Chest Wall Tissue Research Articles

SU‐E‐J‐90: Quantitative PET Imaging to Evaluate Clinical Complications Associated with Stereotactic Body Radiotherapy in Non‐Small Cell Lung Tumors

Purpose: To investigate correlation of standard‐uptake values (SUV) from post‐treatment PET imaging representing clinical complications such as muscular inflammation with dose delivered in non‐small cell lung cancer patients treated with large hypo‐fractions using stereotactic body radiation therapy (SBRT). Method and Materials: Clinical complications represented as chronic inflammation and rib fractures in ten non‐small cell lung cancer patients treated with large hypo‐fractionated stereotactic body radiation therapy were investigated. SBRT was delivered in three fractions with each fraction 20 Gy or five fractions with each 12 Gy. These patients were scanned with PET imaging at three and seven months after treatment for follow up to evaluate tumor control and clinical complications post‐ radiotherapy. The dose distributions calculated by treatment planning and delivered were extracted and compared with SUV distributions obtained from PET imaging. The correlation between dose deposited in the chest wall and clinical complications represented by higher SUV from PET imaging were quantified. Results: The dose distribution calculated by treatment planning from the different beams overlaid on a CT axial image for a lung patient correlates strongly with SUV obtained from PET imaging. The enhanced SUV represents chronic inflammation of the chest wall tissue that has received high doses by the individual entering beams. The profiles from the regions in the chest wall that have received high dose deposition correspond to enhanced SUV in anatomically matching regions from PET images. Significant proportion of pixels from dose distribution correlates linearly with corresponding pixels that have high SUV‐dose in the chest wall. Conclusions: Large doses deposited in normal tissue from SBRT in treatment of non‐small cell lung tumor correlate well with the SUV values measured by PET images. This correlation may be useful in predicting clinical complications by measurement of the delivered dose and SUV values associated with SBRT.

Imaging of Primary Chest Wall Tumors with Radiologic-Pathologic Correlation

Neoplasms and tumorlike lesions that originate from chest wall tissues are uncommon compared with tumors in other parts of the body, and unfamiliarity with these disease entities can cause diagnostic difficulties for radiologists. Furthermore, the imaging features of many of these tumors are nonspecific, particularly those that are locally aggressive. However, a systematic approach based on patient age, clinical history, lesion location, and characteristic imaging findings often helps limit the differential diagnosis. Primary chest wall tumors can be classified as bone or soft-tissue tumors, with the latter being further classified into adipocytic tumors, vascular tumors, peripheral nerve sheath tumors, cutaneous lesions, fibroblastic-myofibroblastic tumors, and so-called fibrohistiocytic tumors, largely based on the 2002 World Health Organization classification. Within each category, it is possible to further limit the differential diagnosis with cross-sectional imaging. Information on specific features (eg, mineralization, fibrosis, hemosiderin deposits) and imaging patterns (eg, the "target sign" and "fascicular sign" seen in neurogenic tumors) can aid in making the diagnosis. Radiologists can achieve a sufficiently specific diagnosis of bone tumors and soft-tissue tumors if typical findings are present.

Soft Tissue Squamous Cell Carcinoma in Chest Wall with an Incomplete Border Sign

Squamous cell carcinoma (SCC) of the soft tissue in chest wall from an unknown primary site is extremely rare. We report a case with soft tissue metastasis with histology of SCC to chest wall with an incomplete border sign in chest radiography. Chest radiography revealed a radio-opaque lesion in the left lung field. Computed tomography (CT) detected the mass under the musculus pectoralis major invading the left 2nd - 6th ribs with increase in pleural thickness. Careful radiological observations, including chest radiography and CT, may aid the diagnosis and planning of treatments. doi:10.4021/jmc115w

