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index terms: Axilla CT Breast neoplasm Lymphoma CT Treatment planning

CT of the axilla:

Normal
Elliot K. Fishman, Eva S. Zinreich, Christopher RobertA. Stanley

anatomy
M.D.* M.D.t G. Jacobs, M.D.*

and pathology

Rostock, S. Siegelman,

M.D.t M.D.*

CT of the axilla is useful in evaluating a palpable brachial piexopathy, staging a known malignant plasm and evaluating a radiation therapy port.
THIS EXHIBIT, A SELECTION OF THE GENERAL RADIOLOGYAND COMPUTED TOMOGRAPHY PANELS, WAS DISPLAYED Al THE 70TH SCIENTIFIC ASSEMBLYAND ANNUAL MEETING OF THE RADIOLOGICAL SOCIETY OF NORTH AMERICA NOVEMBER 25-30. 1984, WASHINGTON. D.C.

mass or neo-

I. Introduction The purposes ofthis exhibit are: I , to review the normal computed tomographic anatomy of the axilla; 2, to illustrate a wide range of disorders
that involve the axilla, with emphasis on a series of patients with recurrent

breast carcinoma and lymphoma; and 3, to discuss the use of CT in the differential diagnosis of axillary masses. The axilla is an important anatomic compartmentthat is involved in a
wide variety of pathologic conditions. Prior to the advent of CT, the radiologic evaluation of the axilla was limited. Lymphangiography, arteriography, venography and xeroradiography were all performed

in

an attempt to demonstrate the presence and define the extent of suspected axillary lesions. These studies, however, were generally not successful, From the Russell H. Morgan Department of Radiology and Radiological Sciences () and the Johns Hopkins Oncology Center (t), The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address reprint requests to E.K. Fishman, M.D., Department of Radiology, Ihe Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21205.
,
.

and

the axilla

remained

an area

thatwas

usuallyevaluated

exclu-

sively by clinical palpation. Unfortunately, the accuracy of palpation for the detection of small axillary masses and nodes is limited, particularly with respect to those located in the apex of the axilla. Computed tomographic scanning offers a noninvasive method for direct visualization of the axilla with which the boundaries of the region can be located, and masses or adenopathy can be detected. In addition,
CT often allows for specific identification of masses based upon their

appearance its branches


brachial
-

and attenuation. Finally, although the brachial plexus and cannot be individually identified, masses in the course of the
that cause clinical signs and

plexus

symptoms

can

be identified.

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-

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II. Computed Tomography Standard Examination Technique


For the examination ofthe axilla by CT, the patient is scanned in the supine position with arms extended over the head. Care is taken to assure that the patients arms are positioned symmetrically. A continuous infusion of Hypaque-601 is begun in an antecubital vein or a dorsal vein of the hand. The infusion should not be too rapid so that the contrast agent becomes slightly diluted. This will help prevent streak artifacts which may be produced by concentrated contrast material in the axillary vein, and which may detract from the quality of the study. Contiguous scans are performed from 06 through the level of the diaphragm at 8 mm intervals with 8 mm collimation. Additional scans at the level of the neurovascular axillary sheath may be made at 4 mm intervals using 4 mm collimation. Exposure factors used routinely are 3.2 sec. I 25 kVp, 230 mAs or 5.2 sec, 125 kVp, 450 mAs. it is importantto choose a large enough circle of reconstruction to include the entire axillary zone in the reconstructed image.

III.

The Normal

Axilla
(Figure 1)

A. BOUNDARIES The axilia is a pyramidal shaped space beIween the upper part of the arm and the side of the chest, the apex of which is directed towards the neck while the base is directed downward. The boundaries of the axilla are: (17) Anterior wall pectoralis major, pectoralis minor, subclavius, the clavipectoral facia and the suspensory ligament of the axilla Posterior wall subscapularis, latissimus dorsi and teres major Medial wall ribs I through 5, their intercostal spaces, and serratus anterior Lateral wall humerus, coracobrachialis, and biceps brachii. This wall is produced by the convergence of the anterior and posterior axillary fold musdes and their insertions into the lip ofthe intertubercular groove. Apex clavicle, upper border of the scapula, and outer border of the first rib Base anterior axiliary fold, posterior axillary fold, serratus anterior, and chest wall. This boundary is formed by the axillary fascia which is a layer that extends from the pectoralis major to the latissimus dorsi, arching inward to form the hollow of the armpit.

