ct scan of the axilla

8/13/2019 CT scan of the Axilla

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V o lum e 6 , N um be r 3 {149}M ay , 1 986 { 1 4 9 }Rad ioGraph ic s 4 7 5

in dex te rm s:AxillaC TBreas tneop la smLymphoma

C TTrea tmentp lann ing

C T o f th e ax illa :N o rm a l ana tom y and pa tho logyE llio t K . F is h m an , M .D .*E v a S . Z in re ic h , M .D .tC h ris to p h e r G . Ja co b s , M .D .*R o b e rtA . R o s to c k , M .D .tS ta n le y S . S ie g e lm a n , M .D .*

T H IS E XH IB IT , A S E LE C TIO N O F T H EG E N E R A L R A D IO L O G Y A N D C O M -P U T E D TO MO G R A P H Y P A N E L S , W ASD IS P LA Y E D A l T HE 7 0T H S C IE N TIF ICA S S E M B LY A N D A N N U A L M E E T IN G O FT H E R A D IO L O G IC A L S O C IE T Y O FN O R T H A M E R IC A N O V E M B E R 25 -3 0 .19 84 , W AS H IN G T O N . D .C .

F rom th e R u sse ll H . M org anD e partm en t o f R ad io lo gy andR ad io log ica l S cienc es () an dthe Jo hns H o pk ins O nco log yC e n te r (t), T he John s H opk insM ed ic al Ins titu tions , B alt im ore ,Mary land .

A d dress rep rin t re que sts toE .K . F is hm an , M .D ., D ep artm en to f R ad io logy , Ih e Jo hns H o pk insHosp i ta l , 600 N o rth W olfe S tree t,B a lt im ore , M D 212 05 .

C T o f th e a x illa is u s e fu l in e v a lu a tin g a p a lp a b le m a s s o rb ra c h ia l p ie x o p a th y s ta g in g a k nown m a lig n a n t n e o -p la s m a n d e v a lu a tin g a ra d ia tio n th e ra p y port .

I. In tro du ctio nT h e pu rpo ses o fth is exh ib it a re : I , to rev ie w th e n orm a l co m pu te d to -

m o gra ph ic an a tom y o f th e a x illa ; 2 , to illus tra te a w id e ra ng e o f d iso rd e rstha t invo lve the ax illa , w ith em p has is on a se rie s o f pa tien ts w ith recu rren tb rea s t ca rc in om a a nd ly m ph om a ; a nd 3 , to d isc us s th e use o f C T in thed iffe re n tia l d iag nos is o f ax illa ry m ass es .

T h e a x illa is a n im po rtan t a na to m ic c om p artm en tth a t is i nvo lv ed in aw ide va rie ty o f pa tho log ic co nd ition s. P rio r to the adven t o f C T , therad io log ic eva lu a tio n o f the ax illa w as lim ite d . Lym ph ang iog ra phy ,a rte rio g rap hy, veno grap hy a nd xe ro rad iog ra phy w ere a ll pe rfo rm e d ina n a tte m p t to de m on stra te th e p res en ce a nd de fine the e x ten t o f su s-pe c ted a x illa ry les ion s . T he se s tu d ies , ho w e ve r, w e re ge ne ra lly n o t su c-cessfu l, a nd the a x illa re m a ined a n area tha tw as usua llye va lua ted exc lu -s ive ly by c lin ic a l p a lpa tion . U n fo rtu na te ly , the ac cu ra cy o f pa lp a tion fo rth e d e tec tion o f sm a ll a x illa ry m as ses a nd no des is lim ite d , pa rticu la rly w ithres pe c t to tho se loca ted in th e a pe x o f th e ax illa .C om pu te d to m og ra ph ic sc an n ing o ffe rs a no n inv as ive m e tho d fo rd irec t v isua liza tion o f the a x illa w ith w h ic h the bou nd aries o f th e re g ionca n be loc a ted , an d m ass es o r ad en op a thy ca n be d e tec te d . In ad d ition ,C T often a llow s fo r spec ific ide n tifica tion o f m a sses ba se d upon th e irap pe ara nce a nd a tte nua tio n . F ina lly , a lth ou gh th e b rach ia l p lexu s a ndits b ra nc he s c an no t be ind iv id ua lly id en tifie d , m a sse s in th e c ou rs e o f thebra ch ia l p le xus tha t cause c lin ica l s igns a nd sym p tom s can be id en tified .

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F or the exam ina tion o fthe ax illa by C T , th e pa -

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t ien t is scann ed in the sup ine pos ition w ith a rm se xte nde d ove r the h ead . C a re is t a ken to assu retha t the pa tien ts a rm s a re po s ition ed sym m etri-ca lly . A con tinu ous in fu s io n o f H yp aqu e-60 1 isbe gun in an an tecu b ita l ve in o r a do rsa l ve in o fthe h and . T he in fus ion shou ld no t b e too ra p id sotha t the co n tras t ag en t becom es s ligh tly d ilu ted .T h is w ill he lp p reve n t s treak a rtifa c ts w h ich m ay beprod uced by con cen tra te d con tras t m a te ria l inthe a x illa ry ve in , a nd w h ich m ay d e trac t fro m the

T he ax ilia is a p yram ida l shap ed sp ace be -Iw e en the upp er p a rt o f the a rm an d the s ide o fthe ch est, the ap ex o f w h ich is d irec ted to w a rdsth e n eck w h ile th e base is d irec ted dow nw ard . T hebou nda ries o f th e a x illa a re : 17 )A n te rio r w a ll -

pec to ra lis m a jo r, pec to ra lis m in o r, sub c la v ius ,th e c lav ip ecto ra l fac ia and the su sp enso rylig am e n t o f the ax illa

P oste rio r w all -su bscapu la ris , la t iss im us d ors i and te res m a jo r

M e d ia l w a ll -r ibs I th ro ugh 5 , the ir in te rco sta l spaces , a nds erra tu s an te rio r

La te ra l w all -hum erus , co racob ra ch ia lis , a nd b ice psbrachi i .T h is w a ll is p rod uced by the con ve rgence o fth e an te rio r and p oste rio r a x illa ry fo ld m us -d es a nd th e ir in se rtion s in to th e lip o fth e in te r-tube rcu la r g roove .

