Surgical closure of chest wall in noninflammatory locally advanced breast carcinoma with ulceration of the skin

Patients with noninflammatory locally advanced breast cancer with ulceration of skin or muscle or parietal wall infiltration, better named "extended locally advanced breast cancer," may require cancer surgery and plastic reconstruction of the chest wall after multidisciplinary evaluation. The decision is made to improve quality of life, independently of prognosis, and severity of the disease. The aim of this study is to evaluate the best method for surgical closure of the chest wall and to check whether ablative surgery is an appropriate procedure in regards to the treatment of cancer. From October 1997 to June 2006, 27 patients with noninflammatory extended locally advanced breast cancer with ulceration of the skin, who were not candidate or did not respond to a neo-adjuvant treatment, underwent radical mastectomy and reconstructive surgery. Sixteen patients (59%) were affected by primary tumors of the breast, and eleven patients (41%) had local recurrence after mastectomy or conservative breast surgery. Two main techniques were used for breast reconstruction: transverse rectus-abdominis musculo cutaneous flap in 19 patients (70%), and a fasciocutaneous flap in eight patients (30%). The best procedure in each patient was chosen according to the extent of skin loss or previous radiotherapy to the chest wall. Fourteen patients (52%) died during the follow-up and the median length of survival was 16 months (range 3-79) in transverse rectus-abdominis musculo cutaneous group and 4 months (range 2-23) in fasciocutaneous flap group. The median length of follow-up after treatment for patients still alive was 32.5 months (range 0-96) in transverse rectus-abdominis musculo cutaneous flap group, and 18 months (range 8-41) in fasciocutaneous flap group. At the end of the follow-up, 10 patients were alive without evidence of disease and three patients developed metastatic lesion or local recurrence. The longest recorded disease free interval for a patient still alive and tumor free was 96 months. Only three patients (11%) had local complications: two wound infections and one partial necrosis of the transverse rectus-abdominis musculo cutaneous flap. Median hospital stay was 7 days (range 3-13) for transverse rectus-abdominis musculo cutaneous and 6 days (range 3-13) for fasciocutaneous flap. Our results confirmed that transverse rectus-abdominis musculo cutaneous group and fasciocutaneous flap flaps are good reconstructive options in patients with extended locally advanced breast cancer. Quality of life has improved in this group of patients, with acceptable survival periods and in some cases very important survival rates.     

PRIMARY RECONSTRUCTION AFTER EXTENSIVE CHEST WALL RESECTION

Background : Chest wall resection and reconstruction has been proven to be a safe surgical procedure. This is particularly useful for breast cancer patients with chest wall recurrences or for those who first present with locally advanced cancer in the chest wall where there is both a large soft tissue and bony defect that need repair. In addition, many of these patients have had irradiation or chemotherapy, which can significantly impair wound healing. Methods : Thirty-four patients underwent chest wall resection and primary reconstruction over an 8-year period. Results : Twenty-three patients had breast carcinomas and six had breast and chest wall sarcomas. Of the breast carcinoma patients, 12 had local recurrences and 11 presented with locally advanced primary disease. Bony resection of the chest wall was required in 16 (47%) cases. Thirty myocutaneous flaps (18 rectus abdominis, four pectoralis major, eight latissimus dorsi) and three omental flaps were used for reconstruction. One required a deltovertebral skin flap. Skeletal reconstruction was necessary in four cases. All except one (97%) achieved primary wound healing. There was one mortality (3%) and three patients required further surgery for complications that were related to the reconstruction. Post-resection metastases occurred in 13 (42%) patients and only 2 (6%) had local recurrences. The 2-year survival rate was 78% with a mean survival time of 25.5 months. Conclusions : Primary reconstruction for curative or palliative purposes is a useful and safe surgical procedure for patients with recurrent or locally advanced chest malignancies after extensive chest wall resection. Pedicled myocutaneous flap is the preferred option for skeletal and soft-tissue coverage.     

