Infections and Radiation Injuries Involving the Chest Wall

A radiation ulcer that required partial lung resection and recurred in a small residual area of ectopic calcification

INTRODUCTION AND IMPORTANCE

Surgery for chest radiation ulcers must involve appropriate wide margins, but it is not usually possible to remove all radiation-damaged tissue. Therefore, it is difficult to determine how extensive such surgery should be. There have not been any reports about the recurrence of such ulcers years after surgery. In addition, how ectopic calcification should be treated and the need for partial lung resection in such cases have not been fully elucidated. We report the case of a patient who had a large severe radiation ulcer.

CASE PRESENTATION

A 46-year-old patient underwent cancer resection and received postoperative radiotherapy. Seventeen years later, a chest ulcer developed. Computed tomography showed a depression of the lung parenchyma, which exhibited old radiation pneumonitis, and pathological fractures of the ribs around the ulcer. We excised a region of skin that exhibited a clear change in color together with an additional 1 cm around this area including 4 ribs and grossly calcified area. The lung was partially resected because of strong adhesion, and the chest wall was reconstructed. Two small calcifications remained and which required additional surgery several years later.

CLINICAL DISCUSSION

Since multiple surgeries were required, we consider that more generous resection margins were necessary from the beginning.

CONCLUSION

In such cases, it might be necessary to perform more extensive surgery that includes asymptomatic calcified areas.

Diagnosis and management of sternoclavicular joint infections: a literature review

The sternoclavicular joint (SCJ) is anatomically and clinically significant considering its proximity to important neuro-vascular structures like the subclavian vessels and the phrenic nerve. Infections of this joint masquerade multiple disorders, delay diagnosis and spread to the bone and deep tissues. There is no standardized workup and treatment protocol for sternoclavicular joint infections (SCJI) as defined in literature. Here, we review the existing literature to understand the current knowledge of the diagnosis and treatment of SCJI. We searched English publications in PubMed and included clinical trials, case reports, case series, retrospective cohort studies, literature and systematic reviews after excluding non-infectious etiology of SCJ pathologies. There are many risk factors for SCJI, such as immunocompromised status, intravenous drug use, trauma and arthropathies. But a large percentage of patients with disease have none of these risk factors. SCJIs can present with fever, joint swelling, immobility, and rarely with vocal cord palsy or dysphagia. While Staphylococcus aureus causes over 50% of SCJI cases, other pathogens such as Pseudomonas and Mycobacterium are frequently seen. When diagnosed early, the infection can be medically managed with antibiotics or joint aspirations. Most cases of SCJI, however, are diagnosed after extensive spread to soft tissue and bones requiring en-bloc resection with or without a muscle flap. Complications of undertreatment can range from simple abscess formation to mediastinitis, even sepsis. SCJIs are rare but serious infections prompting early detection and interventions. Most cases of SCJI treated adequately show complete resolution in months while retaining maximum functionality. Key features of proper healing include aggressive physiotherapy to prevent adhesive shoulder capsulitis and decreased range of motion.

Osteoradionecrosis of the sternoclavicular joint after laryngopharyngeal radiation

OBJECTIVES

Adequate treatment of laryngopharyngeal malignancy often incorporates radiation therapy. Structures surrounding laryngopharynx exposed to traditional radiation doses are susceptible to posttreatment toxicity. Among poorly understood sequelae is the rare manifestation of sternoclavicular joint (SCJ) osteoradionecrosis (ORN).

METHODS

Three institutional encounters prompted a comprehensive literature search, generating three published case reports. Systematic extraction and analysis (n = 6) of demographics, cancer history, comorbidities, ORN presentation, imaging, and management established the largest series to investigate this pathology.

RESULTS

Patients were males (6), 54 to 70 years old, smokers (4), with Hypertension/dyslipidemia, myocardial infarction/coronary artery disease, second primary (2), diabetes mellitus (1), and myelofibrosis(1). Four underwent total laryngectomy, one primary, three as salvage. Five patients had concurrent chemoradiation (≥70 Gy). All patients presented with swollen, tender neck wounds concerning for persistent/recurrent malignancy. Computed tomography (CT) demonstrated bone erosion (5 of 5) and increased bone scan uptake (2 of 2). All responded to surgical exploration with drainage alone (1), sequestrectomy (2), or bone resection with synovectomy (3). Complete healing took 2 months to 3 years. One unrelated patient death occurred before control of ORN was achieved.

DISCUSSION

Given varied patient characteristics, synergistic risk factors exist that alter bone radiation threshold, resulting in irreversible ischemic damage and osteoradionecrosis. Vascular susceptibility and inability to repair may regulate that threshold. Understanding this relationship will facilitate early detection and intervention.

CONCLUSION

Integrating cases of sternoclavicular joint ORN promotes awareness of atypical laryngopharyngeal radiation complications, elucidates contributing factors, educates physicians on presentation and management, and provides a platform for prospective investigation.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:865-870, 2019.

