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Chest Wall Resection in the Treatment of Locally
Recurrent Breast Carcinoma
Indications and Outcome for 44 Patients
Ian F. Faneyte, M.B.
Emiel J. Th. Rutgers, M.D., Ph.D.
Frans A. N. Zoetmulder, M.D., Ph.D.
Department of Surgery, The Netherlands Cancer
Institute/Antoni van Leeuwenhoek ziekenhuis,
Amsterdam, The Netherlands.
BACKGROUND. Locoregional recurrence after initial treatment of breast carcinoma
occurs in up to 35% of patients. In selected patients, chest wall resection (CWR)
can be performed to regain local control. Extensive surgery is justifiable only if
good palliation and possibly a better prognosis can be offered and the morbidity
is limited.
METHODS. The authors conducted a retrospective review of the medical records
of 44 females with locally recurrent breast carcinoma who underwent chest wall
resection between 1979 and 1995 at the Netherlands Cancer Institute. Preoperative
patient characteristics were recorded, and complications were scored. Analysis was
made of disease free and overall survival after resection as well as the influence
of presumed prognostic factors on survival. The median duration of follow-up was
3.2 years.
RESULTS. The mean patient age at diagnosis of breast carcinoma was 47.5 years.
The median interval between first treatment and relapse was 3.9 years. Thirty
patients (68%) underwent CWR with curative intent. Postoperative complications
occurred in 18 patients, but no mortality occurred. The median disease free interval
after curative CWR was 3.3 years; the projected 5-year disease free survival rate
was 35%. A disease free interval of more than 2 years after primary treatment
predisposed patients to significantly longer tumor free survival after CWR, compared with an interval shorter than 2 years (P Å 0.0001). New local recurrence
after curative CWR occurred in 6 patients (20%), and distant metastases occurred
in 17. Median overall survival was 4.8 years; the projected 5-year survival rate was
45%. After curative resection, these figures were 8.9 years and 58%, respectively,
whereas palliative resection resulted in a median survival of 2.3 years and a projected 5-year survival of 21% (P Å 0.008). Age ¢35 years at the time of the first
diagnosis of breast carcinoma predisposed patients to significantly better survival
than age õ35 years (P Å 0.02).
CONCLUSIONS. CWR can provide local control, good palliation, and an acceptable
Presented at: 1) Eight Congress of the European
Society of Surgical Oncology, Dublin, Ireland,
September 4–7, 1996 (poster presentation); 2)
Seventh EORTC Breast Cancer Working Conference, Bordeaux, France, September 10–13,
1996(oral presentation).
Address for reprints: Emiel J. Th. Rutgers, M.D.,
Ph.D., The Netherlands Cancer Institute/Antoni
van Leeuwenhoek ziekenhuis, Plesmanlaan 121,
1066 CX, Amsterdam, The Netherlands.
Received January 16, 1997; revision received
April 14, 1997; accepted April 14, 1997.
prognosis for patients with recurrence of breast carcinoma. Outcome mainly depends on the completeness of the resection. Cancer 1997;80:886–91.
q 1997 American Cancer Society.
KEYWORDS: breast carcinoma, local recurrence, chest wall resection, morbidity,
ocoregional recurrence of breast carcinoma is reported to occur
in up to 35% of patients after some form of mastectomy or breastconserving therapy (BCT).1 – 5 The choice of therapy is still subject to
discussion. If initial treatment was BCT, subsequent recurrences are
usually treated with salvage mastectomy. Wide local excision followed
by irradiation is the usual treatment for patients with relapse after-
q 1997 American Cancer Society
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W: Cancer
Chest Wall Resection of Breast Carcinoma/Faneyte et al.
