Lower Chest Wall Research Articles

Sorting lung tumor volumes from 4D-MRI data using an automatic tumor-based signal reduces stitching artifacts.

To investigate whether a novel signal derived from tumor motion allows more precise sorting of 4D-magnetic resonance (4D-MR) image data than do signals based on normal anatomy, reducing levels of stitching artifacts within sorted lung tumor volumes. (4D-MRI) scans were collected for 10 lung cancer patients using a 2D T2-weighted single-shot turbo spin echo sequence, obtaining 25 repeat frames per image slice. For each slice, a tumor-motion signal was generated using the first principal component of movement in the tumor neighborhood (TumorPC1). Signals were also generated from displacements of the diaphragm (DIA) and upper and lower chest wall (UCW/LCW) and from slice body area changes (BA). Pearson r coefficients of correlations between observed tumor movement and respiratory signals were determined. TumorPC1, DIA, and UCW signals were used to compile image stacks showing each patient's tumor volume in a respiratory phase. Unsorted image stacks were also built for comparison. For each image stack, the presence of stitching artifacts was assessed by measuring the roughness of the compiled tumor surface according to a roughness metric (Rg). Statistical differences in weighted means of Rg between any two signals were determined using an exact permutation test. The TumorPC1 signal was most strongly correlated with superior-inferior tumor motion, and had significantly higher Pearson r values (median 0.86) than those determined for correlations of UCW, LCW, and BA with superior-inferior tumor motion (p<0.05). Weighted means of ratios of Rg values in TumorPC1 image stacks to those in unsorted, UCW, and DIA stacks were 0.67, 0.69, and 0.71, all significantly favoring TumorPC1 (p=0.02-0.05). For other pairs of signals, weighted mean ratios did not differ significantly from one. Tumor volumes were smoother in 3D image stacks compiled using the first principal component of tumor motion than in stacks compiled with signals based on normal anatomy.

Localised plasmacytoma presenting as right chest wall swelling

Development of any swelling in the right lower chest wall or right upper abdomen is an unusual presentation. Hence the localisation of the origin of swelling becomes difficult to ascertain through clinical examination alone. Accurate diagnosis requires detailed investigation and ruling out of differentials one by one. We would like to share one such case of a patient presenting to surgery OPD with complaint of swelling in the lateral aspect of right chest wall which on investigations turned out to be a rib tumour arising from the bone marrow. Lady of age 57 years presented to us with h/o swelling in lateral aspect of right chest wall which gradually increased in size over 3 years and associated with pain for last 5 months. On exam an oval swelling of size 8×5 cm seen in lateral wall of right lower chest wall. On detailed investigations, the swelling was diagnosed as a plasma cell tumour of right 8th rib. Any chest wall or abdominal swelling needs detailed evaluation before proceeding for surgical intervention. It is important to keep various differential diagnosis in mind considering clinical factors and site of swelling to make an accurate diagnosis.

PROFIL PENGOBATAN OBAT ISPA NON PNEUMONIA PADA ANAK DI PUSKESMAS MANTANG LOMBOK TENGAH

Acute Respiratory Infection (ARI) is an acute infection that attacks the organs of the upper respiratory tract and lower respiratory tract. Acute respiratory infection is a disease that mostly affects children and adults in developing and developed countries. Non-pneumonic acute respiratory tract infections include a group of patients with under-fives with a cough that does not show symptoms of an increase in respiratory rate and does not show any pull from the lower chest wall. This study aims to see the description of ARI non-pneumonia treatment at the Mantang Health Center, Central Lombok. Sampling in this study used all patients who met the inclusion criteria, and data obtained were 21 patients with a diagnosis of ARI Non Pneumonia in children from 665 patient populations. The results obtained in this study were obtained the most patients, namely patients aged 4-6 years with a percentage of 42.85%, ages 1-3 years 7 with a percentage of 33.33%, age &lt; 6 months of 14.28% and 6-12 months with a percentage of 14.28%. The classes of drugs prescribed for the May 2021 period are antibiotics, antihistamines, analgesics, mucolytics, anti-inflammatory, and multivitamins . The conclusion obtained in this study is that pediatric patients with ARI Non-Pneumonia at the Mantang Health Center who received the most treatment at the age of 4-6 years had the highest percentage and received the most therapy with a diagnosis of ARI Non-Pneumonia, which was given antihistamins

