1. The document discusses the approach to chest wall tumors and reconstruction following resection. It covers anatomy, diagnosis, classification, surgical planning and considerations, resection techniques, and reconstruction options for both bone and soft tissue. 2. Resection aims to remove the tumor with adequate margins while reconstruction seeks to replace the chest wall rigidity and restore respiratory mechanics. 3. Reconstruction methods include mesh, plates, and flaps to repair bone and muscle flaps, skin grafts, or free flaps to replace soft tissue. The goal is to protect underlying structures and allow for pulmonary function.

1. Department of Thoracic Surgery
DMCH
TOPIC:
An approach to chest wall tumor
followed by chest wall reconstruction
Presented by:-
Dr. Bijay Kumar Sah
Phase B, Resident
MS, CVTS
BSMMU

2. ANATOMY
Surface features of anterior thoracic wall.

3. ANATOMY
Anterior and posterior views of the bony thorax

4. ANATOMY
Internal view of the anterior
thoracic wall
Anterior thoracic wall

5. ANATOMY
Posterior thoracic wall
Lateral view of the muscles of right
hemithorax

6. ANATOMY
Veins of thoracic wall
Arteries of thoracic wall

7. DEFINITION
 Chest wall tumors includes primary and metastatic
neoplasms of both the bony skeleton and soft tissues and
the primary neoplasms that invade the thorax from
adjacent structures, such as the breast, lung, pleura, and
mediastinum.

8. INCIDENCE
 Most of the primary chest wall tumors are malignant.
Incidence ranges from 50% to 80%(average 60%).
 Metastatic lesions are the most common chest wall tumor.
 The soft tissues are the major source of chest wall
neoplasms.

9. CLASSIFICATION
A. PRIMARY-
1. MALIGNANT-
a. SOFT TISSUE ORIGIN- Malignant fibrous
histiocytoma, Rhabdomyosarcoma, Myeloma,
Liposarcoma, Neurofibrosarcoma, Haemangiosarcoma,
Leiomyosarcoma, Lymphoma.
b. BONY ORIGIN- Chondrosarcoma, Ewings
sarcoma, Osteosarcoma
Note: In adults, the most common primary malignant lesions are
chondrosarcoma, plasmacytoma, and fibrosarcoma.

10. CLASSIFICATION
1. BENIGN-
a. SOFT TISSU ORIGIN- Desmoid, Lipoma,
Fibroma, Neurilemmoma
b. BONY ORIGIN- Osteochondroma,
Chondroma.
B. METASTATIC-
Lung, Breast, Kidney, and Prostate carcinomas.

11. DIAGNOSIS
 Careful history taking
 Physical examination.
 CXR
 CT scan of Chest, MRI of Chest
 FNAC
 Core niddle biopsy.
 Excisional/ Incisional biopsy.
 Bone Scan, PET (if metastases are suspected).

12. HISTORY
 Age: 26 years (Benign) and 40 years (Malignant)
 Male : Female = 2 : 1 (exception desmoid tumor, 1:2).
 In approximately 20% of patients tumor discovers as
incidental findings.
 Chest wall tumors generally present as slowly enlarging
masses.

13. HISTORY
 Starts as asymptomatic, but with continued growth, pain
invariably occurs (25-50% cases). Mostly in malignant
tumors.
 History of fever, weight loss, malaise, trauma, prior
cancers, radiation therapy, operations, infections should be
elicited.

14. PHYSICAL EXAMINATION
 If a mass is present, it should be palpated to see if it hard or
soft, mobile or fixed, and tender or not tender.
 Its location should be carefully documented. It is often
helpful to palpate the lesion with the patient in the same
position he or she will be in for surgery.
 Lymphadenopathy, if present, should be palpated and
other lumps, scars, or tender spots examined.

15. CHEST X-RAY
 Plain chest radiograph (CXR) may be the initial radiograph
that discovers the chest wall lesion.
 Old CXRs should be obtained and examined in an attempt
to establish a growth rate of the lesion.
 Rib films can be used to help determine bony erosion or
lytic lesions

16. CT-SCAN OF CHEST
 The CT gives information about the location of the lesion
and its relationship to the rib, soft tissue, pleura, and any
vascular structures or nerves in the local area.
 Careful viewing of the CT will usually narrow the
diagnostic possibilities and in some patients is diagnostic.

