Soft tissue sarcomas of the chest wall. Results of surgical resection

Primary soft tissue sarcomas of the chest wall are uncommon, and data concerning treatment and results are sparse. Most studies have categorized these tumors as truncal sarcomas and inferred a poor prognosis. To assess the results of surgical treatment, we reviewed our 40-year experience. Methods: Records of 189 patients admitted to our institution from 1948 to 1988 were reviewed. Pathologic material was available for review in the 149 cases (79%) that comprise this report. Survival was calculated by the Kaplan-Meier method, with comparisons by log-rank analysis and significance defined as p less than 0.05. Results: Ages ranged from 3 weeks to 86 years (median, 38 years); the ratio of male to female patients was 2:1. The initial complaint was mass or pain in 97% of the cases. Ninety sarcomas (60%) were high grade and 59 (40%) were low grade. Histologic types were as follows: desmoid tumor (n = 32, 21%); liposarcoma (n = 23, 15%); rhabdomyosarcoma (n = 18, 12%); fibrosarcoma (n = 17, 11%); embryonal rhabdomyosarcoma (n = 14, 9%); malignant peripheral nerve tumor (n = 13, 9%); malignant fibrous histiocytoma (n = 11, 7%); spindle cell sarcoma (n = 4, 3%); tenosynovial sarcoma (n = 3, 3%); hemangiopericytoma (n = 3, 3%); alveolar soft part sarcoma (n = 3, 3%); and other types (n = 12, 9%). Resection was the primary treatment in 140 cases (94%). Local recurrence developed in 27%. Metastases occurred in 52 (35%) of the cases (metachronous in 42, synchronous in 10) and were more common in patients with high-grade disease (46/90, 51%) than in those with low-grade disease (6/59, 10%). Overall 5-year survival was 66%. Five-year survival rate for those with high-grade sarcomas (49%) was significantly lower than that for low-grade sarcomas (90%, p less than 0.0001). Tumor size and age of patient were not prognostic. Conclusions: Survival of patients with primary soft tissue sarcomas of the chest wall after resection is similar to that of patients with sarcomas of the extremities. Resection alone provides acceptable survival (90% at 5 years) for those with low-grade sarcomas, but adjuvant treatment should be considered for those with high-grade sarcomas.     

Problems in resection of chest wall sarcomas.

To illustrate the problems of reconstruction in major chest wall resection, five patients with a variety of soft tissue tumors of the chest wall, located at different sites, are presented. Patients, who underwent a lateral or posterolateral chest wall resection required removal of two to five ribs sequentially as well as the adjacent soft tissue. Those who underwent an anterior chest wall resection required resection of the manubrium or the body of sternum as well as of adjacent costal cartilages. To prevent instability of the chest, herniation, and to minimize flailing, the chest defect was bridged with the use of Marlex mesh. Whenever possible, the omentum was brought into the chest cavity to increase the vascularity of the reconstruction. Since, in most instances, the tumors involved the skin because of previous damage from radiation therapy, extensive skin coverage was planned well in advance of resection. Pedicle skin flaps or rotation flaps were used to cover the skin defect. Ventilatory support by volume respirator, was required for three to four days. In all patients, the chest wall was completeley stable after three to six weeks.     

Repair of chest wall defects after full thickness surgical resection

The authors discuss the development of their approach to the repair of full-thickness chest wall resection based on a series of twenty-two patients operated between 1967 and 1989. The defect resulting from resection of all tissue planes, either for breast in situ, recurrences, radiation lesions or primary tumours, raises difficult problems. Mammary or cutaneous autoplasties, performed during the early years, have become less frequent, essentially because of the development of musculo-cutaneous flaps (pectoralis major, rectus abdominis, latissimus dorsi) which provide global anatomical and functional repair. The greater omentum island flap, used since 1974, still occupies an important place because of its plastic and trophic qualities in irradiated regions. When chest wall rigidity is compromised, Mersilene patch remains the material of choice. The quality of the results obtained in terms of comfort justifies the use of this major surgery which is now well defined.     

Scoliosis after chest wall resection

Background data

There has been an increased focus on the role of rib abnormalities in the development of scoliosis. Rib resection may influence the development of scoliosis. Although scoliosis has been identified in patients after thoracotomy, most of the currently available information is from case reports.