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Figure 1
The boundaries of the axilla

1Winthrop-Breon

Laboratories,

New York.

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B. CONTENTS

(Figures

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I 0)

The axillary artery and vein and the cords of the brachial plexus are enclosed in a connective tissue sheath, called the axillary sheath, to form a neurovascular bundle. The axillary artery and vein can usually be defined by CT as distinct structures within the neurovascular bundle. The axillary vein begins at the lower border of the teres major muscle with the union ofthe venae comitantes of the brachial artery and basilic vein. The vein courses cephalad and lies successively on the anterior, medial and inferior sides of the axillary artery, ifthe arm is held at the side of the body. Ifthe arm is above the head, the vein is more completely anterior to the artery throughout its course. The axillary vein becomes the subclavian vein at the lateral border of the first rib (22,24). The axillaryartery begins atthe lateral border of the first rib as a continuation of the subclavian artery and ends at the lower border of the teres major muscle, where it continues as the brachial artery. The brachialplexus is formed in the posterior triangle of the neck by the union of the anterior rami of the fifth, sixth, seventh, and eighth cervical and first thoracic spinal nerves. The roots, trunks and divisions of the plexus also lie in the posterior triangle. The cords of the brachial plexus lie in the axilla and are intimately related to the axillary artery and vein (7). The axillary lymph nodes drain lymphatics from the breast, the thoracoabdominal wail above the level of the umbilicus, and from the upper limb. The division ofthe axillary lymph node groups varies depending on the literature reviewed. Most clinical researchers group the axillary nodes into three levels: Level I nodes located beIween the inferolateral margin of the pectoralis minor muscie, and the latissimus dorsi muscle Level 2 nodes located behind the pectoralis minor muscle in the axilla Level 3 nodes located beIween the superomedial margin of the pectoralis minor muscle and the thoracic inlet.

Figure 2
The structures ofthe normal axilla

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Figures 3 through I 0 represent numbers correspond to levels

successively more shown in Figure 2.

caudal

sections.

Level

Coracobrachialis
Biceps short head

&

Pectoralls

major

Neurovascular
Latissimus &Teres Triceps long head Lesser tubercle dorsi

Figures 3A&B
Normal CT anatomy of a section corresponding to level I in Figure 2

Axillary sheath & Neurovascular bundk


L. dorsi/ T. major Tr. long H.

Coracold
Figures 4A&B
Normal CT anatomy at level 2 (see Figure 2)

process

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Subciavlus
Pectoralis minor

Ax. sh. Subscapularis

A B Figures 5A&B
Normal CT anatomy at level 3 (see Figure 2)

Serratus

anterior

P. major

Suprasp. B Figures 6A&B


Normal CT anatomy at level 4 (see Figure 2)

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Figures 7A&B
Normal CT anatomy atlevel 5 (see Figure 2)

S.ant. Figures 8A&B


Normal CT anatomy at level 6 (see Figure 2)

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P major

L.

dorsi

T.m Tr. long T. minor Del.

B Figures 9A&B
Normal CT anatomy at level 7 (see Figure 2)

L.
T. major

T. minor

B Figures IOA&B
Normal CT anatomy at level 8 (see Figure 2)

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IV.

The Abnormal

Axilla

The axilia may be involved by a wide variety of neoplasms, both malignant and benign. In addition, axillary adenopathy secondary to an inflammatory process is not uncommon. In evaluating the axilia for the presence of adenopathy, the potential specificity and sensitivity of the procedure depends upon the criteria used to define nodal size. Unlike a pathological section or lymphangiogram, CT must rely on nodal size and number, not on architectural changes, for the detection of abnormalities. In our study, numerous tiny axillary nodes whose aggregate size was less than I cm were frequently found; these we regarded as normal. Whenever a

group of nodes whose aggregate diameter was greater than I cm was seen, a pathologic process was always present, but it was not necessarily neoplastic. Single nodes less than I cm in diameter werejudged to be within normal limits. A single node greater than I .5 cm was considered pathologic except that a node the center of which was replaced by fat was not considered to be pathologic, even when greater than I .5 cm in diameter (18). It is most infrequent to detect any nodes in Level I , while normal nodes are most commonly seen in Level 3. In our experience, breast cancer and lymphoma are the Iwo pathologic processes that most commonly involve the axilla.

