Anterior Chest Wall Resection and Identification of Externally Occult Lesions

<p dir="ltr">This video shows the case of a forty-year-old man who presented for evaluation of several months of anterior chest wall pain. Cross sectional imaging demonstrated a calcified anterior fourth rib lesion arising from the posterior table and projecting inward into the left hemithorax, measuring up to 3.8 cm (Figure 1). </p><p dir="ltr">Physical examination was notable for an outwardly normal chest wall with no palpable abnormalities. The patient carried a history of multiple exostoses syndrome with multiple prior resections of long bone osteochondromas from infancy until 20 years of age (1). His family history was significant for multiple first-degree relatives with multiple exostoses syndrome.</p><p dir="ltr">While the lesion was without radiographic features commonly associated with malignancy, patients with multiple exostoses syndrome exhibit higher rates of malignant degeneration (2-4). Furthermore, the inward projection was thought to contribute to the patient’s chest wall pain. Thus, he underwent resection (5).</p><p dir="ltr">Surgeons elected to begin the operation by performing a thoracoscopic evaluation to localize the lesion and evaluate for any pleural adhesions. The patient was placed in a semi-right lateral decubitus position. An incision was made at the seventh intercostal space at the anterior axillary line and a thoracoscope was introduced. Inspection of the pleural space demonstrated a bony spur arising from the fourth rib (Figure 2). </p><p dir="ltr">Surgeons made an inframammary incision, splitting the pectoralis fibers longitudinally and carrying the dissection down to the chest wall. A finder needle was used to identify the correct rib and the anterior and posterior transection points, minimizing the extent of the removal. Surgeons then performed a rib resection, electing to forgo chest wall reconstruction given the location and small size (Figure 3). The patient recovered well and was discharged home on postoperative day one.</p><p dir="ltr"><b>Reference(s)</b></p><p dir="ltr">1. D'Arienzo A, Andreani L, Sacchetti F, Colangeli S, Capanna R. Hereditary Multiple Exostoses: Current Insights. Orthop Res Rev. 2019;11:199-211. Published 2019 Dec 13. doi:10.2147/ORR.S183979</p><p dir="ltr">2. Levine BD, Motamedi K, Chow K, Gold RH, Seeger LL. CT of rib lesions. AJR Am J Roentgenol. 2009;193(1):5-13. doi:10.2214/AJR.08.1216</p><p dir="ltr">3. Zuntini M, Pedrini E, Parra A, et al. Genetic models of osteochondroma onset and neoplastic progression: evidence for mechanisms alternative to EXT genes inactivation. Oncogene. 2010;29(26):3827-3834. doi:10.1038/onc.2010.135</p><p dir="ltr">4. Rozeman LB, de Bruijn IH, Bacchini P, et al. Dedifferentiated peripheral chondrosarcomas: regulation of EXT-downstream molecules and differentiation-related genes. Mod Pathol. 2009;22(11):1489-1498. doi:10.1038/modpathol.2009.120</p><p dir="ltr">5. Gonfiotti A, Salvicchi A, Voltolini L. Chest-Wall Tumors and Surgical Techniques: State-of-the-Art and Our Institutional Experience. J Clin Med. 2022;11(19):5516. Published 2022 Sep 20. doi:10.3390/jcm11195516</p><p dir="ltr">6. Alabdullrahman LW, Byerly DW. Osteochondroma. In: StatPearls. Treasure Island (FL): StatPearls Publishing; February 5, 2023.</p>