Outcome of full-thickness chest wall resection for isolated breast cancer recurrence

An ascorbic acid-decorated nanostructured surface on titanium inhibits breast cancer development and promotes osteogenesis

The chest wall is the most frequent metastatic site of breast cancer (BC) and the metastasis usually occurs in a solitary setting. Chest wall resection is a way to treat solitary BC metastasis, but intraoperative bone defects and local tumor recurrence still affect the life quality of patients. Titanium-based prostheses are widely used for chest wall repair and reconstruction, but their inherent bio-inertness makes their clinical performance unfavorable. Nanostructured surfaces can give titanium substrates the ability to excellently modulate a variety of cellular functions. Ascorbic acid is a potential stimulator of tumor suppression and osteogenic differentiation. An ascorbic acid-decorated nanostructured titanium surface was prepared through alkali treatment and spin-coating technique and its effects on the biological responses of BC cells and osteoblasts were assessed. The results exhibited that the nanorod structure and ascorbic acid synergistically inhibited the proliferation, spreading, and migration of BC cells. Additionally, the ascorbic acid-decorated nanostructured surface significantly promoted the proliferation and osteogenic differentiation of osteoblasts. This work may provide valuable references for the clinical application of titanium materials in chest wall reconstruction after the resection of metastatic BC.

Chest wall resection for breast cancer: 21st century Mayo clinic experience

BACKGROUND

We hypothesized full-thickness chest wall resection (FTCWR) with advanced surgical techniques and modern systemic therapy is safe, provides local control, and good overall survival.

METHODS

Retrospective review of FTCWR (including rib or part of sternum) for breast cancer between 2000 and 2020. Primary endpoints included 90-day morbidities and all-cause mortality. Secondary endpoints were loco-regional and distant recurrence, DFS and overall survival (OS).

RESULTS

A total of 35 patients met the criteria. 34 FTCWR were for recurrence and the median time to chest wall recurrence was 6 years. Tumor subtype was triple-negative in 51% and the remainder HR+ Her2-. 58% were palliative resections. FTCWR included rib(s) in 89% and portion of sternum in 57%; 94% required reconstruction and 80% were R0 resections. There were no 90-day mortalities. Overall morbidity was 10/35(28%). 17(49%) patients received neoadjuvant systemic therapy for their recurrence and three received neoadjuvant radiation. Adjuvant treatment included chemotherapy (8), endocrine therapy (3), and both (8). Ten patients (28%) received adjuvant radiation. The Median follow-up was 31 months and there were 6 (17%) loco-regional and 7 (20%) distant recurrences. OS was 86% and 67% at 1 and 3 years, respectively.

CONCLUSION

FTCWR was associated with low morbidity, mortality, recurrence rates, and good OS. Selective FTCWR is safe and has acceptable short-term survival rates.

Surgical Morbidity of Full-Thickness Chest Wall Resection for Breast Cancer: A Retrospective Study of a National Database

BACKGROUND

Full-thickness chest wall resection (FTCWR) is an underused modality for treating locally advanced primary or recurrent breast cancer invading the chest wall, for which little data exist regarding morbidity and mortality. We examined the postoperative complication rates in breast cancer patients undergoing FTCWR using a large multinational surgical outcomes database.

METHODS

A retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. All patients undergoing FTCWR for breast cancer between 2007 and 2016 were identified (n = 137). Primary outcome measures included 30-d postoperative morbidity, composite respiratory complications, and hospital length of stay (LOS). The secondary aim was to compare the postoperative morbidity of FTCWR to those of patients undergoing mastectomy. One-to-one coarsened exact matching was conducted between two groups, which were then compared with respect to morbidity, mortality, reoperations, readmissions, and LOS.

RESULTS

The overall rate of postoperative morbidity was 11.7%. Two patients (1.5%) had respiratory complications requiring intubation. Median hospital LOS was 2 d. In the coarsened exact matching analysis, 122 patients were included in each of the two groups. Comparison of matched cohorts demonstrated an overall morbidity for the FTCWR group of 11.5% compared with 8.2% for the mastectomy group (8.2%) (P = 0.52).

