Malignant Melanoma Presenting as Thoracic Midline Malignancy: Clinicopathologic and Molecular Features.

Because of rarity, clinicopathologic and genomic profiles of noncutaneous malignant melanoma (MM) are not well characterized. In this study, we provide a detailed evaluation of 6 cases of MM presenting as thoracic midline malignancy. The tumors occurred in 6 white patients (5 males and 1 female; medium age, 71.5 y; range, 55 to 81 y). At presentation, the disease was confined to the chest (6/6) with 4 cases subsequently showing brain metastasis. All 6 tumors featured epithelioid and 1 case also spindle cell morphology. Three of 6 tumors had melanin and all 6 expressed melanocytic markers. Molecular characterization showed 2 of 6 tumors with BRAF"hot spot" genetic alterations (both with BRAFV600K) and 1 with NF1mutation. All 6 patients died of the disease within 1 year (mean survival, 4.8 mo). One patient showed a partial response to BRAF inhibitor. Our study shows that MM in this location has a spectrum of genetic alterations. The findings highlight the need for comprehensive next generation sequencing-based molecular testing to optimize targeted therapies of this aggressive malignancy.

Comparison of 2D and 3D modeled tumor motion estimation/prediction for dynamic tumor tracking during arc radiotherapy.

Many real-time imaging techniques have been developed to localize a target in 3D space or in a 2D beam's eye view (BEV) plane for intrafraction motion tracking in radiation therapy. With tracking system latency, the 3D-modeled method is expected to be more accurate even in terms of 2D BEV tracking error. No quantitative analysis, however, has been reported. In this study, we simulated co-planar arc deliveries using respiratory motion data acquired from 42 patients to quantitatively compare the accuracy between 2D BEV and 3D-modeled tracking in arc therapy and to determine whether 3D information is needed for motion tracking. We used our previously developed low kV dose adaptive MV-kV imaging and motion compensation framework as a representative of 3D-modeled methods. It optimizes the balance between additional kV imaging dose and 3D tracking accuracy and solves the MLC blockage issue. With simulated Gaussian marker detection errors (zero mean and 0.39 mm standard deviation) and ~155/310/460 ms tracking system latencies, the mean percentage of time that the target moved >2 mm from the predicted 2D BEV position are 1.1%/4.0%/7.8% and 1.3%/5.8%/11.6% for the 3D-modeled and 2D-only tracking, respectively. The corresponding average BEV RMS errors are 0.67/0.90/1.13 mm and 0.79/1.10/1.37 mm. Compared to the 2D method, the 3D method reduced the average RMS unresolved motion along the beam direction from ~3 mm to ~1 mm, resulting in on average only <1% dosimetric advantage in the depth direction. Only for a small fraction of the patients, when tracking latency is long, the 3D-modeled method showed significant improvement of BEV tracking accuracy, indicating potential dosimetric advantage. However, if the tracking latency is short (~150 ms or less), those improvements are limited. Therefore, 2D BEV tracking has sufficient targeting accuracy for most clinical cases. The 3D technique is, however, still important in solving the MLC blockage problem during 2D BEV tracking.

Applicability of the Japanese equation for estimating glomerular filtration rate in patients with advanced-stage thoracic cancer.

BACKGROUND: The 24-h creatinine clearance (24-h Ccr) and the Cockcroft-Gault equation (CG) are commonly used as markers of renal function in clinical practice. However, the utility of the Japanese equation for estimating glomerular filtration rate (eGFR) in cancer patients has not yet been evaluated. The aim of this cross-sectional study was to investigate the extent and correlating factors for differences between eGFR and both 24-h Ccr and CG in advanced-stage thoracic cancer patients. METHODS: eGFR, 24-h Ccr, and CG were calculated in 90 patients with thoracic malignancies. We evaluated how these three parameters are affected by clinical factors, including age, body surface area, serum creatinine concentration, and body mass index. RESULTS: eGFR and CG were significantly correlated with 24-h Ccr (r=0.64, p<0.001 and; r=0.67, p<0.001, respectively). However, the median value derived from eGFR was higher than the median 24-h Ccr and the CG value (74.0, 65.2, and 63.9mL/min, respectively). Age had a significant positive correlation with the differences between eGFR and both 24-h Ccr and CG value (r=0.30, p=0.005 and; r=0.47, p<0.001, respectively). The differences between eGFR and the other two parameters were significantly higher in older patients (age≥70 years) than in younger patients (age<70 years) (p=0.023, p<0.001, respectively). CONCLUSIONS: eGFR is likely to overestimate the renal function of elderly cancer patients. A modified equation for evaluating the renal function of Japanese older patients might be needed.

