Superficial thoracoepigastric vein thrombophlebitis or Mondor’s disease

Background: Inflammatory breast cancer (IBC) is a rare and aggressive type of advanced breast cancer with a poor long-term outcome and a high risk of recurrence. Although one of the most common clinical manifestations of IBC is erythema of the skin overlying the breast, whether inflammation is involved in IBC has not yet been tested by pathologic examination of IBC specimens. Therefore, whether inflammation pathways are involved in the pathogenesis of IBC is still not clear. A large body of evidence indicates that chronic inflammation is a risk factor for cancer. Nonsteroidal anti-inflammatory drugs have been reported to reduce the risk of developing some solid cancers, including breast cancer. Cyclooxygenase (COX)-2 is the inducible isoenzyme catalyzing the conversion of arachidonic acid to prostanoids. COX-2 upregulation has been linked to breast tumorigenesis or inflammatory diseases, and COX-2 overexpression increases the growth rate and invasiveness of breast cancer cells. We tested the hypothesis that the COX-2 pathway is involved in IBC tumor growth and metastasis. Methods and Results: We examined the expression level of COX-2 and the concentrations of its enzymatic products by mass spectrometry (LC/MS/MS). We also determined the effect of inhibition of the COX2 pathway on cell proliferation, migration, invasiveness, and epithelial-mesenchymal transition (EMT) in IBC both in vitro and in vivo. We found that levels of COX-2 and its enzymatic products prostaglandins (PG), such as PGE2 and PGF2α, were higher in IBC than in non-IBC cell lines. Both PGE2 and PGF2α markedly enhanced the migration and invasion of SUM149 IBC cells, suggesting that COX-2 and its metabolites may play an important role in IBC development and progression. We examined the expression levels of COX-2 and EGFR in 25 IBC patient biopsy samples and found that the expression of COX-2 was positively correlated with the levels of EGFR in these tissues. To illustrate how COX-2 and EGFR are regulated in IBC cells, we treated SUM149 cells with EGF. We found that EGF stimulation increased COX-2 levels. COX-2 expression was notably downregulated in EGFR shRNA stably transfected SUM149 cells, suggesting that the upregulation of COX-2 is mediated through EGFR signaling. Furthermore, a selective COX-2 inhibitor, celecoxib, dramatically inhibited IBC tumor growth in a SUM149 IBC xenograft model. These celecoxib-treated tumors exhibited high expression of the epithelial marker E-cadherin and low expression of the mesenchymal marker vimentin compared with untreated tumors, suggesting that celecoxib inhibits epithelial-mesenchymal transition. Conclusions: Our results suggest that inflammatory mediators indeed play an important role in IBC cells. Targeting inflammatory pathways may represent an effective therapeutic approach to suppress tumorigenicity and prevent metastasis in IBC. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 569. doi:1538-7445.AM2012-569

