241
Reconstruction of ehest Wall Defects 1. Hasse
Summa ry
Versorgung von Tho raxwa ndde fe kte n
Aseries of 61 consecutive procedur es of ehest wall resection and reconstru ction in 58 patients during the period between Augus t. 1986 a nd December. 1990 is reported. The ages ra nged between 6- 77 years. The ehe st wall res ection wa s indicated for maligna nt afTectio ns in 54 ca ses. Among these, there we re 24 patients with bron ch ial ca rci noma lnvad lng the ehes t \v-all. 17 patients with primary or metastatic sarcoma. 11 paüerus with reeurrent breast ca nce r a nd 3 with ca nce r me ta stases of varying origin. Pulmonary resection included pn eumonectomy in 8 cases. Iobectomy in 19. segm en tal and wedge resection s in 26. In th e majority of resections. the reconstruction was accomplishe d without impla nts. In cases with fullthi ckness remova l of the ehes t wall. th e pla ne ofl he rib cage a nd/or the sternum was reconstru cted using Vicryl mesh (n :: 7). PTFE soft tissu e patch (n = 11), ma rlex-mesh (n ... 0 , or methyl-metacrylat e (n = 3), Ther e was one case of hospital mortality, 6 week s postope ra tively, du e to neurologreal failure from an Independent preoperat ively undiagnose d bra in tumor. There we re 4 reope ratio ns : one ea rly a nd one late (4 months) infection, one case of limited superficial necrosis of a flap a nd one wlth ehre nie lymphous dr ainage from a large myocutan ec us fla p. In no instance wa s pri ma ry postop erat ive vent ila tion th era py necessa ry. Mecha nical ventilat icn wa s ins tituted only on day 8 in the patient wh n accou nts for th e mortality in this ser ies . In the presence of prima ry infection, th e gr eater ome ntum was used for the rest orat ion ofthe integu me nt.
In der Zeit von August 1986 bis Dezemb er 1990 wu rden bei 58 Patient en 6 1 konsekutive Brustwa nd resektionen vorgen ommen. Die Altersspanne reicht von 6- 77 Ja hren. Bei 54 Pati enten wur den die Brustwan d rese ktio nen wegen maligne r Erkra nkun gen notwen dig. In 24 Fä llen hand elte es sich um ei ne Brustwandinvasion du rch ein Bronchialk arzinom , in 17 Fä llen um Patienten mit prim ä rem ode r me tas ta tischem Sark om . Bei 11 Fra uen lag ein loco-regtonäres Rezidiv na ch Mam maka rz inom vor , bei 3 weiteren Patienten die Bru stwandmetast as e sonstiger Karzin ome. Gleichzeitig mit der Thor a xwan dr esektion wurd en in 8 Fällen Pneumonektomien ausgefüh rt. 19 x eine Lobektom ie sow ie isoliert oder in Verb indun g mit ei ne r Lobekt omie 26 Segme nt - und Keilresektionen. In der Mehr zah l der Fälle wurde bei der Rekons truktion der Brustw a nd auf Impla ntate verzichtet. Insbesondere bei Resektion sä mtlicher Brustwa ndschichten wu rde d ie innere Brustwa nd . d. h. Rippenthorax und ggf. Sternum mit Vicrylnetz (7 Fälle), PTFE so ft
Ke~'
werds
e hest wa ll tumor - Metastases - En bloc res ection - Stern al res ection - Allop lastic mat eri al
tissue 11 1 Fälle). Marlex11 FallJ und Methyl-Metacrylat (3 Fälle) ersetzt. Die 30-Tage-Letalität war Null. Ein Todes fall 6 Wochen postoperativ geht auf eine schwere neurologische Störung bei prä opera tiv nicht beka nnt em una bhängigen Hirntum or zurüc k. Es ,..-urden 4 Reoperat ion en erforde rlich: je 1 x bei Früh- und Späti nfektion (4 Monate) sowie je 1 x wegen l .appenra nd nekrose und per sistieren der Lymphd rai nage. Keine r der Patien ten bedu rfte ei ner primä ren Nachbeatrnung. Die Beatmung sindikat ion be i der versto rb en en Patientirr ergab sich arn 8 . postope ra tiven Tage. Bei pro blem ati schen Weichteilver hältnissen insbeso nde re mit pr imä rer Infektion und be i der Behandlun g der per sistierenden Lymphsekretion - wurde das Omen turn majus verwend et,
Inlroduclion Defeets of the thoraeie wall mostly result from the resection of mali gnan t disease. This ean be mesenehymal tumo rs prim arlly originating from stru etures of the ehest wall, metastases from previous tum ors of distant location, loeal recurrence of brea st cancer in fema Je patients, and, finally, invasion of lung cancer. But also a non-m alignan t lesion may require exten ded reseetion of tb e tho racie wall as weil as neerotic lesions after radiotherapy of brea st cancer. Especially in malignant tum ors an d in cas es of radi onecroses, generous excision is man datory in orde r to improv e long-terrn prognosis and un eomp lieated healing. lt has been learn ed in the past th at large areas of the ehest wall ca n be Thorac. cardiovasc. Surgeon 39 (1991) (Supplement1241- 247 © Georg Thieme Verlag Stuttgart . New York
sacrificed, on condition that adequate reconstru ction has been planned and aeeomplished. Surprisingly, with proper care, respiratory problems caused by temporary instabilit y ar e of minor concern. There is an importan t difTerence between lesions arising from layers of the ehest wall and those originat ing from the lung, seeon darily infiltrating ribs and inter eostal muscles. The former very often requi re full thiekness removal of th e ehest wall includi ng the eutaneous and sub eutan eous strata . The necessity of reseetion of a ehest wall area together with part or even all of th e und erlying lung ca n be the ease in either event. Al pr esent, a eonsiderable speetrum oft eehnieal solutions for reeonstru etive surgery is avallable. These include the reestablish ment of the stability and the
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Department of Thoraeie Surgery. University of Frei burg . Fre iburg. Ger ma ny
1. Hasse
Thorac. cardiOl'asc. Surgeon 39 (199 1)
closure of even ver y larg e defects of the soft tissu e layers including th e skin. Even in patient s with mer ely palliative indication, there fore, large resections are ju stified in orde r to prevent or tr eat severe pain or , in the cas e of radiation necrosis or tumor ulceration , to ab olish chronic infection and terminate permanent medical care. In th e case oflo cally aggressive lung cancer, the development of re constructive techniques has allowed for the extension of the indication for surgical tr eatment at a rath er low risk. \Vith complete resection and in the absence of lymphatic spread, a 54 % 5yea r-survival has been reported by Grillo (6) and even 62 % by Martini et al. (9). With incomp lete resection and desp ite postoperative radiation therapy, the langest survival was 2 1/ 2 years in their experience. Since technical asp eets are th e main topic of this contribution , ehest wall resection s of all oft he aforementioned indi cations have been includ ed.
