SURGERY 3

“Orientation to the course Chest Wall”

Dr. Henrette Jude B. Palileo, MD

 THORAX

• The thorax is the upper conical part of the

trunk, wherein are lodged the heart with
some of the great vessels, the lungs, and some
other important structures.
 THORAX
• The osseocartilaginous framework of the
thoracic cage is made up by:
1. POSTERIORLY – twelve thoracic vertebrae with
the attached ribs up to their angles.
2. LATERALLY – by the body of the ribs, as they
slope obliquely downwards and forwards.
3. ANTERIORLY – the sternum and the anterior
portions of the first ten ribs and their
corresponding cartilages.
 THORAX
• The resulting intercostal spaces are covered by
the intercostal muscles and membranes,
which together with the muscles attached to
the front, side and back of the trunk, complete
the thoracic wall.
 THORAX
COMMUNICATIONS
1. THORACIC INLET – the somewhat kidney-shaped
opening at the apex of the conical thoracic cage,
communicating with the root or base of the neck.
2. THORACIC OUTLET – the large irregular inferior
boundary corresponding to the base of the cone,
covered by the respiratory diaphragm separating
the thorax from the abdominal cavity.
 THORAX
CONTENT OF INTERCOSTAL SPACES:
1. External intercostal muscles
2. Interior intercostal muscles
3. Anterior intercostal muscles
4. Posterior intercostal membrane
5. Intercostal Artery (Anterior & Posterior)
6. Intercostal Veins (Anterior & Posterior)
7. Intercostal Nerves
8. Azygos Vein
9. Hemi Azygos Vein (Superior & Inferior)
 THORAX
• MEDIASTINOSCOPY
– Is used for diagnositic assessment of mediastinal
lymphadenopathy and staging of lung cancer and is
performed through 2-3 cm suprasternal notch incision.
– Blunt dissection along the anterior trachea is performed
to the level of the carina.
– The mediastinoscope is inserted and anatomic definition
of the trachea, carina, and lateral aspect of both proximal
main bronchi is achieved with blunt dissectionusing long
suction catheter. Long biopsy forceps can be inserted
through the scope sampling.
 THORAX
– The standard staging procedure for lung cancer includes
biopsies of the paratracheal and subcarinal lymph nodes.
– In patients with left upper lobe tumors, lymph node spread
is often to the regional aortopulmonary and preaortic
lymph nodes.
– This approach also may be used to biopsy anterior masses.
– The posterolateral thoracotomy incision is the most
common incision for the majority of pulmonary resections,
esophageal operations, and for accessto the posterior
mediastinum and vertebral column.
 THORAX
– The skin incision typically starts at the anterior axillary line just
above the nipple level and extends posteriorly below the tip of
the scapula.
– Typically, the fifth interspace is entered and a rib spreader is
used to separate the rib space.
– The anterolateral thoracotomy has traditionally been used in
trauma victims.
– In the face of hemodynamic instability, this approach is better
than the lateral decubitus position.
– Should more exposure be necessary, the sternum can be
transected and the incision carried to the contralateral
thoracic cavity (“clamshell” thoracotomy)
 THORAX
– A bilateral anterior thoracotomy incision with the
transection of the sternum (“clamshell” thoracotomy) is a
standard operative approach to the heart and mediastinum
in certain elective circumstances such as double-lung
transplantation.
– A median sternotomy also can be added to an anterior
thoracotomy (“trap-door” thoracotomy) for access to
mediastinal structures.
– The median sternotomy incision allows exposure of anterior
mediastinal structures and principally used for cardiac
operations and for anterior and middle mediastinal tumors.
 THORAX
• VIDEO-ASSISTED THORACOSCOPY SURGERY (VAST)
– Is a common approach to the diagnosis and
treatment of pleural effusions, recurrent
pneumothoraces, lung biopsies, lobectomy,
resection of bronchogenic and mediastinal cysts,
esophageal myotomy and intrathoracic
esophageal mobilization for esophagectomy.
