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Seminars in Ultrasound, CT, and MR Dec 2017Necrosis of the fat adjacent to the heart, referred to as pericardial fat necrosis, epipericardial fat necrosis, and mediastinal fat necrosis, is a rare, self-limited... (Review)
Review
Necrosis of the fat adjacent to the heart, referred to as pericardial fat necrosis, epipericardial fat necrosis, and mediastinal fat necrosis, is a rare, self-limited condition. It presents as a sudden onset of severe chest pain that mimics symptoms of pulmonary embolism and acute coronary syndrome. Computed tomography (CT) findings are quite typical and consist of a round- or oval-shaped mass-like lesion containing soft tissue and fat density components in the cardiophrenic space. Lack of familiarity with this condition has led in the past to surgical interventions to remove the mass-like mediastinal fat necrosis. Until the early 2000s, surgical removal of these lesions was deemed the treatment of choice, to exclude a neoplasm. However, the observation that the CT findings of the paracardiac mass resemble fat necrosis seen in other parts of the body and its involution on follow-up CT has led to the realization that the process is a benign and self-limiting one. A dramatic shift in the paradigm of treatment has ensued and surgical treatment is no longer advocated. Awareness of this condition is, therefore, vital so as to diagnose it accurately and avoid unnecessary future surgical interventions.
Topics: Acute Coronary Syndrome; Acute Pain; Aged; Chest Pain; Diagnosis, Differential; Fat Necrosis; Female; Humans; Magnetic Resonance Imaging; Male; Mediastinal Diseases; Middle Aged; Pericardium; Prognosis; Tomography, X-Ray Computed
PubMed: 29179902
DOI: 10.1053/j.sult.2017.08.003 -
Radiotherapy and Oncology : Journal of... Oct 2022Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and...
BACKGROUND AND PURPOSE
Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and optimized a traffic light protocol (TLP) used in lung cancer patients to identify patients requiring treatment adaptation.
MATERIALS AND METHODS
First, CBCT review requests of 243 lung cancer patients were retrospectively analyzed and divided into 6 pre-defined categories. Frequencies and follow-up actions were scored. Based on these results, the TLP was optimized and evaluated in the same way on 230 patients treated in 2018.
RESULTS
In the retrospective study, a total of 543 CBCT review requests were created during treatment in 193/243 patients due to changed anatomy of lung (24%), change of tumor volume (24%), review of match (18%), shift of the mediastinum (15%), shift of tumor (15%) and other (4%). The majority of requests (474, 87%) did not require further action. In 6% an adjustment of the match criteria sufficed; in 7% treatment plan adaptation was required. Plan adaptation was frequently seen in the categories changed anatomy of lung, change of tumor volume and shift of tumor outside the PTV. Shift of mediastinum outside PRV and shift of GTV outside CTV (but inside PTV) never required plan adaptation and were omitted to optimize the TLP, which reduced the CBCT review requests by 23%.
CONCLUSIONS
The original TLP selected patients that required a treatment adaptation, but with a high false positive rate. The optimized TLP reduced the amount of CBCT review requests, while still correctly identifying patients requiring adaptation.
Topics: Humans; Radiotherapy, Image-Guided; Retrospective Studies; Radiotherapy Planning, Computer-Assisted; Workflow; Lung Neoplasms; Cone-Beam Computed Tomography; Radiotherapy Dosage; Radiotherapy, Intensity-Modulated
PubMed: 36067908
DOI: 10.1016/j.radonc.2022.08.030 -
Paediatric Respiratory Reviews Mar 2021To develop a clinical guideline for structured assessment and uniform reporting of congenital lung abnormalities (CLA) on Computed Tomography (CT)-scans. (Review)
Review
OBJECTIVES
To develop a clinical guideline for structured assessment and uniform reporting of congenital lung abnormalities (CLA) on Computed Tomography (CT)-scans.
MATERIALS AND METHODS
A systematic literature search was conducted for articles describing CT-scan abnormalities of congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE) and bronchogenic cyst (BC). A structured report using objective features of CLA was developed after consensus between a pediatric pulmonologist, radiologist and surgeon.
RESULTS
Of 1581 articles identified, 158 remained after title-abstract screening by two independent reviewers. After assessing full-texts, we included 28 retrospective cohort-studies. Air-containing cysts and soft tissue masses are described in both CPAM and BPS while anomalous arterial blood supply is only found in BPS. Perilesional low-attenuation areas, atelectasis and mediastinal shift may be found in all aforementioned abnormalities and can also be seen in CLE as a cause of a hyperinflated lobe. We have developed a structured report, subdivided into five sections: Location & Extent, Airway, Lesion, Vascularization and Surrounding tissue.
CONCLUSIONS
CT-imaging findings in CLA are broad and nomenclature is variable. Overlap is seen between and within abnormalities, possibly due to definitions often being based on pathological findings, which is an unsuitable approach for CT imaging. We propose a structured assessment of CLA using objective radiological features and uniform nomenclature to improve reporting.
