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Background: Interventional pain management is essential for patients with cancer who experience medically uncontrollable chest wall pain to help control their symptoms and improve their quality of life. However, there is a lack of data on this topic, so there is an urgent need for further research. Objectives: To identify the effects of radiofrequency ablation (RFA) of the thoracic nerve roots on pain outcomes in patients with cancer and intractable chest wall pain. Study Design: Retrospective, observational cohort study. Setting: National Cancer Center in Korea. Methods: The medical records of patients with cancer who were referred to the pain clinic at our National Cancer Center for intractable chest wall pain and who underwent thoracic nerve root RFA between Jan. 1, 2011 and Dec. 31, 2015 were analyzed. The primary outcome was the change in Numeric Rating Scale (NRS) scores between pre-procedure and one week, one month, and 6 months post-procedure. The secondary outcomes were the change in morphine equivalent daily dose (MEDD) between pre-procedure and one week, one month, and 6 months post-procedure, and whether the primary cancer type (lung vs. non-lung) or radiotherapy to the chest within one month affected the outcomes of RFA. The Wilcoxon signed-rank test was used to compare RFA data between pre and post-procedure and P values less than 0.05 were considered statistically significant. Results: One hundred patients were included in the final analysis. The median NRS score in patients who underwent RFA decreased from 7 (range 3–10) pre-procedure to 4 (0–9) at one week and one-month post-procedure (both P < 0.001) and 4 (1–8) at 6 months post-procedure (P < 0.001). The median MEDD value decreased from 200 (range 30–1800) mg pre-procedure to 180 (10–1600) mg at one week post-procedure (P < 0.001), but there was no statistically significant change at one month (P = 0.699) or 6 months (P = 0.151) post-procedure. There was no difference in RFA outcome according to type of primary cancer or radiotherapy to the chest within one month. Limitations: Retrospective design. Conclusion: Radiofrequency thermocoagulation of the thoracic nerve roots achieved effective short-term pain control in patients with cancer and intractable chest wall pain. Key words: Radiofrequency ablation, thermocoagulation, thoracic nerve root, cancer, chest wall pain, radiotherapy, pain relief

Author(s): Chao, Hann-Hsiang; Valdes, Gilmer; Luna, Jose M; Heskel, Marina; Berman, Abigail T; Solberg, Timothy D; Simone, Charles B | Abstract: Background and purposeChest wall toxicity is observed after stereotactic body radiation therapy (SBRT) for peripherally located lung tumors. We utilize machine learning algorithms to identify toxicity predictors to develop dose-volume constraints.Materials and methodsTwenty-five patient, tumor, and dosimetric features were recorded for 197 consecutive patients with Stage I NSCLC treated with SBRT, 11 of whom (5.6%) developed CTCAEv4 grade ≥2 chest wall pain. Decision tree modeling was used to determine chest wall syndrome (CWS) thresholds for individual features. Significant features were determined using independent multivariate methods. These methods incorporate out-of-bag estimation using Random forests (RF) and bootstrapping (100 iterations) using decision trees.ResultsUnivariate analysis identified rib dose to 1nccnln4000ncGy (Pn=n0.01), chest wall dose to 30nccnln1900ncGy (Pn=n0.035), rib Dmaxnln5100ncGy (Pn=n0.05) and lung dose to 1000nccnln70ncGy (Pn=n0.039) to be statistically significant thresholds for avoiding CWS. Subsequent multivariate analysis confirmed the importance of rib dose to 1ncc, chest wall dose to 30ncc, and rib Dmax. Using learning-curve experiments, the dataset proved to be self-consistent and provides a realistic model for CWS analysis.ConclusionsUsing machine learning algorithms in this first of its kind study, we identify robust features and cutoffs predictive for the rare clinical event of CWS. Additional data in planned subsequent multicenter studies will help increase the accuracy of multivariate analysis.

Purpose Stereotactic ablative radiation therapy (SABR) to lung tumors close to the chest wall can cause rib fractures or chest wall pain. We evaluated and propose a clinically practical solution of using noncoplanar volumetric modulated arc radiation therapy (VMAT) to reduce chest wall dose from lung SABR. Methods and materials Twenty lung SABR VMAT plans in which the chest wall volume receiving 30 Gy or higher (V30) exceeded 30 mL were replanned by noncoplanar VMAT with opposite 15° couch kicks. Dosimetric parameters including chest wall V30 and V40; lung V5, V10, V20, and mean dose; Paddick high-dose conformity index; intermediate-dose conformity index; and monitor units (MU) for each plan were used to evaluate the plan quality. The treatment time was also estimated by delivering the entire treatment. Two-sided paired t test was used to evaluate the difference of the dosimetric parameters between coplanar 1 arc (cVMAT1), coplanar 2 arcs (cVMAT2), and noncoplanar two arcs (nVMAT2) plans; differences with P Results V30 and V40 for chest wall were reduced on average by 20% ± 9% and 15% ± 11% (mean ± standard deviation) from cVMAT2 plans to nVMAT2 plans (P Conclusions We found that noncoplanar VMAT plans are feasible, clinically practical to deliver, and significantly reduce V30 and V40 of chest wall without increasing lung dose.

The present study compares dosimetric parameters between volumetric-modulated arc therapy (VMAT) and 3D conformal radiation therapy (3D-CRT) in lung tumors adjacent to the chest wall treated with stereotactic body radiation therapy (SBRT). The study focused on the radiation dose to the chest wall of 16 patients who had developed radiation-induced rib fractures (RIRF) after SBRT using 3D-CRT. The targets in all patients were partially overlapping with the fractured ribs, and the median overlapping rib–PTV distance was 0.4 cm. Stereotactic body radiation therapy was re-planned for all patients. The prescribed dose was 48 Gy in four fractions to cover at least 95% of the planning target volume (PTV). Evaluated dosimetric factors included D98% and the conformation number (CN) of the PTV, the D2cm3, V40 and V30 of the fractured ribs, the V30 of the chest wall, and the Dmean, V20 and V5 of the lung. A comparison of 3D-CRT with the VMAT plan for PTV revealed that CN was significantly improved in the VMAT plan, whereas D98% did not significantly differ between the two plans. Regarding organs at risk (OARs), the D2cm3, V40 and V30 of fractured ribs, the V30 of the chest wall, and the Dmean, V20 and V5 of the lung, were significantly decreased in the VMAT plan. We concluded that the dose to OARs such as ribs and chest wall could be reduced with improved target conformity using VMAT instead of 3D-CRT for SBRT to treat peripheral lung tumors.

