Pneumomediastinum: Experience with 87 Patients.

OBJECTIVE: The aim of the present series was first to present our experience in the management of 37 patients with spontaneous pneumomediastinum (SPM), and further to indicate the necessity of identifying true SPM cases as they are currently inadequately defined. METHODS: This is a single-center, retrospective study, conducted in a university hospital. Consecutive adult patients with pneumomediastinum (PM) between January 2009 and March 2020 were involved in the series. The data about age, gender, symptoms, signs, treatment, length of hospital stay (LOS), and in-hospital mortality were evaluated. RESULTS: In total, 87 cases with pneumomediastinum (37 with spontaneous and 50 with secondary PM) were analyzed. Patients in both groups were of similar ages (P=0.4). Sufferers with secondary PM were more likely to have: an associated pneumothorax (19% vs 58%, P<0.05), a chest tube placed (18.9% vs 58%, P<0.05), an associated pleural effusion (0% vs 18%, P<0.05). They presented with a longer LOS (3.9 vs 5.3 days, P<0.05), and were more likely to die (0% vs 10%, P<0.05). Additionally they showed a higher prevalence of radiologic subcutaneous emphysema (49% vs 74%, P<0.05). CONCLUSION: Spontaneous pneumomediastinum is an onset of clinical importance with a low mortality rate, short LOS and good longterm prognosis. It often presents with chest pain, dyspnea and/or subcutaneous emphysema. However, secondary causes of mediastinal air must be ruled out, due to their potential devastating outcome if not diagnosed promptly. A consensus aimed at an update of the classification guidelines is more than indispensable.

Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients.

OBJECTIVE: The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS: The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS: There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS: Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.

Synchronous occurrence of breast cancer and refractory diffuse large B-cell abdominal lymphoma: Management and review of the literature.

The synchronous occurrence of primary breast cancer and lymphoid tissue malignant tumors has been rarely reported in the literature. We present an exceedingly rare case of synchronous breast invasive ductal carcinoma with an abdominal diffuse large B-cell lymphoma (DLBCL). A 78-year-old woman who was diagnosed with a luminal A invasive breast cancer on core biopsy, and complaint of progressively worsening low back pain. An abdominal computed tomography (CT) scan that was performed as part of the preoperative staging showed a large abdominal mass measuring 10.5 × 4.8 × 9.5 cm surrounding the lower part of the abdominal aorta, the right common iliac, right external, right internal iliac, and the left internal iliac arteries. A CT-guided fine-needle aspiration biopsy (FNAB) of the abdominal mass was then performed, to exclude the possibility of being an abdominal tumor metastasis of the known primary breast cancer. Histopathological findings were suggestive of DLBCL. Following a multidisciplinary team discussion, chemotherapy was initiated for DLBCL. The tumor however was refractory to multiple chemotherapy regimens and exhibited a highly aggressive clinical course. The diagnostic evaluation and management of the patient are discussed, along with a review of the relevant literature. This case underscores the fact that the presence of synchronous malignancies may pose both diagnostic and treatment challenges. Accurate staging of both malignancies and multidisciplinary team discussion is of utmost importance to guide an optimal therapeutic approach. Histopathological evaluation is essential for both tumors, for the second malignancy not to be misinterpreted as a secondary deposit of the primary one.

Subtle signs of breast cancer as an important pitfall in mammographic interpretation: Establishing an accurate diagnosis in an equivocal case.

Mammogram is the standard imaging modality for the early detection of breast cancer, and it has been shown to reduce disease-related mortality by up to 30%. Mammogram, however, has its limitations. It is reported that 10-30% of breast cancers may be missed on a mammogram. Delay in the diagnosis and treatment may adversely affect the prognosis of patients with breast cancer. We present a case of multifocal invasive early breast carcinoma, which was misinterpreted twice as intramammary lymph nodes, thus resulting in a delay in diagnosis for eighteen months. The tumors were detected incidentally after the patient presented to our Breast clinic for symptoms related to a concomitant benign lesion involving the same breast. We describe the tumors' imaging features and discuss the possible reasons that likely led to repeated misinterpretation. Awareness of possible causes for missed breast cancer is necessary to avoid delay of treatment initiation that may adversely affect prognosis.

