Major Chest Wall Resection Research Articles

Chest wall reconstruction, prosthesis and allografts: a narrative review.

What is the best material in the case of prosthesis used to replace major chest wall resection is still unknown. We reviewed most significant literature focused on the type of prosthetic materials available by highlighting their relative pros and cons. We reviewed most significant articles, including clinical results of relevant case series (retrospective studies), published in English in the last 23 years: PubMed, Embase and Scopus databases were used in our search in the period between the 1st January 1999 and 31st December 2022. Overall, our literature review revealed lack of uniformity or conformity in the surgical strategies described for chest wall reconstruction with no internationally accepted standard in terms of decisions and optimal prosthetic materials and type of prostheses (soft, rigid, biological). Despite the increased interest in chest wall reconstruction, we observed a general lack of substantial prospective and multicentric studies. Likewise, there are not substantial data which may guide to the choice of optimal prosthetics in terms of characteristics and biocompatibility. A variety of materials are available for reconstruction, including synthetic and biological meshes, flexible and rigid patches, and metal osteosynthesis systems. The material chosen should be optimized to each patient and damaged tissues to be restored. Prospective and multicentric studies are necessary to address current limits in this surgical field.

Massive chest wall resection and reconstruction for malignant disease.

ObjectiveMalignant chest wall tumors are rare neoplasms. Resection with wide-free margins is an important prognostic factor, and massive chest wall resection and reconstruction are often necessary. A recent case series of 20 consecutive patients is reported in order to find any possible correlation between tumor histology, extent of resection, type of reconstruction, and adjuvant treatment with short- and long-term outcomes.MethodsTwenty patients were submitted to chest wall resection and reconstruction for malignant chest wall neoplasms between 2006 and 2014. The mean age (ten males) was 59±4 years. The size and histology of the tumor, the technique of reconstruction, and the short- and long-term follow-up records were noted.ResultsThe median maximum diameter of tumors was 10 cm (5.4–32 cm). Subtotal sternal resection was performed in nine cases, and the resection of multiple ribs was performed in eleven cases. The median area of chest wall defect was 108 cm2 (60–340 cm2). Histology revealed soft tissue, bone, and cartilage sarcomas in 16 cases (80%), most of them chondrosarcomas. The rest of the tumors was metastatic tumors in two cases and localized malignant pleural mesothelioma and non-Hodgkin lymphoma in one case. The chest wall defect was reconstructed by using the “sandwich technique” (propylene mesh/methyl methacrylate/propylene mesh) in nine cases of large anterior defects or by using a 2 mm polytetrafluoroethylene (e-PTFE) mesh in nine cases of lateral or posterior defects. Support from a plastic surgeon was necessary to cover the full-thickness chest wall defects in seven cases. Adjuvant oncologic treatment was administered in 13 patients. Local recurrences were observed in five cases where surgical reintervention was finally necessary in two cases. Recurrences were associated with larger tumors, histology of malignant fibrous histiocytoma, and initial incomplete resection or misdiagnosis made by nonthoracic surgeons. Three patients died during the study period because of recurrent disease or complications of treatment for recurrent disease.ConclusionChest wall tumors are in their majority mesenchymal neoplasms, which often require major chest wall resection for their eradication. Long-term survival is expected in low-grade tumors where a radical resection is achieved, while big tumors and histology of malignant fibrous histiocytoma are connected with the increase rate of recurrence.

Recent and Future Developments in Chest Wall Reconstruction

Reconstruction following major chest wall resection can be challenging. Conventional methods of using mesh with or without incorporation of methyl methacrylate are slowly being replaced by chest wall reconstruction prosthetic systems that use titanium plates or bars. The most popular systems in use are the titanium STRATOS bars and MatrixRIB plates, which have different systems for securing to the chest wall. In general, these new approaches are user friendly, are more ergonomic, and may avoid certain complications associated with the more conventional methods of reconstruction. However, the successful implantation of these titanium prosthetic systems requires the operator to be familiar with the limitations and potential pitfalls of the process. Follow-up data are only just emerging on the risk factors for implant failure of these prosthetic systems, as well as certain device-specific complications, with fracture failure being increasingly recognized as a significant problem. In the future, emerging intraoperative real-time imaging and 3-dimensional printing technology, as well as development in biomaterials, will allow chest wall reconstruction to become increasingly personalized.

121 Physiotherapy rehabilitation of patients following major chest wall resection: the Birmingham Heartlands experience

121 Physiotherapy rehabilitation of patients following major chest wall resection: the Birmingham Heartlands experience

Pariétectomie élargie dans le traitement du cancer du sein invasif : à propos d’une série de 33 cas

Breast cancer can spread to the chest wall. It is an aggressive stage of poor prognosis. We have developed a technique of major chest wall resection extended beyond the breast area in order to reduce the recurrence.This is a retrospective single-center series of 33 patients with breast cancer spread to the chest wall without metastasis (13 patients present with primary breast cancer and 20 patients present with recurrent breast cancer) treated by major chest wall resection between January 1993 and January 2013, by the same surgeon. Analysis of the results was made by another surgeon.Patients aged between 27-83years with an average of 55years. The removed parts measured 350cm(2) to 1200cm(2), and the average duration of complete healing was 7.9months. The mean follow-up time was 122months (6months-240months). The 1 year survival was 84.4%, at 2years 72.6%, at 3years 69.5% and at 5 years of 66.4%.The technique of major chest wall resection is simple and reproducible. Breast cancer with chest wall extension has a poor prognosis. At the end of the study, 20 of 33 patients who benefit from this technique are still alive.

