Entire Chest Wall Research Articles

NIMG-04. MASSIVE THORACIC MENINGOCELE IN A PATIENT WITH NF1

Abstract Thoracic meningoceles are uncommon but when seen are often associated with neurofibromatosis 1 (NF1). Here we present a unique case where a massive thoracic meningocele presented with chest pain in a patient with NF1. A 56-year-old female with a diagnosis of NF1 presented with pain in the entire chest wall. She described the pain as circumferential around the entire chest “like a barrel”. Cardiology evaluation (with echocardiography) revealed no pulmonary hypertension or other cardiac disorder. MR angiogram of the chest also revealed no intrathoracic vascular structural abnormality. Inflammatory myopathy was considered to explain the pain but electromyography was unremarkable as were creatine kinase and erythrocyte sedimentation rate. MRI of thoracic spine demonstrated a large thoracic meningocele involving the spinal canal from T5-T10 and extending into the left hemithorax with measurements of 11.5 x 6.1 x 12.5 cm. Imaging was also notable for leftward displacement of the spinal cord toward the meningocele starting at the T6 level and extending to the T9 level with kyphosis of the thoracic spine centered on the block vertebral bodies forming the T7-T8 levels. Significant posterior scalloping was evident from T6-T10 with attendant dural ectasia. Neurosurgical consultation recommended no intervention to correct the meningocele as plication carried a risk of producing a subarachnoid-pleural fistula from the meningocele into the pleural space of the thoracic cavity. This case adds to our understanding of how unique and diverse the presentations of NF1 can be, and of the surgical challenges posed by NF1-associated meningoceles.

‘Short Bars Crossed’ to Remodel the Entire Chest Wall in Children and Adolescents with Pectus Excavatum

BackgroundThe cross-bar technique of minimally invasive pectus excavatum (PE) correction remains underreported, which is especially true of pediatric patients. We therefore reviewed the experience of a Turkish and an Austrian center. An additional novelty characterizing both pediatric cohorts was the use of short bars. MethodsIn a retrospective study, pediatric PE corrections involving ‘short bars crossed’ were analyzed for complications and intra-/postoperative outcomes. Cases with two or three bars were included, given that a horizontal third bar was placed whenever considered useful for upper-chest elevation. All bars were fitted with a single stabilizer near the surgical entry point. In the Austrian center, intercostal nerve cryoablation was used for pain management. Descriptive statistics are presented. ResultsSeventy-eight patients ≤18 years old were evaluable at the Turkish (n = 56) and Austrian (n = 22) centers. Total median values were 16.2 (IQR: 15.1–17.4) years for age and 4.60 (IQR: 3.50–6.11) for Haller index. Ten mild or moderate complications (12.8%) were observed, including just one revision requirement due to bar migration (1.28%). Intercostal nerve cryoablation (n = 13) was associated with longer surgical procedures at 150 (IQR: 137–171) versus 80 (IQR: 60–100) minutes but with shorter hospital stays, given an IQR of 3–4 days versus 4–5 days. Conclusion‘Short bars crossed’—with a single stabilizer in a ventral position close to the surgical entry point—ensure a wide distribution of forces, protect against bar migration, are safe and effective, and offer stability at an age characterized by growth and physical activity. Level of EvidenceIV.

Crane-powered pectus excavatum repair: the NeoPectus surgery.

The conventional technique for pectus excavatum repair was pushing up the depressed chest wall by turning over the convexity of the bent pectus bar. We developed a new concept in which a total crane lift was used as the source of power to elevate the depressed sternum without using pectus bar leverage. This study aims to verify the efficacy of exclusively crane-powered pectus excavatum repair in recent years. Among the 3622 pectus deformity repairs since 1999, 691 cases repaired with the total crane power between 2017 and 2022 were enrolled. The mean age was 12.0 years (3-45). The operative technique involved wire/screw crane elevation of the sternum, the entire chest wall remodeling with the cross or parallel bars, the bridge/claw bar fixations, and other adjunctive techniques. Outcome analysis included morphological variations, patterns of pectus bar placement, and complication rates. The crane technique and pectoscopy (100%) were used. The bar placements were parallel (22.0%) and cross-bar (47.5%). The bar fixations were the claw fixators for a single bar (30.5%) and the bridge plates for multiple bars (69.5%). The flare-buster and magic strings were liberally used. No serious complications or catastrophic events occurred, but minor complications occurred in 16.9%: pneumothorax in 7.4% (51), pleural effusion in 1.6% (11), and wound problems in 0.4% (3). There was no case of bar displacement. The crane-powered pectus excavatum repair showed excellent results with minimal complications and no bar displacement. This innovative approach, part of the NeoPectus surgery, represents a significant advancement in correcting pectus excavatum deformities by utilizing a crane machine to elevate the chest wall.

Recent Advancements in Pectus Surgery: Crane Lifting, Multiple-Bar Approach, Bridge Stabilization, and Sandwich Technique

PurposeThe most recent procedure for pectus excavatum repair involves crane-powered entire chest wall remodeling, which employs crane lifting, multiple-bar approach, bridge stabilization, and sandwich techniques.This resulted in a paradigm shift in pectus deformity repair from merely lifting the sunken bone to remodeling the chest wall into normal anatomy. MethodsWe analyzed 649 patients who underwent surgery for pectus excavatum or complex combined deformities between March 2018 and January 2022. A crane with sternal wiring or screwing was used to lift the chest wall without using the pectus bar turning power. Multiple bars with bridge connections were placed to eliminate bar displacement. Modified sandwich techniques were applied to relieve the lower coastal flare (flare-buster) and focal protuberance (magic string). ResultsThe mean age of the patients included in the study was 12.2 years (range: 3–45 years). A single bar was used for 202 patients until 2021. For the multiple-bar technique, parallel bars (n = 142), crossbars (n = 166), and crossbars plus upper horizontal bars (XI pattern; n = 139) were used. The overall complication rate was 6.2 %. There was no cases of bar displacement were observed, but other minor complications such as pneumothorax (n = 20, 3.1 %), pleural effusion (n = 7, 1.1 %), and wound infection (n = 5, 0.8 %) were detected. Three patients required reoperation (infection, two: hemorrhage, one). ConclusionsThe crane-powered entire chest wall remodeling technique improved the safety and comprehensiveness of the repair procedure. By incorporating bridge stabilization and the use of multiple bars, we effectively resolved the issues related to bar displacement and incomplete repair. Type of StudyRetrospective Cohort Study. Level of Evidence3.

Complication Avoidance of Reconstruction Implant Radiation Therapy (CARIT): A Retrospective Case-Cohort Analysis.

Patients are increasingly offered implant-based reconstruction prior to radiotherapy. However, it is unclear if the radiation treatment technique itself impacts upon toxicity. We performed this study to compare outcomes following implant-based reconstruction amongst breast cancer patients treated with a standard radiotherapy technique that irradiates the entire chest wall versus a novel technique which uses a smaller clinical target volume (CTV) to spare the implant. Need for corrective surgery, capsular contracture, and cosmetic outcomes were evaluated, with the hypothesis that the novel technique would result in fewer adverse outcomes and less need for corrective surgery. A retrospective case-cohort analysis of 57 patients who had post-mastectomy, implant-based reconstruction was conducted. Patients with invasive mammary carcinoma (IMC) or ductal carcinoma in-situ (DCIS) who were treated either with the novel radiotherapy technique (n = 26) or standard PMRT (n = 31) were included. Patient demographics such as age, BMI, TNM stage, implant size, hormone receptor status, and radiation course was collected. Primary endpoint was the need for corrective surgery within two years and cosmetic outcomes, measured using the Baker Classification Scale for capsular contracture and the Modified Harvard Harris Cosmetic Scale. Secondary endpoint was radiation-induced toxicity measured using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE). Cosmesis and toxicity were evaluated at 3 months post-radiation, 1 year, and after 13 months. Unpaired t-tests were used to compare need for corrective surgery, cosmesis (Baker Grade 2 or higher and Harvard Harris "Good" or worse), and toxicity (NCI CTCAE Grade 2 or higher). For the primary endpoint, need for corrective surgery, there was no significant difference between the novel and standard groups (two-sided p = 0.378, CI -0.38-0.14). The other primary endpoint of cosmesis, measured with the Baker scale and Harvard Harris, was also not significantly different (two-sided p = 0.147, CI -0.06-0.45), with the Harvard Harris cosmesis differences remaining insignificant across the 3 month, 1 year, and greater than 13 month periods (two-sided p = 0.854, 0.351, 0.468, respectively). The secondary endpoint, toxicity, was not significantly different between the novel and standard PMRT groups across 3 months and 1 year time periods (two-sided p = 0.328, 0.323, respectively). We will also be reporting the analysis for predictive factors related to toxicity, need for corrective surgery and cosmesis. Compared with standard PMRT, the novel technique was not significantly different in rates of reoperation, toxicity and cosmetic outcomes. Better understanding the factors involved in PMRT outcomes for breast cancer patients with implant-based reconstructions will aid in the development of standardized approaches to treating the breast cancer patient population.

