Anterior Chest Wall Resection Research Articles

Radiation-Induced Undifferentiated Pleomorphic Sarcoma after Breast Conserving Therapy: Case Report

Introduction: Breast sarcoma is a rare form of malignancy that arises from connective tissue, comprising less than 5% of all sarcomas. Undifferentiated pleomorphic sarcoma (UPS) of the breast is a rare and aggressive subtype of radiation-induced sarcoma that can occur in treated breast cancer patients. The diagnosis is challenging and often missed due to the low incidence, long latency period, unspecific imaging finding, and difficulties in clinical and histological detection. Case report: A 56-year-old woman was diagnosed with early-stage triple-negative breast cancer in 2013 and underwent breast-conserving therapy (BCT). After five years follow-up, she developed mastalgia and breast induration, and after mammography and ultrasound without suspicious lesions, a magnetic resonance imaging (MRI) was performed and showed a highly suggestive malignancy mass measuring 8.0 cm and invading the chest wall. The core biopsy revealed a spindle cells malignant tumor, negative for pan cytokeratin and most of immuno-histochemical markers, suggesting sarcoma, but requiring investigation of surgical specimen to exclude metaplastic carcinoma. She underwent Halsted radical mastectomy, full-thickness left anterior chest wall resection contemplating segments of the 4th and 5th ribs and reconstruction with synthetic mesh. The surgical specimen evidenced a UPS with clear margins. The patient had good postoperative recovery and remains in follow-up with the mastology team. Conclusion: This report shows that radiation-induced sarcomas of the breast can be difficult to diagnose, and how later treatment can demand a major surgery with higher morbidity. Prognosis may improve if detected early.

Importance of Physiotherapy in Post Pneumonectomy Renal Transplant Recipient: A Case Report

Pulmonary mucormycosis is a rare but opportunistic fungal infection that complicates immunosuppressed solid organ transplant recipients. Although antifungal medication is the remedial dependence in management of pulmonary mucormycosis, early surgical intervention provides advantage over medical treatment alone. However, major impairments and complications such as altered pulmonary and physical function induced by surgery are known to occur. We report the case of a 25-year-old male post renal transplantation on immunosuppression who developed invasive pulmonary mucormycosis in right middle and lower lobe. Liposomal Amphotericin B therapy provided insufficient infection control and lesion invaded the adjacent chest wall, ribs and intercostal muscles. After right pneumonectomy combined with anterior chest wall resection, the initial post-operative physiotherapy assessment was carried out. The patient was found to have productive cough, dyspnoea, chest pain, reduced chest expansion and excursion, limited range of motion of shoulder on affected side and limited activities of daily living. Six weeks of inpatient physiotherapy regime was given which included breathing exercises, thoracic mobility exercises, incentive spirometry, active range of motion exercises, positioning, bed mobility and early ambulation. Follow up assessment showed reduced pain intensity and improvement in oxygen saturation, dyspnoea, Timed up and go test (TUG) time, handgrip strength, activities of daily living and quality of life [Short form 36 (SF-36)]. Keywords: Pneumonectomy, Thoracic Surgery, Renal Transplant, Physiotherapy

