Chest Wall Sarcoma Research Articles

Chest wall resection and reconstruction for primary chest wall sarcomas: Analysis of survival, predictors of outcome, and long-term functional status

ObjectivesWe aimed to analyze survival, predictors of outcome, and the long-term functional status of patients with a diagnosis of primary chest wall sarcoma who undergo chest wall resection and reconstruction. MethodsWe analyzed a prospectively maintained database, including all patients operated on between 2008 and 2021. The primary outcome measures were overall and disease-free survival and analyses were employed to determine the risk factors for poor survival and recurrence. ResultsOne hundred thirty-nine patients were included, 55% were men. The majority (96%) had an R0 resection and 75.1% had no postoperative complications up to 30 days postprocedure; median length of hospital stay was 7 days (range, 6-10 days). Median overall and disease-free survival was 58.8 and 53.6 months, respectively. For those alive, at long-term follow-up, 80% had a Medical Research Council dyspnea score of 0 and Karnofsky index >80%. Survival and mortality rates were better in chondrosarcomas compared with nonchondromatous sarcomas (P < .05). Previous history of radiotherapy, previous history of cancer, the type of sarcoma (Ewing's or soft tissue), the need for adjuvant treatment and tumor grade were significant predictors of mortality and recurrence on univariate testing. Extended resection, a higher number of ribs removed, and the incidence of postoperative complications were significantly associated with a worse postoperative Medical Research Council dyspnea score. ConclusionsCareful patient selection and multidisciplinary decision making is crucial. This leads to clear resection margins, good overall, and disease-free survival and good functional outcomes.

Clinical characteristics and prognosis of patients with incidentally discovered chest wall sarcoma compared with those of symptomatic patients.

Sarcomas of the bone and soft tissues are detected after the onset of pain, detectable mass and related symptoms in the absence of a standardized screening examination. However, primary chest wall sarcomas can be incidentally detected upon chest X-ray or computed tomography. Previous studies of incidental primary chest wall sarcomas lack prognosis and disease-specific clinical data. This study aimed to investigate the prognoses of patients with incidental chest wall sarcomas and compare them with those of symptomatic patients. This study included 18 patients diagnosed with primary chest wall sarcoma between 2010 and 2023. Patient information such as age, sex, tumour diameter, tumour location, symptoms, treatment, time to treatment initiation, pathological diagnosis and outcome were retrospectively analysed. Among the 18 patients, the sarcomas were incidentally detected in five by chest X-ray and computed tomography in three and two patients, respectively. The pathological diagnoses of the patients were Ewing sarcoma, Chondrosarcoma grade 1, grade 2, periosteal osteosarcoma and malignant peripheral nerve sheath tumour. The patients had no symptoms at the first visit to our hospital, and no lesions in other organs were detected at the time of the initial examination. At the final follow-up, the patients remained disease-free after radical treatment. The tumour sizes of the five patients were significantly smaller than those of patients with symptoms (P=0.003). The incidental detection of chest wall sarcomas and consequent early detection and treatment of tumours improves patient prognosis relative to that of symptomatically diagnosed patients.

The Breast-Pectoralis Flap: A New Advance in Autologous Breast Reconstruction-A Preliminary Report on 20 Cases.

In the past, several publications have described breast reconstruction techniques that utilize the contralateral breast; however, interest diminished because of technical difficulty, scarring, and poor aesthetic results. This study aimed to present a new breast reconstruction technique that uses a combination of the breast-pectoralis flap and the abdominal advancement flap. This retrospective study analyzed the results and complications of 20 consecutive breast reconstructions with the breast-pectoralis flap technique. The authors present a series of 20 breast reconstructions that utilized the breast-pectoralis flap. Delayed breast reconstruction was performed in 13 cases (65%), breast reconstruction in 5 patients (25%) with Poland syndrome, sequela correction after a chest wall sarcoma in 1 patient (5%), and sequela correction after breast cystic lymphangioma resection in 1 patient (5%). One complication required surgical reintervention without long-term consequences. The outcomes were considered very good in 50% of the cases, good in 45%, and fair in 5%. The combination of the breast-pectoralis flap and the abdominal advancement flap is an interesting advance in breast reconstruction. Evaluation of the presented cases suggests wider indications for this technique.

