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a Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
b Department of Orthopaedic Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
c Department of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
Accepted for publication February 17, 2011.
* Address correspondence to Dr Klepetko, Department of Thoracic Surgery, Vienna General Hospital, Medical University Vienna, Waehringer Guertel 18, 1090 Vienna, Austria (Email: walter.klepetko{at}meduniwien.ac.at).
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Abstract |
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Methods: Chest wall reconstruction was achieved by implantation of a polytetrafluoroethylene patch (n = 5) or a combination of a metal implant (Stratos System R, MedXpert GmbH, Heitersheim, Germany) and a polytetrafluoroethylene patch (n = 1). Myocutaneous coverage of the defects was achieved by use of pedicled flaps from adjacent tissue (n = 3) or by free myocutaneous flaps harvested from the amputated forearm (n = 3).
Results: No perioperative mortality occurred; however, significant morbidity was seen after the use of the free forearm flaps based on occurring vascular problems. All 3 patients had to undergo surgical revision of the flap. Survival ranged from 5 to 50 months (median = 23.5 months) with 3 patients still alive at the time of this investigation.
Conclusions: Forequarter amputation in combination with chest wall resection is a feasible and potentially curative treatment for malignant tumors of the shoulder girdle with invasion of the chest wall. The operation results in immediate palliation and long-term survival can be obtained in selected cases.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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All patients underwent full functional assessment with emphasis on pulmonary function, blood, and coagulation parameters, and cardiac function. Assessment of the individual history of the patients was performed in detail and the possibility of other treatment alternatives to the operative procedure, such as further chemotherapy or radiotherapy, were excluded before the operation.
Central to the preoperative evaluation was the assessment of the extension of the disease on the thoracic wall, the technical respectability of the tumor, as well as the planning strategies for later restoration of the mechanical stability of the chest wall and coverage of the defect with vital tissue. Four other patients who presented with diffuse involvement of the thoracic wall or further intrathoracic extension of the disease, seen in the same period of time, were excluded from operative treatment. In the same way, all patients with evidence for multiple metastatic spread of the disease were excluded from operation. In patient no. 6 a singular metastases to the left upper lobe was present at time point of operation but there was no evidence for further metastases.
Operative Technique
Operations were performed in general anesthesia, with the patient in a lateral position and the arm mobile and accessible from all sides in the center of the operating field. Prior to start of the operation the line of resection was marked, with the goal to achieve radical resection and to preserve as much tissue as possible for later coverage of the resulting soft tissue defect.
Once the cutaneous and subcutaneous layers had been divided with the electrocautery the muscles of the shoulder girdle were transected, the scapula was mobilized, and the clavicle was divided close to the sternoclavicular junction. Then the involved part of the thoracic wall was identified, the chest was entered, and the involved ribs were resected with adequate safety margins. This was followed by identification and preparation of the subclavian vessels and the brachial plexus, with consequent ligation and transection of these structures. Care was taken to preserve long vascular pedicles either from the thoracic internal vessels or from suitable vessels at the neck to allow for later vascular anastomosis, in case the use of a free flap would become necessary. In one patient the dissection at the neck had to be extended toward the midline and the sternocleidomastoid muscle, together with the jugular vein, had to be included into the resection. After completion of this dissection the whole arm including the scapula, clavicle, and the resected thoracic wall was removed en bloc.
Thereafter, the thoracic cavity and the lungs were inspected. In 2 patients the phrenic nerve had to be included into the resection, which resulted in diaphragmatic paralysis. In order to prevent chronic atelectasis of the lung an immediate diaphragmatic plication was performed. In one patient, upper lobe lobectomy was performed for simultaneous resection of a pulmonary metastasis.
Reconstruction of the chest wall was started by restoration of its mechanical stability. In the majority of the patients this was achieved by covering the defect with a mash of polytetrafluoroethylene (PTFE; n = 5). However, in 1 patient with extended resection of 7 ribs, simple coverage of the defect with a mesh would have significantly diminished the volume of the remaining thoracic cavity. The configuration of the rib cage was therefore reconstructed by placement of two metal bars (Stratos System R; Fig 2A), followed by coverage with a PTFE mesh (Fig 2B). This allowed the creation of a thoracic cavity that was similarly sized to its initial volume.
