Contralateral Chest Wall Research Articles

Mediastinal Shift Index: A Novel Postnatal Measurement of Mediastinal Movement that Predicts Survival in Neonates With Congenital Diaphragmatic Hernia on Extracorporeal Membrane Oxygenation

PurposeMediastinal position varies in neonates with congenital diaphragmatic hernia (CDH), reflecting contralateral shift due to mass effect. We aimed to create and validate a postnatal measurement of mediastinal positioning using chest radiographs in neonates with CDH who require extracorporeal membrane oxygenation. MethodsChart review identified neonates with CDH who required veno-arterial extracorporeal membrane oxygenation between 2017 and 2022. Mediastinal shift index (MSI) is the ratio of the distance between the venous cannula tip and the contralateral chest wall divided by the total width of the contralateral hemithorax. Three raters completed MSI measurements at designated timepoints: after cannulation, post- CDH repair, and immediately before decannulation. Intraclass correlation coefficients (ICC) assessed inter-rater agreement. Initial MSI and observed/expected lung head ratio (O/E LHR) were correlated and compared between survivors and non-survivors. Receiver operative characteristic (ROC) curve analysis evaluated the ability of MSI and O/E LHR to predict survival. Results38 neonates were included. MSI demonstrated excellent agreement (ICC>0.98) amongst raters. Initial MSI and O/E LHR had a moderate positive correlation (Spearman correlation = 0.47, p = 0.014). Initial MSI differed significantly between survivors and non-survivors (0.52 vs. 0.33, p = 0.035) as did O/E LHR (0.36 vs. 0.26, p = 0.036). ROC analysis revealed initial MSI >0.35 was predictive of survival with 73% sensitivity and 70% specificity. ConclusionMediastinal shift index is reliable and predicted survival with a higher specificity than O/E LHR. Future studies will elucidate the role of trending MSI over a patient's course to inform interventions to optimize mediastinal position. Level of Evidence3.

Establishment of an orthotopic model of lung cancer by transthoracic lung puncture using tumor fragments.

Orthotopic models of lung cancer have been widely utilized, and the purpose of this study was to demonstrate the viability of our proposed modified modeling approach. A total of 50 female BALB/c mice were implanted with 1×1×1 mm fragments of a tumor sample into the left lung lobe. After 2 months of observation, the mice were humanely euthanized through CO2 inhalation. The macroscopic specimens were photographed, and the most representative neoplastic lesions were collected for histological analysis. Small-animal positron emission tomography/computed tomography (PET/CT) scans were conducted on 6 randomly selected mice. Local tumor formation, ipsilateral thoracic tissue infiltration, the contralateral chest wall, right lung metastases, and distant kidney metastases were observed in these models. Overall, the tumor development and metastasis rates were 60.86% (28/46) and 57.14% (16/28), respectively. The 3 mice that had a small-animal PET/CT scan developed a local tumor, but no distant metastases were observed. This modified method was deemed reliable, reproducible, minimally invasive, straightforward, and comprehensible; it might serve as the foundation for developing patient-derived orthotopic xenografts of lung cancer.

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

Assessment of Tissue Oxygenation and Radiation Dermatitis Pre-, During, and Post-Radiation Therapy in Breast Cancer Patients.

Over 95% of breast cancer patients treated with radiation therapy (RT) undergo an adverse skin reaction known as radiation dermatitis (RD). Assessment of severity or grading of RD is clinically visual and hence subjective. Our objective is to determine sub-clinical tissue oxygenation (oxygen saturation) changes in response to RT in breast cancer patients using near-infrared spectroscopic imaging and correlate these changes to RD grading. A 4-8 week longitudinal pilot imaging study was carried out on 10 RT-treated breast cancer patients. Non-contact near-infrared spectroscopic (NIRS) imaging was performed on the irradiated ipsilateral and the contralateral breast/chest wall, axilla and lower neck regions before RT, across the weeks of RT, and during follow-up after RT ended. Significant changes (p < 0.05) in oxygen saturation (StO2) of irradiated and contralateral breast/chest wall and axilla regions were observed across weeks of RT. The overall drop in StO2 was negatively correlated to RD scaling (in 7 out of 9 cases) and was higher in the irradiated regions when compared to its contralateral region. Differences in the pre-RT StO2 between ipsilateral and contralateral chest wall is a potential predictor of the severity of RD. The subclinical recovery of StO2 to its original state was longer than the visual recovery in RD grading scale, as observed from the post-RT assessment of tissue oxygenation.

