Significance of internal mammary lymph nodes in patients after mastectomy with tissue-expander reconstruction: a case-control study.

AIM: To retrospectively assess the frequency of internal mammary lymph nodes (IMNs) in patients after mastectomy and tissue-expander reconstruction. MATERIALS AND METHODS: Statistical analysis was performed for all available data in patients with mastectomy and tissue-expander reconstruction from 2004-2007 (study group). The data were compared with that of a control population with mastectomy who did not have reconstruction (control group). Patients with recurrent breast cancers, previous breast reconstruction, surgeries performed at outside hospitals, no available pre- or postoperative computed tomography (CT) or magnetic resonance imaging (MRI) data, or inadequate imaging follow-up were excluded. RESULTS: There were eight patients in the study group (median age 50.5 years, seven breast cancers), and eight patients in the control group (median age 52 years, seven breast cancers). No patients had IMNs on their preoperative imaging examinations. New IMNs were present in postoperative imaging in seven of eight patients (7/8, 87.5%) in the study group. All of them were stable or decreased in size on subsequent imaging examinations. None of the patients in the control group had IMNs (0/8). CONCLUSION: IMNs are common on imaging after mastectomy and tissue-expander placement. The IMNs decreased or remained stable on follow-up imaging and may represent reactive nodes.

Needle localization of peripheral lung nodules for video-assisted thoracoscopic surgery.

Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by the surgeon, we have placed a Kopans hook wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n = 4), nodules too small for PNAB (n = 2), nodules inaccessible to PNAB (n = 3), and planned resection of a known peripheral tumor less than 1 cm (n = 1). The localization procedure was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm deep the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans hook wire. Patients were sent directly to the operating room in a dependent position. All ten nodules were successfully resected, including hamartoma (n = 1), carcinoid tumors (n = 2), granulomas (n = 3), adenocarcinoma (n = 1), fibrosis (n = 1), benign metastasizing leiomyoma (n = 1), and lymphoma (n = 1). In two patients, the wire slipped out of the lung. Small focal pneumothoraces developed in five patients. There were no major complications. This procedure can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic purposes or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.

Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection).

Twenty-one patients underwent combined therapy (irradiation and radical resection) for a Pancoast tumor at the Massachusetts General Hospital between 1976 and 1985. All patients underwent en bloc removal of the apical chest wall and underlying lung. In addition four patients required subclavian artery resection, and in five patients a portion of the vertebral body was resected. There were three operative deaths. Median survival was 24 months and actuarial survival rate was 55% at 3 years and 27% at 5 years. Long-term palliation of pain was achieved in 72% of the patients. Involvement of the subclavian artery, vertebral body, or rib did not preclude long-term survival. Computed tomographic scanning in these patients is often indeterminate regarding invasion of chest wall structures but is more helpful than plain films alone. When compared to recent series in which irradiation alone was used, the combined approach appears to produce better results.

Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery.

