Chondrosarcoma of the chest wall: a retrospective clinical analysis

Outcomes and Management of Positive Margins in Chondrosarcoma With Soft Tissue Extension: A Case Series and Review of Literature

BACKGROUND

Chondrosarcoma accounts for 20% of all bone sarcomas and may present with soft tissue extension. The presence of an extraosseous component, along with positive surgical margins, independently have been associated with increased risk of local recurrence and decreased survival. The purpose of this investigation is to describe the treatment and outcomes of six chondrosarcoma patients who presented with chondrosarcoma with soft tissue extension along with positive surgical margins post negative en bloc resection.

CASE

This was a retrospective review over a consecutive 13-year period. Data including treatment details and outcomes were included. All patients underwent attempted negative margin en bloc resection and encountered unplanned positive margins on intraoperative determination or postoperative pathology (R1). A total of six cases were identified. Average age (SD) was 61.8 years (6.11) with median (IQR) follow-up of 17.0 months (10.3-39.5). Three (50.0%) cases arose in the extremities, and 3 (50.0%) cases in the pelvis. All patients underwent attempted negative margin en bloc resection. Three (50.0%) cases recurred with median (IQR) time to recurrence of 10.0 months (9.0-31.0). At study conclusion, 5 (83.3%) were alive with median (IQR) survival of 20.5 months (11.3-41.0).

CONCLUSION

Despite limited sample size, our data reflected a significantly higher recurrence rate compared to either chondrosarcomas with positive margins or extraosseous extension. Our cohort represents a high-risk subgroup of chondrosarcoma patients, which may dictate increased monitoring and guide future treatment recommendations for these patients.

Chondrosarcoma of the Chest Wall: A Single Institution Review of 50 Cases

INTRODUCTION

Chondrosarcoma (CS) is most common primary osseous tumor of the chest wall. The aim of this study was to report results from surgical procedures and evaluate clinical factors predicting survival of patients with chest wall CSs treated in a single tertiary sarcoma center.

MATERIALS AND METHODS

Fifty patients with primary CS located in the ribs and sternum were included. Details of the clinical data and oncological outcomes, including local recurrence (LR) and disease-specific survival (DSS), were collected.

RESULTS

The tumor was primarily originated in the sternum in 6 patients (12.5%) and in ribs 2 to 11 in the remaining patients. Specimens were histologically graded 1 in 13 patients (26%), 2 in 28 (56%), 3 in 8 (16%), and 1 (2%) as mesenchymal grade 3 CS. R0 margins were obtained in all cases. Reconstruction was warranted in 47 (94%) cases. Local recurrence developed in 3 (6%) patients, and the median time to LR was 17 (range, 16-68) months. Eight (16%) patients developed metastasis. Increasing tumor volume was a statistically significant factor for reduction of DSS.

CONCLUSIONS

Chondrosarcoma of the chest wall can be treated effectively with clear margins, resulting in lower LR rate and higher DSS than CS of the extremities and pelvis. Metastasis of the chest wall mostly occurs in high-grade tumors, and the locations of the metastases differ greatly from those observed in CS of the extremities and pelvis. Metastases are commonly extrapulmonary, indicating the need for postoperative follow-up with multiple imaging modalities to monitor recurrence and metastases.

Surgical Management of Chest Wall Sarcoma

Chest wall sarcoma is a rare and challenging pathology best managed by a multidisciplinary team experienced in the management of a multiple different pathologies. Knowledge of the management sequence is important for each sarcoma type in order to provide optimal treatment. Surgical resection of chest wall resections remains the primary treatment of disease isolated to the chest wall. Optimal margins of resection and reconstruction techniques have yet to be determined.

Primary thoracic chondrosarcoma with intra-abdominal extension in a renal transplant recipient: A case report

Primary thoracic bone tumors are relatively rare. The most common type is chondrosarcoma, accounting for up to 48% of all cases. Patients with primary thoracic bone tumors commonly present with atypical thoracic pain or a solitary palpable chest mass, which gradually develops over months to years. The bones most often affected are the ribs, scapula, costochondral junctions and the sternum. The present study presents a case of a 79 year old previous transplant recipient with a large intra-abdominally expanding chondrosarcoma originating from the left lower thoracic cage and associated vague abdomdinal symptoms. Early recognition and awareness of atypical presentations of this disease are important in to appropriately guide diagnostic evaluation and therapeutic procedures.

Overall survival and tumor recurrence after surgical resection for primary malignant chest wall tumors: a single-center, single-surgeon experience

BACKGROUND AND OBJECTIVES

Malignant primary chest wall tumors (PCWTs) comprise a rare group of thoracic tumors with unique anatomical considerations, and experience with wide surgical resection is limited to specialty referral centers and specific diagnoses. We investigated the tumor recurrence and overall survival (OS) for patients with a variety of PCWTs diagnoses at our institution.