CONCLUSIONS

FTCWR for the local treatment of breast cancer can be performed with relatively low morbidity and respiratory complications. This is the largest study looking at postoperative complications for FTCWR in the treatment of breast cancer. Future studies are needed to determine the long-term outcomes of FTCWR in this patient population.

[Chest Wall Reconstruction Using Polypropylene Mesh: a Single-Center 8-Year Analysis]

BACKGROUND

Chest wall resection for malignant tumours is usually combined with reconstruction of the bony defect. We analysed our single centre, 8-year, experience using polypropylene mesh for chest wall reconstruction. The goal of our retrospective study was to identify material-related complications and to compare them with the existing literature.

METHODS

The inclusion criterion in our retrospective cohort was a full-thickness chest wall excision and reconstruction using a polypropylene mesh with a mainly oncological indication spectrum (e.g. sarcomas, metastases, lung carcinomas with infiltration of the chest wall) in the period from January 2008 to January 2017. Primary endpoints were material-related complications: local infection, seroma, material migration, mesh explantation and chest wall instability. Secondary endpoints were the following postoperative complications: pneumonia, acute respiratory distress syndrome (ARDS), postoperative bleeding and prolonged postoperative ventilation (> 24 h postoperatively).

RESULTS

A total of 202 chest wall resections were performed in our clinic over a period of 8 years. Of these, 138 defects were reconstructed using a polypropylene mesh. Pneumonia was the most common postoperative complication at a rate of 12.3%. In 5.7% of the cases, a wound seroma developed that made it necessary to insert a Redon suction drain. Local wound infection was confirmed microbiologically in three cases (2.1%). In one of these cases, the reconstruction material had to be removed. The 30-day mortality rate was 1.4% with two postoperative deaths. Material migration or chest wall instability with a paradoxical pattern of breathing movement were not documented.

CONCLUSION

Chest wall reconstruction using polypropylene mesh is a technique with low material-related complication rate. The low rate of local infections, material explantation, and chest instability documented in our cohort can be a helpful decision factor for the operating thoracic surgeon looking for the appropriate reconstruction material.

Chest Wall Resection for Recurrent Breast Cancer in the Modern Era: A Systematic Review and Meta-analysis

OBJECTIVE

To review the literature on chest wall resection for recurrent breast cancer and evaluate overall survival (OS) and quality-of-life (QOL) outcomes.

BACKGROUND

Full-thickness chest wall resection for recurrent breast cancer is controversial, as historically these recurrences have been thought of as a harbinger of systemic disease.

METHODS

A systematic search in MEDLINE, EMBASE, and Cochrane CENTRAL identified 48 eligible studies, all retrospective, accounting for 1305 patients. The review is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary end points were patient-centered QOL outcomes and OS; secondary outcomes included disease-free survival (DFS) and 30-day morbidity. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies instrument and the Oxford Centre for Evidence-Based Medicine's levels of evidence tool. Random-effects meta-analysis was used to create pooled estimates. Meta-regressions and sensitivity analyses were used to explore study heterogeneity by age, year of publication, risk of bias, and surgical intent (curative vs palliative).

RESULTS

Studies consistently reported excellent OS and DFS in properly selected patients. Pooled estimates for 5-year OS in all studies and those from the past 15 years were 40.8% [95% confidence interval (CI) 35.2-46.7) and 43.1% (95% CI 35.8-50.7), whereas pooled 5-year DFS was 27.1% (95% CI 16.6-41.0). Eight studies reported excellent outcomes related to QOL. Mortality was consistently low (<1%) and 30-day pooled morbidity was 20.2% (95% CI 15.3%-26.3%). Study quality varied, and risk of selection bias in included studies was high.

CONCLUSIONS

Full-thickness chest wall resection can be performed with excellent survival and low morbidity. Few studies report on QOL; prospective studies should focus on patient-centered outcomes in this population.

The Lack of Consensus of International Contouring Guidelines for the Dorsal Border of the Chest Wall Clinical Target Volume: What is the Impact on Organs at Risk and Relationships to Patterns of Recurrence in the Modern Era?

