Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Chest Wall Reconstruction Following Resection of Thoracic Tumours

  Thoracic tumours invading the chest wall present a dual surgical problem: achieving clear oncologic margins and restoring structural integrity of the thoracic cage. In Australia, where lung cancer remains the leading cause of cancer-related death, thoracic surgeons in Sydney, Melbourne, and Brisbane regularly manage locally advanced disease requiring en bloc resection of ribs, sternum, or soft tissue. The aim of reconstruction is to protect intrathoracic organs, preserve respiratory mechanics, and permit timely adjuvant therapy.

  Decisions about reconstruction begin during preoperative planning and extend through recovery. Tumour histology, defect size and location, and patient functional reserve all influence technique. Consensus discussions at gatherings such as the APSR 2022 congress emphasise a multidisciplinary pathway that integrates thoracic surgery, plastic reconstruction, anaesthesia, and rehabilitation within frameworks familiar to Australian practice.

  This overview outlines the central principles of chest wall reconstruction after thoracic tumour resection, with attention to material choices, surgical workflow, and outcomes relevant to local care. The role of the Therapeutic Goods Administration in regulating implantable devices and Medicare-funded multidisciplinary review shapes several decisions discussed below.

  Indications and Patient Selection

  The leading indication in Australia is non-small cell lung cancer with direct chest wall invasion, classified as T3 or T4 disease. Other indications include primary chest wall sarcomas, metastases from breast or renal cancer, and, less commonly, aggressive infections. Pancoast (superior sulcus) tumours represent a demanding subgroup, often requiring combined lung and vertebral resection.

  Patient selection requires assessment of cardiopulmonary reserve, nutritional state, and comorbidities. Smokers, still overrepresented in regional and coastal Australian populations, benefit from smoking cessation, pulmonary rehabilitation, and preoperative nutrition optimisation before surgery. Contrast-enhanced CT, MRI for soft tissue involvement, and PET-CT for staging are standard.

  Multidisciplinary tumour board review is standard in New South Wales and Victorian public hospitals, supported by Medicare funding for cancer case conferencing. This ensures surgical candidacy, neoadjuvant therapy, and reconstruction approach are aligned before the patient enters theatre.

  Anatomy of Defects After Tumour Resection

  Defect patterns vary widely. Posterior defects beneath the scapula often tolerate larger windows without reconstruction due to natural buttressing, whereas anterior and lateral defects exceeding 5 cm usually require prosthetic support to prevent paradoxical motion. Full-thickness defects including skin need vascularised soft tissue coverage, typically with pedicled or free flaps.

  Resected structures may include one or more ribs, costal cartilage, the sternum, or portions of vertebral bodies. When lobectomy accompanies chest wall resection, the prosthesis must withstand greater inspiratory and cough pressures during recovery. Surgical margins remain the oncologic priority, with frozen section used intraoperatively to confirm adequacy, supported by national pathology accreditation standards.

  Materials for Reconstruction

  Reconstruction uses a blend of biological and synthetic materials selected by defect characteristics, infection risk, and the likelihood of postoperative radiotherapy. Polypropylene and polyester meshes are commonly used for small to moderate defects, particularly posteriorly where flexibility matches native behaviour.

  For larger, rigid reconstructions, methyl methacrylate cement sandwiched between mesh layers provides a custom-moulded plate that restores skeletal contour. Titanium plates, increasingly available through Australian suppliers, suit sternal and load-bearing defects but cost more. Biologic matrices integrate well within irradiated or contaminated fields yet carry higher price and variable TGA-listing implications.

  Comparison of Common Strategies

  Strategy	Best Suited For	Strengths	Limitations
  Synthetic mesh alone	Posterior defects under 5 cm	Flexible, inexpensive, easy to handle	Insufficient rigidity for anterior defects
  Mesh-cement sandwich	Large anterior or lateral defects	Strong, customisable contour	Infection risk, heat during curing
  Titanium plates and bars	Sternal or load-bearing sites	Rigid fixation, MRI conditional	Cost, limited flexibility
  Biologic matrices	Irradiated or contaminated fields	Integrates with host tissue	Higher cost, variable availability
  Combined rigid plus flaps	Large composite defects with skin loss	Restores skeleton and cover	Long operative time, dual surgical teams

  Choice depends on institutional resources. Australian tertiary centres with on-site thoracic and plastic surgery teams complete combined reconstructions in a single operation, reducing anaesthetic time for high-risk patients. Delegates tracking updates at apsr2022 news alongside program content can monitor current material selections.

  Surgical Technique and Intraoperative Workflow

  The sequence typically begins with oncologic resection, defect measurement, prosthesis selection, and fixation. Dual-lumen intubation enables single-lung ventilation, and thoracic epidural or paravertebral block is standard, aligned with Australian and New Zealand College of Anaesthetists guidance.

  Mesh is secured with interrupted non-absorbable sutures or modern bone-anchor systems. Cement sandwiches require moulding before exothermic curing. Titanium plates are pre-contoured and affixed with locking screws. Haemostasis, pleural drainage, and layered closure follow; antibiotic irrigation and, in selected cases, negative-pressure wound therapy reduce infection in contaminated fields. Operative time frequently exceeds four hours, scheduled under the National Elective Surgery Categorisation framework.

  Postoperative Care and Complications

  Recovery centres on pulmonary hygiene, analgesia, and early mobilisation. Patients typically stay in high-dependency care for 24 to 48 hours, with drains removed once output and air-leak criteria are met. Paradoxical motion, infection, and prolonged air leak are the most common early problems, mitigated by physiotherapy-led breathing protocols.

  Late complications include seroma, mesh infection, plate loosening, and chronic pain. Approximately 10 to 20 percent of patients experience a wound complication, particularly those receiving neoadjuvant therapy for Pancoast tumours. Outpatient follow-up occurs through the originating public hospital or via private specialist rooms.

  Functional and Oncologic Outcomes

  Long-term outcomes depend mainly on tumour biology. Five-year survival after R0 resection of T3 lung cancer with chest wall invasion is reported between 30 and 50 percent in international series, with Australian single-centre data showing comparable figures. Respiratory function generally returns to within 10 to 15 percent of preoperative values, with greater permanent loss in patients with extensive resections and underlying chronic obstructive pulmonary disease.

  Local recurrence drives mortality, and reconstruction must enable rather than delay postoperative radiotherapy. Material selection should account for the radiation tolerance of the chosen implant or graft.

  Chest wall reconstruction after thoracic tumour resection is technically demanding but rewarding. The points to retain are that anatomic restoration, rigid fixation where indicated, reliable soft tissue coverage, and multidisciplinary perioperative care together determine recovery and quality of life. For Australian surgeons, alignment with TGA-approved devices, Medicare-supported multidisciplinary review, and access to combined thoracic and plastic teams at metropolitan tertiary hospitals underpins consistent, evidence-based practice.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)