Chest Wall Muscles Research Articles

A case report of Poland Syndrome with Absent Limb Anomalies.

Introduction:Poland Syndrome(PS) is a rare congenital condition associated with the absence of unilateral chest wall muscles and sometimes ipsilateral symbrachydactyly (abnormally short and webbed fingers). The condition typically presents with unilateral absence of the sternal portion of the pectoralis major muscle which may or may not be associated with a hypoplasia of the breast, an ipsilateral webbing of the fingers (cutaneous syndactyly) and agenesis of 2, 3, 4, and 5 ipsilateral costal cartilages, and athelia.Case Report:We report a 13-year-old patient with an atypical variant of PS without any limb anomalies. In view of the good function of the upper limb, no surgical treatment was offered, and the patient and his family were counseled regarding the condition. A follow-up of the patient at 2 years revealed that the patient is still asymptomatic with good functional status of the upper limb.Conclusion:It is hoped that this paper will further improve our understanding of this rare syndrome and its atypical presentations.

Correction by the skin-to-chest wall distance in near-infrared spectroscopy and assessment of breast cancer responses to neoadjuvant chemotherapy

The measurement of hemoglobin (Hb) concentrations in breast cancer by near-infrared spectroscopy is useful for the assessment of responses to neoadjuvant chemotherapy (NAC). However, the chest wall muscles may affect this measurement. We corrected Hb concentrations based on the skin-to-chest wall distance. Corrected Hb was compared with uncorrected Hb as a marker of treatment responses in breast cancer patients. We measured total Hb (tHb) in breast cancer using a near-infrared time-resolved spectroscopy system in 10 patients before chemotherapy and after the first and second courses of NAC. To assess the skin-to-chest wall distance and thickness of tumors, ultrasound images were obtained using an ultrasonography probe with the spectroscopic probe. Net tHb (tHbnet) was calculated by subtracting tHb in normal breast tissue from cancer tHb. Patients underwent positron emission tomography with [18F] fluorodeoxyglucose (FDG) before chemotherapy and after the second course of NAC. FDG uptake was evaluated using the maximum standardized uptake value (SUVmax). tHb, tHbnet, and SUVmax in cancer significantly decreased in the course of chemotherapy. The change in tHbnet was larger than that in tHb. Although a correlation was not observed between the change in tHb and that in SUVmax, a positive correlation was noted between the change in tHbnet and that in SUVmax. Corrections by the skin-to-chest wall distance in spectroscopy led to the change in Hb concentrations being more similar to that in FDG uptake after NAC in breast cancer. tHbnet has potential as a reliable biomarker of breast cancer.

Comparative study of computed tomography of normal and lymphoid follicular hyperplasia thymus in myasthenia gravis patients.

The aim of the present study was to evaluate the thymuses of non-thymomatous myasthenia gravis (MG) patients by computed tomography (CT) for differentiating lymphoid follicular hyperplasia (LFH) thymus from normal/involuted thymus in order to assist surgeons in determining whether a non-thymomatous MG patient requires an operation. In the present retrospective review over 10 years, 80 patients who received CT scan and thymectomy at the Affiliated General Hospital of Tianjin Medial University (Tianjin, China) were included. According to the pathological records, 54 of the cases initially detected on CT were confirmed as LFH thymus. Thymic measurements, including anteroposterior and transverse dimensions, width (the longest axis of the lobe on a transverse scan) and thickness (the largest dimension perpendicular to the long axis of the lobe) and CT attenuation of the thymus region, adipose tissue and chest wall musculature in each CT slice were included to assess differences between the LFH group and the normal/involuted thymus group. Although a negative association between patient age and the CT attenuation of the thymus region was identified (r=-0.779, P<0.05, Pearson's correlation test), the LFH thymus group featured nodular changes on CT, while no such changes were observed in the normal/involuted thymus group. The mean age of disease onset in the LFH thymus group was significantly lower than that in the normal thymus group (40.2±17.3 vs. 59.2±9.3 years). Furthermore, significant differences in CT attenuation were identified between the LFH group and the normal/involuted thymus group [-41.21±54.42 vs. -108.23±8.72 Hounsfield units (HU) on unenhanced CT; -25.57±58.65 vs.-117.40±6.22 HU on contrast-enhanced CT]. In the LFH group, the difference in mean CT attenuation between the thymus region and adipose tissue was significant, while no significant difference was observed in the normal/involuted thymus group. In conclusion, CT may be used to distinguish LFH thymus from normal/involuted thymus in MG patients.

