Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall：a case report.

Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall：a case report. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall：a case report. Caiyang Liu, Qinyan Yang, Deyuan Zhong, Hongtao Yan, Hang Gu, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4815833/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Nov, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Background: Chondrosarcoma primarily occurs in the pelvis and femur, with occasional cases in the ribs. Surgical resection remains the main treatment method for costal chondrosarcoma. However, complete resection often leads to a large range of chest wall defects and a challenging reconstruction. Case presentation: A 49-year-old female patient presented with progressive swelling of the right chest and abdominal wall over 15 years. Chest CT revealed a 20.1 × 15.6 × 13.7 cm multilocular cystic-solid mass with internal calcification, encircling the 8th to 12th ribs and causing elevation of the right diaphragm. Compression of the liver resulting in a significant reduction in volume. Based on an ultrasound-guided biopsy, chondrosarcoma Grade I was diagnosed. After a multi-disciplinary discussion, we performed a complete resection of the tumor, including the 8th to 12th anterolateral ribs and part of the diaphragm. The diaphragm was then reconstructed by suturing it to the ribs and intercostal muscles. The thoraco-abdominal wall defects were reconstructed with a hernia mesh. Finally, we excised the excess skin and then closed the incision. Histopathologic diagnosis was chondrosarcoma Grade II. The postoperative course was uneventful. Conclusions: Wide en-bloc resection followed by reconstruction using mesh is feasible and effective for costal chondrosarcoma with limited invasion. This case illustrates the importance of meticulous preoperative planning and multi-disciplinary discussion. Chondrosarcoma Thoraco-abdominal wall Reconstruction Case report Figures Figure 1 Figure 2 Figure 3 Background Chondrosarcoma, a rare type of solid tumor, primarily occurs in the pelvis and femur, with occasional cases in flat bones like the sternum and ribs [ 1 ]. Costal chondrosarcoma accounts for merely 5 − 15% of all chondrosarcoma cases [ 2 ] and tends to reach a significant size before symptoms begin to manifest. The effects of radiotherapy and chemotherapy on chondrosarcoma are quite limited [ 3 ]; prognosis mainly depends on the tumor grade and the completeness of surgical resection. Although surgical resection remains the main treatment method, it faces some challenges. For example, a giant costal chondrosarcoma may invade the chest and abdominal wall simultaneously, and has close connections with surrounding tissues; complete resection often leads to a large range of chest wall defects and a challenging reconstruction, especially when it involves the sternum, spine, or multiple consecutive ribs [ 4 ]. Therefore, multi-disciplinary discussion and developing a meticulous preoperative plan which includes a way of reconstruction are important. Here, we present a case study involving surgical resection and thoraco-abdominal wall reconstruction for a patient suffering from a giant costal chondrosarcoma. Case presentation A 49-year-old female patient presented with progressive swelling of the right chest and abdominal wall over 15 years. There was no associated fever, coughing, shortness of breath, pain, chills, or night sweats. The physical examination revealed a giant well-circumscribed mass located at the junction of the right chest and abdominal wall, between the anterior axillary line and the posterior axillary line (Fig. 1 A). Upon palpation, it was hard and immobile, with no tenderness observed. Her laboratory test results were all normal. Chest CT showed a 20.1 × 15.6 × 13.7cm multilocular cystic-solid mass with internal calcification encircling the 8th to 12th ribs (Fig. 1 B). The mass invaded and elevated the right diaphragm. Muscles and skin of the right abdominal wall were displaced. The liver and right kidney were compressed, resulting in a significant reduction in liver volume (Fig. 1 C). Three-dimensional reconstruction indicated that the mass was likely compressing the liver and right kidney, or that its invasion was limited (Fig. 1 D). Based on an ultrasound-guided biopsy performed on this site, chondrosarcoma Grade I was diagnosed. Due to the tumor's adjacency to several organs and the relatively large resection area, we conducted a multi-disciplinary discussion before the surgery, involving a radiologist, oncologist, pathologist, thoracic surgeon, hepatobiliary surgeon, and urological surgeon. The focus of the discussion was on: 1) diagnosis; 2) preparations for partial resection of the liver and right kidney if invaded by the tumor; and 3) reconstruction of the chest and abdominal wall after resection. As a result, We decided to perform a collaborative surgery involving both thoracic