Urea Use for SIADH: A Case Report and Review of the Literature

Introduction: Hyponatremia is the most frequent electrolyte abnormality among hospitalized patients associated with increased morbidity and mortality. There is a demanding need for affordable and well-tolerated therapies, and urea is a compelling alternative for the syndrome of inappropriate diuretic hormone (SIADH). Urea increases renal water excretion due to osmotic diuresis and reduce urinary sodium leading to an increase in serum sodium. This case illustrates the effect and safe use of urea in a hospitalized patient with SIADH. Clinical Case: An 80-year-old male with history of recurrent anterior chest wall chondrosarcoma despite 3 chest wall resections presented to the hospital for a 4th anterior chest wall resection with reconstruction. Physical examination was notable for euvolemia with no neurologic deficits. Pre-operative labs were significant for a plasma sodium (PNa) 118 mmol/L, potassium 4 mmol/L, BUN 9 mg/dL, Cr 0.72 mg/dL, TSH 2.9 mIU/L, cortisol 21.3 mcg/dL, serum osmolality 267 mOsm/kg, urine osmolality 423 mOsm/kg, and urine sodium 115 mmol/L. Underlying SIADH was initially treated with water restriction of 800 mL/24 h. Previously, he was given a trial of salt tabs, which he did not tolerate due to nausea and emesis. Due to profound hyponatremia, he was started on 2% hypertonic saline. Once PNa levels reached 130 mmol/L, 2% saline was discontinued. Repeated PNa showed a decrease to 128mmol/L. Tolvaptan was not initiated due to lack of insurance coverage and hepatotoxicity, and demeclocycline was not considered due to his known allergy. He was ultimately started on urea powder at 15 g/day and tittered to 30 g/day. In one week PNa improved to 135 mmol/L and remained stable until discharge. Clinical Lessons: The cornerstone of therapy for SIADH relies on reducing free water intake but this is not always feasible or sufficient. Winzer et al. [1] showed that fluid restriction is effective in only 59% of the patient with SIADH. As a result, pharmacology therapy is often needed. European guidelines, as compared to American guidelines, recommend the use of urea instead of vaptans therapy as second-line treatment. The above is based on different studies [2] that have shown that urea has similar efficacy, is more cost-effective, and safer since it does not cause liver toxicity like vaptans. Given this response, it appears that urea should be considered as a second-line therapy to fluid restriction given its tolerability and cost-effectiveness when compared to its alternatives.

Anterior chest wall resection and sternal body wedge for primary chest wall tumour: reconstruction technique with biological meshes and titanium plates.

Chest wall tumours are heterogeneous neoplasms, either primary or metastatic, with a malignancy rate of 50%. Surgical resection is one of the mainstays of the treatment, however, chest wall resections can be particularly challenging depending onto the resection size, site and patient habitus. The surgical strategy should be carefully analysed preoperatively, keeping in mind the need of an oncological radical resection (R0) in accordance to the reconstruction principles elicited by le Roux and Sherma since 1983, which include restoring the chest wall rigidity, preserving pulmonary mechanics, protect the intrathoracic organs, avoiding paradox movements of the chest cavity and, possibly, to reduce the thoracic deformity. In this context, we herewith report our surgical reconstruction technique following an anterior chest wall resection and sternal body wedge for a primary chest wall tumour (chondrosarcoma).

Anterior Chest Wall Reconstruction Using Polypropylene Mesh: A Retrospective Study.

Anterior chest wall resection for oncological purposes is usually combined with a form of reconstruction. Most surgeons are convinced that ventrally located defects more than 4 to 5 cm require adequate reconstruction to minimize the risk of lung herniation and respiratory distress through paradox motion. We describe our in-house results of ventral chest wall reconstruction using polypropylene mesh without the use of metallic or biological implants regardless of the extent of chest wall resection. Patient selection involved ventral chest wall resection and reconstruction by polypropylene mesh for all indications such as primary tumors, metastasis, or infiltration by lung cancer from January 2008 to December 2016. Primary end point was the difference between both sides. Secondary end points were postoperative complications such as infection, surgical revision, and pulmonary complications. Forty-five cases of isolated anterior reconstruction could be identified. In 34 cases, postoperative computed tomography scan of the thorax was available. Fifteen males and 19 females with a median age of 70.5 years were operated. The evaluation of maximum hemithorax diameter between operated and nonoperated sides was documented in centimeters, and the difference was documented in percentage. The mean percentage difference was 11.1% (minimum: 0.3, maximum: 44.4). In one case, wound infection with positive culture could not be treated conservatively and required operative revision and removal of the polypropylene mesh. Polypropylene mesh, though not rigid, can safely be used for anterior chest wall reconstruction.

Sternal resection and reconstruction for secondary malignancies

Limited data on sternal and/or anterior chest wall resections for secondary malignancies exist. The purpose of this study was to examine the perioperative outcomes and postoperative overall survival (OS) in patients who underwent sternal and/or anterior chest wall resections for secondary sternal tumors (SSTs). A retrospective analysis of all patients who underwent resection of SSTs at single institution between 2000 and 2016 has been performed. OS was estimated using the Kaplan-Meier method. Ten patients underwent sternal and/or anterior chest wall resection for SSTs with curative (70%) or palliative (30%) intent. Two (20%) patients underwent complete and 8 (80%) partial sternal and/or anterior chest wall resection. There were no perioperative deaths, major complications occurred in 3 (30%) patients. Tumor resection was complete (R0) in 5 (50%) patients. The 5-year OS rate was 40%. No OS difference in R0 vs. R1 resections was observed. Sternal and/or anterior chest wall resections for SSTs can be performed with low morbidity and mortality. Complete SST resection does not assure favorable OS. Sternal resections can be considered palliative treatment option in patients with stable stage IV disease with isolated sternal involvement.

