Massive chest wall resection and reconstruction for malignant disease

Abstract

Objective: Malignant 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.

Methods: Twenty 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.

Results: The 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 cm(2) (60-340 cm(2)). 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.

Conclusion: Chest 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.

Keywords: chest wall reconstruction; chest wall resection; chest wall tumors; chondrosarcoma; soft tissue sarcomas; sternal tumors.

Figure 1

Sandwiched methyl methacrylate prosthesis for sternal reconstruction after the resection of sternal chondrosarcoma. Notes: Four stainless steel wires fix the prosthesis to the remnants of the sternum to avoid dislocation. Inset: PET/CT scan showing the sternal tumor: low FDG uptake by the tumor (SUV_max =1.7). Abbreviations: PET/CT, positron emission tomography/computed tomography; FDG, Fluorodeoxyglucose (18F); SUV, standardized uptake value.

Figure 2

surgery specimens. Notes: (A) Large malignant SFT of the posterior chest wall. (B) Reconstruction of the chest wall defect with 2 mm e-PTFE mesh after resection of the SFT. Abbreviations: SFT, solitary fibrous tumor; e-PTFE, polytetrafluoroethylene.

Figure 3

CT scans of the patient. Notes: (A) CT scan reconstruction showing a chondrosarcoma of the right costal arch. (B) Reconstruction of the chest wall defect with e-PTFE mesh. Abbreviations: CT, computed tomography; e-PTFE, polytetrafluoroethylene.

Figure 4

CT scan slices showing two large chest wall tumors where a local recurrence was observed after resection with tumor-free margins. Notes: (A) Giant malignant fibrous histiocytoma of the chest wall measuring 32 cm in its maximal diameter. (B) Large chondrosarcoma measuring 20 cm in its maximal diameter. Abbreviation: CT, computed tomography.

Figure 5

Asymptomatic fracture of the sandwiched methyl methacrylate prosthesis; incidental finding during routine follow-up CT scan performed at 1.5 years after resection of sternal chondrosarcoma. Abbreviation: CT, computed tomography.

Figure 6

3D reconstruction of the sandwiched methyl methacrylate prosthesis in the patient experiencing restriction in adduction and internal rotation of both upper arms after resection of the upper half of the sternum. Note: 3D reconstruction (A) and; Chest x-ray (B). Fixation of the clavicles to the large sandwiched methyl methacrylate prosthesis with stainless steel sutures could be one of the responsible factors for patient’s malfunction. Abbreviation: 3D, three dimensional.