Navigating the challenges of chest wall resection and reconstruction

Chest wall sarcomas still represent one of the most challenging procedures in thoracic surgery, requiring a delicate balance between oncologic radicality and functional preservation. The study by Budacan and colleagues accurately addresses a significant advance in understanding the outcomes associated with chest wall resection and reconstruction (CWRR) for primary chest wall sarcomas (1).

These rare and aggressive malignant tumours, originating from bone/cartilage, soft or neurogenic tissue in the chest cavity, require highly specialised centres to achieve the best therapeutic option for each patient, aiming to a radical oncologic removal while preserving respiratory function and aesthetic outcome (2-5). The authors analyse a robust cohort of 139 patients treated over a 13-year period and provide valuable insights not only into survival rates and predictors of outcomes but also long-term functional status after CWRR.

Key findings of the study include a median overall survival of 58.8 months and a 5-year survival rate of 72%. In the authors’ data achieving R0 resection margins lead to a success rate of 95.5, showing the pivotal role of a surgical radical resection in controlling the disease. Extensive resections, while associated with increased long-term mortality, were critical in the treatment of aggressive tumour subtypes. Patients with chondrosarcomas showed significantly better survival, while patients with radiation-induced sarcomas fared worse, highlighting one more time the role of tumour histology in patients’ prognosis.

Despite the complexity of these procedures, the study reports promising functional outcomes, with 80% of surviving patients having a Karnofsky index ≥90% and minimal long-term respiratory compromise.

The postoperative structured physiotherapy regimen along with regular pain killers and adequate nutritional intake are noteworthy and with no doubts played a significant role in low percentage of hospital acquired pneumonias and the already mentioned good long-term results in quality of life.

The study also highlights the essential role of a multidisciplinary team (MDT) in ensuring optimal outcomes (6). Preoperative optimization, including functional assessments and nutritional support, was critical, especially in patients who required extensive resections.

Moreover, a careful and tailored selection of reconstructive techniques and materials reached the goal of preserving the integrity of the chest wall while minimizing complications (7,8). We know there is still a global debate about the perfect prosthetic material and the best type of flap, but the authors clearly highlight that, beyond the surgeon’s preference, it is also advisable to consider patients’ future perspectives, such as an increased risk of infections or the need for postoperative chemo-radiotherapy.

Nowadays chest wall reconstruction employs a wide array of techniques and materials, each with unique advantages and considerations. From smaller defects where local muscle flaps may suffice to larger and more complex resections, particularly those involving multiple ribs or the sternum, where rigid skeletal reconstruction is required. This can involve synthetic meshes [i.e., polypropylene, polytetrafluoroethylene (PTFE)], often combined with rigid plates or bars (i.e., titanium, methyl methacrylate sandwich prostheses, three-dimensional (3D) printed) to prevent paradoxical motion and protect underlying organs. Autologous options, such as rib grafts or muscle flaps, are also valuable, offering excellent biocompatibility, though they may have donor site morbidity. Biological prostheses, derived from animal or human tissue, offer a more natural scaffold for tissue ingrowth and regeneration, potentially reducing the risk of infection. As previously said, the ultimate choice among these techniques is highly individualized, depending on defect size and location, patient comorbidities, the risk of infection, and the anticipated need for postoperative therapies.

Central to this approach is a close and integrated collaboration between thoracic and plastic surgeons, whose combined expertise is fundamental in planning and executing complex resections and reconstructions. The distinct yet complementary roles of the thoracic surgeon, primarily focused on radical oncological resection and management of intrathoracic structures, and the plastic surgeon, specializing in soft tissue coverage, skeletal reconstruction and aesthetic and functional considerations, are vital.

This comprehensive approach not only facilitated oncologic cure, but also preserved long-term quality of life, which is a critical factor for this kind of patients who are often young and active (9).

Despite its strengths, the study is not without limitations. The retrospective design and the fact that it is a single centre leads to inherent selection biases and limits generalizability. In addition, although the sample size is one of the largest in studies of primary chest wall sarcomas, it remains relatively small due to the rarity of the disease. Additionally, the heterogeneity of the cohort, which includes different sarcoma subtypes and treatment modalities, poses a challenge for consistent conclusions. The lack of randomized controlled data or multivariate analyses limits the ability to isolate specific factors that influence the outcomes too. Future research should aim to address these gaps by incorporating multicentre data, standardizing treatment protocols and investigating the role of new therapies such as advanced imaging, targeted therapies, 3D printed prostheses and minimally invasive surgical techniques.

In conclusion, the findings of Budacan et al. underscore the importance of a tailored approach in the treatment of chest wall sarcomas. While surgical resection remains the cornerstone of treatment, the integration of individualized preoperative, operative and postoperative strategies is of paramount importance. Achieving tumour-free margins, utilizing advanced reconstructive techniques and optimizing patient fitness are critical to balance oncologic and functional outcomes. The study highlights the value of a multidisciplinary collaboration in addressing the complexity of these rare and difficult tumours, as well as the need for future investigations to refine patients’ selection criteria and surgical strategies, increasing our understanding of the biological behaviour of chest wall sarcomas to further improve survival and quality of life of affected patients.

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-25-10/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-25-10/coif). A.G. is a scientific advisor for Medtronic. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Budacan AM, Patel AJ, Babu P, et al. Chest wall resection and reconstruction for primary chest wall sarcomas: Analysis of survival, predictors of outcome, and long-term functional status. J Thorac Cardiovasc Surg 2025;169:1120-30.e1. [Crossref] [PubMed]
2. Gonfiotti A, Salvicchi A, Voltolini L. Chest-Wall Tumors and Surgical Techniques: State-of-the-Art and Our Institutional Experience. J Clin Med 2022;11:5516. [Crossref] [PubMed]
3. Pastorino U, Leuzzi G, Sabia F, et al. Long term outcome of complex surgical resection and reconstruction for rare thoracic cancers. Tumori 2023;109:450-7. [Crossref] [PubMed]
4. Burt M. Primary malignant tumors of the chest wall. The Memorial Sloan-Kettering Cancer Center experience. Chest Surg Clin N Am 1994;4:137-54.
5. Salimbene O, Viggiano D, Muratori F, et al. Primary Chest Wall Ewing Sarcoma: Treatment and Long-Term Results. Life (Basel) 2024;14:766. [Crossref] [PubMed]
6. Widhe B, Bauer HC. Surgical treatment is decisive for outcome in chondrosarcoma of the chest wall: a population-based Scandinavian Sarcoma Group study of 106 patients. J Thorac Cardiovasc Surg 2009;137:610-4. [Crossref] [PubMed]
7. Gonfiotti A, Viggiano D, Vokrri E, et al. Chest wall reconstruction with implantable cross-linked porcine dermal collagen matrix: Evaluation of clinical outcomes. JTCVS Tech 2022;13:250-60. [Crossref] [PubMed]
8. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588-592. [Crossref] [PubMed]
9. Salo JTK, Repo JP, Roine RP, et al. Health-related quality of life after oncological resection and reconstruction of the chest wall. J Plast Reconstr Aesthet Surg 2019;72:1776-84. [Crossref] [PubMed]