Successful surgical management of polyostotic costal fibrous dysplasia-a case report.

Polyostotic costal fibrous dysplasia is a rare cause of chest pain. This report describes a young male with polyostotic fibrous dysplasia with partial vertebral involvement, who presented to us with disabling pain refractory to medical therapy. He was managed successfully with resection of dysplastic ribs, while conserving the asymptomatic vertebral lesion.

Predictors of postoperative complications after sternectomy on oncologic patients.

BACKGROUND: Chest wall tumors are uncommon. The surgical objective is local disease control and the relief of symptoms. Due to the heterogeneity of cases, the great variety of reconstructions, size of resection, and clinical and surgical outcomes are still uncertain. METHODS: Patients were submitted to sternectomies for tumors between 1997 and 2019. Oncological, and surgical characteristics were taken into consideration. The outcomes were related to the size of resection and classified into local and systemic complications. The authors used univariate and multivariate analyses to determine predictors of complications. Survival analysis and Kaplan-Meier curves were obtained. RESULTS: Thirty resections were performed due to metastatic disease. Partial sternectomy was accomplished in 48.8 %, followed by subtotal in 40 %. Primary closure using Pectoralis major was performed in 48.8 %, and Latissimus dorsi in 35.5 %. Polypropylene mesh was used in 86.6 % of reconstructions. The prosthesis removal was necessary in 6.66 %. Respiratory failure was evidenced in 6.66 %. The resection area was a predictor of local and systemic complications (p = 0.0029; p = 0.0004 respectively) in univariate analysis. However, the size of resection was the only predictor of systemic complications regarding multivariate analysis (p = 0.014, 95 % CI 1.00‒1.07). CONCLUSION: The size of the resection was related to systemic complications, and the mesh reconstruction resulted in a low percentage of prosthesis removal and respiratory failure. This suggests a high resistance to local issues and a low respiratory failure rate.

Intravenous Bolus Injection of Fentanyl Triggers an Immediate Central and Upper Airway Obstructive Apnea via Activating Vagal Sensory Afferents.

Intravenous bolus (IVb) injection of fentanyl induces an immediate apnea, but the characteristics of the apnea and relevant mechanism remain unclear. Here, we tested whether IVb injection of fentanyl induced an immediate central and upper airway obstructive apnea associated with chest wall rigidity via activating vagal C-fibers (VCFs) and vagal afferent opioid receptors (ORs). Cardiorespiratory and electromyography of external and internal intercostal, thyroarytenoid and superior pharyngeal constrictor muscles (EMGEI, EMGII, EMGTA and EMGSPC) responses to IVb injection of fentanyl were recorded in anesthetized and spontaneously breathing rats with or without bilateral peri-vagal capsaicin treatment or intra-vagal microinjection of naloxone. Immunohistochemical approach was employed to define the presence of opioid mu-receptor (MOR) expression in vagal C-neurons and a patch clamp technique utilized to determine the evoked current responses of vagal C-neurons to fentanyl in vitro. Fentanyl induced an immediate apnea and subsequent respiratory depression. The apnea was characterized by cessation of EMGEI activity and augmentation of tonic discharges of EMGII, EMGTA, and EMGSPC, i.e., central expiratory apnea, laryngeal closure and pharyngeal constriction/collapse accompanied with chest wall rigidity. The apneic response was abolished by blockade of VCF signal conduction and largely attenuated by antagonism of vagal afferent ORs. The latter significantly alleviated the initial (within 5 min post injection), but not the later, respiratory depression. Vagal C-neurons expressed MORs and were activated by fentanyl. We conclude that IVb injection of fentanyl causes a VCF- and vagal afferent OR-mediated immediate central apnea, upper airway obstruction and chest wall rigidity.

Tuberculosis Causing a Pectoral Mass Mimicking Malignancy: A Rare Presentation of Tuberculosis.

