Keywords
malignant tumor - chest wall tumor - chest wall reconstruction
Introduction
Primary chest wall malignant tumor is rare and represents about 5% of all thoracic
neoplasms.[1]
[2]
[3]
[4] It is from various origins, including bones and cartilage, skin, muscles, blood
vessels, nerves, and even some hematologic disorder.[4] The chest wall that allows to breathe and pump blood to be delivered to whole body
is a complex and protective structure of the vital organ, which is possible due to
the integrity of all the chest wall layers.[5] Chest wall reconstruction needs skeletal and soft tissue reconstruction. Skeletal
support to prevent a flail chest and subsequent respiratory failure is important for
the successful management of chest wall malignant tumor.[6] If the reconstruction of the chest wall failed, it could result in serious life-threating
condition. Reconstructive surgeon should take various factors into consideration that
can affect chest wall reconstruction, especially in multiple ribs resection case or
sternotomy case to restore chest wall integrity. The treatment methods of malignant
chest wall tumor are reported previously, however, there are no clear conclusions
yet about the complication rate based on the number of resected ribs; the methods
for skeletal fixation depend on location and defect size. Even though there are not
many cases of malignant chest wall tumor due to its prevalence, we retrospectively
reviewed and analyzed our experience with malignant chest wall tumor resection followed
by chest wall reconstruction.
Materials and Methods
This study is a retrospective review. From April 2013 to February 2022, medical records
of patients with chest wall defect due to chest wall tumor were collected. In the
cases, patients who needed the chest wall reconstruction as malignant tumor arising
from structures that support the thorax, including bone, cartilage, and associated
soft tissue, were included in this study. Patients who had the chest wall reconstruction
as malignant tumor arising from structures that support the thorax, including bone,
cartilage, and associated soft tissue, were included in this study. Medical records,
such as gender, age, pathology of chest wall carcinoma, surgical record, such as size
of the tumor excision and defect, method of reconstruction, and surgical outcomes
were collected. The materials used, method of skeletal fixation, and location of skeletal
reconstruction were noted in cases of skeletal reconstruction.
Results
The total number of cases that met the required criteria is 13 ([Tables 1] and [2]). There were seven males and six females. Mean age was 57.0 years (range, 16–77
years). The causes of the chest wall defect were nine primary chest tumors, three
breast cancer, and one metastatic carcinoma from laryngeal cancer. In pathological
details of the tumors, there were four fibrosarcoma, three squamous cell carcinoma,
three invasive carcinoma of breast, two chondrosarcoma, and one pleomorphic sarcoma
([Table 1]). The most common symptoms were palpable mass (54%) and bleeding (23%). The size
of soft tissue chest wall defect was from 54 to 230 cm2 (mean: 151.8 cm2). Six cases had necessary skeletal reconstruction due to multiple rib defects and
sternal defects. Chest wall tumor resection and reconstruction were performed in all
patients simultaneously. Five patients had postoperative radiotherapy.
Table 1
Patients demography, medical history, surgical complications
|
Number
|
|
Age
|
16–77 y (57 y)
|
|
Sex
|
|
|
Male
|
7 (54%)
|
|
Female
|
6 (46%)
|
|
DM
|
3 (23%)
|
|
Hypertension
|
1 (8%)
|
|
Coronary artery occlusive disease
|
1 (8%)
|
|
Tuberculosis
|
1 (8%)
|
|
Symptoms
|
|
|
Mass
|
7 (54%)
|
|
Bleeding
|
3 (23%)
|
|
Pain
|
3 (23%)
|
|
Pathological diagnosis
|
Number
|
|
Sarcoma
|
|
|
Fibrosarcoma
|
4 (23%)
|
|
Chondrosarcoma
|
2 (8%)
|
|
Pleomorphic sarcoma
|
1 (8%)
|
|
Squamous cell carcinoma
|
3 (23%)
|
|
Invasive breast carcinoma
|
3 (23%)
|
Table 2
Factors influencing for reconstruction
|
Factors.
