Primary lung tumors invading the chest wall

Malignant Chest Wall Tumors: Complex Defects and Their Management-A Review of 181 Cases

BACKGROUND

Chest wall tumors are a heterogeneous group of tumors that are managed by surgeons from diverse specialties. Due to their rarity, there is no consensus on their diagnosis and management.

MATERIALS

This retrospective, descriptive analysis includes patients with malignant chest wall tumors undergoing chest wall resection. Tumors were classified as primary, secondary, and metastatic tumors. The analysis includes clinicopathological characteristics, resection-reconstruction profile, and relapse patterns.

RESULTS

A total of 181 patients underwent chest wall resection between 1999 and 2020. In primary tumors (69%), the majority were soft tissue tumors (59%). In secondary tumors, the majority were from the breast (45%) and lung (42%). Twenty-five percent of patients received neoadjuvant chemotherapy, and 98% of patients underwent R0 resection. Soft tissue, skeletal + soft tissue, and extended resections were performed in 45%, 70%, and 28% of patients, respectively. The majority of patients (60%) underwent rib resections, and a median of 3.5 ribs were resected. The mean defect size was 24 cm2. Soft tissue reconstruction was performed in 40% of patients, mostly with latissimus dorsi flaps. Rigid reconstruction was performed in 57% of patients, and 18% underwent mesh-bone cement sandwich technique reconstruction. Adjuvant radiotherapy and chemotherapy were given to 29% and 39% of patients, respectively.

CONCLUSIONS

This is one of the largest single-institutional experiences on malignant chest wall tumors. The results highlight varied tumor spectra and multimodality approaches for optimal functional and survival outcomes. In limited resource setting, surgery, including reconstructive expertise, is very crucial.

The oncologic efficacy of extended thoracic resections

Locally invasive lung cancers pose unique challenges for management. Surgical resection of these tumors can pose high morbidity due to the invasion into surrounding structures, including the spine, chest wall, and great vessels. With advances in immunotherapy and chemoradiation, the role for radical resection of these malignancies and associated oncologic outcomes is evolving. This article reviews the current literature of extended thoracic resections with a focus on technical approach, functional outcomes, and oncologic efficacy.

Primary lung tumors invading the chest wall

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.

Management of Early-Stage Resected Non-Small Cell Lung Cancer: Consensus Statement of the Lung cancer Consortium

BACKGROUND

Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease.

METHODS

Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members.

RESULTS

The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region.

CONCLUSION

The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

[Reconstruction of post-resection chest wall defects in surgical treatment of invasive non-small cell lung cancer]

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.

Primary lung tumour invading the chest wall

Introduction

This case study describes a primary lung tumour invading the chest wall, that clinically was thought likely to be a lipoma, and was imaged first using ultrasound.

Case Report

A 67 year old male presented to his GP with a six month history of a lump increasing in size on the left upper chest wall. The ultrasound scan demonstrated a hypoechoic and hypervascular soft tissue mass, extending out of the chest into the subcutaneous tissue and starting to erode the overlying rib. The appearances were highly suspicious for a chest malignancy. Further imaging and an ultrasound guided biopsy confirmed the diagnosis of a squamous cell carcinoma.

Discussion

The majority of patients who present to their general practitioner with a soft tissue mass commonly have benign abnormalities such as a lipoma or epidermoid cyst. Tumours of the chest wall are varied and are divided into benign and malignant tumours, and those that arise from the rib cage. Primary lung tumours are uncommonly seen on ultrasound. Lung cancers account for around 20% of all cancer deaths and the chest wall is involved in around 5% of primary lung tumours.

Conclusion

This case highlights the need for prompt investigation of enlarging superficial masses. Ultrasound imaging offers excellent detail for superficial structures and in this case, due to the location of the mass, identified a primary lung tumour.

Primary lung cancer with chest wall involvement: Outcomes of a multimodality management approach

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.

