Vascular origin of Poland syndrome? A comparative rheographic study of the vascularisation of the arms in eight patients

A de novo SFMBT1 pathogenic variant identified in a boy with Poland syndrome

Poland syndrome is a rare developmental disorder characterized by unilateral, complete or partial, absence of the pectoralis major (and often minor) muscle, accompanied with ipsilateral hand malformations. To date, no clear genetic cause has been associated with Poland syndrome, although familial cases have been reported. We report the employment of trio exome investigation and the identification of a heterozygous de novo pathogenic variant in the SFMBT1 gene, a transcription factor associated with transcriptional repression during development, in a 14-yr-old boy with Poland syndrome. We further demonstrate by means of cDNA sequencing and western blot analysis that this variant results in SFMBT1 exon 10 skipping and a lower concentration of the SFMBT1 wild-type protein. To our knowledge, the heterozygous pathogenic SFMBT1 variant identified in association with this condition is novel as it has not been elsewhere described in the literature and it can be incorporated to the limited reported cases published.

Breast Reconstruction with Perforator Flaps in Poland Syndrome: Report of a Two-Stage Strategy and Literature Review

Background

Poland syndrome is a congenital deformity presenting unilateral hypoplasia of the breast, pectoralis muscle, and ipsilateral skeletal anomalies. In complex female cases, the significant amount of soft tissue needed for reconstruction continues to be a surgical challenge. Perforator flaps offer alternative methods with sufficient tissue volume, minimal donor site morbidity, and natural cosmetic outcome; however, their role in Poland syndrome breast reconstruction is seldom discussed. This study aims to present a new 2-stage strategy for esthetic restoration of the Poland syndrome chest anomaly that achieves breast symmetry while maintaining a scarless appearance.

Case Presentation

A 38-year-old female presented with Poland syndrome on the right side, and amastia, athelia, and absence of pectoralis major muscle were observed. We present an innovative 2-stage approach consisting of tissue expansion and, successively, a deep inferior epigastric perforator flap transfer. A pleasing breast appearance had been achieved at 6 months of follow-up. A literature review regarding the use of free perforator flaps in Poland syndrome was conducted to demonstrate the applicability of this method. Seven articles described a total of 15 cases using free perforator flaps met the inclusion criteria and were summarized. A satisfactory correction was reported in all the cases.

Conclusion

Perforator flaps provide reliable alternatives for Poland syndrome breast and chest-wall reconstruction. Proper patient selection and thorough assessment are vital to the success of the surgery.

Brachysyndactyly in Poland Syndrome

A 36-year-old man presented with incidental findings of an asymmetric chest with hypoplastic and flattened left anterior chest wall due to absent left pectoralis major. He also had short and webbed fingers in the left hand. These deformities were present since birth. Chest X-ray showed hyperlucency on the left side. Computerized tomography (CT) scan showed an absence of the left pectoralis major. X-ray of the left hand showed hypoplasia of the proximal phalanx and aplasia of the middle and distal phalanges of the second digit, and aplasia of the middle phalanges of the third and fourth digits. A diagnosis of left-sided Poland syndrome with associated ipsilateral brachysyndactyly, which is a very rare entity, was made. The patient opted against any reconstructive procedure as he had a minimal functional limitation.

Poland syndrome accompanied by internal iliac artery supply disruption sequence: a case report

Background

Poland syndrome is a congenital malformation characterized by ipsilateral hand and chest wall depression, including an absence or hypoplasia of the breast and pectoral muscles. These hypoplastic defects are reportedly caused by a subclavian artery supply disruption sequence.

Case presentation

A 45-year-old Japanese woman, an out-patient, underwent an emergency examination for intense left lower abdominal pain. Computed tomography images revealed a hydronephrotic left kidney and dilatation of the left ureter. No ureteral calculus or neoplasm was found. In addition, no abnormalities connected to her left abdominal pain were found. Nephritis was diagnosed based on the results of urine analysis, and a course of antibiotics was administered. Computed tomography images also revealed a history of breast reconstruction with a custom-made silicone implant in her right breast. The present case showed symptoms of Poland syndrome, which were absence of the sternal head of the right pectoralis major and asymmetrical malformation of the chest wall due to hypoplasia of the right rib cage. In addition to typical Poland syndrome symptoms, she had hypoplasia of her right kidney, hypoplasia of the right gluteus minimus muscle, right-sided pelvic hypoplasia, spinal curvature to the right, and a cystic mass in her right ovary.