Original "double-step" technique for large superior sulcus tumors invading the anterior chest wall without subclavian vessels involvement.

In some patients with complex Superior Sulcus tumors, a combination of surgical accesses may be required. For patients with very large tumors which invade the first ribs anteriorly and without subclavian vessels involvement, we developed a "double-step" technique to facilitate resection and reduce surgical trauma. The technique was performed on five patients with a bulky non-small cell lung cancer (NSCLC), four of whom had a Superior Sulcus tumor. All patients received a radical wide thoracectomy en-bloc with an upper lobectomy. Neither significant flail chest nor postoperative respiratory complications were observed. The method is based on the possibility of interrupting the medial extremity of the first rib beneath the clavicle through a limited, preliminary parasternal incision. The remaining ribs involved in the resection are also interrupted at the costo-chondral junction, leaving the sternum and clavicle intact. Once the medial limit of the involved ribs has been sectioned, multiple stitches are placed through the peristernal tissues and temporarily left inside the chest. Through a second posterior incision, the en-bloc chest wall and lung resection is easily completed. The previously placed peristernal stitches are collected and used for the medial fixation of the prosthesis. Using this technique the resection was radical in all cases. No major postoperative complications were registered. The technique has several advantages: trauma related to double access is negligible; radical resection is facilitated, anterior chest wall resection is accomplished without sternal or clavicular injury, en-bloc chest wall and lung resection is made straightforward despite the extended area of resected ribs attached to the tumor, released within the chest cavity; chest wall stabilization is simple and reliable. The only disadvantage is that the patient's surgical position needs to be changed.

Posterior thoracic approach for Pancoast tumour resection

Pancoast tumour is an uncommon presentation of lung cancer. Its specific location and surrounding structures invasion characterizes the Pancoast’s syndrome clinical presentation—shoulder pain, radicular arm affection and Horner’s syndrome. At the same time thoracic outlet location makes it difficult to detect by simple chest X-ray and delays the diagnosis. Pancoast tumour is considered a locally advanced lung cancer. In consequence aggressive staging and accurate surgical planning are mandatory. Induction therapy, although no entirely accepted is used to increase resectability in our centre’s protocol. Anterior and posterior approaches have been described to resect superior sulcus tumours. Selection is normally based on tumour location and peripheral structures involvement as well as surgeon’s personal experience and preferences. In the following text we describe the posterior approach technique for tumour resection and the tricks and tips we learned in our experience to minimize surgical risks. We prefer the posterior approach in those tumours with no major vessel involvement evidence. Anterior chest wall resection and posterior costo-vertebral junction disarticulation are carried out before the lobectomy to achieve a complete en bloc resection. Special care must be taken during the dissection and division of the first rib because of thoracic outlet structures proximity. After resection, we prefer not to reconstruct the wall systematically. It is reserved for selected patients who had a large chest wall resection and have higher risk of complications.

One-stage thyroidectomy with complete sternal removal and anterior chest wall resection for metastatic thyroid cancer

One-stage thyroidectomy with complete sternal removal and anterior chest wall resection for metastatic thyroid cancer

A rigid and bioabsorbable material for anterior chest wall reconstruction in a canine model.

