Thermoplastic Patient Fixation

BACKGROUND AND PURPOSE: Several methods have been developed to reduce tumor motions and patient movements during radiotherapy of lung cancer. In this study, a multislice CT-based analysis was performed to examine the effect of a thermoplastic patient immobilization system on the chest wall and tumor motions. PATIENTS AND METHODS: Ten patients with stage II-IV lung cancer were enrolled into the study. According to tumor localization, five patients had peripheral, and five patients central lung cancer (T2-T4). In total, six series of measurements were made with a multislice CT scanner, both with and without mask fixation, in normal breathing, at maximal tidal volume inhalation, and at maximal tidal volume exhalation. RESULTS: Movements of chest wall, diaphragm and tumor, with and without mask, under different breathing conditions were registered. With the use of the immobilization system, no significant difference was found in diaphragmatic movements (mean deviation of diaphragm: 41.7-40.5 mm to the right, and 40.5-36.8 mm to the left side) and in tumor motions (mean deviation of tumor: 15.3-12.4 mm in craniocaudal, and 11.5-8.8 mm in posterolateral direction, mean medial deviation: 4.6-4.1 mm, mean lateral deviation: 7.2-5 mm). Significant differences were observed concerning tumor motions in anteroposterior direction (mean: 8.9-6.3 mm) and transverse chest movements in anteroposterior direction. CONCLUSION: Besides the advantage of optimal patient positioning, the movements of the bony chest wall can be considerably reduced by using the immobilization system. However, this fixation system has limitations concerning its suitability for minimizing tumor motions.     

Local recurrence of breast cancer demonstrated on 99mTc-MIBI scintigraphy

We present a postmastectomy patient in whom a mass was palpated in the chest wall. It appeared to be difficult to determine whether the chest wall mass was local recurrence of breast cancer or granulation induced by mastectomy on computed tomography (CT). The mass was successfully demonstrated on 99mTc-methoxyisobutylisonitrile (99mTc-MIBI) scintigraphy as an area of increased accumulation, and was considered to be a recurrent tumor. Surgical resection was performed, and the mass was histopathologically proven to be recurrence. 99mTc-MIBI scintigraphy may contribute to the detection of local recurrence or distant metastasis in addition to the diagnosis of primary breast cancer and axillary metastasis.     

Tumor invasion of the chest wall and mediastinum in lung cancer: evaluation with pneumothorax CT

For preoperative evaluation of chest wall and mediastinal invasion by lung cancer, computed tomography (CT), combined with artificial pneumothorax (pneumothorax CT), was performed in 43 patients with lung cancer in whom conventional CT scans showed that the mass was contiguous to the chest wall (n = 30) and/or mediastinum (n = 25) but without evidence of definite tumor invasion. Invasion was diagnosed on the basis of whether an air space existed between the mass and the adjacent structures. In three patients pneumothorax was not produced. After the procedure, four patients developed symptomatic pneumothorax, and one, subcutaneous emphysema. Comparison of diagnoses based on findings at pneumothorax CT, surgery, and pathologic examination showed that pneumothorax CT is 100% accurate for chest wall invasion and 76% accurate for mediastinal invasion. The authors conclude that this procedure is helpful in accurate evaluation of the T criterion in lung cancer, especially for patients in whom findings at conventional CT suggest tumor invasion of the chest wall and mediastinum.     

A first described chest wall metastasis from colon cancer demonstrated with (18)F-FDG PET/CT

