Mediastinal Area Research Articles

A scanning system for chest radiography with regional exposure control: practical implementation.

An experimental scanning apparatus for chest radiography is described which offers good scatter rejection and regional manipulation of film exposure. The apparatus is capable of studying two scanning geometries that uses either a fan of radiation swept laterally over the film in 5s or a spot of radiation scanned over two dimensions in a raster pattern in 8.8s. The manipulation of tube output during the scan is achieved by pulse width modulation with film exposure monitored by a fluorescence detector placed behind the film cassette. Measurement of the scatter rejection properties of the system show that it is superior to that of a 10:1 grid when used with 120-kVp radiation. Phantom images with both geometries demonstrate the capability of the system to improve uniformity of film exposure and soft tissue contrast throughout the mediastinal, diaphragmatic, and retrocardiac areas. The relative characteristics of the one- versus two-dimension scan geometries are given. Clinical raster images formed with the 8.8-s scan time show signs of motion unsharpness which becomes insignificant when the scan time is reduced to 4.5 s.

Lessons of parathyroid reoperations

The case histories of the 23 patients in this series demonstrate the importance of a systematic approach to parathyroid surgery. Ligation of the superior thyroid vessels and mobilization of the upper pole of the thyroid are often necessary to find the superior parathyroid glands that are located on the posterior surface of the thyroid. Devascularization of the thyroid gland does not occur with this maneuver because of abundant collateral circulation from the inferior thyroid artery and tracheal vessels. Normal appearing parathyroid glands should not be resected because this procedure does not treat hypercalcemia and may leave the patient with insufficient parathyroid tissue if an adenoma is found at a later date. Bilateral cervical exploration [35,36] is performed before resection of any abnormal appearing parathyroid tissue. Patients with hyperplasia may also have supernumerary parathyroid glands [16], especially in the inferior cervical and superior mediastinal areas that are associated with the thymus [37,38].

Rotating disk device for slit radiography of the chest.

A pair of rapidly rotating disks was assembled with multiple radial slits for obtaining chest radiographs in 1/60-1/20 sec., using automatic exposure timing, without visible images of individual slits. Substantial reduction of scattered radiation levels is achieved (one half to one fourth), especially in the retrocardiac and central mediastinal areas of the chest film. Full realization of the potential contrast improvement resulting from this degree of scatter reduction is impaired by the limited latitude of x-ray films used for radiography. These problems and potential solutions are discussed.

A reevaluation of intrathoracic lymphadenopathy in sarcoidosis.

Chest radiographs of 62 patients with sarcoidosis and intrathoracic lymphadenopathy were evaluated retrospectively for anatomic distribution of lymph nodes. All but two cases had bilateral hilar lymphadenopathy. Approximately 75% of the patients had nodal enlargement in the right paratracheal or aortopulmonic window regions and about 20% in the subcarinal or anterior mediastinal areas. The most frequent combination of lymphadenopathy, found in 37% of cases, included the aortopulmonic window, bilateral hilar, and right paratracheal regions. Right paratracheal and bilateral hilar lymph node enlargement was seen in only three patients. Aortopulmonic window nodes were almost always found with hilar or hilar and mediastinal lymphadenopathy. Anterior mediastinal or subcarinal involvement was never found without some combination of right paratracheal, bilateral hillar, and aortopulmonic window lymphadenopathy. We therefore conclude that aortopulmonic window, anterior mediastinal, or subcarinal lymph node enlargement often accompany the characteristic lymphadenopathy of sarcoidosis.