Soft Tissue Squamous Cell Carcinoma in Chest Wall with an Incomplete Border Sign

Squamous cell carcinoma (SCC) of the soft tissue in chest wall from an unknown primary site is extremely rare. We report a case with soft tissue metastasis with histology of SCC to chest wall with an incomplete border sign in chest radiography. Chest radiography revealed a radio-opaque lesion in the left lung field. Computed tomography (CT) detected the mass under the musculus pectoralis major invading the left 2nd - 6th ribs with increase in pleural thickness. Careful radiological observations, including chest radiography and CT, may aid the diagnosis and planning of treatments. J Med Cases. 2011;2(1):31-33 doi: https://doi.org/10.4021/jmc115w

Optimized intrapleural cisplatin chemotherapy with a fibrin carrier after extrapleural pneumonectomy: A preclinical study

Our objective was to evaluate whether platinum concentrations in chest wall tissue and in serum are optimized by intracavitary application of cisplatin loaded to a fibrin carrier compared with cisplatin solution in a randomized setting of a pig model. After left-sided pneumonectomy including parietal pleurectomy, pigs were randomly assigned to receive either 90 mg/m(2) cisplatin intracavitary solution (n = 6) or to receive 5 mg cisplatin-fibrin (n = 5) applied on a predefined area of the chest wall. Platinum concentration in serum as well as in chest wall tissue was determined at several early time points until day 5 after treatment. Platinum levels were measured by inductively coupled plasma sector field mass spectrometric detection with a matrix-matched calibration procedure. The dose- and surface-corrected (geometric) mean concentration of cisplatin in chest wall tissue 2 hours but also at day 5 after the application was doubled in animals treated with cisplatin-fibrin compared with the animals treated with cisplatin-solution. In serum, the dose- and surface-corrected exposure toward cisplatin (area under the curve(0-5d)) was significantly lower with cisplatin-fibrin than with cisplatin-solution (P < .0005). This is also reflected by significantly reduced serum creatinine and urea values in the cisplatin-fibrin group (P < .0001). Animals treated with cisplatin-fibrin additionally had a significantly better postoperative course as assessed by a well-being score (P < .001). After cisplatin-fibrin treatment, cisplatin tissue concentration was increased whereas systemic cisplatin concentrations were significantly reduced in comparison with cisplatin-solution treatment. This finding offers a clear advantage inasmuch as rate and severity of systemic adverse events can be reduced while local cytotoxic concentrations are at least maintained.

Giant-Cell Anaplastic Carcinoma With Osteoclastic Giant Cells of the Chest Cavity: A Distinctive Form of Thymic Carcinoma?

Here, the authors describe a case of giant-cell anaplastic carcinoma with osteoclastic giant cells of the chest cavity-which could be a distinctive form of thymic carcinoma-which expressed CD5 and CD45. To the authors' knowledge, there has been no previous report on this subject. A 62-year-old woman presented with continuous pain in the left back associated with coughing and shortness of breath for more than 2 months prior to referral to the hospital. Palliative resection of a mediastinal tumor was performed. During the operation, it was found that the mass occupied most of the chest invading the chest wall, aorta, vena cava, and lung tissue. The patient soon died from diabetic complications in spite of anti-infection treatment. The tumor was composed of large areas of necrosis and anaplastic neoplastic giant cells with high mitotic activity, and osteoclast-like cells; there was marked inflammatory cell infiltration. The anaplastic neoplastic giant cells were immunoreactive for CKpan, CD5, CD45, VIM, and p53. Approximately 50% to 60% of the tumor cells showed immunoreactivity for Ki-67. In situ hybridization for Epstein-Barr virus-encoded RNA was negative for tumor cells and nonneoplastic osteoclastic giant cells. Because this tumor is very rare, extensive clinical, radiological, and morphological examinations as well as immunohistochemical studies are essential to make the diagnosis.

Thoracoscopic Chest Wall Resection: What Is Its Role?

