Chest Wall Resection and Reconstruction for Locally Recurrent Breast Cancer : An Experience Over a 5-Year Period

Expanded local resection is suitable for recurrent breast cancer patients who have isolated local lesion and have not metastasized. The extend of chest wall resection must be overall radical resection of the tumors diagnosed by pathology. However, surgery often leads to huge defects, even full-thickness defects, and these defects are dicult to repair. Methods Chest wall resection was performed in 5 patients with locally recurrent breast cancer, followed by chest wall reconstruction with a pedicled rectus abdominis musculocutaneous ap or a pedicled latissimus dorsi musculocutaneous ap and, if necessary, a piece of titanium mesh. were were myocutaneous and myocutaneous 37] can dorsi


Abstract Background
Expanded local resection is suitable for recurrent breast cancer patients who have isolated local lesion and have not metastasized.
The extend of chest wall resection must be overall radical resection of the tumors diagnosed by pathology. However, surgery often leads to huge defects, even full-thickness defects, and these defects are di cult to repair.

Methods
Chest wall resection was performed in 5 patients with locally recurrent breast cancer, followed by chest wall reconstruction with a pedicled rectus abdominis musculocutaneous ap or a pedicled latissimus dorsi musculocutaneous ap and, if necessary, a piece of titanium mesh.

Results
Chest wall resection and reconstruction were successfully achieved in all 5 patients. No complication and recurrence were observed, except one patient died of late lymphatic metastasis. Other patients reported good quality of life.

Conclusions
For locally recurrent breast cancer, complete tumor resection is complete tumor resection is essential and ensures no recurrence.
Appropriate material and the blood-rich ap or myocutaneous ap should be used to reconstruct the chest wall defect as an effective treatment for surgical procedure.

Background
Comprehensive therapy of breast cancer, including surgical excision, radiotherapy, chemotherapy, endocrinotherapy, and a combination of above approaches, is increasing bene cial for prolonging life [1][2][3]. However, it is sometimes di cult to avoid tumor recurrence. Although the main goal of chest wall resection is to achieve local tumor control, it may lead to long-term remission [4]. For primary breast cancer, an expanded radical resection is not required. However, regardless of the adjuvant therapy, expanded surgical excision is the essential procedure for the treatment of locally recurrent breast cancer. Repairing huge chest wall defects, especially full-thickness defects, is very di cult. If it is not repaired in time, it will not only damage the internal organs of the thorax, but also cause pathophysiological changes, such as chest wall softening, abnormal breathing and longitudinal swing, which will seriously affect the patient's respiratory cycle function [5]. Furthermore, locally advanced primary breast cancer and radiotherapy following a mastectomy are associated with chest wall defects. Therefore, chest wall resection is an important and essential procedure for the treatment of locally recurrent breast cancer, but ideal reconstruction is a guarantee to completely expanded resection.
It has been reported that chest wall resection has many surgical procedures [6][7][8][9], and is usually followed by reconstruction [3]. The purpose of reconstruction of chest wall is to restore the continuity of the chest wall structure, protect the thoracic organs, maintain the normal respiratory cycle function, and at the same time obtain a good thoracic shape, including chest wall bone reconstruction. Chest wall bone reconstruction used titanium mesh to stabilize the chest wall, local skin aps to cover soft tissue, pedicled musculocutaneous aps or free musculocutaneous aps to cover the chest wall [10][11][12].
Titanium micromesh reconstruction of the chest wall has the following advantages: tough texture, good shape, simple surgical method, good biocompatibility, and no need to place subcutaneous drainage. This is because that the subcutaneous exudate can be discharged into the chest tube through meshes of the titanium mesh [13].
Herein, we reported our experience in chest wall resection and reconstruction of patients with locally recurrent breast cancer using a pedicled latissimus dorsi musculocutaneous ap or a pedicled rectus abdominis musculocutaneous ap, and a piece of titanium mesh if necessary.

Clinical data
Between April 2010 and June 2014, chest wall resection and reconstruction was performed in 5 women with locally recurrent breast cancer and chest wall invasion at the First Hospital of China Medical University.