and hepatobiliary surgeons. Using standard anesthesia and bilateral lung ventilation, a 25cm fusiform incision was made on the surface of the tumor (Fig. 2 A), and the superior and inferior skin flaps were freed to a sufficient distance to fully expose the tumor on the chest. The 8th to 12th anterolateral ribs and intercostal muscles were resected to expose the tumor in the thoracic and abdominal cavities, maintaining a margin of more than 2 cm around the tumor [ 5 ]. We found the tumor invaded the diaphragm, compressed the liver and the right kidney, and had partial adhesion to the mesentery. Therefore, we dissected the adhesion, resected part of the diaphragm and removed the tumor entirely (Fig. 2 B). And then, the diaphragm was reconstructed by suturing it to the ribs and intercostal muscles, the thoraco-abdominal wall defects were reconstructed with a 15 cm × 15 cm hernia mesh (Fig. 2 C). Drainage tubes were placed in both the abdominal cavity and subcutaneous cavity. Finally, we made an inverted triangular incision on the inferior skin flap, excising the excess skin and closing the incision (Fig. 2 D). The surgical area was compressed and bandaged to ensure that the skin and mesh remain firmly attached. Postoperative histopathology confirmed chondrosarcoma Grade II with negative margins (Fig. 3 ). The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Discussion 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. Conclusions Wide en-bloc resection followed by reconstruction using mesh is feasible and effective for costal chondrosarcoma with limited invasion. The successful management of giant costal chondrosarcomas hinges on multi-disciplinary discussion, meticulous preoperative planning, and suitable surgical and reconstructive techniques. This case contributes valuable insights into the complex interplay of these factors, reinforcing the need for tailored strategies to optimize patient outcomes in similar scenarios. Abbreviations CT: Computed tomography MRI: Magnetic Resonance Imaging Declarations Ethics approval and consent to participate Our study was approved by the Ethics Committee for Medical Research and New Medical Technology of Sichuan Cancer Hospital Consent for publication Informed consent for publication was obtained Availability of data and materials Not applicable Competing interests The authors declare that they have no competing interests Funding This work was supported by Sichuan Science and Technology Program [2023YFH0075] and Sichuan Province Key Clinical Specialty Construction Project (no grant number). Authors' contributions Caiyang Liu, Qinyan Yang, and Deyuan Zhong performed the literature review and drafted the manuscript. Hongtao Yan, Hang Gu, and Xiaozun Yang participated in the diagnosis and treatment of the case and provided expertise in clinical knowledge. Xiaojun Yang, Qiang Li, and Xiaolun Huang provided important academic and language advice and critically revised the manuscript. Wei Dai supervised and guided the research, and contributed to significant decisions throughout the study. All authors read and approved the final manuscript Acknowledgements Not applicable References Brito ÍM, Teixeira S, Paupério G, et al. Giant chondrosarcoma of the chest wall: a rare surgical challenge. Autops Case Rep. 2020 Jun 5;10(3):e2020166. Emori M , Hamada K I , Kozuka T ,et al.Case of an unusual clinical and radiological presentation of pulmonary metastasis from a costal chondrosarcoma after wide surgical resection: A transbronchial biopsy is recommended[J].World Journal of Surgical Oncology, 2011, 9(1):50-50. Tahir M, Rahman J, Arekemase H, et al. Chondrosarcoma of the Ribs. Cureus. 2020 Jul 12;12(7):e9158. Al-Refaie RE, Amer S, Ismail MF, et al. Chondrosarcoma of the chest wall: single-center experience. Asian Cardiovasc Thorac Ann. 2014 Sep;22(7):829-34. Wang L, Yan X, Zhao J, et al. Expert consensus on resection of chest wall tumors and chest wall reconstruction. Transl Lung Cancer Res. 2021 Nov;10(11):4057-4083. Dorfman HD, Czerniak B. Bone cancers. Cancer. 1995 Jan 1;75(1 Suppl):203-10. Gelderblom H , Hogendoorn P C W , Dijkstra S D ,et al.The Clinical Approach Towards Chondrosarcoma[J].Oncologist, 2008, 13(3). Doyle L A .Sarcoma classification: An update based on the 2013 World Health Organization Classification of Tumors of Soft Tissue and Bone[J].Cancer, 2014, 120(12). Dantis K , Singh R , Goel A ,et al.An innovative reconstruction of an enbloc resected composite giant chest and abdominal wall chondrosarcoma with 3D-composite mesh[J].Journal of Cardiothoracic Surgery, 2024, 19(1). Khurana J S , Mccarthy E F .Tumors and Tumor-Like Lesions of Bone[J].Springer-Verlag, 2010. Jiang Z M, Zhang H z.Diagnostic Challenges and Grading Criteria for Chondrosarcoma[J].Chinese Journal of Pathology, 2016(9):4. Xu P, Yu G, Wang H, et al. Surgical Resection of Giant Chest Wall Chondrosarcoma Combined with Sandwich Chest Wall Reconstruction in One Case. Ann Ital Chir. 2024;95(2):126-131. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Nov, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 28 Aug, 2024 Reviews received at journal 26 Aug, 2024 Reviews received at journal 26 Aug, 2024 Reviewers agreed at journal 26 Aug, 2024 Reviewers agreed at journal 26 Aug, 2024 Reviews received at journal 25 Aug, 2024 Reviewers agreed at journal 24 Aug, 2024 Reviewers agreed at journal 24 Aug, 2024 Reviewers agreed at journal 24 Aug, 2024 Reviewers agreed at journal 22 Aug, 2024 Reviewers agreed at journal 22 Aug, 2024 Reviewers invited by journal 22 Aug, 2024 Editor assigned by journal 30 Jul, 2024 Submission checks completed at journal 30 Jul, 2024 First submitted to journal 28 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4815833","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":344842295,"identity":"4856e425-22f6-4e84-a1fe-e130ec7a6599","order_by":0,"name":"Caiyang Liu","email":"","orcid":"","institution":"The First People's Hospital of Neijiang","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Caiyang","middleName":"","lastName":"Liu","suffix":""},{"id":344842296,"identity":"f224adc4-f57d-4164-b1d3-f23b59dd97b6","order_by":1,"name":"Qinyan Yang","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qinyan","middleName":"","lastName":"Yang","suffix":""},{"id":344842297,"identity":"0283c1e9-39af-44b2-beb2-86e6839b043d","order_by":2,"name":"Deyuan Zhong","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Deyuan","middleName":"","lastName":"Zhong","suffix":""},{"id":344842298,"identity":"606b68d0-c1d2-41d5-87bd-eee8ba4523e4","order_by":3,"name":"Hongtao Yan","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongtao","middleName":"","lastName":"Yan","suffix":""},{"id":344842299,"identity":"ee105875-b06d-4165-a003-7cebb0981806","order_by":4,"name":"Hang Gu","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hang","middleName":"","lastName":"Gu","suffix":""},{"id":344842300,"identity":"3f10c1cb-ea82-49ba-b7ff-692684aede4c","order_by":5,"name":"Xiaozun Yang","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaozun","middleName":"","lastName":"Yang","suffix":""},{"id":344842301,"identity":"76f8f6eb-7ac1-47df-8a78-b8e66ec805eb","order_by":6,"name":"Xiaojun Yang","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Yang","suffix":""},{"id":344842302,"identity":"8c09f50d-bd58-489d-a86b-ea533c846e0b","order_by":7,"name":"Qiang Li","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Li","suffix":""},{"id":344842303,"identity":"7df65696-0fa9-446c-ac45-2a7049c1f3d2","order_by":8,"name":"Xiaolun Huang","email":"","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaolun","middleName":"","lastName":"Huang","suffix":""},{"id":344842304,"identity":"1a27849d-9769-45fe-9646-36eec78354b0","order_by":9,"name":"Wei Dai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIie3PMWsCMRjG8fcQdInX9YIUv0LkoB3aJl8lIXBdRApdHG96Xezux7ix3Q4OdEl768lBQZwLBy4KFhq7p3iblPwh2X48CYDPd4nlQQrA7qELpB1JWpHfu7DnXBKuCoyap1KEvfdldHjlw9tesWxg+slTB6FGIV2wWiGZJPTF6NHbPNELMM/aRViusCaslt2I3ER9zIOsIjEEKLXrYazcYH1kH+JE6DfmIquudn+Tyq7YrQAtGdgVZVc6J8JdhFab2WHOtP3LOL67Rq0zk8QgjZQuEpaPW7Y/cjGcmdH6C/lDtiq20EylcBFHdkKlLQ1A2xWfz+f7v/0AViJYhWhDD7AAAAAASUVORK5CYII=","orcid":"","institution":"Sichuan Cancer Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Dai","suffix":""}],"badges":[],"createdAt":"2024-07-28 08:36:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4815833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4815833/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-03145-4","type":"published","date":"2024-11-30T15:58:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63831718,"identity":"2dd991d4-b085-4a89-9ab1-c7da3d826532","added_by":"auto","created_at":"2024-09-02 19:11:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1349219,"visible":true,"origin":"","legend":"\u003cp\u003eA: A giant mass located at the junction of the right chest and abdominal wall, between the anterior axillary line and the posterior axillary line. B: CT showed a 20.1 × 15.6 × 13.7cm multilocular cystic-solid mass with internal calcification compressed the liver, resulting in a significant reduction in volume. C: CT Showed the relationship between the tumor and the liver and right kidney in the sagittal plane. D:Three-dimensional reconstruction visually illustrated the relationship between the tumor and its surrounding tissues.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4815833/v1/065a3201cf44c37026e2cfe3.png"},{"id":63831719,"identity":"57c73302-c519-456d-a183-90dc627ec1fb","added_by":"auto","created_at":"2024-09-02 19:11:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2112713,"visible":true,"origin":"","legend":"\u003cp\u003eA: A 25cm fusiform incision was made on the surface of the tumor. B: Display of the completely excised tumor. C: Costal chondrosarcoma was removed and thoraco-abdominal wall defects were reconstructed with a hernia mesh. D: The excess skin was excised, and the incision was closed. Drainage tubes were placed in both the abdominal cavity and subcutaneous cavity.