Which Should Be Considered For The Clear Surgical Margin Of Postradiation Malignant Fibrous Histiocytoma: Tumor-Free Or Radiation-Free Margin?

摘要

Malignant fibrous histiocytoma is one of the most common soft tissue sarcomas originating from extremities. Its presentation after radiation, especially in chest wall, is a very rare event. The prognosis is poor due to its aggressiveness and local recurrence rate is high. Its main treatment is surgical excision. The presented case describes postradiation malignant fibrous histiocytoma treated with repetitive extensive resection and reconstruction of the chest wall in a patient diagnosed with breast cancer ten years ago with long survival. We suggest that patients who undergo wide excision with negative margins (radiation-free) have long survival. Introduction Malignant fibrous histiocytoma (MFH) is one of the most common soft tissue sarcomas arising from differentiation of fibroblasts and histiocytes (1). Firstly, it was defined by O'Brien and Stout in 1964. The incidence in middle and advanced ages is high. Its most common locations are extremities (70%) and retroperitoneal space (12-14%) (1,2). MFH in the chest wall is a very rare entity, especially in patients previously treated with radiation for breast cancer, and it is rarely reported in the literature (3). Restricted surgery is not recommended for the treatment of MFH of the chest wall, because of the high incidence of local recurrence and distant metastasis. The main recommended treatment is aggressive radical surgery performed after diagnosis (4). The rationale of this article is to discuss the aggressive surgical treatment of postradiation MFH of the chest wall with long survival and to review the related literature. Case A forty-one-year-old woman was hospitalized for a mass of the left anterior chest wall. She had undergone left modified radical mastectomy for infiltrative ductal carcinoma 10 years before. The disease stage was T1NM0 and estrogen, progesterone receptors and c erb B2 expression were negative. She had antracyclin based chemotherapy and radiation therapy in the postoperative period at a dosage of 40 Gray (Gy). She was in remission without any problem during the past 10 years of survey. Six months ago, she was admitted because of a 7cm mass located at the mastectomy incision. A limited excision was performed. The pathological examination revealed a MFH. Three months later she was referred to our institution because of tumor relapse reaching a diameter of 5cm within 10 days. We performed a large excision of the tumor, including the major and minor pectoral muscles with intact surgical margins (tumor free). The defect was reconstructed with a split thickness skin graft. Two months later, she was rehospitalized because of a rapidly growing mass with a diameter of 10 cm in its largest dimension. The ulcerated, hemorrhagic and stinking mass, restricting the abduction of the arm and rotations, was determined on the left chest wall. It was surpassing the clavicula, coming down to the level of the sixth rib, 3cm away from the sternum at the medial margin. Laterally, it invaded the left forearm, medially it reached the posterior axillary line (Figure 1). Magnetic resonance examination of the thorax revealed a mass of 7x9x11cm in the upper part of left hemithorax. There was no metastasis to the other parts of the body or invasion to the chest detected. Extensive surgery was planned for the removal of the mass. The patient had been informed and she accepted the operation. The clavicula was excised; the left subclavian artery and vein were tied and cut. Together with the scapula, the left arm, the former grafted location and the tumor tissue was excised completely (a flap containing the lateral surface of the arm from deltoid muscle to tumor-free area has been prepared). The part exposed to radiation was excised together with the tumor with a surgical margin (histopathologically verified) of 4cm (Figure 2). There was no invasion on ribs. The defect was restored with a deltoid flap (Figure 3). In the postoperative period, chemotherapy has been planned for the patie