EARLY AND SHORT-TERM RESULTS OF CHEST WALL
RESECTION AND RECONSTRUCTION: (A REVIEW
OF 22 CASES)
Ayman Gabal MD,
Nabil El Sadek MD,
Mahmood Abd Rabo MD
Mohamad khairy MD
Khalid Abdel-Bary MD
Rady Kamal MD
Mamdouh El-Sarawy MD
Mostafa Abdel-Sattar MD
Accepted for publication
Address reprint request to :
Dr. Ayman Gabal
Department of Cardiothoracic
Surgery, Zagazig & Banha
Univeristies
Email:
Codex:
Background :Since the first known chest wall resection in the 18th
century, improvements in surgical technique and anesthesia,
critical care units, antibiotics, and the development and refinements
in reconstruction techniques have allowed extensive chest wall
resections to be performed with acceptable morbidity and mortality.
Methods :We conducted a retrospective review of 22 patients with
chest wall masses (Soft tissue – Bony or cartilaginous) underwent
chest wall resection and reconstruction in our unit from December
2002 up to April 2004.
For patients with a mass and chest roentgenography a computed
tomography (CT) scan or magnetic resonance imaging (MRI) scan
of the chest was done to evaluate the extent and exact nature of the
lesion, and a tissue diagnosis utilizing fine needle aspiration was
attempted.
Results:Mean age (40.8 + 13.2 years). Females were more suffered
(54.45%) than males (45.54) located at the anterior chest wall, two
cases (9%) were at the back of chest wall. Masses with soft
consistency were in 5 cases (22.7%), firm in 14 cases (63.63%), and
hard in 3 cases (13.6%).
Resection of the chest wall skeleton was performed in 18 cases
(81.8%), and resection of chest wall layers (except the bony
skeleton) was performed in 4 cases (18.1%).
En bloc resection was done in 4 cases (18.1%).
Palliative resection was performed in 1 case (4.5%), Blood
transfusion was required for 5 cases (22.7%), 3 cases (13.6%) intra
operatively, and 2 cases (9%) post operatively.
Average time spent in ICU was one day, average duration of
hospitalization was 10 days.
No mortality was recorded in the early post operative period, but 1
case (4.5%) died late post operatively after about 6 months due to
distant metastsis.
Conclusion :Successful outcome in these complex cases is the
coordinated effort by the surgical teams in individualizing the care
of these patients utilizing total resection of the disease process,
reconstruction of the chest wall integrity, and soft tissue coverage of
the defect.
ince the first known chest wall resection in the 18 th
century, improvements in surgical technique and
anesthesia, critical care units, antibiotics, and the
development and refinements in reconstruction
techniques have allowed extensive chest wall resections to be
performed with acceptable morbidity and mortality.
S
The most common indications for chest wall
resection include primary or metastatic chest
wall neoplasms, tumors contiguous from breast
or lung cancer, radiation necrosis, congenital
defects, trauma, or infectious processes from
osteomyelitis or median sternotomy or lateral
thoracotomy wounds (1).
After radical en bloc chest wall resection,
skeletal reconstruction when appropriate and
adequate skin coverage to preserve the
reconstruction are the essential elements for
successful management of these complex chest
wall defects.
If chest wall integrity is compromised, synthetic
mesh (eg, Marlex, Prolene, Polytetrafluoroethylene)can be utilized for attaining rib
cage or sternal stability.
Although primary closure of muscle and skin
after chest wall resection is attainable in most
cases, many patients commonly require more
sophisticated reconstructive soft-tissue and skin
coverage (2).
Surgical excision sometimes, is considered the
only line left for management.
A variety of techniques including pedicled
muscle transposition, free muscle flaps, and
omental flaps have been used to provide
adequate wound coverage that allows for quick
healing, rehabilitation, and cosmosis.
The purpose of this study is to retrospectively
review short term results of chest wall resection
and reconstruction in our unit of chest surgery.
PATIENTS AND METHODS :
We conducted a retrospective review of 22
patients underwent chest wall resection and
reconstruction in our unit from December 2002
up to April 2004.
