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RADIATION TO THE CHEST WALL

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Background

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Radiation is a frequent adjunct for cancer treatment. Over 1.5 million persons have been diagnosed with cancer in the United States and of these, over two-thirds require radiation treatment.1 Radiation is frequently combined with surgery to assist with local control. Furthermore, it can reduce the dosage of chemotherapy required through a synergistic effect. It is more commonly used in breast and lung tumors due to contiguous spread of disease or inability to achieve completely negative margins. It also plays a role in the treatment of recurrent and metastatic tumors of other cell-line etiologies including lymphomas. Physiologically, radiation induces damage to the double-stranded DNA through the generation of free radicals.

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While radiation therapy techniques have advanced over the 100 years of its existence, it continues to impact normal tissue in its path. Radiation injures small vessels thereby decreasing oxygen delivery to normal tissues. It also causes fibrosis of surrounding tissue, further diminishing oxygen delivery.2 This directly damages the quality of the tissue present in an irradiated area and worsens its ability to respond to environmental or physiologic stresses. Complications associated with radiation to the chest wall include ulceration of the skin and soft tissue with resultant infection, rib fracture, osteonecrosis, recurrent tumor, and pulmonary fibrosis to name a few.

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Chest wall tumors frequently require a multidisciplinary approach. Because local soft tissues become fibrotic following irradiation, these tissues are often not amenable to primary closure or local tissue rearrangements to achieve a closed wound. Irradiated chest wall defects following tumor resection frequently require the incorporation of well vascularized, nonirradiated tissue in the form of flaps. Despite the delivery of well-vascularized tissue, chest wall reconstruction in the setting of radiation remains a complex proposition with higher than normal complication rates.3

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BASIC PRINCIPLES

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The chest wall provides protection to intrathoracic and intra-abdominal organs, supports shoulder and upper extremity function, and provides a platform for respiratory muscles to increase or decrease intrathoracic pressure to stimulate air exchange.4 Chest wall reconstruction involves combining two goals: restoration of functional integrity and aesthetics.

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Prior to any reconstructive effort in an irradiated field, it is important to establish clear margins. In addition, any infection must be cleared with serial debridement and IV antibiotics. Inadequate debridement may lead to persistent drainage.5 Once the final defect is established, it is important to assess the size and location of defect, depth of defect, quality of surrounding tissues, and patient prognosis.6 These factors will guide the selection of an optimal reconstructive method while also providing for potential contingencies. Knowledge of a wide variety of reconstructive options allows for adaptation to potential intraoperative developments.

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The size and location of the defect will help to determine what will likely be affected as part of the resection plan. Based on excision location, the ideal method ...

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