Experimental study of ASCs combined with POC-PLA patch for the reconstruction of full-thickness chest wall defects

To explore the repairing effect of combination of adipose stem cells (ASCs) and composite scaffolds on CWR, the electrospun Poly 1, 8-octanediol-co-citric acid (POC)-poly-L-lactide acid (PLA) composite scaffolds were prepared, followed by in vitro and in vivo biocompatibility evaluation of the scaffolds. Afterwards, ASCs were seeded on POC-PLA to construct the POC-PLA-ASCs scaffolds, and the POC-PLA, POC-PLA-ASCs, and traditional materials expanded polytetrafluoroethylene (ePTFE) were adopt for CWR in New Zealand white (NZW) rabbit models. As results, the POC-PLA-ASCs patches possessed good biocompatibility as the high proliferation ability of cells surrounding the patches. Rabbits in POC-PLA-ASCs groups showed better pulmonary function, less pleural adhesion, higher degradation rate and more neovascularization when compared with that in other two groups. The results of western blot indicated that POC-PLA-ASCs patches accelerated the expression of VEGF and Collagen I in rabbit models. From the above, our present study demonstrated that POC-PLA material was applied for CWR successfully, and ASCs seeded on the sheets could improve the pleural adhesions and promote the reparation of chest wall defects.

Partial replacement of left hemidiaphragm in dogs by either cryopreserved or decellularized heterograft patch

OBJECTIVES

Large diaphragmatic defects are still a challenging issue for reconstruction using either synthetic prosthesis or bioprosthesis. To evaluate the possibility of using diaphragm allograft as a natural bioprosthesis in humans, we conducted a two-group study and compared cryopreserved and decellularized diaphragmatic heterograft patched in a canine model.

METHODS

At the end of organ harvesting from a human donor, the left hemidiaphragm was taken to the laboratory in phosphate-buffered saline solution. The next step was freezing the grafts at -80°C, and preserving them for up to 2 months in Group 1. It was subjected to a detergent-enzymatic method (containing sodium deoxycholate/DNase lavations) of decellularization for 25 cycles in Group 2. Through left thoracotomy in the eighth intercostal space, cryopreserved patches in six dogs and decellularized patches in five dogs replaced the diaphragm. During the follow-up, sonography was done in all animals, but three and two dogs in Group 1 and 2 underwent computed tomography (CT) scan, respectively. The animals were euthanized after 6 months.

RESULTS

There was no mortality. Sonography showed only motion impairment of the patches in all cases. In Group 1, CT scan showed mild atelectasis and scattered infiltration in the left lower lobe, fibrotic bands and minimal fluid collection under the diaphragm. In Group 2, CT scan showed scattered fibrotic bands and mild to moderate elevation of the left hemidiaphragm. There was no evidence of gross disruption and complete healing of the suture line. Necropsy in both groups showed patches were completely replaced with a dense fibrous tissue. In Group 1, focal calcification was noticeable in every case and foreign body-type granulomas were clearly seen all over the grafted tissue. Histology in Group 2 animals showed less inflammatory cell infiltration and scattered foreign body granulomas in comparison with the cryopreserved patch graft.

CONCLUSIONS

The gross healing process in the decellularized heterograft is similar to the cryopreserved diaphragm but with fewer inflammatory cells and foreign body granulomas on histology. Both of them can be used instead of bioprostheses with regard to the fact that the decellularized patch technique is more complex and expensive. It is recommended to compare them with commercial bioprostheses.

Properties of novel composite meshes in chest wall reconstruction: A comparative animal study

PURPOSE

Novel composite meshes routinely used in laparoscopic hernia repair reportedly lead to fewer and less dense visceral adhesions and may provide a viable alternative in thoracic surgery as well.

METHODS

A total of 15 adult domestic pigs underwent full thickness chest wall resection and reconstruction with Parietene (polypropylene composite; PTE, n = 5), Parietex (polyester composite; PTX, n = 5) or Bard (purely polypropylene, n = 5) mesh. After an observation period of 90 days all animals were sacrificed, intrathoracic adhesions classified via thoracoscopy (VATS), meshes explanted and peak peal strength required for lung/mesh separation recorded.

RESULTS

Adhesions assessed through VATS-exploration were strongest in the PTX-Group while PTE and BM showed comparable results. Tensiometric analyses of peak peal strength confirmed lower values in BM than for PTE and PTX. Both composite materials showed good overall bioincorporation with post-surgical perigraft-fibrosis being strongest in BM.

CONCLUSION

We consider composite grafts a suitable alternative for chest wall reconstruction. They are characterized by good overall biointegration and limited perigraft-fibrosis, thus potentially facilitating redo-procedures, even though a hydrophilic coating per se does not appear to prevent intrathoracic adhesion formation.

A clinical study of internal fixation, debridement and interbody thoracic fusion to treat thoracic tuberculosis via posterior approach only

PURPOSE

We evaluated the clinical efficacy and feasibility of one-stage posterior internal fixation, debridement and interbody thoracic fusion in the treatment of thoracic tuberculosis.

METHODS

Sixty adult patients with monosegmental thoracic tuberculosis were studied retrospectively: 34 men and 26 women with an average age of 37.5 years. Operating time, blood loss, time in bed, complications, neurological function, rate of deformity correction and rate of interbody fusion were investigated.

RESULTS

All cases were followed up for 27.5 months on average. Average mean operating time was 251 min, evaluated blood loss during operation 780 ml, rate of kyphosis correction 79%, corrected kyphosis angle 25° and loss of corrected angle 1.2°. Patients whose neurological function improved accounted for 90.1%. Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) decreased to normal levels three months after operation. The rate of bone fusion was 100%, with a 100% cure rate. No severe complications or spinal cord injury occurred.

CONCLUSIONS

This approach can successfully remove the focus of tuberculosis with complete interbody thoracic fusion after operation, which restores spinal stability.