lNTRODUCTlON

The incidence of chest wall ulcers due to chronic radiation is about 25%-30%. The radiation dose,radiation time and patient’s condition are the risk factors known to affect its occurrence. It has been reported that radiation doses exceeding 70 Gy/7 wk/30 fractions are prone to cause such ulcers[1].Radiation-induced ulcers of the chest wall are secondary, progressive and irreversible, with a duration of as short as several months and as long as years or decades. Moreover, they can be classified as a special type of protracted wound. In addition, radiation can cause vascular contracture, reduce the amount of blood supplied to the skin, induce fibrosis of the skin, and directly impair the repair function of the skin tissue[2-5].

Now there was no one left in the house but the innkeeper s daughter. She meant well and had not taken part in their godless deeds. She opened all the doors for the stranger and showed him piles of treasure. However, the prince said that she should keep everything. He wanted none of it, and with his servant he rode on his way.

Chronic radiation-induced ulcers of the chest wall are often associated with infection and easily cause rib necrosis and osteomyelitis. This seriously affects the quality of life of patients and is a detriment to a patient’s confidence in treating cancer. In the past, surgeons have tried to treat it with debridement and dressing change or skin grafting, but it is difficult to achieve the ideal therapeutic effect.At present, chest wall reconstruction includes two parts:Bone reconstruction of the chest wall, and soft tissue reconstruction of the chest wall. The former uses biological or artificial materials to restore stability of the chest wall,while the latter realizes the tightness of the chest wall by transferring its own tissue flap to cover the defect. In the repair of the chest wall, titanium alloy plates and high-density polyethylene(HDPE) patches are two commonly used materials. Some scholars have pointed out that HDPE patches have sufficient toughness and can better maintain the stability of the chest wall without interference with radiotherapy[6]. In terms of soft tissue repair, a banded myocutaneous flap is better to repair chest wall defects; however, the excessive muscle harvested during the surgery causes the patient sustains greater trauma, resulting in prolonged recovery time and affecting the subsequent treatment of patients.Due to the development of microsurgical techniques, the application of free flaps to repair chest wall defects has become a clinical hot spot.

In this report, the breast cancer patient suffered from a chronic radiation-induced ulcer of the chest wall combined with necrosis of the second to fifth ribs. The chest wall defect was repaired by deep inferior epigastric perforator (DIEP) flap combined with a HDPE patch, with good postoperative recovery.

It was mostly he who talked and he seemed afraid to stop for fear she d ask him to leave her by herself. Nothing in her face had supported the idea of helplessness conveyed by the wheelchair, and he knew that his assistance was not viewed as a favor.5 He asked the cause of her handicap; not because it was so important for him to know, but because it was something to keep the conversation going.

CASE PRESENTATlON

Chief complaints

A 74-year-old female patient was admitted for a radioactive ulcer on the chest wall for more than 4 mo.

History of present illness

The patient’s chest wall ulcer occurred 1 wk after the 6radiotherapy treatment and lasted about 4 mo.The area of the ulcer was 4 cm × 6 cm. The surface of the ulcer was dirty, and the basal granulation tissue was sparse. The ulcer surface bled easily, which indicated that it was closely attached to deep tissue. The ulcer was hard and surrounded by scar tissue.

History of past illness

All laboratory tests were normal.

Personal and family history

In summary, for patients with smaller chest wall defects accompanied by rib necrosis, DIEP combined with HDPE patch repair can be used to obtain satisfactory clinical efficacy and reduce the occurrence of postoperative complications. This may be a better way to treat large chest wall radiation-induced ulcers.

Physical examination

An irregularly shaped ulcer was observed on the surface of the skin of the left chest wall and measuring 4 cm × 6 cm. It was accompanied by red coloration, fishy odor, and pus-like discharge. The skin around the ulcer was red and swollen, hard in consistency and tender (Figure 1A). No significantly enlarged lymph nodes were palpable in the left axilla or supraclavicular region.