OMENTAL TRANSPOSITION FLAP FOR GROSS LOCALLY RECURRENT BREAST CANCER

Background : The omentum has been employed to cover the defect produced after resection of gross breast cancer recurrence for nearly three decades. Methods : A series of 11 patients undergoing omental transposition flap for very wide resection of gross local recurrence (LR) of breast cancer is reported. The median age was 39 years, with a short interval (median = 21 months) from the treatment of the primary tumour to LR. Local recurrence was gross and predominantly inflammatory. Results : All except one patient had lymphovascular invasion in the recurrent tumour. The omental graft was 100% viable but one patient required re-application of further split-thickness skin graft. The mean hospital stay was 16 days. Two cases of seroma formation were encountered. New recurrence developed around the periphery of the flap in eight patients after a median duration of local control of only 2.5 months. Eight patients died with metastatic disease after a median period of 6 months, six patients with uncontrolled local disease. Five patients were free from LR in over half of their remaining period of life. Conclusion : Omentoplasty is a safe and reliable procedure but the length of palliation achieved is often far from satisfactory.     

Omental transposition and skin graft in patients for advanced or recurrent breast cancer

Nine patients, including 4 with primary advanced breast cancer (stage IV) and 5 with local recurrent cancer, underwent chest wall reconstruction using an omental flap and mesh skin grafting. In 2 of these patients the defect of bony chest wall was reconstructed with an acryl-resin plate and omental flap. The postoperative course in all patients was uneventful, except for a slight necrosis on the transposed mesh skin. Flail chest or dypsnea did not occur in those with a bony chest wall reconstruction. The immediate postoperative performans status in 6 of 9 patients and also quality of life improved.     

Management of radiation-induced sarcomas in a tertiary referral centre: A review of 25 cases

IntroductionRadiation-induced sarcomas are a rare and late complication of radiotherapy for breast carcinoma which often have poor prognosis.MethodsThis study is a retrospective review of 25 patients referred to a regional sarcoma unit between 1978 and 2009.ResultsRadiation-induced sarcoma following the diagnosis and treatment of breast cancer occurred after a mean period of 156 months. Anatomical sites involved were the breast, chest wall, clavicle, scapula, humerus and axilla. Twenty one patients had wide local excision followed by chest wall reconstruction, latissimus dorsi flap cover or limb amputation. The estimated five years survival following the diagnosis of the radiation-induced sarcoma was 27% and the local recurrence rate 52%.ConclusionRadiation-induced sarcoma following breast cancer has high local recurrence rate and poor prognosis. They should be managed in a multi-disciplinary setting. Long-term follow-up of patients treated with radiotherapy for breast cancer is therefore advisable.     

The Integrated Evaluation of the Results of Oncoplastic Surgery for Locally Advanced Breast Cancer

The optimal surgical management of locally advanced breast cancer (LABC) remains undefined. The aim of the study was to obtain long‐term results of oncoplastic surgery in terms of overall survival, loco‐regional recurrence, and quality of life in case of LABC. Prospective cohort study enrolled 60 patients with stage III breast cancer. Forty‐two (70%) patients received neo‐adjuvant chemotherapy, 28 patients were considered suitable for surgery as initial treatment option. Type II oncoplastic surgery was performed for all patients: hemimastectomy and breast reconstruction with latissimus dorsi flap – for 29 (48.3%), lumpectomy – 31 (51.7%), and reconstruction with subaxillary flap for four (6.7%), with bilateral reduction mammoplasty – 14 (23.3%) and with J‐plastic – 13 (21.7%) patients. Adjuvant chemotherapy and hormonal therapy followed surgery for all, except one, patients. Sequential radiotherapy was administered for all patients. The mean period of follow‐up was 86 months. Postoperative morbidity rate was 5%. Local‐regional recurrence was detected in six (10%) patients. After reoperation no local relapse was diagnosed. However, three of these patients had systemic dissemination of the disease. Distant metastasis was detected in 23 (38.3%) patients. Distant metastasis‐free survival at 5 years was 61.7%. Fourteen patients died (23.3%). A total of 87.2% of the patients had good and excellent esthetic outcome. Oncoplastic breast‐conserving surgery can be proposed for selected patients with LABC with acceptable complication, local recurrence rate, and good esthetic results.     