Primary ectopic breast carcinoma in the axilla: A rare presentation and review of the literature.

Ectopic breast tissue (EBT) develops as the result of the incomplete embryologic regression of the mammary ridge, which extends bilaterally from the anterior axilla folds to the inguinal folds in the fifth and sixth weeks of gestation. EBT is encountered in 0.3%-6% of women and 1%-3% of men and can be found anywhere along the milk line. It is subject to the same pathologic changes that affect the orthotopic breast. Primary carcinoma arising on the ectopic breast (PEBC) is a very rare occurrence accounting for 0.3%-0.6% of all breast cancers and is most frequently found in the axilla. Due to the rarity and atypical presentation of the disease, the diagnosis is often delayed. We herein present a very rare case of PEBC in the axilla along with a review of the literature. Any subcutaneous hypoechoic nodule located along the milk line without evidence of inflammation should raise concern for ectopic breast carcinoma. Accurate staging and differential diagnosis with detailed immunohistochemical analysis are required. No specific guidelines on diagnosis and treatment are available and the tumor is treated similarly to the orthotopic breast cancer of a similar stage. Physicians should be aware of this rare entity to avoid treatment delays.

Benign cyst of the male breast. An exceedingly rare entity that may pose a diagnostic dilemma. Management and literature review.

Cysts represent the most common cause of a breast mass in women. On the contrary, in men, the presence of a benign apocrine cyst is an exceedingly rare occurrence, with only a few cases reported in the literature. We describe herein a case of benign apocrine breast cyst without concurrent gynecomastia in a 41-year-old male. Diagnostic evaluation and management are discussed, along with a review of the literature. Given the extreme rarity of benign breast cysts in males, a thorough investigation is essential in male patients presenting with cystic breast lesions. Diagnostic breast imaging may be challenging. Surgical resection of the cyst should be considered in the presence of atypical imaging features to exclude underlying malignancy.

The current role of surgery in the treatment of cardiac metastases from malignant melanoma: an educational presentation

Abstract A 71 year-old male with a history of multiple excisions of an initial Clark's level V melanoma of the breast followed by combined radiation and interferon treatment, as well as a recurrence, 3 years later, of a BRAF-positive tumor of the shoulder, with subsequent therapy with dabrafenib and trametinib, presented again with progressive intracardiac masses causing significant right ventricular outflow obstruction. Additionally, the patient complained of dyspnea and fatigue on exertion, thus he was scheduled for surgical resection.

The Current Role of Surgery in the Treatment of Cardiac Metastases from Malignant Melanoma: an Educational Presentation.

A 71 year-old male with a history of multiple excisions of an initial Clark's level V melanoma of the breast followed by combined radiation and interferon treatment, as well as a recurrence, 3 years later, of a BRAF-positive tumor of the shoulder, with subsequent therapy with dabrafenib and trametinib, presented again with progressive intracardiac masses causing significant right ventricular outflow obstruction. Additionally, the patient complained of dyspnea and fatigue on exertion, thus he was scheduled for surgical resection.

Primary breast carcinoma en cuirasse. A rare presentation of an aggressive malignancy and review of the literature.

Breast carcinoma en cuirasse is a very rare form of cutaneous metastases of breast cancer. The clinical presentation is that of a diffuse indurated carcinomatous infiltration of the skin and subcutaneous tissues of the mammary region and the anterior aspect of the chest. In most cases, breast carcinoma en cuirasse develops post-mastectomy and represents a dramatic presentation of an aggressive tumor associated with a dismal prognosis. Because of the rarity of this type of malignancy, the optimal approach to treatment has not been clearly defined. The systemic treatment has been associated with limited efficacy, and the primary goal is palliative care and preservation of the quality of life through skin-directed therapies. Herein, a very rare case of primary breast carcinoma en cuirasse is presented, along with a review of the literature. Early diagnosis and prompt treatment of any potential skin metastases of breast cancer are essential to prevent the catastrophic natural progression of the disease.

