Resection and primary reconstruction of a massive chest wall chondrosarcoma

Case report on the approach to surgical management for a large chest wall chondrosarcoma

Introduction and importance

Primary chest wall tumours are uncommon. Challenges arise in management due to delays in diagnosis and timing of treatment. The mainstay of treatment remains complete resection as adjuvant therapy has a limited role. Choice of repair and materials for chest wall reconstruction vary depending on the size and location of the defect. There are no published reports on management of chondrosarcomas arising from the rib in the Caribbean.

Case presentation

A 61-year-old female was referred from a rural clinic with a 10-month history of a progressively enlarging, painless right anterior chest wall lump. Computed Tomography (CT) shows features of a conventional chondrosarcoma arising from the ribs and including surrounding soft tissue, muscle and pleura. Surgical specimen confirms a grade 2 chondrosarcoma.

Clinical discussion

This case illustrates the importance of a multidisciplinary team discussion. Differentiating a chondrosarcoma from a benign cartilaginous tumour requires consideration of clinical features, radiological characteristics and histological features. Chest wall reconstruction aims to preserve functional and structural integrity with adequate soft tissue coverage. The patient had good cosmesis as well as pulmonary function postoperatively and no recurrence at the 3 year follow up.

Conclusion

This case highlights that the MDT is essential to a good outcome for the surgical management of a chest wall chondrosarcoma. Wide en-bloc resection followed by reconstruction using polypropylene mesh and a latissimus dorsi flap as a one-stage procedure can be successful.

•

Primary Chest wall tumors are uncommon.

•

Chondrosarcomas less commonly occur in the chest wall, accounting for 15% of cases.

•

Diagnosis and management can be challenging- a Multi- Disciplinary Team approach is required.

•

Treatment remains surgical as chemotherapy has a limited role.

•

Chest wall reconstruction can be done as a single-step surgical procedure using synthetic mesh and autologous muscle flap.

Reconstruction of massive chest wall defects: A 20-year experience

BACKGROUND

Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions.

METHODS

A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors.

RESULTS

We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm²). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; p = 0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (p = 0.021 and p < 0.001, respectively).

CONCLUSIONS

Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.