JTCS KCI
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Gaetano Rocco
Francesco Scognamiglio
Carmine La Manna
Antonello La Rocca
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Rocco, G.
Right arrow Articles by De Lutio, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Rocco, G.
Right arrow Articles by De Lutio, E.
Related Collections
Right arrow Mediastinum
Right arrow Diaphragm

J Thorac Cardiovasc Surg 2007;133:1112-1114
© 2007 The American Association for Thoracic Surgery

Brief Communication

The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma

Gaetano Rocco, MD, FRCS (Ed)a,*, Flavio Fazioli, MDb, Francesco Scognamiglio, MDa, Valerio Parisi, MDb, Carmine La Manna, MDa, Antonello La Rocca, MDa, Rocco Cerra, MDb, Rosanna Accardo, MDb, Elisabetta De Lutio, MDc

a Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy
b Department of Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy
c Department of Radiology, National Cancer Institute, Pascale Foundation, Naples, Italy.

Received for publication October 29, 2006; accepted for publication November 28, 2006.

* Address for reprints: Gaetano Rocco, MD, FRCS (Ed), FECTS, Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Via M Semmola, 81, 80131 Naples, Italy. (Email: Gaetano.Rocco{at}btopenworld.com).

Primary sarcomas represent a serious oncologic challenge because, at times, their surgical removal creates large defects requiring covering with several autologous, homologous, or prosthetic materials used in 1 or 2 graft combinations.1-4Go Although the experience is more limited, relapsing sarcomas often call for even more extensive demolitions of the chest wall and difficult reconstructive efforts.5Go

Clinical Summary

A 64-year-old man presented in January 2006 with a massive locoregional recurrence of a chest wall chondrosarcoma (Figure 1) originally resected 10 months earlier, on tumor-free margins, by removing the anterior right-sided ribs III to VI and covering the chest wall defect with Marlex (Bard, Cranston, RI) mesh reinforced by a latissimus dorsi flap.


Figure 1
View larger version (117K):
[in this window]
[in a new window]

  		Figure 1. Chest computed tomography showing the extent of the recurrence from chondrosarcoma at different levels.

 
An extensive demolition of the anterior chest wall was performed by dividing the manubrium and the anterior ribs from ribs II to VIII along the hemiclavicular line and the anterior axillary line of the left and right sides, respectively. The anterior pericardium, the central tendon, and part of the muscle component of the diaphragm were also removed. Both rectus abdominis muscles were divided in their most cranial aspect. The tumor was noted to infiltrate the liver capsule and marginally the right middle lobe of the lung. The involved areas were resected, and the specimen was removed on tumor-free margins.

The reconstructive stage of the operation (Figure 2) included the replacement of the diaphragm by a polytetrafluoroethylene patch (Gore-Tex; WL Gore and Associates, Flagstaff, Ariz) through which an omentum flap was transposed into the chest. The omentum was placed to protect the heart and provide a vascularized bed for a cryopreserved iliac crest homograft that was shaped to fit in the sternal position by securing it to the residual part of the host manubrium. Two methyl-methacrylate sandwiches (Simplex, Stryker, Mawhaw, NJ) were then anchored medially to the bone homograft by interrupted nonabsorbable sutures, laterally to the remaining rib segments, and caudally to the prosthetic diaphragmatic patch to configure the new anterior chest wall ensemble. In addition, a myocutaneous pectoralis major flap was rotated medially to cover the neosternum superficially, thereby requiring an isolated skin graft from the left inguinal region to cover the cutaneous defect in the deltoid-pectoral area.


Figure 2
View larger version (156K):
[in this window]
[in a new window]

  		Figure 2. Intraoperative sequence. a, Intrathoracic view at the end of the resection. b, Completion of the diaphragmatic patch and omental transfer to protect the mediastinum. c, Neosternum in place. d, Completion of the anterior chest cage reconstruction.

 
The patient was successfully discharged 2 weeks after surgery with no immunosuppressants other than low-dose steroids (Figure 3). He went back to his normal activities, including amateur swimming. At more than 10 months from surgery, the patient is alive and well, albeit with isolated liver and lung recurrences for which he is undergoing chemotherapy.


Figure 3
View larger version (126K):
[in this window]
[in a new window]

  		Figure 3. Patient’s picture at discharge.

 
Discussion

The primary aim of a complex reconstructive strategy after extensive chest wall demolition is to restore the geometric configuration of the chest cage using materials that could guarantee protection of the intrathoracic organs and structural and functional integrity.2,3Go This is especially true after removal of the sternum and contiguous ribs,2Go thus, in our case, the choice of the iliac crest homograft for sternal replacement and the lateral methylmethacrylate sandwiches to replace the bony chest wall to reproduce, as closely as possible, the anterior chest wall geometric configuration. The "flail chest" physiology was also avoided by recreating the costophrenic recesses by suturing the diaphragmatic patch to the remaining diaphragmatic muscle and the caudal portions of the methyl-methacrylate sandwiches.3Go

We believe that the uniqueness of this case of recurrent chest wall tumor resides in the simultaneous use in the same patient of almost all available reconstructive materials and techniques enabling the surgeon to perform extended demolitions and replace elements of the crucial structural frame of the chest cage to warrant margin-free oncologic resections and provide an acceptable functional outcome.

References

  1. Lequaglie C, Brega Massone P, Giudice G, Conti B. Gold standard for sternectomies and plastic reconstructions after resection of primary or secondary sternal neoplasms. Ann Surg Oncol 2002;9:472-479.[Medline]
  2. Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, et al. Early and long term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588-592.[Abstract/Free Full Text]
  3. Weyant MJ, Bains MSD, Venkatraman E, Downey RJ, Park BJ, Flores RM, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279-285.[Abstract/Free Full Text]
  4. Garcia-Tutor E, Yeste L, Murillo J, Aubà C, Sanjulian M, Torre W. Chest wall reconstruction using iliac bone allografts and muscle flaps. Ann Plast Surg 2004;52:54-60.[Medline]
  5. Fisher S, de Perrot M, Sekine Y, Keshavjee S. Long term survival after multiple resections of a fibrosarcoma involving the lung and the chest wall. Eur J Cardiothorac Surg 2001;20:421-423.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
G. Rocco, F. Fazioli, R. Cerra, and R. Salvi
Composite reconstruction with cryopreserved fascia lata, single mandibular titanium plate, and polyglactin mesh after redo surgery and radiation therapy for recurrent chest wall liposarcoma
J. Thorac. Cardiovasc. Surg., March 1, 2011; 141(3): 839 - 840.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
G. Rocco, F. Fazioli, C. La Manna, A. La Rocca, S. Mori, R. Palaia, N. Martucci, and R. Salvi
Omental Flap and Titanium Plates Provide Structural Stability and Protection of the Mediastinum After Extensive Sternocostal Resection
Ann. Thorac. Surg., July 1, 2010; 90(1): e14 - e16.
[Abstract] [Full Text] [PDF]

Home page
 MMCTSHome page
G. Rocco and F. Fazioli
Cryopreserved biomaterials for chest wall reconstruction
MMCTS, January 1, 2009; 2009(0209): mmcts.2008.003277 - mmcts.2008.003277.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Gaetano Rocco
Francesco Scognamiglio
Carmine La Manna
Antonello La Rocca
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Rocco, G.
Right arrow Articles by De Lutio, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Rocco, G.
Right arrow Articles by De Lutio, E.
Related Collections
Right arrow Mediastinum
Right arrow Diaphragm

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS