Left Pectoral Region Research Articles

Pectoralis Major Metastasis of Esophageal Adenocarcinoma: An Unusual Site

Esophageal cancer is a tumor of poor prognosis and its most common sites of metastases are lymph nodes, lung, liver and bones. However, it has also been reported some unexpected metastasis to uncommon sites which has consequently affected the pathway of diagnosis, management and staging. We report the case of a 31year old man patient with history of dysphagia, weight loss and induration in the left pectoral region. Endoscopic, radiological and pathological examination confirmed the diagnosis of Esophageal adenocarcinoma with pectoralis major metastasis. The patient was qualified for radiotherapy and concurrent systemic chemotherapy. Unfortunately, the patient died 3 months after the first CRT.

Pectoralis Major Metastasis of Esophageal Adenocarcinoma: An Unusual Site Abdelfettah Touibi, Imane Mouslim, Rachid Laaroussi, Sanaa Berrag, Fouad Nejjari, Tarik Adioui, Mouna Tamzaourte Published: May 30, 2023 | 10 19 DOI: 10.36347/sjmcr.2023.v11i05.069 Pages: 1034-1037 Downloads Abstract Esophageal cancer is a tumor of poor prognosis and its most common sites of metastases are lymph nodes, lung, liver and bones. However, it

The case revolves around a 62-year-old male patient who was a smoker and had inadequately-controlled hypertension and dyslipidemia. He was admitted to the Medical Intensive Care Unit after having an emergency PCI (percutaneous coronary intervention) performed on his LMS (left main stem) and LAD (left anterior descending). The patient had gone into acute cardiogenic pulmonary edema, which immediately warranted intubation. He had been diagnosed with a case of anterolateral STEMI (an ST-elevation myocardial infarction) which had led him to develop this condition. A bedside ECHO carried out revealed problems with his heart as well, and particularly the left ventricle. This put him at a great risk of developing cardiac arrest, which could have fatal consequences if not appropriate interventions were not carried out. To resolve this condition, an IABP (an intra-aortic balloon pump) was inserted under the guidance of an ECHO, and only once the ROSC (return of spontaneous circulation) had been achieved. Once everything had been settled, an infusion of noradrenaline and vasopressin was started. The IABP was maintaining pressure at 100 mm Hg. The patient was extubated after six days and his IABP was removed four days later. To assess if there was any internal damage to his brain, a plain CT scan of the brain without contrast was ordered, which revealed cerebellar infarcts. This infarct had manifested itself in the form of hypophonia and wide-based ataxia. By the end of his stay at the hospital, the patient had started to walk and had greatly stabilized. The prognosis seemed favorable and the patient’s life was saved on discharge medications protocol. This case study is an example of how cardiopulmonary resuscitation, if done correctly and promptly, can help save the life of a patient with very little hope. It can be a matter of seconds before a patient’s condition deteriorates or turns fatal. The same applies to patients undergoing sudden cardiac arrest (SCD), .........

PSEUDOMONAS AERUGINOSA COSTOCHONDRITIS ASSOCIATED WITH RECENT IV DRUG USE

PSEUDOMONAS AERUGINOSA COSTOCHONDRITIS ASSOCIATED WITH RECENT IV DRUG USE

A Case of Extrapulmonary Tuberculosis

A 21 years old man immigrant from Nigeria came to our observation for swelling of the chest wall and fever. The laboratory tests showed neutrophilic leukocytosis and absence of HIV / others viruses’ infection. Chest X-ray was not conclusive. An abdomen echography showed diffuse lymphadenopathy. In the suspicion of a lymphoproliferative disease we performed a total body CT, that detected colliquated lymph nodes in the later cervical, abdominal and pelvic stations; at the left pectoral region there was an abscess collection (58x54mm) crossing the intercostal spaces until to the anterior pleura (Figure 1). Echocardiography showed mild pericardial effusion. The thoracic abscess was drained and a sample of PCR for Mycobacterium tuberculosis was positive. We started therapy with rifampicin, isoniazid, pyrazinamide, ethambutol and methyl prednisone, waiting for cultural examination The patient was discharged in good clinical status with diagnosis of disseminated lymph node tuberculosis (LNTB) fistulized to the chest wall abscess and he was referred to specialist follow-up

Calcifying Aponeurotic Fibroma in the left pectoral region in an adult: A Case report.

