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  IBS27 - Chestwall Tumors (Ticketed Session) (ID 58)

  • Event: WCLC 2019
  • Type: Interactive Breakfast Session
  • Track: Thymoma/Other Thoracic Malignancies
  • Presentations: 1
  • Now Available
  • Moderators:
  • Coordinates: 9/10/2019, 07:00 - 08:00, Dublin (1997)

  • 29513

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    IBS27.01 - Management of Chest Wall Tumors (Except Sternum) (Now Available) (ID 3399)

    07:00 - 08:00  |  Presenting Author(s): Gaetano Rocco
    • Abstract
    • Presentation
    • Slides

    Abstract
    

    The principles to surgically manage chest wall tumors vary according to the origin of the tumor (primary vs secondary), the pre-existing conditions of the chest wall (previously operated, irradiated or infected) and the available materials for reconstruction (1). Primary chest wall tumors require resection with at least 4 cm margin as well as careful removal of the periosteum/perichondrium of the remaining rib segments (1 to 2 cm) which may harbor the cancer-cells filled lymphatics responsible for early recurrence (2,3). As a rule, the uppermost and lowermost ribs around the primary tumor including the intercostal muscles need to be removed. For tumors located posteriorly in the first three to four ribs, reconstruction may be avoided albeit the extravasation of pleural fluid in the subcutaneous tissues may be a source of complication and affect the patient’s perception of a successful result (1,2). To ensure consistent intrathoracic physiology and avoid lung herniation through anterior and lateral chest wall defects, especially if larger than 1 rib with the upper most and lowermost intercostal spaces, reconstruction is advisable (2,3). Secondary tumors can present as solitary soft tissue or bony metastases requiring localized resection or can infiltrate the chest wall in continuity (3). The latter is the case of T3/4 lung cancer which needs to be resected en-bloc with the chest wall, keeping the line of resection at least at 2 cm from the edge of the infiltration (3). The reconstructive materials to be used are represented by time-honored rigid and soft meshes (Vycril, Polypropilene, Marlex, PTFE) which can still be effectively used for primary reconstruction in the absence of complication factors, such as redo procedures, previously irradiated or infected fields (1,4,5). More recently, new materials have been introduced in the clinical practice, namely, new generation titanium plates, acellular collagen matrices, Poly-4-hydroxybutyrate (P4HB), and, cryopreserved homograft of cadaveric origin (1). These materials present a common advantage of being biocompatible, amenable to modeling and incorporable into the host without the need to remove them should local infection complicate the postoperative period (1). However, all of these prosthetic materials need to be covered with viable tissue, ie, muscle flap, fat and omentum since direct exposure to skin may cause wound seroma or breakdown (1). New perspectives are provided by obtaining adequate biomimesis in the reconstruction of large chest wall defects through 3D printing from CT chest wall templates (6). However, the choice of the reconstructive materials is still a matter of surgeon’s preference, resource availability, and costs (2). Apart from some important exceptions (ie, Ewing’s sarcoma), primary chest wall tumors may be chemo- and/or radioresistant (7). The resort to a multimodality approach (ie, chemoradiotherapy followed by surgery) for the involvement of the bony as well as the neurovascular structures at the thoracic inlet has been associated to significantly improved survival rates (8). While the role of adjuvant treatment for non-Pancoast T3N0-1 lung cancer invading the chest wall is established, the recent literature identifies promising survival advantage in administering induction treatment in this selected subset of patients (9,10).

    Rocco G. Chest wall resection and reconstruction according to the principles of biomimesis. Semin Thorac Cardiovasc Surg. 2011;23(4):307-13.

    Rocco G, Martucci N, La Rocca A, et al. Postoperative local morbidity and the use of vacuum-assisted closure after complex chest wall reconstructions with new and conventional materials. Ann Thorac Surg. 2014;98(1):291-6.

    <>3.Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg. 2006;81(1):279-85.

    <>5.Moradiellos J, Amor S, Córdoba M, et al. Functional Chest Wall Reconstruction With a Biomechanical Three-Dimensionally Printed Implant. Ann Thorac Surg. 2017;103(4):e389-e391.

    <>7.8.9.10.Kawaguchi K, Yokoi K, Niwa H, et al; Central Japan Lung Study Group. A prospective, multi-institutional phase II study of induction chemoradiotherapy followed by surgery in patients with non-small cell lung cancer involving the chest wall (CJLSG0801). Lung Cancer. 2017;104:79-84.

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