It is well known that, haematogenous colon cancer metastases are most commonly found in the liver, less likely in the lungs through the paravertebral venous system and rarely in other organs. Sporadic clinical cases of colon cancer metastases to the abdominal wall, the thyroid or the adrenal glands have been reported. Here, we present an uncommon case of chest wall metastasis from colon cancer demonstrated with 2-fluoro [fluorine-18]-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT). A 52 years old female patient was examined after she felt a swelling mass above her left breast. Tumor makers, such as serum cancer embryonic antigen (CEA) 146.22kU/L (normal range:0.00~37.0kU/L) and CA19-9 (258.16μg/L (normal range:0.00~10.0μg/L) and neuron-specific enolase (NSE) 78.2 (normal range: 0.00~17.00) were abnormally high. Chest CT revealed the soft tissue density mass on the left anterior chest wall with invasion of left 4th rib, and CT-guided biopsy showed a poorly differentiated adenocarcinoma of unkown origin. The patient was then referred for the (18)F-FDG-PET scan which was performed one hour after the intravenous injection of 370MBq of (18)F-FDG (Discovery Camera, VCT, GE, USA) and showed in addition to the chest mass, abnormal (18)F-FDG accumulation in both lungs, left supraclavicular and peritoneal lymph nodes. Furthermore, high (18)F-FDG uptake was detected in the sigmoid. Pathology findings from colonoscopy confirmed that this was a sigmoid colon adenocarcinoma. So far, chest wall metastasis from colon cancer as an initial finding has not been reported. Usually, an initial chest wall mass is hardly suspected to be a colon cancer metastasis. Abnormal serum tumor markers such as CEA and CA19-9 supported the diagnosis of a gastrointestinal adenocarcinoma. In our case, we found high serum NSE and normal findings of bowel wall on the CT scan, thus without the positive (18)F-FDG findings, one would probably consider as first diagnosis: chest wall metastasis from lung cancer, or a neuroendocrine tumor. The unusual finding in this case was that on the CT images there was no obvious local density of the intestine, no bowel wall thickening, or suspicious nodular lesions. Segmental (18)F-FDG accumulation seen in the sigmoid colon had early maximum standardized uptake value (SUV(max)) 7.3 and in 1h delayed estimation, 8.1. Colonoscopy showed that the (18)F-FDG-avid area at the colon was circular and thickened. "Hot" lesions found in both lungs, the supraclavicular and retroperitoneal lymph nodes by (18)F-FDG PET/CT scan were considered to be most probably metastases from colon adenocarcinoma. In conclusion, PET as a rather simple procedure and less dependent on bowel preparation diagnosed the primary colon cancer, its metastases and specifically a first described chest wall metastasis, while CT alone did not show the primary tumor.     

A case of multiple primary cancers, hepatoma and seminoma, detected by 67Ga citrate and 99mTc-HIDA scintigraphy]

A case of multiple primary cancers, hepatoma and seminoma, was detected by 67Ga citrate and 99mTc-HIDA scintigraphy. 67Ga citrate accumulated in the chest wall, the hepatic lesion and the testis. 99mTc-HIDA accumulated in the chest wall. Therefore we suspected that the chest wall lesion was a tumor metastasized from hepatocellular carcinoma and another cancer was present in the testis. After these examinations orchiectomy and needle biopsy were done. Pathologically, the testicular tumor was seminoma and hepatic and chest wall tumors were hepatocellular carcinoma (Edmondson-II).     

Radiation-induced osteoradionecrosis of the ribs in a patient with breast cancer: A case report

Osteoradionecrosis of the chest wall after radiation therapy for breast cancer is rare; however, it is one of the most severe complications of radiation treatment. Radiologically, osteoradionecrosis can manifest as a focal lucent area in bone, periostitis, sclerosis, and cortical irregularity of bones on X-ray or computed tomography; therefore, differentiation from bone metastasis can be challenging. Associated insufficiency fractures, ulceration, and skin necrosis may also occur. We encountered a patient with osteoradionecrosis in the left anterior ribs after radiation therapy for breast cancer. Chest computed tomography revealed cortical irregularity with severe sclerotic changes of the anterior arc of the left fist to the fourth ribs. The patient''s skin on the left chest wall exhibited ulceration with purulent discharge. Ultrasonography of the left chest wall revealed diffuse skin thickening with hyperechoic changes in the subcutaneous fat layer of the left chest wall with calcifications. The patient underwent rib resection and chest wall reconstruction. Recognizing characteristic imaging features of osteoradionecrosis is important for radiologists to differentiate it from bone metastasis and plan appropriate treatment.     

Endovascular therapeutic occlusion following bilateral carotid artery bypass for radiation-induced carotid artery blowout: case report

A patient with breast cancer received radiation therapy to the upper chest wall. Twenty-two years later, she presented with repeated severe bleeding through a left lower neck ulcer. She was taken to surgery for hemostasis, which was not successful because the carotid artery was surgically inaccessible. To manage for explosive carotid blowout, we performed common carotid artery ligation and endovascular coil embolization after contralateral-external-carotid to ipsilateral-common-carotid artery bypass with a polytetrafluoroethylene (PTFE) graft. The patient has experienced no ischemic events or bleeding since this treatment.     

Pleural effusion in patients with isolated chest wall recurrences of breast cancer

The reports of 66 patients with isolated chest wall recurrences of breast cancer after mastectomy who developed a pleural effusion were analyzed. The location of the pleural effusion was ipsilateral in 71.2%, contralateral in 21.2% and bilateral in 7.6%. The cumulative incidence of ipsilateral effusions after onset of chest wall recurrence is 81.4% within two years. The high frequency of ipsilateral effusions and the shorter interval after chest wall recurrence supports the hypothesis of locoregional tumor progression to the pleural space in patients with chest wall recurrences. High-voltage irradiation of the thoracic wall might effectively reduce the spread through to the pleural space.     

Bolus electron conformal therapy for the treatment of recurrent inflammatory breast cancer: a case report

The treatment of locoregionally recurrent breast cancer in patients who have previously undergone radiation therapy is challenging. Special techniques are often required that both eradicate the disease and minimize the risks of retreatment. We report the case of a patient with an early-stage left breast cancer who developed inflammatory-type recurrence requiring re-irradiation of the chest wall using bolus electron conformal therapy with image-guided treatment delivery. The patient was a 51-year-old woman who had undergone lumpectomy, axillary lymph node dissection, and adjuvant whole-breast radiation therapy for a stage I left breast cancer in June 1998. In March 2009, she presented at our institution with biopsy-proven recurrent inflammatory carcinoma and was aggressively treated with multi-agent chemotherapy followed by mastectomy that left a positive surgical margin. Given the patient's prior irradiation and irregular chest wall anatomy, bolus electron conformal therapy was used to treat her chest wall and draining lymphatics while sparing the underlying soft tissue. The patient still had no evidence of disease 21 months after treatment. Our results indicate that bolus electron conformal therapy is an accessible, effective radiation treatment approach for recurrent breast cancer in patients with irregular chest wall anatomy as a result of surgery. This approach may complement standard techniques used to reduce locoregional recurrence in the postmastectomy setting.     

Anterior chest wall involvement in patients with pustulosis palmoplantaris

With the aim of determining the frequency and radiographic features of anterior chest wall involvement in patients with pustulosis palmoplantaris, a questionnaire was sent to 107 patients. Ninety-three patients returned the questionnaire, five of whom were excluded from further analysis due to the appearance of psoriatic lesions. Twenty-five (28%) of the remaining 88 patients reported pain and/or swelling of joints or bones in the anterior chest wall. All were examined radiographically, using tomography, and a group of 20 patients without anterior chest wall complaints were examined similarly. Sixteen of the patients with, but none of the patients without, complaints were found to have arthro-osteitis of the anterior chest wall, consisting of diffuse sclerosis of the manubrium sterni in one patient, localized sclerosis in seven patients, and sequelae of arthritis of the sternoclavicular, upper sternocostal and/or manubriosternal joint in eight patients.     

八例Askin瘤的影像诊断

目的研究Askin瘤的影像表现，提高对该病的认识及鉴别诊断能力。方法回顾性分析经病理证实的8例Askin瘤的影像表现。8例均行X线检查，7例行CT检查，1例行MR检查，4例行核素骨扫描。结果8例Askin瘤均表现为位于胸壁或胸腔的软组织肿物，其中左侧4例，右侧4例。6例大病灶密度不均匀，2例较小病灶内密度或信号均匀；CT扫描4例可见囊变、坏死区。CT、MRI、核素骨扫描共显示肋骨破坏6例，其中CT显示4例，MRI显示1例，核素骨扫描显示放射性核素浓集3例。胸腔积液6例。瘤肺交界面清楚1例，不清楚7例。8例病灶中均未见钙化。结论Askin瘤影像学表现为胸腔或胸壁的软组织肿物，但不具有特异性，对发生于儿童及青少年的胸壁肿物，应注意鉴别诊断。     

A case of mesenchymal hamartoma of the chest wall of a child

Mesenchymal hamartoma of the chest wall is a rare benign tumor that usually occurs in infants and children. The clinical presentations and imaging features are atypical and difficult to differentiate from malignant tumors. In this article, we present a case with a large mesenchymal hamartoma tumor of the chest wall. A large right-sided chest wall mass was discovered in a 6-month-old boy by his mother. Chest X-ray revealed a thoracic mass with well-defined margins on the right side that expanded into the right ribs. Chest computed tomography showed that the mass originated from the thoracic wall. The patient underwent complete removal of the mass, and histopathology results confirmed a mesenchymal hamartoma.     