Technical Advances in Pectus Bar Stabilization in Chest Wall Deformity Surgery: 10-Year Trends and an Appraisal with 1,500 Patients.

We aimed to demonstrate the advances we have achieved in pectus excavatum surgery over the last 10 years, with a particular focus on the refinement of pectus bar stabilization techniques and devices. In total, 1,526 patients who underwent minimally invasive repair of pectus excavatum surgery from 2013 to 2022 were enrolled and analyzed. We have pursued a new paradigm of crane-powered remodeling of the entire chest wall. The method of bar stabilization has changed from claw fixators to hinge plates and, finally, to bridge plate connections. We also evaluated the effectiveness of the hinge plate (group H) and the bridge plate (group B). The bar displacement rates were 0.1% (n=2) for the claw fixator, 0% for the hinge plate (n=0), and 0% for the bridge plate (n=0). We stopped using the claw fixator in 2022 and the hinge plate in 2019. Since 2022, when we shifted to a multiple-bar technique for all patients, the bridge plate has replaced both the claw fixator and the hinge plate. No bar displacement occurred in either group. Group H had more pleural effusion, wound problems (p<0.05), and longer stays (5.5 vs. 6.2 days, p=0.034) than group B. We have made significant progress in pectus repair surgery over the last decade, particularly in stabilizing the pectus bar and reducing perioperative complications. Our current strategy is the multiple-bar approach with bridge stabilization. Since the bridge-only technique resulted in no bar displacement, we could eliminate the invasive claw fixator or hinge plate.

The Cross-Bar Technique for Pectus Excavatum Repair: A Key Element for Remodeling of the Entire Chest Wall.

The multiple bar approach was developed to cover broader and heavier teenager/adult chest wall deformities. We designed the cross-bar technique to achieve remodeling of the entire chest wall. This study aimed to demonstrate the role of cross-bar and its benefits over the parallel bar. The cross-bar technique involves placing two bars diagonally and then cross on the target. The primary purposes are to double the lifting forces by making two bars converge on a single target to lift inflexible heavy chest wall depressions or cover lower lateral areas. The results of the cross-bar and parallel bar are compared for the indications, postrepair outcomes, and complications. From 2016 to 2019, 247 patients who underwent multiple bar pectus excavatum (PE) repair were enrolled in the study: 157 with cross-bar and 90 with parallel bar. In the cross-bar group, 33% (51/157) received three bars in XI fashion to cover the upper depression. The cross-bar group was older (18.0 ± 6.1 vs. 15.7 ± 5.0), had higher depression index (1.9 ± 0.7 vs. 1.8 ± 0.3), and was less asymmetric (45% vs. 71%) than those in the parallel bar group. The overall complication rates were not different between the two groups (9.6% vs. 10%, p = 1.0), although the cross-bar group was more rigid and complex. There was no bar displacement or reoperation in both groups. The cross-bar technique is as safe and effective as the parallel-bar technique, even though it was selected to correct more complexities. The cross-bar technique could be a method for complex PE deformities for remodeling of the entire chest wall.

