Rethinking surgical strategies for primary chest wall sarcomas: path to improve outcomes

Surgical resection and reconstruction of primary chest wall sarcomas remain a significant challenge in thoracic oncology considering the aggressive nature of these tumors and uniqueness of each case. Surgical treatment must be meticulously planned, often requiring an oncoplastic approach, specifically tailored to the patient’s needs and sarcoma subtype. The recent study by Budacan et al. (1) provides valuable insights into the clinical and functional outcomes of a large cohort undergoing chest wall resection and reconstruction for primary chest wall sarcomas, as they aim to identify risk factors influencing survival and recurrence.

Budacan et al. (1) deepen our understanding of several critical aspects of chest wall resection and reconstruction. Achieving negative margins (R0) is paramount for improving survival outcomes of chest wall sarcomas. The low R1 resection rate (4.5%) reported in their study underscores the importance of wide-margin resections, even when they necessitate extensive skeletal or soft tissue reconstruction. These outcomes were achieved through a multidisciplinary approach, involving oncoplastic surgeons, skilled in complex (chest wall) reconstructions. Oncoplastic strategies such as the use of rigid and non-rigid reconstruction materials, alongside autologous and regional flaps for soft tissue coverage, have been shown to be critical in maintaining structural integrity, supporting not only postoperative respiratory function, but also reducing complications (2-4). In particular, sternal resection presents unique challenges, especially in maintaining structural chest wall stability, emphasizing the preoperative selection of appropriate reconstructive material such as plates or even custom-made prostheses for rigid support, accompanied by muscle or myocutaneous flaps to achieve reliable soft tissue coverage (5,6). These aspects reflect the complexity and multidisciplinary nature of chest wall sarcoma care.

While extended resections are often guided by the widely accepted and cited 4 cm margin standard (7), Budacan et al. (1) do challenge this paradigm. Their results show that extended resections were associated with a significantly increased hazard of mortality, emphasizing the importance of careful patient selection including screening for frailty, and preoperative optimization for advanced tumors. Recent consensus suggests that a margin of >2 cm is sufficient and helpful to achieve R0 resection in chest wall tumors, unless vital organs or structures such as the great vessels, heart, trachea, joints, or spine are involved (8). Emerging technologies like three-dimensional (3D) imaging and 3D printing (9) can show critical structures such as nerves, blood vessels, and organs in proximity to the tumor, enabling surgeons to define margins that minimize harm to these structures while achieving oncological safety with the preservation of quality of life. Using real-time imaging technologies, such as intraoperative 3D ultrasound or fluorescence-guided surgery, could even allow for dynamic intraoperative adjustments of margins based on findings during the chest wall resection. These techniques can be beneficial for precisely localizing and resecting the sarcoma, potentially leading to better surgical margins and reduced recurrence rates (10,11). Technologies based on 3D imaging can also provide a tumor-specific understanding of different growth patterns over time, aiding in tailoring the localization of tumor, the resection margin, and the extent of chest wall resection and needs for reconstruction, especially when using preoperative 3D surgical simulation and perioperative navigation systems (12). Furthermore, by integrating data from 3D images with clinical outcomes, an evidence-based guideline for tumor-specific resection margins tailored to specific tumor types and locations can be developed in the future.

The multidisciplinary approach highlighted by Budacan et al. (1) in combination with individualized treatment for managing extensive chest wall resections and reconstruction possibilities also underscores the necessity of specialized high-volume centers. The timely referral to regional specialist centers is in place to ensure optimal care in achieving surgical success and improving patient prognosis and quality of life. When access to such centers is limited, collaboration within a network of experts dedicated to managing chest wall sarcomas, including reconstructive surgeons, is vital. Future management of chest wall sarcomas should also incorporate expertise in emerging therapeutic modalities, such as (neo)adjuvant treatment strategies (13,14), to potentially limit the extension of resections and improve survival outcomes.

As a single-institution retrospective study, the findings of Budacan et al. (1) must be interpreted with caution due to potential selection bias and limited generalizability. Nonetheless, the study’s large cohort size and long-term follow-up offer valuable contributions to the sparse literature on primary chest wall sarcomas. Future research should prioritize investigating, for instance, the identification of prognostic biomarkers, exploration of gene expression profiles linked to treatment response in (neo)adjuvant setting, and discovery of novel therapeutic targets specific to sarcoma subtypes to generate improved survival and lower recurrence rates. These improvements should offer clearer treatment guidance according to sarcoma subtype and provide advancements in personalized treatment strategies and outcomes.

Budacan et al. (1) should be commended for their in-depth analysis of a large cohort undergoing chest wall surgery and reconstruction for chest wall sarcoma. Their findings highlight that extensive resection, when executed thoughtfully, can preserve long-term functional outcomes. However, it remains imperative to optimize the resection margin for chest wall sarcomas, which can be aided by the integration of the latest advancements in 3D imaging technologies. Certainly, recognizing key prognostic factors and leveraging advanced reconstruction techniques are critical in addressing the challenges of these malignancies, which requires centralization of care for this patient group.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-3/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-3/coif). The authors have no conflicts of interest to declare.

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