Apical Tumors Research Articles

Magnetic Resonance Imaging of Pulmonary Apical Tumors

Magnetic Resonance Imaging of Pulmonary Apical Tumors

Magnetic Resonance Imaging of Pulmonary Apical Tumors

Freundlich, Irwin M. M.D.; Chasen, Marvin H. M.D.; Varma, Datla G. K. M.D. Author Information

Resection of a superior sulcus tumor: Ginsberg RJ. Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Ctr., 1275 York Avenue, New York, NY 10021. Chest Surg Clin North Am 1995;5:315–331

All of these approaches are valuable and worthwhile, depending on the site of the apical tumor (anterior or posterior). When using an anterior approach, however, if significant posterior chest wall involvement is also present, a combined approach may be necessary, turning the patient after closure of the anterior wound, and completing the excision from the posterior approach. Thoracic surgeons involved in the management of these tumors should have all of these approaches available in their armamentarium. The overall 5-year cure rate following surgical resection of superior sulcus tumors is about 30%. In our experience, when a complete resection is performed, including a lobectomy, the 5-year cure rate is doubled. The results of en bloc resection of adjacent involved organs (subclavian vessels, vertebral body) are less optimistic in most reported series, which may reflect inadequate resections.

Postero-lateral microsurgical approach to orbital tumors.

A modification of the lateral orbitotomy is reported for the microsurgical approach to tumors located in the posterior intraconal space. The orbital apex is entered through a small bone opening on the orbital and temporal portions of the greater wing of the sphenoid, with the lesser sphenoidal wing, the orbital plate of the frontal bone, and the lateral orbital rim being left intact. This surgical technique was employed in 8 cases of pure apical tumors, out of a consecutive series of 103 orbital growths. It proved to be reliable with regard to either adequate exposure and radical excision of the lesions or low rate of operative morbility.

Improved Treatment Planning for the Syed-Neblett Template Using Endorectal-Coil Magnetic Resonance and Intraoperative (Laparotomy/Laparoscopy) Guidance: A New Integrated Technique for Hysterectomized Women with Vaginal Tumors

The Syed template (Alpha-Omega Services, Bellflower, CA) represents an advance in interstitial gynecologic brachytherapy; however, its appeal is diminished by inaccuracies in target definition secondary to suboptimal imaging of gynecologic tumors and the risk of viscus perforation during a "blind" procedure. Magnetic resonance (MR) scanning with an endorectal coil and computed tomography were studied as a possible tool to improve target definition and maximize treatment planning with Syed templates. Abdominopelvic contents could be visualized directly through a laparotomy incision or indirectly with a laparoscopic video display to allow further target definition and minimize complications associated with blind procedures after hysterectomy. The synthesis of these techniques with Syed template applications was attempted to potentiate the utility of this brachytherapy system. Five patients with apical vaginal tumors which arose after previous hysterectomies (two endometrial cancer recurrences, one recurrent uterine sarcoma, two primary vaginal cancers) were referred for radiotherapy. In three cases, external beam pelvic radiotherapy (median dose, 45 Gy; range, 45-50.4 Gy) was delivered initially. In all cases, the Syed applicator was used for the brachytherapy component of the treatment. In two cases, high-resolution MR images (400 × 400/μm) of the vaginal apex were obtained after insertion of an endorectal surface coil. The images defined the relationships between the template, target volume, bladder, rectum, and intestine. The other three cases were planned with computerized tomography (CT). In all cases, intraoperative examination of the abdominopelvic contents was provided when laparotomy and/or laparoscopy was performed by the surgical team. The median brachytherapy dose prescribed to the isodose envelope covering the target volume was 40 Gy (range, 31-50 Gy). In all cases, the target volumes could be encompassed by the 60 cGy/hr isodose line. Tumor volume estimation was better with MR than CT. Procedure time was shorter with laparoscopy than with laparotomy. In two cases, bowel displacement was performed (one tissue expander, one omental sling) to prevent viscus perforation by interstitial needles. Four of five patients responded completely to the treatment. In three cases, local control was maintained at a median follow-up of 11 months. In conclusion, endorectal coil MRI may be advantageous to CT of the pelvis in that it allows preplanning to be achieved with greater precision and with less planning time. Major intraoperative complications (i.e., perforation of hollow viscus organs) can be avoided when the course of interstitial catheters is visualized from above by the surgical team. The integration of these innovative techniques with an effective brachytherapy system has the potential of improving control and reducing complications when treating challenging gynecologic tumors.

