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Interact CardioVasc Thorac Surg 2005;4:250-255. doi:10.1510/icvts.2004.103432 © 2005 European Association of Cardio-Thoracic Surgery
Reconstruction of chest wall defects after resection of large neoplasms: ten-year experience
a Section of Thoracic Surgery, Salamanca University Hospital, 37007 Salamanca, Spain Received 2 December 2004; received in revised form 25 February 2005; accepted 28 February 2005
*Corresponding author. Tel./fax: +34 923 291 383.
We review our experience in the treatment of complex large chest-wall defects needing a multidisciplinary approach due to primary or secondary neoplasms. Non-small cell lung cancer with chest-wall invasion cases are excluded. Fifteen patients underwent whole thickness resection of the chest wall due to lesions affecting at least three ribs, sternum, clavicle or thoracic spine and the surrounding soft tissue. Previously operated breast cancer and sarcoma were the most frequent diagnoses. Partial or total sternectomy plus rib resection was performed in 8 patients. Immediate closure of the defects was performed in all cases: 12 with single prosthesis placement and 3 with a rigid one of methylmethacrylate. Coverage was achieved using myocutaneous flaps in most cases and, in one case, using the greater omentum that supported a free split-thickness skin graft. No 30-days mortality was recorded. Three patients had a post-operative complication. Mean hospital stay was 11.7±9 days. All cases of primary tumours were alive at the time of review (range: 6–126 months). In conclusion, resection and immediate reconstruction of large chest wall defects can be accomplished without operative mortality and low morbidity whenever close cooperation between plastic and thoracic teams exists.
Key Words: Chest wall resection and reconstruction; Myocutaneous flaps; Chest-wall prosthesis; Omentoplasty
Primary or metastatic chest-wall neoplasms tend to infiltrate the external thoracic layers and need large resections to assure free margins. Such surgery poses difficult technical problems due to the necessity of assuring a full coverage of the thoracic defect. Then, before any major resection, careful planning of the reconstruction possibilities by a multidisciplinary team is mandatory [1]. The objective of this paper is to review our experience on resection and reconstruction of large chest-wall defects with a multidisciplinary approach. Cases of non-small cell lung cancer with chest-wall invasion are not considered here.
2.1. Studied population We conducted a retrospective review of patients operated on in our unit from March 1994 to March 2004, with the following inclusion criteria: (1) diagnosis of primary or metastatic chest wall neoplasm different from lung cancer; (2) affecting at least three ribs, sternum, clavicle or thoracic spine; (3) affecting thoracic surrounding soft tissue. Charts were reviewed for age at the time of surgery, sex, previous medical and surgical history, and surgical performed procedures: anatomical defects and reconstruction techniques, total length of stay, postoperative morbidity, in-hospital mortality and survival. All reviewed clinical variables were codified and prospectively recorded in a computerized database. Follow-up data were obtained by phone calls to the patient or physician in charge. 2.2. Preoperative work-up Prior to surgery, patients' charts, including radiological images and patient pictures in cases with skin ulceration or massive external overgrowth were reviewed by a multidisciplinary team including thoracic and plastic surgeons, anaesthesiologists and a respiratory physiotherapist. CT scan was used routinely in the diagnostic work-up and in some cases MRI was also indicated (Fig. 1). Surgical therapy was considered a valid option in cases where all malignant local disease, including free surgical margins, was amenable to resection and reconstruction. In patients with evidence of a former cancer, biopsies for a histological proof were not taken routinely. In the other cases, samples were obtained by fine-needle aspiration or incision biopsy.
Besides technical considerations, a patient was judged operable in the absence of major non-treatable co-morbidity. In all cases pulmonary function tests were measured prior to surgery but no specific lower limits were established for resection. 2.3. Surgery All surgical procedures were performed under general anaesthesia. A thoracic epidural catheter was placed for analgesia. Double-lumen endobronchial tube was inserted if lung involvement was expected. After induction, antibiotic prophylaxis was indicated and repeated every 6 h up to the end of the procedure. Only 3 additional doses of antibiotic were prescribed postoperatively.En-block chest wall resection was achieved by the thoracic surgery team. Extent of resection was considered sufficient when absence of neoplastic involvement was demonstrated at frozen sections of the margins. Reconstruction included prosthesis placement for stabilization in most cases. The thoracic team decided on the prosthesis indication and the type of prosthesis to be used dependent the unit policy. Plastic surgery team was in charge of soft tissue reconstruction manoeuvres. If necessary, patient positioning was changed to allow flap harvest. 2.4. Postoperative course and follow-up All patients were extubated immediately after surgery and transferred to the recovery room for control during the first 6–8 h. If no complication was recognized, the patient returned to the ward where physical activity was initiated the morning after under the supervision of a physiotherapist. At discharge, all cases were reviewed by both thoracic and plastic surgeons up to complete wound healing and then send to their referring physician for oncological therapy or follow-up.
