Perioperative Brachytherapy for Pretreated Chest Wall Recurrence of Breast Cancer

PURPOSE: To demonstrate the technical aspects of high-dose-rate afterloading (HDR-AL) brachytherapy for isolated local chest wall recurrence of breast cancer pretreated with mastectomy and axillary node dissection plus postoperative radiotherapy. CASE REPORT: A 63-year-old female patient with left ductal breast cancer, pT2pN1biM0, was reoperated for an isolated local chest wall recurrence 13 years after primary treatment (mastectomy, axillary dissection, and 50 Gy postoperative irradiation). Radical surgery would have involved extreme mutilation. Reoperative surgical margins of 3 mm width were involved, and four parallel afterloading catheters were placed intraoperatively in this histologically positive margin site. Perioperative HDR-AL (Ir-192 stepping source, 370 GBq activity, dose rate: reference air kerma rate at 1 m 40.84 mGy/h kg) was performed. Dose per fraction: 6 Gy to the reference line, two fractions per week, total dose 30 Gy. Follow-up after secondary treatment: 5 years. RESULTS: Firm local control and 5-year disease-free survival were obtained with perioperative HDR-AL therapy; staging procedures (clinical exam, MRI, abdominal ultrasound, and bone scan) showed no evidence of disease. The development of radiodermatitis did not exceed grade 2 level and healed spontaneously within 6 weeks. CONCLUSIONS: Isolated local chest wall relapse can be effectively controlled by wide surgical excision and perioperative reirradiation with HDR-AL. This technique may represent a treatment alternative to ultraradical surgery, with equal healing probability and a better quality of life. Small-volume irradiation of the postoperative scar can be performed with HDR-AL brachytherapy, and long-term local control can be achieved with a total dose of 30 Gy.     

DR床边胸部摄影辐射剂量优化的实验研究

目的 探讨数字化移动DR床边机在胸部正位摄影中的条件最优化.资料与方法 采用岛津MobileDaRt床旁机分别用固定管电流、增加管电压和固定管电压、增加管电流两种方法对人体胸部模型进行曝光,同时测量距阴极1 m处的辐射剂量,辐射测量仪离地高80 cm.每组获得的图像请2名有经验的放射科医师采用双盲法进行评分.对计数资料进行t检验,计量资料进行卡方检验.结果 固定管电流,管电压从70 kU增加到85 kU,每组得到的图像质量所对应的受试者操作特性曲线(ROC)曲线下的而积(Az值)分别为0.383,0.733,0.675,0.250.固定管电压,管电流从0.5 mAs增加到1.8 mAs,每组得到的图像质量所对应的Az值分别为0.650,0.683,0.817,0.725.kV和mAs分别与图像质量R×C卡方检验P=0.012,P=0.001.结论 管电压和管电流的改变都会影响到辐射剂量,并且两者都与辐射剂量呈正相关.在实际的临床运用中应该选取合理的曝光条件.     

急性创伤性胸壁血肿（附50例报告）

本文报告了急性创伤性胸壁血肿５０例。右侧２２例，左侧２７例，胸骨体内壁血肿１例。共有血肿５９个，（其中９例出现２个血肿）。血肿出现多在骨折处。４７例为两根以上多发性肋骨骨折，但亦有２例无肋骨骨折。对胸壁解剖特点及血肿形成机制、ｘ线表现及其临床意义进行了讨论。并将血肿分为三种类型：（１）胸壁内型；（２）胸壁外型；（３）双向型。     

原发性胸壁肿瘤的影像学诊断(附35例分析)

目的探讨原发性胸壁肿瘤的影像学表现及其诊断价值. 资料与方法搜集原发性胸壁肿瘤病例35例,其中胸壁骨肿瘤11例,软组织肿瘤24例;良性25例,恶性10例.35例均摄有胸部正侧位片,17例行CT增强扫描,对全部病例影像学表现进行了回顾性分析. 结果胸壁肿瘤的影像学诊断步骤为(1)明确肿块是否来源于胸壁;(2)明确肿块来自于胸壁软组织抑或胸壁骨组织;(3)明确肿块是良性抑或恶性;(4)肿瘤组织学分类诊断.将该组疾病影像学表现分为Ⅵ型,分型对肿块的定位及定性诊断均有重要的临床价值. 结论综合分析X线与CT表现,不仅可对大多数胸壁肿瘤进行精确的定位及定性诊断,而且尚可对大部分胸壁脂肪瘤、神经源性肿瘤及血管瘤等作出组织学诊断.     