INTERCOSTAL NERVE SCHWANNOMA IN THE LATERAL CHEST WALL: AN UNCOMMON OCCURENCE

I read the case report “Lactating breast abscess: a rare presentation of adenosquamous breast carcinoma” by Alipour et al(1) with great interest. The authors presented an interesting case of breast cancer in a lactating woman who presented with a longstanding breast abscess of two months’ duration. They have diligently reiterated the need to perform abscess wall biopsy in all atypical breast abscesses. They also ruled out the possibility of inflammatory breast cancer (IBC) on account of the absence of tumour emboli in the dermal lymphatics. However, I would like to stress that the presence of tumour emboli in the dermal lymphovascular spaces is neither sufficient nor required for the diagnosis of IBC. IBC is clinically diagnosed by a short duration of symptoms, typical clinical signs on examination of the affected breast, and pathological diagnosis of breast carcinoma either through skin biopsy or core/needle biopsy of the underlying lump, if present. Rapidly progressing diffuse erythema (pink or mottled pink hue) and oedema of more than one-third of the breast distinguishes IBC from noninflammatory locally advanced breast cancer (LABC) with skin involvement.(2,3) The breast oedema manifests as an increase in the size of the breast and exaggerated hair follicle pits, classically known as peau d’orange. These skin changes represent the dermal lymphatic obstruction, resulting from invasion by the tumour emboli; this phenomenon is considered a pathological hallmark of IBC.(4) It is necessary to highlight here why dermal lymphatic invasion by tumour emboli is not considered diagnostic of IBC. Firstly, dermal tumour emboli may not be identified in all cases of IBC despite adequate sampling of the skin, and secondly, dermal tumour emboli, though less numerous and smaller in size, may also be seen in noninflammatory LABC.(2) In a consensus statement, an international expert panel agreed that the following minimum criteria are required for the diagnosis of IBC: a history of rapid onset of breast erythema; a duration of history of no more than six months; oedema and/or peau d’orange and/or warm breast (with or without an underlying palpable mass); erythema occupying at least one-third of the breast; and pathological confirmation of invasive carcinoma.(4) However, the panel also strongly recommended that skin biopsy be done in all patients suspected to have IBC, as it may confirm the presence of dermal tumour emboli and may also give the pathological diagnosis of carcinoma if no underlying lump or regional metastatic lymphadenopathy is detected. A set of uniform diagnostic criteria for IBC, which can be used worldwide, will help medical practitioners obtain more accurate epidemiological data, and also provide better understanding of the clinicopathological profile and treatment outcomes of IBC across different geographical regions. Yours sincerely,

Background A computer-aided detection (CAD) system may help surveillance for pulmonary metastasis at chest radiography in situations where there is limited access to CT. Purpose To evaluate whether a deep learning (DL)-based CAD system can improve diagnostic yield for newly visible lung metastasis on chest radiographs in patients with cancer. Materials and Methods A regulatory-approved CAD system for lung nodules was implemented to interpret chest radiographs from patients referred by the medical oncology department in clinical practice. In this retrospective diagnostic cohort study, chest radiographs interpreted with assistance from a CAD system after the implementation (January to April 2019, CAD-assisted interpretation group) and those interpreted before the implementation (September to December 2018, conventional interpretation group) of the CAD system were consecutively included. The diagnostic yield (frequency of true-positive detections) and false-referral rate (frequency of false-positive detections) of formal reports of chest radiographs for newly visible lung metastasis were compared between the two groups using generalized estimating equations. Propensity score matching was performed between the two groups for age, sex, and primary cancer. Results A total of 2916 chest radiographs from 1521 patients (1546 men, 1370 women; mean age, 62 years) and 5681 chest radiographs from 3456 patients (2941 men, 2740 women; mean age, 62 years) were analyzed in the CAD-assisted interpretation and conventional interpretation groups, respectively. The diagnostic yield for newly visible metastasis was higher in the CAD-assisted interpretation group (0.86%, 25 of 2916 [95% CI: 0.58, 1.3] vs 0.32%, 18 of 568 [95% CI: 0.20, 0.50%]; P = .004). The false-referral rate in the CAD-assisted interpretation group (0.34%, 10 of 2916 [95% CI: 0.19, 0.64]) was not inferior to that in the conventional interpretation group (0.25%, 14 of 5681 [95% CI: 0.15, 0.42]) at the noninferiority margin of 0.5% (95% CI of difference: -0.15, 0.35). Conclusion A deep learning-based computer-aided detection system improved the diagnostic yield for newly visible metastasis on chest radiographs in patients with cancer with a similar false-referral rate. © RSNA, 2021 Online supplemental material is available for this article.

Background: Pulmonary Tuberculosis (PTB) has high morbidity and mortality. It kills an estimated 2-3 million people a year with 95-98% of this mortality in developing countries. Nigeria ranks 4 th among 22 high burden countries in the world. It is associated with marked weight loss which can be evident at the lateral chest wall soft tissue thickness on the chest radiographs. Objectives: To compare the lateral chest wall soft tissue thickness on the chest radiographs of normal adult subjects and pulmonary TB patients in Zaria, also to determine sex difference in the lateral chest wall thickness in aforementioned subjects. Methodology: This prospective study was conducted over a six month period at the Radiology Department of Ahmadu Bello University Teaching Hospital, Zaria. Two hundred adults who were bacteriologically proven to have pulmonary tuberculosis were consecutively recruited into the study as cases. The same number of age and sex matched healthy individuals that had chest radiograph grossly normal were recruited as controls. Their lateral chest wall soft tissue thickness (subcutaneous fat and muscle layers) on the chest radiographs was measured. Results: A total of 400 patients, aged 18 to 70 years. Average age was 39.12 ± 11.89years.They were 135 (62.5%) females and 65 (37.5%) males The mean and standard deviation obtained for pre-treated PTB patients and control group were 12.66 ± 2.63 mm and 19.37 ± 2.65 mm respectively, and the difference was statistically significant (P < 0.0001). However, no significant increase is noted in lateral soft tissue thickness among different sexes. Conclusion: The lateral soft tissue thickness (muscle and fat) was generally lower in PTB patients compared to the healthy individuals.

