[A new paradigm for the treatment of sternomediastinitis]. / Novaya paradigma lecheniya sternomediastinita.

OBJECTIVE: To analyze the results of simultaneous surgical treatment of sternomediastinitis compared to stage-by-stage approach. MATERIAL AND METHODS: The study included 27 patients between October 2022 and March 2023. All patients underwent heart surgery through median sternotomy. There were 11 (40.7%) women and 16 (59.3%) men. Mean age of patients was 68.4±9.8 years. All patients were divided into 2 groups: 12 patients underwent partial necrectomy and vacuum wound therapy (or long-term dressings) before surgery (group 1), 15 patients underwent surgery without prior conservative treatment (group 2). RESULTS: The most common causative agent of infection was staphylococcus (48.1%). In all patients, we found histological signs of osteomyelitis. Preoperative clinical status was similar in both groups. There were differences in the following indicators: C-reactive protein upon admission - 74.9±18.6 versus 94.8±23.8 mg/l, procalcitonin - 0.13 [0.02; 1.43] versus 0.21 [0.02; 0.94] ng/ml. Postoperative outcomes were similar in both groups. Mortality was 8.3% (n=1) and 13.3% (n=2), respectively. CONCLUSION: Simultaneous combined surgical treatment (sequestrectomy + muscle flap grafting) demonstrates optimal results in the treatment of sternomediastinitis.

Partial sternectomy with reconstruction of a giant cell tumor of the sternum, a case report, Saudi, Arabia.

BACKGROUND: Giant cell tumor (GCT) is a relatively common and locally aggressive benign bone tumor that rarely affects the sternum. CASE PRESENTATION: We report a case of giant cell tumor of the sternum in a 28-year-old Saudi with painful swelling at the lower part of the sternum. Subtotal sternectomy and reconstruction with a neosternum using two layers of proline mesh, a methyl methacrylate prosthesis, and bilateral pectoralis muscle advancement flaps were performed. CONCLUSIONS: Giant cell tumor of the sternum is a rare diagnosis. Surgical resection with negative margins is the ideal management. To avoid defects or instability of the chest wall, reconstruction of the chest wall with neosternum should be considered.

[A rapidly growing skin lesion on the sternum]. / Een snelgroeiende huidafwijking op het borstbeen.

This case involves a man with a medical history of multiple myeloma and osseous metastasis of prostate carcinoma. He presented with a progressively growing red tumor on his chest for the past three weeks. Histopathological examination revealed many atypical CD0138-positive plasmablastic cells, which matches a cutaneous manifestation of multiple myeloma.

Multiple local recurrences of primary sternal chondrosarcoma: tumor manipulation or self-seeding.

BACKGROUND: Primary sternal chondrosarcoma, although rare, is the most common malignant tumor of the sternum. The gold standard treatment is complete surgical excision, which frequently causes the instability of the thorax necessitating future reconstruction. Local recurrence is common increasing the risk of distant metastasis. CASE PRESENTATION: A 60-year-old male patient was diagnosed with primary sternum chondrosarcoma and underwent surgical excision with negative resection margins. Later, he was found to have two local recurrences at 11 months and 37 months post initial excision. The two recurrences were surgically removed followed by local adjuvant radiation. CONCLUSION: The seeding theories have been reported more frequently with relation to diagnostic biopsy procedures, tumor manipulation and self-seeding tumors. The patient developed two local recurrences despite total resection with negative margins, without concerns regarding seeding in distant metastasis.

Internal Thoracic Vein Tumor Thrombus From Sternal Melanoma Metastasis on 18 F-FDG PET/CT.

ABSTRACT: We present 18 F-FDG PET/CT findings of an internal thoracic vein tumor thrombus from melanoma in a 76-year-old woman. Restaging 18 F-FDG PET/CT shows a progressive disease with an internal thoracic vein tumor thrombus from a sternal bone metastasis. Although cutaneous malignant melanoma may metastasize to any body part, a direct tumor invasion of veins and the formation of a tumor thrombus represent an extremely rare complication.

Conventional chondrosarcoma of the rib cage and sternum: clinicopathological and molecular analysis of 27 patients treated at a single institution.

