cdi&ropaI;~;ic

Original

articles

surgery

: 0 Springer-Verlag 1991 Em J Cardio-thorac

Surg (1991) 5: 346-351

Surgery for primary, invasive and metastatic malignancy of the chest wall J. Hasse Division of Thoracic Surgery, University

Hospital,

University

of Freiburg, Freiburg i. Br., FRG

Abstract. Forty-four patients with primary (n =6), invasive (n= 19) and metastatic (n =21) chest tumours underwent complete resection between 1986 and 1989 in a total of 46 consecutive procedures. Nineteen patients were female and 25 male; 2 patients, 1 male, 1 female, had second operations. The underlying disease was bronchial carcinoma in 17 (14 male), mesenchymal tumours in 17, metastatic breast cancer in 7 and miscellaneous in 5. The chest wall resection included up to 6 ribs. The manubrium was resected in 2 patients, the corpus sterni in 5. Pulmonary resection was performed in 36 cases in an en-bloc fashion. Other concomitant resections included the pericardium, diaphragm or transverse process of the vertebrae. Amputation of the right arm was necessary in two cases. Reconstruction of the thoracic cage was accomplished with PTFE soft tissue patches in 7, methyl methacrylate implants in 2, Marlex mesh in 1 and Vicryl net in 6 cases. In the majority of cases, particularly in dorso-apical and posterior defects, no substitutes were used. A variety of plastic procedures including the use of omentum, musculo- and fasciocutaneous flaps was employed for the reconstruction of the integument. There was no operative mortality. Fourteen patients died after surviving 2-25 months. Serious infection occurred in 1 patient and minor delay of healing in 2. Good palliation can be achieved at low risk. The effect on long-term survival remains uncertain, depending on the basic pathology. [Eur J Cardio-thorac Surg (1991) 5:346-3511 Key words: Chest wall resection - Bronchial carcinoma - Breast cancer - Sarcoma - Allograft implants

Chest wall resection is an important element of thoracic tumour surgery. It allows extension of the indications for operative treatment of lung cancer and is also often the best and/or the only possible therapy of primary and metastatic malignancies affecting the thoracic wall. In general, pulmonary tumours invading the chest wall impose minor difficulties in closing the resulting defect, but usually need more extensive lung resections. Conversely, tumours originating from the chest wall tend to infiltrate the external layers and involve the underlying lung superficially, if at all. Resection of such tumours necessitates more extensive reconstruction of the integument. Principles, technical aspects and results in both types are reported with special consideration of the need for alloplastic and/or autologous substitutes. Material and methods Between August 1986 and December 1989, 44 (19 female and 25 male) patients underwent resection of the chest wall for malignant Read at the 4th Annual Meeting of the European Association Cardio-thoracic Surgery. Naples, September 17-19, 1990

for

disease. In the majority of cases, this was combined with pulmonary resection. The age range was 6 to 77 years with 3 patients under 15 years and 5 patients over 70 years of age. In 17 cases, the chest wall was infiltrated by simultaneous lung cancer. In a further 17 cases, the malignancy was a sarcoma or malignant histiocytoma, either primary or metastatic in origin. Seven patients had a chest wall malignancy in connection with (n= 1) or after (n=6) resection of breast cancer. All had postoperative radiotherapy and 3 had bilateral mastectomy. Five patients had chest wall resection for metastatic thyroid cancer, melanoma or mesothelioma. Of 17 patients with underlying bronchial carcinoma, 14 were male (Table 1). In all but 10 procedures, additional pulmonary resections were necessary for tumour involvement. In 1 patient with a malignant histiocytoma, the right upper lobe was resected solely to permit plastic closure of the chest cavity. Resection of extrapulmonary structures included the pericardium, a segment of the aortic wall, parts of vertebrae, total left diaphragm and the right arm (Table 2). The maximum number of ribs resected was 6, which included ribs l-6 in 2 patients and 5-10 in 1 patient. Two patients underwent resection of the sternal manubrium with adjacent rib segments and 5 patients had removal of the corpus sterni together with up to 4 rib segments. Reconstruction was determined by the size of the resected chest wall area. In most cases of chest wall involvement by bronchial carcinoma, the use of alloplastic material was unnecessary, especially when only 3 ribs were resected. No alloplastic material was used in both patients who underwent resection of 6 ribs combined

