Chest wall reconstruction with a latissimus dorsi musculocutaneous flap via the pleural cavity

Abstract

This report presents the case of a 79-year old woman who developed radionecrosis after irradiation following a radical mastectomy at the age of 50 and complicated lung adenocarcinoma in the left upper lobe. Chest wall resection and reconstruction were performed simultaneously with left upper lobectomy, and a latissimus dorsi musculocutaneous flap was used for reconstruction via the left pleural cavity after lobectomy. The flap was well adapted to the defect of the chest wall. This clinical course indicates that a transpleural musculocutaneous flap can be a reconstructive procedure for such patients showing chest wall radionecrosis complicated with an intrathoracic disease.

CASE

A 79-year old Japanese woman was admitted for thoracic surgery complaining of an intractable skin ulcer on the anterior chest wall producing a purulent discharge (Fig. 1A), and a chest CT scan showed a lung tumour with spicules in the left upper lobe (Fig. 2A). The ulcerative lesion was clinically diagnosed as radionecrosis of the chest wall following the radical mastectomy, and the histopathological diagnosis obtained after the bronchoscopic examination of the lung tumour was adenocarcinoma. Surgery was planned to treat both the chest wall radionecrosis and lung carcinoma at the same time, but it was difficult to know how to reconstruct the chest wall because of her extensive surgical history of the anterior chest wall: subtotal thyroidectomy for Basedow's disease at the age of 38, bilateral radical mastectomy and irradiation of the left chest wall for a bilateral breast cancer at the age of 50 (left) and 54 (right) and total thymectomy (age 70) with median sternotomy for myasthenia gravis. It was considered that a latissimus dorsi musculocutaneous flap was the best reconstruction option; because the left chest wall was inadequate to pass a musculocutaneous flap through the subcutaneous space due to a marked atrophic change caused by irradiation, transfer of the flap through the left pleural cavity was considered the best option for the reconstruction of the chest wall (Fig. 2B). First, video-assisted thoracoscopic (VATS) lobectomy and the preparation of the latissimus dorsi musculocutaneous flap were performed in the right lateral decubitus position. Lobectomy was performed with a thoracotomy window at the fifth intracostal space 6 cm in length and a scope port in the lateral chest wall. The skin incision was then extended on the posterior side of the VATS window to prepare the latissimus dorsi muscle with a properly designed skin-island preserving blood supply from the thoracodorsalis artery. After the musculocutaneous flap had been prepared, the graft was placed in the left pleural cavity. Next, the resection and reconstruction of the chest wall were performed in the dorsal position. The defect of the full thickness of the chest wall measured 7 × 4 cm, including part of the sternum and the left third and fourth ribs (Fig. 1B). The flap was pulled out of the pleural cavity through the anterior chest wall defect and tightly sutured. Although the left latissimus dorsi muscle was markedly hypoplastic (Fig. 2A), the musculocutaneous flap has well adapted to the defect of the chest wall (Figs 1C and 2C). The histopathological diagnosis was adenocarcinoma with mixed subtypes (left S⁵, 3.2 × 2.5 × 2.5 cm, p-T₃N₁M₀, Stage IIIA), radiation dermatitis of the skin and degeneration and sequestration of the bony thorax with osteomyelitis. Unfortunately, the patient suffered a thoracolumbar compression fracture during the post-operative stay and had to wear a hard corset over the body trunk. A decubitus ulcer appeared at part of the graft edge due to pressure from the corset; however, the graft has maintained a normal colour and good adaptation for 1 year after surgery.

Figure 1:

Pre- (A), intra- (B) and post-operative (C) findings of the anterior chest wall. The infectious skin ulcer with the severe degeneration of the bony thorax (A), the defect of the chest wall after full-thickness resection (B) and the well-adapted musculocutaneous graft (C).

Figure 2:

Chest CT scan showing pre- (A) and post-operative (C) findings and the schematic view of the operation (B). Preoperative CT scan shows a left lung tumour and markedly hypoplastic muscles of the left-side chest wall compared with the right side (arrow).

DISCUSSION

Radionecrosis of the chest wall is a severe delayed complication and is most commonly found in patients after irradiation following a mastectomy. It sometimes appears as an intractable infectious ulcer complicated with degeneration of the chest wall, including the skin, soft tissue and bony thorax [1,2]. Surgical management is indicated to improve the quality of life of patients. Many surgical procedures have been reported for the resection and reconstruction of the full thickness of the chest wall [3–6]; however, a prosthesis is often not available to graft onto a lesion with an inveterate infectious ulcer. Therefore, reconstruction using various musculocutaneous flaps has been reported; however, a usable muscle flap is limited in patients after the radical mastectomy because of the lack of the pectoralis major muscle, and the rectus abdominalis muscle is some distance from the upper chest wall lesion [6]. A latissimus dorsi musculocutaneous flap is a common graft for chest wall reconstruction in such patients; however, no reports have addressed the surgical approach of passing a musculocutaneous flap through the pleural cavity. In this case, the resectable lung cancer was incidentally detected at the same time, and the subcutaneous space was inadequate to pass the graft due to the atrophic degeneration of the chest wall. Preoperatively, other flaps were also considered, e.g. left sternocleidmastoideus, right latissimus dorsi, left or right rectus abdominalis musculocutaneous flap and an omentum flap with free-skin grafting. These flaps had advantages and disadvantages, and no flaps, including the left latissimus dorsi muscle, could be passed through the subcutaneous space due to the marked atrophic change caused by irradiation. The two usable approaches were considered as follows: passing through the pleural cavity, or suturing onto the subcutaneous tissue after skin excision of the tract. The former approach is superior cosmetically and is less invasive, and only the ipsilateral latissimus dorsi muscle could be prepared as a flap via the transpleural cavity. There were some fears that this procedure would result in post-operative complications, graft ischaemia compressed by the rib cage and disturbance of lung expansion by the graft, and that if graft necrosis or infection occurred, an open thoracotomy would be necessary; however, the post-operative course was uneventful, although the left latissimus dorsi muscle was hypoplastic. It was considered that the transpleural cavity was the shortest route to the defect of the chest wall and that the graft could be sutured without tension, so this was a useful procedure in this case.

Chest wall resection and reconstruction are needed for various patients to treat a variety of types and locations of disease [3–6], neoplasm on the chest wall, malignant tumour with chest wall invasion, radionecrosis and so on, and the surgical procedure should be tailored to the specific needs of the individual patient. This is a report of an unusual patient with an extensive surgical history on the anterior chest wall who presented with the resectable lung cancer. Musculocutaneous grafting via the pleural cavity may be a useful surgical procedure for such patients with severe degeneration of the chest wall after irradiation following the radical mastectomy and who also show an intrathoracic disease with tolerance for thoracotomy.

Conflict of interest: none declared.