Table 1 Type ot ehest wa ll dtsease Diagnosis
No. of Patients
No. of Procedures
Bronchialcercmoma Mesenchymal tumors Breast cancer Othermetastatic cancer Benign
24
24 20
Total
58
Table 2
17 11
11 3
3 3
3
61
Age distributtön within the main diagnostic groups Age (years) Range
Mean
36-76 14- 76 34-67
Lung cancer Mesenchymal tumors Breast cancer
61 47 55
Material and Methods The pr esen t re port deals with 58 patients and a total of 61 consec utivc chestwall resections. isola ted or combined with pulmonary rese ction within the time period from August 1986 to December 1990 . With the exce ption of 3 cases (1 with multiple excstosis. 2 with ra diatio n nccrosts and osteo myelitis after radi ation thera py of br east cancer). all were for maligna nt afTections. There were 27 fernale a nd 31 male patient s. Table 1 shows th e brea kdow n into indica tory groups with 41.4 % bron chial carc inoma . 29.3% sa rcoma or other mesenchymal tumors a nd 19 % breast cancer. The youngest pat ient was 6 years of age , the oldes t was a female pati en t of 78 yea rs . The mea n age differ ed among the main diagn ostic groups as shcw n in Table 2 with th e highes t average age in the group ofl ung ca ncer patient s. Pulmonary rese ction was ca rrie d out in not only in all cases oftnvastve br onch ial ca rcinoma, but also in a high perce ntag e of othe r ehes t wall maHgnan cies. There were 8 pneum onectomies in this se ries : 4 with bronchial carci noma , 2 Ior gross involvemen t by (one osteoge nic, onc neur ofibro) sa rcoma and one each melan om a a nd mescth elioma. A com plete overv iew of all pulmona ry resections wit hin the se ries is show n in Table 3. With regard to the extensio n of the excised ehest wall area , up to 6 ribs were resec ted. Ther e we re 6 patien ts in th e gro up of rec urrent breast cancer with partial or complete resection ofthe ste rnal body. Furthermore . 3 ste rnal resectio ns were perfo rme d for osteogenic sarcoma and meta static th yroid cancer and . in a female with sub total ste rnal resection includi ng onc qua rter of eac h clavtcula . for metastatic invclvement after form er adenocarci noma ofthe uterus. Any decision in favor of such a surgic al treatme nt in a given condition was mad e by an interd isciplin ary conference cons ideri ng the abs ence of efficient alternative treatm ent . the severity of pain . the th reat of complications , aud . in a number of cases, the cha nce of eure with complete removal of the tu mor . In the lung cancer gro up. preopera tively prove n N2·s ituatio ns were excluded by the diagnostic findi ngs including CT-scan in every patient an d mediastin oscopy in those with en larged mediastinal Iymph nodes. Neve rtheless . mediastinal Iymph node involvement was confirm ed during th e operation in 3 patients. The y all received postope rativ e ra diotherapy. Th ree other patie nts had preoper ative and postoperative radi ation with 30 Gy each. Previous rad ioth er ap y precluded furt he r radlaüon in a subgroup of patie nts with breast cancer recurren ce. In the patients with sa rcoma , malignant mescthelioma an d various other condlttons . su rgical treatme nt was inst itute d after form er chemo thera py ha d prove n to be une fficient or th e patien t' s refusa l to cont inue . Functional impairme nt a nd increased risk was affirme d in the majority of pat ients with lung cancer but was uncomm on in other categories.
Tabl. 3 Pulmonary resections asscciated with ehest wall exctsicn
Bronchial carcin. Sarcoma Mesothehoma Melanoma Breast cancer
Pn
Lob
Segm
4
15 1 1
4
2 1 1
1
Pn
=
4 7 1 1
3 4
other Total
Wedge
8
18
6
20
pneumonectomy, l ob = lobectomy, Segm = segmental resction
Tec hnique of r econstruction The mode of reconstru ction was significantly diITerentl y cornparing th e group of pat ient s with lung cancer and the majority of patient s in the other subgroups. In particular , patients with ehest wall reeurrenee of breast cance r requ ired a much more complex str ategy, since major area s of wh ole - Iayer thorac ic wall had to be resected .
Pulmonary tumo rs with ehest wall invasio n Operating on this category of tumors means following the principles oflung cancer surgery with early control of th e hilar vasc ular stru ctur es of the alTected lobe or lung if at all possible. With the periphera l invasive fixation , advanced skill for the exposu re of th e centra l vasc ular and bron chial structures might be required. The inner ehest wall, in the majority of cases, will not be penetr ated by th e tumor, thereb y giving an easy plan e of cleavage. Ribs and intercostal muscles can be severe d at an app ropr iate distance to the zone of invasion . Therefore, usually, th e reconstru ction of the defect is technicallyless demanding. The overlyin g muscular struct ures. the subcutaneous and th e cutaneous layers can be reun ited without tension . Whether it is either feasible or unn ecessary to care for the defect of Ihe chest wall itself, depends on its size and location. In defects res ulting from the resection of limited segments of no more th an 3 ribs, even in the lateral and anterior region . nothing needs to be done. Replacing th e resected par t with a PTFE' implant 1
Fa. W. L. Gore & Assoe. GmbH, Herman n- Überth -Str . 22 , 80 11 Putzbrunn , Mün chen
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242
Recanst ructicn of e hest Wall Defects
Thorac. cardiova sc. S urgeon 39 (1991)
243
Fig. 1 c Appeara nce 8 weeks after the oper-
cr
seanin e68-year-old femalewithsrnoking history.Peripheral Fig. 1a adenoeareinomaofth e right upper lobewith grossinvasion andpenetration of the ehest wall
minor resections. It is of importa nce, however, to str ive for minima l air Ieakage and prop er ehest drainage. Fig. 1 shows one of our most extended ehest wall reseetion for invasive adenocarcinoma of the right upp er lobe in a fernale with the rath er atypieal penetration into the subseapu lar muscle layer (Fig. l bl. The eosmetie result is shown in Fig. l c. No implants were used in thi s pati ent and in most of the 24 procedur es in lung cancer patients.
