Salvage cytoreductive surgery for pleural dissemination of low-grade endometrial stromal sarcoma using rib-cross thoracotomy with argon beam coagulation: strategies to achieve a grossly complete resection—a case report

Abstract

We present a case of low-grade endometrial stromal sarcoma (LG-ESS) treated with salvage resection of disseminated nodules in the unilateral thorax by using the rib-cross thoracotomy approach with argon beam coagulation (ABC). To our knowledge, this is the first reported case of intrathoracic pleural dissemination of LG-ESS for which grossly complete resection was achieved. A 69-year-old woman was found to have multiple tumors of various sizes and locations in the right thoracic cavity, including a 10-cmsized tumor invading the right ventral thoracic wall and diaphragm. At age 50 years, the patient underwent a hysterectomy for uterine LG-ESS. The thoracic lesions were diagnosed as disseminated recurrence of the LG-ESS. As the lesions were enlarged despite hormone therapy, including medroxyprogesterone acetate and letrozole, in addition to platinum-based chemotherapy, salvage tumor debulking was considered. Ribcross thoracotomy was adopted; the sixth, seventh, and eighth ribs were cut along the mid-axillary line, and the thorax was entered posteriorly at the fifth intercostal space and anteriorly at the eighth intercostal space, providing wide exposure of the caudal side of the thorax. The largest lesion was excised with combined resection of the soft tissue of the chest wall and diaphragm. Twelve gross nodules were resected, and smaller lesions were cauterized using ABC. Combined with magnifying thoracoscopy and ABC, a grossly visible complete resection of the disseminated tumors could be achieved. Although 4 years after the surgery, some small nodules were observed in the ipsilateral thorax, the patient remains in good health at age 73 years, 23 years after the surgery for the primary uterine LG-ESS, while continually receiving letrozole therapy. For low-grade malignant tumors with no other effective treatment available, if technically possible, cytoreductive surgery can be chosen in a salvage setting for disease control, even with dissemination. In this report accompanied with a short video, we discuss the surgical treatment used, including an uncommon type of modified extended thoracotomy and ABC, to achieve a grossly complete resection of pleural dissemination of slowly progressing soft tissue malignant tumors.