Case Report: Multidisciplinary approach to metastatic disease, and lessons learned

Chest wall resection with pulmonary segmentectomy for metastatic breast cancer.

a multi-disciplinary approach: plastics, surgical oncology and thoracic surgery

Title:  Chest wall resection with pulmonary segmentectomy for metastatic breast cancer

Summary: Breast cancer remains the second leading cause of mortality in females in Mexico, aged 30 to 55, and is usually self-detected in later stages.  Due to disparities in health care within the country, even patients with early detection may not receive optimal or timely treatment leading to more recurrent or metastatic disease.  Surgery remains the best, but underutilized option for definitive treatment in patients with surgically resectable disease.  In this case, a patient with advanced disease was successfully resected using a multi-disciplinary approach.

Authors: K. Eckland, ACNP-BC, Hospital General de Mexicali, Thoracic Surgery

Carlos Ochoa Gaxiola, MD, Hospital General de Mexicali, Thoracic Surgery

Gabriel Ramos Orozco, MD, Instituto Mexicano Seguro Social (IMSS), Surgical Oncology

Corresponding author: Carlos Ochoa Gaxiola, MD


Announcement text: a multidisciplinary approach to recurrent metastatic breast cancer with chest wall resection and free flap graft creation.

Subject/ Classification terms: chest wall resection, rib resection, metastatic breast cancer, pulmonary segmentectomy, breast cancer in Mexico

Disclosures:  The authors have no disclosures.

History/ Case Summary:

The patient was a 70-year-old Hispanic female with a past medical history significant for local breast cancer in the left breast, initially diagnosed in 1994.  This was treated with chemotherapy and radiation.  She was then maintained on tamoxifen until 2000.  In 2011, she presented with a recurrent mass in the left breast.  There was no other history of chronic or active medical conditions such as HTN, CAD or diabetes.

After referral to a surgical oncologist for further evaluation, patient underwent additional evaluation.  A PET/ CT scan was positive for a metabolically active lesion in the left breast with an SUV of 9.6 with lytic lesions in anterior ribs with max SUV of 3.0.  There was no evidence of distal metastasis to other organs including the brain, lungs, or abdominal cavity on PET or other diagnostic imaging.  All pre-operative labs were within normal ranges including alk phos, and serum calcium.

Pre-operative Chest X-ray

After initial surgical evaluation, a multi-disciplinary surgical plan utilizing a general surgical oncologist, thoracic surgery and plastic surgery was devised for surgical resection of breast mass with rib resection and free flap creation.

surgeons planning approach

Operative Course:  The left breast including all skin, tissue and lymphatics was excised to the depth of the rib cage.  Further dissection and resection of the anterior portion of ribs #2, 3 and #4 was completed.

following rib resection

Following rib resection, upon exploration of the left thoracic cavity, the patient was found to have a large greyish-white lesion, estimated at 3.5 cm in diameter in the left upper lobe.  The lesion was hard, and located on the peripheral portion of the upper lobe.  No additional lesions were found.

during surgery, a previously undetected pulmonary lesion was discovered

The decision to undertake pulmonary resection was based on the possibility of complete surgical resection of existing disease.  At the time, a discussion was undertaken with the patient’s primary surgeon, and the thoracic surgeon on the feasibility of resection by lobectomy versus segmentectomy.  The decision was made to proceed with a lung-sparing procedure as the patient’s baseline pulmonary function was not known.

Following successful lung resection and hemostasis, a 32 french chest tube was placed, and surgical mesh was placed for coverage of chest wall / rib defect. After mesh was sutured into place, the patient was re-positioned for harvesting of a free flap from the posterior chest. Abdominal free flap harvest was not undertaken due to patient anatomy.  The plastic surgeon involved in the case, Dr. Nastia Gonzalez then proceeded with free flap grafting for breast reconstruction.   There was no significant bleeding, hypoxia or hemodynamic instability intraoperatively.

Post-operative Course:

The patient was successfully extubated at the conclusion of the case, and transferred to the post-operative care unit in stable condition.  Post-operative course was uncomplicated with the chest tube removed on POD#3, and the patient discharged home on POD#5.   The patient’s oxygen saturations were within the normal range (92% or above) and she was discharged home without supplemental oxygen.

