Osteosarcoma of the rib - iKnow

(1)

CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports81(2021)105777

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Osteosarcoma of the rib: A challenge of diagnosis and surgical intervention: A case report

Suprayitno Wardoyo

^a

, Achmad Fauzi Kamal

^b

, Muhammad Aris Furqon

^c,∗

, Jonathan Grantomo

^c

, Witantra Dhamar Hutami

^d

aDivisionofCardiothoracicandVascularSurgery,DepartmentofSurgery,FacultyofMedicine,UniversitasIndonesia/CiptoMangunkusumoGeneral Hospital,Jakarta,Indonesia

bDepartmentofOrthopedicsandTraumatology,UniversitasIndonesia/CiptoMangunkusumoGeneralHospital,Jakarta,Indonesia

cResidentofCardiothoracicandVascularSurgery,FacultyofMedicine,UniversitasIndonesia/CiptoMangunkusumoGeneralHospital,Jakarta,Indonesia

dResidentofOrthopaedicandTraumatology,UniversitasIndonesia/CiptoMangunkusumoGeneralHospital,Jakarta,Indonesia

a rt i c l e i nf o

Articlehistory:

Received21February2021

Receivedinrevisedform13March2021 Accepted14March2021

Availableonline16March2021

Keywords:

Chestwalltumour Osteosarcomaoftheribs Chestwallreconstruction

a b s t ra c t

INTRODUCTIONANDIMPORTANCE:Chestwalltumourcouldgrowfromvarioustissuescomposingthe chestwall.Diagnosisandtreatmentofpatientswithchestwalltumourposeseveralchallenges.

CASEPRESENTATION: Wepresentacaseof55yearoldwomanwithchiefcomplaintofapainfullmass onherchestwall.Patientwasdiagnosedwithosteosarcomaoftheribs.Patientunderwentsurgeryand washospitalizedforsevendaysbeforedischarged.

CLINICALDISCUSSION:Osteosarcomaoftheribsisararecasewithwideresectionasthemaintreatment.

Inthiscase,chestwallreconstructionwasneededtopreventimpairedchestwallmechanicalfunction inrespiration.

CONCLUSION:Diagnosisandtreatmentofosteosarcomaoftheribsposechallenges.Themaintreat- mentoftheosteosarcomaoftheribsiswideresection,followedbyreconstructionofchestwallwhen needed.Reconstructioncouldbeperformedwithautologoustissue,gore-tex,andmesh.Theadjuvant chemotherapywasconsideredtogiveforbetteroutcome.

1. Introduction

Chestwalltumourcouldgrowfromvarioustissuescomposing thechestwall.Tissuessuchasbones,connectivetissue,adiposetis- sue,bloodvessels,nerve,cartilage,andmusclescouldbetheorigin oftumourcells.Theincidenceofmalignancyofthebonesandjoints is0.9per100,000peopleperyear[1].Diagnosisandtreatmentof patientswithchestwalltumourposeseveralchallenges.

Inthis carereport,weelaborateourexperienceintreatinga 55yearoldwomanwithchiefcomplaintofapainfulmassonher chestwall.Patientwasdiagnosedwithosteosarcomaoftheribs.

Patientunderwent surgeryandwashospitalizedfor sevendays beforedischarged.

2. Presentationofcase

A55-year-oldwomancametoourcliniccomplainingofamass onherleftchestwall.Initially,themasswassmallandunpainful,

∗ Correspondingauthorat:DivisionofThoracic,Cardiac,andVascularSurgery, CiptoMangunkusumoHospital,FacultyofMedicine,UniversityofIndonesia,Jalan DiponegoroNo.71,Senen,JakartaPusat,DKIJakarta,10430,Indonesia.

E-mailaddress:[email protected](M.A.Furqon).

butsincesixmonthsbeforeadmission,shestartedtofeelpainon herleftchest.Patienthadsoughtmedicaltreatmentandhadbeen evaluatedforheartdisease,butnoabnormalitieswasfound.No historyofsmoking.

Uponphysicalexamination,a6×6cmmasswasfoundonleft lateralchestwall.Themasswasﬁxedtothechestwallwithclear bordersandhardconsistency.Therewasnosignofinﬂammation onthelump.

Chestradiographsshoweddestructionofthefourthribsandsur- roundingsofttissue.Bonelesionwassuspected.Nopleuraleffusion wasseen(Fig.1).Computedtomography(CT)scanshowed5.5× 5.3cmdestructionofthefourthribsandsurroundingsofttissue withcontrastenhancementandintralesionalcalciﬁcation(Fig.2).

Bloodtestsshowednosigniﬁcantabnormalitybesideincreased phosphatasealkali(353U/L).