Chest Wall Mass as the Dominant Presentation of Low-Grade B-Cell Non-Hodgkin's Lymphoma: A Case Report.

Low-grade B cell non-Hodgkin's lymphoma with dominant presentation of chest wall mass is presented in this report. The patient, a 65-year-old woman, presented with pain, rising skin temperature and redness, and swelling on the right lower chest wall. The histopathological examination revealed non-Hodgkin's lymphoma; the staging fluorodeoxyglucose-positron emission tomography/computed tomography demonstrated stage IVE disease, with hypermetabolic active disease in the right anterolateral chest wall in the form of large soft tissue mass and subcutaneous tissue with underlying bony erosion with extension into right anterior cardiophrenic space and superiorly up to right second costosternal region along the right internal mammary vessels. This was along with hypermetabolic active right axillary, right supraclavicular and left inguinal lymphadenopathy, and thickened hypermetabolic posterior right pleura with ametabolic right-sided pleural effusion. Bone marrow biopsy revealed uninvolved bone marrow. On follow-up after eight cycles of R-CHOP chemotherapy, the mass had completely resolved on contrast-enhanced computed tomography.

Water, Sanitation, and Hygiene and Nutritional Risk Factors for Acute Respiratory Illness in the Democratic Republic of the Congo: REDUCE Prospective Cohort Study.

The objective of this cohort study was to examine the prevalence of acute respiratory illness among children under 5 years of age and to identify water, sanitation, and hygiene (WASH) and nutritional risk factors. This prospective cohort study was conducted in Walungu Territory, South Kivu, and Democratic Republic of the Congo (DRC), and enrolled 512 participants. Spot checks of the household environment were conducted at baseline. Baseline minimum dietary diversity (MDD) was defined by consumption of five or more of the following food groups: 1) breast milk; 2) grains, roots, and tubers; 3) legumes and nuts; 4) dairy products; 5) flesh foods; 6) eggs; 7) vitamin A rich fruits and vegetables; and 8) other fruits and vegetables. Acute respiratory illness was defined as caregiver reported rapid breathing, difficulty breathing, lower chest wall in drawing, or coughing in the previous 2 weeks obtained at a 6-month follow-up based on the use of this definition in previous studies in Bangladesh and Kenya. A total of 58% of children had acute respiratory illness, 19% had soap present in the cooking area, and 4% in the defecation area, and 21% of children met MDD. A decreased odds of acute respiratory illness was associated with soap being present in the cooking area (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.38-0.88) and MDD (OR: 0.62, 95% CI: 0.38-1.00). These findings highlight the need for interventions targeting hygiene and improved dietary diversity among rural DRC households to reduce the rate of respiratory illnesses in children under 5 years.

Young Woman with Left Chest Pain

A 15-year-old adolescent girl fell under a decelerating train at a suburban railway station, which resulted in head and left-sided truncal injuries. The primary survey revealed that she was alert with repetitively questioning. She had a systolic blood pressure of 95 mm Hg, a pulse rate of 105 beats/min, and an oxygen saturation level of 96% on ambient air. She had a large contusion to the left flank and lower chest wall.

