Crossed Kirschner’s wires for the treatment of anterior flail chest: an extracortical rib fixation

Objective: Thoracic trauma may be a life-threatening condition. Flail chest is a severe chest injury with high mortality rates. Surgery is not frequently performed and, in Literature, data are controversial. The authors report their experience in the treatment of flail chest by an extracortical internal-external stabilization technique with Kirshner’s wires (K-wires). Methods: From 2010 to 2015, 137 trauma patients (109 males and 28 females) with an average age of 58.89 ±19.74 years were observed. Seventeen (12.41%) patients presented a flail chest and of these, 13 (9.49%) with an anterior one. All flail chest patients underwent early chest wall surgical stabilization (within 48 hours from the injury). Results: In the general population, an overall morbidity of 21.9% (n = 30 of 137) and a 30-day mortality rate of 5.1% (n = 7 of 137) were observed. By clustering the population according to the treatment (medical or interventional vs surgical), significant statistically differences between the two cohorts were found in morbidity (12.65% vs. 34.48%, P = 0.002) and mortality rates (1.28% vs. 10.34%, P = 0.017). In patients undergoing chest wall surgical stabilization, with an average Injury Severity Score of 28.3 ± 5.2 and Abbreviated Injury Score (AIS) of 8.4 ± 1.7, an overall morbidity rate of 52.9% (n = 9) and a mortality rate of 17.6% (n = 3) were found. Post-surgical device removal, in local anesthesia or mild sedation, was performed 42.8 ± 2.9 days after chest wall stabilization and no cases of wound infection, dislodgment of the wires or osteosynthesis failure were reported. Moreover, in these patients, an early postoperative improvement in pulmonary ventilation (ΔpaO2 and ΔpCO2: +9.49 and -5.05, respectively) was reported. Conclusion: Surgical indication for the treatment of flail chest remains controversial and debated both due to an inadequate training and the absence of comparative prospective studies between various strategies. Our technique for the surgical treatment of the anterior flail chest seems to be anachronistic, but the aspects described, both in terms of technical features and of outcome and benefits (health, economic), allow to evaluate the effectiveness of this approach

Crossed Kirschner’s wires for the treatment of anterior flail chest: an extracortical rib fixation

Objective: Thoracic trauma may be a life-threatening condition. Flail chest is a severe chest injury with high mortality rates. Surgery is not frequently performed and, in Literature, data are controversial. The authors report their experience in the treatment of flail chest by an extracortical internal-external stabilization technique with Kirshner’s wires (K-wires). Methods: From 2010 to 2015, 137 trauma patients (109 males and 28 females) with an average age of 58.89 ±19.74 years were observed. Seventeen (12.41%) patients presented a flail chest and of these, 13 (9.49%) with an anterior one. All flail chest patients underwent early chest wall surgical stabilization (within 48 hours from the injury). Results: In the general population, an overall morbidity of 21.9% (n = 30 of 137) and a 30-day mortality rate of 5.1% (n = 7 of 137) were observed. By clustering the population according to the treatment (medical or interventional vs surgical), significant statistically differences between the two cohorts were found in morbidity (12.65% vs. 34.48%, P = 0.002) and mortality rates (1.28% vs. 10.34%, P = 0.017). In patients undergoing chest wall surgical stabilization, with an average Injury Severity Score of 28.3 ± 5.2 and Abbreviated Injury Score (AIS) of 8.4 ± 1.7, an overall morbidity rate of 52.9% (n = 9) and a mortality rate of 17.6% (n = 3) were found. Post-surgical device removal, in local anesthesia or mild sedation, was performed 42.8 ± 2.9 days after chest wall stabilization and no cases of wound infection, dislodgment of the wires or osteosynthesis failure were reported. Moreover, in these patients, an early postoperative improvement in pulmonary ventilation (ΔpaO2 and ΔpCO2: +9.49 and -5.05, respectively) was reported. Conclusion: Surgical indication for the treatment of flail chest remains controversial and debated both due to an inadequate training and the absence of comparative prospective studies between various strategies. Our technique for the surgical treatment of the anterior flail chest seems to be anachronistic, but the aspects described, both in terms of technical features and of outcome and benefits (health, economic), allow to evaluate the effectiveness of this approach

Clinical Features and Outcome of Patients With Non–Small-Cell Lung Cancer Harboring BRAF

Purpose To investigate the prevalence, distribution, and prognostic role of BRAF mutations in a large cohort of white patients with non–small-cell lung cancer (NSCLC). Patients and Methods A retrospective series of 1,046 NSCLCs—comprising 739 adenocarcinomas (ADCs) and 307 squamous cell carcinomas (SCCs)—was investigated for BRAF mutations. High-resolution melting analysis followed by sequencing and strip hybridization assay were used. All patients were also analyzed for KRAS and EGFR mutations. Results BRAF mutations were present in 36 ADCs (4.9%) and one SCC (0.3%; P = .001). Twenty-one of the mutations (56.8%) were V600E, and 16 (43.2%) were non-V600E. V600E mutations were significantly more prevalent in females (16 of 187 patients; 8.6%) than in males (five of 552 patients; 0.9%), as indicated by multivariate logistic regression analysis (hazard ratio [HR], 11.29; P < .001). V600E-mutated tumors showed an aggressive histotype characterized by micropapillary features in 80% of patients and were significantly associated with shorter disease-free and overall survival rates on both univariate (HR, 2.67; P < .001 and HR, 2.97; P < .001, respectively) and multivariate analyses (HR, 2.19; P = .011 and HR, 2.18; P = .014, respectively). All non-V600E mutations were found in smokers (P = .015) and were associated with neither clinicopathologic parameters nor prognosis. BRAF and EGFR were concomitantly mutated in two tumors. Conclusion We report for the first time to our knowledge that V600E and non-V600E BRAF mutations affect different patients with NSCLC. V600E mutations are significantly associated with female sex and represent a negative prognostic factor. In addition, we identified a number of other clinicopathologic parameters potentially useful for the selection of patients carrying BRAF mutations

