Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps.

Background: Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments. Methods: At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed. Results: No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection. Conclusion: Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Transaortic removal of a large primary sarcoma from the left ventricle assisted by strategic partial resection and endoscopic guidance: a case report.

BACKGROUND: Surgical resection remains the mainstay of treatment for cardiac sarcoma, a rare but lethal disease. Achieving complete removal of a large-sized left ventricular sarcoma remains a challenge even with various surgical approaches that have been employed. CASE PRESENTATION: We present a case of a 74-year-old woman with shortness of breath who underwent surgical removal of a primary cardiac sarcoma, measuring 6 × 3.5 × 3 cm, attached to the septum of the left ventricle and caused sub-aortic valve obstruction. Transaortic approach was chosen and the access to this entire huge mass was enabled by using interim partial resection which created a space for further dissection and subsequent deeper endoscopic views. The further dissection was finally able to be advanced on the apex, and the residual mass was completely resected with gross tumor-free margins. CONCLUSION: Interim partial resection and endoscopic guidance can highly facilitate the transaortic removal of even large left ventricular sarcomas.

Continuous vagal intraoperative neuromonitoring during video-assisted thoracoscopic surgery for left lung cancer: its efficacy in preventing permanent vocal cord paralysis.

OBJECTIVES: We investigated the safety and efficacy of continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic lobectomy for left lung cancer in preventing recurrent laryngeal nerve injury. METHODS: From August 2015 to March 2020, 22 patients with left lung cancer without CIONM (unmonitored) and 20 patients with left lung cancer with CIONM underwent thoracoscopic lobectomy with complete mediastinal lymph node dissection including 4L dissection. Clinical outcomes from these 2 groups were compared. RESULTS: The incidence of 4L metastasis was 7.14% (3 patients). There was no significant difference in the total number of dissected 4L lymph nodes between the 2 groups (3.23 ± 2.2 in the unmonitored group, 3.95 ± 2.0 in the CIONM group). CIONM was successful in all of the cases. There was no significant difference in the incidence of postoperative vocal cord palsy (22.7% in the unmonitored group, 20% in the CIONM group, P = 1.000). All of the 5 patients (100%) had permanent vocal cord palsy in the unmonitored group. Although statistically insignificant, 75% (3 patients) had total recovery of the vocal cord function, with only 1 patient remaining in permanent vocal cord palsy in the CIONM group. CONCLUSIONS: CIONM was safe and efficient. CIONM might be helpful to avoid permanent vocal cord palsy by immediately warning the surgeon about impending nerve injury, so the surgeon can stop delivering further injury to the recurrent laryngeal nerve.

Comparable Clinical Outcome Using Small or Large Gross Tumor Volume-to-Clinical Target Volume Margin Expansion in Neoadjuvant Chemoradiotherapy for Esophageal Squamous Cell Carcinoma.

The purpose of this study was to evaluate the feasibility of small primary gross tumor volume (GTV)-to-clinical target volume (CTV) margin expansion in neoadjuvant chemoradiation for esophageal squamous cell carcinoma. Medical records of 139 patients with locally advanced esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiation and radical esophagectomy were retrospectively reviewed. Patients treated with longitudinal primary GTV-to-CTV margin expansion of 2 cm and no additional expansion of the CTV through the esophagus were classified into a small margin (SM) group (37 patients). The remaining 102 patients were classified as a large margin (LM) group. Patterns of recurrence including local and out-field regional recurrence rates were compared between the two groups. Clinical outcomes including rates of local control, regional control, failure-free survival, and overall survival were also compared. More patients in the SM group underwent paclitaxel + carboplatin, Mckeown esophagectomy, and intensity-modulated radiation therapy than in the LM group. With a median follow-up of 25.6 months, there was no significant difference in the crude rate of local recurrence (10.8% vs. 6.9%, P=0.694), out-field regional recurrence (27.0% vs. 19.6%, P=0.480), or out-field regional recurrence without in-field recurrence (10.8% vs. 12.7%, P=0.988) between the two groups. There was no significant difference in failure-free survival (5-year, 34.4% vs. 30.6%, P=0.652) or overall survival (44.1% vs. 38.5%, P=1.000), either. Esophageal fistula was not reported in the SM group (0.0% vs. 7.9%, P=0.176). In conclusion, a radiation field with 2 cm of longitudinal primary GTV-to-CTV was feasible in the neoadjuvant setting for esophageal squamous cell carcinoma treatment.

Is Hypertrophic or Keloid Wound Scar a Risk Factor for Stricture at Esophagogastric Anastomosis Site after Esophageal Cancer Operation?

