Images for surgeons
wound management in the early postoperative period has been shown to be superior to closure with muscle flap.7 The introduction of NPWT has further improved these results with fewer postoperative complications, less repeat procedures, shorter hospital stays and decreased morbidity.7 In summary, this case aims to raise the awareness about this infrequent but serious surgical condition, particularly in susceptible, immunocompromised patients. The importance of early recognition and treatment is highlighted, with delay resulting in progression of infection, lengthy hospital stay and ongoing wound care. Early imaging to identify extra-articular involvement should be performed in any patient with signs or symptoms suggestive of SCJI and referral to a thoracic surgical service for further management should follow. Open wound management with the use of NPWT gives the most favourable outcomes following debridement of affected tissue.
References 1. Nusselt T, Klinger HM, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch. Orthop. Trauma Surg. 2011; 131: 319–23. 2. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine 2004; 83: 139–48.
195
3. Womack J. Septic arthritis of the sternoclavicular joint. J. Am. Board Fam. Med. 2012; 25: 908–12. 4. El Ibrahimia A, Daoudia A, Boujrafb S, Elmrini A, Boutayeb F. Sternoclavicular septic arthritis in a previously healthy patient: a case report and review of the literature. Int. J. Infect. Dis. 2009; 13: 119–21. 5. Arab WA, Khadragui I, Echave V, Deshaies A, Sirois C, Sirois M. Surgical management of sternoclavicular joint infection. Eur. J. Cardiothorac Surg. 2011; 40: 630–5. 6. Burkhart HM, Deschamps C, Allen MS, Nichols FC III, Miller DL, Pairolero PC. Surgical management of sternoclavicular joint infections. J. Thorac. Cardiovasc. Surg. 2003; 125: 945–9. 7. Puri V, Meyers BF, Kreisel D et al. Sternoclavicular joint infection: a comparison of two surgical approaches. Ann. Thorac. Surg. 2011; 91: 257–62. 8. Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternocalvicular joint infection. Ann. Thorac. Surg. 2002; 73: 427–31.
Mathew P. Doyle, MBBS Scott B. Jennings, MBBS (Hons) Matthew D. A. Horton, MBBS, FRACS Cardiothoracic Surgery, St George Hospital, Kogarah, New South Wales, Australia doi: 10.1111/ans.12414
Giant cell tumour of the rib: an unusual location for an impressive tumour A 38-year-old gentleman of Polynesian descent presented acutely to the cardiothoracic service with a 2-week history of anterior chest pain and shortness of breath. He had noticed a mass in his left anterior chest, slowly increasing in size over 2 years. He was a morbidly obese (calculated BMI of 53) and current smoker with treated hypertension. Chest CT showed a 15-cm anterior chest wall mass with associated destruction of the fourth rib. The tumour had both a large intra and extra thoracic component. There was a small pleural effusion with no evidence of distant metastases (Fig. 1). A thoracoscopy was performed – no pleural metastases were identified and cytology was negative for malignancy. An open biopsy was taken of the mass, which suggested this mass was a giant cell tumour (GCT). Given the localized nature of the disease, an en bloc resection and chest wall reconstruction was undertaken, with the assistance of the Plastic and reconstructive surgery department. The anterior portions of the third to sixth ribs were resected along with pectoralis major and minor, a wedge of the lingula of the left upper lobe, where the tumour was densely adherent, and an ellipse of skin including the previous biopsy site (Figs 2 and 3). The chest wall was reconstructed using a methylmethacrylate strengthened polypropylene mesh and covered using a pedicled latissimus dorsi musculocutaneous flap. Initially, the patient recovered well following his procedure. He was discharged from hospital 7 days postoperatively. Unfortunately, he presented approximately 3 weeks following surgery with a Staphylococcus aureus empyema and draining sinus. Given the mor-
© 2013 Royal Australasian College of Surgeons
Fig. 1. Computed tomography scan showing large left sided chest wall mass with intra- and extrathoracic components, destruction of the fourth rib (red arrow) and a small pleural effusion (blue arrow).
bidity associated with surgically desterilizing the remaining space and mesh, the patient was treated with long-term antibiotics. He had a good response to prolonged intravenous antibiotic therapy in the community and was able to be stabilized on oral rifampicin. One year following his operation and subsequent empyema, he continues to do well and is free of tumour recurrence.
