Reconstruction of the thorax with Ley prosthesis after resection of the sternum

Chest wall reconstruction after tumor resection

Pediatric chest wall tumors are rare. Malignancies predominate of which sarcomas are the most common. Their resection and the subsequent reconstruction of the chest wall has been a surgical challenge since Dr. Frederick W. Parham published his first comprehensive account on the subject in 1898. Chest wall reconstruction is age, site and pathology dependent, must preserve long term function and cosmesis, must accommodate future growth and development, and must not be a hindrance to adjuvant radiotherapy. Bony reconstruction can be relatively simple or complex involving combinations of synthetic meshes, bioprosthetic materials, steel or titanium constructs, autografts, homografts and porcine or bovine xenografts. Soft tissue coverage can be achieved with direct closure, skin grafts, local advancement flaps, pedicled or free myocutaneous or osseomyocutaneous flaps or a combination of these. Complications to be avoided include scoliosis, pain and activity restriction, restrictive pulmonary deficits and interference with adjuvant radiotherapy which may result in tumor recurrence. Advances in cancer therapy have improved short- and long-term survival but significant functional and cosmetic challenges remain particularly for large chest wall defects in the very young. The future may lie with absorbable semi-rigid meshes, biointegratable acellular homografts and xenografts, demineralized bone matrices and bone marrow stromal cells, the patient's own lab-grown stem-cell based vascularized osseomyocutaneous chest wall grafts or the obsolescence of surgical resection altogether in the age of targeted anti-tumor and immune based therapy.

Chest reconstruction using a custom-designed polyethylene 3D implant after resection of the sternal manubrium

Introduction

Resection of manubrium or body of the sternum is associated with a necessity of chest wall reconstruction. Large sternal defects require the use of different types of implants to ensure acceptable esthetic effect for the patient and chest stabilization.

Aim

The purpose of this case report is to present a novel method of reconstruction of manubrium removed due to renal cancer metastasis to the sternum.

Case

We present the case of a patient, who had underwent right nephrectomy for clear cell kidney cancer, diagnosed with a metastatic tumor in the sternum resulting in destruction of manubrium. The patient undergone tumor resection with primary reconstruction with an individual prosthesis. Sternal defect was filled with a personalized, computed tomography scan-based 3D-milled implant made of polyethylene.

Results

Sternal reconstruction was uneventful. The patient endured surgery well, and has been under surveillance in outpatient clinic, without any respiration disorders, implant movement or local recurrence.

Conclusion

Custom-designed sternal implants created by 3D technique constitute an interesting alternative for previous methods of filling defects after resection of a tumor in this location.

Materials and techniques in chest wall reconstruction: a review

Extensive chest wall resection and reconstruction are a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeon, plastic surgeon and oncologist. In particular chest wall neoplastic pathology is associated with high surgical morbidity and can result in full thickness defects hard to reconstruct. The goals of a successful chest wall reconstruction are to restore the chest wall rigidity, preserve pulmonary mechanic and protect the intrathoracic organs minimizing the thoracic deformity. In case of large full thickness defects synthetic, biologic or composite meshes can be used, with or without titanium plate to restore thoracic cage rigidity as like as more recently the use of allograft to reconstruct the sternum. After skeletal stability is established full tissue coverage can be achieved using direct suture, skin graft or local advancement flaps, pedicled myocutaneous flaps or free flaps. The aim of this article is to illustrate the indications, various materials and techniques for chest wall reconstruction with the goal to obtain the best chest wall rigidity and soft tissue coverage.

[Treatment of lung cancer with chest wall invasion]

The aim of this study was to analyze chest wall invasion, the indication and multidisciplinary nature of treatment, the methods used for parietal reconstruction and the technical problems posed by this procedure in patients with lung cancer and chest wall invasion. Chest wall invasion from adjacent malignancies affects 5% of patients with a bronchogenic carcinoma. Preoperative determination of parietal invasion aids the planning of an appropriate therapeutic approach. Positron emission tomography combined with computed tomography (PET/CT) improves the study of T-factor and metastatic nodal involvement and distant metastases. As a rule, surgical treatment should attempt complete tumoral resection: lobectomy, resection of the parietal pleura and/or of the chest wall--ensuring tumor-free margins--and hilar and mediastinal lymphadenectomy. We also analyzed the distinct prognostic factors for survival, as well as the indication for induction or adjuvant therapy. Chest wall reconstruction involves recreating the most anatomical and physiological conditions possible in the chest cavity and surrounding muscles. The ideal reconstruction would achieve adequate parietal stability and coverage to preserve functionality, with the cosmetic result being an important, but secondary, consideration. Many materials are available for reconstruction and the choice of material should be individualized in each patient. A multidisciplinary team able to plan and perform the resection and subsequent reconstruction, oversee postoperative management and treat complications early is essential.

