Thoracoscopic resection and re-resection of an anterior chest wall chondrosarcoma

The limits of thoracoscopic resections are expanding, with improved instruments for manipulating and dividing tissues such as the bone. We encountered a patient with a primary chest wall tumor that had exposure characteristics similar to our limited, but promising, experience with en bloc rib resections for primary lung cancer. A 71-year-old female patient presented with a symptomatic right meningocele, at which time a 7.7-cm left anterior mediastinal mass bulging through the second interspace was detected. With the patient in the lateral decubitus position, a modified three-incision approach similar to that for a video-assisted thorascopic surgery (VATS) lobectomy was performed but angled slightly different to expose the anterior chest wall. Using this approach, the mass was excised intact en bloc, with ribs 2 and 3 (9.5-cm total specimen with 6-cm longest rib). No chest wall reconstruction was necessary. The patient did well and had her chest tube removed on postoperative day (POD) 1, was discharged with minimal pain on POD 3, and was pain free on POD 14. Because a microscopic focus of chondrosarcoma was found at the second rib intramedullary margin on the final pathologic review, she returned for VATS re-resection of an additional 5 cm of rib on POD 43 using the same incisions, and her postoperative recovery was replicated. The operative times were 160 and 90 minutes, and blood loss was 400 and 100 mL, respectively. This case demonstrates that if traditional surgical values of exposure and oncologic safety can be replicated using enhanced instrumentation, it is reasonable to attempt more complex operations thoracoscopically. Even though ribs were removed, pain control was similar to other VATS operations.