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Pancoast tumour T3N0M0 right (a) before and (b) after radio-chemotherapy, access Shaw-Paulson, lobectomy, resection of the 1st to 3rd rib in combination with the transversal process and the 1st thoracic nerve root.
Source publication
Lung cancer invasion of the chest wall is not a common challenge and represents only about 5% of all patients resected for lung cancer. In T3N0M0 tumours, long-term survival reaches 40-50%, provided certain conditions are fulfilled. The number of explorative thoracotomies and the rate of non-radical resections might be high due to the local extensi...
Context in source publication
Context 1
... of the parietal pleura. However, this early stage of infiltration may be difficult to clarify even intraoperatively. Therefore, in the study published by Rusch et al. [16], preoperative radio-chemotherapy was administered only in patients with Pancoast's syndrome or infiltration of bone or infraclavicular vessels demonstrated by MRI or a CT scan (Figs. ...
Citations
... The proportion of operable non-small cell lung cancer (NSCLC) invading the chest wall is about 5% [1]. After surgical removal of involved structures, reconstructive procedures using a rigid prosthesis, such as absorbable synthetic polyglactin mesh or expanded polytetrafluoroethylene (PTFE) sheet, are often necessary to maintain or re-establish thoracic cage stability and function [2]. ...
Background
Among a cohort of patients who underwent chest wall resection and reconstruction by rigid prosthesis, 6% required removal of the prosthesis, and in 80% of these cases the indication for prosthesis removal was infection. Although artificial prosthesis removal is the primary approach in such cases of infection, the usefulness of vacuum-assisted closure (VAC) has also been reported.
Case presentation
A 64-year-old man with diabetes mellitus underwent right middle and lower lobectomy with chest wall (3rd to 5th rib) resection and lymph node dissection because of lung squamous cell carcinoma. The chest wall defect was reconstructed by an expanded polytetrafluoroethylene (PTFE) sheet. Three months after surgery, the patient developed an abscess in the chest wall around the PTFE sheet. We performed debridement and switched to VAC therapy 2 weeks after starting continuous drainage of the abscess in the chest wall. The space around the PTFE sheet gradually decreased, and formation of wound granulation progressed. We performed wound closure 6 weeks after starting VAC therapy, and the patient was discharged 67 days after hospitalization.
Conclusions
We experienced a case of chest wall reconstruction infection after surgery for non-small cell lung cancer that was successfully treated by VAC therapy without removal of the prosthesis. Although removal of an infectious artificial prosthesis can be avoided by application of VAC therapy, perioperative management to prevent surgical site infection is considered essential.
... Als Implantat-Materialien etabliert sind nicht-rigide Materialien wie monofile Netze aus Polypropylen oder Membrane aus Polytetrafluorethylen (PTFE). Die Implantation von rigiden Implantaten wurde aus Furcht vor sekundären Komplikationen durch Implantatbrüche bis vor wenigen Jahren nicht empfohlen [1]. Das Strasbourg Thoracic Osteosynthesis System (STRATOS; MedXpert GmbH, Eschbach) ist das erste System für eine Osteosynthese der Rippen, das eine CE-Zulassung für Defektüberbrückungen hat und unter maßgeblicher Mitwirkung des Thoraxchirurgen Jean Marie Whilm entwickelt und in den Verkehr gebracht wurde [2]. ...