341 Table 1. Indications

for chest wall resection

Bronchial carcinoma Mesenchymal tumors Metastatic breast cancer Metastasis of thyroid cancer Malignant melanoma Diffuse malignant melanoma

17 17 7 1 2 2

Total

46

Table 2. Concomitant

resection with chest wall removal

Pulmonary

Other

Wedge Segmentectomy Lobectomy Pneumonectomy None

IO 6 16 4 10

Pericardium Aortic wall Transv. proc. of vertebra Total diaphragm Upper extremity

3

1 4 1 2

with right upper lobectomy. In 7 patients, the inner chest wall was reconstructed using 2 mm Gore-Tex’ soft tissue patches. Two patients with precordial chest wall resection received methyl methacrylate implants (Fig. 2) and 1 patient a Marlex mesh. Temporary chest wall stabilisation was achieved in 6 patients using Vicryl net. In 1 patient, a Gore Tex soft tissue patch was used to reinforce the abdominal wall after harvesting a musculocutaneous rectus abdominis flap. Various methods have been used for the repair of the soft tissue defects including fasciocutaneous and musculocutaneous flaps as well as omentum major plasty with skin mesh-grafting (Fig. 10).

Principles

of chest wall resection

Diagnostic investigarions. The presence of distant disease was precluded by the usual investigations including clinical investigation, chest X-ray and CT as well as routine bone scintigraphy. In the case of metastatic disease, absence of local recurrence was ascertained. In the lung cancer group, no patient with small cell undifferentiated histology and, with one exception, no patient with known lymph node involvement was operated upon. Every patient underwent the usual lung function tests and identical criteria were employed for estimation of the functional operability as are adopted in uncomplicated lung cancer. The main indication for chest wall resection, with or without pulmonary resection was an attempt to achieve cure or to prolong life. In several patients, intractable pain and/or a desire by the patient for relief from unsightly ulcerations were of additional, or even dominant importance for the therapeutic decision.

adequate chest drainage. In defects of the lower and lateral parts, and after resection of more than 3 ribs, a resorbable mesh (Vicryl) * was sewn into the cage defect. In both patients with resection of the upper 6 ribs (in connection with right upper lobectomy), muscle flaps were used to close the residual pleural cavity. Reconstruction of the rib cage with allografts seemed to be necessary when large defects were combined with pneumonectomy and in defects of the anterior chest wall especially after resection of the sternum. In patients in whom vigorous pulsation of the heart would have been troublesome, Marlex mesh was used in 1 case and individually shaped methyl methacrylate inserts in 2 other instances. In one of the latter, after subtotal resection of the pericardium, the chest wall was restored by using a large piece of Teflon felt. To facilitate fixation, prostheses were prepared with small holes around the margins before terminal solidification, so as to allow suturing with wire or heavy nylon. Metastatic or primary diseases of the chest wall, particularly in cases of breast cancer and sarcoma, required larger procedures for the reconstruction of the integument. This applied to most of the patients with bilateral mastectomy and/or patients with postoperative radiotherapy. Smaller defects were covered with fasciocutaneous or musculocutaneous flaps. However, in some cases, as a consequence of former operations and/or radiotherapy, the latissimus dorsi and pectoralis major muscles were not available. On those occasions, closure of the defect necessitated other procedures such as use of rectus flap after sternal resection from the side on which the internal mammary artery could be preserved. Typical procedures for large resections have been described and are illustrated below for detailed technical information on the basis of case reports. Case A.H., male, had an exarticulation at hip level for osteosarcoma at the age of 20 years. One year later, he underwent transsternal resection of pulmonary metastases. In June 1987. a further transsternal resection of a metastasis in the right lower and another in the left upper lobe was repeated. For a recurrent metastasis in the left lower lobe with pleural invasion, the lobe was resected en-bloc with ribs 5-7 anteriorly. The defect was closed with a doubled Vicryl net and a serratus muscular flap. The patient was readmitted with a painful tumour bulge of the left anterolateral chest and extension of recurrent tumour to the heart (Fig. 1) only 5 months later. He had received 40 Gy of radiotherapy with no effect on tumour size or pain. Therefore, in a fourth thoracotomy. en-bloc resection including all layers of the chest wall but with residual myocardial tumor was performed. The plane of epimyocardial resection was covered with a large piece of teflon felt. The new additional defect in the thoracic wall was replaced by a 12 cm x 16 cm methyl methacrylate implant which was held in place with heavy nylon sutures and completely covered with a latissimus dorsi muscular and an independant fasciocutaneous flap. The postoperative CT scan (Fig. 2) depicts the layers of reconstruction and a small accumulation of fluid at the interior surface of the implant. Figure 3 shows the patient 2 weeks after an uneventful recovery and free of pain. Death occurred 5 months later at the age of 24 years.