High-Dose-Rate (HDR) or Pulsed-Dose-Rate (PDR) Perioperative Interstitial Intensity-Modulated Brachytherapy (IMBT) for Local Recurrences of Previously Irradiated Breast or Thoracic Wall Following Breast Cancer

PURPOSE: In patients receiving salvage high-dose-rate (HDR) or pulsed-dose-rate (PDR) brachytherapy for a local recurrence on the chest wall or in the previously treated breast, clinical outcome and benefit were investigated. All patients had previously been treated with full-dose adjuvant external-beam irradiation (EBRT). Disease-free interval after salvage treatment, local tumor control and side effects were analyzed retrospectively. PATIENTS AND METHODS: Between 1996 and 2002, a total of 32 consecutive patients were treated. 13 patients initially treated with mastectomy and postoperative irradiation and 19 patients initially treated with breast-conserving surgery and postoperative irradiation developed a local recurrence. The mean dose of previous radiation therapy was 58 Gy (range, 42-64 Gy), applied by conventional fractionation. After implantation +/- surgery of recurrent disease and CT-based 3-D planning, 15 patients were irradiated with HDR-IMBT (intensity-modulated brachytherapy) with a mean dose of 28 Gy (range, 10-30 Gy, 2 x 2.5 Gy/day at 6-h daily interfraction interval) and 17 patients received PDR-IMBT with a mean dose 30 Gy (range, 10-45 Gy, 5 x 1 Gy/day at 2-h pulse intervals). Four patients underwent additional EBRT using a dose of 24-40 Gy electrons. Treatment was performed only on working days. RESULTS: After a mean post-implant follow-up of 19 months (range, 1-83 months), no signs of local recurrence were observed in 20 of the 32 patients. In twelve patients, local recurrence occurred after a mean follow-up of 13 months (range, 1-78 months). 20 of the 32 patients experienced an additional systemic progress. In one patient, an EORTC/RTOG grade 3 side effect (ulceration of the skin) was described, which was followed by a local recurrence 12 months posttherapeutically. CONCLUSION: Perioperative interstitial HDR/PDR-IMBT of localized breast or thoracic wall recurrences following previous full-dose EBRT appears to be a meaningful salvage treatment with acceptable toxicity.     

CR与普通摄影曝光剂量和剂量当量的比较

目的比较CR与普通摄影曝光剂量和受照剂量当量大小。方法通过热释光测量计、线对卡等工具,对中速屏-片、感绿屏-片及IP板3种影像载体的曝光剂量和剂量当量均值进行检测与比较。结果显示2.0L.P/mm时,IP板曝光剂量只有中速屏-片的5%、感绿屏-片的33%,剂量当量均值是中速屏-片的3%、感绿屏-片的35%。而显示4.0L.P/mm时,IP板曝光剂量接近中速屏-片的200%、感绿屏-片的950%,剂量当量均值是中速屏-片的180%、感绿屏-片的1110%。在2.5~3.2L.P/mm范围内,IP板的曝光剂量分别是中速屏-片的50%~75%、感绿屏-片的220%~290%,剂量当量均值又分别是中速屏-片的37%~66%、感绿屏-片的190%~270%。结论在2.5~3.2L.P/mm内,CR的曝光剂量和剂量当量均值比中速屏-片低约1/2~3/4倍mAs、1/3~2/3倍mSv,但比感绿屏-片高约2~3倍mAs、2~3倍mSv。在这一范围内投照,均可获得优质的影像。     