Simultaneous Viscum pleurodesis and video-assisted thoracic surgery (VATS) bullectomy in patients with primary spontaneous pneumothorax

Although surgery is the gold standard for treatment of primary spontaneous pneumothorax (PSP), recurrence after surgery remains a concern. This study sought to evaluate the efficacy of simultaneous pleurodesis using Viscum album (VA) extract and video-assisted thoracic surgery (VATS) bullectomy for the treatment of PSP. From March 2016 to June 2020, 175 patients with PSP underwent bullectomy and intraoperative pleurodesis with VA extract at a single institution. All operations were performed through thoracoscopy by one surgeon. Upon completion of bullectomy, a polyglycolic acid sheet was used to cover the stapler lines, and 40 mg of VA extract was instilled over the entire chest wall before chest tube placement. The median operating time was 20 min (interquartile ranges, 15–30) and the median indwelling time of chest drainage was 2 days (interquartile ranges, 2–3). There were no postoperative complications over grade 3. During the median follow-up period of 38 months (interquartile ranges, 15–48), no recurrence of pneumothorax was observed. The results of this study demonstrated that simultaneous Viscum pleurodesis and VATS bullectomy provides a feasible and effective treatment option for preventing postoperative pneumothorax in patients with PSP.

Challenging chest drainage: a case report

Introduction. Chest trauma is one of the most common causes of death corresponding to 20 to 25 % of cases. The majority of the patients (85%), can be managed with only a tube thoracostomy. Our objective by presenting this case report is to provide an example of how to manage a challenging chest tube thoracostomy in a patient with cardiac hernia diagnosed in the preoperative phase, based on signs of computed tomography.&#x0D; Case report. A 45-year-old male presented to our emergency department who fell from a light pole 7 meters high. He fell to the ground on his back. Physical examination revealed a huge subcutaneous emphysema on his entire anterior chest wall and presented no sensitivity or movements below the navel line. After the initial assessment and management care, the patient improved. As the patient stabilized we decided to go to CT. The scan revealed pericardial rupture with only the right pericardial circumference intact, the heart herniated into the left pleural space, bilateral pneumothorax, small right hemothorax and a relevant subcutaneous emphysema surrounding the chest. We decided to perform the blunt dissection technique to insert chest tubes bilaterally because of safety. After performed it the patient was transferred to cardiothoracic department.&#x0D; Discussion. There is a variety of techniques to perform tube thoracostomy but the blunt dissection remain the safer, especially when we are facing an anatomic distortion of the heart.&#x0D; Conclusion. We present a case report of a challenging thoracic drainage performed in a patient with traumatic cardiac hernia, which procedure was successful.

En bloc resection and reconstruction of a huge chondrosarcoma involving multilevel upper thoracic spine and chest wall: case report

BackgroundEn bloc resection of malignant tumors involving upper thoracic spine is technically difficult. We surgically treated a patient with grade 2 chondrosarcoma involving T1–5, left upper thoracic cavity, and chest wall.Case presentationA 37 years old, male patient was referred to our hospital for a huge lump involved left shoulder and chest wall. In order to achieve satisfied surgical margins, anterior approach, posterior approach, and lateral approach were carried out sequentially. After en bloc tumor resection, the upper thoracic spine was reconstructed with a 3D-printed modular vertebral prosthesis, and the huge chest wall defect was repaired by a methyl methacrylate layer between 2 pieces of polypropylene mesh. Postoperatively, the patient suffered from pneumonia and neurological deterioration which fully recovered eventfully. At 24 months after operation, the vertebral prosthesis and internal fixation were intact; there was no tumor local recurrence, and the patient was alive with stable pulmonary metastases.ConclusionThis case report describes resection of a huge chondrosarcoma involving not only multilevel upper thoracic spine, but also entire left upper thoracic cavity and chest wall. Although with complications, en bloc tumor resection with combined surgical approach and effective reconstructions could improve oncologic and functional prognosis in carefully selected spinal tumor patients.