Omental transposition and skin graft in patients for advanced or recurrent breast cancer

Nine patients, including 4 with primary advanced breast cancer (stage IV) and 5 with local recurrent cancer, underwent chest wall reconstruction using an omental flap and mesh skin grafting. In 2 of these patients the defect of bony chest wall was reconstructed with an acryl-resin plate and omental flap. The postoperative course in all patients was uneventful, except for a slight necrosis on the transposed mesh skin. Flail chest or dyspnea did not occur in those with a bony chest wall reconstruction. The immediate postoperative performance status in 6 of 9 patients and also quality of life improved.     

Omental transposition in the treatment of locally advanced and recurrent breast cancer

An analysis was carried out of 43 patients treated by omental transposition for locoregional problems associated with breast cancer. Indications for surgery included advanced primary tumour (five), locally recurrent tumour (32), radiation induced sarcoma (two), and radionecrosis (four). Tumours were typically extensive (mean diameter 7.2 cm) and skin ulceration affected 30 patients. Other treatment modalities had been exhausted. Surgical excision followed by reconstruction using transposed omentum resulted in worthwhile local control and symptom relief in 31 patients (median duration 22 months). Chest wall disease rapidly recurred peripheral to the omental graft in 12 patients. On multiple regression analysis, duration of local control was significantly related to tumour diameter, ulceration, and earlier radioresistance (hazard ratios 15.8, 3.8 and 14.8 respectively). Survival (median 21, range from 1.5 to 122 months) correlated with tumour size, previous chemotherapy, and early re-recurrence (hazard ratios 7.2, 3.0 and 4.3). Omental transfer is a reliable method of restoring epithelial cover after radical surgery and is particularly useful after previous irradiation injury. In advanced and recurrent breast cancer, an aggressive surgical approach significantly improved the quality of life of most patients, but careful case selection is required to avoid inappropriate surgery for irremediable tumours.     

Laser-Induced Thermotherapy (LITT) for Retreatment of Locally Advanced Recurrences of Breast Cancer

The effect of laser-induced thermotherapy (LITT) as a palliative method for treatment of patients with local recurrence of breast cancer is investigated. This report describes the use of interstitial laser photocoagulation to manage such lesions. The interstitial laser applications were performed in seven women with locally recurrent breast carcinoma on the chest wall after mastectomy. All patients had been heavily pretreated with conventional modes of therapy (radiotherapy, chemotherapy, hormonal therapy, surgical resection). A Nd:YAG laser with a wavelength of 1064 nm was used to heat the lesions. Heat expansion was controlled digitally and monitored by ultrasonography and colour-coded duplex sonography (CCDS). In five women this minimally invasive method enabled the precise coagulation of the subcutaneous tumour without destruction of the skin or ulceration, although these areas had been pretreated by irradiation up to 60 Gy. In two patients with extensive multiple metastases and with skin infiltration, secondary skin ulceration and delayed healing was observed. For palliative reasons, LITT under CCDS guide can aid in local control of chest wall recurrence following mastectomy in selected patients. Paper received 3 January 1998; accepted after revision 30 July 1998.     

How Wide Should Margins Be for Phyllodes Tumors of the Breast?