Tuberculosis is an infectious disease that may involve all systems, with the respiratory system being the most commonly affected. Tuberculosis of the chest wall and its structures is rare, in which malignancy and abscess may be counted among possible differential diagnoses. In this case report, a patient with pectoral muscle tuberculosis will be presented. A 47-year-old female with a history of hypertension and epilepsy was evaluated for a rapidly enlarging painful mass under the left breast, which was later considered a cold abscess. The routine laboratory tests showed elevated C-reactive protein and erythrocyte sedimentation rate. Further radiological imaging with computed tomography confirmed the mass with chest wall involvement. The performed biopsy revealed granulomatous inflammation and subsequent tests confirmed acid-fast bacteria, with later confirmation of Mycobacterium tuberculosis in the culture. The patient was treated with an intensive regimen of anti-tuberculosis (TB) drugs consisting of isoniazid, rifampin, pyrazinamide, and ethambutol. After nine months, including a treatment extension due to possible vertebral involvement, the patient showed no symptoms and is under follow-up. Extrapulmonary TB, particularly musculoskeletal TB, comes with many diagnostic challenges due to its nonspecific symptoms. Tissue sampling remains the most important aspect of diagnosis confirmation and treatment planning; hence, TB should always be kept in mind among possible differential diagnoses, especially in endemic regions.

Neither Carinatum nor Excavatum: Insights Regarding the Novel Postprematurity Thoracic Dysplasia and Traditional Harrison Grooves.

BACKGROUND/PURPOSE: In recent years, a new chest wall malformation (CWM), the postprematurity thoracic dysplasia (PPTD), was reported. It was characterized as an inward deviation of the anterior tips of the 6th ribs and a personal history of prematurity and respiratory distress. At the moment, PPTD's prevalence and etiology are yet to be defined. Thus, we aimed to explore and identify patients with a compatible morphology within a large cohort of patients with CWM. METHODS: Retrospective analysis of electronic health records including medical photographs of 4640 consecutive patients with chest wall malformations at our Pectus Clinic between 2002 and 2023. Patients presenting with bilateral inward curvature of the 6th to 8th ribs were included. Among the variables analyzed, the history of preterm birth and ventilatory support requirement were evaluated. RESULTS: From 2069 patients with non-excavated deformities, 29 (1.4%) patients presented a PPTD morphology. After excluding 12 for incomplete records, we found that 9 patients (52.9%) had a positive history of prematurity (group PT) and 8 (47.1%) didn't (group T). However, both groups showed a high incidence of respiratory comorbidities (PT: 89% vs. T: 76%, p = 0.91). The median age of deformity onset was 12 months (IQR 2; 12) and 24 months (IQR 1; 60) for the PT and T groups, respectively (p = 0.37). Both groups showed a low incidence of family history of CWM (PT: 38% and T: 14%, p = 0.57). CONCLUSIONS: In this retrospective study including 4640 patients with chest wall malformations, the presence of a phenotype described as postprematurity thoracic dysplasia was similarly distributed among patients with or without a history of prematurity. We hypothesize that this condition, different from pectus excavatum and carinatum, might correspond to the Harrison grooves, a deformity whose etiology was profusely discussed in the medical literature from the first half of the 20th century. TYPE OF STUDY: Comparative retrospective study. LEVEL OF EVIDENCE: III.

Imaging of thoracic tuberculosis: pulmonary and extrapulmonary.

Tuberculosis (TB) remains the leading cause of death from a single infectious agent globally, despite being a potentially curable disease. This disease typically affects the lungs but may involve many extrapulmonary sites, especially in patients with risk factors such as HIV infection. The clinical features of extrapulmonary TB may mimic many different disease entities, particularly at less common thoracic sites such as the heart, chest wall, and breast. Imaging has an important role in the early diagnosis of TB, helping to detect disease, guide appropriate laboratory investigation, demonstrate complications, and monitor disease progress and response to treatment. Imaging supports the clinical objective of achieving effective treatment outcome and complication prevention. This review aims to highlight the imaging spectrum of TB affecting both pulmonary and extrapulmonary sites in the thorax. We also briefly provide key background information about TB, such as epidemiology, pathogenesis, and diagnosis.

Three-dimensional printed titanium chest wall reconstruction for tumor removal in the sternal region.

Resection of thoracic wall tumors results in significant defects in the chest wall, leading to various complications. In recent years, the use of three-dimensional (3D) printed titanium alloy prostheses in clinical practice has demonstrated enhanced outcomes in chest wall reconstruction surgery. A cohort of seven patients with sternal tumors was identified for this study. Following a helical CT scan, a digital model was generated for the design of the prosthesis. Subsequently, the tumors were then removed together with the affected sternum and ribs. The chest wall was then reconstructed using 3D-printed titanium alloy prosthesis for bone reconstruction, mesh for pleural reconstruction, and flap for soft tissue reconstruction. Patients were monitored for a period of one year post-surgery. In the seven cases examined, the tumors were found in various locations with varying degrees of invasion. Based on the scope of surgical resection and the size of the defect, 3D-printed titanium alloy prosthesis was custom-designed for chest wall reconstruction. Prior to bone reconstruction, pleural reconstruction was achieved with Bard Composix E/X Mesh, while soft tissue repair involved muscle flap and musculocutaneous flap procedures. A one-year follow-up assessment revealed that the utilization of the 3D-printed titanium alloy prosthesis led to secure fixation, favorable histocompatibility, and enhanced lung function. The findings demonstrate that the utilization of 3D printed titanium alloy prostheses represents a significant advancement in the field of chest wall reconstruction and thoracic surgical procedures.