Das Strasbourg Thoracic Osteosynthesis System (STRATOS) der Firma MedXpert (Eschbach, Deutschland) ist gut für die Rekonstruktion nach (Teil-) Resektion der Rippen geeignet. Seit 2017 ist das multidirektionale STRATOS in Deutschland zugelassen, mit dem die Durchführung paravertebraler und parasternaler Rekonstruktionen deutlich einfacher möglich ist. Von Vorteil ist die technisch einfache Implantation, die eine dreidimensional sichere und funktionsstabile Fixierung ermöglicht. Die Implantate werden teilweise mit rotierenden Klammern fixiert, damit die Implantatbrücken zwar sofort bewegungsstabil sind, aber die postoperative Mobilisation der Patienten nicht eingeschränkt wird. Der Beitrag berichtet über Erfahrungen bei der Rekonstruktion nach Resektion paravertebraler Tumoren. ++++++++++++++++++ Der Artikel ist abrufbar unter: https://www.kaden-verlag.de/publikationen/zeitschriften/chirurgie/chirurgische-allgemeine ++++++++++++++++++++++++++++++++
... In fact, the National Comprehensive Cancer Network (NCCN) consensus panel recommends definitive chemoradiation therapy as the only treatment option for cT3 (invasion) N2 disease and does not explore the role of surgery. 1,2 Although the role of en bloc chest wall resection is established for patients without nodal disease, [3][4][5][6] the presence of lymph nodes is commonly viewed as a poor prognosticator. 7,8 Older studies have debated the role of surgery when there is N2 nodal disease. ...
Objectives
Current National Comprehensive Cancer Network guidelines recommend definitive chemoradiation rather than surgery for patients with locally advanced clinical stage T3 and N2 (stage IIIB) lung cancer involving the chest wall. The data supporting this recommendation are controversial. We studied whether surgery confers a survival advantage over definitive chemoradiation in the National Cancer Database.
Methods
We identified all patients with clinical stage T3 and N2 lung cancer in the National Cancer Database from 2004 to 2017 who underwent a lobectomy with en bloc chest wall resection and compared them with patients with clinical stage T3 and N2 lung cancer who had definitive chemoradiation. We used propensity score matching to minimize confounding by indication while excluding patients with tumors in the upper lobes to exclude Pancoast tumors. We used 1:1 propensity score matching and Kaplan–Meir survival analyses to estimate associations.
Results
Of 4467 patients meeting all inclusion/exclusion criteria, 210 (4.49%) had an en bloc chest wall resection. Patients undergoing surgical resection were younger (mean age = 60.3 ± 10.3 years vs 67.5 ± 10.4 years; P < .001) and had more adenocarcinoma (59.0% vs 44.5%; P < .001) but were otherwise similar in terms of sex (37.1% female vs 42.0%; P = .167) and race (Whites 84.3% vs 84.0%; P = .276) compared with the definitive chemoradiation group. After resection, there was an unadjusted 30- and 90-day mortality rate of 3.3% and 9.5%, respectively. A substantial survival benefit with surgical resection persisted after propensity score matching (log-rank P < .001).
Conclusions
In this large observational study, we found that in select patients, en bloc chest wall resection for locally advanced clinical stage T3 and N2 lung cancer was associated with improved survival compared with definitive chemoradiation. National Comprehensive Cancer Network guidelines should be revisited.
... Upper ribs have adequate coverage from pectoral muscle while resection of lower ribs may require application of net or prosthesis. [9] Chest wall resection and potential reconstruction are associated with some complications, of which infections and seromas are often encountered. [10] Different strategies of postoperative care have been proposed in the literature, including adjuvant and neoadjuvant chemotherapy, as well as radiotherapy. ...
Lung cancer is a leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) is a predominant subtype and treatment may include immunotherapy, radiotherapy, chemotherapy, and surgery. Tumors of bigger size infiltrating large bronchi and vessels require more invasive resection such as pneumonectomy. To save lung parenchyma, sleeve lobectomy can be performed in certain patients.
We report the case of a patient with NSCLC infiltrating the chest wall who underwent arterial sleeve lobectomy with rib resection. Furthermore, we discuss other surgical treatment strategies.
A 58-year-old female patient was admitted to the hospital in 2020 with pain in her left posterolateral chest. Radiological imaging revealed a tumor (5.0×3.5×4.8 cm) in the top of the left lung, infiltrating pulmonary artery and ribs. Therefore, left upper sleeve lobectomy together with resection of rib blocks II to V was performed. The surgery was uncomplicated, but a few weeks postoperatively, the patient experienced repeated episodes of consciousness disturbances. Contrast CT revealed a cerebral malformation in the patient who died 3.5 months after surgery.
Sleeve lobectomy can be safely performed in patients with lung tumors infiltrating larger bronchi and vessels who would not tolerate pneumonectomy.