PURPOSE/OBJECTIVE(S) We aimed to evaluate the safety of and maximum tolerated dose (MTD) for 5-fraction stereotactic ablative radiotherapy (SABR) for early-stage lung squamous cell carcinoma (SCC), for which local failure rates appears higher than that of early-stage adenocarcinomas. MATERIALS/METHODS A single institution phase I study was conducted in pathologically confirmed early-stage lung SCC. The 3+3 design involved 4 dose levels of 11, 12, 13, and 14 Gy x 5 fractions delivered every other day (dose levels DL1, DL2, DL3, and DL4, respectively). The primary objective was to determine the MTD of 5-fraction SABR, which was defined as the dose associated with a 33% rate of dose-limiting toxicities, defined as grade ≥3 respiratory/mediastinal or cardiac events (or grade ≥4 gastrointestinal or chest wall events), with toxicities reported until data lock in October 2020. Target volume delineation and organ-at-risk (OAR) constraints were based on RTOG 0813, using OAR constraints expressed in percent of prescription as fixed constraints from the 11 Gy per fraction prescription for all DL. Institutional constraints for the chest wall were used (V30 < 30cm3, up to 70 cm3 acceptable; maximum point dose 52.5 Gy). Target coverage objectives included ≥95% of the planning target volume (PTV) to be covered by 100% of the prescription dose, and 100% of the internal target volume (ITV) to receive ≥110% of the prescription dose. For technically challenging cases, it was permitted to prescribe as low as 50 Gy (BED of 100 Gy10) to a small portion of the GTV, ITV (if used) and corresponding PTV adjacent to a critical OAR (split target volume prescription). SABR was delivered using free breathing, deep inspiration breathhold, or expiratory gating. Thus, ITVs were not used for all patients. RESULTS From October 2017 to June 2020, 13 patients were enrolled: 3 in DL1, 3 in DL2, 4 in DL3, and 3 in DL4. Seven (IASLC definition) or 6 (RTOG) patients had central lesions, and the rest abutted the chest wall. All patients completed SABR per protocol without major deviations. At 18.4 months median follow-up (range, 2.4-25.6 months), no patient developed dose limiting toxicities. There were no grade 4-5 events and 1 grade 3 event (painful brachial plexopathy, which occurred in DL1 at 16 months post-SABR at the time of local progression). There were 7 instances of grade 2 toxicities. These included fatigue (n = 1, DL2), chest wall pain (n = 2, DL2 & DL4), cough (n = 1, DL3), dyspnea (n = 2, DL3 & DL4), nausea (n = 1, DL4), and wheezing (n = 1, DL4). Eight (62%) patients required utilization of "split target volume" prescriptions. The mean total dose to the GTV ranged from 60.9-62.2 Gy for DL1, 63.2-68.6 Gy for DL2, 67.3-78.8 Gy for DL3, and 75.5-82.2 Gy for DL4. The median GTV was 19.9 cc (range 5-57cc). CONCLUSION 5-fraction SABR for early-stage lung SCC up to 14 Gy x 5 fractions using a split target prescription for OAR adjacent tumor appears safe. Long term follow up will be needed to assess late toxicities and tumor control. (NCT03321747).

BACKGROUND Regaining and maintaining sternal stability is key to recovering from cardiac surgery and resuming normal life. MontageTM (ABYRX, Irvington, NY, USA) is a settable, resorbable putty that adheres to bleeding bone and achieves rigid sternal fixation following application (Image). We evaluated feasibility, safety, and efficacy of enhanced sternal closure (ESC) with a novel bone putty to accelerate post-operative functional recovery in patients receiving median sternotomy. METHODS AND RESULTS A single-center, single-blinded (participant only), randomized controlled trial was performed (NCT03365843). Consenting patients for elective cardiac surgery via sternotomy received sternal closure using either 8-10 cc of bone putty with wire cerclage (ESC) or wire cerclage alone (control). To date, 32 patients with ESC and 25 control patients reached 6 weeks with 100% follow-up. Student t-test and Fischer's exact test analyzed continuous (mean ± SEM) and categorical variables (Table). Both groups had similar BMI. There were no device-related safety concerns. The ESC group had a shorter time to discharge. Bedside spirometry was used when COVID-19 restrictions allowed. At 5 days or discharge, more patients with ESC recovered to 60% of their baseline FVC (22/28 patients vs 11/23 patients; p=0.04; ESC vs Control). A Likert-type 11-point scale quantified incisional, chest wall, and back pain/discomfort. The ESC group had less incisional pain while resting and at post-operative day 5 or discharge; while breathing at day 5 or discharge; while sleeping at day 5 or discharge and 2 weeks; and while walking at day 5 or discharge. The ESC group had less chest wall pain at day 3 and day 5 or discharge; and less back pain at day 3 and day 5 or discharge. Standardized patient-reported outcomes measures assessed health-related quality of life (EQ-5D index) and physical disability (Health Assessment Questionnaire). ESC improved physical functional recovery with a lower HAQ Index at day 5 or discharge, 2 weeks, and 4 weeks. More patients with ESC recovered to baseline HAQ at 2 weeks and 4 weeks. ESC increased EQ-5D Index scores for quality of life at day 5 or discharge, 2 weeks, and 4 weeks. More patients with ESC recovered to baseline EQ-5D Index by 5 days or discharge. CONCLUSION Enhanced sternal closure with a novel hardening bone putty for rigid fixation accelerates patient recovery. ESC improved ventilatory recovery, reduced pain, and accelerated recovery to baseline function and quality of life. Earlier hospital discharge with ESC may provide substantial cost benefits for the healthcare system.

