Overview
Definition:
Chest wall resection and reconstruction is a complex surgical procedure involving the removal of a portion of the chest wall (ribs, intercostal muscles, pleura, and sometimes sternum or scapula) due to malignant or benign tumors, followed by restoration of chest wall integrity and function.
Epidemiology:
Primary chest wall tumors are rare, accounting for less than 1% of all thoracic neoplasms
Secondary involvement from contiguous structures (lung, breast, mediastinum) or distant metastases is more common
Incidence varies based on tumor type
chondrosarcomas and osteosarcomas are frequent primary bone tumors, while sarcomas and carcinomas are common soft tissue malignancies.
Clinical Significance:
Effective management of chest wall tumors is crucial for local tumor control, palliation of symptoms (pain, dyspnea), and improving quality of life
The complexity lies in achieving oncologic clearance while preserving respiratory mechanics and cosmesis, demanding multidisciplinary collaboration
This is a challenging area for surgical trainees preparing for DNB and NEET SS exams.
Clinical Presentation
Symptoms:
A palpable mass or swelling
Localized chest pain, often worsening with respiration or movement
Dyspnea or shortness of breath, especially with larger tumors or pleural involvement
Cough
Weight loss and fatigue in advanced stages
Pathological fractures of ribs or sternum.
Signs:
A visible or palpable chest wall mass
Tenderness over the mass
Skin changes over the mass (erythema, ulceration)
Restricted chest wall expansion
Crepitus if bone involvement
Signs of pleural effusion or respiratory compromise.
Diagnostic Criteria:
Diagnosis is primarily based on imaging and histopathology
No specific clinical diagnostic criteria exist for chest wall tumors
suspicion arises from clinical findings and is confirmed by investigations
Management decisions are guided by staging and tumor characteristics, adhering to established oncologic principles for surgical resection margins.
Diagnostic Approach
History Taking:
Detailed history of symptom onset and progression
Presence of pain and its characteristics (location, intensity, aggravating/relieving factors)
History of prior malignancy (lung, breast, melanoma)
Family history of cancer
Exposure history (radiation, occupational).
Physical Examination:
Thorough palpation of the chest wall mass (size, consistency, mobility, tenderness)
Assessment of overlying skin
Examination of respiratory system for adventitious sounds or reduced breath sounds
Evaluation of overall chest wall symmetry and respiratory excursion.
Investigations:
Imaging: Chest X-ray (initial assessment, bony abnormalities)
CT scan of the chest (precise tumor size, location, extent, relationship to adjacent structures, pleura, mediastinum, and bony involvement
crucial for surgical planning)
MRI of the chest (superior for soft tissue detail, nerve involvement, and marrow infiltration)
PET-CT scan (staging, distant metastasis assessment, differentiating benign from malignant)
Biopsy: Core needle biopsy or incisional biopsy under image guidance for histopathological diagnosis and grading
Laboratory tests: Routine blood counts, liver and renal function tests, tumor markers (e.g., CEA, AFP, PSA, CA 125, if indicated based on suspected primary).
Differential Diagnosis:
Benign bone tumors (osteochondroma, enchondroma)
Benign soft tissue tumors (lipoma, fibroma)
Infectious processes (empyema, osteomyelitis)
Hematoma or seroma
Metastatic disease to the chest wall from other primary sites
Primary lung cancer invading the chest wall
Breast cancer invading the chest wall
Desmoid tumors
Sarcoidosis.
Management
Indications:
Complete resection for potentially curable primary malignant tumors
Palliation of pain or respiratory compromise due to unresectable or symptomatic tumors
Resection of large or symptomatic benign tumors causing mass effect or deformity.
Surgical Management:
Surgical resection is the cornerstone for malignant chest wall tumors
The goal is complete en bloc resection with wide negative margins (R0 resection)
Techniques vary based on tumor location and extent: Rib resection (segmental or full-length)
Sternectomy
Scapulothoracic resection
Reconstruction methods: Mesh (synthetic or biological) for small to moderate defects
Local tissue flaps (pectoralis major, latissimus dorsi, rectus abdominis)
Free flaps for extensive defects
Prosthetic materials (methyl methacrylate, silicone).
Preoperative Preparation:
Multidisciplinary team discussion (thoracic surgeon, surgical oncologist, plastic surgeon, medical oncologist, radiation oncologist, radiologist, pathologist)
Detailed imaging review for surgical planning
Optimization of cardiorespiratory status
Nutritional assessment
Psychosocial support
Consent for extensive surgery and potential reconstruction.
Postoperative Care:
Intensive care unit (ICU) monitoring
Pain management (epidural, PCA, multimodal analgesia)
Respiratory support (mechanical ventilation if needed, chest physiotherapy)
Chest tube management
Wound care and infection prevention
Early mobilization
Nutritional support
Monitoring for complications.
Supportive Care:
Palliation of pain and dyspnea
Nutritional support to optimize healing
Psychological support for patients and families
Rehabilitation services
Management of oncological treatments (chemotherapy, radiation therapy) in conjunction with surgical care.
Complications
Early Complications:
Wound infection
Flap necrosis
Pneumothorax or hemothorax
Respiratory failure or hypoventilation
Pain
Seroma or hematoma
Chest wall instability and paradoxical motion
Pleural effusion
Chylothorax.
Late Complications:
Chronic pain
Chest wall deformity
Adhesions and restrictive lung disease
Recurrence of tumor
Chronic respiratory compromise
Graft infection or dehiscence
Poor cosmesis.
Prevention Strategies:
Meticulous surgical technique and hemostasis
Adequate soft tissue coverage for mesh or prostheses
Prophylactic antibiotics
Judicious use of drains
Chest physiotherapy and early mobilization
Appropriate pain control
Careful patient selection and optimization.
Prognosis
Factors Affecting Prognosis:
Tumor type (benign vs
malignant)
Histological grade
Stage of disease (TNM staging)
Completeness of surgical resection (R0 vs
R1/R2)
Presence of lymph node metastasis
Patient's overall health status and comorbidities
Response to adjuvant therapy.
Outcomes:
For benign tumors, resection generally leads to excellent outcomes with good functional recovery
For malignant tumors, prognosis is highly variable and depends on the factors listed above
Local recurrence rates are significant for inadequately resected tumors
Survival rates are best for completely resected early-stage primary tumors
For advanced or metastatic disease, prognosis is poorer.
Follow Up:
Regular clinical examination and imaging (CT chest) are essential to detect local recurrence, regional spread, or distant metastases
Follow-up intervals are typically every 3-6 months for the first 2-3 years, then annually
Long-term surveillance is crucial, especially for malignant tumors
Duration of follow-up depends on tumor biology and risk of recurrence.
Key Points
Exam Focus:
DNB and NEET SS candidates must understand the indications for resection, principles of R0 resection, common reconstruction techniques (mesh, flaps), and management of chest wall instability
Know the common types of chest wall tumors and their typical presentations.
Clinical Pearls:
Preoperative imaging (CT chest with IV contrast) is paramount for precise surgical planning
Multidisciplinary team approach is essential for optimal outcomes
Reconstruction requires careful consideration of defect size, location, and patient factors to ensure respiratory function and cosmesis.
Common Mistakes:
Inadequate resection margins leading to recurrence
Underestimating the complexity of reconstruction
Failure to adequately address respiratory mechanics and pain postoperatively
Delay in diagnosis or referral
Not considering the potential for distant metastasis in malignant lesions.