胸壁病变的计算机X线摄影和CT检查

目的：探讨胸壁病变的计算机Ｘ线摄影（ＣＲ）和ＣＴ表现及其诊断价值,提高对胸壁病变的认识。材料和方法：回顾分析经手术病理、穿刺细胞学检查或临床随访资料证实的３９例ＣＲ和ＣＴ资料。结果：感染组１２例中（包括化脓性感染４例,胸壁结核８例）,ＣＲ准确诊断４例,ＣＴ诊断１１例;软组织肿瘤组１６例中（包括脂肪瘤７例,纤维肉瘤４例,血管瘤、神经纤维瘤、恶性纤维组织细胞瘤、侵袭性纤维瘤病和脂肪肉瘤各１例）,ＣＲ准确诊断３例,ＣＴ诊断１４例;骨肿瘤和肿瘤样病变组１１例中（包括骨纤维异常增殖症７例,软骨瘤２例,多发性骨髓瘤和骨嗜酸性肉芽肿各１例）,ＣＲ准确诊断８例,ＣＴ诊断１０例。结论：ＣＲ简便,能诊断大多数胸壁骨性病变。ＣＴ对各种胸壁病变尤其是软组织病变的诊断较ＣＲ明显优越,对鉴别胸壁肿瘤的良恶性有肯定作用,但仍有一定限制。     

Implementing a Novel Through-Glass Chest Radiography Technique for COVID-19 Patients: Image Quality,Radiation Dose Optimization,and Practical Considerations

Rationale and objectives: The novel coronavirus (COVID-19) pandemic has presented many logistical challenges, including unprecedented shortages of personal protective equipment (PPE). A technique of obtaining portable chest radiographs (pCXR) through glass doors or windows to minimize technologist-patient contact and conserve PPE has gained popularity, but remains incompletely evaluated in the literature. Our goal was to quickly implement this technique and evaluate image quality and radiation dose. Materials and methods: An infographic and video were developed to educate nurses and technologists on the through-glass pCXR technique. Imaging parameters were optimized using a phantom and scatter radiation was measured. Three reviewers independently evaluated 100 conventionally obtained and 100 through-glass pCXRs from March 13, 2020 to April 30, 2020 on patients with suspected COVID-19, using criteria for positioning and sharpness/contrast on a 1 (confident criteria not met) to 5 (confident criteria met) scale. Imaging parameters, including deviation index (DI) were recorded for all radiographs. Results: The through-glass method was rapidly adopted and conserved one isolation gown per interaction. Although there was a statistically significant difference in the positioning (P value 0.018) and sharpness/contrast (P value 0.016), the difference in mean ratings was small: 4.82 vs 4.65 for positioning and 4.67 vs 4.50 (conventional vs modified) for sharpness/contrast. Scatter radiation was measured using a thorax phantom and found to be acceptable for the patient and nearby personnel. Standard deviation was higher for the DI for the through-glass technique (2.8) compared to the conventional technique (1.8), although the means were similar. Conclusion: The through-glass technique was quickly implemented, producing diagnostic quality chest radiographs while conserving PPE and reducing risks to radiology staff. There was more variability with imaging technique and DI using the through-glass technique, likely due to technologist uncertainty regarding technical modifications. Further work to reduce this variation is necessary to optimize quality and dose.     

胸壁神经鞘瘤的CT表现与病理分析

目的 对照分析胸壁神经鞘瘤的CT表现与病理基础,以期提高术前诊断水平.方法 搜集经手术病理证实的9例胸壁神经鞘瘤患者资料,均行CT平扫和增强,着重分析肿瘤部位、大小、形态、边界、均质性、瘤肺界面、压迹、钙化及强化方式,并与病理结果进行对照.结果 9例神经鞘瘤均为良性单发肿瘤,边界清晰.位于右侧胸壁5例,左侧胸壁4例.肿瘤平均最大径为3.7 cm(2.3 ～6.0 cm),肿块形态呈圆形(3例)和椭圆形(6例).平扫质地均匀6例,增强后轻度强化4例,中度强化和明显强化各1例,镜下以Antoni A细胞为主;质地不均匀3例,均呈外周高、中间偏低密度,增强后表现为外周轻度强化1例,中度强化2例,中央稍低密度区无明显强化,镜下以Antoni B细胞为主.瘤肺界面8例光整,1例模糊,1例伴有钙化,邻近骨质压迫弧形压迹3例,肋间隙增宽2例,无胸腔积液.结论 把握胸壁神经鞘瘤的CT表现和病理基础有助于进行诊断和鉴别诊断.     

