Extended resection of chest wall tumors with reconstruction using poly methyl methacrylate-mesh prosthesis

الملخص EN

Purpose : This prospective study evaluates the early result of patients with massive chest wall tumors treated by extended resection and reconstruction using Propene or Marled mesh-enforced with Poly Methyl Methacrylate Bone Cement (PMMC) prosthesis.

Material and Methods : this surgery was performed on 40 patients with a mean age of 45±18 (12-62) at the Department of Surgery, National Cancer Institute, Cairo University between 1998-2001.

Primary chest wall tumors were the indications of surgery in 42.5 %, while secondary involvement extending from other sites principally breast cancer were the indications for 57.5 %.

In 85 % of patients more than 3 ribs were involved by tumors and lesions were more than 10 cm in the greatest dimension in 50 % of cases.

Resection involved sternum in 15 (37.5 %) cases and in 45% of cases complete extensive rib resections extended between cost vertebral junctions and the costochondral junctions were performed.

Additional resections of nearby organs were needed in 20 (50%) of cases including partial lung resection in 14 cases, partial vertebral resection in 3 cases and diaphragm resection for 3 cases.

Immediate bony reconstruction by inserting Prolene or Marlex mesh-enforced with Poly Methyl Methacrylate Bone Cement (PMMC) prosthesis to the resulting chest wall defect was performed in 36 cases, whereas, 4 cases had delayed reconstruction.

Primary simple soft tissue closure was sufficient for 37.5 % of patients; whereas 35% were covered by local rotational flap and 27.5 % needed my cutaneous flaps.

Results : No patient with this immediate reconstruction needed ventilator support or tracheostomy and flail chest was not noticed.

ICU stay was markedly reduced; whereas 85% required less than 7 days.

Immediate post-operative (40 days) complications were found in 14 patients (35%) and cases with additional lung resection had more complication rate than others (64 % vs 19 %).

Infection occurred in 3 patients and conservative treatment for 3-4 weeks using frequent irrigation and antibiotics was sufficient to keep infection under control.

Prostheses were removed without functional respiratory disturbance.

Follow-up was carried out for a mean period of 18 months (6-43).

Ten patients (27 %) suffered relapses including 4 cases (10.8 %) with local chest wall recurrence and 6 (16.2 %) with distant metastases.

Actuarial two year relapse free survival rate was 65 % and survival rate was better for primary chest tumors than secondary tumors (78.5 % for primary tumors and 65.2 % for chest wall lesions secondary to breast cancer).

Conclusions : this type of reconstruction obviated the need for postoperative ventilator support and / or tracheostomy for such a major chest wall resection.

It enabled us to resect large tumors with acceptable morbidity and mortality.

Chest wall resection should be attempted aggressively in primary tumors.

However, resection for secondary lesions should be selective and limited to palliation mainly.