Reconstruction method for massive lateral chest wall sarcoma using titanium plates and mesh: a case report

BackgroundVery large chest wall resections can lead to acute thoracic insufficiency syndrome due to the interdependence of lung expansion and thoracic volume. Chest wall tumor surgeries often encounter complications, with the size of the chest wall defect being a significant predictor. Several methods for large chest wall reconstruction have been described, aiming to provide stability, prevent flail chest, and ensure airtight closure. However, no single method fulfills all requirements. Composite chest wall reconstruction using titanium plates and Gore-Tex patches has shown the potential to minimize physiologic abnormalities caused by extensive defects.Case presentationA 42-year-old man with myxofibrosarcoma underwent multiple surgeries, chemotherapies, and radiation therapies due to repeated local recurrences. After right arm amputation and resection of the right third to fifth ribs, a local recurrence was detected. A 30 × 40 cm chest wall defect was resected en bloc, and a titanium plate was used for three-dimensional formability, preventing flail chest and volume loss. The Gore-Tex patch was then reconstructed into an arch shape, allowing lateral thoracic mobility. The patient recovered well and did not experience respiratory dysfunction or local recurrence but later succumbed to distant metastasis.ConclusionsIn this case, the combination of a titanium plate and a Gore-Tex patch proved effective for reconstructing massive lateral chest wall defects. The approach provided stability, preserved thoracic volume, and allowed for lateral mobility. While the patient achieved a successful outcome in terms of local recurrence and respiratory function, distant metastasis remained a challenge for myxofibrosarcoma patients, and its impact on long-term prognosis requires further investigation. Nevertheless, the described procedure offers promise for managing extensive chest wall defects.

Resection to restoration: Assessing the synergy of polypropylene mesh (Marlex®) combined with methyl-methacrylate and latissimus dorsi flap for primary chest wall sarcomas

BackgroundChest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications. ObjectiveWe aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection. Patients and methodsAmong the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap.Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction. ResultsIn this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1–5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm2 with an average size of 73 cm2. The mean follow-up period for these patients was approximately 63.80 months ConclusionThe combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas.

Chest wall reconstruction with a non-rigid synthetic rib prosthesis: a multicenter study

This retrospective multicenter study included 22 patients who underwent chest wall tumor resection with subsequent Codubix rib endoprosthesis reconstruction from 2019 to 2023. Four medical institutions participated in the study: P.A. Herzen Moscow Cancer Research Institute, Sverdlovsk Regional Oncology Hospital, Morozov Children's City Clinical Hospital and Kaluga Regional Oncology Hospital. Inclusion criteria were the presence of chest wall tumors, both primary and secondary, removal of more than 2 ribs, resection of the rib arch and the sternum. The median age was 60 years (48-66), 11 (50%) patients were females and 11 (50%) males. Operations for chest wall sarcoma, metastatic lesions, and lung cancer were performed in 9 (40.9%), 4 (18.2%), and 3 (13.6%) patients, respectively. The median number of removed ribs was 3 (2-4), with a maximum of 7. Sternotomy was performed in 9 (40.9%) patients, and subtotal resection of the body or handle of the sternum was carried out in 77.7%. Combined resections were performed in 14 (63.6%) patients. Radical tumor removal (R0) was achieved in 21 (95.5%) patients. Complications were observed in 9 (40.9%) patients, with intermuscular seroma being the most common in three (33.3%), followed by hydrothorax in 2 (22.2%), bilateral pneumonia, acute respiratory failure, and postoperative delirium in 1 (11.1%) patient each. One patient had the Codubix plate removed due to postoperative wound infection. The median overall and recurrence-free survival was not reached, and the 1-year recurrence-free survival was 63.9%, with an overall survival of 86.8%. Reconstruction with Codubix material allows for satisfactory functional and cosmetic results, characterized by a low complication rate and good adaptive properties.

