Multidisciplinary Oncoplastic Approach Reduces Infection in Chest Wall Resection and Reconstruction for Malignant Chest Wall Tumors

Abstract

Background: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes.

Methods: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009-2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning.

Results: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm(2) (mean, 154 cm(2)). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%).

Conclusions: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.

Fig. 1.

A, Large moderate grade malignant phyllodes tumor of the right breast with pressure necrosis of overlying breast skin. B, Computed tomographic (CT) scan defining the lesion with extensive loss of tissue plan along the lower half of the chest plane underlying ribs and intercostal space, necessitating the resection of ribs to achieve negative surgical margins. C, Intraoperative photo post en bloc tumor resection, including 4 ribs demonstrating the skeletal defect exposing underlying thoracic viscera. D, Methyl methacrylate cement sandwiched in polyprolene mesh in preparation to reconstruct the skeletal defect.

Fig. 2.

Postoperative (6 months) photograph showing soft tissue coverage achieved using muscle-sparing–free abdominal rectus abdominus muscle flap (type I) with complete healing and acceptable aesthetic results.

Fig. 3.

A, Large aggressive malignant desmoid tumor in the right upper anterior chest wall with preoperative radiotherapy, note radiotherapy skin changes. B, Magnetic resonance imaging delineating the extent of the mass, which is insinuating itself between the intercostal spaces and extending into the pleural space. C, Posttumor extipiration with resection of mass, including right first to fifth ribs, costal cartilages, clavicle, part of manubrium, and sternocleidomastoid, preservation of neurovascular bundle, and innominate vein. D, Reconstruction of the skeletal defect using polyprolene mesh and STRATOS osteosynthesis titanium plates.

Fig. 4.

Postoperative (6 months) picture showing complete survival of free muscle-sparing TRAM (type I) and healing of wounds with primary intention.

Figure 5.

A, Ewing sarcoma in the right eighth rib. The patient underwent neoadjuvant chemotherapy for down staging and systemic therapy; note the preoperative wire localization to identify the affected rib. B, Post en bloc resection specimen revealing the entire eighth rib with soft tissue mass, part of seventh and ninth ribs, including overlying skin paddle with wire in situ (previous biopsy site). C, Skeletal defect reconstructed with polyprolene mesh and one STRATOS osteosynthesis titanium bar; note the latissimus dorsi muscle flap folded subcutaneously, which has harvested beforehand to allow exposure and resection of tumor. D, Soft tissue coverage was achieved with latissimus dorsi muscle flap only as no skin deficiency was encountered, flap insetted, and suture to edges of the defect.

Fig. 6.

Postoperative/radiotherapy (6 months) photograph revealing complete scar healing with primary intention with minimal skeletal contour deformity.

Fig. 7.

A, Computed tomographic scan showing a large leiomyosarcoma right posterior chest wall post neoadjuvant chemotherapy and radiotherapy with weak response; note that fat plane with lattissimus dorsi is preserved. B, Harvesting and dissection of the latissimus dorsi were performed first to salvage muscle allowing exposure of tumor in preparation of resection; the photo is showing the skeletal defect post resection of 3 ribs, including transverse process of T8–T9–T10 to posterior axillary line and partial pneumonectomy. Note that the latissimus dorsi flap has been folded laterally away from the resection zone. Stabilization of the spine was achieved using prosthetic spinal rods fixed to the transverse process. Note the stapler line at the resected lung zone. C, Nonrigid reconstruction of the skeletal defect achieved by using polyprolene mesh. D, Reinsetting of latissimus dorsi flap to achieve full soft tissue coverage.

Fig. 8.

Postoperative (12 months) photograph showing complete healing with mature scar and no functional or neurological deficit in lower limbs.

Video Graphic 1.

See video, Supplemental Digital Content 2, demonstrating the preoperative planning and design for resection of chondrosarcoma left costal margin by the thoracic oncoplastic team. The options for potential soft tissue reconstruction either using latissimus dorsi or vertical rectus myocutaneous flap (VRAM) are outlined. During en bloc resection of the tumor, the reconstructive surgeon is assessing the proximity of the resection margins to the left superior epigastric vessels, which could be potentially used as main blood supply for the left VRAM if integrity was preserved. This was followed by skeletal reconstruction using STRATOS bars and polyprolene mesh by the thoracic surgeons. Assessing of the resultant defect was performed to determine the extent of the required skin paddle. Harvesting and insetting of the VRAM flap with primary closure. This video is available in the “Related Videos” section of the full-text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A227.