Mesenehyma l and metastatic ehest wall disease
Fig. 1b Situation afterreseetionofth euppe r and, partially,themiddlelobe in eontinuity with 6 ribs. Note the dislocatton of the scaputa (_)
might be considered for mainly cosmetic rea son s an d with larger defeets. If temporary support is des ired , a resorba ble mesh will suffice. In the posterior position. we very much prefer a circular fixation of the over lying muscles using resorbabIe suture material. This provides satisfaetory restitution of the pleural cavity avoiding external fluid accumulation in the case of a pneumonectomy and contributing to the avoidance of soft tissue emph ysema after
In a relatively large proportion of cases, the mese ncbyma I tumors were ofcon siderable size involving lar ge areas of the ehest wall sometimes also req uiring lung resection includlng pneumoneetomy. In those patients who belonged to the youngest age group (Table 2), not only for eosmetie purposes but also for support of the soft tissue pIast y, lar ge sheets of PTFE soft tlssue material of one or two millimeter thickness were usually inserted, or, in one case each, a MarIex-mesh and an individually sba ped methyI-metae rylate prosthesis. Fig. 2 shows the C'I' sean of a 37-year-o ld femal e after operation and radlotherapy of right-sided breast cancer with the development of a radi o-Indu eed huge osteosareoma. Large parts of the ehest wall and the entire right lung were Involved. After rlght-sided pneumo neetom y with removal of 5 ribs sta rting at the sternal border, a lar ge PTFE sheet was insert ed. The reconstruction oft he exte rnal tissue layers was faeilitated by the gross reduetion of the rlght ehest volume (Fig. 2b). She ha s survlved without complaints for 8 months, but recently underw ent resection of a 1 em recurrent nodule close to the former site of oper ation . The cosmetic appearance is acceptable. Anothe r example ofthe very universal use of PTFE implant s is dem onstrated in the case of a young female with a large tumor orlglnatin g from the lower ehest wall on the right side IFig. 3a). Histologically, this was an ade nocarcinoma of hitherto unknown origin with preoperatively undetected pleural metastases.
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ation
Thorac. cardiovasc. Surgeon 39 (1991 )
Clinically, the tumor exhibited a macbine-like murrnur due
1. !fasse
postoperative CT (Fig. 3c).
the skeletal involvement ofribs and ste rn um, the extension of tumor sprea d in the overlying soft tissue might be considerable. Although pain is not inevitable in every case , the unpleasant appea rance and missing therap euti c alterna tives cause the patient to seek surgical relief. Replacement of ribs and sternum can be achieved by alloplastic implants . For the res titution of the integument, in critical cases , the greater omenturn should be employed which can be covered with a skin meshgraft immediat ely or in a staged
Tumors involving the sternum
process. In spite of extended sternal resection. in most cases the internal mammary ves sels of one side ean be preserved
to rieh vase ularization from intercostal vessels. The resec-
tion included a large area of the lower posterolateral ehest wall an d part of the right diaphragm. A small su perficially located nodule of the liver was equally excised. Fig. 3b shows the situation after reconstruction of diaphragm and ehes t wall in a eombined manner. The funetional and eos metic result was exee llent, as can be imagined from the
In the case of recurrent breast cancer , usually multiple unfavorable conditions enhanee the problems of reeon-
struction. The surrounding tissue is often dama ged by former scars and/o r the sequela of radiotherapy. Besides
allowing for the use of a large and wide-ranging musculocutaneous rectus flap (13). Altern atively, muscolocutan eous flaps can be derived from the back with the use of the latissimus dorsi muscle and its vascular supply. For this procedur e, the patient must be positioned on her less involved side. If the resection extends frontally far to the opposite side or if post radiation/po st surgical cieatrization reaches far posterolaterally, we do not recommend this choiee. Replacement of the inn er ehest wall has been successfully achieved in two cases ofbreast cancer with the aid of methyl-metacrylate implants in the precordial position, as demonstr ated by Fig. 4, in a patient who has survived for 3 years without evidenee of disease after complete reseetion of reeurrent duetal breast cancer. In this ease, there was
little involvement ofthe extrat horacic soft tissue layers, and in spite of incomplete excision elsewhere, an elliptoid defect of 12 x 10 cm could prim arily be reconstru cted with a large fascio-cutan eous flap (Fig. 4). Total removal of the ste rn um can be successfully compensated with the use of large PTFE grafts of 2 mm thickness. Fig. 5a shows the CT scan section of a male patient with osteochondrosa rcoma of the stern um infiltrating the pericardium and the anterior diaphragm. The resection
Fig. 2 a Cl scanofa 37·year-oldtemale withosteogenic sarcoma after operationand radiotherapy of rfght-sided breast cancer
included the stern um and adjacent ribs of both sides . A 2mm-PTFE-graft was sewn into place with num erou s heavy sutures upholstered with small pieces of additional PTFE pledges (Fig. 5b). The width of the implant had exactly Fig.2 b Postoperativefmdmgwithseropneumothorax.Reconstruction withPTFE implant. The breast siliconIrrorant (see Flg. 2a) wasremoved
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244
Reccnstruction of ehest
wett Defects
Thora c. card iov(Jsc. Surgeo/l3lJ (199 1)
245
Fig.4 Lateral ehest x.rayafterresectton of thelower sternumand the left precordial ehest wallfor loeal recurrenceof breast cancer.Situation 18 monthspostoperativeIy.Survival time3 yearswithoutevidence of new recurrence
ma tch ed to the measurem ent of th e removed spe cim en . Postoper atively, pe rs isting serous drain age was observerl from the space betwee n th e covering myocutan eou s Gap an d th e impl ant layers. With th e int erposition ofthe gre a ter om enturn in a sec ond procedure. thi s ceased im me dia tely.