Complex Mutations & Subpopulations of Deletions at Exon 19 of EGFR in NSCLC Revealed by Next Generation Sequencing: Potential Clinical Implications

<div><p>Microdeletions at exon 19 are the most frequent genetic alterations affecting the Epidermal Growth Factor Receptor (EGFR) gene in non-small cell lung cancer (NSCLC) and they are strongly associated with response to treatment with tyrosine kinase inhibitors. A series of 116 NSCLC DNA samples investigated by Sanger Sequencing (SS), including 106 samples carrying exon 19 EGFR deletions and 10 without deletions (control samples), were subjected to deep next generation sequencing (NGS). All samples with deletions at SS showed deletions with NGS. No deletions were seen in control cases. In 93 (88%) cases, deletions detected by NGS were exactly corresponding to those identified by SS. In 13 cases (12%) NGS resolved deletions not accurately characterized by SS. In 21 (20%) cases the NGS showed presence of complex (double/multiple) frameshift deletions producing a net in-frame change. In 5 of these cases the SS could not define the exact sequence of mutant alleles, in the other 16 cases the results obtained by SS were conventionally considered as deletions plus insertions. Different interpretative hypotheses for complex mutations are discussed. In 46 (43%) tumors deep NGS showed, for the first time to our knowledge, subpopulations of DNA molecules carrying EGFR deletions different from the main one. Each of these subpopulations accounted for 0.1% to 17% of the genomic DNA in the different tumors investigated. Our findings suggest that a region in exon 19 is highly unstable in a large proportion of patients carrying <em>EGFR</em> deletions. As a corollary to this study, NGS data were compared with those obtained by immunohistochemistry using the 6B6 anti-mutant EGFR antibody. The immunoreaction was E746-A750del specific. In conclusion, NGS analysis of EGFR exon 19 in NSCLCs allowed us to formulate a new interpretative hypothesis for complex mutations and revealed the presence of subpopulations of deletions with potential pathogenetic and clinical impact.</p> </div

Sanger sequencing (SS) analysis of two mutated cases (#70 and #31) compared with a wild type reference DNA.

<p>Wild type and deleted alleles are superimposed in SS electropherograms. In case #70, carrying a 2236–2250del, the peaks are perfectly aligned and the starting point of the deletion at base 2236 is easily detectable. Next generation sequencing (NGS) confirmed this type of deletion. In case #31, carrying the same mutation, as detected by NGS, peaks in the SS electropherogram are not well aligned and the starting point of the deletion was incorrectly positioned by the operator at base 2237.</p

Examples of subpopulations of EGFR deletions at exon 19.

<p>The Figure reports 10 selected cases of tumors (#53, #59, #47, #38, #84, #27, #89, #49, #17, #77) showing subpopulations of EGFR deletions at exon 19. In each case the first line corresponds to the wild type sequence. The different bases are highlighted by different colours. Deleted bases are reported as dashes. The black bars under the sequences indicate the consensus for the different bases involved in deletions. On the right of each case is reported the percentage with which the wild type and deleted molecules were present in tumor DNA. The number (N) of sequences obtained in each case were as follow: #53 (N = 6.484), #59 (N = 5.835), #47 (N = 5.629), #38 (N = 4.776), #84 (N = 2.641), #27 (N = 4.389), #89 (N = 3.855), #49 (N = 2.172), #17 (N = 2.856), #77 (N = 3.526). Cases carrying subpopulations in less than 0.1% of the DNA molecules are labeled with an asterisk.</p

Different interpretation of sequence data in case of complex mutations.

<p>A complex in frame deletion of 15 bp (A) can be considered as composed of two non-in frame deletions of 8 bp and 7 bp separated by a consensus sequence of 7 bp, in other words a double deletion. Conventionally, this mutation could have been interpreted as the sum of a non-in frame deletion of 19 bp and non-in frame insertion of 4 bp. Accordingly, in B and C are reported different interpretations for mutations giving rise to complex in frame deletions of 18 bps. Deleted bases are indicated by dashes. Inserted bases are reported a in a frame under the sequence. Correspondence with numbers of tumor samples: A (#59); B (#22); C (#53).</p

Immunohistochemical staining with deletion specific 6B6 monoclonal antibody in Non-Small Cell Lung Cancers carrying different deletions at exon 19 of the <i>EGFR</i> gene detected by Next Generation Sequencing.

a<p>The score system is described in detail in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0042164#s4" target="_blank">Materials and Methods</a>.</p

Cases in which the accurate sequence of deleted bases was incorrectly determined or not assessable by Sanger sequencing compared with data obtained by Next generation sequencing.

<p>Abbreviations: NA, the exact sequence of deleted bases could not be accurately defined (not assessable).</p>a<p>Novel mutation.</p