A perspective on chest wall resection in patients with breast cancer

The morbidity from locally recurrent breast cancer or osteoradionecrosis and accompanying infection is substantial. The selective use of surgical resection offers good palliation. Extended full-thickness chest wall resection is facilitated by a variety of techniques available for closure and coverage including use of latissimus dorsi myocutaneous flap, rectus abdominus myocutaneous flap, pectoralis myocutaneous flap, breast flap, and omentum with skin graft. The experience with 43 consecutive chest wall resections in patients with breast cancer affords the opportunity to define indications and contraindications for such palliative procedures. Indications include local symptoms of pain and infection, tumor recurrence refractory to radiation therapy, and infection that precludes chemotherapy. Relative contraindications are pulmonary metastases, bone metastases, hepatic metastases, and malignant pleural effusions. Absolute contraindications are brain metastases, bone marrow involvement, bulky disease in two organs, and breakthrough on multiple chemotherapy regimens. Operative revision was only required in 4 of 43 patients. Minor wound complications occurred in 12 (28%). Three patients who underwent resection for local recurrence have survived 40 months or more free from disease. This procedure provides substantial palliation by relieving pain, controlling infection, removing a weeping wound, and allowing chemotherapy for metastatic disease. In the proper setting, chest wall resection is an important part of the armamentarium for palliation of the patient with breast cancer. It can markedly improve quality of life and occasionally may result in long-term survival.