Preoperative preparation
Preoperative evaluation of the 5 patients included clinical examination, blood analysis, CT scan, and so on, to ensure that patients can tolerate surgery and completely reconstruct the defects. In addition, all patients underwent vessel detections, such as Doppler ultrasound.

Surgical method
In all patients, an expanded local resection (including at least 2 cm normal tissue around the lesion) was rst performed, and pathologically con rmed by negative tissue margins. Afterward, chest wall reconstruction was achieved using a pedicled rectus abdominis musculocutaneous ap or a pedicled latissimus dorsi musculocutaneous ap [10][11][12]. The type of skin ap was provided based on the result of vessel detection, and then selected according to patient's wishes. For example, if both of the two skin aps were available, but the patient was overweight. The patient may choose a pedicled rectus abdominis musculocutaneous ap, but do not choose a pedicled latissimus dorsi musculocutaneous ap to reduce abdominal weight. For the full-thickness defect, a titanium mesh (Solothurn, Switzerland) may be used to stabilize the chest wall. The edge of margin of titanium mesh was 1-2 cm larger than the margin of the defect to secure the titanium mesh on libs with titanium screws (Solothurn, Switzerland).

Statistical analysis
Data collected in this study included patient demographics, diagnosis, clinical examination, blood analysis, surgical data, adjuvant therapy data, and postoperative care data. Surgical data were obtained from operative reports, including indication and type of surgery, location and size of chest wall defects, number of resected ribs, prosthesis, type of skin aps, and histological diagnosis.
Postoperative care data mainly included postoperative hospital stay, follow-up time, complications, and patient status and satisfaction.

Results
In four years, a total of ve patients with locally recurrent breast cancer, who underwent follow-up visit, were con rmed to statistics.
The mean age of the 5 patients was 53.4 years, ranging from 33 to 72 years old (Table 1).
After diagnosis, there were 3 cases of ductal-invasive carcinoma, 1 case of metaplastic carcinoma, and 1 case of malignant phyllodes tumor. All patients' tumors were removed completely under the microscope. Four patients underwent the plastic reconstruction with a pedicled latissimus dorsi musculocutaneous ap, and the other underwent the plastic reconstruction with a pedicled rectus abdominis musculocutaneous ap. In addition, two patients underwent costectomy using a piece of titanium mesh to stabilize the chest walls were. The chest tubes were removed respectively 3 and 8 days after surgery.
All patients underwent a 3-day antibiotic treatment, except that one patient underwent a 5-day antibiotic treatment, and the chest tube was removed 8 days after surgery. After surgery, 3 patients received both adjuvant radiotherapy and chemotherapy, and 1 patient received only adjuvant chemotherapy. The other patient diagnosed with malignant phyllodes tumor did not received any adjuvant therapy.
Under prophylactic antibiotic treatment, all wounds showed a pattern of physiologic healing. There is no postoperative complications, such as ap necrosis, haematoma or seroma, herniation, local infection, hemia, respiratory failure, and pleural effusion.
All patients were followed up for 5 years after surgery, with a minimal interval of 1 year. At that time, only 1 patient died of late distant lymphatic metastasis at 27 months after surgery. The other 4 patients were still alive and had no local recurrence.