"Multimodality imaging of the extrapleural space lesions"

Extrapleural space (EPS) is a potential space between the outer layer of the parietal pleura and the inner layer of the chest wall and the diaphragm. Many different pathologies including chronic inflammatory conditions, infections, trauma, neoplastic disease (both benign and malignant) as well as many infiltrative disorders can involve the EPS. It is one of the frequently overlooked entity on imaging due to relative lack of understanding of the anatomy and the imaging appearances of the diseases localized to this space. The knowledge of the EPS is essential for the radiologists as the pathologies which involve the EPS may require different treatment approach compared to pleural or parenchymal lung disease. Additionally, the EPS involvement may influence the staging and treatment planning for chest malignancies. In this review, we give an overview of the anatomy and various pathologies involving EPS, utility of different imaging modalities in the evaluation of EPS lesions with emphasis on cross sectional imaging and emerging technologies like spectral CT and its role in recognizing the imaging features which enable specific diagnosis of various pathologies.

Risk factors of chest wall invasion in non-small cell lung cancer

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 (SUV_max) 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 (P_max) (P<0.01), SUV_max (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), P_max (P=0.02), SUV_max (P=0.01), and LDH (P<0.01) were significant risk factors.

Conclusions

The age, P_max, SUV_max, and LDH levels might be associated with CWI.

Reconstrucción de pared torácica con material de fijación en pacientes con lesiones tumorales. Serie de casos

Introducción. El manejo quirúrgico de las lesiones de la pared costal con resección y reconstrucción con material protésico ha venido en aumento, debido al avance en las técnicas quirúrgicas y en la experiencia del cirujano, así como en la innovación y las características de los materiales protésicos, que permiten realizar resecciones amplias de la pared garantizando una mayor estabilidad esquelética, una menor alteración de la mecánica respiratoria y mejores los resultados estéticos. Métodos. Se presenta la experiencia en la clínica CardioVID, Medellín, Colombia, entre los años 2015 y 2019, mediante una revisión retrospectiva de 8 casos sometidos a resección de lesiones benignas de la pared torácica y reconstrucción con material protésico. Resultados. Se encontró una adecuada evolución de los pacientes, con un buen resultado estético y funcional, con adecuado control de la enfermedad, sin reportes de complicaciones ni de recidiva en el seguimiento. Discusión. Una técnica adecuada permite la reconstrucción de estos defectos con complicaciones mínimas y bajas tasas de extracción de prótesis, finalizando con excelentes resultados funcionales y cosméticos. Con nuestra experiencia podemos concluir que la elección adecuada de los pacientes candidatos a manejo quirúrgico, una buena técnica quirúrgica y un personal con experiencia son cruciales para lograr buenos resultados en cuanto a función pulmonar y estética. Además de lograr una sobrevida bajo los parámetros establecidos posterior a lograr una resección R0.

Anterior chest wall resection and sternal body wedge for primary chest wall tumour: reconstruction technique with biological meshes and titanium plates

Chest wall tumours are heterogeneous neoplasms, either primary or metastatic, with a malignancy rate of 50%. Surgical resection is one of the mainstays of the treatment, however, chest wall resections can be particularly challenging depending onto the resection size, site and patient habitus. The surgical strategy should be carefully analysed preoperatively, keeping in mind the need of an oncological radical resection (R0) in accordance to the reconstruction principles elicited by le Roux and Sherma since 1983, which include restoring the chest wall rigidity, preserving pulmonary mechanics, protect the intrathoracic organs, avoiding paradox movements of the chest cavity and, possibly, to reduce the thoracic deformity. In this context, we herewith report our surgical reconstruction technique following an anterior chest wall resection and sternal body wedge for a primary chest wall tumour (chondrosarcoma).

Point of care ultrasound in thoracic malignancy

Ultrasonography is a safe, efficient and cost-effective mode of imaging that can assist clinicians with important treatment decisions and provide procedural guidance. Today, point of care ultrasound plays an essential role in the assessment of benign and malignant conditions of chest, both in the outpatient and inpatient setting. Small, ultra-portable, affordable units can now be carried in the coat pocket. Advanced lung cancer, metastatic diseases to the lungs or thoracic malignancies can present with pleural effusion, pulmonary edema, post-obstructive pneumonia, or ascites that can be assessed by the clinician with ultrasound. It can be used to evaluate the extent of thoracic tumors beyond the parenchyma to the parietal pleura or chest wall, assess cervical, supraclavicular lymphadenopathy prior to fine needle aspiration or to determine venous thromboembolism (VTE) associated with malignancy. Thoracic ultrasound is currently being practiced by the pulmonologists, thoracic surgeons and intensivists to provide guidance during placement of pleural catheters, chest tubes or to evaluate the pleural cavity before thoracoscopy. Point of care ultrasound can improve efficiency in procedures by decreasing complications, increasing success and reducing financial strain on the health care system.

