Radical resection of radiation-induced sarcoma of the chest wall: report of 15 cases

Clinical recommendations for treatment of localized angiosarcoma: A consensus paper by the Italian Sarcoma Group

Angiosarcoma (AS) represents a rare and aggressive vascular sarcoma, posing distinct challenges in clinical management compared to other sarcomas. While the current European Society of Medical Oncology (ESMO) clinical practice guidelines for sarcoma treatment are applicable to AS, its unique aggressiveness and diverse tumor presentations necessitate dedicated and detailed clinical recommendations, which are currently lacking. Notably, considerations regarding surgical extent, radiation therapy (RT), and neoadjuvant/adjuvant chemotherapy vary significantly in localized disease, depending on each different site of onset. Indeed, AS are one of the sarcoma types most sensitive to cytotoxic chemotherapy. Despite this, uncertainties persist regarding optimal management across different clinical presentations, highlighting the need for further investigation through clinical trials. The Italian Sarcoma Group (ISG) organized a consensus meeting on April 1st, 2023, in Castel San Pietro, Italy, bringing together Italian sarcoma experts from several disciplines and patient representatives from "Sofia nel Cuore Onlus" and the ISG patient advocacy working group. The objective was to develop specific clinical recommendations for managing localized AS within the existing framework of sarcoma clinical practice guidelines, accounting for potential practice variations among ISG institutions. The aim was to try to standardize and harmonize clinical practices, or at least highlight the open questions in the local management of the disease, to define the best evidence-based practice for the optimal approach of localized AS and generate the recommendations presented herein.

Angiosarcoma of the Breast: Overview of Current Data and Multimodal Imaging Findings

Angiosarcoma of the breast is a rare breast cancer, which can arise de novo (primary breast angiosarcoma, PBA) or as a secondary malignancy (secondary breast angiosarcoma, SBA) as a result of a biological insult. In the latter case, it is usually diagnosed in patients with a previous history of radiation therapy following a conserving treatment for breast cancer. Over the years, the advances in early diagnosis and treatment of breast cancer, with increasing use of breast-conserving surgery and radiation therapy (instead of radical mastectomy), brought about an increased incidence of the secondary type. PBA and SBA have different clinical presentations and often represent a diagnostic challenge due to the nonspecific imaging findings. The purpose of this paper is to review and describe the radiological features of breast angiosarcoma, both in conventional and advanced imaging to guide radiologists in the diagnosis and management of this rare tumor.

Carbon-fiber-reinforced polyetheretherketone orthopedic implants in musculoskeletal and spinal tumors: imaging and clinical features

Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) orthopedic implants are gaining popularity in oncologic applications as they offer many potential advantages over traditional metallic implants. From an imaging perspective, this instrumentation allows for improved evaluation of adjacent anatomic structures during radiography, computed tomography (CT), and magnetic resonance imaging (MRI). This results in improved postoperative surveillance imaging quality as well as easier visualization of anatomy for potential image-guided percutaneous interventions (e.g., pain palliation injections, or ablative procedures for local disease control). CFR-PEEK devices are also advantageous in radiation oncology treatment due to their decreased imaging artifact during treatment planning imaging and decreased dose perturbation during radiotherapy delivery. As manufacturing processes for CFR-PEEK materials continue to evolve and improve, potential orthopedic applications in the spine and appendicular skeleton increase. An understanding of the unique properties of CFR-PEEK devices and their impact on imaging is valuable to radiologists delivering care to orthopedic oncology patients in both the diagnostic and interventional settings. This multidisciplinary review aims to provide a comprehensive insight into the radiologic, surgical, and radiation oncology impact of these innovative devices.