Changes in training posture induce changes in the chest wall movement and respiratory muscle activation during respiratory muscle training.

Postural changes induce changes in chest wall kinematics and eventually pulmonary function, and affect chest wall shape and chest motion. This study aimed to examine the effects of postural change on changes in the chest wall during respiratory muscle training. Using a repeated measures design, this study followed 13 healthy adults (13 men; mean age, 23.73 years). All participants performed four postures (neutral, full trunk rotation, half-range trunk rotation, and lateral ribcage shift postures) during respiratory muscle training. The chest wall movement during the four postures was measured using a three-dimensional motion-analysis system during respiratory muscle training. Surface electromyography data were collected from the diaphragm and sternocleidomastoid muscles, and the asymmetric ratio of muscle activation was calculated based on the collected data. The chest wall movements of the upper costal and middle costal region were greater in the neutral posture than in the full rotation, half rotation, and lateral ribcage shift postures (P<0.05). The respiratory muscle activation on diaphragm of left was greater in the full rotation posture than in the neutral posture, half rotation, and lateral ribcage shift postures (P<0.05). The asymmetric ratio of muscle activation was greater in the full rotation posture than in the neutral posture, half rotation, and lateral ribcage shift postures (P<0.05). This study verified that postural change during respiratory muscle training may affect chest wall movement and muscle activation. Thus, this study recommends respiratory muscle training to be performed in neutral posture.

Poland Syndrome- A Rare Congenital Condition

Named after Sir Alfred Poland, Poland syndrome is a rare congenital anomaly classically characterized by the absence of unilateral chest wall muscles and sometimes ipsilateral symbrachydactyly (abnormally short and webbed fingers). The aetiology is probably a vascular disruption sequence of the subclavian arteries. In most cases, Poland Syndrome is sporadic. We report a 26 year old male patient with typical features of Poland Syndrome associated with bronchiectasis and mitral valve prolapse- a very rare association. To the best of our knowledge, this is the first documented case of a Poland Syndrome with rare association reported from Bangladesh.J Bangladesh Coll Phys Surg 2018; 36(4): 166-169

Inspiratory pre‐motor potentials during quiet breathing in ageing and chronic obstructive pulmonary disease

A cortical contribution to breathing, as indicated by a Bereitschaftspotential (BP) in averaged electroencephalographic signals, occurs in healthy individuals when external inspiratory loads are applied. Chronic obstructive pulmonary disease (COPD) is a condition where changes in the lung, chest wall and respiratory muscles produce an internal inspiratory load. These changes also occur in normal ageing, although to a lesser extent. In the present study, we determined whether BPs are present during quiet breathing and breathing with an external inspiratory load in COPD compared to age-matched and young healthy controls. We demonstrated that increased age, rather than COPD, is associated with a cortical contribution to quiet breathing. A cortical contribution to inspiratory loading is associated with more severe dyspnoea (i.e. the sensation of breathlessness). We propose that cortical mechanisms may be engaged to defend ventilation in ageing with dyspnoea as a consequence. A cortical contribution to breathing is determined by the presence of a Bereitschaftspotential, a low amplitude negativity in the averaged electroencephalographic (EEG) signal, which begins ∼1s before inspiration. It occurs in healthy individuals when external inspiratory loads to breathing are applied. In chronic obstructive pulmonary disease (COPD), changes in the lung, chest wall and respiratory muscles produce an internal inspiratory load. We hypothesized that there would be a cortical contribution to quiet breathing in COPD and that a cortical contribution to breathing with an inspiratory load would be linked to dyspnoea, a major symptom of COPD. EEG activity was analysed in 14 participants with COPD (aged 57-84years), 16 healthy age-matched (57-87years) and 15 young (18-26years) controls during quiet breathing and inspiratory loading. The presence of Bereitschaftspotentials, from ensemble averages of EEG epochs at Cz and FCz, were assessed by blinded assessors. Dyspnoea was rated using the Borg scale. The incidence of a cortical contribution to quiet breathing was significantly greater in participants with COPD (6/14) compared to the young (0/15) (P=0.004) but not the age-matched controls (6/16) (P=0.765). A cortical contribution to inspiratory loading was associated with higher Borg ratings (P=0.007), with no effect of group (P=0.242). The data show that increased age, rather than COPD, is associated with a cortical contribution to quiet breathing. A cortical contribution to inspiratory loading is associated with more severe dyspnoea. We propose that cortical mechanisms may be engaged to defend ventilation with dyspnoea as a consequence.

