The incidence of local–regional recurrence following breast conservation surgery or mastectomy varies between 5% and 40%. The probability of recurrence depends upon the presenting pathobiological characteristics of the primary neoplasm and/or the American Joint Committee on Cancer (AJCC) clinical tumor stage. Currently, no international standards for local recurrence have been fully defined, but, typically, the combination of surgery, radiation therapy, chemotherapy, and/or targeted immunotherapy is directed for principal control. Following local–regional recurrence that defines a clinical and radiographically resectable tumor, protocol will typically embrace resection with pathologically negative margins followed by subsequent radiation therapy; many clinics will also utilize hormone-receptor markers (ER, PR, and HER2/neu status) to assist in therapeutic guidance.

For many clinics internationally, despite curability with isolated metastases, chest wall recurrences are left untreated. In contradistinction, while resection of chest wall metastases related to breast carcinoma or other primary neoplasms (e.g., melanoma and sarcoma) may be therapeutically achievable, such recurrences cannot be completed with curative intent. Previous surgical dogma suggesting that chest wall recurrences are the “harbinger of systemic disease” does not necessarily apply when the patient has been fully staged clinically and radiographically and only the isolated breast cancer recurrence is evident.

We have previously published guidelines at the University of Alabama at Birmingham for resection of the chest wall in patients presenting with recurrence/advanced disease related to breast carcinoma.

The indications for operation, as discussed, pertain only to an isolated chest wall recurrence/advanced disease that can be surgically managed with curative intent.

Following patient intubation with a double-lumen, endotracheal tube, the patient is positioned in the supine or lateral decubitus position depending upon the planned resection of the local recurrence and flap choice. An appropriately sized double-lumen, endotracheal tube should be selected. The area for harvest of the potential skin flap and graft-donor sites should also be prepped and draped into the operative field.

Preferentially, we prefer a minimal 2-cm margin developed 360 degrees around the periphery of the planned resection area (Fig. 1). It is critical that both the oncological surgeon and the plastic surgeon plan the operative incision prior to skin incision, estimating the maximum cephalad, caudad, medial, and lateral extent of the tumor, such that the estimate for margins of resection can be discussed with the patient and family prior to the planned resection. Such estimates are simultaneously planned with radiographic imaging, if necessary.

The pectoralis major and minor are incised outside the tumor-bearing area to the level of the chest wall; all ribs for planned resection are medially and laterally exposed. The incision will include all previous punch
biopsied areas. In the cephalad-most extent of the planned rib resection, the rib is incised on its cephalad surface, and the ipsilateral lung is deflated by the anesthesiologist at the instruction of the surgeon. The thoracotomy should be initiated via the superior margin of the planned resection (Fig. 2). Upon entering the thorax, previous pleural adhesions created by prior radiation therapy and/or surgery should be sharply dissected and mobilized. Attention must be directed to avoidance of injury to the parietal pleura and inadvertent damage to the pulmonary parenchyma. When dissection is incomplete or inadequate, lysis of adhesions should be completed and performed with sharp dissection to avoid the formation of an alveolar–pleural fistula. With dense adhesions related to tumor invasion of the parietal pleura of the lung, complete pleurectomy with simultaneous segmental resection of the focally involved lung segment may be necessary. Repair of any parenchymal tears may be completed by stapling or suturing with a 3-0 absorbable polypropylene suture after adequate deflation of the lung without injury. The incision is thereafter extended around the peripheral margins of the tumor mass through the intercostal muscles (Figs. 3 to 6). The surgeon must be cognizant of ligation of the intercostal neurovascular bundles on the inferior margins of the rib with 2-0 silk suture ligatures (Fig. 5).

As the incision is extended around the margins of the resection, the periosteum of the rib should be elevated with a Doyen retractor followed by a periosteal elevator prior to initiating rib division with a rib cutter (Fig. 5A). Following completion of the entire incision, the surgeon should be cognizant about including all the punch biopsy sites to ensure negative surgical margin.

When the tumor margin extends medially to the sternum, it may be necessary to utilize a sternal saw or osteotome to create a partial sternotomy up to and inclusive of the biopsied skin that establishes a clear surgical margin. Moreover, the incision should be extended to the sternocostal margin where the internal mammary artery (IMA) can be palpated, ligated, and divided. The sternum thereafter may be partially resected, but diligence must be exercised to protect the pericardium, which may be centrally adherent to the investing parietal pleura of the sternum, secondary to irradiation.

In all circumstances, the specimen should be resected en bloc, thus exposing the chest wall defect with the exposed,
inflated, protuberant lung. Insufflation of the underlying lung following resection of tumor invasion requires visualization of alveolar–parenchymal leak; repair must be instituted for closure of such leaks. If in-vasive disease is detected grossly or with biopsy, the well-exposed lung can then be managed by a wedge resection of the involved lung with a stapler. Leaking defects should again be oversewn and tested for air leaks prior to tube placement and chest closure (Fig. 6).