Left Chest Wall Research Articles

P-756. Primary Mycobacterium Infections presenting in patients of Rheumatic diseases - A Case Series

Abstract Background We present a study about patients with rheumatic diseases who were diagnosed for mycobacterium infections in their follow-up visit. The role of side effects of immunosuppressants have been established. However, their association with mycobacteria in endemic countries like India is yet to be understood well. ABDOMINAL CT - CASE 1 (TUBERCULAR PERITONITIS) Moderate to gross ascites with thickened enhancing parietal peritoneum, significant with caking and abdominal lymphadenopathy hence pointing towards Tubercular Peritonitis. Methods Consent was obtained from the patients to use their data for a case series. Relevant data related to the cases was collected, and organised. HRCT THORX - CASE 3 (PULMONARY TB) HRCT THORAX shows multiple, discrete, randomly distributed nodules in both the lungs, multiple enlarged lymph nodes in left axilla and in left anterior chest wall, some of which are confluent in nature and two calcifications in one of the lymph node. Results First case is about a 54 yr-old male patient, known case of Ankylosing spondylitis treated with 9 doses of Anti-TNF alpha drug Adalimumab presented with severe abdominal pain, fever with chills, vomiting & diarrhea for which he underwent abdominal CT-scan which revealed thickened enhancing parietal peritoneum, significant with caking and abdominal lymphadenopathy hence pointing towards Tubercular Peritonitis. Second case is about Non-Tuberculous Mycobacteria(NTM) or atypical mycobacteria diagnosed in a patient with Ankylosing Spondylitis who had negative tests for primary TB. Third case about a 28 year-old female, known case of bilateral iridocyclitis and recurrent multiple medium-vessel vasculitic/throm2botic occlusions treated with mycophenolate-mofetil and cyclosporine-A, was started on adalimumab. Later she presented with fever for which pulmonary workup was done which revealed positive TB. Fourth case is of a patient having symptoms similar to Rheumatoid arthritis but not responsive to treatment which led to extensive workup and mycobacterium leprae was found as a culprit. Fifth case is of a 16 year-old male, known case of GPA who was refractory to cyclophosphamide was started on rituximab, after which he presented with complaints of fever with chills and rigors, and breathlessness on exertion which was followed by the diagnosis of miliary tuberculosis. TB patients were given Anti-tubercular therapy(ATT) and Leprosy patient was given Multi-drug therapy(MDT) and all are now improving. Leonine Facies - Case 4 Conclusion • Our study shows that immunosuppressants can be considered to have even increased risk of primary mycobacterium infection. • Leprosy can present with similar manifestations of RA (Rheumatoid Arthritis) so signs of suspicion need to be kept in mind and screening should be done in such cases. Leprosy mimicking RA - Case 4 Disclosures All Authors: No reported disclosures

Tracheal perforation and subcutaneous emphysema secondary to pseudomembranous invasive Aspergillus tracheobronchitis successfully managed with endotracheal tube manipulation

Introduction: Aspergillus is a ubiquitous fungus causing various pulmonary diseases depending on the host’s immune status. Aspergillus tracheobronchitis, a rare form of invasive aspergillosis, primarily affects severely immunocompromised or critically ill patients. We present the first known case of Aspergillus tracheobronchitis complicated by tracheal perforation and subcutaneous emphysema successfully treated with conservative endotracheal tube manipulation. Case description: A 64-year-old male with type 2 diabetes mellitus presented with generalized weakness and abdominal discomfort, later diagnosed with a perforated cecum requiring right colectomy. His postoperative course in the intensive care unit was complicated by septic shock, acute kidney injury, and failed extubation due to airway compromise. Seven days after the failed extubation, he developed subcutaneous emphysema in the neck. Chest computed tomography scan showed neck, left chest wall, and mediastinal emphysema. Bronchoscopy identified a focal black necrotic lesion on the left proximal tracheal wall and multiple small mucosal ulcerations throughout the proximal to distal trachea. The endotracheal tube was advanced beyond proximal tracheal necrotic lesion. Subcutaneous emphysema reduced overnight, suggesting that the lesion was the source of the air leak. Bronchial washings confirmed Aspergillus fumigatus, establishing a diagnosis of invasive Aspergillus tracheobronchitis. Treatment with voriconazole prevented further expansion of emphysema, which gradually resolved. Conclusion: Subcutaneous emphysema in ventilated patients with tracheobronchitis is a rare and challenging complication. This case demonstrates successful management through endotracheal tube manipulation to tamponade the lesion, highlighting subcutaneous emphysema as a potential manifestation of Aspergillus tracheobronchitis and offering a minimally invasive treatment approach.