Author(s): Chandwani, Deepak; Arnold, Jeff; Terrusa, John | Abstract: Case Presentation: A 30-year-old healthy male presented with a complaint of chest pain after mild thoracic trauma sustained while rescuing stranded flood victims during Hurricane Harvey. Careful physical examination revealed a tender palpable cord along the lateral aspect of his chest consistent with a superficial thrombophlebitis.Discussion: Mondor’s disease is a superficial thrombophlebitis with myriad underlying causes that can involve the thoracic wall. Although Mondor’s disease has been well described in the literature, this case describes a unique presentation in an austere environment with blunt trauma as the underlying cause.

Background: Lymphedema of the breast/chest wall after breast cancer treatment is often associated with pain and reduced quality of life. We conducted a pilot study to evaluate whether the use of a compression vest reduced symptoms of breast/chest wall edema in breast cancer patients. Methods and Results: This single-center study included patients (n = 25) with symptomatic breast/chest wall edema with a pain score of ≥3 on the Numerical Rating Scales (range 1-10). The patients were instructed to wear a compression vest (Lymphatrex, Class II) for 6 months. Wilcoxon signed-rank tests were used to compare differences in patient-reported pain intensity/severity. Analyses included all patients with available data. In total, 17 (68%) continued to wear their vests for 6 months, whereas the other 8 withdrew prematurely. At baseline, median pain severity (4.9, interquartile range [IQR] 3.6-6.0) and pain interference (4.3, IQR 2.1-5.9) scores were significantly higher compared with pain scores after wearing the compression vest for 6 months (1.8 IQR 1.0-4.8 and 1.4 IQR 0.9-4.4, resp.). Patient-reported breast/chest wall swelling decreased from 92% (n = 22) at baseline to 71% (n = 12) at 6 months. The prevalence of moderate/severe patient-reported breast/chest wall pain declined from 63% (n = 15) at baseline to 18% (n = 3) at 6 months. Physical, emotional, and social functioning improved over time and was comparable to scores of the Dutch reference population. Conclusion: The results of this pilot study suggest that a compression vest could be an acceptable and effective treatment option for patients with painful breast/chest wall edema. In compliant patients, swelling and pain was significantly reduced.

Introduction: Diabetic polyneuropathy involves peripheral, cranial or autonomic nerves causing well known clinical presentations, easily identifiable by clinicians. Rarely, diabetic neuropathy affects the intercostal neural roots causing severe and difficult to treat thoracic and abdominal pain. We present an interesting case where diagnosis of thoracic radiculopathy was made 8 years later. Case Presentation: A 62-year-old man with type 1 diabetes mellitus presented with a history of severe right lower thoracic and flank pain. He was diagnosed with diabetes at age 20 and developed complications such as peripheral polyneuropathy. His pain was sharp and burning in nature in a “band like” distribution in the right lateral subcostal margin. The intensity ranged from 3-10/10. Exam showed tenderness to touch in the right lateral subcostal margin with no sensory deficits. He visited different specialists within a year in attempts to obtain pain relief. Therapeutic attempts done included opiates, duloxetine, gabapentin and NSAIDs with minimal improvement. Initial workup included a normal bone scan and thoracic spine MRI which showed degenerative disk disease at the level of T7-T8. Corticosteroid injection at T7-T9 resulted in no pain relief. Then a pain specialist made the diagnosis of DTR. A T10 nerve block was given with significant relief. Since then, he has received intermittent nerve blocks with complete resolution of his symptoms. Discussion: Diabetic neuropathy is the most common complication of diabetes mellitus. Truncal roots originating from the spinal cord can be affected causing a distinct disorder termed Diabetic Truncal Radiculopathy (DTR). DTR is a rare form of diabetic neuropathy that is significantly underdiagnosed. DTR is of three types - Cervical, thoracic and lumbosacral. It is commonly unilateral following the distribution of an intercostal nerve in a band like pattern. The pain is described as burning or aching in nature, frequently intensified at night associated with sensitivity to touch. The patients are usually middle aged or older adults with long standing history of diabetes. There is certain preference for men with DM type 2. It is a diagnosis of exclusion. EMG typically demonstrates denervation potentials in the intercostal, anterior abdominal wall and paraspinal muscles. The differential diagnosis is primarily based on the localization of neural injury. Involvement of upper thoracic nerves causes chest pain whereas lower thoracic nerves causes upper abdominal pain. The management is similar to other diabetic related neuropathies but challenging. Intensive glycemic control is ineffective in pain relief. DTR should be considered as a possible cause of atypical flank or chest wall pain not explained by other causes. Simple interventions such as intercostal nerve blocks are successful in improving the pain, quality of life and functionality of patients. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Introduction: The relationship between chronic empyema and malignant tumors, most of which are lymphoma, has been recognized for many decades. Sarcomatoid carcinoma associated with chronic empyema is extremely rare, may metastasize to other organs in the early stage, and rapidly progresses to death. As far as we know, this was the first case report on sarcomatoid carcinoma associated chronic empyema. The patient's main concerns and important clinical findings: A 59-year-old man presented to our hospital with a 9-year history of chronic empyema and a chief complaint of left chest wall pain for 5 months. The diagnostic contrast-enhanced computed tomography (CT) showed a large irregular soft tissue mass located on the left lower hemithorax at the margin of the empyema cavity extending to the adjacent chest wall and lung parenchyma. In addition, CT revealed pleural and pulmonary metastases surrounded by ground glass opacity. The main diagnosis, therapeutics interventions, and outcomes: The patient underwent CT guided percutaneous core needle biopsy (PCNB). The histopathological evaluation showed carcinomatous proliferation of pleomorphic spindle cells with extensive necrosis. Immunohistochemically, tumor cells were positive for cytokeratin and vimentin. The final histopathological diagnosis was sarcomatoid carcinoma underlying chronic empyema. The tumors showed rapid progression on serial simple radiography. Palliative treatments were performed, but the patient still developed severe dyspnea and died shortly after on day 16. Conclusion: Sarcomatoid carcinoma can occur very rarely as a complication of chronic empyema, and is more aggressive than usual. Early detection of developing malignancy during the follow-up of chronic empyema is an important factor for patient prognosis.

