Midline raphé, sternal cleft, and other midline abnormalities: a new dominant syndrome?

Radiological findings of partial expression pentalogy of Cantrell and other multiple congenital anomalies: A rare case report

Pentalogy of Cantrell is a rare syndrome of anomalous malformation. In the present case, the syndrome was initially diagnosed as a complete pentad, including a supra-umbilical abdominal wall defect, a sternal defect, pericardial defects, an anterior diaphragmatic defect, and heart malformation. Diagnosis required several imaging modalities, including computed tomography (CT) and magnetic resonance imaging (MRI). In this case report, we present an 8-month-old female patient with a thoracic wall defect with ectopia cordis and a bilateral cleft lip and palate. In addition, a head CT scan showed craniosynostosis, hypogenesis of the corpus callosum, and tonsillar cerebellar herniation. Thoracoabdominal CT revealed herniation of the transverse colon up to the subcutaneous layer, diaphragmatic hernia, atrial septal defects (ASD), ventral septal defects (VSD), and a persistent left superior vena cava (PLSVC). A multidisciplinary approach is required for the optimal management of this syndrome. We describe a female infant who presented with pentalogy of Cantrell syndrome and include the findings from postnatal CT imaging.

Pentalogy of Cantrell Associated with Ectopia Cordis: A Case Report

Pentalogy of Cantrell is a congenital anomaly of the median mesodermal constructions with a poor prognosis. It is characterized by defects of the anterior diaphragm, the lower sternum, the abdominal wall, pericardium, and various congenital heart malformations. We present a case of ectopia cordis and Pentalogy of Cantrell in a newborn of a healthy 35-year-old woman with no history of embryotoxic exposure or smoking. The infant was first diagnosed with the anomaly in the second trimester of pregnancy and was delivered at 35 weeks of gestational age via a caesarian section. Shortly after birth, he was transferred to the neonatal intensive care unit (NICU) due to progressive respiratory failure, which ultimately, along with septicemia, led to infant death on the second day. In conclusion, the Pentalogy of Cantrell should be appropriately assessed for effective prenatal counseling and postnatal management with a multidisciplinary team; since infant survival assessment and early diagnosis give the parents the option of terminating the pregnancy.

Primary closure of superior partial sternal cleft in a 2-month-old girl: case report

BACKGROUND

Sternal cleft is a quite rare malformation. It is seen 1 out of 100,000 live births and makes up less than 1% of all chest wall deformities, seen more often among females. The deformity can be partial or complete. Partial deformities can be superior or inferior. It is generally diagnosed at birth when paradoxical respiratory movements are seen. Patients are often asymptomatic when they are born and generally other abnormalities accompany. As sternal clefts can be repaired primarily at early ages, they are repaired using autologous or synthetic grafts in the following years. We present a 2-month-old girl with superior partial sternal cleft repaired primary and accompanying hemangiomas in this case report.

CASE PRESENTATION

A girl who was born in another center and had a sternal cleft, who did not have any problems in the early period, was admitted to our hospital with respiratory distress at the age of 43 days. The patient was monitored with mechanical ventilator support, and there were hemangiomas around his left ear and lips. There were paradoxical respiratory movements in front of the heart, in the upper midline of the chest. Three-dimensional computed tomography showed that the upper part of the sternum did not develop, and there were hypoplasic sternal bars on both sides. It was evaluated as superior partial sternal cleft, and surgery was planned. In the operation, the sternal bars were released from the pericardium and pleura. The periosteum in the medial of both sternal bars was then released and connected in the midline, in front of the pericardium.

CONCLUSION

Although neonates with a sternal cleft are asymptomatic at birth, respiratory symptoms may develop in later periods. In addition, because the structures are more flexible in the neonatal period, the primary repair of the cleft is easier and the risk of cardiac compression is lower. In our case, sternal bars could be approached primary, and no chondral grafts, patches, or steel wires were required.

Successful surgical repair of a sternum cleft using composite mesh: A case report and new technical note

Sternal clefts are infrequent congenital malformations, particularly in their complete presentation. There are less than 100 descriptions of these defects published in the literature worldwide. We report a clinical case of lower sternal cleft associated with congenital laparoschisis in a 2-year-old boy. Surgery was performed because of recurrent pneumopathy and the risk of cardiorespiratory decompensation in the midterm. A semi-resorbable prosthesis was used for sternal closure. We have not observed any complications with this sternal closure system in our patient. This approach is easy, safe, effective and not harmful to a child's growth.