Woman with a Painful Rash

Case presentation: A 21-year-old woman with a history of eczema presented to the emergency department with a painful rash over the previous three days spreading from her left axilla to herleft arm, left chest and left abdominal wall. The rash consisted of clusters of small, erythematous vesicles on hyperpigmented patches of skin. The patient was treated empirically with intravenous cyclovir for eczema herpeticum with improvement. Polymerase chain reaction testing of the fluid obtained from the rash vesicles later confirmed the presence of herpes simplex virus-1. Discussion: Eczema herpeticum is a cutaneous superinfection with herpes simplex virus on pre- existing sites of eczema. Left untreated, it can have a mortality rate over 50%. Early identification and treatment of this high morbidity condition with antiviral agents is key to improving outcome.

Multifocal Tuberculous Osteomyelitis of Ribs with Active Pulmonary Infection

Abstract Skeletal tuberculosis (TB) is a type of extrapulmonary TB affecting bony structures. Surprisingly, rib involvement is rare, comprising only 0%–5% of bone TB cases. Multifocal tuberculous osteomyelitis of the rib is a very rare condition, affecting only 0.1% of individuals with TB. We present here the case of a 28-year-old male who is an accountant in a travel agency with no comorbidities presented with complaints of cough with expectoration and swelling over the left posterolateral chest wall for 3 months’ duration. Imaging by computed tomography and magnetic resonance imaging of the chest showed features of multifocal tuberculous osteomyelitis of ribs with active pulmonary TB. Pus was aspirated from chest wall swelling detected mycobacterium TB in Catridge based nucleic acid amplification test, and the patient was started on antitubercular therapy. This case emphasizes skeletal TB, despite being the prevalent form of extrapulmonary TB, and presents an intriguing aspect with rib involvement remaining a relatively rare phenomenon.

Isolated advanced chest wall recurrence with a rectified reconstruction

In developed nations, breast cancer stands as the primary cause of cancer-related death among females. Local recurrence is often considered an initial sign of treatment ineffectiveness, occurring on the chest wall, axilla, or ipsilateral breast post Breast-Conserving Surgery (BCS). Local recurrence is observed in approximately 30% of patients with locally advanced breast cancer. A 58-year-old postmenopausal woman, who is a known case of triple negative breast cancer presented to us with an ulcerative lesion over left chest wall. In the past, she underwent neoadjuvant chemotherapy followed by left MRM and received adjuvant chemotherapy for left breast carcinoma. The staging of her previous disease is yT2N1aM0. Now presenting as locally advanced recurrent infiltrating lesion in the anterior wall of pericardium with sternal erosion of size 7.7×9.7×15 cms. Isolated chest wall recurrences of breast cancer can be surgically treated with chest wall resection, sternal resection, and reconstruction, providing a good quality of life and disease-free survival. Titanium mesh, gaining recent popularity as a reliable and promising bone replacement, was utilized in this case.

Mammary myofibroblastoma of the male breast: a case report and literature review.

Mammary myofibroblastoma (MFB) is a rare benign spindle cell tumour predominantly affecting males, but also observed in postmenopausal females. Its diagnosis remains challenging owing to overlapping histological features with malignant lesions and limited tissue sampling in core biopsies. We present a case of incidentally discovered mammary MFB in a 63-year-old man and review its clinical, radiological and histopathological characteristics. The patient, who had a history of distal pancreatectomy and splenectomy, presented with an incidental left anterior chest wall nodule discovered on computed tomography scan. Clinical examination revealed a benign left retroareolar lump, confirmed by breast ultrasound and mammography. Ultrasound-guided core biopsy demonstrated characteristic spindle cells, prompting immunohistochemical staining confirming the diagnosis of MFB. The lesion was surgically excised with clear margins. Mammary MFB is commonly seen in postmenopausal women and older men, presenting as painless, mobile breast lumps. Imaging findings are nonspecific, resembling fibroadenomas or fat necrosis. Histologically, MFB lacks mammary ducts or lobules and displays characteristic spindle cells with collagenous stroma. Immunohistochemistry aids in differentiating it from other spindle cell tumours. Surgical excision is curative, with no reported cases with recurrence. Mammary MFB should be considered in the differential diagnosis of breast masses in males and postmenopausal women. Despite the challenges in diagnosis, its benign nature and favourable prognosis warrant timely recognition and appropriate management through surgical excision. Further research is needed to establish clear management guidelines and explore its underlying pathogenesis.

