|Year : 2020 | Volume
| Issue : 2 | Page : 76-78
Malawer limb salvage surgery for large chondrosarcoma of scapula with functional outcome – A case report
K P Kunhi Mohammed, Prafulla Kumar Das, Supratim Bhattacharyya, Bharat Bhusan Satpathy
Department of Surgical Oncology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, Odisha, India
|Date of Submission||26-Jan-2020|
|Date of Decision||19-Jul-2020|
|Date of Acceptance||27-Jul-2020|
|Date of Web Publication||17-Aug-2020|
Department of Surgical Oncology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack - 753 007, Odisha
Source of Support: None, Conflict of Interest: None
Chondrosarcoma is a malignant cartilaginous bone tumor. It commonly occurs in the pelvis and femur. However, scapula primary is relatively rare, accounting for 5%–7% of all the chondrosarcomas. Although wide local excision with negative margins is sufficient for chondrosarcoma, amputation is commonly performed for large tumors at the scapula location. Malawer limb salvage surgery can be performed in a large-sized tumor in order to retain the function. Here, we report a case of large scapular chondrosarcoma in a 53-year-old male, and the case was successfully treated with Malawer limb salvage surgery without any residual or positive margin. The patient was on regular follow-up with a well-preserved anatomical function of the shoulder girdle and without any recurrence of the disease after 24 months of surgery.
Keywords: Chondrosarcoma, functional outcome, Malawer limb salvage surgery, scapula
|How to cite this article:|
Mohammed K P, Das PK, Bhattacharyya S, Satpathy BB. Malawer limb salvage surgery for large chondrosarcoma of scapula with functional outcome – A case report. Oncol J India 2020;4:76-8
|How to cite this URL:|
Mohammed K P, Das PK, Bhattacharyya S, Satpathy BB. Malawer limb salvage surgery for large chondrosarcoma of scapula with functional outcome – A case report. Oncol J India [serial online] 2020 [cited 2020 Sep 24];4:76-8. Available from: http://www.ojionline.org/text.asp?2020/4/2/76/291904
| Introduction|| |
Chondrosarcoma is a malignant bone tumor arising from cartilage, which accounts for 20% of all the sarcomas of bone. It often develops in the pelvis and femur, but the incidence of scapular chondrosarcoma is relatively rare, which accounts for about 5%–7% of all the reported cases. Complete resection with negative margins remains the standard of care for chondrosarcoma. Amputation was the preferred treatment for a large scapular malignant tumor, until 1970. However, nowadays, limb preservation is possible with near-normal function due to the advent of advancement in imaging methods. However, the majority of limb salvage surgery was performed for small tumors of the scapula, not damaging to the underlying soft tissue, nerves, and blood vessels. Only a few cases of limb salvage surgery were performed for extremely large scapular malignant tumors with unknown efficacy of such therapy. Here, we report a case of large chondrosarcoma of the scapula and treated successfully with retained limb function.
| Case Report|| |
A 53-year-old male, farmer by occupation, presented with the complaints of painless swelling over the left scapula for the past 5 years. The swelling restricted his arm movement and routine activities. The patient did not have a family history of any malignancy. Local examination revealed massive swelling of size approximately 22 cm × 18 cm over the left scapula, hard in consistency with an incisional biopsy scar over the swelling [Figure 1]. The extension of the lesion revealed the superior border 3 cm from the acromion, the lateral border reaching up to the midaxillary line, the medial border 3 cm away from the midline, and the inferior border reaching up to the seventh rib. The supraspinous part of the scapula and left shoulder joint was clinically free.
|Figure 1: A swelling of size 22 cm × 18 cm over the left scapula with a scar over the swelling|
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Incisional biopsy revealed cartilaginous matrix separating cells having mild atypia. The tumor cells were seen permeating the adjacent bone and have a lobulated architecture, favouring a low-grade chondrosarcoma [Figure 2]. Magnetic resonance imaging of the back at the level of the scapula showed an ill marginated heterogeneous lytic mass of size 13.7 cm × 7.0 cm × 12.4 cm with soft-tissue component arising from the scapular body with tumor matrix calcification and deeper chest wall infiltration [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. There was involvement of the subscapularis, infraspinatus, and deltoid muscles without the involvement of major neurovascular bundles and the left shoulder joint by the tumor. Contrast-enhanced computed tomography (CT) scan showed a calcific exophytic lesion of size 7.8 cm × 13.1 cm arising from the left scapula with a mild amount of soft-tissue component and its relation with glenohumeral joint and acromioclavicular joint.
