Case 5

A 53-year-old man with a heavy exposure to asbestos 25 years earlier was admitted to the East Orange Veterans Administration Medical Center with a rapidly enlarging chest wall mass of 4-5 weeks duration.

The mass, overlying the ninth and tenth ribs in the infraaxillary area, was firm. On X-ray the ribs appeared eroded and the mass was seen to extend into the pleural space. A chest wall resection was performed, and the tumor was sharply dissected from the diaphragm to which it was firmly adherent. Grossly, it measured 7.5 X 5.0 X 3.0 cm and was yellow-tan with homogeneous and nodular areas The inferior aspect of the ninth rib was obviously involved and the tumor extended between the pleura and intercostal muscle.

The patient did not receive further therapy and was asymptomatic 7 months after surgery.     

Giant cell tumor originating from the anterior arc of the rib

We report a case of giant cell tumor originating from the anterior arc of the rib. The tumor and the surrounding chest wall were completely resected, and the chest wall defect was covered with Marlex mesh. Giant cell tumor of the bone usually originates from the epiphysis of long bones. Even when the tumor occur in ribs, it usually occur in the posterior aspect. However, giant cell tumor should be included in the differential diagnosis of a tumor originating from the anterior arc of the ribs.     

Pulmonary leiomyosarcoma presenting as a pancoast tumor

A patient presenting with Pancoast syndrome was definitely diagnosed to have pulmonary leiomyosarcoma. The patient underwent a right upper lobectomy combined with resection of the chest wall, including the 1st to 3rd ribs. The disease recurred rapidly at the local and distant sites. No previous reports about pulmonary sarcoma presenting as a Pancoast tumor were found in the literature. The possibility of primary pulmonary leiomyosarcoma should be considered, and early detection and surgical resection are necessary when a round or oval tumor with necrosis is observed in the apex of the lung.     

数字化定制个体化钛合金胸骨假体在胸骨肿瘤根治性切除胸壁缺损重建术中的临床应用

目的 探讨数字化定制的个体化钛合金胸骨假体应用于胸骨肿瘤根治性切除患者胸壁缺损重建的可行性。方法 病例系列报告。纳入2020年8月—2021年10月武汉大学人民医院胸外科收治的5例原发性胸骨肿瘤患者的病例资料,均为男性,年龄23~60岁（平均43.5岁）,其中胸骨柄肿瘤1例、胸骨体肿瘤4例。基于患者术前胸廓CT扫描数据,采用3D打印技术制作1∶1大小的患者胸骨以及与之连接的部分肋骨、锁骨的三维骨骼及肿瘤模型,同时设计并数字化定制个体化的钛合金胸骨假体;在3D打印模型上模拟肿瘤切除术,再将钛合金假体植入缺损的胸骨模型中进行匹配,模拟假体植入手术。全组均在全身麻醉下行胸骨肿瘤根治性切除术,并植入术前定制的个体化钛合金胸骨假体,完成胸骨缺损的修复;其中1例胸骨柄肿瘤患者,肿瘤切除后使用自体肌腱重建了胸锁关节。观察手术时间、术中出血量、围手术期死亡,术后胸壁稳定性、慢性疼痛、患者生存状态、胸锁关节重建患者的肩关节功能,以及术后胸骨假体移位或断裂、胸腔积液、肺部感染等并发症发生。结果 全组5例患者手术过程顺利,围术期无死亡病例,无再次手术病例,手术时间为115~165 min,术中出血量80~260 mL。术后病理诊断：骨巨细胞瘤1例、髓系肉瘤1例、软骨肉瘤2例和孤立性浆细胞瘤1例。全组均无需进行肌皮瓣转移修复胸壁;手术切口均为甲级愈合,无植入物感染;胸壁完整稳定,无胸壁浮动和反常呼吸。有1例术后因胸腔积液延迟拔除胸管。全组术后随访12~24个月,未发生术后植入物断裂、移位,或胸腔积液、肺部感染、慢性疼痛等并发症;其中1例胸锁关节重建患者,术后关节功能无障碍。结论 数字化定制的个体化钛合金胸骨假体用于胸骨肿瘤根治性切除后胸壁缺损的重建,手术方案可行,操作简单,术后胸壁稳定性好、并发症少。     

Case 9

A 66-year-old woman was shown on routine X-ray to have a well-circumscribed anterior mediastinal mass (Fig. 1). The mass was totally excised, and no extension was noted beyond the mediastinum. Grossly, the tumor measured 7.5 × 7.5 × 7.5 cm, weighed 102g, had a firm, gray cut surface, and appeared encapsulated. No further therapy was given. Recurrent disease was noted radiographically in the anterior mediastinum 5 years later. A sternal split revealed three tumor masses situated on the aortic arch, superior vena cava, and right pulmonary hi/us, respectively; the largest measured 10 × 10 × 5 cm, weighed 80 g, and, on section, was brown and firm, with hemorrhagic areas. Tumor was also noted on the visceral pleura of the right lung. A formal thoracotomy, performed 2 months later, identified a 4 × 3 cm anterior mediastinal mass attached to the right middle lobe of the lung and invading the pericardium. Many implants were noted on the posterior and lateral parts of the chest wall.

Throughout the course up to this point, the patient had been remarkably asymptomatic; there had been no symptoms or signs suggestive of any activity by the tumor. Three and one-half years following the last thoracotomy, massive local recurrence developed in the mediastinum and pleural spaces, which led to the death of the patient by respiratory insufficiency. There was no clinical evidence of distant metastases. Autopsy was not obtained.     

External rib structure can be predicted using mathematical models: An anatomical study with application to understanding fractures and intercostal muscle function

As ribs adapt to stress like all bones, and the chest behaves as a pressure vessel, the effect of stress on the ribs can be determined by measuring rib height and thickness. Rib height and thickness (depth) were measured using CT scans of seven rib cages from anonymized cadavers. A Finite Element Analysis (FEA) model of a rib cage was constructed using a validated approach and used to calculate intramuscular forces as the vectors of both circumferential and axial chest wall forces at right angles to the ribs. Nonlinear quadratic models were used to relate rib height and rib thickness to rib level, and intercostal muscle force to vector stress. Intercostal muscle force was also related to vector stress using Pearson correlation. For comparison, rib height and thickness were measured on CT scans of children. Rib height increased with rib level, increasing by 13% between the 3rd and 7th rib levels, where the 7th/8th rib was the widest part or “equator” of the rib cage, P < 0.001 (t‐test). Rib thickness showed a statistically significant 23% increase between the 3rd and 7th ribs, P = 0.004 (t‐test). Intercostal muscle force was significantly related to vector stress, Pearson correlation r = 0.944, P = 0.005. The three nonlinear quadratic models developed all had statistically significant parameter estimates with P < 0.03. External rib morphology, in particular rib height and thickness, can be predicted using statistical mathematical models. Rib height is significantly related to the calculated intercostal muscle force, showing that environmental factors affect external rib morphology. Clin. Anat. 28:512–519, 2015. © 2015 Wiley Periodicals, Inc.     

Malignant transformation of intrathoracic ancient neurilemmoma in a patient without Von Recklinghausen's disease

Malignant transformation of a neurilemmoma is an exceedingly rare event. We describe a case of intrathoracic ancient neurilemmoma undergoing a malignant change in a 39-yr-old man. The patient presented with right flank and chest pain for several months. Plain radiography and CT scan of the chest showed a soft tissue mass lesion at the extrapleural space with erosion of surrounding ribs at the right basal lung area. The excised mass was encapsulated and measured 4.5 x 3.5 x 2.3 cm. The cut surface showed grayish-white and glistening with a focal cystic change and hemorrhage. Necrosis was not seen. Histologically, the tumor showed the features of classic neurilemmoma composed of the Antoni type A and B areas with perivascular hyalinization. In addition, obviously histo-logically malignant foci manifested by presence of markedly increased cellularity with fascicular arrangement, active mitotic activity, hyperchromasia, and gradual loss of original neurilemmomatous feature were noted.     