胸壁软组织肿瘤的影像学研究与诊断

胸部软组织包括皮肤、皮下脂肪、乳房、肌肉和筋膜间隙,肋间隙中有肌肉、筋膜,血管和神经等软组织填充[1].胸壁软组织肿瘤,是指不包括皮肤、皮下组织及乳腺来源的肿瘤.分原发性与继发性2类.影像学检查有助于确定其性质、部位及范围.良、恶性胸壁肿瘤的影像学表现常重叠,但其发生的位置和表现的不同特点常能帮助鉴别诊断[2].     

Influence of Average Glandular Dose for Breast Cancer Screening and Diagnosis in Mammography

目的 通过调节乳腺X线摄影的曝光剂量,评价乳腺X线摄影中平均腺体剂量( average glandular dose,AGD)对图像质量的影响.资料与方法 应用数字化全景乳腺机系统和PASMAM模体,手动控制条件(kV、mAs),对不同厚度的PASMAM模体在不同AGD条件下进行摄影.采用非参数统计分析不同AGD相同厚度以及相同AGD组不同厚度模体钙化和肿块的显示程度差异是否存在统计学意义,并分析图像信号噪声比(SNR)随剂量和厚度的变化.结果 相同曝光剂量条件下,SNR随模体厚度的增加而下降,相同模体厚度SNR随曝光剂量的增加而增加.实验范围内的相同厚度模体组合,在不同AGD条件下,显示钙化和肿块的能力差异无统计学意义(P＞0.05).结论 数字化全景乳腺X线摄影盲目提高AGD值会增加患者受辐射量,并不能提高显示钙化和肿块的能力.     

乳腺X线摄影射线剂量对乳腺X线片质量的影响

目的通过调节乳腺X线摄影的曝光剂量,评价乳腺X线摄影中平均腺体剂量(average glandular dose,AGD)对图像质量的影响。资料与方法应用数字化全景乳腺机系统和PASMAM模体,手动控制条件(kV、mAs),对不同厚度的PASMAM模体在不同AGD条件下进行摄影。采用非参数统计分析不同AGD相同厚度以及相同AGD组不同厚度模体钙化和肿块的显示程度差异是否存在统计学意义,并分析图像信号噪声比(SNR)随剂量和厚度的变化。结果相同曝光剂量条件下,SNR随模体厚度的增加而下降,相同模体厚度SNR随曝光剂量的增加而增加。实验范围内的相同厚度模体组合,在不同AGD条件下,显示钙化和肿块的能力差异无统计学意义(P>0.05)。结论数字化全景乳腺X线摄影盲目提高AGD值会增加患者受辐射量,并不能提高显示钙化和肿块的能力。     

Percutaneous Cryoablation: Safety and Efficacy for Pain Palliation of Metastases to Pleura and Chest Wall

PurposeTo assess safety and efficacy of percutaneous cryoablation for pain palliation of metastases to pleura and chest wall.Materials and MethodsThis retrospective single-center cohort study included 22 patients (27% female, mean age 63 y ± 11.4) who underwent 25 cryoablation procedures for pain palliation of 39 symptomatic metastases measuring 5.1 cm ± 1.9 (range, 2.0–8.0 cm) in pleura and chest wall between June 2012 and December 2017. Pain intensity was assessed using a numerical scale (0–10 points). Statistical tests t test, χ², and Wilcoxon signed rank were performed.ResultsPatients were followed for a median of 4.1 months (interquartile range [IQR], 2.3–10.1; range, 0.1–36.7 mo) before death or loss to follow-up. Following cryoablation, pain intensity decreased significantly by a median of 4.5 points (IQR, 2.8–6; range, 0–10 points; P = .0002 points, Wilcoxon signed rank). Pain relief of at least 3 points was documented following 18 of 20 procedures. Pain relief occurred within a median of 1 day following cryoablation (IQR, 1–2; range, 1–4 d) and lasted for a median of 5 weeks (IQR, 3–17; range, 1–34 wk). Systemic opioid requirements decreased in 11 of 22 patients (50%) by an average of 56% ± 34. Difference in morphine milligram equivalents was not significant (P = .73, Wilcoxon signed rank). No procedure-related complications occurred despite previous radiation of 7 tumors. Of 25 procedures, 22 (88%) were performed on an outpatient basis.ConclusionsPercutaneous cryoablation for metastases to pleura and chest wall can safely provide significant pain relief within days following a single session.     