initial mastectomy if the patient has not received irradiation previously. Especially in this situation, recurrences
are likely to penetrate the chest wall because of the previous loss of soft tissue. Occasionally, these locally recurrent
tumors show a limited tendency toward hematogenous
dissemination. Resection of the tumorous process, including parts of the bony chest wall, is then a therapeutic
option. Even for patients with overt but limited distant
dissemination, palliative resection of seriously symptomatic local recurrences has to be considered.6,7 Extensive
surgery, however, is only justifiable if other treatment modalities have failed and the patient is in an acceptable
condition. If chest wall resection (CWR) is considered, the
morbidity that will be caused by the surgery should be
weighed against the palliative gain and prolonged survival. Surgery should result in both limited morbidity and
mortality and, most importantly, a regaining of local control. In this report, we evaluate our findings for a group
of 44 patients who underwent CWR for local recurrence
of breast carcinoma involving the chest wall at the Netherlands Cancer Institute/Antoni van Leeuwenhoek ziekenhuis (NCI/AvL) between 1979 and 1995. Emphasis is on
patient selection and outcome with respect to postresection disease free interval and survival.
The medical records of all patients who underwent
CWR at the NCI/AvL for locally recurrent breast carcinoma between 1979 and 1995 were analyzed. Chest
wall resection was defined as full-thickness resection
of a part of the chest wall, including (parts of ) at least
2 adjacent ribs or (part of ) the sternum. A total of 44
female patients were thus treated. In the majority of
patients, involvement of the chest wall was established
by computed tomography.
An overview of patient selection was obtained by
looking into the preoperative situation of each patient:
the patient’s age and tumor stage at primary diagnosis
of breast carcinoma, the initial treatment and subsequent interval before the first recurrence, the total
number of recurrences, diagnosis of distant metastases, and the treatment modalities used prior to CWR
were all taken into consideration. The policy regarding
indications and contraindications for CWR used at the
NCI/AvL is summarized in Table 1.
The microscopic completeness of CWR and postresection complications were recorded. Analysis of outcome after chest wall resection was performed according to the Kaplan–Meier method. For overall survival, the cutoff point was either the date of last followup (censored observation) or the date of death; and for
disease free survival, the cutoff point was the date of
first diagnosis of local or distant tumor progression (uncensored observation). Groups were compared using
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Indications and Contraindications for CWR Performed at the NCI/
AVL between 1979 and 1995 on Patients with Local Recurrences of
Breast Carcinoma after Mastectomy
Indications for CWR
Contraindications for CWR
Long disease free interval after
primary treatment
No distant metastases
Young age
Pain and ulceration
Carcinomatous lymphangitis
Multifocal recurrence
Insufficient pulmonary function
Distant metastases
Advanced age
Disease free interval after primary treatment
õ5 years
NCI/AVL: The Netherlands Cancer Institute/Antoni van Leeuwenhoeliziekenhuis; CWR: chest wall
the log rank test to establish the statistical significance
of differences. Median follow-up after chest wall resection was 3.2 years. No patients were lost to follow-up.
Surgery had been performed according to the following standards: lateral margins were established by
resecting a minimum of 2 cm, preferably 5 cm, of macroscopically uninvolved tissue around the palpable lesion. If there was doubt about the extent of the tumor,
deep skin and subcutaneous biopsies were taken at
the intended line of dissection and examined by frozen
section. The median number of ribs resected was 3
(range, 0 – 6). In 26 patients, part of the sternum was
resected, and the entire sternum was removed from 1
patient. The deep margin was usually the parietal
pleura, unless en bloc resection of lung tissue (n Å 3)
or part of the diaphragm (n Å 1) was indicated. In
seven patients, additional dissection of lymph nodes
was performed during the same session. Chest wall
stability was restored by using steel wire (n Å 9), resorbable Vicryl meshes (Ethicon, Johnson and Johnson
Medical, Morderstedt, Germany) (n Å 12), or permanent Marlex meshes (Bard, Cranston) (n Å 20). Implants were used in all but three cases. Soft tissue
coverage was established by transposing the omentum
based on one of the gastroepiploic arteries (n Å 28),
by primary closure (n Å 7), or by a combination of
these techniques (n Å 3). Other techniques of soft tissue reconstruction were transposition of the contralateral breast (n Å 3) and the use of a myocutaneous
latissimus dorsi flap (n Å 2). Split skin grafts were used
in 28 cases to complete soft tissue coverage.