Biopsy and preoperative histopathology examination result indicated that the tumour was consistent with osteosarcoma (Fig. 3). In our clinical and pathological conference, the team decidedtodo widesurgicalresectionandreconstructionofthe chestwall,andfollowedbyadjuvantchemotherapy.

Surgerywasperformedbyanexpertteamofsurgicalorthopedic oncologistsandthoracicsurgeons.Patientwasputinsupineposi- tionandthenasepticandantisepticprocedureswereperformed onthesurgicalﬁeld.Tumourwasidentiﬁedand dissectedfrom

https://doi.org/10.1016/j.ijscr.2021.105777

creativecommons.org/licenses/by-nc-nd/4.0/).

(2)

Fig.1. PreoperativeChestX-rayofpatient.Noticearoundmass(pointedbyyellowarrow)onlefthemithoraxanddestructionofthefourthribs.

Fig.2. PreoperativeCTscanshowingbonedestructionofthefourthribsandintralesionalcalciﬁcation.

(3)

CASE REPORT – OPEN ACCESS

S.Wardoyo,A.F.Kamal,M.A.Furqonetal. InternationalJournalofSurgeryCaseReports81(2021)105777

Fig.3.(A,B,andC)Excisedtumormass,(D)HistopathologicalpicturewithHaematoxylinandeosinstainwith100xmagniﬁcation.

surrounding tissues.The tumour wasfoundonthe fourthribs, extendingtothethirdandﬁfthribs.Tumourresectionwasper- formedbyexcisingthethird,fourth,andﬁfthribs.Tumourexcision wasperformedaswideaspossibleandincludedthepleura.Chest cavitywasleftopen.Adrainwasplacedinpleuralspaceandcon- nectedtoWSD.Chestwallwasreconstructedwithbiologicalmesh.

Skin wasthenclosed layerbylayer(Fig.4).There’snoperiop- erativecomplication.Post-operativehistopatologicalevaluationis consistentwith,preoperativebiopsy,osteosarcoma.

Aftersurgery,patientwasextubatedandmonitoredintheICU fortwentyhoursbeforemovedtoward.Chestdrainwasremoved ontheﬁfthdayandpatientwasdischargedontheseventhday.

Uponroutineclinicalexamination,therewerenocomplications reportedandthepatientwassatisﬁedwiththesurgeryresults.

3. Discussion

Chestwalltumourcouldbecausedbybothbenignandmalig- nant lesions. Benignlesions are more commonly foundamong

elderlieswhilelesionsonyoungerpatientsaremorelikelytobe benign[2].

Osteosarcomaisanoncommontypeofchestwallmalignancy.

Epidemiologyofchestwallmalignancyisnotwellstudied.Based ona publication by AndrianapolousEG et al., most chest wall tumoursarebenign(85%).Themostcommonmalignantlesions aremetastaseslesionandprimarychondrosarcoma[2,3].Basedon areportbySakellaridisTetal.,from15-yeardata,mostribtumours arebenign(70.33%).Theyreportedthat48.15%ofthemalignant lesionsare metastases lesions, mostcommonly from renal cell carcinoma,followedbybreastcarcinoma.Themostcommonpri- marymalignantlesionoftheribsischondrosarcoma,followedby osteosarcoma[4].

Eventhoughepidemiological studiesreportedthat osteosar- comamostcommonlyoriginatesfromlongbonesoftheextremities (especiallylowerextremities),inthiscase,thechestwalltumour wasosteosarcoma.Osteosarcomaisrarelyfoundonﬂatbonessuch astheribs.Themostcommonoriginofosteosarcomaarefemur (42%),tibia(19%),andhumerus(10%)[4].Flatbonesthatarecom-

(4)

Fig.4.(A)intraoperativemassidentiﬁcation;(B)wideexcisionofthemass;(C)chestwalldefectafterwideexcision;(D)Chestwalldefectreconstructionwithmesh.

monoriginofosteosarcomaincludeskull andjaws(8%)aswell aspelvic(8%)[1].Meanwhile,ribsosteosarcomaaccountsforonly 1.25%ofallosteosarcomacases[1].

Kundu ZS suggested alkaline phosphatase (ALP) and lactate dehydrogenase(LDH)asbiomarkersandprognosispredictors of osteosarcoma[5].Meta-analysisbyHaoHshowedthathighserum ALPisanindicatorofpoorprognosiswhileameta-analysisbyFuY showedthatpatientswithhighLDHhavepoorprognosis[6,7].

Radiographic examination is a standard examination for all patients withthoracic abnormalities. For more detailed assess- ment, CT scan or magnetic resonance imaging (MRI) could be performed.CTscancouldprovideadetailedenoughimagetoeval- uatealmostallchestwalltumours.MRIoutperformsCTscan in depictingsofttissues.

