Version May 2024
INTRODUCTION — Chest wall tumors can be benign or malignant, and either primary to the chest wall or arising from direct extension from a primary lung tumor or from a metastatic lesion. Primary pleural malignancies can also involve the chest wall. Chest wall tumor resections are some of the most challenging surgeries for thoracic and reconstructive surgeons and can lead to significant postoperative pulmonary dysfunction. Such tumors are best approached in a multidisciplinary fashion to adequately address defects and optimize postoperative outcomes.
Following tumor resection, reconstruction of the chest wall requires reestablishment of the functional framework of the chest wall followed by coverage with healthy, well-vascularized tissue. Soft tissue flaps are used in conjunction with synthetic or bioprosthetic materials to provide soft tissue coverage and skeletal stability. Soft tissue coverage can often be accomplished with rotation skin and muscle flaps; however, more complex reconstructions may be needed. Outcomes related to resection of chest wall tumors relate to the extent of resection and the natural history of the underlying tumor.
The indications, patient evaluation and preparation, basic principles of chest wall resection and reconstruction, complications, and overall outcomes are reviewed here. Management of specific tumors is reviewed in separate topic reviews, the links of which are provided below. (See 'Indications for chest wall resection' below.)
INDICATIONS FOR CHEST WALL RESECTION — Chest wall tumors are a heterogeneous group with widely varied pathology (benign, malignant). Chest wall tumors can arise from the tissues of the chest wall as primary tumors, or secondarily from direct invasion from an adjacent primary lung tumor, a metastatic lung lesion, or pleural cancer [1,2]. About 55 percent of chest wall tumors are malignant [3].
Benign tumor — Benign chest wall tumors may originate from nerve, blood vessel, bone, cartilage, or fatty tissue [4]. This heterogenous group includes enchondromas (benign bone tumor) and osteochondromas (benign cartilage tumor) [5,6]. Osteochondromas are common at the costochondral junction. Surgical resection is aimed at decreasing chest wall pain from the associated mass as well as minimizing risk of future malignant transformation.
Chondromas account for 15 to 20 percent of benign chest wall lesions. They more commonly affect the femur, proximal humerus, and small bones of the hand [7].
Other types of benign tumors that can affect the chest wall and require resection include the following:
●Fibrous dysplasia – Fibrous dysplasia occurs most frequently in the lateral or posterior ribcage.
●Eosinophilic granuloma – Eosinophilic granuloma (Langerhans cell histiocytosis) may develop in the anterior chest wall and manifest as significant pain with fevers with characteristic diffuse infiltrative inflammation [8,9].
●Lymphangiomas – Lymphangiomas result from developmental malformations and have been reported to occur within the mediastinum and chest wall [10,11].
●Desmoid tumors – Desmoid tumors arise from a fibroblast precursor. The tumors are relatively slow growing, considered benign or low grade, and are associated with local invasion and frequent recurrence (picture 1) [12,13].
Malignant tumor — Malignant chest wall tumors are frequently fast growing and present at a larger size compared with benign lesions [14].
Chondrosarcoma is the most common malignancy of the chest wall, making up approximately 30 percent of primary malignancies [15]. Chondrosarcomas are characteristically painful, hard, fixed masses and will have synchronous lung metastases in 10 percent of patients [16]. These are typically located on the anterior chest wall (costochondral junction or sternum) and can arise from a degenerated chondroma. Surgical resection is a mainstay of treatment with tumor-free margin the best predictor of local recurrence. Definitive treatment requires wide margins of at least 4 cm and is curative in most patients. Patients with negative margins have a 10 percent recurrence rate, whereas patients with positive margins have a 75 percent rate of local recurrence [17]. Chondrosarcomas are generally resistant to radiation therapy and chemotherapy. High-dose radiation therapy or proton-beam radiation has been used with limited efficacy [18]. (See "Chondrosarcoma", section on 'Radiotherapy' and "Chondrosarcoma", section on 'Systemic treatment'.)