Bilateral volume reduction surgery (VRS) improves lung function for selected patients with emphysema. However, predictors of outcome are not well defined. We reviewed the preoperative characteristics of the first 47 consecutive patients who underwent bilateral VRS at the Massachusetts General Hospital in order to define potential predictors of unacceptable outcome. Preoperative data included spirometry, plethysmography, diffusion of carbon monoxide (Dco), maximum inspiratory pressure (MIP), maximum expiratory pressure, resting arterial blood gases (ABG), cardiopulmonary exercise testing with ABG and lactate sampling, and radionuclide ventriculography. Prepulmonary and postpulmonary rehabilitation 6-min walk tets (6MWT), and preoperative chest CT scans were also obtained. Twenty-two subjects were male and 17 of the subjects were on the lung transplant list. Patient characteristics included age of 60.5 +/- 7.5 years, FEV1 of 0.67 +/- 0.20 L, total lung capacity of 7.56 +/- 1.7 L, Dco of 7.40 +/- 4.1 mL/min/mm Hg, and PaCO2 of 41.6 +/- 6.4 mm Hg (mean +/- SD). The FEV1, vital capacity, MIP, resting room air PaCO2, prepulmonary and postpulmonary rehabilitation 6MWT, and PaCO2 at maximum oxygen consumption correlated with length of hospitalization (p < 0.05). Based on analysis of 41 of 47 patients for whom there were complete data, the inability to walk more than 200 m on the 6MWT before or after preoperative pulmonary rehabilitation, and resting PaCO2 > or = 45 mm Hg were the best predictors of an unacceptable outcome. If either of these characteristics was present, six of 16 vs zero of 25 died (Fisher's Exact Test, p = 0.0025, one-tailed) and 11 of 16 vs four of 25 had hospital courses > 21 days (p < 0.002). Both the 6MWT < 200 m and resting PaCO2 > or = 45 mm Hg alone correlated with death (p = 0.004 and p = 0.012, respectively) and the resting PaCO2 > or = 45 mm Hg correlated with hospital days > 21 (p = 0.0002). In conclusion, the data suggest that the inability to walk at least 200 m in 6 min before or after pulmonary rehabilitation and a resting room air PaCO2 > or = 45 mm Hg are excellent preoperative predictors of unacceptable postoperative outcomes.

Respiratory syncytial virus-associated infections in adult recipients of solid organ transplants.

BACKGROUND: Although respiratory syncytial virus (RSV) infection is known to cause severe pulmonary infections in bone marrow transplant recipients, less is known concerning its clinical course, diagnosis, and treatment in solid organ transplant recipients. METHODS: We have conducted a retrospective review of seven cases of RSV infection in adult recipients of solid organ transplants. Four patients received lungs, two received kidneys, and one received a heart. RESULTS: The most common presenting complaints were dyspnea (100%), cough (86%), and purulent sputum (57%). Physical findings included fever (43%), rales (100%), and wheezing (29%). Admission studies were significant for leukocytosis (29%), a left shift in the white blood cell differential (86%), and hypoxemia (mean PaO2 = 64). Chest radiographs were unchanged in 29% and showed infiltrates that were bilateral in 43% and unilateral in 29%. Pulmonary function tests in lung transplant recipients showed a mean fall in forced expiratory volume in 1 second of 26% and a fall in diffusion capacity for carbon monoxide of 24%. Five patients were treated with aerosolized ribavirin. Adverse events associated with treatment included wheezing (80%) and mild dyspnea (20%). The conditions of three of five treated patients were believed by their physicians to have improved 7 days after the initiation of therapy. One of the five treated patients died, and both untreated patients survived. CONCLUSIONS: RSV infection in this population has an extremely variable severity and clinical course, usually dominated by lower respiratory symptoms and obstructive airway disease. Ribavirin therapy is well tolerated, but its efficacy remains unknown.

Postpneumonectomy syndrome: diagnosis, management, and results.

Airway obstruction may be caused by extreme mediastinal shift and rotation after right pneumonectomy or after left pneumonectomy in the presence of a right aortic arch. Eleven adults (aged 18 to 58 years) with severe symptoms were treated surgically between 5 months to 17 years after pneumonectomy (7 right, 4 left). An initial patient with only one functional lobe was treated unsuccessfully by aortic division and bypass graft. Ten underwent mediastinal repositioning. After two recurrences prostheses were used to maintain mediastinal position. Five patients who underwent such repositioning are doing well from 5 months to more than 5 years later. One died 1 month after operation probably of pulmonary embolism. One who showed residual airway collapse after operation has some recurrent obstruction. Three other patients who showed severe malacic obstruction of the airway after mediastinal repositioning variously underwent aortic division with bypass graft and tracheal and bronchial resection. One is well almost 6 years later. Two died postoperatively. Occurrence of the syndrome is unpredictable. Where malacic changes have not occurred, mediastinal repositioning may reasonably be expected to correct obstruction. Optimal treatment for concurrent severely malacic airways is unclear.

