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Pedicle Muscle Flaps in Intrathoracic Cancer Resection: Imaging Appearance and Evolution¹

¹ From the Departments of Diagnostic Radiology (G.W.G., B.S.S., M.T.T., E.M.M., R.F.M.) and Thoracic Surgery (D.C.R.), University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Room 3B.4622, Box 0371, Houston, TX 77030. Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received October 12, 2005; revision requested December 14 and received August 25, 2006; accepted November 1. All authors have no financial relationships to disclose.

View larger version (69K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 1e.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (81K): [in this window] [in a new window] [Download PPT slide]   Figure 1f.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 1g.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 1h.  (a, b) Preoperative CT images from a 67-year-old woman with right upper lobe lung cancer. Axial image at the level of the ascending aorta (Ao) (a) shows a tumor (arrow) that surrounds the right upper lobe bronchus. Subsegmental atelectasis (arrowheads) also is visible. Three-dimensional volume rendering (b) demonstrates the relationship of the tumor (blue) to the airway (pink) and the native location of the fifth intercostal muscle (red). (c–h) Postoperative CT images obtained after right upper lobectomy. Cropped axial images at successively lower levels (c–f) and oblique reformatted image (g) demonstrate the typical appearance of an intercostal muscle flap (arrows) that extends from the thoracotomy site in the posterior chest wall below the fifth rib (5 on c), along the mediastinum, to the resection site in the hilum. The flap was used to buttress the bronchial staple line and separate the bronchus from an arterioplasty site. Three-dimensional volume rendering (h) shows the flap extending from the chest wall below the fifth rib to the airway at the lobectomy site. Note the thoracotomy defect (arrowhead) at the sixth rib.

 

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Linear calcification in a pedicle flap in a 60-year-old woman 3 months after a right pneumonectomy for lung cancer. Cropped axial CT image at the level of the ascending aorta (Ao) shows an intercostal muscle flap (arrows) used to buttress the bronchial closure. The flap contains a linear calcification (arrowhead), presumably the remnants of periosteum; a prominent fat component; and small linear soft-tissue components. The flap extends directly through the postpneumonectomy space instead of paralleling the spine and mediastinum and is surrounded by pleural fluid.

 

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Ossification in a pedicle flap in a 43-year-old man 4 weeks after a right pneumonectomy for lung cancer. Cropped axial CT image at the level of the ascending aorta (Ao) shows an intercostal muscle flap used to buttress the bronchial closure. The flap contains marked calcification that has already progressed to ossification (arrows), with a fat component (arrowheads) between the ossified portions. The postpneumonectomy space is filled with fluid.

 

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 4d.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 4e.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 4f.  (a, b) Preoperative CT images from a 44-year-old man with a second primary cancer in the right lung. Axial CT image at the level of the ascending aorta (Ao) (a) shows a tumor (white arrows) that surrounds the middle lobe bronchus (black arrow), which has been displaced upward after a previous right upper lobectomy. Note the normal serratus anterior muscles (S). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the right serratus anterior muscle (red). (c–f) Postoperative CT images obtained after pneumonectomy. Axial (c) and coronal reformatted (d) images at the level of the left atrium (LA) demonstrate elevation of the liver, a normal left serratus anterior muscle (S on c, arrowheads on d), and a right serratus anterior flap (arrows on d). The latissimus dorsi muscles (L on c, * on d) are in their normal positions. Cropped axial view of the upper chest (e) demonstrates the typical appearance of a serratus anterior muscle flap (arrows), which fills the apex of the thoracic cavity. The flap was used to buttress the bronchial closure. Prominent fat strands are present that are not directed toward the resection site at the hilum. Three-dimensional volume rendering (f) shows the flap (red), which extends from the upper right chest wall, through the rib cage, and into the apex of the right hemithorax, to the resection site.