METHODS

From 1991 to 2010, patients with malignant PCWT undergoing wide surgical resection for curative intent under a single surgeon were reviewed. Diagnosis and grade (if applicable) of surgical pathology, along with patient demographics, neoadjuvant chemotherapy or radiation therapy, and outcomes (complications, recurrence, and OS) at follow-up were analyzed.

RESULTS

One hundred fifteen patients were included in the study. The most common tumor diagnoses included pleomorphic sarcoma and liposarcoma. Negative margins were achieved in 70 (74%) of cases. Postoperative complications were reported in 21 (20%) cases. The 5-year survival rate was 54%, while the 10-year survival rate was 29%. The local and distant recurrence rates were 50% and 38%, respectively. OS was significantly less in patients with any recurrence ( p < 0.001) but not significantly different between pathology grades ( p = 0.28).

CONCLUSIONS

Wide resection for malignant PCWT is feasible when undertaken for a heterogenous group of diagnoses.

Clinical features and prognostic analysis of patients with chest wall chondrosarcoma

Chest wall chondrosarcoma is a rare malignant tumor of the bone. This study is aimed to identify the prognostic determinants of chest wall chondrosarcoma. We used the Surveillance, Epidemiology, and End Results (SEER) database to identify patients with chest wall chondrosarcoma from 1973 to 2015. Statistical analyses were performed using Kaplan-Meier method and Cox regression proportional hazards. A total of 779 patients were identified from the SEER database. The overall survival (OS) and cancer-specific survival (CSS) rates of the entire group at 10 years were 66.2% and 77.2%, respectively. On multivariate Cox regression, age ≤40 years, localized tumor stage, low tumor grade, surgery, and no radiotherapy were significantly associated with improved both OS and CSS. This study may help clinicians to predict survival of patients with chest wall chondrosarcoma and to provide appropriate treatment recommendations.

Costal chondrosarcoma requiring differential diagnosis from metastatic tumor

Although chondrosarcoma is a common malignant bone tumor, cases arising in the rib are relatively rare. We experienced a case of chondrosarcoma arising in the right 10th rib during follow-up after lung cancer surgery. Although the finding of an osteolytic mass suggested a metastatic bone tumor, 18F-fluorodeoxyglucose positron-emission tomography demonstrated low fluorodeoxyglucose uptake, and a primary bone tumor was suspected. The bone tumor was resected and diagnosed as chondrosarcoma. Four years after resection, there has been no recurrence or metastasis. Positron-emission tomography was useful for differential diagnosis between a chondrosarcoma and a metastatic bone tumor.

Excision of Thoracic Chondrosarcoma: Case Report and Review of Literature

Chondrosarcomas are cartilage-matrix-forming tumors that make up 20-27% of primary malignant bone tumors and are the third most common primary bone malignancy after multiple myelomas and osteosarcomas. Radiographic assessment of this condition includes plain radiography, computed tomography, and magnetic resonance imaging for tumor characterization and delineation of intraosseous and extraosseous involvement. Most chondrosarcomas are refractory to chemotherapy and radiation therapy; therefore, wide en bloc surgical excision offers the best chance for cure. Chondrosarcomas frequently affect the pelvis and upper and lower extremities. In rare instances, the chest wall can be involved, with chondrosarcomas occurring in the ribs, sternum, anterior costosternal junction, and posterior costotransverse junction. In this article, we present a patient with thoracic chondrosarcoma centered at the left T7 costotransverse joint with effacement of the left T7-T8 neuroforamen. We also detail our operative technique of wide en bloc chondrosarcoma excision and review current literature on this topic.

Prognosis of Primary and Recurrent Chondrosarcoma of the Rib

BACKGROUND

Chondrosarcoma of the rib is a rare disease. Although surgery is the only curative treatment option, rib resection with an adequate margin can be challenging and local recurrence is a frequent problem. In this study, the prognosis of primary and recurrent chondrosarcoma of the rib is reported.

METHODS

Retrospective analysis was performed of patients treated for chondrosarcoma of the rib between 1984 and 2014 in three major tertiary referral centers in The Netherlands. Clinical and histopathological features were analyzed for their prognostic value using Kaplan-Meier and Cox proportional hazard analysis. Endpoints were set at local recurrent disease, metastasis rate, or death.

