Multimodal surgical decision-making for chest wall sarcomas: a clinical practice review

Introduction

Background

Primary chest wall sarcomas are exceedingly rare, comprising only 0.04% of newly diagnosed cancers, with primary chest wall tumors in general representing only 5% of thoracic neoplasms (1-4). In contrast, secondary chest wall tumors are more common and most often originate from distant metastases or direct invasion from adjacent structures (5,6). Primary chest wall sarcomas arise from multiple sites along the chest wall, with 55% of chest wall sarcomas involving bone (i.e., ribs, sternum, clavicle, and scapula) and 45% involving soft tissues (3,5-7). Most secondary chest wall malignancies arise from distant metastases (6).

The spectrum of sarcoma subtypes includes, but is not limited to, undifferentiated pleomorphic sarcoma, liposarcoma, desmoid-type fibromatosis, rhabdomyosarcoma, leiomyosarcoma, malignant peripheral nerve sheath tumor, and angiosarcoma (3,8). Among bone and cartilage sarcomas, chondrosarcoma is the most common primary malignant bone tumor of the adult chest wall, followed by Ewing sarcoma and osteosarcoma (3).

Demographic characteristics (such as age and gender) vary by histologic subtype: Chondrosarcoma (fifth decade), Ewing sarcoma (adolescence and young adulthood), and osteosarcoma (peak distribution adolescence and in older adults) (9-11). Primary chest wall sarcomas more commonly affect men than women (2:1) (9,12,13). In contrast, there is no clear gender predilection for secondary chest wall sarcomas that originate from distant sites or direct invasion; however, treatment-associated secondary chest wall sarcomas, such as angiosarcoma after breast cancer radiation treatment, predominantly affect women (14,15).

Rationale and knowledge gap

Given the rarity, histologic heterogeneity, and lack of standardized surgical and reconstructive algorithms for chest wall sarcomas, a contemporary synthesis of diagnostic evaluation, oncologic management, and reconstructive strategies is needed (3). Current management goals focus on achieving negative surgical margins, while optimizing perioperative functional status. Despite these objectives, the biological diversity of these tumors necessitates a complex, multimodal approach integrating systemic therapy, radiation, and advanced reconstruction to optimize outcomes.

Objective

This clinical practice review provides an updated multidisciplinary overview of the current literature and emerging approaches to guide clinical decision-making for chest wall sarcomas, including evolving roles for minimally invasive and robotic resection, artificial intelligence (AI) in surgical planning, and novel systemic and immunotherapeutic strategies. In addition, we present a practical multidisciplinary decision-making framework and surgical flowchart to support clinicians in navigating complex diagnostic, oncologic, and reconstructive management pathways.

Preoperative assessment & workup

Due to their biological heterogeneity, chest wall tumors may present as indolent or as clinically debilitating disease in the setting of locally advanced disease (4,9,11). The majority of chest wall sarcomas are symptomatic, presenting with an enlarging palpable mass, pain, or discomfort with exertion, mainly when cartilaginous or bony tumors damage the periosteum (6,16). Larger tumors may cause additional symptoms or findings, including impaired movement and muscle atrophy (3,6). Chest wall sarcoma is less commonly diagnosed incidentally on chest radiograph or computed tomography (CT), with small, single-center studies showing that 18–28% of patients with chest wall sarcoma are diagnosed incidentally (15,17-19). Predisposing risk factors for chest wall sarcomas include thoracic radiation, genetic predisposition, and other primary sarcomas, while traumatic injury and burns are potential but not widely proven associations (20-24). Due to the disease’s rarity, a high index of suspicion is necessary to recognize atypical features of chest wall masses (rapid growth, pain, size >5 cm, deep/infiltrative on imaging) to prompt further imaging and biopsy (15,25).

Evaluation of suspected chest wall sarcoma begins with imaging (Figure 1). Cross-sectional imaging is a cornerstone for diagnosis and provides insight into tumor extent, involvement (bone, soft tissue, pleura, mediastinum, and lung), and biological behavior (26). Surgical reconstruction and optimal oncologic resection rest on the adequacy of timely and precise imaging studies. Most patients undergo chest CT at the time of initial evaluation, especially in the setting of known risk factors (16). CT demonstrates high sensitivity for detecting osseous destruction and calcifications, with reported sensitivities exceeding 85–90% for chest wall bone involvement (15,27). Magnetic resonance imaging (MRI) is preferred for assessing tumor infiltration into soft tissues, potential need for soft tissue flaps during surgery, and local staging (6,16). MRI provides superior soft-tissue contrast and local staging accuracy, with sensitivity and specificity for assessing tumor extent and adjacent soft-tissue infiltration generally reported in the 90% range for soft-tissue sarcomas (15,27). Positron emission tomography (PET)/CT and CT abdomen/pelvis are useful in cases of secondary chest sarcoma, and they have pooled sensitivities (85–95%) for detecting metabolically active disease and distant metastasis, although specificity may be limited by inflammatory uptake (15,27). Additional preoperative evaluation may also include pulmonary function tests, cardiac assessment, and three-dimensional (3D) reconstruction, particularly if aggressive resection and reconstruction is planned.