Partial chest wall radiation therapy for positive or close surgical margins after modified radical mastectomy for breast cancer without lymph node metastasis.

AimWhole‐breast radiation therapy after breast‐conserving surgery can control local recurrence with a long‐term survival rate equivalent to that of radical mastectomy for patients with early breast cancer. However, the significance of radiation therapy for patients with positive/close margins after mastectomy remains controversial. Following radical mastectomy, no residual breast parenchyma remains, and thus radiation therapy of the entire chest wall may represent overtreatment in the patients, especially those without lymph node metastasis (N0). We therefore implemented partial chest wall radiation therapy for patients with N0 breast cancer and positive and/or close margins after mastectomy.MethodsA total of 22 patients with N0 status but positive/close margins underwent partial chest wall radiation therapy to irradiate the predetermined clinical target volume, which had margins of at least 2 cm medial, lateral, superior, and inferior to the primary tumor bed. With reference to chest wall thickness, 4‐10‐MV photons or 5‐8‐MeV electrons with/without a bolus were delivered. The total dose was 50‐66 Gy. We compared the results with those from 18 nonradiation therapy patients using Pearson's χ 2 test.ResultsAll patients in the partial chest wall radiation therapy group achieved good local control despite having a significantly higher proportion of positive margins (77.3%) compared with the nonradiation therapy group (27.8%) (P = 0.002). Both groups showed 100% recurrence‐ and disease‐free survival.ConclusionPartial chest wall radiation therapy may offer recurrence‐ and disease‐free survival without local recurrence in N0 mastectomy patients with positive/close surgical margins.

Post-operative imaging of pulmonary vessels.

Complications following cardiothoracic surgery are responsible for prolonged hospital stay, increase cost in patient care and increased morbidity and mortality. Vascular complications in particular are significant contributors to poor patient outcome due to either hemorrhage or thrombosis and ischemia. Evaluation of vascular complications in the postoperative patient requires a rapid and reliable imaging approach. Vascular complications after cardiothoracic surgery include pulmonary artery thrombosis, pseudoaneurysm, pulmonary vein thrombosis, vascular fistulas, stenosis and infarction. Multidetector CT (MDCT), often the imaging modality of choice, offers a one-stop-shop capability to visualize the entire cardiothoracic vasculature, airways, lung parenchyma, mediastinum and chest wall with excellent temporal and spatial resolution.

Pivotal Role of Major Aortic Arch Branches in Subtending the Mammalian Heart

Hypothesis and Background: A high prevalence of downwardly sloping type 3 Aortic Arch (AA) in elderly humans with Left Ventricular Hypertrophy (LVH) led us to hypothesize that Major Aortic Arch Branches (MAAB) acting through the AA and ascending Aorta are pivotal in subtending the heart in its anatomic position. Based on established commonality in comparative anatomy of terrestrial mammals we tested our hypothesis in the even-toed ungulate model. Methods and Results: We observed 5 animals (2 sheep and 3 goats) at a licensed abattoir as they were being dressed, in a requested order. In vertical orientation, midline incision bisecting the entire chest and anterior abdominal wall was made and after retracting the ribs the heart was visualized. In stepwise fashion: abdominal organs, diaphragm, lungs and Vertebropericardial Ligaments (VPL) were removed; in all animals, the heart maintained its position in the thorax after the above steps. Subsequently, Sternopericardial Ligaments (SPL) were transected and the heart still maintained its position. Only after ascending aorta was severed just above the Aortic valve, did the heart lose its position and drop down to the pelvis. Conclusion: In even-toed ungulate animal model, MAAB acting through AA and ascending aorta are pivotal in subtending the heart in its usual anatomic position. Invoking basic principles of comparative anatomy it would be safe to extrapolate that same may run true in humans. Indirect evidence of above in humans may reside in a high prevalence of downwardly sloping type 3 AA in elderly with LVH.