All patients with chest wall masses (Soft tissue
– Bony
or cartilaginous), masses were
amenable to resection and reconstruction
(Besides technical considerations,a patient was
judged operable in the absence of major nontreatable co-morbidity), were included in this
study.
Patients with sternal infections after median
sternotomy for cardiac surgery were not
included in this study.
Patients charts were retrospectively reviewed
for age, sex, medical history, surgical history
(Each patient was asked about any previous
lesion or operations in the chest wall).
After physical examination (General and local),
all patients received conventional chest
roentgenography to spot the light on the origin
of the mass and occasionally detect a defect.
For patients with a mass, a computed
tomography (CT) scan or magnetic resonance
imaging (MRI) scan of the chest was done to
evaluate the extent and exact nature of the
lesion, and a tissue diagnosis utilizing fine
needle aspiration was attempted.
In patients with suspected distant metastasis CT
and MRI were used.
Open biopsy was proceeded in some cases with
negative results of closed biopsy, however, it
should be borne in mind to place the biopsy in a
site where it will be excised during the surgery.
The commonest indications for surgery were :
- Primary chest wall tumors (91%).
- Primary lung cancer (4.5%) with extension to
the chest wall.
Primary breast cancer (4.5%).
All surgical procedures were performed under
general anesthesia, except for two patients with
lipoma of chest wall were removed under local
anesthesia using 2% lidocaine and the mass was
removed with drain in the resulting cavity.
A thoracic epidural catheter was placed for
analgesia in patients with unlimited or major
resection.
Double lumen endo- bronchial tube was
inserted if lung involvement was expected.
Radical wide excision with removal of involved
structure, either bony or soft tissue was done for
all our patients with good safety margin
according to previous tissue diagnosis.
Malignant chest wall tumors which occurred in
patients with lung cancers involved the chest
wall, resected by en-block resection method.
After completion of resection, the decision was
made as to whether chest wall reconstruction
was required and if so, what type of
reconstruction needed.
Reconstruction of the chest wall was made
either by one of the following :
By edge to edge approximation in most of our
cases.
By using latissmus dorsi muscle and
musculocutaneous flaps.
By prosthesis placement for chest wall
stabilization.
By using latissmus dorsi muscle flap with
prolene mesh combination.
All patients were extubated immediately after
surgery and transferred to the recovery room
during the first 6 to 8 hours.
If no complications was recognized, the patient
returned to the ward where physical activity
was initiated the morning after, under the
supervision of a physiotherapist.
At discharge, all cases were reviewed for
complete wound healing and then send for
oncological therapy if needed, and for follow
up at our out-patient department.
RESULTS :
A total number of 22 patients with chest wall
masses fulfilled the inclusion criteria were
studied in the cardio-thoracic surgery
department in Zagazig University Hospital
from December 2002 up to April 2004.
Patients age ranged from 18 to 65 years (mean
40.8 years), it was apparent that females were
more suffered from chest wall masses
(54.45%) than males (45.54).
According to the location of the masses, 19
cases (86.36%) were located at the anterior
chest wall, two cases (9%) were at the back of
chest wall, one case (4.5%) only was found at
left side of chest wall (Table I),this table also
shows that masses with soft consistency were in
5 cases (22.7%), firm in 14 cases (63.63%), and
hard in 3 cases (13.6%).
According to the mobility of the mass showed
that 17 cases (77.27%) were with immobile
masses, and others were mobile.
Our study encompassed 22 patients, 9 of them
had benign chest wall tumors ; 8 patients had
primary malignancy ; and 5 patients had
metastatic chest wall malignancies.
Regarding the benign cases, chondroma was
found in 2 cases (9%), fibrous dysplasia was
found in 2 cases (9%), lipoma in 3 cases
(13.6%), fibroma in 1 case (4.5%), and desmoid
tumor in 1 case (4.5%) (Table II).