Case Report: Surgical Reconstruction of a Massive Thoracic Wall Defect After the Resection of an Undifferentiated Radiation-Induced Sarcoma of the Breast

A 54-year-old lady was referred to our institute because of a massive thoracic neoplasm arising from the thoracic wall which infiltrated and dislocated the left breast. Twenty years before, the patient had undergone a quadrantectomy with axillary dissection for an infiltrating ductal carcinoma of the left breast, followed by adjuvant radiotherapy and chemotherapy. A true-cut biopsy of the mass showed a low differentiated malignant neoplasm with spindle-shaped cells. The patient underwent a total-body CT scan which showed a 16 × 15 × 10 cm largely necrotic mass with irregular and undefined margins, with little homolateral round-shaped cervical and mesenteric lymph nodes but no distant metastases. After a multidisciplinary discussion, we proposed surgery as the first therapeutic option. The planned treatment was a wide excision of the mass with the underlying ribs (II-VI) followed by the reconstruction of the thoracic wall using titanium bars covered by the acellular porcine dermis, latissimus dorsi flap, and finally, skin grafts from the thighs.

Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses

Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ^©RSNA, 2021.

Canyons and Volcanoes: The Effects of Radiation on the Chest Wall

Tumors involving the sternum often require complete removal of the bony structure to achieve cure and prevent recurrence. The type and extent of reconstruction must be carefully selected. Full-thickness sternal defects often necessitate semirigid or rigid biocompatible prostheses and carefully transposed myocutaneous flaps. Superimposed infection on radiation-induced cancer or osteoradionecrosis involving the sternum is also observed, and optimal treatment relies on an experienced multidisciplinary team. We report the successful management of two cases of sternal involvement after radiation: a canyon-like lesion and a volcano-like lesion.

Surgical Management of Chest Wall Sarcoma

Chest wall sarcoma is a rare and challenging pathology best managed by a multidisciplinary team experienced in the management of a multiple different pathologies. Knowledge of the management sequence is important for each sarcoma type in order to provide optimal treatment. Surgical resection of chest wall resections remains the primary treatment of disease isolated to the chest wall. Optimal margins of resection and reconstruction techniques have yet to be determined.

Surgical outcomes and prognostic factors of non-metastatic radiation-induced sarcoma of bone

BACKGROUND

The survival and prognostic factors in non-metastatic, radiation-induced bone sarcomas of bone have not been described. Moreover, the quantitative data about surgical outcomes and complications after limb-salvage surgery versus amputation are quite limited.

METHODS

Twenty-five patients with non-metastatic, radiation-induced sarcoma of bone who underwent definitive surgery were analysed. Histological diagnosis was osteosarcoma in 19 and undifferentiated pleomorphic sarcoma in six. The definitive surgery was limb-salvage surgery in 15 patients and an amputation in 10.

RESULTS

The 5-year overall survival rate (OS) and the 5-year event-free survival rate (EFS) were 53% (95% CI 31%-70%) and 40% (21%-59%), respectively. Patients with wide or radical surgical margins (n = 13) showed significantly better OS compared with those with marginal (n = 8) or intralesional (n = 2) margins (5-year OS, radical or wide = 74%, marginal = 17%, intralesional = 0%, p = 0.044). The risk of local recurrence was significantly higher in the limb-salvage group compared to the amputation group (49% vs 0%, p = 0.011). OS and EFS were not significantly different between limb-salvage group and an amputation group (p = 0.188 and 0.912, respectively).

CONCLUSIONS

We believe non-metastatic, radiation-induced sarcoma of bone should be resected with the aim of achieving wide or radical margins. Although limb-salvage surgery was related to higher rates of local recurrence compared with those of the amputation group, OS and EFS were not different among two groups. Surgeons need to discuss the higher risk of local recurrence in limb-salvage surgery.

Post-radiation sarcoma: A study by the Eastern Asian Musculoskeletal Oncology Group

