Long-term outcomes after chest wall resection and repair with titanium bars and sternal plates

Abstract

Objectives: En-bloc complete resection remains the treatment of choice for localized chest wall (CW) tumors. Titanium bars reconstruction demonstrated encouraging results with satisfactory early outcomes. However, long-term outcomes remain under-reported. The purpose of this study is to evaluate long-term outcomes after CW resection and repair with titanium devices.

Methods: From June 2012 to December 2018, we retrospectively reviewed all patients with CW tumors who underwent surgical resection and repair using titanium. Long-term outcomes were assessed.

Results: We identified 87 patients who underwent CW tumor resections and titanium reconstruction. Sixty-eight patients were included in the study (excluding benign tumors, Pancoast tumors, palliative surgeries, or clavicle reconstruction). There were 29 sarcomas, 20 isolated CW metastases, eight lung cancers, four breast cancers, three thymic malignancies, two sarcomatoid mesothelioma, and one desmoid tumor. Complete resection was achieved in 64 patients (94%), while R1 resection in four patients (6%). Resection involved one rib in two patients, two ribs in thirteen, three ribs in eighteen, four ribs in nine, five ribs in two, seven ribs in one, partial sternum in fifteen, and full sternum in sixteen patients. No patient experienced flail chest. The 1-year, 3-year, and 5-year overall survival rates and disease-free survivals were 82.3%, 61.4%,57.3%, and 67.6%,57.3%,52.6%, respectively. Surgical site infection occurred in 18% (n = 12) of cases. Eleven of twelve patients had an early infection (<1 year), which required material removal in six patients. Asymptomatic connector unsealing occurred in 6% (n = 4), with only one re-intervention. Titanium allergy has never been reported. Chronic chest pain (lasting more than 3 months after surgery, with daily use of pain killer) was reported in 24% of patients.

Conclusion: CW resections with titanium reconstruction are associated with long-term survivors. Titanium devices were safe, reliable, and achieved satisfactory oncological results with low morbidity and implant-related complication rates.

Keywords: chest wall resection; fracture; infection; long term; titanium bars.

Figure 1

Flow chart of the study.

Figure 2

Operative field pictures showing: (A) Thorib® bar for lateral chest wall reconstruction with vicryl mesh interposition and pedicled homolateral latissimus dorsi flap. (B) Trionyx® sternal plate reconstruction after total sternectomy covered by homolateral latissimus dorsi pedicled flap. (C) Thorib® bar reconstruction after manubrial resection. (D) Thorib® bar crossing the midline and attached to the contralateral rib.

Figure 3

Postoperative chest x-rays after (A) Thorib® bar interposition and (B) Trionyx® sternal reconstruction.

Figure 4

Survival and recurrence of the study population: (A) Overall survival of the whole cohort. (B) Freedom from recurrence of the whole cohort. (C) Overall survival according to the type of titanium reconstruction (Thorib® or Trionyx®). (D) Overall survival according to the completeness of resection. (E) Overall survival according to the primitive or metastatic nature of the tumor. (F) Overall survival according to the tumor's histopathology. (G) Overall survival according to the presence of surgical site infection. (H) Overall survival according to the presence of implant failure.

Figure 5

Long-term respiratory function before and after chest wall tumor resection and repair. (A) Forced vital capacity (FVC) before surgery and after surgery (≥3 months). (B) First second of forced expiration (FEV1) before surgery and after surgery (≥3 months).