Search Results (406)

Background/Objectives: Chronic wounds are a major source of morbidity in patients with paraplegia, often resulting in repeated treatment, prolonged hospitalization, and reduced quality of life. Reconstruction becomes particularly challenging when a wound arises in a scarred trunk region and is further complicated by deep infection, osteomyelitis, or enteric fistula. We describe the staged management of a complex left flank wound in a paraplegic patient, initially reconstructed with a quadrilateral pinwheel flap and later requiring multidisciplinary salvage for recurrence associated with rib osteomyelitis and a colocutaneous fistula. Methods: A paraplegic man in his 50s presented with a chronic left flank wound after repeated full-thickness skin graft failure and persistent Pseudomonas aeruginosa infection. After wide debridement, the approximately 7 × 7 cm defect was reconstructed with a quadrilateral pinwheel flap composed of four Limberg-style rhomboid fasciocutaneous flaps positioned at the 12, 3, 6, and 9 o’clock orientations, elevated at the level of the deep fascia, and transposed into the central defect, with adjunctive negative-pressure wound therapy (NPWT). Approximately 1 year later, recurrence with rib osteomyelitis required rib resection. During NPWT, feculent drainage led to the diagnosis of a colocutaneous fistula. Subsequent multidisciplinary treatment included fistula tract resection, colonic repair with omental patching, transposition of vascularized omentum into the chest wall cavity to obliterate dead space, continued NPWT, and delayed primary closure. Results: Initial local flap reconstruction achieved wound coverage, and immediate postoperative clinical assessment, including pinprick and refill testing, confirmed satisfactory flap perfusion; however, delayed recurrence developed in association with rib osteomyelitis. After definitive fistula surgery, dead-space management with vascularized omentum, wound conditioning with staged NPWT, and delayed primary closure, the wound healed completely. At 6 months after delayed closure, no recurrence of fistula, osteomyelitis, wound dehiscence, or soft-tissue breakdown was observed, and the patient’s daily comfort and functional independence were improved compared with the preoperative condition. Conclusions: A quadrilateral pinwheel flap may provide an effective tension-dispersing local fasciocutaneous option for selected scarred trunk defects in high-risk patients. However, when chronic wounds are compounded by deep infection and enteric fistula, durable healing depends not on flap design alone but on staged multidisciplinary management incorporating definitive source control, vascularized tissue transfer for dead-space elimination, NPWT, and appropriately timed closure. Full article

Background: Plasma cell granuloma is generally considered a pseudotumor formed by reactive, polyclonal plasma cells. Although most cases can show polyclonal gammaglobulin production, quite a minority may exhibit monoclonal gammopathy, which mimics plasma cell neoplasms such as multiple myeloma or plasmacytoma. Because of this overlap, distinguishing reactive monoclonal proliferation from true malignancy is clinically essential. Case report: A 79-year-old man was presented with an anterior chest wall mass that had grown during investigation for fever of unknown origin. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) revealed a sternal bone mass (SUVmax 9.04), aortic uptake of bifurcation (SUVmax 7.08), and Th7/8 soft tissue mass (SUVmax 5.32). Results from the FDG-PET revealed infectious reactions. A chest wall biopsy revealed high degree proliferation of plasma cells. Hematologists suspected plasmacytoma. The pathologist did not diagnose plasmacytoma; thus, there remains a possibility of reactive granuloma lesion. Lastly, the patient’s vertebral soft tissue mass culture yielded Staphylococcus aureus. The patient was treated with antimicrobials and responded well. Discussion: In the presented case, FDG-PET revealed an aortic mass with an aortic aneurysm, a sternal mass, and a vertebral mass, as multiple lesions. The abscess lesions that initially resembled multiple plasmacytomas were identified as plasma cell granuloma. The final diagnosis required demonstrating biopsy and definitive monoclonality. Light-chain restriction or monoclonal protein should be considered in the clinical context. Ultimately, this case highlights the diagnostic value of FDG-PET and the importance of differentiating reactive plasma cell granuloma from true plasma cell neoplasm to guide appropriate management. In conclusion, a reactive plasma cell granuloma associated with infectious aortitis can exhibit monoclonal gammopathy, mimicking plasma cell neoplasm. Careful pathological and clinical evaluation is essential to avoid misdiagnosis and ensure proper treatment. Full article