 

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 5d.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 5e.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 5f.  (a, b) Preoperative CT images from a 55-year-old woman with adenocarcinoma of the left main bronchus. Axial image at the level of the pulmonary artery (PA) (a) demonstrates a mass (M) adjacent to the right main bronchus (arrow), complete collapse of the left lung, and a small left pleural effusion. Note the normal positions of the latissimus dorsi muscles (L). Three-dimensional volume rendering (b) shows the relationship of the tumor (blue) to the airway (pink) and the normal position of the left latissimus dorsi muscle (red). (c–f) Postoperative CT images. Axial image at the level of the left ventricle (LV) (c), coronal reformatted image (d), and cropped view at the level of the left atrium (LA) (e) after an intrapericardial pneumonectomy show a left latissimus dorsi flap (arrows on d and e) that extends through the chest wall and into the postpneumonectomy space. At surgery, the tumor was found to focally involve the wall of the esophagus. The flap was used to buttress the bronchial stump and cover the esophageal mucosa at the resection site. Note the strands of fat in the flap (arrowheads on e). Fluid (* on c and e) has filled the remainder of the postpneumonectomy space. The serratus anterior (S on c and d) and right latissimus dorsi (L on c and d) muscles remain in their normal locations. Surgical changes are evident at the normal location of the left latissimus dorsi muscle ( on c). Three-dimensional volume rendering (f) shows the flap (red), which extends from the left shoulder, through the rib cage, and into the left hemithorax, to the resection site.

 

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Increase in fat content in a serratus anterior muscle flap in a 61-year-old woman after a right upper lobectomy for lung cancer. The flap was used to buttress the bronchial closure and to stop a cerebrospinal fluid leak at a vertebral transverse process resection site. (a) Cropped axial CT image obtained at the level of the aortic arch (Ao), 2 weeks after surgery, demonstrates little internal fat in the flap (arrows). (b) CT image obtained at approximately the same level, 1 year after surgery, shows atrophy of the muscle fibers and an increased fat component in the flap (arrows).

 

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Increase in fat content in a serratus anterior muscle flap in a 61-year-old woman after a right upper lobectomy for lung cancer. The flap was used to buttress the bronchial closure and to stop a cerebrospinal fluid leak at a vertebral transverse process resection site. (a) Cropped axial CT image obtained at the level of the aortic arch (Ao), 2 weeks after surgery, demonstrates little internal fat in the flap (arrows). (b) CT image obtained at approximately the same level, 1 year after surgery, shows atrophy of the muscle fibers and an increased fat component in the flap (arrows).

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 7.  Blood vessels in an intercostal muscle flap in a 62-year-old man 3 days after a right pneumonectomy for lung cancer. The flap was used to buttress the bronchial closure. Cropped axial CT pulmonary angiogram at the level of the ascending aorta (Ao) depicts curvilinear and punctate features that represent blood vessels (arrows) in the flap. These small vessels are most clearly demonstrated with CT pulmonary angiography. A prominent fat component also is evident in the flap.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 8.  Enhancing vessels in a pedicle flap in a 55-year-old woman after a right upper lobectomy and right lower lobe superior segmentectomy for lung cancer and abscess. An intercostal muscle flap was used to buttress the right lower lobe staple line, and a serratus anterior flap was used to buttress the upper lobe bronchial closure and fill the space at the right apex to prevent abscess recurrence. Cropped axial CT image at the level of the aortic arch (Ao) demonstrates enhancing vessels (arrows) in the serratus anterior flap. Small vessels are frequently identifiable among the minimal muscle strands and prominent fat components that are common in serratus anterior flaps.

 

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Calcification in an intercostal muscle flap in a 37-year-old woman after resection of a lymphomatous tracheoesophageal fistula. The flap was used to close the fistula. (a) Cropped axial CT image at the level of the thoracic inlet demonstrates prominent calcification (arrow) in the flap. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate an area of FDG uptake in the flap (arrow) similar to the uptake in normal bone. The area of increased FDG uptake in the esophagus (*) represents a recurrent lymphoma. Tr = trachea.

 

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Calcification in an intercostal muscle flap in a 37-year-old woman after resection of a lymphomatous tracheoesophageal fistula. The flap was used to close the fistula. (a) Cropped axial CT image at the level of the thoracic inlet demonstrates prominent calcification (arrow) in the flap. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate an area of FDG uptake in the flap (arrow) similar to the uptake in normal bone. The area of increased FDG uptake in the esophagus (*) represents a recurrent lymphoma. Tr = trachea.

