Massive chest wall resection and reconstruction for malignant disease

Abstract

ObjectiveMalignant chest wall tumors are rare neoplasms. Resection with wide-free margins is an important prognostic factor, and massive chest wall resection and reconstruction are often necessary. A recent case series of 20 consecutive patients is reported in order to find any possible correlation between tumor histology, extent of resection, type of reconstruction, and adjuvant treatment with short- and long-term outcomes.MethodsTwenty patients were submitted to chest wall resection and reconstruction for malignant chest wall neoplasms between 2006 and 2014. The mean age (ten males) was 59±4 years. The size and histology of the tumor, the technique of reconstruction, and the short- and long-term follow-up records were noted.ResultsThe median maximum diameter of tumors was 10 cm (5.4–32 cm). Subtotal sternal resection was performed in nine cases, and the resection of multiple ribs was performed in eleven cases. The median area of chest wall defect was 108 cm2 (60–340 cm2). Histology revealed soft tissue, bone, and cartilage sarcomas in 16 cases (80%), most of them chondrosarcomas. The rest of the tumors was metastatic tumors in two cases and localized malignant pleural mesothelioma and non-Hodgkin lymphoma in one case. The chest wall defect was reconstructed by using the “sandwich technique” (propylene mesh/methyl methacrylate/propylene mesh) in nine cases of large anterior defects or by using a 2 mm polytetrafluoroethylene (e-PTFE) mesh in nine cases of lateral or posterior defects. Support from a plastic surgeon was necessary to cover the full-thickness chest wall defects in seven cases. Adjuvant oncologic treatment was administered in 13 patients. Local recurrences were observed in five cases where surgical reintervention was finally necessary in two cases. Recurrences were associated with larger tumors, histology of malignant fibrous histiocytoma, and initial incomplete resection or misdiagnosis made by nonthoracic surgeons. Three patients died during the study period because of recurrent disease or complications of treatment for recurrent disease.ConclusionChest wall tumors are in their majority mesenchymal neoplasms, which often require major chest wall resection for their eradication. Long-term survival is expected in low-grade tumors where a radical resection is achieved, while big tumors and histology of malignant fibrous histiocytoma are connected with the increase rate of recurrence.

Case Report: A New Tool for Anterior Chest Wall Reconstruction After Sternal Resection for Primary Or Secondary Tumors

“…In case of anterior chest wall tumors involving bones, muscles and soft tissues, surgical resection with wide-free margins is the most relevant prognostic factor for disease-free survival, and often massive demolitions are required to obtain a radical resection ( 10 ). The sternochondral replacement approach is not yet standardized.…”

“…This approach is associated with optimal functional results and the encapsulation of methyl methacrylate reduces the risk of dislocation, even in case of rupture. In addition, the “sandwich” is well-anchored to the chest wall using stainless-steel sutures, which decreases even more the risk of displacement ( 10 ). Among other available surgical strategies, the original “rib-like” technique proposed by Girotti et al ( 19 ) reproduces the best possible anatomy.…”

Ventilatory failure in a cat following radical chest wall resection for feline injection site sarcoma

“…In humans, extensive defects are reconstructed with either a single sheet of polytetrafluoroethylene mesh, or via the ‘sandwich technique’, where a methyl methacrylate prosthesis is surrounded by two sheets of polypropylene mesh. 11 Both techniques are reported to provide excellent functional chest stability. 11 In our patient, a single sheet of polypropylene mesh was used, which is the most common technique reported in the veterinary literature.…”

“… 11 Both techniques are reported to provide excellent functional chest stability. 11 In our patient, a single sheet of polypropylene mesh was used, which is the most common technique reported in the veterinary literature. 9 , 10 , 15 , 16 However, it is possible that a more rigid prosthesis may have provided a better mechanical outcome in this patient.…”

“…In humans, radical chest wall resection is defined as resection of five or more consecutive ribs requiring reconstruction to restore chest wall stability. 11 The size of the defect rather than the method of reconstruction is the most significant predictor of complication rate (11–31%), although overall mortality is low (3–7%). 12 – 14 In companion animals, the term ‘radical resection’ has not been defined and there is little published information available regarding the safety of extensive chest wall resection and reconstruction in these patients.…”