Background/Aims: Anastomotic stricture at the esophagus and the conduit anastomosis site after the surgical resection of esophageal cancer is relatively common. This study examined whether a hypertrophic scar or keloid formation at a surgical wound is related to an anastomotic stricture. Methods: From March 2007 to July 2017, 59 patients underwent curative surgery for esophageal cancer. In 38 patients, end-to-end anastomosis (EEA) of the esophagus and the conduit was performed using EEA 25 mm. A hypertrophic wound scar was defined when the width of the midline laparotomy wound scar exceeded 2 mm. The relationship between the hypertrophic scar and stricture and the other risk factors for anastomotic stricture in these 38 patients was analyzed. Results: Of the 38 patients, eight patients (21.1%) had an anastomotic stricture, and a hypertrophic skin scar was observed in 14 patients (36.8%). Univariate analysis revealed lower BMI and hypertrophic scars as risk factors (p=0.032, p=0.001 respectively). Multivariate analysis revealed a hypertrophic scar as an independent risk factor for an anastomotic stricture (p=0.010, OR=27.06, 95% CI 2.19-334.40). Conclusions: Hypertrophic wound scars can be a risk factor for anastomotic stricture after surgery for esophageal cancer. An earlier prediction of anastomotic stricture by detecting hypertrophic wound healing in patients undergoing esophagectomy may improve the patients' quality of life and surgical outcomes by earlier treatments.

Clinical significance of radiation dose-volume parameters and functional status on the patient-reported quality of life changes after thoracic radiotherapy for lung cancer: a prospective study.

PURPOSE: To date, limited data exist about the relationship between radiation dose-volume parameters and patient-reported quality of life (QOL) after thoracic radiotherapy (RT) for lung cancer. We conducted this prospective study to investigate which clinico-dosimetric factors have an impact on functional declines and symptom developments after thoracic RT for lung cancer. MATERIALS AND METHODS: The study included 44 patients who had underwent thoracic three-dimensional conformal RT at our institution from 2016 to 2017. The health-related QOL was assessed using the EORTC QLQ-C30 and QLQ-LC13 questionnaires before RT (preRT), at the end of RT (endRT), and 3, 6, and 12 months after the completion of RT. RT dose-volume parameters of adjacent normal organs such as the lung, heart, and esophagus were retrieved and used for regression analysis. RESULTS: Thoracic RT induced a temporary deterioration of many of the functional statuses and symptoms, but most of those improved and recovered to baseline levels 3 months after RT. However, the role function (RF) decline persisted until 6 months after RT (p < 0.05). Dysphagia showed the most noticeable change at the endRT (p < 0.001). In the multiple regression analysis, the absolute volume of body received at least 50 Gy (p = 0.021) and a preRT RF score (p = 0.001) was significantly associated with the endRT RF scores. Dysphagia at the endRT was significantly associated with the V40 of the esophagus (p = 0.047), preRT emotional function (p = 0.029), and receipt of concurrent chemotherapy (p = 0.022). CONCLUSIONS: Both the dosimetric parameters and preRT functional status have an impact on the weak aspect of patient-reported QOL, which may cause poor treatment compliance during and after thoracic RT. For patients with a low preRT QOL score or those having large tumor which may result in higher dose volumes, careful RT planning could prevent the deterioration of QOL after RT.

Pulse wave velocity is a new predictor of acute kidney injury development after off-pump coronary artery bypass grafting.

BACKGROUND: Brachial-ankle pulse wave velocity (baPWV) is the simple, non-invasive, gold-standard method for assessing arterial stiffness. However, baPWV has been shown to be associated with renal dyfunction, with a few reports demonstrating an association between baPWV and postoperative acute kidney injury (AKI) among surgical patients. METHODS: We retrospectively analyzed preoperative baPWV data that were prospectively collected from 164 patients who underwent off-pump coronary artery bypass grafting (CABG) between April 2013 and July 2019 (mean age: 66.2 ± 10.3 years, 29.3% females). Primarily, baPWV was investigated as an independent predictor of postoperative AKI development; secondarily, the patients were divided into high and low PWV groups according to the optimal baPWV cut-off value. Postoperative complications, mortality, and mid-term survival were compared between the two groups. RESULTS: AKI developed in 30 patients (18.3%). Univariate analysis showed that AKI was significantly associated with baPWV (20.2±7.3 vs. 16.2±2.8 m/s, p < 0.001), age, preoperative serum creatinine, and EuroSCORE. Multivariable logistic regression analysis revealed baPWV as independently associated with postoperative AKI even after adjustment for preoperative creatinine, old age (> 75 years), hypertension, diabetes under insulin therapy, and EuroSCORE. Moreover, area under the curve (AUC) analysis indicated that PWV can predict AKI better than preoperative creatinine levels (AUC, 0.781 [95% confidence interval, 0.688-0.874] vs. 0.680 [0.568-0.792]). The group-dividing baPWV cut-off value for AKI was 19 m/s. There were no 30-day mortality. The in-hospital mortality rates in the high and the low PWV groups were 2.2% (n = 1) and 0.8% (n = 1), respectively (p = 0.484). Midterm survival rates were not different between the two groups, but the rate of composite neurologic complication composed of stroke and delirium, was higher, and rate of mechanical ventilatory support was longer, in the high PWV group. CONCLUSION: Brachial-ankle pulse wave velocity was an independent predictor of postoperative AKI following off-pump CABG, and high baPWVs may affect the composite neurologic outcome and the duration of mechanical ventilatory support.