Efficacy of pyrotinib and capecitabine in recurrent breast cancer with a HER2-negative genetic switch following systemic therapy: A case report and literature review

Despite the demonstrated safety and efficacy of pyrotinib and capecitabine in treating human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer, their efficacy in recurrent breast cancer in which the HER2 status has changed to negative remains unexplored. Here, we report a case of a 38-year-old female diagnosed with invasive ductal adenocarcinoma of the left breast, staged as mcT2N0M0. Fluorescence in situ hybridization (FISH) confirmed that the tumor was hormone receptor (HR) positive with low HER2 expression (2+) and a HER2/CEP17 ratio of 3.56. Following neoadjuvant targeted therapy and chemotherapy, she underwent a modified radical mastectomy. Post-surgical histopathological examination revealed a non-pathological complete response, classified as ypT1cypN1M0. The tumor remained HR positive with low HER2 expression (2+), but the FISH result was negative (HER2/CEP17 ratio of 1.65). For 1 year, she was administered dual-targeted therapy with goserelin and exemestane. Sequential therapy with neratinib was initiated; however, it was discontinued due to grade IV diarrhea. Despite ongoing endocrine therapy, she experienced tumor recurrence on the left chest wall. A biopsy of the recurrent lesion revealed it to be HR positive with low HER2 expression (2+) and a negative FISH result (HER2/CEP17 ratio of 1.33). The recurrent lesion responded to combination therapy consisting of pyrotinib and capecitabine, with tolerable adverse events. This case highlights the potential advantages of combining pyrotinib and capecitabine when the HER2 status changes to negative following systemic therapy.

A Unique Case of Unilateral Pseudogynecomastia.

Gynecomastia is a common condition characterized by the benign enlargement of male breast tissue, often resulting from hormonal imbalances. A rare variant, unilateral pseudogynecomastia, involves enlargement due to adipose tissue accumulation without glandular proliferation and can be associated with occupational factors. We report the case of a 45-year-old male mechanic presenting with unilateral enlargement of the left breast. The patient reported daily microtrauma on his left axilla and chest wall. The clinical evaluation and imaging revealed lipomatosis with pronounced fibrous tissue and no glandular tissue involvement. The hormonal assays were within the normal limits. The patient underwent surgical excision of excess adipose tissue using the Kornstein technique, preserving the nipple-areola complex. The histopathological examination confirmed the absence of malignancy. The postoperative recovery was uneventful, and the follow-up examination at 12 months demonstrated a symmetrical breast appearance with no recurrence. This case underscores the importance of differentiating pseudogynecomastia from true gynecomastia and recognizing potential occupational risks. Surgical management using techniques that preserve the nipple-areola complex can achieve excellent cosmetic outcomes.

Use of Laxative-Augmented Contrast Medium Increases the Accuracy in the Detection of Colorectal Neoplasms.

Colonic adenomas are considered a precursor of colorectal cancer. A 75-year-old woman had a history of post-operation left breast cancer. She received an excision when the left chest wall recurred. A later FDG PET/CT scan revealed a focal intense FDG accumulation in the sigmoid, a focal mild FDG uptake in the pericolic lymph node, and a focal increased FDG accumulation in the transverse colon. A delayed FDG PET/CT scan after the per-rectal administration of the laxative-augmented contrast medium revealed a filling defect with persistent FDG uptake in the sigmoid and transverse colon and mild FDG uptake in the pericolic lymph node. In addition, more lesions were observed in the rectum and descending colon. The pathology reports showed sigmoid adenocarcinoma with lymph node metastasis, and adenomas in the transverse colon, descending colon, and rectum.

How Effective is Deep Inspiration Breath Hold in Minimizing Cardiac Doses During Hybrid Radiotherapy Treatment for Left-Sided Breast Cancer with Comprehensive Regional Nodes?