Conclusions

In the present case of Poland syndrome, computed tomography images revealed malformation of the chest wall, absence of the pectoral muscle, and hypoplasia of a left kidney. Unilateral visceral hypoplasia is reported to be caused by a subclavian artery supply disruption sequence that occurs around 7 to 8 weeks of gestation. The present case can be considered a rare atypical phenotype of Poland syndrome with possible subclavian artery supply disruption sequence with internal iliac artery supply disruption.

Symbrachydactyly

Background: Symbrachydactyly is a unilateral congenital hand malformation characterized by failure of formation of fingers and the presence of rudimentary digit nubbins. The management is variable and are investigated in this review. Methods: A detailed review of the literature was compiled into succinct clinically relevant categories. Results: Etiology, classification, non-surgical management, surgical intervention, and patient oriented outcomes are discussed. Conclusions: All interventions should prioritize realistic, evidence-supported appearance and functional gains. Studies of the baseline function and quality of life of children with symbrachydactyly would allow surgeons to better understand functional changes associated with various interventions and would help surgeons and parents to make the best treatment decisions.

Congenital amastia

A 3-d-old female baby presented with bilateral congenital absence of breast tissue, areolae and nipples. No other anomalies were noted. There was also a history of absence of nipples, areolae and breast tissue in the mother and two other family members of maternal side. Investigations done during the hospital stay including ultrasound of the chest wall, abdomen and head were all normal. Congenital isolated bilateral amastia was diagnosed after complete investigations.

Poland syndrome: from embryological basis to plastic surgery

Poland syndrome is a rare congenital anomaly described by Sir Alfred Poland over 170 years ago. Combination of unilateral aplasia of the sternocostal head of musculus pectoralis major, and an ipsilateral hypoplastic hand with simple syndactyly and short fingers is typical for this condition. It occurs more frequent among males, and is usually situated on the right hemithorax in the unilateral form. The pathogenesis of Poland syndrome is not clear. Most of the authors assume that the etiologic insult is vascular in nature. During the sixth week of gestation, not only the pectoral mass splits (future muscles of the thorax) and intervening tissue between the finger rays of hands starts to disappear but also the vascular differentiation from six aortic arches begins. In our paper we report two cases of children with Poland syndrome, who underwent surgical procedure in the Department of Pediatric Surgery, Comenius University in Bratislava, Slovakia. Our case reports are focused on pre-operatively and also post-operatively imaging (RTG, CT, and 3D CT imaging) of the affected thorax and arm, as well as the operative reconstruction technique of abnormal ribs. We also discussed the possible embryonic backgrounds of this anomaly as well as the importance of plastic surgery resulting in patients' normal life.

Unilateral absence of latissimus dorsi muscle

Latissimus dorsi (LD) is the broadest muscle of the back responsible for extension and adduction of shoulder. The authors report a case of isolated unilateral absence of the latissimus dorsi muscle observed during an ablative surgical procedure and flap reconstruction. The left LD muscle was completely absent in our patient and no tendon fibers belonging to this muscle could be observable on further dissection. The surrounding muscle anatomy was normal and in place suggesting a developmental etiology for its absence. Awareness of this possible variation is of importance in considering reconstructive options.

Off-pump coronary artery bypass in poland syndrome with dextrocardia: case report

Poland Syndrome is a congenital disorder characterised by hypoplasia of the pectoral muscles along with upper extremity deformities. We encountered a patient with Poland syndrome associated with dextrocardia and also failed pectus excavatum repairs who presented to us with symptomatic ischaemic heart disease requiring intervention. He underwent successful off-pump coronary artery bypass surgery (OPCABG). As far as we are aware, this is the first case report of OPCABG in a case of Poland syndrome with dextrocardia. We describe here the management of this complex patient and wish to emphasise that the off-pump option is feasible in dextrocardia with some technical modifications.