Phrenic Nerve Injury From Subclavian Vein Catheterization

A SUSTAINED phrenic nerve injury occurred following the placement of a central venous catheter (CVC) when a percutaneous supraclavicular approach to the subclavian vein was used. We call attention to the usefulness of electromyography (EMG) in confirming the diagnosis of a paralyzed hemidiaphragm. Report of a Case A 59-year-old man was transferred to University Hospital for management of bleeding esophageal varices. A CVC was inserted via a supraclavicular approach to the left subclavian vein. The unusual location of the catheter tip in the left mediastinal area and the widened mediastinum on a subsequent chest roentgenogram (Fig 1) were not appreciated. The CVC was discontinued after 1,700 ml 10% dextrose in water had been infused. A chest roentgenogram 48 hours later showed almost complete opacification of the left hemithorax. At thoracentesis, 650 ml of fluid with a protein concentration of less than 1.0 gm/100 ml was removed. After several weeks the

Phrenic nerve injury from subclavian vein catheterization. Diagnosis by electromyography

A SUSTAINED phrenic nerve injury occurred following the placement of a central venous catheter (CVC) when a percutaneous supraclavicular approach to the subclavian vein was used. We call attention to the usefulness of electromyography (EMG) in confirming the diagnosis of a paralyzed hemidiaphragm. <h3>Report of a Case</h3> A 59-year-old man was transferred to University Hospital for management of bleeding esophageal varices. A CVC was inserted via a supraclavicular approach to the left subclavian vein. The unusual location of the catheter tip in the left mediastinal area and the widened mediastinum on a subsequent chest roentgenogram (Fig 1) were not appreciated. The CVC was discontinued after 1,700 ml 10% dextrose in water had been infused. A chest roentgenogram 48 hours later showed almost complete opacification of the left hemithorax. At thoracentesis, 650 ml of fluid with a protein concentration of less than 1.0 gm/100 ml was removed. After several weeks the

Postinflammtory pseudotumor of the lung in children.

Three cases of pseudotumors of the lung in children are presented. In one case an asymptomatic parapleural mass was noted. A persistent consolidated pneumonia of the left upper lobe, mimicking a mediastinal tumor was seen in the second case. The third case was unusual in that an apparent respiratory infection and well circumscribed mass were followed by development of a second lesion which invaded the mediastinal area and encroached on the right inferior pulmonary vein. The gross anatomy and histology of pseudotumor of the lung are described. These lesions may radiographically mimic true tumors, but by recognizing their benign characteristics, extensive resection can and should be avoided.

Transfer factor for CO during exercise in children

Aim: The aim of this study was to evaluate the clinical outcomes and prognostic factors of thoracoscopic esophagectomy with two-field lymph node dissection for lower thoracic esophageal cancer. Patients and Methods: From January 2003 to December 2011, 84 patients with lower thoracic esophageal cancer underwent thoracoscopic esophagectomy with two-field lymph node dissection. Clinicopathological information, postoperative complications, mortality, type of recurrent diseases and factors predictive of survival were analyzed. Results: Postoperative complications were diagnosed in 37 patients and the mortality was 1.2%. Lymph node metastases were found in 43 patients (51.2%). The 5-year survival rate of all patients was 60.5%. Pathological T factor, lymph node metastasis, pathological staging, and venous invasion were independent prognostic factors. Among the patients with lymph node metastasis, the survival rate of those with upper mediastinal and/or celiac area involvement was significantly worse than that of those without involvement of these areas. Conclusion: Thoracoscopic esophagectomy with two-field lymph node dissection is a safe and appropriate surgical intervention for patients with lower thoracic esophageal cancer without complication of lymph node metastases to the upper mediastinum and/or celiac area.

Gastrotomy with double gastrostomy in the performation of the esophagus.

Nine cases of esophageal perforation in children were treated surgically. An operation used in two of them is described which consists of a gastrotomy with a double gastrostomy in order to exclude the esophagus temporarily from use. Nasopharyngeal suction and suction through the upper gastrostomy prevent contamination of the mediastinal area by salivary and gastric reflux. The lower gastrostomy permits early administration of food. In two of the cases spontaneous healing was observed within a period of two weeks. The other patients in whom different methods were used required a longer time for convalescence and experienced postoperative complications.

Calcification in intrathoracic nodes in Hodgkin's disease.