Conventional chondrosarcoma of the chest wall is rare, accounting for 15% of cases. Our purpose was to document clinicopathological, imaging and outcome results from a novel set of chest wall chondrosarcomas, and to analyze for IDH mutations and novel molecular alterations. Gross and microscopic pathology, imaging and clinical charts were reviewed. Targeted next-generation sequencing was performed to identify somatic mutations and copy number alterations. The cohort consisted of 27 patients: 16 men and 11 women (mean age 51 years; range 23-76). Palpable mass was the most common presentation. Five were discovered incidentally. Among 20 tumors with complete imaging, 15 arose from a rib and 5 from the sternum. Seven rib tumors were central/intramedullary, 5 were periosteal, 2 were secondary peripheral chondrosarcomas, and one was indeterminate. Among sternal tumors, 4 were central/intramedullary and one was periosteal. Half the periosteal tumors arose from the costochondral junctional cartilage (CCJ). Periosteal chondrosarcomas were sometimes mistaken for extraskeletal masses on initial clinical or radiological examinations. Fifty-nine percent of all tumors were grade 1 and 41% were grade 2. None were dedifferentiated chondrosarcomas. Heterozygous IDH1 mutation was detected in one tumor and heterozygous RAD50 mutation in another. Local recurrence(s) happened in 41% and metastasis in 41%. Grade had strong association with local recurrence (25% grade 1 vs. 64% grade 2 [P = .0447]), metastatic recurrence (19% grade 1 vs. 73% grade 2 [P = .0058]), and survival. Although chest wall chondrosarcomas share morphologic and molecular features with other chondrosarcomas, there is a much higher incidence of periosteal chondrosarcomas. IDH mutant tumors are uncommon. Early diagnosis and margin-negative resection is treatment of choice since chondrosarcomas are chemo- and radioresistant.

3D Printing Technology for Chest Wall Reconstruction With a Sternum-Ribs-Cartilage Titanium Implant: From Ideation to Creation.

OBJECTIVE: We describe the use of 3-dimensional (3D) printing technology to plan and reconstruct the sternum, adjoining cartilages, and ribs with a custom-made, anatomically designed, 3D-printed titanium implant for an isolated sternal metastasis complicated with a pathological fracture. METHODS: We imported submillimeter slice computed tomography scan data into Mimics Medical 20.0 software and by manual bone threshold segmentation created a 3D virtual model of the patient's chest wall and tumor. For all-around tumor-free margins, we grew the tumor by 2 cm. The replacement implant was designed in 3D using the anatomical features of the sternum, cartilages, and ribs and manufactured using TiMG 1 powder fusion technology. Physiotherapy was provided prior to and following surgery, and the impact of reconstruction on pulmonary functions was assessed. RESULTS: At surgery, the precise resection, clear margins, and a secure fit were achieved. At follow-up, there was no dislocation, paradoxical movement, change in performance status, or dyspnea. There was a decrease in forced expiratory volume in 1 s (FEV1) from 105% prior to surgery to 82% following surgery and in forced vital capacity (FVC) from 108% to 75%, with no difference in the FEV1/FVC ratio, suggesting a restrictive pattern of impairment. CONCLUSIONS: With 3D printing technology, reconstructing a large anterior chest wall defect with a custom-made, anatomical, 3D-printed titanium alloy implant is feasible and safe, and it preserves the shape, structure, and function of the chest wall, albeit with a restrictive pattern of pulmonary function, which can be addressed with physiotherapy.

From Stem to Sternum: The Role of Shp2 in the Skeleton.

Src homology-2 domain-containing phosphatase 2 (SHP2) is a ubiquitously expressed phosphatase that is vital for skeletal development and maintenance of chondrocytes, osteoblasts, and osteoclasts. Study of SHP2 function in small animal models has led to insights in phenotypes observed in SHP2-mutant human disease, such as Noonan syndrome. In recent years, allosteric SHP2 inhibitors have been developed to specifically target the protein in neoplastic processes. These inhibitors are highly specific and have great potential for disease modulation in cancer and other pathologies, including bone disorders. In this review, we discuss the importance of SHP2 and related signaling pathways (e.g., Ras/MEK/ERK, JAK/STAT, PI3K/Akt) in skeletal development. We review rodent models of pathologic processes caused by germline mutations that activate SHP2 enzymatic activity, with a focus on the skeletal phenotype seen in these patients. Finally, we discuss SHP2 inhibitors in development and their potential for disease modulation in these genetic diseases, particularly as it relates to the skeleton.

Commercial layer hybrids kept under organic conditions: a comparison of range use, welfare, and egg production in two layer strains.