Background: The pectoralis minor muscle can be a source of musculoskeletal-related chest pain by contributing to thoracic outlet syndrome. Needling interventions applied to chest wall muscles have an inherent risk of puncturing sensitive structures, e.g., the pleura. Objective: The objective of this study was to preliminarily investigate the safety and accuracy of two needling approaches targeting the pectoralis minor muscle. Methods: A pincer- and flat-needle approach targeting the pectoralis minor muscle was conducted in five Thiel-embalmed cadavers and 10 healthy volunteers by an experienced and a novice clinician. The needle was inserted until the clinician considered that the pectoralis minor muscle was reached. Each clinician conducted 10 needle insertions with each approach. In cadavers, the accuracy of needle placement was identified with both ultrasound imaging and anatomical dissection. In healthy volunteers, needle placement accuracy was evaluated with ultrasound imaging. Results: Accurate needle penetration of the pectoralis minor muscle was 80–90% and 40–70% for experienced and novice clinicians, respectively, with the pincer approach. One pleural puncture was observed in one cadaver specimen with this approach by the novice clinician. Accurate needle penetration of the pectoralis minor muscle was 100% and 90% for experienced and novice clinicians, respectively, with the flat approach. The novice clinician required 3.5 times longer to perform the flat approach than the experienced clinician. Conclusions: The results of this pilot feasibility study suggest that a pincer-needle approach seems to be less accurate than the flat-needle approach and substantially more error-prone for a novice clinician, which, in a clinical context, could pose a potential risk of pneumothorax based on the pleural puncture observed in one cadaver specimen. In contrast, our preliminary results revealed that the flat-needle approach could have better accuracy and safety, particularly when performed under real ultrasound guidance. Full article

Acute respiratory distress syndrome (ARDS) has traditionally been managed with population-based, protocolized mechanical ventilation strategies designed to limit ventilator-induced lung injury. While these approaches have improved outcomes, they fail to account for the pronounced biological, mechanical, radiological, and temporal heterogeneity that characterizes ARDS. Accumulating evidence shows that patients differ markedly in functional lung size, recruitability, chest wall mechanics, inflammatory burden, and tolerance to ventilatory stress, making uniform ventilatory targets physiologically imprecise and, at times, harmful. This narrative review examines the evolution from conventional lung-protective ventilation toward a precision-based paradigm that aligns ventilatory support with individual patient physiology. We conceptualize ARDS not as a static syndrome but as a dynamic spectrum, viewing the injured lung as a heterogeneous mechanical system susceptible to regionally amplified stress and strain. Within this framework, we discuss key principles underlying precision ventilation, including functional lung size (the “baby lung”), driving pressure, mechanical power, patient–ventilator interaction, spontaneous breathing-associated injury, and the time-dependent evolution of lung mechanics. We synthesize current evidence supporting mechanical, biological, and radiological subphenotyping as complementary strategies to individualize ventilatory management, while critically appraising their current limitations. This review also evaluates bedside tools that may operationalize precision ventilation in clinical practice, including esophageal pressure monitoring, lung ultrasound, and electrical impedance tomography, and examines the role of artificial intelligence as a clinician-directed decision-support aid rather than a prescriptive substitute for physiological reasoning. Implications for clinical trial design, ethical considerations, and future directions toward predictive and adaptive ventilation strategies are also addressed. Precision mechanical ventilation represents a shift from rigid thresholds toward proportional, physiology-guided intervention across the disease trajectory. By integrating evolving lung mechanics, ventilatory load, and patient effort over time, this approach provides a coherent framework for safer and more effective mechanical ventilation in ARDS while preserving the core principles of lung protection. Full article