Extended operations after induction therapy for stage IIIb (T4) non-small cell lung cancer

Twenty-three patients with stage IIIb (T4) non-small cell lung cancer received induction chemotherapy (median, 2 cycles) with (n = 12) or without (n = 11) radiation (median, 45 Gy) before operation. Nine tumors involved the carina (n = 8) or lateral trachéal wall (n = 1), 11 were located centrally and invaded the proximal pulmonary artery (n = 6), veins (n = 3), or both (n = 2), three were apical tumors involving T4 structures, and six were associated with historically diseased mediastinal nodes. Five complete and 18 partial responses were observed after induction treatment. Resection of all residual tumor at the primary site and involved vestiges was possible in 21 patients (91%); in two apical tumors, tumor was left behind. Nine right tracheal sleeve and 11 intrapericardial pneumonectomies and three resections of apical rumors were performed; 11 patients (48%) had radical mediastinal lymph node dissection. Complete sterilization of the primary tumor was observed in 3 patients (13%). Mean operating time was 209.3 ± 86.8 minutes, and mean blood loss was 896.9 ± 1031 mL. Major postoperative complications occurred in 6 patients (26%), including hemothorax requiring drainage (n = 1) or reoperation (n = 1), acute distress syndrome (n = 2), and bronchopleural fistula (n = 2), and their incidence was significantly higher ( p = 0.003) among patients receiving induction chemoradiation than among those receiving chemotherapy alone (42 versus 9%). Early (<1 month) postt oerative mortality was 8.6% (n = 2). With a median follow-up of 25 months (range, 12 to more than 39 months), the projected 3-year overall survival was 54%. Further follow-up will define whether this aggressive approach should become standard care for selected IIIb (T4) non-small cell lung cancer patients.

Villaret's syndrome: A report of two cases

The syndrome resulting from lesions of the lower four cranial nerves (CN) and the cervical sympathetic chain is known as Villaret's syndrome. We report two cases of the syndrome and emphasize the localizing value of this constellation of signs. The second case is unusual because involvement of the cervical sympathetic chain produced sympathetic overactivity, instead of the usual sympathectomy effect. Increased sympathetic outflow expressed as pupillary dilation, widened palpebral fissure, and facial sweating (the Claude Bernard syndrome) usually occurs as an early manifestation of apical thoracic tumors and has not been previously associated with Villaret's syndrome.

Episcleral plaque thermoradiotherapy in patients with choroidal melanoma

From 1988 to 1991, 21 patients with uveal melanoma were treated in a Phase I study with episcleral plaque radiotherapy (EPRT). This irradiation was combined with localized current field episcleral hyperthermia (LCFHT). Tumor stage was: T 3 = 15 (71%) and T 2 = 6 (29%). Follow-up ranged from 2 to 42 months (mean 9.2 months). EPRT was given using custom built 1–125 gold plaques. Radiation doses to the tumor apex ranged from 13 to 123 Gy (mean dose 70.0 Gy) given at a mean dose rate of 55 cGy/hr. LCFHT was given with 500 KHz frequency for 45 min immediately before EPRT. The temperature was controlled on the scleral surface using four thermocouples. T mean ranged from 42.5°C to 45°C ± 0.5°C (mean 43.4°C). The study patients showed rapid tumor necrosis. A 25% mean decrease of apical tumor dimension was noted, p = 0.0007. At least ambulatory vision (> 5 200 ) was maintained by 17 21 (81%) patients. Visual acuity was seen to improve > 6 months post-plaque therapy in 10 (48%) study patients. This was following an intermediate decrease in visual acuity. Severe complications, including large hemorrhagic retinal detachment and large vitreous hemorrhage, were seen in two (9.5%) of the early study patients. A mean scleral temperature reduction to ≤ 44°C ± 0.5°C resulted in good treatment tolerance and a lack of serious complications in subsequently treated patients. A Phase II prospective randomized trial comparing LCFHT with 60 versus 80 Gy EPRT dose to the tumor apex is currently being activated for patients with choroidal melanoma.

Serum leucine-enkephalin in bronchial carcinoma and its relation to tumour location.

