Breast Cancer in Poland Syndrome:

Bilateral Free Deep Inferior Epigastric Artery Perforator Flaps for Reconstruction following Mastectomy in Poland Syndrome Patients

Background

Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought to be caused by intrauterine interruption in subclavian arterial flow and often includes breast hypoplasia. Affected vasculature can pose a challenge for reconstruction with free flaps because inflow may not be reliable in this patient population.

Methods

We present the rare case of a 28-year-old woman with left-sided Poland syndrome, significant family history of breast cancer, and BRCA1+ mutation who underwent bilateral prophylactic nipple-sparing mastectomies with successful immediate bilateral deep inferior epigastric artery perforator free flap reconstruction. The surgical literature in this clinical scenario is also reviewed.

Results

Preoperative computed tomography angiography of the chest successfully demonstrated the patency and quantified the caliber of the internal mammary vessels to support free flap breast reconstruction.

Conclusions

Free tissue transfer is a viable option for breast reconstruction in patients with Poland syndrome undergoing mastectomy guided by preoperative computed tomography angiography to characterize the internal mammary vasculature.

[Poland's syndrome]

Breast and thoracic deformities of Poland syndrome is a rare malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sterno-costal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction manoeuvre highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, Breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.

18F-FDG PET/CT in a Rare Case of Poland Syndrome and Gastric Cancer

ABSTRACT

Poland syndrome is a rare congenital anomaly characterized by unilateral aplasia of the sternoclavicular head of pectoralis major muscle with varying degree of same side upper limb anomalies. A 44-year-old man, with a case of adenocarcinoma of stomach, whose CECT chest revealed complete absence of pectoralis major and minor muscles on the left side, was diagnosed with Poland syndrome without presence of typical ipsilateral limb anomalies. Follow-up PET/CT revealed metabolically active recurrent disease with typical findings of Poland syndrome. It is important to be aware of oncologic association in a patient of Poland syndrome as highlighted in the present case.

Poland Sequence: Retrospective Analysis of 66 Cases

INTRODUCTION AND OBJECTIVES

The literature reports many variations of Poland syndrome, which is a congenital disorder and a rare condition. The associated features are extremely variable, including alterations in the ipsilateral thorax and upper extremity and other malformations. This is used to designate the condition as Poland sequence (PS) because a sequence is a primary defect with a secondary cascade of structural changes. It is generally accepted that it is characterized as pathognomonic by absence/aplasia of the sternocostal aspect of the pectoralis major muscle of one side. Because it is considered a rare disease, and the incidence is low, we aimed to determine the features in all patients diagnosed at our institution to analyze the patterns and outcomes. We also revised the diagnosis according to the new classification proposed by Romanini et al to facilitate future treatments as well as to propose an improvement in the assessment and initial behavior when PS is suspected.

METHODS

We performed a retrospective study using our database from 1988. We identified 66 patients with a clinical diagnosis of PS in the Pediatric Plastic Surgery Unit of Hospital Sant Joan de Deu, Barcelona. We analyzed the medical charts, records, photographs, and imaging information to gather all the epidemiological information and clinical history, as well as the treatments received to analyze our experience with these patients. We used the TBN classification of Romanini et al, adding an S if there was upper extremity involvement (TBNS).We also conducted a systematic review consulting the following databases: PubMed, Cochrane Plus, Scopus, Web of Science, and Europe PMC.

RESULTS

Among the 66 patients, 27 were men, and 39 were women. The right side was affected in 51 patients (77.3%) (19 men and 32 women). In a total of 37 patients (56.1%; 16 men and 21 women), there was no upper extremity involvement. We found 40 cases with other associations, with scoliosis being the most common. Before 2007, the team performed surgery in 1 male patient and 4 female patients; after 2007, the actual team has performed reconstruction in 8 male patients and 16 female patients. In the female patients, the average volume of breast implants was 252.5 cc, and the average volume for fat grafting was 103.5 cc on the side affected with PS. There is a wide range of chest-breast clinical involvement, which was why we decided to readdress all the imaging and clinical history to classify the patients using a new classification system to learn how to optimally treat these cases in the future. In female patients, we used Romanini's TBN classification and added an S for upper extremity involvement; the T1B1N1S0 was the most frequently observed classification. Owing to the sample size and the disparity in sex distribution, we also reassessed publications in PubMed, Cochrane Plus, Scopus, Web of Science, and Europe PMC with more than 5 cases; we found that there were a total of 1600 patients with PS in the literature and that the distribution was almost 50% for men and women, including the patients in our study (611 women, 561 men).

