CHEST-WALL RECONSTRUCTION FOLLOWING RESECTION OF LARGE PRIMARY MALIGNANT-TUMORS

Reconstructive procedures following radical resection of large primary malignant chest wall tumors (PMCWT) continue to evolve. Between 1982 and 1993, 32 consecutive patients (18 males/14 females) with a median age of 47 years (range, 12 - 77) underwent radical resection for large (median 10 +/- 5.4 cm) PMCWTs arising either from the bone (n = 15) o r soft tissues (n = 17) of the chest wall. Nine (28%) had previous sur gical resection before referral. Sixteen (50%) required extensive skin excision. Twelve sternectomies (5 total and 7 partial) and 20 lateral chest wall resections were performed. In this latter group, 16 patien ts (80%) had at least three ribs resected. Resection extended to the l ung (10 wedge resections, 2 lobectomies and 1 pneumonectomy) in 13 pat ients, diaphragm in 3, abdominal wall in 2, brachiocephalic and subcla vian vessels in 5, superior vena cava in 1 and upper limb in 1. Stabil ity of the chest wall was obtained with prosthetic material in 27 pati ents, including Marlex (n = 21), polytetrafluoroethylene (PTFE) (n = 4 ) and polyglactin (n = 2) meshes. After sternectomy, six patients had a methyl methacrylate mesh reinforcement while soft tissue reconstruct ion was carried out using the pectoralis major muscle (PM), either alo ne with skin advancement (n = 8) or as a myocutaneous flap in three ma les (unilateral n = 2, bilateral n = 1) and by a latissimus dorsi (LD) myocutaneous flap in one female. Muscle transposition was used to rec onstruct defects of the lateral chest wall and included 10 LD, 6 PM an d 2 serratus anterior (SA) muscles, with associated advancement of the diaphragm in two cases. Two patients required rectus abdominis myocut aneous flaps because other local muscles had been previously excised a nd irradiated. One (3%) hospital death occurred as a result of bacteri al pneumonia. Two septic local complications after total sternectomy r equired removal of the prosthetic material but both myocutaneous naps were preserved. With a median follow-up of 38 months, overall 2- and 5 -year survival rates were 66% and 50%, respectively. Local recurrence developed in four cases (12.5%). Chest wall stabilization is essential after resection of large anterior and lateral PMCWTs; soft tissue cov erage is possible using well vascularized muscle or myocutaneous flaps .