Treatment ofpenetratinq radionecrosis Fig.3 b Operativesitusaftersubstitution of the diaphragmatic andttcracrc wall defect with theuse of a PTFE implant showedbyCf scan 3 rnontns postoperatively
\ Vith rega rd to thc min or vasc ula rity of th e surrounding tissue in ehe st wa ll necro sis even a fter generous excis ion, aga in, the use of th e greate r om entum is the most appropriate method of re pa ir in our opinio n. In a fem a le sufTering from ad ditiona l nec ro tic ab scess formati on of the left upp er lobe a nd consec utive empyema, our a pproach was seg me n tal resection and decortication al ong with the excisio n oft he subax illary ehes t wa ll a rea. The defeet was reco nst ructed wit h the a id oft he greate r omen turn which was brought int o posit ion trans pleu ra lly. Loca l heali ng was a chi eved prorn pt ly (Fig. 61. Rcsulls ofre const rurt ion
Fig. 3 c
Postoperative Cl sean
In th e who le se ries, th er e wa s one postoperative death which is comme nted on below. ln one pati ent, a s mention ed be fore, increa sed chronic Iym ph produ ction ha d to be tr eat ed by interpo sition of the greate r ome nt urn. In two pati ents . cor rec tive ope ra tions were necessary for infection, one du rin g th e primary hos pital stay, one aft er 4 months wit hout bridging sy mpto ms . In the lauer, th e imp lan ted a llograft was re mov ed as it had induced astr an g tiss uc formation towards the pleura l space. In a ddit ion. the re were 2 supe rficial skin nec roses in a fascio-cutan eous a nd a mu sculo-cut aneou s fla p, resp ectively. In th e patien t w ho died 6 weeks after co mplet e rem ova l of the ste rnum and seg rnents of both clav icles, th e ca use of death was du e to ne urological failure from a form er ly unk nown ind ep enden t brain tumo r. However, in this 69 -yea r-o ld obcse female
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Fig. 3 a Cl scan ot afemalepatient with carcmomaof unknownprimaryorigin. Note the invasion 01the diaphragmand impression of tne liver surface
i . Hasse
Thorac. cardiolJasc. Surg eo1l 3 9 (199 1)
Fig. 5 b Reconstructionof thedefect after subtotal removal of sternum,biateral ribs andanterior diaphragrnin continutty with thepericardium. Fixation withfigure ct U-suturesreinforced by PTFEpledges
Fig.5a
Cl scanwith lower section of osteochondrosarcorna of the sternum
Fig. 6a Photograph of apatientwithaxillary ehestwall necrosis, lung abscess and empyema3 yearsafter curative radiation of breastcancer (refusal of surgicaltherapy) withthegreater omentumtranspleurally brought into theoperative thoraclc field
Fig.Bb Situation prior to skin mesh graftingon day 8 postoperatively
wit h me tastati c ste rnal involveme nt from loeally eured ovarian cancer , we observed th e ph enomen on that the sutu re ho les of th e PTFE imp lant had st retehe d und er ten sion in the course of iner easin g aetivity of the fully mobilized patient. Subseq uently thi s led to limited soft tissu e n eer osis a nd infeetion requiring seconda ry ome nt urn plasty an d postop er ati ve ven tila tion the ra py. Apa rt fro m this patient postoperative mech ani eal ventilati on was not neeess ary in an y of'the opera tions . Disc ussion Large se ries of pati ent s wit h exte nded ehes t wall rese ction ha ve been reported by Amold a nd Pairolero, the grou ps of Mart ini, Mounte in an d othe rs O . 5, 10 , 11 , 12). The pr ogress ma de with in this field was due to increasing expe rienee with the us e of myoe utaneous fla ps whieh allowed
eom plete reseetion a nd on e-st age reconstruction. Th e reliability of this technique was an esse ntial pr erequisite for th e use of alloplastie impl ants substituting la rge defeets of th e skeletal thoraeie wall , in partieular after exte nded an terior ehest wall resection . Th is , in turn, was a major pr crequisite for the pr evention of serious re spiratory failures. Th e most cr itica l situa tion arise s whe n the tota l st ern um togeth er with the clavicular junction has to be re seeted . Different meth ods have bee n used to rest or e th e sta bility of the ehest wa ll. thereby overeoming paradoxical respiration . Com posite imp lan ts usin g methyl-metacrylat e in conj uncti on with Marlex-m esh have been used by several groups (2, 5, 11) and in seleeted eases also by ourselves (7). In contrast, Pairolero and A m old 0 21favor non-rigid prosthetie material Iike Prolen e mesh a nd, sin ee thi s is available, 2-mrn PTFE inser ted unde r ten sion . As sho wn by Erluird et al. (4), even very large defects of the lateral ehest wa ll ea n be
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246
0/
reconstructed by th e us e of a vicryl mesh serving tempora rily as a mechanical support for th e overlying myocutan eous layers. A major contribution to ehest wall reconstruction certainly is the idea of making use of th e great er omenturn which , through its rich vas cularity, is able to support imm ediate healing even und er compro mising conditions (3, 8).
There remains th e ques tion of long-term survival. Considering the fact tha t in most series , as in this one, except for invasive lung ca ncer , a large va riety of conditions is responsible for the need for ehest wa ll resection, only a few pap ers deal with long-term surviva l. McCormack et al. (10) had an ovcrallS -yea r-survival rate of 23 %. Orten however , a priori, the cha nce of complete recovery from th e disease is minima l or absent. With a 10w ra te of morbidity, complications and mortality, nevertheless, resection is justifi ed in or der to improve the qua lity of life.
References I
2
1 4
5
Th ora c. ca rdi m ·asc. Surgeon39 (199 1)
e hes t Wall Defe ct s
A motd. P. G.• and P. C Pairolero: Chest Wall Tu mo rs : Expe rience with 100 Consecutive Patients. An n. Surg. 90 (198 5) 36 7 -3 i2 Boyd. A. D.. l"':W:S haw. J. G..\fcCarlhy. D. C Bak er, X. K. Trehan. A J. Acinapu ra. a nd F. C Spencer: Imm edi ate Recon stru ction of Fu ll-Thic kne ss Che st Wall Defects . Ann. Th orac. Surg. 32 (19 81) 33 7-346 Dingm an. R. 0.. a nd L. C Argenta: Recon stru ct ion of the Chest Wa l1. Ann. Th ora c. Su rg. 3 2 (19 81 ) 20 2- 20 8 Emard . J.• N. Rohm. an d J. Macn ato. Thoraxw a nd re kon stru ktio n. Th orac . ca rdiovasc . Su rge on 35 (19 87) 119 - 123 Eschapasse, 11.. 1. Gaillard. E. /fe tlry. B. vassa tlo. a nd M. Laeheheb: Chest Wa ll Tum ors : Surgica l Ma nage me nt. In: Grille . 11 . C., a nd H. Escha pa sse Ieds.): Maj or Challenges . Philad elphi a . Sa u nders 198 7. pp 292 - 307
" Grillo. lI. C: Pleu ra l a nd Chest Wa lli nvolvemen t.ln : Delarue. X. c.. a nd 11. Escha pa sse Ieds .l. Lung Cance r . Ph ila de lph ia . W. H. Sau nder, 1985, pp 134 -1 38 7 Hasse. J.: Surgery for Prima !"}' lnvasive a nd Metastarie ~I a li gn an · eies of th e Chest Wall. Eur. J. Tborac . Cardiovas . Su rg . 5 099 0 346- 35 1 8 Hollender. L. F.. a nd F. Bur: Chi ru rgie d es großen Netze s. Springe r. Berlin-Heidelbe rg 198 5. p p 9 8 - 10 1
Reconstruction of ehest Wall Defects 1. Hasse
Summa ry
Versorgung von Tho raxwa ndde fe kte n
Aseries of 61 consecutive procedur es of ehest wall resection and reconstru ction in 58 patients during the period between Augus t. 1986 a nd December. 1990 is reported. The ages ra nged between 6- 77 years. The ehe st wall res ection wa s indicated for maligna nt afTectio ns in 54 ca ses. Among these, there we re 24 patients with bron ch ial ca rci noma lnvad lng the ehes t \v-all. 17 patients with primary or metastatic sarcoma. 11 paüerus with reeurrent breast ca nce r a nd 3 with ca nce r me ta stases of varying origin. Pulmonary resection included pn eumonectomy in 8 cases. Iobectomy in 19. segm en tal and wedge resection s in 26. In th e majority of resections. the reconstruction was accomplishe d without impla nts. In cases with fullthi ckness remova l of the ehes t wall. th e pla ne ofl he rib cage a nd/or the sternum was reconstru cted using Vicryl mesh (n :: 7). PTFE soft tissu e patch (n = 11), ma rlex-mesh (n ... 0 , or methyl-metacrylat e (n = 3), Ther e was one case of hospital mortality, 6 week s postope ra tively, du e to neurologreal failure from an Independent preoperat ively undiagnose d bra in tumor. There we re 4 reope ratio ns : one ea rly a nd one late (4 months) infection, one case of limited superficial necrosis of a flap a nd one wlth ehre nie lymphous dr ainage from a large myocutan ec us fla p. In no instance wa s pri ma ry postop erat ive vent ila tion th era py necessa ry. Mecha nical ventilat icn wa s ins tituted only on day 8 in the patient wh n accou nts for th e mortality in this ser ies . In the presence of prima ry infection, th e gr eater ome ntum was used for the rest orat ion ofthe integu me nt.
