Large Soft Tissue Research Articles

Surgical Strategies: Necrotizing Fasciitis of the Foot and Ankle Treated With Dermal Regeneration Matrix for Limb Salvage.

Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity.Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain.We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option.Level of Evidence: Level V, expert opinion.

Aesthetic functional reconstruction of the mutilated hand: Indications and selection of reconstructive techniques

Advances in microsurgery together with improvements in reconstructive surgical techniques over recent decades have enlarged the scope of available techniques for mutilated hand reconstruction, shifting the reconstructive paradigm from restoring hand function to providing the best functional and aesthetic results with minimal donor-site morbidity. Successful reconstruction of a mutilated hand should no longer be measured only by the degree of improvement of hand function but also by a more aesthetic hand appearance as well as by improved psychological well-being. In this article, the authors present their concept of aesthetic functional reconstruction of the mutilated hand with a focus on the indications and selection of reconstructive techniques. They emphasize that in order to select the most appropriate technique, providing the best functional and aesthetic outcomes with minimal donor-site morbidity for each individual patient, it is imperative for the reconstructive hand surgeon to possess perfect mastery of all available surgical techniques, thorough understanding of functional and aesthetic requirements and accurate appreciation of multidimensional reconstruction of a given defect of the hand. They have concluded that in precisely indicated cases, successful replantation of an amputated hand or digits remains the best reconstructive procedure designed to obtain a more functional and more normal-appearing hand, whereas, toe-to-hand transplantation, in cases of failed or impossible digit replantation, provides better results than any other digit reconstruction techniques aimed at achieving functioning digits with good appearance. Although skin graft and various distant pedicled flaps and free flaps may be valid options for coverage of some soft tissue defects of the hand, reverse flow forearm flaps, especially those based on the secondary arteries of the forearm, are often the best-suited reconstructive options for like-with-like hand reconstruction. They can provide the best matching of color, texture, soft-tissue volume, donor-recipient tissue interface and fulfill all the aesthetic and functional reconstruction requirements of moderate-sized or even large soft tissue defects of the hand, with acceptable donor site morbidity.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery.

.Significance: Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.Aim: The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.Approach: The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.Results: Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.Conclusion: While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Vernet’s syndrome (jugular foramen syndrome) secondary to osteoma of the tympanic bulla in a young male dog

A one-year-old male neuter dog initially presented with clinical signs of pharyngitis and suspected oesophageal reflux. The dog subsequently developed unilateral (left side) Horner’s syndrome. CT examination of the head...

Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties

BackgroundMultiply revised total knee arthroplasties (TKAs) may present with large anterior soft tissue defects, which can be challenging to reconstruct. In the rare cases where local flaps are insufficient, we use free latissimus dorsi (LD) myocutaneous flaps to achieve soft tissue coverage. This study looked to determine implant survivorship, infection status, and patient-reported outcomes of patients undergoing simultaneous revision TKA and LD flaps in a tertiary unit. MethodsThis was a retrospective study of 18 consecutive patients who had revision TKA and free LD flap reconstruction. Twelve were male and the median age was 65 years (range, 35-83). Patients had undergone a median of 4 previous arthroplasty procedures (range, 3-6). Median follow-up was 49 months (range, 18 to 110). The primary outcome was revision-free implant survival. Secondary outcomes included soft tissue integrity, Oxford Knee Score, and EuroQol 5-domain score at latest follow-up. ResultsAt latest follow-up, 14 of 18 patients had maintained their implant. Seven patients were infection-free, 7 were on suppressive antibiotics with the implant in situ, and 4 had undergone above-knee amputation. Five-year implant survival was 75% (95% confidence interval, 46-90). At median follow-up (49 months), mean Oxford Knee Score was 13.4 (range, 2-35) and mean EuroQol 5-domain index was 0.071 (range:−0.427 to 0.747). ConclusionLD free flap is a viable option for limb salvage in patients with large anterior soft tissue defects following multiple revisions of TKA. However, functional outcomes can be poor and there is a significant risk of ongoing infection and amputation in this complex patient cohort.

Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects.

Utilization of combined local muscle flaps for Gustilo type IIIB open tibial fractures has not been clearly delineated. We describe a combination of medial gastrocnemius and hemisoleus flaps for managing open tibial fractures accompanying large or double soft tissue defects. Twelve patients with Gustilo IIIB open fractures of the tibial shaft with large (9) or double (3) defects were operated on by fracture stabilization and combined medial gastrocnemius and hemisoleus flap coverage. Data were collected on types of implants, types of flaps, union time, postoperative complications, and Puno functional scores. Regarding implants for fixation, an intramedullary nail was used in three patients, plate and screws in five, combined plate and intramedullary nail in one, and definitive external fixation was used in three. Regarding soft tissue coverage, combined medial gastrocnemius and hemisoleus flaps were used in ten patients, combined hemigastrocnemius and hemisoleus in one, and combined medial gastrocnemius and reversed hemisoleus in one. All flaps survived, and all fractures were united with a mean union time of 19.7weeks (range 16-24). Tip necrosis of the hemisoleus flap occurred in two patients. Regarding Puno functional score, one was determined to be excellent, nine was good and two was fair. Combined medial gastrocnemius and hemisoleus flaps are reliable and effective for open tibial fractures complicated with large or double soft tissue defects.

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts.

The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage. Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments. All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3months after their final surgery. At 24months follow-up, 90% amputation free survival is still maintained. Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.

Temporal Muscle Bipartition and Tripartition Transposition for Reconstructing the Orbital and Oral Empty Space in Mucormycosis of the Middle Third of the Face.

Temporal muscle has great versatility to cover defects, caused by resections or large soft tissue losses of the middle facial third, has been used for more than 100 years. In the skin, the temporal muscle is transformed by the phenomenon called skin dermalization and mucolization in the oral cavity. This article shows how the temporal muscle is divided into two segments (bipartition) or three segments (tripartition) achieving a transposition of the muscle to cover large empty spaces caused by orbital exenteration or in maxilectomy. In coronal slice tomography, we demonstrate the perfect adaptation of the temporal muscle to the periorbital soft tissues in 360 degrees of the orbital region. In the defect produced by the maxilectomy, a perfect seal is obtained to achieve the separation of the nasal cavity from the oral cavity. The treatment was carried out in 3 immunocompromised adult patients, who presented mucormycosis of the middle third of the face and could not swallow or feed. The result we have in the survival of rhinocerebral mucormycosis is very high, due to extensive resections. Achieving that the patient has an adequate swallowing. We consider that the treatment is excellent due to the proximity of the temporal muscle to the surgical defect, achieving the objective of reconstruction without rejection.

Options for soft tissue reconstruction in pseudarthrosis

Pseudarthrosis can develop as acomplication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop acoherent and interdisciplinary treatment plan. Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via apedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.

Primary central nervous system diffuse large B-cell lymphoma: a report on unusual presentation with acute onset diplopia and proptosis

Acute onset of diplopia with proptosis in case of primary CNS lymphoma has not been reported yet in the literature. Blurred vision, reduced vision, and floaters are the commonest reported presentations. We report a case of a 41-year-old HIV positive male who presented with diplopia in left eye for two weeks with proptosis of left eyeball. CT Scan study of head and orbit showed heterogeneously enhancing large soft tissue calcified orbital mass pushing the left eyeball out of orbit. Right fronto-temporo-orbito-zygomatic (FTOZ) osteoplastic craniotomy with gross total excision of tumor was performed. Histopathological evaluation was suggestive of Non-Hodgkins Lymphoma. Immunohistochemistry confirmed the diagnosis of diffuse large B-cell lymphoma, non-germinal center type. Five months follow-up showed good recovery with no evidence of recurrence.

