Treatment of left sided breast cancer for a patient with funnel chest: volumetric-modulated arc therapy vs. 3D-CRT and intensity-modulated radiotherapy

This case study presents a rare case of left-sided breast cancer in a patient with funnel chest, which is a technical challenge for radiation therapy planning. To identify the best treatment technique for this case, 3 techniques were compared: conventional tangential fields (3D conformal radiotherapy [3D-CRT]), intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT). The plans were created for a SynergyS® (Elekta, Ltd, Crawley, UK) linear accelerator with a BeamModulator™ head and 6-MV photons. The planning system was Oncentra Masterplan® v3.3 SP1 (Nucletron BV, Veenendal, Netherlands). Calculations were performed with collapsed cone algorithm. Dose prescription was 50.4 Gy to the average of the planning target volume (PTV). PTV coverage and homogeneity was comparable for all techniques. VMAT allowed reducing dose to the ipsilateral organs at risk (OAR) and the contralateral breast compared with IMRT and 3D-CRT: The volume of the left lung receiving 20 Gy was 19.3% for VMAT, 26.1% for IMRT, and 32.4% for 3D-CRT. In the heart, a D(15%) of 9.7 Gy could be achieved with VMAT compared with 14 Gy for IMRT and 46 Gy for 3D-CRT. In the contralateral breast, D(15%) was 6.4 Gy for VMAT, 8.8 Gy for IMRT, and 10.2 Gy for 3D-CRT. In the contralateral lung, however, the lowest dose was achieved with 3D-CRT with D(10%) of 1.7 Gy for 3D-CRT, and 6.7 Gy for both IMRT and VMAT. The lowest number of monitor units (MU) per 1.8-Gy fraction was required by 3D-CRT (192 MU) followed by VMAT (518 MU) and IMRT (727 MU). Treatment time was similar for 3D-CRT (3 min) and VMAT (4 min) but substantially increased for IMRT (13 min). VMAT is considered the best treatment option for the presented case of a patient with funnel chest. It allows reducing dose in most OAR without compromising target coverage, keeping delivery time well below 5 minutes.

[Lady Windermere syndrome]

We describe the case of a 68 year old lady with a pectus excavatum, chronic cough, dyspnoea, and fever. The CT scan showed fibronodular infiltrates and bronchectases. Bacterial culture revealed a Mycobacterium avium-intracellulare infection. A tritherapy was initiated and, 10 months later, the patient had greatly improved.

Chest wall kinematics in young subjects with Pectus excavatum

Quantifying chest wall kinematics and rib cage distortion during ventilatory effort in subjects with Pectus excavatum (PE) has yet to be defined. We studied 24 patients: 19 during maximal voluntary ventilation (MVV) and 5 during MVV and cycling exercise (CE). By optoelectronic plethysmography (OEP) we assessed operational volumes in upper rib cage, lower rib cage and abdomen. Ten age-matched healthy subjects served as controls. Patients exhibited mild restrictive lung defect. During MVV end-inspiratory and end-expiratory volumes of chest wall compartments increased progressively in controls, whereas most patients avoided dynamic hyperinflation by setting operational volumes at values lower than controls. Mild rib cage distortion was found in three patients at rest, but neither in patients nor in controls did MVV or CE consistently affect coordinated motion of the rib cage. Rib cage displacement was not correlated with a CT-scan severity index. Conclusions, mild rib cage distortion rarely occurs in PE patients with mild restrictive defect. OEP contributes to clinical evaluation of PE patients.

An unusual presentation of Kartagener's syndrome

Kartagener's syndrome is a rare disorder which is seen in nearly half of the cases of primary ciliary dyskinesia. We report an unusual case of Kartagener's syndrome where the patient had associated ventricular septal defect, pectus excavatum and was fertile.

The search for stability: bar displacement in three series of pectus excavatum patients treated with the Nuss technique

OBJECTIVES

To compare bar displacement and complication rates in three retrospective series of patients operated on by the same surgical team.