|Figure 2: Microscopic examination (H and E, ×40) showing binucleated chondrocytes within a lacuna with mild atypia and increased cellularity|
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|Figure 3: T1- and T2-weighted magnetic resonance imaging sagittal view (a and b) and axial view (c and d) showing a large lytic left scapular swelling of size 13.7 cm × 7.0 cm × 12.4 cm with complex heterogeneous tumor signal and areas of large matrix calcification|
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Malawer Type-II resection of the left shoulder girdle was performed. Infraspinous part of the left scapula with tumor removed with 2 cm margin all around. The left axillary vessels and thoracodorsal pedicle were not involved by the tumor. The feeding vessel from the circumflex scapular artery was dissected and ligated. Part of the involved muscle such as infraspinatus, subscapularis, deltoid, triceps latissimus dorsi, and rhomboids removed with adequate margin [Figure 4]a. The intraoperative and postoperative period was uneventful. On postoperative day 2, the patient was advised to elevate the left upper limb with support, and he was able to abduct the limb up to about 45° with support.
|Figure 4: Malawer Type II resection of the left shoulder girdle (a) and postoperative clinical image showing healthy scar with the functional outcome (b)|
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Intravenous analgesia was continued for 5 days during the postoperative period. Drain removed on postoperative day 10 and physiotherapy exercise continued as advised. The patient came for the first follow-up visit after 3 weeks of surgery, and he was able to lift his left upper limb to 70–80° without support [Figure 4]b. The final histopathology report was found to be of similar features of low-grade chondrosarcoma as the initial incisional biopsy findings, and all margins were negative. Hence, the patient was kept on regular follow-up. During the second follow-up after 3 months postoperative, the patient was able to do all the routine activities without functional compromise. He restarted his labor activities after the second follow-up. The patient was on regular follow-up on a 3-monthly basis and had no local recurrence or distant metastasis at 24-month follow-up. The patient had well-preserved anatomical function postoperatively.
| Discussion|| |
Resection with adequate negative margin remains the mainstay of treatment for chondrosarcoma. Sarcoma of the scapula looks to be an inoperable entity in the scenario of conservation of limb. Many a case, they land up in forequarter amputation. With the advancement of imaging technology like CT scan with 3-dimensional reconstruction, one can evaluate the shoulder joint involvement and go for conservative surgery. Now-a-days, most of the malignant tumors around the scapula are treated with limb salvage surgery. However, the limb salvage surgery was complicated for large-sized scapular tumors. The question of joint instability may come into the picture, but eventually, this problem settles in due course without any functional disability. Bickels et al. in a report on 134 patients of shoulder girdle tumor who underwent a limb-sparing resection, found good local tumor control along with good functional outcomes in the majority of patients after 2-year of follow-up.
There is no difference in disease-free survival and recurrence rate for chondrosarcoma between limb salvage surgery with adequate negative margin and amputation.,, High-grade histological differentiation affects the prognosis of chondrosarcoma. However, several studies suggested that factors such as age, gender, tumor volume, and resection method had no significant influence on the recovery of the limb function.
In 1991, Malawer et al. proposed a classification system for limb-sparing shoulder girdle resections based on anatomic location, the extent of tumor, and tumor grade and classified into resection types I to VI. The types I to III are intra-articular resection, which mainly used for managing low-grade malignant tumors. Types I, II, and III resections are proximal humeral resection, partial scapulectomy, and total scapulectomy, respectively. The resection types IV to VI are extra-articular, used for high-grade tumors. Types IV, V, and VI resections are scapular plus humeral head resection, humeral plus glenoid resection, and humeral plus total scapular resection, respectively. Chang et al. reported that type III Malawer limb-reserving surgery was successfully performed for large chondrosarcoma of the scapula in a 59-year-old male patient preserving limb function without any postoperative complication. In our case, we performed type II intra-articular resection (partial scapulectomy) with partial resection of surrounding muscles, as described in case details. The patient retained limb function postoperatively, and no complications were reported.
| Conclusion|| |
In our case, the limb salvage surgery was successfully performed for large scapular chondrosarcoma preserving the shoulder function with good recovery, which provides an example toward successful treatment for giant chondrosarcomas.
The written informed consent was obtained for publication of the report with the use of the images.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]