A large mandibular soft tissue lesion in an 8-year-old boy

A large mandibular soft tissue lesion in an 8-year-old boy

Hinged multiperforator-based extended dorsalis pedis adipofascial flap for dorsal foot defects.

BackgroundAdipofascial flaps covered with a skin graft address the challenges involved in reconstructing dorsal foot defects. The purpose of this study was to describe a large adipofascial flap based on the perforators of the dorsalis pedis artery for large foot defects.MethodsTwelve patients aged 5–18 years with large soft tissue defects of the dorsal foot due to trauma were treated with an extended dorsalis pedis adipofascial flap from May 2016 to December 2018. The flap was elevated from the non-injured half of the dorsum of the foot. Its length was increased by fascial extension from the medial or lateral foot fascia to the plantar fascia to cover the defect. All perforators of the dorsalis pedis artery were preserved to increase flap viability. The dorsalis pedis artery and its branches were kept intact.ResultsThe right foot was affected in 10 patients, and the left foot in two patients. All flaps survived, providing an adequate contour and durable coverage with a thin flap. Follow-up lasted up to 2 years, and patients were satisfied with the results. They were able to wear shoes. Donor-site morbidity was negligible. Two cases each of partial skin graft loss and superficial necrosis at the tip of the donor cutaneous flap occurred and were healed by a dressing.ConclusionsThe hinged multiperforator-based extended dorsalis pedis adipofascial flap described herein is a suitable method for reconstructing dorsal foot defects, as it provides optimal functional and aesthetic outcomes with minimal donor site morbidity.

A Novel Acellular Dermal Scaffold Prepared Using High-Intensity Focused Ultrasound Energy for the Repair of Soft Tissue Defects

Abstract Objective To evaluate a naturally derived acellular dermal scaffold for soft tissue reconstruction using high-intensity focused ultrasound energy (HIFU). Materials and Methods Acellular dermal scaffolds (ADSs) were prepared by purification of bovine skin. Half of the scaffolds were subjected to high-intensity focused ultrasound energy (HIFU) to modify collagen structure, whereas the other half was used as control. A large skin defect was made in the dorsum of white mice, and the scaffolds were used to cover the induced defects. Wound healing was evaluated histologically after 2, 6, and 12 weeks using common and specific stained sections (n = 20). Statistical Analysis Mean values and standard deviations were calculated for each group, and Student’s t-test was used for statistical analysis (α= 0.05; n = 20). Results After 2 weeks, all examined specimens revealed the presence of inflammatory cellular infiltration and early immature blood vessel formation. After 6 weeks, inflammatory cellular infiltration was reduced, with evidence of maturation of new blood vessels observed for all groups. After 12 weeks, there was a significant increase (F = 124, p < 0.01) in new collagen formation and count of mature blood vessels observed for the HIFU group compared with control. Evidence of remodeling of new collagen fibers and biodegradation of the grafts was also observed. Conclusions HIFU-modified ADSs enhanced wound healing and could be used to cover large soft tissue defects.

The cadaveric human skin allograft as a paradigm shift for the management of a large wound of necrotizing soft tissue infection: an interesting case report

Necrotizing soft tissue infection (NSTI) is an uncommon but fatal and rapidly progressing disease which requires emergent recognition and prompt treatment. Patients of NSTI frequently suffer from large soft tissue defects, which require coverage of these defects by auto-skin graft or flap cover. It becomes a challenge to cover the soft tissue defects in an already sick patient. The patient of NSTI has a restricted skin graft donor site and a poor skin grafting bed. Here authors report a case of 50 years old female, known case of type 2 diabetes mellitus, who suffered from NSTI post intramuscular injection of the left gluteal region. Her left thigh, left gluteal region, lower back, pubic and perineal region were involved. She underwent multiple radical debridement’s followed by the use of Cadaveric human skin allografts to cover the raw area temporarily. Meanwhile, authors optimized the patient nutrition state and controlled the infections. Finally, raw areas were covered with an autologous skin graft, and the patient discharged in stable condition.