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In the other 3 patients, the defect was too large to be closed with the remaining soft tissue. Therefore, a free musculocutaneous flap from the resected forearm was prepared on the back table, which was used for reconstruction. The forearm was filleted (Fig 2C), the main artery and vein were identified, and all collaterals were ligated. Thereafter the flap was transposed into the thoracic defect and vascular anastomoses to the previously prepared vascular stumps were created with 9-0 Prolene (Ethicon, Somerville, NJ) under microscopic magnification. Finally, the subcutaneous tissue and the skin were adapted to the remaining soft tissue at the former resection line.
Patients were anticoagulated with 5,000 to 10,000 units low molecular heparin daily and the intraoperatively started broad spectrum antibiotic prophylaxis was continued. Intensive physiotherapeutic mobilization was performed during the immediate postoperative course, especially in those patients who had diaphragmatic plication.
Patients were followed up in regular time periods (3 to 6 months). Chest and abdominal computed tomography were performed at least once a year to check for local recurrence or distal spread of disease.
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Results |
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No immediate or operation-related mortality occurred in this series. However, significant morbidity resulted from the use of a free forearm flap in all 3 patients who had this type of reconstruction. In 1 patient, thrombosis of the venous anastomosis and in 2 patients, a complete necrosis of the free flap occurred. In the first case, surgical revision and thrombectomy resulted in restoration of blood supply to the flap. In the other 2 cases the flap had to be removed and either be replaced by a new free flap from the rectus muscle, or by a combination of a new free flap and mesh-graft coverage.
Chylothorax occurred in 1 patient, which was managed with a conservative approach. Length of hospital stay ranged from 33 to 120 days (mean = 61 days). Time of hospitalization was significantly prolonged in the 3 patients who underwent flap revision (mean stay, 82 days) as compared with the patients without flap complications (mean hospital stay, 41 days).
At the time of discharge, all patients had a significant improvement in their local symptoms, as well as quality of life in general, compared with their preoperative situation. Phantom limb pain, however, occurred in 3 of the 6 patients, which required continuous pharmacologic treatment (a stepwise combination of anticonvulsants like gabapentin and carbamazepine, andopioids with joined infiltration with local anesthetics have shown to be highly effective) in combination with mirror therapy. With this combined regimen it was possible to reduce pain, to a tolerable degree, what represented a significant improvement compared to the preoperative situation.
Two patients received adjuvant chemotherapy, one of them additional radiotherapy. In one patient, surgical removal of the PTFE mesh became necessary one year after operation because of chronic infection.
Median survival time after forequarter amputation was 23.5 months (range from 5 to 35 months) with a mean follow-up time of 20.5 months. Relapse free time ranged from 1 to 31 months (median = 12 months). Three of the 6 patients are still alive at time of publication. Two of them are free of disease. In the third patient lung metastases were diagnosed. In all deceased patients cause of death was either uncontrollable local relapse or distant metastatic spread of disease (Table 2).
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Comment |
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Indications for forequarter amputation represent locally advanced malignant tumors, which extend to the axilla and involve the nerve roots and vessels and thus become unresectable with a limb-sparing operation [9]. By etiology, these tumors most frequently are high-grade osteosarcomas of the proximal humerus or the scapula, axillary soft tissue sarcomas involving the brachial plexus [10], recurrent bone or soft-tissue sarcomas after a failed limb-sparing procedure, and radiation-induced sarcomas of this region or recurrent breast carcinomas involving the brachial plexus [11]. In fact, in this series, 5 of 6 cases represented secondary tumors after former radiotherapy of other primary malignancies, mainly breast cancer. This finding is in concordance with the existing literature [7, 12], which demonstrates that the majority of the patients treated with forequarter amputation in combination with chest wall resection had received preceding radiation therapy of the shoulder area for various diseases. When following such patients it should therefore be kept in mind that this population is of high risk to develop malignant sarcomas of the shoulder girdle.
Usually, broader tumor spread to the thoracic wall is considered to be a contraindication for any surgical resection. However, the broad armamentarium of surgical techniques that presently is available allows to offer surgery even in those situations where the resection has to include significant parts of the chest wall.
The question arises, where to set the indications and limits for such an extended resection, especially with regard to the relatively limited chances to perform a curative surgery. However, in the discussion of this it has to be kept in mind that patients who are candidates for forequarter amputation, in the majority also suffer from extreme symptoms including severe untreatable pain, already established complete functional loss of the affected limb, and not infrequently pronounced lymphedemas. In this situation, palliation, even when achieved only temporarily, becomes an even more important aspect [13].