A p e x -c lav ic le , up pe r bo rd e r o f th e scap u la , an do u te r bo rde r o f the firs t r ib

B a se -a n te rio r ax ilia ry fo ld , po ste rio r a x illa ry fo ld ,se rra tu s an te rio r, an d ches t w a ll.T h is boun dary is fo rm e d b y the a x illa ry fa sc iaw h ich is a la ye r tha t ex ten ds from the pe c-to ra lis m a jo r to the la tis s im us d ors i, a rch ing in -w a rd to fo rm th e ho llow o f the a rm p it.

qu a lity o f the stu dy. C o n tig uou s sca ns a re p e r-fo rm ed fro m 06 th ro ugh the leve l o f the d ia -p h rag m at 8 m m in te rva ls w ith 8 m m co llim a tion .A dd itiona l scans a t the leve l o f the ne urovascu la rax illa ry sh ea th m a y b e m a de a t 4 m m in te rva lsu s in g 4 m m co llim a tion . E xpo su re fa cto rs use dro u tin e ly a re 3 .2 sec . I 2 5 kV p , 230 m A s or 5 .2 sec,125 kV p , 450 m A s. it is im p ortan tto choo se a la rgeeno ugh c irc le o f recons truc tio n to inc lud e theen tire ax illa ry zo ne in th e re con stru c ted im age .

F ig ure 1T he b oun daries o f the ax illa


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F ig ure 2T he struc tu re s o fthe no rm al ax illa

F ishm an e t a l CTofth e ax illa

V o lum e {2 43 },um ber 3 { 1 4 9 }M a y, I 9 86 { 1 4 9 }Rad loGraph ic s 4 7 7

3.0

B . C O N T E N T S (F ig u res 2 th rou gh I 0 )T h e ax illa ry a rte ry a nd ve in and the co rd s o f

the b rach ia l p lexus a re e nc lose d in a con nec tivetis sue shea th , ca lled the ax illa ry shea th , to fo rm ane urovascu la r b und le . T he a x illa ry a rte ry an d ve incan u su a lly be de fine d by C T as d is tinc t s truc tu resw ith in the neuro va scu la r bun d le .

T he ax illa ry ve in b eg ins a t the lo w er bo rde r o fthe te res m a jo r m usc le w ith th e un ion o fthe vena ecom itan tes o f the b rach ia l a rte ry an d bas ilic ve in .T he ve in cou rses ce pha lad a nd lie s su ccess ive lyo n the an te rio r, m ed ia l an d in fe rio r s ides o f th ea x illa ry a rte ry , ifthe a rm is he ld a t the s id e o f theb ody . Ifthe a rm is a bo ve th e h ead , th e ve in is m orecom p le te ly an te rio r to the a rte ry th roug hou t itscou rse . T he a x illa ry ve in becom e s the sub c lav ianve in a t the la te ra l bo rd e r o f the firs t r ib 22 ,24 ) .

T he axi l laryar tery beg ins a tthe la te ra l b o rde ro f the firs t r ib a s a con tinua tio n o f the su bc lav ianartery and ends a t the low er bo rde r o f the te resm a jo r m usc le , w h ere it co n tinues as the b rach ia lar tery.

T he brachia lp lexus is fo rm ed in the pos te rio rtr ia ng le o f th e ne ck b y the un io n o f th e an te rio rra m i o f the fif th , s ix th , seve n th , an d e ig h th ce rv ica land firs t tho rac ic sp ina l ne rves . T he roo ts , trun ksand d iv is ions o f th e p lexu s a lso lie in the pos te rio rtr ia ng le . T h e co rds o f the b rach ia l p lexus lie in th eax illa and a re in tim a te ly re la te d to the ax illa ryartery and ve in 7) .

T he ax illa ry lym ph nodes dra in ly mp ha ticsfrom th e b reas t, th e tho racoa bdo m in a l w a ilab ove the leve l o f the um b ilicu s, an d fro m theupp er lim b . T h e d iv is ion o fth e ax illa ry lym ph no degrou ps va rie s dep end ing on the lite ra tu re re -v iew ed . M o st c lin ica l resea rche rs g ro up th e ax il-la ry nod es in to th ree le ve ls :Leve l I n ode s loca ted be Iw een th e in fe ro la t-

e ra l m a rg in o f th e pe cto ra lis m in o r m u s-c ie , a nd th e la tis s im us dors i m usc le

Leve l 2 n ode s loca ted be h in d the pec to ra lism in o r m usc le in th e a x illaLeve l 3 no des loca ted be Iw een the supe rom e -d ia l m arg in o f the pe cto ra lis m in o r m u s-c le a nd the tho rac ic in le t.


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F ig u re s 3 A & BN orm al C T an a tom y o f a sec tio n co rrespon d in g to le ve l I in F igu re 2

F ig u re s 4 A & BN orm al C T ana to m y a t leve l 2 (se e F igu re 2 )


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Fishman et al. CT of the ax illa

V o lu m e 6 , N um ber 3 {149}M ay , 1 986 { 1 4 9 }Rad ioGraph ic s 4 7 9

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Fishman et ai. CT of the a x illa

V o lu m e 6 , N um b er 3 { 1 4 9 }M ay, I 986 { 1 4 9 }Rad ioGraph ic s 4 8 1


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- T ab le l D i s tr ib u t io n o f l e si o ns i n 5 0 P a t ie n t sw i t h R ec ur ren t B reas t C arc inom a

17 341 4 2 811 223 6 14

14 28

CTo f the ax illa Fishman et ai.

4 8 2 Rad loGraph ic s {149}M a y, 19 86 { 1 4 9 }V o lum e 6 , N um ber 3

IV . Th e A bno rm a l A x illaT he ax ilia m ay be invo lved by a w ide va rie ty

o f n eop lasm s , bo th m a lign an t a nd be n ign . Inad d it ion , ax illa ry ade nop a thy seco nda ry to anin f lam m ato ry p rocess is n o t uncom m on .

In eva lua ting th e a x ilia fo r the p resence o fa den opa thy , the p o ten tia l spec ific ity and sens itiv -ity o f the p rocedu re de pen ds up on th e crite riaused to de fine n oda l s ize . U n like a pa tho log ica lsec tion o r lym ph ang iog ram , C T m us t re ly on n oda ls ize an d num be r, no t o n a rch itec tu ra l chan ges ,fo r th e d e tec tio n o f ab norm alit ies .In ou r s tud y, num erou s tin y a x illa ry n ode s w ho seagg rega te s ize w a s less than I cm w e re frequ en tlyfou nd ; th ese w e reg a rde d as n orm a l. W hen eve r a

g ro up o f n ode s w ho se ag grega te d iam e te r w a sg rea te r th an I cm w as seen , a pa th o lo g ic p ro cessw a s a lw ays p rese n t, bu t it w as n o t necessa rilyne op las tic . S ing le no des less tha n I cm in d ia m e-te r w ere jud ged to b e w ith in n o rm a l lim its . A s in g leno de g rea te r tha n I .5 cm w a s co ns ide re d p a tho -log ic e xcep t tha t a no de the ce n te r o f w h ich w a srep laced by fa t w a s no t cons id e red to b e pa tho -log ic , even w hen g rea te r th an I .5 cm in d iam e te r 18) . It is m os t in freq uen t to de tect an y n ode s inLeve l I , w h ile n o rm a l nod es a re m os t com m o n lysee n in Leve l 3 . In ou r expe rience , b rea st can ce ran d lym pho m a a re the Iw o p a th o lo g ic p rocesse stha t m os t com m on ly in vo lve th e a x illa .