|
Number (%)
|
|
Indication
|
|
|
Primary chest wall tumor
|
9 (69%)
|
|
Breast cancer
|
3 (23%)
|
|
Laryngeal cancer
|
1 (8%)
|
|
Defect size
|
|
|
100 cm2<
|
4 (31%)
|
|
100 cm2≥
|
9 (69%)
|
|
Defect type
|
|
|
Only a Soft tissue defect
|
7 (54%)
|
|
Skeletal and soft tissue defect
|
6 (46%)
|
|
Reconstruction methods
|
|
|
Latissimus dorsi (LD) musculocutaneous rotation flap
|
8 (62%)
|
|
Vertical rectus abdominis myocutaneous (VRAM) free flap
|
2 (15%)
|
|
Pectoralis major muscle advancement flap
|
2 (15%)
|
|
Latissimus dorsi (LD) free flap
|
1 (8%)
|
|
Rib resection
|
|
|
Yes
|
6 (46%)
|
|
No
|
7 (54%)
|
|
Multiple ribs (>3)
|
6 (46%)
|
|
Sternal resection
|
|
|
Partial sternotomy
|
1 (8%)
|
|
Total sternotomy
|
1 (8%)
|
The process of skeletal reconstruction method as an algorithm was presented based
on our experiences. For soft tissue defect, considering rotation arc and defect size,
local flap was first choice if possible. If rotation arc was not available or defect
size was too large to perform local flap, free flap was selected with appropriate
donor. For stabilization of skeletal structure, metal plates and screws and artificial
material were used for skeletal reconstruction ([Figs. 1], [2]) ([Table 3]). The location of defect is as follows: five middle lateral defect, four median
defect, two posterolateral defect, one upper lateral defect, and one inferolateral
defect. Appropriate flap selection according to the defect size and location was conducted
([Table 4]). In soft tissue reconstruction, there were eight latissimus dorsi musculocutaneous
(LDMC) rotation flap ([Fig. 1]), two pectoralis major musculocutaneous (PMMC) flap, two vertical rectus abdominis
musculocutaneous (VRAM) free flap ([Fig. 2]), and one LDMC free flap. All flaps survived. Two patients had partial necrosis
of the flap treated with debridement and secondary wound healing. There were six postoperative
pulmonary complications: four temporary atelectasis, one pneumonia, and one acute
respiratory distress syndrome treated with conservative pulmonary care and antibiotics.
Three patients had postoperative chemotherapy and five patients had postoperative
radiotherapy. Two patients complained temporary limitation of shoulder mobilization
after radiotherapy. The mean follow-up period was 11.52 months (range, 6–30 months).
Fig. 1 Case 1. (A) Anterolateral chest wall defect including second to fifth rib resection. Exposed
lung and pericardium. (B) Skeletal reconstruction with bone cement, titanium plate, and Marlex mesh. (C) Soft tissue reconstruction with pedicled latissimus myocutaneous flap. (D) Final result after partial necrosis due to surgical site infection.
Fig. 2 Case 2. (A) Midline chest wall defect including third to sixth rib resection and total sternum.
Exposed lung and pericardium. (B) Skeletal reconstruction with titanium plate, screw, and Prolene mesh. (C) Soft tissue reconstruction with free vertical rectus abdominis myocutaneous flap.
(D) Final result.
Table 3
Our reconstruction methods for skeletal reconstruction
|
Patient
|
Defect location
|
Defect size
|
Skeletal defect
|
Reconstruction method
|
Material
|
|
Patient 1
|
Median
|
15 × 15 cm2
|
Six ribs removed
Sternum resected
|
VRAM free flap
|
Goretex
Titanium plate with screw
|
|
Patient 2
|
Infero-lateral
|
11 × 20 cm2
|
Four ribs removed
|
LD free flap
|
Goretex
|
|
Patient 3
|
Mid-lateral
|
15 × 7 cm2
|
Four ribs removed
|
LD rotation flap
|
Marlex mesh and bone cement
Titanium plate with screw and wire
|
|
Patient 4
|
Midian/inferior-Medial
|
12 × 8 cm2
|
Eight ribs removed
Sternum resected
|
VRAM free flap
|
Prolene mesh
Titanium plate with screw and wire
|
|
Patient 5
|
Mid-lateral
|
10 × 8 cm2
|
Three ribs removed
|
LD rotation flap
|
Prolene mesh
|
|
Patient 6
|
Infero-lateral
|
15 × 15 cm2
|
Four ribs resected
|
LD rotation flap
|
Prolene mesh and bone cement
Titanium plate with screw and wire
|
Abbreviations: LD, latissimus dorsi; VRAM, vertical rectus abdominis musculocutaneous.