胸壁结核CT分型及其对手术治疗的指导价值

目的 总结胸壁结核的CT表现并尝试进行分型,探讨CT分型与临床手术方式的相关性.方法 收集142例经手术病理证实的胸壁结核患者的CT资料.采用骨算法进行重建,容积再现肋骨三维重建,观察肋骨情况.结果 按照CT表现分为4型：Ⅰ型：胸膜结核瘤型27例.行单纯病灶切除术;Ⅱ型：胸骨或肋骨结核18例.手术切除受侵肋骨及周围病灶内的干酪样坏死物和结核性肉芽肿;Ⅲ型：肋骨外侧结核性脓肿21例.其中12例行单纯病灶清除术,9例行病灶清除加小段肋骨切除术;Ⅳ型：混合型76例.行脓肿切除加肋骨切除术65例,行脓肿切除加胸壁（肋骨和肋间肌）切除及肌瓣填塞术11例.结论 CT能清晰显示胸壁结核的位置、大小、累及范围,可据此进行CT分型,对术前选择手术方式具有重要指导意义.     

Preoperative embolization in surgical treatment of a primary hemangiopericytoma of the rib: a case report

Primary hemangiopericytoma of the rib is extremely rare and only a few cases have been reported. A 62-yr-old man presented with an aching chest pain and dyspnea. Thoracic computed tomography revealed a homogenous mass expanding the right seventh rib. A diagnosis of hemangiopericytoma was established by percutaneous needle biopsy. Preoperative embolization of the feeding vessels of the tumor was performed in order to prevent perioperative bleeding. There was no significant bleeding during the surgery, where complete resection of the tumor with 7th to 9th ribs with a surgical margin of 5 cm was performed. Postoperative course was uneventful and there has been no recurrence for thirteen months. To our knowledge, there has been no report to apply a preoperative embolization of a primary hemangiopericytoma of the rib.     

Surgical treatment of tuberculous cold abscess of the chest wall

The incidence of tuberculosis (Tbc) infection is high in some parts of the world and tuberculous cold abscess of the chest wall (CACW) often fails to respond to medical treatment. Medical records of 178 patients who underwent surgical treatment of chest wall abscesses from July 1970 to Sept. 2000 were reviewed and 89 patients who were pathologically confirmed as Tbc cold abscess cases were included in this study. Their ages ranged from 9 to 71 years (mean 33.3 years) and the male to female ratio was 1.2:1 (49 male, 40 female). The symptoms were palpable chest wall mass, pain and pus discharge, and three patients had multiple lesions. Twenty-five patients (28%) underwent excision of chest wall abscesses and 64 patients (72%) underwent chest wall and rib resection. Tbc medication was given preoperatively in 39 patients for an average of 6.3 months and all patients were given Tbc medication postoperatively for an average of 12 months. Postoperative complications were bleeding, pus discharge, empyema, pleural effusion, wound dehiscence, subcutaneous emphysema and activation of pulmonary Tbc. The disease recurred in 7 patients (7.8%) and these 7 patients all underwent a second operation. We recommend preoperative Tbc medication and complete resection of chest wall abscesses including any suspicious ribs. Postoperative Tbc medication for a minimum of 12 months is essential to decrease the risk of a relapse.     

Chest wall reconstruction in a canine model using polydioxanone mesh,demineralized bone matrix and bone marrow stromal cells

Extensive chest wall defect reconstruction remains a challenging problem for surgeons. In the past several years, little progress has been made in this area. In this study, a biodegradable polydioxanone (PDO) mesh and demineralized bone matrix (DBM) seeded with osteogenically induced bone marrow stromal cells (BMSCs) were used to reconstruct a 6 cm × 5.5 cm chest wall defect. Four experimental groups were evaluated (n = 6 per group): polydioxanone (PDO) mesh/DBMs/BMSCs group, polydioxanone (PDO) mesh/DBMs group, polydioxanone (PDO) mesh group, and a blank group (no materials) in a canine model. All the animals survived except those in the blank group. In all groups receiving biomaterial implants, the polydioxanone (PDO) mesh completely degraded at 24 weeks and was replaced by fibrous tissue with thickness close to that of the normal intercostal tissue (P > 0.05). In the polydioxanone (PDO) mesh/DBMs/BMSCs group, new bone formation and bone-union were observed by radiographic and histological examination. More importantly, the reconstructed rib could maintain its original radian and achieve satisfactory biomechanics close to normal ribs in terms of bending stress (P > 0.05). However, in the other two groups, fibrous tissue was observed in the defect and junctions, and the reconstructed ribs were easily distorted under an outer force. Based on these results, a surgical approach utilizing biodegradable polydioxanone (PDO) mesh in combination with DBMs and BMSCs could repair the chest wall defect not only in function but also in structure.     

