Ayman Gabal MD, Nabil El Sadek MD, Mahmood Abd Rabo MDMohamad khairy MDKhalid Abdel-Bary MDRady Kamal MDMamdouh El-Sarawy MDMostafa Abdel-Sattar MD

EARLY AND SHORT-TERM RESULTS OF CHEST WALL RESECTION AND RECONSTRUCTION: (A REVIEW

OF 22 CASES)

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 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.

SThe 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

Accepted for publicationAddress reprint request to :Dr. Ayman Gabal Department of Cardiothoracic Surgery, Zagazig & Banha UniveristiesEmail:Codex:

essential elements for successful management of these complex chest wall defects.If chest wall integrity is compromised, synthetic mesh (eg, Marlex, Prolene, Polytetra-fluoroethylene)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 non-treatable 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).

%No.Examination of the mass

86.3619Site : Ant. Chest Wall

9.094.5

21

Back of chest wall Lat. Side of chest wall

22.763.6313.63

5143

Consistency : Soft Firm Hard

77.2722.7

175

Mobility : Immobile Mobile

Table I : Common signs of the masses and their percentages.

%No.Etiology 40.99Benign diseases36.368Primary malignant diseases22.75Malignant metastasis

Table II : Etiology of chest wall masses.

%No.Surgical intervention done59.0913Resection of the chest wall skeleton only18.14Resection of chest wall layers ( except the bony skeleton)18.14" En-bloc " resection 4.51Palliative resection

Table III :Types of surgical intervention done.

%No.Reconstruction techniques4.51Muscle flap, prolene mesh combination (using latissmus dorsi muscle

flap)72.716End to end approximation using absorbable sutures only 18.184Direct resection and approximation of bony skeleton using stainless

steal wire4.51Prolene mesh with approximation of covering muscle layers

Table IV : Techniques used for chest wall reconstruction.

%No.Complications and mortality

NSNS

9.094.5

21

Morbidity: - Wound infection - Local recurrence

NS4.51Mortality 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).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. REFERENCES1- 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 : 838-843.10- 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 : 1353-1359.16- Warzelhan J, Stoelben, Imdahl A, Hasse J. Results in surgery for primary and metastatic chest wall tumors. Eur J Cardio-thoracic Surg 2001 ; 19 : 584-588.

Figure 1 : operative view (Latissimus dorsi muscle flap)

الملخصالعربي

استئصال القصيرلعمليات المدى وعلى المبكرة النتائجالصدر جدار واصالح

والعناية: مقدمة والخدير الجراحة وسائل فى التقدم اننتائج فى التقدم على ساعد قد الحيوية المضدات المركزةواستخدام , النتائج دراسة الى الدراسة هذه وتهدف الصدر جدار واصالح استئصال

. الحاالت لهذه المبكرةالبحث على: خطة مراجعة جدار 22أجرينا فى بأورام مصاب مريض

لجدار واصالح لالورام استئصال عمليات قبل من لهم أجرى الصدرقدورنين , ومقطعية عادية أشعة المرضى لهؤالء أجرى وقد الصدر

اجراء قبل االورام هذه لتقييم وذلك باالبرة عينة وأخذ مغناطيسىالجراحة.هو: النتائج المرضى هؤالء فى العمر متوسط وكانت , 40,8كان سنة

هى االناث فى االصابة , 45,54مقابل% 54,45نسبة مكان% وكان للذكورفى للصدر االمامى الجدار هو للصدر 19االورام الخلفى والجدار حالة . فى االورام استئصال تم حالتان فقد 18فى الباقية حاالت االربع أما حالة

. بعد الصدر لجدار اصالح عملية الورم استئصال الى باالضافة لهم أجرىومتوسط واحد يوم هو المركزة العناية فى البقاء متوسط كان الجراحة

هو المستشفى فى , 10البقاء , وبعد وفيات هناك تكن لم أشهر 6أيام. للورم ثانويات حدوث نتيجة واحدة حالة توفيت

الحاالت: الخالصة هذه لمثل الناجحة النتائج أن البحث هذا من يستخلصباستئصال يقوم الذى الجراحة فريق بين المشترك التعاون نتيجة تكون

, استخدام الجراحة فريق على يجب وأنه الصدر جدار أورام واصالحبعد موجود يكون الذى الفراغ رتق فى والعضالت الصناعية المواد

. االورام هذه استئصال