136: Sternal and Clavicular Chest Wall Resection and Reconstruction

Introduction

Sternal resection is primarily required for primary or secondary malignancy, infection, or radiation osteonecrosis (radiation osteitis).^1,2 The resulting chest wall defect involving loss of skeleton and often overlying soft tissue depends on tumor extent and type, and severity of infection or radiation necrosis. Full-thickness sternal resections can compromise chest wall stability or have paradoxical respiratory movements, highlighting the importance of proper reconstruction of the thoracic wall and sternum.

Primary tumors of the thoracic skeleton are rare, accounting for 4.5% to 8% of published series of primary bone tumors with 11% in the sternum and 9% in the clavicles.³ Sternal tumors are classified as primary tumors (i.e., benign or malignant), adjacent tumors with local invasion (i.e., lymphoma or primary neoplasm of lung, breast, pleura, or mediastinum), metastases (i.e., primary neoplasm of breast, lung, or thyroid), and nonneoplastic lesions (i.e., inflammatory masses or bone cysts). The majority of sternal tumors are malignant and frequently represent metastasis or direct invasion by adjacent tumor.^1,4,5 The majority of primary sternal malignancies are bony or cartilaginous in origin.^3–5 The most common primary malignancy of the sternum is chondrosarcoma, and other common primary malignancies include osteosarcoma, solitary plasmacytoma, and Ewing sarcoma.^3–5 Although primary benign tumors of the sternum are rare, the most common benign tumors of the sternum are chondroma and osteochondroma.⁶

Most clavicle tumors are malignant and much more likely to be metastases than primary tumors. Primary neoplasms of the clavicle are rare. The most common primary malignancy of the clavicle is solitary plasmacytoma.⁷ Isolated clavicular resection is rare. Indications for resection include (1) exposure of the base of the neck, superior mediastinum, or brachial plexus, (2) tumor, infection, or injury/trauma of the clavicle itself or in association with sternal/chest wall resection, and (3) dysfunction of the sternoclavicular and acromioclavicular joints.⁸ Distal clavicle pathology generally entails dysfunction of the acromioclavicular joint which is usually managed by orthopedic surgeons specializing in shoulder reconstruction. The distal end of the clavicle is commonly resected for arthritis and dislocation of the acromioclavicular joint. Partial, medial clavicular resection is required during an anterior approach to superior sulcus tumor resection (Chapter 80).⁹ In addition, clavicular resection may be sufficient to provide exposure of the ipsilateral superior mediastinum during head and neck operations obviating the need for a partial or complete median sternotomy.

Patient Selection and Preoperative Assessment

Careful preoperative evaluation, including assessment of cardiopulmonary reserve, is critical for successful outcome. A detailed history should identify comorbid factors such as advanced age, malnutrition, overall debilitation, and cardiopulmonary disease. Severe respiratory insufficiency is considered a contraindication for extensive sternal resection. There should be a clear understanding of the patient's prior operations with attention to location of previous incisions and radiation treatment history, including location and dosage of exposure. This information is critical ...