196
Images for surgeons
Fig. 2. Intraoperative photos showing the large left sided chest wall mass prior to removal (red arrow) and the defect following complete resection (blue arrow).
Fig. 3. Gross histological specimen shown from the external and internal aspects. The tumour can be seen as an irregular mass on measuring 15 cm in diameter (blue arrow). The previous biopsy site can be seen in the skin ellipse (red arrow).
GCTs of bone are uncommon, accounting for only 4–5% of primary bone tumours.1–4 The most common sites affected are the metaphyseal plates of long bones, with only 0.6% of all GCTs arising from the ribs.1–5 Of GTCs reported in ribs, the majority occur in the posterior arc of the rib and tend to grow internally.2–4 There are a few reports of anterior GCTs of ribs and can easily be confused with diseases of the breast and even thymus.1,3,5 Histologically, GCTs are well vascularized and composed of plump, spindled cells with numerous multinucleated cells.1,4,5 However, it can be difficult to distinguish these tumours histologically from other bone neoplasms such as osteosarcomas, as such diagnosis can rarely be made with fine needle aspiration.3,5 GCTs are considered to be primarily benign but they can be locally invasive.3 There have been reports of GCTs developing malignant potential through sarcomatous transformation of a benign lesion (approximately 4%) but de novo malignant GCTs can also occur.1,4 Pulmonary metastases occur in up to 5% of patients affected but are often felt to be benign.3,6 Treatment is predominantly surgical resection of all affected bone and surrounding structures to ensure surgical clear margins. However, even in complete surgical resection, the recurrence rate can be up to 40%.3,6 When multiple ribs are resected, then chest wall reconstruction is usually required to ensure integrity of the chest wall and prevent physiological flail.7 Reconstruction can be performed with autologous bone grafts (rib, tibia or iliac crest) or alloplastic materials such as titanium, steel, fibre glass; or gortex, polypropylene and vicryl mesh strengthened with methyl methacrylate using a sandwich technique and shaped before setting to maintain the arc of the chest wall.7 Where extensive soft tissue resection is required, pedicled or free myocutaneous flaps are used to correct to deficit.7 Unfortunately, there is little role for adjuvant therapy, and radiotherapy is best avoided to prevent malignant transformation.1,4 Appropriate management of rib-based GCTs, and
other large bony masses, often requires a multidisciplinary approach to obtain the correct diagnosis, adequate surgical resection and reconstruction to minimize chance of recurrence and to ensure full functional recovery.
References 1. Riddle ND, Yamauchi H, Caracciolo JT, Cheong D, Khakpour N, Bui M. Giant cell tumour of the anterior rib masquerading as a breast mass: a case report and review of the current literature. Cases J. 2010; 3: 51–5. 2. Gupta V, Mittal R. Giant cell tumor of rib–rare location on the anterior aspect. Arch. Orthop. Trauma Surg. 2000; 120: 231–2. 3. de Biasi Cordeiro S, de Biasi Cordeiro P, Sousa AMC, Lannes DC, de Moura Peirro GS. Giant cell tumour of the rib occupying the entire hemithorax. J. Bras. Pneumol. 2008; 34: 185–8. 4. Sharma A, Armstrong AE. Giant cell tumour of the rib arising anteriorly as a large inframammary mass: a case report and review of the literature. Case Rep. Med. 2012; doi: 10.1155/2012/850509 5. Volmar KE, Sporn TA, Toloza EM, Martinez S, Dodd LG, Xie HB. Giant cell tumor of rib masquerading as thymoma. A diagnostic pitfall in needle core biopsy of the mediastinum. Arch. Pathol. Lab. Med. 2004; 128: 452–5. 6. Fletcher C, Unni K, Mertens F (eds). Pathology and Genetics of Tumours of Soft Tissue and Bone: International Agency for Research on Cancer. Lyon: World Health Organization, 2002. 7. Kozower B. Chest wall resection and reconstruction for non–small-cell lung cancer. Oper. Tech. Thorac. Cardiovasc. Surg. 2007; 12: 279–85.