 THORAX
• POSTOPERATIVE CARE
A. CHEST TUBE MANAGEMENT
• Pleural tubes are left two reasons:
1. To drain fluid – thereby, preventing pleural fluid
accumulation.
2. To evacuate air if an air leak is present.
• A drainage volume of 150 mL or less over 24 h has
been thought necessary to safely remove a chest
tube.
 THORAX
B. PAIN CONTROL
• Good pain control permits to actively participate in
breathing maneuvers designed to clear and manage
secretions, and promotes ambulation and a feeling well
being.
• The two most common techniques of pain management:
A. Epidural
B. Intravenous
• Alternatively, intravenous narcotics via patient-controlled
analgesic can be used, often in conjunction with ketoralac.
 CHEST WALL
• Chest Wall Mass
– All chest wall tumors should be considered
malignant until proven otherwise.
– These tenets must be applied from the initial
biopsy, as the placement of the incision can
impact significantly on the successful complete
resection and reconstruction of the chest wall.
– Complain of a slowly enlarging palpable mass
(50%–70%), chest wall pain (25%–50%), or both.
 CHEST WALL
• Evaluation and Management:
1. Plasmacytoma: overproduction of one
immunoglobulin from the malignant plasma cell
clone.
2. Osteosarcoma: Alkaline phosphatase levels may
be elevated.
3. Ewing’s sarcoma: Erythrocyte sedimentation
rates may be elevated.
 CHEST WALL
• Radiography
– CXR may reveal rib destruction, calcification within the
lesion, and if old films are available, a clue to growth rate.
– CT scanning, however, is necessary to determine the
relationship of the chest wall mass to contiguous
structures, evaluate for pulmonary metastases, and assess
for extraosseous bone formation and bone destruction,
both typically seen with osteosarcoma.
– MRI provides multiple planes of imaging (coronal, sagittal,
and oblique), better definition of the relationship
between tumor and muscle.
 CHEST WALL
• Biopsy
– Tissue diagnosis is accomplished using one of
three methods:
1. Needle biopsy:
– A needle biopsy (FNA or core) has the advantage of avoiding
wound and body cavity contamination (a potential
complication with an incisional biopsy).
2. Incisional biopsy:
– If a needle biopsy is nondiagnostic, an incisional biopsy may
be performed, with caveats.
 CHEST WALL
3. Excisional biopsy:
– Any lesion less than 2.0 cm can be excised as long as the
resulting wound is small enough to close primarily.
Otherwise, excisional biopsy is performed only when the
initial diagnosis (based on radiographic evaluation) indicates
that the lesion is benign or when the lesion has the classic
appearance of a chondrosarcoma.
 CHEST WALL
• BENIGN CHEST WALL NEOPLASMS
1. Chondroma:
• Seen primarily in children and young adults.
• They usually occur at the costochondral junction anteriorly
and may be confused with costochondritis, except that a
painless mass is present.
• Radiographically, the lesion is lobulated and radiodense.
• May grow to huge sizes if left untreated.
• Treatment is surgical resection with a 2-cm margin.
• Large chondromas may harbor well-differentiated
chondrosarcoma and should be managed with a 4-cm margin
 CHEST WALL
2. Fibrous dysplasia:
• Most frequently occurs in young adults
• Pain is an infrequent
• Lesion is typically located in the posterolateral aspect
of the rib cage
• Radiographically, an expansile mass is present, with
cortical thinning and no calcification.
• Local excision with a 2-cm margin is curative.
 CHEST WALL
3. Osteochondroma.
• Often found incidentally as a solitary lesion on
radiograph are the most common benign bone tumor.
• They arise at or near the growth plate of bones.
Osteochondromas in the thorax arise from the rib
cortex.
 CHEST WALL
4. Eosinophilic granuloma:
• Eosinophilic granulomas are benign osteolytic lesions.
• Eosinophilic granulomas of the ribs can occur as solitary
lesions or as part of a more generalized disease process of
the lymphoreticular system termed Langerhans cell
histiocytosis.