3.1. Patients Fifteen patients (11 females) fulfilled the inclusion criteria. All of them underwent whole thickness resection of the chest wall (Table 1). Patients age ranged from 18 to 75 years (mean 54.8 years).
Most of the patients with relapsing tumours were referred by their oncologist after different regimens of chemotherapy treatment. Most frequent co-morbidities were hypertension (7 cases) and diabetes mellitus (3 cases). Preoperative FEV1 range was 1520–2740 ml (mean: 2062.5 ml; S.D.: 454). Previously operated breast cancer (40%) and sarcoma (47%) were the most frequent diagnoses. Different types of sarcomas were diagnosed, including: primary or relapsing chondrosarcoma (3 cases), malignant fibrous histiocytoma (2 cases), osteosarcoma, neurofibrosarcoma and sinovial sarcoma from the scapular-humeral junction (one case each). One patient had a squamous carcinoma secondary to local radiotherapy for infantile rabdomiosarcoma and the latest case had a sternal metastasis of a follicular thyroid carcinoma. 3.2. Chest wall resection Partial or total sternectomy (plus rib resection in most cases) was performed in 8 patients. In 6, several ribs were removed. The anterior portion of the ribs was most commonly affected but in three cases lateral or posterolateral areas of the chest were resected. Depending on the extent and location of the lesion, vertebral processes or clavicle were also removed. One patient required forequarter amputation (plus four ribs) (Figs. 1, 2) and in other one, only the paravertebral muscles and vertebral processes were involved.
3.3. Reconstruction procedures Immediate closure of the defects was performed in all cases. In three, no prostheses were used for chest-wall stabilization. In case 9 (Table 1), repair was achieved with a pectoralis major muscle flap and in case 15 (Table 1), placing a transverse rectus abdominis myocutaneous flap (TRAM). Reconstruction in case 1 (Table 1) was much more complex because a combined lumbar perforator flap and a latissimus dorsi myocutaneous flaps were needed to cover the resected area. No vertebral stabilization was required. In this case, the patient remained in prone position for 72 h. All the remaining twelve cases needed prosthesis placement. In 9, a single 2 mm wide e-PTFE (7 patients) or polypropylene mesh (2 patients) was adequate. In 3 cases a sandwich of two layers of non-absorbable mesh with a filler of methylmethacrylate was used. In 14 cases, myocutaneous flaps were used to cover the prosthesis. Latissimus dorsi and contralateral pectoralis major muscles (alone or combined) were mobilized in most cases to achieve a perfect coverage of the defects. One patient (case 2, Table 1) required a combined flap of rectus abdominis and pectoralis major for total closure of an extensive right low anterior defect. In case 14 (Table 1), a strong myocutaneous flap was harvest at the time of ablation including trapezius, deltoid and scalene muscles that gave perfect cover to the anterolateral prostesis(Fig 2). Case 13 (Table 1), required greater omentum flap mobilisation to cover a rigid sandwich prosthesis and to support a free split-thickness skin graft (Figs. 3, 4, 5).
3.4. Outcomes Thirty-day mortality was nil. Postoperative course was uneventful in 11 patients. One case required prolonged mechanical ventilation. Three patients had to be reoperated due to flap dehiscence, bleeding and infection of the prosthesis (one case each). Patient 5 (Table 1) suffered infection of the prosthesis which had to be explanted. She had a paradoxical movement of the costal cage for weeks but respiratory function was within the normal limits with a FVC of 86% and a FEV1 of 79%. Patient 15 (Table 1) suffered a wide TRAM flap necrosis and she had to be reoperated to close the chest wall defect by a trapezious myocutaneous flap. Further wound healing was uneventful. Mean hospital stay was 11.7±9 days (median 9 days, range 5 to 43 days). Information about survival was obtained for all the patients. 3 women died because of distant relapse of the breast cancer at 12, 22 and 30 months. All cases of primary tumours (8 cases) were alive at the time of review (range: 6–126 months; median: 61). Patients with metastases had a lesser survival (range: 11–36 months; median: 24 months) but differences were not statistically different due to the number of cases (Fig. 6).