Osteosarcomas comprise 10 to 15 percent of malignant chest wall tumors and commonly manifest in the rib, scapula, and clavicles. The Ewing sarcoma group of tumors includes Ewing sarcoma, Askin's tumor, and primitive neuroectodermal tumor and accounts for 5 to 10 percent of chest wall malignancies [19]. (See "Osteosarcoma: Epidemiology, pathology, clinical presentation, and diagnosis" and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and superficial trunk".)
Soft tissue sarcomas represent about 45 percent of chest wall primary malignant tumors and are the most common primary malignant soft tissue chest wall lesions. The most common examples of soft tissue sarcomas are malignant fibrous histiocytomas and rhabdomyosarcoma (picture 2). These tumors can spread along fascial planes and between muscle fibers, resulting in high recurrence rates after resection with five-year survival rates between 60 and 75 percent [20,21]. Other malignant soft tissue tumors include liposarcomas and neurofibrosarcomas; wide local excision is the only treatment option in many patients. (See "Clinical presentation, histopathology, diagnostic evaluation, and staging of soft tissue sarcoma" and "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and superficial trunk", section on 'Superficial trunk sarcomas'.)
Breast and lung malignancies can recur in or may metastasize to the chest wall, and surgical resection may be indicated for local disease control [22]. In these situations, chest wall and sternal resection for metastatic cancers can provide pain relief as well as removal of ulcerations. Patients with limited identifiable disease, such as solitary skeletal metastasis, may be amenable to surgical resection. (See "Surgical resection of pulmonary metastases: Benefits, indications, preoperative evaluation, and techniques" and "Surgical resection of pulmonary metastases: Outcomes by histology".)
Radiation-associated malignant tumors of the chest wall following breast, lung, or lymphoma treatment are rare with approximately 6 percent of chest wall tumors arising in patients with a history of chest irradiation [23]. Wide local excision is the preferred treatment, and patients demonstrate similar survival rates to de novo tumors. Tumors arising after radiation have a similar prognosis when treated surgically but are commonly radio-resistant compared with tumors arising outside of radiation toxicity.
PREOPERATIVE EVALUATION AND PREPARATION — Chest wall tumors can be asymptomatic or symptomatic. Pain is the most common symptom for both benign and malignant tumors and may be a sign of bony invasion. A thorough physical examination should be performed to assess the patient's general condition, the integrity of the chest, the extent and location of any chest wall abnormalities, and the presence of scars that could become an obstacle to raising reliable muscle flaps. As an example, a previous thoracotomy incision may have disrupted necessary blood supply essential to flap coverage.
Most patients undergoing major chest wall resection will have some degree of postoperative respiratory dysfunction, though the severity is often less compared with that following trauma [24,25]. Thus, in addition to routine laboratory tests, pulmonary function tests (ie, spirometry) should be obtained preoperatively to determine the patient's candidacy for the proposed resection and to provide a comparison for postoperative comparison. (See "Evaluation of perioperative pulmonary risk" and "Preoperative physiologic pulmonary evaluation for lung resection".)
Patients with primary lung tumor can present as cachectic and nutritionally compromised, which will have negative effects on wound healing and recovery if not adequately addressed. Thus, the patient's general medical condition and nutritional status should be evaluated and optimized before surgery. (See "Overview of perioperative nutrition support" and "Preoperative evaluation and management of patients with cancer".)
Immunosuppressive therapies, a history of radiation or planned future radiation, and prior thoracic surgeries need to be taken into account when planning chest wall resection since these may affect wound healing and the options for reconstruction. Neoadjuvant chemotherapy is effective for treating osteosarcoma, rhabdomyosarcoma, Ewing sarcoma, and other small cell sarcomas. Adjuvant radiation therapy may be required in the event of positive margins or for palliative resection. Indications for neoadjuvant chemotherapy and radiation therapy and targeted immune therapy are being investigated for some tumor types but have not yet been widely adopted.
The thoracic surgeon should communicate with the reconstructive surgeon to develop a clear surgical plan. Reconstructive surgeons should be familiar with the possible adverse sequelae of pulmonary resection, such as bronchopleural fistula and empyema. Reconstructive plans should take into account the likelihood of these potential complications to determine whether a more robust reconstruction such as a soft tissue flap may be indicated to optimize blood flow to the area (picture 3). (See "Bronchopleural fistula in adults".)
