A woman underwent radiation therapy for a breast carcinoma 20 years ago. She 
has developed the lesion seen on the photographs. The best management is

A. biopsy and additional radiation therapy.
B. chemotherapy.
C. local excision and primary closure.
D. wide excision and closure with a myocutaneous flap.
E. wide excision and primary closure.

Answer D

This patient has a long-term complication of radiation therapy. 
She has developed an osteogenic sarcoma in the field of radiation therapy. This lesion is 
difficult to care for, but treatment is necessary since it may become a foul-smelling, 
chronically draining chest wound. Maximal irradiation has usually been given previously, and 
additional treatments risk vital organ damage and poor healing. Chemotherapy is usually 
ineffective for this type of tumor since the irradiated tissue is unlikely to heal. 

Operative 
planning must focus not only on the tumor but also the entire irradiated field, including the 
full thickness of the chest wall. Local excision will not suffice for this lesion because the 
grossly devascularized or infected tissue will not heal primarily even with supportive wound 
care. Aggressive resection, including en bloc chest wall resection and reconstruction with 
viable tissue is required to control the wound. Prosthetic graft reconstruction is unwise in the 
face of infection and is usually not necessary. Surprising stability is achieved with 
myocutaneous flap coverage alone.

Pairolero PC, Arnold PG: Chest wall tumors: Experience 
with 100 consecutive patients. J Thorac Cardiovasc Surg 1985;90:367.
One hundred consecutive patients with chest wall tumors undergoing resection during the 
past 8 years were reviewed. There were 55 female and 45 male patients with ages ranging from 12 
to 84 years (median 54.5 years). Fifty patients had primary malignant neoplasms, 32 had 
metastases, and 18 had benign tumors. The tumor was located in the ribs in 78 patients and in the 
sternum in 22. The number of ribs resected ranged from one to eight (median 3.4). Sternotomy was 
performed in 22 patients. Overlying soft tissue was resected en bloc in 47 patients. 
Reconstruction was with prosthetic material in 57 patients and autogenous ribs in 11. There were 
100 muscle transpositions, including 45 pectoralis major, 33 latissimus dorsi, and 9 serratus 
anterior. Hospitalization ranged from 4 to 80 days (median 9.6 days). Complications occurred in 
nine patients. One patient required tracheostomy. There was one operative death. Median follow-up 
was 31.5 months. Recurrent tumor developed in seven patients. All patients with benign tumor and 
95% of patients with primary tumor not previously treated were alive. However, only 41% of 
patients with metastatic tumor were alive. Metastases were responsible for 89% of late deaths. We 
conclude that aggressive resection for chest wall tumor with reliable reconstruction can be 
accomplished safely and that early wide resection is potentially curative treatment.

Stelzer P, Gay WA Jr: Tumors of the chest wall. Surg Clin North Am 1980;60:779.
Primary tumors of the chest wall are uncommon but should be considered in the evaluation 
of patients with persistent chest wall pain or the presence of a chest wall mass, especially when 
this is near the costal cartilages. Special radiographic techniques may help to define the 
diagnostic possibilities and the extent of local involvement. Since at least half of the primary 
rib tumors and virtually all of the sternal tumors are malignant, these problems demand prompt 
investigation, accurate tissue diagnosis, and, usually, generous surgical excision. With 
appropriate attention to skin, soft tissue, and skeletal involvement, resection of major chest 
wall tumors can be done safely, and there are a variety of reconstructive techniques available to 
deal with the resulting defects. Radiotherapy has little role in the treatment of chest wall 
tumors except for the myeloproliferative disorders and possibly some cases of Ewing's sarcoma. 
Chemotherapy has similarly been ineffective for the cartilaginous tumors but shows some promise 
in the multidisciplinary approach to osteogenic sarcoma. Surgical resection, however, remains the 
mainstay for the treatment of most tumors of the chest wall. Even in instances of recurrent 
disease there are many whose long-term survival has been achieved by multiple operative 
procedures.

Pairolero PC, Arnold PG. Thoracic wall defects: Surgical management of 205 consecutive patients. 
Mayo Clin Proc 1986;61:557.
In this article, we review our experience during the past 9 years with 205 consecutive 
thoracic wall reconstructions. The 100 female and 105 male patients ranged in age from 12 to 85 
years (mean, 53.4 years). One hundred fourteen patients had thoracic wall tumors, 56 had 
radiation necrosis, 56 had infected median sternotomy wounds, and 8 had costochondritis. 
Twenty-nine of these patients had combinations of the aforementioned conditions. One hundred 
seventy-eight patients underwent skeletal resection. A mean of 5.4 ribs were resected in 142 
patients. Total or partial sternotomies were performed in 60. Skeletal defects were closed with 
prosthetic material in 66 patients and with autogenous ribs in 12. One hundred sixty-eight 
patients underwent 244 muscle flap procedures: 149 pectoralis major, 56 latissimus dorsi, 14 
rectus abdominis, 13 serratus anterior, 8 external oblique, 2 trapezius, and 2 advancement of 
diaphragm. The omentum was transposed in 20 patients. The mean number of operations per patient 
was 1.9 (range, 1 to 8). The mean duration of hospitalization was 16.5 days. One perioperative 
death occurred (at 29 days). Four patients required tracheostomy. During a mean follow-up of 32.4 
months, there were 49 late deaths, predominantly due to malignant disease. All 204 patients who 
were alive 30 days after operation had excellent surgical results at last follow-up examination 
or at the time of death due to causes unrelated to the reconstructive procedure.