In der Zeit von August 1986 bis Dezemb er 1990 wu rden bei 58 Patient en 6 1 konsekutive Brustwa nd resektionen vorgen ommen. Die Altersspanne reicht von 6- 77 Ja hren. Bei 54 Pati enten wur den die Brustwan d rese ktio nen wegen maligne r Erkra nkun gen notwen dig. In 24 Fä llen hand elte es sich um ei ne Brustwandinvasion du rch ein Bronchialk arzinom , in 17 Fä llen um Patienten mit prim ä rem ode r me tas ta tischem Sark om . Bei 11 Fra uen lag ein loco-regtonäres Rezidiv na ch Mam maka rz inom vor , bei 3 weiteren Patienten die Bru stwandmetast as e sonstiger Karzin ome. Gleichzeitig mit der Thor a xwan dr esektion wurd en in 8 Fällen Pneumonektomien ausgefüh rt. 19 x eine Lobektom ie sow ie isoliert oder in Verb indun g mit ei ne r Lobekt omie 26 Segme nt - und Keilresektionen. In der Mehr zah l der Fälle wurde bei der Rekons truktion der Brustw a nd auf Impla ntate verzichtet. Insbesondere bei Resektion sä mtlicher Brustwa ndschichten wu rde d ie innere Brustwa nd . d. h. Rippenthorax und ggf. Sternum mit Vicrylnetz (7 Fälle), PTFE so ft
Ke~'
werds
e hest wa ll tumor - Metastases - En bloc res ection - Stern al res ection - Allop lastic mat eri al
tissue 11 1 Fälle). Marlex11 FallJ und Methyl-Metacrylat (3 Fälle) ersetzt. Die 30-Tage-Letalität war Null. Ein Todes fall 6 Wochen postoperativ geht auf eine schwere neurologische Störung bei prä opera tiv nicht beka nnt em una bhängigen Hirntum or zurüc k. Es ,..-urden 4 Reoperat ion en erforde rlich: je 1 x bei Früh- und Späti nfektion (4 Monate) sowie je 1 x wegen l .appenra nd nekrose und per sistieren der Lymphd rai nage. Keine r der Patien ten bedu rfte ei ner primä ren Nachbeatrnung. Die Beatmung sindikat ion be i der versto rb en en Patientirr ergab sich arn 8 . postope ra tiven Tage. Bei pro blem ati schen Weichteilver hältnissen insbeso nde re mit pr imä rer Infektion und be i der Behandlun g der per sistierenden Lymphsekretion - wurde das Omen turn majus verwend et,
Inlroduclion Defeets of the thoraeie wall mostly result from the resection of mali gnan t disease. This ean be mesenehymal tumo rs prim arlly originating from stru etures of the ehest wall, metastases from previous tum ors of distant location, loeal recurrence of brea st cancer in fema Je patients, and, finally, invasion of lung cancer. But also a non-m alignan t lesion may require exten ded reseetion of tb e tho racie wall as weil as neerotic lesions after radiotherapy of brea st cancer. Especially in malignant tum ors an d in cas es of radi onecroses, generous excision is man datory in orde r to improv e long-terrn prognosis and un eomp lieated healing. lt has been learn ed in the past th at large areas of the ehest wall ca n be Thorac. cardiovasc. Surgeon 39 (1991) (Supplement1241- 247 © Georg Thieme Verlag Stuttgart . New York
sacrificed, on condition that adequate reconstru ction has been planned and aeeomplished. Surprisingly, with proper care, respiratory problems caused by temporary instabilit y ar e of minor concern. There is an importan t difTerence between lesions arising from layers of the ehest wall and those originat ing from the lung, seeon darily infiltrating ribs and inter eostal muscles. The former very often requi re full thiekness removal of th e ehest wall includi ng the eutaneous and sub eutan eous strata . The necessity of reseetion of a ehest wall area together with part or even all of th e und erlying lung ca n be the ease in either event. Al pr esent, a eonsiderable speetrum oft eehnieal solutions for reeonstru etive surgery is avallable. These include the reestablish ment of the stability and the
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Department of Thoraeie Surgery. University of Frei burg . Fre iburg. Ger ma ny
1. Hasse
Thorac. cardiOl'asc. Surgeon 39 (199 1)
closure of even ver y larg e defects of the soft tissu e layers including th e skin. Even in patient s with mer ely palliative indication, there fore, large resections are ju stified in orde r to prevent or tr eat severe pain or , in the cas e of radiation necrosis or tumor ulceration , to ab olish chronic infection and terminate permanent medical care. In th e case oflo cally aggressive lung cancer, the development of re constructive techniques has allowed for the extension of the indication for surgical tr eatment at a rath er low risk. \Vith complete resection and in the absence of lymphatic spread, a 54 % 5yea r-survival has been reported by Grillo (6) and even 62 % by Martini et al. (9). With incomp lete resection and desp ite postoperative radiation therapy, the langest survival was 2 1/ 2 years in their experience. Since technical asp eets are th e main topic of this contribution , ehest wall resection s of all oft he aforementioned indi cations have been includ ed.
