Left Clavicular Region Research Articles

SAT541 Pleural Effusion As First Manifestation Of Recurrent Follicular Thyroid Cancer

Abstract Disclosure: N.S. Kadakia: None. C.A. Poku: None. Pleural effusions are a rare presentation of Follicular Thyroid Cancer (FTC). We portray a case of a patient with a remote history of FTC who presented with pleural effusion 57 years later as the first sign of recurrence. A 80 year old male presented to the hospital 8/2021 with shortness of breath and was found to have a pleural effusion. He had a history of FTC diagnosed at age 23 status post total thyroidectomy, external beam radiation and radioactive iodine. He was started on thyroid hormone replacement and was subsequently lost to follow up. Chart review showed unremarkable neck ultrasounds completed in 2004 and 2006. During admission 8/2021, a malignant pleural effusion was diagnosed after the effusion tested positive for TTF-1 and thyroglobulin (Tg). He was diagnosed with recurrent metastatic thyroid cancer. A CT scan of the neck showed a small paratracheal nodule while a PET scan revealed hypermetabolic activity in the left pleura. A neck ultrasound reported a 2 cm cervical lymph node on the right with preserved fatty hilum and an ovoid 1 cm isoechoic solid nodule in the left surgical bed. There was evidence of bulky calcified lymph nodes on CT. The pleural lesion was not accessible however biopsy of a supraclavicular lymph node was consistent with metastatic follicular carcinoma. After a delay due to iodine contrast exposure, a whole body scan with radioactive iodine was completed in 1/2022 and showed multiple foci of uptake in the right neck, right thyroid, left clavicular region, and lung bases. He was treated with 250 mCi I-131 sodium iodide in 1/2022 and levothyroxine dose was increased with a target TSH of less than 0.1. His Tg level was mildly increased. Thyroglobulin antibodies (Tg ab) were positive but have continued to trend down after treatment. A follow up CT chest done 7/2022 had persistent pleural thickening but significant improvement in pleural effusion and thus thyroxine kinase inhibitors (TKI) chemotherapy has not been initiated. Malignant pleural effusion is a rare presentation of FTC metastasis with a reported median survival of 11 months (Kazushige). Pleural effusion is a poor prognostic sign in patients with FTC and distant metastases (Broome). This affirms that prompt recognition is of essence however it also raises the question of how effective current therapies are. A retrospective study evaluated 20 patients who received RAI for pulmonary metastasis from FTC, and found the efficacy rate was relatively low (40%). There is insufficient data to determine the effectiveness of RAI as treatment for metastatic FTC to the pleura. This case adds to the limited literature on recurrence of FTC with pleural effusion and highlights limitations of current management. If the response to RAI is deemed inadequate then consideration should be given to the use of TKI. Presentation Date: Saturday, June 17, 2023

Tiger Trauma

A 40-year-old woman presents to the trauma bay after being mauled by a tiger. She was emergently transported to the local tertiary community hospital for stabilization and treatment. She suffered from 33 different lacerations of multiple puncture wounds across her chest, full thickness lacerations to her left and posterior neck, left posterior scalp, and left arm. Vitals were stable and GCS 15. She was able to move all extremities with some weakness to her LUE and right sided facial droop with ptosis. She was subsequently intubated for distress, potential airway decompensation, and possible carotid artery injury. CT imaging illustrated a stable spinous process fractures at C5 and C6, non-displaced fractures of the left transverse process at C7 and T1, extensive subcutaneous emphysema within the inferior neck, superior right chest, and left clavicular region, as well as, air within the cervical canal and extrinsic to the thecal sac. MRI suggested ligamentous strain in the posterior longitudinal ligament at the C2-3 level, small amount of paraspinal hemorrhage on the left C2-3, within the interspinous ligaments C3-7 and marked edema/hemorrhage within the trunks and divisions of the left brachial plexus highly suspicious for brachial plexus injury. ENT and neurosurgeon diagnosed right facial palsy and began dexamethasone treatment. ID physician tailored antibiotics to vancomycin for human skin flora and ampicillin/sulbactam for Pasteurella multocida from the tiger. She was to switch to doxycycline, amoxicillin/clavulanate, and wound care after discharge. She was transferred for reconstructive surgery for the brachial plexus injury, electromyography, and electroneuronography testing.