Although thoracoscopic operations like pulmonary lobectomy are gaining popularity because of reduced complications and improved quality of life, the role of more complex procedures is unknown. From January 2007 to April 2009, 3 patients (2 women) aged 61, 71, and 79 years, underwent thoracoscopic lobectomy with en bloc chest wall resection in an attempt to reduce perioperative morbidity. During the same time, 4 additional patients underwent thoracoscopic explorations before open en bloc resections and 10 underwent thoracotomy to remove primary or secondary chest wall neoplasms. Innovations that facilitated the thoracoscopic operations were the use of an endoscopic rib cutter and division of other chest wall tissues with thermal sealing technology. Tumors were stage IIb-IIIa and sized 3.2 to 5 cm. Two patients received neoadjuvant therapy before resection. No patients required reconstruction. The first patient required thoracoscopic reexploration to evacuate a hematoma attributed to aggressive anticoagulation required because of high-risk cardiac comorbidities. No other complications occurred. By 3 weeks after resection, the first patient had discontinued narcotics, and the other patients denied pain and analgesic use entirely. All patients were alive, with no evidence of disease, at 26, 16, and 6 months after their operations. Highly selected cases of lung cancer with chest wall extension are appropriate candidates for thoracoscopic resection. Advanced thoracoscopic instrumentation makes this procedure feasible while following oncologic principles.

Chest Wall Chondrosarcoma

A 75-year-old man presented with pleuritic chest pain and right shoulder pain. A palpable right anterior chest wall mass was noted on physical examination. His past medical history was significant for testicular cancer treated with radiation therapy in 1974. A computed tomography (CT) scan of the chest, performed without intravenous contrast due to renal insufficiency, revealed an 8-cm lobulated soft tissue mass arising from the right third anterior rib and involving the costal cartilage (Figure ​(Figure11). Scattered internal calcific deposits were present. It was uncertain if these represented chondroid matrix or destruction of calcified costal cartilage. The mass extended into the chest wall with elevation of the pectoralis muscles. Medially, the mass abutted the right anterior mediastinum. No additional osseous lesions or enlarged mediastinal or hilar nodes were seen. A few nonspecific 1- to 2-mm noncalcified pulmonary nodules were noted. CT of the abdomen and pelvis showed no evidence of metastatic disease. Figure 1 CT images through the chest at the level of the carina in both (a) soft tissue and (b) bone windows demonstrate a lytic mass involving the right anterior third rib, centered at the costochondral junction. A large, lobulated soft tissue component elevates ... Given the internal calcifications, the leading differential diagnostic consideration was chondrosarcoma; however, the classic “ring and arc” calcifications described in chondroid neoplasms were not definitively present on imaging. Metastasis was another consideration given the patient's history of testicular cancer; however, the location and appearance would be very atypical. The lesion appeared to arise from the chest wall and not the lung itself. Other considerations would include extramedullary plasmacytoma or lymphoma. An ultrasound-guided needle biopsy of the lesion, prepared for rapid cytologic evaluation using hematoxylin and eosin, showed a myxoid chondroid matrix with chondrocytes present (Figure ​(Figure22). The subsequently prepared paraffin block from the core biopsy showed a similar chondroid matrix with increasing cellularity at the periphery of the nodule (Figure ​(Figure33). Though no distinctly atypical chondrocytes were seen, the cellularity was concerning for a possible low-grade chondrosarcoma, and the tumor was excised along with the second, third, and fourth ribs. Grossly, the tumor did not involve the lateral margins but was 12 mm from the inferior resection margin of the fourth rib and 3 mm from the periosteal soft tissue of the superior aspect of the second rib. The neoplasm clearly demonstrated cartilage synthesis, as well as areas of hemorrhage and necrosis (50% of total tumor volume) (Figure ​(Figure44). Figure 2 Scrape preparation at time of ultrasound-guided biopsy demonstrating a myxoid chondroid matrix, increased cellularity, and chondrocytes. Diff-Quik stain, (a) ×100, (b) ×400. Figure 3 Paraffin cell block prepared from ultrasound-guided biopsy showing focal increased cellularity, chondroid matrix, and chondrocytes. Hematoxylin and eosin stain, (a) ×40, (b) ×100. Figure 4 Gross images of the resected tumor, showing the lesion (a) anteriorly, (b) posteriorly, (c) in cross-section, and (d) invading and destroying the third rib. Microscopically, the tumor showed features suggesting increasing histologic grade, such as areas with distinct marked hypercellularity, increasing nuclear size/atypia, and multinucleated cells (Figure ​(Figure55). However, the proliferation index, as demonstrated by MiB-1, was low, with most areas demonstrating 1% and focal areas demonstrating 5%. The tumor expanded the medullary cavity and in areas extended beyond the cortex, forming subpleural nodules posteriorly and involving the chest wall tissue anteriorly. The anterior chest wall surgical resection margin was focally involved by tumor. Extension through the pleural surface was not seen. Focal vascular invasion was present, with tumor grossly and microscopically surrounding and invading one blood vessel specifically. The tumor was considered grade 2. Figure 5 (a) Subpleural tumor nodule (×100). (b) Tumor at anterior resection margin (arrow) (×40). (c, d) Tumor expanding marrow cavity with markedly increased cellularity, nuclear atypia, and occasional multinucleated cells (×400). (e) ... Given the positive margin, radiation therapy was recommended. The patient received 3060 cGy of the planned 5940 cGy of radiation but could not complete the full course due to locoregional side effects. No additional therapy was recommended. A CT scan performed approximately 2 months after radiation therapy showed expected radiation changes and minimal pleural fluid without overt evidence of tumor recurrence. The patient is currently 4 months postradiation.