Unilateral hypoplastic breast in a male-to-female transsexual with Poland syndrome after gender reassignment--reconstructive considerations

Gender reassignment procedures are performed more frequently nowadays due to a multidisciplinary approach and improved techniques and selection process. Many male-to-female patients require bilateral breast augmentation as part of the transformation following the gender reassignment if they fail to develop female breast features after hormonal treatment. We report on a very rare incidence of male-to-female gender reassignment in a patient with Poland syndrome. A male-to-female transsexual on hormonal therapy for gender reassignment developed one normal female-shaped breast whereas the other breast remained hypoplastic. As a male, he was not aware of his chest wall deformity but it became a major issue after successful gender reassignment surgery. Our experience with the specific reconstructive considerations and recommendations regarding our surgical approach to this complex reconstructive problem are discussed.

Titanium mesh prosthesis repair of symptomatic Poland syndrome in a premature infant

The authors describe a case of Poland syndrome in a ventilator-dependent premature infant with severe chest wall deformities treated during the neonatal period with a prosthetic titanium mesh. The implant significantly improved lung volume and provided stabilization of the chest wall allowing for weaning from ventilator, extubation, and discharge of the patient.

Poland syndrome associated with an aberrant subclavian artery and vascular abnormalities of the retina in a child exposed to misoprostol during pregnancy

BACKGROUND

Poland syndrome has been attributed to a process of vascular disruption, and exposure to misoprostol at 6-8 weeks of gestation has been shown to produce defects attributed to vascular disruption. Herein we report the first case of a patient with Poland syndrome associated with an aberrant subclavian artery and vascular abnormalities of the retina, whose mother used misoprostol during pregnancy.

CASE

A White boy of 1 year and 7 months of age, whose mother used misoprostol during the second month of pregnancy, presented with bilateral epicanthal folds, aplasia of the sternocostal head of the pectoralis major muscle with a hypoplastic nipple on the right side, and asymmetry between the upper limbs. The results of an angiotomographic study showed the presence of an aberrant right subclavian artery. Ultrasonographic evaluation showed turbulence and a high peak in the diastolic velocity in both carotid arteries, suggesting stenosis. Ophthalmologic assessment disclosed an intense bilateral tortuosity of the retinal blood vessels, with arterialnarrowing and rarefaction of the retinal pigment epithelium.

CONCLUSIONS

This case suggests that the mechanism of vascular disruption of misoprostol could be related to the aberrant subclavian artery and the observed Poland syndrome. His retinal findings are different from those in cases described thus far in the literature, and this pattern of anomaly has never been associated with a gestational exposure to misoprostol. The possibility of a relationship of the aberrant right subclavian artery and the pattern of blood flow verified in the carotid arteries with the eye fundus abnormalities could be causally related or simply coincidental.

Poland's syndrome: different clinical presentations and surgical reconstructions in 18 cases

BACKGROUND

The literature reports many variations of Poland's syndrome. This article describes 18 cases of Poland's syndrome in different stages of treatment, with variable clinical presentations and reconstructive techniques.

METHODS

This study evaluated 15 females and 3 males, ages 2 to 43 years, for breast deformity, nipple-areolar complex position, pectoralis muscle malformation, thoracic deformities, and the presence of brachysyndactyly. Surgical treatment was performed for 14 patients, individualized for each case.

RESULTS

For the women, the hypoplastic breast was treated with a latissimus dorsi muscular flap associated with silicone gel implant in five cases. Two other patients still are receiving tissue expansion for a future muscular and prosthetic reconstruction. Prosthetic implants alone were used on the affected side in four cases. The nipple-areolar complex was reconstructed for two patients. Seven women underwent contralateral breast surgery: reduction mammoplasty in three cases, mastopexy in two cases, and prosthetic implants in two cases. The only man who underwent surgery was treated with endoscopic rotation of the latissimus dorsi muscle flap.

CONCLUSIONS

This study demonstrated several breast reconstruction options for patients with Poland's syndrome, reinforcing the importance of an individualized treatment to achieve complete and adequate rehabilitation.