HODGKIN'S DISEASE is an entity of unknown etiology and uncertain nature which exhibits traits suggesting infection, immune reaction, and neoplasia. It often involves the intrathoracic nodes and particularly those tissues lying behind the sternum. Disease that is limited to or predominant in the thorax is commonly of a nodular sclerotic type and often follows a slow clinical course. Many patients suffering from well-differentiated forms of Hodgkin's disease live for many years, especially following radiation therapy to the thorax (1, 2). In some long-term survivors of this disease, calcification may appear in intrathoracic lymph nodes following irradiation. The first occurrence of such calcification was noted by us in 1951. Since then we have collected an additional 8 examples of calcified lymph nodes in the chest. In most of these, it was possible to follow the events from the appearance of uncalcified enlarged lymph nodes in the mediastinal, paratracheal, and hilar areas through the regression of these nodes following external roentgen therapy to the development of increasingly evident foci of calcification within the nodes. In our 9 cases, consisting of 4 males and 5 females, the calcification appeared from one to fourteen years after treatment (Table I). Radiation dosages, which could not be ascertained accurately in some instances, ranged from 1,000 to 6,000 R. No correlation could be drawn between the type or amount of treatment and the degree of calcification. One patient received 2 courses to the mediastinal lymph nodes; one received 3 courses; the others each received 1 course. No specific characteristics of the lymph node calcification were recognized. The nodes most commonly involved lay behind the middle and upper sternum, and less often in the paratracheal and hilar regions. In some cases, the diseased nodes were initially observed to be enlarged though not calcified, but they shrank in size following x-irradiation. Several months or years later, they were found to be partly calcified; with the passage of several more months or years, these calcifications became more and more dense, and the nodes seemed to shrink still further with increasing conglomeration of these calcific densities (Fig. 1). Most often the calcification was diffuse, finely stippled, or irregular and nodular. In two instances the periphery was accentuated in an eggshell pattern reminiscent of the calcification in silicosis (Fig. 2). As the calcific densities enlarged, more conglomeration occurred, with the formation of irregular masses (Fig. 1, C). None of our patients was known to have tuberculosis, histoplasmosis, or other associated inflammatory processes. One had a negative tuberculin test; the others were not tested for tuberculosis and fungi. These patients have been followed for relatively long periods of time. One was studied for thirty-two years, while others were observed for twenty-six, twenty-three, twenty-two, and seventeen years.

Diffuse idiopathic fibrosis

A case of diffuse idiopathic fibrosis involving both mediastinal and retroperitoneal areas is described. This is apparently the second such case reported involving structures above and below the diaphragm. Diagnosis of the condition is helped by obtaining appropriate venograms. The technic of intraosseous venography described by Schobinger, Cooper and Rousselot [II] should permit a definitive evaluation of mediastinal collateral circulation. Medical treatment of this condition is ineffective. Surgical treatment is seldom helpful and carries a high mortality because of intravascular clotting. Naturally developing collateral circulation and a tendency for the disease to be self-limited will usually permit the untreated patient to lead a handicapped life of relatively normal duration.

Fibrogenic mesodermal tumors, an unusual cause of hyperinsulinism

Severe hypoglycemia suggesting an organic etiology and fulfilling Whipple's triad may occasionally be associated with non-pancreatic fibrogenic tumors of mesodermal origin. Such tumors, usually mesotheliomas, fibromas or fibrosarcomas, are located ordinarily in the mediastinal, diaphragmatic or retroperitoneal areas. They have a tendency to encapsulate and only occasionally metastasize. Their successful removal is followed by relief of hypoglycemic symptoms, and insulin activity has been measured from extracts of freshly frozen tumor tissue. It has been suggested that areas of cystic degeneration within the large primary tumor are the sites of origin of the insulin activity, but the exact mechanism of the uncommon association of hypoglycemia with fibrogenic tumors has not been clarified.

Variations in the terminal portion of the human thoracic duct.

