Treatment of Chest Wall Sarcomas: A Single-institution Experience Over 20 Years

Spindle cell sarcoma of the chest wall: a pediatric case report

Chest wall sarcomas are reported to be infrequent among thoracic tumors. The spindle cell subtype makes up a small percentage of this group. These tumors can be asymptomatic or cause symptoms of chest pain and shortness of breath due to the mass effect, which can lead to a delay in diagnosis. A 10-year-old female with a persistent cough, shortness of breath on exertion, and left-sided chest pain presented to the ED. Imaging indicated a chest wall mass filling the left hemithorax with a rightward mediastinal shift. During surgical resection, two tumors were removed, with resection of parts of the latissimus dorsi and serratus anterior. A diagnosis of MGA:NUTM1 spindle cell sarcoma was made pathologically. The patient was successfully treated with surgery and adjuvant chemoradiotherapy. We hope to add to our academic knowledge by presenting the presentation and treatment of SCS in a pediatric patient.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

Undifferentiated pleomorphic sarcoma of the chest wall: a rare diagnosis

A 31-year-old man with no predisposing factors and no history of chronic disease presented with a small painless lump over his anterior chest wall. On evaluation, it was found to be undifferentiated pleomorphic sarcoma. He underwent wide local excision of the tumour with clear margins, followed by adjuvant radiotherapy. At 6-month follow-up, the patient is clinically and radiologically disease free.

The accuracy and dosimetric analysis of 3D-printing non-coplanar template-assisted iodine-125 seed implantation for recurrent chest wall cancer

Purpose

To investigate the accuracy and dosimetry of 3D-printing non-coplanar template (3D-PNCT)-assisted computed tomography (CT)-guided iodine-125 seed implantation (¹²⁵I-SI) for recurrent chest wall cancer (rCWC).

Material and methods

This was a retrospective study of 19 patients with 22 rCWC treated with 3D-PNCT-assisted CT-guided ¹²⁵I-SI, from Mar 2017 to Mar 2020 in our institute.

Results

Mean needle entrance deviation was 4.50 ±2.70 mm, mean angular deviation was 3.40 ±3.10 degrees, and mean depth deviation was 5.20 ±5.20 mm. No significant difference was found for dosimetric parameters (except conformity index) between pre-plan and post-plan; D₉₀, D₁₀₀, V₁₀₀, V₁₅₀, and V₂₀₀ were 157.74 ±24.23 and 151.71 ±33.62 (p = 0.228), 85.36 ±34.09 and 70.46 ±23.48 (p = 0.067), 0.93 ±0.04 and 0.90 ±0.07 (p = 0.068), 0.64 ±0.16 and 0.64 ±0.16 (p = 0.984), and 0.35 ±0.17 and 0.37 ±0.18 (p = 0.382) for pre-plan and post-plan, respectively. Conformity index, external index, and homogeneity index were 0.57 ±0.16 and 0.52 ±0.15 (p = 0.007), 0.73 ±0.55 and 0.79 ±0.53 (p = 0.096), and 0.31 ±0.15 and 0.30 ±0.14 (p = 0.504) for pre-plan and post-plan, respectively. Median follow-up time was 8 months (range, 3-30 months). Complete response was observed in 4/22 (18.1%), partial response in 13/22 (59.1%), stable disease in 4/22 (18.1%), and progression disease in 1/22 (4.5%) of the cancers. Among patients with pain before ¹²⁵I-SI, pain relief rate was 87.5% (7/8). No peri-operative complications of more than grade 2 were observed.

Conclusions

3D-PNCT-assisted CT-guided ¹²⁵I-SI may be safe and feasible as palliative therapy for non-surgical candidates and painful patients with rCWC.

Surgical Treatment for Primary Chest Wall Sarcoma: A Single-Institution Study

BACKGROUND

Primary sarcomas of the chest wall are rare aggressive tumors. Surgery is part of the multimodal treatment. We describe our institutional patient cohort and evaluate prognostic factors.

METHODS

All patients who had curative intent surgery for primary chest wall sarcoma from 2004 to 2019 were retrospectively reviewed. Impact on survival-calculated from the date of surgery until last follow-up- was assessed for the following variables: age, gender, type of resection, size, grading, stage, completeness of resection, and neoadjuvant and adjuvant therapy.

RESULTS

Twenty-three patients (15 males, 65%) with a median age of 54 y (4 to 82) were included. Most common histology was chondrosarcoma (n = 5, 22%). Seven patients (30%) received neoadjuvant and 13 patients (57%) received adjuvant treatment. R0 resection was achieved in 83%. Extended chest wall resection was performed in 14 patients (61%), including lung (n = 13, 57%), diaphragm (n = 2, 9%) and pericardium (n = 1, 4%). Morbidity and 90-day mortality were 23% and 0%, respectively. Three- and 5-year overall survival was 53% and 35%, respectively. R0 resection was predictor of overall survival (P = 0.029). Tumor grade and extended resections were predictors for recurrence (P = 0.034 and P = 0.018, respectively).