The sandwich technique for repair of pectus carinatum and excavatum/carinatum complex

Simple external compression of pectus carinatum seems to have its limitations, particularly the repair of asymmetric pectus carinatum or excavatum/carinatum complex. We devised the sandwich technique (press-molding) to remodel the entire chest wall. The purpose of this study is to introduce the sandwich technique and appraise the early results. Between January 2007 and January 2016, 523 consecutive patients with pectus carinatum and its variants were analyzed retrospectively. No patients were excluded during the study period. The sandwich 1 and 2 techniques using the internal and external pectus bars were for pectus carinatum repair. Modified techniques using the external string and the internal bar were to treat the lower costal flare (the flare-buster) and focal protuberances (the magic string) in pectus excavatum repair. Statistical analyses were carried out using paired and unpaired t-test or Wilcoxon signed rank tests. The sandwich repair with the external and internal bars was applied to 58 pectus carinatum patients: seven symmetric (12.1%), 14 asymmetric (24.1%), and 37 carinatum-excavatum complex (63.8%). After pectus excavatum repair, 426 patients had the flare-buster and 39 patients received the magic string. The sandwich 1 technique achieved near-complete resolution of carinatum in 52 patients (86.2%). The sandwich 2 technique accomplished almost symmetric configuration with no residual carinatum in all six cases. The sandwich technique using the external and internal bars seems to be effective in treating asymmetric pectus carinatum and complex excavatum/carinatum deformities. The flare-buster and the magic string effectively relieve the costal flare and focal protuberances in pectus excavatum repair.

Understanding the Fascial Supporting Network of the Breast

The fascial system of the breast has, to date, only been described in general terms. This anatomical study has developed two distinct methods for better defining existing breast structures such as the inframammary fold, as well as defining previously unnamed ligamentous structures. The authors harvested and examined 40 frozen, entire chest wall cadavers. Initially, 15 embalmed cadavers were studied with a combination of blunt and sharp dissection, which proved to be inaccurate. A further 20 fresh and five embalmed chest walls were harvested, frozen, and then sectioned with a bandsaw (3-cm slices) and knife (1.5- to 4-cm slices) depending on the area studied. Sagittal, horizontal, and oblique sections along the length of the ribs were created and then dissolved using either sodium hydroxide or alcohol dehydration followed by xylene immersion. Constant fascial connections between the breast parenchyma, superficial fascia, pectoralis muscle (deep) fascia, and bone were observed. Specimens clearly demonstrated internal structures responsible for the surface landmarks of the breast. The precise configuration of the infra mammary fold was clearly visible, and new ligamentous structures were identified and named. Knowing the location and interrelationship of these structures is particularly important in breast augmentation. Reappraisal of the anatomy in this area has enabled precise identification of ligamentous structures in the breast. Correlation of the findings in this article to specific clinical conditions or modes of treatment can be proven only by a clinical series that scientifically addresses the necessity and efficacy of preserving, releasing, or repositioning any of these structures.

Thoracopleuropneumonectomy with Riblike Reconstruction for Recurrent Thoracic Sarcomas

Large intrathoracic tumors may occasionally present with massive infiltration of the lung and chest wall that would require pneumonectomy and total removal of the rib cage to obtain radical surgical excision, but this operation carries a prohibitive risk of death for cardiopulmonary failure in the absence of adequate chest wall reconstruction. We report here four consecutive cases of thoracopleuropneumonectomy (TPP) with en-bloc resection of the entire lung, chest wall, and diaphragm and immediate riblike reconstruction for recurrent thoracic sarcomas. Patients had undergone the initial thoracic surgical resection with curative intent 2-14 years before TPP. There was no postoperative mortality, and all patients were alive and free of disease 8-21 months after TPP. To our knowledge, this is the first report in the medical literature of such an extensive operation, demonstrating technical feasibility, tolerability, and efficacy of one-stage resection and reconstruction by a semirigid three-dimensional riblike prosthesis modeled on a human-derived aluminum cast. Selected patients with advanced low-intermediate thoracic sarcomas are the ideal candidates for this extreme procedure, to maximize the chance of long-term tumor control and possibly cure.