Table 1 Type ot ehest wa ll dtsease Diagnosis
No. of Patients
No. of Procedures
Bronchialcercmoma Mesenchymal tumors Breast cancer Othermetastatic cancer Benign
24
24 20
Total
58
Table 2
17 11
11 3
3 3
3
61
Age distributtön within the main diagnostic groups Age (years) Range
Mean
36-76 14- 76 34-67
Lung cancer Mesenchymal tumors Breast cancer
61 47 55
Material and Methods The pr esen t re port deals with 58 patients and a total of 61 consec utivc chestwall resections. isola ted or combined with pulmonary rese ction within the time period from August 1986 to December 1990 . With the exce ption of 3 cases (1 with multiple excstosis. 2 with ra diatio n nccrosts and osteo myelitis after radi ation thera py of br east cancer). all were for maligna nt afTections. There were 27 fernale a nd 31 male patient s. Table 1 shows th e brea kdow n into indica tory groups with 41.4 % bron chial carc inoma . 29.3% sa rcoma or other mesenchymal tumors a nd 19 % breast cancer. The youngest pat ient was 6 years of age , the oldes t was a female pati en t of 78 yea rs . The mea n age differ ed among the main diagn ostic groups as shcw n in Table 2 with th e highes t average age in the group ofl ung ca ncer patient s. Pulmonary rese ction was ca rrie d out in not only in all cases oftnvastve br onch ial ca rcinoma, but also in a high perce ntag e of othe r ehes t wall maHgnan cies. There were 8 pneum onectomies in this se ries : 4 with bronchial carci noma , 2 Ior gross involvemen t by (one osteoge nic, onc neur ofibro) sa rcoma and one each melan om a a nd mescth elioma. A com plete overv iew of all pulmona ry resections wit hin the se ries is show n in Table 3. With regard to the extensio n of the excised ehest wall area , up to 6 ribs were resec ted. Ther e we re 6 patien ts in th e gro up of rec urrent breast cancer with partial or complete resection ofthe ste rnal body. Furthermore . 3 ste rnal resectio ns were perfo rme d for osteogenic sarcoma and meta static th yroid cancer and . in a female with sub total ste rnal resection includi ng onc qua rter of eac h clavtcula . for metastatic invclvement after form er adenocarci noma ofthe uterus. Any decision in favor of such a surgic al treatme nt in a given condition was mad e by an interd isciplin ary conference cons ideri ng the abs ence of efficient alternative treatm ent . the severity of pain . the th reat of complications , aud . in a number of cases, the cha nce of eure with complete removal of the tu mor . In the lung cancer gro up. preopera tively prove n N2·s ituatio ns were excluded by the diagnostic findi ngs including CT-scan in every patient an d mediastin oscopy in those with en larged mediastinal Iymph nodes. Neve rtheless . mediastinal Iymph node involvement was confirm ed during th e operation in 3 patients. The y all received postope rativ e ra diotherapy. Th ree other patie nts had preoper ative and postoperative radi ation with 30 Gy each. Previous rad ioth er ap y precluded furt he r radlaüon in a subgroup of patie nts with breast cancer recurren ce. In the patients with sa rcoma , malignant mescthelioma an d various other condlttons . su rgical treatme nt was inst itute d after form er chemo thera py ha d prove n to be une fficient or th e patien t' s refusa l to cont inue . Functional impairme nt a nd increased risk was affirme d in the majority of pat ients with lung cancer but was uncomm on in other categories.
Tabl. 3 Pulmonary resections asscciated with ehest wall exctsicn
Bronchial carcin. Sarcoma Mesothehoma Melanoma Breast cancer
Pn
Lob
Segm
4
15 1 1
4
2 1 1
1
Pn
=
4 7 1 1
3 4
other Total
Wedge
8
18
6
20
pneumonectomy, l ob = lobectomy, Segm = segmental resction
Tec hnique of r econstruction The mode of reconstru ction was significantly diITerentl y cornparing th e group of pat ient s with lung cancer and the majority of patient s in the other subgroups. In particular , patients with ehest wall reeurrenee of breast cance r requ ired a much more complex str ategy, since major area s of wh ole - Iayer thorac ic wall had to be resected .
Pulmonary tumo rs with ehest wall invasio n Operating on this category of tumors means following the principles oflung cancer surgery with early control of th e hilar vasc ular stru ctur es of the alTected lobe or lung if at all possible. With the periphera l invasive fixation , advanced skill for the exposu re of th e centra l vasc ular and bron chial structures might be required. The inner ehest wall, in the majority of cases, will not be penetr ated by th e tumor, thereb y giving an easy plan e of cleavage. Ribs and intercostal muscles can be severe d at an app ropr iate distance to the zone of invasion . Therefore, usually, th e reconstru ction of the defect is technicallyless demanding. The overlyin g muscular struct ures. the subcutaneous and th e cutaneous layers can be reun ited without tension . Whether it is either feasible or unn ecessary to care for the defect of Ihe chest wall itself, depends on its size and location. In defects res ulting from the resection of limited segments of no more th an 3 ribs, even in the lateral and anterior region . nothing needs to be done. Replacing th e resected par t with a PTFE' implant 1
Fa. W. L. Gore & Assoe. GmbH, Herman n- Überth -Str . 22 , 80 11 Putzbrunn , Mün chen
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242
Recanst ructicn of e hest Wall Defects
Thorac. cardiova sc. S urgeon 39 (1991)
243
Fig. 1 c Appeara nce 8 weeks after the oper-
cr
seanin e68-year-old femalewithsrnoking history.Peripheral Fig. 1a adenoeareinomaofth e right upper lobewith grossinvasion andpenetration of the ehest wall
minor resections. It is of importa nce, however, to str ive for minima l air Ieakage and prop er ehest drainage. Fig. 1 shows one of our most extended ehest wall reseetion for invasive adenocarcinoma of the right upp er lobe in a fernale with the rath er atypieal penetration into the subseapu lar muscle layer (Fig. l bl. The eosmetie result is shown in Fig. l c. No implants were used in thi s pati ent and in most of the 24 procedur es in lung cancer patients.