Laparoscopic repair of transdiaphragmatic intercostal hernia following blunt trauma

Background Transdiaphragmatic intercostal hernia (TIH) is a rare clinical entity that generally occurs following trauma or surgical intervention, but it may occur spontaneously Case Report An 82-year-old Korean man presented with left-sided chest pain after falling off an agricultural vehicle. Physical examination revealed a bruised painful swelling in the left lower chest wall confirmed as hernia of the transverse colon and omentum through a defect in the diaphragm into the 7th intercostal space. Laparoscopic repair with a prosthetic mesh was successful with no sign of hernia recurrence 3 years after injury. Discussion TIH is uncommon. Depending on the associated injuries they may be repaired via the chest or abdomen and with the widespread advent of minimally invasive surgery this can be achieved laparoscopically or thoracoscopically. Small defects can be closed directly, but larger defects will require mesh coverage. Care should be taken to avoid using fixation tacks close to the central tendon and are best suited to peripheral defect repairs.

Case 289

History An 8-year-old girl presented to our hospital with painful swelling of the left thigh and soft-tissue swelling in the right chest wall. The patient's history revealed that the swelling had been present since birth but had grown slowly. She had no history of relevant trauma. Her blood pressure was 145/95 mmHg (normal value, <115/76 mmHg), and her heart rate was 105 beats per minute (normal value, 75-118 beats per minute). The patient's electrocardiogram displayed sinus tachycardia. Physical examination revealed soft-tissue hypertrophy in the left thigh and right lower chest wall. A painful soft and flexible mass measuring approximately 5 × 6 × 15 cm (in the anteroposterior, transverse, and craniocaudal directions, respectively) was detected at the left thigh. Moreover, a painless soft mass measuring approximately 3 × 8 × 10 cm (in the anteroposterior, transverse, and craniocaudal directions, respectively) was detected in the right lower chest wall, and the overlying skin was intact. Pink macules with a 3-cm diameter on the anterior left superior thigh and a 2.5-cm diameter in the left inguinal region were detected. Examination of other systems, including the cardiovascular system, revealed normal findings. Laboratory test results were within normal limits. Abdominal US showed perirenal vascular collaterals, and musculoskeletal US of the left thigh revealed vascular collaterals (images not shown). Therefore, thoracoabdominal CT angiography (Fig 1a-1c) and contrast material-enhanced MRI of the bilateral thigh (Fig 2a-2c) were performed.

Abdominal Pain- Non-athlete

HISTORY: A 48-year-old former pizza shop worker presents with >2 years of intermittent abdominal pain with extensive GI work up. Patient reports that pain is worse with bowel movements, tying shoes, bending over, and reaching with arms. Significant history of alcohol and cigarette use. He feels as if he is bruised or experienced a “Charlie horse” after these ~1 minute episodes occur. PHYSICAL EXAMINATION: Tenderness of right lower chest wall and right upper quadrant without guarding or rebound. Negative McBurney’s point and Murphy’s sign. Intermittent abdominal distention over the course of disease. Patient brought video showing abnormal chest wall movement to more recent appointment. DIFFERENTIAL DIAGNOSIS: 1. Slipping Rib Syndrome 2. GERD 3. Intercostal/Oblique muscle spasm TEST AND RESULTS: CT abdomen pelvis 9/30/19 No bowel obstruction or acute renal pathology. Mild fluid and air to distention of small-bowel loops without obstruction. The stomach is underdistended. Gastric wall thickening cannot be excluded. US Abdomen 1/24/17 Normal right upper quadrant ultrasound. EGD 7/2019 - Esophageal mucosal changes suspicious for short-segment Barrett's esophagus. Biopsied. - Normal antrum. Biopsied. - Granular gastric mucosa. Biopsied. - Normal duodenum. FINAL WORKING DIAGNOSIS: Slipping rib syndrome of right side TREATMENT AND OUTCOMES: Patient still seeing GI for possible GERD related causes. Awaiting follow up for referral to OMT clinic for manipulation. Diclofenac gel prescription for pain relief. If OMT and analgesic treatment unsuccessful, referral for surgical resection or intercostal nerve block