Thoracic Malignancies and Pulmonary Nodules in Patients under Evaluation for Transcatheter Aortic Valve Implantation (TAVI): Incidence, Follow Up and Possible Impact on Treatment Decision.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic valve stenosis who are not eligible for operative replacement and an alternative for those with high surgical risk. Due to high age and smoking history in a high proportion of TAVI patients, suspicious findings are frequently observed in pre-procedural chest computer tomography (CCT). METHODS: CCT scans of 484 consecutive patients undergoing TAVI were evaluated for incidentally discovered solitary pulmonary nodules (SPN). RESULTS: In the entire study population, SPN ≥ 5 mm were found in 87 patients (18%). These patients were compared to 150 patients who were incidentally collected from the 397 patients without SPN or with SPN < 5 mm (control group). After a median follow-up of 455 days, lung cancer was diagnosed in only two patients. Neither SPN ≥ 5 mm (p = 0.579) nor SPN > 8 mm (p = 0.328) were significant predictors of overall survival. CONCLUSIONS: Despite the high prevalence of SPNs in this single center TAVI cohort lung cancer incidence at midterm follow-up seems to be low. Thus, aggressive diagnostic approaches for incidentally discovered SPN during TAVI evaluation should not delay the treatment of aortic stenosis. Unless advanced thoracic malignancy is obvious, the well documented reduction of morbidity and mortality by TAVI outweighs potentially harmful delays regarding further diagnostics. Standard guideline-approved procedure for SPN can be safely performed after TAVI.

Desmoid-Type Fibromatosis of the Thorax: CT, MRI, and FDG PET Characteristics in a Large Series From a Tertiary Referral Center.

The purpose of this study was to describe the radiologic findings of computed tomography (CT), magnetic resonance (MR) imaging, and ¹8F-fluorodeoxy glucose positron emission tomography (FDG PET) in desmoid-type fibromatosis of the thorax. We retrospectively evaluated 47 consecutive patients with pathologically proven desmoid-type fibromatosis from January 2005 to March 2015. Patients underwent CT (n = 36) and/or MR (n = 32), and 13 patients also underwent FDG PET. Based on CT and MR, the sizes, locations, margins, contours, presence of surrounding fat, extra-compartment extension, bone involvement, and neurovascular involvement of the tumors were recorded. The attenuation, signal intensity, enhancement pattern, and presence of internal low signal band or signal void of the tumors were evaluated. Initial image findings were then compared between 2 groups of tumors: group 1 with recurrence or progression, and group 2 with no recurrence or stable without treatment. Median age at diagnosis of the tumors was 45 years, range 4 to 96, female-to-male ratio 1.8. Median tumor long diameter was 65 mm (range, 22-126 mm). The most common locations were chest wall (42.6%), followed by supraclavicular area, shoulder or axillary area, and mediastinum. The tumors had well-defined margins (83.0%), lobulated in contours (66.0%) surrounding fat (63.8%), extra-compartment extensions (42.6%), bone involvements (42.6%), and neurovascular involvements (27.7%). On CT, tumors had low attenuation (60.0%) with mild enhancement (median 24 HU, range 0-52). On MR, they showed iso-signal intensity (SI) (96.9%) on T1-weighted images (WI), and high SI (90.6%) on T2WI images, with strong (87.5%) and heterogeneous (96.9%) enhancement. Internal low signal bands (84.4%) and signal voids (68.8%) were noted. The median value of maxSUV was 3.1 (range, 2.0-7.3). In group 1 (n = 19, 40.4%), 13 patients suffered recurrence and 6 experienced progression. Group 2 (n = 28, 59.6%) consisted of 21 patients with no recurrence and 7 stable patients receiving no treatment. Partially ill-defined margins (OR, 0.167; 95% CI 0.029-0.943; P = 0.043) was the independent predictor for recurrence or progression of tumor. Knowledge of the radiological findings in desmoid-type fibromatosis on CT, MR, and FDG PET may help to improve diagnosis. Tumors with partially ill-defined margins have a tendency to recur or progress.