Axillary Artery Injury Encountered During Chest Wall Tumor Resection.

Axillary artery injuries are rare because of their anatomy but are sometimes fatal because of the difficulty of obtaining vascular integrity. We report a 50-year-old patient with an iatrogenic axillary arterial injury that occurred during the resection of a chest wall tumor. The injury occurred during an incision of the intercostal muscle along the superior margin of the second rib. Following primary hemostasis achieved by forceps and amputation of the pectoralis minor muscle, the injury site was exposed sufficiently and successfully repaired by a vascular surgeon. This successful case provided valuable insight into strategies, primary hemostasis, and subsequent revascularization for an intraoperative vascular injury.

Ultrasound-Assisted Liposuction for Top Surgery in Transgender Men: Clinical Experience and Evaluation of Satisfaction and Quality of Life with TRANS-Q and BREAST-Q.

BACKGROUND: During the last decade, the demand for top surgery in female-to-male transgender (FMT) has increased worldwide. This study aims to present our initial experience with the novel use of ultrasound-assisted liposuction (UAL) in top surgery. Additionally, we evaluate the satisfaction and quality of life with TRANS-Q and BREAST-Q. METHODS: We conducted a retrospective study analyzing FMT undergoing UAL in top surgery from 2019 to 2021 at a single institution. We analyzed demographic variables, comorbidities, surgical techniques, operative time, complications, and follow-up time. We used TRANS-Q and BREAST-Q to evaluate patient-reported outcomes. A p value < 0.05 was considered significant. RESULTS: We performed 34 UAL combined subcutaneous mastectomies in 17 patients. Twelve patients (70.6%) underwent mastectomy double incision with free nipple grafting (DIFNG), and 29.4% underwent concentric circular mastectomy. In the DIFNG group, BMI (p < 0.02), the weight of each mammary gland (p < 0.001), and use of chest binder (p < 0.03) were significantly higher. The mean operative time was 115 min. The complication rate was 11.7% (one hematoma and three hypertrophic scars). The mean follow-up was 29.4 months, and no aesthetic revision surgeries was reported. The response rate for TRANS-Q and BREAST-Q was 76.5%, and high satisfaction with the results and significant improvement in quality of life were reported. CONCLUSIONS: We present the first cohort of transgender men who underwent UAL in top surgery. With proper training, the use of UAL could be a feasible and safe technique, offering good long-term esthetic results. Additionally, TRANS-Q and BREAST-Q demonstrated improved satisfaction and quality of life. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management and Surgical Repair of Neonatal Sternal Cleft: A Case Report of Two Successful Interventions.

The sternal cleft (SC) is a rare congenital anomaly characterized by a complete or partial separation of the sternum, leading to significant clinical concerns, including respiratory and cardiac instability. Due to its rarity, the SC often poses surgical challenges. This case report highlights the management of two neonates with SCs, emphasizing the critical role of early multidisciplinary intervention. The first patient, a neonate, was born with a severe sternal deformity identified as a partial superior SC with a supraumbilical raphe. The patient was transported to a tertiary care center for further evaluation and management by a multidisciplinary team. Similarly, the second patient, another neonate, presented with similar sternal changes. Both patients were assessed for potential complications associated with sternal instability. The treatment involved surgical correction by closing the gap of the SC for both patients. The procedure included a midline skin incision, dissection and lateral reflection of the pectoralis major muscle, resection of cartilaginous plates for healthy cartilage fusion, and extension of the cleft through the manubrium to achieve anatomic closure by approximation and suturing. Intraoperative monitoring ensured the stability of cardiac and respiratory functions. Postoperative outcomes were favorable, with both patients recovering well and being discharged without complications on postoperative days 5 and 9. These cases highlight the significance of early surgical intervention with multidisciplinary management in neonates with SCs. The successful outcomes underscore the effectiveness of surgical intervention in preventing possible complications, ensuring rapid recovery, and stabilizing the chest. Further research into long-term outcomes and potential genetic factors may provide deeper insights into the management of this rare condition.