Technicalconsiderations. According to CT, intraoperative and histological findings, penetration into external layers occurred only in 1 patient with bronchial carcinoma invading the chest wall. In planning the thoracotomy, the level of incision was chosen at a defined distance to the assumed border of invasion. No attempt was made to separate the affected part of the lung and the adjacent chest wall. It was usual for resection of the ribs to precede that of the lung. Closure of the defect, if located in the apico-posterior region, was usually achieved by suturing overlying muscle to the margins of the chest wall without necessarily seeking tightness, but rather with

Case MM. was a 37-year-old patient with a malignant histiocytoma of his left thigh resected 15 months earlier. He was referred for bilateral intrathoracic metastases involving the parietal pleura on the left side. Two-stage treatment was performed with resection of a large metastasis pedicled on the left lower lobe. Pleural effusion cytology and histology of excised pleura were negative for malignancy. After 9 months, the patient was readmitted with a giant, grossly calcified tumour in the left chest cavity extending into the retroperitoneal area (Figs. 4a and b). Computed tomography showed the tumour penetrating the chest wall and causing displacement of the mediastinum. Clinically, the patient presented with dyspnoea on exertion. In a second surgical approach, en-bloc resec-

’ W L. Gore & Assoc. GmbH, Hermann-Oberth-Strasse Putzbrunn/Miinchen. FRG

’ Vicryl-Netz, Fa. Ethicon GmbH & Co. KG, Strasse 1. W-2000 Norderstedt, FRG

22, W-801 1

Robert-Koch-

348

Fig. 1. CT findings in case A. H. with rt:current chest wall metastasis from osteoger lit sarcoma. Extension of the tumour from the skin to the heart (upper sections), chest wall deficit from the former resection (lower sections)

Fig. 2. Postoperative CT imaging with I the methyl methacrylate implant. Small se rous effusion on the inner side, external lay ers constituted by latissimus dorsi and a separate fasciocoutaneous flap

tion of the diaphragm, ribs 6 to 10, the transverse processes of the corresponding vertebra, total left lung and separate excision of an aortic wall segment was performed. The major part of the peritoneum could be preserved by closing a central defect with anterior parietal pleura. No further measures were taken for replacement of the diaphragm. The chest wall defect was repaired with the aid of two 15 cm x 20 cm 2 mm Gore-Tex soft tissue patches sewn together as shown in Fig. 5. The patient’s general and respiratory condition dramatically improved and the healing was undisturbed favoured by the fact that the excision of muscle and cutaneous layers was limited. Recovery and cosmetic appearance are illustrated in Fig. 6. The patient survived with excellent quality of life until unexpected local recurrence of the primary and new metastases became evident after 4 months leading to death within 4 weeks. The tumour patterns by that time had histologically converted to a highly malignant neurofibrosarcoma. Case E.H. was a 68-year-old female with an infiltrate in her right upper lobe which had been treated with antibiotics and kept under