多层螺旋CT仿真支气管镜对气管支气管病变的诊断价值

目的评价多层螺旋CT仿真支气管镜（CTVB）对气管、支气管病变的诊断价值。方法对42例患者进行多层螺旋CT检查，在工作站得到仿真支气管图像，采用螺距1．35，重组间隔1mm，重组层厚1．25mm。其中35例为中央型肺癌、3例支气管内膜结核、3例支气管良性肿瘤经病理证实，1例支气管异物经临床证实。所有图像均经2名熟悉气管支气管解剖的放射科医师进行分析。结果42例中，35例中央型肺癌CTVB表现为气管支气管腔内结节状或丘状隆起者22例，狭窄13例，以上35例中央型肺癌横断面CT均显示病变部位支气管壁呈不同程度增厚。3例支气管内膜结核CTVB均表现为支气管腔狭窄，横断面CT显示管壁增厚，管壁增厚范围长。3例气管支气管良性肿瘤CTVB表现为腔内结节，横断面CT无相邻支气管壁的增厚。另1例支气管腔内异物CTVB表现为支气管腔内隆起性阻塞，横断面CT无相邻支气管壁的增厚。CTVB可以越过狭窄部位对远端支气管进行观察。结论多层螺旋CTVB可以反映气管支气管腔内病变的形态，结合横断面CT对气管支气管病变的诊断具有参考价值。     

Incidentally Detected Small Intestine Intussusception Caused by Primary Small Intestine Carcinoma on <Superscript>18</Superscript>F-FDG PET/CT

Small intestine intussusception in adults is a rare condition mainly caused by primary or metastatic small intestine malignancy. Here, we present a 72-year-old male patient who was diagnosed with small intestine cancer that was presented as small intestine intussusception on hybrid ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT). The patient was initially referred for an abnormality on a chest radiography and severe anemia. FDG PET/CT showed the lung lesion in the right upper lobe of lung as a high FDG uptake mass. Accidentally, FDG PET demonstrated another intense hypermetabolic intraluminal lesion in the small intestine accompanied with intussusception shown as a circumferential hypermetabolic wall. By pathologic examination, the patient was diagnosed as primary small intestine cancer with lung metastasis. This case highlights usefulness of hybrid FDG PET/CT to identify unexpected malignancy.     

FDG PET/CT findings in recurrent malignant schwannoma

Malignant schwannoma is an uncommon but aggressive sarcoma that most commonly arises in young and middle-aged adults. We present a 28-year-old male patient with a recurrent chest wall malignant schwannoma. An FDG PET/CT was performed to evaluate the management of the patient. The PET/CT images showed hypermetabolic mass lesions in the left upper chest wall and increased FDG uptake in the left axillary region. The pathologic results confirmed the PET findings. We conclude that FDG PET/CT could play an important role in the staging, restaging, and post-therapy follow-up of malignant schwannomas.     

Ga-67 and Tl-201 scintigraphy in extramedullary plasmacytoma: a case report.

Extramedullary plasmacytoma is a rare form of plasma cell tumor occurring in a wide variety of organs and tissues. Most tumors occur in the head and neck, involving the nasal cavity, paranasal sinuses, and upper airway. Tl-201 and Ga-67 scan findings in a patient with extramedullary plasmacytoma in the right side of the chest wall are presented. Only a few publications have described Tl-201 or Ga-67 uptake in extramedullary plasmacytoma. This is the first report of both Tl-201 and Ga-67 uptake in an extramedullary (or intramedullary) plasmacytoma.     