Chest wall resection is a frequent procedure in thoracic surgery units. As stated above, most chest wall resections are performed because of rib involvement in peripheral NSCLC patients but surgery is not usually considered in cases of massive invasion of soft tissue surrounding structures. This is not the case in other types of tumours where en-block resection and reconstruction is judged to be the only effective therapy. Close cooperation among multidisciplinary surgical teams is highly desirable for the extent of tumour resection should not be compromised because of concern on the ability to reconstruct large and complex defects [2]. It has been largely discussed what can be considered a safe resection margin. McCormack et al. [3] suggested that in sarcomatous tumours, resection should include the superior and inferior sound ribs and intercostals muscles besides all the affected tissues. Later on, King et al. [4] recommended a 4 cm free margin for highly aggressive primary tumours and 2 cm for metastases or benign or low-grade malignancies to avoid local recurrences. Following McKormack's recommendations, in 2001 Warzelham et al. [5] found a 64% 3-year and 58% 5-year survival rates in chest wall sarcomas. In our series, the absence of neoplastic involvement demonstrated at frozen sections was considered safe enough and no specific distance was required from the tumour edges. This criterion seems reasonable when dealing with large tumours that need extensive tissue extirpation. Survival rates in our cases could justify this attitude. Stabilization of chest wall with prosthesis is considered to decrease the need of prolonged mechanical ventilation and improve postoperative pulmonary function [6]. The size and site of the lesion influence the selection of the prosthesis. A rigid one seems necessary for sternal and parasternal defects but soft prosthesis are enough in anterolateral defects in order to avoid paradoxical chest movement [4]. Losken et al. [1] reported that mesh closure was required more often for lateral defects when compared to posterior and anterior ones. In our series all but three cases (one posterior and two apical resections) required prosthesis for stabilization. The use of prosthesis has not been reported to increase septic complications or foreign body reactions [7]. Thus, in our opinion, when in doubt due to the size or position of the defect, prosthesis is recommended. Little differences exists between polypropylene mesh and e-PTFE in terms of resistance to infection and rejection [8] so final decision on the type of prosthesis to be used depends on the unit policy. Muscle and musculocutaneous flaps are the tissues of choice to cover the wound, avoid or decrease the risk of infection, obliterate spaces and cover the synthetic mesh [9,10]. In this series, only pedicle flaps were used. They were chosen by proximity, knowing the arc of rotation and calculating the area of possible coverage. In most cases, only a single muscle was transferred. Also the greater omentum can be transposed to any area on the anterior and lateral chest wall, bringing a reliable blood supply and allowing to cover very large areas [9]. As we have shown, massive chest wall resection can be safely performed and most published series, including this one, report no 30-day mortality [2,6,11–13]. In our experience, three cases needed reoperation, one of them due to myocutaneous flap failure. Reported prevalence of flap loss is around 5% [13,14] although, 0% has been reported by Rivas et al. [15]. Total or partial flap necrosis represents a serious problem since reconstruction has to be attempted using alternative myocutaneous flaps. In our case a trapezius flap successfully replaced a wide necrotic TRAM flap with no further complications. Reported 5-year survival after resection of a locally recurrent breast cancer ranges from 34 to 58% [7]. Breast cancer relapse is considered a systemic disease and this determine survival. In our patients, survival was poor due to massive systemic spread of the disease even though no patient experienced locoregional failure. Survival after chest wall resection for primary malignant tumours depends on the histology, the existence of free resection margins and the absence of distant metastases [7]. Reported 5-year survival is around 50%. Our 100% survival rate in this subset of cases is biased by the fact that we have studied a non-representative highly selected group of patients but, the results are encouraging and indicate that even in extend neoplasms large relapse-free periods can be obtained without operative mortality. In conclusion, resection and reconstruction of large chest wall defects can be accomplished without operative mortality, low morbidity and short recovery period whenever close cooperation between plastic and thoracic teams exists.
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Abstract
1. Introduction