Topics: Child; Cystic Adenomatoid Malformation of Lung, Congenital; Humans; Lung; Pulmonary Atelectasis; Respiratory System Abnormalities; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 32178987
DOI: 10.1016/j.prrv.2019.12.004 -
Journal of Thoracic Disease Jan 2023
PubMed: 36794129
DOI: 10.21037/jtd-22-1420 -
Pneumologie (Stuttgart, Germany) Jun 2020An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis.
HISTORY
An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis.
INVESTIGATIONS AND DIAGNOSIS
The ECG showed 2nd degree Mobitz atrio-ventricular block. The chest x-ray and computerized tomography identified a shift of the mediastinum and the heart to the left. The left lung was completely destroyed whilst the right lung was enlarged and crossed the midline. Pulmonary function tests revealed a moderate restrictive ventilation disorder. The diagnosis of autopneumonectomy was based on patient history together with radiological findings.
TREATMENT AND COURSE
A pacemaker was implanted with two stimulation electrodes via a left cephalic venous cutdown. A carotid endarterectomy was also performed without any complication.
CONCLUSION
After autopneumonectomy, postpneumonectomy like syndrome may occur in very rare cases, whereupon operative treatment is mandatory. Any respiratory infections should be treated with antibiotics. Pacemaker electrode placement via the subclavian vein is contraindicated due to the risk of a catastrophic pneumothorax.
Topics: Aged, 80 and over; Carotid Stenosis; Endarterectomy, Carotid; Female; Hemoptysis; Humans; Lung; Lung Diseases; Pacemaker, Artificial; Pneumonectomy; Respiratory Function Tests; Subclavian Vein; Treatment Outcome; Venous Cutdown
PubMed: 32557508
DOI: 10.1055/a-1148-8770 -
Fetal and Pediatric Pathology Oct 2022One-third of fetal soft tissue tumors are malignant and include congenital fibrosarcoma (CF). We report two fetal CFs arising in the posterior mediastinum. In case 1,...
One-third of fetal soft tissue tumors are malignant and include congenital fibrosarcoma (CF). We report two fetal CFs arising in the posterior mediastinum. In case 1, the CF resulted in a mediastinal shift, extensive infiltration of the tumor around adjacent structures, pulmonary hypoplasia, pleural effusion, and rapid growth. The pregnancy was terminated. Case 2 had multiple intrathoracic masses, thoracic hypoplasia, pleural effusion, and fetal death. Both were diagnosed as fibrosarcoma at fetopsy. Although congenital CF tends to be locally aggressive with a low metastatic rate, it tends to grow rapidly and the tumor location can affect fetal survival. In Case 1, the tumor demonstrated locally aggressive behavior whereas multiple distant metastases such as lung, liver, adrenals, and left eye were detected in Case 2. The tumor was directly responsible for intrauterine fetal demise in the second case.
Topics: Female; Fetus; Fibrosarcoma; Humans; Mediastinum; Pleural Effusion; Pregnancy; Soft Tissue Neoplasms
PubMed: 34622726
DOI: 10.1080/15513815.2021.1988010 -
Praxis Nov 2022Pulmonary Opacities - What Lies Beneath? Abstract: Pulmonary opacities are among the most common findings that general practitioners and internists have to interpret in...
Pulmonary Opacities - What Lies Beneath? Abstract: Pulmonary opacities are among the most common findings that general practitioners and internists have to interpret in everyday life. Conventional chest x-rays are still important, but computed tomograms often provide additional information. Patient history, clinical examination but also additionally collected laboratory findings are important prerequisites for the interpretation of imaging studies. Likewise, radiological patterns should be recognized and correctly described. The density, distribution to one or both sides, basal or apical, unifocal or multifocal, also the involvement of the interstitial tissue, bronchioles, the alveolar space and pleura can provide decisive differential diagnostic information. Space-occupying or shrinking processes may be suspected on behalf of the course of pleural lines. Tumours may be differentiated from shrinking lung volume as seen in atelectasis by shift of the mediastinum or the shape of pleural lines. Occasionally control images can support the interpretation of the radiological results.
Topics: Humans; Pleura; Diagnostic Imaging
PubMed: 36415984
DOI: 10.1024/1661-8157/a003932 -
Journal of Thoracic Disease Aug 2018The role of radiation therapy (RT) in thymic malignancies has long been subject to considerable controversy. The main role for RT is in the setting of adjuvant therapy... (Review)
Review
The role of radiation therapy (RT) in thymic malignancies has long been subject to considerable controversy. The main role for RT is in the setting of adjuvant therapy after surgical tumor resection, especially in advanced or incompletely resected cases. However, recent studies with larger patient numbers and cleaner study populations than previous studies have indicated a potentially clearer than previously assumed benefit after post-operative RT (PORT) even for completely resected patients with earlier stages of thymoma. In marginally resectable patients RT may be used in combination with neoadjuvant chemotherapy to shrink tumors and thereby potentially enable resection. In unresectable patients concurrent or sequential chemotherapy and RT can be employed as the definitive nonsurgical approach. The tendency of thymic tumors to recur in the pleural space highlights the necessity for more effective approaches to identify and treat high risk patients. Experiences in other pleural malignancies may pave the way to novel treatment modalities, for example pleural IMRT. The role of these techniques in thymic malignancies has yet to be determined and is not advisable at the current time outside of a clinical study. As the disease often takes an indolent course with excellent long-term local control (LC) and survival, late toxicities related to radiation of the mediastinum and adjacent organs at risk (OARs) have to be taken into consideration and may jeopardize the benefit patients experience from RT, especially in younger patients with a long-anticipated life expectancy. Radiation techniques, such as intensity modulated RT (IMRT) and proton beam therapy (PBT), have substantially reduced the exposure of OARs to ionizing radiation which is expected to translate into reduced long-term toxicities. Hence, the risk-benefit ratio of RT in early stage thymoma patients may be shifted favorably.