SO09P ‘PORTACATH INSERTION’ AND ITS LEARNING CONSTRAINTS FOR THE SURGICAL TRAINEES

Purpose: 1 To discuss the difficulties encountered in Portacath insertion by the surgeons. 2 To point out that the follow up of a patient with Portacath rarely happens in surgical clinic until there is some complication. Methods: Hospital records of three years were followed to generate the data. Over 169 patients have been done Portacath in a rural hospital. In last four years from January 2005 to December 2008. 157 patients have been for cancer, 2 for IDDM with no available vein to access and one patient for prolonged IV antibiotic therapy. Infection of Portacath happened in 8 improved with oral AB – 6, 2 needed removal and reinsertion later. Last two patients been diabetic. We use assembled Portacaths produced by ‘BARD’. We prefer left infraclavicular area as reservoir site unless contraindicated. Results: In female patients anchorage of the reservoir is must, but in male patients because of thin soft tissue in chest wall, a good primary positioning may avoid suture anchorage. Surgical trainees have very minimum chance to learn how to insert a Portacath. This is not an easy procedure as it is often thought. Learning curve in this procedure towards perfection is very much subjective and diverse. Conclusion: our experience says: – Assembled ones are better. – Left infraclavicular area is better. – Angulations at the lower border of clavicle should not be very close to clavicle – Kinking should be avoided at the time of insertion. – Image intensifier guidance is mandatory. – Patency test should not be with smaller syringe.

Unusual Metastases to Soft Tissue of Chest and Abdominal Wall from Head and Neck Squamous Cell Carcinoma

Unusual Metastases to Soft Tissue of Chest and Abdominal Wall from Head and Neck Squamous Cell Carcinoma

Abstract No. 354: Does Tip of the Implantable Port Catheter Really Migrate to the Cephalic Direction Dragged by Downward Force of the Implantable Venous Access Port in Upright Position?

To reassess whether catheter tip of the implantable venous access port really migrates to the cephalic direction dragged by downward force of the port in upright position. A total of 87 patients who underwent placement of the port through internal jugular vein under fluoroscopic guidance were included in this study. There were 36 men and 51 women, aged 54.4 years (range, 23-76 years). The catheter position was evaluated on the image obtained in the supine position during the procedure and chest radiograph in the upright position just after the procedure. In each position, we calculated the vertical distance from the highest point of the catheter to the catheter tip (long segment) and point of port and catheter (short segment) junction. We drew a horizontal line crossing the upper margin of the transverse process of the first thoracic spine and measured the vertical distance from the line to the highest point of the catheter. Difference in magnification on both images was corrected by measurement of the height of the first 3 thoracic vertebral bodies including disc spaces. Length differences of matching two segments in each position were attained. Correlation analysis was used to demonstrate statistical significance. Vertical lengths from the first thoracic spine to the long and short segments increased by 10.3mm±7.37 and 15.3mm±2.12, respectively. They showed statistically significant (r=-0.425, p<0.01) proportional increase in length. The highest point of the catheter moved downward an average of 12.75mm±1.78 in the upright position. This tendency did not change according to sex or side of insertion. The length of the implantable port catheter tip from the highest point actually increased in the upright position rather than being dragged and shortened by the downward migration force of the port. We presume that both segments of the catheter simply appear to have moved downward in the upright position due to gravitational effects and redundant soft tissue of the anterior chest wall.

Impact of fat grafting the chest wall prior to implant reconstruction in high risk patients.

Abstract Abstract #4143 Background: Breast reconstruction with implants in patients that have either received chest wall irradiation or have relatively thin mastectomy skin flaps carry a higher risk of short and long term failure compared to patients undergoing autologous reconstructions. Patients treated with chest wall irradiation are at highest risk of complications, ranging from 30.2% to 37% and 9.2% to 68% respectively. Improvement in the complication rates in patients identified at higher risk can be achieved through either sequential or singular fat grafts to the subcutaneous tissue of the chest wall prior to implant reconstruction.&amp;#x2028; Material and Methods: Patients undergoing implant reconstruction identified through either a history of chest wall irradiation or thin tissue coverage of the chest on physical exam were considered candidates for pre-reconstruction fat grafting. After grafting and completion of implant reconstruction the patients were followed prospectively for a mean of 6 months to evaluate for both early and late complication rates as well as the aesthetic outcome. The lipo-aspirate used in grafting was obtained from either the abdomen or inner thigh areas. The components of the aspirate were then separated by centrifugation at a rate of 3000rpm for 3 minuets. Isolated fat component was injected into both the subcutaneous tissue and retro-muscular plane.&amp;#x2028; Results: There were 9 patients that had pre-operative lipofilling prior to implant reconstruction. Of these patients 3 underwent radiation to the skin overlying the chest wall and the remaining 6 had poor chest wall tissue coverage. Follow-up length ranged from 3 – 12 months. During the course of treatment no patients had either short (&amp;lt;2 months) or long term (&amp;gt;2 months) complications that involved: infection, seroma, hematoma, and skin flap necrosis. Revision surgery was performed in 1 patient 2 months after reconstruction due to implant malrotation. Both patient and surgeon satisfaction with the overall breast shape and appearance was good to very good. None of the patients had a local recurrence of their cancer during the follow-up interval nor complications related to the lipofilling procedures.&amp;#x2028; Conclusion: Fat grafting prior to delayed implant reconstruction can decrease complication rates and improve cosmetic outcome in high risk patients. The improvement seen with fat grafting may be attributed to increased thickness and improved vascularity of the overlying subcutaneous tissue and skin. The real and theoretical complications of fat grafting such as the oncogenic potential of the lipo-aspirate in patients with a history of breast cancer needs further consideration.&amp;#x2028; 1 Krueger EA, Wilkins EG, Pierce LJ, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiation Oncology Biol Phys 2001;49(3):713-721.&amp;#x2028; 2 Clough KB, O'Donoghue JM, Fitoussi AD, Nos C, Falcou MC. Prospective evaluation of late cosmetic results following breast reconstruction: I. implant reconstruction. Plast Reconstr Surg. 2001;107(7):1702-9. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4143.

Variations of respiratory mechanics in the rat during the day

We applied the end-inflation occlusion method to measure resistive and elastic properties of the rat's respiratory system at two different hours of the day, 8.00 a.m. and 4.00 p.m. Contextually lung hysteresis surface areas were also measured. We found a significant reduction of resistive pressure necessary for the movement of air in the airways and for the movement of lung and chest wall tissue, hence of respiratory and lung resistances, in the afternoon with respect to morning hours (Rrs, min 0.037 vs 0.117 cm H2O/ml sec−1, p = 0.008, Rl, min 0.021 vs 0.068 cm H2O/ml sec−1, p = 0.001). The areas of hysteresis were significantly higher in the afternoon compared to the morning (3.71 vs 2.51 cm H2Oml, p = 0.039). No other significant differences in respiratory mechanical parameters were found. Thus we show in the rat that airways and lung and chest wall resistances exhibit variations during the day, confirming previously reported data describing a circadian rhythm of resistance in other animal species. Hysteretic behaviour of the lungs also changes during the day, suggesting diurnal variations of alveolar surfactant activity.

