Chondrosarcoma is a relatively rare malignant bone tumor with an incidence of approximately 1–2 cases per million people per year in the general population. It originates from cartilage or chondrogenic connective tissue, and is characterized by their production of chondroid (cartilage-like) matrix [6, 7]. The World Health Organization categorizes chondrosarcoma into Grades I to III, depending on their histological characteristics, making it valuable not only as a prognostic indicator but also as a guideline for their management [8]. Chondrosarcoma exhibits low responsiveness to chemoradiotherapy, therefore, R0 resection with a guaranteed negative margin is the preferred treatment.
Costal chondrosarcoma is extremely rare and is mostly reported as individual cases. Only around 40 case reports were found by searching the PubMed and the vast majority of tumors reported were confined to the chest. Dantis et al [9] reported a similar case with simultaneous involvement of the chest and abdominal wall and emphasized the unique advantages of 3D-composite mesh in reconstructing large-area defects of the chest and abdominal wall. However the clinical challenge was to prevent recurrence and to find better treatment options, and a team consisting of experienced surgeons, radiologists, medical oncologists, and pathologists was important [7]. By bringing these specialists together, a detailed and holistic approach can be devised to address the intricacies of cases. This collaborative effort allows for a thorough evaluation of the tumor extent, identification of critical anatomical structures, and consideration of optimal surgical approaches tailored to the individual patient's needs. Importantly, the involvement of multiple disciplines fosters a synergy of expertise, leading to enhanced decision-making and improved patient outcomes. Through meticulous preoperative planning and interdisciplinary coordination, potential challenges can be anticipated and mitigated, thus optimizing the safety and efficacy of surgical intervention while minimizing morbidity. Therefore, multi-disciplinary discussion serves as a cornerstone in the management of costal chondrosarcoma, providing a framework for personalized and integrated care delivery.
In our case, preoperative multi-disciplinary discussion revolved around diagnosis and detailed surgical planning was conducted. The pathological diagnosis of the tumor was crucial for formulating the surgical plan. Chondrosarcoma was both invasive and metastatic, with its invasiveness and metastatic potential increasing with higher grades. Therefore, surgery must achieve adequate margins and be prepared to excise any invaded tissues. As detailed in the case presentation, an ultrasound-guided biopsy revealed a diagnosis of Grade I chondrosarcoma. Pathologists generally believed that it was impossible to accurately distinguish between benign enchondroma and well-differentiated chondrosarcoma based solely on pathological morphology, whether through needle biopsy or surgical biopsy, because the two shared significant morphological similarities [10]. The differentiation between benign and malignant tumors largely depended on the tumor location, patient age, clinical symptoms, and imaging characteristics. Chondrogenic tumors occurring in long bones, flat bones, vertebrae, and craniofacial bones should be highly suspected of being chondrosarcoma, even in the absence of atypical chondrocytes, if they exhibit the following characteristics: (1) enlargement of the tumor after age 40; (2) pain at rest; (3) a maximum diameter exceeding 5 cm; (4) imaging evidence of bone cortex changes; and (5) MRI detection of periosteal or peritumoral edema [11]. After multi-disciplinary discussions, we unanimously concluded that the diagnosis of costal chondrosarcoma was established, and we speculated that the right kidney might simply be compressed by the tumor. The relationship between the liver and tumor was difficult to judge solely based on imaging data, therefore, collaborative surgery with hepatobiliary surgeons was a necessary condition to ensure complete tumor resection and the integrity of thoraco-abdominal wall reconstruction.
The main purpose of reconstruction was to restore the integrity and stability of the chest wall, to avoid chest wall softening and abnormal breathing, and to ensure the stability of respiratory circulation. Xu et al [12] used the "sandwich" technique for chest wall reconstruction, involving the combination of an anatomical plate with hernia mesh and muscle soft tissue, enables comprehensive reconstruction of the pleura, bony structure, and soft tissues. In our case, the 8th to 12th anterolateral ribs were removed, however, we believed that this patient was not suitable for reconstruction using an anatomical plate. Firstly, the 8th to 12th ribs were false ribs, the removed ribs had little impact on respiratory movement. Secondly, most of the defects were located on the abdominal wall. Finally, it was challenging to form a secure connection between the anatomical plate and costal cartilage/soft tissues. If reconstruction was performed using an anatomical plate, repeated friction might cause patient discomfort, plate displacement or dislodgement, and even damage to surrounding organs. So we sutured the diaphragm to the ribs and intercostal muscles, using a hernia mesh to reconstruct the thoraco-abdominal wall. Although this may lead to a little reduction in the chest cavity volume, it nonetheless guarantees the stability of the chest wall and minimizes the likelihood of complications stemming from complex reconstruction. The patient's postoperative course was uneventful, and was discharged without any complications. Histopathological analysis confirmed the complete removal of the tumor with negative margins. These proved that our treatment had been successful.