Thin superficial inferior epigastric artery perforator flap for reconstruction of the tongue.

The superficial inferior epigastric artery (SIEA) flap is widely used in the repair of large soft tissue defects of the extremities and in breast reconstruction. Because of the high fat content of the abdomen, it has been less used for glossectomy reconstruction. Here we present a series of seven patients who each underwent reconstruction with a thin SIEA flap after resection of the tongue. There were six men and one woman (mean age 48, range 24-66 years). All patients underwent preoperative computed tomographic (CT) angiography, and colour Doppler ultrasound (US) was used to select and map the most suitable SIEA. The flap was raised above the Scarpa's layer while adjusted the plane of dissection according to the specific needs for bulk in each case. All the flaps survived; one flap required a secondary anastomosis because of a venous anastomotic embolus. The size of flap used was 5.0cm×6.0cm - 7.0cm×9.0cm, and the flap was 0.8cm-1.4cm thick. The functional outcome was evaluated at 6 - 18 months follow up, when speech and swallowing were both good in all cases. The dissection above the pubic symphysis is an important refinement of the SIEA flap, and we conclude that the thin SIEA flap is a good choice for reconstruction after excision of cancer of the tongue.

Combining the superficial circumflex iliac artery perforator flap with the superficial inferior epigastric artery flap or the deep inferior epigastric artery perforator flap for coverage of large soft tissue defects in the extremities and the trunk.

The superficial circumflex iliac artery perforator (SCIP) flap cannot be used for coverage of large defects. We introduce a novel flap design to overcome the SCIP flap's size limitation. Data of patients who underwent coverage of defects exceeding 113 cm2 (12 × 12 cm) using combined flaps composed of an SCIP flap and either a superficial inferior epigastric artery (SIEA) flap or a deep inferior epigastric artery perforator (DIEP) flap from September 2015 to September 2019 were retrospectively reviewed. After elevation of the SCIP flap, the SIEA was dissected. If the diameter of the SIEA was smaller than 0.5 mm, a DIEP included in the flap design was identified. For minimal donor site morbidity, the DIEP dissection was limited to its takeoff point from the deep inferior epigastric artery (DIEA), and a small T-portion of the DIEA was harvested. Six patients met inclusion criteria. The average defect size was 18.5 ± 2.3 × 15.7 ± 3.7 cm, and all defects were sufficiently covered. The mean dimensions of the SCIP flap, the SIEA flap, and the DIEP flap were 18.5 ± 2.5 × 7.5 ± 1.0 cm, 15.5 ± 2.1 × 6.6 ± 1.6 cm, and 17.5 ± 2.1 × 6.5 ± 0.7 cm, respectively. All flaps survived completely with no healing complications, and no donor site complications were observed. The SCIP flap was combined with the SIEA flap in four cases and with the DIEP flap in two cases. The average follow-up period was 12.7 ± 6.7 months. The final outcome was satisfactory in all cases. Large defects (up to 20 × 20 cm) can be covered with minimal donor site morbidity, with primary closure, by combining either the SIEA or the DIEP flap with the SCIP flap.