Table 4
Flap selection according to the defect size and location
|
Defect location
|
Average defect size
|
Reconstruction method
|
Number of cases
|
|
Mid-lateral
|
136 cm2
|
First choice: LD rotation flap
Second choice: LD free flap
|
Five cases
|
|
Median
|
159 cm2
|
First choice: VRAM free flap
Second choice: Pectoralis major muscle advancement flap
|
Four cases
|
|
Postero-lateral
|
119 cm2
|
First choice: LD rotation flap
Second choice: Serratus anterior perforator flap
|
Two cases
|
|
Infero-lateral
|
225 cm2
|
First choice: LD rotation flap
Second choice: LD free flap
|
One case
|
|
Upper lateral
|
54 cm2
|
First choice: LD rotation flap
Second choice: LD free flap
|
On case
|
Abbreviations: LD, latissimus dorsi; VRAM, vertical rectus abdominis musculocutaneous.
Discussion
Chest wall tumors are not common and are presented with different symptoms. Patients
usually get symptomatic with palpable mass or pain and both symptoms at the site of
tumor.[2]
[7]
[8] Defects of the chest wall occur due to tumor ablation, radiation injury, infection,
and trauma.[9] Chest wall may be reconstructed with musculocutaneous flaps, such as latissimus
dorsi (LD) musculocutaneous flap or free flaps combined with the synthetic or autologous
materials used to prevent pneumothorax and paradoxical chest wall motion.
According to previous studies, importance of rigid stability for the prevention of
uncoordinated chest wall motion is unclear. In addition, there is no direct association
between the number of resected ribs and the need for skeleton reconstruction. After
chest wall resection, however, skeletal reconstruction is necessary to protect intrathoracic
contents as well as to preserve respiratory capacity in our experiences.
Previous history of radiotherapy is a factor that makes surgery difficult because
of radiation-induced tissue toxicity. Some of the studies revealed that radiation
reduces osteogenic cell numbers, alters cytokine capacity, and delays or damages bone
remodeling. It can affect the chest wall stability and immunity.[10] Therefore, in those cases, we favored skeletal reconstruction with metal plate with
musculocutaneous flap when the patient had a radiation history. The lack of sternal
or spinal stability in antero/anterolateral aspect makes the patient more prone to
flail chest deformities following chest wall resection.[11]
[12] The method of skeletal reconstruction of the chest wall depends on the location,
number of the ribs loss, and the size of the defect. Deschamps et al said, skeletal
reconstruction is not necessary in cases, such as the skeletal defect with less than
5 cm diameter sized, the very apex of the chest, under the scapula and very close
to the vertebrae.[9] The thickness of the muscle at anterior and lateral chest wall is thinner than that
of the muscle at posterior chest wall and fragile, so whenever defect of the anterior
and lateral chest wall is greater than 5 cm, skeletal reconstruction with autologous
or artificial materials is mandatory and most of them simultaneously need soft tissue
flap reconstruction.[13] When four or more ribs are resected, skeletal reconstruction is necessary in chest
wall reconstruction.[12]
[14] In five patients, more than four ribs were removed during surgery and they had skeletal
operation in our study. There were no significantly different outcomes compared with
other patients in our study. As per research by Scarnecchia et al, multiple resected
ribs (≥4) influenced the incidence of deformities. Furthermore, a significant statistical
correlation was found between the site of demolition and the incidence of chest wall
deformities and flail chest. Patients who underwent chest wall reconstruction in anterior
or lateral chest area get significant aggravation of chest wall stability so that
they are vulnerable to get acute respiratory complications, flail chest, and deformities
of the chest wall.[12] Early trials at chest wall resection were severely restricted by the availability
of appropriate materials for reconstruction. Primary materials consisted of autogenous
tissue such as fascia lata grafts, rib grafts, or large cutaneous grafts.[3]
[15] Since the 1980s, the prosthetic materials including poly-tetrafluoroethylene, polypropylene
mesh, and polypropylene mesh–methyl methacrylate have been used in conjunction with
musculocutaneous flaps to successfully reconstruct even the largest chest wall defects.[9] These materials can provide structural stability and support the mechanical forces
applied during respiration. When patients underwent two to three ribs resection without
sternal resection, surgeons could reconstruct the soft tissue defect without skeletal
reconstruction. When multiple ribs (≥4) or sternal resection is performed, metal plates
and screw fixation is considered in mostly cases for structural stability. The useful
materials for chest wall reconstruction have utilized a variety of synthetic patches,
meshes, or acellular dermal matrix (ADM).[16] We thought adequate mesh usage helps to provide good skeletal support and pliability.
