Intralobar bronchopulmonary sequestra in adults over age 50: case series and review.

INTRODUCTION: Bronchopulmonary sequestration (BPS) is a rare congenital lung malformation, comprising only 0.15 to 6.4% of all cases of congenital lung malformation. It is characterized by an abnormal segment of bronchopulmonary tissue supplied by an aberrant systemic artery. Diagnostic delays are common in the adult patients since the symptoms often mimic other common diseases such as pneumonia, emphysema, and lung abscess. In 60% of cases, intralobar pulmonary sequestration (ILS) is typically diagnosed at age 20 or younger and is rarely found in adults older than 40 years. Since a heightened clinical suspicion needs to be maintained to entertain this diagnosis in the adult population, we conducted a retrospective chart review of all adult patients at our institution over age 50. MATERIALS AND METHODS: A retrospective chart review of all adult patients evaluated at our institution with a pathological proven diagnosis of BPS and subsequent surgical correction from January 1993 through December 2008 was conducted. Data obtained included demographics, clinical presentation, diagnostic procedures, location and origin of the lesion, operative therapy, histology of the surgical specimen, and postoperative complications. RESULTS: Three patients had undergone surgical correction for BPS. All three patients at our institution were female. The average age was 59 years with a range from 57 to 62 years. All three patients had symptoms preoperatively including intermittent cough and recurrent pneumonia. Radiologic evaluation revealed an enlarging lung mass in one patient and lesions suggestive of BPS in two of the patients. Two patients had a right lower lobe sequestration and one patient had a left lower lobe sequestration. All three patients underwent lower lobectomies without any significant postoperative complications. CONCLUSION: BPS in patients older than 50 is very rare. Persistent lower lobe consolidation in medial or posterior basal segments accompanied by an aberrant artery in adults should heighten suspicion for it. Recurrent pneumonias, cough, chest pain occur in the majority of patients. Surgical excision after correctly identifying the aberrant vessel is curative and also diagnostic in some cases.

Population-based differences in the outcome and presentation of lung cancer patients based upon racial, histologic, and economic factors in all lung patients and those with metastatic disease.

To investigate the interrelation between economic, marital, and known histopathologic/therapeutic prognostic factors in presentation and survival of patients with lung cancer in nine different ethnic groups. A retrospective review of the SEER database was conducted through the years 2007-2012. Population differences were assessed via chi-square testing. Multivariable analyses (MVA) were used to detect overall survival (OS) differences in the total population (TP, N = 153,027) and for those patients presenting with Stage IV (N = 70,968). Compared to Whites, Blacks were more likely to present with younger age, male sex, lower income, no insurance, single/widowed partnership, less squamous cell carcinomas, and advanced stage; and experience less definitive surgery, lower OS, and lung cancer-specific (LCSS) survival. White Hispanics presented with younger age, higher income, lower rates of insurance, single/widowed partnership status, advanced stage, more adenocarcinomas, and lower rates of definitive surgery, but no difference in OS and LCSS than Whites. In the TP and Stage IV populations, MVAs revealed that OS was better or equivalent to Whites for all other ethnic groups and was positively associated with insurance, marriage, and higher income. Blacks presented with more advanced disease and were more likely to succumb to lung cancer, but when adjusted for prognostic factors, they had a better OS in the TP compared to Whites. Disparities in income, marital status, and insurance rather than race affect OS of patients with lung cancer. Because of their presentation with advanced disease, Black and Hispanics are likely to have increased benefit from lung cancer screening.

The anatomy of the ribs and the sternum and their relationship to chest wall structure and function.

As with all parts of the body, the anatomy and physiology of the chest wall are intimately intertwined. To carry out the unique functions performed by the chest wall, the anatomic structures are formed precisely for maximal efficiency. This article focuses on the unique structural characteristics in the internal thoracic diameters. It discusses the specific anatomy of the ribs and costal cartilages, along with the sternum. How these parts interrelate through joints is described also. Finally, it describes the muscles that cause the motion in the chest wall.

Clinical role of F-18 fluorodeoxyglucose positron emission tomography imaging in patients with lung cancer and suspected malignant pleural effusion.

STUDY OBJECTIVES: The goals of this study were to determine the sensitivity, specificity, and predictive accuracy of F-18 fluorodeoxyglucose positron emission tomography (PET-FDG) imaging in detecting metastatic disease involvement of pleura and/or presence of malignant pleural effusion in patients with proven lung cancer. We wanted to compare efficacy of PET-FDG imaging to CT scanning in differentiating benign pleural effusion from malignant effusion and/or pleural involvement in patients with lung cancer. METHODS: We studied 35 patients with biopsy-proven lung cancer and abnormal findings on CT scanning for presence of pleural effusion (n = 34) and/or pleural thickening or nodular involvement (n = 4). The results of positron emission tomography and CT scanning were compared to pleural cytology (n = 31), histologic findings of pleural biopsy (n = 3), and/or clinical follow-up (n = 3) for at least 1 year for presence or absence of malignant pleural effusion. RESULTS: PET-FDG imaging correctly detected the presence of malignant pleural effusion and malignant pleural involvement in 16 of 18 patients and excluded malignant effusion or pleural metastatic involvement in 16 of 17 patients (sensitivity, specificity, and accuracy of 88.8%, 94.1%, and 91.4% respectively). CONCLUSION: PET-FDG imaging is a highly accurate and reliable noninvasive test to differentiate malignant from benign pleural effusion and/or pleural involvement in patients with lung cancer and findings of suspected malignant pleural effusion on CT scanning.

Current concepts in the management and reconstruction of the dehisced median sternotomy.

This review will delineate the underlying conditions that predispose patients to deep mediastinal infection and sternal dehiscence, discuss the principles of thorough debridement and preparation of the wound, and assess the appropriate options available for successful reconstruction.

Volume Modulated Arc Therapy (VMAT) for pulmonary Stereotactic Body Radiotherapy (SBRT) in patients with lesions in close approximation to the chest wall.

PURPOSE: Chest wall pain and discomfort has been recognized as a significant late effect of radiation therapy in historical and modern treatment models. Stereotactic Body Radiotherapy (SBRT) is becoming an important treatment tool in oncology care for patients with intrathoracic lesions. For lesions in close approximation to the chest wall with motion management, SBRT techniques can deliver high dose to the chest wall. As an unintended target of consequence, there is possibility of imposing significant chest wall pain and discomfort as a late effect of therapy. The purpose of this paper is to evaluate the potential role of Volume Modulated Arc Therapy (VMAT) technologies in decreasing chest wall dose in SBRT treatment of pulmonary lesions in close approximation to the chest wall. MATERIALS AND METHODS: Ten patients with pulmonary lesions of various sizes and tomography in close approximation to the chest wall were selected for retrospective review. All volumes including tumor target, chest wall, ribs, and lung were contoured with maximal intensity projection maps and four-dimensional computer tomography planning. Radiation therapy planning consisted of static techniques including Intensity Modulated Radiation Therapy compared to VMAT therapy to a dose of 60 Gy in 12 Gy fraction dose. Dose volume histogram to rib, chest wall, and lung were compared between plans with statistical analysis. RESULTS: In all patients, dose and volume were improved to ribs and chest wall using VMAT technologies compared to static field techniques. On average, volume receiving 30 Gy to the chest wall was improved by 74%; the ribs by 60%. In only one patient did the VMAT treatment technique increase pulmonary volume receiving 20 Gy (V20). CONCLUSIONS: VMAT technology has potential of limiting radiation dose to sensitive chest wall regions in patients with lesions in close approximation to this structure. This would also have potential value to lesions treated with SBRT in other body regions where targets abut critical structures.