Peking University First Hospital: Neoadjuvant Downstaging and Resection of a Massive Chest Wall Sarcoma

Massive invasive soft tissue sarcomas involving the great vessels are frequently deemed "unresectable" due to prohibitive surgical risk. Recently, the Bone Tumor Department at Peking University First Hospital, in close collaboration with thoracic surgery, cardiac surgery, interventional vascular surgery, anesthesiology, and critical care, successfully performed a curative resection for a 23-year-old male with a massive chest wall undifferentiated sarcoma.

Clinical Baseline

The patient presented with cough and chest pain, revealing a massive anterior chest wall mass eroding through the sternum and ribs, protruding through the skin. Imaging and pathology confirmed:

• Tumor size: 18.3×11.1×11.3 cm
• Pathology: Undifferentiated sarcoma (high-grade)
• Invasion: Encasing the ascending aorta, compressing the right pulmonary artery/bronchus, with extensive adhesion to the pericardium and mediastinal pleura

Clinical Dilemma

The patient had been declined surgery at multiple institutions due to the tumor's massive size and high-risk location. Dense adhesion to the great vessels made direct resection prone to catastrophic hemorrhage, yet inaction risked progressive airway and cardiac compromise.

Strategy: "Defuse Then Disarm"

Following institution-wide MDT consultation (bone tumor, thoracic surgery, cardiac surgery, interventional vascular surgery, anesthesiology, critical care), the team designed a neoadjuvant-first, staged surgical protocol:

• Neoadjuvant Chemotherapy: AI regimen (Doxorubicin + Ifosfamide), with interval CT reassessment every 3 cycles;
• Dynamic Imaging Surveillance: The tumor progressively regressed and its vascular interface became increasingly defined, opening a surgical window;
• Multidisciplinary Surgical Planning: Preoperative embolization of tumor-feeding vessels; multi-access IV lines and continuous arterial monitoring; cardiopulmonary bypass team on standby throughout.

Surgical Core: "Disarming" Without Bypass

Bone tumor surgeons first resected the involved sternal body and bilateral costal cartilages to establish surgical access. Thoracic and cardiac surgery teams then meticulously dissected the tumor from its adhesions to the ascending aorta and superior vena cava—entirely on a beating heart, without initiating cardiopulmonary bypass—achieving complete en bloc resection along with the invaded right middle lobe and partial pericardium, while preserving bilateral phrenic nerve continuity.

Chest Wall Reconstruction

The massive defect was reconstructed using rib plates, titanium mesh, and artificial ligaments, restoring structural rigidity and preventing postoperative flail chest and mediastinal shift.

Clinical Outcome

The patient was extubated on postoperative day 2, mobilized in bed by day 3, and ambulatory after chest tube removal at 2 weeks, with a stable, non-collapsed chest wall reconstruction.

Clinical Significance: This case demonstrates the pivotal role of neoadjuvant downstaging combined with precision multidisciplinary surgery in converting an "unresectable" massive invasive sarcoma into a curative resection for a young patient.