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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.
| 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).
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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.
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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.
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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).
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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).
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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).
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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).
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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.
Explanations to objectives
Objectives
- 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.
Surgical flaps
A surgical flap is when any type of tissue is raised from a donor site and transferred to a recipient site with its neurovascular supply. This is different from a graft, in which the transferred tissue does not maintain its original blood supply. In the case of the pectoralis major, the flap would include the muscle belly, the pectoral branches to the muscle from the thoracoacromial artery, and likely its nerve supply from the lateral pectoral nerve.
Ligation and anatomy of the internal thoracic artery
The internal thoracic artery arises as a branch of the first part of the subclavian artery and descends, traversing the thoracic wall immediately lateral to the sternum (Figure 8). The artery supplies the muscles of the chest wall and also the breast. The artery terminates in the sixth intercostal space by bifurcating into the musculophrenic and superior epigastric arteries. This artery had to separated from the chest wall in the patient because it was within the region of the superior thoracic wall that was extirpated.
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Removal of scalene muscles
The scalene muscles act primarily to raise the first and second ribs so that in a normal individual the removal would result in depression of the ipsilateral ribs and possibly some associated respiratory distress during forced respiration . However, these muscles may be purposely removed in patients with severe thoracic outlet syndrome in which spasticity in these muscles causes parasthesia and/or pain in the upper limb because of impingement of the lower trunk of the brachial plexus by the first rib.
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Lung tumors
Cancer occurs when normal cells undergo a genetic transformation that causes them to become abnormal and grow uncontrollably. Malignant cancers spread to other parts of the body (metastasis). The cancerous growth of cells is life-threatening because they consume oxygen, nutrients, and space from healthy cells and because they invade and reduce the ability of normal tissues to function. Within the lungs, which have a very rich vascular network, tumors are particularly dangerous because the delicate lung tissue is easily damaged, and eventually growing lung tumors interfere with respiratory and cardiac functions.
Tumor cells can metastasize through the lymphatic or venous system. If a cancer cell can migrate to the venous system in the primary organ, it can gain access to the systemic circulation. Because all the blood in the venous systemic circulation passes through the capillaries in lungs before returning to the arterial systemic circulation, many tumor cells can get trapped in lung capillaries and have the potential to extravasate and grow as new metastatic foci. Therefore, many tumor types frequently metastasize to the lungs. A similar concept is responsible for metastasis of tumors from the gastrointestinal tract to the liver through the portal vein.
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