V.

Breast

Cancer

(Figures

1 1 through

I 5)

The regional lymph nodes that are most cornmonly involved in breast cancer are the axillary, internal mammary and supraciavicular groups, with the axillary nodes providing the major regional drainage (2, 13, 14). Approximately 40-50% of patients with breast cancer have axillary metastases when first seen. When axillary nodes are not palpable, histologic involvement is detected in approximately 30% of cases. Axillary node involvement not only has major prognostic implications, it is critical in treatment planning (9, 10). Following primarytherapy, 6-20% of patients will experience local recurrence involving the chest wall, and approximately 5% will develop axillary recurrences. Fitly consecutive patients with breast carcinoma who underwent CT evaluation for staging of local or regional recurrent disease were studied. The results of the CT findings are presented in Table I. A. RADIATION THERAPY PLANNING IN BREASTCARCINOMA (Figure 16) In this study, 25 patients with recurrent breast carcinoma had CT scans of the chest and axilla prior to radiation therapy planning. in 62.5% of these patients, radiation treatment fields had to be adjusted on the basis of the CT data. CT data were used to construct more accurate radiation therapy portals to reduce the risks of upper extremity edema and the delayed complication of lymphangiosarcoma.

There are Iwo sources of potential error in the use of CT of the axilla for radiation therapy planning: I , It is imperative that the patient positioning during the CT scan simulate the positioning used during simulation and actual radiotherapy. Otherwise, the adequacy and accuracy of the therapy port will be compromised. 2, If the patient is scanned with one arm extended above the head and one arm by the side, there is the potential for confusion owing to the lack of symmetry. In cases in which one arm must be placed by the side, as in the case of a patient who is unable to raise her arm because of pain, it is advisable to place the other arm in a similar position.

Tablel Distribution of lesions in 50 Patients with RecurrentBreastCarcinoma


Number of Patients

%
34

Chestwall

involvement

17

Axillary node involvement

homolateral
contralateral

14 11
3

28 22
6 14

Internal mammary node involvement Metastasis(i.e.,lung or skeletal)

14

28

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B Figures IIA&B
This 61 year old woman noted diffuse skin thickening and a painful mass in her left breast. Extensive breast cancer is seen involving the left breast (arrowheads) with involvementofthe skin surface. Leffaxillary nodes (arrow) and bilateral internal mammary nodes (curved arrows) are noted.

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Figures 12A&B
This 36 year old woman had a palpable right breast mass. Extensive axillary adenopathy is seen extending high into the apex of the axilla (arrowheads). Adenopathy was seen in the lower portion ofthe axilla as well. The primary breast lesion is also seen (arrow).

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Figures 13A&B
This 72 year old woman with a history of breast cancer complained of increasing right arm pain and weakness. A large recurrenttumor is seen involving the right axillary nodes. The study was performed with the patients arms by her side because she was unable to raise her right arm. Notice the tumor infiltration of the neurovascular bundle (arrows).

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Figure 14
This patient had a history of left mastectomy for breast cancer and of partial left lobectomy for lung cancer. This study was done to rule outtumor recurrence. Evidence of contralateral right axillary node enlargement (curved arrow) and a solitary lung metastasis (arrow) are seen. Node biopsy was positive for metastatic breast cancer.

A Figures ISA
This 47 year old woman had had a right mastectomy tion for carcinoma. and axillary node dissec-

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Figure 15B&C
Chestwall recurrence (arrowhead) with bilateral internal mammary node involvement (arrows) is seen. Enlarged contralateral axillary nodes are also
noted.

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Figures 16A&B
Shown here are isodose curves for treatment of recurrent carcinoma ofthe internal mammary nodes - an example ofthe use of CT in radiation treatment planning (16 Mevelectron beam).

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Vi.