The optimal material for anterior chest wall reconstruction following chest wall resection remains controversial. The aim of this experimental study was to evaluate short-term, morphological and histological outcomes of anterior chest wall reconstruction with a rigid and bioabsorbable material in a canine model. Twenty adult beagle dogs underwent anterior chest wall resection. In the experimental group (n = 10), the anterior chest wall was reconstructed with a rigid and bioabsorbable material composed of poly-L-lactide acid matrix (60 wt%) and uncalcined and unsintered hydroxyapatite particles (40 wt%), whereas in the control group it was (n = 10) reconstructed with dual polypropylene mesh sheets. Short-term complication rates were compared with a χ(2) test. Postoperative sternal deviations were evaluated with sternal alignment angles using computed tomography and multiplanar reconstruction and were compared with Mann-Whitney U-test immediately after reconstruction, and at 1, 3, 6, 9 and 12 months postoperatively. Histological findings of the regenerated chest wall tissue were obtained after staining with haematoxylin and eosin and Elastica van Gieson (EVG) and compared at 3, 6, 9 and 12 months. There was not a significant difference in the short-term postoperative complication rate (P = 0.53) and the complication rate was 20% (wound infection, n = 1 and lethal mediastinitis, n = 1) in the control group and 10% (wound infection, n = 1) in the experimental group. The postoperative sternal deviation was significantly less remarkable at 1 month (123.3 ± 32.2° vs 159.4 ± 19.7°, P = 0.027), 3 months (109.8 ± 34.7° vs 150.9 ± 34.2°, P = 0.039) and 12 months (61 ± 15.6° vs 170.3 ± 6.6°, P = 0.046) in the experimental group than in the control group, whereas no significant difference was noted immediately after reconstruction (165.7 ± 6.4° vs 168.4 ± 9.1°, P = 0.50). Histological findings showed dense connective tissue in the regenerated chest wall in both groups and showed chondroblasts in the regenerated chest wall tissue at 3 and 6 months only in the experimental group. Our results suggest that anterior chest wall reconstruction with a rigid and bioabsorbable material is feasible and may be a valuable alternative to reconstruction with a non-rigid and non-absorbable material.

Sternal allograft transplantation for anterior chest wall reconstruction

Background Reconstruction of the chest wall after an anterior chest wall resection remains a difficult and controversial issue, therefore a correct reconstruction of these large resections is fundamental to avoid secondary complications. Different materials have been used to reconstruct the sternum, but none of them are considered the gold standard procedure. We propose a new technique using sternal-allograft to reconstruct the anterior chest wall after sternal resection.

Vascularized rib support for chest wall reconstruction using Gore-Tex(R) dual mesh after wide sternochondral resection

Only a few reports describe chest wall reconstruction after sternal resection using Gore-Tex dual mesh, and very few reports describe the use of a vascularized rib to support the thoracic cage. We present a case of a breast cancer patient who underwent anterior chest wall resection for recurrent sternal cancer. Her sternoclavicular joints bilaterally and lower sternum were divided using an electric saw. The bony chest wall was reconstructed using Gore-Tex dual mesh, and a vascularized rib was used to bridge the space between the clavicular heads to support the thoracic cage. The patient's postoperative course was uneventful, without complications, such as paradoxical respiration or pneumonia.

Percutaneous subclavian artery stent-graft placement following failed ultrasound guided subclavian venous access

BackgroundUltrasound guidance for central and peripheral venous access has been proven to improve success rates and reduce complications of venous cannulation. Appropriately trained and experienced operators add significantly to diminished patient morbidity related to venous access procedures. We discuss a patient who required an arterial stent-graft to prevent arterial hemorrhage following inadvertent cannulation of the proximal, ventral, right subclavian artery related to unsuccessful ultrasound guided access of the subclavian vein.Case presentationDuring pre-operative preparation for aortic valve replacement and aorto-coronary bypass surgery an anesthetist attempted ultrasound guided venous access. The ultrasound guided attempt to access the right jugular vein failed and the ultrasound guided attempt at accessing the subclavian vein resulted in inappropriate placement of an 8.5 F sheath in the arterial system. Following angiographic imaging and specialist consultations, an arterial stent-graft was deployed in the right subclavian artery rather than perform an extensive anterior chest wall resection and dissection to extract the arterial sheath. The patient tolerated the procedure, without complication, despite occlusion of the right internal mammary artery and the right vertebral artery. There were no neurologic sequelae. There was no evidence of hemorrhage after subclavian artery sheath extraction and stent-graft implantation.ConclusionThe attempted ultrasound guided puncture of the subclavian vein resulted in placement of an 8.5 F subclavian artery catheter. Entry of the catheter into the proximal subclavian artery beneath the medial clavicle, the medial first rib and the manubrium suggests that the operator, most likely, did not directly visualize the puncture needle enter the vessel with the ultrasound. The bones of the anterior chest impede the ultrasound beam and the vessels in this area would not be visible to ultrasound imaging. Appropriate training and supervised experience in ultrasound guided venous access coupled with quality ultrasound equipment would most likely have significantly diminished the likelihood of this complication. The potential for significant patient morbidity, and possible mortality, was prevented by implantation of an arterial stent-graft.

