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Ann Thorac Surg 1997;63:214-219
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Radical Resection of Radiation-Induced Sarcoma of the Chest Wall: Report of 15 Cases

Departments of Thoracic and Vascular Surgery and Heart-Lung Transplantation and Pathology, Hôpital Marie-Lannelongue, Paris-Sud University, Le Plessis-Robinson, France

Accepted for publication August 16, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Surgical management of radiation-induced sarcoma of the chest wall remains difficult because of its impressive local aggressiveness.

Methods. Between 1987 and 1995, 15 patients (median age, 58 years) underwent radical resection of radiation-induced sarcoma of the chest wall. This type of tumor was defined as a metachronous, histologically different neoplasm in the irradiated field of the original tumor. Ten patients had a history of primary breast cancer and 5 patients, Hodgkin's disease. The median delivered radiation dose to the primary tumor area was 45 Gy, and the median interval between radiotherapy and diagnosis of sarcoma was 14 years. Seven tumors were located on the sternum, three on the lateral chest wall, and five in the thoracic outlet. Four total and three partial sternectomies, three lateral chest wall resections and five resections of tumors in the thoracic outlet (three first-rib resections) were performed. Seven patients required stabilization of the chest wall with prosthetic material. Soft tissue reconstruction was carried out with either muscle flaps and skin advancement in 9, musculocutaneous flaps in 4, or skin flaps alone in 2 patients.

Results. One patient died 3 months after total sternectomy of respiratory failure. Two patients (13.3%) had a local complication: sepsis after sternectomy in 1 and cutaneous necrosis in 1. Local recurrence occurred in 7 patients after a median interval of 10 months. Two of them died, and 4 underwent a repeat resection, 3 of whom are still alive. Four patients died of systemic recurrence. With a median follow-up of 30 months, overall 5-year survival and 5-year disease-free survival rates were 48% and 27%, respectively.

Conclusion. Despite poor long-term disease-free survival, radical resection of radiation-induced sarcoma of the chest wall is justified on the basis of low postoperative morbidity and the lack of other available therapies.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Many patients are surviving breast cancer and Hodgkin's disease. Some of them will have development of a sarcoma in the irradiated chest wall. These tumors are associated with a poor prognosis [1, 2]. Few cases of radiation-induced sarcomas (RIS) of the chest wall have been reported to date [3, 4]. Radical resection is the only chance of cure. However, the impressive local aggressiveness of these tumors and the difficulties encountered in trying to adequately reconstruct wide chest-wall defects make radical resection a hazardous endeavor. This study reviews our experience with the surgical management of these tumors.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between 1987 and 1995, 15 patients with a median age of 58 years (range 33 to 72 years) underwent radical resection of RIS of the chest wall. Radiation-induced sarcoma was defined as a metachronous, histologically different neoplasm in or adjacent to the field of radiation of the original tumor [5]. Ten women were seen with a history of primary breast cancer and 5 patients (3 men and 2 women), with primary Hodgkin's disease. Patient characteristics and anatomic location of the RIS are shown in Table 1. In most cases, details of the radiotherapy were not available. The median delivered radiation dose to the primary tumor area was 45 Gy (range, 40 to 90 Gy), and the median interval between radiotherapy and occurrence of RIS was 14 years (range, 6 to 27 years). Five patients (33%) had had previous surgical resection before referral. The tumors were located on the sternum in 7 patients and the lateral chest wall in 3 and had invaded the thoracic outlet in 5.

Operative Procedure
Our surgical technique has been extensively detailed elsewhere [6]. It consists of aggressive wide local resection of invaded skin and subcutaneous tissues, previously irradiated tissues, and scars, including a margin of at least 4 cm of macroscopically normal surrounding tissue. Resection of sternal tumors was started over the costal margins and included 3 cm of free ribs on each side but spared the unaffected lateral part of the pectoralis major (PM) muscles. A total sternectomy was undertaken for tumors located over the midsternum and for large tumors of the manubrium, including the internal third of the clavicles. For lateral chest wall tumors, the free margins of the resection were one normal rib above and one below. The pleural cavity was entered far away from any chest wall involvement. Tumor extension into the chest cavity was evaluated. Lung and involved mediastinal structures were resected en bloc. Tumors invading the thoracic outlet required a transcervical thoracic approach for radical resection of involved structures [7, 8], including an L-shaped cervicotomy extending into the deltopectoral groove and resection of the internal half of the clavicle. Microscopic evaluation of the margins by frozen section was done routinely.

Resection
Ten patients (67%) required wide skin excision. In 6 of them, the skin was invaded or ulcerated by the tumor, and in 2, the skin was inflammatory. All patients underwent radical resection of the tumor and involved structures (Table 2). Seven sternectomies (four total and three partial) and three resections of at least three ribs of the lateral chest wall were performed. Five resections of tumors invading the thoracic outlet were performed, and included the first rib in 3 patients.