Many modern surgical procedures involve the area near the distal portion of the thoracic duct, in both the neck and the upper mediastinal area. The distal portion of the duct is the most commonly injured, resulting in either a chylothorax or a chylous fistula unless recognized at the time of injury and repaired. Such injuries have been reported as complications of block dissections in the neck for tuberculous nodes or malignant tumor, scaleniotomy, esophageal resection, the Blalock operation for congenital pulmonary stenosis, radical breast amputation, operation for left-sided torticolis and during left phrenicoexeresis.* Anatomical studies have indicated that variations occur which may account for some of the injuries.9Methods used to investigate the variations have included x-ray visualization of the duct18and cadaver dissections.† Seventy-five cadavers used for anatomical dissection by the medical students of the University of Tennessee during the years 1950 through 1953 were studied for

LYMPHOSARCOMA OF THE INTESTINE&lt;subtitle&gt;Report of a Case in a Ten-Year-Old Child with a Seven-Year Cure&lt;/subtitle&gt;

LYMPHOSARCOMA of the intestinal tract in children is a rare disease, and rarer still are reports of its cure. The diagnosis is not readily made preoperatively, nor is the clinical picture often characteristic. Systemic spread occurs sooner or later in the neglected patient, and whatever the treatment, whether surgical or radiologic, there is little chance of cure.1Most authors on this subject believe that a combination of radical surgical extirpation of the involved bowel and mesentery followed by heavy roentgen therapy to abdominal and mediastinal areas offers the optimal chance of survival.2 Because of the rarity of this condition in children and the very low percentage of cures, this case with an apparent seven-year cure following surgical resection and roentgen therapy is presented. REPORT OF CASE C. S., a 10-year-old boy, was admitted to the service of one of us (H. M. E.) on April 26, 1947, with

A Case of Carcinoma of the Thymus

A case of thymic tumor is reported in which the clinical diagnosis was cellulitis of the neck, with sinus thrombosis; the roentgen diagnosis was abscess or tumor of the upper mediastinum, and the pathologic diagnosis, made postmortem, was carcinoma of the thymus, with metastases to the lungs, liver, and mesenteric lymph glands. Anamnesis.—The patient, colored, male, aged 28, was admitted to the John D. Archbold Memorial Hospital on Aug. 25, 1930, and died on Aug. 28, 1930. The past history was unimportant. The present illness began five weeks previous to admission with sore throat, toothache, fever, and general malaise. Several days later swelling of the neck was noted which soon became progressively more marked. Edema of the eyelids appeared and later marked difficulty in breathing and swallowing was noted. For three or four days previous to admission nothing could be swallowed except small amounts of fluid. Physical Examination.—Temperature 101 degrees F., pulse 120, respiration 30. The patient was a well-nourished, well-developed colored male. Respiration was labored, the neck markedly swollen, the face and eyelids edematous, and there was a bilateral exophthalmos. The swelling of the neck was uniformly hard and smooth; nothing suggesting enlarged glands in this or any other area was found. No dilatation or prominence of the superficial vessels was discernible. A bloody mucus discharge exuded from the mouth and nose. There were coarse râles and exaggerated breath sounds throughout both lungs. There was a wide area of dullness over the upper mediastinum. No edema of the arms or thorax was noted. Laboratory Findings.—White blood cells, 9,150; polymorphonuclear leukocytes, 80 per cent; eosinophiles, 2 per cent; transitional cells, 4 per cent; lymphocytes, 14 per cent. Red blood cells, 3,350,000. Hemoglobin, 60 per cent. The blood sugar and non-protein nitrogen were within normal limits. The urine, which contained a few granular casts, had a specific gravity of 1.035. The Kahn test was negative. Roentgen Report.—Examination of the chest was made August 26, 1930. A single film only was made because of the semicomatose condition of the patient. There was a large dense mass, 11 cm. in width, in the upper mediastinal area, extending laterally on both sides beyond the mediastinum. The upper border extended above the sternoclavicular articulations and the lower border fused with the heart shadow. The lateral borders were well defined and regular. There was definitely a diminished aëration of the upper lobe of the right lung but no other evidence of pathology. Considering the history and course of the illness it was thought that the condition was mediastinal abscess rather than tumor. The patient died on his fourth day in the hospital.