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4815833/v1/c94a2fc55656813f2944a3a3.png"},{"id":63831717,"identity":"b3377b2d-ee62-4115-82bf-266b4239b500","added_by":"auto","created_at":"2024-09-02 19:11:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1201889,"visible":true,"origin":"","legend":"\u003cp\u003eA few mitotic figures were visible, with extensive myxoid degeneration in the cartilaginous matrix, suggesting a Grade II chondrosarcoma (HE ×200).\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4815833/v1/22ad9aefa865fef906da3b75.png"},{"id":70390973,"identity":"237ad079-1fa0-4f72-810f-f67ff82ac754","added_by":"auto","created_at":"2024-12-02 17:30:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9485089,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4815833/v1/0ce62c30-bf93-43cc-8543-fc339fdd6e34.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall：a case report.","fulltext":[{"header":"Background","content":"\u003cp\u003eChondrosarcoma, a rare type of solid tumor, primarily occurs in the pelvis and femur, with occasional cases in flat bones like the sternum and ribs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Costal chondrosarcoma accounts for merely 5\u0026thinsp;\u0026minus;\u0026thinsp;15% of all chondrosarcoma cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and tends to reach a significant size before symptoms begin to manifest. The effects of radiotherapy and chemotherapy on chondrosarcoma are quite limited [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; prognosis mainly depends on the tumor grade and the completeness of surgical resection. Although surgical resection remains the main treatment method, it faces some challenges. For example, a giant costal chondrosarcoma may invade the chest and abdominal wall simultaneously, and has close connections with surrounding tissues; complete resection often leads to a large range of chest wall defects and a challenging reconstruction, especially when it involves the sternum, spine, or multiple consecutive ribs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, multi-disciplinary discussion and developing a meticulous preoperative plan which includes a way of reconstruction are important. Here, we present a case study involving surgical resection and thoraco-abdominal wall reconstruction for a patient suffering from a giant costal chondrosarcoma.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 49-year-old female patient presented with progressive swelling of the right chest and abdominal wall over 15 years. There was no associated fever, coughing, shortness of breath, pain, chills, or night sweats. The physical examination revealed a giant well-circumscribed mass located at the junction of the right chest and abdominal wall, between the anterior axillary line and the posterior axillary line (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Upon palpation, it was hard and immobile, with no tenderness observed. Her laboratory test results were all normal. Chest CT showed a 20.1 \u0026times; 15.6 \u0026times; 13.7cm multilocular cystic-solid mass with internal calcification encircling the 8th to 12th ribs (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The mass invaded and elevated the right diaphragm. Muscles and skin of the right abdominal wall were displaced. The liver and right kidney were compressed, resulting in a significant reduction in liver volume (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Three-dimensional reconstruction indicated that the mass was likely compressing the liver and right kidney, or that its invasion was limited (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Based on an ultrasound-guided biopsy performed on this site, chondrosarcoma Grade I was diagnosed. Due to the tumor's adjacency to several organs and the relatively large resection area, we conducted a multi-disciplinary discussion before the surgery, involving a radiologist, oncologist, pathologist, thoracic surgeon, hepatobiliary surgeon, and urological surgeon. The focus of the discussion was on: 1) diagnosis; 2) preparations for partial resection of the liver and right kidney if invaded by the tumor; and 3) reconstruction of the chest and abdominal wall after resection. As a result, We decided to perform a collaborative surgery involving both thoracic and hepatobiliary surgeons. Using standard anesthesia and bilateral lung ventilation, a 25cm fusiform incision was made on the surface of the tumor (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), and the superior and inferior skin flaps were freed to a sufficient distance to fully expose the tumor on the chest. The 8th to 12th anterolateral ribs and intercostal muscles were resected to expose the tumor in the thoracic and abdominal cavities, maintaining a margin of more than 2 cm around the tumor [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We found the tumor invaded the diaphragm, compressed