The surgical management of phyllodes tumors (PTs) is still controversial. Some studies have suggested surgical margins ≥1 cm, but recent studies suggested that negative margins could be appropriate regardless of their width. To evaluate recurrence rates of PTs following surgery according to margins. Retrospective study of women who attended a tertiary breast cancer reference center between 1998 and 2010: 142 patients with a PT diagnosis, either at minimally invasive breast biopsy or at surgery, were identified. Clinical, pathologic and follow‐up characteristics were assessed. Among 140 patients who underwent surgery, 64.3% of biopsies accurately predicted the final PT diagnosis at surgery. Forty‐two (42/87, 48.3%) PTs had positive margins. Twenty‐one (21/42, 50.0%) patients had a surgical revision of margins. Only one (1/42, 2.4%) had margins greater or equal to 1 cm. After a median follow‐up of 1.29 years in benign PTs, 4.99 years in borderline PTs, and 5.42 years in malignant PTs, there were five local recurrences, three in originally benign PTs and two in borderline PTs. All were managed with surgery. Four had initial margins ≤1 mm. One patient with borderline PT had a local recurrence and later progressed to regional recurrence and metastasis. Free surgical margins are necessary to treat PT, and margins of at least 1 mm might be sufficient to prevent recurrence. Core needle biopsy might not be the best diagnostic tool for PTs.     

Full-thickness chest wall resection for recurrence of breast malignancy

We present outcomes in 13 consecutive patients with solitary, local chest wall recurrence subsequent to mastectomy for breast malignancy who were operated on in 1983--2001. All patients underwent full-thickness chest wall resection (FTCWR) and immediate reconstruction. The mean chest wall defect area was 108 cm(2). The choice of reconstruction method was individualized. The reconstruction was accomplished with the patient's own tissues, in three cases supported by artificial mesh. Most commonly we used the contralateral breast or myocutaneous flap. We did not observe postoperative complications. The tissues used for the reconstruction provided sufficient stiffness of the rib cage. In all specimens the surgical margins were negative. The estimated 5-year survival after excision of recurrent tumor is 62%. FTCWR with immediate reconstruction with soft tissues should be considered in patients with local solitary recurrence after mastectomy for breast malignancy. This option offers good long-term results and minimal morbidity.     

Utility of the free deep inferior epigastric perforator flap in chest wall reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.     

A perspective on chest wall resection in patients with breast cancer

The morbidity from locally recurrent breast cancer or osteoradionecrosis and accompanying infection is substantial. The selective use of surgical resection offers good palliation. Extended full-thickness chest wall resection is facilitated by a variety of techniques available for closure and coverage including use of latissimus dorsi myocutaneous flap, rectus abdominus myocutaneous flap, pectoralis myocutaneous flap, breast flap, and omentum with skin graft. The experience with 43 consecutive chest wall resections in patients with breast cancer affords the opportunity to define indications and contraindications for such palliative procedures. Indications include local symptoms of pain and infection, tumor recurrence refractory to radiation therapy, and infection that precludes chemotherapy. Relative contraindications are pulmonary metastases, bone metastases, hepatic metastases, and malignant pleural effusions. Absolute contraindications are brain metastases, bone marrow involvement, bulky disease in two organs, and breakthrough on multiple chemotherapy regimens. Operative revision was only required in 4 of 43 patients. Minor wound complications occurred in 12 (28%). Three patients who underwent resection for local recurrence have survived 40 months or more free from disease. This procedure provides substantial palliation by relieving pain, controlling infection, removing a weeping wound, and allowing chemotherapy for metastatic disease. In the proper setting, chest wall resection is an important part of the armamentarium for palliation of the patient with breast cancer. It can markedly improve quality of life and occasionally may result in long-term survival.     