Mesenehyma l and metastatic ehest wall disease
Fig. 1b Situation afterreseetionofth euppe r and, partially,themiddlelobe in eontinuity with 6 ribs. Note the dislocatton of the scaputa (_)
might be considered for mainly cosmetic rea son s an d with larger defeets. If temporary support is des ired , a resorba ble mesh will suffice. In the posterior position. we very much prefer a circular fixation of the over lying muscles using resorbabIe suture material. This provides satisfaetory restitution of the pleural cavity avoiding external fluid accumulation in the case of a pneumonectomy and contributing to the avoidance of soft tissue emph ysema after
In a relatively large proportion of cases, the mese ncbyma I tumors were ofcon siderable size involving lar ge areas of the ehest wall sometimes also req uiring lung resection includlng pneumoneetomy. In those patients who belonged to the youngest age group (Table 2), not only for eosmetie purposes but also for support of the soft tissue pIast y, lar ge sheets of PTFE soft tlssue material of one or two millimeter thickness were usually inserted, or, in one case each, a MarIex-mesh and an individually sba ped methyI-metae rylate prosthesis. Fig. 2 shows the C'I' sean of a 37-year-o ld femal e after operation and radlotherapy of right-sided breast cancer with the development of a radi o-Indu eed huge osteosareoma. Large parts of the ehest wall and the entire right lung were Involved. After rlght-sided pneumo neetom y with removal of 5 ribs sta rting at the sternal border, a lar ge PTFE sheet was insert ed. The reconstruction oft he exte rnal tissue layers was faeilitated by the gross reduetion of the rlght ehest volume (Fig. 2b). She ha s survlved without complaints for 8 months, but recently underw ent resection of a 1 em recurrent nodule close to the former site of oper ation . The cosmetic appearance is acceptable. Anothe r example ofthe very universal use of PTFE implant s is dem onstrated in the case of a young female with a large tumor orlglnatin g from the lower ehest wall on the right side IFig. 3a). Histologically, this was an ade nocarcinoma of hitherto unknown origin with preoperatively undetected pleural metastases.
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ation
Thorac. cardiovasc. Surgeon 39 (1991 )
Clinically, the tumor exhibited a macbine-like murrnur due
1. !fasse
postoperative CT (Fig. 3c).
the skeletal involvement ofribs and ste rn um, the extension of tumor sprea d in the overlying soft tissue might be considerable. Although pain is not inevitable in every case , the unpleasant appea rance and missing therap euti c alterna tives cause the patient to seek surgical relief. Replacement of ribs and sternum can be achieved by alloplastic implants . For the res titution of the integument, in critical cases , the greater omenturn should be employed which can be covered with a skin meshgraft immediat ely or in a staged
Tumors involving the sternum
process. In spite of extended sternal resection. in most cases the internal mammary ves sels of one side ean be preserved
to rieh vase ularization from intercostal vessels. The resec-
tion included a large area of the lower posterolateral ehest wall an d part of the right diaphragm. A small su perficially located nodule of the liver was equally excised. Fig. 3b shows the situation after reconstruction of diaphragm and ehes t wall in a eombined manner. The funetional and eos metic result was exee llent, as can be imagined from the
In the case of recurrent breast cancer , usually multiple unfavorable conditions enhanee the problems of reeon-
struction. The surrounding tissue is often dama ged by former scars and/o r the sequela of radiotherapy. Besides
allowing for the use of a large and wide-ranging musculocutaneous rectus flap (13). Altern atively, muscolocutan eous flaps can be derived from the back with the use of the latissimus dorsi muscle and its vascular supply. For this procedur e, the patient must be positioned on her less involved side. If the resection extends frontally far to the opposite side or if post radiation/po st surgical cieatrization reaches far posterolaterally, we do not recommend this choiee. Replacement of the inn er ehest wall has been successfully achieved in two cases ofbreast cancer with the aid of methyl-metacrylate implants in the precordial position, as demonstr ated by Fig. 4, in a patient who has survived for 3 years without evidenee of disease after complete reseetion of reeurrent duetal breast cancer. In this ease, there was
little involvement ofthe extrat horacic soft tissue layers, and in spite of incomplete excision elsewhere, an elliptoid defect of 12 x 10 cm could prim arily be reconstru cted with a large fascio-cutan eous flap (Fig. 4). Total removal of the ste rn um can be successfully compensated with the use of large PTFE grafts of 2 mm thickness. Fig. 5a shows the CT scan section of a male patient with osteochondrosa rcoma of the stern um infiltrating the pericardium and the anterior diaphragm. The resection
Fig. 2 a Cl scanofa 37·year-oldtemale withosteogenic sarcoma after operationand radiotherapy of rfght-sided breast cancer
included the stern um and adjacent ribs of both sides . A 2mm-PTFE-graft was sewn into place with num erou s heavy sutures upholstered with small pieces of additional PTFE pledges (Fig. 5b). The width of the implant had exactly Fig.2 b Postoperativefmdmgwithseropneumothorax.Reconstruction withPTFE implant. The breast siliconIrrorant (see Flg. 2a) wasremoved
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244
Reccnstruction of ehest
wett Defects
Thora c. card iov(Jsc. Surgeo/l3lJ (199 1)
245
Fig.4 Lateral ehest x.rayafterresectton of thelower sternumand the left precordial ehest wallfor loeal recurrenceof breast cancer.Situation 18 monthspostoperativeIy.Survival time3 yearswithoutevidence of new recurrence
ma tch ed to the measurem ent of th e removed spe cim en . Postoper atively, pe rs isting serous drain age was observerl from the space betwee n th e covering myocutan eou s Gap an d th e impl ant layers. With th e int erposition ofthe gre a ter om enturn in a sec ond procedure. thi s ceased im me dia tely.