the liver and the right kidney, and had partial adhesion to the mesentery. Therefore, we dissected the adhesion, resected part of the diaphragm and removed the tumor entirely (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). And then, the diaphragm was reconstructed by suturing it to the ribs and intercostal muscles, the thoraco-abdominal wall defects were reconstructed with a 15 cm \u0026times; 15 cm hernia mesh (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Drainage tubes were placed in both the abdominal cavity and subcutaneous cavity. Finally, we made an inverted triangular incision on the inferior skin flap, excising the excess skin and closing the incision (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). The surgical area was compressed and bandaged to ensure that the skin and mesh remain firmly attached. Postoperative histopathology confirmed chondrosarcoma Grade II with negative margins (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The postoperative course was uneventful, and the patient was discharged on postoperative day 5.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChondrosarcoma is a relatively rare malignant bone tumor with an incidence of approximately 1\u0026ndash;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 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Chondrosarcoma exhibits low responsiveness to chemoradiotherapy, therefore, R0 resection with a guaranteed negative margin is the preferred treatment.\u003c/p\u003e \u003cp\u003eCostal 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 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] 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 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eIn 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 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eThe 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 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] 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.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWide en-bloc resection followed by reconstruction using mesh is feasible and effective for costal chondrosarcoma with limited invasion. The successful management of giant costal chondrosarcomas hinges on multi-disciplinary discussion, meticulous preoperative planning, and suitable surgical and reconstructive techniques. This case contributes valuable insights into the complex interplay of these factors, reinforcing the need for tailored strategies to optimize patient outcomes in similar scenarios.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT: Computed tomography\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study was approved by the Ethics Committee for Medical Research and New Medical Technology of Sichuan Cancer Hospital\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Sichuan Science and Technology Program [2023YFH0075] and Sichuan Province Key Clinical Specialty Construction Project (no grant number).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaiyang Liu, Qinyan Yang, and Deyuan Zhong\u0026nbsp;performed the literature review and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eHongtao Yan, Hang Gu, and Xiaozun Yang participated in the diagnosis and treatment of the case and provided expertise in clinical knowledge.\u003c/p\u003e\n\u003cp\u003eXiaojun Yang, Qiang Li, and Xiaolun Huang provided important academic and language advice and critically revised the manuscript.\u003c/p\u003e\n\u003cp\u003eWei Dai supervised and guided the research, and contributed to significant decisions throughout the study.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBrito \u0026Iacute;M, Teixeira S, Paup\u0026eacute;rio G, et al. Giant chondrosarcoma of the chest wall: a rare surgical challenge. Autops Case Rep. 2020 Jun 5;10(3):e2020166.\u003c/li\u003e\n\u003cli\u003eEmori M , Hamada K I , Kozuka T ,et al.Case of an unusual clinical and radiological presentation of pulmonary metastasis from a costal chondrosarcoma after wide surgical resection: A transbronchial biopsy is recommended[J].World Journal of Surgical Oncology, 2011, 9(1):50-50.\u003c/li\u003e\n\u003cli\u003eTahir M, Rahman J, Arekemase H, et al. Chondrosarcoma of the Ribs. Cureus. 2020 Jul 12;12(7):e9158.\u003c/li\u003e\n\u003cli\u003eAl-Refaie RE, Amer S, Ismail MF, et al. Chondrosarcoma of the chest wall: single-center experience. Asian Cardiovasc Thorac Ann. 2014 Sep;22(7):829-34.\u003c/li\u003e\n\u003cli\u003eWang L, Yan X, Zhao J, et al. Expert consensus on resection of chest wall tumors and chest wall reconstruction. Transl Lung Cancer Res. 2021 Nov;10(11):4057-4083.\u003c/li\u003e\n\u003cli\u003eDorfman HD, Czerniak B. Bone cancers. Cancer. 1995 Jan 1;75(1 Suppl):203-10.\u003c/li\u003e\n\u003cli\u003eGelderblom H , Hogendoorn P C W , Dijkstra S D ,et al.The Clinical Approach Towards Chondrosarcoma[J].Oncologist, 2008, 13(3).