Laparoscopic treatment of nonparasitic cysts of the liver with omental transposition flap

Background: Between 1991 and November 1994, 18 patients with large, solitary, nonparasitic liver cysts underwent laparoscopic deroofing; the last 13 of them also received an omental transposition flap in addition. Methods: Using three to four trocars, the cystic contents were first aspirated, and the cyst derooted widely using diathermia. An omental transposition flap was fashioned and stapled into the cyst cavity itself. Results: Postoperative complications included one case of pulmonary atelectasis. Another patient developed a subhepatic bile collection which was aspirated percutaneously. On average, patients were discharged on the 4th (2–14) postoperative day. Follow-up was performed with abdominal ultrasound for 2–43 months (mean 19 months). There were two early cyst recurrences, both in cases without an omental transposition flap (overall recurrence rate, 11%; in patients with omental flap, 0). Conclusions: Deroofing in combination with an omental transposition flap is a safe and effective therapy for symptomatic solitary liver cysts and can be performed using minimal-access surgical techniques. Received: 19 January 1996/Accepted: 26 August 1996     

可扩张乳房假体加背阔肌肌皮瓣的乳房再造术

目的：报告应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体（BECKER）置入,修复乳腺癌根治术后的胸壁畸形,同时再造乳房的手术方法。方法：根据乳腺癌病灶清除术后患者胸部的畸形状况,设计患侧带蒂背阔肌肌皮瓣的肌瓣长度、体积以及皮瓣的面积和形状,切取肌皮瓣后经腋部皮下隧道转移至胸前。用肌瓣修复胸前软组织缺损,皮瓣则用于弥补胸部皮肤的不足。肌瓣与胸壁间置入可扩张的乳房假体。术后经注射壶注水,逐步扩张至额定值。6个月后,可抽除注射壶并重建乳头,完成治疗。结果：自1999年以来,对各种乳腺癌术后患者行乳房再造术共26例,获得了满意效果。结论：应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体置入,不仅可修复乳腺癌病灶清除术后的胸部软组织的缺损、锁骨下的凹陷畸形而且可重建乳房。该法具有创伤小、恢复快、再造乳房的外形及质感逼真等特点。     

The omentum: an account of its use in the reconstruction of the chest wall.

Ten patients with lesions of the chest wall amenable to surgical therapy were reconstructed by a transposition flap of the greater omentum. Eight of these patients had been previously treated for cancer of the female breast by mastectomy and irradiation or by irradiation alone (in one instance). Of these 8, 6 had progressive ulceration of the chest wall consistent with radiation necrosis and three had residual carcinoma within the ulcer. One patient had melanoma of the chest wall still persistent after surgical resection and irradiation. Another had epidermoid carcinoma, whereas two sought breast reconstruction after successful mastectomy for cancer. In five patients the omentum was transposed directly on the pleura and lung or chest wall. In three patients prolene mesh was interposed to stabilize the chest wall. In two patients the defect attendant upon a Halsted mastectomy was ameliorated by a one-stage reconstruction using transposed omentum to cover a silastic gel prosthesis and to support an overlying skin graft. In three patients there were mild transient symptoms of gastric outlet obstruction postoperatively. In one patient delayed healing occurred because of partial separation of the omentum from the underlying irradiated pleura and in another there was partial loss of skin graft and omentum due to hematoma. A closed wound was achieved in all cases without infection.     

Dermoglandular rotation flap with subaxillary advancement flap as an oncoplastic technique for breast cancer

We propose a novel oncoplastic surgical technique, dermoglandular rotation flap with subaxillary advancement flap, as a feasible one‐stage operation. Breast conserving surgery, incorporating the dermoglandular rotation flap with subaxillary advancement flap, was performed in 49 female patients with breast cancer, between January and December 2015. After a full‐thickness fibroglandular resection including the tumor, an inferior‐ or a superior‐based rotation flap was performed according to the location of the defect. The subaxillary flap consisted of skin, dermis, and subcutaneous fat tissue and was mobilized from the chest wall musculature. Since subaxillary skin has greater redundancy, it can be easily moved to reach the lateral aspect of the breast. Approximation of the subaxillary flap to the lateral side of rotated dermoglandular flap served to relieve skin tension and avoid displacement of the nipple‐areola complex (NAC). Consequently, there was wider dermoglandular tissue rotation and efficient filling of defect without any significant postoperative deformity. The mean follow‐up period was 46.5 ± 3.1 months (range, 42.4‐52.1 months). Mean tumor size, on pathology, was 2.1 cm (range, 0.4‐6.0). Mean excised breast tissue weight was 78.4 g (range, 28.6‐195.0). More than half of the patients (51%) studied had excised breast tissue weighing more than 80 g. None of the included patients had positive surgical margins in final pathologic reports. Most patients answered excellent or good for self‐estimated cosmetic outcomes including symmetry of the breast and NAC, breast shape, scarring, and overall satisfaction. A modified dermoglandular rotation flap technique along with subaxillary advancement flap is a feasible and effective oncoplastic technique for breast cancers.     