Purpose

Variation exists in cooperative group recommendations for the dorsal border for the chest wall clinical target volume (CTV). We aimed to quantify the impact of this variation on doses to critical organs and examine patterns of chest wall recurrence relative to the pectoralis muscle.

Methods and Materials

We retrospectively assessed patterns of chest wall recurrence quantified to the recommended CTV borders for women treated between 2005 and 2017. We compared treatment plans for 5 women who were treated with left postmastectomy radiation therapy, with the chest wall contoured using varying dorsal borders for CTV: (1) Anterior pleural surface (Radiation Therapy Oncology Group), (2) anterior surface of pectoralis major (European Society for Radiotherapy and Oncology), and (3) anterior rib surface (institutional practice). Treatment plans were generated for 50 Gy in 25 fractions. Doses to organs-at-risk were compared using paired-sample t tests.

Results

Institutional patterns of chest wall recurrence were 64.7% skin and subcutaneous tissue, 23.5% both anterior to and between the pectoralis muscles, and 11.8% isolated to the tissue between the pectoralis major and minor. No chest wall recurrences were noted deep to pectoralis minor. When comparing the plans generated per the Radiation Therapy Oncology Group versus European Society for Radiotherapy and Oncology contouring guidelines, the mean lung V20Gy, heart mean dose, and left anterior descending artery mean dose were 33.5% versus 29.4% (P < .01), 5.2 Gy versus 3.2Gy (P = .02), and 27.3Gy versus 17.8Gy (P = .04), respectively.

Conclusions

The recommended variations in the dorsal chest wall CTV border have significant impact on doses to the heart and lungs. Although our study was limited by small numbers, our institutional patterns of recurrence would support a more anterior dorsal border for the chest wall CTV consistent with older literature.

Sternal resection and reconstruction for secondary malignancies

Background

Limited data on sternal and/or anterior chest wall resections for secondary malignancies exist. The purpose of this study was to examine the perioperative outcomes and postoperative overall survival (OS) in patients who underwent sternal and/or anterior chest wall resections for secondary sternal tumors (SSTs).

Methods

A retrospective analysis of all patients who underwent resection of SSTs at single institution between 2000 and 2016 has been performed. OS was estimated using the Kaplan-Meier method.

Results

Ten patients underwent sternal and/or anterior chest wall resection for SSTs with curative (70%) or palliative (30%) intent. Two (20%) patients underwent complete and 8 (80%) partial sternal and/or anterior chest wall resection. There were no perioperative deaths, major complications occurred in 3 (30%) patients. Tumor resection was complete (R0) in 5 (50%) patients. The 5-year OS rate was 40%. No OS difference in R0 vs. R1 resections was observed.

Conclusions

Sternal and/or anterior chest wall resections for SSTs can be performed with low morbidity and mortality. Complete SST resection does not assure favorable OS. Sternal resections can be considered palliative treatment option in patients with stable stage IV disease with isolated sternal involvement.

Oncoplastic techniques in breast surgery for special therapeutic problems

Resection of large tumors can be challenging, from the view point of breast preservation. Oncoplastic techniques are a valuable component of breast surgery in patients with large breast tumors who desire breast preservation. These techniques have been shown to be oncologically safe, while maintaining acceptable breast cosmesis. For locally advanced or recurrent breast cancers, the goals of surgery include local disease control and palliation of clinical symptoms. Oncoplastic surgery is also effective and oncologically safe in these situations. The need to completely remove all foci of cancers with adequate surgical margins often requires the displacement of adjacent or distant skin and soft tissue to cover the resulting soft tissue defect. Sometimes doing so can be cosmetically pleasing as well. In this article we present three special therapeutic problems in three distinct conditions, all resolved with oncoplastic techniques: the benign breast condition, malignant breast condition, and the palliative setting.

