Operative Management Considerations in a Patient With Multiple Occult Penetrating Cardiac Injuries

Penetrating cardiac injury remains one of the deadliest traumatic injuries. Early identification and definitive operative management are critical tenets for patient survival; however, variable clinical presentations can obscure the diagnosis. Here, we present the case of a 58-year-old obese man who presented to an urban level 1 trauma center with multiple stab wounds to the epigastrium and lateral left chest in the axillary line with an unknown weapon. The patient was taken emergently to the operating room for exploratory laparotomy, median sternotomy, and attempted repair of multiple full-thickness lacerations of the right ventricle and left and right atrium. This case demonstrates several instructive points. First, a high index of suspicion for penetrating cardiac injury is needed, especially during triage of multiple injuries. Second, careful release of cardiac tamponade is critical. Finally, there are several indications for cardiopulmonary bypass, which include multichambered injuries, uncontrollable hemorrhage, and concern for intracardiac injury.

Dosimetric Evaluation of Photons Versus Protons in Postmastectomy Planning for Ultrahypofractionated Breast Radiotherapy

Background: Ultrahypofractionation can shorten the irradiation period. This study is the first dosimetric investigation comparing ultrahypofractionation using volumetric arc radiation therapy (VMAT) and intensity-modulated proton radiation therapy (IMPT) techniques in postmastectomy treatment planning. Materials and methods: Twenty postmastectomy patients (10-left and 10-right sided) were replanned with both VMAT and IMPT techniques. There were 4 scenarios: left chest wall, left chest wall including regional nodes, right chest wall, and right chest wall including regional nodes. The prescribed dose was 26 Gy (RBE) in 5 fractions. For VMAT, a 1-cm bolus was added for 2 in 5 fractions. For IMPT, robust optimization was performed on the CTV structure with a 3-mm setup uncertainty and a 3.5% range uncertainty. This study aimed to compare the dosimetric parameters of the PTV, ipsilateral lung, contralateral lung, heart, skin, esophageal, and thyroid doses. Results: The PTV-D95 was kept above 24.7 Gy in both VMAT and IMPT plans. The ipsilateral lung mean dose of the IMPT plans was comparable to that of the VMAT plans. In three of four scenarios, the V5 of the ipsilateral lung in IMPT plans was lower than in VMAT plans. The Dmean and V5 of heart dose were reduced by a factor of 4 in the IMPT plans of the left side. For the right side, the Dmean of the heart was less than 1 Gy for IMPT, while the VMAT delivered approximately 3 Gy. The IMPT plans showed a significantly higher skin dose owing to the lack of a skin-sparing effect in the proton beam. The IMPT plans provided lower esophageal and thyroid mean dose. Conclusion: Despite the higher skin dose with the proton plan, IMPT significantly reduced the dose to adjacent organs at risk, which might translate into the reduction of late toxicities when compared with the photon plan. Key words: proton therapy, ultrahypofractionation, postmastectomy, breast irradiation

Primary chest wall Burkitt lymphoma in a case of HIV infection with immune reconstitution

Burkitt lymphoma (BL) develops at an increased frequency in patients with HIV irrespective of the CD4 count. Lymph nodes and gastrointestinal tract are common sites of involvement by BL; however, primary chest wall BL is rare. A 52-year-old man on highly active antiretroviral therapy (HAART) for HIV with a CD4 count of 0.204 x 109 cells/L presented with a 3-month history of enlarging chest wall mass. PET-CT scan imaging showed a bulky mass involving the musculoskeletal planes of left chest wall with the involvement of underlying pleura. Biopsy with immunohistochemistry confirmed BL. Patient received EPOCH-R (infusional etoposide, vincristine, and doxorubicin with prednisone, cyclophosphamide and rituximab) regime for six cycles along with HAART, attained complete remission (CR) and remains free of BL at 5 years. BL should be considered in the differential diagnosis of soft tissue masses in HIV-infected patients irrespective of their CD4 count.

Schwannoma of Left Chest Wall: a Case Report and Literature Review

Background: Schwannoma of chest wall is rare intercostal nerve tumor originated from Schwann cells. Here, we present a rare case about schwannoma was misdiagnosed as solitary fibroma by preoperative biopsy. We intend to improve clinicians' understanding of the disease by discussing the clinical manifestations, diagnostic points and differential diagnosis of patients with thoracic wall schwannoma.Case presentation: A 38-year-old male presented with "left chest pain for more than 1 month". Enhanced Computer Tomography(CT) can of the lung revealed space occupying lesions in the left lower posterior chest wall. Preoperative biopsy was solitary fibroma. After the improvement of preoperative preparation, the patients were given surgical treatment, postoperative pathology showed: schwannoma of chest wall. Chest pain improved after operation. The patients were followed up for 8 months.Discussion and Conclusions: Schwannoma, especially in the chest wall, is rare, with atypical clinical symptoms, single imaging manifestations, high variable rate of puncture pathology, and easy to be misdiagnosed. Complete surgical resection of tumor is the main treatment, and no new adjuvant / adjuvant therapy has been reported yet.

