances released from the tumors transported along the lymphatic system (18,19). However, sarcoidosis has been considered to be a disease closely associated with immunologic disorders. In fact, there have been a number of reported cases of sarcoidosis complicated with various autoimmune or allergic diseases. In contrast, little is known of sarcoid reactions associated with immunological disorders (20–23). In this study, however, it was intriguing to find that eight (36%) out of the 22 patients suffered from immunological complications: four with autoimmune diseases and five with severe multi-drug allergy. As a control, the incidence of such pre-operative complications in surgically resected lung cancer patients was recently shown to be only about 8% in our institute (unpublished data). Although statistical analysis could not be performed, the incidence (36%) in the present series seems relatively high. These findings suggest that sarcoid reaction complicated with malignancy may also have mechanisms common to immunological responses to autoimmune or allergic diseases. For example, it was proposed that this disease might be caused by an anti-tumor hypersensitive response of macrophages through T-lymphocyte activation induced by some soluble antigenic factors derived from cancer cell (18,19).

It is generally reported that patients with malignant tumors co-existing with sarcoid reactions had a good prognosis because this reaction commonly occurs in lymph nodes without metastasis (6). In Hodgkin's disease and gastric cancer, patients with sarcoid reactions in the regional lymph nodes have been reported to have a good prognosis (24–26). With regard to lung cancer with sarcoid reactions, there have been few reports, however (9,10). Kamiyoshihara et al. reported seven cases of primary pulmonary carcinoma with sarcoid reactions, and concluded that the sarcoid reaction did not influence the prognosis of lung cancer (10). In this study, four patients (18%) were classified as having node metastasis and eight (36%) were in advanced-stage disease. Besides, although follow-up periods after surgery were insufficient, there was no significant difference in the overall survival rates between the lung cancer patients with sarcoid reactions and those without the reactions. If limited to patients stage I (IA and IB), there was no significant difference, either. Therefore, it is concluded that this reaction associated with lung cancer does not influence the grade of malignancy of the tumor.


   Conflict of interest statement
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
References
 
None declared.


   References
TOP
 Abstract
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 SURGICAL OUTCOME
 DISCUSSION
 Conflict of interest statement
 References
 
1 Gorton G and Linell F. (1996) Malignant tumours and sarcoid reactions in regional lymph nodes. Acta Radiol 47 381–92.

2 Llombart A Jr and Escudero JM. (1970) The incidence and significance of epithelioid and sarcoid-like cellular reaction in the stromata of malignant tumours. A morphological and experimental study. Eur J Cancer 6 545–51.

3 Gregorie HB Jr, Othersen HB Jr, Moore MP Jr. (1962) The significance of sarcoid-like lesions in association with malignant neoplasms. Am J Surg 104 577–86.[CrossRef][ISI][Medline]

4 The Japan Lung Cancer Society. (2003) General Rules for Clinical and Pathological Record of Lung Cancer. 6th edn Tokyo, Kanehara.

5 Naruke T, Suemasu K, Ishikawa S. (1978) Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 76 832–9.[Abstract]

6 Brincker H. (1986) Sarcoid reactions in malignant tumours. Cancer Treat Rev 13 147–256.[CrossRef][ISI][Medline]

7 Brincker H. (1972) Sarcoid reactions and sarcoidosis in Hodgkin's disease and other malignant lymphomata. Br J Cancer 26 120–3.[ISI][Medline]

8 Giunti G, Mancini AM, Fontanili M. (1964) Sarcoidosis-like findings in the tributary lymph nodes of breast neoplasms. Arch Ital Anat Istol Patol 38 19–46.[Medline]

9 Laurberg P. (1975) Sarcoid reactions in pulmonary neoplasms. Scand J Respir Dis 56 20–27.[ISI][Medline]

10 Kamiyoshihara M, Hirai T, Kawashima O, Ishikawa S, Morishita Y. (1998) Sarcoid reactions in primary pulmonary carcinoma: report of seven cases. Oncol Rep 5 177–180.[ISI][Medline]

11 Deslauriers J, Ginsberg RJ, Piantadosi S, Fournier B. (1994) Prospective assessment of 30-day operative morbidity for surgical resections in lung cancer. Chest 106 329–30.