Subsequent post-operative visit was uneventful with no evidence of infection, or impaired healing of the graft or harvest site.  As of the date of publication, there has been no further evidence of recurrence or metastatic disease.

Conclusions:  For patients with metastatic disease limited to adjacent and surgically resectable tissue, surgery remains the best option for longevity and overall survival.  However, despite the available and use of advanced imaging studies, surgeons should prepare for and anticipate the possibility of discovery of evidence of additional disease.  In this case, a more complete anatomic resection of the newly discovered lung lesion was hindered by the lack of pre-operative evaluation of pulmonary disease.

Chest wall resection and defect closure have been managed with a variety of techniques over the years, including muscle flaps, plastic ribcage creation, mesh closures for stabilization after rib resection (Khalil et al.).  In this case, which required a radical mastectomy, surrounding musculature was removed for full resection.  Tissue was harvested for free flap grafting but this gives lesser structure than attached muscle, so synthetic mesh was used.

Historically, hardware installation was plagued with a variety of problems including infection and erosion.  However, preliminary reports of evolving hardware for oncologic chest resections may change closure techniques in the future (Fabre et al, 2012).

References/ Additional Information

Akiba T, Takeishi M, Kinoshita S, Morikawa T. (2011).  Vascularized rib support for chest wall reconstruction using Gore-Tex dual mesh after wide sternochondral resection. Interact Cardiovasc Thorac Surg. 2011 Nov;13(5):536-8. Case report of breast ca with sternal reconstruction. Note the one month post-op photo.

Billè A, Okiror L, Karenovics W, Routledge T. (2012). Experience with titanium devices for rib fixation and coverage of chest wall defects.  Interact Cardiovasc Thorac Surg. 2012 Jul 19.  Report of 18 patients with chest wall defects repaired using titanium.  (Majority of cases were trauma related).

Fabre D, El Batti S, Singhal S, Mercier O, Mussot S, Fadel E, Kolb F, Dartevelle PG.  A paradigm shift for sternal reconstruction using a novel titanium rib bridge system following oncological resections. Eur J Cardiothorac Surg. 2012 May 2. No free full text available. Parisian study of titanium bridge system for use after oncological resections.

Gharagozloo F, Meyer M, Tempesta BJ, Margolis M, Strother ET, Tummala S. (2012).  Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results. Innovations (Phila). 2012 Jan-Feb;7(1):39-44.  No free text available.  Report on robot-assisted rib resection. (Less relevant but interesting.)

Khalil el-SA, El-Zohairy MA, Bukhari M.  (2010).  Reconstruction of large full thickness chest wall defects following resection of malignant tumorsJ Egypt Natl Canc Inst. 2010 Mar;22(1):19-27.   Excellent report on series of 18 patients who underwent major chest wall resections for onocologic disease.  Review of available materials and type of resections.

Mohajeri G, Sanei MH, Tabatabaee SA, Hashemi SM, Amjad E, Mohajeri MR, Shemshaki H, Jazi AH, Kolahdouzan M. (2012). Micrometastasis in non-small-cell lung cancer: Detection and staging.  Ann Thorac Med. 2012 Jul;7(3):149-52.  Using bone marrow biopsy for diagnosis of lytic lesions.

Müller AC, Eckert F, Heinrich V, Bamberg M, Brucker S, Hehr T. (2011).  Re-surgery and chest wall re-irradiation for recurrent breast cancer: a second curative approach.  BMC Cancer. 2011 May 25;11:197.

Seki M. (2012). Chest wall reconstruction with a latissimus dorsi musculocutaneous flap via the pleural cavityInteract Cardiovasc Thorac Surg. 2012 Jan;14(1):96-8. Case Report. Transpleural musculocutaneous flap used for defect repair in long term cancer survivor with radiation-related necrosis.

This case study has been published with the gracious consent of the patient.  However, in accordance to the patient’s wishes, and privacy – no photos showing the pre-operative site (breast) or the graft after surgery will be published.

Outpatient Treatment for Malignant Effusions

Discussion of treatment goals, and patient centered care for Malignant pleural effusions. This is the first in a series of articles on lung cancer, and lung surgery topics. Originally posted at our sister site.

Not all conditions are curable, and not all treatments are curative. Some treatments are based on improving quality of life, and alleviating symptoms. This is a hallmark of patient centered care – doing what we can to make the patient feel better even when we can’t ‘fix’ or cure the underlying disease. No where is this more evident than in the treatment of malignant effusions.