Microsurgical neck reconstruction in an elderly patient

Introduction: The incidence of dermatological malignancies increases with age and a considerable percentage of older adults will require radical surgeries and adjuvant treatments, microsurgery allows repair and coverage of major defects with success rates of up to 90%. Case Report: We present the case of an elderly patient with an ulcer in the left clavicular region without evidence of healing. Histological and imaging studies were performed, a basal cell carcinoma subtype morphea was found. A wide excision and axillary lymph node dissection were performed, subsequently covering the defect with a free flap. There is an 11-year follow-up. Conclusion: Complications in microsurgical reconstructions are more associated with comorbidities than with the age of the patient. The same success rates can be obtained in elderly patients.

Chronic non-bacterial osteomyelitis of clavicle

The patient was a 10-year-old girl with pain and swelling of the left clavicle. The physical examination was normal except swelling and tenderness of the left clavicular region. All the...

Radiation-induced thoracic necrosis with a pulmonary cutaneous fistula repaired using a free omental flap: a case report

BackgroundChest wall necrosis can manifest as a late effect of radiation therapy for breast cancer. Only two cases of fistulas communicating with the respiratory tract as a result of radiation-induced necrosis of the lungs or bronchi have been reported. To the best of our knowledge, we report the first case of a pulmonary cutaneous fistula arising as a late effect of radiation therapy for breast cancer, which was successfully repaired using a free omental graft.Case presentationA 64-year-old woman underwent Halsted surgery and postoperative radiation therapy for breast cancer 25 years earlier. One year before visiting our hospital, she developed a fistula and bleeding in her left clavicular region, which was expanding. On initial examination, a 6-cm-wide skin defect was observed in the left clavicular region and the clavicle appeared sequestrated. Computed tomography revealed part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Several rounds of debridement revealed approximately 10 bronchial stumps on the surface of the collapsed lung, from which exhaled air and sputum were effusing. Surgery was performed to implant a free omental flap with vascular anastomosis and a skin graft in the neck region, and the pulmonary cutaneous fistula was closed. Two years after surgery, emphysema remained inside the omentum, which spontaneously resolved by the 3rd postoperative year.ConclusionsVarious treatment options are conceivable for the repair of pulmonary cutaneous and bronchocutaneous fistulas induced by radiation damage (e.g., free tissue grafts and endoscopic bronchial occlusion); however, these are rarely reported, and the most reliable method thus remains unclear. Positive outcomes in our case indicate that implanting a free omental graft may be effective. Furthermore, spontaneous healing can be expected for the residual emphysema inside the omentum.

OA148] A multi-center dosimetry study to evaluate imaging dose from Elekta XVI and varian OBI KV-CONE beam CT systems to cardiovascular implantable electronic devices (CIEDS)