Pulmonary and chest wall imaging — Preoperative imaging, particularly computed tomography (CT; contrast enhanced), is important to identify the extent of tumor and to estimate postresection defect characteristics and local vascularity, which are all helpful for planning reconstruction.
Chest radiography, CT, magnetic resonance (MR) imaging, and positron emission tomography (PET) may all be useful in evaluating a chest wall tumor [26]. Calcifications, ossification, or bone destruction are all signs of a malignancy and may be appreciated on CT scans or chest radiograph (image 1). Contrast CT can demonstrate tumor vascularity and the relationship of the mass to adjoining vasculature. PET/CT may be beneficial in demonstrating regional lymph node involvement and the presence of metastatic disease. PET/CT may be more accurate than CT alone for both initial staging, and also in evaluating treatment response for sarcomas [27].
Tissue diagnosis — Certain histologies have characteristic findings on imaging (eg, fibrous dysplasia, eosinophilic granuloma), but due to the wide variety in chest wall tumors, radiographic diagnosis can be challenging. Thus, prior to definitive chest wall resection, all possible attempts should be made to obtain tissue (fine needle aspiration biopsy, incisional/excisional biopsy) for pathologic evaluation to confirm a specific diagnosis before proceeding with the surgery. An excisional biopsy may be possible for smaller, easily accessible lesions.
Antimicrobial and thromboprophylaxis — Antimicrobial prophylaxis to prevent surgical site infection, and thromboprophylaxis to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE), are recommended. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement" and "Overview of control measures for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Thoracic surgery'.)
Plastic surgery consultation — It is wise to approach chest wall resections in a multidisciplinary fashion, with preoperative assessment by both the thoracic and plastic surgeon.
While the majority of commonly used rotation flaps are straightforward and can be harvested by the thoracic surgeon, more complex reconstructions generally require the expertise of a reconstructive surgeon. The need for more complex reconstruction may not be recognized until the time of the surgery.
SURGICAL RESECTION AND RECONSTRUCTION — Chest wall tumors generally require wide local excision, which can improve progression-free and overall survival. In most cases, chest wall resections that include three or more ribs (more than 30 cm2) will require reconstruction with prosthetic material (rigid or semirigid) to preserve chest wall mechanics and prevent paradoxical breathing. Larger defects may not require semirigid reconstruction if completely covered by the scapula. Small defects at the tip of the scapula should have the chest wall reconstructed to avoid scapular entrapment. However, a thick soft tissue flap may provide enough stability for smaller full-thickness defects of the chest wall [28].
Wide tumor excision — Negative margins are a critical predictor of local recurrence rates. For high-grade, aggressive, or highly infiltrative malignancies, wide local excision with 4 cm margins is generally indicated; however, resection for a particular patient depends on type of tumor and anatomic location. For benign processes and low-grade malignancies, 1 to 2 cm margins are usually sufficient. For tumors that invade a rib, resection of adjacent ribs may be indicated. Achieving an adequate margin becomes a little more complicated higher in the chest, where taking the first rib or dealing with structures in the thoracic inlet may be needed. Invasion into adjacent structures such as overlying skin or underlying lung needs to be appreciated preoperatively on imaging and resected with the mass, when appropriate. (See 'Pulmonary and chest wall imaging' above.)
Chest wall stabilization — Following resection of both rib and soft tissue, reconstruction of the chest wall typically requires the addition of elements to provide chest wall stability and coverage with well-vascularized soft tissue. Restoring skeletal stability is necessary to reduce the negative impact on respiratory function [28]. Objectives include:
●Avoidance of lung hernia
●Avoidance of paradoxical chest wall motion
●Avoidance of scapular impaction into the defect in posterior chest wall resections
●Protection of the underlying mediastinal organs in anterior chest wall resections
●Providing an aesthetically acceptable chest contour
Whether the chest wall defect is reconstructed with prosthetic material depends upon defect size and location. Chest wall resections that include three or more ribs (more than 30 cm2) generally require reconstruction. The absolute need for skeletal reconstruction for smaller defects has been challenged [29,30].