Phrenoplasty Techniques for the Reconstruction of Basal Chest Wall Defects.

BACKGROUND: Primary and secondary tumors of the abdominal lower third of the bony thorax are relatively rare. Therefore, indications and techniques for chest wall reconstructions in this area are not well defined. METHODS: The techniques for reconstructing basal chest wall defects using the diaphragm are described. Indications for phrenoplasty are limited to reconstruction after full-thickness resection of at least two of the last four ribs in the midaxillary line. The diaphragm can be used for reconstructive purposes both if it is intact and if it is partially involved in the resection of the chest wall. RESULTS: At our institution, the abovementioned reconstructive technique was successfully performed in five patients with an uneventful post-operative course. CONCLUSIONS: The main advantages of these methods are the use of promptly available, high-quality autologous tissue and the exclusion of the pleural space from the defect area, thus transforming a thoracic defect into an abdominal one. The disadvantage is a variable reduction in the volume of the hemithorax. These techniques could be compared with other reconstruction techniques using pre-/post-operative respiratory functional tests.

Development and evaluation of an automated breathing-synchronized chest wall vibration stimulation system.

[Purpose] Vibratory stimulation of the upper intercostal region enhances inspiratory movement, whereas stimulation of the lower intercostal region enhances expiratory movement and ventilation. Previous vibration stimulation devices for intercostal muscles required manual stimulation, causing a time lag between breathing and vibration stimulation. The purpose of this experiment was to compare the effects of an automatic vibration stimulation system with manual vibration stimulation in a group of individuals and to verify whether there was an increase in upper and lower chest wall displacement and respiratory flow. [Participants and Methods] Twenty healthy adults were divided into two groups, as follows: an automatic vibration stimulation group using a chest wall vibration stimulation system and a manual vibration stimulation group. Vibration stimulation was applied to the second intercostal space on both sides during inspiration, and to the seventh intercostal space on both sides during expiration. [Results] The vibration stimulation system group showed significantly higher synchronization rates during inspiration and expiration than the manual vibration stimulation group, and there was a significant increase in chest wall displacement and respiratory flow during inspiration and expiration. [Conclusion] The chest wall vibration stimulation system can effectively provide vibration stimulation to the intercostal muscles in synchrony with breathing.

Sternalis Muscle: A Cadaveric Case Report of a Rare Variant With Multiple Branching.

The sternalis muscle is a rare anatomical variant located in the anterior thoracic wall. Understanding variations in the sternalis muscle anatomy is essential for clinicians, especially radiologists and surgeons to prevent misdiagnosis and avoid complications during surgical procedures in the anterior thoracic region. We present a unique case of bilateral branched sternalis muscles. On either side, the sternalis muscle lies deep to the breast and superficial fascia and superficial to pectoralis major muscle and pectoral fascia. Each sternalis muscle is branched into medial and lateral slips with the medial slip larger than the lateral slip. The medial slip of the right sternalis was larger than the medial slip of the left sternalis. The lateral slip of the left sternalis was larger than the lateral slip of the right sternalis. The lateral slip of the left sternalis muscle has a curved course with superior-lateral convexity and inferomedial concavity. Near its middle, the left sternalis lateral slip is branched into two smaller slips separated by a narrow cleft. The left sternalis muscle in our report is a new variant with multiple branching, which cannot be matched to any type of the previously described classifications. In this case report, we discussed the need of modification of the currently available sternalis classification system to accommodate all types of the previously reported sternalis muscles including the branching pattern of this muscle.

Chest wall muscle area, ventilatory efficiency and exercise capacity in systemic sclerosis.