Purpose By increasing the use of daily CBCT, additional delivered imaging dose to the patient became a matter of concern. This can also raise concerns about patients with CIEDs since accumulated dose to these devices highly needs to be limited. The aim of this study is to investigate the imaging dose to the CIEDs from Elekta XVI and Varian OBI kV-CBCT systems performed by a multi-institutional study. Methods Four geographically separated centers with different CBCT imaging systems and three different dosimetric measurement methods including Gafchromic films, metal-oxide-semiconductor field-effect transistor (MOSFET) and thermoluminescence dosimeters (TLDs) participated in this multi-center study. At each center an anthropomorphic phantom (Alderson RANDO phantom) was used and the CIED was placed in the alderson’s left clavicular region using the same setup. The dosimeter was fixed on top of the device over which a 1-cm thick bolus was used to simulate patient’s skin. Different standard CBCT-imaging protocols which are commonly used in clinical practice of each center were applied namely, Head&Neck (HN), Chest, Thorax, Symmetry, Prostate and Pelvis. Results The maximum values of imaging doses were found once CIEDs were inside the CBCT field. They were between the following values: HNS20 (XVI):2.57 mGy/100 mAs, Thorax (OBI):2.92 mGy/100 mAs, ChestM15-left (XVI): 1.52 mGy/100 mAs, Symmetry-left (XVI): 5.67 mGy/100 mAs. However, they received much lower dose once the CIEDs were not inside the field. Conclusion This study shows that although imaging doses received by CIEDs outside the CBCT field is negligible, a special attention should be paid to this value when CIEDs are inside the CBCT field because daily use of CBCT can make a considerable contribution to the total dose received by CIED. Based on the obtained results, it is possible that in some protocol like symmetry total imaging dose to CIED in a 30-fraction reach as high as 50 cGy. Therefore in such cases, this additional imaging dose should not be ignored when classifying CIED patients into risk groups.

Massive Skull Metastasis From Follicular Thyroid Carcinoma − How Ignorance Can Harm Your Health

We report a 70 years old female, who presented with huge swellings over the left forehead, left clavicular region, anterior neck, occipital region and the right side of the scalp. The first swelling appeared 8 years back. She had deranged thyroid function tests and highly raised serum thyroglobulin levels. Her T3 level was 300.75 ng/dl (normal range: 40–181 ng/dl); T4 level was 6.7 µg/dl (normal range: 5–10.7 µg/dl) and thyroid stimulating hormone (TSH) level was 0.09 µIU/ml (normal range: 0.5–8.9 µIU/ml). Her serum thyroglobulin level was 30,000 ng/ml (normal range: 0.73–84 ng/ml). We have reported this case due to the unusual presentation of the patient with massive metastatic lesions from a primary thyroid cancer with highly raised serum thyroglobulin levels. Metastatic tumors to the skull are most often from breast, lung and prostate malignancies. In thyroid cancer, Nagamine et al. reported skull metastasis in only 2.5% of the cases. Along with radioactive iodine therapy, curative resection of solitary bone metastasis, wherever possible, is associated with improved survival, especially in younger patients of metastatic thyroid cancer. Only the light of knowledge and health education can dispel the darkness of ignorance. This rare case report highlights the importance of educating the masses, especially the people living in villages, so that it does not take 8 years, as in our case, to present oneself to a tertiary health care facility.

Interdisciplinary approach to the management of Ewing sarcoma: a case report

Ewing sarcoma is a common primary bone malignancy occurring in childhood and adolescence. This case report describes a 4-year-old female patient who had Ewing sarcoma in the left clavicular region. The patient underwent total excision of the left clavicle and subsequently developed periodontitis and multiple carious lesions after chemotherapy. Caries risk and salivary flow rate tests were performed, followed by periodontal treatment, topical fluoride application, restoration of caries, and oral hygiene instruction. The care of this patient demonstrates that an interdisciplinary approach is essential to eliminate all foci of infection, minimize morbidity, and improve the patient's general health before, during, and after oncological treatment.

Primary cutaneous CD30+ anaplastic large-cell lymphoma in a young patient with psoriasis