In the context of left breast cancer radiotherapy, long term cardiopulmonary toxicity has been well-documented, significant efforts have been undertaken to mitigate such toxicity by using 4D gating, deep inspiration breath-hold(DIBH) and active breath control(ABC) techniques. To evaluate and compare the cardio-pulmonary radiation doses incurred during postmastectomy radiotherapy (PMRT) in two distinct breathing conditions such as DIBH and Free Breathing (FB), with a specific focus on the left chest wall with comprehensive regional nodal irradiation. A prospective dosimetric study was conducted on 15 patients who received adjuvant loco-regional radiotherapy of chest-wall (CW), supraclavicular fossa(SCF), and internal mammary region(IMC), with or without axilla. Two sets of planning CT scans were taken in DIBH and FB conditions. The dosimetric difference between DIBH CT and FB CT plans analyzed using Wilcoxon signed-rank test, employing SPSS software version 21.0. Comparison of DIBH and FB parameters for target coverage revealed a statistically significant advantage with DIBH in SCF(D95, V90, p<0.017) and IMC(D98, V90 & V95, p<0.03). Dosimetric characteristics of heart and LAD exhibited statistically significant lower doses with DIBH (V20, V25, and Dmean, p<0.001) compared to FB plans. Lung doses were similar with no discernible advantage of one technique over the other. Other OARs such as contralateral breast (p=0.027) and esophagus (p=0.001) received lower doses with the DIBH technique while the spinal cord (p=0.691) and thyroid(p=0.496) showed no significant difference. Maximum heart distance (p= 0.001), central lung distance (p= 0.011) and Haller index (p= 0.001) exhibited statistical significance between the two techniques, whereas chest wall separation showed no significant statistical difference (p=0.629). DIBH demonstrates a substantial reduction in cardiac and LAD doses compared to the FB technique. This study underscores the efficacy of DIBH as a viable strategy for mitigating cardiac and LAD radiation doses in left-sided breast cancer patients undergoing PMRT of chest wall with comprehensive regional nodes.

A retrospective study of 96 cases of adrenal metastases

Objective: To analyze the clinical characteristics, etiological composition, imaging features, and prognosis of adrenal metastases. Methods: This study is a retrospective case series that included 96 patients with pathologically confirmed adrenal metastases who were treated at West China Hospital, Sichuan University, from 2007 to 2017. Clinical features such as sex, age, tumor size, biochemical tests, imaging characteristics, postoperative pathology, treatment methods, and prognosis were collected and analyzed. The prognosis of patients and its influencing factors were analyzed by Kaplan-Meier survival curve and single-factor Cox risk proportional model. Results: Among the 96 included patients, 64 were male and 32 were female, with a median age of 60 years. There were 89 cases of unilateral adrenal metastases, five cases of bilateral metastases, and two cases with unspecified laterality. The median diameter of the metastases was 3.5 cm×2.9 cm, with an average CT value of 31 HU. Thirty-four cases of adrenal hormones were evaluated, and no abnormality was found.The primary tumor sites were as follows: lung (n=36), kidney (n=19), liver (n=12), pancreas (n=7), rectum (n=3), stomach (n=2), and one case each of tumor in the esophagus, skin, thyroid, left maxillary muscle, breast, bladder, cervix, chest wall, and gastrointestinal tract. There were three cases with unknown primary tumors. The most common pathological type was lung adenocarcinoma (20.8%, 20/96), followed by hepatocellular carcinoma (9.4%, 9/96) and high-grade invasive urothelial carcinoma of the kidney (8.3%, 8/96). Thirty-nine cases were diagnosed concurrently with the primary tumor, while 37 cases were diagnosed after the primary tumor, with a median interval of 15 months (range: 2-144 months). There was no significant correlation between the death risk of adrenal metastatic tumor patients and gender, age, and the size of the metastatic tumor (all P>0.05). There were 4 patients with radiotherapy and chemotherapy alone, 19 patients with surgery alone, and 6 patients with combined radiotherapy and chemotherapy. The median overall survival was 1, 3, and 7 years, respectively. Conclusions: Adrenal metastases were mostly diagnosed at the same time as the primary tumor or within 15 months after the diagnosis of the primary tumor. Unilateral metastasis is common. The lungs are the most common primary lesion, followed by the kidney and liver. CT is the preferred method for the diagnosis of adrenal metastases, and the plain CT value is more than 30 HU. The overall prognosis of adrenal metastases is poor. The prognosis was better for patients who underwent surgery combined with radiotherapy and chemotherapy than those who received only surgery or radiotherapy and chemotherapy alone.