observation for 1 year. She presented with destruction of 4 ribs and invasion into the subscapular muscles by a squamous cell bronchial carcinoma (Fig. 7). There was moderate chronic pulmonary obstruction due to 30 pack-years of smoking. A posterolateral thoracotomy was performed avoiding transverse splitting of the latissimus dorsi muscle. En-bloc resection of the right upper lobe, a wedge of the adjacent middle lobe and ribs 1 to 6, including the overlying subscapular muscle were carried out. Resection started at the anterior ribs, followed by pulmonary resection and finishing with the exarticulation of the ribs posteriorly. The large defect at the top of the pleural cavity was closed with the preserved muscle flaps and a wide fasciocutaneous flap. In this case, a 2 cm x 7 cm necrosis of the plasty at the superior margin of the incision induced an infection with Staphylococcus aureus within the subscapular space which required a second operative procedure with drainage and correction of the dehiscent scar. Pleural empyema was probably prevented by a persisting chest tube for prolonged air leak. Figure 8 presents the definite result at the end of a 6 weeks hospitalization with the scapula fitting into the defect.

349 lying thickened and apparently uninvolved pleura. The medial half of the defect was closed with a left rectus abdominis musculocutaneous flap (Fig. 9); the other half with omentum majus and secondary mesh grafting. Fascial reconstruction at the donor site for prevention of a hernia was achieved by inserting a 1 mm PTFE soft tissue graft. This patient had an uneventful course. The result is seen in Fig. 10 after 9 weeks at a follow-up visit. She is presently well and alive 9 months postoperatively.

Results No operative, 30-day or hospital mortality was registered in this series. Beside the necrosis and infection described in case E.H., two further events of limited superficial necroses were observed, one of which required debridement and resuturing in a female with a methyl methacrylic implant whereas the other healed by granulaFig. 3. Aspect of patient A. H. (same case as Figs. 1 and 2) after two transsternal resections of pulmonary metastases and two procedures of chest wall removal. The lower defect is reconstructed with a methyl methacrylic implant. Situation 2 weeks postoperatively

tion. None of the patients needed postoperative mechanical ventilation for respiratory failure or for other reasons. Due to the variety of basic diseases and the widely differ-

Fig. 4. a P.a. CT imaging of a huge r netastasis of malignant histiocytoma (case M. M.) b Crossectional appearance with vast calcilication, penetration of the thoracic wa.I1(dotted line) and infiltration of the aortic wall

ing indications within the subgroups of this series, as well as considering the limited follow-up period of 0.5 to 3.2 years (mean 1.4 years), survival has not been calculated. No late infections or complications related to alloplastic implants have been observed. Of 7 patients with chest wall resection for invasive recurrent breast cancer, 6 are still alive 8-30 months after surgery. Patients operated upon for metastatic melanoma or malignant histiocytoma and both patients with chest wall resection in surgically treated mesothelioma died from progressive and generalized disease at intervals of 2 to 15 months. Death is documented in a total of 14 patients with 25 months being the longest survival. Relief of pain and improvement of the quality of life was achieved in virtually every patient. Fig. 5. Intraoperative situation after chest wall replacement 6-10) with two sheets of 2 mm PTFE soft tissue patches

(rib

Case I. R., a 64-year-old female, is an example of chest wall resection for invasive and exophytic recurrence of breast cancer after bilateral mastectomy and radiotherapy 8 and 3 years ago, respectively. The diseased area was resected with removal of the corpus sterni and approximately 12cm segments of adjacent ribs retaining the under-

Discussion

Completeness is a crucial demand when dealing with malignant chest wall disease surgically. It still is a surgical challenge when adjuvant therapeutic regimens are exhausted. In patients with earlier surgery for breast cancer

Fig. 6. Posterior aspect of patient M. M. two weeks postoperatively after uneventful healing and recovery (long standii rg psoriasis diffuss)