BackgroundSevere flail chest is a life-threatening situation. The Nuss procedure is a new effective treatment for severe flail chest patients who cannot be weaned from prolonged mechanical ventilation in the last few years. However, the procedure is not suitable when there are multiple fractures in both the anterior and lateral chest walls. Here, we reported a rare case of severe flail chest in a patient who suffered multiple fractures in both the anterior and lateral chest walls in a traffic accident.Case presentationA 49-year-old patient suffered severe flail chest by a steering wheel in a traffic accident with multiple fractures in both the anterior and lateral chest walls. In the beginning, the patient was administrated with mechanical ventilation because of acute respiratory distress syndrome (ARDS) for more than 1 week. Then the patient suffered from a severe lung infection and decreased blood oxygen saturation. After a multidiscipline discussion (MDT), three rib fixation plates were first used to rebuild the stability of lateral chest walls, then two Nuss bars were inserted to eliminate paradoxical movement in the anterior chest wall. Finally, the patient recovered smoothly after the combining procedure.ConclusionsSevere flail chest patients with both the anterior and lateral chest walls after trauma are in a life-threatening situation, and require an appropriate procedure to get out of danger in time. Rib fixation is an effective treatment when the fractured sites are few and the fractured area is small. The Nuss procedure is a new effective method for severe flail chest with multiple fractures in an anterior chest wall, which is also a minimally invasive and short time-consuming procedure. However, it does not suitable for the patient with multiple fractures in lateral chest walls. Combining the use of Nuss procedure and rib fixation can solve severe flail chest with multiple ribs and sternum fractures in both the anterior and lateral chest walls, and the outcome of this procedure is satisfying in the present rare case.

BackgroundMycobacterium chelonae, a nontuberculous mycobacterium, commonly causes skin, soft tissue, eye, pulmonary, catheter-related, and post-surgical infections in patients with immunosuppression or trauma. M. chelonae breast infections are rare, and most cases occur following cosmetic surgery. Here, we report the first case of spontaneous breast abscess due to M. chelonae.Case presentationA 22-year-old Japanese woman presented at our hospital with swelling and pain in the right breast for the past 2 weeks without any fever. She had a 19-month-old child and stopped breastfeeding 1 month after giving birth. The patient had no history of trauma or breast surgeries, no family history of breast cancer, and was not immunocompromised. Breast ultrasonography revealed a heterogeneous hypoechoic lesion with multiple fluid-filled areas suspected to be abscesses. Dynamic contrast-enhanced magnetic resonance imaging revealed a 64 × 58 × 62 mm, ill-defined, high-signal-intensity lesion with multiple ring enhancements in the upper half of the right breast. The first diagnosis was inflammatory breast cancer or granulomatous mastitis with abscess. A core needle biopsy led to drainage of pus. Gram staining did not reveal any bacteria in the pus, but the colonies from the biopsy grew on blood and chocolate agar cultures. Mass spectrometry detected M. chelonae in these colonies. Histopathological findings revealed mastitis without malignancy. The patient's treatment regimen was oral clarithromycin (CAM) based on susceptibility. Three weeks later, although the pus had reduced, the induration in the breast did not resolve; therefore, multidrug antibiotic treatment was initiated. The patient received amikacin and imipenem infusion therapy for 2 weeks, followed by continuation of CAM. Three weeks later, tenderness in the right breast recurred with slight pus discharge. Hence, minocycline (MINO) was added to the treatment. The patient stopped CAM and MINO treatment 2 weeks later. There was no recurrence 2 years after treatment.ConclusionWe report a case of M. chelonae breast infection and abscess formation in a 22-year-old Japanese woman without obvious risk factors. M. chelonae infection should be considered in cases of intractable breast abscess, even in patients without immunosuppression or trauma.