BackgroundThere is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.MethodsA systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.ResultsTwenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.ConclusionsGiven the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.Level of evidenceLevel IV systematic reviews and meta-analyses.

Management of intractable cancer-associated chest wall pain is difficult once patients have reached dose-limiting side effects of opioids and coanalgesic medications. This case series describes 11 patients with intractable cancer-associated chest wall pain who were treated with a diagnostic intercostal nerve block. Six patients subsequently received chemical neurolysis with phenol using the same approach. No serious adverse events were observed. Radiopaque contrast dye spread into the paravertebral space in all 11 patients, and in 1 patient contrast dye spread into the epidural space. Seven of 11 patients experienced pain relief from the diagnostic blockade. Four of six patients experienced pain relief from the neurolytic blockade. The principal reportable finding from this case series is the observation that contrast dye spread liberally from the intercostal space into other anatomic spaces, even though very small volumes of injectate (less than 5 mL) were used. Definitive evidence of safety and efficacy of intercostal nerve block and neurolysis for cancer pain will require a prospective randomized clinical trial.

Many recent studies have described rib fractures and chest wall pain following stereotactic body radiation therapy (SBRT). Although these toxicities generally are not life-threatening, the chest wall and ribs are considered dose-limiting tissues because of the potential effect on patients׳ quality of life. Few studies have reported dose-response models that can provide quantitative estimates of risk as a function of dose and volume. Notably, Memorial Sloan Kettering Cancer Center (Mutter et al(8)) analyzed grade 2 or higher chest wall toxicity in a cohort of 126 patients treated with linear accelerator-based SBRT; the authors provided detailed dose-volume histogram (DVH) data to allow for pooled analyses. We pooled these 126 patients with an additional 44 patients treated with CyberKnife at the Erlanger Medical Center to create an updated dose-response model for chest wall tolerance. In the aggregate analysis, the 10% risk level for grade 2 or higher complications for D70cc was 16.2Gy in 4 fractions, and the 50% risk level was D70cc = 65.1Gy in 4 fractions. For D2cc, the 10% and 50% risk levels in 4 fractions were 43.0Gy and 87.9Gy, respectively. These dose-tolerance limits may help quantify chest wall toxicity risks. Further research continues to determine more accurate estimates of grade 3 risk levels.

In this case report, we described the use of the continuous erector spinae plane (ESP) block in a patient presenting with severe chest wall pain due to terminal metastatic breast cancer. Her pain was refractory to most treatment modalities despite being on huge doses of parenteral opioids for 6 months. A single shot ESP block was initially trialed, which provided her complete pain relief. This was followed by an ESP catheter insertion and continuous infusion of local anesthetic, which helped her wean off the parenteral opioids over the next 4 days. She was discharged home with the catheter in situ, attached to a delivery pump.

A 71-year-old female presented to the emergency room eight weeks status post open heart surgery for aortic valve replacement with right-sided chest wall pain and swelling. Computed tomographic (CT) angiography demonstrated a hyperattenuating structure arising from the right internal mammary artery surrounded by a heterogeneously-attenuating fluid collection in the anterior right chest wall, compatible with a right internal mammary artery pseudoaneurysm with surrounding chest wall hematoma. Follow up color Doppler ultrasound confirmed the diagnosis. Under direct ultrasound visualization, we injected four hundred units of thrombin into the neck of the pseudoaneurysm using a 25-gauge spinal needle. Post-injection imaging demonstrated a successful cessation of flow within the pseudoaneurysm sac.

Background Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. Case Report A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. Why Should an Emergency Physician Be Aware of This? In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.

Background. The aim of the study was to determine the diagnostic agreement between the discharge diagnosis and the suspected diagnosis by the prehospital emergency physician and to run a sensitivity analysis of the most common diagnoses by the prehospital emergency physician. Methods. The diagnostic agreement was determined by a systematic comparison of the discharge diagnosis with suspected diagnosis by the prehospital emergency physician in a period of 24 months at the emergency medical services in Bad Belzig. The diagnostic agreement of the 13 most common discharge diagnoses was compared to the remaining diagnostic agreement. The results were tested for statistical significance using the chi-squared test. Results. In 64.1% of cases included, a diagnostic agreement occurred. There was a high proportion of diagnostic agreement for hypoglycemia (97%), atrial fibrillation (87%), cramping seizure (86%), hypertensive crisis (85.5%), and syncope (81%). There was a low proportion of diagnostic agreement for chest wall pain (27%), pneumonia (32%), and cardiac decompensation (53%). Conclusions. Our attention in practice and emergency medical courses should be directed to chest pain patients and the main symptom of dyspnea, because of the high proportion of incorrect diagnoses by the prehospital emergency physician. It should be noted that 92% of incorrectly diagnosed chest wall pain cases were overestimated with an acute coronary syndrome.

Conditions affecting the musculoskeletal structures of the chest wall are among the most common causes of chest pain. It is vital to rule out coronary syndromes in patients presenting with chest wall pain, who have risk factors for coronary artery disease. Presented are some of the more common causes of chest wall pain and their clinical findings, diagnostics and treatment.