METHOD

A retrospective medical chart analysis of the three patient series was performed. In the first series, the original, unmodified Nuss technique was performed. In the second, we used the ''third point fixation'' technique,and in the last series, the correction was performed with modifications to the stabilizer and stabilizer position.

RESULTS

There were no deaths in any of the series. Minor complications occurred in six (4.9%) patients: pneumothorax with spontaneous resolution (2), suture site infection (2), and bar displacement without the reoperation need (2). Major complications were observed in eight (6.5%) patients: pleural effusion requiring drainage (1), foreign body reaction to the bar (1), pneumonia and shock septic (1), cardiac perforation (1), skin erosion/seroma (1), and displacement that necessitated a second operation to remove the bar within the 30 days of implantation (3). All major complications occurred in the first and second series.

CONCLUSION

The elimination of fixation wires, the use of shorter bars and redesigned stabilizers placed in a more medial position results in a better outcome for pectus excavatum patients treated with the Nuss technique. With bar displacement and instability no longer significant postoperative risks, the Nuss technique should be considered among the available options for the surgical correction of pectus excavatum in pediatric patients.

Pectus deformities: tomographic analysis and clinical correlation

OBJECTIVE

To assess, with computed tomography (CT) studies, features of anterior chest wall development that can be related to different types of pectus deformities.

MATERIALS AND METHODS

From 71 patients with pectus deformities and chest coronal CT scans, 48 (40 male and 8 female), with a mean age of 15.8 years (ranging from 5 years to 38.4 years) were selected and divided into five groups, according to clinical type of deformity and image quality. A similar CT study was performed in a sixth group of 14 individuals with no underlying pectus deformity (control group), six male and eight female, mean age 19.3 years, (range 10.8 years to 30.5 years), totaling 62 subjects. Tomographic studies were performed on a 64-section CT scanner, with parameters varied according to the subject's body mass index (BMI). Coronal reconstructions were used to assess six features of the sternum and costal cartilages in the groups. Two other factors, a sternal index, created to estimate the sternal body width, and the sternocostal angles, were also studied.

RESULTS

Feature I was noted in 13 patients and in no controls (P = 0.002), feature II in 39 patients and in one control (P = 0.000), feature III in 37 patients and in two controls (P = 0.002), and feature IV in two patients and in no controls (P = 0.002). The sternal index was significant to one group of patients.

CONCLUSION

The features studied and the index provide measurable and applicable data for the interpretation of anterior chest wall tomography, with possible implications for prognosis and treatment of different types of pectus deformities.

External splinting for treatment of pectus excavatum in a dog with right ventricular outflow obstruction

Right ventricular outflow tract obstruction was diagnosed by Doppler echocardiography in a young dog with a cardiac murmur, severe dyspnea, and a prominent sternal depression. Thoracic radiography confirmed a diagnosis of pectus excavatum involving the caudal third of the sternum. The right ventricular outflow obstruction was attributed to cardiac compression from the dorsally deviated sternum. External surgical splinting of the sternabrae, demonstrated by video in this report, was used to treat the pectus excavatum. Radiographic and Doppler echocardiographic examination 3 weeks and 4 months post-splinting documented resolution of both pectus excavatum and right ventricular outflow obstruction.

Automatic detection and characterization of funnel chest based on spiral CT

Funnel chest (Pectus excavatum) is the most common deformity of the anterior chest in children. Present paper describes a method to process and classify CT slices representing funnel chest deformities. A manually chosen CT slice was processed to detect the inner curvature of the chest for characterization. Normalized data from the detected inner curvature was gained and saved next to a manually-given deformity type for further classification rule determinations. Based on the multiple correlations of the values gained from the inner curvature, a hierarchical classification was performed on 199 patient data. Results have shown that the calculated values gained from the inner curvature can accurately characterize the deformity type of the chest. Since minimal user interaction was necessary to detect and characterize the inner curvature, our method is considered to be an effective automated procedure for funnel chest deformity classifications.