Serum concentrations of the opioid peptide leucine-enkephalin were measured by radioimmunoassay in 30 patients with histologically confirmed bronchial carcinoma and 10 control subjects. This peptide, which is present in greatest amounts in the central and autonomic nervous systems, has previously been found in bronchial neoplasms. The mean serum concentration of leucine-enkephalin was significantly greater in the patients with carcinoma (1035 pg/ml) than in the control subjects (426 pg/ml). In the 23 patients with a tumour in non-apical regions of the lung, however, the mean concentration of the peptide (422 pg/ml) did not differ significantly from that in control subjects; serum concentrations in the seven patients with an apical neoplasm (mean 3050 (range 1259-5820) pg/ml) were significantly greater than values in either the control subjects or the patients with non-apical lung tumours. All seven subjects with an apical tumour had one or more features of Horner's syndrome and the three with all four components of the syndrome had the highest serum concentrations. Serum concentrations of leucine-enkephalin were unrelated to tumour type or presence of metastatic disease. No patient had evidence of metastases in the central nervous system or adrenal glands. Raised serum concentrations of leucine-enkephalin in patients with an apical tumour probably reflect invasion of cervical sympathetic ganglia with release of the peptide into the circulation rather than elaboration of the peptide by the neoplasm.

Immunohistochemical Expression of Keratin Proteins in Urinary Bladder Carcinoma

Transitional carcinomas of the urinary bladder were examined immunohistochemically for keratin proteins with the use of polyclonal antiserum (TK, 41-65 kDa) and 3 monoclonal antibodies (KL 1, 55-57 kDa; PKK 1, nos. 19, 18, 8; and K 8.12, nos. 16, 13). Umbrella cells gave particularly strong staining for TK, KL 1 and PKK 1, whereas they were negative for K 8.12. Basal- and intermediate-layer cells in urothelial epithelium were moderately positive for all keratins. Brunn's nests cells showed comparatively slight or moderate keratin staining, and K 8.12 staining of Brunn's nests was higher than in urothelial epithelial cells. Transitional carcinoma (grades I and II) indicated uniform keratin distribution, and staining was strong with TK, while that of KL 1, PKK 1 and K 8.12 varied, and grade III tumors showed the lowest intensity of staining. K 8.12 staining in papillary transitional carcinomas was strongly positive in basal located tumor cells, as compared with apical tumor cells. Squamous cell carcinoma was varying positive to keratin reactions dependent on the degree of keratinization. Heterogenity of keratin distribution in papillary transitional carcinomas was given between basal tumor cells and well differentiated tumor cells including umbrella-like cells.

A plea for postero-lateral orbitotomy for microsurgical removal of tumours of the orbital apex.

Lateral orbitotomy including the lateral rim of the orbit allows adequate surgical exposure for most intraorbital tumours. However, by dealing with intraconal lesions located deep at the orbital apex, the control of the posterior aspect of the growth is often less than optimal. The postero-lateral route, with bone removal mainly confined to the greater sphenoidal wing, allows a more direct approach to the posterior portion of these lesions along a plane tangential to the lateral aspect of the temporal pole. A modified surgical technique is reported, which in three consecutive cases allowed radical removal of pure apical tumours without added neurological deficits.

Primary adenocarcinoma of the small intestine with emphasis on microvillous differentiation.

A detailed ultrastructural study was made of 12 primary adenocarcinomas of the small intestine. A comparative analysis of microvilli identified three characteristic features in various proportions on the apical tumor cell surface. These were; 1) "long rootlets," which are long intravillous filamentous cores penetrating into the cytoplasm and identical to those observed in colonic adenocarcinoma; 2) a regular arrangement of uniform microvilli similar to the brush border of normal intestinal epithelium; and 3) sparse rudimentary microvillous structures. Because of the rarity of adenocarcinoma in the small intestine no previous study defined these ultrastructural characteristics. The results of the present study suggest that the diverse ultrastructural findings may be related to different stages of tumor cell maturation and that the neoplastic state may increase the variation and range of microvillous differentiation regardless of capacity of mucin secretion by the tumor cells. For diagnostic purposes, brush borders as well as two other microvillous features may serve to identify adenocarcinoma of mucosal origin of the small intestine, if an ultrastructural study discloses these three features.

Cervical Approach for Percutaneous Needle Biopsy of Pancoast Tumors

Aspiration needle biopsy techniques have simplified the cytohistological diagnosis of peripheral pulmonary lesions, particularly those close to or involving the chest wall. In the past, the inaccessibility of some Pancoast tumors in the thoracic inlet posed difficulty in obtaining histological proof before combined therapy was instituted, except in the case of large apical tumors. A safe and accurate technique for percutaneous needle biopsy of tumors in the superior pulmonary sulcus using a cervical approach has been developed. We have found that this technique is easy to perform and more productive for small or shallow lesions at the extreme apex than are needle biopsies performed through a posterior approach, and that it makes open biopsy unnecessary.