Treatment ofpenetratinq radionecrosis Fig.3 b Operativesitusaftersubstitution of the diaphragmatic andttcracrc wall defect with theuse of a PTFE implant showedbyCf scan 3 rnontns postoperatively
\ Vith rega rd to thc min or vasc ula rity of th e surrounding tissue in ehe st wa ll necro sis even a fter generous excis ion, aga in, the use of th e greate r om entum is the most appropriate method of re pa ir in our opinio n. In a fem a le sufTering from ad ditiona l nec ro tic ab scess formati on of the left upp er lobe a nd consec utive empyema, our a pproach was seg me n tal resection and decortication al ong with the excisio n oft he subax illary ehes t wa ll a rea. The defeet was reco nst ructed wit h the a id oft he greate r omen turn which was brought int o posit ion trans pleu ra lly. Loca l heali ng was a chi eved prorn pt ly (Fig. 61. Rcsulls ofre const rurt ion
Fig. 3 c
Postoperative Cl sean
In th e who le se ries, th er e wa s one postoperative death which is comme nted on below. ln one pati ent, a s mention ed be fore, increa sed chronic Iym ph produ ction ha d to be tr eat ed by interpo sition of the greate r ome nt urn. In two pati ents . cor rec tive ope ra tions were necessary for infection, one du rin g th e primary hos pital stay, one aft er 4 months wit hout bridging sy mpto ms . In the lauer, th e imp lan ted a llograft was re mov ed as it had induced astr an g tiss uc formation towards the pleura l space. In a ddit ion. the re were 2 supe rficial skin nec roses in a fascio-cutan eous a nd a mu sculo-cut aneou s fla p, resp ectively. In th e patien t w ho died 6 weeks after co mplet e rem ova l of the ste rnum and seg rnents of both clav icles, th e ca use of death was du e to ne urological failure from a form er ly unk nown ind ep enden t brain tumo r. However, in this 69 -yea r-o ld obcse female
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Fig. 3 a Cl scan ot afemalepatient with carcmomaof unknownprimaryorigin. Note the invasion 01the diaphragmand impression of tne liver surface
i . Hasse
Thorac. cardiolJasc. Surg eo1l 3 9 (199 1)
Fig. 5 b Reconstructionof thedefect after subtotal removal of sternum,biateral ribs andanterior diaphragrnin continutty with thepericardium. Fixation withfigure ct U-suturesreinforced by PTFEpledges
Fig.5a
Cl scanwith lower section of osteochondrosarcorna of the sternum
Fig. 6a Photograph of apatientwithaxillary ehestwall necrosis, lung abscess and empyema3 yearsafter curative radiation of breastcancer (refusal of surgicaltherapy) withthegreater omentumtranspleurally brought into theoperative thoraclc field
Fig.Bb Situation prior to skin mesh graftingon day 8 postoperatively
wit h me tastati c ste rnal involveme nt from loeally eured ovarian cancer , we observed th e ph enomen on that the sutu re ho les of th e PTFE imp lant had st retehe d und er ten sion in the course of iner easin g aetivity of the fully mobilized patient. Subseq uently thi s led to limited soft tissu e n eer osis a nd infeetion requiring seconda ry ome nt urn plasty an d postop er ati ve ven tila tion the ra py. Apa rt fro m this patient postoperative mech ani eal ventilati on was not neeess ary in an y of'the opera tions . Disc ussion Large se ries of pati ent s wit h exte nded ehes t wall rese ction ha ve been reported by Amold a nd Pairolero, the grou ps of Mart ini, Mounte in an d othe rs O . 5, 10 , 11 , 12). The pr ogress ma de with in this field was due to increasing expe rienee with the us e of myoe utaneous fla ps whieh allowed
eom plete reseetion a nd on e-st age reconstruction. Th e reliability of this technique was an esse ntial pr erequisite for th e use of alloplastie impl ants substituting la rge defeets of th e skeletal thoraeie wall , in partieular after exte nded an terior ehest wall resection . Th is , in turn, was a major pr crequisite for the pr evention of serious re spiratory failures. Th e most cr itica l situa tion arise s whe n the tota l st ern um togeth er with the clavicular junction has to be re seeted . Different meth ods have bee n used to rest or e th e sta bility of the ehest wa ll. thereby overeoming paradoxical respiration . Com posite imp lan ts usin g methyl-metacrylat e in conj uncti on with Marlex-m esh have been used by several groups (2, 5, 11) and in seleeted eases also by ourselves (7). In contrast, Pairolero and A m old 0 21favor non-rigid prosthetie material Iike Prolen e mesh a nd, sin ee thi s is available, 2-mrn PTFE inser ted unde r ten sion . As sho wn by Erluird et al. (4), even very large defects of the lateral ehest wa ll ea n be
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246
0/
reconstructed by th e us e of a vicryl mesh serving tempora rily as a mechanical support for th e overlying myocutan eous layers. A major contribution to ehest wall reconstruction certainly is the idea of making use of th e great er omenturn which , through its rich vas cularity, is able to support imm ediate healing even und er compro mising conditions (3, 8).
There remains th e ques tion of long-term survival. Considering the fact tha t in most series , as in this one, except for invasive lung ca ncer , a large va riety of conditions is responsible for the need for ehest wa ll resection, only a few pap ers deal with long-term surviva l. McCormack et al. (10) had an ovcrallS -yea r-survival rate of 23 %. Orten however , a priori, the cha nce of complete recovery from th e disease is minima l or absent. With a 10w ra te of morbidity, complications and mortality, nevertheless, resection is justifi ed in or der to improve the qua lity of life.
References I
2
1 4
5
Th ora c. ca rdi m ·asc. Surgeon39 (199 1)
e hes t Wall Defe ct s
A motd. P. G.• and P. C Pairolero: Chest Wall Tu mo rs : Expe rience with 100 Consecutive Patients. An n. Surg. 90 (198 5) 36 7 -3 i2 Boyd. A. D.. l"':W:S haw. J. G..\fcCarlhy. D. C Bak er, X. K. Trehan. A J. Acinapu ra. a nd F. C Spencer: Imm edi ate Recon stru ction of Fu ll-Thic kne ss Che st Wall Defects . Ann. Th orac. Surg. 32 (19 81) 33 7-346 Dingm an. R. 0.. a nd L. C Argenta: Recon stru ct ion of the Chest Wa l1. Ann. Th ora c. Su rg. 3 2 (19 81 ) 20 2- 20 8 Emard . J.• N. Rohm. an d J. Macn ato. Thoraxw a nd re kon stru ktio n. Th orac . ca rdiovasc . Su rge on 35 (19 87) 119 - 123 Eschapasse, 11.. 1. Gaillard. E. /fe tlry. B. vassa tlo. a nd M. Laeheheb: Chest Wa ll Tum ors : Surgica l Ma nage me nt. In: Grille . 11 . C., a nd H. Escha pa sse Ieds.): Maj or Challenges . Philad elphi a . Sa u nders 198 7. pp 292 - 307
" Grillo. lI. C: Pleu ra l a nd Chest Wa lli nvolvemen t.ln : Delarue. X. c.. a nd 11. Escha pa sse Ieds .l. Lung Cance r . Ph ila de lph ia . W. H. Sau nder, 1985, pp 134 -1 38 7 Hasse. J.: Surgery for Prima !"}' lnvasive a nd Metastarie ~I a li gn an · eies of th e Chest Wall. Eur. J. Tborac . Cardiovas . Su rg . 5 099 0 346- 35 1 8 Hollender. L. F.. a nd F. Bur: Chi ru rgie d es großen Netze s. Springe r. Berlin-Heidelbe rg 198 5. p p 9 8 - 10 1