Deep Inferior Epigastric Perforator Flap for Successful Simultaneous Breast and Chest Wall Reconstruction in a Poland Anomaly Patient

Breast reconstruction in female Poland anomaly remains a surgical challenge with variable chest wall deformity and nipple position. Pedicled latissimus dorsi myocutaneous flap with implant reconstruction may have several drawbacks and complications. Free deep inferior epigastric flap (DIEP) flap is a reliable option for postmastectomy breast reconstruction, but rarely reported in Poland anomaly. We presented a 52-year-old Poland anomaly patient who underwent successful reconstruction for breast and chest wall deformity using DIEP flap. Preoperative ultrasound Doppler study for internal mammary vessels is recommended for microsurgical anastomosis. Care should be taken with regard to the flap inset and the location of the nipple areolar complex.

Poland syndrome: description of an atypical variant

Poland syndrome comprises a unilateral absence of the large pectoral muscle, ipsilateral symbrachydactyly, and occasionally other malformations of the anterior chest wall and breast. The condition is more frequent among males, and usually occurs on the right hemithorax in the unilateral form. The syndrome is believed to be caused by a genetic disorder that reduces the embryonal circulation in the interior chest artery: the stronger the interaction, the more severe the pathology. This article analyzes an unusual pathologic case in which the 17-year-old patient lacked the large pectoral muscle on the left side, but showed no arterial alteration. This case raises questions as to the true pathogenesis of this syndrome.

Breast Cancer in a Patient with Poland's Syndrome

Poland's syndrome is a congenital anomaly that occurs in 1 of every 32,000 live births. Only two published cases of breast cancer in patients with this congenital anomaly have been previously reported. We describe a case of breast cancer in a 71 year-old female with a clinical diagnosis of Poland's syndrome. A detailed description of the clinical manifestations is provided.

Poland anomaly--report of an unusual family

A family with classical Poland anomaly presenting in the son and a partially affected mother is reported. We hypothesize that Poland anomaly has a multifactorial basis involving vascular compromise in early development. Two possible predisposing factors are aberrant vascular formation and thrombophilia. The investigation of our family has not demonstrated an abnormality in coagulation, therefore, we surmise that an inherited structural variant of blood vessel formation is responsible.

[Poland's syndrome: clinic series and thoraco-mammary reconstruction. Report of 27 cases]

The authors evaluate the quality of thoraco-mammary reconstructions in Poland's syndrome. There was 34 patients in our serie, and 27 were operating between 1982 and 2001. There was 19 women and 8 men; the mean age was 19 years (9-40 years). Because of the clinical variability, the authors propose a classification of the malformation's importance in 3 degrees. In our serie, there is 35% of degree I, 53% of degree II and 12% of degree III. Each patient had an average of 2 general anaesthesias (1-6). For the first operation time, men had translation of the homolateral latissimus dorsi muscle flap in 25%, and a thoracic prosthese in 75%. Women had mammary prosthese in 50%, expansion prosthese in 20%, mammary prosthese and thoracic prosthese in 20%, muscle flap in 10%. The same person analysed the results in terms: good, middle or bad. The results are good in 67%, middle in 22%, poor in 11%. In degree 1, the results are always good; in degree II, they are good in 59%, middle in 29% and poor in 12%; in degree III, the results are good, middle and poor in 33%.

Poland's syndrome revisited

Poland's syndrome is a rare congenital anomaly characterized by unilateral chest wall hypoplasia and ipsilateral hand abnormalities. Literary data suggest its sporadic nature. The prevailing theory of its cause is hypoplasia of the subclavian artery or its branches, which may lead to a range of developmental changes. The incidence of Poland's syndrome varies between groups (male versus female patients, congenital versus familial cases, and so on) and ranges from 1 in 7,000 to 1 in 100,000 live births. Cases of Poland's syndrome associated with leukemia, carcinoma of the hypoplastic breast, and other conditions, confirm the relationship between developmental defects and tumors, and require oncologic awareness. Various manifestations, age, and gender require different surgical approaches. Our experience, which includes 27 patients (15 male, 12 female), 20 of whom (12 male, 8 female) underwent operation, suggests that the repair should be done in two stages in children and in a single stage in adults. Reconstruction and/or stabilization of the aplastic ribs may be achieved using bone grafts or prosthetic mesh. Muscle flaps and breast implants may be used to correct muscle deficiency and breast hypoplasia and to help achieve a complete cosmetic repair.