Imaging of lung transplantation.

Lung transplantation is an accepted treatment for a large number of end-stage pulmonary diseases. There are several complications that pertain specifically to lung transplant recipients, including airway ischemia, reperfusion edema, infections, acute rejection, obliterative bronchiolitis, and other postoperative problems relating to surgical technique and immuno-suppressive therapy. Imaging procedures play an important role in the diagnosis and management of these problems.

Relationship between pulmonary artery diameter at computed tomography and pulmonary artery pressures at right-sided heart catheterization. Massachusetts General Hospital Lung Transplantation Program.

RATIONALE AND OBJECTIVES: The purpose of the study was to determine the relationship between pulmonary artery (PA) size at computed tomography (CT) and PA pressures, to develop a noninvasive CT method of PA pressure measurement, and to determine a PA diameter that can enable differentiation of normal subjects from those with pulmonary hypertension. METHODS: PA vessel diameters in 55 candidates for lung and heart-lung transplantation were measured at CT and correlated with PA pressures with both linear and stepwise multiple regression. The multiple regression equations were then tested prospectively in 35 pretransplantation patients. RESULTS: Combined main and left main PA cross-sectional area corrected for body surface area showed the best correlation with mean PA pressure (r = .87). The multiple regression equations helped predict mean PA pressure within 5 mm Hg in 50% of patients with chronic lung disease and in only 8% of patients with pulmonary vascular disease. CONCLUSION: There was a very good correlation between main and left main PA size and mean PA pressure. At present, however, CT has not demonstrated sufficient accuracy to be used clinically.

The bronchi: an imaging perspective.

Recent advances in high-resolution computed tomography (HRCT), inspiratory/expiratory CT staining of the lung, helical multiplanar reconstruction CT, and a broadened experience in magnetic resonance imaging of bronchial pathological conditions provide additional diagnostic information about the bronchi. This article reviews diffuse and focal lesions involving the large bronchi and small airways of the lung.

Postpneumonectomy syndrome: another twist.

This report describes the clinical, radiographic, and surgical findings in a patient with a rare postoperative complication, the postpneumonectomy syndrome. To our knowledge, it is the first reported case of postpneumonectomy syndrome after left pneumonectomy in a patient with a left-sided aortic arch.

Differentiation of bronchogenic carcinoma from postobstructive pneumonitis by magnetic resonance imaging: histopathologic correlation.

Obstructive pneumonitis frequently occurs distal to hilar bronchogenic carcinomas or in lung adjacent to peripheral tumors. The article evaluates the role of MRI in the differentiation of tumor from pneumonitis. Twelve patients underwent MRI of the thorax before surgery. T1-weighted (SE 310/20) and T2-weighted (SE 2000/60-120) images were obtained through the tumor and presumed areas of pneumonitis. Five histologic types of pneumonitis were identified on pathologic examination of the 12 specimens. Cholesterol pneumonitis, found in 7 patients, was the most common type. Organizing pneumonitis, bronchiectasis with mucus plugs, atelectasis, and abscess were found in 3, 4, 2, and 1 patients, respectively. MRI was able to differentiate tumor from pneumonitis in 5 of 6 patients with a hilar mass and in 5 of 6 patients with a peripheral tumor. This was achieved by a visual difference in signal intensity on heavily T2-weighted (SE 2000/120) images. Cholesterol pneumonitis and bronchiectasis with mucus plugs were always hyperintense relative to tumor, and organizing pneumonitis and atelectasis were isointense and indistinguishable from tumor. MRI can differentiate tumor from pneumonitis provided that pneumonitis is of the cholesterol type or if there are mucus plugs in the collapsed lung.

The impact of group B streptococcus prophylaxis on late-onset neonatal infections.