17. MRI OF CHEST
 MRI is useful as well because it can delineate between soft
tissue, bone, nerve, or vascular structures in a multiplanar
fashion .
 Edema and hemorrhage may mimic malignant infiltration
on MRI.
 Because of the presence of a pseudocapsule of compressed
parenchyma, a tumor may appear sharply demarcated on
MRI when in actuality there is tumor invasion.

18. TISSUE DIAGNOSIS & CYTOLOGY
 The standard methods for tissue diagnosis are fine-needle
aspiration, core-needle biopsy, incisional biopsy, and wide
local excision of small lesions.
 Fine-needle aspiration (FNA) is not useful except when a
metastatic lesion is suspected because FNA limits the
amount of histologic tissue and tissue architecture.

19. TISSUE DIAGNOSIS & CYTOLOGY
 Incisional biopsies may confuse the histologic diagnosis.
 If an incisional biopsy is performed, it is made in such a
way that the definitive excision will not be compromised.
 If the lesion is small (i.e., <3 cm) and in a favorable location
(lateral chest wall away from vital structures), an excisional
biopsy can be undertaken.

20. TISSUE DIAGNOSIS & CYTOLOGY
 The incision for the biopsy should also be placed with
consideration for further resection, because if the
pathology returns malignant, the biopsy site should be
excised
 Extensive flaps or dissection should be avoided in the
initial biopsy, because cure rate is related to margins of
resection.
 For large tumors (i.e., ≥3 cm) or tumors located in a critical
area (near great vessels), a core needle biopsy can be done.

21. PET & BONE SCAN
 Proton emission tomography (PET) and bone scanning can
be used to search for metastatic disease.
 PET imaging may have the advantage of predicting
recurrence based on metabolic activity of the tumor as well
as predicting the potential benefit of adjuvant therapy.
 PET is not a method to definitively determine if a mass is
malignant or benign.

22. PREOPERATIVE EVALUATION
 The cardiovascular system should be investigated with
regard to possible ischemic heart disease and pulmonary
dysfunction.
 Pulmonary function testing should be done to determine
the risks of removing a portion of the chest wall and its
deleterious effects on pulmonary mechanics.
 If patients are smoking, they should stop.
 As in all surgery, diabetes should be under control.

23. PLANNING OF OPERATION:
Planning the operation is dependent on the assessment
of several factors:
1 Exact histological diagnosis
2 The extent of chest wall involvement
3 History of previous radiation or surgical operation at
the site of the disease
4 Medical conditions of the patient
5 Aim of the treatment: cure or palliation

24. ANESTHETIC CONSIDERATIONS
 Chest wall resections are usually done under general
endotracheal anesthesia.
 If lung resection is anticipated or special exposure is
required, a double-lumen tube can be used.
 Pain control postoperatively is accomplished with epidural
analgesia and supplemented with parenteral narcotics and
NSAIDs.

25. INTRAOPERATIVE
CONSIDERATIONS
 Resection of the mass should be complete, the margin of
resection depending on the histologic type of the tumor
and its location on the chest wall.
 The initial resection is the best, and perhaps only, chance
for a curative operation as reoperations for recurrent
tumors are unlikely to be curative.
 The resection should be en bloc, including overlying skin,
soft tissue, and muscle and with an adequate margin.

26. CHEST WALL TUMOR RESECTION
 The incision done over the tumor to improve the exposure
and reduce the vascular damage to the cutaneous area if
the skin is spared.
 The pleural cavity is usually entered one intercostal space
below or above the first uninvolved rib, and the intra
thoracic extension of the tumor is evaluated by finger
palpation.

27.  Wide resection of primary malignant chest wall neoplasm
is essential to successful management.
 For many surgeons, a resection margin of 2 cm would be
considered adequate.
 Consequently, all primary malignant neoplasms initially
diagnosed by excisional biopsy undergo further resection
to include at least a 3-4 cm margin of normal tissue on all
sides followed by frozen section is consider sufficient.

28. CHEST WALL RECONSTRUCTION
 After wide excision, the goals of reconstruction are to
replace the rigid chest wall to provide protection to the
underlying viscera and restore the mechanics of
respiration.
 Primary closure remains the best option available if
possible.
 If full-thickness reconstruction is required, consideration
must be given to both the structural stability of the thorax
and the soft tissue coverage.

