Indian Journal of Plastic Surgery Medknow Publications on behalf of Indian Journal of Plastic Surgery ISSN: 0970-0358 EISSN: 1998-376x Vol. 38, Num. 1, 2005, pp. 43-47

Indian Journal of Plastic Surgery, Vol. 38, No. 1, January-June, 2005, pp. 43-47

Case Report

Large lateral thoracic defect by chondrosarcoma resection chest wall reconstruction using myocutaneous latissimus dorsal flap without parietal rigid repair

Guerrissi JorgeO, Brunini JoseL

Plastic Surgery Service, Argerich Hospital, Buenos Aires, Argentina

Correspondence Address: Dr. Jorge O. Guerrisse, Libertad 985, Quilmes (1878), Argentina, Email: guerrisi@speedy.com.ar

Code Number: pl05009

Abstract

Keywords: Chondrosarcoma, chest wall, myocutaneous flap

INTRODUCTION

Primary chest wall tumors are uncommon and constitute 0.2-2% of all tumors.[1] Metastatic tumors and tumors of local extension are more common. Myeloma and chondrosarcoma are the most common primary malignant tumors arising from cartilaginous and bony structures and account for nearly 60% of all malignant rib tumors.[2] The treatment of large chest wall tumors was limited for many years until 1898 when Parham described the first thoracic resection of a chest neoplasm.[3] Initially the risks of surgery were related to pneumothorax and respiratory failures. Advances in anaesthesia and controlled airway ventilation with positive pressure allowed chest wall resections to be done safely. Chest wall surgery progressed when measures were taken to reconstruct the defect left after the tumor was removed.

Early attempts at reconstruction included the use of fascia lata, rib grafts.[4] As early as 1960, Graham and Usher introduced the use of prosthetic materials when they described using Marlex mesh to repair defects of the chest wall[5] Today, the success of thoracic tumor resection is due to advances in critical care and functional reconstructive surgery.

A combination of prosthetic materials and rotational flaps, with improvement in mechanical ventilation provide good cosmetic and functional results and short hospital stays. Latissimus dorsi myocutaneous flap is the most used methods for extensive soft tissue defects in chest wall reconstruction.

We are presenting a case in which a large Latissimus dorsi myocutaneous flap was used for lateral chest wall reconstruction after extensive chondrosarcoma resection was performed without the use of alloplastic mesh for thoracic stability. The mechanics of ventilation was not altered and respiratory function was normal from the immediate postoperative period.

CASE REPORT

A 66-year-old women with an extensive right lateral chest wall tumor was referred to our Service. The lesion was firm, attached to the rib arches and involving the right breast; the borders were distinct and the skin covering it was healthy. [Figure - 1] The CT scan demonstrated a destructive lesion involving parietal pleura, 3^rd, 4^th and 5^th lateral rib arches, surrounding muscles and mammary tissues. An excision biopsy was done and the subsequent histology test showed the lesion to be characterized by; "Irregularly shaped lobules of cartilage with variable size, often separated by narrow fibrous bands. Chondocytes arranged in clusters or groups, slightly enlarged nuclei and occasionally bizarre nuclei with mitotic figures". The diagnosis was malignant chondrosarcoma.

The lesion was removed together with parietal pleura, affected rib arches, soft tissues (including skin) and right breast. A 20x20 cm defect was created [Figure - 2] The chest wall was reconstructed with a large ipsilateral latissimus dorsi myocutaneous flap; alloplastic mesh was not used for rigid parietal repair. [Figure - 3]

The skin portion of the flap was elliptical and horizontal and the donor area was closed directly.

The patient was ventilated artificially for 24 hours, then she was weaned without difficulty, her respiration was normal but with a light movement of the flap, no dyspnoea was detected. After 6 months the flap movements had disappeared almost completely in normal breathing. Excellent aesthetic result was obtained [Figure - 4], [Figure - 5].

One year after surgery a CT scan showed the complete absence of recurrence and a neopleura formation was noticed under the flap.