Regarding
the
malignant
cases,
chondrosarcoma in 3 cases (13.6%),
fibrosarcoma
in
2
cases
(9%),
neurofibrosarcoma in 1 case (4.5%), malignant
lymphoma in 1 case (4.5%), malignant
myeloma in 1 case (4.5%), small cell carcinoma
"metastatic" in 1 case (4.5%), undifferentiated
metastatic carcinoma in 2 cases (9%),
metastatic mammary carcinoma in 1 case
(4.5%), and metastatic adenocarcinoma in 1
case (4.5%).
Chest wall resection ;
Resection of the chest wall skeleton was
performed in 18 cases (81.8%), and resection of
chest wall layers (except the bony skeleton) was
performed in 4 cases (18.1%).
EN BLOC RESECTION (Resection of all
layers of chest wall : bones, muscles,
subcutaneous layers, their skin covers , and
lobectomy was done in 4 cases (18.1%)).
Palliative resection was performed in 1 case
(4.5%), this case was chondrosarcoma of the
sternum (Table III).
Reconstruction procedures ;
Immediate closure of the defects was performed
in all cases.
In one case (4.5%), muscle flap" latissimus
dorsi muscle flap ", was used to cover the
prosthesis "prolene"mesh, prolene mesh alone
with approximation of covering muscles was
done also for one case (4.5 %).
Direct resection with end to end approximation
using absorpable sutures was done in 16 cases
(72.7%), direct resection and approximation of
bony skeleton using stainless steel wires was
performed in 4 cases (18.18%) (Table IV).
Follow up and prognosis ;
Blood transfusion was required for 5 cases
(22.7%), 3 cases (13.6%) intra operatively, and
2 cases (9%) post operatively.
All the patients in our series were extubated
within two hours. Average time spent in ICU
was one day, average duration of
hospitalization was 10 days.
Wound infection occurred in 2 cases (9.09%)
which was significant, and required good
debridement and secondary suturing with good
antibiotic coverage.
Post operation local recurrence of the
malignant etiology (Chondro sarcoma of the
sternum) occurred in one case (4.5%)which was
non-significant, and the patient called for redo
operation.
No mortality was recorded in the early post
operative period, but 1 case (4.5%) died late
post operatively after about 6 months due to
distant metastsis (Table V).
Examination of the mass
No.
%
Site : Ant. Chest Wall
Back of chest wall
Lat. Side of chest wall
Consistency : Soft
Firm
Hard
Mobility : Immobile
Mobile
Table I : Common signs of the masses and their percentages.
19
2
1
5
14
3
17
5
86.36
9.09
4.5
22.7
63.63
13.63
77.27
22.7
Etiology
Benign diseases
Primary malignant diseases
Malignant metastasis
Table II : Etiology of chest wall masses.
No.
9
8
5
%
40.9
36.36
22.7
Surgical intervention done
Resection of the chest wall skeleton only
Resection of chest wall layers ( except the bony skeleton)
" En-bloc " resection
Palliative resection
Table III :Types of surgical intervention done.
No.
13
4
4
1
%
59.09
18.1
18.1
4.5
Reconstruction techniques
Muscle flap, prolene mesh combination (using latissmus dorsi muscle
flap)
End to end approximation using absorbable sutures only
Direct resection and approximation of bony skeleton using stainless
steal wire
Prolene mesh with approximation of covering muscle layers
Table IV : Techniques used for chest wall reconstruction.
No.
1
%
4.5
16
4
72.7
18.18
1
4.5
Complications and mortality
Morbidity:
- Wound infection
- Local recurrence
Mortality
Table V : Morbidity and Mortality.
DISCUSSION :
Primary tumors of the chest wall are uncommon
(1).Nearly half of all chest wall tumors
originate in the cartilaginous tissue (2).
No.
%
2
1
1
9.09
4.5
4.5
NS
NS
NS
Primary malignant tumors originated in our
series, in the cartilaginous ends of ribs near to
sternum.This finding also noticed by others
like(13)(15).