Prepectoral breast reconstruction: Do we need to use the chest wall muscle at all?

Prepectoral breast reconstruction: Do we need to use the chest wall muscle at all?

Sciatic nerve stimulation and its effects on upper airway resistance in the anesthetized rabbit model relevant to sleep apnea.

Obstructive sleep apnea (OSA) is a disorder characterized by collapse of the velopharynx and/or oropharynx during sleep when drive to the upper airway is reduced. Here, we explore an indirect approach for activation of upper airway muscles that might affect airway dynamics, namely, unilateral electrical stimulation of the afferent fibers of the sciatic nerve, in an anesthetized rabbit model. A nerve cuff electrode was placed around the sciatic and hypoglossal nerves to deliver stimulus while airflow, air pressure, and alae nasi electromyogram (EMG) were monitored both before and after sciatic transection. Sciatic nerve stimulation increased respiratory effort, rate, and alae nasi EMG, which persisted for seconds after stimulation; however, upper airway resistance was unchanged. Hypoglossal stimulation reduced resistance without altering drive. Although sciatic nerve stimulation is not ideal for treating OSA, it remains a target for altering respiratory drive. NEW & NOTEWORTHY Previously, sciatic nerve stimulation has been shown to activate upper airway and chest wall muscles. The supposition that resistance through the upper airway would be reduced with this afferent reflex was disproven. Findings were in contrast with the effect of hypoglossal nerve stimulation, which was shown to decrease resistance without changing muscle activation or ventilatory drive.

Hodgkin Lymphoma Presentation With Extensive Chest Wall Muscle Involvement in an Adult

Hodgkin Lymphoma Presentation With Extensive Chest Wall Muscle Involvement in an Adult

Demonstration of simulated annealing optimization for permanent breast seed implant treatment planning

PurposePermanent breast seed implant (PBSI) is a developing brachytherapy technique for the treatment of early-stage breast cancer. In current practice, PBSI uses manual planning strategies to generate clinical treatment plans. In this work, a simulated annealing-based algorithm is developed to demonstrate the first application of inverse optimization for PBSI. Methods and MaterialsTarget, skin, and chest wall muscle contours, exported from a treatment planning system in digital imaging and communications in medicine format, are used as inputs. To optimize, the user defines the dose–volume histogram objectives for the target and specifies a relative weighting for target and skin constraints. A 10-patient cohort of previously treated patients was planned by using the inverse optimization algorithm. Plan quality was compared to the clinically treated manually generated plans using the V90%, V100%, V150%, and V200% for the planning target volume (PTV), V90% and D0.2 cc for skin dose, and PTV conformity indices. ResultsFor each of the 10 patients, patient-wise paired differences between inverse and manual plans were analyzed and presented in box plots. Comparing inverse and manual planning techniques, a statistical difference was not observed (p > 0.05) in PTV coverage criteria (V90%, V100%) and dose to skin2mm. A statistical difference was observed in the inverse plans as a reduction of the V150% (mean of 6.2%) and increase in conformity index of the 20%, 50%, 90%, and 100% isodose lines. ConclusionsThis work presents the first application of inverse optimization used to generate PBSI treatment plans. A 10-patient cohort previously treated with PBSI was retrospectively planned for comparison with the clinically treated manually generated plans.