PubMed: 30206499
DOI: 10.21037/jtd.2018.01.154 -
Translational Pediatrics Apr 2024In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development... (Review)
Review
In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development of pulmonary hypoplasia and hypertension, which is the primary determinant of morbidity and mortality for affected newborns. The severity is determined using prenatal imaging as early as the first trimester and is related to the laterality of the defect, extent of lung compression, and degree of liver herniation. Comprehensive evaluation of fetal CDH includes imaging-based severity assessment, severity assessment, and evaluation for structural or genetic abnormalities to differentiate isolated from complex cases. Prenatal management involves multispecialty counseling, consideration for fetal therapy with fetoscopic endoluminal tracheal occlusion (FETO) for severe cases, monitoring and intervention for associated polyhydramnios or signs of preterm labor if indicated, administration of antenatal corticosteroids in the appropriate setting, and planned delivery to optimize the fetal condition at birth. Integrated programs that provide a smooth transition from prenatal to postnatal care produce better outcomes. Neonatal care involves gentle ventilation to avoid hyperinflation and must account for transitional physiology to avoid exacerbating cardiac dysfunction and decompensation. Infants who have undergone and responded to FETO have greater pulmonary capacity than expected, but cardiac dysfunction seems unaffected. In about 25-30% of CDH neonates extracorporeal life support is utilized, and this provides a survival benefit for patients with the highest predicted mortality, including those who underwent FETO. Surgical repair after initial medical management for the first 24-48 hours of life is preferred since later repair is associated with delayed oral feeding, increased need for tube feeds, and increased post-repair ventilation requirement and supplemental oxygen at discharge. With overall survival rates >70%, contemporary care involves management of chronic morbidities in the context of a multidisciplinary clinic setting.
PubMed: 38715680
DOI: 10.21037/tp-23-602 -
Heart, Lung & Circulation Dec 2020Pneumonectomy in the adult patient is associated with a mortality of 1-9%. Death is often due to post pneumonectomy pulmonary oedema (PPPO). The use of balanced chest... (Observational Study)
Observational Study
BACKGROUND
Pneumonectomy in the adult patient is associated with a mortality of 1-9%. Death is often due to post pneumonectomy pulmonary oedema (PPPO). The use of balanced chest drainage system (BCD) in the setting of post pneumonectomy has been reported to be of benefit in the prevention of PPPO. This study seeks to compare the incidence of PPPO in patients who underwent pneumonectomy and whose empty pleural space was managed either with CRD or BCD.
METHODS
This retrospective observational cohort study involved 98 patients who were operated on by one surgeon at Liverpool Hospital, Sydney, Australia from 1997 to 2019. The patients were divided into two groups according to the era in which they had their pneumonectomy. Group 1 consisted of 18 patients managed with clamp-release drainage between 1997 and 2002. Group 2 consisted of 80 patients managed with balanced chest drainage between 2003 and 2019. The primary outcomes of interest were the development of PPPO and death. Demographic and clinico-pathological variables between the groups were compared including whether the phrenic nerve was sacrificed, volume of infused intraoperative fluid, duration of single lung ventilation, intraoperative tidal volumes, agents of anaesthetic induction and maintenance, mean urine output in the first 4 postoperative hours, institution of a postoperative 1.5 L fluid restriction, total chest drainage, day of chest drain removal, presence of radiological postoperative mediastinal shift, post-pneumonectomy pulmonary oedema and death. Group characteristics were compared using t-test and chi-squared for continuous and categorical variables respectively. Univariate and multivariate analysis was also undertaken using the Firth method of logistic regression for rare occurrences in a stepwise fashion.
RESULTS
Through univariate analysis, balanced chest drainage, postoperative fluid restriction and intraoperative fluid infusion showed significant effect on PPPO. Through multivariate analysis, balanced chest drainage was found to have independent protective value for PPPO and mortality.
CONCLUSION
Compared with clamp-release drainage, balanced chest drainage results in a lower incidence of post-pneumonectomy pulmonary oedema and death.
Topics: Chest Tubes; Drainage; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pneumonectomy; Postoperative Complications; Pulmonary Edema; Retrospective Studies; Thorax
PubMed: 32327311
DOI: 10.1016/j.hlc.2020.03.006