Lymphoma

(Figures

1 7 through

22)

In lymphoma, proper staging of the involvement of the axilla is imperative if one is to design therapy and assess tumor response accurately (3). Since the apex of the axilla is particularly difficult to assess clinically, CT scanning offers a means both to detect and to quantify disease in this location. In this study, 46 patients with non-Hodgkins lymphoma and 54 patients with Hodgkins disease had CT scans of the chest and axilla (Tables II and Ill). Overall, 43% of patients with non-Hodgkins lymphoma and 24% of patients with Hodgkins dis-

in Hodgkins disease (16). Even when complete remission appears to have been obtained clinically, CT evaluation may show residual disease, especially in the apex of the axilla. Further therapy is then required to render the patient disease free. The treatment of non-Hodgkins lymphoma may be influenced by the axillary findings on the CT scan. In Stage I diffuse lymphoma, and Stage I and II nodular lymphoma, local radiation therapy offers a high cure rate with low morbidity. Since axillary involvement is usually associated with dis-

ease had axillary


CT scans can

node

involvement.
to assess the patients

ease in other sites, if present, therapy


phoma therapy

it renders

diffuse
chemo-

lym-

be used

response

to chemotherapy

or radiation

patients at least Stage II, with the treatment of choice.

Tableli CTEvaluation of the Chestand Axilla in 54 Patientswith Hodgkins Lymphomat


Purpose ofstudy Staging 24
Follow-up 7

# of patients

Axill. node involvement U B

mt. mamm node involv. U B 4


.

Mediast. involvement
16

Pericard. involvement 3 5

2 3

1 3 10

3 3 7 15

30
-

U unilateral B bilateral tCTscans of 100 consecutive patientswith lymphomawere reviewedwith respecttothe distribution ofadenopathy. Fifty-four (54) of these patients had Hodgkins lymphoma.
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Table Ill CTEvaluation of the Chestand AxIlla In 46 PatientswIth Non-HodgkinsLymphomat


Purpose ofstudy Staging
21

# of patients

Axill. node involvement U B

Int. mamm node involv. U B


.

Mediast.
involvement

Pericard.
involvement

4
13

9 2 7

2 5 4 5

3 9 1 11 2 1

Follow-up 25
-

U unilateral B bilateral tClscans of 100 consecutive patients with lymphoma were reviewed with respect to the distribution of adenopathy. Forty-six (46) of these patients had non-Hodgkins lymphoma.
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Figures 17A&B
These scans show extensive bilateral axillary adenopathy. The patient had a history ofchronic lymphocyfic leukemia. Enlarged nodes are seen both anterior and inferior to the neurovascular bundle. The nodes surround the vessels (arrows) butdo notinvadethe neurovascular bundles. Mediastinal adenopathy is noted incidentally.

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Figures 18A&B
These scans show extensive axillary adenopathy in a patientwho has diffuse histiocytic lymphoma. Mediastinal adenopathy is also present.

Figure 19
This scan shows enlarged axillary nodes bilaterally without evidence of mediastinal adenopathy. The study was done for tumor staging in a patient with diffuse histiocyfic lymphoma.

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Figure 20
This 29 year old woman had diffuse histiocyfic lymphoma proved by biopsy. Chest CT was performed as a part of staging the lesion. This scan demonstrafes adenopathy in the left axillaryzone (arrow)thafwas not apparent clinically. Mediastinal adenopathy (arrowhead) is also seen.

Figure 21
The study was performed for staging diffuse histiocyfic lymphoma. Notice the bilaterally enlarged axillary nodes (right greaterthan left). Asymmetry of the chest wall is due to the patients left arm being by his side because of recent biopsy. Notice that the nodal chains tend to lie anterior to the axillary vein (arrow) on these views.

Figures 22A&B
This 35 year old patient had a palpable left chestwall mass. CT demonstrates thatthe mass arises in the left axilla, and extends well beneath the pectoralis minor muscle (arrowheads). The mass displaces muscle rather than invading it. The lesion which was primary in the axilla was proved by biopsy to be a lymphoma.

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VII.

Differential

Diagnosis
LESIONS gions are involved, lymphoma must be considered in the differential diagnosis. Axillary nodes are commonly seen in patients with lymphoma, butthe axilla may be involved in sarcoidosis, as in the case illustrated. In this atypical presentation, the nodes are identical in distribution and appearance to those seen in lymphoma.

A. INFLAMMATORY

1. Sarcoidosis (Figure 23) Sarcoidosis is a systemic, granulomatous disease of unknown etiology that most commonly involves the chest and mediastinum. The classic pattern of involvement is bilateral paratracheal lymphadenopathy with hiiar adenopathy (5). Involvement of other lymph node chains may occur, but is less frequent. When other zones including the subcarinal or axillary re-

B Figures 23A&B
Bilateral axillary nodes are seen in this 31 year old woman. Extensive mediastinal adenopathy is present. The CT appearance is indistinguishable from lymphoma.