Chest Wall Reconstruction
To limit paradoxical respiration, chest wall stability was obtained with prosthetic material in 7 patients with wide anterior and lateral defects. We used Marlex mesh (Bard Inc, Murray Hill, NJ), polyglactin (Ethnor Inc, Summerville, NJ), and polytetrafluoroethylene (W. L. Gore & Assoc, Flagstaff, AZ) in 4 patients, 2, and 1 patient, respectively. Three of the 7 patients who had a sternectomy also had a methyl methacrylate mesh reinforcement.

Soft tissue reconstruction of sternal defects was carried out using a PM muscle flap in 4 patients, with skin advancement in 3 and contralateral breast flap in 1 (Table 3; Fig 1). Concomitant omentoplasty was performed in 2 of these patients. In 1 patient with a wide, overlying skin excision, a bilateral PM musculocutaneous flap based on the thoracoacromial vessels was done. In another patient, reconstruction was performed with a latissimus dorsi (LD) musculocutaneous flap because the PM had previously been excised on one side and irradiated on the other. In a woman with a fourth recurrence of malignant fibrous histiocytoma, we were able to preserve a previously performed rectus abdominis musculocutaneous flap. Reconstruction after lateral chest wall resection was performed with LD transposition in 2 patients; in 1 additional patient with LD transposition, a wide anterolateral defect associated with upper limb disarticulation was covered with a posterior brachial skin flap. After resection of tumors invading the thoracic outlet, reconstruction was done with sternocleidomastoid muscle and primary skin closure in 2, skin advancement in 1, and posterior skin flap after upper limb resection in 1. One patient required a rectus abdominis musculocutaneous flap because of concomitant removal of the ipsilateral irradiated breast (Fig 2).

View larger version (61K): [in this window] [in a new window]   Fig 1. . (Patient 2). (A) Computed tomographic scan showing radiation-induced osteosarcoma of sternum (B) Total sternectomy and soft tissue coverage with pectoralis major muscle and contralateral breast flap.

View larger version (67K): [in this window] [in a new window]   Fig 2. . (Patient 11.) (A) Radiation-induced fibrosarcoma of thoracic outlet. (B) Subclavian arteriography showing patency of internal mammary artery. (C) Final reconstruction with rectus abdominis musculocutaneous flap after radical resection of tumor and ipsilateral irradiated breast.

Statistical Analysis
Overall survival and recurrence-free survival were calculated from the date of operation to death or date of last follow-up for patients who are alive and to date of local or systemic recurrence. Survivals were estimated by the Kaplan-Meier product-limit method.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Mortality
One patient who underwent total sternectomy required a tracheostomy and died 3 months later of acute respiratory insufficiency.

Histology
All tumors except chondrosarcoma were highly infiltrative. Margins were tumor free in all patients. The median tumor size was 10 cm (range, 5 to 20 cm). Histologic subtypes of RIS are shown in Table 2 and included six fibrosarcomas, three malignant fibrous histiocytomas, two undifferentiated sarcomas, one chondrosarcoma, one osteosarcoma, and two malignant schwannomas. Grade differentiation was high in 11 patients (73%), low in 3, and intermediate in 1 patient.

Local Complications
There were two serious local complications (13.3%). In 1 patient, a major septic complication occurred after total sternectomy when a seroma became infected. The infected prosthetic composite material was removed after 4 weeks, with preservation of the bilateral PM myocutaneous flap and without affecting the stability of the chest wall at that time. A partial upper cutaneous dehiscence remained, resulting 2 months later in hemorrhage by ulceration of the superior vena cava. It was successfully managed by venous reconstruction and coverage with a myocutaneous LD flap. In the second patient, who underwent upper limb disarticulation, necrosis of the posterior skin flap developed and was successfully treated by a rectus abdominis myocutaneous flap. A minor cutaneous dehiscence occurred in 1 additional patient.

Local and Systemic Recurrence
Local recurrence occurred in 7 patients (47%) at a median interval of 10 months (range, 9 to 30 months). Two patients died of local recurrence. The other 4 underwent a repeat resection an average of 15 months (range, 9 to 33 months) after the first resection. One repeat resection was an upper limb disarticulation. Three of these patients are alive without evidence of tumor. Metastases developed in 4 patients. Two had multiple pulmonary lesions; 1, a cerebral lesion; and 1, multiple lesions. All 4 patients died. Among the 4 patients treated with chemotherapy, 3 remained free from disease, and 1 had recurrence, both locally and systemically.

Survival
With a median follow-up of 30 months (range, 3 to 87 months), the overall 5-year survival rate was 48%. The 5-year recurrence-free survival rate was 27% (Fig 3).