V . B reas t C ance r (F igu res 1 1 th rou gh I 5 )T he re g ion a l lym ph nod es th a t a re m o st co rn -

m on ly invo lved in b reas t can ce r a re the ax illa ry ,in te rna l m a m m a ry a nd supra c ia v icu la r g rou ps,w ith the ax illa ry no des p rov id ing the m a jo r re -g iona l d ra in age 2 , 13 , 14 ). A pprox im a te ly 4 0 -50 %of p a tie n ts w ith b re ast can ce r have ax illa ry m e tas-tases w he n firs t seen . W hen ax illa ry n ode s a re no tpa lpab le , h is to log ic invo lvem e n t is d e te cte d inap p rox im a te ly 30 % o f cases .

A x illa ry n ode invo lvem e n t no t on ly ha s m a jo rp ro gnos tic im p lica tio ns, it is crit ica l in trea tm en tp lan n in g (9 , 10) . F o llow in g p rim a ry the rapy , 6 -2 0%of pa tien ts w ill exp e rie nce loca l recu rren ce in -vo lv in g th e ches t w a ll, a nd ap prox im a te ly 5% w illde ve lop ax illa ry recu rren ces . F it ly co nse cu tive pa -t ien ts w ith b re ast ca rc in om a w ho unde rw en t C Teva lua tion fo r s tag ing o f loca l o r re g io na l recu r-ren t d isease w ere s tud ied . T he re su lts o f the C Tfind ings a re p re sen ted in T ab le I.

A . R A D IA T IO N T H E R A P Y P L A N N IN G INB R E A S T C A R C IN O M A (F igu re 16 )

In th is s tudy , 25 pa tien ts w ith recu rren t b reas tca rc ino m a had C T sca ns o f the ches t an d ax illap rio r to rad ia tio n the ra py p la nn in g . in 62 .5 % ofthe se pa tien ts , rad ia tio n trea tm e n t fie lds h ad tobe a d ju sted on the bas is o f th e C T da ta . C T d a taw e re used to con stru c t m ore accu ra te rad ia tio nthe ra py p orta ls to red uce the risks o f u pper ex -trem ity e dem a an d th e d e la yed com p lica tion o fl ymphang iosa rcoma.

T here a re Iw o sources o f p o te n tia l e rro r in theuse o f C T o f the a x illa fo r rad ia tion th e rap yp lann ing :

I , It is im pe ra tive th a t the p a tien t p os itio n ingd u ring the C T scan s im u la te the pos itio n in g use dd uring s im u la t ion and a ctu a l rad io th e rap y. O th e r-w ise , th e ade qua cy an d accu ra cy o f the the rapypo rt w ill b e com prom ised .

2 , If th e pa tien t is scan ned w ith o ne a rm e x-tend ed ab ove the he ad an d one arm by the s ide ,the re is t h e po ten tia l fo r con fus ion ow ing to th ela ck o f sym m etry . In case s in w h ich one arm m us tbe p la ce d by th e s ide , a s in the ca se o f a pa tien tw h o is u nab le to ra ise he r a rm b eca use o f pa in , itis a dv isa b le to p lace th e o the r a rm in a s im ila rposi t ion.

C h es tw a ll in vo lv em e ntA x il la ry n o d e i nv o lv e m e n t hom o la t e ra l

con tra la te ra l Internalm a m m a r y n od e in vo lv em e nt Metastasis(i .e. , lungo r s k e le t al )

Number ofPat ien ts %


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B

Fishman et al. CT o f the ax illa

V o lu m e 6 , N um b er 3 { 1 4 9 }M ay , 19 86 { 1 4 9 }Rad ioGr aph ics 4 8 3

F ig u re s I IA & BT h is 6 1 ye ar o ld w om an no ted d iffu se sk in th icken in g and a pa in fu l m ass in he rleft bre ast. E xtens ive b re ast c anc er is s een invo lv ing the le ft b reas t (a rro w-he ads ) w ith inv olv em en to fthe s kin s urfac e. L effa xilla ry nod es (a rrow ) a nd b ila t-e ra l in te rn a l m am mary node s (cu rved a rro w s) a re n o ted .

I


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A

CT of the ax illa Fishman et al.

4 8 4 Rad ioGr aph ics { 1 4 9 }M ay , I 9 8 6 { 1 4 9 }V o lum e 6 , N u m b er 3

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BF ig u re s 1 2 A & BT h is 36 yea r o ld w om an h ad a p a lp ab le righ t b re ast m ass. E xte ns ive ax illa ryade nop a thy is s ee n ex ten d in g h igh in to th e ape x o f the a x illa (a rrow hea ds).A de nop a thy w as se en in the lo w er po rt ion o fth e ax illa a s w ell. T he p rim aryb re as t le sio n is a ls o s ee n (a rro w).


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Fishman et al. CT o f the ax illa

V o lum e 6 , N um ber 3 {149}M ay , I 9 8 6 {149}Rad loGraph ic s 4 8 5

F ig u re s 1 3 A& BT h is 72 ye ar o ld w om an w ith a h is to ry o f b re ast can ce r com pla ined o f inc rea s-in g rig h t a rm pa in and w eakness. A la rg e recu rren ttum or is s een invo lv ing therig ht ax illa ry n ode s. T he stu dy w as perfo rm ed w ith the pa tien ts a rm s b y h er s id ebe cau se she w as una b le to ra ise h e r rig h t a rm . N otice the tu m or in filtra tio n o fth e n eu ro va sc ula r b un dle (a rro ws ).

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A

CTof the ax illa Fishman et al.