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2. Toxoplasmosis (Figure 24) Toxoplasmosis gondii is an obligate intracellular protozoan that is ubiquitous in the environmentand thatoccurs in congenital and acquired forms (15). Congenital toxoplasmosis occurs as a result oftransplacental transmission, when the pregnant woman acquires the infection during or just prior to a pregnancy. The most common clinical manifestation of congenital toxoplasmosis is ocular chorioretinitis. The clinical manifestations of acquired toxoplasmosis range from an asymptomatic infection to a disseminated, severe disorder (19). Lymph-

adenopathy is the most common clinical manifestation in acute, acquired toxoplasmosis. Most often the cervical nodes are involved; but suboccipital, supraclavicular, axillary, inguinal and mediastinal nodes may also be involved. The nodes are usually discrete and may be single or multiple. When the mesenteric and retroperitoneal nodes are involved, abdominal pain and fever may occur. When asymptomatic, the lymphadenopathy of toxoplasmosis may mimic lymphoma; and its involvement of axillary lymph nodes may be mistaken for metastatic breast cancer.

a B B a
0
1

0 0 3

UI

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Figure 24 This I 8 year old homosexual was admitted to the psychiatric service. Mediastinal widening was seen on an admission chest radiograph. CT demonstrated bilateral axillary adenopathy with individual nodes of up to 2 cm in diameter. Axillary node biopsy was positive for toxoplasmosis.

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B. BENIGN 1. CystIc Hygroma (Figure 25) Cystic hygroma (8) (cystic lymphangioma) resultsfrom a congenital, abnormal development of the lymphatic systern. Although the exact etiology is undetermined, it is most likely the result of sequestration of primitive embryonic lymph sacs that fail to establish normal communications with the lymphatic system. Lymphangiomas may be classified as simple, cavernous, and cystic. In 65% of cases, the mass is present at birth; and in up to 90%, it is apparent by

TUMORS the end of the second year of life. Though most commonly found in the neck, cystic hygromas may occur in the axilla (20-21). The masses usually are homogeneous and smooth. They displace, but do not invade, adjacent muscular structures. Cystic hygromas have a CT attenuation of I 0 to 30 H which, though low, is higher than that of water. They can be differentiated from lipomas that have a fatty attenuation of - 90 to - 120 H.

Figures 25A,B&C
This 37 year old woman had a palpable right axillary mass. A diffuse mass with a
low CTattenuation of 10-15 H

is seen

(arrows). The mass is homogeneous and displaces rather than invades muscle planes. Notice the sharp planes between the tumor mass and the adjacent muscle. The superior aspect of the mass extended through the apex of the axilla into the posterior triangle of the neck. This lesion was surgically proved to be a cystic hygroma.

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2. Lipoma (Figure 2#{243}) Lipomas are benign faity tumors that commonly occur in the extremities, though they may occur in other locations including the axilia. They are usually well defined, sharply marginated, homogeneous, faity masses and may contain occasional septations. CT attenuation values are highly accurate in the diagnosis of faily tumors (6). Lipomas have a characteristic CT attenuation of 90 to I 20 H, which is usually less than or equal to the attenuation of normal subcutaneous fat. This comparison can help distinguish lipomas from liposarcomas, the CT attenuation of which is usually higher than that of normal fat. Another distinction is that liposarcomas, unlike lipomas, are often infiltrative
-

with poorly defined margins. Lipomas are usually avascular when studied with angiography, and they usually do not show any contrast enhancement on CT. Liposarcomas, on the other hand, are typically heterogeneous and show contrast enhancement both on angiography and CT (12). A lipoma may first be noted clinically as a solid mass, which may feel hard but is usually not tender or painful. Based solely on clinical examination, however, it may be impossible to distinguish a benign lipoma from a malignant fally tumor. CT scanning makes this differentiation possible.