Inclusion of a latissimus dorsi segment in an extended lower trapezius musculocutaneous flap facilitates complex defect reconstruction

The pedicled lower trapezius musculocutaneous flap (LTMF) can extend far beyond the lateral border of the trapezius muscle, with a reliable blood supply. However, the distal part of the extended LTMF lacks a muscular component, limiting its usage in complex defect reconstruction, which often requires obliteration of dead space and coverage of vital structures. To overcome this limitation, we modified the LTMF by adding a segment of latissimus dorsi muscle (LDM). Between 2014 and 2021, the modified extended LTMF was used to reconstruct complex defects in the head, neck, shoulder, and contralateral chest wall and back in 19 patients. By preserving the interconnections between the branches of the posterior intercostal arteries, we were able to include various amounts of LDM within the extended LTMF. The LDM component was used to obliterate dead space and repair wounds involving cerebrospinal fluid leakage, infection, radioactive osteomyelitis, exposed carotid artery, lung, and implant materials. The average flap size was 30.7cm × 10.9cm (range: 25 × 8 cm-40 × 14cm). The average size of the LDM was 113.9 cm2 (range: 27.7-216.6 cm2). Partial flap necrosis occurred in two patients and the secondary defects were reconstructed using a local flap. The remaining 17 flaps survived completely. The LTMF carrying a segment of the LDM could be considered for patients undergoing reconstruction of complex defects in the head, neck, shoulder, and contralateral chest wall and back and for patients who are ineligible for free flap reconstruction.

Chest Wall Pain In A Marathon Runner

HISTORY: A 39-year old male marathon runner presented with 1 year of left-sided anterolateral chest wall pain at ribs 10 and 11. Pain started insidiously, without trauma or other inciting incident. Pain primarily occurred with running, and typically worsened as his pace increased. Lifting weights, deep breathing, and prolonged sitting did not exacerbate pain. He denied cough, dyspnea, or wheezing. PHYSICAL EXAMINATION: Normal chest wall expansion. No visual deformity along the ribs or costal cartilage. Tenderness to palpation was noted along the left 10th and 11th ribs and intercostal muscle anterior to the mid-axillary line. No tenderness at adjacent segments or at the same segment on the contralateral chest wall. Mild left-sided chest wall pain with leftward thoracic rotation. DIFFERENTIAL DIAGNOSIS: 1. Costochondritis 2. Tietze syndrome 3. Slipping rib syndrome 4. Thoracic radiculitis 5. Pleurisy TESTS AND RESULTS: MRI Chest Wall: Focal thickening and edema along left lower ribs at region of pain, with surrounding soft tissue swelling. No pleural or pericardial effusion. No bone marrow edema within visualized osseous structures. Ultrasound Chest Wall: Significant signal impedance and focal thickening noted along the intercostal muscle of the left 10th and 11th ribs at the area of maximal tenderness along the anterolateral chest wall. No comparable signal changes are observed at adjacent segment levels or the same segment on the contralateral chest wall. FINAL/WORKING DIAGNOSIS: 1. Tietze syndrome TREATMENT AND OUTCOMES: 1. Performed corticosteroid/lidocaine injection to left 10th-11th rib intercostal muscle under ultrasound guidance 2. Pain diary for 6 hours immediately following injection 3. Routine marathon training as tolerated 4. Ice as needed after running 5. Pain resolved following injection. Inflammation and intercostal muscle hypertrophy resolved on repeat ultrasound 2 months later. 6. Patient completed Berlin and Chicago Marathons in 2019

Negative-pressure wound therapy (NPWT) for the treatment of pacemaker pocket infection in patients unable or unwilling to undergo CIED extraction.

