Chest wall resection and reconstruction for primary and metastatic sarcomas: an 11-year retrospective cohort study

 Open in a separate windowOBJECTIVESChest wall sarcomas are rare, aggressive malignancies, the management of which mainly revolves around surgery. Radical tumour excision with free margins represents the optimal treatment for loco-regional clinically resectable disease. The objective of this study was to review our 11-year experience with chest wall resection for primary and metastatic sarcomas, focusing on surgical techniques and strategies for reconstruction. METHODSRetrospective analysis of a comprehensive database of patients who underwent chest wall resection for primary or secondary sarcoma at our Institute from January 2009 to December 2019.RESULTSOut of 26 patients, 21 (81%) suffered from primary chest wall sarcoma, while 5 (19%) had recurring disease. The median number of resected ribs was 3. Sternal resection was performed in 6 cases (23%). Prosthetic thoracic reconstruction was deemed necessary in 24 cases (92%). Tumour recurrence was observed in 15 patients (58%). The median overall survival was 73.6 months. Primary and secondary tumours showed comparable survival (P = 0.49). At univariate analysis, disease recurrence and infiltrated margins on pathological specimens were associated with poorer survival (P = 0.014 and 0.022, respectively). In patients with primary sarcoma, the median progression-free survival was 13.3 months. Associated visceral resections were significantly associated to postoperative complications (P = 0.02).CONCLUSIONSChest wall resection followed by prosthetic reconstruction is feasible in carefully selected patients and should be performed by experienced surgeons with the aim of achieving free resection margins, resulting in improved long-term outcomes.     

Large Chest Wall Reconstruction Using Titanium Micromesh and a Pedicled Latissimus Dorsi Musculocutaneous Flap: Report of a Case

The patient was a 54-year-old woman with a dermatopleural fistula and necrosis of the third to the fifth anterior ribs after postoperative adjuvant radiation for right breast cancer. After resection of the chest wall and combined partial resection of the right upper and middle lobes of the lung, the thoracic cage defect was stabilized by titanium micromesh and the soft tissue defect was covered by an ipsilateral pedicled latissimus dorsi musculocutaneous flap. The dorsal skin defect was covered by split-thickness skin grafts 3 weeks later. The advantages of titanium micromesh lie not only in its good biocompatibility and mechanical strength, but also in its light weight and low radiological interference. No paradoxical movement or other prosthesis-related complications occurred during the follow-up period. Thus, we consider that titanium micromesh is a suitable material to use in the reconstruction of a large chest wall defect.     

Reconstruction of the chest wall following extended interscapulothoracic amputation and chest wall resection

Summary Extended interscapulothoracic amputation is a major operative procedure indicated in the treatment of malignant primary bony and soft tissue tumors involving the shoulder girdle and chest wall. The technique of chest wall resection and its reconstruction is described in two patients with recurrent malignant fibrous histiocytoma following extended interscapulothoracic amputation some months earlier. The stability of the chest wall was restored by using marlex mesh as a sandwich of two layers of mesh with methylmethacrylate interposed. Because of damage of the tissue around the chest wall resection by previous radiation therapy, free myocutaneous flaps were used for closure of the defects. Using this technique for reconstruction of large areas of the chest wall, it is feasible to restore sufficient pulmonary function and to obtain closure under unfavorable conditions. This operative technique can be used as a curative or palliative treatment following interscapulothoracic amputation of recurrent musculoskeletal tumors.     

Chest wall lipoblastoma in a seven-month-old girl: a case report

Lipoblastoma is a rare benign tumor of adipose tissue seen almost always in infanthood and early childhood. It is typically located in the extremities and the trunk and less frequently in the head-neck region, mediastinum, and retroperitoneum. However, cases of pleural, thoracic wall, and pulmonary lipoblastoma have also been reported in the literature. Lipoblastoma is a tumor with good prognosis despite its potential for local invasion and rapid growth. Our patient is a 7-month-old girl who was brought to our clinic for a rapidly growing mass in the right hemithorax. With the aim of both diagnosis and treatment, the mass was removed by thoracic wall resection and the resultant defect covered with an absorbable polyglactine mesh. The excised mass was diagnosed pathologically as a benign lipoblastoma. In the postoperative period, the thorax wall was stable, and after 24 months of follow-up no recurrence was observed. In the literature, 4 types of thoracic wall lipoblastomas have been reported, but thoracic wall resection has not been applied in any benign lipoblastoma case. To the best of our knowledge, the only benign lipoblastoma case in which a thoracic wall resection was carried out, with its clinical and histopathologic specifications alongside that in the literature, is presented here for the first time.     

Chest wall resection and reconstruction for locoregionally advanced or recurrent breast cancer

Ten patients, including 7 with local recurrent breast cancer, 2 with primary advanced cancer and 1 with radionecrosis, underwent chest wall resection and immediate reconstruction, using large pedicled skin flaps or musculocutaneous flaps. A rectus abdominis musculocutaneous flap was used in 4 cases and a latissimus dorsi musculocutaneous flap was used in 1 case. The postoperative course of all the patients was uneventful and there was no incidence of flail chest or respiratory failure. The postoperative performance status and also the quality of life were improved in 9 of the 10 patients. Eight of the 10 patients are presently alive with or without disease, the longest survival time thus far being 8 years.     