Comprehensive Analysis of Chest Wall Resection: Indications, Reconstruction, and Results: A Systematic Review

Introduction: Chest wall neoplasms encompass primary, locally invasive, and metastatic tumours. Malignant chest wall tumours are typically uncommon, comprising roughly 5% of all thoracic neoplasms and 1 to 2% of all primary tumours. This systematic review addresses the imperative need for a comprehensive analysis of chest wall resection, focusing on indications, reconstruction techniques, and outcomes, to provide clinicians with evidence-based guidelines for optimal patient management. Aim: To comprehensively review indications for chest wall resection, explore reconstruction techniques, and analyse complications and outcomes associated with the procedure. Materials and Methods: A thorough electronic database search was performed on PUBMED Central, MeSH, NLM Catalog, Bookshelf, and PUBMED utilising the search terms “Chest wall,” “Chest wall Resection,” and “Chest wall Reconstruction.” Fulltext articles published in English within a 20-year period (from 1999 to 2020) were selected based on pre-defined inclusion and exclusion criteria and subjected to analysis as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. Results: In total, 24 full-text records met the inclusion and exclusion criteria and underwent critical analysis for this systematic review. Chest wall sarcomas emerged as the primary indication for chest wall resection in the present study, with recurrent or locally advanced breast carcinoma also noted as significant causes. Various artificial soft meshes, notably Marlex or Goretex, were commonly employed for reconstruction, while soft-tissue coverage was achieved through various myocutaneous flaps, both pedicled and free. Respiratory complications predominated among the observed complications, with wound-related issues also documented. Conclusion: Patient selection is paramount in chest wall reconstruction, with the ideal method still under debate. However, prioritising minimal patient morbidity during reconstruction is crucial. Adherence to these principles can lead to better outcomes in terms of complications, survival, and quality of life, especially in appropriately selected patients.

Outcome Analysis of Treatment Modalities for Thoracic Sarcomas

Background: Primary chest wall sarcomas are a rare and heterogeneous group of chest wall tumors that require multimodal oncologic and surgical therapy. The aim of this study was to review our experience regarding the surgical treatment of chest wall sarcomas, evaluating the short- and long-term results. Methods: In this retrospective single-center study, patients who underwent surgery for soft tissue and bone sarcoma of the chest wall between 1999 and 2018 were included. We analyzed the oncologic and surgical outcomes of chest wall resections and reconstructions, assessing overall and recurrence-free survival and the associated clinical factors. Results: In total, 44 patients underwent chest wall resection for primary chest wall sarcoma, of which 18 (41%) received surgery only, 10 (23%) received additional chemoradiotherapy, 7% (3) received surgery with chemotherapy, and 30% (13) received radiotherapy in addition to surgery. No perioperative mortality occurred. Five-year overall survival was 51.5% (CI 95%: 36.1–73.4%), and median overall survival was 1973 days (CI 95% 1461; -). As determined in the univariate analysis, the presence of metastasis upon admission and tumor grade were significantly associated with shorter survival (p = 0.037 and p &lt; 0.01, respectively). Five-year recurrence-free survival was 71.5% (95% CI 57.6%; 88.7%). Tumor resection margins and metastatic disease upon diagnosis were significantly associated with recurrence-free survival (p &lt; 0.01 and p &lt; 0.01, respectively). Conclusion: Surgical therapy is the cornerstone of the treatment of chest wall sarcomas and can be performed safely. Metastasis and high tumor grade have a negative influence on overall survival, while tumor margins and metastasis have a negative influence on local recurrence.

Ewing Sarcoma of Chest Wall (Askin\'s Tumor) in a 3-year-old Child: A Case Report

Fever and difficulty in breathing in a child are common symptoms encountered in routine practice. Often, the underlying cause will be infectious etiology due to bacterial, viral, or tuberculous. However, a malignancy of the paraspinal soft tissue region mimicking infectious disease clinically in a child is challenging to diagnose and treat. Here, we report the Askin's tumor of the chest wall diagnosed in a child presented with fever, worsening dyspnea, and unilateral lung whiteout on a chest radiograph to insist on the importance of extensive and earlier evaluation even for common clinical symptoms.

Epirubicin, cisplatin plus ifosfamide versus standard chemotherapeutic regimens for advanced/unresectable primary thoracic sarcomas.