[Role of the Sonic Hedgehog pathway in thoracic cancers]. / Rôle de la voie Sonic Hedgehog dans les cancers thoraciques.

INTRODUCTION: Sonic Hedgehog (Shh) pathway is physiologically activated during embryogenesis and development. It plays a role in idiopathic lung fibrosis and is also activated in several solid cancers. STATE OF THE ART: Shh pathway is reactivated in thoracic cancers, as small cell lung carcinoma, non-small cell lung carcinoma and malignant pleural mesothelioma. Shh pathway is associated with cancer stem cells and seems to have a crucial role in tumor proliferation, aggressiveness and chemoresistance in these cancers. This review describes the activation mode of Shh pathway in thoracic cancers and its role in small cell lung carcinoma, non-small cell lung carcinoma and malignant pleural mesothelioma, using in vitro and in vivo models. Notably, data from literature show that inhibition of Shh pathway has an antitumor action and sensitizes to chemotherapy. PERSPECTIVES: These results incite to develop targeted therapies against Shh pathway in the treatment of thoracic cancers.

The use of strain tensor to estimate thoracic tumors deformation.

PURPOSE: Respiration-induced kinematics of thoracic tumors suggests a simple analogy with elasticity, where a strain tensor is used to characterize the volume of interests. The application of the biomechanical framework allows for the objective determination of tumor characteristics. METHODS: Four-dimensional computed tomography provides the snapshots of the patient's anatomy at the end of inspiration and expiration. Image registration was used to obtain the displacement vector fields and deformation fields, which allows one for the determination of the strain tensor. Its departure from the identity matrix gauges the departure of the medium from rigidity. The tensorial characteristic of each GTV voxel was determined and averaged. To this end, the standard Euclidean matrix norm as well as the Log-Euclidean norm were employed. Tensorial anisotropy was gauged with the fractional anisotropy measure which is based on the normalized variance of the tensors eigenvalues. Anisotropy was also evaluated with the geodesic distance in the Log-Euclidean framework of a given strain tensor to its closest isotropic counterpart. RESULTS: The averaged strain tensor was determined for each of the 15 retrospectively analyzed thoracic GTVs. The amplitude of GTV motion varied from 0.64 to 4.21 with the average of 1.20 cm. The GTV size ranged from 5.16 to 149.99 cc with the average of 43.19 cc. The tensorial analysis shows that deformation is inconsiderable and that the tensorial anisotropy is small. The Log-Euclidean distance of averaged strain tensors from the identity matrix ranged from 0.06 to 0.31 with the average of 0.19. The Frobenius distance from the identity matrix is similar and ranged from 0.06 to 0.35 with the average of 0.21. Their fractional anisotropy ranged from 0.02 to 0.12 with the average of 0.07. Their geodesic anisotropy ranged from 0.03 to 0.16 with the average of 0.09. These values also indicate insignificant deformation. CONCLUSIONS: The tensorial framework allows for direct measurements of tissue deformation. It goes beyond the evaluation of deformation via comparison of shapes. It is an independent and objective determination of tissue properties. This methodology can be used to determine possible changes in lung properties due to radiation therapy and possible toxicities.

Treatment of medically refractory cancer pain with a combination of intrathecal neuromodulation and neurosurgical ablation: case series and literature review.

OBJECTIVE: Up to 90% of patients with advanced cancer experience intractable pain. For these patients, oral analgesics are the mainstay of therapy, often augmented with intrathecal drug delivery. Neurosurgical ablative procedures have become less commonly used, though their efficacy has been well-established. Unfortunately, little is known about the safety of ablation in the context of previous neuromodulation. Therefore, the aim of this study is to present the results from a case series in which patients were treated successfully with a combination of intrathecal neuromodulation and neurosurgical ablation. DESIGN: Retrospective case series and literature review. SETTING: Three institutions with active cancer pain management programs in the United States. METHODS: All patients who underwent both neuroablative and neuromodulatory procedures for cancer pain were surveyed using the visual analog scale prior to the first procedure, before and after a second procedure, and at long-term follow-up. Based on initial and subsequent presentation, patients underwent intrathecal morphine pump placement, cordotomy, or midline myelotomy. RESULTS: Five patients (2 male, 3 female) with medically intractable pain (initial VAS = 10) were included in the series. Four subjects were initially treated with intrathecal analgesic neuromodulation, and 1 with midline myelotomy. Each patient experienced recurrence of pain (VAS ≥ 9) following the initial procedure, and was therefore treated with another modality (intrathecal, N = 1; midline myelotomy, N = 1; percutaneous radiofrequency cordotomy, N = 3), with significant long-term benefit (VAS 1-7). CONCLUSION: In cancer patients with medically intractable pain, intrathecal neuromodulation and neurosurgical ablation together may allow for more effective control of cancer pain.