Primary Closure of a Partial Superior Sternal Cleft in a 27-day-old Neonate: Case Report with Short Review of Literature

A sternal cleft is a chest wall malformation resulting from a failure of sternal fusion. It is a rare anomaly with an incidence of 2:100,000 live births representing less than a percent of all chest wall deformities. The aim of surgery is to provide bony protection over the mediastinal structures. We present a 27-day-old neonate with an upper partial sternal cleft for whom successful primary sternal closure was performed.

Reconstruction of Congenital Sternal Clefts: Surgical Experience and Literature Review

Background:

Sternal cleft is a rare anomaly with a reported incidence of 1:100,000 cases per live births. Surgical intervention represents a crucial factor altering the overall patient prognosis, since they are at high risk of impaired oxygenation, as well as multiple chest infections. Herein, we are reporting our experience of surgical management of such rare cases, alerting plastic surgeons to their possibly crucial role in the reconstructive team.

Methods:

A retrospective chart review of 2 cases presenting with chest wall defects. All perioperative data were collected and presented.

Results:

Two patients with sternal clefts of variable degrees were managed. The first was an 18-month-old boy with partial inferior sternal cleft, who was otherwise asymptomatic. The patient underwent reconstruction at the same age using autologous rib graft and pectoralis major flaps due to ectopia cordis that was putting the patient at higher risk for cardiac trauma. The second patient was a 3-month-old girl having a V-shaped partial superior cleft with lung herniation. Surgical reconstruction was applied due to difficulty in weaning the patient off of ventilator support. Initially, reconstruction was applied with SurgiMend dermal matrix, but this was complicated by chest retraction and high oxygen requirement. Definitive reconstruction was later applied with allogeneic bone graft and pectoralis major flaps.

Conclusions:

Meticulous patient assessment and screening for associated anomalies are crucial. Surgical intervention is warranted at an early age. The use of acellular dermal matrix products in the reconstruction is of interest, but should be approached with caution.

Surgical Repair of a Superior Sternal Cleft in an Infant

Sternal cleft is a rare congenital malformation with little more than 100 cases published worldwide. Incomplete sternal clefting in a female newborn is the most frequent form seen. First-line treatment is the surgical defect closure in the neonatal period. Presurgical examination has to focus on common associated malformations, in particular cardiac defects. The surgical repair of sternal cleft itself shows satisfying functional and cosmetic results with low complication rates. We present the case of a 4-month-old male infant with a superior sternal cleft.

Pentalogy of Cantrell: first case reported in Saudi Arabia

Pentalogy of Cantrell (PC) is a rare congenital anomaly involving defects in the anterior diaphragm, supraumbilical abdominal wall, diaphragmatic pericardium, and lower sternum, and other congenital intracardiac abnormalities. Here, we report the case of a newborn infant who was born at 32 weeks of gestation and had all 5 features of PC, in addition to absent kidneys and a deformed left hand. Medical intervention would not be able to save the patient, so we allowed her to die in peace. We discuss here the etiology, prenatal diagnosis, and severity of and the mortality associated with this condition. To our knowledge, this was the first reported case of PC in Saudi Arabia.

Pentalogy of cantrell with complete ectopia cordis in a fetus with asplenia

Cantrell's pentalogy (CP) is a rare, mainly sporadic spectrum of congenital midline thoracoabdominal defects that includes sternal anomalies, ventral diaphragmatic hernia, partial absence of the pericardium, supraumbilical abdominal wall defects, and congenital heart malformations. The approximate incidence is 1 in 100 000, with a 2∶1 male predominance. A 25-year-old pregnant woman was referred to the Prenatal Diagnosis Unit of the University Hospital of Padua for multiple congenital malformations at 21 weeks of gestation. A level 2 ultrasound scan was performed and confirmed the presence of multiple anomalies compatible with the diagnosis of CP associated with complete ectopia cordis. Fetal autopsy furthermore revealed asplenia, which usually presents as part of the heterotaxia spectrum. To our knowledge, an association of CP and complete ectopia cordis with asplenia has never been reported so far.