Blunt chest trauma is defined as a high energy injury to the thorax and its structures, and it is usually a strong indicator of severe injury. Its clinical presentation can vary from rib fractures to pneumothorax, hemothorax, lung and soft tissue contusion; these lesions and consequential pain predispose to respiratory failure by compromising respiratory mechanics and by exacerbating pre-existing lung disease. This picture can lead to a number of complications, such as pneumonia or ARDS, that have a significant impact on patients’ morbidity and mortality. One of the cornerstones of blunt chest trauma management is providing early and effective analgesia: pain control improves respiratory mechanics, reduces possible complications and allows effective and aggressive physiotherapy. In literature, there are few clinical trials comparing different analgesic techniques for pain relief in blunt thoracic trauma; our review aims to detail the clinical implication, adequacy and possible complications of different analgesic approaches commonly used in thoracic trauma management, such as epidural anesthesia, regional anesthesia, endovenous and intrathecal analgesia. This review is also focused on management and prevention of chronic pain. Pain management, lung toilet, aggressive respiratory therapy and early mobilization are key to a successful patient recovery. In selected patients, operative fixation may lead to better outcomes although further research is needed to clearly identify the category of patients and the ideal timing for surgical intervention. Chronic pain develops in up to 50% of the patients after a thoracic trauma. A multimodal approach tackling both its somatic and neuropathic component is essential to chronic pain prevention. Early and effective pain control demonstrated to have a pivotal role on patient recovery. While endovenous analgesia constitutes the method of choice for intensive care unit (ICU) sedated patients, regional unilateral analgesia should be considered in awake and spontaneously breathing patients. The approach of choice should be tailored on the single patient and, if possible, a multimodal strategy should be established.

Background and purposeChest wall toxicity is observed after stereotactic body radiation therapy (SBRT) for peripherally located lung tumors. We utilize machine learning algorithms to identify toxicity predictors to develop dose-volume constraints.Materials and methodsTwenty-five patient, tumor, and dosimetric features were recorded for 197 consecutive patients with Stage I NSCLC treated with SBRT, 11 of whom (5.6%) developed CTCAEv4 grade ≥2 chest wall pain. Decision tree modeling was used to determine chest wall syndrome (CWS) thresholds for individual features. Significant features were determined using independent multivariate methods. These methods incorporate out-of-bag estimation using Random forests (RF) and bootstrapping (100 iterations) using decision trees.ResultsUnivariate analysis identified rib dose to 1cc&nbsp

Studies have confirmed that, for severe flail chest or sternal fractures and even multiple rib fractures, surgical treatment can effectively reduce hospital stay and relieve chest wall pain. However, fixation of multiple costal cartilage fractures in such a small area is a challenge if an internal fixator is simply placed directly on the sternum. This case report shares a method of simultaneous fixation of multiple costal cartilage and sternal fractures through a small incision, and it is also appropriate for multiple costal cartilage fractures without sternal fracture.

Postherpetic neuralgia (PHN) is a debilitating condition that frequently arises after herpes zoster (HZ) caused by the varicella-zoster virus. It is characterized by severe neuropathic pain and sensory disturbances persisting after the resolution of characteristic vesicular skin lesions. Most commonly affected are the thoracic dermatomes. Trigeminal (V1), cervical, and lumbar nerves are other frequently affected sites. Early treatment shortens the duration of acute HZ and may prevent the onset of PHN. A variety of modalities are utilized to treat PHN, including chemical compounds, interventional pain techniques, and neuromodulation. HZ vaccine is recommended for individuals more than 60 years old, and it is currently the best method of averting HZ and consequent progression to PHN.

Background No consensus on how to best predict for chest wall injury following SABR exists. We report our experience in chest wall dose assessment when treating peri-pleural lung lesions with stereotactic ablative radiotherapy (SABR) delivered with volumetric modulated arc therapy (VMAT). Methods 40 patients with peri-pleural peripheral lung tumors underwent SABR between July, 2012 and February, 2015. Chest wall toxicity, dose distribution, and the influence of chest wall delineation method were investigated. Results After a median follow up of 16 months, no rib fracture or skin toxicity was observed. 4 patients (10%) reported persistent chest wall pain (grade 1–2). High dose rate's association with chest wall pain trended toward statistical significance ( p =0.06). PTV exclusion and reducing chest wall expansion to 1 cm led to significant dose reduction in the chest wall dose volume parameters ( p Conclusions The risk of chest wall pain following SABR delivered with VMAT is low. High dose rate, which is 1400 MU/min with flattening filter free (FFF) beams vs. 500–600 MU/min with non-flattening filter free (non-FFF) beams, may contribute to it. Chest wall dose volume parameters may vary with PTV exclusion; while chest wall expansion of 1 cm may fail to account for some high dose regions in the chest wall.

Context.Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one.Objectives.To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions.Methods.Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article.Results.Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient.Conclusion.Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

The aim of this study was to investigate quantitatively the dosimetric factors that increase the risk of clinical complications of rib fractures or chest wall pain after stereotactic body radiation therapy (SBRT) to the lung. The correlations of clinical complications with standard-uptake values (SUV) and FDG-PET activity distributions from post-treatment PET-imaging were studied. Mean and maximum doses from treatment plans, FDG-PET activity values on post-SBRT PET scans and the presence of clinical complications were determined in fifteen patients undergoing 16 SBRT treatments for lung cancer. SBRT treatments were delivered in 3 to 5 fractions using 5 to 7 fields to prescription doses in the range from 39.0 to 60.0 Gy. The dose and FDG-PET activity values were extracted from regions of interest in the chest wall that matched anatomically. Quantitative evaluation of the correlation between dose deposition and FDG-PET activity was performed by calculating the Pearson correlation coefficient using pixel-by-pixel analysis of dose and FDG-PET activity maps in selected regions of interest associated with clinical complications. Overall, three of fifteen patients developed rib fractures with chest wall pain, and two patients developed pain symptoms without fracture. The mean dose to the rib cage in patients with fractures was 37.53 Gy compared to 33.35 Gy in patients without fractures. Increased chest wall activity as determined by FDG-uptake was noted in patients who developed rib fractures. Enhanced activity from PET-images correlated strongly with high doses deposited to the chest wall which could be predicted by a linear relationship. The local enhanced activity was associated with the development of clinical complications such as chest wall inflammation and rib fracture. This study demonstrates that rib fractures and chest wall pain can occur after SBRT treatments to the lung and is associated with increased activity on subsequent PET scans. The FDG-PET activity provides a useful parameter that can be used clinically to predict chest wall complication in lung patients.