The oncologic risk of ionizing radiation is widely known. Sarcomas developing after radiotherapy have been reported, and they are a growing problem because rapid advancements in cancer management and screening have increased the number of long-term survivors. Although many patients have undergone radiation treatment in Asian countries, scarce reports on post-radiation sarcomas (PRSs) have been published. We investigated the feature and prognostic factors of PRSs in an Asian population. The Eastern Asian Musculoskeletal Oncology Group participated in this project. Cases obtained from 10 centers were retrospectively reviewed. Patients with genetic malignancy predisposition syndrome, or who had more than one type of malignancy before the development of secondary sarcoma were excluded. Forty-two high-grade sarcomas among a total of 43 PRSs were analyzed. There were 29 females and 13 males, with a median age of 58.5 years; 23 patients had bone tumors and 19 had soft tissue tumors. The most common primary lesion was breast cancer. The median latency period was 192 months. There were no differences in radiation dose, latency time, and survival rates between bone and soft tissue PRSs. The most common site and diagnosis were the pelvic area and osteosarcoma and malignant fibrous histiocytoma for bone and soft tissue PRSs. The median follow-up period was 25.5 months. Five-year metastasis-free and overall survival rates were 14.5% and 16.6%, and 39.1% and 49.6% for bone and soft tissue PRSs. Survival differences depending on initial metastasis and surgery were significant in soft tissue sarcomas. Although this study failed to find ethnic differences, it is the largest review on PRS in an Asian population. As early recognition through long-term surveillance is a key to optimal management, clinicians should take efforts to understand the real status of PRS.

Radiation-induced chondrosarcoma of the scapula after radiotherapy for lung cancer: a case report and review of the literature

Background

Radiotherapy associated with chemotherapy is a well-established treatment modality for locally advanced non-small cell lung cancers. Radiation-induced second malignancies, particularly radiation-induced sarcomas, are rare. Some authors reported a recent increase in the incidence of this rare complication, especially because of the improved prognosis and survival of patients after radiotherapy. Pathogenic mechanisms of radiation-induced sarcomas are poorly understood. However, diagnosis criteria are well established. Treatment options must be discussed and adapted to the patient’s profile. Surgery in irradiated tissue is challenging, with limited treatment options with chemotherapy and radiotherapy.

Case presentation

We report the case of a 62-year-old Moroccan man diagnosed as having chondrosarcoma of his right scapula, who was irradiated 10 years ago for stage IIIB non-small cell lung cancer. This case was managed by a complete resection of the tumor with good functional and oncological outcomes. To the best of our knowledge, the scapular location of radiation-induced sarcoma after irradiation for lung cancer has never been described in the literature.

Conclusion

Radiation-induced sarcoma of the scapula represents a rare situation that must be actively researched to have access to an optimal therapeutic approach.

Soft Tissue Neoplasms Causing Apparent Venous Thoracic Outlet Syndrome

Venous thoracic outlet syndrome (vTOS) usually results from compression of the subclavian vein classically as a result of narrowing of the costoclavicular space. We report 2 rare cases of soft tissue neoplasms resulting in apparent vTOS. The first case is a 46-year-old female with a 2-year history of intermittent unilateral shoulder pain, who was initially diagnosed with intervertebral disk herniation. Cervical fusion was performed; however, her symptoms progressed and she additionally developed paresthesias and venous congestion. Computed tomography (CT) angiogram demonstrated a 13-cm-encapsulated mass within the subscapularis muscle compressing the axillary vein. Radiological findings suggested lipoma. She subsequently underwent complete resection via a transaxillary approach with extension along the lateral border of the latissimus. Final pathology confirmed an intramuscular lipoma. The second case is a 21-year-old female who presented with acute onset of unilateral chest wall pain, palpable nodularity, and venous congestion. CT chest showed pulmonary embolism and an anterior chest wall mass. An initial attempt at resection was aborted due to proximity of the mass to the subclavian vein. The mass enlarged on serial imaging, measuring 3.8 cm in greatest dimension. Additionally, tumor thrombus was seen, and a subsequent ultrasound-guided biopsy was positive for high-grade synovial sarcoma. Positron emission tomography scan showed a pulmonary nodule that was resected thoracoscopically with pathology confirming metastatic synovial sarcoma. Subsequently, she underwent neoadjuvant chemoradiation followed by successful resection of the chest wall mass. An extended infraclavicular approach with a secondary transaxillary incision was utilized to achieve adequate exposure and margins. Final pathology was consistent with preoperative biopsy. Venous reconstruction was not needed. Although rare, an extrinsic mass as a cause of apparent TOS should be in the differential diagnosis. Surgical approach is based on tumor type, location, and proximity to the neurovascular bundle.