RESULTS

Overall, 76 patients underwent a resection for a primary chondrosarcoma, and 26 patients underwent a resection for a recurrent chondrosarcoma. Five-year overall survival in the primary group was 90%, local recurrence rate was 17%, and metastasis rate was 12%. The 5-year outcome after recurrent chondrosarcoma was lower, with an overall survival of 65%, local recurrence rate of 27%, and metastasis rate of 27%. For primary chondrosarcoma, tumor size >5 cm and a positive resection margin were correlated with worse overall survival [hazard ratio (HR) 3.28, 95% confidence interval (CI) 1.03-10.44; HR 2.92, 95% CI 1.03-8.25). A higher histological grade was correlated with a higher local recurrence and metastasis rate (HR 5.92, 95% CI 1.11-31.65; HR 6.96, 95% CI 1.15-42.60).

CONCLUSION

Surgical resection of both primary and recurrent chondrosarcoma of the rib is an effective treatment strategy. The oncological outcome after surgery is worse in tumors >5 cm, in tumors with positive resection margins and grade 3 chondrosarcoma.

Surgical therapy of primary malignant bone tumours and soft tissue sarcomas of the chest wall: a two-institutional experience

PURPOSE

Primary malignant bone tumours and soft tissue sarcomas of the chest wall are exceedingly rare entities. The aim of this study was a retrospective two-institutional analysis of surgical therapy with respect to the kind and amount of the resection performed, the type of reconstruction and the oncological outcome.

METHODS

Between September 1999 and August 2010 31 patients (seven women and 24 men) were treated due to a primary malignant bone tumour or soft tissue sarcoma of the chest wall in two centres. Eight low-grade sarcomas were noted as well as 23 highly malignant sarcomas. The tumours originated from the sternum in six cases, from the ribs in 12 cases, from the soft tissues of the thoracic wall in 11 cases and from a vertebral body and the clavicle in one case each.

RESULTS

In 26 cases wide resection margins were achieved, while four were intralesional and one was marginal. In all 31 cases the defect of the chest wall was reconstructed using mesh grafts. At a mean follow-up of 51 months 20 patients were without evidence of disease, three were alive with disease, seven patients had died and one patient was lost to follow-up. One recurrence was detected after wide resection of a malignant triton tumour.

CONCLUSIONS

Primary malignant bone tumour or soft tissue sarcoma of the chest wall should be treated according to the same surgical oncological principles as established for the extremities. Reconstruction with mesh grafts and musculocutaneous flaps is associated with a low morbidity.

The imaging of cartilaginous bone tumours. II. Chondrosarcoma

Chondrosarcoma is the third most common primary malignant bone tumour. There are various histological subtypes of chondrosarcomas, of which conventional intramedullary chondrosarcoma is by far the most common. Rarer sub-types include clear cell chondrosarcoma, myxoid chondrosarcoma, mesenchymal chondrosarcoma and dedifferentiated chondrosarcoma. Chondrosarcoma is also classified into central, peripheral and periosteal, dependent upon the lesion site, and into primary chondrosarcoma if the lesion arises de novo and secondary chondrosarcoma if the tumour arises in a pre-existing lesion. The various subtypes of chondrosarcoma have characteristic imaging features that may aid diagnosis and may guide biopsy, therefore potentially preventing misdiagnosis. The aim of this article is to provide an overview of the pertinent clinical and imaging findings of the different forms of chondrosarcoma.

An unusual cause of precordial chest pain

Extraskeletal chondrosarcoma in anterior mediastinum is very rare. A 45-year-old male patient was admitted to the hospital with precordial chest pain. A large and well-shaped mass in the anterior mediastinum was seen radiologically, and there was a clearly compression of the heart by the mass. The lesion was totally resected, and extraskeletal mediastinal chondrosarcoma was histopathologically diagnosed. We aimed to present and discuss the radiologic, clinic, and histopathologic features of unusual presentation of extraskeletal chondrosarcoma in a case.

The "rib-like" technique for surgical treatment of sternal tumors: lessons learned from 101 consecutive cases

BACKGROUND

Sternal tumors represent a rare subgroup of chest wall neoplasms in which indication, surgical issues, and long-term results are rarely reported. Thus, in this study we reevaluated our experience in sternal replacement from a series of 101 consecutive cases during the last 30 years.

METHODS

Clinical records of patients who underwent sternal resection between January 1980 and December 2008 were reviewed. The technique of reconstruction after sternectomy varied over time, including mesh replacement in 52 patients (group A), rigid prosthesis in 27 patients (group B), and the "rib-like" technique, a semi-rigid tridimensional prosthesis reproducing the shape of native ribs, in 22 patients (group C). Postoperative outcomes and long-term survival were analyzed.