Feasibility of Attachable Ring Stimulator for Intraoperative Neuromonitoring during Thyroid Surgery.

OBJECTIVE: Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator. METHODS: Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point. RESULTS: Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500 µV. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279 µV, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217 µV, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99 µV, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2. CONCLUSION: The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.

Application of Continuous Intraoperative Neuromonitoring During VATS Lobectomy for Left Lung Cancer to Prevent Recurrent Laryngeal Nerve Injury.

We applied continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic surgery (VATS) lobectomy for left lung cancer and evaluated its safety and usefulness. An electrode was attached to a double-lumen tube, and placed at vocal cord level to detect the EMG signal evoked by vocal cord movement. Before 4 L lymph node dissection, an automatic periodic stimulation device was applied to the vagus nerve to stimulate vagus nerve continuously. Surgery was suspended if the amplitude decreased lower than the threshold and was resumed when the amplitude recovered. Ten patients (6 male, 4 female) were enrolled. CIONM was successfully performed in all patients without technical failure, and there was no hemodynamic instability. Amplitude decreased below the threshold in four patients. One patient did not recover amplitude and experienced transient vocal cord palsy. In the three other patients, the amplitude recovered above the threshold and no vocal cord palsy occurred. The six patients who did not exhibit amplitude decrease experienced no vocal cord palsy. Our results suggest that CIONM may be applied safely for VATS left lobectomy and may be used to predict postoperative vocal cord function. This approach may be helpful to prevent RLN injury during VATS left lobectomy.

Association between Image Characteristics on Chest CT and Severe Pleural Adhesion during Lung Cancer Surgery.

The aim of this study was to investigate the association between image characteristics on preoperative chest CT and severe pleural adhesion during surgery in lung cancer patients. We included consecutive 124 patients who underwent lung cancer surgeries. Preoperative chest CT was retrospectively reviewed to assess pleural thickening or calcification, pulmonary calcified nodules, active pulmonary inflammation, extent of emphysema, interstitial pneumonitis, and bronchiectasis in the operated thorax. The extent of pleural thickening or calcification was visually estimated and categorized into two groups: localized and diffuse. We measured total size of pulmonary calcified nodules. The extent of emphysema, interstitial pneumonitis, and bronchiectasis was also evaluated with a visual scoring system. The occurrence of severe pleural adhesion during lung cancer surgery was retrospectively investigated from the electrical medical records. We performed logistic regression analysis to determine the association of image characteristic on chest CT with severe pleural adhesion. Localized pleural thickening was found in 8 patients (6.5%), localized pleural calcification in 8 (6.5%), pulmonary calcified nodules in 28 (22.6%), and active pulmonary inflammation in 22 (17.7%). There was no patient with diffuse pleural thickening or calcification in this study. Trivial, mild, and moderate emphysema was found in 31 (25.0%), 21 (16.9%), and 12 (9.7%) patients, respectively. Severe pleural adhesion was found in 31 (25.0%) patients. The association of localized pleural thickening or calcification on CT with severe pleural adhesion was not found (P = 0.405 and 0.107, respectively). Size of pulmonary calcified nodules and extent of emphysema were significant variables in a univariate analysis (P = 0.045 and 0.005, respectively). In a multivariate analysis, moderate emphysema was significantly associated with severe pleural adhesion (odds ratio of 11.202, P = 0.001). In conclusion, severe pleural adhesion might be found during lung cancer surgery, provided that preoperative chest CT shows substantial pulmonary calcified nodules or emphysema.

Banked vena caval homograft replacement of the inferior vena cava for primary leiomyocsarcoma.