To investigate the potential contribution of chest wall muscle area (CWMA) to the ventilatory efficiency and exercise capacity in patients with Systemic Sclerosis (SSc) without interstitial lung disease (ILD). Forty-four consecutive SSc patients [F = 37, median age 53.5 years (IQR 43.5-58)] were examined using chest high-resolution computed tomography (HRCT), pulmonary function tests and cardiopulmonary exercise testing (CPET). The CWMA was evaluated at the level of the ninth thoracic vertebra on CT images by two independent evaluators blinded to the patient information. CPET parameters analyzed were maximum oxygen uptake (VO2 max) and VO2 at anaerobic threshold (VO2@AT); minute ventilation (VE); maximum tidal volume (VT). A statistically significant positive correlation was found between CWMA and maximum workload (r = 0.470, p < 0.01), VO2 max ml/min (r = 0.380, p < 0.01), VO2@AT (r = 0.343, p < 0.05), VE (r = 0.308, p < 0.05), VT (r = 0.410, p < 0.01) and VO2/heart rate (r = 0.399, p < 0.01). In multiple regression analysis, VO2 max (ml/min) was significantly associated with CWMA [ß coefficient = 5.226 (95% CI 2.824, 7.628); p < 0.001], diffusing capacity for carbon monoxide (DLco) [ß coefficient = 6.749 (95% CI 1.460, 12.039); p < 0.05] and body mass index (BMI) [ß coefficient = 41.481 (95% CI 8.802, 74.161); p < 0.05]. In multiple regression analysis, maximum workload was significantly associated with CWMA [ß coefficient = 0.490 (95% CI 0.289, 0.691); p < 0.001], DLco [ß coefficient = 0.645 (95% CI 0.202, 1.088); p < 0.01] and BMI [ß coefficient = 3.747 (95% CI 1.013, 6.842); p < 0.01]. In SSc-patients without ILD, CWMA represents an important variable in exercise capacity and can be evaluated by the mediastinal window available in the HRCT images required for lung disease staging.

Tubercular Costochondritis Presenting as Chest Wall Swelling: A Case Report of an Atypical Tuberculosis Presentation.

Costochondritis is an inflammatory condition of the costochondral junctions, rarely due to tuberculosis (TB). One-quarter of the world's population is affected by tuberculosis, while musculoskeletal tuberculosis accounts for only 1-2% of the total cases. Among these cases, the involvement of the ribs is extremely rare. The following case report describes a 60-year-old male with diabetes who had recurrent thoracic wall swelling with greenish discharge for 23 years, misdiagnosed and treated as sebaceous cysts. Recently, at its exacerbation, imaging and biopsy revealed tubercular costochondritis, a very rare form of extrapulmonary tuberculosis that affects the ribs. Antituberculous therapy administered for nine months showed complete resolution of symptoms. This case underscores the key issue of placing tuberculosis within the differential diagnosis for a chest wall swelling, highlighting its diagnostic challenge in this atypical presentation. Advanced imaging and histological examination were of importance in coming up with an accurate diagnosis; hence, clinical suspicion needs to be increased and more research done in the light of management guidelines for this rare condition.

Chest Wall Reconstruction Using Titanium Mesh in a Dog with Huge Thoracic Extraskeletal Osteosarcoma.

A 6-year-old castrated male mixed dog presented with a rapidly growing mass at the right chest wall two weeks after initial detection. A mesenchymal origin of the malignancy was suspected based on fine-needle aspiration. Computed tomography (CT) revealed that the mass originated from the right chest wall and protruded externally (6.74 × 5.51 × 4.13 cm3) and internally (1.82 × 1.69 × 1.50 cm3). The patient revisited the hospital because of breathing difficulties. Radiography confirmed pleural effusion, and ultrasonography-guided thoracocentesis was performed. The effusion was hemorrhagic, and microscopic evaluation showed no malignant cells. Before surgery, CT without anesthesia was performed to evaluate the status of the patient. The 7-10th ribs were en bloc resected at a 3-cm margin dorsally and ventrally, and two ribs cranially and caudally from the mass. After recovering the collapsed right middle lobe of the lung due to compression from the internal mass with positive-pressure ventilation, a 3D-printed bone model contoured titanium mesh was tied to each covering rib and surrounding muscles using 2-0 blue nylon and closed routinely. The thoracic cavity was successfully reconstructed, and no flail chest was observed. The patient was histo-pathologically diagnosed with extraskeletal osteosarcoma. A CT scan performed 8 months after surgery showed no evident recurrence, metastasis, or implant failure. This is the first case report of chest wall reconstruction using titanium mesh in a dog. The use of a titanium mesh allows for the reconstruction of extensive chest wall defects, regardless of location, without major postoperative complications.

Chest wall subcutaneous mass leading to the diagnosis of pericostal tuberculosis.

When diagnosing a chest wall mass, even in the absence of pulmonary lesions, it is crucial to consider pericostal tuberculosis as a differential diagnosis. Attention must be paid to the characteristic findings on contrast-enhanced computed tomography, such as central low attenuation, peripheral rim enhancement of soft tissue, and pleural involvement.