Red breast as a presenting complaint at a breast center: An institutional review

Inflammatory breast cancer is a rare but highly aggressive form of breast cancer. It is considered a distinct entity with unique clinicopathologic features. Symptoms of erythema and increase in breast size usually develop over the course of a few weeks. The clinical symptoms result from lymphovascular tumor emboli, which are pathognomonic for inflammatory breast cancer. Timely diagnosis may be challenging, as inflammatory breast cancer can mimic infectious disease such as mastitis or breast abscess. However, timely diagnosis and treatment are very important to provide trimodality management as early as possible. Patients should be imaged for distant metastasis at diagnosis. A combination of neoadjuvant systemic therapy, modified radical mastectomy, and adjuvant radiotherapy is standard of care for inflammatory breast cancer and improves local-regional and systemic control. This review contains 7 figures, 3 tables, and 59 references. Key Words: clinical presentation, diagnosis, imaging, inflammatory breast cancer, modified radical mastectomy, multimodality treatment, neoadjuvant systemic therapy, radiation therapy, staging

Inflammatory breast cancer is a rare but highly aggressive form of breast cancer. It is considered a distinct entity with unique clinicopathologic features. Symptoms of erythema and increase in breast size usually develop over the course of a few weeks. The clinical symptoms result from lymphovascular tumor emboli, which are pathognomonic for inflammatory breast cancer. Timely diagnosis may be challenging, as inflammatory breast cancer can mimic infectious disease such as mastitis or breast abscess. However, timely diagnosis and treatment are very important to provide trimodality management as early as possible. Patients should be imaged for distant metastasis at diagnosis. A combination of neoadjuvant systemic therapy, modified radical mastectomy, and adjuvant radiotherapy is standard of care for inflammatory breast cancer and improves local-regional and systemic control. This review contains 7 figures, 3 tables, and 59 references. Key Words: clinical presentation, diagnosis, imaging, inflammatory breast cancer, modified radical mastectomy, multimodality treatment, neoadjuvant systemic therapy, radiation therapy, staging

The contribution of the lateral chest wall to overall aesthetic outcome following breast augmentation, breast reduction, or breast reconstruction has been understudied. The authors of this study aim to determine whether a patient-perceived "ideal" lateral extension of the chest wall exists and whether it is influenced by respondents' demographic factors or body perceptions. The authors seek to provide plastic surgeons with valuable insights to optimize aesthetic results in breast procedures and better manage patient expectations. Realistic female figures were modeled to represent different body types. For each body type, 3 torsos were created with increasing lateral chest wall fullness (concave, neutral, and full). An anonymous online survey was sent to subscribers of a beauty magazine to determine their aesthetic preference toward lateral chest wall contours related to their perceived body type. A total of 1131 individuals responded to the survey, with 894 meeting the inclusion criteria: 48.7% selected the neutral lateral chest wall as the most aesthetically appealing, 46.0% the concave contour, and 5.3% the full contour. First-choice preferences varied significantly by self-selected body type (P < .001) and cosmetic procedure history (P = .01). With increasing BMI, respondents ranked the concave contour less favorably (P < .001), whereas the neutral (P = .007) and full (P = .01) contours received higher rankings. The aesthetics of the lateral chest wall are highly dependent on individual anatomy as well as patient perception of their body morphology. A contour ranging from slightly concave to neutral is generally preferred, with preferences correlating directly with body composition. These insights suggest that plastic surgeons should discuss the lateral chest wall with patients in consultation for breast procedures. Additionally, surgeons should adopt personalized surgical plans that consider the breast-chest wall relationship and integrate ancillary procedures to optimize patient satisfaction.