Data about persistent pain after breast cancer treatment (PPBCT) after cosmetic or reconstructive breast surgery is limited and focuses on subpectoral implant placement or intercostal nerve injury. We report one patient who presented with bilateral PPBCT and thoracodorsal neuroma after immediate breast reconstruction with the latissimus dorsi myocutaneous flap (LDMF) and subpectoral tissue expander (TEs). This case demonstrates that thoracodorsal neuroma can be a potential cause of post-reconstruction breast pain. A 65-year-old woman with a history of right breast cancer presented for evaluation of bilateral chronic breast pain following bilateral skin-sparing mastectomy, right axillary lymph node dissection, and bilateral immediate breast reconstruction with the LDMF and TEs 2 years prior. During the initial operation, the thoracodorsal nerves were not divided surgically and the tissue expanders were placed in the subpectoral and sub-latissimus dorsi plane. She had no chemotherapy or radiotherapy. Postoperatively, she developed significant chest wall pain. Five months later, the TEs were removed and exchanged for silicone breast implants. The pain persisted postoperatively and was attributed to bilateral Baker grade 4 capsular contracture. Three months after implant exchange, she underwent a third surgery where bilateral thoracodorsal nerve main trunk transection, capsulotomy, implant exchange and breast fat grafting were performed. Unfortunately, pain relief only lasted 1.5 months. She was evaluated in a chronic pain clinic and had tried numerous conservative measures without success including bilateral intercostal nerve blocks, supportive bras, topical ketamine, and medications, including gabapentin, celecoxib, diazepam, acetaminophen, oxycodone, and lidocaine 5% patch. At her initial clinical evaluation with us, the patient described breast pain rated at 8/10 on visual analog scale, and spasms located over the anterior lower pole of her breasts which felt like a constricting belt around her chest. Physical examination revealed active LD muscle contraction and involuntary muscle spasms. This prompted us to offer surgical exploration. Intraoperatively, bilateral thoracodorsal nerve trunks were found intact, with a visible intraneural mass in both nerves (Fig. 1). The LD muscles were found in the lower pole of both breasts, and were attenuated. Because the patient desired to reduce her breast size in hope of alleviating pain, it was decided to excise the LD myocutaneous flaps by performing a proximal myotomy. A 3 cm segment of thoracodorsal nerve was sent to pathology from each side, and the proximal thoracodorsal nerve stumps were ligated with permanent suture. To minimize the risk of postoperative muscle spasms, the mastectomy defect was recreated, the pectoralis major was repositioned in anatomic position on the chest wall, and TEs were circumferentially wrapped with acellular dermal matrix (Fig. 2) and secured to the chest wall in the subcutaneous plane. Fig. 1 Bilateral thoracodorsal neuroma: Bilateral thoracodorsal nerves were dissected and isolated. A visible area of enlargement of the proximal thoracodorsal nerve was noticed on both sides, corresponding to the neuroma. (A) Right side. (B) Left side. Fig. 2 Tissue expander (TEs) wrapped with acellular dermal matrix: to minimize the risk of postoperative muscle spasms, the mastectomy defect was recreated, the pectoralis major was repositioned in anatomic position on the chest wall, and TEs were circumferentially ... In the early postoperative course, pain was improved bilaterally. Three months later, the patient underwent bilateral removal of TEs and exchange for silicone breast implants. Six months postoperatively, she remained pain free. Histology of bilateral thoracodorsal nerves revealed dense fibrosis consistent with neuroma (Fig. 3). Fig. 3 Histology of thoracodorsal nerve biopsies: The thoracodorsal nerve biopsies showing haphazardly arranged tangles of variably sized nerve twigs set in a fibrous stroma, characteristic findings of traumatic neuroma. (A) H&E, ×40. (B) H&E, ... PPBCT is a common but poorly understood problem without a clear definition. PPBCT symptoms include altered skin sensations, burning or electric pains, pressure sensations, numbness, aching, and tightening in the breast and axilla. Development of PPBCT is complex and involves multiple preoperative, intraoperative, and postoperative elements [1]. Cosmetic and reconstructive breast surgery may be associated with persistent breast pain, but relevant research on this topic is rare and focuses on subpectoral implant placement or intercostal nerve injury [2]. Limited data show breast reconstruction with subpectoral implant does not confer increased prevalence of persistent pain [3], but capsule formation, compression of the lateral and medial pectoral nerves and intercostal nerve injury may cause chronic pain [2]. The lateral aspect of the breast is most susceptible to intercostal injury. Nearly 80% of intercostal neuromas were seen in this anatomic location [2]. Our case confirmed the complex and heterogenous presentation of PPBCT. We hypothesize that thoracodorsal neuromas-in-continuity were the initial etiology of pain. This would explain why the pain appeared shortly after the first reconstructive surgery. A neuroma-in-continuity is a neuroma that occurs within an intact nerve resulting from failure of the regenerating nerve growth cone to reach peripheral targets and resulting in a distal portion of the nerve that no longer functions properly [4]. The recurrent pain following the third surgery - where thoracodorsal nerve transection was performed - was most likely caused by the thoracodorsal neuroma and LD muscle reinnervation, which occurred either from incomplete nerve resection or spontaneous neurotization [5]. Mechanical injury during flap dissection or traction could be other possible causes. Meanwhile, capsular contracture, compression of the lateral and medial pectoral nerves under the pectoralis muscle are all additional potential additional causes of pain [2]. Since its first introduction in 1896, use of the LD flap for breast reconstruction has remained popular, but whether and when to cut the thoracodorsal nerve is still controversial. Some authors believe that cutting or saving the nerve does not have an effect on the flap volume or muscle activity in the long run. Thus, both practices seem to be justified [3]. But this case offers new evidence why denervation of thoracodorsal nerve should be performed when harvesting the LD flap: keeping the nerve intact can increase the possibility of voluntary muscle spasm and chronic breast pain. Proximal nerve resection at the axillary apex, with a nerve transection of at least 1 cm, was suggested for a successful denervation [5]. PPBCT has a significant negative effect on quality of life. Non-steroidal anti-inflammatory drugs, benzodiazepines and antidepressants are the most commonly used medications, none of which are very effective. If the pain is caused by the presence of a neuroma, surgical resection can result in complete pain relief. A heightened awareness of the diagnosis and management of neuroma is very important, since this is a treatable cause of pain. When having a consultation about chronic pain after LD breast reconstruction, surgeons should always keep in mind that this is a complex and heterogenous condition for both diagnosis and treatment. Thoracodorsal neuroma should be considered as a possible cause.