Endoscopically assisted reconstruction of male and female poland syndrome

Poland syndrome produces deformities of the breast and chest wall that can be highly disfiguring in both men and women. Incisions from traditional surgical approaches can be unsightly, especially if a muscle harvest is used as part of the reconstruction. Herein is described a case series in which minimally invasive techniques were used to reconstruct defects in male and female patients with Poland syndrome. When evaluating patients with Poland syndrome, one should consider using minimally invasive techniques as an alternative reconstructive option.

[Corrective surgery of thoracic anomalies in Poland syndrome. General review of 20 patients]

Breast and thoracic anomalies in Poland's syndrome, whether associated or not with hypoplasia of the upper limb, have no functional impairment. They present an important cosmetic disgrace. Several methods for correction were proposed: muscular transfer with or without implants. Each one has its advantages and drawbacks.

MATERIAL AND METHODS

We operated 20 adolescents and adults with this deformity: 13 females and 7 males. If the inferior bundle of the pectoralis major was always absent, other muscular anomalies such as aplasia of the latissimus dorsi may complicate the corrective procedure. The choice of the treatment depends upon the importance of the muscular and sometimes associated costal aplasia, in the young girl, the breast development and in both sexes the position of the nipple.

RESULTS

The latissimus dorsi transfer may be considered as the most adapted technique for the pestoralis major replacement. The results are often disappointing due to the secondary muscular atrophy. A composite implant with a part for breast reconstruction and another to fill the subclavicular gap gives satisfactory results but it has the hazards of implants.

Partial unilateral absence of the trapezius muscle in a human cadaver

We report here the partial unilateral absence of the trapezius muscle found during dissection. The left trapezius was significantly reduced in size when compared to the right trapezius, especially in its inferior third. Moreover, the existing fibers of the left trapezius inferior to the scapula were only one-third to two-thirds as thick as those on the right. The vertebral attachment of the inferior fibers of the left trapezius was also notably higher than that on the right. Morphometric analysis indicated that the surface area of the left trapezius was approximately 50% that of the right trapezius. Fiber orientation along the left and right trapezius muscles was also markedly different. An examination of nerve supply yielded no apparent anomalies, therefore suggesting that the absence of trapezius has a developmental etiology.

Poland's Syndrome and Carcinoma of the Breast: A Case Report

Poland's syndrome is a rare congenital anomaly that may include mammary hypoplasia and has been described in association with various malignancies. We report the case of a 42-year-old woman with unilateral Poland's syndrome who developed carcinoma in the hypoplastic breast. A review of the literature reveals no previous report of carcinoma of the hypoplastic breast with Poland's syndrome.

Poland's syndrome and recessive X-linked ichthyosis in two brothers

Poland's syndrome consists of unilateral congenital absence of the pectoralis major muscle with a variable degree of ipsilateral upper limb deformity. The aetiology of Poland's syndrome is unknown, although an inherited tendency to develop a compromised embryonic vascular supply in the affected areas has been suggested. The majority of reported cases are sporadic, and in only a few instances is there a familial incidence. We describe the occurrence of Poland's syndrome in two brothers who also had recessive X-linked ichthyosis. To the best of our knowledge this is the first report of such an association.

Smoking during pregnancy and Poland sequence: results of a population-based registry and a case-control registry

As Poland sequence (PS) could have a vascular disruptive origin, here we analyzed the possible relationship between maternal smoking during pregnancy and PS, using data from two registries with different methodologies: the Hungarian Congenital Abnormality Registry (HCAR), which is a population-based registry, and the Spanish Collaborative Study of Congenital Malformations (ECEMC), which is a hospital-based and case-control study. The results presented here in a multivariate analysis, although based on a small sample size, suggest that maternal smoking during pregnancy may increase the risk for PS by about 2-fold. This result was similar in the two studied programs with different methodologies and different uncontrolled confounding factors. However, as this is the first time that PS has been associated with maternal smoking during pregnancy, further analyses are needed to confirm our findings.

Poland sequence with dextrocardia: which comes first?