Clinical features and imaging analysis of primary bone lymphoma of the jaw

Objective: To investigate the clinical characteristics and imaging manifestations of primary bone lymphoma (PBL) located in the jaw. Methods: Clinical data of 14 PBL patients admitted to The First Affiliated Hospital of Zhengzhou University from January 2014 to April 2019 were retrospectively analyzed, which including age, gender, location, chief complaint, laboratory test, imaging manifestations and so on. Results: Among the 14 PBL patients, 10 were male and 4 were female. Age range from 4 to 79 years, median age was 56 years old. There were 6 cases involved maxillary, 7 cases involved mandible and 1 case involved mandible and maxillary simultaneously. Twelve patients were admitted with local mass as the chief complaint, 3 had a history of toothache, 4 had loosen tooth and 2 had numbness of lips and cheeks. Two cases of oral mass with mucosal surface ulcer or abscess formation. One case complained of fever, night sweats and other systemic symptoms. The imaging findings showed 8 cases of osteolytic lesions, 1 case of sclerosis, 4 cases of mixed lesions and 1 case of cystic lesions. One case had periosteum reaction. In 12 cases, there was an obvious mass, which was characterized by the large soft-tissue mass and marrow changes were associated with surprisingly little cortical destruction. Conclusions: PBL is more common in middle aged male. The upper and lower jaw bones can be involved. Clinical and imaging manifestations lack characteristics, and common dental or periodontal symptoms such as toothache, tooth loosening, and paresthesia may occur. However, the imaging characteristics of large soft tissue masses with small degree of bone destruction can be used as an important basis for the differential diagnosis of osteomyelitis, squamous cell carcinoma, osteosarcoma and other diseases.

Double Antero-lateral Thigh Flow-Through Free Flaps in Series Connection to Reconstruct a Huge Defect in Back

Soft tissue sarcomas can occur anywhere in the body. In the back, they pose a significant problem due to their large size. Surgery is the main stay of treatment for soft tissue sarcoma management. However, removal of such tumors results in large soft tissue defects. Skin grafts can resurface large defects, but skin grafts have their own limitations and can delay initiation of radiotherapy. Providing a stable soft tissue cover which can withstand post-op radiotherapy is desirable. Single flap cannot cover large defects. We report one such technique where two antero-lateral thigh free flaps were connected in series for the first time as “chain flaps” for large defect coverage. Six months follow-up showed no complications following radiotherapy. We recommend this technique to cover large size defects which are not amenable to cover via single flap, for optimal outcome.

0562 Differences in Upper Airway Soft Tissue Volumes Between African American and Caucasian Patients with Obstructive Sleep Apnea Using Magnetic Resonance Imaging

Abstract Introduction Research suggests greater obstructive sleep apnea (OSA) severity in African-Americans than Caucasians. However, the underlying mechanisms causing this ethnic disparity are unknown. To evaluate possible mechanisms, we compared the size of the tongue between African American and Caucasian OSA patients using magnetic resonance imaging (MRI), controlling for age, body mass index (BMI) and apnea-hypoxia index (AHI). Given prior evidence of more severe OSA in African Americans, we hypothesized these patients would have larger soft tissue volumes compared to Caucasians. Methods Upper airway soft tissue volumes, (total tongue, tongue fat, lateral walls, pterygoids, total soft tissue) were quantified using MRI and compared between Caucasian (n=133) and African American (n=175) patients with moderate OSA. Analyses were conducted using regression models controlling for age, sex, BMI and AHI. Results Among all OSA patients, African Americans had higher BMI than Caucasians (40.0±8.6 vs. 37.1±8.1 kg/m2, p=0.0024) and a higher proportion of females (66.3% vs. 36.1%; p<0.0001). There were no significant differences in age (p=0.143) or AHI (p=0.314). Controlling for these covariates, there were no differences between African American and Caucasian OSA patients in tongue fat volume (mean [95% confidence interval] difference = 479 [-3156, 4115] mm3; p=0.794). However, African Americans had a 13,286 (6,439, 20,132) mm3 larger total tongue volume compared to Caucasians (p=0.0002). Larger volumes in African Americans were also observed for the soft palate (p<0.0001), retropalatal lateral walls (p=0.003), pterygoid (p=0.034) and total soft tissue volume (p=0.0003). Conclusion African Americans were observed to have larger volumes of the tongue, soft palate, retropalatal lateral walls, pterygoids and total soft tissue volume compared to Caucasians, although there were no differences in AHI and tongue fat volume. The study contributes to the overall understanding of ethnic-specific pathology of OSA and can potentially influence how African Americans and Caucasians are diagnosed and treated specifically for the disease. Support