Preoperative Situation
Preoperative clinical data are given in Table 2. The
mean age at the time of primary breast carcinoma
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CANCER September 1, 1997 / Volume 80 / Number 5
Clinical Data before CWR and Probability Values of Influence on
Disease Free Interval and Overall Survival after CWR; Comparison by
Log Rank Test
Disease free interval
No. of
All patients
Age at primary diagnosis (yrs)
Primary lymph node stage
pN ú 0
Disease free interval (yrs)
õ2 (õ5)
¢2 (¢5)
Local relapses pre-CWR
Metastases pre-CWR
Radiotherapy pre-CWR
Systemic therapy pre-CWR
Age at the time of CWR (yrs)
Intent of CWR
Adjuvant therapy post-CWR
P value
Overall survival
No. of
0.0001 (0.4)
4 (14)
26 (16)
0.07 (0.06)
11 (24)
33 (20)
P value
CWR: chest wall resection.
diagnosis was 47.5 years (range, 22 – 73 years); 4 patients were younger than 35 years. In 27 patients, no
lymph node metastases were found at the time of primary diagnosis (pN0), and 17 had at least 1 tumor
positive lymph node (pNú0). Primary treatment had
been surgical in 43 patients: 35 underwent mastectomies, 7 underwent breast-conserving surgery, and 1
patient in whom no primary tumor could be assessed
was initially treated with axillary lymph node dissection alone. Irradiation was part of the initial treatment
in 28 patients. Adjuvant chemotherapy was administered in six cases, hormonal treatment in two.
The median disease free interval after initial treatment was 3.9 years (range, 0.3 – 23 years) and was
shorter than 2 years for 11 patients. CWR was performed for a first local relapse in 22 patients. The other
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22 patients underwent CWR for a second up to a sixth
local relapse. Distant metastases were diagnosed before chest wall resection in 12 patients. Metastases
were found in extraregional lymph nodes (n Å 3), bone
(n Å 2), lungs (n Å 3), dermis, pleura, and diaphragm.
Other malignancies, besides those associated with the
primary breast carcinoma, were present at the date of
resection in two patients; one was fibrosarcoma and
the other was Paget’s disease of the contralateral
Prior to CWR, all patients had undergone ablative
surgery of the breast either as primary treatment or as
treatment for an earlier recurrence. Radiotherapy was
administered to 39 patients, chemotherapy to 10, and
hormonal therapy to 4. The mean age at the time of
CWR was 56.8 years (range, 31 – 79 years); 8 patients
were older than 70 years.
Postoperative Situation
Patients were hospitalized postoperatively for a median period of 21 days (range, 8 – 64 days). Median stay
in the intensive care unit was 4 days (range, 0 – 29
days), and the median postoperative intubation time
was 1 day (range, 0 – 29 days). No postoperative deaths
Complications were met in 18 instances (41%).
Seven patients had wound infections, 8 had pulmonary complications (embolus, infection, or other), 5
patients needed intubation longer than 2 days, 2 had
partial necrosis of a skin graft, and 1 had a necrotizing
pedicle flap. Surgery for treatment of complications
was performed on 10 patients. Besides excision of necrotic grafts, one tracheotomy for reintubation was
performed. Pleural infection in one patient necessitated decortication of the lung, and broken steel reconstruction wires had to be excised to overcome pain,
infection, and fistulae in four patients. No correlation
was established between patient age and risk of complications in the postoperative course.
Adjuvant Therapy
Chest wall resection was not routinely followed by any
form of adjuvant treatment. Systemic treatment was
administered to 12 patients, mainly because of incomplete resection or known metastatic disease. Eight patients were treated with hormones only (tamoxifen),
two received irradiation only, and two received both.
Two patients also underwent adjuvant oophorectomy.
Follow-up, Survival, and Treatment
Data on follow-up, survival, and treatment are given
in Table 2. Of 44 chest wall resections, 30 (68%) were
performed with curative intent, leaving the patient apparently tumor free (no metastases were present, and
W: Cancer
Chest Wall Resection of Breast Carcinoma/Faneyte et al.