Outdoor range areas provide laying hens with improved opportunities to perform natural behaviors and increase the available space per bird, however, birds are also exposed to potentially stressful factors including weather and predators. Ability to cope with challenging environments varies between different strains and must be considered to ensure good welfare. The aim of this study was to determine how suitable 2 hybrids, the Dekalb White (DW) and the Bovans Brown (BB), are for organic production with special emphasis on ranging behavior. A total of 1,200 hens were housed according to organic regulations across 12 flocks of 100 birds. Range and shelter use, effect of weather, vegetation cover, egg production and quality, and mortality were assessed in addition to a range of clinical welfare indicators. Initially a greater proportion of DW hens accessed the range. However, after approximately 2 mo, a greater proportion of BB were using the range and venturing further from the house. DW hens were more likely to use the shelters than BB hens (P < 0.001). Vegetation was also worn away to a greater extent in the BB ranges. Weather affected the proportion of hens that went outside, the distance ranged from the popholes, and shelter use. BB hens were found to have better plumage condition (P < 0.001), fewer footpad lesions (P < 0.001), fewer comb wounds (P < 0.001), and lower mortality rates (P = 0.013). Both hybrids experienced keel bone fractures, though DW hens had more at the cranial portion (P < 0.001) and BB at the caudal portion (P < 0.001). DW hens had an earlier onset of lay and higher egg production than BB hens (P < 0.001), though BB hens laid heavier eggs (P < 0.001) with thicker shells (P = 0.001). Overall, BB hens seemed to perform superiorly or equivalently to the DW hens for all variables apart from egg production. These results demonstrate the importance of considering the strain of bird selected for organic production systems in order for the birds to reap the potential benefits that are offered by outdoor access.

Primary fibroblastic osteosarcoma of sternum: A case report.

RATIONALE: Osteosarcoma, a malignant bone tumor, rarely occurs in the sternum, especially the fibroblastic type, and is associated with poor survival. This case report describes a patient with a neoplasm of the sternum who underwent tumor resection 3 times and reconstruction twice because of the high risk of recurrence. PATIENT CONCERNS: A 60-year-old Chinese man presented with a 3-cm palpable bulging mass located in front of his sternum. Chest computed tomography (CT) revealed an anterior chest wall neoplasm with sternal destruction. DIAGNOSIS: Pathological examination revealed that the mass was a low-grade malignant primary fibroblastic osteosarcoma. INTERVENTIONS: Locking plates were used for chest wall reconstruction, demonstrating good structural stability and economic applicability. Regarding the ineffectiveness of current therapies, whole-exome sequencing was conducted, and no targets matched any of the currently available agents. OUTCOMES: No recurrence was found on regular reexamination. LESSONS: Surgery is the first choice of treatment for patients with primary fibroblastic osteosarcoma of the sternum. The reconstruction-locking plate is a good alternative for chest wall reconstruction. Whole-exome sequencing can shed new light on this uncommon disease and help identify novel therapeutic targets.

The illusion of a chest wall tumor: a case-report of sternal tuberculosis.

The incidence rate of tuberculosis in developed countries is low. The most common presentation of this disease is its pulmonary form but with the increasing use of immunosuppressive drugs, extra-pulmonary tuberculosis is re-emerging. Nevertheless, sternal bone involvement is uncommon. We report the case of an eighty-three-year-old man who presented a painful sternal mass which progressed towards cutaneous ulceration. The first diagnostic hypothesis was neoplasia. The pathological and microbiological diagnosis of tuberculosis was achieved after surgical biopsy. The patient received treatment against tuberculosis for nine months enabling recovery without surgery. This case illustrates the importance of having a diagnosis prior to any kind of treatment facing any voluminous parietal thoracic lesions.  This diagnosis is made possible by surgical samples and interdisciplinary teamwork. This case underlines that tuberculosis remains a differential diagnosis that must be evoked in case of unusual bone mass.

Spectrum of anatomical variants, normal findings and pathology in and around the paediatric sternum.

Abnormalities of the sternum and adjacent structures are an uncommon presentation in the paediatric population and can have a variety of benign and malignant causes, including normal and developmental variants of the chest wall. Although there is overlap with adults, many sternal abnormalities are unique to the paediatric population. Following clinical examination, radiography is usually the first type of imaging used; however, it is limited and often ultrasound and cross-sectional imaging are needed for further assessment. An understanding of the normal anatomy is important; however, this can be challenging due to the varied appearances of age-related changes of the sternum. The purpose of this article is to familiarize the general paediatric radiologist with the expected anatomy and imaging findings of the developing sternum, anatomical variants and pathology of the sternum and adjacent structures encountered in this group of patients.