“Triple hit” SOX11−, MME+, TP53 mutated high‐grade pleomorphic mantle cell lymphoma

A 61-year-old woman presented with a four-week history of breathing difficulty, fatigue, edema and left breast mass. She had performance status of three, pedal edema, bilateral neck lymphadenopathy (>5 cm), oral thrush, diminished breath sounds on left chest and a large soft tissue swelling involving left breast and left anterior chest wall. Laboratory studies showed hemoglobin 9.2 g/dL, leukopenia (WBC 2.4 K/μL) with left-shifted granulocytes and monocytosis, and platelet count of 157 K/uL. She had elevated LDH (2925 IU/L) and low serum albumin 3.1 g/dL. Chest X-ray showed collapse of left lung, massive pleural effusion. The CT scan showed bulky cervical lymphadenopathy, mediastinal mass (6.1 cm × 4.4 cm) with extension into the anterior chest wall and large left pleural effusion, a 13 cm left chest wall mass, contiguous with bulky mediastinal lymphadenopathy and bulky retroperitoneal, pelvic, mesenteric and inguinal lymphadenopathy. A PET-CT confirmed these findings (Image 1I). Further work up was initiated. Thoracentesis confirmed presence of large monoclonal kappa+ CD5 + MME+ B cells. Bone marrow (BM) aspiration and biopsy with cytogenetic analyses were performed. Bone marrow was extensively involved with pleomorphic mantle cell lymphoma (MCL) cells (Image 1A-C) showing the cytomorphology of aggressive MCL cells, which were CD5 dim, and MME positive. Complex karyotype was detected (Image 1D) and FISH studies were positive for IGH/CCND1 and deletion of TP53. Chest wall mass biopsy showed pleomorphic MCL with similar morphology as seen in BM. Immunohistochemical stains were positive for CD5 (dim), MME, CD20, PAX5, MYC, BCL2, BCL6, CyclinD1 and negative for CD3, SOX11, and MUM1. The Ki-67 proliferative index was 90%. Epstein-Barr virus-encoded small RNA (EBER) was negative. Flow cytometry confirmed monoclonal kappa light chain expressing MCL cells with same immunophenotype as in the BM. Note, FISH analyses revealed IGH/CCND1 (Image 1E), IGK/MYC (Image 1F-G) and BCL6 rearrangement (Image 1H) with an unknown partner gene on 11q13; TP53/CEP17 dual-color probes revealed one copy TP53 deletion and trisomy 17 in 47% of cells, and the BCL2 break apart probe was negative for BCL2 rearrangement. The patient was given one cycle of R-CHOP but she developed multiple complications (severe sepsis, pneumonia, worsening pleural effusion needing bilateral chest tube insertion, respiratory distress requiring intubation and ventilator support. She developed pulmonary emboli and progressive disease within a week after chemotherapy and remained in the intensive care unit for 3 weeks. After discharge, she was bed bound, oxygen dependent, severely deconditioned and malnourished. We discussed regarding starting her on acalabrutinib as a salvage, however considering the patient's worsening clinical picture and very poor prognosis, the patient and family decided to transfer to hospice facility. This patient had an ultra-high risk MCL variant with a constellation of poor risk features (pleomorphic histology,1 complex karyotype including MYC rearrangement and P53 deletion, CD10+,2 Ki-67 90%). The SOX11 negative MCL generally exhibits an indolent clinical course3 but the presence of high-risk features have likely subdued the impact of SOX11 negativity. Triple-hit MYC-BCL6-CCND14 with deleted TP53 is a very rare and high risk category of MCL. These patients are uncommon and demonstrate a poor response to various therapies. If feasible, CAR-T therapy5 might be beneficial in such patients. The authors do not have any disclosures/conflicts of interest related to this manuscript. P.J., G.T., S.L. and M.W. collected and analyzed pathology and wrote the paper. P.J. and M.W. managed the patient. All authors have reviewed and approved the manuscript.