View larger version (15K): [in this window] [in a new window]   Fig 3. . Overall survival and disease-free curves.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Signs of RIS of the chest wall are usually highly suggestive. The diagnosis can be confirmed by needle biopsy, which is preferable to an incision biopsy to avoid tumor dissemination. Imaging studies are essential to delineate the tumor and any infiltration of adjacent organs. Radical resection of RIS remains the only chance for cure in patients with localized disease. Resection frequently requires a large skin excision including previously irradiated surrounding tissues and the ipsilateral breast in some women. Soft tissue coverage must be carefully planned, specifically when a wide chest-wall defect is anticipated. Preoperative angiography is highly recommended to assess the anatomy of the blood supply of available muscle or myocutaneous flaps. This is especially important in patients who have had previous irradiation at the future donor site.

Because the interpretation of frozen sections is particularly difficult in RIS, radical resection must be large enough to obtain tumor-free margins, which minimizes the risk of local tumor recurrence. In our series, RIS of the chest wall frequently arose in or involved the thoracic outlet and required an anterior transcervical thoracic approach for radical resection of the involved structures. This includes an L-shaped cervicotomy, which extends into the deltopectoral groove, and resection of the internal half of the clavicle [7, 8]. Any resectable involved structure, such as lung, mediastinal vessel, and pericardium, must be resected en bloc. Involvement of subclavian and brachiocephalic veins is managed by ligation and excision; involvement of the superior vena cava and the subclavian artery requires prosthetic revascularization with polytetrafluoroethylene because of its long-term permeability [10]. On the basis of our prior results [7], we believe it is justified to resect the T1 or C8 nerve roots or the lower trunk of the brachial plexus to obtain tumor-free margins. However, only major involvement of the brachial plexus can justify disarticulation of the upper limb.

Stabilization of the chest wall is necessary only in patients with large anterior and anterolateral defects, especially after total sternectomy. Stabilization can be obtained with a variety of prosthetic materials [11]. Composite material with methyl methacrylate reinforcement increases the risk of infection. One patient in this series had an infection after total sternectomy and reconstruction with Marlex and methyl methacrylate and required late removal of the prosthetic material.

Soft tissue reconstruction after radical resection of RIS should be accomplished using a muscle or musculocutaneous flap [6, 12]. After sternectomy, the PM is the muscle most frequently transferred on a thoracoacromial vascular pedicle, either bilaterally with skin advancement or as a musculocutaneous flap. When the PMs have been previously irradiated or excised, an LD musculocutaneous flap can be used [13]. Concomitant omentoplasty can be performed in some instances, particularly after resection of an RIS of the upper sternum with extension into the neck. Large defects of the lateral chest wall are usually reconstructed with LD transposed on thoracodorsal vessels with skin advancement. In patients with a wide soft-tissue defect and ipsilateral breast resection, anterolateral reconstruction is best carried out with a rectus abdominis musculocutaneous flap by an experienced plastic surgeon. It is imperative that the ipsilateral internal mammary artery be patent before this latter flap is transposed to the chest wall [14]. In the few patients in whom amputation of the upper limb and scapula is required, reconstruction should be done with a posterior brachial skin flap and an abdominal flap, if necessary.

A tumor size greater than 5 cm in patients having complete resection of RIS is traditionally considered as being of prognostic significance [5]. The median tumor size in this series was 10 cm. Most of the tumors were high grade, and the histopathologic subtypes were those usually observed in RIS, including two malignant schwannomas, a particularly aggressive sarcoma developing in a previously irradiated chest wall [15].

The overall 3-year and 5-year survival rates for RIS do not appear to be different from those observed after radical resection of other sarcomas of the chest wall. However, with respect to local and systemic recurrence rates, the recurrence-free survival rate is low in this group of patients. In select patients, we were able to treat local recurrence aggressively with a repeat resection.

The role of adjuvant chemotherapy after complete resection of RIS remains inconclusive [16, 17]. However, it is encouraging that 3 of our 4 recent patients who received adjuvant therapy after operation are alive.

In conclusion, our results provide evidence that RIS of the chest wall in patients with localized disease can be successfully managed by radical resection and satisfactory reconstruction of the chest wall with low mortality and morbidity. However, despite aggressive management, recurrence-free long-term survival remains poor.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Chapelier, Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, 133 Ave de la Résistance, 92350 Le Plessis-Robinson, France.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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6. Chapelier A, Macchiarini P, Rietjens M, et al. Chest wall reconstruction following resection of large primary malignant tumors. Eur J Cardiothorac Surg 1994;8:351–7.[Abstract/Free Full Text]
7. Dartevelle P, Chapelier A, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025–34.[Abstract]
8. Macchiarini P, Dartevelle P, Chapelier A, et al. Technique for resecting primary and metastatic nonbronchogenic tumors of the thoracic outlet. Ann Thorac Surg 1993;55:611–8.[Abstract/Free Full Text]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Emile A. Bacha Paolo Macchiarini Philippe G. Dartevelle Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chapelier, A. R. Articles by Dartevelle, P. G. Search for Related Content PubMed PubMed Citation Articles by Chapelier, A. R. Articles by Dartevelle, P. G.