Ann Thorac Surg 2008;85:2118-2120. doi:10.1016/j.athoracsur.2007.12.045
© 2008 The Society of Thoracic Surgeons
Case Reports
Aneurysmal Bone Cyst in the First Rib
Chao Cheng, MD, PhDa,
Sai-Ching J. Yeung, MD, PhDb,
Fo-tian Zhong, MDa,
Ying Xiong, BSa,
Hong-he Luo, MDa,
Sheqing Ji, MDc,
Jingxuan Pan, MD, PhDd,*
a Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou
c Department of General Surgery, Henan Tumor Hospital, Zhengzhou
d Department of Pathophysiology, Sun Yat-sen University Medical School, Guangzhou, Peoples Republic of China
b Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
Accepted for publication December 14, 2007.
* Address correspondence to Dr Pan, Department of Pathophysiology, Sun Yat-sen University Medical School, Guangzhou, 510089, Peoples Republic of China (Email: jingx_pan{at}yahoo.com.cn).
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Abstract
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Aneurysmal bone cyst is a benign tumor of the skeletal system that rarely occurs in ribs. We report two cases of aneurysmal bone cyst in the first rib. The first patient was a 21-year-old woman with an aneurysmal bone cyst in the left first rib that was resected with an L incision. The second patient was a 42-year-old man with an aneurysmal bone cyst in the right first rib that was resected with a posterolateral incision but recurred 1 year later. An en bloc resection was performed, without recurrence to date. We also review this disease with emphasis on the etiology, clinicopathology, and treatment approaches.
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Introduction
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Aneurysmal bone cyst (ABC) is a benign pathology that is usually located in the metaphysis of long bones, but very few cases involving the ribs have been reported [1]. It is characterized by spongy, fibroosseous, locally destructive tissue and a multicystic lesion filled with blood. Here we describe two cases of ABC in the first rib.
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Case Reports
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Patient 1
A 21-year-old woman was referred for a palpable supraclavicular mass for 1 year. The patient had no complaints of chest pain or respiratory distress and no signs of Horner syndrome. There was no history of trauma. A physical examination revealed a 4- x 3.5-cm palpable mass in the left supraclavicular fossa. A computed tomography (CT) scan of the chest showed a 4.8- x 3.6-cm expansile mass in the anterior half of the first rib, which was surrounded by a thin calcified cortex with periosteum (Fig 1).
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Fig 1. Chest computed tomographic scan in patient 1 revealed the expansile mass destroying the anterior half of the first rib and bulging into the chest cavity. The cyst was surrounded by a thin and calcified cortex with periosteum. The arrows point to the aneurysmal bone cyst.
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A manubrial L-shaped transection with Spaggiari's modification of a Dartevelle approach [2] was used to adequately expose the 4.6- x 3.6-cm mass originating from the anterior half of the first rib (Fig 2). The left upper lobe of the lung was partly adhering to the mass. The adhesion was lysed, and the mass was excised en bloc with part of the first rib, the periosteum, and the adjacent intercostal muscle.
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Fig 2. A manubrial L incision with Spaggiari's modification of a Dartevelle approach was used to adequately expose the 4.6- x 3.6-cm mass originating from the anterior half of the first rib in patient 1. A and B indicate the two arms of an L incision; the arrow at C indicates the aneurysmal bone cyst.
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Pathology confirmed that the mass was an ABC. Microscopically, the ABC contains multiple blood-filled cysts, scattered small vessels, and osteoid tissue enclosed in a capsule. Some scattered calcification foci are visible (Fig 3). The patient was discharged in good physical condition.
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Fig 3. Multiple cysts containing blood or osteoid tissue are observed in the capsule from patient 1 (hematoxylin and eosin stain at x100 original magnification). Structures visible include the membrane of a cyst (A), blood (B), a small vessel (arrow at C), and osteoid tissue (D).
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Patient 2
A 42-year-old man was found to have a mass in the right first rib by routine examination. The patient had no complaints. A chest CT scan showed a 3.2- x 3.2- x 2.4-cm mass lying behind the right clavicle.
The patient underwent resection of the mass with posterolateral incision in 2002, and the pathology report confirmed ABC. It recurred in June 2003 with a large mass of 8.3- x 9.5-cm (Fig 4). Embolization therapy with 50 mg of polyvinyl alcohol (90 to 180 µm) was not effective in shrinking the mass. Therefore, en bloc resection with an L incision [2] was performed in August 2003. The pathology confirmed ABC with giant cell tumor of the bone. No recurrence has been detected since then.
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Fig 4. A computed tomographic scan in patient 2 showed the recurrent 8.3- x 9.5-cm mass adhering to the pleura. The arrows point to the aneurysmal bone cyst.
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Comment
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Aneurysmal bone cyst accounts for only 5% of all primary bone tumors [1]. It is extremely rare in the first rib. To those cases that have been documented in the literature to date [3], we add a report of ABC in the first rib in the Chinese population.
The etiology of ABC is unclear. Some investigators think that it may be secondary to an increased circulatory venous pressure or trauma, causing bone absorption and blood-filled cysts formation, thus explaining the expansile nature of ABC [1]. The first patient presented here may be consistent with this pathogenetic theory. Others think that ABC may be secondary to other preexisting bone diseases, giant cell tumor of bone being the most common [4]. In our second patient, bone giant cell tumor was found in the specimen from the second operation.
Symptoms of ABC in the first rib are nonspecific, and it is usually found incidentally by routine examination. A CT scan is of great value to demonstrate the characteristic findings of the disease. The differential diagnosis of ABC will include Ewing sarcoma and eosinophilic granuloma, among others [5]. Some have used core needle biopsy specimens to confirm the diagnosis. We do not think this is necessary, however, and it will increase the risk of bleeding due to the abundant blood cysts inside the ABC.
An en bloc resection with a clear margin is still the best approach for treatment of ABC. An L incision allows retraction of an osteomuscular flap, including but sparing the clavicle and its muscular insertion, and excellent access to the subclavicular region [2]. No recurrence in our cases with the above approaches has been observed to date.
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Acknowledgments
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This study was supported in part by National Natural Science Fund of China (Grant 90713036), and the National High Technology Research and Development Program of China (Grant 2007AA02Z490).
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References
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- Friedman B, Yellin A, Huszar M, Blankstein A, Lotan G. Aneurysmal bone cyst of the rib: a review and report of two cases Br J Dis Chest 1988;82:179-185.[Medline]
- Grunenwald D, Spaggiari L. Transmanubrial osteomuscular sparing approach for apical chest tumors Ann Thorac Surg 1997;63:563-566.[Abstract/Free Full Text]
- Sirmali M, Agackiran Y, Aydin E, Kaya S. Aneurysmal bone cyst of the first rib Eur J Cardiothorac Surg 2004;26:826-827.[Free Full Text]
- Kransdorf MJ, Sweet DE. Aneurysmal bone cyst: concept, controversy, clinical presentation, and imaging Am J Roentgenol 1995;164:573-580.[Abstract/Free Full Text]
- Andiran F, Ciftci AO, Senocak ME, Akcoren Z, Gogus S. Chest wall hamartoma: an alarming chest lesion with a benign course J Pediatr Surg 1998;33:727-729.[Medline]
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Abstract
Introduction
