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Clinical case: Giant first rib tumor: want to learn more about it?

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Clinical case: Giant first rib tumor

In this article, we describe a case of a woman who was diagnosed with a malignant spindle cell tumor in the anterior portion of the chest. We will take a look at the tumor characteristics revealed by the paraclinical tests together with its complex surgical management. We will also look at anatomical considerations that should be taken into account when dealing with such a clinical case.

Key facts
Surgical flap vs. graft

Flap: a tissue raised from a donor site and transferred to a recipient site with its neurovascular supply

Graft: a tissue transferred tissue does not maintain its original blood supply

Internal thoracic artery

Origin: first part of the subclavian artery

Supply: chest wall and breast

Terminal branches: musculophrenic and superior epigastric arteries

Functions of the scalene muscles Elevation of the first and second ribs and unilateral contraction of the cervical spine
Dangers of lung tumors Lung tissue is easily damaged, interference with the respiratory and cardiac functions, frequent place of metastasis due to the passage of the venous systemic circulation through the lungs

After reviewing this case you should be able to describe the following:

  • What constitutes a surgical “flap"? In the specific case of a pectoralis major flap, as used in this study, what would this flap consist of?
  • Why it was necessary in this case to ligate the internal thoracic artery; where the artery originates, where it runs, what it supplies and how it terminates.
  • What disability might the patient have after removal of all three left scalene muscles?
  • How tumors within the lungs eventually lead to death, as in this patient.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

Case description

Investigations and diagnosis

A 64-year old woman presented with a growing mass in her left superior anterior chest (Figure 1).

Figure 1. The chest radiograph on the left (A) shows the large tumor that was growing on the anterior chest wall. The radiograph on the right (B) shows the patient three months after the preoperative image with the large tumor removed. However, in the short three month period, two metastatic lesions had developed in the right lung.

Chest CT indicated an 11 × 6 cm tumor growing on the patient’s left first rib, which had partly invaded the sternum (Figure 2A-B). Three-dimensional CT reconstruction revealed the anatomical location and relations of the tumor to the sternum, ribs, clavicle and subclavian vessels (Figure 2C). Based on a CT-guided needle biopsy of the tumor, the tumor was found to be a malignant spindle cell tumor.

Figure 2. A: Axial CT showing the first rib tumor. B: Coronal CT also showing the tumor. C: 3D reconstruction showing the tumor size and location (in green; the “A” in the box in the lower right shows the orientation of the frontal (anterior) plane.

A thoracotomy at the second intercostal space facilitated the removal of the tumor as well as the first and second ribs. Specifically, after displacing the left internal thoracic artery and vein, the second rib cartilage was cut at the left parasternum.

Figure 3. Cadaveric image showing the chest region.

Both ribs were resected anterior to the transverse process of the vertebrae. To facilitate this removal, the anterior, middle, and posterior scalene muscles were transected at their insertion into the ribs. These cuts allowed extrication of the entire tumor (Figures 3&4).

Figure 4. Whole (top) and bisected (bottom) photographs of the extirpated tumor.

The separated osteomuscular part of the manubrium was reattached to the sternum with stainless steel wire (Figure 5). The defect in the chest was repaired with mesh and covered by the pectoralis major flap (Figure 5).

Figure 5. Intraoperative photograph showing partial repair of the thoracotomy.

Evolution

The immediate postoperative clinical course was uneventful. However, within a year the patient was found to have metastases to both lungs (Figure 1 right) and suprarenal glands. Although she received treatment for the disseminated lesions, she died 14 months after the initial surgery.

Surgical and anatomical considerations

The tumor in this case partially invaded the thoracic inlet, which is also known as the superior thoracic aperture. This space is bounded posteriorly by the first thoracic vertebra, the first pair of ribs laterally, and anteriorly the space is bounded by the costal cartilage of the first rib and the superior border of the manubrium (Figure 6).

Figure 6. Superior view of the thoracic inlet.

The surgeons were concerned in this case about possibly damaging the many structures that pass through this space, which include: trachea, esophagus, thoracic duct, apices of the lungs, phrenic nerves, vagus nerves, sympathetic trunks, brachiocephalic veins, common carotid arteries and subclavian arteries (Figure 7).

Figure 7. Dissection image showing the complex anatomy of the thoracic inlet.

The esophagus lies adjacent to the body of the T1 vertebra, separated from it by the prevertebral fascia, and the trachea lies anterior to the esophagus and slightly to the right, and may be in contact with the manubrium. The apices of the lungs extend slightly superior to the superior level of the inlet, thus reaching the loser neck.

The thoracic inlet and adjacent structures may be involved in different clinical issues other than a first rib tumor including superior sulcus tumors (anterior Pancoast tumors), neurogenic tumors and metastatic lesions.
 

Clinical case: Giant first rib tumor: want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

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“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

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