Surgical Management of the Radiated Chest Wall and Its Complications

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

Radiation-Induced Intraspinal Chondrosarcoma: A Case Report

Study Design Case report and review of the literature. Objective To report a unique case of an intraspinal chondrosarcoma that was diagnosed 18 years after radiotherapy for a cervical carcinoma and its remarkably unusual clinical presentation. Methods A retrospective case description of an intraspinal mass lesion that occurred 6 weeks after previous spinal surgery. Results Within ∼9 weeks, the tumor had infiltrated the peritoneal cavity and reached the lumbar subcutaneous tissue. Conclusion Radiation-induced sarcomas are rare, are highly aggressive, and may be difficult to diagnose. Furthermore, the only means of achieving long-term survival is through early and extensive surgery.

Multidisciplinary approach to treatment of radiation-induced chest wall sarcoma

Radiation-induced sarcoma (RIS) is a rare complication following therapeutic external irradiation for lung cancer patients. Patients with RIS may develop recurrence or metastasis of the previous disease and also at high risk for early chest wall complications following operation, which requires close follow-up and multidisciplinary approach. We present a challenging case of RIS with a multidisciplinary teamwork in the decision-making and successful management.

Radiation-induced sarcoma of the breast: a systematic review

INTRODUCTION

Radiation-induced sarcoma (RIS) is a rare, aggressive malignancy. Breast cancer survivors treated with radiotherapy constitute a large fraction of RIS patients. To evaluate evidenced-based practices for RIS treatment, we performed a systematic review of the published English-language literature.

METHODS

We performed a systematic keyword search of PubMed for original research articles pertaining to RIS of the breast. We classified and evaluated the articles based on hierarchical levels of scientific evidence.

RESULTS

We identified 124 original articles available for analysis, which included 1,831 patients. No randomized controlled trials involving RIS patients were found. We present the best available evidence for the etiology, comparative biology to primary sarcoma, prognostic factors, and treatment options for RIS of the breast.

CONCLUSION

Although the evidence to guide clinical practice is limited to single institutional cohort studies, registry studies, case-control studies, and case reports, we applied the available evidence to address clinically relevant questions related to best practice in patient management. Surgery with widely negative margins remains the primary treatment of RIS. Unfortunately, the role of adjuvant and neoadjuvant chemotherapy remains uncertain. This systematic review highlights the need for additional well-designed studies to inform the management of RIS.

Chest wall resection for adult soft tissue sarcomas and chondrosarcomas: analysis of prognostic factors

Background

Wide resection with tumor-free margins is necessary in soft-tissue sarcomas to minimize local recurrence and to contribute to long-term survival. Information about treatment outcome and prognostic factors of adult sarcoma requiring chest wall resection (CWR) is limited.

Methods

Sixty consecutive patients were retrospectively studied for overall survival (OS), local recurrence-free survival (LRFS), and disease-free survival (DFS). Twenty-one prognostic factors regarding survival were analyzed by univariate analysis using the Kaplan-Meier method and the log-rank test.

Results

With a median survival of 2.5 years, the OS was 46% (33%) at 5 (10) years. The LRFS was 64% at 5 and 10 years, and the DFS was 30% and 25% at 5 and 10 years. At the end of the study period, 26 patients (43%) were alive, of which 20 patients (33%) had no evidence of disease and 40 patients (67%) had no chest wall recurrence. In the group of 9 patients with a radiation-induced soft-tissue sarcoma, the median survival was 8 months. Favorable outcome in univariate analysis in OS and LRFS applied for the low-grade sarcoma, bone invasion, and sternal resection. For OS only, age below 60 years and no radiotherapy were significant factors contributing to an improved survival. CWR was considered radical (R0) at the pathological examination in 43 patients. There were 52 patients with an uneventful recovery. There was one postoperative death.

Conclusions

CWR for soft-tissue sarcoma is a safe surgical procedure with low morbidity and a mortality rate of less than 1%. With proper patient selection acceptable survival can be reached in a large group of patients. Care must be given to patients with radiation-induced soft-tissue sarcoma who have a significantly worse prognosis.