Synthetic mesh sutured under tension provides a sufficiently rigid (ie, semirigid) chest wall repair that reduces ventilator dependence and hospital stay [31]. Since the introduction of synthetic mesh, rigid reconstruction using autologous rib grafts or semirigid fascial grafts has become less common; these require a donor site harvest. The ideal synthetic mesh should be rigid enough to minimize paradoxical chest wall movement, porous enough to allow tissue ingrowth, malleable, radiolucent (ie, to see any radiographic evidence of tumor relapse), and inert (ie, not inflammatory, or eliciting an immune response) [32]. Autologous grafts may still be used if synthetic mesh is not readily available or the wound is at a high risk of infection.
The preferred semirigid material for large chest wall repairs is synthetic mesh (eg, polypropylene, polytetrafluoroethylene). Mesh is less rigid compared with polymethylmethacrylate (PMMA), which is no longer commonly used [33-36]. Mesh is economical but in the long term can stretch with laxity developing at the site of repair. In addition, when mesh is placed directly in contact with the viscera such as the lung, or exposed bowel (eg, when the diaphragm requires partial resection), or when the operative site has been irradiated, the risk of complications is increased [37]. Synthetic mesh is contraindicated in contaminated wounds.
Bioprosthetic mesh is another alternative for chest reconstruction, and many different types are available. One example is acellular dermal matrix (ADM), which can be derived from human (ie, allograft) or nonhuman (ie, xenograft) sources. Bioprosthetic mesh allows tissue ingrowth, and over time these become incorporated and revascularized. Bioprosthetic mesh may be particularly useful for patient with risk factors for impaired wound healing or infection [38]. It also tolerates cutaneous exposure without the need for explantation. Acellular dermal matrix of porcine bovine origin is the preferred choice for the bony chest wall reconstruction in patients at risk of infection such as patients with an expected prolonged air leak or those with an open wound at the time of surgery. The main limitations of bioprosthetic mesh are their high cost. (See "Skin substitutes".)
The chest wall reconstruction must be tightly sutured to the surrounding bony chest wall using heavy nonabsorbable sutures. We prefer to insert the mesh in an inlay fashion to prevent lung herniation. In very large defects involving four or more ribs, the mesh can be reinforced with a metallic rib strut that is screwed to the periphery of the defect. One or two struts are sufficient to increase the rigidity of the chest wall. The mesh is then suspended to the metallic strut with heavy sutures. Once the chest wall defect is stabilized, well-vascularized soft tissue coverage should be provided to minimize the risk of graft exposure and potential infection.
For situations where uncertainty exists on the ability to completely resect a tumor, surgeons may selectively use a temporary negative-pressure wound dressing (NPWT) to cover the wound while awaiting for finalization of the pathology. This may be beneficial for cases in which resection margins are questionable, a complex soft tissue reconstruction may be required, and frozen section determination of the resection margins may be difficult. An example of such a situation is when gross tissue planes and extent of disease are obscured by previous radiation therapy to the area. In such cases, delaying the complex repair until after the status of the resection margins has been finalized would avoid the possibility of needing to take down or completely resect a complex reconstruction to re-revise the involved margins. Note that a reasonable effort of tumor resection should be performed before applying NPWT; it should not be applied to temporize gross tumor that is contraindicated by the manufacturer's instructions for use. The indications, contraindications, and application of NPWT are discussed in more detail separately. (See "Negative pressure wound therapy".)
Soft tissue coverage — A variety of muscle flaps are generally readily available for rotation to cover most chest wall defects [33]. The choice of flap coverage is chosen based upon the location and size of the defect, the availability and condition of adjacent muscles, prior or possibly future radiation, and the overall condition of the patient. (See "Overview of flaps for soft tissue reconstruction".)
It is useful for the surgeon to define a number of potential operative scenarios in advance, so that if the planned flap is inadequate, backup option(s) are available and ready to implement. Complex reconstructions, which may require the expertise of plastic surgery, may involve less commonly used muscle flaps, free tissue transfer, or flap supercharging.
Muscle flaps — Muscle flaps commonly used to provide coverage for chest wall defects include the pectoralis flap, latissimus dorsi flap, and rectus abdominis flap. These are described briefly below. The general principles of flap choice and construction are discussed in detail elsewhere. (See "Overview of flaps for soft tissue reconstruction".)