Primary cardiac osteosarcoma with recurrent episodes and unusual patterns of metastatic spread

Primary osteosarcoma of the heart is an extremely rare entity. In this report, we describe a case of primary osteosarcoma of the heart that recurred and metastasized. The patient is a 50-year-old woman who presented with an abrupt onset of dyspnea, dizziness, and palpitations. Echocardiography results showed a left atrial tumor that was resected and had histological features of high-grade osteosarcoma. The patient was treated with adjuvant chemotherapy. The tumor recurred in the same location 4 years later and was resected. Three years later, the patient presented with a 4-cm polypoid mass in the stomach that was consistent with metastatic osteosarcoma. One year later, the patient presented with recurrent high-grade sarcoma in the soft tissue of the left chest wall. We herein present the spectrum of histological findings and molecular genotyping data.

Intrathoracic Insertion of the VAC Device in a Case of Pleural Empyema 20 Years After Pneumonectomy

We report a 72-year-old man suffering from pleural empyema after pneumonectomy due to nonsmall cell lung cancer 20 years previously. Insufficiency of the bronchial stump was ruled out by bronchoscopy and bronchography. Thoracic computed tomographic scan of the thorax detected an abscess located in the subcutaneous tissue of the right ventrolateral chest wall originating from severe pyogenic osteomyelitis of the fifth and sixth ribs. Our surgical management included partial resection of the chest wall followed by insertion of the vacuum-assisted closure system into the thoracic cavity. The patient fully recovered and was discharged on postoperative day 32.

Pulmonary and thoracic sarcomas

Summary Pulmonary and thoracic sarcomas are rare tumours arising from any of the tissues of the chest, including soft tissue and bone of chest wall, lung, pleura and thymus and heart. They show a wide range of histological appearances and are classified on histological grounds by the presence of specific and characteristic differentiation features and, increasingly, the presence of specific chromosomal translocations. The relative frequency of individual tumour types varies with the anatomical site and age of the patient. Most pulmonary and thoracic sarcomas present as large, heterogeneous masses, although presentation as solitary pulmonary nodules, central endobronchial tumours, and intraluminal masses within the pulmonary arteries has also been described. Metastatic sarcomas are much more likely to be encountered than primary lesions and, as such, the diagnosis of primary sarcoma of the thorax should be made only after sarcoma-like primary lung and pleural malignancies and metastatic disease have been excluded.

Experimental study of degradable chitin long fiber reinforced polycaprolactone for reconstruction of chest wall defects

To investigate the application of a novel degradable biomaterial as a chest wall prosthesis and provide valuable scientific basis for clinical application. Preparation of chitin long fiber reinforced polycaprolactone (PCL) by means of melt blending and modeling. Full-thickness chest wall defects of 10 cm x 8 cm was created in 10 dogs and then repaired with long chitin fiber reinforced PCL artificial rib in 8 dogs (tested group) and Marlex mesh in 2 dogs (control group). It was dynamically observed that the situation of the implanted chest wall prosthesis and the progress of the regeneration of the chest wall tissue postoperatively. No operative and perioperative deaths were observed in all experimental dogs. In tested group, slight paradoxical respiration occurred in 2 dogs and could not be seen in 2 weeks. No chest wall subsidence and infection occurred. New bone tissue obviously regenerated around both resection ends of the ribs and integrated tightly with artificial ribs. In control group, there were evidently paradoxical respiration and chest wall subsidence. Marlex mesh folded and was enveloped by fibrous tissue. Degradable chitin long fiber reinforced PCL can provide effective support to chest walls and is a practicable material for chest wall reconstruction.

