Chest Wall Extension Research Articles

Pulmonary nocardiosis: CT findings.

To evaluate CT findings of pulmonary nocardiosis in immunocompromised patients. MATERIALS ALND METHODS: Five patients with bacteriologically confirmed pulmonary nocardiosis were evaluated. Four patients were receiving corticosteroids with or without other immunosuppressive drugs for lupus nephritis (two patients), idiopathic thrombocytopenic purpura (one patient), and renal transplantation (one patient), and one patient had long-standing diabetes. Nocardia asteroides was isolated from blood culture, bronchial washing, pleuropulmonary aspirates, or open lung biopsy. Plain chest radiography and CT were performed on all patients, and follow-up CT was performed on one patient. On CT there were pleural effusion (four patients), air-space consolidation with internal low attenuation with or without cavities (four patients), multiple noncavitating pulmonary nodules and subpleural pulmonary nodules (three patients), and chest wall extension (three patients). Follow-up CT after treatment showed marked improvement of the pleural and pulmonary lesions. In the immunocompromised and chronically debilitated host, pulmonary nocardiosis should be included in differential diagnosis if chest CT shows consolidation with low attenuation areas with or without cavitation, multiple pulmonary nodules, pleural effusion, and chest wall extension.

MR imaging of superior sulcus carcinoma.

Magnetic resonance (MR) imaging was performed in 10 patients with biopsy proven superior sulcus carcinomas to determine the extent of local tumor invasion. Chest wall invasion or extension into the base of the neck was demonstrated in five patients. This finding was facilitated by the contrast between the bright signal intensity of tumor and the low signal intensity of muscle on T2-weighted images. In three patients, MR clearly depicted direct invasion of the mediastinum. This finding was facilitated on the MR image because of inherent contrast between the mediastinal fat and tumor. Coronal and sagittal images showed the relationship of tumor to the subclavian artery and brachial plexus in all cases. Encasement of the artery was confirmed in two cases and brachial plexus involvement in three. However, MR failed to detect evidence of rib destruction in five patients in whom rib involvement was confirmed by other studies. Magnetic resonance appears to be a useful imaging modality in determining the extent of local disease and, therefore, the selection of patients for surgical resection. Multiplanar imaging and contrast between tumor and muscle and tumor and fat allow assessment of invasion of the mediastinum and base of the neck, subclavian artery, and brachial plexus.

Median Sternotomy as a Standard Approach for Pulmonary Resection

Pulmonary resection was performed electively through a median sternotomy in 174 patients. The first 61 of these patients were compared with an equal number having pulmonary resection through a lateral thoracotomy. Both groups were similar in regard to sex, age, pathological condition, and type of resection. The patients undergoing median sternotomy had a shorter operative time and less postoperative pain, and were discharged from the hospital sooner than the patients having resection through a lateral thoracotomy. The cardinal technical essentials to expeditious pulmonary resection through a median sternotomy involve unilateral pulmonary ventilation with a double-lumen endotracheal tube, arterial pressure and gas monitoring, and proper lung packing and retraction. Two patients died, 1 of infection and 1 of bleeding; neither death was related to the incision. Certain pulmonary procedures are better performed through a lateral thoracotomy, and these include resection of a superior sulcus carcinoma, pulmonary resection with posterior chest wall extension, and left lower lobe resection in patients who demonstrate obesity, cardiomegaly, or an elevated diaphragm.

CT scan modification in the treatment of mediastinal Hodgkin's disease.

Seventy-one patients with Hodgkin's disease who were initially treated at Johns Hopkins with radiation or radiation-chemotherapy from 1975--1980 had a five-year cumulative disease-free survival of I-A--100% (12 patients); II-A--85% (33 patients); II-B--83% (seven patients); III-A--75% (ten patients); and III-B--66% (nine patients). Fifty patients with mediastinal masses at the time of treatment demonstrated no marginal misses, two mediastinal recurrences (96% local control), and three lung disseminations. CT scan data yielded stage and treatment modification in 60% (9/15) of recent patients with mediastinal Hodgkin's disease. This demonstrates the need for routine thoracic scans and individual treatment planning in all mediastinal cases. Recommendations for combination treatment in early stage disease are made only for pericardial or extrathoracic chest wall extension based on CT scan findings, our low failure rates, radiation organ tolerances, and available relapse data in the literature, not arbitrary size designations from upright chest radiographs. It can be concluded that patients with mediastinal Hodgkin's disease require CT scan analysis to identify unusual patterns of presentations, sites at risk, and to allow for proper application of radiation portals and/or chemotherapeutic management.

The role of postoperative irradiation in carcinoma of the breast

Chest wall and regional nodal recurrences, and survival following postmastectomy radiation therapy, were analyzed in 352 patients. Patients with T1 and T2 central and medial breast lesions, negative axillary nodal findings, and no evidence of skin or chest wall extension received irradiation to the peripheral lymphatics alone. There were no chest wall recurrences among these patients. The remainder of the patients, including those with axillary nodal involvement, regardless of the site of the primary breast lesion received irradiation by a three-field technique directed to both chest wall and regional nodes. The chest wall recurrence rate was 1.9% when axillary nodes were negative for metastatic disease, 1.3% when the axillary nodes showed less than 50% positivity, and 14.2% when axillary nodes showed greater than 50% involvement. The overall chest wall recurrence rate was 5.1%. A possible mechanism of chest wall recurrence is discussed. Cumulative 5-year survival for stage I is 76%, for stage II, 79%, and for stage III, 57%. If chemotherapy proves to be effective in controlling distant microscopic disease local control may become an equally critical issue in long-term survival of patients with breast carcinoma.