CONCLUSIONS

We propose to include the presence of upper extremity involvement in Romanini's TBN classification (TBNS) for optimal management of these patients and use a standard number and profile for image documentation presurgery and postsurgery. We found that in the literature the ratio of men and women with PS was not 2 to 3:1, but 1:1. The most frequent phenotype of PS was T1B1N1S0 (hypoplasia or aplasia of the pectoralis muscles and soft tissue/breast hypoplasia/nipple-areolar complex with dislocation of <2 cm / absence of upper extremity involvement). There was no relationship between the side involved and patients' sex for the severity of the deformity and between the severity of the thoracic involvement and ipsilateral upper extremity association. In the literature, there are several plastic reconstruction methods available ranging from standard implants to microsurgery techniques. The selected procedure depends on the phenotype, patients' needs and expectations, availability of surgery in the hospital, and surgeons' criteria; thus, surgery has to be personalized while providing a match related to the risk/benefit, taking into account the degree of functional impairment. Since the author started her practice in the hospital in 2007, the timing for procedures has been proposed at the end of adolescence with 2 consecutive appointments without changes in the breast-thorax measures. The procedure performed has included implant use with lipofilling, yielding no major complications and a high rate of satisfaction during a maximum of 10 years of follow-up.

Controversies in Poland Syndrome: Alternative Diagnoses in Patients With Congenital Pectoral Muscle Deficiency

PURPOSE

Poland syndrome was first described as a deficiency of the pectoral muscle with ipsilateral symbrachydactyly. Currently, numerous case reports describe variations of Poland syndrome in which pectoral muscle deficiency is often used as the only defining criterion. However, more syndromes can present with pectoral muscle deficiency. The aim of this review is to illustrate the diversity of the phenotypic spectrum of Poland syndrome and to create more awareness for alternative diagnoses in pectoral muscle deficiency.

METHODS

A systematic literature search was performed. Articles containing phenotypical descriptions of Poland syndrome were included. Data extraction included number of patients, sex, familial occurrence, and the definition of Poland syndrome used. In addition, hand deformities, thoracic deformities, and other deformities in each patient were recorded. Alternative syndrome diagnoses were identified in patients with a combination of hand, thorax, and other deformities.

RESULTS

One hundred-and-thirty-six articles were included, describing 627 patients. Ten different definitions of Poland syndrome were utilized. In 58% of the cases, an upper extremity deformity was found and 43% of the cases had an associated deformity. Classic Poland syndrome was seen in 29%. Fifty-seven percent of the patients with a pectoral malformation, a hand malformation, and another deformity had at least 1feature that matched an alternative syndrome.

CONCLUSIONS

Pectoral muscle hypoplasia is not distinctive for Poland syndrome alone but is also present in syndromes with other associated anomalies with a recognized genetic cause. Therefore, in patients with an atypical phenotype, we recommend considering other diagnoses and/or syndromes before diagnosing a patient with Poland syndrome. This can prevent diagnostic and prognostic errors.

CLINICAL RELEVANCE

Differentiating Poland syndrome from the alternative diagnoses has serious consequences for the patient and their family in terms of inheritance and possible related anomalies.

[Correction of thoraco-mammary deformity of Poland syndrome]

Breast deformity of Poland syndrome is a malformation known to be difficult to treat. Numerous descriptions of surgical corrections have been published but none achieved to correct severe cases before description of lipomodeling technique. The aim of this article is to present thoraco-mammary deformity of Poland syndrome, corrections techniques already available and therapeutical indications in primary and secondary cases. Constant anomaly of Poland syndrome is agenesis of sternocostal part of pectoralis major muscle but other muscular anomalies can be associated. Skin and glandular anomalies present with a fine skin and an absent or hypoplasic subcutaneous fat with a glandular hypoplasia of various degree. Osteo-cartilaginous anomalies can be associated in very severe cases. Clinical sign of Poland syndrome is forced adduction maneuver highlighting pectoralis major agenesis. Functional impact of the deformity is low but psychological and psychosocial implications can be very important, supporting an early surgical correction. Therapeutic means are various and accurate descriptions are given in this article: thoracic bony reconstruction, thoracic implant made of silicone elastomer, breast implant, skin expansion, latissimus dorsi pedicled flap, free flaps, breast lipomodeling, breast-pectoralis flap. Principles of each technique are described and balanced with their actual use in this malformation. Indications have been completely modified these last years due to lipomodeling contribution which represented a huge step in this deformity treatment. In our practice, if autologous reconstruction with lipomodeling is possible, we choose this solution at first. In case of severe thoracic deformity, a silicone elastomer implant made with the help of computed assisted conception can be an important adjunct, mainly by thin young man. In secondary cases, if implant is well tolerated, we found logical to stay in the same reconstruction path and do one or two sessions of lipomodeling in order to improve reconstruction. If implant tolerance is low and skin very thin at risk of exposure, we do recommend a conversion of implant reconstruction to autologous reconstruction. In conclusion, thoraco-mammary deformities of Poland syndrome are rare and hard to treat and should be managed by well trained and experimented surgeons. Breast lipomodeling is a huge step in the treatment of these deformities and should be regarded, in our opinion, as first line treatment if fat deposits are sufficient. In case of low fat provisions or in the thin young man, composite techniques should be used with silicone elastomer implant.