The little hyaena gazed at him in surprise, saying to herself, What! was it really this tiny beast who put to death all our best people? when suddenly a gust37 of wind rustled38 the reeds that surrounded the enclosure, and the little hare, in a fright, hastily sprang back into Big Lion s skin

Tsarevitch Ivan opened the door of the stables and there he saw the Horse with the Golden Mane, whose brightness was such that the whole stall was lighted by it. But as he was leading it out he saw the golden bridle, and its beauty tempted32 him to take it also. Scarcely had he touched it, however, when there arose a great clanging and thundering, for the bridle was tied by many cords to instruments of brass33. The noise awakened34 the stablemen, who came running, a hundred of them, and seized Tsarevitch Ivan, and in the morning led him before Tsar Afron.

Laboratory examinations

The patient underwent modified radical mastectomy of the left breast in our department 5 mo prior. The patient did not have hypertension, diabetes or hyperlipidemia.

When the girl was alone the little man appeared for the third time, and said: What ll you give me if I spin the straw for you once again? I ve nothing more to give, answered the girl

Imaging examinations

Radiation injury causes soft tissue damage and leads to necrosis of the sternum and ribs. Surgical reconstruction of the chest wall includes two parts:Thoracic reconstruction and soft tissue repair. It is generally believed that if the anterolateral chest wall defect is less than 6 cm × 6 cm and the posterior chest wall defect is less than 10 cm × 10 cm, then generally no thoracic reconstruction is required[10,12].Soft tissue coverage alone can eliminate the abnormal respiratory movement of the chest wall after surgery. However, large defects require thoracic reconstruction to restore the firmness and stability of the thorax in order to protect the viscera and maintain normal respiration.

MULTlDlSClPLlNARY EXPERT CONSULTATlON

The consultation included specialists in breast surgery, thoracic surgery and radiology. After discussion by several specialists, the decision was made to perform an expanded excision of the ulcer on the chest wall of the patient, including the invaded muscle and ribs. Then, the thoracic defect would be repaired with a patch, and the chest wall defect would be covered with a free flap (Figure 1B).

FlNAL DlAGNOSlS

Radiation-induced ulcer of the left chest wall (Figure 1C).

TREATMENT

OUTCOME AND FOLLOW-UP

The patient was followed-up for 6 mo after the operation. The skin flap showed no pigmentation and no edema. The skin growth and healing of the donor site were acceptable. The donor site was not complicated with abdominal skin necrosis, abdominal bulge, abdominal weakness, nor abdominal hernia (Figure 1F).

DlSCUSSlON

Zhang YQ contributed to conception and design of the case report; Li JW contributed administrative support; Huang SC and Qiu P contributed to provision of study materials or patients; Liang ZZ, Yan ZM and Luo KW contributed to collection and assembly of data; Huang BY, Chen CY and Chen WZ contributed to data analysis and interpretation; Qiu P, Chen CY, Huang SC, Yan ZM, Chen WZ, Liang ZZ, Luo KW, Huang BY, Li JW and Zhang YQ contributed to manuscript writing and final approval of the manuscript.

17. High fever: High fever is always a medical threat and would be disturbing in the heir to the throne. The implication that the prince has made himself sick in love is a highly romantic element of the story.Return to place in story.

According to scholars, conservative treatment of radiation-induced ulcers using debridement,dressing change and antibiotics is ineffective for most patients[7]. Many clinicians have tried different methods to treat chronic radiation-induced ulcers of the chest wall. According to Nishimoto[8], an ideal therapeutic effect was observed in 4 patients upon transfusing platelet-rich plasma and simultaneous skin grafting. Other studies have reported that chronic radiation-induced ulcers of the chest wall have been cured by intravenous infusion of plasma-purified mannan-binding lectin to patients[9,10]. Researchers have also conducted an animal experiment (in guinea pigs) and administered arginine glutamate after artificially causing radiation-induced ulcers, and the therapeutic effect of the ulcers was adequate[10,11]. However, due to individual differences, the above treatment has not been widely promoted in clinical practice, and surgical treatment is still the main treatment.

Chest computed tomography:Irregular subcutaneous soft tissue of the left anterior chest wall and multiple small nodular high-density shadows in the local area were observed. These were predicted to change after radiotherapy. Slightly disordered structure of the left axilla was also observed but no enlarged lymph nodes were found.