Evaluation and selection of anatomic sites for magnetic resonance imaging-guided mild hyperthermia therapy: a healthy volunteer study

Purpose: Since mild hyperthermia therapy (MHT) requires maintaining the temperature within a narrow window (e.g. 40–43 °C) for an extended duration (up to 1 h), accurate and precise temperature measurements are essential for ensuring safe and effective treatment. This study evaluated the precision and accuracy of MR thermometry in healthy volunteers at different anatomical sites for long scan times.Methods: A proton resonance frequency shift method was used for MR thermometry. Eight volunteers were subjected to a 5-min scanning protocol, targeting chest wall, bladder wall, and leg muscles. Six volunteers were subjected to a 30-min scanning protocol and three volunteers were subjected to a 60-min scanning protocol, both targeting the leg muscles. The precision and accuracy of the MR thermometry were quantified. Both the mean precision and accuracy <1 °C were used as criteria for acceptable thermometry.Results: Drift-corrected MR thermometry measurements based on 5-min scans of the chest wall, bladder wall, and leg muscles had accuracies of 1.41 ± 0.65, 1.86 ± 1.20, and 0.34 ± 0.44 °C, and precisions of 2.30 ± 1.21, 1.64 ± 0.56, and 0.48 ± 0.05 °C, respectively. Measurements based on 30-min scans of the leg muscles had accuracy and precision of 0.56 ± 0.05 °C and 0.42 ± 0.50 °C, respectively, while the 60-min scans had accuracy and precision of 0.49 ± 0.03 °C and 0.56 ± 0.05 °C, respectively.Conclusions: Respiration, cardiac, and digestive-related motion pose challenges to MR thermometry of the chest wall and bladder wall. The leg muscles had satisfactory temperature accuracy and precision per the chosen criteria. These results indicate that extremity locations may be preferable targets for MR-guided MHT using the existing MR thermometry technique.

Using a whole-body 31P birdcage transmit coil and 16-element receive array for human cardiac metabolic imaging at 7T.

PurposeCardiac phosphorus magnetic resonance spectroscopy (31P-MRS) provides unique insight into the mechanisms of heart failure. Yet, clinical applications have been hindered by the restricted sensitivity of the surface radiofrequency-coils normally used. These permit the analysis of spectra only from the interventricular septum, or large volumes of myocardium, which may not be meaningful in focal disease. Löring et al. recently presented a prototype whole-body (52 cm diameter) transmit/receive birdcage coil for 31P at 7T. We now present a new, easily-removable, whole-body 31P transmit radiofrequency-coil built into a patient-bed extension combined with a 16-element receive array for cardiac 31P-MRS.Materials and methodsA fully-removable (55 cm diameter) birdcage transmit coil was combined with a 16-element receive array on a Magnetom 7T scanner (Siemens, Germany). Electro-magnetic field simulations and phantom tests of the setup were performed. In vivo maps of B1+, metabolite signals, and saturation-band efficiency were acquired across the torsos of eight volunteers.ResultsThe combined (volume-transmit, local receive array) setup increased signal-to-noise ratio 2.6-fold 10 cm below the array (depth of the interventricular septum) compared to using the birdcage coil in transceiver mode. The simulated coefficient of variation for B1+ of the whole-body coil across the heart was 46.7% (surface coil 129.0%); and the in vivo measured value was 38.4%. Metabolite images of 2,3-diphosphoglycerate clearly resolved the ventricular blood pools, and muscle tissue was visible in phosphocreatine (PCr) maps. Amplitude-modulated saturation bands achieved 71±4% suppression of phosphocreatine PCr in chest-wall muscles. Subjects reported they were comfortable.ConclusionThis easy-to-assemble, volume-transmit, local receive array coil combination significantly improves the homogeneity and field-of-view for metabolic imaging of the human heart at 7T.