Malignancy must always be considered and its
possibility kept in mind when any one presents
with chest wall tumor. This is particularly true
when multiple sites of involvement are
discovered (3)(4).
As far as solitary chest wall lesions are
concerned, metastatic lesions occur about the
same frequency as primary tumors (5).
The presence of pain and or a mass were the
most common symptoms in patients with chest
wall
tumors,although
many
patients
experienced both (6).In our series, about 70%
of our patients, complained of these signs and
those with malignant etiology were more likely
to present with them. Approximately 95% of
our malignant cases had symptoms with only
70% of the benign cases.
The anatomical site of pain or mass, is
sometimes giving much help to the diagnosis.
The majority of tumors of cartilaginous origin
usually occur along the costochondral junction,
whereas fibrous dysplasia tends to occur over
the posterior thoracic wall (8).
Many authors commonly believe that tumors of
the sternum are almost always malignant and
should be assumed so until proved other wise
(8). In our series, we noticed similar findings,
the only sternal tumor was proved malignant
(chondrosarcoma).
Ewing"s sarcoma is more likely to occur in the
adolescent age group and myeloma is more
common in persons over 50 years (7)(9),
however primary chest wall tumors can occur in
any age group. Chest wall tumors of both
benign and malignant etiology are twice as
frequent in men as in women(10).
The results of our study group have a favorable
versatility that chest wall tumors of different
pathologies seen matched well with our patients
age group.
In our, as well as in others opinion. The
diagnostic evaluation of patients with a chest
wall tumor which is suspected to be malignant
should include, beside careful history and
clinical examination, a good quality
conventional plain and tomographic chest
radiology, computed tomographic scanning
should be performed to delineate soft tissue,
pleural,
mediastinal,
and
pulmonary
involvement (11).
We used this policy for evaluating our patients
especially when the pathology of their lesions
was doubted between the benign or the
malignant possibilities. When questions were
still persistent after these investigations, a
needle aspiration (Fine needle aspiration or
cutting needle), or an incisional biopsy was
usually performed.
Our reasons for performing pre operative
biopsy included the ability to identify the terror
histology that may be susceptible to peri
operative chemo and or radiotherapy. We
among many other workers found little
evidence to suggest that biopsy is harmful to
our patients.
Patient with tumors diagnosed as malignant,
should then undergo wide excision. However,
the extent of resection should not be
compromised to allow the ability to close the
residual chest wall defect. Opinions in this
context, differ as to what extent "wide resection
" should be (10)(11).
In all our patients who had malignant tumors,
we planed our margin of resection at least 2cm
around the tumor (rang from 2 to 5 cm). The
extent of the resected margin, in our opinion
showed no influence on survival.
Our observation was also reported by other
workers like Zusulu et al.,1998, who reported
that the extent of the margin resected did not
influence patient survival but may have affected
the rate of the tumor recurrence. They could not
demonstrate a significant difference in survival
because all patient had a margin of resection of
at least 2cm.
Many surgeons agree with the opinion that a
margin grossly free by several centimeters,
from macroscopic tumor growth should be
considered an adequate resection (12)(13).
Although this may be sufficient for benign or
low grade malignant primary tumors, higher
grade tumors have the potential to spread within
the marrow cavity, along the periosteum, or
along the parietal pleura.Consequently, excision
of these higher grade tumors with a 2cm safety
margin would not be an adequate resection
(5)(7).
A basic tenet prior to the initiation of chest wall
reconstruction is an appropriate and thorough
chest wall resection that leaves healthy, viable
margins to which materials and tissues used in a
reconstruction may be anchored securely.
Careful pre operative assessment for the extent
of disease in patients with primary or metastatic
malignancies is necessary prior to chest wall
resection or reconstruction (14).
Large chest wall defects frequently result from
treatment of primary tumors , chest wall
reconstruction should include stabilization of
the bony thorax and coverage of any soft tissue
defect (15). Defects with a maximum diameter
less than 5cm any where on the thorax are
usually not constructed. Posterior defects of less
than 10cm do not require reconstruction
because the overlying scapula provides support
(2)(16).