Our own attitude is to offer this kind of operation only to those patients, who either have a potential for a curative and radical resection, or are suffering from the local symptoms in such an extent that the aspect of palliation, even if achieved only for a limited period of time, becomes of crucial importance for them.
All the mentioned consequences need to be carefully discussed with the patient and his relatives before the final decision for a forequarter resection is taken. Not all patients will be in favor of this extensive operation, and in fact we have seen several patients who decided against this option, whereas other potential candidates for such a procedure were excluded from surgery, either based on diffuse involvement of the chest wall, untreatable distant metastasis, or significantly reduced performance status.
In this series of patients, all operations were performed with radical intent, and R0 resection was achieved in 5 out of 6 patients. However, all patients experienced an immediate improvement in local symptoms although none of them was able to achieve normal quality of life due to the presence of phantom pain and posture problems. Another severe limitation was the limited freedom from recurrence of disease, which occurred despite the radical resection.
Once the decision for the operation is taken, the operation itself needs a carefully coordinated and planned multidisciplinary approach. The operation has to focus on the balance between radicality of the resection and preservation of important structures, especially those needed for later coverage of the resulting defect. The addition of resection of the chest wall to the more limited procedure of forequarter amputation leaves the performing surgical team with a number of challenges. Most importantly, the resulting soft tissue defect becomes significantly larger than what is commonly the case after forequarter resection alone. The management of this defect becomes the crucial part of the operation and owns two important aspects: preservation of the anatomic and functional properties of the thoracic wall and coverage of the soft tissue defect.
If only a limited number of ribs are resected, the mechanical reconstruction of the chest wall can be performed by simple use of a mash, preferentially PTFE, which is sutured into the defect. However, with increasing size of the defect and an increasing number of ribs resected, it becomes important to restore the convexity of the thoracic wall in order to preserve the volume of the thoracic cavity and to allow for adequate expansion of the underlying lung. This was especially the case in patient no. 6, in whom a total of 7 ribs, in an extent of two thirds of its length, had to be resected. The reconstruction was performed with metal bars (Stratos System R) that allowed to restore the contour of the thoracic wall, in combination with a PTFE mash, which was sutured above it (Fig 3 ). In this way, a normal volume and shape of the hemithorax was reconstructed and the described resection most likely belonged to the most extended ones that have ever been performed. The limit, where additional stabilization with metal bars becomes mandatory, is not clearly defined and not only depends on the number of ribs resected but also on its length. We consider a resection of 5 ribs and more as an indication for additional use of a metallic stabilization.
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Use of the free filet extremity flap has been described as a safe and feasible procedure in patients undergoing forequarter amputation [14]. Cordeiro and colleagues [7] reported a series of 4 patients undergoing forequarter amputation including chest wall resection and reconstruction with a total volar musculocutaneous free flap. No complications from the use of the free flap were reported in this work. Furthermore, the myocutaneous free flap from the amputated upper extremity has been used as an osteomyocutaneous flap, which incorporates bony parts like the elbow joint or the ulna that can be used for better reconstruction of the shoulder contour or the chest wall itself [5].
Analysis of our series, however, clearly demonstrates that the relevant postoperative morbidity resulted from the use of such a forearm flap. One possible explanation for the observed vascular complications in our series could lie in the fact that the limbs of all 3 patients were already affected from a significant edema over a longer period of time before the operation. This, in combination with sequelae from preoperative radiation, might have impacted on the microcirculation and on the functional integrity of the vessel wall, resulting in the loss of the graft in the 2 patients.
Another technical difference in the work by Cordeiro and colleagues, compared with experiences from our series, lies in the technique of dissection of the flap. Whereas in our work this has been done after resection of the extremity, in the report from Cordeiro and colleagues this was carried out while the extremity was still perfused. The reduced ischemic time, based on this approach, might have had an impact on the results as well.
In conclusion, our results indicate that forequarter amputation including resection of the chest wall is a complex but feasible procedure. In some patients, this procedure is the only possible therapeutic option for a curative therapy. However, it also owns an important palliative aspect in situations where complete loss of function of the limb and insufferable pain are present.
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