Background. Chondrosarcomas of the manubrium are exceedingly rare, accounting for approximately 20% of all primary bone malignancies, and present unique challenges in surgical management and reconstruction. Reliable reconstructive strategies for medial clavicular stabilization remain limited. Case Presentation. We report the first documented use of STRATOS bars for unilateral clavicular stabilization following manubrial chondrosarcoma resection. A 19-year-old woman with a poorly differentiated (G3) chondrosarcoma of the manubrium underwent neoadjuvant chemotherapy followed by en bloc resection of the manubrium, medial clavicle, and first rib. Reconstruction and clavicular stabilization were achieved using STRATOS, which is traditionally employed for chest-wall reconstruction. This represents a novel use of the device for medial clavicular stabilization after SCJ resection. At the 6-month follow-up, the patient remained disease-free, with preserved shoulder function and stable reconstruction. STRATOS provided stable fixation, preserved shoulder function, and an excellent cosmetic outcome. A brief review of the literature on sternal chondrosarcoma and reconstruction techniques is also presented. Conclusion. This unique application expands the reconstructive possibilities of modular titanium systems. It may offer a more reliable biomechanical alternative to traditional fixation methods in cases requiring stability of the shoulder girdle after SCJ resection. Further validation through biomechanical studies and larger case series is warranted. Full article

Cutaneous metastases are an uncommon but clinically relevant manifestation of breast cancer (BC), often indicating advanced disease and biological progression. Temporal heterogeneity between primary tumors and metastatic lesions, particularly involving hormone receptors (HRs) and HER2 status, may influence prognosis and treatment decisions. We retrospectively analyzed BC patients with cutaneous metastases diagnosed at a tertiary care center between 2015 and 2024. Clinical data, histopathological features, and immunohistochemical profiles of estrogen receptor (ER), progesterone receptor (PgR), and HER2 were evaluated in paired primary tumors and cutaneous metastatic lesions under uniform pre-analytic and analytic conditions. Receptor discordance and survival outcomes were assessed. Among 660 patients with metastatic BC, 28 (4.2%) developed cutaneous metastases. Median age at diagnosis was 63 years, with chest wall as the most frequent site of skin involvement. HR-positive/HER2-negative tumors were predominant, while triple-negative breast cancer accounted for 19.4% of cases and was associated with a shorter disease course and earlier cutaneous metastatic spread. Receptor discordance occurred in 18.2% for ER, 36.4% for PgR and 41.4% for HER2, mainly involving transitions to or from HER2-low status. After skin involvement, prognosis remained poor. Cutaneous BC metastases show marked receptor heterogeneity, reflecting dynamic tumor evolution. These findings support re-biopsy and biomarker reassessment to guide personalized treatment in metastatic BC. Full article

Context/Objectives: Pectus excavatum (PE), the most common anterior chest wall deformity in children and adolescents, impacts posture and is frequently associated with axial deviations due to biomechanical alterations of the spine and the properties of the involved musculature. Methods: We assessed 35 patients with PE with a Haller index below 3.25, aged between 5 and 17 years, who completed a three months specialized physical exercise program after proper training and instruction by a specialist. All patients were assessed before starting the exercise program and at the end of the treatment. The assessment method used was myotonometry, employing the MyotonPRO device, targeting the trapezius muscle with all three fascicles and the pectoralis major muscle both on the left and the right side, measuring: frequency (Hz), stiffness (N/m), decrement, relaxation time (ms), and the ratio between relaxation time and deformation time (creep). Results: The analysis of myotonometric parameters reveals a pattern of selective adaptation, predominantly involving the left hemibody in most of the groups analyzed, without significant functional imbalances. This asymmetry may reflect either the functional predominance of the left hemibody during participants’ daily activities or increased activation induced by the exercise program; however, by the end of the intervention, bilateral stability was observed in most parameters. Conclusions: A three-month physical exercise program in children and adolescents with PE results in improvements in muscle properties, particularly in the pectoralis major and middle trapezius muscles bilaterally, and contributes to the restoration of functional symmetry, thereby supporting the effectiveness of the exercise program in optimizing neuromuscular control, tissue elasticity, and scapular stability. Full article