Development of new cardiac deformity indexes for pectus excavatum on computed tomography: feasibility for pre- and post-operative evaluation

PURPOSE

The aim of this study was to evaluate new cardiac deformity indexes (CDIs) for diagnosis of pectus excavatum as well as morphological assessment of heart on computed tomography (CT).

MATERIALS AND METHODS

We retrospectively evaluated the CT images of the control group (n=200), and the pectus excavatum before and after correction groups (n=178), and calculated the CDIs; cardiac compression index (CCI), and cardiac asymmetry index (CAI). We also calculated chest wall compression index (CWCI) and asymmetry index (CWAI) on the axial images. We performed logistic regression analysis using each index and age as predictor variables.

RESULTS

The CDIs (CCI and CAI) were significant (p < 0.05) in the diagnosis of pectus excavatum, regardless of age (p = 0.4033, p = 0.8113). The CWCI and CWAI were significant (p < 0.05) and significantly affected by age (p < 0.05). If we selected 1.82 as the cutoff of the CCI, the sensitivity and specificity were 99.4% and 98%, respectively. The following cutoffs and the sensitivity and specificity were obtained: 1.15 for the CAI gave 94.4% and 94.5%, 3.05 for the CWCI gave 92.1% and 92%, and 1 for the CWAI gave 62.4% and 65%, respectively. The CCI after repair improved from 2.83 +/- 0.84 to 1.84 +/- 0.33, while the CWCI improved from 4.49 +/- 1.61 to 2.57 +/- 0.44.

CONCLUSION

CDIs such as the CCI and CAI may be potentially useful to detect and estimate repair for pectus excavatum.

Radiological changes after Nuss operation for pectus excavatum

The objective of this study was to evaluate sternovertebral distance and the chest wall deformation after Nuss procedure.

MATERIALS AND METHODS

Anteroposterior and lateral chest radiographs were performed before Nuss procedure, 1, 6, and 12 months after operation and finally 1 month after bar removal. Sternovertebral distance and transversal chest dimension were measured on radiographs, as well as Haller and vertebral indexes were calculated.

RESULTS

A total of 84 children with funnel chest were operated on. Preoperative sternovertebral distance was 79.81+/-6.96 mm; 1 month after operation, 97.84+/-17.08 mm; 6 months, 110.55+/-13.85 mm; and 12 months, 113.6+/-14.61 mm. After removal of the bar, the distance was 105+/-11.95 mm. The mean increase in sternovertebral distance during the first month was 18 mm (P<0.0001); 1-6 months, 12.8 mm (P=0.0006); and 6-12 months, 3 mm (P=0.48). The mean decrease in sternovertebral distance after removal of the bar was 8.6 mm (P=0.47). The decrease in transversal chest dimension during the first month was significant (13.3+/-12.86 mm, P=0.012).

CONCLUSIONS

The sternovertebral distance was significantly increased after Nuss operation. Restoration of deformation proceeds during all the first year after operation. The dynamics of deformation is better depicted by means of vertebral index rather than Haller index.

Pectus excavatum in two littermate dogs

One male and 1 female, 8-week-old, schnauzer littermates were presented with moderate and mild pectus excavatum, respectively. External application of a coaptation splint to the ventral aspect of the thorax was used for correction of the sternal deformity in the male; conservative treatment was used in the female.

[Non-thoracoscopic Nuss procedure for correction operation of pectus excavatum ]

OBJECTIVE

To review the experience in correction operation of pectus excavatum with non-thoracoscopic Nuss procedure.

METHODS

From September 2005 to August 2007, 108 patients with pectus excavatum were surgically corrected by non-thoracoscopic Nuss procedure. There were 91 male patients and 17 female patients. The age was from 2 years and 10 months old to 25 years old with an average of 7 years and 9 months old. The Haller indexes were from 3.6 to 10.1 before the operation.