Abstract Psoriasis is a common chronic inflammatory cutaneous disease, while primary cutaneous CD30+ anaplastic large-cell lymphoma (PC-ALCL) is a rare T-cell lymphoma which always has an excellent prognosis, although multifocal PC-ALCL tends to relapse after systemic chemotherapy. Psoriasis associated with PC-ALCL is exceptionally rare. We report a 29-year-old Chinese female with a 5-year history of psoriasis treated with Chinese herbs alone, who was referred to our institution with a tumor on the left clavicular region for 1 year and another one on the left palm for 2 months. Skin biopsies of both lesions showed diffuse infiltration of tumor cells, composed of large atypical cells with marked nuclear pleomorphism, prominent nucleoli, and eosinophilic cytoplasm. Large numbers of neutrophilic infiltrations were also noted in the lesion. Immunostaining revealed the lesion to be positive for CD30, vimentin, CD45, and CD68, and weakly positive for epithelial membrane antigen, but negative for anaplastic lymphoma receptor tyrosine kinase. The patient was diagnosed to have psoriasis associated with PC-ALCL; she died 18 months after the final diagnosis with unknown cause. We consider that immune dysregulation and/or Chinese herbs may play roles in the development of the present PC-ALCL.

Unintended pregnancy during radiotherapy for cancer

A 27-year-old woman with upper mediastinum stage IIA Hodgkin lymphoma was treated with six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy. Two months later she received a total of 4,250 cGy to the upper mediastinum and left clavicular region over a 1-month period. One week after completion of radiotherapy she was found to be 13-weeks pregnant. Her physician advised her to terminate pregnancy. She contacted a teratology information service for further information regarding the risks of radiation exposure for her fetus. Estimation of fetal radiation exposure, literature review and synthesis of published cases and effects of fetal radiation exposure. Estimated fetal radiation dose between 5 and 18 cGy. Counseling on the possible risks to the fetus as a result of radiation exposure.

Carcinoma tubárico primitivo y polimiositis

We report a case of a primitive fallopian tube carcinoma associated with polymyositis. A 53-year-old woman consulted for pelvic pain, metrorrhagia, and leukorrhea. Physical examination revealed a renitent and mobile mass in the pelvis. Ultrasonography showed a right lateral uterine mass with hydrosalpinx. Pathological examination of the right annexectomy specimen provided the definitive diagnosis. No residual tumor was found at total hysterectomy with bilateral annexectomy. The patient was lost to follow-up for 3 years without complementary treatment and then consulted again for functional disability first of the upper limbs and subsequently of the lower limbs with myalgia, swallowing disorders and left supraclavicular node enlargement resulting from pelvic relapse of the right fallopian tube adenocarcinoma and left supraclavicular metastasis with paraneoplastic polymyositis. The patient was given 6 courses of chemotherapy with radiotherapy (45 Gy) centered on the left clavicular region. The patient showed excellent response to treatment, and remains in complete remission 50 months after diagnosis. The association of fallopian tube carcinoma with polymyositis is exceptional, requiring rapid treatment effective against the cancer and paraneoplastic polymyositis.

Spontaneous Partial Fracture of the Catheter of a Totally Implantable Subcutaneous Infusion Port

A totally implantable subcutaneous infusion port was inserted via the left subclavian vein with peel-away sheath in a 45-year-old male patient receiving home parenteral nutrition. Sixteen months after implantation, the patient noted pain in his left clavicular region during home infusion. This was found to be due to the leakage of infusion fluid resulting from partial fracture of the catheter at the level where the catheter passed between the clavicle and first rib. Because the fracture was partial, the catheter did not embolize to the heart or large vessels. Although subcutaneous infusion ports afford patients greater freedom and the ability to lead a more active life than do external catheters, it is emphasized that there may be the risk of spontaneous catheter fracture in patients using subcutaneous infusion ports.

A Case of Eosinophilic Granuloma in the Left Clavicula

A case of eosinophilic granuloma in the left clavicula is reported.A boy aged 4. was admitted to our clinic on August 1972, complaining of pain and swelling in the left clavicular region. The rentogenographic examination revealed a round lytic lesion of the cortex in the proximal end of clavicula with excessive periosteal reaction. At operation the cortex showed partial destruction although pathological fracture was not seen. The lesion was completely removed and its appearance was a raddish-tan solid granulation. Smears and culuture of curettage material were negative for pathogens. Pathological diagnosis was eosinophilic granuloma. Five month after surgery a radiograph showed the lesion to have healed almost completely.