Expert Consensus on Resection of Chest Wall Tumors and Chest Wall Reconstruction

Lei Wang; Xiaolong Yan; Jinbo Zhao; Chang Chen; Chun Chen; Jun Chen; Ke-Neng Chen; Tiesheng Cao; Ming-Wu Chen; Hongbin Duan; Junqiang Fan; Junke Fu; Shugeng Gao; Hui Guo; Shiping Guo; Wei Guo; Yongtao Han; Ge-Ning Jiang; Hongjing Jiang; Wen-Jie Jiao; Mingqiang Kang; Xuefeng Leng; He-Cheng Li; Jing Li; Jian Li; Shao-Min Li; Shuben Li; Zhigang Li; Zhongcheng Li; Chaoyang Liang; Nai-Quan Mao; Hong Mei; Daqiang Sun; Dong Wang; Luming Wang; Qun Wang; Shumin Wang; Tianhu Wang; Lunxu Liu; Gaoming Xiao; Shidong Xu; Jinliang Yang; Ting Ye; Guangjian Zhang; Linyou Zhang; Guofang Zhao; Jun Zhao; Wen-Zhao Zhong; Yuming Zhu; Karel W. E. Hulsewé; Yvonne L. J. Vissers; Erik R. de Loos; Jin Yong Jeong; Giuseppe Marulli; Alberto Sandri; Zsolt Sziklavari; Jacopo Vannucci; Luca Ampollini; Yuichiro Ueda; Chaozong Liu; Andrea Bille; Masatsugu Hamaji; Beatrice Aramini; Ilhan Inci; Cecilia Pompili; Hans Van Veer; Alfonso Fiorelli; Ricciardi Sara; Inderpal S. Sarkaria; Fabio Davoli; Hiroaki Kuroda; Servet Bölükbas; Xiao-Fei Li; Lijun Huang; Tao Jiang

Disclosures

Transl Lung Cancer Res. 2021;10(11):4057-4083. 

In This Article

Abstract and Introduction

Abstract

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T3–4N0–1M0. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

Introduction

Chest wall tumors concern benign and malignant neoplasms involving the chest wall, including primary tumors arising from muscle, fat blood vessel, nerve sheath, cartilage, or bone, metastatic tumors, and local invasion of tumors arising from adjacent organs like the lung, mediastinum, pleura, or breast.[1] The incidence of primary chest wall tumors is low, accounting for only 5% of all chest wall tumors. Most primary chest wall tumors are sarcomas accounting for 15–20% of all sarcomas, categorized according to the 4th edition of World Health Organization (WHO) Classification.[2] Due to the low incidence of chest wall sarcoma and lack of high-level clinical evidence, there is no TNM staging about chest wall sarcomas up to now. Currently, only the 8th edition TNM staging criteria of bone tumors (trunk, extremities, skull and maxillofacial) and soft tissue sarcomas (trunk and extremities) can be referenced according to the postoperative pathological diagnosis.[3]

Moreover, the staging and treatment principles can refer to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines of bone tumors and soft tissue sarcomas.[4,5] The histopathological biodiversity of sarcomas imply different therapeutic approaches depending on the site of origin, the histological grade and histological nature which can be scarcely described by the three factors of TNM. However, most of the studies on which current guidelines have been made up on, mainly focused on bone tumors and soft tissue sarcomas of the extremities, excluding chest wall sarcomas. This is mostly due to the fact that published studies about chest wall tumors include mostly few patients, describe anecdotical surgeries and are almost all single-center retrospective studies. This is the reason why evidences regarding the clinical management of chest wall tumors are lacking, and some controversial issues on surgical and multimodality treatment have yet to be agreed upon.

In January 2019, 73 Chinese experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese expert consensus on chest wall tumor resection and chest wall reconstruction (2018 edition).[6] Although this consensus has provided clinical guidelines for the diagnosis and treatment of chest wall tumors, numerous experts also put forward new perspectives on some academic issues, pointing out the necessity to further discuss the points of contention. Therefore, we conducted a survey through the administration of a questionnaire to 85 experts to develop a new version of the expert consensus, addressing the controversial points about surgical therapy of chest wall tumors.

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