Calcified aponeurotic fibroma is a rare benign fibroblastic tumor. The lesion has property of local invasion and high recurrence. Because of this property, tumor should be accurately diagnosed pre-operatively. We report a case of 29 years old male, with a palpable painful mass on the anterior chest wall near left pectoral region, describes radiographic and MR findings. No skin defect was detected but patient feels discomfort. An excision procedure was done. The excised tissue was sent for biopsy and calcified aponeurotic fibroma was diagnosed.

A Case of Extrapulmonary Tuberculosis

A 21 years old man immigrant from Nigeria came to our observation for swelling of the chest wall and fever. The laboratory tests showed neutrophilic leukocytosis and absence of HIV / others viruses’ infection. Chest X-ray was not conclusive. An abdomen echography showed diffuse lymphadenopathy. In the suspicion of a lymphoproliferative disease we performed a total body CT, that detected colliquated lymph nodes in the later cervical, abdominal and pelvic stations; at the left pectoral region there was an abscess collection (58x54mm) crossing the intercostal spaces until to the anterior pleura (Figure 1).

B-PO02-191 THE LV LEAD PLACEMENT FOR CARDIAC RESYNCHRONIZATION THERAPY (CRT) BY THE FEMORAL VEIN CORONARY SINUS (CS) CANNULATION: A TECHNICAL EXTENSION

CRT is a mainstay of treatment in refractory dilated cardiomyopathy in chronic systolic heart failure and prolonged QRS duration of more than120 ms. The limiting factor for successful CRT is the CS cannulation for LV lead placement. The study aimed to assess if the femoral vein CS cannulation facilitated LV lead placement for the CRT after failed cannulation from the intended site. The study included 39 patients (17 Female) and severe non-ischemic cardiomyopathy (Table1). The left pectoral region was the preferred site for implantation. Initially, anterograde CS cannulation was attempted from the intended site. In anterograde success (48.7%), the CS cannulation was under 10 minutes. In anterograde failure (51.28%), time was over 10 minutes. The CS was cannulated doubly, initially from the right femoral vein using a steerable decapolar EP catheter. This facilitated subsequent CS cannulation and LV lead placement from the intended site. The time duration among the 19 anterograde success cases: mean = 7.2 minutes, median = 7.0 minutes, interquartile range is [6.0, 8.0]. The total duration (Table1) for LV lead placement was 42.4 ± 2.0 minutes in anterograde success, and in femoral vein facilitated (anterograde failure) technique was 37.7 ± 2.1, P<0.0001. The multivariable logistic regression model shows, age is positively associated with anterograde failure (OR and 95% CI: 1.23 (1.08, 1.40), while sodium level is negatively related to anterograde failure (OR and 95% CI: 0.37 (0.17, 0.81). The CS cannulation from the femoral vein is a possibility. CRT failure rate and fluoroscopy duration can be reduced by this method.

Rarely Seen Poland–Moebius Syndrome: A Comprehensive View with Perspective of Pediatric Neurology

Background Moebius syndrome is a rare congenital disorder characterized by a unilateral or bilateral congenital facial weakness with impairment of ocular movements. Poland syndrome is an occasional disease defined as the unilateral absence of pectoralis major muscle and ipsilateral syndactyly. As to, Poland–Moebius syndrome is a rare condition which consists of assembly components of Poland and Moebius syndromes. Patients and Methods Patient 1 is a 12-year-old male patient referred for evaluation of difficulties in eye movements to the hospital. On admission, facial, abducens, trochlear, and oculomotor cranial nerves involvement was determined in the neurological examination. His right pectoralis major muscle was hypoplastic in the examination. Patient 2 is a 4-month-old female patient who was admitted with restricted eye movements, weakness of crying, and difficulty in swallowing. Neurological examination indicated facial, abducens, trochlear, oculomotor, glossopharyngeal, and vagus cranial nerves involvement. Her physical examination demonstrated hypoplastic left pectoralis major muscle and hypoplastic left hand. Results The biochemical laboratory studies, creatinine kinase levels, and tests for inborn error of metabolism of both patients were normal. Chest X-ray studies revealed the lack of muscle tissue development in the left pectoral region. Cranial magnetic resonance imaging, echocardiography, and abdominal ultrasound were also normal. Conclusion This report highlights two cases of Poland–Moebius syndrome in two patients of varying age and clinical presentations, with a comprehensive review from the perspective of pediatric neurology.