Various techniques have been used successfully
for closure of chest wall defects. Since 1970,
methylmethacrylate substitutes consisting of
two layers of marlex. Mesh and filter of
methylmethscrylate have gained the popularity
for bridging large antero-lateral chest wall
defects providing enough stability for normal
spontaneous breathing and coughing and
cosmetic acceptability (15)(16).
The numerous advances in chest wall
reconstruction over the years with the
introduction of muscle and musculocutaneous
flaps have made them the mainstay in chest
wall reconstruction (9).
In our series we used latissimus dorsi muscle
and musculocutaneous flaps combined with
prolene mesh in one case to reconstruct large
anterolateral chest wall defect and other case
reconstructed by using prolene mesh covered
by approximating muscle layers, other cases
reconstructed by edge to edge approximation
either by using absorbable sutures to
approximate muscle layers and subcutaneous
tissues or using stainless steel wires to
approximate the bony skeleton.
In our series the relatively short hospital stay
found in most of our patients is in line of those
reported by many working centers (2).
IN CONCLUSION :
Successful outcome in these complex cases is
the coordinated effort by the surgical teams in
individualizing the care of these patients
utilizing total resection of the disease process,
reconstruction of the chest wall integrity, and
soft tissue coverage of the defect. The team of
surgeons should be well versed in chest wall
reconstruction utilizing prosthetic materials and
free or pedicled muscle flaps.
REFERENCES
1- Anderson BO, Burt NE.Chest wall
neoplasms and their management. Ann Thorac
Surg 1994 ;58 :1774-1781.
2- Chapelier A, Fadel E, Macchiarini P, Lenot
B, Cerrina J, Dartevelle P. Factors affecting
long term survival after en bloc resection of
lung cancer invading the chest wall. Eur J
Cardio-thoracic Surg 2000 ; 18 : 513-518.
3- Graeber G.M., Langenfeld J. Chest wall
resection and reconstruction. In : Franco K.L.,
Putman J.R., eds. Advanced therapy in thoracic
surgery. London : BC Decker, 1998 :175-185.
4- Halm BM, Hoffman C, Winkelmann W. The
use of Gore-Tex soft tissue patch to repair
large full thickness defects after sub-total
sternectomy :Report of three cases. J Bone and
Joint Surg 2001 ; 83 : 420-427.
5- Hasse J. Surgery for primary invasive, and
metastatic malignancy of the chest wall. Eur J
Cardio-thoracic Surg 1991 ; 5 : 346-351.
6- Lardinios D, Muller M, Furrer M,Banic A,
Gugger M, Krueger T, Ris HB. Functional
assessment of chest wall integrity after
methylmethacrylate reconstruction. Eur J
Cardio-thoracic Surg 2000 ; 69 : 919-923.
7- Losken a, Thourani VH, Carlson GW, Jones
GE, Culbertson JH, Miller JI, Mansour KA. A
reconstructive algorithm for plastic surgery
following extensive chest wall resection. Br J
Plast Surg 2004 ; 57 : 295-302.
8- Magdeleinat P., Alifano M., Benbrahem C.,
et al. Surgical treatment of lung cancer invading
the chest wall : results and prognostic factors.
Ann Thorac Surg 2001 ; 71 : 1094-1099.
9-Kamal A. Mansour,Vinod H, Albert L . Chest
wall resection and reconstruction : a 25 years
experience. Br J Plast Surg 2001 ; 55 : 838843.
10- Martini N, Huvos AG, Burt NE, et al.
Predictors of survival in malignant tumors of
the sternum. J Thorac Cardiovasc Surg 1996 ;
11 ; 96-105.
11- Michael J, Weyant, MD, Manjit S, et al.
Results of chest wall resection and
reconstruction with and without rigid
prosthesis. Ann Thorac Surg 2006 ; 81 : 279.
12- Pairolero PC. Chest wall tumors. In Shields,
edited by Malvem, Williams & Wilkins.,
General Thoracic Surgery. 5TH ed. 2000 ; Vol
42 : 579-588.