4 8 6 Rad ioGraph ic s { 1 4 9 }M a y, I 986 {149}V o lum e 6 , N um be r 3

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F ig ure 1 4T h is p a tie n t h a d a h is to ry o f le ft m aste ctom y fo r b re as t can ce r an d o f pa rtia l le ftlo bec tom y fo r lun g can ce r. T h is s tu dy w as don e to ru le o u ttu m or recu rrence .E viden ce o f co n tra la te ra l r igh t a x illa ry no de e n la rg em en t (cu rved a rrow ) an da so lita ry lun g m eta sta sis (a rrow ) a re se en . N ode b io psy w as pos itive fo r m eta -s ta tic b re as t c an ce r.

F ig u re s I S AT h is 4 7 yea r o ld w om an h ad had a righ t m aste cto m y and a x illa ry nod e d issec -t io n f or c a rc in o m a.


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F ishm an e t a l CTof the ax illa

V o lum e 6 , N u m be r 3 { 1 4 9 }M ay , I 9 8 6 {149}R ad loGraph i c s 4 8 7

F ig u re 1 5 B& CC he stw all recu rrence (a rrow head ) w ith b ila te ra l in te rn a l m am mary no de in -v olv em en t (a rrow s) is s ee n. E nla rg ed co ntra la te ra l a xilla ry node s a re a lsonoted.

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CTof the ax illa Fishman et al.

4 8 8 Rad ioGraph ic s { 1 4 9 }M ay, 1 986 {149}V o lum e 6 , N um ber 3

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F ig u re s 1 6 A & BS how n he re a re isodo se cu rves fo r trea tm en t o f recu rren t ca rc in om a o fthe in -te rna l m am mary n odes - an exa m ple o fth e use o f C T in rad ia tio n trea tm en tp la nn in g (16 M eve lec tron be am ).


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T a b le I llC T E v a l ua t io n o f t h e C h e s t a n d A x Il la I n 4 6 P a t ie n t s w I th N o n - H o d g ki n s L y m p h o m a t

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Fo l low-up 25 5 27 4 15 11 2U - uni la tera l

B - bi la tera ltC ls ca ns o f 1 00 c on se cu tiv e p atie nts w ith ly m ph om a w e re re vie w ed w ith re sp ec t to t he d is trib utio n o f a de no pa th y. F orty -s ix (4 6) o f th es e

p a tie n ts h a d n o n- H od g kin s l ym p h om a . L l . . .-

F ishm an et a l. CTo fthe ax illa

V o lum e 6 , N um ber 3 { 1 4 9 }M ay , I 9 8 6 {149}Rad ioGraph ic s 4 8 9

V i. L ym phom a (F ig u re s 1 7 th rou gh 22 )In lym pho m a, p rop e r s tag ing o f the in vo lve -

m en t o f the ax illa is im pera tive if one is to d es ignthe rap y and asse ss tum o r respon se accu ra te ly 3) .S in ce th e ap ex o f th e ax illa is pa rticu la rly d ifficu ltto a sse ss c lin ica lly , C T scan n in g o ffe rs a m ean sbo th to d e tec t and to qua n tify d isea se in th is loca -t ion . In th is s tud y, 4 6 pa tie n ts w ith non -H o dgk in slym pho m a an d 5 4 p a tie n ts w ith H od gk in s d iseasehad C T sca ns o f the ches t an d ax illa (T a b les II a ndIll). O ve ra ll, 4 3% o f pa tien ts w ith non -H odgk in slym ph om a an d 2 4% of pa tie n ts w ith H odg k in s d is -e ase ha d ax illa ry n od e inv o lvem en t.

C T sca ns can b e used to a ssess the pa tie n tsresp on se to c he m othe rap y o r ra d ia tion th e ra py

in H od gk in s d isease 16 ) . E ve n w h en com p le te re -m iss ion ap pea rs to h ave b een ob ta ined c lin ica lly ,C T eva lu a tion m ay show res idu a l d isea se , e spe -c ia lly in the ape x o f th e a x illa . F u rth e r the rapy isthe n requ ired to re nde r the pa tien t d isea se free .

T h e trea tm en t o f n on -H od gk in s lym pho m am ay b e in flue nced by the ax illa ry find in gs on th eC T scan . In S ta ge I d iffuse lym pho m a, and S tage Ian d II n od u la r lym pho m a, lo ca l rad ia tio n the ra pyo ffe rs a h igh cu re ra te w ith low m orb id ity . S inceax illa ry invo lvem e n t is usua lly asso c ia ted w ith d is-e ase in o the r s ites , if p rese n t, it re nd e rs d iffus e lym -ph om a pa tien ts a t le ast S tag e II, w ith che m o-the ra py the tre a tm en t o f cho ice .

Table l iC T E v al ua tio n o f t he C h e st a n d A x ill a i n 5 4 P a ti en ts w i th H o d g kin s L y m p h o m a tPurposeo fs tudy

ofpatients

Axi l l . nodeinvo lvemen tU B

m t . m a m mn o d e i nv o lv .U B

Med iast .invo lvemen t

Per ica rd .invo lvemen t

Stag ing24

2 13

4 3. 16 3

Fo l low -up30

7 310

4 37 1 5 5

U - unilateralB - b i la te ra l

tC T sc an s o f 1 00 c o n se cu tiv e p atie nts w it h ly m ph om a we re re vie w ed w ith re sp ec tto th e d is trib utio n o fa de no pa th y. F ifty -fo ur (5 4) o f th es ep at ie nt s h a d H o dg k in s ly m p ho m a .. . S . . _ .- . { 149 } 1


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CTo f The ax illa F ishm an et a l.

4 9 0 Rad ioGraph ic s { 1 4 9 }M a y, 19 86 {149}V o lum e 6 , N um ber 3

a0Ca.

F ig u re s 1 7 A & BT he se scan s show extens ive b ila te ra l ax illa ry ad eno pa th y. T he p a tie n t ha d ah is to ry o fc hro nic ly mph oc yfic leuk em ia . E nla rged no des a re se en bo th an te rio rand in fe rio r to the ne urov as cu la r bu nd le . T he n odes su rroun d the v es se ls(a rrow s) bu tdo n otin va de th e ne urov asc ula r bu nd les. M ed ia stina l ade nopa thyis n o te d in c id en ta ll y.


17/28

IA

B

F ishm an et a i. CTofthe ax illa

V o lu m e 6 , N um b er 3 { 1 4 9 }M a y, I 9 86 { 1 4 9 }Rad ioGraph ic s 4 9 1

F ig u re s 1 8 A & BT he se s ca ns s ho w e xte ns iv e a xilla ryad enop a th y in a pa tien tw ho h as d if-fu se h is tio cy tic ly mp ho ma . M ed ia stin alad enop ath y is a lso p res en t.

