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A Giant Necrotic and Hem orrhagic Papillary Carcinom a of the Breast: A Case Report Emily Klosterman, DO, MS MEd, PGY-1 Kai Huang, MD, PGY-2 Subhasis Misra, MD, MS, FACS 3/23/2019 This research was supported (in whole or in part) by HCA and/or

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SLIDE 1 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 1 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA or any of its affiliated entities.

A Giant Necrotic and Hem orrhagic Papillary Carcinom a of the Breast: A Case Report

Emily Klosterman, DO, MS MEd, PGY-1 Kai Huang, MD, PGY-2 Subhasis Misra, MD, MS, FACS 3/23/2019

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SLIDE 2 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 2

AV 78 year old female cc: “left breast bleeding” x 1 day

10/17/2018

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SLIDE 3 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities.

HPI

  • c/o left breast bleeding x 1 day, after minimal

trauma

  • Left breast swelling and skin changes x 3 years
  • PMhx: None
  • PShx: None

Labs: WBC- 15.0, Hgb-11.1, lactic acid-2.8 Physical Exam:

  • Afebrile, vitals stable
  • No findings, except…
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SLIDE 4 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 4
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SLIDE 5 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 5

Im aging

CT Chest

  • Partially necrotic left chest wall mass (14.1 x 19 x

20.3 cm)

  • Invasion into pectoralis muscle
  • Adjacent left axillary lymphadenopathy
  • Large necrotic lymph node (3.0x3.5 cm)
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SLIDE 6 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 6
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SLIDE 7 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 7
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SLIDE 8 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 8
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SLIDE 9 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 9
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SLIDE 10 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 10
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SLIDE 11 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 11
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SLIDE 12 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 12
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SLIDE 13 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 13
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SLIDE 14 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 14
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SLIDE 15 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 15
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SLIDE 16 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 16
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SLIDE 17 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 17
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SLIDE 18 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 18

Pathology

Invasive papillary carcinoma- Margins negative 95% of specimen comprised of necrotic tissue ER-positive, 3+, 100%, PR-positive, 3+, 75%, HER2-negative

  • 6/6 nodes within specimen-positive for metastatic

adenocarcinoma

  • 3 from limited axillary node dissection positive for metastatic

adenocarcinoma

  • extranodal spread evident
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SLIDE 19 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 19

Sum m ary

  • 78 year old female with giant necrotic and

hemorrhagic invasive papillary carcinoma with metastasis to axillary nodes

  • Status post emergent left total mastectomy,

partial chest wall resection, and limited axillary dissection

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SLIDE 20 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 20

Invasive Papillary Breast Cancer

  • Rare form of breast cancer (< 1% of cases)
  • Typically in post menopausal women
  • Rarely metastatic
  • As a result, usually a more favorable prognosis
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SLIDE 21 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 21

Questions?

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SLIDE 22 This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) do not necessarily represent the official views of HCA or any of its affiliated entities. 22

Fakhreddine, M. H., Haque, W., & Ahmed, A., et, al. (2018). Prognostic Factors, Treatment, and Outcomes in Early Stage, Invasive Papillary Breast

  • Cancer. American Journal of Clinical Oncology,41(6), 532-537.

Misra, Subhasis et al. (2010). Screening Criteria for Breast Cancer. Advances in Surgery , 44 (1) , 87 – 100. Pal, S. K., Lau, S. K., Kruper, L., Nwoye, U., Garberoglio, C., Gupta, R. K., Paz, B., Vora, L., Guzman, E., Artinyan, A., Somlo, G. (2010). Papillary carcinoma of the breast: an overview. Breast cancer research and treatment, 122(3), 637-45. Soo, M.S, Williford, M.E., Walsh, R, et, al. (1995). Papillary carcinoma of the breast: imaging findings. American Journal of Roentgenology, 164(2), 321- 326. Wei, Shi (2016). Papillary Lesions of the Breast: An Update. Archives of Pathology & Laboratory Medicine, 140 (7), 628-643. Zheng, Y. Z., Hu, X., & Shao, Z. M. (2016). Clinicopathological Characteristics and Survival Outcomes in Invasive Papillary Carcinoma of the Breast: A SEER Population-Based Study. Scientific reports, 6, 24037. References:

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SLIDE 23

A complication of conservative management in penetrating chest trauma

Chris Jacobs, MD; Tyler Loftus, MD; Frederick Moore, MD; Eddie Manning, MD; Scott Brakenridge, MD Department of Surgery, Division of Trauma Acute Care Surgery University of Florida

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SLIDE 24

Disc lo sure s

  • No financial relationships to disclose
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Case Pre se ntatio n

  • 46yM presented as a

trauma alert with a GSW to the LLQ

  • GCS 15, SBP 80s, HR 110s,

Hct 35

  • No exit wound, +

peritoneal signs

  • Transported emergently to

trauma hybrid room for exploratory laparotomy

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I ntrao pe rative findings

  • Multiple penetrating injuries
  • Left tube thoracostomy  500cc blood
  • Small bowel and transverse colonic resection
  • Diaphragmatic repair and gastrorraphy
  • Subxiphoid pericardial window  minimal clotted

blood

  • Copiously irrigated and no active bleeding noted
  • Washed out, anastomosed and closed by hospital day 2
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SLIDE 27