FIGURE 1. Projected actuarial disease free survival after curative chest
FIGURE 2. Projected actuarial overall survival after curative versus pal-
wall resection is shown for 30 patients, regardless of first relapse site.
liative chest wall resection is shown for 44 patients.
the resection was microscopically complete). Curative
CWR was followed by tumor recurrence in 18 patients
(60%): 6 patients (20%) had a new local recurrence, 1
of which was isolated and 5 of which were combined
with distant disease; 12 patients had distant metastases alone. Metastases were found in bone, the brain,
and the skin (each n Å 4) and also in the kidney,
spleen, lung, pancreas, bone marrow, and contralateral breast (each n Å 1). The median disease free interval after CWR for 18 patients with recurrent disease
was 1.5 years. The median disease free interval after
curative CWR for all 30 patients was 3.3 years. Projected 2-year and 5-year disease free interval rates
were 60% and 35%, respectively. Median survival without local failure was 3.3 years. These data are shown
in Figure 1. Patients who developed breast carcinoma
recurrence within 2 years of first treatment had a significantly shorter disease free interval after CWR than
those with a longer initial disease free interval (P Å
0.0001). The longest recorded disease free interval after
CWR for a patient still alive and tumor free at the date
of last follow-up was 9.8 years. The projected 5-year
survival rate after CWR with curative intent was 58%;
the median overall survival was 8.9 years.
Chest wall resection was palliative for 14 patients
(32%). Patients who underwent palliative surgery (incomplete resection or metastases present) were not
considered to be tumor free postoperatively. Microscopy of the resectional margins remained doubtful for
4 of these patients. These patients had a median survival of 2.3 years. The projected 5-year survival rate
after palliative resection was 21%.
As expected, patients who underwent curative
CWR had a longer survival than those who underwent
palliative CWR (P Å 0.008); this is shown in Figure 2.
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FIGURE 3. Projected actuarial overall survival after chest wall resection
is shown for 44 patients.
Furthermore, 4 patients who were younger than 35
years at the time of first breast carcinoma diagnosis
had a statistically significant shorter survival after CWR
than the 40 patients who were age 35 years or older
(P Å 0.02). Significant differences in outcome were not
observed between other groups; this was especially
notable in comparing patients with or without known
metastases and patients older or younger than 70
years, both at the time of CWR.
Median overall survival of all 44 patients, regardless of the intent of CWR, was 4.8 years. The projected
5-year survival rate of all 44 patients was 45%. Five
patients survived longer than 10 years. These data are
shown in Figure 3. The longest recorded survival was
14.7 years. At the time of registration, 21 patients were
alive, 5 of whom were tumor free. The cause of death
W: Cancer
CANCER September 1, 1997 / Volume 80 / Number 5
for the 23 patients who had died by the time of registration was associated with the primary cancer in 19
cases; 1 patient died with locally uncontrollable disease, without known distant metastases; and 18 died of
disseminated cancer (7 also had locally uncontrollable
disease). For two patients, the cause of death was not
known; both were registered as free of tumor at the
time of last follow-up. One patient, free of tumor, died
of myocardial infarction. One other patient, who was
known to have cerebral metastases, died of a cerebrovascular accident.
Chest wall recurrence of breast carcinoma after mastectomy is very difficult to manage. Although local excision combined with radiotherapy, with or without
hyperthermia, will control most cases, a small group
of therapy-resistant chest wall recurrences remains.
They often progress into painful, ulcerating lesions
and cause great distress to patients.
Chest wall resection as a therapy for locally recurrent breast carcinoma was first performed as early as
1886 by Schede.8 The number of reports on the outcome of this procedure in larger groups of patients is
limited, indicating the relatively small number of chest
wall resections performed. Extensive surgery for local
recurrence of breast carcinoma is generally considered
only justifiable as a last option for patients who have
failed with radiotherapy and systemic therapy. Moreover, the recurrence should ideally be limited to a single location in absence of distant metastases. Advanced age as well as a short disease free interval after
primary treatment are considered to be contraindications.9,10
All of the patients in our cohort were medically
fit to undergo CWR, and all but five had previously
undergone radiotherapy or chemotherapy. Patients
without distant metastases had limited chest wall disease that was thought to be completely resectable with
curative intent. Patients with distant metastases were
so much impaired that CWR was indicated as a palliative measure only. Thus, the results for those patients
have to be interpreted within the framework of a set
of subjective selection criteria that are not always used
consequently. Notwithstanding this caution, the results for this series are encouraging. They show that
in a small subset of patients with chest wall recurrences of breast carcinoma, a long disease free interval
and possibly a cure can be obtained with CWR.