... The chest wall is involved in approximately 5% of all primary lung neoplasms, and this clinical condition is more common than primary chest wall tumors that invade the lung. [2] According to the 8th tumor node metastasis (TNM) classification, lung tumors invading the chest wall are classified as T3, and they account for approximately 45% of all T3 lung cancers. [3] Surgical resection consisting of excision of the primary lung cancer with associated chest wall resection and lymph node dissection is the treatment of choice for locally advanced tumors. ...
... [4] The chest wall is involved in approximately 5% of all primary lung tumors. [2] Chest wall infiltration is usually caused by peripherally located tumors and develops slowly. The tumor invades the parietal pleura, followed by the soft tissues and intercostal muscles, and finally the ribs. ...
... Firm materials are not recommended because they have a high risk of damaging the surrounding tissues and tend to break due to respiratory movements. [2] All synthetic materials used for reconstruction carry the risk of causing a foreign body reaction in the body. Infection at the operation site and allergic reactions due to the material used may be observed. ...
Objective:
Lung cancer remains the leading cause of cancer deaths worldwide. The surgical approach to locally advanced non-small cell lung cancer (NSCLC) goes beyond the classical approach and requires a multidisciplinary approach both preoperatively and postoperatively. In addition to the tumor size, the location of T3 tumors affects the extent of the surgery.
Materials and Methods:
Patients who underwent lung resection for cancer between March 2019 and October 2022 were retrospectively reviewed. Patients who underwent chest wall resection were evaluated in terms of age, gender, pathology, type of operation, survival, recurrence, complications, receipt of preoperative chemotherapy, tumor node metastasis (TNM) stage, whether or not mediastinoscopy was performed, STAS (The spread through air spaces) positivity, visceral pleural invasion, parietal pleural invasion, lymphovascular invasion, perineural invasion, and alveolar/bronchial wall invasion.
Results:
Thoracic wall resection was performed in nine patients with locally advanced NSCLC. The use of prolene mesh was required in eight patients. All patients complained of pain in the thoracic wall in the preoperative period. Postoperative pathology results showed STAS positivity in four patients; alveolar/bronchial wall invasion in four; and visceral, parietal, pleural, and lymphovascular invasion in seven. The mean survival of the patients was 24.20 months (0.63–39). No patient developed recurrence during the follow-up period.
Conclusion:
Chest wall resection and reconstruction for lung cancer is a surgical treatment method that should be performed without violating respiratory physiology and by using a small amount/number of synthetic materials.
... A wide local excision is the standard surgical treatment [1][2][3][4]. Depending on their extent, local tumours infiltrating the chest wall, such as breast cancer or non-small-cell lung carcinoma as well as metastatic lesions, may also require a wide resection of ribs and soft tissue [5,6]. Due to improvement in surgical techniques and perioperative management, chest wall resections can be performed with acceptable morbidity and mortality [1,[7][8][9][10]. ...
Objectives
The reconstruction of the chest wall defect after tumour resection presents a challenge. Titanium rib plates were presented as a reconstruction option due to its biocompatibility, flexibility and pliability. The aim of this study was to evaluate the outcome of single-center cohort treated with chest wall reconstruction after tumour resections, with a focus on the titanium rib plates reconstruction.
Methods
We retrospectively reviewed the data of 26 patients who underwent wide resection for malignancies of the chest wall, where reconstruction was performed using polypropylene mesh, porcine dermal collagen mesh with or without titanium rib plates, operated on between 2012 and 2019. Events being associated with the surgery requiring revision were rated as complications.
Results
Most of the patients had primary tumors (n = 19; 73%). A mean of 3.7 ribs (range: 1 to 7) was resected. Reconstruction was performed with titanium rib plates (13 patients, 50%), of these 11 with additional mesh grafts. Remaining 13 patients (50%) underwent reconstruction with mesh-grafts only. Fourteen patients (54%) developed a complication requiring surgical revision, after a median of 5.5 months. The most common complication was wound healing deficit (n = 4), plate fracture (n = 2), mesh-rupture (n = 2), infection (n = 2) and local recurrence (n = 2). The only factor being associated with the development of complications was the usage of a plate (p = 0.015), irrespective of defect size (p = 0.29).