Sensing performance, safety, and patient acceptability of long-dipole cardiac monitor: An innovative axillary insertion.

The recommended location for implantable cardiac monitor (ICM) insertion is the left pectoral region. We tested whether an innovative left axillary implantation approach could be applicable for a new ICM, characterized by a long sensing dipole. We considered a series of 55 patients consecutively implanted with a long-dipole ICM (BioMonitor 2); the first 30 subjects underwent prepectoral location insertion, while the subsequent 25 received the ICM in the axillary region. Sensing performances collected at 1-month follow-up were compared between the two groups. During the visit, each patient was also asked to fill in a brief questionnaire to assess patient acceptability of the device. All patients had a successful insertion of ICM. Mean R-wave amplitude was 0.87 ± 0.44mV in the prepectoral group and 1.00 ± 0.45mV in the axillary one, without any significant difference. The percentage of patients with visible P wave was also comparable between the two approaches (65.5%vs 68.2%, P=0.84). None of the patients reported device-related issues or discomfort, and ICM was generally well accepted and tolerated by all the involved patients. Axillary insertion may represent a valid alternative to the standard one for long-dipole ICM technology providing not only patient acceptability but also high-quality sensing performances.

073_16956-Q1 Migration of a Pacemaker Lead to an Unusual Site

An 80-year-old female patient with mechanical mitral valve prosthesis, complete heart block and atrial fibrillation was referred to our arrhythmia center for implantation of a pacemaker. Through the left pectoral region and the axillary vein a single chamber pacemaker with an active fixation lead

073_16955-Q1 Low Anterior Axillary Implantation of an Implantable Cardioverter-Defibrillator in a Patient with Recurrent Bilateral Pectoral Infection

A 38-year-old male with ischemic cardiomyopathy had recurrent implantable cardioverter-defibrillator (ICD) device infections with two infections on the left pectoral region and one infection on the right pectoral region in a few months. We performed a low anterior axillary line incision with

Transvenous lead implantation in a patient with mechanical prosthesis in the tricuspid position: Transvenous route should be the first choice

A 36-year-old male patient with Ebstein's anomaly and severe aortic stenosis having two mechanical valve prostheses in the aortic and tricuspid valves was referred to our center for previously implanted pacemaker malfunction. Permanent pacemaker with VVI mode was implanted on the right ventricular apical epicardial surface using left thoracotomy because of complete heart block after valve surgery. After 1 year from implantation, however, another permanent pacemaker with VVI mode was implanted on the right ventricular free wall epicardial surface using right thoracotomy due to pacemaker malfunction with very high pacing threshold. Similarly, approximately 3 years after implantation very high pacing threshold was detected with complete heart block on surface ECG. Therefore we decided to implant a permanent pacemaker with DDD mode via transvenous route. After appropriate patient preparation double puncture was performed to the subclavian vein. First, coronary sinus was cannulated and a bipolar coronary sinus lead was implanted in the great cardiac vein with excellent pacing and sensing values (0.4 V of pacing threshold and 16 mV of R-wave amplitude). Second, a bipolar active fixation lead was implanted in the right atrial appendage region with excellent pacing and sensing values (0.3 V of pacing threshold and 6 mV of p-wave amplitude). Last, a permanent pacemaker with DDD mode was implanted in the left pectoral region with good atrioventricular synchronous pacing on surface ECG (Fig. 1 and Video). Extraction of remaining two pulse generators was postponed to a later date and no extraction of epicardial leads was decided to avoid the risks of surgery. Transvenous route should be the first approach to implant permanent pacemaker or implantable cardioverter–defibrillator in patients with mechanical prosthetic valve in the tricuspid position because surgical implantation needs a requirement of a thoracotomy which is associated with longer hospitalization period, and higher morbidity and mortality. In addition, epicardial implantation is associated with a higher incidence of lead failure as in our case [ [1] Cay S. Transvenous cardioverter–defibrillator lead implantation in a patient with three mechanical prosthetic valves: all in one solution. Int J Cardiol. 2013; 165: e33-4 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ].