RESULTS

The operation in all patients had been performed successfully without any severe complications. The average time of operation was 40 minutes. The average bleeding volume during procedure was 10 ml. Uneventful recovery was achieved in all the cases. Excellent outcome was obtained in the follow-up of 2 months to 21 months in 92 patients.

CONCLUSIONS

Non-thoracoscopic Nuss procedure for correction of pectus excavatum is safe and effective. It is unnecessary to perform the procedure into thoracic cavity so that there is less trauma and shorter time for the operation.

Anthropometric index for Pectus excavatum

BACKGROUND

Pectus excavatum (PEX) is a depression of the sternum in relation to the costal cartilages. Clinical and objective measures for classifying the defect are rare and difficult to apply. The present study aimed to create an anthropometric index (AI) for PEX as a method for diagnosis and for preoperative and postoperative assessment by comparing it to the Haller index (HI) and to the lower vertebral index (LVI).

METHODS

From December 2001 to February 2004, 2 groups of patients were studied at our institution: a) 30 patients with normal configuration of the thoracic cage, upon physical examination; b) 20 patients with PEX. The latter underwent surgery according to the Ravitch technique modified by Robicsek, and they were evaluated in the postoperative period. All patients were assessed by means of the AI (clinical), HI (tomographic), and LVI (radiographic) measures at the level of deepest deformity in the case of the PEX patients, and in the distal third of the sternum in the normal patients. The patients who had undergone surgery were once again measured between the 60th and the 80th postoperative days.

RESULTS

There was a high correlation between the AI and the HI (80% P < .001) and between the AI and the LVI (79% P < .001). The accuracy of the 3 indices was similar, in that the following cut points were established: AI = 0.12, HI = 3.10, and LVI = 0.25. Upon analyzing the preoperative results, we verified that for the 3 indices, over 75% of the patients with pectus excavatum were above the cut points and were confirmed as having the defect. In the postoperative results, the value of the indices found below the cut point was considered within the normal standard, and this occurred in 100% for the AI, in over 50% for the HI, and in 50% for the LVI.

CONCLUSIONS

The AI allowed adequate measurement of the defect, maintaining a) a high correlation with the HI and the LVI and a high accuracy, similar to the already acknowledged and published indices and b) an efficient comparison between the preoperative measurement and the postoperative results.

Modified Ravitch Procedure: Using a Pectus Bar for Posttraumatic Pectus Excavatum

Guidelines for surgical management of posttraumatic pectus excavatum have not been established due to the variable clinical manifestations and limited number of cases. A 34-year-old man who was involved in a truck-mixer vehicle crash 6 months previously complained of a depressed anterior chest wall deformity. The patient had successfully undergone subperichondral resection, sternal osteotomy, and pectus bar insertion placed under the depressed sternum, followed by bar rotation for elevation of the chest wall. This case illustrates that a modified Ravitch procedure, using a pectus bar, may be an alternative for posttraumatic pectus excavatum.

Congenital chest wall deformities: a modified surgical technique

BACKGROUND

Congenital chest wall deformities are the most common disorders among the other congenital diseases in thoracic surgery. Standard surgical techniques seem to be sufficient, but to prevent recurrence and complications other surgical approaches have to be chosen, such as freeing the sternum from the second rib cartilage to the costal arch, completely and bilaterally, and external application of Kirschner wire for stabilization.

PATIENTS AND METHODS

Between 1996 and 2005, 47 patients with congenital chest wall deformities were examined. The surgical method consists of resecting rib cartilages from the second rib up to the costal arch bilaterally and the application of Kirschner wire for the stabilization of the chest wall.