VP007 MULTIRECIDIVATED DESMOÍD TUMOR OF THE THORAX-ABDOMINAL WALL

Aim Treatment of recurrent desmoid tumors represents a real challenge for the surgeon. The purpose of the video is to show the treatment of a multirecidivated complex desmoid tumor that affects the lateral thoracoabdominal wall. Material and Methods 24-year-old woman with the diagnosis of recurrent desmoid tumor. She was operated in 2014 for a 10 cm desmoid tumor in the left chest wall with affected margins in the biopsy. In 2016 she underwent surgery for a 5 cm recurrence, which was excised en bloc along with the 6th, 7th, 8th and 9th rib arches. In 2018 she presented a recurrence in the scar treated by radiotherapy. She now presents a recurrence that in the CT scan is seen as an 8 cm tumor that affects the thoraco-abdominal wall. Results We perform a complete resection with free margins and “en bloc” resection of the 8th, 9th, 10th and 11th rib arches. We repair the defect using a reverse TAR and rebuild the wall with the Madrid APPROACH technique with BioA and polypropylene meshes. The patient was discharged 11 days after surgery without any complications. The pathological study showed an 8 cm desmoid tumor with free surgical margins. The patient a year after surgery remains disease free. Conclusions The resection of a desmoid tumor that affects the abdominal and/or thoracic wall, especially if it is recurrent, represents a challenge for the surgeon. Component separation techniques and Madrid APPROACH may be very useful to achieve an optimal repair.

Frailty Assessment Using a Novel Approach Based on Combined Motor and Cardiac Functions: A Pilot Study

Background: Previous research showed association between frailty and an impaired autonomic nervous system; however, the direct effect of frailty on heart rate (HR) behavior during physical activity is unclear. The purpose of the current study was to determine the association between HR increase and decrease with frailty during a localized upper-extremity function (UEF) task to establish a multimodal frailty test. Methods: Older adults aged 65 or older were recruited and performed the UEF task of rapid elbow flexion for 20 seconds with the right arm. Wearable gyroscopes were used to measure forearm and upper-arm motion, and electrocardiography were recorded using leads on the left chest. Using this setup, HR dynamics were measured, including time to peak HR, recovery time, percentage increase in HR during UEF, and percentage decrease in HR during recovery after UEF. Results: Fifty-six eligible participants were recruited, including 12 non-frail (age=76.92±7.32 years), and 44 pre-frail/frail (age=81.23±8.14 years). Analysis of variance models showed that the percentage increase in HR during UEF and percentage decrease in HR during recovery were both 47% smaller in pre-frail/frail older adults compared to non-frails (p<0.01, effect size = 1.42 and 1.17 for increase and decrease percentages). Using logistic models with both UEF kinematics and HR parameters as independent variables, frailty was predicted with a sensitivity of 0.82 and specificity of 0.83. Conclusion: Current findings showed evidence of strong association between HR dynamics and frailty. It is suggested that combining kinematics and HR data in a multimodal model may provide a promising objective tool for frailty assessment.

Left Chest Pain: Possible Causes and What to Do?

Chest pain on the left side can be a sign of heart problems, so it is very common that when it appears, the person thinks they might be having a heart attack. However, this type of pain can also indicate less serious problems, such as excessive intestinal gas, reflux or an anxiety attack, for example. This article aims to carry out a brief review of the literature on the possible causes of pain from the left side of the chest.

Aggressive malignant phyllodes tumor of breast with omental metastases – A case report

Distant metastasis from malignant Phyllodes tumour (PT) is rare. They generally metastasize to the lung, bone, pleura, and liver. We present a very rare case of a 25-year-old woman with intraabdominal metastases from malignant phyllodes tumour of the breast. She presented with left breast lump and the biopsy was Phyllodes tumour. She underwent a two staged surgery; left modified radical mastectomy followed by left latissimus dorsi musculocutaneous flap cover. She received adjuvant radiation therapy to left chest wall. Following which she developed intrabdominal mass which was proven to be metastasis from Phyllodes tumour. She was then advised palliative chemotherapy. Malignant Phyllodes with distant metastases has a dismal prognosis. We propose it is preferable to have a CT Thorax and Abdomen as a staging workup for patients with malignant PT to identify those with poor prognosis.

Tricuspid chordal rupture following stab injury: a case of successful repair

We report a case of a 32-year-old male patient who sustained an isolated stab injury to the left chest wall. He was initially treated with emergency surgery for right ventricular free wall rupture, with an uneventful postoperative course. During follow-up, the patient complained of exercise intolerance and dyspnea on effort. Transthoracic echocardiography (TTE) demonstrated a previously undiagnosed severe tricuspid regurgitation due to flail of the anterior leaflet and a ruptured chorda. A redo operation was scheduled, and the valve was successfully repaired, with different techniques employed. This case highlights the importance of careful clinical evaluation of victims of chest penetrating trauma and how early diagnosis of hidden valvular lesions might increase the odds of valve repair. It also demonstrates the clover technique as a valuable technique in the correction of traumatic tricuspid regurgitation.