Imaging studies of patients with malignant fibrous histiocytoma using C-11-alpha-aminoisobutyric acid (AIB)

Alpha-aminoisobutyric acid (AIB), a synthetic, nonmetabolized amino acid which is rapidly transported into viable cells by the A-type or alanine-preferring amino acid transport system, has been labeled with the short-lived, positron-emitting radionuclide carbon-11. Carbon-11 labeled AIB is currently being evaluated as a tumor imaging agent for in vivo amino acid transport studies in patients with cancer. In this study, C-11 AIB was used to image two patients with malignant fibrous histiocytoma (MFH), a pleomorphic sarcoma. Following intravenous administration of C-11 AIB, tumors in the distal femur of one patient and in the anterior chest wall of another patient were well visualized using high energy gamma scintigraphy. Since therapy may alter the accumulation of amino acids in tumor tissue, studies using C-11 AIB in patients with MFH before and after chemotherapy are in progress.     

PET/CT appearance of desmoid tumour of the chest wall

Desmoid tumours are rare, poorly circumscribed tumours that have a firm consistency and, although benign, have a remarkable tendency to infiltrate into surrounding structures. Extra-abdominal desmoid tumours involve mainly the extremities or the chest wall and are usually managed by wide radical resection. Moreover, desmoid tumours involving the chest wall are locally aggressive tumours with a high recurrence rate. We report a case of a pathologically proven desmoid tumour of the chest wall in a patient with a history of bilateral breast cancer and oesophageal cancer. We discuss the imaging appearances of this tumour on positron emission tomography combined with computed tomography (PET/CT) and magnetic resonance imaging.Desmoid tumours are poorly circumscribed tumours that are firm, rubbery and have a remarkable tendency to infiltrate into surrounding structures with a strong propensity to recur locally after resection [1]. Desmoid tumours of the chest wall are uncommon tumours that have been described extensively in the pathological and surgical literature.¹⁸F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography combined with computed tomography (FDG-PET/CT) has been shown to be very useful in the staging of patients with breast cancer and oesophageal cancer, as well as in the evaluation of treatment response [2]. It has a specific ability to discriminate responders from non-responders more accurately and earlier than conventional imaging methods [2]. PET/CT also plays an important role in the assessment of malignant soft-tissue tumours of the chest wall, such as sarcoma, by improving the accuracy of staging and helping to determine the appropriate therapy [3]. The PET/CT imaging characteristics of chest wall desmoid fibromatosis, a benign condition that may clinically mimic metastatic disease or sarcomatous degeneration, has not yet been reported to our knowledge.We describe the PET/CT and MRI appearances of a biopsy-proven desmoid tumour of the chest wall in a patient with a history of bilateral breast cancer and oesophageal cancer.     

Askin瘤的影像诊断

目的:分析8例Askin瘤的影像征象。材料和方法:回顾性分析8例Askin瘤的胸部平片、B超和CT资料。年龄13~62岁,平均29.8岁。全组均拍摄正侧位胸片和CT扫描,6例胸壁肿瘤行B超检查。全组均经病理组织学和免疫组织化学检查证实。结果:6例原发于胸壁软组织,肿瘤较小(平均大小3cm),术后半数近期复发,复发灶平均大小为5.5cm。2例原发于纵隔,肿瘤平均大小为7cm。瘤实质主要为软组织,散在液化、坏死或出血。CT增强后扫描呈不规则强化。5例受累胸膜表现为不规则状、结节状增厚。结论:Askin瘤典型影像表现为胸壁、胸膜和纵隔病灶相互融合成巨大肿块。因此,面对青少年患者的胸部软组织肿瘤,鉴别诊断时应考虑到Askin肿瘤。     

胸壁原发恶性肿瘤的CT诊断

目的　分析胸壁原发恶性肿瘤的CT表现 ,探讨CT对其定位、定性及鉴别诊断的价值和限度。方法　对经手术、活检证实的 7例原发胸壁恶性肿瘤的CT表现 ,结合病理所见进行回顾性分析。结果　 7例胸壁恶性肿瘤中 ,5例发生于胸壁软组织 (脂肪肉瘤和纤维肉瘤各 2例 ,横纹肌肉瘤 1例 ) ,2例发生于胸壁骨组织 (胸骨骨肉瘤、肋软骨肉瘤各 1例 )。CT表现 :肿瘤向胸壁外生长 3例 ,向胸壁内生长 2例 ,同时向胸壁内外生长 2例 ,其中 5例有明显的胸壁骨质破坏 ,4例伴有肺转移。结论　CT对胸壁原发恶性肿瘤的部位、范围以及肺脏是否受侵等有较大的诊断价值。