The lateral chest wall is an aesthetic unit often overlooked in breast surgery. Abnormalities are often seen in candidates for aesthetic and reconstructive breast surgery and in the massive weight loss population. Preoperative evaluation of the lateral chest wall is necessary to address this area properly. These deformities are intimately associated with the final outcome of any breast operation. To better define deformities of the lateral chest wall, a series of 522 patients who had aesthetic or reconstructive breast surgery was reviewed retrospectively. The preoperative and postoperative photographs were evaluated by two surgeons independently. Any surgical approaches used to correct lateral chest wall deformities were documented. In evaluating the lateral chest wall, the authors identified three subunit areas that need to be addressed to maximize aesthetic result: the axilla, the lateral breast, and the chest wall. Deficiency and excess of skin and fat contribute to any deformities in this region; deficiency or excess was found in 39 percent of patients. These deformities, when identified, were surgically addressed in 40 percent of patients, as management strategies included transfer of autologous tissue, fat injection, liposuction, or direct excision. Lateral chest wall deformities are often found among breast surgery candidates and can affect the final outcome. This area should be treated as a separate aesthetic unit from the breast. Patients with deficiency or excess should be counseled appropriately, as proper treatment may require procedures in addition to the primary breast procedure. The classification system presented can serve as a guideline for management of deformities in this region.

Many patients that have undergone mastectomy surgery are left with residual lateral fat under the arm. While the fat may be associated with pain and cause undesirable bulges in clothing and skin irritation, most post-mastectomy patients are not interested in additional surgery. Cryolipolysis is a nonsurgical procedure for fat reduction. The procedure is typically performed for aesthetic improvement in the abdomen, thighs, and flanks, but cryolipolysis was explored in this study for reconstructive purposes. Efficacy was evaluated for nonsurgical reduction of lateral chest wall thickness post-mastectomy. A contoured cup vacuum applicator was used to treat 31 post-mastectomy patients under the arms. All subjects had undergone mastectomy but had never received cryolipolysis or any surgical procedures to reduce lateral chest wall fat. Treatments were evaluated by independent photo review and patient surveys. Three blinded, independent physicians correctly identified 84% of the baseline photographs, demonstrating treatment efficacy. The surveys also found that 87% of subjects reported that cryolipolysis met their expectations; 84% noticed reduction in undesirable tissue; 85% reported better bra fit; and 74% noted that clothing fit more comfortably. Patient questionnaires reveal quality of life improvements post-treatment. While 61% of subjects reported pain in the lateral wall prior to the study, when queried post-treatment, only 13% reported pain; the remaining 87% reported no lateral wall pain. Results from this study indicate that cryolipolysis nonsurgically reduces unwanted fat and may reduce discomfort from residual lateral chest wall fat in post-mastectomy patients.

Nonsteroidal Anti-Inflammatory Drug-Induced Enteropathy: Case Discussion and Review of the Literature

To report normative data for diaphragmatic compound muscle action potentials (DCMAPs) recorded from over the sternum and lateral chest wall (LCW) and highlight factors that may contribute to variations in DCMAP parameters at the two sites. The phrenic nerve of seventy-three healthy subjects was bilaterally stimulated at the posterior border of the sternocleidomastoid muscle. DCMAPs from over the sternum and LCW were recorded (inspiration/expiration). Normative values of sternal and LCW DCMAPs were presented. The mean values of latency of LCW DCMAPs, duration of sternal DCMAPs and area from both recording sites are close to values reported by other studies. The mean values of latency of sternal DCMAPs are higher than that reported by other studies. Significant differences were found between sternal and LCW potentials in the mean latency, amplitude, and area (p < 0.001). The duration did not differ between the two sites. Differences were found between inspiration and expiration, right and left sides, and men and women. Regression analysis showed a relation between latency of sternal and LCW potentials and age. Latency (LCW potentials) and amplitude and area (sternal/LCW potentials) were related to gender. Amplitude (LCW potentials/inspiration) and area (sternal potentials/inspiration) were related to chest circumference (p = 0.023 and 0.013 respectively). Area (sternal potentials/expiration) was related to the BMI (p = 0.019). Our normative values for sternal and LCW DCMAPs are provided. Notable differences in the DCMAPs parameters were detected between the two recording sites, inspiration and expiration, right and left, and men and women. The technique of phrenic nerve should be standardized.