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor. Herein, we report the case of a 52-year-old male patient who had postprandial abdominal distension and right upper quadrant abdominal pain. The abdominal computed tomography (CT) angiogram showed an IVC mass extending from the infrahepatic to the suprarenal inferior vena cava. The radiologic findings were suggestive of an IVC leiomyosarcoma. Surgical resection and reconstruction with a cryopreserved homograft were performed. The follow-up abdominal CT angiogram revealed the patient to be disease-free 6 months after surgery with patency of the IVC and renal vein.

Successful Endovascular Management of Intraoperative Graft Limb Occlusion and Iliac Artery Rupture Occurred during Endovascular Abdominal Aortic Aneurysm Repair.

For high-risk patients, endovascular aortic aneurysm repair (EVAR) is a good option but may lead to serious complications, which should be addressed immediately. A 75-year-old man with a history of abdominal surgery underwent EVAR for an aneurysm of the abdominal aorta and iliac arteries. During EVAR, iliac artery rupture and graft limb occlusion occurred, and they were successfully managed by the additional deployment of an iliac stent graft and balloon thrombectomy, respectively. We, herein, report a rare case of the simultaneous development of the two fatal complications treated by the endovascular technique.

A case of bilateral giant bullae in young adult.

Giant bullae are large bullae occupying at least one-third of the hemithorax and surgical bullectomy is the treatment of choice. We report a case with symptomatic giant bullae which were resected successfully. A 35-year-old man presented with bilateral giant bullae that occupied almost the entire left hemithorax and a third of the right hemithorax. He was a current smoker with a 30 pack-year history and he presented with dyspnea on exertion. An elective surgical bullectomy was performed with video-assisted thoracoscopic surgery. The patient recovered without any adverse events and stayed well for 1 month after surgery.

Preoperative computed tomography of the chest in lung cancer patients: the predictive value of calcified lymph nodes for the perioperative outcomes of video-assisted thoracoscopic surgery lobectomy.

OBJECTIVES: To determine the predictive value of identifying calcified lymph nodes (LNs) for the perioperative outcomes of video-assisted thoracoscopic surgery (VATS). METHODS: Fifty-six consecutive patients who underwent VATS lobectomy for lung cancer were included. We evaluated the number and location of calcified LNs on computed tomography (CT). We investigated clinical parameters, including percentage forced expiratory volume in 1 s (FEV1%), surgery duration, chest tube indwelling duration, and length of hospital stay. We performed linear regression analysis and multiple comparisons of perioperative outcomes. RESULTS: Mean number of calcified LNs per patient was 0.9 (range, 0-6), mostly located in the hilar-interlobar zone (43.8 %). For surgery duration (mean, 5.0 h), FEV1% and emphysema severity were independent predictors (P = 0.010 and 0.003, respectively). The number of calcified LNs was an independent predictor for chest tube indwelling duration (P = 0.030) and length of hospital stay (P = 0.046). Mean duration of chest tube indwelling and hospital stay was 8.8 days and 12.7 days in no calcified LN group; 9.2 and 13.2 in 1 calcified LN group; 12.8 and 19.7 in ≥2 calcified LNs group, respectively. CONCLUSIONS: The presence of calcified LNs on CT can help predict more complicated perioperative course following VATS lobectomy.

[Clinicopathologic feature of esophageal submucosal tumors treated by surgical approach].

BACKGROUND/AIMS: Submucosal tumors of the esophagus are rare lesions among all esophageal neoplasms. The purpose of this study was to evaluate the clinicopathologic features of esophageal submucosal tumors treated by surgical approach. METHODS: We analyzed the clinicopathologic and endoscopic ultrasonographic features of 18 esophageal submucosal tumors which were treated by surgical approach at Boramae Medical Center and Seoul National University Bundang Hospital from January 2005 to June 2012. RESULTS: The mean age was 48.9 years old and male to female ratio was 2.6 : 1. Asymptomatic patients were most common (77.8%). In endoscopic ultrasonographic finding, the majority tumor arouse in the middle (55.6%) and lower (44.4%) esophagus, and appeared as hypoechoic lesion (72.2%) in the 4th layer (83.3%). The most common indication for surgical approach was unclear biological behavior of the tumor. Minimally-invasive technique using thoracoscopy was applied for the enucleation (83.3%). The mean diameter of the tumor was 5.4 cm, and the final diagnosis was leiomyoma (89.9%) and gastrointestinal stromal tumor (11.1%). CONCLUSIONS: Leiomyoma was the most common submucosal tumor in esophagus. However, endoscopic ultrasonography was not able to differentiate between leiomyoma and gastrointesinal stromal tumor. For more accurate diagnosis and treatment, minimally-invasive approaches may be suitable for the surgical enucleation of indicated esophageal submucosal tumor.