RESULTS

Of 101 patients, 42 underwent resection for primary chest wall tumors, 30 for breast cancer, 15 for locally advanced tumors, 11 for metastatic disease, and 3 for benign disease. One patient died postoperatively. The overall major complications rate was similar between groups. Local infection required prosthetic removal in 7 patients of groups A and B (9%). No infection occurred in group C (p = 0.02). Median survival exceeded 60 months for primary sternal tumors and 22 months for other cancer (p = 0.01). The worst survival was recorded in radioinduced sarcoma (17 months) and in patients who underwent previous resection before salvage sternectomy (18 months).

CONCLUSIONS

Results from this study showed that an adequate sternal resection should be done at the first operation and that improving prosthetic integration with surrounding tissues may reduce the local complication rate.

Chest wall sarcomas and induction therapy

Chest wall sarcomas are uncommon tumors. The best patient outcomes likely result from a formalized multidisciplinary treatment plan in a specialized center. No clear guidelines exist to determine whether patients with chest wall sarcomas benefit from preoperative adjuvant therapy. Most decisions are made on a case-by-case basis with little available evidence. It is unclear whether established guidelines for the more commonly occurring extremity sarcomas can be appropriately extrapolated to the care of patients with chest wall disease. The single most important factor in local control and long-term survival is a wide, complete, R0 resection.

Chest wall resection for adult soft tissue sarcomas and chondrosarcomas: analysis of prognostic factors

Background

Wide resection with tumor-free margins is necessary in soft-tissue sarcomas to minimize local recurrence and to contribute to long-term survival. Information about treatment outcome and prognostic factors of adult sarcoma requiring chest wall resection (CWR) is limited.

Methods

Sixty consecutive patients were retrospectively studied for overall survival (OS), local recurrence-free survival (LRFS), and disease-free survival (DFS). Twenty-one prognostic factors regarding survival were analyzed by univariate analysis using the Kaplan-Meier method and the log-rank test.

Results

With a median survival of 2.5 years, the OS was 46% (33%) at 5 (10) years. The LRFS was 64% at 5 and 10 years, and the DFS was 30% and 25% at 5 and 10 years. At the end of the study period, 26 patients (43%) were alive, of which 20 patients (33%) had no evidence of disease and 40 patients (67%) had no chest wall recurrence. In the group of 9 patients with a radiation-induced soft-tissue sarcoma, the median survival was 8 months. Favorable outcome in univariate analysis in OS and LRFS applied for the low-grade sarcoma, bone invasion, and sternal resection. For OS only, age below 60 years and no radiotherapy were significant factors contributing to an improved survival. CWR was considered radical (R0) at the pathological examination in 43 patients. There were 52 patients with an uneventful recovery. There was one postoperative death.

Conclusions

CWR for soft-tissue sarcoma is a safe surgical procedure with low morbidity and a mortality rate of less than 1%. With proper patient selection acceptable survival can be reached in a large group of patients. Care must be given to patients with radiation-induced soft-tissue sarcoma who have a significantly worse prognosis.

Surgical treatment is decisive for outcome in chondrosarcoma of the chest wall: a population-based Scandinavian Sarcoma Group study of 106 patients

OBJECTIVES

Chondrosarcoma of the chest wall is the most frequent primary malignant chest wall tumor. Surgery remains the only effective treatment. Sarcoma treatment in Sweden is centralized to sarcoma centers; however, sarcomas of the chest wall have also been handled by thoracic and general surgeons.

METHODS

One hundred six consecutive reports of chondrosarcomas of the rib and sternum over a 22-year period (1980 to 2002) were studied, with a median of 9 (4 to 23) years of follow-up for survivors. Clinical files were gathered and pathologic specimens reviewed and graded 1 to 4 by the Scandinavian sarcoma pathology group. Surgical margins were defined as wide, marginal, or intralesional.

RESULTS

Ninety-seven patients were treated with a curative intent. Patients operated with wide surgical margins had a 10-year survival of 92% compared with 47% for those with intralesional resections. The 10-year survival was 75% for patients treated at sarcoma centers and 59% for those treated by thoracic or general surgeons. Local recurrence rate was highly dependent of the surgical margins-4% after wide resections and 73% after intralesional resections. The proportion of intralesional resections was higher outside sarcoma centers. Prognostic factors (multivariate analysis) for local recurrence included surgical margin and histological grade; for metastases, prognostic factors included histologic grade, tumor size, and local recurrence. Metastases occurred in 21 of the patients and only 2 were cured.

CONCLUSIONS

Patients operated with wide surgical margins resulted in fewer local recurrences and better overall survival. Patients with chest wall tumors should be referred to sarcoma centers and not to general thoracic surgery clinics for diagnosis and treatment.