Cytologic spectrum of 227 fine-needle aspiration cases of chest-wall lesions

This study was carried out with the objective of studying the cytomorphology of the wide variety of chest-wall lesions. Two hundred twenty-seven chest-wall lesions were studied over a period of 4 yr. Routine May-Grünwald-Giemsa (MGG) and hematoxylin-eosin (H&E) slides were studied along with special stains, whenever required. The malignant lesions comprised 36.13% of all cases (81/227). Of the 126 benign lesions, the majority were inflammatory in nature (68/126), the next commonest lesion being lipoma (38/126). Rare cases of tuberculosis involving the sternum, epithelioid leiomyosarcoma, and neuroendocrine tumors involving ribs, malignant nerve sheath tumors involving the chest wall, metastatic carcinoma of the stomach and prostate, and papillary carcinoma thyroid are reported in this series. Histopathology was available in 24 cases, and hematological correlation in one case. A 100% cytohistological and cytohematological correlation was found, with no false positives or false negatives. In conclusion, fine-needle aspiration cytology is a rapid, diagnostic tool, eliciting many interesting lesions in the chest wall. It is useful not only in detecting primary and metastatic lesions, but also in follow-up of tumor recurrence.     

Estimating the probability that the Taser® directly causes human ventricular fibrillation

This paper describes the first methodology and results for estimating the order of probability for Tasers® directly causing human ventricular fibrillation (VF). The probability of an X26 Taser® causing human VF was estimated using: (1) current density near the human heart estimated by using 3D finite-element (FE) models; (2) prior data of the maximum dart-to-heart distances that caused VF in pigs; (3) minimum skin-to-heart distances measured in erect humans by echocardiography; and (4) dart landing distribution estimated from police reports. The estimated mean probability of human VF was 0.001 for data from a pig having a chest wall resected to the ribs and 0.000006 for data from a pig with no resection when inserting a blunt probe. The VF probability for a given dart location decreased with the dart-to-heart horizontal distance (radius) on the skin surface.     

Dedifferentiated chondrosarcoma of the rib with a malignant mesenchymomatous component: An autopsy case report

A rare variant of dedifferentiated chondrosarcoma wlth malignant mesenchymomatous component in a 57-year-old male is reported. The patient presented with a posterior mediastinal mass arising from the left eighth and ninth ribs showing well differentiated, low-grade chondrosarcoma. Five years later, local recurrence occurred and an excised specimen also showed the same histological features as the primary tumor. Another 6 years later, the tumor recurred and metastasized to the multiple organs, the patient dying 4 months later. Autopsy revealed that the recurrent and metastatic tumors showed malignant mesenchymomatous 'dedifferentiation' of chondrosarcoma composed of rhab domyosarcoma, angiosarcoma, chondrosarcoma, osteosarcoma, and leiomyosarcoma, in addition to fibrosarcomatous areas. Although the less differentiated component of dedifferentiated chondrosarcoma usually shows the histological features of malignant fibrous histiocytoma and fibrosarcoma, multilineage differentiation can occur in that component. The phenomenon of 'dedifferentiation' in chondrosarcoma and the relationship to and distinction from malignant mesenchymoma of soft tissue and bone are discussed.     