External defibrillation on an implantable defibrillator

To the Editor: Despite the best efforts of healthcare providers, guideline-conform treatment failure is expected to occur, particularly in real-world emergency situations [1]. In the case reported here, a 79-year-old man with a history of coronary artery disease and implantation of a cardioverter defibrillator (ICD) presented to the emergency room with recurrent ventricular tachycardia. The junior physician-incharge applied an external biphasic DC shock of 200 J to the patient, holding the paddle in one hand and placing it directly over the ICD (Electronic Supplementary Material Fig. 1)—but without success. Arrhythmic stability was finally achieved by multiple, appropriate ICD shocks and intravenous amiodarone. Subsequent device interrogation and defibrillation testing of the ICD showed no instance of device malfunction. Coronary angiography revealed arteries free of significant stenoses. Strong electromagnetic interference induced by transthoracic DC shocks may cause permanent damage or alter the operation of the implanted device [2]. When attempting external defibrillation, clinicians are advised to place the paddles/pads as far as possible from any pulse generator and to choose biphasic over monophasic shock waveforms. A less deleterious effect might be expected if the orientation of the applied electric field is perpendicular—and not parallel—to the device with its lead(s), whereas if the device is located in the left pectoral region, an anterior– apex paddle position may be also acceptable. With an anterior–posterior electrode orientation and a distance between device and hand-held shock electrode of [8 cm, Manegold et al. [3] did not observe any dysfunction in patients with rightor left-sided implanted pacemakers or ICDs treated with external cardioversion for atrial fibrillation.

Radiotherapy of primary cutaneous follicle center lymphoma: case report and review of literature

Primary cutaneous follicle center lymphoma is an indolent primary cutaneous B-cell lymphoma originating from the follicle center cells, composed of a combination of centrocytes (small and large cleaved cells) and centroblasts (large noncleaved cells) with a follicular, follicular/diffuse, or diffuse growth pattern. Lesions are mostly located on the head, neck and trunk. A case is presented of a 56-year-old male patient with primary cutaneous follicle center lymphoma, with lesions involving the skin of the back, shoulders, presternal area and right forearm. As the patient presented a disseminated cutaneous form of the disease that involved several anatomical regions, complete work-up was followed by superficial fractionated radiotherapy of eight fields in VI expositions, with total irradiation dose of 1400 cGy upon the following fields: right and left pectoral region, left and right shoulders, right suprascapular region, and proximal third of the right forearm. Total irradiation dose applied upon each field for the lesions located on the left and right side of the back was 1500 cGy. This therapy resulted in significant reduction of visible tumor. The patient was regularly followed up on outpatient basis for 12 months of radiotherapy, being free from local recurrence and systemic spread of the disease.

Significance of intraoperative testing in right-sided implantable cardioverter-defibrillators

BackgroundImplantation of implantable cardioverter-defibrillators (ICD) from the left pectoral region is the standard therapeutical method. Increasing numbers of system revisions due to lead dysfunction and infections will consecutively increase the numbers of right-sided implantations. The reliability of devices implanted on the right pectoral side remains controversially discussed, and the question of testing these devices remains unanswered.MethodsIn a prospectively designed study all 870 patients (60.0±14 years, 689 male) who were treated with a first ICD from July 2005 until May 2012 and tested intraoperatively according to the testing protocol were analyzed. The indication for implantation was primary prophylactic in 71.5%. Underlying diseases included ischemic cardiomyopathy (50%), dilative cardiomyopathy (37%), and others (13%). Mean ejection faction was 27±12%. Implantation site was right in 4.5% and left in 95.5%.ResultsFive patients supplied with right-sided ICD (13%, p = 0.02 as compared to left-sided) failed initial intraoperative testing with 21 J. 3 patients were male. The age of the patients failing intraoperative testing with right-sided devices appeared higher than of patients with left-sided devices (p = 0.07). The ejection fraction was 28±8%. All patients reached a sufficient DFT ≤ 21 J after corrective procedures.ConclusionImplantation of ICDs on the right side results in significantly higher failure rate of successful termination of intraoperatively induced ventricular fibrillation. The data of our study suggest the necessity of intraoperative ICD testing in right-sided implanted ICDs.