F ig ure 1 9T his s ca n s ho w s e nla rg ed a xilla rynod es b ila te ra lly w ithou t e vi-de nc e o f m ed iastina l ade no-pa thy. T he s tudy w as don e fo rtum or s ta g in g in a pa tien t w ithd iffu se h is tio cy fic ly m ph om a .


18/28

CTo f th e ax illa Fishman et al.

4 9 2 Rad ioGraph ic s {149}M ay , I 9 8 6 {149}V o lum e 6 , N u m be r 3

a0

F ig u re 2 0. T h is 2 9 ye ar o ld w o m an had d if-

fu se h is tio cy fic ly m ph om apro ved by b io psy . C hes t C T w asperfo rm ed as a pa rt o f s tag ingth e le sio n. T his s ca n d em on -s tra fes ad eno pa th y in th e le ftax illa ryz on e (a rrow )tha fw as no ta pp are nt c lin ic ally . M e dia stin alade nop a thy (a rrow head ) is a lsoseen .

F ig u re 2 1T h e s tud y w as perfo rm ed fo rs ta gin g d iffu se h is tio cy fic ly m-p ho ma . N otic e th e b ila te ra llye nla rg ed a xilla ry n od es (rig htg re ate rth an le ft). A sym m etry o fthe che st w all is d ue to the p a-tie n ts le ft a rm be ing by h is s ideb eca us e o f rece nt b iops y.N otice tha t the n oda l ch a in sten d to lie an te rio r to th e ax illa ryve in (a rrow ) on th es e v iew s.

F ig u re s 2 2 A & BT h is 3 5 ye ar o ld pa tien t had apa lpab le le ft ches tw all m ass. C Tde m onstra tes tha tthe m assa rise s in the le ft ax illa , and ex -te nds w ell ben ea th the p ec-to ra lis m in or m us cle (a rro w-hea ds). T he m as s d isp lac es m us-c le ra th e r tha n invad ing it. T heles ion w hich w as prim ary in theax illa w as p roved by b iopsy tob e a ly mp ho ma .

A


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F ishm an e t a l. CT of the ax illa

V o lum e 6 , N um ber 3 {149}M ay , I 9 8 6 {149}Rad ioGraph ic s 4 9 3

BV3.0Ba


20/28

A

B

CTofthe ax illa Fishman et al.

4 9 4 Rad ioGraph ic s {149}M a y, 19 86 {149}V o lum e 6 , N um b er 3

V II. D iffe ren tia l D iagnos isA . IN F L A M M A T O R Y LE S IO N S

1 . Sarco idos is (F ig u re 23 ) S arco id os is is a sys-tem ic , g ran u lo m atous d ise ase o f un kn ow n e tio l-ogy tha t m os t com m on ly in vo lves the che st an dm e d ia stinum . T h e c lass ic pa tte rn o f invo lve m en t isb ila te ra l pa ra trachea l lym phad eno pa thy w ithh iia r a de no pa th y 5) . In vo lve m en t o f o the r lym phno de ch a in s m a y o ccu r, bu t is le ss frequ en t. W he no the r zo nes in c lu d in g th e sub ca rina l o r ax illa ry re -

g ions a re invo lved , lym phom a m us t b e con s id -e re d in th e d iffe ren tia l d ia gno s is . A x illa ry no desa re co m m on ly see n in pa tien ts w ith lym pho m a,bu tthe ax illa m a y b e in vo lve d in sa rco idos is , as inth e case illus tra ted . In th is a typ ica l p resen ta tio n ,th e n ode s a re ide n tica l in d is tribu tion and a p-pea ra nce to those se en in lym phom a.

F ig u re s 2 3 A & BB ila te ra l a xilla ry nod es a re see n in th is 3 1 y ear o ld w om an . E xten siv e m ed ia sti-n al ad eno pa thy is p rese nt. T he C T a pp eara nce is ind is ting uis hab le froml ym p h o m a .


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3aBBa010UI03UI

F ishm an e t a l. CTofthe ax illa

V o lum e 6 , N um ber 3 { 1 4 9 }M a y, 198 6 { 1 4 9 }Rad ioGraph ic s 4 9 5

2 . T o xop lasm o s is (F igu re 24 ) Toxop lasmosisgond i i is an ob lig a te in tra ce llu la r p ro to zoa n tha tis ub iqu itou s in the en v iro nm en ta nd tha to ccu rs incon gen ita l a nd acqu ired fo rm s 15 ) .

C ong en ita l toxop la sm osis occu rs as a resu lto ftran sp lacen ta l tra nsm iss ion , w hen the p reg nan tw om a n acqu ires the in fec t ion du ring o r jus t p rio rto a p regn ancy. T h e m o st com m on clin ica l m an -ifes ta tio n o f con gen ita l toxop lasm os is is o cu la rchor ioret in i t is.

T h e c lin ica l m a n ife s ta tio ns o f a cqu ired to xo -p lasm os is ran ge fro m a n asym ptom atic in fe c tionto a d issem ina ted , seve re d iso rd e r 19) . L ym p h -

ad enop a th y is the m o st com m on clin ica l m an ifes-ta tion in acu te , acq u ire d toxop lasm os is . M os to ften the ce rv ica l nod es a re invo lved ; bu t sub -occ ip ita l, sup rac lav icu la r, ax illa ry , ing u in a l a ndm ed ias tin a l node s m a y a lso be invo lved . T henod es a re u sua lly d isc re te an d m ay be s ing le o rm u ltip le . W he n th e m e sen te ric a nd re trop e rito -nea l n odes a re invo lved , ab dom ina l pa in andfe ve r m ay occu r. W h en asym p tom atic , th e lym ph-ad enop a th y o f to xop lasm os is m ay m im ic lym -pho m a; an d its in vo lve m en t o f ax illa ry lym phnod es m a y b e m is ta ken fo r m e tasta tic b reas tcance r .

F igu re 24T h is I 8 ye a r o ld ho m osexua l w as adm itte d to the psych ia tric se rv ice . M ed ias ti-n a l w ide n ing w as seen on an adm iss ion ches t ra d iog raph . C T d em ons tra tedb ila te ra l ax illa ry ad enop a th y w ith ind iv idua l no des o f up to 2 cm in d iam ete r.Axi l la ry n od e b io ps y w as p os itiv e fo r to xo pla sm os is .


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B

C

CTofthe ax illa F ishm an e t a l.