Muscular sarcoidosis involving the chest and abdominal walls: case report with MR imaging

Sarcoidosis is an inflammatory disorder that is characterized by the presence of noncaseating granulomas in tissues, involving many organs and tissues. Extra-pulmonary, especially muscular sarcoidosis is a rare condition. The most common location of the muscular sarcoidosis is known to be the proximal muscles of the extremities; however, there have been no cases of diffuse involvement of the chest and abdominal wall muscles. Here, we report a rare muscular sarcoidosis with infiltrative pattern in the chest and abdominal wall muscles and describe the MR imaging findings that were mistaken as lymphoma at initial diagnosis. Although our case did not show characteristic MR findings of muscular sarcoidosis, clinicians or radiologists who are aware of these imaging features can perform early systemic survey for sarcoidosis. Also muscle biopsy is very important to confirm the sarcoidosis and distinguish it from other tumors.

Poland’s syndrome: a rare case report

Poland’s syndrome is a rare congenital condition. It is classically characterized by absence of unilateral chest wall muscles and sometimes ipsilateral symbrachydactyly (abnormally short and webbed fingers). The condition typically presents with unilateral absence of the sternal or breast bone portion of the pectoralis major muscle which may or may not be associated with the absence of nearby musculoskeletal structures. We report a 25-year-old male patient with typical features of Poland’s syndrome. To the best of our knowledge, this is the first documented case of a patient with Poland’s syndrome reported from Chennai.

In Vivo Dosimetry for Single Fraction Intraoperative Electron Radiation Therapy for Early Stage Breast Cancer

Patients with early stage breast cancer are offered adjuvant breast radiation to reduce the likelihood of recurrence. This is usually in the form of whole breast radiation. Recent data shows that partial breast radiation may be appropriate in some patients with early stage disease. Partial breast radiation, in the form of intraoperative radiotherapy (IORT) is one form of partial breast radiation. Little data has been published on in vivo dosimetry for IORT using electrons. We set out to prospectively measure the dose at three points within the tumor cavity using in vivo dosimeters (nanodots) for patients receiving single fraction IORT using electrons. Eligible patients with early stage breast cancer undergoing breast conservation and single fraction IORT were assessed. Following lumpectomy and sentinel node evaluation, the tumor bed was prepared for IORT. A chest wall shield was placed with in-vivo dosimeters (nanodots) placed above and below the shield. The tumor bed was then approximated and intraoperative ultrasound was used to determine depth from top of tumor cavity to top of shield. A 3rd in-vivo dosimeter was placed on the surface of the tumor bed. After 2100 cGy was delivered, the dosimeters were retrieved and the three dose points recorded. Energies, cone size, cone angles and presence/absence of bolus were also recorded. Regression coefficient was used to determine dose as a function of the above factors. Nanodots for a total of 136 patients were evaluated. Cone size ranged from 4.5- 7.5 cm. The majority of cases (86%) used cone size >/= 5.0 cm. Energies used included 6 (54.4%), 9 (38.2%), and 12 (7.4%) Mev. 58% of cones used had 0 degree angle. The mean surface dose was 1983 cGy (range 1706-2321), the mean dose above the shield was 1396.7 (range 2.4-2702) and the mean dose below the shield was 34.66 (1.4-748.3). Using the regression coefficient, surface dose was dependent on energy and cone size (P= 0.26, 0.28 respectively) but not cone angle (p= 0.06). The dose above shield did not appear to be dependent on energy, cone size or angle, (p= 0.62, 0.21, 0.28 respectively). The dose below shield does not appear to be dependent on the cone size or angle (p= 0.21, 0.19), but is dependent on energy (p=0.0). Our data shows that surface dose and dose below shield is consistent. Surface dose appears to be dependent on energy and cone size while dose below the shield seems to be dependent on energy. Dose above the shield was quite variable and not dependent on either three factors. The variability may be due to various issues including shield placed below chest wall muscle, off centering of dosimeters and inaccurate measurement of depth to chest wall. The top of the shield may also not be an appropriate surrogate for the base of the tumor bed.

Inspiratory muscle activation increases with COPD severity as confirmed by non-invasive mechanomyographic analysis.