Typical Case
A 57-year-old female patient underwent radical mastectomy in 1995. However, the wound did not healed, and gradually became larger and worse. Even worse, she developed local ductal-invasive carcinoma recurrence (Fig. 1A).
Resection of the lesion: in December 2012, expanded local resection was performed according to pathologic demonstration, and the left chest wall defect was approximately 20 cm × 15 cm (Fig. 1B). The full-thickness defect was from the second to fth ribs, about 12 cm × 10 cm. The heart and lung were all exposed.
Reconstruction of chest wall defect: A piece of titanium micromesh was used to stabilize the thoracic cage defect (Fig. 1C). Thereafter, the defect was further reduced to 17 cm × 14 cm, which was larger than 15 cm × 13 cm of preoperative estimation. It was considered that the pedicled rectus abdominis musculocutaneous ap was the best reconstruction option. This is because that in addition to epigastric vessels, Doppler ultrasound cannot detect adjacent vessels that may contribute to reparation. The ap turned up 180°t owards the defect through the subcutaneous space without tension (Fig. 1D). Thoracic surgeon completed closed thoracic drainage.
Repair of abdominal defect: The pedicled aponeurosis ap of obliquus externus abdominis was about 10 cm × 5 cm, sutured with the white line below the arcuate line and the free edge of the anterior sheath of the rectus abdominis. The abdominal wall was then repaired and reinforced with a piece of e-PTFE about 8 cm × 6 cm (Fig. 1E). An incision about 10 cm long was made on the left umbilical level to form a rotation and advancement ap, which was then sutured with a advancement ap formed by the residual tissue of the right abdomen.
The patient left hospital 7 days after operation. The postoperative procedure was uneventful without any complication, such as paradoxical respiration, abdominal hernia, ap necrosis, wound infection, and so on (Fig. 1F). In addition, no signs of recurrence were found during the 5-year follow-up period.

Discussion
Therapy for locally recurrent breast cancer Approximately 30% of patients experienced recurrence of breast cancer, but most patients with metastases may lose their chance of surgery [14]. The incidence of locally recurrent breast cancer was 4% (2-20%), and can occur as an isolated cancer or in combination with distant metastasis in other organ systems [15]. That's why we reported a small number of surgical cases within 5 years. Whenever possible, isolated local recurrence should be treated with a curative intent. If feasible, it was recommended to pathologically con rm the margin of negative tissue and completely remove the recurrent tumor [16]. The resection area must contain at least 2 cm of normal tissue around lesion [17,18]. Then, the chest wall defect coverage should be performed immediately instead of breast reconstruction. This was due to limited tissue, limited surgical tolerance, and poor patient willingness to perform breast reconstruction immediately. Adjuvant treatments for recurrent breast cancer were radiotherapy, endocrine therapy in patients with estrogen or progesterone receptor-positive cancer, and chemotherapy in patients with receptor-negative cancer [19][20][21].