Thoracic sarcomas are rare malignancies, with limited data for unresectable/advanced scenarios. Our goal is to provide insights of a three-drug chemotherapy regimen improving patient survival compared to standard regimens. Retrospective cohort analysis of patients diagnosed with unresectable/advanced primary thoracic sarcoma divided between primary pulmonary sarcomas (PPS) and chest wall sarcomas (CWS) comparing chemotherapeutical regimens efficacy. Not true soft tissue sarcomas (STS) for PPS were excluded from the analysis. Univariate and multivariate analysis performed via Cox-regression model. Progression-free survival (PFS) and overall survival (OS) analysis via Kaplan-Meier with hazard ratio (HR) obtained via Mantel-Haenszel or log rank. 157 total cases were included, from which 50 cases were PPS and 107 cases CWS. For PPS, 4 cases were excluded from the analysis as they were not true STS. The most common histology was undifferentiated sarcomas, 63% of cases were treated with E/C/I and 37% with another regimen. The E/C/I regimen demonstrated a benefit for both OS (p = 0.020) and PFS (p = 0.010) when compared to any other regimen as well as when compared to non-platinum regimens (p = 0.016 and p = 0.001). Regarding CWS, the most common histology was synovial and undifferentiated sarcomas, 55.1% were treated with E/C/I and 44.9% treated with another regimen. The E/C/I regimen did not demonstrate a benefit for OS or PFS compared to any other regimen, neither when compared to other non-platinum regimens. However, a benefit was observed in favor of E/C/I when compared to other platinum regimens in both OS (p = 0.049) and PFS (0.015). Both analyses for PPS and CWS demonstrated a benefit in favor of cisplatin therapies compared to carboplatin in both OS and PFS. This study demonstrates that platinum therapy alone does not work, and that cisplatin must be the agent of choice and it's used in combination could increase treatment response. The E/C/I regimen demonstrated a in PPS but not for CWS, this is due do their rarity of PPS and that no standard treatment is established yet. The regimen proposed here could represent a possible new standard of treatment for PPS as long as it is validated in a prospective study.

Survival prognostic factors in unresectable/advanced primary thoracic sarcomas.

BackgroundPrimary thoracic sarcomas (PTS) including primary pulmonary and chest wall sarcomas (CWS), are aggressive lung malignancies with limited information specially in an advanced/unresectable setting. Unfortunately, prognostic factors for these malignancies are not well identified.MethodsRetrospective cohort analysis of patients diagnosed with unresectable/advanced soft tissue PTS from a third level reference institute. Univariate and multivariate analysis performed via Cox-regression model. Progression-free survival (PFS) and overall survival (OS) analysis via Kaplan-Meier method.ResultsA total of 157 patients were identified, 55.4% female, mean age 51.8 years (range, 18–90 years), 19.1% tobacco exposure and 10.8% asbestos exposure. The most common performance status was Eastern Cooperative Oncology Group (ECOG) 1 (38.9%), most common clinical presentation cough (58.4%) and thoracic pain (55.4%). Undifferentiated sarcoma (37.6%) followed by synovial sarcoma (34.4%) were the most common histologies. Most patients received five chemotherapeutic cycles (37.6%), 57.3% of patients obtained a partial response and 61.1% an overall response rate (ORR). Median PFS was 9 months [95% confidence interval (CI): 8.717–9.283 months]. The multivariable analysis identified ECOG ≥2, a poorer response to chemotherapy (less number of chemotherapy cycles) and an increase Response Evaluation Criteria in Solid Tumors (RECIST) to be associated with a shorter progression-free period. Median OS was 11 months (95% CI: 10.402–11.958 months) with an ECOG ≥2 and a poorer response to chemotherapy (less number of chemotherapy cycles) associated with a shorter survival.ConclusionsAge, gender, comorbidities, tobacco and asbestos exposure, clinical presentation and histopathological diagnosis are not useful prognostic factors in unresectable/advanced PTS, however, an adequate initial ECOG, RECIST and a better response to chemotherapy should be used as prognostic factors in the management of these tumors.

Aggressive Multimodality Therapy for Treatment of a Locally Advanced Radiation-Related Chest Wall Sarcoma

Aggressive Multimodality Therapy for Treatment of a Locally Advanced Radiation-Related Chest Wall Sarcoma

Macrophages and vimentin in tissues adjacent to megaprostheses and mesh in reconstructive surgeries