Lung cancer with chest wall involvement: Predictive factors of long-term survival after surgical resection

Multimodal management of lung cancer extending to chest wall and type of surgical procedure to be performed are still debated. The aim of this retrospective analysis was to analyze the predictive factors of long-term survival after surgery, focusing on depth of infiltration, type of surgical intervention and possible role of preoperative therapies, comparing survival of these patients with that of a group of patients affected by a Pancoast tumour and surgical treated in the same period. We reviewed records of 83 consecutive patients with NSCLC in stage T3 (owing to direct extension to chest wall), who underwent surgical resection in our Thoracic Surgery Unit between January 1994 and December 2003. Patients were classified in two groups: pancoast tumours (PT) or chest wall extending tumours (CW): survival and prognostic factors of each category were analyzed. In the CW group we had 68 patients: 45 were in stage IIB (pT3N0), 23 in stage IIIA (pT3-N1-2). Histology revealed adenocarcinoma in 23 cases, squamous cell carcinoma in 34, large cells anaplastic carcinoma in 8, adenosquamous carcinoma in 3. An involvement of chest wall tissues beyond the endothoracic fascia was found in 21 patients, while in the remaining 47 the invasion of chest wall tissues was confined to the parietal pleura. An extrapleural dissection was performed in 48 patients while combined pulmonary and chest wall en bloc resection was required in 20 patients. Resection was incomplete in three cases. In the PT group we had 15 patients: 11 were in stage IIB and 4 in stage IIIA. Histological type was adenocarcinoma in 10 cases, squamous cell carcinoma in 4 and adenosquamous carcinoma in 1. A univariate analysis performed in the CW group showed that survival was significantly affected by nodal status, stage, extension of chest wall invasion, type of lung resection and residual disease. In a multivariate analysis we found that nodal status, completeness of resection and extension of chest wall involvement maintained a significant prognostic value. There was no difference between the survival curve of CW and PT group: considering the two subset of CW patients, on the basis of depth of infiltration, survival of PT patients was significantly better than that of CW patients with involvement of muscular tissues and ribs (p=0.02). Nodal status, radical resection and depth of chest wall infiltration are the main predictive factors affecting long-term survival, while surgical procedure does not impact on it if margins of resection are free from disease. The better survival observed in PT patients let us to hypothesize that an induction chemo-radiation therapy, as routinely administered to PT patients, could have a potential benefit in survival of patients with CW tumour extending beyond parietal pleura.

The contralateral pectoralis muscle flap: a valuable alternative to cover chest wall tissue defects

The blood supply of the pectoralis major muscle is provided by the thoracoacromial artery and by segmental branches of the lateral thoracic artery and the internal thoracic artery. To close defects in the area of head, neck or chest, pectoralis flaps are commonly used pedicled on their major vessel. As the segmental medial vessels are capable of supplying the entire muscle, the pectoralis flap can be detached from its clavicular and acromial origin. Its main vessel is ligated and the flap can be transposed to the opposite side of the thorax to close tissue defects due to breast cancer, radiodermatitis and infectious or traumatic loss of tissue.

Hydatid cysts with unusual localizations: diagnostic and treatment dilemmas for surgeons

Although the liver and lung are by far the most common localizations for the larval cysts of Echinococcus granulosus in humans, the cysts may develop in other sites and there cause signs and symptoms that may be easily confused with those of other illnesses. In a retrospective study in Turkey, six male and 11 female cases of cystic echinococcosis, each with at least one cyst in an unusual site, were investigated. The patients, who had a mean age of 41.6 years, had cysts in the pancreas, intra-abdominal cavity, kidney, spleen, ovary, breast, mediastinum, chest wall, muscle and/or subcutaneous tissue. In terms of Gharbi's classification, 15 (75%) of the 20 cysts in these patients were type I and five (25%) were type II. Fourteen of the cases each had single cysts, two had multiple cysts, and one had an unknown number of cysts. All but one of the cases (who had a pancreatic cyst) were treated by total cystectomy. In areas where cystic echinococcosis is endemic, any patient presenting with a cystic mass, in any tissue or organ, should be considered a potential case of the disease and be carefully investigated by radio-imaging and/or ultrasonography.