Background Skeletonization of the internal mammary artery for single left internal mammary artery (LIMA) use remains controversial. We sought to elucidate the effect of different harvesting techniques applied in single LIMA grafting. Method Between January 2006 and January 2012, 982 patients undergoing off-pump coronary artery bypass with pedicled LIMA conduits (P Group) and 928 patients undergoing the same operation with skeletonized LIMA conduits (S Group) were enrolled. The length and blood flow of the conduits, and in-hospital and mid-term outcomes with one-year postoperative graft angiographic results were analyzed and compared between groups. Results Twenty-five (2.7%) patients in the S group died in hospital, compared with 26 (2.6%) in the P group, with similar rates of sternal wound infection, chest wall pain, and low-output syndrome. Although the length and blood flow of conduits were increased in the S Group, postoperative conduit patency was similar between groups (p = 0.470). During a median follow-up of 32.2 months, the groups showed similar total survival (88.3 ± 3.2%, S Group; 85.5 ± 2.0%, P Group; p = 0.118) and cardiac event-free survival (82.7 ± 3.3%, S Group; 80.3 ± 2.0%; P Group; p = 0.129), with similar postoperative complications. Conclusions Skeletonization of single LIMA has no extra benefit in early or mid-term outcomes, suggesting no advantage over the pedicled technique. doi: 10.1111/jocs.12551 (J Card Surg 2015;30:494–499)

Chest pain is one of the most common complaints causing patients to seek medical attention. The vast majority of these patients will have a “benign,” nonlife-threatening cause for their chest pain with many of them being labeled with “chest wall syndrome,” a broad term encompassing all causes of musculoskeletal pain. This chapter reviews some of the bone- and cartilage-related causes of chest wall syndrome focusing on the slipping rib syndrome, as well as briefly reviewing other pathologies the practitioner may encounter.

The prevalence of mid- and upper back chronic pain is significantly lower than low back and neck pain with reports showing pain of thoracic origin in 5–15% of the patients, compared to 24–44% with neck pain and 33–56% with low back pain. Thoracic intervertebral discs, nerve roots, and facet joints are capable of transmitting pain in the thoracic spine with radiation into the chest wall and abdominal wall. Chronic, persistent thoracic and chest wall pain and radicular pain may be secondary to disc herniation, discogenic pain, spinal stenosis, or post-thoracic surgery syndrome.

This report presents a case of malignant pleural mesothelioma (MPM) producing granulocyte colony-stimulating factor (G-CSF) that was treated by tumor resection. A 76-year-old male presented with a huge right-side chest wall tumor, along with a slight fever and chest wall pain. Laboratory findings showed an increased white blood cell count (64600 cells/μL) and C-reactive protein level (20.57 mg/dL). The patient underwent surgical removal of the tumor along with tissue from the chest wall and histopathological analysis led to a diagnosis of sarcomatous type of MPM. Immunohistochemical findings for both anti-human G-CSF and interleukin-6 monoclonal antibodies were positive. Although the general condition of the patient quickly improved after surgery, local recurrence occurred two months later and he died of respiratory failure seven months after the operation, though surgery provided symptom relief. G-CSF-producing MPMs usually show a poor prognosis, though less-invasive surgery may be considered for relief of symptoms.

Simultaneous pneumoperitoneum and pneumomediastinum is a rare clinical occurrence. It has been reported in the literature as a complication of various medical and dental procedures. To our knowledge, we present the first case of a non-iatrogenic and traumatic simultaneous pneumoperitoneum and pneumomediastinum in a previously independent 91-year-old man who presented to hospital with back and chest wall pain following mechanical fall from standing. A new radiological diagnosis of diverticular disease with possible perforation was made following admission. Despite appropriate management and supportive measures, the patient died 12 days after admission from a kidney injury.

Chest wall pain is a common complaint after thoracic and chest wall surgery, radiation, and tumor invasion, with significant impact on patients and the healthcare system. If left unmanaged, chest wall pain can significantly impair quality of life. Detection and diagnosis are paramount to management and recovery. Chronic pain also is highly prevalent after breast surgery and thoracotomy. Although many therapies may reduce chest wall pain, a comprehensive treatment plan incorporating potent and targeted interventions may relieve pain and restore function. Chest wall procedures carry several specific risks unique to thoracic anatomy. In this chapter, we explore these risks and present a case of pneumothorax after paravertebral radiofrequency ablation.