We report on two cases of Poland sequence (defect of the pectoralis major and hand on the same side) with dextrocardia, and review the literature on such patients. In all 16 reported cases, the Poland defect was on the left side, and associated with a rib defect, whereas most cases of Poland sequence involve the right side, and few have a rib defect. The dextrocardia appeared to be a dextroposition, and was not associated with other cardiac defects, whereas isolated dextrocardias (without situs inversus) frequently are. These observations suggest that the dextrocardia associated with Poland sequence is usually secondary to it.

Poland's syndrome and vascular malformations

Unilateral hypoplasia of the breast and the pectoralis muscle with a missing anterior axillary fold as part of Poland's syndrome are of major concern, especially for women. The latissimus dorsi is one of the most suitable flaps for breast and anterior thorax reconstructions but it may be hypoplastic or absent. If so, a free tissue transfer of the contralateral latissimus dorsi muscle is the next possible option for reconstruction. As Poland's syndrome is additionally associated with vascular malformations of the diseased hemithorax such as hypoplastic or missing vessels, a preoperative angiography is mandatory for planned microvascular tissue transfer.

Poland sequence in two siblings suggesting an autosomal inheritance transmission

We report on Poland sequence observed in two siblings (a girl and a boy) in the same family. This suggests an inheritance pattern consistent with an autosomal recessive or dominant trait transmission with reduced penetrance.

Goldenhar, Möbius and hypoglossia-hypodactyly anomalies in a patient: syndrome or association?

The Möbius, Goldenhar and hypoglossia-hypodactyly anomalies are usually sporadic conditions with a recurrence risk of about 2%. The combination of Goldenhar and one or the two others is rare, whereas the concomitant occurrence of Möbius and hypoglossia-hypodactyly, and/or Poland, and/or Klippel-Feil anomaly is well known. Pathogenetically, vascular disruptions around the 4th embryonic week have been hypothesized. In vivo and pathological studies as well as animal models support this theory for all the above-mentioned combinations. Whether a preceding blastogenetic alteration is an influencing factor or a disorganization mutation, remains unclear. We describe a 3-year-old girl with bilateral anotia, epidermoid on the right eye, 6th and 7th nerve palsy, hypoglossia, left hypodactyly, and ventricular septal defect.

CONCLUSION

We wish to emphasize the aetiological relevance of vascular disruptions in this previously unreported combination of Möbius, Goldenhar and hypoglossia-hypodactyly anomalies. The concurrence of anomalies in this patient represents an association and not a pleiotropic syndrome.

Poland anomaly after in vitro fertilization

OBJECTIVES

To describe an extremely rare anomaly in an infant born after IVF-ET, and to assess its possible relationship to the artificial reproductive technology.

DESIGN

Case report.

SETTING

Infertility and IVF Unit, in a tertiary academic medical center.

PATIENT

A 31-year-old healthy patient with a 9-year history of secondary, unexplained infertility.

INTERVENTION

Standard IVF-ET treatment cycle, using GnRH-a (short protocol) and hMG for controlled ovarian hyperstimulation.

RESULTS

Poland anomaly (asymmetric thorax with absence of the right pectoralis major muscle, low set rudimentary right nipple, and very mild hypoplasia of the right upper limb) is described for the first time in an infant who is one of a trizygotic triplet after IVF treatment.

CONCLUSIONS

In view of the currently held hypothesis concerning the pathogenesis of Poland anomaly, the possibility of a teratogen or an event related to the reproductive procedure as the cause of this anomaly seems unlikely.

Monozygotic twins discordant for spondylocostal dysostosis

Spondylocostal dysostosis (SCD) is a rare skeletal dysplasia with clinical and radiological manifestations, consisting of short neck and trunk, barrel-shaped chest, protuberant abdomen, scoliosis and abnormalities of vertebral segmentation and of the ribs. Both autosomal recessive and autosomal dominant inheritance have been described. We report on monozygotic twins discordant for the syndrome, either due to a post-zygotic mutation or development of a phenocopy. To our best knowledge, this is the fourth report of SCD in identical twins, and the first one of discordance in monozygotic twins.

Poland anomaly with contralateral ulnar ray defect

We report an atypical case of the Poland anomaly. Unreported features are that the hand abnormality is on the contralateral side to the chest wall defect, there is an ulnar ray predominance, and lack of syndactyly.