Use of human dura in pediatric chest wall reconstruction after tumor resection

The most difficult aspect of the surgical treatment of chest wall tumors is reconstruction of the large residual defect. Materials that have been used include Marlex, Goretex, Vicryl, bone, metal, and fascia. The authors' successful experience with dehydrated human dura (Tutoplast) for moderate-size defects is described. A large Askin's tumor in a 13-year-old boy required resection of the right posterior aspect of the 9th to 11th ribs and the transverse process of T-10. The 12− × 12-cm thoracic defect was closed with dura. Partial soft-tissue coverage was obtained with the latissimus dorsi muscle. Although a scoliosis secondary to paraspinal muscle resection has developed, the chest wall is stable, without evidence of a flail chest, at 18 months of follow-up. A 6-year-old girl underwent left anterior chest wall resection of three ribs for an epithelioid sarcoma. Human dura and a myocutaneous flap were used for reconstruction, with good functional and cosmetic results at 16 months of follow-up. Dura is simple to use, has low antigenicity, and in experimental studies appears to be incorporated into the tissues, acting as a collagen matrix. For moderate-size chest wall defects, it appears to be an excellent alternative to synthetic prosthesis.

Radical forequarter amputation with hemithoracectomy and free extended forearm flap: Technical and physiologic considerations

A radical forequarter amputation with partial chest wall resection (one to four ribs) has been reported for benign and malignant lesions involving the shoulder and chest wall region. Concerns about reconstruction and postoperative pulmonary function have previously limited more extensive chest wall resections. The current report describes the first case in which a complete unilateral anterior and posterior chest wall resection and pneumonectomy (hemithoracectomy) accompany a forequarter amputation. A novel reconstructive technique used the full circumference of the forearm tissue with an intact ulna as a free osseomyocutaneous flap. In this case, a 21-year-old patient presented with an extensive recurrent desmoid tumor that involved the shoulder, brachial plexus, subclavian vein, and chest wall from the lateral sternal border to the midportion of the scapula and down to the eighth rib. The operative technique involved removal of the entire right hemithorax from the midline sternum to the transverse process posteriorly, down to the ninth rib inferiorly. Due to the absence of a rigid hemithorax, the uninvolved ipsilateral lung was also removed. The forearm flap was prepared before final separation of the specimen and division of the subclavian vessels. Postoperatively, the patient maintained excellent oxygenation without atelectasis or fever and was extubated on the 15th postoperative day. As expected after pneumonectomy, significant decreases from preoperative to immediate postoperative values were noted for the vital capacity (VC) (from 4.87 L to 1.29 L), forced 1-s expiratory volume (FEV1) (from 3.77 L to 1.02 L), and inspiratory capacity (IC) (3.33 l to 0.99 l). Rehabilitation included a specially designed external prosthesis to provide cosmesis and prevent scoliosis. By the 15th postoperative week the patient had returned to normal social and physical activities, with a gradual improvement in all respiratory parameters: VC 1.52 L, FEV1 1.29 L, IC 1.04 L. There has been no evidence of tumor recurrence at 1 year. This report provides evidence that a complete hemithoracectomy, pneumonectomy, and forequarter amputation can be safely performed for selective tumors involving the shoulder region with extensive chest wall invasion. Reconstruction may be achieved with an extended forearm osseomyocutaneous free flap with an excellent functional outcome.

The Value of Adjuvant Radiotherapy in Pulmonary and Chest Wall Resection for Bronchogenic Carcinoma

Thirty-five patients, 29 men and 6 women, underwent pulmonary and chest wall resection for treatment of bronchogenic cancer which had extended into the chest wall. Anterior chest wall resection was performed in 6 patients, lateral resection in 2, and posterior resection in 27. Marlex mesh was employed as a prosthetic material in 13 patients. Radiotherapy was given as part of the planned therapeutic regimen in 13 patients. Three patients (8.5%) died in the postoperative period. There were 21 late deaths. Eleven patients are alive 7 months to 12 years after resection. The overall actuarial survival, including operative mortality, is 38% at 5 years. Actuarial survival of the 13 irradiated patients is 56% at 2 and 5 years. We believe that bronchogenic carcinoma with chest wall involvement is not hopeless, and that resection of the lung and chest wall can be performed with an acceptable mortality rate.