4 9 6 Rad ioGraph ic s { 1 4 9 }M ay , 198 6 { 1 4 9 }V o lum e 6 , N um b er 3

B . B E N IG N T U M O R S1. C ystIc H yg rom a (F igu re 25 ) C ystic hyg rom a

8) (cys tic lym ph ang iom a) resu lts fro m a cong en i-ta l, abn o rm a l d eve lop m en t o f th e lym ph a tic sys -te rn . A lth oug h the exac t e t io logy is und e te rm ine d ,it is m ost like ly th e resu lt o f se ques tra t ion o f p rim i-tive em bryo n ic lym ph sacs th a t fa il to e sta b lishn o rm a l co m m u n ica tions w ith the lym ph a tic syste m .

Lym p han g io m as m ay be c lass if ied as s im p le ,cave rno us, a nd cystic . In 65 % of cases, the m ass isp re sen t a t b irth ; and in up to 90 % , it is a pp aren t byF ig u re s 2 5 A ,B & CT h is 3 7 ye ar o ld w om an ha d a pa lpab lerigh t ax illa ry m as s. A d iffuse m ass w ith alow CTattenuation of 10 1 5 H iseen(a rro ws ). T he m ass is h om ogen eou s a ndd is pla ces ra th er th an in vad es m usc lep lan es. N otice th e sh a rp p la nes be -tw e e n th e tum or m ass an d th e ad ja -cen t m usc le . T h e supe rio r asp ect o f them ass e xte nde d th roug h th e ap ex o f thea xilla in to the pos te rio r tr ia ng le o f then ec k. T his le sio n w as s urg ic ally p ro ve dto b e a cy stic hy gro ma.

the end o f th e second year o f life . T h ough m o stco m m o n ly fou nd in the n eck , cystic hyg rom asm a y o ccu r in the a x illa 20 -21 ) . T he m asse s u sua llya re h om oge neou s and sm oo th . T hey d isp lace ,bu t d o no t invade , ad jace n t m uscu la r s truc tu re s.C ys tic hyg rom a s h ave a C T a tten ua tion o f I 0 to30 H w h ich , thou gh low , is h ig he r than th a t o fw a te r. T he y can be d iffe ren tia ted from lip om asth a t ha ve a fa tty a tten ua tion o f - 90 to - 12 0 H .


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03(a3

-4CB0U)

Fishman et al. CTo fthe ax illa

V o lu m e 6 , N u m b er 3 { 1 4 9 }M ay, 19 86 { 1 4 9 }Rad ioGraph ic s 4 9 7

2 . L ipo m a (F ig u re 2 {243 })ipom as are ben ignfa ity tum o rs th a t com m on ly occu r in th e ex-trem ities , tho ugh they m ay o ccu r in o the r loca -t ion s inc lud ing the a x ilia . T h ey a re usua lly w e ll de -f ine d , sha rp ly m arg ina ted , ho m og ene ous , fa itym asses an d m ay co n ta in occas ion a l se p ta tion s.

C T a ttenu a tion va lu es a re h ig h ly accu ra te inthe d ia gnos is o f fa ily tum ors (6 ). L ip om a s ha ve acha racte ris tic C T a tte nua tion o f - 90 to - I 2 0 H ,w h ich is usu a lly less th an or eq ua l to th e a ttenu a -t ion o f no rm a l sub cu tane ous fa t. T h is co m pa risoncan he lp d is tingu ish lipo m a s from lipo sa rcom as,the C T a ttenu a tion o f w h ich is usua lly h ig he rthan th a t o f no rm a l fa t. A no the r d is tinc tio n is t ha tliposa rco m a s, un like lipo m as , a re o fte n in f iltra tive

w ith poo rly de fined m arg ins . L ipom as are usua llyava scu la r w hen stu d ie d w ith an g iog raph y, andthe y u sua lly do no t sh ow an y con tras t enh ance -m en t on C T . L ipo sa rcom as, on the o the r han d , a retyp ica lly he te roge neo us a nd sh ow co n tra s t en -ha nce m en t bo th on an g io g rap hy and C T 12 ) .

A lipom a m ay firs t b e n o ted c lin ica lly as aso lid m a ss , w h ich m a y fee l h a rd bu t is u sua lly n o ttend e r o r pa in fu l. B a sed so le ly o n c lin ica l exa m i-na tio n , how ever, it m ay be im p oss ib le to d is tin -gu ish a ben ign lip om a fro m a m a lig nan t fa llytum or. C T scan n in g m akes th is d iffe ren tia tion p os -sib le.

F ig ure s 2 6A & BT his 3 yea r o ld g irl had a p alp ab le righ t a xilla ry m ass . A d iffuse m as s is s ee n in f il-tra t ing the rig ht a xilla . T he m ass d is pla ce s th e ax illa ry v ein an te rio rly (a rrow ); itsa tte nua tion is - 90 H . The a ppe aran ce is c ons is ten t w ith th a t o f a lipo m a.


24/28

U0E3

I-Ca)C0m

CTofthe a x illa Fishman et al

4 9 8 Rad ioGr aph ics { 1 4 9 }M a y, I 986 { 1 4 9 }o lum e 6 , N um b er 3

3 . D esm o id T um or (F igu re 2 7 ) A desm o idt u m o r 1) (a gg re ss ive fib rom ato s is ) re p resen ts am a ss o f b en ign , invas ive fib ro us tis sue w h ich p ro lif-e ra tes in va rio us ana tom ic a re as. T h e m a ss , co n -s ide red by som e ins titu tion s to be a lo w grad efib ro sa rcom a, m ay be e ithe r d iffuse ly in filtra tive o rfa ir ly w e ll d e fin ed w ith a p se udocap su le .

A de sm o id tum or ten ds to invade n earbystru c tu re s m ak ing to ta l su rg ica l exc is io n d ifficu lt.T he frequ ency o floca l recu rrence w as 63% in o nela rge se ries , a nd 77% in ano the r. it is usu a llyne cessa ry fo r pa tien ts to rece ive pos tope ra tiverad ia tion , p a rticu la rly if the tum or is n o tto ta lly ex-c ised .

O n une nha nced C T sca ns , the a ttenu a tio n o fd esm o id tum o rs is usua lly s im ila r to tha t o f m u sc le ,a nd the les ion s m ay o r m ay n o t be w e ll de fin ed .F o llo w ing th e bo lus in je c tion o f an iod ina te d con -tras t a gen t, th e les io ns enh ance , an d a ppe ar w e llm arg ina te d , in m os t cases , de sp ite the p re sen ceo f m icro scop ic invas ion 1 1 ).