Respiratory dynamic magnetic resonance imaging for determining aortic invasion of thoracic neoplasms.

OBJECTIVE: An accurate radiological method for evaluating the presence or extent of aortic invasion by thoracic cancer is essential in the preoperative setting. The aim of this study was to assess whether respiratory dynamic (RD) magnetic resonance imaging (MRI) more accurately detects aortic invasion of mediastinal tumors and lung cancer compared with conventional MRI or computed tomography (CT). METHODS: Twenty-six patients (19 male, 7 female; mean age, 63.08 ± 12.05 years) with inconclusive evidence of aortic invasion on chest CT underwent MRI (conventional and RD MRI using a balanced fast field echo sequence with a 1.5 T unit). The presence of aortic invasion was determined by fixation of the aorta and lack of synchronous motion during respiration on RD MRI. The results of CT and MRI were compared with the pathology results. The sensitivity, specificity, and accuracy of CT, conventional MRI, and conventional MRI with RD MRI were compared. RESULTS: Of 26 patients, 5 patients had invasion of the aorta. The sensitivity for determining aortic invasion was 100% using CT alone, conventional MRI alone, and conventional MRI with RD MRI. The specificity and accuracy for conventional MRI with RD MRI were significantly higher (71.4% and 76.9%, respectively) than for CT (28.5% and 42.3%, P < .05) or conventional MRI alone (33.3% and 46.1%, P < .05). CONCLUSIONS: RD MRI may improve the diagnostic accuracy of MRI by predicting aortic invasion use in preoperative staging.

Reconstrução da parede torácica após a ressecção de extensos tumores / Reconstruction of chest wall after resection of large tumors

INTRODUÇÃO: Nos estágios finais da reconstrução torácica, consequente a exéreses tumorais, são necessários procedimentos complexos e implantes. O que requer cuidados multidisciplinares, com a participação dos cirurgiões torácicos, plástico, radiologista e fisioterapeuta. O objetivo foi descrever as opções de reconstrução torácica após ressecção de neoplasia, realizado no Hospital Sarah Brasília. MÉTODO: Estudo retrospectivo de reconstrução torácica em tempo único, após excisão de tumor, fisioterapia respiratória com ventilação não invasiva e exercícios. RESULTADOS: Entre 2007 a 2012 foram operados 10 pacientes, sete homens e três mulheres; idade 10 a 31 anos; oito apresentavam tumores torácicos metastáticos (osteosarcoma, sinoviosarcoma, Fibrosarcoma epitelioide esclerosante e Rabdomiosarcoma) e dois originários da parede torácica (fibromatose e condrosarcoma). Observou-se boa evolução no pós-operatório imediato, com extubação ao final da cirurgia, retirada do dreno torácico entre 5° e 8° PO. As complicações foram: atelectasia (10%), recorrência tumoral (10%), e óbito em 3 (30%) casos . CONCLUSÃO: Foi possível a reconstrução torácica em tempo único utilizando tela de polipropileno, polimetilmetacrilato e retalhos musculares, com recuperação precoce da função pulmonar e baixo índice de complicações imediatas.