钛板联合Teflon补片重建胸骨肿瘤切除后胸廓

目的探讨胸骨肿瘤切除术后采用钛板联合Teflon补片重建胸廓的方法及疗效。方法 2006年10月-2009年11月,收治4例胸骨肿瘤患者。男2例,女2例;年龄30～55岁。以胸部肿块、疼痛1～6个月后入院。检查见胸前区范围为4 cm×3 cm～10 cm×8 cm的肿块,质硬。CT检查见骨质破坏。采用胸骨肿瘤扩大切除术,切除范围为10 cm×8 cm～18 cm×14 cm,采用钛板联合Teflon补片重建胸廓。结果患者手术均顺利完成。术后切口Ⅰ期愈合,未出现反常呼吸、皮下气肿、气胸、感染等并发症。术后6个月1例失访,1例术后25个月因颅内出血死亡;余2例分别获随访1年及4年,肿瘤未见复发。所有患者胸壁塑形良好,随访期间钛板无松动、外露,无呼吸困难、胸闷、胸痛等不适。结论胸骨肿瘤切除后采用钛板联合Teflon补片重建胸廓,具有手术操作简便、塑形效果满意、术后并发症少等优点。     

Chondrosarcoma of the chest wall: a clinical analysis

Purpose. To discuss the management of different histological types of chondrosarcoma (CS) in the chest wall based on our clinical experience. Methods. The subjects of this study were 16 patients with CS of the chest wall surgically treated by resection at our institute between September 1981 and August 2000. There were 11 men and 5 women ranging in age from 23 to 74 years. The median follow-up period was 54 months. The tumor was located only in the ribs in ten patients, in the sternum and ribs in three, only in the sternum in two, and in the ribs and spine in one. The surgical margins were wide in 12 patients and marginal in four. Reconstruction using Marlex mesh combined with moldable metal plates was carried out to prevent flail chest in nine patients, resection alone was performed in five patients, and a muscular flap was used in two patients. Results. The survival rate was 86% after a median follow-up period of 54 months. One operative death (6.2%) occurred, and another required temporary tracheostomy. There were no infections in this series. Oncological outcome was clinically related to surgical margins and recurrence. The postoperative respiratory function test result was 10% less than the preoperative one. Conclusion. This series demonstrated that wide resection is the treatment of choice for chest wall CS and that Marlex mesh combined with metallic mouldable plates is a reliable technique for reconstruction. Received: April 3, 2001 / Accepted: November 20, 2001     

Hodgkin lymphoma presenting with chest wall involvement: a case series

Chest wall tumors in the pediatric population can have a variety of etiologies, malignancy being the most worrisome. Hodgkin lymphoma (HL) rarely presents as a chest wall mass in the pediatric population. In this report, we describe 3 male pediatric patients, all of whom had chest wall masses present at the initial diagnosis of HL. We also discuss the literature on this topic. We conclude that malignancy and, more specifically, HL should always be considered when evaluating a pediatric patient who presents with a chest wall mass.     

Chest wall invasive non-small cell lung cancer: Patterns of failure and implications for a revised staging system

Background: To assess outcomes and patterns of failure for chest wall invasive non-small cell lung cancer (T₃ or IIIA NSCLC), data were acquired prospectively on 47 consecutive patients at a single institution over 6 years. Methods: Preresectional stagings included bone scan, head and chest/abdominal computed tomography, and mediastinoscopy. There were 25 superior sulcus tumors (radiation and/or chemotherapy followed by resection) and 22 other chest wall invasive NSCLCs (resection alone). Results: There were no perioperative deaths. Seventeen patients (36%) had an operative complication (median length of stay increased from 7 to 12 days; p<0.05). A complete pathologic resection was achieved for 44 of 47 patients (94%). The median survival was 38 months (actuarial 2- and 5-year survival rates of 62% and 50%, respectively). Median lengths of survival for superior sulcus and other chest wall tumors were 36 and >60 months, respectively. Significant univariate predictors of decreased overall and cancer-free survival were poor performance status, positive margins, and positive lymph nodes. Recurrence was observed in 22 of 47 patients (46%) at a median of 8 months (range 2–24); patterns of failure were in the ipsilateral chest (n=2; 4%) and at a distant site (n=15; 32%) or both (n=5; 11%). Conclusions: The operative risk for chest wall invasive NSCLC is acceptable, even after neoadjuvant therapy, allowing for a 94% complete resection rate. The survival of this subset of stage IIIA patients may warrant a reappraisal of the international staging system. Presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Chest wall mesenchymal hamartoma associated with a massive fetal pleural effusion: a case report

We report on an extremely rare chest wall mesenchymal hamartoma associated with a massive fetal pleural effusion. Prenatal ultrasound examination demonstrated a heterogeneous mass in the right thorax associated with a massive pleural effusion and right lung compression at 29 weeks of gestation. The patient underwent pleuroamniotic shunting at 30 weeks and was delivered at 33 weeks by cesarean delivery secondary to fetal distress. After management of the respiratory distress and evaluation of the mass, surgery was performed at day of life 8. Histological examination confirmed the diagnosis of a chest wall mesenchymal hamartoma.     

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report

IntroductionTrauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities.Presentation of caseThe patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up.DiscussionHepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance.ConclusionDelayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.     

Reconstruction of Chest Wall Using a Two-Layer Prolene Mesh and Bone Cement Sandwich

Wide surgical resection is the most effective treatment for the vast majority of chest wall tumors. This study evaluated the clinical success of chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Surgical indications, the location and size of the chest wall defect, diaphragm resection, pulmonary performance, postoperative complications, and survival of each patient were recorded. From 1998 to 2008, 43 patients (27 male, 16 female; mean age of 48 years) underwent surgery in our department to treat malignant chest wall tumors: chondrosarcoma (23), osteosarcoma (8), spindle cell sarcoma (6), Ewing''s sarcoma (2), and others (4). Nine sternectomies and 34 antero-lateral and postero-lateral chest wall resections were performed. Postoperatively, nine patients experienced respiratory complications, and one patient died because of respiratory failure. The overall 4-year survival rate was 60 %. Chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich is a safe and effective surgical procedure for major chest wall defects.