• The cause is unknown.
• Because of the associated pain and tenderness, they may
be confused with Ewing’s sarcoma or with an
inflammatory process such as osteomyelitis.
• Healing may occur spontaneously, but the typical
treatment is limited surgical resection with a 2-cm margin.
 CHEST WALL
5. Desmoid tumors:
• Soft tissue neoplasms arising from fascial or musculoaponeurotic
structures, desmoid tumors consist of proliferations of benign-
appearing fibroblastic cells.
• Associations with other diseases and conditions are well documented,
such as familial adenomatous polyposis (Gardner’s syndrome).
• Clinically, The tumor is usually fixed to the chest wall, but not to the
overlying skin.
• There are no typical radiographic findings, but MRI may delineate
muscle or soft tissue infiltration.
• Desmoid tumors do not metastasize.
• Surgery consists of wide local excision with a 2- to 4-cm margin and
intraoperative frozen section assessment of resection margins.
 CHEST WALL
• PRIMARY MALIGNANT CHEST WALL TUMORS
– Malignant tumors of the chest wall are either
metastatic lesions from another primary tumor or
sarcoma. Soft tissue sarcomas of the chest wall
include fibrosarcomas, liposarcomas, malignant
fibrous histiocytomas (MFHs),
rhabdomyosarcomas, angiosarcomas.
 CHEST WALL
– The initial treatment is either:
a) Preoperative chemotherapy (for patients with osteosarcoma,
rhabdomyosarcoma, primitive neuroectodermal tumor, or
Ewing’s sarcoma) followed by surgery and postoperative
chemotherapy.
b) Primary surgical resection and reconstruction (for patients with
nonmetastatic MFH, fibrosarcoma, liposarcoma, or synovial
sarcoma)
c) Preoperative chemotherapy followed by surgical resection if
indicated in patients presenting with metastatic soft tissue
sarcomas.
– Median survival with surgical resection is 25 months
compared to 8 months without resection.
 CHEST WALL
• Several chest wall sarcomas
1. Chondrosarcoma.
• Chondrosarcomas are the most common primary chest wall
malignancy.
• CT scan shows a radiolucent lesion often with stippled
calcifications pathognomonic for chondrosarcomas.
• Any lesion in the anterior chest wall likely to be a low-grade
chondrosarcoma should be treated with wide (4-cm) resection
after metastatic disease to the lungs or bones is ruled out.
• Chondrosarcomas are not sensitive to radiation or
chemotherapy. Prognosis is determined by tumor grade and
extent of resection.
 CHEST WALL

Chest computed tomography scan showing a right posterior lung tumor. In the
appropriate clinical setting, stippled calcifications (white streaks in right lung mass)
are highly indicative of chondrosarcomas.
 CHEST WALL
2. Osteosarcoma
• Osteosarcomas are the most common bone malignancy.
• They primarily occur in young adults as rapidly enlarging,
painful masses.
• Radiographically, the typical appearance consists of spicules
of new periosteal bone formation producing a sunburst
appearance.
• Osteosarcomas have a propensity to spread to the lungs.
• Osteosarcomas are potentially sensitive to chemotherapy.
• After chemotherapy, complete resection is performed with
wide (4-cm) margins, followed by reconstruction.
• Induction chemotherapy may be given.
 CHEST WALL
3. Malignant fibrous histiocytoma.
• MFHs are generally the most common soft tissue
sarcoma of late adult life.
• Radiographically, a mass is usually evident, with
destruction of surrounding tissue and bone.
• Treatment is wide resection with a margin of 4 cm or
more.
4. Liposarcoma.
• Most liposarcomas are low-grade tumors.
• Treatment is wide resection and reconstruction.
• Intraoperative margins should be evaluated.
 CHEST WALL
5. Fibrosarcoma.
• Often presenting as a large, painful mass, these lesions are
visible on plain radiograph or CT, with surrounding tissue
destruction.
• Treatment is wide local excision with intraoperative frozen-
section analysis of margins, followed by reconstruction.