 

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Calcification in an intercostal muscle flap in a 37-year-old woman after resection of a lymphomatous tracheoesophageal fistula. The flap was used to close the fistula. (a) Cropped axial CT image at the level of the thoracic inlet demonstrates prominent calcification (arrow) in the flap. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate an area of FDG uptake in the flap (arrow) similar to the uptake in normal bone. The area of increased FDG uptake in the esophagus (*) represents a recurrent lymphoma. Tr = trachea.

 

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  FDG uptake due to postirradiation inflammation in a 58-year-old man after a right middle and lower lobectomy for lung cancer. (a) Cropped axial CT image at the level of the ascending aorta (Ao), 10 months after radiation therapy, demonstrates a region of consolidation and bronchiectasis (arrows) adjacent to an intercostal muscle flap (arrowheads) used to buttress the bronchial closure. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate active FDG uptake in the irradiated lung tissue (arrows) but not in the flap (arrowheads).

 

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  FDG uptake due to postirradiation inflammation in a 58-year-old man after a right middle and lower lobectomy for lung cancer. (a) Cropped axial CT image at the level of the ascending aorta (Ao), 10 months after radiation therapy, demonstrates a region of consolidation and bronchiectasis (arrows) adjacent to an intercostal muscle flap (arrowheads) used to buttress the bronchial closure. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate active FDG uptake in the irradiated lung tissue (arrows) but not in the flap (arrowheads).

 

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  FDG uptake due to postirradiation inflammation in a 58-year-old man after a right middle and lower lobectomy for lung cancer. (a) Cropped axial CT image at the level of the ascending aorta (Ao), 10 months after radiation therapy, demonstrates a region of consolidation and bronchiectasis (arrows) adjacent to an intercostal muscle flap (arrowheads) used to buttress the bronchial closure. (b, c) PET (b) and fused PET/CT (c) images at the same level demonstrate active FDG uptake in the irradiated lung tissue (arrows) but not in the flap (arrowheads).

 

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Flap calcification and a metastatic pleural nodule in a 70-year-old man after pneumonectomy for lung cancer. An intercostal muscle flap was used to buttress the bronchial closure. (a) Cropped axial CT image at the level of the ascending aorta (Ao) demonstrates linear calcification in the flap (arrow) with an adjacent enhancing metastatic pleural nodule (arrowheads). Fluid fills the postpneumonectomy space. (b, c) T1-weighted (repetition time msec/echo time msec, 700/8) (b) and T2-weighted (4000/90) (c) MR images obtained 3 months later show marked growth of the nodule into a mass (M) that has displaced the flap. The flap (arrow) has intermediate and high signal intensity on b and low signal intensity on c, findings indicative of muscle and fat, respectively. Ao = aorta.

 

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Flap calcification and a metastatic pleural nodule in a 70-year-old man after pneumonectomy for lung cancer. An intercostal muscle flap was used to buttress the bronchial closure. (a) Cropped axial CT image at the level of the ascending aorta (Ao) demonstrates linear calcification in the flap (arrow) with an adjacent enhancing metastatic pleural nodule (arrowheads). Fluid fills the postpneumonectomy space. (b, c) T1-weighted (repetition time msec/echo time msec, 700/8) (b) and T2-weighted (4000/90) (c) MR images obtained 3 months later show marked growth of the nodule into a mass (M) that has displaced the flap. The flap (arrow) has intermediate and high signal intensity on b and low signal intensity on c, findings indicative of muscle and fat, respectively. Ao = aorta.

 

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 11c.  Flap calcification and a metastatic pleural nodule in a 70-year-old man after pneumonectomy for lung cancer. An intercostal muscle flap was used to buttress the bronchial closure. (a) Cropped axial CT image at the level of the ascending aorta (Ao) demonstrates linear calcification in the flap (arrow) with an adjacent enhancing metastatic pleural nodule (arrowheads). Fluid fills the postpneumonectomy space. (b, c) T1-weighted (repetition time msec/echo time msec, 700/8) (b) and T2-weighted (4000/90) (c) MR images obtained 3 months later show marked growth of the nodule into a mass (M) that has displaced the flap. The flap (arrow) has intermediate and high signal intensity on b and low signal intensity on c, findings indicative of muscle and fat, respectively. Ao = aorta.

 

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