INTRODUCTION: Complex procedures and implants are required in the final stages of chest wall reconstruction after tumor excision. This process requires multidisciplinary care with participation from thoracic and plastic surgeons, a radiologist, and a physical therapist. The goal of this study was to describe the options for chest wall reconstruction after neoplasm resection at Hospital Sarah Brasilia. METHOD: A retrospective study of one-time chest wall reconstruction after tumor excision, respiratory physical therapy with noninvasive ventilation, and exercises was conducted. RESULTS: Between 2007 and 2012, 10 patients underwent surgery (seven men, three women; age range: 10-31 years); eight patients had metastatic thoracic tumors (e.g., osteosarcoma, synovial sarcoma, sclerosing epithelioid fibrosarcoma, and rhabdomyosarcoma) and two had tumors originating from the chest wall (fibromatosis and chondrosarcoma). The outcomes were good after the immediate postoperative period, with extubation occurring at the end of surgery and chest tube removal between the fifth and eighth postoperative day. Three cases (30%) involved complications of atelectasis (10%), tumor recurrence (10%), or death. CONCLUSION: One-time chest wall reconstruction using polypropylene mesh, polymethylmethacrylate, and muscle flaps was possible and was associated with early recovery of pulmonary function and a low rate of immediate complications.

[Surgical treatment of desmoid fibroma and sarcoma of the thoracic and abdominal wall].

The article analyses the 17-year (1993-2009 yy) experience of surgical treatment of desmoid fibroma and sarcoma of the thoracic and abdominal wall. 46 operations were analyzed. The radical excision according to the principles of surgical oncology remains the mainstay in the treatment of such patients. The combined technique with the use of polymeric implantates allows to cover large wall defects, thus extending the operability borders and being one of the main factors of the better treatment prognosis.

Deformation effect on SUVmax changes in thoracic tumors using 4-D PET/CT scan.

Respiratory motion blurs the standardized uptake value (SUV) and leads to a further signal reduction and changes in the SUV maxima. 4D PET can provide accurate tumor localization as a function of the respiratory phase in PET/CT imaging. We investigated thoracic tumor motion by respiratory 4D CT and assessed its deformation effect on the SUV changes in 4D PET imaging using clinical patient data. Twelve radiation oncology patients with thoracic cancer, including five lung cancer patients and seven esophageal cancer patients, were recruited to the present study. The 4D CT and PET image sets were acquired and reconstructed for 10 respiratory phases across the whole respiratory cycle. The optical flow method was applied to the 4D CT data to calculate the maximum displacements of the tumor motion in respiration. Our results show that increased tumor motion has a significant degree of association with the SUVmax loss for lung cancer. The results also show that the SUVmax loss has a higher correlation with tumors located at lower lobe of lung or at lower regions of esophagus.

Registration of sliding objects using direction dependent B-splines decomposition.

Sliding motion is a challenge for deformable image registration because it leads to discontinuities in the sought deformation. In this paper, we present a method to handle sliding motion using multiple B-spline transforms. The proposed method decomposes the sought deformation into sliding regions to allow discontinuities at their interfaces, but prevents unrealistic solutions by forcing those interfaces to match. The method was evaluated on 16 lung cancer patients against a single B-spline transform approach and a multi B-spline transforms approach without the sliding constraint at the interface. The target registration error (TRE) was significantly lower with the proposed method (TRE = 1.5 mm) than with the single B-spline approach (TRE = 3.7 mm) and was comparable to the multi B-spline approach without the sliding constraint (TRE = 1.4 mm). The proposed method was also more accurate along region interfaces, with 37% less gaps and overlaps when compared to the multi B-spline transforms without the sliding constraint.

Giant chondrosarcoma of chest wall.

Primary chest wall tumours are very rare. Chondrosarcoma is the most common tumour arising from the chest wall. We describe the occurrence of a slow-growing chondrosarcoma arising from the anterior chest wall in a 35-year-old male patient. The tumour was resected successfully and chest wall was reconstucted with prolene mesh and muscle flap. The patient was discharged uneventfully without any respiratory compromise. There was no recurrence after a three-year follow-up. Wide surgical resection with chest wall reconstruction appears to be the preferred treatment option for this rare tumour of the chest wall.

[The surgical treatment of thoracic tumors, invading the upper vena cava and the pulmonary trunk].

The actual problems of technique and tactics by surgical treatment of thoracic tumors, invading the upper vena cava and the pulmonary trunk are highlighted in the article. The thorough analysis of clinical cases is adduced.

[Role of conventional pulmonary function tests and cardiopulmonary exercise test in the prediction of postoperative cardiopulmonary complications in high risk thoracic cancer patients].