[Moldable titanium mesh for chest wall reconstruction, an elegant solution about a case report]

INTRODUCTION

Several surgical techniques are available for full thickness chest wall reconstruction. The choice has to be adapted to the size of the loss of tissue, its location, and must finally be accepted by the patient's. We propose a new and unpublished solution.

CASE REPORT

We have in our care a 54 years-old patient suffering from a previous loss of chest wall tissue measuring 7 cm(2) due to surgical treatment of mediastinal Hodgkin's disease with sternal and costal invasion. Because of the sequelae, the goal focused on aesthetic reconstruction. Heartbeat was visible under the skin due to a loss of secondary left breast tissue from an initial treatment with absorbable Vicryl(©) mesh followed by a local skin, and glandular flap. Our choice of reconstruction consisted of inserting a moldable titanium mesh followed by 200 g implants in each breast during the same operation. We did not experience any complications and the patient is satisfied with the results.

DISCUSSION

No example of reconstruction using only a moldable titanium mesh was found in the literature on chest wall reconstruction. Our elegant choice is innovative in our discipline. However, this reconstruction materiel is already part of therapy procedures in other specialized surgeries.

CONCLUSION

This case report illustrates the various facets of our speciality: bring a solution at once repair, aesthetic and unique according to the request of the patient. The use of a moldable titanium mesh allows the reconstruction of stable chest wall. The small size does not present any functional difficulties, but rather unsightly sequel.

Surgical resection of sternal tumors and reconstruction with titanium mesh

OBJECTIVE

To evaluate the use of titanium mesh reconstruction after sternal tumor resection.

METHODS

From January 2007 to January 2011, 14 patients with sternal tumors were admitted into Peking Union Medical Hospital. The clinical characteristics, surgical resection, and technique of reconstruction were reviewed.

RESULTS

Of the 14 patients, 3 had a metastatic sternal tumor, the primary sites of which were as follows: hepatic carcinoma in one case (metastasis 19 years after operation), breast carcinoma in another case (metastasis 5 years after operation), and renal carcinoma in the other case (found simultaneously). Two patients showed local involvement of the sternum: 1 had thymic carcinoma, and the other had myofibrosarcoma. The remaining 9 patients had primary tumors: 4 were osteochondroma, 3 chondrosarcoma, 1 eosinophilic granuloma, 1 non-Hodgekin's lymphoma. En bloc resection of the sternal tumor was performed in all the 14 patients. The defect was repaired with the titanium mesh adjusted to the shape of the defect and fixed with the stainless steel wire. Eleven patients were followed up for a period from 2 months to 4 years, during which no translocation or broken of the titanium mesh was observed.

CONCLUSIONS

Radical en bloc excision remains the treatment of choice for sternal tumors. Sternum defect reconstruction using titanium mesh as a rigid replacement proves appropriate and effective.

Overview on current and future materials for chest wall reconstruction

This article focuses on new materials available to thoracic surgeons for the reconstruction of chest wall defects. Each surgeon is called to select the best reconstructive strategy based on the disease for which the resection is needed, the possible extension to adjacent structures, the availability of professional colleagues for multidisciplinary involvement, and the preferred (or available) material for full or partial thickness reconstruction.

Prosthetic reconstruction of the chest wall

Chest wall reconstructions can be complex and challenging procedures, especially when huge thoracic defects have been generated by radical excisions. Nonrigid reconstructions with meshes or patches have the goal of avoiding a lung hernia caused by the chest wall defect, or preventing the impaction of the scapula in case of posterior chest wall resections, especially when the resection is extended down to the 5th and 6th ribs. Large anterior and lateral resections result in thoracic instability and alteration of pulmonary physiology, and render intrathoracic structures vulnerable to external impact. They necessitate rigid reconstructions according to several techniques using alloplastic materials (eg, methyl methacrylate-based customized plates or neo-ribs, osteosynthesis systems, or dedicated prosthesis). Nowadays, the availability of these multiple, possibly combined, more adapted, and better tolerated materials have pushed past the limits of resection to those involving soft tissue coverage.