RESULTS

No mortality occurred. Three patients had complications, such as wound infection and pneumothorax. Kirschner wire was removed on the 15th day (between 10-21 days). Mean hospital stay was 16.5 days (10-23 days). Patients were followed up between 2 months and 6 years. No recurrence was observed.

CONCLUSION

To prevent recurrence and complications for cosmetic surgery is quite important. For this reason, the surgical technique has to be carried out carefully. Kirschner wire is useful for the stabilization of the chest wall with no risk of infection, foreign body reaction, or the need for a second operation for removal.

Clinical impact of optical imaging with 3-D reconstruction of torso topography in common anterior chest wall anomalies

BACKGROUND

Standard modalities to assist in determining the extent of chest wall developmental deformities in patients include x-ray and computed tomography (CT). The purpose of this study is to describe an optical imaging technique that provides accurate cross-sectional images of the chest, and to compare these with standard CT-derived images of chest wall abnormalities.

PATIENTS AND METHODS

Ten patients (5 pectus excavatum and 5 pectus carinatum) underwent imaging that included limited CT and optical cross-sectional imaging. Severity indices of the deformity using the standard Haller index (HI) were calculated from CT scans. A similar severity measurement of deformity was derived from the outline of torso cross sections (ie, from skin to skin measurements) obtained from optical images. To assess the severity of carinatum defects, a modified pectus index was derived, which measures the anterior chest protrusion from the central chord of the chest cross section. We performed regression analyses, comparing the indices obtained from CT and optical imaging methodologies.

RESULTS

Optical measures of cross-sectional deformities correlated well with standard HI (r2 = 0.94) and even better with the modified pectus index (r2 = 0.96). Adaptation of the HI for pectus carinatum deformity evaluation was effective, and consistent with the torso surface deformity measures.

CONCLUSIONS

Torso models from optical imaging offer 3-D images of the chest wall deformity with no radiation exposure. This preliminary study showed promising results for the use of torso surface measurement as an alternative index of pectus deformities; if validated in larger studies, these measures may be useful for following chest wall abnormalities, using repeated studies in patients.

Radiological assessment of children with pectus excavatum

OBJECTIVE

To assess what degree of chest wall deformation changes statistically reliably after surgery, using pre- and postoperative radiological examination data.

METHODS

Radiological chest examinations were performed for 88 children before and after remedial operations. Pre- and postoperative chest radiograph and CT were performed to measure transversal chest width; sagittal left chest side depth, sagittal right chest side depth, sternovertebral distance and vertebral body length. Derivative indices were also estimated: Vertebral index (VI), Frontosagittal index (FI), Haller index (HI) and asymmetry index. Computerized assessment of data was used. For statistical analysis, the software "Statistica 6.0" was used.

RESULTS

Postoperatively VI increased approximately by 2.37+/-2.72, FI decreased by 4.60+/-4.34 and HI value increased approximately up by 0.45+/-0.49. Statistically significant deformation index difference before and after surgery was not detected when VI was below 26.2 (p=0.08), FI was above 32.9 (p=0.079) and HI was less than 3.12 (p=0.098).

CONCLUSION

Preoperative CT and X-ray assessment of chest wall deformation degree is important for pediatric patients. The following deformation indices are indications for surgical treatment: VI>26, FSI< 33 and HI>3.1.

Surgical approach for Stanford type A aortic dissection in a patient with Marfan syndrome and pectus excavatum

Acute Stanford type A aortic dissection in a patient with severe pectus excavatum constitutes a surgical emergency and presents a major challenge for the surgeon. Decisions must be made regarding the operative approach and whether the pectus excavatum should be corrected during the same session. Herein, we describe a case of acute aortic dissection in a patient who had Marfan syndrome with severe pectus excavatum. Combined partial upper sternotomy and left anterior thoracotomy provided excellent surgical exposure, and the aortic root and ascending aorta were completely replaced. The procedures were successful, and the patient recovered. Technical and surgical considerations led us to postpone concomitant correction of the pectus excavatum.