Chest wall resection and reconstruction for lung cancer: Surgical techniques and example of integrated multimodality approach

Surgery is a mainstay in the treatment of non-small cell lung cancer (NSCLC). Involvement of chest wall accounts for approximately 5–10% of operable NSCLC and in such cases extended resection is needed to maximize chances of durable disease control (1). After surgical removal of involved structures, reconstructive procedures are often necessary to maintain or re-establish thoracic cage stability and function, in order to preserve satisfying long-term functional outcome and cosmesis, while dealing satisfactorily with postoperative outcome (2). Despite advances in surgical procedures and postoperative care and wide availability of prosthetic replacement materials, chest wall surgery stands as a challenge to thoracic surgeon, resulting in a stringent trade-off between achievement of adequate resection margins and risk of long-term sequelae. Careful candidate selection and surgical planning on individual basis are mandatory. Most notably, chest-invading NSCLC display heterogeneous presentation ranging from parietal pleura infiltration to full-thickness invasion of the chest wall, with or without involvement of neighboring anatomic structures such as intercostal space including neurovascular bundle, vertebrae, mediastinal vascular structure, as well as extra-thoracic soft tissues. Furthermore, chest wall invasion may be posterior, lateral, or anterior: hence, choice of surgical technique is critical. Although no real consensus on appropriate management has been reached yet, it should be pointed out that this is more probably related to the multifaceted presentation of the disease than to real discrepancies on surgical opinions and practices. Moreover, increasing use of multimodal integrated treatment, including chemo- and radiotherapy regimen, as well as induction immunotherapy, is expected to increase the number of currently disqualified patients at presentation who can be considered eligible for curative-intent surgery after preoperative treatments. In our paper we will review major operative modalities in this setting.