3
C

-4

B
U)

Figures 26A&B This 3 year old girl had a palpable right axillary mass. A diffuse mass is seen infiltrating the right axilla. The mass displaces the axillary vein anteriorly (arrow); its attenuation is 90 H. The appearance is consistent with that of a lipoma.
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3. Desmoid Tumor (Figure 27) A desmoid tumor (1) (aggressive fibromatosis) represents a mass of benign, invasive fibrous tissue which proliferates in various anatomic areas. The mass, considered by some institutions to be a low grade fibrosarcoma, may be either diffusely infiltrative or fairly well defined with a pseudocapsule. A desmoid tumor tends to invade nearby structures making total surgical excision difficult. The frequency oflocal recurrence was 63% in one large series, and 77% in another. it is usually necessary for patients to receive postoperative radiation, particularly if the tumor is nottotally excised.

On unenhanced CT scans, the attenuation of desmoid tumors is usually similar to that of muscle, and the lesions may or may not be well defined. Following the bolus injection of an iodinated contrast agent, the lesions enhance, and appear well marginated, in most cases, despite the presence of microscopic invasion (1 1). The axilla is not a rare location for these tumors. In one series, 3 of I 3 lesions occurred in the chest wall or axilla. When a desmoid tumor occurs in the axilla, there may be nerve involvement owing to diffuse infiltration by the tumor mass.

Figure 27A&B This 30 year old woman had a palpable right axillary mass. CT sections show a large mass (arrows) infiltrating the right axilla, particularly around the level of the neurovascular bundle. Followingthe injection ofa contrastagent,the mass enhances indicating that it is hypervascular. This lesion was proved at biopsyto be a desmoid tumor.

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Asecond

(CT) study was performed to evaluate the adequacy of the radiation therapy field. Notice that by changing the position of the patients arm, the therapyfield is altered (C&D). (Comparethe positions ofthe humeral head and scapula in Figures 27A and 27D.) The patient was finally treated with her hand placed on her hip. This allowed the delivery of the greatest possible radiation dose to the tumor, while irradiating the smallest possible volume of underlying lung.

Figure 27E This radiation simulation film was constructed on the basis of the CT images.

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C.

OTHER MALIGNANT

NEOPLASMS

(Figures

28 & 29)

Although rare, primary neoplasms of fibrous tissue, muscle or fat do occur in the axilia. The tumors classically do not respect soft tissue and muscle planes. These masses may extend high in the axilia, producing an initial clinical complaint related to brachial plexus involvement, or they may spread along the chest wall. Primary tumors of the head and neck, lung and kidney may all metastasize to the axillary lymph node chains. The CT appearance of metastases to the axilla may simulate primary tumors or lymphoma (423).

Figure 28 This 30 year old man had neuroblastoma with extensive metastases to the left axillary nodes. Notice the extension of adenopathy high into the apex of the axilla beneath the pectoralis minor muscle medially (arrow).

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Figures 29A&B (A) This 55 year old man had a palpable right axillary mass. Clsections show a 5 cm mass which enhanced peripherally following the infusion of a contrast agent. The tumor infiltrated the neurovascular bundle resuiting in atrophy of the muscles of the right shoulder. Biopsy of the tumor mass was interpreted as showing anaplastic carcinoma, primary in the axilla. (B) A sequence of images of the right axilla shows the full extent ofthe mass and its relationship to the neurovascular bundle.

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VIII.

Conclusion

CT of the axilla is indicated in: evaluating a clinically palpable mass to determine its etiology and extent. #{149} evaluating the cause of clinically apparent brachial plexus pathology in a patient with a negative physical examination. #{149} staging a known malignant neoplasm (i.e., breast cancer, lymphoma). #{149} evaluating the adequacy of a radiation therapy port in a patient with a known axillary tumor. #{149} quantifying tumor response to chemotherapy or radiation therapy.
S