Prolene, Marlex, and PTPE mesh were often used. Alloplastic materials can be used
to get advantage due to lack of donor-site morbidity, wide availability, and sizing
options for coverage of large defects. Plastic surgeon can use synthetic grafts such
as expanded polytetrafluoroethylene and ADM to reconstruct chest wall. Some researchers
favor ADM for reconstruction, when there are concerns related to field contamination,
active infection, or delayed wound healing.[16] The choice of suitable materials for skeletal reconstruction of chest wall is still
controversial. Even though rigid materials compared to non-rigid materials are more
vulnerable to infection and can disrupt physiological respiratory movement, there
are some advantages such as providing stability and being inexpensive. Because of
prioritizing early stability over late stability, we performed chest wall reconstruction
using rigid material, especially in multiple ribs resection case or sternotomy case[17] Recently, preoperative computed tomography with reconstructed three-dimensional
(3D) images may be used as reference for manufacturers to customize more unusual implant
configurations.[18]
[19]
The partial thickness loss of the soft tissue defect of the chest wall can be repaired
with skin grafts or local flap. Sometimes, unilateral, or bilateral PMMC pectoralis
and serratus muscle can be used for soft tissue coverage. The availability of reconstructive
options with well-vascularized tissue allows wide and appropriate resection and helps
to ensure successful long-term outcomes.[14] The greater omentum is often available as the reconstructive method provides well-vascularized
tissue to areas of extensive radiation damage or infection.[20] It was described by Jurkiewicz in 1977, for the coverage of anterior chest wall.
In our cases, LDMC flap is preferred to reconstruct defect on lateral aspect of chest
wall. The unilateral or bilateral PMMC flap is preferred for the defect of anterior
aspect of chest wall around midline. Free flap was considered when regional flaps
were unavailable, for large-sized defect, or previously failed reconstruction. We
used the LD free flap and VRAM free flap.
Complications after chest wall resection are relatively common. Deschamps et al said
that overall postoperative complication rate was 46% and the most common complication
was respiratory complication (42.8%).[9] In our study, the proportion of respiratory complication was high (46%) even though
most of these were temporary atelectasis. Number of complications reported in previous
studies was compared with our study[9]
[13]
[21] ([Table 5]). Destruction of chest integrity and pain may lead to prolonged respiratory support
and pulmonary complications in the postoperative period. Despite the increased rate
of postoperative pneumonia, the period of intensive care unit and admission was not
increased in our patients.
Table 5
Comparison of complication with other authors
|
Author
|
No.
|
Surgical site infection
|
Flap loss
|
Myocardial infarction
|
Respiratory
|
Arrhythmia
|
Seroma/Hematoma
|
Other
|
|
Kachroo et al.
|
51
|
2
|
1
|
0
|
1
|
1
|
0
|
5
|
|
Deschamps et al.
|
197
|
9
|
0
|
3
|
48
|
5
|
14
|
12
|
|
Mansour et al.
|
200
|
9
|
10
|
0
|
38
|
5
|
3
|
4
|
|
Our research
|
14
|
1
|
2
|
0
|
6
|
1
|
0
|
0
|
Abbreviation: ARDS, acute respiratory distress syndrome.
In conclusion, with our experience, we recommend our reconstruction algorithm for
chest wall with the defect due to malignant tumor resection ([Fig. 3]). The limitation of this study is that we had relatively few cases and it was difficult
to determine the effect of reconstructive surgery on pulmonary function because pulmonary
function test was not performed before surgery. Further research is necessary by comparing
preoperative respiratory function with the postoperative respiratory function.
Fig. 3 Our reconstruction algorithm for chest wall defect due to malignant tumor resection