Chest wall resection and reconstruction for recurrent breast cancer – A multidisciplinary approach

BackgroundDespite therapeutic advances in the management of breast cancer, a significant number of patients present with locoregional recurrence. Treatment with hormonal, chemo or radiotherapy remains standard in such cases. However, in selected patients of recurrent breast cancer involving chest wall, multidisciplinary surgical approach could be considered.MethodsBetween 2010 and 2018, 21 patients with recurrent breast cancer, involving chest wall, were treated at a tertiary care center with resection and reconstruction. The mean age of the patients was 55 years (22–77 years).ResultsThe median interval from first breast resection to chest wall resection (CWR) for recurrent disease was 6 years (1–24 years). Eighteen patients underwent bony resection and 3 patients required extensive soft tissue resection. Complete resection was achieved in 90% of patients. All patients had chest wall reconstruction. There was no in-hospital mortality. During follow-up, 8 patients died, of which 7 were due to distant metastases. The 1 year and 3-year overall survival were 90% (95% CI 66–97) and 61% (95% CI 31–81) respectively. The disease-free survival at 1 and 3 years was the same at 70% (95% CI 45–86). At a mean follow up of 23 months, the average survival in patients operated for local recurrence is 51.7 months (95% CI 37.7–65.7) and 24.5 months (95% CI 7.3–41.7) for patients with distant metastatic recurrence.ConclusionA multidisciplinary oncoplastic approach for recurrent breast cancer, which includes chest wall resection and reconstruction is a useful adjunct in selected group of patients. This improves local disease control, symptoms and possibly disease-free survival.     

Local recurrence of breast cancer: Treatment of nine patients with a recurrence in the skin flap of the chest wall

From 1975 through 1985, nine patients with a local recurrent lesion (LRL) of breast cancer to the skin flap of the chest wall were treated. Four had undergone primary mastectomies in our clinic and the other five were referred from other surgeons, following signs of recurrence. Aggressive topical therapy, such as resection or irradiation, proved effective in eradicating the LRL in all cases, thereby indicating that topical therapy is useful for improving quality of life. Adjuvant systemic chemo-immunoendocrine therapy is also required for patients with LRL, to increase longevity. Seven of the patients died of a distant metastasis within 66 months after the onset of LRL.     

Single-stage omental flap transposition: modality of an effective treatment for deep sternal wound infection

Deep sternal wound infection (DSWI) is an uncommon life-threatening complication of cardiac surgery performed through median sternotomy. Surgical treatment is considered complicated and challenging. We report our experience with a single-stage omental flap transposition in the treatment of the 14 consecutive patients who were diagnosed with DSWI within 3-16?days after the primary cardiac surgery, between August 2001 and January 2008. The single-stage omental flap transposition was achieved within 70-135?min, at four to eight hours after diagnosis of DSWI. The single-stage omental flap transposition was successfully applied and all 14 patients survived. They displayed a shortened intensive care unit stay (one to nine days) and hospital stay (19-36?days). Follow-up was 100% complete (26-92?months) and demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. However, the very few complications found were slight numbness of anterior chest and minor paradoxical chest movement. We obtained satisfactory outcomes when treating the patients with DSWI by a single-stage omental flap transposition. Based on our solid experience, we recommend this procedure as an option for patients with DSWI, especially those who are not in a state of severe low cardiac output or malnutrition.