Reconstruction after major chest wall resection: Can rigid fixation be avoided?

Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects. All patients who underwent resection of chest wall tumors between 2003-2010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group (<60 cm(2)) and the Large Defect (LD) group (>60 cm(2)). Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57%). The mean size of the chest wall defect was 50.8 cm(2) in the SD group and 149.4 cm(2) in the LD group (P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11% of patients in the SD group and 61% of patients in the LD group (P = .018). The rate of immediate postoperative extubation was 100% in the SD group and 89% in the LD group (P = .42). The rate of postoperative pneumonia was 7% in the LD group vs 0% in the SD group. The rate of surgical site infection was 7% in the LD group and 0% in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used. Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60 cm(2), reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.

Thoracic Wall Reconstruction for Primary Malignancies in Children: Short- and Long-term Results

Primary thoracic wall malignancy is a rare and diverse entity in children. Surgical treatment commonly involves major chest wall resection causing large defects requiring complex reconstruction. In adults, the use of alloplastic and/or xenogenic materials and muscle flap repair is well established. However, literature provides only little information on procedures in children. We report our experience in 8 consecutive children who underwent chest wall resection and reconstruction with regard to surgical treatment and outcome. Retrospective study of all children with primary malignant chest wall tumors requiring rib resection and reconstruction with prosthetic material performed in our institution between November 2002 and April 2010. Endpoints were postoperative complications and long-term results, focusing on scoliosis defined radiologically by the Cobb angle. 8 children (7 male, 1 female) with a median age of 10.6 (4.1-18.9) years underwent resection of thoracic wall tumors. A mean number of 3 (1-5) ribs were resected. Stability was obtained using rigid prosthetic material (STRATOS™ titanium bar) in 2 patients and/or non-rigid prosthetic material (Goretex® patch in 6 patients, Vicryl® patch in 3 patients, Tutopatch® in 1 patient). A muscular flap was added in 5 patients. Postoperative complications included superficial wound infection (n = 2) and dislocation of a titanium bar necessitating removal in 1 patient. No infections of the prosthetic material were observed. No perioperative mortality occurred. At a mean follow-up of 37.5 (4-97) months, 6 patients were alive. 2 patients died due to early tumor recurrence. Mild scoliosis (Cobb angle 10-20°) was detected in 2 of the surviving patients (33%). Surgical reconstruction after resection of malignant thoracic wall tumors using non-rigid prosthetic material is safe and effective in pediatric patients, whereas rigid prosthetic material might dislocate. Scoliosis represents a long-term complication after chest wall reconstruction and should be monitored during routine follow-up.

A suitable system of reconstruction with titanium rib prosthesis after chest wall resection for Ewing sarcoma

The recent improvements in chemotherapy and surgical resection in Ewing sarcoma (ES) increased the overall survival as well as the importance of chest wall reconstruction. These improvements are in order to avoid asymmetrical growth, functional and cosmetic compromise after surgery. Chest wall reconstruction still remains a big issue in young patients with ES. We present a case of ES of the left chest wall, arising from a rib, in a 14-year-old patient. He was admitted after neoadjuvant chemotherapy and radiotherapy. The patient underwent a chest wall resection of three ribs and a wedge lung resection of the upper lobe followed by chest wall reconstruction with Stratos™ rib titanium prostheses. This new device is suitable for reconstruction after major chest wall resection with good cosmetic and functional results. During the follow-up, there was no evidence of local and distant recurrence, the pain was under control and there were no functional alterations in the chest wall.

Chest Wall Reconstruction

Chest wall resection and reconstruction continue to provide a formidable challenge. Prolonged hospitalization of 2 to 3 weeks in often necessary, and patients at our institution have undergone an average of two operations to achieve final closure. However, in multiple reviews of the senior author's personal experience, 85% of patients alive 30 days after operation had a healed, asymptomatic chest wall. Most late deaths occur as a result of the underlying disease process, usually malignancy.

Reconstruction of the chest wall with e-PTFE following major resection.

Nine patients underwent major chest wall resection at Thomas Jefferson University Hospital (Philadelphia, PA) over a 19-month period. Chest wall reconstruction was performed with an expanded polytetrafluoroethylene (e-PTFE) soft tissue patch (Gore-Tex) and vascularized flaps in all patients. The size of the skeletal defects ranged in area from 60 to 400 cm2. The primary indications for resection included chest wall sarcoma and radiation ulcer. Aggressive chest wall resection may be a patient's only opportunity for cure and an improved quality of life. In this series, chest wall resection was able to be performed with a low morbidity and no mortality. This study also demonstrates many of the advantages of e-PTFE as a chest wall substitute compared with other previously described prosthetic materials. The use of a Gore-Tex patch along with described flaps for soft tissue coverage provides good functional and aesthetic results.

A new method of stabilizing the chest wall following major chest wall resection

Prosthetic materials, such as metals, marlex mesh and methyl methacrylate have been used for stabilization of the chest wall after resection of large areas of rib cage. Such materials are contraindicated in an infected area. A new method of providing a stable chest wall using autogenous tissue is presented.

Radiation-induced sarcomas of the chest wall.

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.