Noninvasive Assessment of Inspiratory Muscle Neuromechanical Coupling During Inspiratory Threshold Loading

Diaphragm neuromechanical coupling (NMC), which reflects the efficiency of conversion of neural activation to transdiaphragmatic pressure (Pdi), is increasingly recognized to be a useful clinical index of diaphragm function and respiratory mechanics in neuromuscular weakness and cardiorespiratory disease. However, the current gold standard assessment of diaphragm NMC requires invasive measurements of Pdi and crural diaphragm electromyography (oesEMGdi), which complicates the measurement of diaphragm NMC in clinical practice. This is the first study to compare invasive measurements of diaphragm NMC (iNMC) using the relationship between Pdi and oesEMGdi, with noninvasive assessment of NMC (nNMC) using surface mechanomyography (sMMGlic) and electromyography (sEMGlic) of lower chest wall inspiratory muscles. Both invasive and noninvasive measurements were recorded in twelve healthy adult subjects during an inspiratory threshold loading protocol. A linear relationship between noninvasive sMMGlic and sEMGlic measurements was found, resulting in little change in nNMC with increasing inspiratory load. By contrast, a curvilinear relationship between invasive Pdi and oesEMGdi measurements was observed, such that there was a progressive increase in iNMC with increasing inspiratory threshold load. Progressive recruitment of lower ribcage muscles, serving to enhance the mechanical advantage of the diaphragm, may explain the more linear relationship between sMMGlic and sEMGlic (both representing lower intercostal plus costal diaphragm activity) than between Pdi and crural oesEMGdi. Noninvasive indices of NMC derived from sEMGlic and sMMGlic may prove to be useful indices of lower chest wall inspiratory muscle NMC, particularly in settings that do not have access to invasive measures of diaphragm function.

Ectopia cordis: a case report and review of literature

The Ectopia cordis is a rare congenital condition. It is characterized by the abnormal position of the heart outside the thoracic cavity, associated with defects in the parietal pericardium, diaphragm, sternum, and, in most cases, cardiac malformations. The reported prevalence is 5.5 to 7.9 per million live births. The designation Ectopia cordis was first proposed by Abott in 1998, although cases of patients with similar defects had been reported in past. Only 267 cases have been reported as of 2001, most (95%) associated with other cardiac abnormalities. A 10 hour old, normal, vaginally delivered, full-term male neonate, weighing 2020 grams was brought with an externally visible, beating heart over the lower chest wall. The antenatal period was uneventful, though no ultrasonography was done. The beating heart was covered with a membrane with greenish purulent matter over it, most probably, due to pseudomonas/proteus infection. Rest of the anterior abdominal wall was intact. Ectopia cordis is produced by segmental defects in mesodermal development in the third week of intrauterine life, and/or amniotic band syndrome that causes simultaneous cerebral and Thoraco-abdominal malformations. The existence of Ectopia cordis with severe congenital heart disease may be confirmed in the prenatal period by vaginal echocardiography at 10-12 weeks of gestation or by abdominal echocardiography by 20-22 weeks. Surgery is the only hope of survival, for such patients, although the overall success rate is very poor. In recent years, surgery has been attempted in one or two phases with variable results that depend, mainly on the type of associated heart disease.

Efficacy of feedback respiratory training on respiratory muscle strength and quality of life in children with spastic cerebral palsy: Randomized controlled trial