Conclusion
The high complication rate is found when using titanium plates for chest wall reconstruction after tumour resection. A high caution is recommended in choosing chest wall reconstruction method.
... To provide adequate resection margins and improve patient prognosis, en bloc resection of lung cancers involving the chest wall is crucial (1). Lung resections that require chest wall excision account for approximately 5% of all lung tumours and present a three-times higher death rate than standard lung resections (2). This is mainly due to the impact of major chest wall resections on the mechanics of respiration. ...
Management of chest wall defects after oncologic resection can be challenging, depending on the size and location of the defect, as well as the method of reconstruction. This report presents the first clinical case where patient-specific rib prostheses were created using a computer program and statistical shape model of human ribs. A 64-year-old male was diagnosed with non-small-cell lung cancer originating in the right upper lobe and invading the lateral aspect of the 3rd, 4th, and 5th ribs. Prior to surgical resection, a statistical shape model of human ribs was created and used to synthesise rib models in the software MATLAB (MathWorks, Natick, MA, USA). The patient's age, weight, height, and sex, as well as the number and side of the ribs of interest, were the inputs to the program. Based on these data, the program generated digital models of the right 3rd, 4th, and 5th ribs. These models were 3D printed, and a silicone mould was created from them. The patient subsequently underwent right upper lobectomy with en bloc resection of the involved chest wall. During the operation, the silicone mould was used to produce rigid prostheses consisting of methyl methacrylate and two layers of polypropylene mesh in a “sandwich” fashion. The prosthetic patch was then implanted to cover the chest wall defect. Thirty days after the surgery, the patient has returned to his pre-disease performance and physical activities. The statistical shape model and 3D printing is an optimised 3D modelling method that can provide clinicians with a time-efficient technique to create personalised rib prostheses, without any expertise or prior software knowledge.
... Эволюция хирургических технологий, появление современных интеллектуальных материалов и разработка из них протезов, мультимодальное лекарственное противоопухолевое воздействие привели к значительному увеличению показаний к хирургическому лечению опухолей грудной стенки. Хирургическое лечение местнораспространенного на грудную стенку НМРЛ осуществляли по общепринятым положениям в клинической онкопульмонологии, а также руководствовались авторитетными данными [8,9,35]. Согласно опубликованному в ноябре 2021 г. международному консенсусу экспертов по резекции опухолей грудной клетки и реконструкции грудной стенки [11], дефекты грудной клетки с максимальным диаметром >5 см следует замещать у взрослых и подростков с помощью жестких имплантатов, чтобы предотвратить флотацию грудной клетки, парадоксальное дыхание и/ или дыхательную недостаточность. ...
Objective:
To present the results of reconstruction of post-resection chest wall defects with nickel-titanium (TiNi) implants in patients with invasive NSCLC and to analyze the features of perioperative management.
Material and methods:
We enrolled 9 patients with NSCLC involving the ribs after lobectomy or pneumonectomy with chest wall reconstruction. Defects were closed used TiNi mesh and rib prostheses. We selected the shape and dimensions of artificial ribs individually before surgery according to CT data and 3D models of reinforcing elements.
Results:
There were male smokers aged 64.6±4.6 years among patients (range 58-73). T3N0M0 was diagnosed in 6 patients, T3N1M0 - 2, T3N2M0 - 1. Squamous cell carcinoma was verified in 4 (44.4%) patients, adenocarcinoma - in 5 (55.6%) patients. All patients had comorbidities. Mean Charlson's comorbidity index was 6.56±4.6. Dimension of chest wall defect varied from 78 to 100 cm2. Postoperative period was uneventful without signs of respiratory failure. There were no lethal outcomes. Complications occurred in 33.3% of patients (prolonged air discharge through the drains, pleuritis and atrial fibrillation).