Case report. PET/CT appearance of desmoid tumour of the chest wall

Desmoid tumours are rare, poorly circumscribed tumours that have a firm consistency and, although benign, have a remarkable tendency to infiltrate into surrounding structures. Extra-abdominal desmoid tumours involve mainly the extremities or the chest wall and are usually managed by wide radical resection. Moreover, desmoid tumours involving the chest wall are locally aggressive tumours with a high recurrence rate. We report a case of a pathologically proven desmoid tumour of the chest wall in a patient with a history of bilateral breast cancer and oesophageal cancer. We discuss the imaging appearances of this tumour on positron emission tomography combined with computed tomography (PET/CT) and magnetic resonance imaging.

Breast pseudotumoral radionecrosis as a late radiation-induced injury: a case report

Introduction

New therapies and treatment protocols have led to improved survival rates in many cancers. The improved rates are such that patients are now living long enough to experience some negative long-term side effects of the initial therapy.

Case presentation

We report the case of a 65-year-old Caucasian woman who presented with a rare case of pseudotumoral radionecrosis, a late radiation-induced injury, after combined surgical and cobalt radiation therapy for the treatment of adenocarcinoma of the right breast. The patient underwent resection of this benign, yet progressively growing and painful tumor. A cosmetically satisfying result was achieved by reconstruction of the thoracic wall with a polypropylene mesh and a latissimus dorsi muscle flap.

Conclusion

With improved overall survival, new management strategies for late side effects of therapy are becoming of crucial importance for affected patients. In the future, improving toxicity-free survival will be as important as achieving disease-free survival or local tumor control.

Radical resection of giant chondrosarcoma of the anterior chest wall

Background. Chondrosarcomas represent approximately 30% of primary malignant bone tumors, the most frequent of which is on anterior thoracic wall. Case report. We presented a case of 50-year-old man suffering from a slowgrowing, painless giant chondrosarcoma of the anterior chest wall. A wide resection was performed to excise the tumor including attached skin, right breast, ribs, sternum, soft tissues and parietal pleura. Mediastinum was not affected by the tumor. After resecting a 26 ? 20 ? 22 cm segment, the chest wall defect was reconstructed with a Marlex mesh and extensive latissimus dorsi myocutaneous flap pedicled on the right thoracodorsal vessels. Histopatology diagnosis was chondrosarcoma G 2?3. The mechanics of ventilation was not altered and respiratory function was normal from the immediate postoperative period. Three years after the operation postoperative results showed no local recurrence and excellent functional and aesthetic results were evident. Respiratory function remained unaltered. Conclusion. According to the results it can be concluded that the use of Marlex mash and myocutaneous flap is good method for stabilization of the chest wall and enough to avoid paradoxical respiratory movements in managing giant chondrosarcoma of the anterior chest wall.

Postradiation sarcoma of the chest wall: report of two cases

Postradiation sarcoma is a rare late complication of external radiotherapy. We herein present two cases with this disease. A 54-year-old man had undergone a lobectomy and chest wall resection for Pancoast type lung cancer 7 years previously. He had undergone irradiation with a total dose of 50 Gy. Computed tomography (CT) demonstrated a tumorous expansion of the right lateral thoracic wall. A pathological examination confirmed a diagnosis of osteosarcoma. A 60-year-old woman had undergone a resection of the lateral chest wall mass, which was diagnosed to be Hodgkin's disease in 1991. Chemotherapy was given postoperatively. A tumorous lesion arose again and irradiation was performed with a total dose of 110 Gy. In 2000, two tumors appeared in the irradiation field. A pathological examination showed a sarcoma with divergent differentiation. In 2003, a tumor recurred and was diagnosed to be a liposarcoma. Patients who have received radiotherapy should therefore be followed up while taking into consideration the possible development of postradiation sarcoma.