These principles have been followed in the present series. To restrict extension of bronchial carcinoma, pre- and/or postoperative radiotherapy have been used in nearly half of our cases, although the benefit seems yet to be unproven [5]. In this particular group, reconstruction of the chest wall is often possible without alloplastic material [2]. However, large defects of the anterior chest wall require stabilisation. Several authors have positive experience with the use of Marlex/methyl-methacrylate sandwich prostheses, where the Marlex layers facilitate the fixation [2, 561. In contrast, Pairolero [7] favours the use of PTFE or Prolene mesh in any instance. Rigid methylmethacrylate has been used by us in 2 cases with hitherto perfect function. Individual modelling and simple lixation provide very acceptable cosmetic results. The use of heavy Gore-Tex probably serves assists in respect to the maintainance of lung function; certainly, it is easier and safer to implant and therefore has been preferred. Without the support of a specialised plastic surgeon, the thoracic surgeon has to adopt the knowledge of plastic surgery, particularly when dealing with recurrent

Fig. 7. a CT imaging p.a. and b transversely of bronchial carcinoma with extensive chest wall destruction (patient E. H.) Fig. 8. Photographs of patient E. H., a 68year-old female after right upper lobectomy en bloc with ribs 1-6. Situation after healed subscapular infection. Chest closure without alloplastic implants Fig. 9. Intraoperative situation after excision of an exophytic breast cancer, en-bloc with ribs and corpus sterni with left rectus abdominis musculocutaneous flap turned into the right sided defect. The rectus fascia of the donor site (below) was replaced with 1 mm PTFE soft tissue patch (patient I. R., 64 years) Fig. 10. Same patient 8 weeks postoperatively. Closure of the defect by the musculocutaneous flap (center) and omentum majus/ skin mesh graft (right). The dressing (top) covers a scar from excision of a 4 mm metastasis performed in local anesthesia in the outpatients clinic. The patient has been well and alive for 10 month;

and previous radiotherapy in the historically early attempts for radical excision respiratory problems arose from instability of the thoracic cage. Nowadays, improved techniques of reconstruction have greatly reduced the operative risk [l, 61. In sarcomatous tumour arising from a rib, according to Martini et al. [5], safety margins of one healthy rib superiorly and inferiorly and the entire removal of the affected rib itself is mandatory.

breast cancer. Use of the omentum must be advocated as one of the safest methods avoiding the risk of necrosis [4]. For various reasons such as a wide range of displacement and simple access, we found the rectus abdominis myocutaneous flap advantageous in anterior chest wall and sternal carcinoma [6, 71, feeling that a reinforcement of the fasciomuscular defect of the abdominal wall helps to avoid discomfort and the risk of a hernia [3].

351

References 1. Beattie EJ. Kim Y. Fayos J. Shridar K, Raskin N (1986) Chest

2.

3.

4. 5.

wall carcinoma and pulmonary function. In: Grill0 HC. Eschapasse H (eds) International trends in general thoracic surgery. Saunders, Philadelphia. pp 310-319 Eschapasse H, Gaillard J. Henry E, Vassallo B, Lacheheb M (1987) Chest wall tumors: surgical management. In: Grill0 HC, Eschapasse H (eds) Major challenges. Saunders, Philadelphia. pp 292 Hamer-Hodges DW. Scott NB (1985) Replacement of an abdominal wall defect using expanded PTFE sheet (Gore-Tex). J Royal Co11 Surg Ed 30:65567 Hollender LF, Bur F (1985) Chirurgie des grogen Netzes. Springer, Berlin Heidelberg. pp 99 Martini N. McCormack PM, Bains MS (1987) Chest wall tu-