CONCLUSIONS

Surgical resection of primary chest wall sarcoma is a safe procedure even when extended resection is required.

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.

Single-Institution, Multidisciplinary Experience of Soft Tissue Sarcomas in the Chest Wall

INTRODUCTION

We report our single-institution, multidisciplinary experience of nearly 20 years of working on chest wall soft tissue sarcoma cases. The aim of this study was to evaluate clinical outcomes in patients with chest wall soft tissue sarcoma.

MATERIALS AND METHODS

A retrospective review of 49 surgically treated patients with chest wall soft tissue sarcoma was conducted from 1997 to 2015.

RESULTS

The median age of the patients was 57.0 years. There were 19 full-thickness and 30 partial-thickness resections. Reconstruction was warranted in 37 cases. Sarcomas were high grade in 31 (63.3%) and low grade in 18 (36.7%) cases. Local recurrence developed in 8 and metastasis in 9 patients. No 30-day mortality occurred. By the end of the study period, 35 patients were alive and 14 had died. The 1-, 5-, and 10-year survival rates were 93.8%, 76.0%, and 71.6%, whereas the overall recurrence-free rates were 84.4%, 70.7%, and 70.7% respectively. Favorable prognostic variables for survival included age <50 years and radical treatment (resection with wide margin or resection with marginal margin and adjuvant radiotherapy). Patients who had undergone nonradical treatment had a 3.1-fold lower chance of survival than did those who had undergone radical treatment (95% confidence interval, 0.96-10.12; P = 0.06).

CONCLUSIONS

Our study suggests that surgical resection with wide margins should continue to be the mainstay for patients with chest wall sarcoma. Even extensive chest wall resections and reconstructions are safe. If wide margins are not achieved, (neo)adjuvant radiotherapy should be considered to improve local control.

Radiation Therapy in Resectable Intrathoracic Sarcomas. A Rare Cancer Network Study

PURPOSE

Intrathoracic sarcomas (ITS) are considered rare tumors and have a dismal prognosis. We investigated outcomes and risk factors for local control (LC), disease-free survival (DFS), and overall survival (OS) in patients with resected nonmetastatic ITS treated with or without adjuvant radiation therapy (RT) and/or chemotherapy.

METHODS AND MATERIALS

Patients from the Rare Cancer Network database were studied. A Kaplan-Meier estimate was used to assess survival curves, and Cox proportional hazards regression was used to assess risk factors for LC, DFS, and OS.

RESULTS

Between 2000 and 2017, 121 patients met inclusion criteria. The primary site was lung in 30%, mediastinum in 34%, and pleura in 36%. Thirty-nine percent and 32% received RT and chemotherapy. Median follow-up was 34 months (range, 2-141). LC, DFS, and OS at 10 years were 52%, 18.7%, and 7.2%, respectively. In multivariate analysis, RT (P = .003) and R1 margin status (P = .041) retained a significant association with LC. Only R1 resection (P = .002) remained associated with an increased risk of death in multivariate analysis. Overall, 7 patients (6%) developed grade 3 treatment-related chronic toxicity events.

CONCLUSIONS

This joint analysis revealed that OS remains modest in this group of patients, mainly given by the high risk of local and distant failure. Our results suggest that resected ITS can benefit from adjuvant RT.

R0 resection and reconstruction for a large, rapidly progressive chest wall sarcoma

Background

Chest wall sarcomas are a rare group of soft tissue malignancies with variable presentations. Here we describe the definitive management of a large, rapidly progressing chest wall sarcoma arising from the pectoralis major muscle.

Case report

An obese 42-year-old African American male with multiple medical comorbidities presented with new onset right-sided chest pain and a palpable right chest mass. Initial CT chest demonstrated a 9x9x9cm necrotic mass arising from the pectoralis major. CT-guided core biopsy was positive for high-grade spindle cell neoplasm (positive for smooth muscle actin, desmin, S100, and CD31; negative for CD34, PAX8, and beta-catenin). Staging imaging 2 months later demonstrated growth of the mass to 21.4 × 17.8 × 13.7 cm. The patient underwent neoadjuvant chemoradiation with surveillance CT imaging demonstrating a stable tumor. Then he underwent wide local excision of the mass followed by delayed local myocutaneous flap reconstruction and skin grafting. Final pathology was R0 resection, 38x20x18 cm tumor with 70% gross necrosis. Microscopic examination confirmed high-grade sarcoma with smooth muscle differentiation. Final pathologic staging was Stage III G3 pT2bNxMx.

Conclusions

This patient presented with a rare, rapidly enlarging high-grade leiomyosarcoma of the chest wall without metastases or violation of the thorax. We describe the definitive management including a multidisciplinary team to manage a complex and rapidly progressive sarcoma of the chest wall.