Background/Objectives: Palliative radiotherapy (RT) to the breast or chest wall is an effective option for symptom relief in advanced or metastatic breast cancer. However, real-world data on clinical outcomes, prognostic factors, and optimal RT dose and timing in the modern systemic therapy era remain limited. This study aimed to evaluate the efficacy of palliative breast RT and explore the optimal integration of systemic therapy with RT. Methods: We retrospectively reviewed 38 patients treated with palliative RT between 2015 and 2024 at a regional tertiary center. The median gross tumor volume (GTV) dose was 50 Gy (range, 30–62.5 Gy), corresponding to a median biologically effective dose (BED) to the GTV (α/β = 4) of 78.9 Gy. Treatment response, symptom relief, toxicity, and survival outcomes were analyzed. Results: With a median follow-up of 9.5 months, median overall survival (OS) was 12.8 months. 1- and 2-year in-field local control (LC) rates were both 79.6%. In a parsimonious multivariate analysis, ≥3 prior lines of systemic therapy (HR 3.500, 95% CI 1.278–9.590, p = 0.015) was independently associated with worse OS, whereas use of SIB or GTV boost was associated with improved OS (HR 0.351, 95% CI 0.145–0.848, p = 0.020). Higher planning target volume (PTV)-BED (α/β = 4) correlated with improved LC (HR 0.909, 95% CI 0.839–0.985, p = 0.019). Symptom relief within 3 months occurred in 82%. Treatment-related toxicities were generally mild, with no grade ≥ 4 acute or grade ≥ 2 late toxicities observed. Conclusions: Palliative breast RT achieved durable local control and effective symptom palliation with acceptable toxicity. Dose-tailored RT and earlier integration within the disease course may optimize outcomes in selected patients. Full article

Undifferentiated melanoma (UM) is a rare and diagnostically challenging subtype of malignant melanoma that often lacks traditional histological features and immunophenotypic expression. We report the case of a 58-year-old man with a history of a previously excised melanoma in-situ (lentigo maligna type) of the scalp who later developed a painful chest wall mass. Subsequent workup revealed a high-grade malignant neoplasm with only focal weak S100P positivity while molecular analysis with next-generation sequencing (NGS) revealed an ultra-high TMB tumor mutational burden (>150 mut/Mb), NF1 mutation, TERT promoter mutation, TP53 mutations, PTPRD mutations, and a UV mutational signature (100% SBS7a), supportive of a diagnosis of UM. This case highlights the diagnostic value of comprehensive molecular testing in UM and its role in informing immunotherapy decisions. Full article

Background: Large language models (LLMs) such as DeepSeek-V3, Google Gemini 2.0 Pro, and ChatGPT-4o are increasingly used by patients seeking online medical information. However, their accuracy, reliability, and reproducibility in patient-facing content related to chest wall deformities (CWD) remain unclear. This study aimed to compare the performance of three contemporary LLMs in generating information on pectus excavatum, pectus carinatum, and related thoracic deformities. Methods: Eighty patient-facing questions were developed across eight thematic domains and independently submitted to each model using newly created accounts over two consecutive days. Accuracy was assessed using a validated four-point rubric by blinded physiatrists, and reproducibility was evaluated using agreement metrics and weighted Cohen’s kappa. Results: ChatGPT-4o achieved the highest overall accuracy (median score: 1.20), the greatest proportion of fully accurate responses, and the lowest hallucination rate (5.0%). Gemini showed intermediate accuracy, while DeepSeek-V3 demonstrated the lowest accuracy and highest hallucination rate (11.25%). Across all models, general-information and quality-of-life domains had the best performance, whereas treatment-related questions showed the most errors. Reproducibility was highest for ChatGPT-4o (weighted κ = almost perfect), followed by Gemini and DeepSeek-V3. Inter-rater reliability was substantial (Fleiss’ κ = 0.69). Conclusions: Contemporary LLMs can generate largely accurate and reproducible patient-facing information on CWD, with ChatGPT-4o showing the strongest overall performance. This study provides the first domain-specific comparative evaluation of LLMs in CWD and integrates reproducibility analysis alongside accuracy and reliability assessment. While these tools may support patient education, treatment-related responses require caution, and LLMs should be used as adjuncts rather than substitutes for clinical counseling. Full article