ABSTRACT In reconstructive surgery using artificial materials after wide resection, soft tissues are usually adjacent to metal surfaces or mesh. The purpose of this study was to provide histological evaluation of the soft tissues adjacent to the metal surfaces of megaprostheses and mesh. Tissues from revision surgery of megaprosthesis and from wide resection after recurrent thoracic wall sarcoma were used. Histological analysis was evaluated by hematoxylin/eosin (HE) and Masson’s trichrome staining, and by immunohistochemical staining for markers including cluster of differentiation 68 (CD68), vimentin, collagen type and S100A4. Soft tissue adherence to the smooth metal surface of Ti alloy was not observed. On the surface of capsule, CD68- and vimentin-positive cells formed a thin layer. In contrast, soft tissue adherence to a rough-surface cobalt chrome alloy was observed. Capsule was not apparent for this tissue, in which CD68- and vimentin-positive cells were aggregated randomly. In the resected tissues of recurrent chest wall sarcoma, muscles showed connections to connective soft tissues but did not invade to the inside of the mesh. Around the polypropylene mesh, large numbers of CD68- and vimentin-positive cells were seen. On the ePTFE, small numbers of CD68-positive cells were observed, while a larger number of the cells were vimentin positive. High accumulation of S100A4-positive cells was observed at the metal surface and polypropylene surface. Cells were strongly positive for CD68 and vimentin in tissues adjacent to metal and mesh surfaces. Macrophages and vimentin may play important roles in the foreign body reaction to metal and mesh, and so may contribute to encapsulation and fibrosis.

Surgical resection of chest wall sarcomas: an analysis of survival and predictors of outcome at an Australian multidisciplinary sarcoma service.

Chest wall sarcomas are a rare group of tumours. Surgical resection is considered the mainstay of curative treatment, however, resection and reconstruction of chest wall defects presents complex issues for the clinician. A retrospective analysis of 59 patients undergoing surgical management of chest wall sarcoma between December 1996 and July 2020 was conducted across a multidisciplinary sarcoma service in Melbourne, Australia. Patient demographics, pathologic data, and long-term outcomes were recorded. Mean age at surgery was 48.4 years (SD 18.3), and 66.1% were male. Median follow-up was 29 months (IQR 11.8, 51.0months). Fifty-one patients presented with primary tumours, while the others had secondary tumours resected. Most tumours arose in bone (72.9%) as opposed to soft tissues (27.1%). Chondrosarcoma was the most common histologic subtype (50.8%). The most common reconstructive techniques involved the use of mesh (79.7%) or mesh supplemented with bone cement (33.9%). Overall survival at 1 and 5 years was 92% and 70%, respectively. Seven patients died of metastatic sarcoma during the follow up period with a median survival time of 27 months. Twelve patients had evidence of disease recurrence during the follow-up period. Stage 4 disease, soft tissue tumours, secondary tumours, leiomyosarcoma and UPS subtypes, and plating reconstruction were associated with increased disease recurrence. The results suggest that outcomes for chest wall sarcoma are similar to extremity sarcomas and may be treated in a similar manner. Patients requiring adjuvant radiotherapy and those who develop disease-recurrence are more likely to have worse overall survival outcome despite complete surgical resection.

STERNUM TUMOR SURGICAL TREATMENT METHOD: A CLINICAL CASE

Relevance: Sarcomas are relatively rare tumors. They make up 1% of all malignant neoplasms in adults, of which about 10-15% appear in the chest wall. Unlike primary tumors, metastatic bone tumors occur 2-4 times more often, while the sternum is affected in 9% of&#x0D; all metastatic bone lesions. A review of the literature and analysis of patients with chest wall tumors showed that surgical treatment might&#x0D; be the best option for primary and secondary chest wall tumors.&#x0D; Chondrosarcoma is the most common primary chest bone sarcoma and originates from the anterior segment of the ribs, less often from&#x0D; the sternum, scapula, or clavicle.&#x0D; The study aimed to present the outcome of a sternum sarcoma surgical treatment with a simultaneous reconstruction of an extensive&#x0D; postoperative defect at the Kazakh Institute of Oncology and Radiology (Almaty, Kazakhstan).&#x0D; Methods: The article reviews the literature on the treatment of chest wall tumors and describes a clinical case of a patient with&#x0D; chondrosarcoma of the sternum. After subtotal resection of the sternum 2-3 cm away from the tumor margins, the patient underwent&#x0D; reconstructive plastic surgery. Synthetic material was used to stabilize the chest wall, prevent paradoxical breathing, and replace&#x0D; the defect.&#x0D; Results: No recurrence of the primary process was registered after radical removal of the sternum tumor with the simultaneous reconstruction of the defect with synthetic material. Given the prevalence of the tumor, intraoperative suturing of the subclavian vein was&#x0D; performed, which led to vein thrombosis in the postoperative period.&#x0D; Conclusions: Early recognition and radical removal with adequate margins are essential to successful sternum tumor treatment. Complete excision with broadly negative microscopic margins at the first operation is paramount since local recurrence increases the risk of&#x0D; systemic metastasis and death. Thus, standard guidelines are required to ensure the proper treatment of chest wall sarcomas.