Methods

We examined records of 37 patients who underwent a chest wall or rib resection for rib lesions at our institution during the period of 1992 to 2005. Adequate data was available in 21 patients. We gathered data on demographic information, location of resection, and changes in curvature after resection based on radiograph or scout CT films at the latest follow-up appointment.

Results

Fourteen of 21 patients developed scoliosis with a mean Cobb angle of 25.8° (10°–70°). Eleven of these 14 patients had a progressive spinal deformity after chest wall resection with an average change in curvature of 29° (10°–70°). Eight of those 11 developed a convex toward the resection, while 3/11 developed a convex away from the resection. Seven of the eight patients with resections that included a rib superior to the sixth rib developed scoliosis, while four of 13 with resections below the sixth rib developed scoliosis.

Conclusion

Patients who have had a rib or chest wall resection are at risk for developing scoliosis, particularly if the resection is performed above the sixth rib.     

Outcomes of surgery for chest wall sarcomas

Chest wall resection requires wide local excision, negative margins, and adequate reconstruction. Outcomes are generally good to excellent with wide local excision and negative margins. Mortality is nearly 0% to 1% with mild morbidity. Multispecialty surgical teams may be required for more complex situations. Early diagnosis of chest wall sarcomas, confirmation by an experienced sarcoma pathologist, and multidisciplinary discussion before treatment initiation, are all required for optimal and successful therapy.     

Adjuvant brachytherapy for treatment of chest wall sarcomas

Thirty patients treated with surgical resection and brachytherapy for chest wall sarcoma at Memorial Sloan-Kettering Cancer Center from 1980 through 1987 were reviewed. Patients selected to receive adjuvant irradiation were those for whom there was doubt as to the completeness of surgical resection. Overall 5-year survival and locoregional control after brachytherapy were 65% and 54%, respectively. Locoregional control was similar for tumors treated at initial diagnosis (12 patients), at the time of recurrence (13 patients), or for tumors that were metastatic to the chest wall (five patients). Six patients with tumors larger than 10 cm in maximum dimension had a locoregional recurrence rate of 69% versus a recurrence rate of 39% for 18 patients with smaller tumors (p = 0.27). Fifty-four percent of high-grade tumors recurred locoregionally versus 28% of low-grade tumors (p = 0.37). Bone invasion or the presence of positive resection margins was not clearly associated with a higher locoregional failure rate. Only one patient (1/28; 7%) was known to have had recurrence within the irradiated area. Eight patients (8/28; 37%) had recurrence adjacent to the implanted area, and the precise failure site could not be determined for the remaining two patients. Because of the relatively high risk of regional versus in-field recurrence, patients with chest wall sarcoma who receive adjuvant treatment should be treated primarily with external-beam irradiation to allow more generous coverage of the tumor bed. Brachytherapy could be used as a tumor bed "boost" treatment. In patients undergoing resection of recurrent tumor in a previously irradiated site, adjuvant brachytherapy, without external-beam irradiation, should be considered to reduce the risk of extensive soft tissue necrosis.     

Chest wall reconstruction after resection of primary malignant chest wall tumours

In order to review the development of chest wall reconstruction, 37 cases of primary malignant skeletal chest wall tumours treated since 1958 were studied. These included chondrosarcomas (20), Ewing's tumours (7) and solitary plasmacytomas (10). Skeletal reconstruction was performed in 24 patients. Before 1972, Marlex mesh alone was used. Since then, a sandwich of two layers of Marlex mesh with a filler of methyl methacrylate was utilised successfully producing better functional and cosmetic results. Primary soft tissue closure was possible in all but 5 cases in whom latissimus dorsi myocutaneous flaps were used. All but one patient had an uneventful postoperative recovery with none requiring postoperative ventilatory support. The overall survival of 46% at 5 years and 27% at 10 years was encouraging. Familiarity with the techniques of chest wall reconstruction enables wide excision of primary chest wall tumours and the palliation and treatment of other malignant, infective and degenerative conditions since even large defects can be reconstructed with little functional disturbance.     

Outcome after surgical resection for high-grade anal intraepithelial neoplasia (Bowen's disease).