Phenotypic spectrum and management of sternal cleft: literature review and presentation of a new series

Sternal cleft is a chest wall malformation that can expose mediastinal viscera and vessels to injuries. It can be classified into two forms, complete and partial. Its etiology and incidence are unknown and it is often associated with other defects. The aim of this article is to review the literature and report our experience with this rare anomaly, focusing on clinical presentation and management. We reviewed the English written literature about sternal cleft and collected the clinical data of all the published series. We present seven new cases that we have observed and treated since 1999. Literature reports 51 series including 86 patients, more frequently female (62%) and affected with partial superior form (67%). Sternal cleft is often asymptomatic (74%) and associated with other defects (72%). Surgical treatments include primary closure (73%), bone graft interposition (10%), prosthetic closure (7%), and muscle flap interposition (3%). In our series, primary closure was possible in four cases, while in three cases we placed a prosthesis. Five patients had associated defects and two were affected with PHACES (posterior fossa abnormalities, hemangiomas, arterial lesions, cardiac abnormalities/aortic coarctation, abnormalities of the eye, and sternum defects) syndrome. We report for the first time the association of sternal cleft with connectival nevi in three of our patients. At follow-up, we observed no major complication or recurrences. Although primary closure is the preferred option and should be performed in the neonatal period, the use of prostheses warrants good results as well. Prior to treatment, associated defects and syndromes should be excluded.

Co-occurrence of severe Goltz-Gorlin syndrome and pentalogy of Cantrell - Case report and review of the literature

Goltz-Gorlin syndrome is a highly variable disorder affecting many body parts of meso-ectodermal origin. Mutations in X-linked PORCN have been identified in almost all patients with a classical Goltz-Gorlin phenotype. The pentalogy of Cantrell is an infrequently described congenital disorder characterized by the combination of five anomalies: a midline supra-umbilical abdominal wall defect; absent or cleft lower part of the sternum; deficiency of the diaphragmatic pericardium; deficiency of the anterior diaphragm; and congenital heart anomalies. Etiology and pathogenesis are unknown. We report on an infant with findings fitting both Goltz-Gorlin syndrome (sparse hair; anophthalmia; clefting; bifid nose; irregular vermillion of both lips; asymmetrical limb malformations; caudal appendage; linear aplastic skin defects; unilateral hearing loss) and the pentalogy of Cantrell (absent lower sternum; anterior diaphragmatic hernia; ectopia cordis; omphalocele). The clinical diagnosis Goltz-Gorlin syndrome was confirmed molecularly by a point mutation in PORCN (c.727C>T). The presence of molecularly confirmed Goltz-Gorlin syndrome and pentalogy of Cantrell in a single patient has been reported twice before. The present patient confirms that the pentalogy of Cantrell can be caused in some patients by a PORCN mutation. It remains at present uncertain whether this can be explained by the type or localization of the mutation within PORCN, or whether the co-occurrence of the two entities is additionally determined by mutations or polymorphisms in other genes, environmental factors, and/or epigenetic influences.

Embryology, sternal clefts, ectopia cordis, and Cantrell's pentalogy

Sternal clefts, ectopia cordis, and Cantrell's pentalogy continue to be very rare congenital anomalies in pediatric surgery. Unfortunately, these conditions present as neonatal emergencies and demand early surgical intervention. This article reviews the embryological development of the chest wall, specific sternal defect anomalies, along with available methods of treatment.

Thoracic skeletal defects and cardiac malformations: a common epigenetic link?

Congenital heart defects (CHDs) are the most common birth defects in humans. In addition, cardiac malformations represent the most frequently identified anomaly in teratogenicity experiments with laboratory animals. To explore the mechanisms of these drug-induced defects, we developed a model in which pregnant rats are treated with dimethadione, resulting in a high incidence of heart malformations. Interestingly, these heart defects were accompanied by thoracic skeletal malformations (cleft sternum, fused ribs, extra or missing ribs, and/or wavy ribs), which are characteristic of anterior-posterior (A/P) homeotic transformations and/or disruptions at one or more stages in somite development. A review of other teratogenicity studies suggests that the co-occurrence of these two disparate malformations is not unique to dimethadione, rather it may be a more general phenomenon caused by various structurally unrelated agents. The coexistence of cardiac and thoracic skeletal malformations has also presented clinically, suggesting a mechanistic link between cardiogenesis and skeletal development. Evidence from genetically modified mice reveals that several genes are common to heart development and to formation of the axial skeleton. Some of these genes are important in regulating chromatin architecture, while others are tightly controlled by chromatin-modifying proteins. This review focuses on the role of these epigenetic factors in development of the heart and axial skeleton, and examines the hypothesis that posttranslational modifications of core histones may be altered by some developmental toxicants.