The occurrence of cardiac pacemaker pocket infection has markedly increased and has become a new problem facing cardiovascular internists. The aim of our study was to investigate the effectiveness and safety of treating cardiac pacemaker pocket infection using negative-pressure wound therapy (NPWT) in patients who are unwilling or unable to have their cardiac implantable electronic devices (CIEDs) removed. From March 2013 to April 2019, NPWT was applied to 26 patients with cardiac pacemaker pocket infection who were unwilling or unable to have their CIEDs removed. In the first stage, a negative-pressure drainage system was placed in the pacemaker pocket after debridement. Then, NPWT was used to seal the wound, and the negative pressure (300-400mmHg) was sustained for 5-7days. In the second stage, the pacemaker was relocated to the subpectoral layer, and the wound was closed. In all but three of our 26 patients, the wound healed completely without complications and without evidence of residual infection. The average follow-up period was 26.92 ± 9.46months. Only 3 diabetic patients whose tissue bacterial cultures revealed that methicillin-resistant Staphylococcus epidermidis developed uncontrolled infections. Eventually, the entire original pacemaker systems were removed, and new pacemakers were implanted in the contralateral chest wall. When warranted by strictly selected indications, the method of NPWT without CIED extraction can be considered as a new and effective treatment for patients with pacemaker pocket infection who are unwilling or unable to have the device removed.

Use of a Capture-Guidance Surgical Instrument to Minimize Muscle Stripping During Nuss Repair of Pectus Excavatum.

Background: Pectus excavatum is an anomaly of chest wall development in which anterior ribs curve inward and the sternum is displaced toward the vertebral column. The Nuss procedure is a minimally invasive technique in which one or more metal bars are implanted to brace the sternum in a corrected position. Over time, the chest wall remodels into an anatomically corrected shape and the bar(s) are removed at a later date. During the procedure, passage of an introducer instrument and then the repair bar(s) may shear the intercostal muscles from the adjacent ribs. This creates larger than necessary defects in the chest wall, improper or unstable bar placement, and inadequate repair. Instrument Design: We report a new surgical instrument for guiding the introducer through the contralateral chest wall. This capture-guidance instrument (CGI) redirects and channels forces to keep the introducer true while preventing muscle stripping during passage of the introducer and repair bar(s). Instrument Use: The CGI has been piloted at two pectus centers with a notable decrease in intercostal muscle stripping. Conclusion: The CGI addresses the problem of shear and intercostal muscle stripping during traversal of the chest as part of Nuss repair of pectus excavatum.

Abstract P4-01-17: Aggressive subgroups of metastatic triple-negative breast cancer: Inflammatory breast cancer and young patients in the Dana-Farber cell-free DNA cohort

Abstract Background: Relative to other metastatic breast cancer subtypes, metastatic triple-negative breast cancer (mTNBC) has a shorter duration of response to therapy and worse overall survival. Within mTNBCs, there is a prevailing belief that inflammatory breast cancer and young women tend to have among the most aggressive phenotypes. We investigated clinical and cell-free DNA (cfDNA) characteristics of inflammatory-mTNBC and young-mTNBC. We hypothesized that inflammatory-mTNBC may have distinct clinical and cfDNA characteristics, offering potential novel biomarker and therapeutic strategies. Methods: 164 patients from the Dana-Farber metastatic triple-negative cell-free DNA cohort (Stover DG, et al J Clin Oncol 2018) were included in this secondary analysis. Patients were stratified into three groups: 1) inflammatory breast cancer ('IBC'); 2) non-IBC patients aged 45 years (yr) or younger at primary diagnosis ('non-IBC young'); and 3) non-IBC patients over age 45 yr at diagnosis. For each subset population, we evaluated clinicopathologic characteristics, sites of metastasis, survival outcomes, and cfDNA 'tumor fraction' – the fraction of DNA in circulation derived from tumor. Those patients with adequate cfDNA tumor content for high confidence copy number calls (n=101) were included in an analysis of copy number alterations. Results: Among 164 patients with metastatic TNBC, 13.4% (22/164) had IBC, 37.8% (62/164) were non-IBC young, and 48.8% (80/164) were non-IBC and over 45 yr. Race and primary receptor status were similar. IBC patients were diagnosed at a higher stage (Chi-square p=0.0009) while non-IBC young patients were significantly more likely to harbor a BRCA mutation (Chi-square p=0.03). Analysis of metastatic sites revealed that IBC patients had significantly greater frequency of ipsilateral and contralateral breast chest wall recurrences (p=0.04 and p=0.046, respectively) while non-IBC young patients had the most frequent lung metastases (p=0.002). There were no significant differences in frequency of bone, brain, or liver metastases. cfDNA analyses showed that cfDNA 'tumor fraction' was highest in non-IBC young patients (ANOVA p=0.03 for maximum tumor fraction). Median overall survival from metastatic diagnosis was 22.9 months. IBC and non-IBC young patients had a worse prognosis relative to non-IBC patients over 45 yr (hazard ratio IBC=1.97, 95% CI 1.09-3.57; HR non-IBC young=1.60 95% CI 1.07-2.41; log-rank p=0.023). By subgroup, median overall survival from metastatic diagnosis for IBC was 15.2 months, non-IBC young 21.2 months, and non-IBC over 45 yr 31.2 months. Analyses of genome-wide copy number alterations from cell-free DNA will be presented. Conclusions: Among metastatic TNBCs, IBC patients and non-IBC young patients have a significantly worse overall survival compared with non-IBC patients over 45 yr of age. Young patients have more frequent lung metastases and higher 'tumor fraction' of cfDNA. Confirmation of the reported findings is limited due to cohort size and may reflect referral bias. Citation Format: Singh J, Asad S, Nock W, Zhang Y, Adams E, Damicis A, Parsons HA, Adalsteinsson VA, Winer EP, Lin NU, Partridge AH, Overmoyer B, Stover DG. Aggressive subgroups of metastatic triple-negative breast cancer: Inflammatory breast cancer and young patients in the Dana-Farber cell-free DNA cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-17.