Pectoralis flap — The pectoralis major muscle flap (figure 1) can reliably reach the entire anterior chest wall except the lower sternum as a simple rotation flap when based on its thoracoacromial pedicle. The muscle remains innervated and functional and allows for sternotomy. For lower chest wall defects, the pectoralis muscle can be transferred as a "split-turnover" flap with the release of its humeral insertion and the thoracoacromial pedicle.
Latissimus dorsi flap — The latissimus dorsi flap (figure 2) can easily reach the lateral, posterior, and anterior chest, including the anterior mediastinum. When the latissimus dorsi flap is transferred as a musculocutaneous flap, a large skin paddle can be transposed to the anterior aspect of the chest with high reliability of maintaining vascularity and flap survival. However, if the skin paddle is more than 8 to 10 cm in width, the donor site is not likely to be closed primarily and may need to be skin grafted. The serratus muscle can also be used in combination with the latissimus dorsi muscle to create a larger flap to fill dead space. However, this option may be compromised if there was a previous thoracotomy with latissimus division. If a thoracotomy with a subsequent muscle flap is planned, then a muscle-sparing thoracotomy approach is prudent.
Rectus abdominis flap — The rectus abdominis flap (figure 3) can be transferred as a muscle or as a musculocutaneous flap from the lower abdomen, with vertical or transverse skin orientation. A transverse orientation provides a larger, but less reliably vascularized, cutaneous flap. Less reliable blood supply may result in fat necrosis and skin edge necrosis leading to incisional dehiscence. For sternal reconstruction, the rectus abdominis flap is usually used as a muscle flap. Even following internal mammary vessel ligation such as resulting from a previous coronary artery bypass grafting (CABG), the rectus abdominis muscle may still be perfused through the musculophrenic artery and through the lower intercostal arteries (figure 4), upon which the flap can be based.
Omental flap — The omental flap (figure 5), which is harvested from the abdomen, can easily reach inside the thorax and even up to the level of the neck.
During chest wall reconstruction, the omental flap has been used prophylactically to cover vascular anastomoses considered at high risk for failure, to treat established chest infection, and as a filler to cover prosthetic chest wall replacements after extensive chest wall resection.
The omental flap can also be used to manage large and deep sternal wounds and has compared favorably to muscle flaps when reconstructing the chest wall following treatment of poststernotomy mediastinitis (figure 5). (See "Surgical management of sternal wound complications", section on 'Sternal flap closure'.)
Complications associated with this flap include intra-abdominal problems related to its harvest (eg, small bowel injury, adhesions) and hernia when transposed through a subcutaneous tunnel.
Fasciocutaneous flaps — Pedicled fasciocutaneous flaps from the upper abdomen/lower chest can be used to cover lower chest and breast defects. These can be based either medially on the deep epigastric system perforators or laterally on the intercostal perforators. In a review of 35 patients who underwent breast, chest, mediastinal, or upper extremity reconstruction using medially based thoracoabdominal flaps up to 11 x 35 cm in size, only three cases of partial flap necrosis occurred, which were attributed to excessive flap length. (See "Overview of flaps for soft tissue reconstruction", section on 'DIEP flap'.)
Other chimeric flap options — The subscapular vascular system is very versatile, and multiple flaps can be based on it to provide sufficient tissue to cover large chest wall defects. Chimeric scapular, parascapular, serratus muscle, and latissimus dorsi muscle flaps are commonly used to repair massive chest wall defects with success [39-48].
Free flap options — When local flap options are not possible, potential free flap options include omental flaps, deep inferior epigastric artery flaps, and anterolateral thigh flaps, which can provide coverage over large defects.
POSTOPERATIVE CARE — Depending upon the size of the resection and degree of preoperative pulmonary compromise, postoperative monitoring in an intensive care unit with ventilation support may be required.
Liberal use of drains is important for preventing fluid accumulation and seroma formation. For drains, a suction gradient can be established increasing from outside to inside. As an example, subcutaneous or flap drains can be used with -10 mmHg suction (or a bulb suction) while chest tubes are maintained at -20 mmHg suction.