Cytodiagnosis of a Metastatic Anaplastic Carcinoma of Thyroid Presenting as Multiple Subcutaneous Nodules

Anaplastic thyroid carcinoma (ATC) is a rare malignancy with highly aggressive behavior. It has an overall survival from 3 to 5 months in most of the cases. The most common metastatic sites are the lungs, followed by the intrathoracic and neck lymph nodes. Soft-tissue involvement is extremely rare and only a few cases have been published in English literature. Here, we report a case of ATC in a 22-year-old male who presented in early decade of life with multiple soft-tissue metastases as a rare initial presentation. Clinical examination revealed a diffusely enlarged thyroid gland, cervical lymphadenopathy, and multiple subcutaneous nodules over left thigh, chest and abdominal wall. Cytology from all sites of lesions followed by cell block with immunohistochemistry confirmed a diagnosis of ATC with nodal and cutaneous metastases. The patient succumbed to death before further management.

Respiratory insufficiency after brain metastasectomy for extraskeletal Ewing sarcoma in an adult patient with mucopolysaccharidosis type II: a case report.

Mucopolysaccharidosis is a rare lysosomal storage disease caused by deficiencies in enzymes involved in the degradation of glycosaminoglycans. We report the case of an adult with mucopolysaccharidosis type II who developed respiratory insufficiency after brain metastasectomy for extraskeletal Ewing sarcoma. This report describes the case of a 35-year-old man with a mass on the left chest wall for 3months. Magnetic resonance imaging and computed tomography revealed a large mass on the chest wall. Positron emission tomography revealed multiple metastatic lesions in the lungs, ribs, and sternum. A needle biopsy specimen confirmed extraskeletal Ewing sarcoma, and the fusion gene EWS-FLI1 was positive. Subsequently, multidrug chemotherapy was administered. During radiotherapy for the primary lesion, progressive convulsions occurred suddenly. Computed tomography of the brain revealed metastasis in the frontal lobe. Brain metastasectomy was scheduled; however, endotracheal intubation was not possible because of the deformity of the glottis, and emergency tracheostomy was performed. Thereafter, granulation tissue proliferated in reaction to the tracheostomy cannulae in the trachea, and respiratory insufficiency persisted. Because of the rapid growth of an intrathoracic recurrent tumor, the patient passed away 2months after brain surgery. This is the first report of sarcoma in a patient with mucopolysaccharidosis. Respiratory management is difficult in patients with mucopolysaccharidosis, especially under general anesthesia. Orthopedic surgeons should be aware that surgical planning must be performed carefully when soft tissue sarcomas occur in patients with mucopolysaccharidosis.

1011 A Rare Case of Left Sided Hemiparesis Following a Pneumatic Gun-Shot Injury to Left Anterior Chest Wall in a 13-Year-Old Boy

Abstract Introduction Even though pneumatic weapons rarely cause severe direct trauma, pellet embolisation can lead to unexpected, catastrophic events. Case Report A 13-year-old, previously healthy boy was injured by an accidentally fired pneumatic gun, while playing with his twin brother. He sustained a penetrating wound to left anterior chest wall and resultant bleeding was self-limiting. He was hospitalised within 15minutes. On admission, he was hemodynamically stable with normal Respiratory, Cardiovascular and Neurological system findings. Entry wound measuring 5*5 mm was present at 5th intercostal space just left to the sternum. No exit wound was detected. Initial chest radiograph and ultra-sound abdomen and chest were normal. 2D echocardiogram revealed only a very thin layer(3mm) of pericardial effusion. Four hours later, He developed a focal seizure followed by left sided hemiparesis. Urgent NCCT brain and carotid artery duplex showed a high dense pellet in right internal carotid artery at the level of petrous temporal bone and hypo-dense Middle Cerebral Artery (MCA) suggestive of right MCA thrombosis. He was transferred to a tertiary care centre. Interventional radiological and endo-vascular attempts of pellet retrieval have been failed. Ischemic stroke pursued with worsening cerebral oedema; thus decompression craniotomy was performed on day 3. He is currently being rehabilitated in a specialised centre. Conclusions High degree of suspicion should be maintained on the possibility of projectile embolisation, in pneumatic gun-shot injuries, especially in the absence of an exit wound. Extensive early investigations should be performed to localise the projectile and retrieval should be planned.