Lead extraction for reduction of chronic pain related to cardiovascular implantable electronic device.

Chronic pain at the cardiovascular implantable electronic device (CIED) generator or lead insertion site that is not otherwise manageable carries a IIA indication for extraction. However, limited data exist evaluating causes of pain and outcomes of extraction in eliminating pain. A multi-centre retrospective observational study was conducted to evaluate outcomes of patients undergoing device extraction for treatment of chronic device pain. Twenty-seven out of 2188 lead extraction candidates (1.3%) met the chronic pain IIA indication for extraction [50 ± 16 years; 14 (51%) women]. Onset, severity, triggers, and pain management were measured before and after extraction. Device type, procedure done (with/without reimplantation), and positive tissue cultures were noted. Pain was reported as constant (n = 14; 50%), intermittent (n = 13; 46%), and movement-triggered (n = 14; 50%). Average severity of pain was seven out of 10 (10 being the worst). Post-extraction, 18 (66%) received freedom from pain, including all patients with poorly formed pockets (n = 2) and subclinical infections (n = 2). Of the 18, 11 underwent reimplantation (61%) without recurrent pain. Nine still had pain (44 ± 17 years; seven women) after extraction. Eight of the nine underwent reimplantation, three on the contralateral chest wall and five ipsilaterally. Pain severity decreased (n = 5), increased (n = 1), or was unchanged (n = 3). Chronic pain at the CIED generator site can present as chronic or movement-triggered pain, and can be due to subclinical infection or a poorly formed device pocket. Extraction relieved constant and intermittent pain in two-thirds of patients. Extraction appears less successful in eliminating pain in women who undergo subsequent reimplantation.

Outcome and Late Toxicity of Breast Cancer Patients Treated with Post-Mastectomy Proton Therapy

Post-operative whole-breast proton radiotherapy improves normal tissue sparing in comparison to photon-based approaches. Several studies have reported tolerable acute toxicity profile with limited follow up. We report an update of our institutional experience of PMRT with longer follow up. From December 2013 to February 2015, 42 patients who received mastectomy for non-metastatic breast cancer and no history of prior radiation to the ipsilateral breast or chest wall were treated with adjuvant chest wall and regional nodal proton therapy at a single proton center. 3D conformal uniform scanning with en face matching fields was used to treat all patients. Patient characteristics, early and late toxicities, and failure rates were obtained through chart review. Toxicity was assessed using CTCAE v4.0. Digital photographs were taken at baseline, weekly on treatment visits, and at each follow-up visit to document skin toxicity. The median follow-up among patients was 26 months (range 1 to 43 months). Median age of patients was 49 (range 21 to 86). Twenty-six patients (61.9%) had either implant (25 patients) or autologous reconstruction (1 patient) following mastectomy. All patients received radiation to the reconstructed chest wall and regional lymph nodes. The internal mammary chain was included in the radiation field in 33 patients (78.6%). Median dose of radiation administered was 50 RBE weighted dose Gy (RBE) (range 45 to 61.2 Gy(RBE) ). The median mean heart dose was 0.73 Gy (RBE) and median ipsilateral lung V20 was 16.1% and lung V5 was 33.7%. At 3-year follow-up, there was one local failure in the chest wall, zero regional nodal failures, and five distant failures. One patient died of metastatic disease since the completion of treatment. The 3-year rates of locoregional disease-free survival was 93.3%, metastasis-free survival was 85.0%, and overall survival was 96.9%. Fifteen patients (34.8%) developed grade 1 late hyperpigmentation, telangiectasia, or fibrosis. There was no late grade 2 skin or soft tissue toxicity. Five patients (18.5%) had reconstruction complications requiring revision/replacement but only one patient was left without successful reconstruction at the time of last followup. One patient (2%) with a history of prior contralateral chest wall radiation and underlying lung disease developed grade 3 radiation pneumonitis one year after treatment but made a full recovery with medical therapy. There was no observed cardiac toxicity with no cardiac events or cardiac deaths. Grade 1 lymphedema was observed in six patients, all of whom have had axillary lymph node dissection. With more than two years of median follow up, post-mastectomy proton radiation has excellent locoregional control rates and favorable toxicity profile.

Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance

Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.

Primary infiltrating ductal carcinoma of the axillary breast with metastasis to the contralateral chest wall

Primary infiltrating ductal carcinoma of the axillary breast is rare and has a high frequency of lymph node (LN) involvement. We report a woman with primary infiltrating ductal carcinoma arising from the right axillary breast with metastasis to the contralateral chest wall. Excisional biopsy of the left chest wall nodule and the right axillary mass was carried out and both showed invasive ductal carcinomas histologically. The lesion of the right axillary mass arose from the breast tissue, rather than the LN. Further surgery proved the right axillary LN metastasis. After further review, a primary infiltrating ductal carcinoma of the right axillary breast with metastasis to axillary LNs and contralateral chest wall was diagnosed. The patient also received chemotherapy and radiation and there was no evidence of tumor recurrence after treatment. The present report demonstrated a rare case with uncommon manifestation. Lesions of uncertain origin around the periphery of the breast should be suspected for breast carcinoma.

Bilateral approach of redistributed subclavian arterial infusion chemotherapy for locally advanced breast cancer spreading to the contralateral chest wall

A catheter port system technique called redistributed subclavian arterial infusion chemotherapy (RESAIC) for locally advanced breast cancer was reported and seemed to be effective for local control and as a palliative treatment. However, when the cancer spreads beyond the medial line to the contralateral chest wall, ipsilateral RESAIC would not achieve a favorable drug distribution. We report on two patients with advanced breast cancer spreading to the contralateral chest wall in whom bilateral RESAIC was attempted. In summary, when advanced breast cancer spreads to the contralateral chest wall, bilateral RESAIC may be useful for local control or palliation.

SU‐E‐T‐838: Inverse‐Planned Multi‐Beam Intensity‐Modulated Radiation Therapy versus Three‐Dimensional Conformal Radiotherapy for Left Breast Cancer Patients after Mastectomy

Purpose: The purpose of this study was to compare dose distribution and normal tissue sparing in the treatment of left chest wall, as well as supraclavicular nodes (SCV), and, in one case, internal mammary nodes (IMN) for patients undergoing post mastectomy radiation using three‐dimensional conformal radiotherapy (3D‐CRT) vs. multi‐beam intensity‐modulated radiotherapy (IMRT). Methods: To date, a total of five patients were randomly selected for comparison. All the planning target volumes (PTV) were contoured according to the Breast Cancer Atlas for the Radiation Therapy Planning from Radiation Therapy Oncology Group (RTOG). A dose of 5040cGy was prescribed in 28 fractions to each PTV. Two plans were evaluated for each patient, one with beam split tangents and an additional supraclavicular field for 3D‐CRT, and the other one with five inverse‐planned IMRT beams. To obtain the desired skin dose, bolus was used every other day. Dose comparison metrics included: PTV homogeneity index (HI) and conformity index (CI), V30 and V5, and mean and maximum doses to normal tissue structures, such as heart, left lung, right lung, contralateral chest wall, and V20 to both lungs. Results: Compared to a conventional 3D‐CRT plan, the five‐field IMRT significantly improved PTV HI and CI, and marginally reduced heart and left lung maximum doses without compromising PTV coverage, but at the same time increased contralateral chest wall and lung dose, and heart V5. Conclusions: Five‐field IMRT plan provides far superior target volume coverage and comparable heart V30 and lung V20 to a conventional plan, while increasing low dose to contralateral side. The use of five beams —instead of 9 or 11, as recommended by other studies‐ reduces the treatment time and, consequently, possible setup and internal organ motion errors. Further clinical studies are needed to determine whether IMRT improves tumor control or reduces acute or late toxicities when compared to 3D‐CRT.