Background/aim Respiratory muscle weakness and a low upper to lower chest diameter ratio are common respiratory dysfunction manifestations in children with cerebral palsy (CP), which negatively affect their quality of life. This study was conducted to investigate the effect of incentive spirometry (IS) training on these manifestations in those children. Materials and methods Totally, 30 children with spastic diplegic CP, aged between 6 and 12 years, were randomly assigned into two groups: the study group and the control group. Both groups received a traditional physical therapy program for 60 min. The study group received also IS training twice per session (15 min each). Children in both groups received 20 training sessions (five times/week for 4 weeks). Outcomes Respiratory muscle strength, ratio of upper to lower chest wall, gross motor function, and health-related quality of life were assessed before and after training. Results After training, significant improvements of maximal inspiratory pressure, maximal expiratory pressure, and ratio of upper to lower chest wall were obtained in the study group (P=0.002, 0.002, 0.005, respectively), whereas nonsignificant changes were obtained in the control group (P=0.719, 1, 0.284, respectively). In addition, a significant difference was observed between both groups in maximal inspiratory pressure, maximal expiratory pressure, but in favor of study group (P=0.001, 0.001, respectively), whereas there was a nonsignificant difference in the ratio of upper to lower chest wall, gross motor function, and health-related quality of life (P=0.279, 0.527, 0.876, respectively). Conclusion Feedback respiratory training improves respiratory muscle strength in spastic CP children.

Acute viral bronchiolitis in South Africa: Diagnostic flow

Bronchiolitis may be diagnosed on the basis of clinical signs and symptoms. In a young child, the diagnosis can be made on the clinical pattern of wheezing and hyperinflation. Clinical symptoms and signs typically start with an upper respiratory prodrome, including rhinorrhoea, low-grade fever, cough and poor feeding, followed 1 - 2 days later by tachypnoea, hyperinflation and wheeze as a consequence of airway inflammation and air trapping.The illness is generally self limiting, but may become more severe and include signs such as grunting, nasal flaring, subcostal chest wall retractions and hypoxaemia. The most reliable clinical feature of bronchiolitis is hyperinflation of the chest, evident by loss of cardiacdullness on percussion, an upper border of the liver pushed down to below the 6th intercostal space, and the presence of a Hoover sign(subcostal recession, which occurs when a flattened diaphragm pulls laterally against the lower chest wall).Measurement of peripheral arterial oxygen saturation is useful to indicate the need for supplemental oxygen. A saturation of <92% at sea level and 90% inland indicates that the child has to be admitted to hospital for supplemental oxygen. Chest radiographs are generally unhelpful and not required in children with a clear clinical diagnosis of bronchiolitis.Blood tests are not needed routinely. Complete blood count tests have not been shown to be useful in diagnosing bronchiolitis or guiding its therapy. Routine measurement of C-reactive protein does not aid in management and nasopharyngeal aspirates are not usually done.Viral testing adds little to routine management. Risk factors in patients with severe bronchiolitis that require hospitalisation and may even cause death, include prematurity, congenital heart disease and congenital lung malformations.

Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumor

Chest wall reconstruction (CWR) is desirable, especially after the excision of huge chest wall tumor, and using mechanical prostheses for the closure of defects is fraught with some complications. We present a case of a 45-year-old man with a 6-week history of recurrent left-sided lower chest wall mass. Chest examination showed a linear surgical scar 8 cm lower and lateral to the left nipple with an underlying huge mass, whose histology from the previous excisional biopsy revealed dermatofibrosarcoma protuberance. He had the excision of the chest wall tumor and subsequently the superior advancement of the diaphragm and using rectus muscle for the CWR. This method was effective in closing the defect without the known complications.

Evaluating proton stereotactic body radiotherapy to reduce chest wall dose in the treatment of lung cancer