Reconstruction Materials for the chest wall bone
Local recurrence of breast cancer in the deep chest wall will lead to thoracic defects after surgery. If the diameter of full-thickness defect was greater than 6 cm, or if there were more than three defected ribs, especially in the anterior and lateral chest wall, it is recommended to reconstruct the chest wall bone in order to maintain proper cardio-pulmonary function [22]. Ideally, materials used for chest wall reconstruction should have good tensile strength, elasticity, stable physical and chemical properties, ease of use, ready availability, and high biocompatibility as well as characteristics that do not affect chest inspections [23]. Various materials for chest wall reconstruction were classi ed into autologous tissue, allogeneic tissue, and arti cial materials [24][25][26][27].
Although autologous tissue and allogeneic tissue are considered to be the most suitable repair materials for human physiology, the disadvantages of autologous and allogeneic tissues are limited materials, increased trauma, increased di culty in surgery, poor satisfaction in shaping, poor aesthetics, and insu cient hardness. These disadvantages often lead to postoperative abnormal breathing, thus it is more suitable for smaller defect repair and di cult to repair larger defect area, especially in the case of local infection or radioactive necrosis. Compared with autologous tissue, arti cial materials have better bone support for the chest wall, simplifying the operation process, shortening the operation time, and reducing the surgical trauma. Therefore, for larger chest wall defects, arti cial materials are currently the preferred materials for bone reconstruction [28].
Although many arti cial repair materials were used clinically, none of them can meet all of the above requirements at the same time.
Polytetra uoroethylene (PTFE) patch may injury intrathoracic organs due to thermal reaction. Insu cient rigidity of repair materials such as Marlex mesh, Prolene mesh, Vicryl mesh, Gare-Tex patch may cause abnormal breathing. Autologous tissue and allogeneic tissue are not suitable for bone reconstruction of large chest wall defects. Moreover, titanium mesh has become a better option, originally created for craniofacial reconstruction [29,30]. Thus, we applied titanium mesh to stabilize the chest wall in two cases because titanium mesh has the following characteristics: rigid enough to prevent paradoxical respiration movement; malleability can be shaped into appropriate shape, inertness can avoid immune rejection, radiolucency can used for radiographic tracking of potential problems, and porosity can allow in-growth of brous tissue [31]. Although it affects X-ray inspection, CT and MRI are now more common and accurate for chest examination. Therefore, we recommend titanium mesh for bone reconstruction of large chest wall defects.
Selection of aps for the chest wall reconstruction As a prerequisite for stabilizing the chest wall, care should be taken to cover the soft tissue coverage, not only to cover the arti cial material that reconstructs the chest wall, but also restore the integrity of the chest wall, maintain the function of normal breathing and circulation, and improve the appearance and quality of life of the patients [11,12]. The soft tissue characteristics of recurrent breast cancer are often quite different from those of the primary cancer. There may be no donor vessels in the lesion available for free aps because of resection and radiotherapy. Meantime, for recurrent breast cancer patients, the simpler the surgery, the less invasive. Hence, free aps are not preferred. Especially for closure of large defects, they are not the rst choice for increasing the time of surgery and the incidence of complications. In addition to the local ap, the pedicle ap, or both aps fail to repair [32,33]. Myocutaneous aps are more suitable for the repair of breast cancer patients [33].
The selection of aps depends primarily on the location and area of the defect. On the vertical axis, the latissimus dorsi musculocutaneous ap and the pectoralis major myocutaneous aps are generally recommended for use in the upper 1/3 of the chest wall. It is recommended to use the latissimus dorsi musculocutaneous ap, rectus abdominis myocutaneous ap, pectoralis major myocutaneous ap, and omentum in the middle 1/3 of the chest wall. For the lower 1/3 of chest wall, it is recommended to use the rectus abdominis myocutaneous ap and omentum ap. On the horizontal axis, if the defect is located in the center of the chest wall, the latissimus dorsi musculocutaneous ap [34], the rectus abdominis myocutaneous ap [35] and the pectoralis major myocutaneous ap [36,37] can be repaired. In addition, in the lateral chest wall, the latissimus dorsi musculocutaneous ap is more commonly used.
However, the pectoralis major is usually resected in the locally recurrent breast cancer patients. Although the omentum ap has abundant blood supply, strong anti-infection ability, and strong plasticity, there is still a high risk of complicated operation, prolonged operation time, hemorrhage, abdominal hernia, and gastrointestinal complications after surgery. This is why they are not the rst choice for repairing chest wall defects. Although the latissimus dorsi myocutaneous ap may affect the ability of arm to lift, and the rectus abdominis myocutaneous ap may cause a weakness of the abdominal wall, they are still recommended [1,2,10,11]. In addition, they not only provide enough volume to cover a large soft tissue defect, but also are simple to operate and can achieve good outcome.
Radical mastectomy and subsequent radiation may result in the loss of many important tissues, such as vessels, which may result in some of those aps being unstable for reconstruction. Therefore, it is an important process to detect adjacent vessels by Doppler ultrasound before the operation.

Conclusion
In summary, for locally recurrent breast cancer, complete tumor resection is a crucial step and ensures that there is no recurrence. After surgery, the appropriate material should be selected to reconstruct the chest wall to restore the integrity of the thorax. Finally, according to the location and size of the defect, the blood-rich ap or myocutaneous ap is used to cover the wound, eliminate the dead space, and repair the soft tissue defect of the chest wall. Availability of data and meterials All data generated or analyzed during this study are included in this published article.

Competing interests
The authors declare that they have no competing interests.

Funding
Not applicable.
Authors' contributions SQ, GS and WYX designed this study. JSF, WCC and ZY collected literatures and conducted the analysis of data. ZY drafted the manuscript. SQ wrote the manuscript. All authors contributed to review the manuscript. All authors read and approved the nal manuscript.