T he ax illa is no t a ra re lo ca tion fo r thesetum ors . In on e se ries , 3 o f I 3 les ion s occu rre d in th eche st w a ll o r ax illa . W h en a de sm o id tum or occu rsin th e a x illa , the re m ay be nerve invo lvem e n to w ing to d iffuse in filtra tion by the tu m or m ass.

F ig ure 2 7A & BT h is 3 0 year o ld w o m an had a p a lp ab le righ t a x illa ry m ass. C T se ctions sh ow ala rge m as s (a rro ws ) in filtra ting the righ t a xilla , pa rt icu la rly a ro und the leve l o fthe n euro vas cu la r b und le . F ollo wing th e in je ction o fa co ntras tag en t,the m as se nha nc es ind ica ting tha t it is hy pe rvas cu la r. T his le sion w as p rov ed a t b iop sy tob e a desm oid tum or.


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C

A second (C T ) s tud y w as pe rfo rm ed to eva lua te th e ad equ acy o f the rad ia tionthe rapy fie ld . N otice tha t by ch ang ing the po s it ion o f the pa tien ts a rm , thethe rapy fie ld is a lte red (C &D ). (C om pare the p os itio ns o fthe hum era l head a ndscapu la in F igu re s 27A and 27D .) T he pa tien t w as fina lly trea te d w ith he r h andp laced on he r h ip . T h is a llow ed the de live ry o f the g rea te st poss ib le rad ia tio ndos e to the tum or, w hile irrad ia tin g the sm alles t po ss ib le vo lum e o f un derly in glung.

F ishm an et a l.

V o lum e 6 , N um ber 3 { 1 4 9 }M ay , I 986 {149}Rad ioGraph ic s 4 9 9

CT of the ax illa

F ig ure 2 7ET his ra dia tion s im ula tion film w as co n-s truc te d o n the ba s is o f th e C T im ag es.

03(a3-4CB0U)


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CTo f th e ax illa Fishman et al

5 0 0 Rad loGraph ic s { 1 4 9 }M ay , 198 6 { 1 4 9 }V o lum e 6 , N um b er 3

C . O T H E R M A LIG N A N T N E O P LA S M S (F ig u res 28 & 29 )A lth oug h ra re , p rim ary n eop lasm s o f fib ro us tissue , m u sc le o r fa t do

occu r in the ax ilia . T he tum ors c lass ica lly do n o t respec t so ft t issue andm usc le p lane s. T h ese m asses m ay ex ten d h igh in th e ax ilia , p ro duc ing anin itia l c lin ica l co m p la in t re la ted to b rach ia l p le xus invo lvem en t, o r the ym ay sp rea d a lo ng the ch es t w a ll.

P rim a ry tum ors o f th e h ead a nd n eck , lu ng a nd k idne y m ay a ll m e ta s-tas ize to the a x illa ry lym ph n ode ch a in s. T he C T app eara nce o f m e tas -tases to th e a x illa m ay s im u la te p rim ary tu m o rs o r lym ph om a 423 ) .

F igu re 28T h is 30 year o ld m an h ad neu ro b la s to m a w ith ex ten s ive m etas tases to th e le ftax illa ry no des . N otice the e xten s ion o f ade nop a thy h ig h in to the ap ex o f th eax illa be nea th the p ecto ra lis m ino r m usc le m ed ia lly (a rro w).


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F ishm an et a l CT of the ax illa

V o lum e 6 , N um ber 3 { 1 4 9 }M ay , 1 986 {149}Rad ioGr aph ics 5 0 1

F ig ure s 2 9A & B(A ) T h is 5 5 yea r o ld m an had a p a l-p ab le rig ht a xilla ry m a ss . C ls ec tio nssho w a 5 cm m ass w hich en han cedp erip he ra lly fo llo win g th e in fu sio no f a con tra s t a gen t. T he tum or in f il-tra te d th e neuro va scu la r bu nd le re -su itin g in a tro phy o f the m usc le s o fthe rig ht sho uld er. B iop sy o f th etum or m ass w as in te rp re ted assh ow ing an ap la stic c arc inom a, p ri-m ary in the ax illa . (B ) A sequ ence o fim ages o f th e righ t ax illa sho w s thefu ll ex ten t o fthe m ass an d itsre la tio ns hip to t he n eu ro va sc ula rbund le .

B

03.0

a(a3a3z0aU)BU)


28/28

CTof th e a x illa Fishman et al

C T o f the ax illa is ind ica te d in :VIII . Conc lus ion

S e va lua ting a c lin ica lly pa lpa b le m ass to de te rm in e its e tio logy and e x-tent.

{149 }va lua ting th e cau se o f c lin ica lly ap pare n t b rach ia l p lexu s p a tho log yin a pa tie n t w ith a neg a tive phys ica l exam ina tion .

{149 }tag ing a kno w n m a lig nan t n eop lasm (i.e ., b re as t can ce r, lym p hom a). {149 }va lua ting th e ade quacy o f a rad ia t ion the ra py port in a pa tien t w ith a

kno w n ax illa ry tum or. {149 }uan tify ing tum o r respo nse to ch em o the ra py o r rad ia tion th e rap y.

References1 . A b ram ow ilz D . Zo rnoza J , A ya la AG . R om sdah l MM . So ft t is -

s u e desm oid tum o rs : R ad iog raph ic bone changes . R ad io l-o gy 19 83 ; 1 46 :1 1 1 3.

2 . Co llie r B D . P a lm er DW , W ils on JF , G re enbe rg M , K om ak i R ,C ox JD , L aw son IL , L aw lo r PM . In te rn a l m amm a ry lym pho -sc in tig ra p hy in p a tie n ts w ith b rea s t ca nce r. R a d io log y1 98 3 ; 1 4 7: 8 45 8 4 8 .

3 . E lle r t J , K re e l L . Th e ro le o f com pu ted tom og raphy in th ein i t ia l s ta g ing a nd sub se qu e n t m a na ge m e n t o fthe lym -ph om as . J C om pu tA ss is t T om og r 1 98 0 ; 4 :36 8 -3 9 1 .

4 . Fe in s te in R S , G atew ood 0M B . F ishm an EK . G o ldm an SM .S ie ge lm an 5 5 . C o m p u te d to m og ra ph y o fad u lt n e u ro b la s -tom a. J C om pu tA ss is tT o m o gr 1 9 84 ; 8 :72 0 -72 6 .

5 . F reu nd lich IM , L ib sh itz H I, G lass m a n LM , Is rae l H L . S a r-co idos is - lyp ic a l a n d a lyp ica l th ora cic m an ife sta tion san d co m p lic a tio n s . C lin R a d io l 19 70 ; 2 1 :3 76 -38 3 .