Thoracic Wall Reconstruction after Tumor Resection

Introduction

Surgical treatment of malignant thoracic wall tumors represents a formidable challenge. In particular, locally advanced tumors that have already infiltrated critical anatomic structures are associated with a high surgical morbidity and can result in full-thickness defects of the thoracic wall. Plastic surgery can reduce this surgical morbidity by reconstructing the thoracic wall through various tissue transfer techniques. Sufficient soft-tissue reconstruction of the thoracic wall improves quality of life and mitigates functional impairment after extensive resection. The aim of this article is to illustrate the various plastic surgery treatment options in the multimodal therapy of patients with malignant thoracic wall tumors.

Materials and methods

This article is based on a review of the current literature and the evaluation of a patient database.

Results

Several plastic surgical treatment options can be implemented in the curative and palliative therapy of patients with malignant solid tumors of the chest wall. Large soft-tissue defects after tumor resection can be covered by local, pedicled, or free flaps. In cases of large full-thickness defects, flaps can be combined with polypropylene mesh to improve chest wall stability and to maintain pulmonary function. The success of modern medicine has resulted in an increasing number of patients with prolonged survival suffering from locally advanced tumors that can be painful, malodorous, or prone to bleeding. Resection of these tumors followed by thoracic wall reconstruction with viable tissue can substantially enhance the quality of life of these patients.

Discussion

In curative treatment regimens, chest wall reconstruction enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. In palliative disease treatment, plastic surgical techniques of thoracic wall reconstruction provide palliation of tumor-associated morbidity and can therefore improve patients’ quality of life.

Bleomycin electrochemotherapy in elderly metastatic breast cancer patients: clinical outcome and management considerations

PURPOSE

To evaluate the efficacy and toxicity of electrochemotherapy (ECT) in elderly metastatic breast cancer (BC) patients.

METHODS

Retrospective analysis of 55 patients with superficial metastases who underwent ECT according to the European Standard Operative Procedures of electrochemotherapy. Treatment schedule consisted of intravenous or intratumoral bleomycin followed by locally delivered electric pulses. Statistical comparisons were performed between two groups: the patients aged <70 years (n = 27) and those ≥70 years (n = 28). Treatment outcomes were as follows: complete response (CR) rate, local progression-free survival (LPFS), new lesions-free survival (NLFS), toxicity and patient compliance.

RESULTS

Patient groups were comparable for clinical-pathological features, except for the number of comorbidities (P < .001). The median follow-up was 32 months (range 6-53). Overall, CR rate was 40 % and was significantly higher in elderly patients (57 vs. 26 %, P = .023) and in patients with better performance status (PS = 0-1, 53 vs. PS = 2, 21 %, P = .048), although local tumor control showed a trend for lower values (2-year LPFS, 67 vs. 93 % among elderly and young patients, respectively; P = .061). Older women seemed less likely to progress outside the ECT field (2-year NLFS, 39 vs. 30 %, P = .075), but discontinued treatment more frequently due to impaired performance status (P = .002). Local pain was graded ≥3, according to a 10-point visual analog scale, by 16/28 (57.1 %) and 8/28 (28.6 %) elderly patients at 4 and 8 weeks, respectively. Wound debridement was required in 5/28 (18 %) older women, due to G3 skin ulceration.

CONCLUSIONS

Elderly BC patients are highly responsive to ECT and achieve durable local tumor control. Physicians should be aware of possible debilitating side effects, such as pain and skin toxicity. Performance status and frailty screening could be a helpful addition to improve patient selection.

Sternal replacement with a custom-made titanium plate after resection of a solitary breast cancer metastasis

Bone is the most common metastatic site of breast cancer (BC) and sternal metastasis usually occurs in an isolated setting. We performed sternal reconstruction using a new total titanium custom-made neosternum after subtotal sternectomy for an isolated BC metastasis. Postoperative care was uneventful during a 7-day in-hospital stay. After a 6-month follow-up, the patient denied any shortness of breath, chest pain or limitation on her daily activities. The chest was stable without any paradoxical motion. Chest X-ray did not show any material fracture, pleural effusion or lung abnormalities. As it entails lower postoperative risk than previously existing reconstructive materials, the new material used in our sternal reconstruction may extend the existing range of indications of sternectomy for cancer with curative intent.