Perioperative antibiotics are given for 24 to 48 hours. In select patients with predisposing comorbidities, longer duration antibiotics may be indicated to minimize the risk of infection, particularly in the setting of prosthetics material, and prolonged air leaks.
Free flaps require special monitoring with flow Doppler checks usually every hour for two to three days. (See "Overview of flaps for soft tissue reconstruction", section on 'Evaluation of blood supply' and "Overview of flaps for soft tissue reconstruction", section on 'Identifying vascular compromise'.)
Pain management — Good pain control is essential to a good postoperative outcome. Depending upon the location of planned incisions, pain control may be improved with the use of epidural regional analgesia, paravertebral anesthesia, or intercostal blocks, which will lower postoperative narcotic requirements and its negative side effects. (See "Anesthesia for open pulmonary resection" and "Continuous epidural analgesia for postoperative pain: Technique and management" and "Thoracic nerve block techniques".)
Pulmonary care — For the majority of patients, postoperative pulmonary toilet is vitally important because large chest defects can result in weak cough and inability to clear secretions. Noninvasive pulmonary support with bilevel positive airway pressure (BiPAP) may be used early after surgery to help patients with hypoventilation. If this fails, reintubation or reoperation to increase the rigidity of the chest wall may become necessary. Reconstructions may require revision in cases demonstrating persistent paradoxical motion and flail chest. (See "Strategies to reduce postoperative pulmonary complications in adults" and "Overview of the management of postoperative pulmonary complications".)
CHEST WALL RECURRENCE AND RE-RESECTION — Chest wall recurrence can be very challenging considering that redo surgery occurs in the presence of abundant scar tissue, which distorts anatomy, and commonly in a previously radiated field. Note that complex reoperations for cancer require a complete restaging, and the goals of the surgery should be clarified (ie, whether the repeat procedure is for complete tumor ablation to achieve no evidence of disease). Muscle flap options available in an initial procedure may no longer be available. (See "Overview of multimodality treatment for primary soft tissue sarcoma of the extremities and superficial trunk", section on 'Treatment'.)
As with primary resections, preoperative imaging is important for determining the extent of resection. Intraoperative margin assessment can aid in determining extent of resection required, and reconstruction should be performed after reasonable confidence that margins are clear of disease. Complex reconstructions are often needed and should be planned for in the event that local tissue options are not available. Free tissue transfer using microsurgical techniques may be the only remaining option in a previously operated field.
MORBIDITY AND MORTALITY — Cell type and extent of invasion significantly influence oncologic outcomes and overall survival. As an example, both chondrosarcoma and rhabdomyosarcoma have a better prognosis compared with malignant fibrous histiocytoma [49,50]. Malignant chest wall tumors have an average five-year survival of 60 percent [14,51]. Outcomes for specific tumors are discussed in more detail in separate topic reviews. Survival is significantly worse in patients who received preoperative chemotherapy or preoperative radiation therapy; however, these variables are likely surrogates for the severity and aggressiveness of the patient's disease [52-54]. In one multivariate analysis, independent factors affecting long-term survival of oncologic chest wall resections included the tumor's histologic differentiation and the extent of chest wall invasiveness [55,56]. Oncologic outcomes for individual tumors are presented in separate topic reviews. (See 'Indications for chest wall resection' above.)
Pulmonary complications — In the perioperative period, mortality following chest wall reconstruction is most commonly related to pulmonary complications and sepsis with rates ranging from 0 to 17 percent [57-62].
For patients with poor preoperative respiratory function, failed extubation and prolonged ventilator dependence may follow major chest wall surgery. These patients are at high risk for pneumonia.
Reconstruction-related complications — Reported chest wall reconstruction-related complication rates range from 24 to 46 percent in large reviews [25,63-66].
In a review of 197 patients who underwent chest wall reconstruction using mesh (32.5 percent polypropylene, 67.5 percent polytetrafluoroethylene), complications were significantly associated with the location of the defect [67,68]. As an example, first rib resections and sternectomy defects were associated with a higher rate of complications due to the more pronounced effect on the mechanics of the chest wall. Older age was also a significant factor in the rate of complications (>60 years). While complications are increased with patients over 60 years, increasing age in itself is not a contraindication for surgery.