OBJECTIVE: To determine trends in late-onset neonatal infections and risk factors for ampicillin/penicillin-resistant microorganisms. STUDY DESIGN: Data on 584 infants with positive blood, urine or cerebrospinal fluid cultures for bacteria or fungi at 8-30 days of age from 1990 to 2007 were examined and divided into three epochs, based on intrapartum antibiotic prophylactic (IAP) practices. Pathogens and antibiotic resistance were compared among epochs. RESULT: The number of candidal infections increased over time for the entire population (P=0.006). There was an increased incidence of Gram-negative (P=0.009) and candidal infections (P=0.014) among very low-birthweight infants. Only Escherichia coli infections showed increasing ampicillin resistance over epochs (P=0.006). In regression analysis, ampicillin/penicillin resistance increased with IAP use (odds ratio 2.05). CONCLUSION: Changing microorganisms and increasing antibiotic resistance in late-onset neonatal infections are likely multifactorial but are increased with IAP use, which may identify an at-risk population. Increasing Candida infections require further investigation.

The impact of group B Streptococcus prophylaxis on early onset neonatal infections.

OBJECTIVE: To determine if changes have occurred in the causative pathogens and/or antibiotic susceptibility profiles in early onset neonatal infections since initiation of group B Streptococcus (GBS) prophylaxis and to determine risk factors for ampicillin/penicillin resistant microorganisms. STUDY DESIGN: Data on 220 infants with positive blood, urine, or cerebrospinal fluid cultures for bacteria or fungi at ≤seven days of age from 1990-2007 were examined and divided into three epochs, based on intrapartum antibiotic prophylactic (IAP) practices. Pathogens and antibiotic resistance were compared among epochs. RESULTS: A significant decrease in the incidence of GBS infections occurred over time, with no change in the incidence of other pathogens or the emergence of antibiotic resistance, including the very low-birthweight population. In regression analysis, ampicillin resistance was associated with male gender (OR 3.096). CONCLUSIONS: No emergence of antibiotic resistant pathogens was found following IAP use. Changing microorganisms and increasing antibiotic resistance found in prior studies are likely multifactorial. Further study is needed to continue to reduce the rates of common early onset pathogens.

Relationship between cerebrovascular dysautoregulation and arterial blood pressure in the premature infant.

OBJECTIVE: To evaluate cerebrovascular autoregulation as a function of arterial blood pressure (ABP) in the critically ill, premature infant. STUDY DESIGN: A prospective observational pilot study was conducted in two tertiary care Neonatal Intensive-Care Units. Premature infants (n=23, ≤30 weeks estimated gestational age with invasive ABP monitoring) were enrolled and received routine care while undergoing continuous autoregulation monitoring, using the cerebral oximetry index (COx). The COx is a moving, linear correlation coefficient between cortical reflectance oximetry and ABP. COx values were stratified as a function of ABP for individual subject recordings and for the cohort. RESULT: The mean duration of autoregulation monitoring was 3.2 days (median: 2.97, range: 0.61-3.99). A total of 10 of 23 (43%) developed intraventricular hemorrhage and 1 of 23 (4%) developed periventricular leukomalacia by head ultrasound. No association was found between neurologic injury and percentage of the monitoring periods with autoregulation impairment (defined as COx>0.5). Lower ABP was associated with dysautoregulation (higher COx values, P<0.01). The percentage of time with impaired autoregulation was greater with lower ABP (P=0.013, Spearman r=0.51). CONCLUSION: All infants studied had periods with intact and periods with impaired cerebrovascular autoregulation, measured with the COx. Low ABP was associated with impaired autoregulation.

CT findings in localized fibrous mesothelioma of the pleural fissure.

Three patients with fibrous mesothelioma of a pleural fissure are presented. Although the appearance of lung surrounding a mass is typical of an intraparenchymal lesion, attention to the position of the mass in relationship to the fissure may suggest the possibility of a pleural mass. Localized fibrous mesothelioma should be included in the differential diagnosis of an apparent solitary lung mass located in the region of a fissure.