\u003c/li\u003e\n\u003cli\u003eDoyle L A .Sarcoma classification: An update based on the 2013 World Health Organization Classification of Tumors of Soft Tissue and Bone[J].Cancer, 2014, 120(12).\u003c/li\u003e\n\u003cli\u003eDantis K , Singh R , Goel A ,et al.An innovative reconstruction of an enbloc resected composite giant chest and abdominal wall chondrosarcoma with 3D-composite mesh[J].Journal of Cardiothoracic Surgery, 2024, 19(1).\u003c/li\u003e\n\u003cli\u003eKhurana J S , Mccarthy E F .Tumors and Tumor-Like Lesions of Bone[J].Springer-Verlag, 2010.\u003c/li\u003e\n\u003cli\u003eJiang Z M, Zhang H z.Diagnostic Challenges and Grading Criteria for Chondrosarcoma[J].Chinese Journal of Pathology, 2016(9):4.\u003c/li\u003e\n\u003cli\u003eXu P, Yu G, Wang H, et al. Surgical Resection of Giant Chest Wall Chondrosarcoma Combined with Sandwich Chest Wall Reconstruction in One Case. Ann Ital Chir. 2024;95(2):126-131. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chondrosarcoma, Thoraco-abdominal wall, Reconstruction, Case report","lastPublishedDoi":"10.21203/rs.3.rs-4815833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4815833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Chondrosarcoma primarily occurs in the pelvis and femur, with occasional cases in the ribs. Surgical resection remains the main treatment method for costal chondrosarcoma. However, complete resection often leads to a large range of chest wall defects and a challenging reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 49-year-old female patient presented with progressive swelling of the right chest and abdominal wall over 15 years. Chest CT revealed a 20.1 × 15.6 × 13.7 cm multilocular cystic-solid mass with internal calcification, encircling the 8th to 12th ribs and causing elevation of the right diaphragm. Compression of the liver resulting in a significant reduction in volume. Based on an ultrasound-guided biopsy, chondrosarcoma Grade I was diagnosed. After a multi-disciplinary discussion, we performed a complete resection of the tumor, including the 8th to 12th anterolateral ribs and part of the diaphragm. The diaphragm was then reconstructed by suturing it to the ribs and intercostal muscles. The thoraco-abdominal wall defects were reconstructed with a hernia mesh. Finally, we excised the excess skin and then closed the incision. Histopathologic diagnosis was chondrosarcoma Grade II. The postoperative course was uneventful.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWide en-bloc resection followed by reconstruction using mesh is feasible and effective for costal chondrosarcoma with limited invasion. This case illustrates the importance of meticulous preoperative planning and multi-disciplinary discussion.\u003c/p\u003e","manuscriptTitle":"Complete resection of a giant costal chondrosarcoma with reconstruction of the thoraco-abdominal wall：a case report.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 19:11:45","doi":"10.21203/rs.3.rs-4815833/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-28T12:05:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-26T15:15:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-26T08:25:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53900045269738471611813637255425694995","date":"2024-08-26T08:16:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286935386910827449442771547893649944870","date":"2024-08-26T06:36:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-25T16:14:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106845101551842428125151990941467052149","date":"2024-08-24T17:54:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307545255933110387620500726084498576890","date":"2024-08-24T17:18:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338860996162904242697861430166030936698","date":"2024-08-24T16:22:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190987749058075067513544290648770271746","date":"2024-08-22T16:59:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105834629682239277721157049491810485250","date":"2024-08-22T16:09:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-22T16:01:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-30T06:38:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-30T06:35:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-07-28T08:35:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3e466457-827d-408a-9a61-98d8f9b88554","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:27:41+00:00","versionOfRecord":{"articleIdentity":"rs-4815833","link":"https://doi.org/10.1186/s13019-024-03145-4","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2024-11-30 15:58:34","publishedOnDateReadable":"November 30th, 2024"},"versionCreatedAt":"2024-09-02 19:11:45","video":"","vorDoi":"10.1186/s13019-024-03145-4","vorDoiUrl":"https://doi.org/10.1186/s13019-024-03145-4","workflowStages":[]},"version":"v1","identity":"rs-4815833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4815833","identity":"rs-4815833","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}