A 9-year-old girl from black ethnic origin presented with a history of fever, cough, loss of weight and right-sided chest wall pain for 2 weeks. Chest X-ray demonstrated an effusion, which was shown to be loculated on chest CT scan. She was not responding to medical treatment and at thoracotomy loculated pus was drained. Mycobacterium tuberculosis (TB) was cultured from the pus. TB is a rare cause of loculated empyema with an overlapping clinical and radiological picture with pyogenic infections.

Case report We herein report a case of local recurrence of breast cancer with squamous metaplasia and obvious intratumoral and intertumoral heterogeneity. A 39-year-old female patient was diagnosed with T3N2M0 stage IIIB right breast cancer and underwent right total mastectomy and axillar lymph node dissection. At four years after surgery, she became aware of chest wall pain and diagnostic imaging revealed recurrence in the lung, right thoracic wall and sternum. The recurrent lesions remained stable for 18 months with endocrine therapy. Thereafter, the lesion in the right thoracic wall suddenly became enlarged. Moreover, liver metastasis was confirmed on FDG-PET/CT. She underwent right thoracic wall tumor resection. A biopsy was simultaneously performed to obtain a specimen from the site of liver metastasis. Postoperatively, the right chest wall mass showed obvious intratumoral heterogeneity; squamous differentiation with aggressive features and a papillotubular component similar to the primary tumor. The metastatic liver tumor showed similar pathological features to the primary tumor. Conclusion Intratumoral and intertumoral heterogeneity within primary tumors and associated metastatic sites may contribute to treatment failure and drug resistance.

Background Despite the broad differential diagnosis in any patient referring with symptoms involving the chest or abdomen, a small number of conditions overshadow the rest by their probability. Chest and abdominal wall pain continues to constitute a common and expensive overlooked source of pain of unknown cause. In particular, cutaneous nerve entrapment syndrome is commonly encountered but not easily diagnosed unless its specific symptoms are sought and the precise physical examination undertaken. Case Report A primigravida woman with unbearable abdominal pain was referred repeatedly seeking a solution for her suffering. Numerous laboratory and imaging studies were employed in order to elucidate the cause of her condition. After numerous visits and unnecessary delay, the diagnosis was finally made by a physician fully versed in the field of torso wall pain. The focused physical examination disclosed abdominal cutaneous nerve entrapment syndrome as the diagnosis, and anesthetic infiltration led to immediate alleviation of her pain. Why Should an Emergency Physician Be Aware of This? Cutaneous nerve entrapment is a common cause of abdominal pain that is reached on the basis of thorough history and physical examination alone. Knowledge dissemination of the various torso wall syndromes is imperative for prompt delivery of suitable care. All emergency physicians should be fully aware of this entity because the diagnosis is based solely on physical examination, and immediate relief can be provided in the framework of the first visit. Wider recognition of this syndrome will promise that such mishaps are not repeated in the future.

Chronic chest wall infections may occur in soft tissue, cartilage, and bone. They may present as localized chest wall pain, a discrete mass initially mistaken for neoplasm, a superficial infection, or a draining sinus. Chronic chest wall infections are typically non-necrotizing and associated with lower morbidity than their more acute and necrotizing counterparts. Effective management of chest wall infections ranges from antimicrobial administration to wide surgical resection and subsequent reconstruction.

The surgical resection of primary and secondary tumors involving the chest wall often requires reconstruction with prosthetic and soft tissues, such as muscle flaps. There are situations when a soft tissue reconstruction of the chest wall is preferable. Prosthetic material can become infected and require reoperation for removal of the infected material. Rigid prosthetic materials can result in chest wall pain and deformity. Muscle is the soft tissue of choice for coverage of full-thickness chest wall defects with or without prosthetic material. Muscle flaps can be transferred to chest wall defects with either pedicle muscle transposition or free muscle transfer.

Background To evaluate the incidence of chest wall toxicity after lung stereotactic ablative radiotherapy (SABR) and identify risk factors for the development of rib fracture. Methods Thirty-nine patients with 49 lesions underwent SABR for primary or metastatic lung tumors using Cyberknife® with tumor tracking systems. Patient characteristics, treatment factors and variables obtained from dose-volume histograms (DVHs) were analyzed to find the association with chest wall toxicity. Four-dimensional (4D) dose calculations were done to investigate the effect of respiratory motion on dose to the ribs. Results After follow-up of median 26.7 months (range: 8.4 – 80.0), 8 patients (20.5%) experienced rib fractures and among these patients, three (37.5%) had chest wall pain at 2–3 months after SABR. Median time to rib fracture was 13.4 months (range: 8.0 – 38.5) and the 2-year actuarial risk of rib fracture was 12.2%. Dose to the 4.6 cc of the ribs (D4.6cc) and rib volume received 160 Gy or more (V160) were significant predictor for rib fracture. No significant differences between three-dimensional (3D) and 4D dose calculations were found. Conclusions Parameters from DVH are useful in predicting the risk of chest wall toxicity after SABR for lung tumors. Efforts should be made to reduce the risk of the rib fracture after lung SABR.

Leptomeningeal metastasis (LMM), also referred to as leptomeningeal carcinomatosis, results from diffuse infiltration of the leptomeninges by malignant cells originating from extra-meningeal primary tumors. It occurs in approximately 5%-10% of patients with solid tumor. Among solid tumors, the most common types leading to infiltration of the leptomeninges are breast cancer, lung cancer, and melanoma. Patients with LMM may present various signs and symptoms. Herein, we report a rare case with initial presentation of isolated chest wall pain. Computed tomography of the chest with contrast revealed a 2.5-cm nodule over the left upper lung. Biopsy confirmed the diagnosis of adenocarcinoma. Later, cerebrospinal fluid cytology exam also confirmed leptomeningeal seeding. It is rare for leptomeningeal carcinomatosis patients to present with chest wall pain. Therefore, a high index of suspicion is mandatory for accurate and prompt diagnosis.