Poland syndrome and breast tumor: a case report and review of the literature

Poland syndrome is a rare congenital malformation. Hypoplasia of the sternocostal portion of the pectoralis major muscle is the most significant feature and is most frequently associated with homolateral breast hypoplasia. In this article, the authors present a case of bilateral phyllodes tumors in a 28-year-old woman with Poland syndrome and discuss (1) the relationship between the condition and breast cancer, (2) the modes of surveillance in patients with Poland syndrome, and (3) its impact on breast reconstruction.

Abdominal wall reconstruction in patients with enterocutaneous fistulas

Enterocutaneous fistulas (ECFs) remain a feared complication of surgery, particularly in acute care and trauma patients. Despite advances in medical and surgical therapies, ECFs are associated with significant morbidity and mortality; in addition, significant health care resources are consumed in their treatment. Because of the frequency nowadays of open-abdomen and damage-control surgery, of aggressive treatment for abdominal compartment syndrome, and of necrotizing soft tissue infections of the abdominal wall, ECFs are becoming common; so are enteroatmospheric fistulas (EAFs), which represent a new entity where the lumen of the intestine is directly exposed to the outside environment and has no track through subcutaneous or cutaneous tissue. The surgical management of abdominal wall defects, including ECFs and/or EAFs, is often associated with major hernias and other complexities. Careful planning and advanced surgical techniques are required, often involving the use, alone or in combination, of biologic mesh and composite tissue transfer. The treatment of ECFs in patients with large abdominal wall defects is challenging, but with proper techniques, the results can be excellent. Biologic mesh is the mesh of choice in such patients.

Not all biologics are equal!

BACKGROUND

Although the efficacy of various biologic meshes in the abdominal reconstruction of complex ventral hernia has been shown, the performance profile of various biologic mesh scaffolds in terms of hernia-specific outcomes such as recurrence, mesh explantation, and mesh infections has not been examined.

AIM

To evaluate the clinical outcomes of patients who underwent complex ventral hernia repair with bioprosthetic material.

METHODS

This study is a retrospective analysis of the use of bioprosthetic material in complex ventral hernia at an academic institution from January 2002 to December 2007.

RESULTS

A total of 58 patients with a mean age of 57.2 years and mean body mass index (BMI) of 33.8 who underwent reconstruction of ventral abdominal defects with a bioprosthetic from January 2002 to February 2009 were included in the study. The study patients had about 4.8 previous surgeries and 43.1% of patients had reconstruction in a setting of enterocutaneous fistula, while 46.6% had a previous mesh infection. Complex ventral hernia was seen in 50 patients, while eight patients had ventral and parastomal hernia. The type of biologic used for reconstruction was human-derived (AlloDerm, 29), porcine cross-linked (CollaMend, 3; Permacol, 2), and non-cross-linked porcine (Surgisis, 16; Strattice, 8). At least one complication was seen in 72.4% of patients. Major complications noted were surgical wound infections (19.0%), seroma (8.6%), and abscess formation (5.2%). The one-year hernia recurrence rate was 27.9% and mesh explantation was needed in 17.2% of patients. AlloDerm was less likely to be explanted (13.8%) or become infected (37.9%) but more likely to recur (28.6%) compared to porcine cross-linked bioprosthesis. Porcine cross-linked biologics were more likely to become infected (60%) and explanted (40%) but less likely to recur (20%) compared to AlloDerm. Non-cross-linked porcine biologics were less likely to be explanted (16.7%) but had higher recurrence (29.4%) compared to cross-linked porcine biologics and a higher infection rate (54.2%) compared to AlloDerm.

