Ann Thorac Surg 2010;89:306-308. doi:10.1016/j.athoracsur.2009.06.075
© 2010 The Society of Thoracic Surgeons
Case Reports
Geometric Reconstruction of the Right Hemi-Trunk After Resection of Giant Chondrosarcoma
Giuseppe Marulli, MDa,
Abdel-Mohsen Hamad, MDb,
Marco Schiavon, MDa,
Bruno Azzena, MDc,
Francesco Mazzoleni, MDc,
Federico Rea, MDa,*
a Division of Thoracic Surgery, University of Padova, Padova, Italy
b Department of Cardiothoracic Surgery, University of Tanta, Tanta, Egypt
c Division of Plastic Surgery, University of Padova, Padova, Italy
Accepted for publication June 9, 2009.
* Address correspondence to Dr Rea, Division of Thoracic Surgery, University Hospital of Padova, Via Giustiniani, 2, Padova, 35100, Italy (Email: federico.rea{at}unipd.it).
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Abstract
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We present a case of a giant chondrosarcoma arising from the right anterolateral chest wall and extending to the abdomen. An extensive resection of the right lower chest wall, most of the right hemidiaphragm, and most of the anterior abdominal wall on the right side was carried out. A long titanium plate was used to reconstruct the right costal margin. This plate gave attachment to two polytetrafluoroethylene meshes that were used to cover the abdominal and chest wall defects. The patches were covered with pedicled muscles and omental flaps and subsequently with rotational skin flap.
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Introduction
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Chondrosarcoma represents the most common histotype among primary chest wall tumors [1]. Radical resection with a wide free margin is the mainstay of treatment to guarantee long-term survival and to prevent local recurrence [2]. A multidisciplinary approach involving thoracic and plastic surgeons is of paramount importance to obtain good surgical, functional, and cosmetic results.
A 44-year-old woman presented with a giant mass involving the right anterolateral aspect of the chest and abdominal walls. Magnetic resonance imaging (Fig 1A) delineated the extent of the tumor and showed involvement of the last seven ribs and the hemi-diaphragm. The patient was operated on in collaboration with plastic surgeons; the tumor was resected with a good safety margin of more than 5 cm. However, to save the sternum, the safety margin on the medial aspect of the mass was only approximately 4 cm, hoping that the sternochondral joints would act as a natural barrier against the spread of the tumor. The resected mass measured 29 x 19 x 17 cm and weighed 7 kg. The mass involved the anterolateral part of the sixth to tenth ribs, the anterior part of the eleventh and twelfth ribs, most of the right hemi-diaphragm, and most of the anterior abdominal wall on the right side (Fig 1B). At this stage, the greater omentum flap was prepared to be used later (Fig 1C). Reconstruction was started by recreation of the artificial right costal margin, and for this purpose a long titanium plate (Synthes TM, Solothurn, Switzerland) was adequately modelled to take the shape and configuration of the costal margin, which was then fixed with screws to the sternum anteriorly and the remnant of the tenth rib posteriorly. Another plate was prepared in the same way and was fixed to the sternum and the posterior part of the seventh rib. A polytetrafluoroethylene dual-mesh patch (Gore-Tex; W. L. Gore and Associates, Flagstaff, AZ) was used to close the abdominal wall defect.
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Fig 1. (A) Magnetic resonance imaging shows the giant mass involving the anterolateral chest and abdominal walls with compression of the liver. (B) Intraoperative view of the tumor imprint on the liver is evident with no infiltration. (C) The omental flap is prepared for further use. (D) The newly constructed titanium costal margin is in place; the diaphragmatic and abdominal wall defects are restored with a Gore-Tex dual mesh (W. L. Gore and Associates, Flagstaff, AZ).
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The patch was sutured to the muscular boundaries of the defect (leaving a small gap for passage of the omental flap) and was sutured to the residual part of the right hemi-diaphragm (separating the abdominal from the thoracic cavity). Then the free upper edge was sutured to the newly constructed costal margin (Fig 1D). A second similar patch was applied to cover the chest wall defect, which was sutured to the borders of the defect and the newly formed titanium costal margin inferiorly (Fig 2A). A chest tube was inserted into the left pleural space without compromise of the pectoralis major muscle. The tube was tunnelled subcutaneously across the middle line and came out through the skin on the right side of the chest.
