CASE REPORT

Gen Thorac Cardiovasc Surg (2011) 59:199–201DOI 10.1007/s11748-010-0630-y

Dedifferentiated chondrosarcoma of the chest wall: reconstruction with polypropylene mesh using a transverse rectus abdominis myocutaneous fl ap

Masafumi Noda, MD · Chiaki Endo, MD Tomoko Hosaka, MD · Tetsu Sado, MD Akira Sakurada, MD · Yasushi Hoshikawa, MD Yoshinori Okada, MD · Takashi Kondo, MD

Abstract We report a case of dedifferentiated chondro-sarcoma of the chest wall. After resection, the chest wall defect was reconstructed using polypropylene mesh and a transverse rectus abdominis myocutaneous fl ap. A 61-year-old woman presented with a 16-year history of a slow-growing mass underneath the right chest wall. After percutaneous biopsy, preoperative cytopathologi-cal examination of the large mass revealed dedifferenti-ated chondrosarcoma. The tumor was resected with a wide margin along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a polypro-pylene (Marlex) mesh sheet followed by a left-side trans-verse rectus abdominis myocutaneous fl ap.

Key words Dedifferentiated chondrosarcoma · Transverse rectus abdominis myocutaneous fl ap · Chest wall tumor

Introduction

Dedifferentiated chondrosarcoma is a high-grade sarcoma next to a malignant cartilage-forming mass that also contain areas of noncartilaginous sarcoma. This tumor has a high propensity for local recurrence. We report a patient with a large dedifferentiated chondro-sarcoma of the chest wall that was surgically treated by

resection and reconstruction using a left-side pedicled transverse rectus abdominis myocutaneous (TRAM) fl ap.

Case report

A 61-year-old woman presented with a 16-year history of a progressive, nonpainful, slow-growing mass under-neath the right chest wall. She had not sought treatment until 1 year previously when she presented to our hospi-tal because the tumor had increased in size (Fig. 1). Chest computed tomography (CT) (Fig. 2) demonstrated a large mass (13 cm diameter) containing calcifi cation and compressing the osteomuscular portion of the right chest wall and the abdominal wall. The mass originated from the ribs and contained necrotic and hemorrhagic components of low density. Percutaneous needle biopsy yielded the possible diagnosis of dedifferentiated chon-drosarcoma (Fig. 3).

Adequate local control of a chest wall malignancy requires surgically wide resection. Preoperatively, skin markings were placed above the fascia of the ipsilateral rectus abdominis fl ap. The tumor was then resected with wide margins along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a Marlex mesh sheet followed by a left-side transverse rectus abdominis myocutaneous fl ap (Fig. 4).

She was discharged on day 14 with no complications. Six months postoperatively, recurrent multiple lesions were founded in the bilateral lungs. The patient was started on a chemotherapy regimen based on ifosfamide and adriamycin with monthly intravenous administra-tion. CT scans documented that the disease had stabi-

Received: 1 February 2010 / Accepted: 13 April 2010© The Japanese Association for Thoracic Surgery 2011

M. Noda · C. Endo · T. Hosaka · T. Sado · A. Sakurada · Y. Hoshikawa · Y. Okada · T. KondoDepartment of Thoracic Surgery, Institute of Development, Aging, and Cancer, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, JapanTel. +81-22-717-8526; Fax +81-22-717-8526e-mail: noda.m@idac.tohoku.ac.jp

200 Gen Thorac Cardiovasc Surg (2011) 59:199–201

Fig. 1 Large chest wall tumor is seen with swelling and redness

Fig. 2 Chest computed tomography demonstrates a large tumor on the right chest–abdominal wall

Fig. 3 Histological examination shows features of dedifferentiated chondrosarcoma. An area of low-grade chondrosarcoma is on the left, and a malignant fi brous histiocytoma-like area of high-grade sarcoma is on the right (H&E, ×125)

lized after 3 months and had regressed after three cycles. At that point, video-assisted thoracic surgery (VATS) was performed to remove residual bilateral lung metas-tases: CT revealed one metastasis on the left side and four on the right side. At 18 months after the second surgery, the patient was alive with no evidence of recurrence.

Discussion

Chondrosarcoma accounts for about 15% of malignant primary bone tumors. This tumor originating from the chest wall is reportedly rare. In addition to conventional chondrosarcoma, several subtypes of chondrosarcoma have been discerned. Dahlin and Beabout fi rst described

Fig. 4 Photograph of the wound postoperatively. The transverse rectus abdominis myocutaneous (TRAM) fl ap has been rotated into place

the concept of dedifferentiated chondrosarcoma.1 Dedif-ferentiated chondrosarcoma is a highly malignant variant of chondrosarcoma, accounting for fewer than 10% in all chondrosarcomas. These tumors have a high propensity for local recurrence and then assume an aggressive course. Therefore, the prognosis for patients

Gen Thorac Cardiovasc Surg (2011) 59:199–201 201

with dedifferentiated chondrosarcoma is poor despite adequate wide surgical resection and adjuvant systemic therapy. The 5-year survival rate ranges from 10.5% to 18.0%.2,3

The management of dedifferentiated chondrosarcoma initially is to estimate the clinical stage of the disease with detailed preoperative examinations. The principal and radical treatment is surgery. Surgical resection of the tumor with wide margins should be attempted wherever possible. It was possible to perform a wide marginal resection in our case. In the absence of rectus muscle, the large chest wall defect was repaired using a combination of the abdominal wall component separation technique with a transverse rectus abdominis myocutaneous (TRAM) fl ap, described by Ramirez et al.,4 and addi-tional augmentation with Marlex mesh, which is easy to handle, assimilates well, is resistant to infection, and is radiotransparent. The TRAM fl ap technique developed by Hartrampf et al.5 in 1982 is now well established.

Nevertheless, lung metastasis was detected by CT 6 months after the operation. Generally, the sensitivity of dedifferentiated chondrosarcoma to adjuvant radiother-apy and chemotherapy is uncertain or low.6 Therefore, such therapy should be administered in appropriate cases. We prescribed three courses of weekly ifosfamide and adriamycin in our case. After the three courses, chest CT revealed reduced lung tumor size bilaterally, and the number of tumors had not changed. Finally, VATS for bilateral lung metastasis was performed. His-topathological examination of the lung tumor showed nonviable cells.

Conclusion

Dedifferentiated chondrosarcomas have a poor overall prognosis, and it is essential to perform a wide excision with clear margins. The role of adjuvant chemotherapy is unclear and should be tested in clinical trials to defi ne its use for treating dedifferentiated chondrosarcoma.

References

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2. Frassica FJ, Unni KK, Beabout JW. Dedifferentiated chondro-sarcoma: a report of the clinicopathological features and treat-ment of seventy-eight cases. J Bone Joint Surg Am 1986;68:1197–205.

3. Mitchell AD, Ayoub K, Mangham DC. Experience in the treat-ment of dedifferentiated chondrosarcoma. J Bone Joint Surg Br 2000;82:55–61.

4. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519–26.

5. Hartrampf CR, Schefl an M, Black PW. Breast reconstruction with a transverse abdominal island fl ap. Plast Reconstr Surg 1982;69:216–25.

6. Gelderblom H, Hogendoorn PC, Dijkstra SD, van Rijswijk CS, Krol AD, Taminiau AH, et al. The clinical approach towards chondrosarcoma. Oncologist 2008;13:320–9.