Abstract P5-14-15: Contralateral Prophylactic Mastectomy: Clinical and Pathological Features of Women Treated at the University of Louisville

Abstract Objective: To evaluate the clinical and pathological features of women who underwent contralateral prophylactic mastectomy (CPM) as a component of breast cancer therapy. Materials &amp; Methods: This is a retrospective review of a prospectively-maintained database of patients treated at the multi-disciplinary breast cancer clinic at the University of Louisville from 2003-2009. Patientswith unilateral pre-invasive and invasive adenocarcinoma who underwent mastectomy as primary surgical treatment for the involved breast with CPM were included. All information from surgical, medical and radiation oncology records were reviewed for this analysis. Results: A total of 107 patients are included in this analysis. The median age was 48 years (range 26-80). A previous history of breast cancer was noted in 8% of patients, all of whom received lumpectomy and whole-breast radiotherapy. A family history of breast cancer was identified in 46% of patients and 4% of patients possessed a germline BRCA mutation. Ninety-three percent of tumors were invasive. Evaluation of the pathological tumor (T) stage yielded 7% Tis, 48% T1, 36% T2, 3% T3, and 3% T4. Four percent of tumors were pathologically T0 after a complete response to neoadjuvant chemotherapy. Pathological node (N) staging yielded 56% N0, 23% N1, 14% N2, and 7% N3. Two percent of patients had distant metastasis at diagnosis. Twenty-two percent of tumors were negative for the estrogen, progesterone, and HER2/neu receptors (triple negative). Lobular carcinoma in situ was found in 10% of tumors. Five occult tumors were detected in the contralateral breast, of which 4 were carcinoma in situ and 1 was invasive mucinous carcinoma. With a median follow-up of 27 months (range 7-83), 9 treatment failures have been noted. Four patients failed locoregionally, 3 failed distantly, and 2 failed both locoregionally and distantly. Five patients have died of metastatic disease. No contralateral chest wall failures have occurred. Conclusions: CPM has become more popular over the past 6 years and patients present with a diverse array of clinical and pathological features. Occult disease in the contralateral breast is rare and was not encountered in our series. The pattern of failure is determined by the primary disease and the clinical utility of CPM therefore remains uncertain. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-15.

Local recurrence model of malignant pleural mesothelioma for investigation of intrapleural treatment☆

Local recurrence remains a major problem in the treatment of malignant pleural mesothelioma. The aim of the underlying study was to establish a standardised local recurrence model in rats which enables to study different intrapleural therapies. Fifty microlitre containing 1 x 10(6) cells of a syngeneic rat malignant mesothelioma cell line (II-45), established from mesothelioma in Fischer 344 rats exposed to asbestos, were inoculated subpleurally via a left-sided thoracotomy. Tumour size was assessed 6 days later and the tumour nodule completely resected. Evaluation of recurrence at the resection site was performed after 10 days (n=6) and 6 days (n=6). The recurrent nodule was histopathologically confirmed. In a second experiment, this new recurrence model was evaluated for the effect of intrapleural therapy with different agents: 4 ml of cisplatin-solution (100mg(2)/kg BW), cisplatin combined with the fibrin-based sealant Vivostat, 4 ml taurolidine 2%, repeated injection of 1 microg of the chemokine CCL-19 at the tumour site and 4 ml povidone-iodine in a dilution 1:10. In a control group, the chest cavity was filled with 4 ml 0.9% NaCl. The primary endpoint was the extent of tumour recurrence. Six days after inoculation, all animals presented a standardised tumour nodule at the injection site of a mean diameter of 5.1 (+/-0.8)mm. Evaluation of the recurrence after 10 days showed a relapse directly at the resection site, but additional tumour nodules on the ipsi- and contralateral chest wall were found and histologically confirmed. The animals that were sacrificed 6 days after resection of the tumour nodule showed a recurrence only at the resection site with no macroscopic or microscopic evidence of other tumour. Resection of the tumour nodule combined with intrapleural application of the different agents lead to clear reduction of recurrence. The strongest effect was observed after intrapleural application of cisplatin-Vivostat with significant decrease of the longest, widest and thickest diameter of the recurrence. With this new recurrence model for investigation of malignant pleural mesothelioma in rats, we were able to investigate new intrapleural therapies after pneumonectomy. The intrapleural application of cisplatin-Vivostat significantly reduced the extent of local recurrence.