Co-occurrence of posterior chest wall pilonidal sinus with melanocytic nevus: a challenging presentation: a case report

IntroductionTo date, only a limited number of case reports have documented the co-occurrence of PNS and melanocytic nevus in the medical literature. This study aims to report an exceptionally rare case of posterior chest wall PNS in conjunction with a melanocytic nevus.Case presentationA 46-year-old female presented with a long-standing black lesion on her left upper posterior chest wall, that had become painful in the two months prior to presentation. There was a painful, dark blue, non-erythematous, and non-tender nodule on the left upper posterior chest wall. Based on the patient’s desire for cosmetic purposes, the lesion was excised totally with primary closure under local anaesthesia. Histopathological examination revealed intradermal melanocytic nevus with inflamed pilonidal sinus.DiscussionThe rarity of posterior chest wall PNS associated with nevi poses unique diagnostic and therapeutic challenges for clinicians. The distinct anatomical location, different from the conventional region, and the rare association between the two conditions may delay accurate diagnosis and result in mismanagement or inappropriate interventions.ConclusionThe posterior chest wall PNS is another type of atypical PNS that is extremely rare. The association between PNS and blue nevus is a fascinating medical finding that deserves further investigation.

Dose delivery error from respiratory motion in free breathing left breast irradiation

PurposeMany institutions worldwide currently deliver left breast radiotherapy in free breathing mode, mostly due to the unavailability of a Deep Inspiration Breath Hold technique (DIBH). This study aims at quantifying the error in dose delivery (compared to treatment plan) due to respiratory motion in free breathing irradiation of left breast or chest wall. Since subfields often consist in small, fine-tuned, highly targeted fields, slight intrafractional target motion may compromise their subtle benefit. Thus we analyzed the respiratory motion effect on target dose coverage, dose homogeneity and left lung dose. MethodsTreatment plans for twenty left breast or chest wall cancer patients previously treated at our center were retrieved and retrospectively planned with the introduction of an appropriate shift in isocenter location to simulate free breathing target motion. ResultsNo clinically significant dosimetric changes were found in all twenty cases when breathing motion was accounted for. Changes in target dose coverage (V95%), in target maximum dose (D2%) and in V20Gy lung dose were respectively less than 1.5%, 0.3% and 2.6%. ConclusionThe findings suggest that breast irradiation in free breathing mode does not undermine the dosimetric merits of the field-in-field technique and does not produce clinically significant dosimetric differences in dose delivery for target and lung compared to plan.

Disseminated Cryptococcus neoformans infection involving multiple bones and lung in an immunocompetent patient: a case report

BackgroundCryptococcal osteomyelitis is a rare and potentially serious condition, typically encountered in individuals with compromised immune systems. This case underscores the unusual occurrence of disseminated Cryptococcosis in an immunocompetent person, involving multiple bones and lungs, with Cryptococcus neoformans identified as the causative agent.Case presentationAn Indonesian man, previously in good health, presented with a chief complaint of successive multiple bone pain lasting for more one month, without any prior history of trauma. Additionally, he reported a recent onset of fever. On physical examination, tenderness was observed in the left lateral chest wall and right iliac crest. Laboratory findings indicated mildly elevated inflammatory markers. A computed tomography (CT) scan of the chest revealed an ovoid solid nodule in the right lower lung and multifocal osteolytic lesions in the sternum, ribs, and humeral head. A magnetic resonance imaging (MRI) study of the sacrum showed multiple lesions in the bilateral iliac bone and the lower L4 vertebral body. Confirmation of Cryptococcal osteomyelitis involved a fine-needle biopsy and culture, identifying Cryptococcus neoformans in the aspirate. The patient responded positively to targeted antifungal treatments, leading to a gradual improvement in his condition.ConclusionsThis case emphasizes the need to consider Cryptococcus neoformans osteomyelitis in immunocompetent patients with bone pain. A definitive diagnosis involves a fine-needle biopsy for pathology and culture, and prompt initiation of appropriate antifungal treatment has proven effective in preventing mortality.