Stereotactic body radiotherapy (SBRT) can produce excellent local control of several types of solid tumor; however, toxicity to nearby critical structures is a concern. We found previously that in SBRT for lung cancer, the chest wall (CW) volume receiving 20, 30, or 40Gy (V20, V30, or V40) was linked with the development of neuropathy. Here we sought to determine whether the dosimetric advantages of protons could produce lower CW doses than traditional photon-based SBRT. We searched an institutional database to identify patients treated with photon SBRT for lung cancer with tumors within < 2.5cm of the CW. We found 260 cases; of these, chronic grade ≥ 2 CW pain was identified in 23 patients. We then selected 10 representative patients from this group and generated proton SBRT treatment plans, using the identical dose of 50Gy in 4 fractions, and assessed potential differences in CW dose between the 2 plans. The proton SBRT plans reduced the CW doses at all dose levels measured. The median CW V20 was 364.0cm3 and 160.0cm3 (p < 0.0001), V30 was 144.6cm3vs 77.0cm3 (p = 0.0012), V35 was 93.9cm3vs 57.9cm3 (p = 0.005), V40 was 66.5cm3vs 45.4cm3 (p = 0.0112), and mean lung dose was 5.9Gy vs 3.8Gy (p = 0.0001) for photons and protons, respectively. Coverage of the planning target volume (PTV) was comparable between the 2 sets of plans (96.4% for photons and 97% for protons). From a dosimetric standpoint, proton SBRT can achieve the same coverage of the PTV while significantly reducing the dose to the CW and lung relative to photon SBRT and therefore may be beneficial for the treatment of lesions closer to critical structures.

Weight, inflammation, cancer-related symptoms and health-related quality of life among breast cancer survivors

Maintaining weight is important for better prognosis of breast cancer survivors. The associations between weight and cancer-related symptoms are not known. We examined associations among weight, weight change, inflammation, cancer-related symptoms, and health-related quality of life (HRQOL) in a cohort of stage 0-IIIA breast cancer survivors. Participants were recruited on average 6 months (2–12 months) after diagnosis. Height, weight, and C-reactive protein (CRP) were assessed at approximately 30 months post-diagnosis; cancer-related symptoms (chest wall and arm symptoms, vasomotor symptoms, urinary incontinence, vaginal symptoms, cognition/mood problems, sleep, sexual interest/function), and HRQOL (SF-36) were assessed at approximately 40 months post-diagnosis. Weight was measured at baseline in a subset. Data on 661 participants were evaluable for body mass index (BMI); 483 were evaluable for weight change. We assessed associations between BMI (<25.0, 25.0–29.9, ≥30.0 kg/m2), post-diagnosis weight change (lost ≥5 %, weight change <5 %, gained ≥5 %), and CRP (tertile) with cancer-related symptoms and HRQOL using analysis of covariance. Higher symptoms scores indicate more frequent or severe symptoms. Higher HRQOL scores indicate better HRQOL. Compared with those with BMI <25 kg/m2, women with BMI ≥30 kg/m2 had the following scores: increased for arm symptoms (+25.0 %), urinary incontinence (+40.0 %), tendency to nap (+18.9 %), and poorer physical functioning (−15.6 %, all p < 0.05). Obese women had lower scores in trouble falling asleep (−9.9 %; p < 0.05). Compared with weight change <5 %, participants with ≥5 % weight gain had lower scores in physical functioning (−7.2 %), role-physical (−15.5 %) and vitality (−11.2 %), and those with weight loss ≥5 % had lower chest wall (−33.0 %) and arm symptom scores (−35.5 %, all p < 0.05). Increasing CRP tertile was associated with worse scores for chest wall symptoms, urinary incontinence, physical functioning, role-physical, vitality and physical component summary scores (all P trend < 0.05). Future studies should examine whether interventions to maintain a healthy weight and reduce inflammation could alleviate cancer-related symptoms and improve HRQOL.

Cutaneous Fistula Due to Pulmonary Actinomycosis in a Mapuche Girl

Actinomycosis is a chronic granulomatous disease caused by Gram-positive anaerobic bacteria of the genus Actinomyces. Pulmonary actinomycosis is a rare infection in children, and its extension into the chest wall is infrequently reported. We report a case of pulmonary actinomycosis in a 14-year-old girl of Mapuche descent who presented with chronic respiratory symptoms and multiple discharging skin sinuses on her right lower chest wall. The diagnosis was made by skin biopsy, which showed sulfur granules with actinomyces colonies. She was successfully treated with intravenous ceftriaxone and penicillin G for 6 weeks, followed by oral amoxicillin for 6 months.

