The patient initially presented to her primary care physician with complaints of pain in the right upper portion of her back. Ensuing spine films demonstrated an anterior chest mass. Computed tomography (CT) of the chest followed, which confirmed an anterior mediastinal mass slightly to the left of the midline measuring 6.5 × 5.0 cm in size. The mass extended anteriorly into the left second intercostal space. There was a second smaller component immediately inferior to the main body of this mass but still within the anterior mediastinum in the extrapleural space that measured 2.2 × 2.7 cm. A third mass was identified in the extradural space in the right side in the right paravertebral region.
A positron emission tomographic/CT scan was then obtained, which noted a mass in the left inferior mediastinum bulging through the anterior second intercostal space, with a maximum standardized uptake value of 3.7. There were no enlarged or hypermetabolic mediastinal/hilar lymph nodes. There was a circumscribed fluid density in the right posterior paravertebral region at the T9 level measuring 2.5 × 2.1 × 3.5 cm and having a maximum standardized uptake value of 1.9. This was cystic and diagnosed as a meningocele or pseudomeningocele.
A CT-guided core needle biopsy of the left paramediastinal mass was performed, which reported cartilaginous tissue with mild hypercellularity favoring well-differentiated chondrosarcoma. Surgical resection of the chest wall mass was recommended.
At surgery, the patient was positioned in the standard right lateral decubitus position. A 15-mm incision was made in the posterior axillary line at the eighth intercostal space for the working camera port. The anterior mediastinal mass was able to be identified, and an assessment was made to determine whether there was lung involvement. There was none, and the tumor was also noted to be at a safe distance away from the phrenic nerve. It did seem to be invading the chest wall. Two more thoracoscopic incisions, one 4-cm anterior incision in the fifth intercostal space (deviation from a standard VATS lobectomy fourth intercostal access incision), and one 15-mm posterior incision were then created.
The parietal pleura was incised in a circumferential fashion around the anterior aspect of the mass on the chest wall with electrocautery. At the periphery of the mass, the second and third ribs were identified, and a LigaSure (Covidien, Mansfield, MA USA) cutting device was used to divide the intercostal neurovascular bundles. Thoracoscopic rib cutters (Medtronic Sofamor Danek Inc., Memphis, TN USA) were then used to divide the lateral aspect of the second and third ribs (Fig. 3). Dissection was then carried on the anterior aspect of the ribs toward the sternum. It was clear that the tumor invaded the ribs but did not invade anterior to the rib cage. With a combination of some gentle blunt dissection and LigaSure dissection, the mass en bloc with ribs 2 and 3 was dissected to the anterior border of the sternum. The dissection was then carried around inferiorly, freeing up some fatty attachments to the pericardium. With the ribs partially divided, the mass began to fall into the chest cavity. Further dissection was carried in the intercostal space of the second and third ribs as the mass began to fall into the chest cavity. With the mass completely mobilized, the medial aspect of the second and third ribs was identified at the costochondral junction of the sternum.
An additional 5-mm incision was required in the anterior superior aspect of the left side of the chest, and electrocautery was used to dissect through the cartilaginous portion of the second and third ribs adjacent to the sternum. With the cartilaginous portion of the ribs divided, the internal thoracic artery on the left was identified and controlled with the LigaSure energy sealing device. With the lateral and the medial aspect of the second and third ribs divided, the mass became even more mobile, and the medial attachments to the pericardium were able to be divided. The mass was completely freed. It was removed from the chest cavity in a 5 × 8–inch laparoscopic sac. The periphery of the dissection area was then marked with large hemoclips to identify the circumference of the resection. A 28F chest tube was brought out of the posterior inferior thoracoscopic incision.
Postoperatively, the patient did well, was able to have her chest tube removed on postoperative day (POD) 1, and was discharged home without event on POD 3. Unfortunately, the final pathology of the rib resection margins revealed a microscopic focus of intramedullary chondrosarcoma present at the lateral bony margin of rib 2, making re-resection necessary. Given the need for reoperation, the decision was also made to explore the right paraspinal mass at the time of her second operation.
For her second operation, the patient underwent right VATS with aspiration of her paraspinal cyst, making sure that the needle followed a percutaneous, extrapleural approach to prevent the development of cerebrospinal fluid leakage into the pleural cavity. Fluid analysis demonstrated beta transferrin, confirming cerebrospinal fluid. After intraoperative consultation with neurosurgery, no further intervention was required. The patient was then repositioned as previously described, and the re-resection of her left second rib was again approached thoracoscopically using the same incisions used for the initial resection. An additional 5 cm of the second rib was resected using the endoscopic rib cutter, after sufficient mobilization of the rib. The total area of chest wall resection was 103 cm2 when totaling both resections.
On the basis of the resultant chest wall defect size, chest wall reconstruction with a rigid or a nonrigid prosthesis was not performed. She was discharged home on POD 3 without event. She was off of narcotic pain medications by POD 10. The final pathology revealed grade 2/3 chondrosarcoma with negative margins. At 24 months from her initial surgery, there is no evidence of local or systemic recurrence or lung herniation through the chest wall defect. She is without symptoms.
Here, we describe the thoracoscopic resection and subsequent re-resection of a chest wall chondrosarcoma. Traditional treatment of malignant chest wall sarcomas has involved thoracotomy with en bloc chest wall resection, achieving wide margins. Our case demonstrates that despite requiring re-resection for microscopically positive margins, en bloc chest wall resection for primary malignant tumors of the chest is feasible thoracoscopically with appropriate patient selection. Our patient was able to be discharged home on POD 3 after both procedures and had minimal postoperative pain, requiring no narcotic pain medications by POD 10. At 24 months from her initial procedure, she remains without evidence of the disease.
As minimally invasive surgical instrumentation has evolved, and thoracoscopic surgical techniques have improved, thoracoscopic resection of locally advanced NSCLC, including those tumors with chest wall invasion, is now possible. Endoscopic rib cutters make thoracoscopic rib resection both feasible and safe (Fig. 3). Minimally invasive techniques have been described in the literature for other surgical subspecialties.5 Application of thoracoscopic techniques for the resection of primary chest wall malignancies, for a variety of reasons, has been slower than the adaptation of thoracoscopic techniques for primary lung carcinomas.
This particular case report emphasizes some of the potential advantages and challenges associated with thoracoscopic chest wall resection. We encountered a patient with a primary chest wall chondrosarcoma with anatomic features favorable for thoracoscopic resection using common thoracoscopic approaches and techniques that are promising for NSCLC. The chest wall defect, because of its size, did not require reconstruction with a rigid or a nonrigid prosthesis. Results from a large series of chest wall resections reported in 2006 showed that risk for postoperative complications increased as the total area of chest wall resected increased.6 Our resected area of 103 cm2 was only slightly greater than the median chest wall defect (81 cm2) from that series. The respiratory complication rate was no different in patients reconstructed with a rigid or a nonrigid prosthesis versus those who were not. Lung herniation was not reported for patients undergoing no reconstruction.6 For the above-mentioned reasons, potential for lung herniation was not felt to be a concern at the time of surgery. It has not been a problem postoperatively.
Unfortunately, in this case, a microscopically positive margin from the bone marrow required re-resection. Although clearly suboptimal, this was tolerated extremely well by the patient, potentially because of the minimally invasive nature of the procedures. For highly selected cases, minimally invasive approach for primary chest wall malignancy may be feasible and safe.
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Keywords:Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Thoracoscopic resection; Chondrosarcoma; VATS; Chest wall