Prognosis of radiation-induced bone sarcoma is similar to primary osteosarcoma

Radiation-induced sarcoma of bone (RISB) is thought to be associated with a poor prognosis. The purpose of this study was to determine disease-free and overall survival of patients treated for RISB, and whether there is a role for limb sparing surgery. Twenty-four patients had a mean latency of 16 years between radiation for their index cancer and RISB diagnosis. The most common tumor was osteosarcoma (n = 17). Ten patients with localized disease treated aggressively with chemotherapy and surgical resection had estimated 5-year disease-free and overall survival rates of 58% and 69% respectively. Patients treated by surgery alone or those with metastases at diagnosis had inferior outcomes. Patients who received a complete course of chemotherapy demonstrated better histologic tumor response and improved survival. There was no difference in survival between the limb sparing surgery (n = 12) or amputation (n = 8) groups. However, limb salvage patients had slightly higher rates of local tumor relapse and post-operative complications. Functional outcome following limb sparing surgery for 10 patients with RISB was similar to a matched cohort treated for primary osteosarcoma. An aggressive treatment approach for patients with RISB may provide similar rates of local recurrence and metastasis and functional outcomes compared to patients with primary osteosarcoma.

LEVEL OF EVIDENCE

Therapeutic study, level IV-1.

[Oncoplastic surgery for thoracic wall tumours]

INTRODUCTION

Surgical treatment of tumours of the chest wall (primary or metastatic) requires special skills by the thoracic and the plastic surgeons, from the functional as well as the aesthetic perspective (oncoplastic surgery), when the treatment requires surgical reconstruction.

MATERIAL AND METHODS

We present a series of 14 patients who needed extensive resection of the thoracic wall (external and/or 3 or more ribs) with disease-free margins and reconstruction with prostheses (7 with polytetrafluoroethylene [PTFE(R)] and 7 with the Sandwich Marlex-Methyl Metacrylate) technique with additional covering with muscle-skin flaps (6 pectoral, 5 recto-anterior, 3 dorsal) pedicled during the same surgical intervention.

RESULTS

The aetiology of the extirpated tumours, following pathology assessment, were: 4 chondrosarcoma, 3 metastatic sternum, 2 breast cancer relapse, 1 desmoid tumour, 1 neurofibrosarcoma, 1 rhabdomiosarcoma, 1 malignant schwannoma and 1 radiation induced sarcoma. One patient died from complications and another 4 from disease progression before the conclusion of the study follow-up (3-22 months).

CONCLUSIONS

Extensive resection of tumours of the chest wall with reconstruction using prostheses and muscle-skin flaps is a safe method that can be performed in the same surgical intervention period when combining the skills of the thoracic surgeon with that of the plastic surgeon.

Chest wall resection for invasive lung carcinoma, soft tissue sarcoma, and other types of malignancy. Pathologic aspects in a series of 107 patients

With improvements in surgical techniques for resection and reconstruction of the chest wall, pathologists are confronted with complicated surgical specimens. There are no currently available guidelines specifically dedicated to the handling of these specimens. Extended resections of lung carcinoma chest wall invasions may change the clinical value of some TNM subsets. We reviewed a series of 107 consecutive malignant tumors involving the chest wall and resected in our institution during a 3-year period. The 107 patients included 39 females and 68 males aged 6 to 80 years (mean, 53 years). Ninety-eight cases (92%) were en bloc resection. There were 55 invasions by lung carcinomas including 19 Pancoast tumors. With the current TNM classification, five lung carcinomas, treated with vertebral body resection because of vertebral foramina invasion, were T3. Four lung carcinomas were N3 or M1 only because of supraclavicular or chest wall lymph node invasion. Other tumors included 20 primary soft-tissue tumors, 13 primary skeletal tumors, 12 metastases, four local invasions by breast tumors, and three miscellaneous lesions. Resected structures included one to six ribs (mean, 2.6; n = 89), thoracic inlet (n = 24), three or four vertebral bodies (n = 13), sternum (n = 17), clavicles (n = 15), shoulder blade (n = 4), upper limb (n = 2), skin (n = 29), lung (n = 64), diaphragm (n = 2), and mediastinum (n = 2). Ten cases were incomplete resections including five because of vertebral body or vertebral foramina tumor invasion. The study of surgical specimens resulting from resection of malignant tumors of the chest wall is complicated because of the variety of both tumor histologic types and involved anatomic structures. Specimen radiograms have a great informative value. Assessment of surgical margins, especially vertebral foramina, is imperative. In lung carcinomas invading the chest wall, we suggest that vertebral foramina invasion could be classified T4 and that the prognostic value of chest wall lymph nodes isolated invasions should be assessed for a possible N1 classification.