6. Rhabdomyosarcoma.
• Rhabdomyosarcomas are rare tumors of the chest wall.
• The diagnosis often depends on immunohistochemical
staining for muscle markers.
• Rhabdomyosarcomas are sensitive to chemotherapy.
 CHEST WALL
• Other Tumors of the Chest Wall
1. Primitive neuroectodermal tumors (PNETs) and Ewing’s
sarcoma.
• PNETs (neuroblastomas, ganglioneuroblastomas, and
ganglioneuromas).
• Histologically, PNETs and Ewing’s sarcomas are small, round
cell tumors; both possess a translocation between the long
arms of chromosomes 11 and 22 within their genetic makeup.
• Ewing’s sarcoma occurs in adolescents and young adults who
present with progressive chest wall pain, but without the
presence of a mass.
• Systemic symptoms of malaise and fever are often present.
 CHEST WALL
• Radiographically, the characteristic onion peel
appearance is produced by multiple layers of
periosteum in the bone formation. Evidence of bony
destruction is also common.
• The diagnosis can be made by a percutaneous needle
biopsy or an incisional biopsy.
• Treatment has improved significantly and now consists
of multiagent chemotherapy, radiation therapy, and
surgery.
 CHEST WALL
2. Plasmacytoma
• Solitary plasmacytomas of the chest wall are very rare.
• The typical presentation is pain without a palpable mass.
• Plain radiographs show an osteolytic lesion in the region of the
pain.
• A needle biopsy under CT guidance is performed for diagnosis.
• Evaluation for systemic myeloma is performed with bone
marrow aspiration, testing of calcium levels, and measurement
of urinary Bence Jones proteins.\
• Treatment consists of radiation with doses of 4000 to 5000
cGy. Up to 75% of patients develop systemic multiple myeloma
with 10-year survival of approximately 20%.
 CHEST WALL
• Chest Wall Reconstruction
– The primary determinant of long-term freedom from recurrence and
overall survival is margin status; therefore, adequate margins of
normal tissue must be included in the en bloc resection.
– En bloc resection should include involved ribs, sternum, superior
sulcus, or spine if necessary; invasion of these structures should not
be considered a contraindication to surgery in an otherwise fit patient.
– The resection should include at least one normal adjacent rib above
and below the tumor, with all intervening intercostal muscles and
pleura.
– In addition, an en bloc resection of overlying chest wall muscles is
often necessary, such as of the pectoralis minor or major, serratus
anterior, or latissimus dorsi.
 CHEST WALL
– The extent of resection depends on the tumor’s location and on
any involvement of contiguous structures.
– Laterally based lesions often require simple wide excision, with
resection of any contiguously involved lung, pleura, muscle, or
skin.
– Anteriorly based lesions contiguous with the sternum require
partial sternectomy.
– Primary malignant tumors of the sternum may require
complete sternectomy.
– Posterior lesions involving the rib heads over their articulations
with the vertebral bodies may, depending on the extent of rib
involvement, require partial en bloc vertebrectomy.
 CHEST WALL
– Reconstruction of a large defect in the chest wall
requires the use of some type of material to prevent
lung herniation and to provide stability for the chest
wall.
– Historically, a wide variety of materials have been used
to re-establish chest wall stability, including rib
autografts, steel struts, acrylic plates, and numerous
synthetic meshes.
– The current preference is either a 2-mm
polytetrafluoroethylene (Gore-Tex) patch or a double-
layer polypropylene (Marlex).
 CHEST WALL
– There are several properties that make Gore-Tex an
excellent material for use in chest wall reconstruction:
a) It is impervious to fluid, which prevents pleural fluid from
entering the chest wall and minimizes the formation of
seromas.
b) It provides excellent rigidity and stability when secured
taut to the surrounding bony structure and, as a result,
provides a firm platform for myocutaneous flap
reconstruction. Except for smaller lesions, tissue coverage
requires the use of myocutaneous flaps (latissimus dorsi,
serratus anterior, rectus abdominis, or pectoralis major
muscles).