Primary neuroendocrine carcinoma of the breast: a rare presentation and review of the literature.

Primary neuroendocrine carcinoma of the breast (NEBC) is a very rare occurrence accounting for less than 0.1% of all breast cancers. Typically, the tumor presents with ER- and PgR-positive and HER-2-negative status. Despite its luminal type, NEBC is associated with a more aggressive clinical course and poorer prognosis compared to the other types of invasive breast cancer. Clinical and radiological findings are nonspecific. The most common clinical manifestation is a palpable mass whereas in mammography the tumor most commonly appears as a round or oval mass without spiculated margins. Herein, a very rare case of NEBC is described in an asymptomatic patient who presented with an area of architectural distortion and the presence of microcalcifications that was incidentally detected on a screening mammography. A review of the literature has also been conducted. The diagnosis of NEBC requires a thorough investigation to exclude the possibility of a metastatic neuroendocrine tumor from another site because the two entities require different treatment approaches. Due to the rarity of the disease, the optimal therapeutic approach has not been clearly defined. Surgical resection is the mainstay of treatment. Further research is needed to better understand the molecular characteristics of NEBC and identify novel targeted therapies.

Primary cutaneous follicle center lymphoma of the breast: Management of an exceedingly rare malignancy.

Primary cutaneous follicle center lymphoma (PCFCL) is defined as a low-grade B-cell non- Hodgkins lymphoma, which primarily occurs and remains confined to the skin, without evidence of extracutaneous or systemic involvement at the time of diagnosis. PCFCL affecting the breast skin is an exceedingly rare entity with only two cases reported in the English literature. We present a case of PCFCL affecting the periareolar breast skin and review the relevant literature. Our patient was a 64-year-old female who presented with an erythematous plaque in the periareolar region of the left breast. The diagnosis of PCFCL was confirmed by a biopsy performed with a seven-month delay, as the tumor had been initially misdiagnosed as a benign lesion. The patient was successfully treated with local radiation therapy. PCFCL is an indolent lymphoma associated with an excellent prognosis. For localized lesions, skin-directed therapies mainly consisting of radiation therapy or complete surgical excision are curative therapeutic approaches, while systemic chemotherapy should be reserved for patients with extensive disease. This case highlights the need to consider PCFCL as an important differential diagnosis in patients presenting with non-resolving erythematous breast skin lesions. A timely biopsy should be obtained to avoid delays in the initiation of appropriate treatment.

Spontaneous Pneumomediastinum in a Teenager After Physical Exercise: a Benign and Rare, but Sometimes Challenging, Entity.

INTRODUCTION: Pneumomediastinum defines a condition in which free air is present in the mediastinum usually caused by alveolar rupture resulting from a sudden increase in the intrathoracic pressure and air tracking along the tracheobronchial tree. CASE REPORT: We present a case of a 16-year-old male patient referred to our department due to persisting odynophagia, and retrosternal chest pain. A performed chest-CT revealed presence of free air in the mediastinum, without evidence of pneumothorax, or subcutaneous emphysema. Under the diagnosis of spontaneous pneumomediastinum (SPM) the treatment included conservative therapy with analgesics, rest, and oxygen. CONCLUSION: SPM is a rare benign condition with nonspecific presenting clinical signs; thus its diagnosis remains mostly one of exclusion. Thorough history-taking, beside radiographic studies, may be the key to confirm the diagnosis.

Facing a dilemma in the treatment of an internal mammary artery mycotic pseudoaneurysm: coil embolization or surgery? A case report and brief literature review.

While aneurysms of the internal mammary artery (IMA) complicate occasionally surgical procedures employing median sternotomy, or are associated with direct thoracic trauma, mycotic pseudoaneurysms of the vessel are rarely reported in the literature. We herein report a case of a 22-year-old man who developed a mycotic internal mammary artery pseudoaneurysm secondary to staphylococcal chest wall abscesses and was effectively treated by coil embolization. Additionally, the report provides a brief review focusing on the current state of treatment options for internal mammary artery aneurysms.