Devitalized or ischemic skin flaps can lead to severe complications such as wound separation, breakdown, or infection. Ischemic flaps and wound breakdown should be managed early once identified (within a week) as this can lead to further dehiscence and infection. Ischemic flaps should be debrided back to healthy bleeding tissue and may either be readvanced or skin grafted, or an additional flap may be required. Necrotic tissue will foster infection if not adequately removed.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnosis and management of lung cancer" and "Society guideline links: Soft tissue sarcoma" and "Society guideline links: Bone sarcomas".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Flap surgery (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Indications for chest wall resection – Chest wall tumors can be benign or malignant and can be primary to the chest wall or arise from direct extension from a primary lung tumor, from a metastatic lesion, or from a primary pleural malignancy. The management of malignant tumors requires a multidisciplinary approach for optimal oncologic and functional outcomes. Advances in thoracic oncology have broadened the surgical indications for patients with locally advanced malignancies allowing for curative chest wall tumor resection. (See 'Introduction' above and 'Indications for chest wall resection' above.)
●Preoperative evaluation and preparation – Preoperative evaluation requires chest imaging and, in most cases, tissue biopsy to confirm a specific diagnosis prior to proceeding with chest wall resection. Computed tomography of the chest is particularly useful for identifying the extent of tumor and estimating postresection defect characteristics and local vascularity, which are important for planning reconstruction. Most patients undergoing major chest wall resection will have some degree of postoperative respiratory dysfunction. As such, routine evaluation should also include pulmonary function testing (ie, spirometry) to determine candidacy for the proposed resection and to provide a baseline for postoperative comparison. (See 'Preoperative evaluation and preparation' above.)
●Wide tumor excision – For high-grade, aggressive, or highly infiltrative malignancies, wide local excision with 4 cm margins is generally indicated; however, resection for a particular patient depends on type of tumor and anatomic location. For benign processes and low-grade malignancies, 1 to 2 cm margins are usually sufficient. Negative margins are a critical predictor of local recurrence rates. (See 'Wide tumor excision' above.)
●Chest wall stabilization and soft tissue coverage – In general, chest wall resections that include three or more ribs (>30 cm2) will require chest wall stabilization (rigid, semirigid) followed by coverage with healthy, well-vascularized tissue, typically a pedicled muscle flap. Exceptions may include anatomic regions with better stability, such as those covered by the scapula. For most defects, semirigid reconstruction using mesh (eg, polypropylene, polytetrafluoroethylene) is adequate. For smaller defects, a thick soft tissue flap may provide enough stability. The choice of flap coverage is determined based upon the location and size of the defect, the availability and condition of adjacent muscles, prior or possibly future radiation, and the overall condition of the patient. (See 'Chest wall stabilization' above and 'Soft tissue coverage' above.)
●Postoperative care – Postoperative care includes pain management and pulmonary support. Depending upon the extent of the resection and degree of preoperative pulmonary compromise, monitoring in an intensive care unit may be necessary. Pain control is essential to a good postoperative outcome and may be improved with the use of epidural regional analgesia, paravertebral anesthesia, or intercostal blocks, which will lower postoperative narcotic requirements and its side effects. (See 'Postoperative care' above.)
●Recurrence and re-resection – Morbidity and mortality relate to the extent of resection and the natural history of the underlying tumor. Cell type and extent of invasion significantly influence oncologic outcomes and overall survival; recurrence rates remain high with more aggressive histologies. Chest wall recurrence can be very challenging to manage. Redo surgery is complicated by the presence of abundant scar tissue and an often irradiated field. Muscle flap options available in an initial procedure may no longer be available, and complex reconstructions are frequently needed. (See 'Chest wall recurrence and re-resection' above.)
●Mortality and complications – Complications following chest wall resection and reconstruction include systemic complications, predominantly pulmonary complications, and those related to the reconstruction. Flap-related complications are common but often of a low-grade nature; however, failure of large chest wall reconstruction can result in significant loss of skeletal support leading to flail chest and prolonged ventilator dependence. (See 'Morbidity and mortality' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledges Charles E Butler, MD, FACS, who contributed to an earlier version of this topic review.
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