胸壁神经鞘瘤的CT、超声表现和病理对照研究

目的 探讨胸壁神经鞘瘤的CT、超声表现及其与病理组织学间的关系,提高对胸壁神经鞘瘤影像表现的认识.资料与方法 搜集经手术病理证实的胸壁神经鞘瘤11例,回顾性分析其CT、超声表现和病理表现之间的对照关系.结果 10例良性神经鞘瘤,1例恶性神经鞘瘤,均为单发.CT和超声显示病灶位于胸神经走行分布区.良性病变表现为边界清晰的实性或囊实性肿块,呈中低密度或回声区.恶性病变边缘不规整,累及周围组织.肿瘤密度或回声是否均匀取决于瘤内Antoni B型组织的分布以及囊变、骨化或出血和血栓形成等变化.肿瘤强化表现多样,强化幅度一般为20～35 HU,主要由肿瘤内Antoni A型和Antoni B型组织比例决定;无强化或低强化取决于肿瘤囊变出血、胶原沉积、纤维化或钙化和Antoni B型组织分布.彩色多普勒血流显像(CDFI)显示肿瘤多无显著血流信号.结论 了解胸壁神经鞘瘤的病理学特征与CT和超声影像表现的相关性有助于诊断和鉴别诊断.     

Serial Evaluation of Increased Chest Wall F-18 Fluorodeoxyglucose (FDG) Uptake Following Radiation Therapy in Patients With Bronchogenic Carcinoma

PURPOSE: Following radiation therapy for bronchogenic carcinoma, increased FDG accumulation within the irradiated tissue can be identified. This finding has not been well characterized. Therefore, we retrospectively evaluated the time course, frequency, and intensity of increased FDG uptake over a one-year period in patients who had been treated with radiation therapy. MATERIALS AND METHODS: Serial FDG-PET studies (n = 38) were performed in patients (n = 12) with bronchogenic carcinoma before and after radiation therapy. Regions of interest (ROIs) were placed in the chest wall and activity concentrations of posttherapy studies were compared to pretherapy studies. FDG uptake was also described qualitatively relative to mediastinal activity (1-4 scale) by two observers blinded from clinical information. RESULTS: Chest wall radiation port ROI uptake was 18% higher in the 2-month (P = 0.08), 40% higher in the 6-month (P = 0.003), and 32% higher in the 12-month (P = 0.04) posttherapy studies than in non-port ROIs. In 6 patients that clinically had radiation-induced chest wall fibrosis or pneumonitis, visual interpretation identified abnormal chest wall or pleural region FDG uptake in 5/6. In 2/6 patients without clinical chest wall fibrosis, abnormal, chest wall FDG uptake was seen. CONCLUSIONS: Radiation therapy occasionally causes modestly increased soft tissue FDG uptake within irradiated soft tissue in patients being treated for bronchogenic carcinoma, which persists for up to one year after therapy.     

CT Radiation Dose Optimization and Estimation: an Update for Radiologists

In keeping with the increasing utilization of CT examinations, the greater concern about radiation hazards from examinations has been addressed. In this regard, CT radiation dose optimization has been given a great deal of attention by radiologists, referring physicians, technologists, and physicists. Dose-saving strategies are continuously evolving in terms of imaging techniques as well as dose management. Consequently, regular updates of this issue are necessary especially for radiologists who play a pivotal role in this activity. This review article will provide an update on how we can optimize CT dose in order to maximize the benefit-to-risk ratio of this clinically useful diagnostic imaging method.