Eur J Cardiothorac Surg 2007;32:394-396. doi:10.1016/j.ejcts.2007.04.039
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Long-term survival after resection of giant chondrosarcoma of the chest wall weighing 9.6 kg
Tomasz Grodzki*,
Janusz Wójcik,
Jaros
aw Pieróg,
Bartosz Kubisa
Thoracic Surgery Department of the Regional Hospital for Lung Diseases, Pomeranian Medical University, Sokoowskiego Street 11, PL 70-891 Szczecin Zdunowo, Poland
Received 5 March 2007;
received in revised form 19 April 2007;
accepted 26 April 2007.
* Corresponding author. Tel.: +4891 4427272; fax: +4891 4620836. (Email: grodzki{at}grodzki.szczecin.pl).
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Abstract
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The case of a 43 year old male with giant chest wall tumor weighing 9.6 kg verified as chondrosarcoma is described. The patient was treated by multiple (six times) surgical procedures including left costopleuropneumonectomy and left subclavian artery end-to-end anastomosis between 1998 and 2005. Despite the palliative character of surgery, he achieved long-term survival but finally refused next surgery due to the risk of left upper limb amputation and died a few months later.
Key Words: Giant chest wall chondrosarcoma • Surgical resection • Long-term survival
Giant chondrosarcomas originating from the chest wall are rare. Treatment of the tumors is a challenge and requires a multidisciplinary approach. Wide radical resection is essential to obtain long-term survival. We report a case of giant chondrosarcoma in a 43-year-old man, which seemed to be ‘hopeless’ with little chance for long-term survival. However, aggressive surgery provided a good outcome.
The patient was admitted to our department in 1998 due to a mass, which had been growing slowly in the anterior chest for 3 years (Fig. 1a). He was alcohol abuser and refused any treatment for a long time despite his family doctor's strong suggestions. CT scan of the chest showed a giant mass involving left upper ribs and subclavian vein (Fig. 1b and c). The sternum, vertebra, left scapula were free from the tumor. A tumor biopsy proved sarcoma with suggestion of chondrosarcoma. The patient suffered from a pain, fever and symptoms of sepsis as a consequence of tumor necrosis, therefore, surgical resection was undertaken as an emergency operation. The tumor was removed with I, II, III and IV involved ribs (resected on a distance from parasternal line to a posterior axillary line). The left subclavian vein had to be dissected due to the tumor invasion. The chest wall reconstruction was performed with the patient's own soft tissue. No signs of the flail chest except minor localized paradoxical motion of the chest wall or left upper limb edema were seen. The tumor diameter was 30 cm x 30 cm x 30 cm with a weight of 9600 g. The histopathological examination confirmed chondrosarcoma. The margin of the specimen was free of the tumor. Next surgery was performed five times between 1999 and 2004 (Table 1
).
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Fig. 1. (a) Giant necrotic tumor of the left hemithorax. (b) Preoperative chest CT. (c) Preoperative chest CT. (d) The patient's status after left costopleuropneumonectomy.
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The next tumor relapse in the chest was seen 11 months after the last operation. The relapse was located in the left subclavian region. However, the patient did not permit surgery because he was afraid of losing the left upper limb. He died in April 2005–7 years after the first resection due to systemic recurrence.
Chondrosarcoma is the most common malignant tumor of the chest wall, with a strong tendency for local recurrence after resection, associated with poor prognosis [1]. Local recurrence after margin-free, intentionally radical resection still remains a problem. It is well known that surgery is the treatment of choice because only complete resection can provide long-term survival. Histologically free margin of tumor that should be at least 4 cm plays a pivotal role to avoid recurrence [2,3]. Absence of invasion of adjacent structures is the best prognostic factor [2]. Tumor grade, diameter, and location all influence survival [4]. Multiple recurrences occurred despite margin-free resection in this case. We hypothesize the reason for the recurrences could be small satellite tumorlets too small to identify in soft tissue during surgery. Chest wall reconstruction is equally important to obtain a good outcome. In our opinion even large defects of the chest wall after surgery should be repaired with the patient's own soft tissue especially if sternum and scapula are free of neoplasm. Surprisingly, the patient was in a good condition despite six surgeries including wide chest wall resection, costopleuropneumonectomy and left subclavian artery end-to-end anastomosis. This case demonstrates that wide resection of the giant chondrosarcoma and its recurrences are safe and can provide long-term survival at least in selected cases. The multiple surgeries create a burden for the patient and the surgeon but this approach shows that surgical resection should be the treatment of choice even if giant chondrosarcomas appear to be ‘hopeless’ because of their size or concomitant necrosis.
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References
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