ASSESSMENT OF THE CHEST WALL THICKNESS OF THE LAWRENCE LIVERMORE TORSO PHANTOM USING A VOXEL IMAGE

This paper describes the methodology of measuring the chest wall thickness using the voxel image of the Lawrence Livermore National Lab (LLNL) torso phantom. The LLNL phantom is used as a standard to calibrate a lung counter consisting of a 2 × 2 array of germanium detectors. In general, an average thickness estimated from four counting positions is used as the chest wall thickness for a given overlay plate. For a given overlay, the outer chest surface differs from that of inner one, and the chest wall thickness varies from one position to other. The LLNL phantom with chest plate and C4 overlay plate installed was scanned with a CT (computed tomography) scanner. The image data, collected in DICOM (Digital Imaging and Communication) format, were converted to the MCNP input file by using the Scan2Mcnp program. The MCNP file was visualized and analyzed with the Moritz visual editor. An analytic expression was formulated and solved to calculate the chest wall thickness by using the point detector responses (F 5 tally of MCNP). To map the chest thickness, the entire chest wall was meshed into virtual grids of 1 cm width. A source and detector pair was moved along the inner and outer surface of the chest wall from right to left at different heights from neck to abdomen. For each height (z(k)), (x(i), y(j)) coordinates for the detector source pair were calculated from the visual editor and were scaled on-screen. For each (x(i), y(j), z(k)) position, a mesh thickness was measured from on-screen measurement and by solving the detector responses. The chest wall thicknesses at different positions on the outer surface of the chest were compared and verified using two methods.

SU‐E‐J‐144: Analysis of Intra‐Fraction Chest Wall Motion during Breath Hold Treatment for Left Sided Breast Cancer

Purpose: To quantify chest wall motion during treatment while the patient executes a breath hold (BH) maneuver for left sided breast cancer patients. Methods: Three breast cancer patients (left side) who were to receive radiation utilizing the BH technique were prospectively chosen to take part in this study. Treatment plans were generated according to standard clinical treatment planning guidelines. Images were acquired in cine mode using the EPID (Varian Medical Systems, Palo Alto, CA) on a per fraction basis for non step and shoot fields. The chest wall was defined in each image using a logarithmic edge detection algorithm. The distance of the chest wall orthogonal to the reference axis (collimator jaw parallel to chestwall) was determined in 1 cm intervals along this axis. Motion was assessed by the standard deviation of chest wall position and the maximum distance traveled, for each field, each treatment day. The root mean square (RMS) of the standard deviations was computed as well as the average and standard deviations of maximum motion for each 1 cm interval. Results: 420, 205, and 360 images were acquired respectively for patients 1, 2, and 3 for both medial and lateral tangential fields. The total RMS of the motion computed over the entire length of the chestwall was 0.7mm, 0.8mm, and 0.6mm for patients 1–3 respectively. The maximum motion over the entire chest wall for each treatment day was 1.4+1.6mm, 1.9+1.4mm, 1.1+1.3mm on average for the course of treatment. Conclusions: Chest wall motion during a breath hold treatment was analyzed for three patients and was found to be less than 2mm on average. When using the deep inspiration BH technique to displace the heart from the posterior tangential field border, our study suggests that delivery can be executed with minimal intra‐fractional motion.