Double sternal elevation subxiphoid versus uniportal thoracoscopic thymectomy associated with superior clearance for stage I-II thymic epithelial tumors: Subxiphoid thymectomy compared with VATS.

OBJECTIVE: This study aimed to evaluate the therapeutic efficacy of thymectomy through a subxiphoid video-thoracoscopic approach with double elevation of the sternum compared with traditional intercostal uniportal video-assisted thoracic surgery for stage I-II thymic epithelial tumors (using the Masaoka-Koga staging system). METHOD: Patients with thymic tumors underwent resection through intercostal video-assisted thoracic surgery or subxiphoid video-thoracoscopic approach. Only those with pathologically confirmed thymic epithelial tumors were enrolled. Perioperative short-term/long-term outcomes were compared between 2 groups after propensity-score matching. RESULTS: A total of 141 patients diagnosed with thymic epithelial tumors and scheduled for minimally invasive surgery were included. In the intercostal video-assisted thoracic surgery group, the prevalence for conversion to open surgery was higher than in the subxiphoid video-thoracoscopic approach group for stage III thymic tumors (P = .019). After propensity-score matching for 122 patients undergoing video-assisted thoracic surgery, significantly larger resected specimens were found in the subxiphoid video-thoracoscopic approach group compared to the intercostal video-assisted thoracic surgery group (11.7 ± 3.8 vs 7.1 ± 2.7 cm, P < .001). The pain score on the first postoperative day (1.6 ± 0.6 vs 2.0 ± 0.7, P = .011) and the day of hospital discharge (1.2 ± 0.7 vs 1.6 ± 0.6, P = .017) in the subxiphoid video-thoracoscopic approach group were significantly lower. The operation time (168.4 ± 59.3 vs 92.5 ± 46.0 min, P < .001), chest tube drainage time (3.6 ± 1.2 vs 2.9 ± 0.9 days, P = .001), and hospital stay (3.7 ± 1.3 vs 2.9 ± 0.9 days, P = .004) were longer in the subxiphoid video-thoracoscopic approach group, with higher intraoperative blood loss (69.3 ± 61.0 vs 45.6 ± 42.5 mL, P = .045). No significant differences were found in the hospitalization cost, incidence of complications, or 3-year disease-free survival (96% vs 92%, P = .473) between the 2 groups. Four patients with stage III disease in the subxiphoid video-thoracoscopic approach group reached a 3-year disease-free survival of 75%. CONCLUSION: The subxiphoid video-thoracoscopic approach with double elevation of the sternum shows the potential for more extensive clearance of thymic tissue for thymic epithelial tumors compared to intercostal video-assisted thoracic surgery. Its inferior operation time and blood loss could be a trade-off for improved pain control and equivalent hospitalization cost, complications, and 3-year disease-free survival. The subxiphoid video-thoracoscopic approach may offer an advantage treatment for early-stage thymic epithelial tumors and may also be suitable for unexpected advanced thymic tumors identified intraoperatively.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability. SUMMARY: Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

The sternum: An important review area when reporting pre-surgical staging breast MRI studies.

Identification and assessment of extramammary findings on contrast-enhanced breast MRI scans is particularly important in the setting of newly diagnosed invasive cancer as metastatic lesions may be encountered in the liver, lungs, pleural cavity or bones. Establishing that stage IV disease is present has a profound effect on patient management. The sternum is routinely included on breast MRI studies and can be an early site for breast cancer metastases. These appear as enhancing lesions with high signal on fat-suppressed T2-weighted images. However, incidental benign lesions, notably haemangiomas, may also be encountered, and careful analysis is required to avoid false-positive results. Clinical context is important with a much lower likelihood of malignancy in the setting of routine screening of young women with no personal history of breast cancer. This pictorial essay illustrates findings encountered with lesions in the sternum and offers insights into how to interpret and manage them.

Novel Reconstruction of Neosternum With Steel Wires for Recurrent Chondrosarcoma.

Chondrosarcoma is a primary chest wall tumor causing huge masses arising from rib, sternum, or costochondral junction. Successful treatment warrants complete surgical resection with wide, free margins followed by reconstruction of the bony chest wall and soft tissue coverage of the defect. We report the case of excision of giant recurrent sternal chondrosarcoma followed by reconstruction of neosternum using steel wires. This novel technique portrays steel wire-based reconstructions as a safe, reproducible, and readily available prosthetic material for complex chest wall surgeries.