History of Vitamin A Supplementation Reduces Severity of Diarrhea in Young Children Admitted to Hospital with Diarrhea and Pneumonia

Background: Although the role of vitamin A in childhood pneumonia in association with diarrhea is not fully proven, we did not find any published data demonstrating the impact of lack of vitamin A supplementation in under-five children who present with the co-morbidities of pneumonia and diarrhea. This study examined whether previous vitamin A supplementation was associated with reduced severity and duration of diarrhea and pneumonia for children presenting with both illnesses. Methods: All admitted children (n = 189) aged 0 - 59 months to the Special Care Ward of the Dhaka Hospital of icddr,b with diarrhea and radiological pneumonia from September-December 2007 were enrolled. We compared clinical features of the children who received (n = 96) and did not receive (n = 93) high potency capsule vitamin A supplementation during previous immunization according to EPI schedule. Results: In logistic regression analysis, after adjusting for potential confounders such as respiratory rate, lower chest wall in-drawing, severe wasting and systolic blood pressure, vitamin A non-supplemented children with pneumonia and diarrhea more often presented in their early infancy (95% CI 1.01 - 1.09), had duration of diarrhea for >4 days (95% CI 1.79 - 11.88), had clinical dehydration (95% CI 1.2 - 5.63), and more often required hospitalization for >7 days (95% CI 1.03 - 8.87). But, there was no significant difference in the clinical features of pneumonia, such as history of cough, respiratory rate, lower chest wall in-drawing, nasal flaring, head nodding, grunting respiration, cyanosis, and inability to drink between the groups. Conclusion: Lack of vitamin A supplementation in under-five children with radiological pneumonia and diarrhea is independently associated with young infancy, duration of diarrhea for >4 days, dehydration and hospitalization for >7 days which underscores the importance of routine supplementation of vitamin A in young infancy. However, lack of vitamin A supplementation did not influence any clinical signs of pneumonia.

Definitive treatment of supernumerary lower chest wall primary breast cancer

Ectopic breast tissue is estimated to occur in 1% of the population.1 These include accessory mammary glands (polymastia), supernumerary nipples (hyperthelia) along “milk lines” from the axilla to the groin. Embryologic mammary ridges regress during development, excluding the 2 pectoral areas, later forming the breasts. Failure of regression may yield supernumerary breast tissue.2 Some cases have been associated with congenital urologic anomalies3 and familial inheritance.4 Though difficult to accurately characterize, between 0.28% and 0.6% of breast cancers have been reported to occur in ectopic breast tissue away from the milk line,1,5 or “mammae erraticae.” Reported sites include the axillae,6-8 vulva,9 sub-inframammary fold,10 thigh in a male,11 perineum12, buttock, and face.13 Few publications discuss treatment implications. We report our approach to staging, diagnosis, and treatment and review of the literature for accessory breast cancer.

Gastric Duplication: A Rare Cause of Massive Lower Gastrointestinal Haemorrhage, Chest Wall Mass, and Enterocutaneous Fistula

Gastric duplications are uncommon developmental abnormality reported to present with different clinical scenarios. We present a 2-1/2-year-old Nigerian female who started having intermittent massive lower gastrointestinal haemorrhage at 5 months of age. She subsequently developed a lower chest wall mass and enterocutaneous fistula. She was found to have gastric duplication with fistulous communication with the descending colon, spleen, and lower chest wall. To the best of our knowledge, this is the first paper on gastric duplication resulting in intermittent massive lower gastrointestinal bleeding mainly from splenic capsular erosion and fistula and enterocutaneous fistula resulting from erosion of anterior abdominal wall. Gastric duplication is hence an important rare cause of intermittent massive lower gastrointestinal haemorrhage and spontaneous enterocutaneous fistula in the paediatric population.