[Interdisciplinary surgery of the thorax-from the general surgeon's point of view]

Interdisciplinary professional management is the most important basic principle for successfully mastering thoracic operations including the thoracic wall and adjacent regions such as neck, axilla, mediastinal vessels, upper limb, and spine. Extended oncological resection in advanced malignant diseases, side-effects of radiotherapy and trauma explain the diversity of possible operative procedures. For technical success, the necessity of vascular grafting, reconstruction of the brachial plexus, spine surgery, cardiac surgery, plastic thoracic wall reconstruction, stabilization of the thoracic wall, modern equipment, and know-how are mandatory. We chose some show-cases which-in our opinion-might be appropriate for demonstrating interdisciplinary therapy management. Functional, oncological, and cosmetic/reconstructive aspects should be considered when approaching these cases.

Sternal resection and reconstruction for primary malignant tumors

BACKGROUND

Primary malignant sternal tumors (PMST) are locally aggressive and their optimal surgical management still continues to evolve.

METHODS

From 1986 to 2002, 38 patients (25 females/13 males) underwent radical resection of PMST. This series included 33 sarcomas, 17 of which had been radiation-induced, 3 hematologic tumors, and 2 carcinomas. Seventeen were high-grade tumors. Nine patients had received preoperative chemotherapy. Twelve patients required extensive skin excision. Eight total, seven subtotal, and 23 partial sternectomies were performed. Resection was extended to the anterior chest-wall in 4 patients, lung in 4, brachiocephalic vein in 3, superior vena cava in 2, and pericardium in 1. In 36 patients, chest wall stability was obtained by Marlex (n = 21) or Vicryl (n = 2) mesh and polytetrafluoroethylene patch (n = 13), with methylmethacrylate reinforcement in 12 patients. Soft tissue coverage was done by the pectoralis major muscles with skin advancement in 25 patients, a myocutaneous flap in 11, a breast transposition in 1, and a skin flap in 1. Omentoplasty was performed in 3 patients.

RESULTS

One patient died from pneumonia. Two patients needed a tracheostomy after total sternectomy. No flap-related complication was observed. Four local septic complications required removal of the composite prosthesis with reoperations. Local recurrence occurred in 9 patients, 7 patients having a repeat resection. Metastases developed in eight. The 5-year overall and disease-free survival was 66% and 53%, respectively. The histologic grade of sarcomas was a survival predictor (high grade versus others p = 0.035).

CONCLUSIONS

Wide resection of PMST is necessary to minimize local recurrence. Large sternal defects are safely reconstructed with a musculocutaneous flap. We suggest that the use of methylmethacrylate should be limited to reconstruction after total sternectomy.

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE

To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.

SUMMARY BACKGROUND DATA

Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.

METHODS

From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.

RESULTS

There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.

CONCLUSIONS

Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

Malignant melanoma arising in a radiotherapy field: report of two cases and review of the literature

We report 2 patients who developed melanoma or melanoma metastases in radiation fields 6 and 43 years after radiation therapy, respectively. One of the patients had received adjuvant hyperfractionated photon therapy for Ewing sarcoma, while the other patient had received X-ray therapy for a hemangioma. While postradiation secondary cancers with a long latency period are not uncommon, the development of melanoma is exceedingly rare.

Radiation-induced osteosarcoma of the chest wall

A case of radiation-induced sarcoma of the chest wall is reported. Twenty-seven years 11 months after orthovoltage radiotherapy of the right breast a 69-year-old woman developed a radiation-induced osteosarcoma of the right thoracic wall. Initial diagnosis has been T-cell lymphoma of the skin. The right breast was irradiated with tangential fields and a total dose of 40 Gy, 2 Gy/day, 5 days a week. Orthovoltage treatment was performed in two courses of 20 Gy, 3 months apart. The clinical appearance of the secondary sarcoma was a diffuse infiltrated area in the irradiated breast which seemed to be fixed to the chest wall. Magnetic resonance imaging (MRI) demonstrated a mass in the right anterior thoracic wall which destroyed the fourth to the sixth rib. The tumor infiltrated the thoracic wall, including subcutaneous tissue and pericardium, as well as extending into the subphrenic space. Biopsy of the lesion revealed a poorly differentiated osteosarcoma. The patient's general condition precluded surgical or chemotherapeutic intervention; she died due to a cerebral stroke 6 months later. This case fulfilled all criteria for radiation-induced sarcoma, as there was a prior history of radiotherapy, latency period of several years, development of sarcoma within the irradiated field, and histologic confirmation of sarcoma.

Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms

BACKGROUND

Between January 1980 and December 1999, 88 patients underwent the surgical resection of sternal tumors: 30 primary malignant tumors, 28 local relapses or metastases from breast carcinomas, 16 other types of tumor, and 14 radionecroses.

METHODS

The sternectomies were total in 8 cases, subtotal in 32, and partial in 48. Prosthetic materials covered by flaps of myocutaneous or muscle tissue were used in 55 patients, prosthetic material alone in 13, myocutaneous or muscle flaps alone in 5, and other techniques in the remaining 15. The resection was radical in 78 cases and palliative in the other 10.

RESULTS

Forty-eight of the subjects who underwent radical surgery were alive and disease free at the end of the follow-up period. The expected 10-year survival of the patients treated for primary tumors is approximately 85% (Kaplan-Meier), and that of the patients with relapsing breast carcinomas is the same as after 5 years (41.8%).

CONCLUSIONS

In our experience, the treatment of neoplasms by means of a broad sternal resection followed by a reconstruction based on the use of prosthetic materials is an effective and safe solution that considerably improves the quality of life and makes it possible to perform curative broad radical resections in the case of primary sternal resections.

Sarcoma after radiation therapy: retrospective multiinstitutional study of 80 histologically confirmed cases. Radiation Therapist and Pathologist Groups of the Fédération Nationale des Centres de Lutte Contre le Cancer

PURPOSE

To evaluate the best strategy for treatment of sarcoma that occurs after radiation therapy.

MATERIALS AND METHODS

Records were retrospectively reviewed for 80 patients with a confirmed histologic diagnosis of sarcoma that occurred after radiation therapy performed during 1975-1995. The patients were treated for breast cancer (n = 33, 42%), non-Hodgkin lymphoma (n = 9, 11%), cervical cancer (n = 9, 11%), benign lesions (n = 4, 5%), or other tumors (n = 25, 31%). Sarcoma occurred after a mean latency of 12 years (range, 3-64 years), with most (70%) developing in the soft tissue. Treatment included surgery (28 patients), surgery and chemotherapy (18 patients), chemotherapy only (15 patients), and radiation therapy (14 patients).

RESULTS

By the end of the study, 51 patients were dead, including 46 due to sarcoma. Median survival was 23 months. Overall survival rates at 2 and 5 years, respectively, were 69% and 39% for patients treated with surgery, 10% and 0% for those treated with chemotherapy, and 52% and 35% for those treated with surgery and chemotherapy (P =.001). The 2- and 5-year rates for survival without recurrence were 54% and 32%, respectively.

CONCLUSION

The results confirm the beneficial effect of surgery. Further study is needed to explore the roles of combined treatments.

Chest wall resection and reconstruction

Chest wall reconstruction has been refined and expanded in recent years so that almost any defect may be repaired with an excellent cosmetic and physiological result. The first step in a good reconstruction is an appropriate and thorough resection that leaves healthy, viable margins to which the materials and tissues used in a reconstruction may be anchored securely. In most instances, chest wall stabilization will not be necessary. In some cases in which large areas of chest wall will be removed or a lateral aspect of a chest wall needs to be resected, stabilization may be necessary. Stabilization may also be required in patients who suffer from debilitating lung disease and need a chest wall resection and reconstruction. Soft tissue coverage completes the reconstruction by moving healthy, viable tissue to fill the defect. In most instances, pedicled muscular, musculocutaneous, and omental flaps will provide adequate soft tissue coverage. Very infrequently, a free flap will be necessary to achieve total closure of a chest wall defect. The soft tissue coverage is completed by using meshed, split thickness skin grafts to provide epithelialization of any exposed muscle or omentum.