By definition, a Malignant Effusion is the development of fluid in the fluids related to an underlying (and sometimes previously undiagnosed) malignancy. Malignant effusions can be seen with several different kinds of cancers, most commonly lung and breast cancers. The development of a malignant effusion is a poor prognostic sign as it is an indicator of metastasis to the pleural tissue/ space.

The development of a malignant effusion usually presents with symptoms of shortness of breath, and difficulty breathing. While the treatment of the underlying cancer may vary, the primary goal of treatment of an effusion is palliative (or symptom relief). The best way to relieve symptoms is by removing the fluid.

This can be done several ways – but each has its own drawbacks.

The fluid can be drawn out with a needle (thoracentesis) either bedside or under fluroscopy. This procedure is quick, and can be performed on an out-patient basis, in a doctor’s office, or in radiology.

The potential drawbacks with this treatment strategy are two-fold:

1. There is a chance that during the procedure, the needle will ‘poke’ or ‘pop’ the lung, causing a pneumothorax (or collapse of the lung). This then requires a chest tube to be placed so the lung can re-expand while it heals. However, if the procedure is performed uneventfully, (like it usually does) the patient can go home the same day.

2. The other complication – is rapid re – accumulation – since you haven’t treated the underlying cause, but have only removed the fluid. This also happens when the cause of the effusion (nonmalignant) is from congestive heart failure. This means the fluid (and symptoms of shortness of breath) may return quickly, requiring the patient to return to the hospital – which is hard of the patient and their family.

Video- Assisted Thoracoscopy: (VATs)
Malignant effusions can also be treated by VATS – this is a good option if we are uncertain of the etiology (or the reason) for the effusion. While all fluid removed is routinely sent for cytopathology (when removed during surgery, thoracentesis or chest tube placement) – but cytopathology can be notoriously inaccurate with false negative reports, because the diagnosis is dependent on the pathologist actually seeing cancer cells in the fluid.  However, during the VATs procedure – the surgeon can take tissue samples, and photos along with fluid for diagnostic testing.   This is important because I have had cases in the operating room (VATS) where the surgeon actually sees the tumor(s)** with the camera but the fluid comes back as negative.

** in these cases, we send biopsies of the tumor tissue – which is much more accurate and definitive.

But a VATS procedure requires an operation, chest tube placement and several days in the hospital.

Chest tube placement:
Another option is chest tube placement – which also requires several days in the hospital..

During both chest tube placement and VATS, a procedure called pleurodesis can be performed to try to prevent the fluid from re-accumulating.

But what if we know it’s a malignant effusion? What are the other options for treatment?

Catheter based treatments: (aka PleurX style catheter, or Heimlich valve)
(note: catheter means a small tube – a foley catheter is the type used to drain urine, but other types are used for many things – even an IV is a catheter.)
One of the options used in our practice was pleur X (brand) catheter placement. This catheter was a small flexible tube that could be placed under local anesthesia – either in the office or the operating room – as an ambulatory procedure. After some patient teaching, including a short video, most family members felt comfortable emptying the catheter every two or three days at home, to prevent fluid  re -accumulation (and allowing the patient to continue normal activities, at home.)

PleurX catheter placement is preferred in many cases due to ease of use, and patient convenience. The Heimlich valve is messier – as it tends to leak, and harder for patients to hide under clothing.

Sometimes a visiting nurse would go out and empty the catheter, and in several cases, patients would come to the office, where I would do the same thing – it was a nice way to relieve the patient’s symptoms without requiring hospitalization, and several studies have shown that repeated drainage often caused spontaneous pleurodesis (fluid no longer accumulated.) We would then take the catheter out in the office.. Now, like any procedure, there is a chance for problems with this therapy as well, infection, catheter can clog, etc..

But here’s another study, showing that even frail patients benefit from home-based therapy – which is important when we go back and consider our original treatment goals:
-Improving quality of life
-Relieving symptoms

In the article, the authors used talc with the catheters and then applied a Heimlich valve, which is another technique very similar to pleurX catheter placement.  (Sterile talc is used for the pleurodesis procedure – which we will talk about in more detail in the future.)

Another article, this one by Heffner & Klein (2009) published in the Mayo Clinic Proceedings discusses the diagnosis and treatment of malignant effusions.