OBJECTIVE: To evaluate and compare the value of cardiopulmonary exercise test and conventional pulmonary function tests in the prediction of postoperative cardiopulmonary complications in high risk patients with chest malignant tumors. METHODS: From January 2006 to January 2009, 216 consecutive patients with thoracic malignant tumors underwent conventional pulmonary function tests (PFT, spirometry + DLCOsb for diffusion capacity) and cardiopulmonary exercise test (CPET) preoperatively. The correlation of postoperative cardiopulmonary complications with the parameters of PFT and CPET were retrospectively analyzed using Chi-square test, independent sample t-test and logistic regression analysis. The P value < 0.05 was considered as statistically significant. RESULTS: Of the 216 patients, 57 did not receive operation due to advanced stage diseases or poor cardiopulmonary function in most of them. The remaining 159 underwent different modes of operations. Thirty-six patients (22.6%) in this operated group had postoperative cardiopulmonary complications and 10 patients (6.3%) developed operation-related complications. Three patients (1.9%) died of the complications within 30 days postoperatively. The patients were stratified into groups based on V(O(2)) max/pred (≥ 65.0%, < 65.0%); V(O(2)) max×kg(-1)×min(-1) (≥ 20 ml, 15 - 19.9 ml, < 15 ml) and FEV1 (≥ 2.0 L, 1.2 - 1.99 L, < 1.2 L) according to the criteria in reported papers. There was statistically significant difference among these groups in the parameters (P < 0.05), the rates of postoperative cardiopulmonary complications were much higher in the groups with poor cardiopulmonary function (V(O(2)) max/pred < 65.0%; V(O(2)) max×kg(-1)×min(-1) < 15 ml or FEV1 < 1.2 L). It was shown by logistic regression analysis that postoperative cardiopulmonary complications were significantly correlated with age, associated diseases, poor results of PFT or CPET, operation modes and operation-related complications. CONCLUSIONS: FEV1 in spirometry, V(O(2)) max×kg(-1)×min(-1) and V(O(2)) max/pred in cardiopulmonary exercise test can be used to stratify the patients' cardiopulmonary function status and is correlated well with FEV1. V(O(2)) max×kg(-1)×min(-1) is the best parameter among these three parameters to predict the risk of postoperative cardiopulmonary complications in patients with chest malignant tumors and borderline cardiopulmonary function.

Factors influencing exercise performance in thoracic cancer.

BACKGROUND: Patients with incurable thoracic cancer often complain of a reduced ability to exercise, but the cause of this has been little studied. Thus, we have explored how various physiological and psychological factors relate to exercise performance in this group. METHODS: Inspiratory muscle strength, peripheral muscle power, lung function and mastery over breathlessness were assessed using sniff nasal inspiratory pressure, leg extensor power, simple spirometry and the mastery domain of the Chronic Respiratory Disease Questionnaire respectively. Exercise performance was assessed using the Incremental Shuttle Walking Test (ISWT) during which patients wore a K4 b(2) system permitting measurement of resting and breakpoint heart rate, minute ventilation (VE) and oxygen uptake (VO(2)). Relationships between ISWT distance and the four factors were determined using correlation and ß regression coefficients. RESULTS: Forty-one patients (21 male, mean (SD) age 64 (8) years) walked a median [IQR] of 320 [250-430] metres and reached a mean (SD) of 76 (10), 77 (25), and 48 (14) of their percent predicted maximum heart rate, VO(2), and VE respectively. Exercise performance was significantly associated only with inspiratory muscle strength (r = 0.42, P < 0.01) and peripheral muscle power (r = 0.39, P = 0.01). These factors were also significant determinants of exercise performance (ß coefficients [95%CI] 1.77 [0.53, 3.01] and 1.22 [0.31, 2.14] respectively). CONCLUSION: Of the factors examined, only inspiratory and peripheral muscle performance were significantly related to and predictive of exercise performance. Rehabilitation interventions which include inspiratory and peripheral muscle training are worth exploring further in this group of patients with thoracic cancer.

Endoscopic resection of intrathoracic tumors: experience with and long-term results for 26 patients.