Pancoast's Syndrome and Small Cell Lung Cancer

Four patients with small cell lung cancer (SCC) presenting with Pancoast's syndrome are described. Superior sulcus tumors are usually caused by epidermoid carcinoma or adenocarcinoma of the lung, and are routinely treated with radiotherapy followed by radical surgery. SCC, on the other hand, is widely disseminated at diagnosis and is best treated with chemotherapy. Although not previously reported as a cause of Pancoast's tumor, these four cases of SCC presenting as such clearly indicate the need for pretreatment histologic diagnosis to avoid unnecessary surgical intervention. Transcutaneous needle aspiration biopsy is a means by which the diagnosis can be safely made in patients presenting with apical lung tumors.

Superior sulcus tumors: Results of irradiation of 36 patients

Thirty-six patients with superior sulcus tumors were treated primarily with irradiation at the Medical College of Wisconsin Affiliated Hospitals between 1963–1977. Two patients were Stage II (T2NO) and 34 patients were Stage III (22: T3NO and 12: T1-3N2). Local control correlated positively with the field size for the thoracic irradiation, but not with total dose (between 40 Gy in four weeks and 64 Gy in 6 1/2 weeks). Thirty-one patients (86%) had relief of symptoms for a median of 12 months after irradiation. Seventeen patients (47%) achieved local control and showed a significantly longer median survival (26.5 months vs. 6.5 months) and a higher probability of five-year survival (45% vs. 0) compared with those who did not. Of 19 patients with local failure, distant metastases developed in nine. The most common first and single metastatic site was the brain. Brain metastases developed in seven patients, six of whom had control of the primary tumor. Three of them were alive at 65, 35, and 25 months after whole-brain irradiation. The five-year actuarial survival rate was 23%. There were no major complications. The prognosis was related to local control, but was unrelated to age, histology, symptoms, and signs at presentation, or mediastinal involvement, perhaps the result of the small number of patients studied. The prognosis for patients with superior sulcus tumors is more favorable than other presentations of carcinoma of the lung, but patients are especially at risk for single-organ brain metastases. Primary external radiotherapy is as effective as combined approaches and has a low complication rate; therefore, it is to be preferred for most patients with apical tumors.

Abnormal Location of Innominate Artery and Azygos Vein Simulating Right Apical Lung Tumor

Bronchogenic carcinoma was suspected in a middle-aged black man who was a heavy smoker, a heavy drinker, and met all criteria for the high-risk group. A mass density was apparent in the superior sulcus, right upper lobe. On thoracotomy a tortuous innominate artery and dilated superior vena cava was found simulating a right apical mass. Eng lish literature and sporadic case studies are reviewed. Different noninvasive and invasive diagnostic procedures are described to aid in the diagnosis of possible nonmalignant tumefaction of the thorax mimicking bronchogenic carcinoma, and to help read ers avoid unnecessary thoracotomies.

Benign cementoblastoma (true cementoma)

Two new cases of benign cementoblastoma (true cementoma) are added to the literature. One occurred in a 36-year-old man and the other in a 16-year-old girl. Both odontogenic apical tumors were located at the level of the first and second right lower molars and have not recurred 4 years and 1 year, respectively, after extirpation.

Left ventricular intramural fibroma

The preoperative diagnosis of a left ventricular apical tumor was made in a 17 year old patient by means of left ventriculography and selective right and left coronary arteriography. The intramural ventricular fibroma was successfully resected utilizing total cardiopulmonary bypass. Surgery was followed by an uneventful postoperative recovery.

Multiple pleural plaques.

Abstract The radiological features of 12 cases of multiple pleural plaques are presented. Some of their chest radiographs show, instead of the usual holly leaf calcified plaque, a multinodular type of calcification which may be confused with tuberculosis. Only part of a plaque may be calcified, and some plaques show only a soft tissue density. Serial films of one case show only soft tissue density plaques at one stage, but subsequently linear calcification develops. In another case with no apparent calcification a pre-operative radiological diagnosis of multiple pleural plaques such as occur in asbestosis was confirmed at thoracotomy performed for an apical tumour. This is believed to be the first recorded pre-operative diagnosis in a case showing soft tissue density plaques only. The faintness of such lesions helps to distinguish them from intra-pulmonary nodules; this may be called the “faint shadow sign”. The relationship to asbestos inhalation and the significance of the plaques are discussed.

Apical Pulmonary Tumors—Relation to Apical Scarring

1.Apical pulmonary tumors belong to the group of peripheral carcinomas of the lung and behave like peripheral carcinomas in their tendency to extend peripherally. 2.Peripheral pulmonary carcinomas are of the same pathologic types as all carcinomas of the lung. 3.There is believed to be a causal relationship between small pulmonary scars and peripheral carcinomas including apical tumors. 4.Six cases are reported in which on the basis of roentgen studies, an association between apical scarring and tumors is established.