MRI and cardiac pacing devices — beware the rules are changing

We have been following the development of MRI-compatible cardiac permanent pacemakers (PPM) with great interest. Recently, we have been asked to perform clinical MRI studies in patients with a MRI-compatible PPM. We would like to share our experience in performing one such study and highlight important safety measures that radiologists should undertake prior to imaging. Conventional PPM has always been regarded as an absolute contraindication for MRI. This has prevented a large number of patients from undergoing clinically important MRI studies. MRI-compatible PPM is now available for clinical use following a prospective randomised controlled unblinded multicenter study, involving 464 patients [1,2]. Our first patient had an Advisa DR MRI SureScan (Medtronic, Minneapolis, MN) system, which is one of the most widely used MRI-compatible systems. These devices have been designed to minimise thermal damage and limit induced voltages preventing unintended stimulation of the heart. Performing an MRI study in these patients requires robust preparation and liaison between physicist, radiographer, electrophysiology technicians, consultant radiologist and referring clinician. Informed consent should be obtained from the patient after discussing the benefits of the MRI study and potential complications. The following radiology specific pre-requisites should be fulfilled and adhered to and these may change depending on the manufacturer of the device: Cylindrical bore, clinical MR systems with a static magnetic field of 1.5 T. Gradient systems with maximum gradient slew rate performance per axis of ≤200 T m−1per second. Whole body averaged specific absorption rate (SAR) must be ≤2 W kg−1 and for head <3.2 W kg−1. Implant must consist of an MRI-compatible device as well as the lead. Any other leads or broken leads remain a contraindication. The pacing system should be implanted in either the right or left pectoral region and should have been in place for more than 6 weeks. The patient should not be positioned on his or her side within the scanner. Local transmit/receive coils should not be placed over the pacing system. Prior to taking the patient into the scanner the PPM is programmed to MRI safe mode by electrophysiologists outside the MR safety zone. Once in the scanner, continuous monitoring using electrocardiography (ECG), pulse oximetry and blood pressure is essential. External defibrillator must be readily available and the procedure should be abandoned if patient's haemodynamic function is compromised. After completing the scan, the PPM is turned back on to normal mode and the correct pacing capture threshold is ensured prior to discharging the patient. Our patient was a young man who underwent a cardiac MRI study for cardiomyopathy. He was involved in discussions regarding the safety of the procedure and consented prior to the study. He was extremely anxious when he went into the scanner, but relaxed as the procedure went on. He did not experience any untoward sensations or arrhythmia during the 40 min study. Standard TrueFISP (true fast imaging with steady state precession) images were degraded owing to artefacts from the leads; this was rectified by switching over to FLASH (fast low angle shot) cine images (Figure 1). Overall the image quality was good. Figure 1 Cardiac MRI in standard planes in (a) TrueFISP (true fast imaging with steady state precession) and (b–d) FLASH (fast low angle shot) sequences. Note the clear delineation of the pacing leads (arrow) on the latter sequence with no significant ... We foresee that more patients will undergo MRI scanning with compatible cardiac pacing systems. Currently there is limited evidence regarding its safety and long-term effects. We, therefore, profess extreme prudence and a multidisciplinary approach prior to scanning a patient with an MRI-compatible pacemaker.

Suicide by Extraordinarily Numerous Blade Wounds

A 42-year-old man with a history of suicidal ideation, was found dead in his garage, with over 54 stab wounds and with multiple cuts. The house was locked and the bay door of the attached garage was closed when his live-in girlfriend arrived home and found him. The scene was bloody and a knife was beside the body. Multiple stab wounds involved the neck and the left pectoral region of the chest, and a single stab wound involved the epigastrium. Incised wounds involved the neck and upper extremities. The head, back, genitalia, and lower extremities had no wounds. The blood smears and spatters in the garage, including a bloody footprint, all were attributable to the decedent. The combined consideration of the history, circumstances, and autopsy findings clearly pointed to self-infliction as the manner of death. Most reported cases of suicide by blade involve fewer than 15 stab wounds. This case report, with a brief review of the literature, underscores the concept that multiplicity of stab wounds does not preclude the diagnosis of suicide.