Felicity Meikle, MBChB, MMedSc Glenn McKay, MBChB, FRACS Cardiothoracic Department, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand doi: 10.1111/ans.12413
© 2013 Royal Australasian College of Surgeons
wound management in the early postoperative period has been shown to be superior to closure with muscle flap.7 The introduction of NPWT has further improved these results with fewer postoperative complications, less repeat procedures, shorter hospital stays and decreased morbidity.7 In summary, this case aims to raise the awareness about this infrequent but serious surgical condition, particularly in susceptible, immunocompromised patients. The importance of early recognition and treatment is highlighted, with delay resulting in progression of infection, lengthy hospital stay and ongoing wound care. Early imaging to identify extra-articular involvement should be performed in any patient with signs or symptoms suggestive of SCJI and referral to a thoracic surgical service for further management should follow. Open wound management with the use of NPWT gives the most favourable outcomes following debridement of affected tissue.
References 1. Nusselt T, Klinger HM, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch. Orthop. Trauma Surg. 2011; 131: 319–23. 2. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine 2004; 83: 139–48.
195
3. Womack J. Septic arthritis of the sternoclavicular joint. J. Am. Board Fam. Med. 2012; 25: 908–12. 4. El Ibrahimia A, Daoudia A, Boujrafb S, Elmrini A, Boutayeb F. Sternoclavicular septic arthritis in a previously healthy patient: a case report and review of the literature. Int. J. Infect. Dis. 2009; 13: 119–21. 5. Arab WA, Khadragui I, Echave V, Deshaies A, Sirois C, Sirois M. Surgical management of sternoclavicular joint infection. Eur. J. Cardiothorac Surg. 2011; 40: 630–5. 6. Burkhart HM, Deschamps C, Allen MS, Nichols FC III, Miller DL, Pairolero PC. Surgical management of sternoclavicular joint infections. J. Thorac. Cardiovasc. Surg. 2003; 125: 945–9. 7. Puri V, Meyers BF, Kreisel D et al. Sternoclavicular joint infection: a comparison of two surgical approaches. Ann. Thorac. Surg. 2011; 91: 257–62. 8. Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternocalvicular joint infection. Ann. Thorac. Surg. 2002; 73: 427–31.
Mathew P. Doyle, MBBS Scott B. Jennings, MBBS (Hons) Matthew D. A. Horton, MBBS, FRACS Cardiothoracic Surgery, St George Hospital, Kogarah, New South Wales, Australia doi: 10.1111/ans.12414
Giant cell tumour of the rib: an unusual location for an impressive tumour A 38-year-old gentleman of Polynesian descent presented acutely to the cardiothoracic service with a 2-week history of anterior chest pain and shortness of breath. He had noticed a mass in his left anterior chest, slowly increasing in size over 2 years. He was a morbidly obese (calculated BMI of 53) and current smoker with treated hypertension. Chest CT showed a 15-cm anterior chest wall mass with associated destruction of the fourth rib. The tumour had both a large intra and extra thoracic component. There was a small pleural effusion with no evidence of distant metastases (Fig. 1). A thoracoscopy was performed – no pleural metastases were identified and cytology was negative for malignancy. An open biopsy was taken of the mass, which suggested this mass was a giant cell tumour (GCT). Given the localized nature of the disease, an en bloc resection and chest wall reconstruction was undertaken, with the assistance of the Plastic and reconstructive surgery department. The anterior portions of the third to sixth ribs were resected along with pectoralis major and minor, a wedge of the lingula of the left upper lobe, where the tumour was densely adherent, and an ellipse of skin including the previous biopsy site (Figs 2 and 3). The chest wall was reconstructed using a methylmethacrylate strengthened polypropylene mesh and covered using a pedicled latissimus dorsi musculocutaneous flap. Initially, the patient recovered well following his procedure. He was discharged from hospital 7 days postoperatively. Unfortunately, he presented approximately 3 weeks following surgery with a Staphylococcus aureus empyema and draining sinus. Given the mor-
© 2013 Royal Australasian College of Surgeons
Fig. 1. Computed tomography scan showing large left sided chest wall mass with intra- and extrathoracic components, destruction of the fourth rib (red arrow) and a small pleural effusion (blue arrow).
bidity associated with surgically desterilizing the remaining space and mesh, the patient was treated with long-term antibiotics. He had a good response to prolonged intravenous antibiotic therapy in the community and was able to be stabilized on oral rifampicin. One year following his operation and subsequent empyema, he continues to do well and is free of tumour recurrence.