BACKGROUND: High-grade anal intraepithelial neoplasia (Bowen's disease) may predispose to anal carcinoma. Treatment options include surgical resection but effectiveness remains uncertain. This paper reports long-term follow-up of patients with high-grade anal intraepithelial neoplasia treated by surgical resection. METHODS: Between 1989 and 1996, 46 patients were identified with high-grade anal intraepithelial neoplasia. Thirty-four underwent local excision of all macroscopically abnormal disease and the resulting defect was left open, closed primarily or skin grafted. Regular follow-up subsequently included anoscopy and biopsy of any suspicious lesions. RESULTS: Median follow-up was 41 (range 12-104) months. Total excision was difficult; 19 patients had histological evidence of incomplete excision at the time of initial resection. Some 12 of 19 had histo-logically proven recurrent high-grade intraepithelial neoplasia within 1 year. Even with microscopically complete excision two of 15 patients subsequently developed recurrent high-grade intraepithelial neoplasia at 6 and 32 months after operation. No patient developed carcinoma but five had complica-tions of anal stenosis or faecal incontinence. CONCLUSION: Although no definite recommendations can be made for the treatment of high-grade anal intraepithelial neoplasia, these results illustrate some potential drawbacks of surgical excision with a high potential for incomplete excision and persistent disease, even after complete excision in some patients, and a high morbidity rate.     

Survival after surgical resection for stage IV non-small cell lung cancer

We analyzed 20 patients with stage IV non-small cell lung cancer operated from 1988 to 2003. Fourteen out of 20 were cases with pulmonary metastasis (pm2). The prognosis of patients with pm2 was better than that of those with distant organ metastasis. In pm2 patients, the survival rate of cases without lymph node metastases was higher than those with lymph node metastases. It is suggested that in cases of pm2 without lymph node metastases, surgical operation is possibly effective treatment of choice.     

Port site recurrence after video-assisted thoracoscopic resection of chest wall schwannoma

Schwannoma is a benign neurogenic tumor, and no cases of metastasis or implantation from this tumor have been reported. We first describe a case of port site recurrence after video-assisted thoracoscopic resection of chest wall schwannoma. She has been well with no evidence of disease for 2 years after resection of the recurrent tumor. We stress the importance of using a specimen bag and careful manipulation during video-assisted thoracic surgery, even for benign tumors.     

Diplopia and pneumoencephalocoele after chest wall resection and intraoperative radiation therapy

The dural sheath may be transected in the course of a posterior thoracic procedure. If air is introduced into the subarachnoid space, a cranial nerve palsy may result. Computed tomographic scanning establishes the diagnosis. The condition resolves without treatment.     

Full thickness chest wall reconstruction after tumor resection by myocutaneous flap

Full thickness chest wall defects result when a chest wall tumor resection is necessary. The feasibility of a reconstruction is sometimes unfamiliar to the oncologist or thoracic surgeon; this can be the reason for refusing the possibility of surgical resection or inappropriate coverage of the defect. Our experiences over the last 7 years in collaboration between plastic the thoracic surgical services, shows that it is generally possible to utilize a myocutaneous flap for reconstruction of even extensive full thickness chest wall defects. The reconstruction of any full thickness chest wall defect after tumor resection by myocutaneous flaps is almost always possible with low mortality, acceptable morbidity and good results, mechanically and aesthetically. The experience with the different reconstruction techniques clearly shows the preference for the latissimus dorsi myocutaneous flap, but also emphazises that the other kinds of reconstruction must be kept in mind for special indications.     

复杂胸部肿瘤切除胸壁重建术患者的康复护理

目的总结复杂胸部肿瘤切除胸壁重建患者的围手术期营养与康复护理经验。方法对10例复杂胸部肿瘤胸壁重建患者,实施饮食指导、康复锻炼、皮瓣观察、疼痛管理等围术期护理。结果 10例患者均顺利康复出院,术后出现胸腔积液3例,皮瓣危象、上肢淋巴水肿、自发性气胸、胸壁软化、心律失常各1例,经及时处理后均好转,伤口I期愈合。术后平均住院时间14.6d。结论胸壁重建是胸壁肿瘤尤其是复杂胸壁缺损的重要手术方法,围术期康复护理能促进患者术后恢复进程,改善预后。