STERNUM TUMOR SURGICAL TREATMENT METHOD: A CLINICAL CASE

Relevance: Sarcomas are relatively rare. They make up 1% of all malignant neoplasms in adults, of which about 10-15% appear in the chest&#x0D; wall. Unlike primary tumors, metastatic bone tumors occur 2-4 times more often, while the sternum is affected in 9% of all metastatic bone lesions.&#x0D; A review of the literature and analysis of patients with chest wall tumors showed that surgical treatment might be the best option for primary tumors&#x0D; and some secondary chest wall tumors.&#x0D; Chondrosarcoma (12%) is the most common primary chest bone sarcoma and originates from the anterior segment of the ribs, less often from&#x0D; the sternum, scapula, or clavicle.&#x0D; The purpose was to present the outcome of a sternum sarcoma surgical treatment with a simultaneous reconstruction of an extensive postoperative defect at the Kazakh Institute of Oncology and Radiology (Almaty, Kazakhstan).&#x0D; Methods: The article reviews the literature on the treatment of chest wall tumors and describes a clinical case of a patient with chondrosarcoma of the sternum. After subtotal resection of the sternum 2-3 cm away from the tumor margins, the patient underwent reconstructive plastic&#x0D; surgery. Synthetic material was used to stabilize the chest wall, prevent paradoxical breathing, and replace the defect.&#x0D; Result: No recurrence of the main process was registered after radical removal of the sternum tumor with the simultaneous reconstruction of&#x0D; the defect with synthetic material. Given the prevalence of the tumor, intraoperative suturing of the subclavian vein was performed, which led to&#x0D; vein thrombosis in the postoperative period.&#x0D; Conclusions: The key to successful sternum tumor treatment is early recognition and radical removal with adequate margins. Complete excision with broadly negative microscopic margins at the first operation is paramount since local recurrence increases the risk of systemic metastasis&#x0D; and death. Thus, standard guidelines are required to ensure chest wall sarcomas proper treatment.

Sociodemographic, clinical profile, and treatment characteristics of oncology patients developing radiation recall phenomenon: Two tertiary care center's experience of an eternal unpredictable phenomenon of cancer treatment.

ABSTRACTObjectives:To determine the socio-demographic and clinical profile of cancer patients developing radiation recall phenomenon or radiation recall dermatitis following chemotherapy administration, previously treated with external irradiation. We assessed its incidence, severity, frequency, differentiation from radio-sensitization and radiation-dermatitis, its correlation with radiation dose and chemotherapeutic agent, and various parameters affecting its occurrence.Materials and Methods:This observational prospective study was designed for 1092/2676 (50.2%) patients of histologically proven carcinoma breast, carcinoma lung, lymphomas, chest wall sarcomas, thymomas, thymic carcinomas, nasopharyngeal cancer, bladder carcinoma, rectal cancer, and metastatic cases who received radiation therapy followed by chemotherapy. Intake, treatment, observation, and follow-up were done from July 2014 to July 2021 for 7 years in two tertiary care cancer institutes of government setup.Results:In our study, majority of recall phenomena were reported in breast carcinoma 43/71 (60.5%) followed by carcinoma esophagus with 07/71 (9.8%) cases. Females developed 54.9% grade-I/II and 90% grade-III/IV recall cases compared to males with 45.1% and 10% cases, respectively (P = 0.005). Median radiation dose used was 45 Gy (dose range 8–70 Gy) (P = 0.656). Docetaxel resulted in 55% recall cases followed by paclitaxel with 12.7% of cases. Combination therapy reported 71.8% of cases compared to monotherapy with 28.2% of cases. Recall-cases recorded in the time period of 3–4 weeks between radiation and chemotherapy were 59/71 (83%) and those reported in >4 weeks were 12/71 (17%). Time-gap between 3 and 4 weeks reported 49% grade-I/II and 100% grade-III/IV recall-cases while time-gap >4 weeks resulted in 26% and 0% cases respectively (P = 0.000).Conclusion:In this study, taxanes and platinum-agents were the most common chemotherapeutic drugs involved in the occurrence of the recall phenomenon. Multi-drug regimens resulted in higher recall cases compared to monotherapy. Radiation dosage did not cause any significant impact. The risk and severity of recall reactions increased with female gender and shorter time-interval between radiation and systemic therapy, while early-onset recall cases displayed greater severity. This precedented but unpredictable phenomenon ceases to be a topic to be discarded in this modern era of highly conformal radiation therapy techniques and targeted cancer therapy.