196
Images for surgeons
Fig. 2. Intraoperative photos showing the large left sided chest wall mass prior to removal (red arrow) and the defect following complete resection (blue arrow).
Fig. 3. Gross histological specimen shown from the external and internal aspects. The tumour can be seen as an irregular mass on measuring 15 cm in diameter (blue arrow). The previous biopsy site can be seen in the skin ellipse (red arrow).
GCTs of bone are uncommon, accounting for only 4–5% of primary bone tumours.1–4 The most common sites affected are the metaphyseal plates of long bones, with only 0.6% of all GCTs arising from the ribs.1–5 Of GTCs reported in ribs, the majority occur in the posterior arc of the rib and tend to grow internally.2–4 There are a few reports of anterior GCTs of ribs and can easily be confused with diseases of the breast and even thymus.1,3,5 Histologically, GCTs are well vascularized and composed of plump, spindled cells with numerous multinucleated cells.1,4,5 However, it can be difficult to distinguish these tumours histologically from other bone neoplasms such as osteosarcomas, as such diagnosis can rarely be made with fine needle aspiration.3,5 GCTs are considered to be primarily benign but they can be locally invasive.3 There have been reports of GCTs developing malignant potential through sarcomatous transformation of a benign lesion (approximately 4%) but de novo malignant GCTs can also occur.1,4 Pulmonary metastases occur in up to 5% of patients affected but are often felt to be benign.3,6 Treatment is predominantly surgical resection of all affected bone and surrounding structures to ensure surgical clear margins. However, even in complete surgical resection, the recurrence rate can be up to 40%.3,6 When multiple ribs are resected, then chest wall reconstruction is usually required to ensure integrity of the chest wall and prevent physiological flail.7 Reconstruction can be performed with autologous bone grafts (rib, tibia or iliac crest) or alloplastic materials such as titanium, steel, fibre glass; or gortex, polypropylene and vicryl mesh strengthened with methyl methacrylate using a sandwich technique and shaped before setting to maintain the arc of the chest wall.7 Where extensive soft tissue resection is required, pedicled or free myocutaneous flaps are used to correct to deficit.7 Unfortunately, there is little role for adjuvant therapy, and radiotherapy is best avoided to prevent malignant transformation.1,4 Appropriate management of rib-based GCTs, and
other large bony masses, often requires a multidisciplinary approach to obtain the correct diagnosis, adequate surgical resection and reconstruction to minimize chance of recurrence and to ensure full functional recovery.
References 1. Riddle ND, Yamauchi H, Caracciolo JT, Cheong D, Khakpour N, Bui M. Giant cell tumour of the anterior rib masquerading as a breast mass: a case report and review of the current literature. Cases J. 2010; 3: 51–5. 2. Gupta V, Mittal R. Giant cell tumor of rib–rare location on the anterior aspect. Arch. Orthop. Trauma Surg. 2000; 120: 231–2. 3. de Biasi Cordeiro S, de Biasi Cordeiro P, Sousa AMC, Lannes DC, de Moura Peirro GS. Giant cell tumour of the rib occupying the entire hemithorax. J. Bras. Pneumol. 2008; 34: 185–8. 4. Sharma A, Armstrong AE. Giant cell tumour of the rib arising anteriorly as a large inframammary mass: a case report and review of the literature. Case Rep. Med. 2012; doi: 10.1155/2012/850509 5. Volmar KE, Sporn TA, Toloza EM, Martinez S, Dodd LG, Xie HB. Giant cell tumor of rib masquerading as thymoma. A diagnostic pitfall in needle core biopsy of the mediastinum. Arch. Pathol. Lab. Med. 2004; 128: 452–5. 6. Fletcher C, Unni K, Mertens F (eds). Pathology and Genetics of Tumours of Soft Tissue and Bone: International Agency for Research on Cancer. Lyon: World Health Organization, 2002. 7. Kozower B. Chest wall resection and reconstruction for non–small-cell lung cancer. Oper. Tech. Thorac. Cardiovasc. Surg. 2007; 12: 279–85.
Felicity Meikle, MBChB, MMedSc Glenn McKay, MBChB, FRACS Cardiothoracic Department, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand doi: 10.1111/ans.12413
© 2013 Royal Australasian College of Surgeons