Completeness of the resection with no residual
(disseminated) disease is evidently the most important
determinative of outcome. Factors found to be related
to impaired survival after CWR were young age at the
time of the primary breast carcinoma diagnosis and a
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short disease free interval after initial treatment. The
patients who were younger than 35 years at the time
of the primary breast carcinoma diagnosis (n Å 4) had
a particularly poor outcome. Their overall survival
ranged from 0.7 to 3.1 years; at the time of last followup, 3 had died and 1 was still alive (2.7 years postresection). Even for this small number of patients, the effect
of age appeared significant. Furthermore, we feel that
these results emphasize the importance of distant metastases and advanced age as relative contraindications to CWR: with careful patient selection, a relatively good outcome was obtained for patients with
disseminated disease and for those older than 70
years. As to the disease free interval after primary treatment, we conclude that only an interval shorter than
2 years should be taken into account as a relative contraindication, instead of the stated 5-year minimum
interval. With regard to the ages of patients being a
decisive factor, we conclude that although young age
remains an argument in favor of radical surgery, the
poor gain obtained with CWR for the very young
should be weighed against this. It should be noticed
that the list of indications and contraindications in
Table 1 of this article concerns the NCI/AvL policy for
the years in which these 44 patients were treated.
The primary aim of CWR — regaining local control — was achieved for the majority of patients. Only
6 patients (20%) suffered local relapses after curative
CWR. Moreover, median survival without local failure
in our population (3.3 years) and projected 5-year survival just short of 60% compare equally or favorably
with results from other studies in which less extensive
surgery, radiotherapy, and systemic therapy were used
to treat comparable populations.11 – 16 Overall survival
in our population was 45%, a result comparable to
that observed by Tomin and Donegan for 47 patients
with isolated local recurrences regardless of treatment.17
Concerning the technique of closure of the osseous chest wall, we recommend the use of a nonelastic,
nonresorbable mesh graft to regain chest wall stability.
Particularly in large sternum resections, bone cement
is used. Resorbable mesh grafts will result in flailing
of the chest wall defect, which is functionally as well as
cosmetically unacceptable. For closure of the usually
large soft tissue defect, pedicled omental transposition
is prefered at the NCI/AvL, provided that intra-abdominal dissemination is absent (and the absence is verified by minilaparotomy or laparoscopy before CWR).
The technique is safe, and the omentum always has
enough volume and ensures rapid healing of the previously irradiated and contaminated wound bed. Coverage by a meshed split skin graft will result in an
acceptable function and cosmesis, and breast prosthe-
W: Cancer
Chest Wall Resection of Breast Carcinoma/Faneyte et al.
ses can be worn without problems. The latissimus
dorsi muscle flap often has too little volume, and previous axillary surgery and irradiation of the area might
compromise the flap or its vascular pedicle. The transverse abdominal muscle transposition flap involves a
procedure that will weaken the strength and function
of the muscular abdominal wall, possibly leading to
impaired pulmonary ventilation capacity in addition
to the CWR, and is therefore not our first choice.6,18,19
Positive results of extensive surgery for locally recurrent breast carcinoma have been reported by other
authors.20 – 22 In accordance with such reports, we conclude that CWR can regain lasting local control, leaving
patients with limited morbidity and a relatively good
prognosis or at least good palliation. In the light of the
fact that CWR performed by experienced surgeons is
a relatively simple procedure with little risk of serious
complications23 – 25 (an observation supported by our
findings), we recommend that a surgical approach to
chest wall recurrences of breast carcinoma be considered early in the course of treatment. The interpretation of the relative contraindications we discussed
should not be too strict.
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