Chest wall reconstruction for deep radiation necrosis: case report and overview of surgical options.

INTRODUCTION: To report a case of radiation necrosis after reirradiation for breast cancer and the difficulties encountered when treating these complex cases. PATIENTS AND METHODS: We present an 86-year-old woman with a history of right-sided intraductal breast cancer treated with a right mastectomy followed by local adjuvant radiotherapy (50 Gray). Twelve years later, she was diagnosed with a local recurrence in the mastectomy scar which was treated with local resection (including resection of rib four) and adjuvant radiotherapy up to 32 Gray. In July 2020 she presents at the Department of Plastic and Reconstructive Surgery with a chronic ulcer on the right-sided hemithorax. RESULTS: A multi-staged, multidisciplinary approach was necessary to secure lasting coverage of the extensive defect. CONCLUSION: Thoracic radiation necrosis should be subject to a multidisciplinary approach (plastic and thoracic surgeons) pre-, per-, and post-operatively. Each case may require a different surgical approach depending on the size and depth of the defect, patients' age, comorbidities, and previous medical treatment.

Role of proneurotensin as marker of paediatric coeliac disease.

Neurotensin (NT) is a gut hormone functioning proinflammatory through nuclear factor kappa B (NF-κB) and interleukin (IL)-8 secretion or anti-inflammatory through epidermal growth factor receptors. NT mRNA is down-regulated in duodenal biopsies of children with untreated coeliac disease. The aim of this study was to investigate if plasma pro-NT levels correlated with the degree of intestinal mucosal damage and tissue transglutaminase autoantibody (tTGA) levels in children with coeliac disease. Fasting plasma samples from 96 children with coeliac disease and 89 non-coeliac disease controls were analysed for NT precursor fragment pro-NT 1-117 by a chemiluminometric immunoassay. Pro-NT levels were compared with NT mRNA from duodenal biopsies, assessed previously with quantitative polymerase chain reaction (PCR). Illumina core exome arrays were used for human leucocyte antigen (HLA) typing and the Marsh criteria applied to score mucosal damage. Tissue TGA was measured by radio binding assay. A general linear model compared pro-NT levels with diagnosis of coeliac disease, Marsh score and HLA DQ haplotype. Spearman's rank test was used to compare pro-NT levels with tTGA, age and duodenal NT mRNA levels, respectively. Plasma pro-NT levels were elevated in children with coeliac disease (median 23 pmol/l higher, P = 0·003) and in those with severe intestinal mucosal damage (median 24 pmol/l higher for ≥ Marsh 3b versus not, P = 0·0004). Pro-NT levels correlated further with tTGA (r2 = 0·22, P = 0·002), but not with duodenal NTS mRNA levels (r2 = -0·12, P = 0·14). Pro-NT was not associated with any of the HLA risk-haplotypes. Elevated peripheral pro-NT levels reflect more severe forms of active coeliac disease, indicating a potential role of NT in intestinal inflammation.