Background: Autologous fat grafting is increasingly used in irradiated postmastectomy tissues, but objective imaging-based data describing structural remodeling remain limited. Objective: This pilot study aimed to evaluate ultrasound detectable structural changes following autologous fat grafting in irradiated postmastectomy chest wall tissues. Methods: This prospective pilot study included five female patients with prior radical mastectomy and adjuvant chest wall radiotherapy who underwent a single-session of autologous fat grafting. High-resolution ultrasound was performed preoperatively and at 3–5 months postoperatively using a 12 MHz linear probe. Parameters evaluated included hypodermal thickness, echogenicity (hyperechoic versus hypoechoic patterns), fascial definition, and fibrotic patterns. Results: All patients demonstrated a consistent postoperative increase in hypodermal thickness. Preoperative compact, hyperechogenic architecture transitioned to heterogeneous hypoechogenic patterns suggestive of viable adipose tissue integration consistent with viable adipose tissue. Fascial planes became more clearly defined in four patients. No necrosis, oil cysts, or fluid collections were detected. Conclusions: In this pilot cohort, ultrasound detected consistent postoperative changes in hypodermal thickness, echogenicity, and fascial definition following autologous fat grafting. These findings support the feasibility of ultrasound for the non-invasive assessment of post-radiotherapy structural tissue changes. Full article

Progression of pectus excavatum and carinatum coincides with adolescence, a critical period for identity and self-esteem development. While clinical decision-making and insurance coverage have historically emphasized anatomic severity and cardiopulmonary functioning, increasing evidence suggests that psychosocial burden and quality of life (QoL) impairment represent central components of disease impact. A narrative review was conducted using the PubMed database to synthesize the current literature on the psychological impact of these deformities in adolescents and young adults, including body image distress, social functioning, and mental health effects before and after surgical and non-surgical correction, focusing on validated tools and qualitative studies. Across multiple cohorts, adolescents and young adults with chest wall deformities consistently report impaired body image, reduced self-esteem, social avoidance, and diminished QoL, even in the absence of diagnosable psychiatric disorders. Surgical and non-surgical corrections have positive effects in these domains. Psychological burden, therefore, represents a clinically meaningful component of chest wall deformities and should be considered alongside anatomic and physiologic criteria. Current evidence advocates for the integration of standardized psychosocial screening and support into evaluation and follow-up, which is essential for providing comprehensive, patient-centered care. Greater recognition of psychosocial outcomes may inform advocacy for broader treatment criteria, increasing accessibility among affected individuals. Full article

Background/Objectives: Non-atherosclerotic pathological findings on coronary arteries involve various disorders that might lead to myocardial ischemia, independent of plaque complications and consequent lumen narrowing and obstruction. These patients often present with non-specific symptoms such as shortness of breath, rapid fatigue, and exertional chest tightness. When the underlying causes are non-atherosclerotic, these findings are frequently overlooked in radiology reports as a possible differential diagnosis. Therefore, the objective of this paper is to present the role of multidetector computed tomography (MD CT) coronary angiography in the diagnostic work-up of patients with rare but clinically valuable non-atherosclerotic pathological conditions of coronary arteries. Methods: We performed a literature search on Medline (via PubMed) for works presenting data on rare, non-occlusive, pathological findings on coronary arteries. Results: The review of the collected literature was performed in a narrative manner, intended to summarize mainly findings of imaging characteristics of non-occlusive pathologies: myocardial bridge, coronary aneurysm, ectasia, fistula, stenosis, and dissection. MD CT images of selected cases that were examined at our department, showing non-occlusive pathological changes in the coronary arteries, are displayed in planar and/or volume-rendered formats. Conclusions: Non-atherosclerotic abnormalities of the coronary vessel wall should be considered in the differential diagnosis of coronary causes of chest pain, dyspnea, and arrhythmias, as they may lead to both acute and chronic myocardial ischemia. Based on the presented literature and specific cases from our clinical practice, MD CT is shown to be an important tool for the rapid, non-invasive evaluation of non-atherosclerotic pathologies. Full article