Multiple extranodal follicular dendritic cell tumors initially presenting in the soft tissue in the chest wall

A follicular dendritic cell (FDC) tumor that involved the soft tissue of the chest wall, liver and thyroid was reported in a 72-year-old Japanese man. A biopsy specimen from the chest wall showed an uncommon malignant soft-tissue tumor. No distinct immunohistochemical reactions were found. The patient died 1 year after the initial presentation. No definite diagnosis was given until autopsy was performed. Upon autopsy, each tumor was well-circumscribed and a solid tan-gray color on cut section. Microscopically, the tumor cells were composed of oval to spindle cells arranged in a short fascicular growth pattern. The autopsy specimen from the soft tissue of the chest wall had a strong reaction for CD21/CD35 and clusterin, a new FDC marker, whereas the biopsy specimen had an undistinct reaction for CD21/CD35 and a weak reaction for clusterin. FDC makers assisted in this diagnosis, especially with the autopsy specimen. In conclusion, it was difficult to diagnose an FDC tumor because of the particular tumor sites involved, lack of characteristic microscopic features, and because of aggressive tumor behavior.     

Signet-ring chondrosarcoma: a new morphologic entity.

A 65-year-old, otherwise healthy white man presenting with an asymptomatic anterior chest wall mass diagnosed from a routine preoperative chest x-ray is reported. A fine needle aspirate of the mass was initially interpreted as a metastatic adenocarcinoma with prominent "signet-ring" features, but ultrastructural study of the cell block later suggested a chondrosarcoma. The resected surgical specimen confirmed the diagnosis of a grade 2 chondrosarcoma, with most of the tumor cells containing a large, clear, single vacuole shown to be lipid. The positive immunostaining for vimentin and S-100 as well as the ultrastructural appearance confirmed the diagnosis of a chondrosarcoma. Flow cytometric DNA analysis of the tumor on two separate occasions documented a very large aneuploid cell population (50% to 60%) which, when interpreted with the histologic appearance, suggested an aggressive tumor. This case illustrates the first published example of a "signet-ring" chondrosarcoma.     

Pleural effusion as a complication of solitary eosinophilic granuloma of the rib

A 57 year old man presented with a two week history of right sided chest pain. An admission chest x-ray examination revealed a 2 by 1 cm. lytic lesion of the ninth right rib and right sided pleural effusion. The patient underwent a right thoracotomy during which 700 cc. of blood tinged pleural fluid was drained and a 10 cm. segment of the right ninth rib was excised. The rib lesion showed classic features of eosinophilic granuloma of bone. Cytolygic examination of the pleural fluid disclosed abundant histiocytes and eosinophils, consistent with eosinophilic granuloma invading the pleural space. This case is unusual because of the age of the patient and the development of a pleural effusion secondary to the rupture of the tumor into the pleural cavity, the latter not previously reported in the literature.     

Tuberculosis of the ribs: a recurrent attack of rib caries.

Rib tuberculosis is an extremely rare condition with the incidence not exceeding 3 percent of all skeletal tuberculosis. The authors experienced a recalcitrant case of pulmonary tuberculosis accompanied by chest wall cold abscesses involving ribs recurring at a new site in approximately 10 months despite of medical and surgical treatment. The patient has twice taken thoracotomy for abscess drainage and during the second thoracotomy, a partial resection of involved ribs was performed.     

Tensile Force Transmission in Human Patellar Tendon Fascicles Is Not Mediated by Glycosaminoglycans

Costal cartilage is much understudied compared with the load-bearing cartilages. Abnormally grown costal cartilages are associated with the inherited chest wall deformities pectus excavatum and pectus carinatum resulting in sunken and pigeon chests, respectively. A lack of understanding of the ultrastructural and molecular biology of costal cartilage is a major confounder in predicting causes and outcomes of these disorders. This study analyzed the structure of marginal human costal cartilage (ribs 6–10) through scanning electron and atomic force microscopes and identified the presence of straw-like structures running longitudinally. We also demonstrated that chondrocytes tend to occur singly or as doublets and that centrally located cells produce high levels of aggrecan compared with more peripherally located cells measured using immunohistochemistry. Gene expression from mRNA extracted from cartilage showed high levels of decorin expression, likely associated with the large, complex tubular structures running through this cartilage type. COL2A1, ACAN, and TIMP1 also showed higher levels of expression compared with ACTB. Analysis of gene expression ratios demonstrate that costal cartilage is under differentiated compared with published ratios for articular cartilage, likely due to the vastly different biomechanical environments of each cartilage type. Further studies need to establish whether findings described here from the costal margins are significantly different than the cartilage of the “true ribs” and how these values change with age.