There is a lack of instruments for assessing respiratory muscle activation during the breathing cycle in clinical conditions. The aim of the present study was to evaluate the usefulness of the respiratory muscle mechanomyogram (MMG) for non-invasively assessing the mechanical activation of the inspiratory muscles of the lower chest wall in both patients with chronic obstructive pulmonary disease (COPD) and healthy subjects, and to investigate the relationship between inspiratory muscle activation and pulmonary function parameters. Both inspiratory mouth pressure and respiratory muscle MMG were simultaneously recorded under two different respiratory conditions, quiet breathing and incremental ventilatory effort, in 13 COPD patients and 7 healthy subjects. The mechanical activation of the inspiratory muscles was characterised by the non-linear multistate Lempel–Ziv index (MLZ) calculated over the inspiratory time of the MMG signal. Subsequently, the efficiency of the inspiratory muscle mechanical activation was expressed as the ratio between the peak inspiratory mouth pressure to the amplitude of the mechanical activation. This activation estimated using the MLZ index correlated strongly with peak inspiratory mouth pressure throughout the respiratory protocol in both COPD patients (r = 0.80, p<0.001) and healthy (r = 0.82, p<0.001). Moreover, the greater the COPD severity in patients, the greater the level of muscle activation (r = -0.68, p = 0.001, between muscle activation at incremental ventilator effort and FEV1). Furthermore, the efficiency of the mechanical activation of inspiratory muscle was lower in COPD patients than healthy subjects (7.61±2.06 vs 20.42±10.81, respectively, p = 0.0002), and decreased with increasing COPD severity (r = 0.78, p<0.001, between efficiency of the mechanical activation at incremental ventilatory effort and FEV1). These results suggest that the respiratory muscle mechanomyogram is a good reflection of inspiratory effort and can be used to estimate the efficiency of the mechanical activation of the inspiratory muscles. Both, inspiratory muscle activation and inspiratory muscle mechanical activation efficiency are strongly correlated with the pulmonary function. Therefore, the use of the respiratory muscle mechanomyogram can improve the assessment of inspiratory muscle activation in clinical conditions, contributing to a better understanding of breathing in COPD patients.

Pulmonary MRI at 3T: Non-enhanced pulmonary magnetic resonance Imaging Characterization Quotients for differentiation of infectious and malignant lesions

ObjectiveTo investigate 3T pulmonary magnetic resonance imaging (MRI) for characterization of solid pulmonary lesions in immunocompromised patients and to differentiate infectious from malignant lesions. Materials and methodsThirty-eight pulmonary lesions in 29 patients were evaluated. Seventeen patients were immunocompromised (11 infections and 6 lymphomas) and 12 served as controls (4 bacterial pneumonias, 8 solid tumors). Ten of the 15 infections were acute. Signal intensities (SI) were measured in the lesion, chest wall muscle, and subcutaneous fat. Scaled SIs as Non-enhanced Imaging Characterization Quotients ((SILesion−SIMuscle)/(SIFat−SIMuscle)*100) were calculated from the T2-weighted images using the mean SI (T2-NICQmean) or the 90th percentile of SI (T2-NICQ90th) of the lesion. Simple quotients were calculated by dividing the SI of the lesion by the SI of chest wall muscle (e.g. T1-Qmean: SILesion/SIMuscle). ResultsInfectious pulmonary lesions showed a higher T2-NICQmean (40.1 [14.6–56.0] vs. 20.9 [2.4–30.1], p<0.05) and T2-NICQ90th (74.3 [43.8–91.6] vs. 38.5 [15.8–48.1], p<0.01) than malignant lesions. T1-Qmean was higher in malignant lesions (0.85 [0.68–0.94] vs. 0.93 [0.87–1.09], p<0.05). Considering infections only, T2-NICQ90th was lower when anti-infectious treatment was administered >24h prior to MRI (81.8 [71.8–97.6] vs. 41.4 [26.6–51.1], p<0.01). Using Youden’s index (YI), the optimal cutoff to differentiate infectious from malignant lesions was 43.1 for T2-NICQmean (YI=0.42, 0.47 sensitivity, 0.95 specificity) and 55.5 for T2-NICQ90th (YI=0.61, 0.71 sensitivity, 0.91 specificity). Combining T2-NICQ90th and T1-Qmean increased diagnostic performance (YI=0.72, 0.77 sensitivity, 0.95 specificity). ConclusionConsidering each quotient alone, T2-NICQ90th showed the best diagnostic performance and could allow differentiation of acute infectious from malignant pulmonary lesions with high specificity. Combining T2-NICQ90th with T1-Qmean increased overall performance, especially regarding sensitivity.