Use of a biventricular implantable cardioverter defibrillator in a patient with a neurostimulator: is it a safe combination?

The coincident use of neurostimulators and devices such as ICDs and pacemakers is increasing. This is because of the expanding indications for both devices. The manufacturers of ICDs caution against the combined use of ICDs and neurostimulators because of possible device interaction [1]. A 55-year-old woman was referred because of drug-refractory heart failure. In 2009, a neurostimulator (Synergy Versitrel, Medtronic, Inc, Minneapolis, Minnesota, USA) was implanted because of intractable back pain. She was admitted because of heart failure in the presence of dilating cardiomyopathy. Implantation of a biventricular implantable cardioverter defibrillator was indicated. A CRT-D (Consulta D234TRK, Medtronic, Inc, Minneapolis, Minnesota, USA) was implanted in the left pectoral region. Peri-procedural testing, with the ICD set to maximum sensitivity and the neurostimulator set to maximum therapeutic output, showed no interaction between the two devices (Fig. 1). A chest X-ray after the implantation showed adequate positioning of the leads (Fig. 2). The combination of cardiac resynchronisation therapy defibrillator and neurostimulators can be safe. However, extensive peri-operative testing is essential in preventing device interaction [1–3]. Fig. 1 Post-procedural electrocardiographic registration. Showing leads I and II (surface ECG), Farfield-ECG (from coil to can) and EGM2 (right ventricle). Note that there is no neurostimulator signal present, even though the neurostimulator output is set to ... Fig. 2 Anterior and lateral X-ray images, demonstrating the biventricular ICD system and the neurostimulator electrode (black arrows)

Intralymphatic Histiocytosis and Cancer of the Colon

Intralymphatic histiocytosis is a condition with nonspecific clinical features but with characteristic histopathological and immunohistochemical findings. It presents as a poorly demarcated erythematous plaque or a lesion similar to livedo reticularis, usually located on the limbs. Histologically, dilated vessels containing mononuclear cells are observed in the reticular dermis. In the past, the majority of these cases were thought to be cases of reactive angioendotheliomatosis or intravascular lymphoma, but the development of more specific immunohistochemical markers showed that these were dilated lymph vessels containing histiocytes, and so were considered as a separate condition. We present the case of a man with a past history of left axillary lymphadenectomy for lymphatic tuberculosis, leukocytoclastic vasculitis, and cancer of the colon. The patient developed an erythematous plaque in the left pectoral region. Histology and immunohistochemical stains of the lesion revealed histiocytes within dilated lymph vessels in the reticular dermis, but no neoplastic cells. We present a new case of intralymphatic histiocytosis in a patient with autoimmune and neoplastic diseases.

Histiocitosis intralinfática y neoplasia de colon

Intralymphatic histiocytosis is a condition with nonspecific clinical features but with characteristic histopathological and immunohistochemical findings. It presents as a poorly demarcated erythematous plaque or a lesion similar to livedo reticularis, usually located on the limbs. Histologically, dilated vessels containing mononuclear cells are observed in the reticular dermis. In the past, the majority of these cases were thought to be cases of reactive angioendotheliomatosis or intravascular lymphoma, but the development of more specific immunohistochemical markers showed that these were dilated lymph vessels containing histiocytes, and so were considered as a separate condition. We present the case of a man with a past history of left axillary lymphadenectomy for lymphatic tuberculosis, leukocytoclastic vasculitis, and cancer of the colon. The patient developed an erythematous plaque in the left pectoral region. Histology and immunohistochemical stains of the lesion revealed histiocytes within dilated lymph vessels in the reticular dermis, but no neoplastic cells. We present a new case of intralymphatic histiocytosis in a patient with autoimmune and neoplastic diseases.