Chest wall resection is the main treatment for chest wall tumours[8].Surgerywithwideexcisionextendingtotumour-free bordersisaprincipleinsurgicaloncologyaimedtoreducetherisk ofrecurrence.Inthiscase,consideringthelocationofthechestwall tumour,chestwallreconstructionwasneededtopreventimpaired chestwallmechanicalfunctioninrespiration.

Mesh is oneof the modalities that couldbe usedto recon- structchestwallbesideautologoustissue, gore-tex,andmethyl methacrylate[8].Inthispatient,wereconstructedthechestwall usingmesh.InacasereportbyLimWetal.,theyperformedrecon- structionusingtitaniummeshin asimilarcase [9]. Meanwhile, Tozumetal.treatedasimilarcasewithreconstructionusingcolla- genmeshandmetalplate[10,11].

4. Conclusion

Osteosarcomaofthe ribsisa rare case, hencethediagnosis andtreatmentposemorechallenges.Themaintreatmentofthe osteosarcomaof the ribsis wide resection, followed by reconstruction of chest wall when needed. Reconstruction could be performedwithautologoustissue,gore-tex,andmesh.Theadju- vantchemotherapywasconsideredtogiveforbetteroutcome.

DeclarationofCompetingInterest Nonedeclared.

(5)

CASE REPORT – OPEN ACCESS

S.Wardoyo,A.F.Kamal,M.A.Furqonetal. InternationalJournalofSurgeryCaseReports81(2021)105777

Sourcesoffunding

Thisresearchisfundedbyauthor’spersonalfunding,nospon- sorsinvolved.

Ethicalapproval

Thisstudyisexemptfromethicalapprovalinourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

SuprayitnoWardoyo:studyconceptordesign,datacollection, dataanalysisorinterpretation,writingthepaper.

AchmadFauziKamal:studyconceptordesign,datacollection, dataanalysisorinterpretation,writingthepaper.

MuhammadArisFurqon:studyconceptordesign,datacollection,dataanalysisorinterpretation,writingthepaper.

JonathanGrantomo:studyconceptordesign,datacollection, dataanalysisorinterpretation,writingthepaper.

WitantraDhamarHutami:studyconceptordesign,datacollection,dataanalysisorinterpretation,writingthepaper.

Registrationofresearchstudies Notapplicable.

Guarantor

SuprayitnoWardoyo.

AchmadFauziKamal.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

References

[1]G.Ottaviani,N.Jaffe,Theepidemiologyofosteosarcoma,in:N.Jaffe,O.

Bruland,S.Bielack(Eds.),PediatricandAdolescentOsteosarcoma,Springer, Boston,2009.

[2]A.A.Shah,T.A.D’Amico,Primarychestwalltumors,J.Am.Coll.Surg.210(3) (2010)360–366.

[3]E.G.Andrianopoulos,G.Lautidis,P.Kormas,A.Karameris,S.Lahanis,L.

Papachristos,etal.,Tumoursoftheribs,Eur.J.Cardiothorac.Surg.15(5) (1999)615–620.

[4]T.Sakellaridis,S.Gaitanakis,A.Piyis,Ribtumors:a15-yearexperience,Gen.

Thorac.Cardiovasc.Surg.62(2014)434–440.

[5]Z.S.Kundu,Classiﬁcation,imaging,biopsyandstagingofosteosarcoma, IndianJ.Orthop.48(3)(2014)238–246.

[6]H.Hao,L.Chen,D.Huang,J.Ge,Y.Qiu,L.Hao,Meta-analysisofalkaline phosphataseandprognosisforosteosarcoma,Eur.J.CancerCare26(5) (2017),e12536.

[7]Y.Fu,T.Lan,H.Cai,A.Lu,W.Yu,Meta-analysisofserumlactate

dehydrogenaseandprognosisforosteosarcoma,Medicine(Baltimore)97(19) (2018)e0741.

[8]E.A.David,M.B.Marshall,Reviewofchestwalltumors:adiagnostic, therapeutic,andreconstructivechallenge,Semin.Plast.Surg.25(1)(2011) 16–24.

[9]W.Lim,S.AhmadSarji,Y.Yik,T.Ramanujam,Osteosarcomaoftherib, Biomed.ImagingInterv.J.4(1)(2008)e7.

[10]H.Tozum,A.N.Aydemir,M.Demiroglu,K.Ozkan,A.B.Ceyran,B.Kilic,Arare riblesionduetoparostealosteosarcoma:acasereport,J.Med.CaseRep.13 (1)(2019)19.

[11]R.A.Agha,T.Franchi,C.Sohrabi,G.Mathew,fortheSCAREGroup,TheSCARE 2020guideline:updatingconsensussurgicalCAseREport(SCARE)guidelines, Int.J.Surg.84(2020)226–230.

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.