Discussion Dr. G. Ferrante (Naples, Ita&). I wish to congratulate Professor Hasse on the interesting cases reported. Unfortunately, the assessment of results is usually affected by the different pathological conditions involved. and therefore, for many of them, surgery is justified by the improved quality of life and very poor or even absent mortality. I do agree that we have to perform myoplasty, if possible. more frequently than the application of alloplastic prostheses which have to be reserved for very specific cases. Resection of 5-6 ribs is very rare. Reconstruction is performed more frequently for a carcinoma of 3-4 ribs, and in all anterior and lateral defects we perform myoplasty with success. For carcinoma of the sternal manubrium. we have preferred myoplasty with both major pectoralis muscles since the time we had to reoperate upon a patient in whom we applied a Marlex prosthesis. In the last three carcinomas of sternal manubrium. with myoplasty alone we obtained an excellent result and a fast recovery. Dr. C. Martigne (Pessac, France). Thank you, Dr. Hasse, for this review of the surgical possibilities in the treatment of chest wall malignancies. In our experience, surgery for such tumours is a rare occurrence and represents only 0.6% of our activity in thoracic pathology. Usually, their carcinoma is easy and I agree with you that, in most cases. the use of alloplastic material is unnecessary for large tumors - and when necessary, vicryl net and methyl methacrylic for the chest wall - plastic procedures with cutaneous or musculocutaneous flaps superficially ~ provide a wide range of possibilities to confront all situations. Unfortunately, bad results and poor survival temper surgical enthusiasm. In the treatment of primary or metastatic chest wall tumors, there are often obvious conflicts between the wide surgical possibilities and the poor results and I think that the indications for surgical treatment have to be carefully discussed, taking into account the evolution. the survival expectation, and the feasibility of the large and complete excision including involved ribs and adjacent intercostal spaces along their whole length.

mors: clinical results of treatment. In: Grill0 HC, Eschapasse H (eds) Major challenges. Saunders, Philadelphia, pp 285 6. McKenna RJ. Mountain CF, McMurtrey MJ, Larson D, Stiles PR (1988) Current techniques for chest wall-reconstruction: expanded possibilities for treatment. Ann Thorac Surg 46: 508-512 7. Pairolero PC (1989) Chest wall reconstruction. In: Shields ThW (ed) General thoracic surgery. Lea & Febiger. Philadelphia, pp 56Op 567

Prof. Dr. Joachim Hasse Abteilung fur Thoraxchirurgie Universitatsklinikum Hugstetterstrasse 55 W-7800 Freiburg i. Br. Federal Republic of Germany

In cases of poor functional features, or of predictive poor results, and especially in cases of vertebral involvement, we prefer other palliative treatments, possibly with the aid of neurosurgical procedures which are able to relieve completely all sorts of chest pain. Dr. R. Muto (Laurence, MA, USA). I am quite surprised about the aggressiveness of our colleagues in the surgical treatment of extensive metastatic disease of the chest wall. Unfortunately, statistics show that the biology of the tumor and its pattern of recurrence is such that surgical treatment does not yield a satisfactory result. I believe that we should pay more attention to the biology of the tumor and seek alternative treatment without embarking on extensive surgery. Dr. I. Vogt-Moykopf (Heidelberg, FRG). I cannot agree with this opinion. Especially in the case of metastatic chest wall disease, the surgeon is confronted with few therapeutic non-surgical treatment modalities and the possibility of severe complications. Huge tumor masses can ulcerate and are not sensitive to irradiation or chemotherapy. Even if a prolongation of life cannot be achieved by surgical treatment, surgery can improve quality of life. Dr. J. Hasse: Thank you for the friendly comments. I agree, Dr. it is disturbing to have short survival in several cases, but thinking back to the patients who have been included in this series, I doubt whether I would deny them surgery even in retrospect, but would not rather make the same decision again, because, as Dr. Vogt-Moykopf’ has mentioned, one sometimes stands with one’s back to the wall and there was nothing else to do with some patients with a destroyed and consumed lung, severe pain and malaise because of extensive tumour growth. So I believe, even if it is only a few months of improved quality of live, one should recommend such surgery in younger patients who can tolerate and recover promptly and astonishingly well from such operations. As far as the use of muscle flaps is concerned for the reconstruction of the defects I would certainly consider Dr. Martigne’s proposals. In general. those thoracic surgeons are better off who have the support of a plastic surgeon. Unfortunately, we aren’t in this position. Ferrante,