OBJECT: Thoracoscopy may be used in place of thoracotomy to resect intrathoracic neoplasms such as paraspinal neurogenic tumors. Although these tumors are rare, they account for the majority of tumors arising in the posterior mediastinum. METHODS: A database was maintained of all patients undergoing thoracoscopic surgery for tumors. The authors analyzed the presenting symptoms, pathological diagnoses, and outcomes of 26 patients (7 males and 19 females, mean age 37.2 years) who were treated for intrathoracic tumors via thoracoscopy between January 1995 and May 2009. Fourteen patients were diagnosed incidentally (54%). Five patients (19%) presented with dyspnea or shortness of breath, 4 (15%) with pain, 1 (4%) with pneumonia, 1 (4%) with hoarseness, and 1 (4%) with Horner syndrome. RESULTS: Pathology demonstrated schwannomas in 20 patients (77%). Other diagnoses included ganglioneurofibroma, paraganglioma, epithelioid angiosarcoma, benign hemangioma, benign granular cell tumor, and infectious granuloma. One patient required conversion to open thoracotomy due to pleural scarring to the tumor. One underwent initial laminectomy due to intraspinal extension of the tumor. Gross-total resection was obtained in 25 cases (96%). The remaining patient underwent biopsy followed by radiation therapy. The mean surgical time was 2.5 hours, and the mean blood loss was 243 ml. The mean duration of chest tube insertion was 1.3 days, and the mean length of hospital stay was 3.0 days. Cases that were treated in the second half of the cohort were more often diagnosed incidentally, performed in less time, and had less blood loss than those in the first half of the cohort. There was 1 case of permanent treatment-related morbidity (mild Horner syndrome). All previously employed patients were able to return to work (mean clinical follow-up 43 months). There were no recurrences (mean imaging follow-up 54 months). CONCLUSIONS: Endoscopic transthoracic approaches can reduce approach-related soft-tissue morbidity and facilitate recovery by preserving the normal tissues of the chest wall, by avoiding rib retraction and muscle transection, and by reducing postoperative pain. This less invasive approach thus shortens hospital stay and recovery time.

Thermal characteristics of thermobrachytherapy surface applicators for treating chest wall recurrence.

The aim of this study was to investigate temperature and thermal dose distributions of thermobrachytherapy surface applicators (TBSAs) developed for concurrent or sequential high dose rate (HDR) brachytherapy and microwave hyperthermia treatment of chest wall recurrence and other superficial diseases. A steady-state thermodynamics model coupled with the fluid dynamics of a water bolus and electromagnetic radiation of the hyperthermia applicator is used to characterize the temperature distributions achievable with TBSAs in an elliptical phantom model of the human torso. Power deposited by 915 MHz conformal microwave array (CMA) applicators is used to assess the specific absorption rate (SAR) distributions of rectangular (500 cm(2)) and L-shaped (875 cm(2)) TBSAs. The SAR distribution in tissue and fluid flow distribution inside the dual-input dual-output (DIDO) water bolus are coupled to solve the steady-state temperature and thermal dose distributions of the rectangular TBSA (R-TBSA) for superficial tumor targets extending 10-15 mm beneath the skin surface. Thermal simulations are carried out for a range of bolus inlet temperature (T(b) = 38-43 degrees C), water flow rate (Q(b) = 2-4 L min(-1)) and tumor blood perfusion (omega(b) = 2-5 kg m(-3) s(-1)) to characterize their influence on thermal dosimetry. Steady-state SAR patterns of the R- and L-TBSA demonstrate the ability to produce conformal and localized power deposition inside the tumor target sparing surrounding normal tissues and nearby critical organs. Acceptably low variation in tissue surface cooling and surface temperature homogeneity was observed for the new DIDO bolus at a 2 L min(-1) water flow rate. Temperature depth profiles and thermal dose volume histograms indicate bolus inlet temperature (T(b)) to be the most influential factor on thermal dosimetry. A 42 degrees C water bolus was observed to be the optimal choice for superficial tumors extending 10-15 mm from the surface even under significant blood perfusion. Lower bolus temperature may be chosen to reduce the thermal enhancement ratio (TER) in the most sensitive skin where maximum radiation dose is delivered and to extend the thermal enhancement of radiation dose deeper. This computational study indicates that well-localized elevation of tumor target temperature to 40-44 degrees C can be accomplished by large surface-conforming TBSAs using appropriate selection of coupling bolus temperature.