13- Pascuzi CA, Dahlin DC, Clagett OT.
Primary tumors of the ribs and sternum. Surg
Gynecol Obstet 1957. 104 :298-309. Quoted by
Zuslu BA, Gene O, Ourk S, Balkanii K. Chest
wall tumors. Asian Cardiovasc Thorac Ann
1998. 6 : 212-215
14- Sabanathan S, Shah R, Mearns AJ. Surgical
treatment of primary malignant chest wall
tumors. Eur J Cardio-thorac Surg 1997 : 11 :
1011-1016.
15- Soysal O, Walsh GL, Nesbitt JC,
McMurtery MJ, Roth JA, Putnam JB. Resection
of sternal tumors : extent, reconstruction, and
survival. Ann Thorac Surg 1999. 60 : 13531359.
16- Warzelhan J, Stoelben, Imdahl A, Hasse J.
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Figure 1 : operative view (Latissimus dorsi muscle flap)
‫الملخص العربي‬
‫النتائج المبكرة وعلى المدى القصيرلعمليات استئصال واصالح جدار الصدر‬
‫مقدمة‪ :‬ان التقدم فى وسائل الجراحة والدةد ر والايا ة الزرواسواسةتددام الز ةداي ال ة‬
‫قد سةادد دىةى التقةدم فةى جتةائ استئصةا واالة ج اةدال الصةدل‪ ,‬وتهةد ذة ا الدلاسة الةى‬
‫دلاس اليتائ الزبكرس له ا ال االي‪.‬‬
‫خطة البحث‪ :‬أار يا مرااا دىى ‪ 22‬مر ض مصاب بأولام فى اةدال الصةدلقد أاةره لهة‬
‫مةةق قبةةل دزى ةةاي استئصةةا لة ولام واالة ج لجةةدال الصةةدل ‪ ,‬وقةةد أاةةره لهةةمالض الزر ةةى‬
‫أشةةا داد ة ومق ا ة ولج ة ق موياذ عةةى وأال ة د ي ة بةةاالبرس واللةةم لتق ة ذ ة ا االولام قبةةل‬
‫ااراض الجراح ‪.‬‬
‫النتاائج‪ :‬وةان مت سةا الازةر فةى ذةمالض الزر ةى ذة ‪ 40,8‬سةي ‪ ,‬وواجةن جعةب االالةاب فةةى‬
‫االجةةاه ذةةى ‪ %54,45‬مقابةةل ‪ %45,54‬لى ة و ل‪ ,‬ووةةان مكةةان االولام ذ ة الجةةدال االمةةامى‬
‫لىصدل فى ‪ 19‬حال والجدال الدىفى لىصدل فى حالتان‪ .‬ت استئصا االولام فى ‪ 18‬حال أمةا‬
‫االلبةةح حةةاالي الباق ة فقةةد أاةةره لهة باال ةةاف الةةى استئصةةا ال ة لم دزى ة اال ة ج لجةةدال‬
‫الصدل‪ .‬باد الجراح وان مت سا البقاض فى الايا الزرواس ذ م واحةد ومت سةا البقةاض فةى‬
‫الزعتشفى ذ ‪ 10‬أ ام‪ ,‬ل تكق ذياك وف اي‪ ,‬وباةد ‪ 6‬أشةهر ت ف ةن حالة واحةدس جت جة حةدوه‬
‫ثاج اي لى لم‪.‬‬
‫الخالصة‪ :‬عتدىص مق ذ ا الب ث أن اليتائ الياا لزثل ذ ا ال االي تك ن جت جة التاةاون‬
‫الزشترك ب ق فر ق الجراح ال ه قة م باستئصةا واالة ج أولام اةدال الصةدل‪ ,‬وأجة جة‬
‫دىى فر ق الجراح استددام الز اد الصياد والا ي فى لتق الفراغ ال ه كة ن م اة د‬
‫باد استئصا ذ ا االولام‪.‬‬