DISCUSSION

Primary bone tumors of the chest wall are uncommon. In one of the largest reviews done at the Mayo Clinic by Dahlin and Unni (1986) malignant neoplasm made up 89% of all bony chest wall tumors and are found in the ribs (85%) more often than in the sternum (15%)[2] The most common malignant neoplasms are myeloma, chondrosarcoma, limphoma and Ewing's sarcoma. Chondrosarcoma are the most common neoplasm of the anterior chest wall. Most often arising from the costochondral arches or the sternum, they account for 30% of all primary malignant bone tumors[6] This tumor is seen most often in men in their 40s and 50s.

The presentation is consistent with a slow-growing mass that may have been painful for several months. They may grow into the pleural cavity or through the muscles into the subcutaneous tissues. In our patient a 20x20 cm tumor developed in right lateral chest wall; it was slow-growing involving several rib arches, parietal pleura and ipsilateral mammary tissues. The presence of a chest wall tumor is an indication for surgical intervention; all malignant chest wall tumors should be resected for potential cure at the time of initial presentation.

The key to a successful chest wall tumor resection is obtaining wide margins at the time of initial resection.

Margins are not the only important principle in thoracic wall tumors, high-grade tumors should have the surrounding soft tissues resected with them. For tumors growing from ribs the surgical resection must include not only the affected bone but also portions of several ribs above and below. Chest wall resection and reconstruction are major operations that carry with them life-threatening complications. The position of the patient will be determined by the location of the tumor.

Standard lateral decubitus positioning should be adequate for anterior or laterally located tumors. Access to structures of surrounding soft tissues, neurovascular structures, and underlying structures of the thoracic cavity should be considered. In this position the vascular pedicles to major muscles bundles, particularly the latissimus dorsi muscle can be easily accessed.

Once the complete extension of the tumor is determined ribs above and below must also be resected if there is any question of clear margins. With the reconstructive techniques now available, resection should not be compromised and limited unless the patients will be incapable of tolerating the procedure.

Large defects should be reconstructed with appropriate tissues, but the respiratory mechanism should also be preserved and functional limitations minimized.The materials used by chest wall reconstruction are polypropylene (Marlex) or polytetrafluorethylene (PTFE) mesh such as Gore-Tex.[7]

The use of a mesh allows a rigid chest wall reconstruction avoiding a floating respiratory mechanism. The primary objective is to obtain parietal stability and therefore minimizing functional limitations. Small defects of the chest wall (less than 4 cm in diameter) do not require reconstruction; defects larger than this should be reconstructed.

Yokote and Osada (1996)[8] conclude that the chest wall reconstruction is indicated when

1. The area of the defect is greater than 100 cm².
2. Three or more ribs are resected in the anterior thoracic aspect
3. As many as four ribs are resected in lateral chest wall.

If function is not to be compromised preoperatively, a decision must be made at the time of surgery as to whether reconstruction is possible. A free flap using various muscles or omentum for coverage must be used when a adjuvant radiation therapy is to be performed; distant and protected vascular pedicles must be used avoiding those that could be injured by effect of radiation. Rotational myocutaneous flaps using latissimus dorsi can initially be considered as technique of choice since it not only permits extensive soft tissue repair but also covers wide defects.

In this case, the reconstruction was done using only a large myocutaneous latissimus dorsi flap, no alloplastic mesh was used for chest wall stability. The parietal pleura was replaced using the anterior fascia of the latissimus dorsi muscle. Initial mild paradoxical respiratory movement disappeared two months after surgery achieving rigid thoracic stability, the respiratory function remained unaltered.

Development of a fairly rigid scar and soft tissue fibrosis could explain the progressive flap stability avoiding paradoxical movements. In our experience the reconstruction with prosthetic material has a high percentage of complications, mostly infections. Consequently we attempted the reconstruction without prosthetic material. We decided to implant a mesh for stability secondarily if this was inadequate. This case showed to us that a large chest wall defect including ribs (lateral arches of ribs) can be reconstructed using only a myocutaneous flap and alloplastic mesh is necessary for parietal rigid stability; no respiratory distress developed. We realize one case cannot be used to make a generalized claim but this result is encouraging and more studies are planned on future patients to determine if this is indeed feasible.

References

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