A Confusing Complication of Liver Biopsy: First Case Report of Seeding/ Implantation of Hepatocellular Carcinoma 9 Years from the Original Liver Biopsy

The incidence of seeding/implantation of hepatocellular carcinoma (HCC) after liver biopsy or radio frequency ablation (RFA) is not well reported but estimated to be low. With the introduction of immunosuppression the risk has been increased and most of the seeding sites are chest wall and abdominal muscles. We report the first case report of HCC seeding after 9 years from the original liver biopsy. A 66 years old gentleman with cirrhosis secondary to hepatitis C virus infection and long history of alcohol abuse found to have a liver lesion during his screening by ultrasound and underwent percutaneous liver biopsy, which revealed hepatocellular carcinoma in 2006 and then the patient had a liver transplantation surgery in 2006 from cardiac death donor. The post transplantation course was uneventful and started on dual immunosuppression including Tacrolimus and Mycophenolate mofetil with acceptable levels through the whole treatment duration. All the follow up routine check ups including CT scan, liver biopsy, liver function tests and cancer screening were unremarkable and alphafetoprotein (AFP) was within acceptable level except slight increase in the AFP early 2015. His increase in AFP raised the concern for recurrence of HCC and his work up for possible recurrence or metastasis was negative including CT scan of the chest, abdomen and pelvis. Later in the 2015, the patient presented to his primary care physician complaining of right upper quadrant pain and swelling for which he underwent excisional biopsy of the skin. The skin nodule been fully resected and was 1.5 cm in diameter and its 10-15 cm from the original HCC. The pathology results of the specimen revealed that its metastatic hepatocellular carcinoma involving the subcutaneous tissue with negative margins, the immunostains were positive for Heppar1 immunestains and equivocal for glypican 3. This represents a local seeding of the original HCC 9 years after the liver biopsy location. This finding also was confirmed upon reviewing the images of the original HCC and the new metastatic HCC that showed it has same track of the liver biopsy in 2006. This case report is to increase the awareness of hepatologist and primary care physicians of the risk of skin HCC implantation and consider a routine check during the clinic visits in addition to the dermatologist skin screening visits. More research needed to investigate the rule of immunosuppression on seeding and implantation of HCC.

Rectus sternalis

The sternalis muscle is an uncommon variant of the anterior thoracic chest wall musculature. During mastectomy of a patient, we observed a left-sided unilateral vertical band of texture sternalis muscle fiber overlying the lateral edge of the sternum. We are reporting about the same in this case. The origin of this muscle is a debatable topic. It can be misdiagnosed by the clinicians on a routine mammography. The presence of this muscle can cause alterations in electrocardiography during investigation.

Safety and pain in electrodiagnostic studies

Discomfort is an unavoidable part of electrodiagnostic (EDX) studies. The most readily modifiable mediator of electromyography (EMG)-associated pain is muscle selection. Interventions that may reduce pain include vapocoolant spray, ibuprofen, and techniques such as slapping or stretching the skin. Needlestick injuries to health care workers carry the risk of transmitting bloodborne illnesses, but other infectious complications of EDX studies are very rare. EMG probably contributes to asymptomatic hemorrhage in approximately 1% of patients, but clinically significant bleeding has only been reported a few times. Therapeutic anticoagulation does not significantly increase this risk. With standard procedures, there have been no reports of patients developing cardiac arrhythmia from nerve conduction studies. No special precautions are necessary in patients with implantable cardiac devices or intravenous lines. There is a small risk of pneumothorax associated with EMG of the diaphragm and chest wall muscles. Several techniques have been suggested to improve the safety of diaphragm EMG. Muscle Nerve 55: 149-159, 2017.