The Involvement of Macrophage Colony Stimulating Factor on Protein Hydrolysate Injection Mediated Hematopoietic Function Improvement.

Protein hydrolysate injection (PH) is a sterile solution of hydrolyzed protein and sorbitol that contains 17 amino acids and has a molecular mass of 185.0-622.0 g/mol. This study investigated the effect of PH on hematopoietic function in K562 cells and mice with cyclophosphamide (CTX)-induced hematopoietic dysfunction. In these myelosuppressed mice, PH increased the number of hematopoietic cells in the bone marrow (BM) and regulated the concentration of several factors related to hematopoietic function. PH restored peripheral blood cell concentrations and increased the numbers of hematopoietic stem cells and progenitor cells (HSPCs), B lymphocytes, macrophages, and granulocytes in the BM of CTX-treated mice. Moreover, PH regulated the concentrations of macrophage colony stimulating factor (M-CSF), interleukin (IL)-2, and other hematopoiesis-related cytokines in the serum, spleen, femoral condyle, and sternum. In K562 cells, the PH-induced upregulation of hematopoiesis-related proteins was inhibited by transfection with M-CSF siRNA. Therefore, PH might benefit the BM hematopoietic system via the regulation of M-CSF expression, suggesting a potential role for PH in the treatment of hematopoietic dysfunction caused by cancer therapy.

Keel bone fractures in Danish laying hens: Prevalence and risk factors.

Keel bone fractures (KBF) in commercial poultry production systems are a major welfare problem with possible economic consequences for the poultry industry. Recent investigations suggest that the overall situation may be worsening. Depending on the housing system, fracture prevalences exceeding 80% have been reported from different countries. No specific causes have yet been identified and this has consequently hampered risk factor identification. The objective of the current study was to investigate the prevalence of KBF in Danish layer hens and to identify risk factors in relation to KBF in all major productions systems, including parent stock production. For risk factor identification, production data from the included flocks was used. In total, 4794 birds from 40 flocks were investigated at end-of-lay. All birds were euthanized on farm and underwent inspection and palpation followed by necropsy. All observations were recorded and subsequently analysed using the SAS statistical software package. In flocks from non-caged systems, fracture prevalence in the range 53%-100%, was observed whereas the prevalence in flocks from enriched cages ranged between 50-98%. Furthermore, often multiple fractures (≥4) were observed in individual birds (range 5-81% of the birds with fractures) depending on the flock. The localization of the fractures at the distal end of the keel bone is highly consistent in all flocks (>96%). Macroscopically the fractures varied morphologically from an appearance with an almost total absence of callus, most frequently observed in caged birds, to large callus formations in and around the fracture lines, which was a typical finding in non-caged birds. Despite being housed under cage-free conditions, parent birds had significantly fewer fractures (all flocks were 60 weeks old) per bird, than other birds from cage-free systems. The body weight at end-of-lay had an effect on the risk of having fractures, heavy hens have significantly fewer fractures at end-of-lay. The older the hens were at onset of lay, the lower was the flock prevalence at end-of-lay. Additionally, the daily egg size at onset of lay was of importance for the risk of developing fractures, the production of heavier eggs initially, resulted in higher fracture prevalence at depopulation. The odds ratio of body weight, (+100 g) was 0.97, age at onset of lay (+1 week) was 0.87 and daily egg weight at onset (+1 gram) was 1.03. In conclusion, the study demonstrated a very high prevalence of KBF in hens from all production systems and identified hen size, age at onset of lay and daily egg weight at onset of lay to be major risk factors for development of KBF in the modern laying hen. Further research regarding this is warranted to strengthen the longevity and enhance the welfare of laying hens.

Sternal Metastasis of Brain Meningioma - A Case Report.

BACKGROUND: Metastases of meningiomas are infrequent and the site of extracranial metastasis such as the bone is extremely rare. CASE REPORT: A 75-year-old male had a history of five sessions of surgery and gamma-knife treatment for brain meningioma over a period of 29 years. He visited our hospital because he noticed a swelling in his anterior chest 2 years and 6 months after the final treatment. After an open biopsy, histopathological analysis revealed the mass to be a metastatic grade II meningioma. We resected the tumor along with the sternum, ribs, pleura, and pericardium. The patient had recurrences in the thoracic cavity and pericardium postoperatively and received radiation therapy. He also had metastasis in the abdominal cavity, which spread rapidly. CONCLUSION: We report on a rare instance of metastasis to the sternum in a case of atypical meningioma, showing rapid growth and invasion after long-term treatment.