CONCLUSIONS

The results from this study underscore the difficulty of repairing complex abdominal wall defects in contaminated fields. Cross-linked porcine biologics showed relatively higher infection and explantation rates. Equivalent recurrence and explantation rates were observed for the non-cross-linked porcine biologics and AlloDerm. These data indicate that there is currently no ideal biologic for complex ventral hernia repair.

Poland syndrome with intracranial germ cell tumor in a child

Poland syndrome is an uncommon unilateral deformity of chest wall and upper extremity with variable manifestations. Although numerous case reports of Poland syndrome associated with malignancies have been published, intracranial germ cell tumor in Poland syndrome has not been previously reported. The authors describe a 15-year-old male patient with intracranial germ cell tumor and Poland syndrome.

Poland's syndrome and gastric cancer: report of a case

Poland's syndrome, a rare congenital anomaly characterized by pectoralis muscle defect and ipsilateral hand abnormalities, has been reported in association with various malignancies. Gastric cancer associated with Poland's syndrome has not been described previously. To our knowledge, the case of the 21-year-old man we describe herein represents the first report of Poland's syndrome associated with gastric cancer. Although previously there was no certain evidence that linked Poland's syndrome and cancer, elucidating the molecular mechanisms that cause this syndrome may further clarify the relationship between Poland's syndrome and malignancies. At least, these associations confirm the relationship between Poland's syndrome and malignancies, and require oncologic awareness.

Pneumothorax after a clinical breast fine-needle aspiration of a lump in a patient with Poland's syndrome

We report the first case in the medical literature of a pneumothorax complicating fine needle aspiration cytology (FNAC) of a breast lump in a woman with a mild form of Poland's syndrome. The pneumothorax was treated conservatively. This is the first case of breast FNA-related pneumothorax seen in our clinical practice. We believe that the absence of pectoral muscles has increased the risk of this complication. We have also diagnosed an incidental screen-detected breast cancer affecting the ipsilateral breast in the same patient. We conclude that caution should be exercised when performing FNAC of breast lesions in patients with Poland's syndrome. The procedure should be preferably performed under image guidance in such patients in order to minimise the risk of this complication.

Breast Cancer Development in a Female with Poland’s Syndrome

BACKGROUND

Poland's syndrome, a rare congenital anomaly characterized by a defect of the pectoralis muscles, has been reported in association with lymphoreticular malignancies and some solid tumors.

CASE REPORT

We report the case of a 53-year-old woman with Poland's syndrome who developed breast cancer in the afflicted ipsilateral hypoplastic breast. FNA cytology revealed a moderately differentiated carcinoma and histology was consistent with a well differentiated invasive ductal carcinoma.

CONCLUSION

Poland's syndrome can be associated with breast cancer so all females with the syndrome should be thoroughly examined for early detection of neoplasia.

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.

Tissue engineering strategies for adipose tissue repair

Tissue engineering is a relatively young field that combines engineering, clinical science, and life sciences to, in part, repair or regrow tissues. Adipose tissue has recently become a focus area for tissue engineering, encouraged by the large number of reconstructive, cosmetic, and correctional indications that could be addressed with clinically translatable adipose tissue engineering strategies. This review discusses the three aspects of an adipose construct, namely cell types, scaffold, and microenvironment, and presents current tissue engineering strategies under pursuit.

Adipose tissue engineering: the future of breast and soft tissue reconstruction following tumor resection

Reconstructive surgeons have always been at the forefront of medical technology. The history of reconstructive surgery began with ablative surgery, which was followed by tissue and organ transplantation, leading to contemporary tissue reconstruction. The field of reconstructive surgery is poised at the next stage of its evolution, namely tissue regeneration. The field of tissue engineering has largely defined this evolutionary leap. One active area of investigation is the development of tissue engineering strategies for adipose tissue. Bioengineers, life scientists, and reconstructive surgeons are synergistically coupling expertise in areas such as cell culture technology, tissue transfer, cell differentiation, angiogenesis, computer modeling, and polymer chemistry to regenerate adipose tissue de novo for breast replacement and soft-tissue augmentation following tumor resection. This work presents the current state of the art in adipose tissue engineering, as well the clinically translatable strategies currently under development. Semin. Surg. Oncol. 19:302-311, 2000.