Perioperative chemotherapy is not associated with improved survival in high-grade truncal sarcoma

BACKGROUND

The treatment benefit of perioperative chemotherapy (CTX) for truncal soft tissue sarcoma (STS) is not well established. This study evaluates the association of CTX with survival for patients with resected primary high-grade truncal STS.

MATERIALS AND METHODS

Adult patients with high-grade truncal STS who had curative-intent resection from 2000 to 2016 at seven U.S. institutions were evaluated retrospectively. Patients were stratified by receipt of CTX. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) and recurrence-free survival. Logistic regression models were used to evaluate characteristics associated with OS.

RESULTS

Of patients with primary high-grade truncal STS, 235 underwent curative-intent resections. The most common histology was undifferentiated pleomorphic sarcoma and mean tumor size was 7.8 cm. Thirty percent of the patients received CTX (n = 70). Among patients receiving CTX, 34% (n = 24) had neoadjuvant CTX, 44% (n = 31) adjuvant CTX, and 21% (n = 15) had neoadjuvant and adjuvant CTX. Patients receiving CTX were more likely to receive radiation (51% versus 34%, P = 0.01), have deep tumors (86% versus 73%, P = 0.037) and solid organ invasion (14% versus 3%, P = 0.001). On univariate analysis, patients who received CTX had worse OS (P < 0.01) and a trend toward worse recurrence-free survival (P = 0.08). Margin status was the only variable associated with improved OS on multivariate analysis (odds ratio 4.36, 95% confidence interval 1.56, 12.13, P < 0.01).

CONCLUSIONS

In this multi-institutional retrospective analysis of resected high-grade truncal STS, receipt of perioperative CTX was not associated with improved OS, which may be related to selection bias. Microscopically negative margin status was the only independent factor associated with OS.

Sarcoma Arising from the Chest Wall : A Case Report

Chest wall contains a wide array of tissues ranging from soft tissues like skin and muscle to bone. A variety of sarcomas can present with a painful or painless mass, which often requires histological testing for diagnosis. Chest wall sarcomas are very rare entities which are often growing slow . A multidisciplinary team is necessary for the management of chest wall sarcomas. We present a case of a 30-year-old male with spindle cell sarcoma of the chest wall and he underwent wide local excision along with surgical reconstruction.

Treatment of resectable intrathoracic sarcomas: a single institution experience over twenty years

BACKGROUND

There are very few published data on the management of primary intrathoracic sarcoma, defined as sarcomas arising from the lung, pleura, and mediastinum, excluding the chest wall. Therefore, the aim of this study was to evaluate the outcome of patients with intrathoracic sarcoma treated at an academic referral center over a 21-year period.

METHODS

A retrospective search was performed to identify patients with intrathoracic sarcomas treated with surgical resection from January 1990 to November 2011 at the University of Washington Medical Center. Local control and overall survival were analyzed in relation to the treatment received.

RESULTS

Thirty-five patients were identified. Hazard ratios for local control, adjusted for tumor margin status, at 5 years were 0.74 (95 % CI [0.21, 2.58]) for the addition of chemotherapy (CT) to surgery, 0.57 (95 % CI [0.15, 2.23]) with the addition of (radiation therapy) RT, and 0.50 (95 % CI [0.06, 4.03]) with the addition of both CT and RT. At 7 years, the ratios for local control were 0.69 (95 % CI [0.20, 2.36]) for CT added to surgery, 0.58 (95 % CI [0.15, 2.27]) for RT, and 0.41 (95 % CI [0.05, 3.33]) with the addition of both CT and RT. Hazard ratios for overall survival, adjusted for sarcoma stage, at 5 years were 0.61 (95 % CI [0.16, 2.39]) for the addition of CT to surgery, 1.03 (95 % CI [0.26, 4.08]) for the addition of RT, and 0.54 (95 % CI [0.11, 2.69]) for the addition of both CT and RT. The 7-year hazard ratios for overall survival were 0.77 (95 % CI [0.23, 2.60]) for CT added to surgery, 0.99 (95 % CI [0.25, 3.84]) for the addition of RT, and 0.42 (95 % CI [0.09, 2.05]) for both CT and RT with surgery. At 10 years, hazard ratios for overall survival were 0.71 (95 % CI [0.21, 2.38]) for added CT, 0.81 (95 % CI [0.21, 3.08]) for added RT, and 0.33 (95 % CI [0.07, 1.65]) for the addition of both CT and RT to surgery.

CONCLUSIONS

Our series is the largest published study of intrathoracic sarcoma which focuses on the survival benefit of adding RT, chemotherapy or both to surgery in resectable intrathoracic sarcoma. Our data suggest a potential benefit in local control and survival from adjuvant therapy, with the greatest benefit likely to come from combined CT and RT, though none of the results achieved statistical significance. As intrathoracic sarcomas are rare and histologically heterogeneous, larger collaborative studies are necessary to determine treatment efficacy and elucidate which histologic subtypes are likely to benefit most from adjuvant therapy.