The palmar pocket method: an adjunct to the management of zone I and II fingertip amputations.

In 1979 Brent reported a new replantation method, without vascular anastomosis, that used a subcutaneous pocket. Brent chose the contralateral chest wall as a pocket site, but in other clinical reports, the abdominal wall was used. For both sites there were complications such as stiffness in the wrist, elbow, and shoulder joints and anxiety about pulling out the pocketed finger. To overcome these problems, we chose the ipsilateral palm and named this method the palmar pocket method. We used this method in 16 cases in which a digit other than the thumb had been amputated between the tip and lunula. In 13 cases the method was completely successful, and in 3 cases there was a small area of tip necrosis. The palmar pocket method is a simple and reliable operation for fingertip reattachment and more comfortable for patients than pocketing in the chest wall or abdominal wall.

Transmediastinal approach to exploring the lung contralateral to the thoracotomy site.

The approach to contralateral lung through the mediastinum is assumed useful in managing oddly distributed bilateral lung tumors. To remove a tumor located in the contralateral lung, a transmediastinal approach from the thoracotomy site to the contralateral lung was used in 6 patients having oddly distributed bilateral lung tumors, 1 of which was located in the contralateral lung close to the anterior or posterior mediastinum. All cases were treated successfully. One patient required an additional small incision on the contralateral anterior chest wall to insert an endoscopic stapler without intraoperative postural change. The postoperative course was uneventful and, to date, no local recurrence has been seen at the resected margin of the contralateral lung. This novel approach is useful, offering the advantages of reduced invasiveness and pain, shorter surgical duration, and favorable cosmetic results for patients with a tumor close to the mediastinum in the contralateral lung.

Simultaneously stapled lobectomy: A safe technique for video-assisted thoracic surgery

Currently, techniques for video-assisted thoracic surgery are being borrowed from the open conventional thoracotomy. However, these same techniques have made video-assisted lobectomy difficult, burdensome, and even dangerous. Simultaneously stapled lobectomy (simultaneous stapling of all hilar structures in their natural anatomic configuration) has been performed successfully in 16 patients. Every attempted simultaneously stapled lobectomy is included. The lesions included 14 malignant tumors, one giant benign pulmonary cyst, and one large necrotizing granuloma. Three right upper lobes, one right middle lobe, six right lower lobes, four left upper lobes, and two left lower lobes were resected uneventfully. Nine adenocarcinomas, two large cell carcinomas, and three squamous cell carcinomas ranging in size from 2.5 to 5 cm were removed. Lung fissures, the hilum, and the mediastinum were explored for lymph nodes in each patient. Median operative time was 110 minutes. Average blood loss was less than 100 ml. Median hospitalization was 6 days, altough eight patients were discharged within 3 and 5 days. Three patients had air leaks for an average of 14 days and one patient had mild subcutaneous emphysema for 5 days. There was no surgical mortality. Median follow-up is 15 months (range 8 to 20 months). Simultaneously stapled lobectomy is not meant to replace conventional lobectomy by open thoracotomy. Indications are cardiac or renal problems, contralateral chest wall paralysis, neurogenic deficiencies, adamant refusal to undergo open lobectomy, psychologic abberations, and pain from a previous thoracotomy. Contraindications include absent fissures, enlarged matted invasive nodes, fibrotic hilium, central or bulky lesions, calcific bronchi, chest wall invasion, and lesions crossing a fissure. Precedent for this technique will be discussed. When used with discretion in carefully selected patients, in whom an open lobectomy would be contraindicated, simultaneously stapled lobectomy might eventually prove to be another available option. Time and further experience will be necessary to determine its true merits. (J T HORAC C ARDIOVASC S URG 1995;109:619-25)