Investigation of skin dose of post-mastectomy radiation therapy for the halcyon and tomotherapy treatment machine: Comparison of calculation and in vivo measurements

In treatments such as post-mastectomy radiation therapy (PMRT) for breast cancer patients, skin doses are of great importance in terms of tumor control and side effects. This dosimetric study aimed to measure the skin dose on the chest wall surface for post-mastectomy radiotherapy with Tomotherapy and Halcyon devices using thermoluminescence dosimetry (TLD) and to evaluate the accuracy of the skin dose calculated by treatment planning systems (TPS). Computed tomography (CT) images of the Alderson Rando phantom were obtained. Treatment plans were created with Tomotherapy and Halycon devices for a total of 50 Gy with a fraction dose of 2 Gy to the target volume. The left chest wall was divided into 9 regions for detailed surface dose assessment. 88 dose measurement points were determined on the left chest wall. The phantom was irradiated separately in Halycon and Tomotherapy devices. In vivo, dose measurements were performed with TLD in both devices. TPS and TLD doses were compared for the left chest wall surface. For skin dose, TLD measurements were lower than the dose estimate by Tomotherapy TPS and higher than the dose estimate by Halycon TPS. In addition, the skin dose measurements showed that the skin dose of the Tomotherapy device was higher than that of the Halycon. It is recommended to consider the distance of the treatment device and the accuracy of the TPS dose calculation in skin dose assessment in PMRT.

An innovative reconstruction of an enbloc resected composite giant chest and abdominal wall chondrosarcoma with 3D-composite mesh

BackgroundChest wall chondrosarcomas, although common, pose unique challenges due to their aggressive nature, rarity of abdominal wall involvement, and propensity for recurrence. We highlight the critical role of meticulous surgical planning, multidisciplinary collaboration, and innovative reconstruction techniques in achieving optimal outcomes for patients with composite giant chest and abdominal wall chondrosarcoma.Case PresentationA 38-year-old female patient presented with progressive left chest and abdominal wall swelling for two years; on evaluation had a large lobulated lytic lesion arising from the left ninth rib, scalloping eighth and tenth ribs measuring 13.34 × 8.92 × 10.71 cm (anteroposterior/transverse/craniocaudal diameter) diagnosed with chondrosarcoma grade 2. A three-dimensional (3D) composite mesh was designed based on computed tomography using virtual surgical planning and computer-assisted design and manufacturing technology. She underwent wide local excision and reconstruction of the chest and abdominal wall with 3D-composite mesh under general anesthesia. The postoperative condition was uneventful, with no recurrence at 12 months follow-up.ConclusionA 3D-composite mesh facilitates patient-specific, durable, and cost-effective chest and abdominal wall reconstruction.

Novel KMT2B gene mutation in MUC4 positive low-grade fibromyxoid sarcoma

BackgroundLow-grade Fibromyxoid Sarcoma(LGFM)is a rare fibrosarcoma, which mainly occurs in young people and is mostly seen in the trunk and limbs. The tumor is usually FUS-CREB3L2 fusion caused by t(7;16)(q32-34;p11)chromosome translocation, and rarely FUS-CREB3L1 and EWSR1-CREB3L1 fusion. MUC4 diffuse strong positive can be used as a specific index of LGFM. LGFM is similar to Sclerosing Epithelioid Fibrosarcoma(SEF) and may have the same origin.Case presentationWe report a case of LGFM in the chest wall. A female who is 59 years old. In 2016, CT showed dense nodule shadow and focal thickening of the left pleura, the patient underwent surgery, Pathological report that low to moderate malignant fibrosarcoma(fibromyxoid type). The CT re-examination in 2021 showed that the tumors on the left chest wall were significantly larger than before. Pathological examination showed the disease is composed of alternating collagen like and mucinous areas. Under high-power microscope, the tumor cells are consistent in shape, spindle or short spindle, and the tumor cells are arranged in bundles. In local areas, the density of tumor cells is significantly increased, mixed with collagen fibers, and small focal SEF appear. The result of immunohistochemistry showed that SMA, Desmin, CD34, STAT6, S100, SOX10, HMB45 and Melan A were negative, EMA was weakly positive, MUC4 was diffuse and strongly positive, and Ki67 index was low (3%).ConclusionSequencing results showed that MET, EGFR, KMT2B and RET gene were mutated in LGFM, and KMT2B gene had cancer promoting effect, but there was no literature report in LGFM, which may be of certain significance for the diagnosis and treatment of LGFM.