References
1. Abramowilz D. Zornoza J, Ayala AG. Romsdahl MM. Soft tissue desmoid tumors: Radiographic bone changes. Radiology1983; 146:11-13. 2. Collier BD. Palmer DW, Wilson JF, Greenberg M, Komaki R, Cox JD, Lawson IL, Lawlor PM. Internal mammary lymphoscintigraphy in patients with breast cancer. Radiology 1983; 147:845-848. 3. Ellert J, Kreel L. The role of computed tomography in the initial staging and subsequent management ofthe lymphomas. J ComputAssist Tomogr 1980; 4:368-391. 4. Feinstein RS, Gatewood 0MB. Fishman EK. Goldman SM. Siegelman 55. Computed tomography ofadult neuroblastoma. J ComputAssistTomogr 1984; 8:720-726. 5. Freundlich IM, Libshitz HI, Glassman LM, Israel HL. Sarcoidosis - lypical and alypical thoracic manifestations and complications. Clin Radiol 1970; 21:376-383. 6. Friedman AC, Hartman DS, Sherman JL, Lautin EM, Goldman MJ. CT of abdominal fally masses. Radiology 1981; 139:415-429. 7. Gebarski KS. Glazer GM. Gebarski SS. Brachial plexus: Anatomic, radiologic and pathologic correlation using computed tomography. J Comput Assist Tomogr 1982; 6:1058-1063. 8. Gordon RF, Parkin JL. Lymphangioma ofthe head and neck. Ear Nose Throat J 1982; 61:338-342. 9. Haagensen C.Anatomyofthe mammarygland &the natural history of breast carcinoma. In: Haagensen C. Diseases ofthe breast. 2nd ed. WB Saunders, Philadelphia. 1971:34-52 and 397-413. I 0. Hinz 1W, Bernardino ME, Sones PJ. CI scan evaluation of brachial plexus neuropathy in breast cancer. Noninvasive Medical imaging 1984; 1:69-73. I 1. Hudson TM, Vandergriend RA Springfield DS, Hawkins IF Jr. Spanier 55, Enneking WF, Hamlin DJ. Aggressive fibromatosis: Evaluation of computed tomography and angiography. Radiology 1984; 150:495-501. 12. Hunter JC. Johnston WH, Genant HK. Computed tomography evaluation of fally tumors of the somatic soft tissues: Clinical utilily and radiologic-pathologic correlation. Skeletal Radiol 1979; 4:79-91. 13. Lester RG. The contributions of radiology to the diagnosis, management. and cure of breast cancer. Radiology I 984; 151:1-7. 14. McDiviff RW. Stewart FW, Berg JW. Tumors ofthe breast. In: McDiviff RW. Stewart FW, Berg JW. Atlas oftumor pathology. 2nd Series, Fascicle 2, Armed Forces Institute of Pathology, Washington. D.C.. 1968:112-116. 15. McLeod R, Remington JS. Toxoplasmosis. In: Petersdorf RG, Adams RD. Braunwald E, Isselbacher KJ, Martin JB. Wilson JD. eds. Harrisons principles of internal medicine. 10th ed. McGraw-Hill, New York, 1983:1200-1206. 16. Meyer JE, Linggood RM, Lindfors KK. McCloud TC. Stomper PC. Impact of thoracic computed tomography on radiation therapy planning in Hodgkin disease. J Comput Assist Tomogr 1984; 8:892-894. I 7. Pansky B. Upper extremity. In: Pansky B. Review of gross anatomy, 4th ed. MacMillan Publishing. New York, 1979:188-205. I 8. Pugatch RD. Faling U, Daly BDT. CT in evaluation of the mediastinum of patients with bronchogenic carcinoma. In: Siegelman 55, ed. Contemporary issues in computed tomographycomputed tomography ofthe chest, Vol 4. Churchill Livingstone. New York 1984:21-36. 19. Robbins SL. Cotran RS. Infectious diseases. In: Robbins SL, Cotran RS. Pathologic basis of disease. 2nd ed. WB Saunders, Philadelphia, 1979:462-463. 20. Schnyder PA Gamsu G. CT ofthe pretracheal space. AJR 1981; 136:303-308. 21 . Silverman PM, Korobkin M, MooreAV. CTdiagnosis of cystic hygroma ofthe neck. J ComputAssistTomogr 1983; 7:519520. 22. SneIl R. The upper limb. In: Snell R. Clinical anatomy for medical students, 2nd ed. Little, Brown & Company, Boston, 1972:351-385. 23. Stark DD. Moss AA, Brasch RC, deLorimier Ak Albin AR, London DA Gooding CA Neuroblastoma: Diagnostic imaging and staging. Radiology 1983; 148:101-105. 24. Woodburne R. The upper limb. In: Woodburne R. Essentials of human anatomy, 6th ed. Oxford Universily Press, New York, 1978:67-90. The authors wish to thank Winthrop-Breon Laboratories for support ofthis project. Special thanks to Dan Peters and Don Evans ofWinthrop-Breon. We also would like to thank Adeline 14Jonso for her help in manuscript preparation, Marjorie Gregerman for designing and producing the exhibit, and Barry Lasner for photographic assistance.
their

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