Radial arteriovenous fistula developed late after coronary angiography: a case report.

Transradial access is a widely accepted method for percutaneous coronary diagnostic and interventional procedures, and it has dramatically reduced access site vascular complications compared to transfemoral access. Arteriovenous fistula formation at the access site is an especially rare complication in transradial access. We report an extremely rare case of delayed radial arteriovenous fistula that developed one year after transradial coronary angiography, which was successfully treated by surgical repair.

Well-differentiated liposarcoma of the oesophagus: clinicopathological, immunohistochemical and array CGH analysis.

Liposarcoma develops extremely rarely in the oesophagus. Microscopically, it exhibits subtle atypia of H&E-stained features. Accordingly, immunohistochemical features and chromosomal alterations are used for its confirmatory diagnosis. However, cytogenetic analysis has not been performed for oesophageal liposarcoma. We studied chromosomal alterations using array comparative genomic hybridization (CGH), as well as endoscopic, radiological, H&E-stained and immunohistochemical features in the oesophageal well-differentiated liposarcoma of a 67-year-old man. Array CGH analysis revealed the presence of high-level amplifications at chromosomal locations 1p12-1q21.2, 12q13.2-12q15 and 12q21.33-12q23.1. At least 29 genes were highly amplified (log(2) ratio >2), among which CDK4 and MDM2 were the most highly amplified (log(2) ratio >4) and were accepted as major target genes. Moreover, the amplification of AMDHD1, HAL and LTA4H (log(2) ratio = 3.153) was a novel finding. This case suggests the presence of a characteristic profile of gene amplification in well-differentiated liposarcoma of the oesophagus. The amplified genes may be of pathogenic importance for primary oesophageal well-differentiated liposarcoma.

Pulmonary lymphangioleiomyomatosis: unusual manifestations of multiple large pulmonary nodules with retroperitoneal lymph node involvement mimicking metastatic malignancy.

Pulmonary lymphangioleiomyomatosis (LAM) is a rare, idiopathic disorder that predominantly affects the lung parenchyma of women of childbearing age. While the characteristic radiographic finding of pulmonary LAM consists of multiple well-defined thin-walled cysts, we describe a very unusual case of pulmonary LAM with multiple bilateral large pulmonary nodules and retroperitoneal involvement mimicking metastatic malignancy. A 48-year-old woman who had never smoked with a history of bilateral pneumothorax presented with progressive exertional dyspnea and abdominal discomfort. Imaging studies revealed multiple enlarged retroperitoneal lymph nodes, ascites and bilateral multiple large pulmonary nodules ranging from 3 to 18 mm in diameter. Exploratory laparoscopic surgery for intra-abdominal lesions and video-assisted thoracoscopic wedge resection of lung nodules were carried out to rule out metastatic malignancy. Pathology showed benign looking smooth muscle cell proliferation and immunoreactivity for α-smooth muscle actin and HMB-45 in both specimens. After treatment with GnRH antagonist, the patient was well over a 6-month period without evidence of disease progression.

Adult sail sign: radiographic and computed tomographic features.

BACKGROUND: The sail sign is a well-known radiographic feature of the pediatric chest. This sign can be observed in an adult population as well, but for a different reason. PURPOSE: To investigate the sail sign appearing in adult chest radiography. MATERIAL AND METHODS: Based on two anecdotal adult cases in which frontal chest radiographs showed the sail sign, we prospectively screened radiographs of 10,238 patients to determine the incidence of the sail sign found in adults in their 40s or older. The cause of the sail sign was assessed using computed tomography (CT). RESULTS: The sail sign was revealed in 10 (seven males, three females; median age 60.6 years) of 10,238 patients. Of these 10 patients with a sail sign on frontal radiographs, eight underwent CT. The frontal radiographs of these 10 patients showed a concave superior margin toward the lung in nine patients, a concave inferior margin in five, and a double-lined inferior margin in three. Lateral radiographs disclosed a focal opacity over the minor fissure in five of six patients, which was either fuzzy (n = 4) or sharp (n = 1) in its upper margin, and was sometimes double lined in the inferior margin (n = 3). CT revealed the anterior mediastinal fat to be the cause of the radiographic sail sign, which stretched laterally from the mediastinum to insinuate into the minor fissure. CONCLUSION: The incidence of sail sign on adult chest radiographs is about 0.1%. The sign is specific enough to eliminate the need for more sophisticated imaging.