12 Ichinose Y, Kato H, Koike T, Tsuchiya R, Fujisawa T, Shimizu N, et al. (2001) Japan Clinical Oncology Group: Overall survival and local recurrence of 406 completely resected stage IIIa-N2 non-small cell lung cancer patients: questionnaire survey of the Japan Clinical Oncology Group to plan for clinical trials. Lung Cancer 34 29–36.[CrossRef][ISI][Medline]

13 Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. (1999) Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 117 1102–11.[Abstract/Free Full Text]

14 Pitman AG, Hicks RJ, Binns DS, Ware RE, Kalff V, McKenzie AF, et al. (2002) Performance of sodium iodide based (18)F-fluorodeoxyglucose positron emission tomography in the characterization of indeterminate pulmonary nodules or masses. Br J Radiol 75 114–21.[Abstract/Free Full Text]

15 Lardinois D, Weder W, Hany TF, Kamel EM, Korom S, Seifert B, et al. (2003) Staging of non-small-cell lung cancer with integrated positron-emission tomography and computed tomography. N Engl J Med 348 2500–7.[Abstract/Free Full Text]

16 Wahl RL, Quint LE, Greenough RL, Meyer CR, White RI, Orringer MB. (1994) Staging of mediastinal non-small cell lung cancer with FDG PET, CT, and fusion images: preliminary prospective evaluation. Radiology 191 371–7.[Abstract/Free Full Text]

17 Gould MK, Kuschner WG, Rydzak CE, Maclean CC, Demas AN, Shigemitsu H, et al. (2003) Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer: a meta-analysis. Ann Intern Med 139 879–92.[Abstract/Free Full Text]

18 Gherardi GJ. (1950) Localized lymph node sarcoidosis associated with carcinoma of the bile ducts; report of a case. Arch Pathol 49 163–8.

19 Shimosato Y, Oboshi S, Umegaki Y. (1965) Tuberculoid granulomas in lymph nodes irradiated for metastatic tumors. Acta Pathol Jpn 15 339–53.[Medline]

20 Sharma OP. (2002) Sarcoidosis and other autoimmune disorders. Curr Opin Pulm Med 8 452–6.[CrossRef][ISI][Medline]

21 Coutant G, Bechade D, Mayaudon H, Moulin O, Algayres JP. (2000) Association of sarcoidosis and multiple autoimmune syndrome. Ann Med Interne 151 519–20.[Medline]

22 Wiesenhutter GW and Sharma OP. (1979) Is sarcoidosis an autoimmune disease? Report of four cases and review of the literature. Semin Arthritis Rheum 9 124–44.[ISI][Medline]

23 Enzenauer RJ and West SG. (1992) Sarcoidosis in autoimmune disease. Semin Arthritis Rheum 22 1–17.[CrossRef][ISI][Medline]

24 O'Connell MJ, Schimpff SC, Kirschner RH, Abt AB, Wiernik PH. (1975) Epithelioid granulomas in Hodgkin disease. A favorable prognostic sign? JAMA 233 886–9.[Abstract]

25 Sacks EL, Donaldson SS, Gordon J, Dorfman RF. (1978) Epithelioid granulomas associated with Hodgkin's disease: clinical correlations in 55 previously untreated patients. Cancer 41 562–567.[CrossRef][ISI][Medline]

26 Takeuchi H, Suchi T, Suzuki R, Sato T. (1982) Histological study of immune parameters of regional lymph nodes of gastric cancer patients. Gann 73 420–8.[ISI][Medline]


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
37/2/90    most recent
hyl141v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Tomimaru, Y.
Right arrow Articles by Tsukamoto, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tomimaru, Y.
Right arrow Articles by Tsukamoto, Y.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?