To the Editor:

Computer-assisted surgery is an extremely useful tool for planning the resection of tumors that require anatomical accuracy to achieve tumor-free margins. This technique offers the surgeon precise information on the extent of such margins during the procedure, thus avoiding unnecessary resections.

We report the case of a female patient who underwent navigation-guided resection of a chest wall sarcoma that had been excised in a previous procedure, with positive surgical margins.

This was a 43-year-old woman with a history of resection of a tumor in her back, without resection of thoracic wall. The postoperative pathology report confirmed soft-tissue sarcoma with positive surgical margins.

The case was discussed by the multidisciplinary committee, and given that the resection showed positive margins, oncological surgery was planned with en bloc chest wall resection including soft tissues affected by the previous surgery.

In our patient, we used 2 approaches that are routine in chest wall tumors: virtual surgical planning and navigation, performed on virtual simulation platforms that can be used to merge digital images (MRI pre, MRI post, 2D tomographies, 3D tomographies). Once the virtual surgical planning had been completed, navigation-guided surgery can be used to achieve tumor-free margins with an accuracy of millimeters.

As the tumor had been resected in a previous procedure, we had to decide the anatomical limits for oncological resection with tumor-free margins. We decided to use virtual surgical planning based on a magnetic resonance image obtained prior to the initial surgery, which showed the soft-tissue lesion in contact with the 8th, 9th, and 10th ribs (Fig. 1A). The lesion was reconstructed virtually in a new CT scan performed on the same day of surgery (Fig. 1B). Using the intraoperative navigation system, oncological resection of the chest wall en bloc with soft tissues was performed, and 3 rib sections were resected (Fig. 1C and D) and reconstructed with osteosynthesis material. The postoperative period was incident-free, and the patient was discharged on day 6 post-procedure.

Fig. 1.

A) Magnetic resonance imaging (MRI) of the patient’s chest before the initial surgery. B) Tomographic reconstruction of the original injury generated from the MRI. C) Intraoperative navigation. D) resection.

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Primary tumors of the chest wall are rare cancers that represent less than 5% of all thoracic tumors. The 3 most common subtypes are chondrosarcomas, liposarcomas, and fibrosarcomas. Surgical resection with adequate tumor-free margins is critical to achieve the best oncological outcome. Surgeons should have a broad knowledge of the principles and different methods of chest wall resection and reconstruction.1

The importance of computer-assisted surgery in providing support for both preoperative and intraoperative planning, especially in patients with oncological disease, has already been established in the literature.2

In chest wall tumors, intraoperative navigation is used to orient the surgeon in the 3-dimensional space and guide the surgery by matching the images acquired and processed before surgery with real anatomical landmarks.3

We report a situation which, to our knowledge, has not been previously described in the literature. Magnetic resonance images obtained before the initial surgery were merged with images of a subsequent computed tomography in which the lesion was no longer present (per surgical history). Virtual reconstruction of the resected lesion allowed us to perform oncological surgery obtaining tumor-free margins in a previously operated patient.