Primary Burkitt Lymphoma of the Chest Wall

Abstract Introduction Burkitt lymphoma (BL) originating in the skin and soft tissue is very rare. To our knowledge, this case of primary sporadic BL presenting as an isolated chest wall mass arising from the soft tissue in an adult may be the first report. Case Report A previously healthy 33-year-old Caucasian man presented with a 1-month history of a painful lump over the left breast that he initially noticed as a small “pimple-like” lesion in the area. After a week, the skin lesion became larger, erythematous, and painful. At a local hospital, he underwent an incision and drainage procedure for a presumed chest wall abscess. Several days after debridement, a similar lump recurred around the incised area, which rapidly grew in size. He also started experiencing fever and chills for which he was readmitted with a diagnosis of necrotizing chest wall infection. A second debridement with excisional biopsy of the chest wall revealed atypical lymphoid cells, prompting transfer to our institution. Upon transfer, a large, gaping, erythematous and indurated wound with indistinct, thickened borders and extensive edema and necrosis of subcutaneous tissue and musculature of almost the entire left chest wall was noted. No palpable peripheral lymphadenopathy or organomegaly were observed. He underwent minimal debridement and partial excision. The histopathology revealed atypical lymphocytes with prominent nucleoli, deeply basophilic cytoplasm, and abundant lipid vacuoles in a “starry-sky” pattern. The lymphoid population was CD-20 and CD-10 positive, negative for CD-5 and BCL-2, nearly 100% Ki-67 positive, and indeterminate for light chain restriction. Molecular cytogenetic analysis revealed fusion signals with IgH/Myc t(8;14) dual fusion probe, supporting the diagnosis of BL. Staging positron emission tomography (PET)/computed tomography (CT) scan showed a large subcutaneous defect of the left hemithorax involving the dermis, subcutaneous tissue, and musculature, measuring 19.3 × 13.9 × 31.0 cm, with maximal SUV of 9.8 and an average of 6.2. No additional involved sites were seen. The bone marrow biopsy showed minimal involvement by BL and abnormal hybridization pattern for IgH/Myc t(8;14) and Epstein-Barr virus, while the peripheral blood and cerebrospinal fluid showed no involvement. HIV and hepatitis serologies were negative. Three days after surgery, chemotherapy with granulocyte colony-stimulating factor (G-CSF) support was initiated for high-risk disease. He received CODOX-M (intravenous cyclophosphamide, doxorubicin, vincristine, methotrexate; intrathecal cytarabine, methotrexate) as cycle 1 followed by IVAC (intravenous ifosfamide, etoposide, cytarabine; intrathecal methotrexate) with rituximab as cycle 2. He developed tumor lysis without end-organ damage. However, a few days after completion of cycle 2, he developed neutropenic fever and pneumonia, and died in septic shock. Discussion Primary chest wall tumors are uncommon. Approximately 50% are malignant, and chest wall lymphoma accounts for Conclusion This case illustrates a primary sporadic BL originating in skin and soft tissue in an adult. Whether this case represents a BL that began in the skin and soft tissue and spread to the bone marrow, or began in the bone marrow and spread to the chest wall cannot be determined. The role of tumor debulking procedure is uncertain, although aggressive chemoimmunotherapy with central nervous system (CNS) prophylaxis is warranted as with other BL presentations.

Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia*

To compare lung reaeration measured by bedside chest radiography, lung computed tomography, and lung ultrasound in patients with ventilator-associated pneumonia treated by antibiotics. Computed tomography, chest radiography, and lung ultrasound were performed before (day 0) and 7 days following initiation of antibiotics. A 26-bed multidisciplinary intensive care unit in La Pitié-Salpêtrière hospital (University Paris-6). : Thirty critically ill patients studied over the first 10 days of developing ventilator-associated pneumonia. : Antibiotic administration. Computed tomography reaeration was measured as the additional volume of gas present within both lungs following 7 days of antimicrobial therapy. Lung ultrasound of the entire chest wall was performed and four entities were defined: consolidation; multiple irregularly spaced B-lines; multiple abutting ultrasound lung "comets" issued from the pleural line or a small subpleural consolidation; normal aeration. For each of the 12 regions examined, ultrasound changes were measured between day 0 and 7 and a reaeration score was calculated. An ultrasound score >5 was associated with a computed tomography reaeration >400 mL and a successful antimicrobial therapy. An ultrasound score <-10 was associated with a loss of computed tomography aeration >400 mL and a failure of antibiotics. A highly significant correlation was found between computed tomography and ultrasound lung reaeration (Rho = 0.85, p < .0001). Chest radiography was inaccurate in predicting lung reaeration. Lung reaeration can be accurately estimated with bedside lung ultrasound in patients with ventilator-associated pneumonia treated by antibiotics. Lung ultrasound can also detect the failure of antibiotics to reaerate the lung.