6 . F rie dm an AC , H artm an DS , She rm an JL , Lau tin EM ,G o ld m a n M J. C T o f a bd o m in a l fa lly m a sse s . R a d io lo gy1 9 81 ; 1 3 9: 4 15 4 2 9 .

7 . G e ba rsk i K S . G la ze r G M . G eb a rsk i S S . B rach ia l p le xu s :A na tom ic , rad io lo g ic an d p a th o log ic c o rre la tio n u s ingcom pu ted to m o gra p hy . J C om p u t A s s is t To m o g r 1 98 2 ;6:1058 1063.

8 . G ordo n R F , P a rk in JL . Ly m p ha ng io m a o fth e h e ad a ndne ck . E a r N os e T hro a t J 1 98 2 ; 6 1 :3 3 8 -3 4 2 .

9 . H a ag en se n C .A n a to m y o fthe m a m m ary g lan d & th e na t-u ra l h is to ry o f b re as t ca rc in om a. In : H a a ge ns en C . D is -eases o fth e b reas t. 2 nd ed . W B Saunders , Ph ilad e lph ia .19 71 :3 4 52 a nd 39 7 41 3.

I 0 . H in z 1W , B e rn a rd ino M E , S on e s P J . C I sc an eva lu a tion o fb ra ch ia l p le xus ne urop a th y in b rea s t ca nce r. N o n in vas iveM ed ic a l im a g ing 1 98 4 ; 1 :69 -73 .

I 1 . H u dso n T M , V an d erg rie n d R A S prin g fie ld D S , H a w k ins IF J r.S p an ie r 5 5 , E n ne k in g W F, H a m lin D J . A g gre ss ive fib ro -m a to s is : E va lua tio n o f co m p u te d tom og ra ph y a n d an g i-og ra ph y . R ad io log y 1 98 4 ; 1 50 :49 5 -50 1 .

12 . H u n te r J C . Joh n s ton W H , G e na n t H K . C o m p u te d tom og -ra p hy e va lu a tion o f fa lly tu m ors o f the s om atic so ft t iss ue s :C lin ica l u ti li ly a n d rad io lo g ic -p a th o log ic co r re la tion .S ke le ta l R ad io l 1 97 9 ; 4 :79 -9 1 .

13 . L e s te r R G . T h e co n tribu tio ns o f rad io lo gy to th e d ia gn o s is ,m an a ge m e n t. an d c u re o f b rea s t ca nce r. R ad io lo g y I 9 8 4 ;151:1 7.

14 . M c D iv iff R W . S te w art F W , B e rg JW . T u m o rs o fth e b rea s t. In :M cD iv iff R W. S tew ar t F W , B erg J W . A tlas o ftum or pa tho lo gy .2n d S eries , F a sc ic le 2 , A rm e d F orc es Ins titu te o f P a tho lo gy ,W ash in gto n. D .C .. 19 68 :1 12 -11 6.

15 . M c Le od R , R em in g to n JS . T o xop la sm os is . In : P e te rsd o rf R G ,A da m s R D . B ra un w a ld E , I sse lb ac he r K J , M artin JB . W ilso nJD . ed s . H a rrison s p rinc ip le s o f in te rn a l m e d ic ine . 1 0 th e d .M cG ra w-H ill, N ew Y ork , 1 98 3:1 200 -1 20 6.

16 . M ey er JE , L ing g oo d R M , L ind fo rs K K . M cC lo ud T C . S to m p e rP C . Im p a c t o f tho rac ic c om pu ted tom og ra ph y on ra d ia -tio n the ra py p la n n ing in H o d gk in d is ea se . J C om pu t A ss is tT om ogr 1 98 4 ; 8 :8 9 2 -8 94 .

I 7 . P an sky B . U p pe r ex trem ity . In : P an sky B . R e v iew o f g ros san a to m y, 4 th ed . M acM illa n P ub lish in g . N e w Y ork ,1979 :188 -205 .

I 8 . P ug a tc h R D . F a ling U , D a ly B D T . C T in ev a lua tio n o f th em e d ias tinu m o f p a tien ts w ith b ron ch og e n ic ca rc in o m a .In : S ieg e lm a n 55 , ed . C o n te m p ora ry issu es in co m p u te dtom og ra ph y - c om p u te d to m o g rap hy o fth e che s t, V o l 4 .C hu rch ill L iv in gs to n e . N ew Y ork 19 8 4 :2 1 -3 6 .

19 . R o bb in s S L . C otran R S . I n fe c tio u s d ise as es . In : R o bb in s S L ,C o tra n R S . P a tho lo g ic ba s is o f d ise a se . 2n d e d . W B S au n -de rs , P hila de lp hia , 19 79 :4 62 -46 3.

2 0 . S ch nyd e r P A G a m su G . C T o fthe p re trach e a l spa ce . A JR1 98 1; 1 36 :3 03 -3 08 .

21 . S ilve rm a n P M , K orob k in M , M o o reA V . C T d iag no s is o f cys tichy g ro m a o fthe n e ck . J C om pu tA ss is tT o m o gr 1 98 3 ; 7 :5 19 -5 2 0 .

22 . S ne Il R . T he uppe r lim b . In : Sne ll R . C lin ic a l a n a tom y fo rm e d ica l s tud e n ts , 2 nd e d . L itt le , B row n & C om pa n y , B os -t on , 1 9 72 :3 5 1- 38 5 .

23 . S ta rk D D . M oss A A , B rasch RC , d eLo rim ie r A k A lb in A R , Lon -d on D A G oo d ing C A N e urob la s tom a: D iag n os tic im a g in ga nd s ta g ing . R ad io lo g y 1 98 3 ; 14 8 :1 0 1 -1 05 .

24 . W oodbu rn e R . T he upper lim b . In : W oodbu rn e R . E ssen t ia lso f hum an ana tom y , 6 th ed . O x fo rd U n ive rs ily P re ss , N ewY o rk , 1 9 78 :6 7 -9 0 .

T he au tho rs w ish to th an k W in th rop -B reo n La b ora to ries fo rtheir s up p ort o fth is p ro jec t. S p e c ia l th an ks to D a n P e te rs a n dD o n E va ns o fW in th ro p -B reo n . W e a ls o w o u ld like to tha n kA de line 14 Jo nso fo r he r he lp in m anu sc rip t p re pa ra tion ,M a rjo rie G re ge rm a n fo r d es ig n ing an d p rod u c in g th e e xh ib it,a nd B a rry L a sne r fo r ph o to g rap h ic ass is ta nce .

ct scan of the axilla

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