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Fig 2. (A) Coverage of the chest wall defect with Gore-Tex dual mesh (W. L. Gore and Associates, Flagstaff, AZ) after fixation of the second titanium plate (B) The pectoralis major and latissimus dorsi flaps together with the omentum are then used to cover the patches. (C) Lateral view of the postoperative chest roentgenogram; note the correct position of the lower plate and level of the diaphragm. (D) Cosmetic and functional results 6 months after the operation.
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The pectoralis major and latissimus dorsi muscle flaps were prepared by the plastic surgeon and used together with the omental flap to cover both Gore-Tex patches (W. L. Gore and Associates) (Fig 2B) with two small tubes placed over the patches. A rotational skin flap from the abdominal wall was used to definitely cover the reconstructed area leaving a small defect in the lower abdominal wall. This defect was temporarily covered with Integra dermal regeneration template (Integra, Plainsboro, NJ) that was replaced with a dermo-epidermal autograft harvested from the right leg and placed over the "neodermis" 2 months later. The patient was extubated in the operating room. The postoperative course of the patient was uneventful. A pathologic examination revealed a diagnosis of well-differentiated chondrosarcoma with a free resection margin all around. The postoperative chest roentgenogram demonstrated good lung expansion and correct position of the titanium plates (Fig 2C). At the patient's 1-year follow-up, the patient is doing well with no recurrence. The patient is active with no respiratory or functional limitation, and the cosmetic result is satisfactory (Fig 2D).
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Comment
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After an extensive chest wall resection, most thoracic surgeons concentrate on prevention of the flail chest, maintenance of ventilatory function, and protection of underlying structures [3]. The cosmetic results and physical flexibility of the body are secondary in priority. For many years, various surgical techniques and several materials have been used to repair the defect after chest wall resection and to restore the structural stability of the chest [3, 4]. Unfortunately, in cases of wide chest wall resection, each of the currently used materials has its own limitations. Titanium plates are malleable and can be modelled in different configurations.
In our case, the malleability of titanium allowed us to model the plate to take the shape of the costal arch. This was the cornerstone in the reconstructive procedure. First, the plate gives a geometric restoration of the body shape. Second, the plate provides an attachment for the prosthetic patches used to cover the abdominal wall, diaphragm, and chest wall defects. Consequently, these patches were applied in more or less normal anatomic positions. Third, the plate provides enough stability to the thoracic cage, which allowed us to use nonrigid materials to cover the defect. The postoperative result is the reflection of these advantages. In addition to the outstanding cosmetic result, the maintenance of flexibility of the trunk allows the patient to carry out anterior and lateral flexion of the body without limitation. Moreover, and importantly, is the maintenance of good elastic and dynamic properties of the thoracic cage with preservation of pulmonary function, as proved by negligible loss of lung volumes and capacity on spirometry performed 6 months after the operation.
In conclusion, close cooperation between thoracic and plastic surgeons is important to obtain good surgical and cosmetic results, particularly in difficult cases. Titanium plates are an important additive to the armamentarium of surgeons; the feasibility to configure them in different shapes allows their use as a substitute to ribs.
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References
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- McCormack P. Chest wall tumorsIn: Baue AA, Geha AS, Hammond GL, et al. editors. Glenn's thoracic and cardiovascular surgery. 5th ed.. Stamford, CT: Appleton and Lange; 1991.
- Athanassiadi K, Kalavrouziotis G, Rondogianni D, Loutsidis A, Hatzimichalis A, Bellenis I. Primary chest wall tumors: early and long-term results of surgical treatment Eur J Cardiothorac Surg 2001;19:589-593.[Abstract/Free Full Text]
- Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients Plast Reconstr Surg 1996;98:804-810.[Medline]
- McCormack PM. Use of prosthetic materials in chest-wall reconstruction Surg Clin North Am 1989;69:965-975.[Medline]
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Abstract
Introduction