Conclusion:
Surgical treatment of NSCLC spreading to the chest wall is a complex task requiring further improvement. Bioadaptive TiNi implants are a promising reinforcing material that allows successful reconstruction of post-resection chest wall defects with good anatomical, functional and cosmetic results. «Sandwich» technology is advisable for extensive defects. This approach includes 2 layers of knitted mesh and rib prostheses between these layers.
... [2] Chest wall (CW) involvement in primary lung cancer is uncommon with an incidence of approximately 5%. [1] As per AJCC 8 th edition, primary lung cancer invading the ...
... The rigid reconstruction with bone cement is not recommended since rigid prosthesis tends to penetrate the adjacent tissues due to respiratory movements. [1] It should be avoided particularly in cases where a vascularized muscle cover is missing and postoperative radiation is required. Complications are common after CW resection and it ranges from 24% to 60%. ...
Introduction:
The incidence of lung cancer with chest wall (CW) involvement is approximately 5%. Surgical resection with tumor-free margin is the mainstay of the treatment but these patients generally require multimodality management. CW resection for lung cancer is a complex procedure and requires a balance of radical oncological resection and reconstruction. Herein, we shared an experience of primary lung cancer with CW involvement.
Materials and methods:
Outcome analysis of a prospectively maintained lung cancer database was done for the patients having primary lung cancer with CW involvement. All the patients underwent radical surgical resection of the primary tumor along with the CW.
Results:
Among the 208 patients undergoing surgery for non-small cell lung cancer, 20 (9.5%) were found to have CW involvement radiologically. The most common symptom was chronic cough. A total of 11 patients received neoadjuvant chemotherapy (NACT) and the rest were taken for upfront surgery. Six patients had a partial response to NACT and none of them had tumor progression during the chemotherapy. All the patients underwent en bloc resection of the CW with anatomical resection of lung and systematic mediastinal lymphadenectomy. The mean duration of surgery was 199 min and the average blood loss was 560 ml. Reconstruction was done with a combination of prosthetic mesh and pedicled muscle flap. Median disease-free and overall survivals were 21 and 26 months, respectively.
Conclusion:
Radical resection with reconstruction is required for optimal long-term oncological and functional outcomes for NSCLC with CW involvement.
... Several prognostic factors for NSCLC patients with CWI were reported. The completeness of resection and involvement of lymph nodes were mainly considered prognostic factors, whereas the depth of CWI or tumor size were reported as prognostic factors in some studies (3,4,(6)(7)(8)(9). Although the prognostic factors of NSCLC patients with CWI were not analyzed in the present study, the tumor size was indicated to be a risk factor of CWI. ...
Background:
The risk factors for the development of chest wall invasion (CWI) in non-small cell lung cancer (NSCLC) patients are unclear. If the risk factors for the development of CWI can be clarified, surgical treatment might be able to be performed before CWI development, thus improving the prognosis.
Methods:
In the present study, we enrolled patients who received surgery for NSCLC between January 2008 and December 2019 with available data on the maximum standardized uptake value (SUVmax) on positron emission tomography (PET) with lesions adjacent to the visceral pleura. Furthermore, the preoperative white blood cell (WBC) count, the preoperative neutrophil-to-lymphocyte ratio (NLR), platelet (Plt) count, levels of lactate dehydrogenase (LDH) and C-reactive protein (CRP) were analyzed as predictive factors of CWI.
Results:
The relationships between CWI and clinicopathological variables were analyzed, and there were significant differences between patients with and without CWI in the age (P=0.02), maximum tumor diameter on computed tomography (CT) (P<0.01), diameter of tumors adjacent to the visceral pleura (Pmax) (P<0.01), SUVmax (P<0.01), maximum tumor diameter on a pathological examination (P<0.01), WBC count (P=0.03), Plt count (P=0.04), and levels of LDH (P<0.01) and CRP (P=0.01). Logistic regression analyses of the risk factors related to CWI showed that the age (P=0.02), Pmax (P=0.02), SUVmax (P=0.01), and LDH (P<0.01) were significant risk factors.
Conclusions:
The age, Pmax, SUVmax, and LDH levels might be associated with CWI.