29. In planning the reconstruction of chest wall defects several
factors should be considered:
 The structure of the underlying defect
 The location and size of the defect
 The aim of the operation (palliation or cure)
 The general condition of the patient
 Previous surgical operation that may interfere with the
choice of the flap for reconstruction
 Prior radiation therapy that may change the quality of the
skin and may require full thickness resection of the
irradiated field

30. SKELETAL RECONSTRUCTION
 Reconstruction of the bony thorax is controversial.
 Defects less than 5 cm in greatest diameter anywhere on
the thorax are usually not reconstructed.
 high posterior defects less than 10 cm do not require
reconstruction because the overlying scapula provides
support

31. SKELETAL RECONSTRUCTION
 In the noninfected patient, the rigid chest wall can be
reconstructed with a variety of material.
 Sheets of 2-mm-thick polytetrafluoroethylene (Gore-Tex),
methylmethacrylate Marlex mesh sandwich, Polypropylene
(Prolene) or polyglactin (Vicryl) mesh can be used for bony
chest wall reconstruction.

32. SKELETAL RECONSTRUCTION

33. SKELETAL RECONSTRUCTION
Intraoperative view. (A) Large rib resection of the chest wall with
lung inside; (B) chest wall reconstruction with double layer of
polypropylene and sandwich of methylmethacrylate.

34. SKELETAL RECONSTRUCTION
Intraoperative view of biologic
mesh (bovine pericardium)
reconstruction
Intraoperative view of a large
lateral rib resection reconstructed
with a titanium prosthesis

35. SKELETAL RECONSTRUCTION
Reconstruction of a 5-ribs resection defect with 2 titanium bars fixed on
rib segments by 3 screws for each side and completed with a titanium
prosthesis fixed to the rib segments and bars

36. SKELETAL RECONSTRUCTION
Sternal post-traumatic rupture: (A) intraoperative view of the bars
fixed on the sternal surface with multiple screws; (B) view of sternal
fracture treated with titanium mesh fixed to the rib segments with
multiple interrupted stitches.

37. SKELETAL RECONSTRUCTION
Titanium plate reconstruction of large chest
wall resection for chondrosarcoma and
covered with polypropylene synthetic mesh
fixed to the rib segments and to the plates
with interrupted stitches.
Sternal reconstruction using
fibula allograft for complete
sternal destruction after median
sternotomy.

38. SKELETAL RECONSTRUCTION
Different phase of intraoperative preparation of the allograft. (A,B)
Defrosting of the graft with immersion in saline solution with antibiotics;
(C) removal of all the soft tissues (muscle, fat, etc.) before implantation;
(D) the graft ready for tailoring before implantation.

39. SOFT TISSUE RECONSTRUCTION
 If the defect is small, local tissue can be elevated and
primarily closed over the defect.
 For larger defects, muscle or musculocutaneous flaps are
used to cover the defect. These include latissimus dorsi,
pectoralis major, Transverse rectus abdominis, serratus
anterior and external oblique flaps based on location.

40. The thorax can be divided into three
areas:
Sternal region:-
Pectoralis major is the most
frequent flap because of multiple
perforators entering the skin
through it. When the pectoralis
major is not available and one of
the superior epigastric vessels is
preserved, a transverse or vertical
rectus abdominis flap is a good
alternative.

43. Anterior or lateral defect
Latissimus dorsi flap
can be used to cover any
area of the chest because of
its long pedicle.

44. Posterior defects
More than one
musculofascial layer
separates the skin from the
chest wall, decreasing the
need for additional soft
tissue coverage. The flap of
choice is the latissimus
dorsi. The trapezius remains
an alternative to cover small
defects located over the
upper half of the back.

45. SOFT TISSUE RECONSTRUCTION
 In rare circumstances, a free flap is required to cover the
defect if no local rotational flaps are available.
 Omentum can also be brought into the area, if necessary,
to provide a vascular bed for tissue ingrowth

46. SOFT TISSUE RECONSTRUCTION
The arc of rotation of the omentum
lengthening procedures based on the right
gastroepiploic artery

47. TAKE HOME MESSAGE:
Once the histological type of the tumor has been determined,
the appropriate therapeutic plans must be prepared. Most of the
primary chest wall tumors can be treated by surgical resection
as first line of treatment. In selected cases, preoperative or
adjuvant chemotherapy, radiation, or a combination of both can
play an important role