Pseudoprominent aorta: radiographic findings and CT correlation.

The presence of a persistent left-sided superior vena cava (LSVC) in the absence of a right-sided superior vena cava (RSVC) may be suspected on a posteroanterior (PA) chest radiograph because of a prominent-appearing ascending aorta, which results from the absence of the RSVC. In the absence of an RSVC, the right upper lobe abuts and outlines the course of the ascending aorta, allowing better demonstration of its profile. This report describes a patient with this finding on a PA chest radiograph. Computed tomographic correlation is presented.

High-resolution CT of the lungs.

High-resolution computed tomography (CT) of the lung provides detailed visualization of the lung parenchyma. The technique involves the use of thin-section axial tomography. High-resolution CT can facilitate the diagnosis of certain pulmonary processes. It is useful in differentiating similar patterns of abnormalities seen on chest radiographs, such as those seen in lymphangitic carcinomatosis and sarcoidosis, and in delineating the extent of co-morbid lung diseases, such as emphysema and asbestosis. In some chronic processes such as idiopathic pulmonary fibrosis, high-resolution CT can be used for biopsy of areas of active inflammation, thus increasing the diagnostic yield. As clinicians and radiologists become more familiar with high-resolution CT, it is likely that its role in the diagnosis and assessment of lung disease will increase.

Pseudometastases secondary to film static artifact.

Low density areas in the liver on computed tomography (CT) may be produced by cysts, abscesses, or tumors. A case is reported in which film static resulted in multiple focal low density areas in the liver in a patient with lymphoma. This potential pitfall in CT interpretation can be avoided by taking proper measures to avoid film artifacts and by reviewing all cases on the cathode ray tube (CRT) display as well as the hard copy film.

MR imaging of superior sulcus carcinoma.

Magnetic resonance (MR) imaging was performed in 10 patients with biopsy proven superior sulcus carcinomas to determine the extent of local tumor invasion. Chest wall invasion or extension into the base of the neck was demonstrated in five patients. This finding was facilitated by the contrast between the bright signal intensity of tumor and the low signal intensity of muscle on T2-weighted images. In three patients, MR clearly depicted direct invasion of the mediastinum. This finding was facilitated on the MR image because of inherent contrast between the mediastinal fat and tumor. Coronal and sagittal images showed the relationship of tumor to the subclavian artery and brachial plexus in all cases. Encasement of the artery was confirmed in two cases and brachial plexus involvement in three. However, MR failed to detect evidence of rib destruction in five patients in whom rib involvement was confirmed by other studies. Magnetic resonance appears to be a useful imaging modality in determining the extent of local disease and, therefore, the selection of patients for surgical resection. Multiplanar imaging and contrast between tumor and muscle and tumor and fat allow assessment of invasion of the mediastinum and base of the neck, subclavian artery, and brachial plexus.

The costal cartilages in health and disease.

The costal margin, although imaged in many routine radiologic examinations, has been ignored in the radiology literature. Calcification of the costal cartilages follows gender-related patterns and is generally not evident radiographically until after the age of 30 years. Diffuse enlargement of the costochondral junctions may alert the astute observer to the presence of systemic diseases such as acromegaly and rickets. Focal masses have a subtle appearance on plain radiographs and may be better imaged with computed tomography (CT) or magnetic resonance imaging. Chondrosarcoma of the costal margin typically appears as an expansile mass with coarse calcifications and an associated soft-tissue mass. Radiographic and CT features of costochondritis include chondral enlargement or destruction, low-attenuation cartilage at CT, associated soft-tissue swelling, and localized peripheral cartilage calcification. There appears to be an association between heavy premature costal cartilage calcification and certain systemic conditions, such as malignancy, autoimmune disorders, chronic renal failure, and thyroid disease, particularly Graves disease.