Surgical complication and postoperative pulmonary function in patients undergoing tumor surgery with thoracic wall resection

Postoperative complications of thoracic wall resection include respiratory complications, skin necrosis and infection. The aim of the present study was to examine postoperative complications in patients who required combined thoracic wall resection during the surgical removal of a tumor. The present study included 68 patients; there were 50 patients with lung tumors and 18 patients with musculoskeletal tumors. The clinical factors associated with complications were compared between the two groups. Preoperative and postoperative pulmonary function tests were performed to examine the residual pulmonary function in 16 patients. Thoracic cage reconstruction was performed in 46 patients. Postoperative complications occurred in 30 (44.1%) patients, and one patient died from postoperative pneumonitis. Compared with the pulmonary function preoperative test results, the postoperative results revealed a decrease in the mean vital capacity percentage and an increase in the mean forced expiratory volume within 1 sec as a percent of the forced vital capacity. In patients with lung tumors, pneumonectomy can result in an increased rate of complications following thoracic wall resection. Residual pulmonary function is affected by impaired thoracic cage expansion and removal of the lung. However, the results of the present study demonstrated that these complications can be somewhat stabilized by thoracic wall reconstruction.

MR Imaging of Primary Chest Wall Neoplasms

Primary chest wall neoplasms are uncommon and comprise a heterogeneous group of lesions that may be challenging to classify and diagnose. These tumors may be primary or secondary, malignant or benign, and arise from cartilaginous/osseous structures or soft tissues. The role of magnetic resonance (MR) imaging in the evaluation of chest wall tumors continues to expand given its superior soft tissue contrast relative to computed tomography. MR imaging can facilitate differentiation of neoplasms from normal chest wall structures and other disease processes due to infection and inflammation, and can fully characterize abnormalities by demonstrating the various internal components of complex lesions. It is important that radiologists be able to identify key features of primary chest wall neoplasms on MR imaging to provide focused differential diagnoses and guide patient management.

Chest wall resection and reconstruction for tumors: analysis of oncological and functional outcome

Background

Tumors of the chest wall have a large spectrum of well-assessed indications for resection. However, whether a reconstruction is required or not is not always clear. Complications after chest wall resection and reconstruction (CWRR) are described in literature and potentially severe. There is no evidence of how non-reconstructive management may influence the post-operative complication rate.

Methods

A total of 71 patients underwent thoracic demolition for tumors between April 2000 and October 2016. The patients were divided into two groups based on pathological findings: group 1: primary chest wall tumors; group 2: non-small cell lung cancer (NSCLC) invading the thoracic wall. They were then retrospectively analyzed by means of following criteria: TNM staging, histology, infiltration depth, 5-year survival, overall survival (OS), disease-free survival (DFS), relapse rate, R-0 resection, number of resected ribs, site of surgical resection and post-operative respiratory complications, flail chest, chronic pain, deformity of the chest wall and cosmetic results.

Results

Five-year survival, OS, DFS and risk of relapse showed a significant correlation with the presence of free surgical margins in both groups. In group 2, another parameter which correlated to survival, risk of relapse and DFS was lymph-nodal status. Moreover, the risk of post-operative respiratory complications was directly correlated with non-reconstruction after demolition of the chest wall in certain topographical sites.

Conclusions

free surgical margins are the main oncological prognostic factor in these patients. In patients who underwent resection of two or more ribs in a critical area, reconstruction of the bony thorax can significantly reduce the post-operative respiratory complication rate.

Intra- and Extra-Thoracic Muscle Flaps and Chest Wall Reconstruction Following Resection of Thoracic Tumors

Improvements in surgical technique over the last decade enable surgeons to perform extensive resection and reconstruction in patients presenting with tumors involving the soft tissue or bony structures of the chest wall. The type of surgical resection and its size, depend on the type of tumor resected and its location. In addition to providing a better esthetic result, the reconstruction restores support and functionality of the thoracic cage. The approach to chest wall repair includes primary closure or reconstruction by using transposition flaps, free flaps, prosthetic material, or a mixture of a flap and prosthetic material.