Case Pre se ntatio n

  • On hospital day 5, the patient underwent a left VATS

decortication for retained left hemothorax and persistent pneumothorax

  • Thick clot and rind noted, could not locate bullet
  • Discharged home 2 weeks after admission in good

condition

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SLIDE 28

Case Pre se ntatio n

  • Evaluated in clinic at 1 month and 2 months post discharge

for wound checks without any complaints

  • Presented to clinic 11 months after initial GSW for an

incisional hernia evaluation

  • Patient complained of 2 months of syncopal episodes 

TTE followed by CTA

  • Noted a 5.0 x 4.0 cm bilobed left ventricular

pseudoanuerysm

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SLIDE 31

Ope rative Managme nt

  • Cardiothoracic surgery team took to the OR electively for

median sternotomy under cardiopulmonary bypass

  • Pseudoaneurysm resection
  • LV repair with 3-0 proline horizontal mattresses using felt

strips

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SLIDE 32

Pe ric ardial e xpo sure

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SLIDE 33

L e ft ve ntric ular pse udo ane urysm

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SLIDE 34
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What we le arne d

  • No previously established guidelines for surveillance

following non-operative management of penetrating chest trauma with a positive SPW

  • Natural history of LV pseudoaneurysm is progression to

free rupture

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SLIDE 37

Manag e me nt

  • Historically, patients with penetrating chest trauma and a

positive SPW underwent median sternotomy

  • In recent years, patients with penetrating chest trauma

with a positive SPW without ongoing hemorrhage can be managed without median sternotomy

  • Avoiding morbidity of median sternotomy
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SLIDE 38

UF Surve illanc e Pro to c o l

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SLIDE 39

Re fe re nc e s

  • [1] Navsaria PH, Nicol AJ. Haemopericardium in stable patients after penetrating injury: is subxiphoid pericardial window and

drainage enough? A prospective study. Injury 2005; 36: 745–750.

  • [2] Thorson CM, Namias N, Van Haren RM, Guarch GA, Ginzburg E, Salerno TA et al. Does hemopericardium after chest trauma

mandate sternotomy? J Trauma Acute Care Surg 2012; 72: 1518–1524

  • [3] Hommes M, Nicol AJ, van der Stok J, Kodde I, Navsaria PH. Subxiphoid pericardial window to exclude occult cardiac injury after

penetrating thoracoabdominal trauma. Br J Surg. 2013;100(11):1454–1458.

  • [4] Nicol AJ, Navsaria PH, Hommes M, Ball CG, Edu S, Kahn D. Sternotomy or drainage for a hemopericardium after penetrating

trauma: a randomized controlled trial. Ann Surg. Epub 2013 Apr 18.​

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SLIDE 40

Management of Iatrogenic Tension Pneumoperitoneum and Bilateral Tension Pneumothorax




Advent Health Hospital March 22, 2019

Georg Wiese, Jeffrey Chiu, S cott Bloom, S teve Eubanks

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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SLIDE 41

Initial Presentation

  • 77 yo with pmh of arthritis, GERD, diverticulitis,

hypothyroidsim with psh of cholecystectomy and breast biopsy

  • Presenting to ED after EGD and colonoscopy, found to

be Obtunded, distended, hypoxic and required emergent intubation

  • Immediate chest Xray obtained and S

urgery was called

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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SLIDE 42

Chest Xray

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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In the CT

  • S

urgery assessed Patient in the ED

  • In CT scanner at time of arrival
  • Bilateral chest tubes placed
  • CT notable for compressed IVC consistent with

tension pneumoperitoneum

  • Percutaneous peritoneal catheter placed

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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  • Pt stabilized and transferred to higher acuity center

due to unknown etiology of leak, esophageal versus bowel perforation

  • Went to OR for exploratory laparotomy and upper

endoscopy

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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SLIDE 47

Findings Intraoperatively

  • Notable intraperitoneal air, tracking through prior

defect in abdominal wall into subcutaneous tissues

  • Bowel run distal to proximal
  • Region of gross necrosis in the Right colon
  • Proceeded with Right hemicolectomy

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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SLIDE 48

Intraoperative Endoscopy

  • Given extent of pneumomediastinum and bilateral

pneumothorax, Examination of Esophagus via EGD was performed

  • No frank necrosis, ulceration or perforation was

visualized.

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.

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Conclusion

  • Tension pneumoperitoneum is a dangerous complication

from iatrogenic inj ury to the bowel during endoscopy.

  • Though prior cases have been described in literature, this

case demonstrates an instance when the perforation and leak of air progressed beyond an intra-abdominal process and required utilization of ATLS protocols similar to trauma.

  • Thoracostomy tubes as well as abdominal decompression

via peritoneal catheter allowed for adequate stabilization prior to definitive exploration and colon resection

CONFIDENTIAL: PATIENT SAFETY WORK PRODUCT Protected under the Patient Safety and Quality Improvement Act. Do NOT disclose unless authorized by the PSOrg Advisory Committee.