In the reconstruction of the bony chest wall, two kinds of synthetic materials titanium alloy plates and HDPE soft patch are mostly used. HDPE patches have good toughness and elicit minimal aseptic inflammatory response. In a short time, human tissue can grow on the patch and cover the cavity in the body, which is conducive to wound repair. In addition, the patch is easy to cut and use during surgery.However, compared with a titanium alloy plate, its hardness and support force are not satisfactory.Occasionally, when the patient breathes, the HDPE patch suture loosens, which results in deformation of the chest wall. However, HDPE patches do not interfere with subsequent radiation therapy.

Thorough debridement and myocutaneous flap coverage of the defect are the preferred methods for the surgical treatment of chest wall ulcers. When debridement of thoracic ulcers is performed, it is required to remove the injured skin and subcutaneous soft tissue, necrotic ribs, sternum, clavicle and surrounding muscle fibrous tissue as much as possible. The choice of myocutaneous flaps, such as latissimus dorsi flap, pectoralis major flap and rectus abdominis flap, is preferred[6]. These myocutaneous flaps have the advantages of rich tissue volume, stable vascular pedicle course, and easy operation. However, due to the harvesting of a large amount of autologous muscles from patients, they cause greater trauma to individuals and result in a longer recovery time, which may delay the subsequent treatment time. In contrast, pedicle musculocutaneous flaps are difficult to cover large wounds due to their small incision area.

A few months earlier I had been putting the finishing touches on portraits I had painted of each of my parents. I d planned to give them as Christmas gifts. This would be a surprise for everyone, as I had not studied art or tried serious painting. There had been an undeniable urge within that pushed me relentlessly2 to do this. The portraits did look like them, but I was still unsure of my painting techniques.

In this case, DIEP soft tissue was used to repair the chest wall defect. Without harvesting the muscle,there was a sufficient amount of tissue to cover the defect, which was less invasive to the patient and had less recovery time, that did not disrupt subsequent radiotherapy. However, compared with other myocutaneous flaps, DIEP has a relatively small amount of tissue and cannot be used to cover deeper or larger defects. Moreover, the operation of DIEP is relatively complex and requires knowledge and expertise in microvascular anastomosis surgery, which is difficult to promote in clinical practice.

The main characteristics of this case were:(1) Intraoperative use of DIEP does not cut the rectus abdominis muscle, making it less invasive to the patient and shortening the postoperative recovery time; and (2) Intraoperative use of HDPE patches can maintain stability of the chest wall and does not interfere with the patient’s subsequent radiotherapy.

CONCLUSlON

Personal and family history was unremarkable.

DIEP flap combined with an HDPE patch was used to repair the chest wall ulcer (Figure 1D and E).

Although radiotherapy equipment, technology and design have been developed to varying degrees in recent years, the occurrence of chronic radiation-induced ulcers of the chest wall are still common when radiation therapy is received after breast cancer surgery.

6.That must have been the devil:Pacts with the devil have long been a literary tradition, dating as far back as the Old Testament42 (Lindahl, McNamara, Lindow 360). Usually the hero tricks the devil or is eventually saved by his repentance44 and inner transformation45 (Lindahl, McNamara, Lindow 360). Here the miller is guilty of stupidity. He makes a pact41 with the devil, but he doesn t know it until his wife tells him. The story makes it clear that the father is not wholly to blame and absolve46 him of all that follows because he was tricked (Ashliman).

The patient’s consent was obtained for the anonymized release of the case data.

The authors declare no conflicts of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See:https://creativecommons.org/Licenses/by-nc/4.0/

China

Sheng-Chao Huang 0000-0002-8713-8365; Chun-Yan Chen 0000-0002-7541-9784; Pu Qiu 0000-0003-0792-8808; Ze-Ming Yan 0000-0002-8473-7063; Wei-Zhang Chen 0000-0002-4668-6760; Zhong-Zheng Liang 0000-0002-6223-852X; Kang-Wei Luo 0000-0003-2742-5626; Jian-Wen Li 0000-0002-7657-1876; Yuan-Qi Zhang 0000-0002-7206-2353; Bao-Yi Huang 0000-0002-4282-2008.

Fan JR

In the evening, some one knocked at the door, and when the bridegroom opened it, it was the Devil in his green coat, who said, Seest thou, I have now got two souls in the place of thy one! 33

A

Fan JR