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 T3-4N0-1M0. 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.

Preserving the posterior cortex of the sternum during resection of a superficial anterior chest wall sarcoma.

Following resection of a sternal tumor, respiratory dysfunction can occur and rigid reconstruction is necessary. An 82-year-old woman noted a mass in the anterior chest wall that was increasing in size. The tumor was located on the left aspect of the sternum at the level of the third rib. A radiation-induced malignant spindle cell tumor was diagnosed because of a history of irradiation for hilar lymph node carcinoma. The tumor was resected with the surrounding tissues of the second-to-fourth ribs and sternum. The posterior sternal cortex was preserved by cutting with a curved chisel under fluoroscopy. The chest wall defect was reconstructed with a 2-mm thick Gore-Tex® sheet and a local transpositional flap. Sternal resection with a chisel under fluoroscopy avoids damage to the internal thoracic artery. Preserving the posterior sternal cortex does not require rigid reconstruction. The procedure is minimally invasive.

Unlikely Coexistence of Sporadic Pheochromocytoma and Bilateral Macronodular Adrenal Hyperplasia: A Challenge to Manage

Background: The incidence of bilateral macronodular adrenal hyperplasia (BMAH) is unknown, but growing in an era of increased utilization of imaging. Coexistence of BMAH and pheochromocytoma has not previously been reported.Clinical Case: A 63-year man presented with enlarging left chest-wall mass found to have a poorly differentiated sarcoma. Staging PET/CT identified a hypermetabolic 2.0 cm left adrenal nodule with SVU of 16.6 concerning for metastasis. Hormonal evaluation included dexamethasone suppression test with 7AM serum cortisol of 24.7 ug/dL (<1.8 ug/dL) without dexamethasone level, serum ACTH <5.0 pg/mL (7.2–63 pg/mL), plasma metanephrine of <0.20 nmol/L (0–0.49 nmol/L), and plasma normetanephrine of 0.76 nmol/L (0.00–0.89 nmol/L). Biopsy of this left adrenal nodule was consistent with pheochromocytoma. By history, he lacked any classical symptoms of pheochromocytoma. Repeat testing demonstrated only slight elevations in normetanephrine (1.3 nmol/L and 1.2 nmol/L); he remains asymptomatic at follow-up 4 months later. However, history and exam revealed central obesity, thin skin, type 2 diabetes mellitus on insulin, and hypertension controlled on three agents concerning for Cushing’s. Repeat evaluation showed AM cortisol of 17.9 ug/dL (<1.8 mcg/dL) with dexamethasone level of 917 ng/dL (180–550 ng/dL), ACTH of 6.4 pg/mL with concordant cortisol of 23.1 ug/dL, and 24 hour urine collection with 0.98 L volume, creatinine of 0.58 g/24h (1–2 g/24hr), and urinary free cortisol of 67 ug/24h (3.5–45) altogether suggesting ACTH-independent hypercortisolism. On review of CT abdomen, he has bilateral adrenal nodules measuring >1cm with bilateral gland enlargement consistent with BMAH. Resection of his left adrenal gland was not pursued due to cormorbidities as well as biochemically-silent nature of his pheochromocytoma. To manage his hypercortisolism, he was recently initiated on osilodrostat after completing radiation therapy for his chest-wall sarcoma.Conclusion: This is the first case demonstrating clinical, biochemical, and imaging results consistent with bilateral macronodular adrenal hyperplasia and hypercortisolism also found to have a clinically and biochemically silent, biopsy proven pheochromocytoma. This is also a unique use of osilodrostat to manage BMAH.