Background: Aortic dissection (AoD) is a life-threatening medical emergency characterized by the separation of the layers of the aortic wall. The typical clinical presentation of AoD includes intense thoracic pain in the anterior chest or interscapular region, often described as migratory and tearing in nature. However, in rare cases, AoD can present without classic signs but with neurological symptoms, including seizures. Case Presentation: A 60-year-old patient experienced a sudden loss of consciousness followed by a tonic–clonic seizure and subsequently developed right-sided weakness. He had a medical history of hypertension and smoking. Although the symptoms quickly resolved, the brain imaging revealed signs of an acute ischemic stroke located in the left hemisphere. The seizures resumed, blood D-dimer levels were found to be highly elevated, and subsequent thoracic and abdominal computed tomography angiography revealed the presence of AoD, which originated at the proximal part of the ascending aorta. The patient received symptomatic treatment to alleviate his symptoms and prevent complications and was quickly transferred for surgical intervention, resulting in a favorable outcome. Conclusions: This case demonstrates that a tonic–clonic seizure can be the first clinical manifestation of AoD. Such atypical symptoms highlight the diverse and misleading nature of AoD presentations, underscoring the challenges in the diagnostic process. This emphasizes the need for increased clinical vigilance when treating a patient experiencing their first seizure episode. Full article

Mucus plugs are airway-obstructing accumulations of inspissated secretions frequently observed in obstructive lung diseases (OLDs), including chronic obstructive pulmonary disease (COPD), severe asthma, and cystic fibrosis. Their presence on chest CT is strongly associated with airflow limitation, reduced lung function, and increased mortality, making them emerging imaging biomarkers of disease burden and treatment response. However, manual delineation of mucus plugs is labor-intensive, subjective, and impractical for large cohorts, leading most prior studies to rely on coarse segment-level scoring systems that overlook lesion-level characteristics such as size, extent, and location. Automated plug-level quantification remains challenging due to substantial heterogeneity in plug morphology, overlap in attenuation with adjacent vessels and airway walls on non-contrast CT, and pronounced size imbalance in clinical datasets, which are typically dominated by small distal plugs. To address these challenges, we developed and validated a simulation-driven, annotation-free deep learning framework for automated detection and segmentation of airway mucus plugs on non-contrast chest CT. A total of 200 COPD CT scans were analyzed (98 plug-positive, 83 plug-negative, and 19 uncertain). Synthetic mucus plugs were generated within segmented airways by transferring voxel-intensity statistics from adjacent intrapulmonary vessels, preserving realistic morphology and texture while enabling controlled sampling of plug phenotypes. An nnU-Net trained exclusively on synthetic data (S-Model) was evaluated on an independent, expert-annotated test set and compared with an nnU-Net trained on manual annotations using 10-fold cross-validation (M-Model). The S-Model achieved significantly higher detection performance than the M-Model (sensitivity 0.837 [95% CI: 0.818–0.854] vs. 0.757 [95% CI: 0.737–0.776]; 1.91 false positives per scan vs. 3.68; p < 0.001), with performance gains most pronounced for medium-to-large plugs (≥6 mm). This simulation-driven approach enables accurate, scalable quantification of mucus plugs without voxel-wise manual annotation in thin-slice (<1.5 mm) non-contrast chest CT scans. While the framework could, in principle, be extended to other annotation-limited medical imaging tasks, its generalizability beyond this COPD cohort and imaging protocol has not yet been established, and future work is required to validate performance across diverse populations and scanning conditions. Full article