Figure 1 Surgical decision-making flow chart for chest wall sarcoma. CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography.

Core needle biopsy is a necessary adjunct to diagnosis and may be performed under image guidance (6). In soft-tissue sarcomas overall, core needle biopsies have demonstrated high diagnostic accuracy, with sensitivity and specificity for malignancy above 90% and are generally considered the first-line approach for biopsy (28). Incisional or open biopsies may be necessary for complex or deep tumors and similarly have high diagnostic yield, but they are associated with higher morbidity. Frozen section analysis during biopsy can be a valuable adjunct, particularly when the differential diagnosis includes lymphoma or other hematologic malignancies that require different tissue handling for flow cytometry, cytogenetics, or molecular analysis (29,30). The use of percutaneous biopsy is controversial given the theoretical risk of tumor seeding along the biopsy tract (31,32). However, the incidence of biopsy tract seeding is very low, and needle biopsy tracts do not appear to meaningfully increase local recurrence risk when performed appropriately (31,32). The biopsy site should be carefully planned and positioned within the anticipated surgical incision or resection field for both percutaneous and incisional biopsies to allow en bloc excision of the biopsy tract with the definitive resection specimen (29,33).

Given the rarity and complexity of chest wall sarcomas, multidisciplinary team (MDT) at a chest wall center of excellence is recommended (Figure 1) (3). MDT should include a thoracic surgeon, surgical oncologist, reconstructive/plastic surgeon, radiologist, pathologist, medical oncologist, radiation oncologist, and physical therapist. Additional MDT members may be necessary in cases concerning distant metastases and/or potential involvement of vital structures such as the heart, major vessels, lung, or diaphragm.

Surgical principles and techniques

Surgical resection is an essential component of chest wall sarcoma management (Figure 1). Prognosis is heavily dependent on complete resection with negative margins (R0) (34). In advanced cases, neoadjuvant chemotherapy or radiation can facilitate R0 resection, while adjuvant therapy reduces recurrence risk. In cases where metastatic disease precludes surgery, multimodal therapy (systemic therapy with or without radiation) remains the mainstay of treatment (15,34,35). Molecular profiling can further inform surgical planning by identifying tumors likely to benefit from neoadjuvant therapy versus those in which durable local control depends primarily on complete resection (Table 1) (33,36-40).

The primary surgical goal is a complete pathological resection with negative margins to minimize recurrence while preserving chest wall structure, respiratory mechanics, and functional performance (41). Maintaining skeletal stability prevents lung herniation and paradoxical motion, protecting mediastinal organs. Achieving these objectives requires meticulous planning and multidisciplinary collaboration among thoracic surgeons, plastic surgeons, and oncologists.

Radical resection significantly improves survival and reduces the risk of recurrence (27,34,41-43). R0 resection yielded a 67% 5-year survival rate, compared to 15% for microscopically margin-positive resections (R1) (P<0.02) (35). In a retrospective single institution case series at Mayo Clinic (n=90), 4 cm margins corresponded to a 56% 5-year survival, versus 29% for 2 cm margins (44). Although wider margins improve long-term outcomes, margin width should reflect tumor grade and location (29,33).

While R0 resection is the accepted standard, the ideal margin distance remains debated. Some advocate >2 cm margins for oncologic safety, whereas others argue that 1 cm margins may be acceptable when vital structures are at risk (45). Historically, sarcomas were managed with ≥4 cm margins, mirroring protocols from other anatomic sites (35,46). Recent evidence supports 3 cm margins with resection of adjacent normal ribs to balance oncologic control and functional preservation (15). The Enneking classification defines wide (≥2 cm) and marginal (<2 cm) R0 resections, while R1 resections often warrant re-resection for improved prognosis (47). Ultimately, margin selection should be individualized, guided by tumor biology, anatomy, and multidisciplinary input.

Regardless of margin width, full-thickness resection of involved muscle, bone, and skin may be required for R0 resection. Classically, the entire affected rib or sternum should be removed, including one rib above and below the lesion, to ensure disease-free margins (15). Such resections can produce large defects, risking skeletal instability and impaired respiratory mechanics; thus, reconstruction is critical to restore thoracic integrity (41).

The median number of ribs resected ranges from 2.5 to 3.5, reflecting removal of adjacent uninvolved ribs for oncologic clearance (34,41,46,48). Tumors involving the sternum may require partial, subtotal, or total sternectomy (15,46). Posterior chest wall involvement often necessitates resection of the transverse processes, and involvement of the manubrium or clavicle may allow removal without bony stabilization, using prosthetic grafts and muscle flaps for coverage (45,46,48). Resections extending to the scapula require reconstruction beneath the inferior angle (ribs 5–7) to prevent “scapular sinking” (48).

When chest wall tumors involve vital structures such as the great vessels, heart, or trachea, achieving negative margins can be technically challenging. For example, thoracic outlet tumors with major vascular involvement may require extended exposure, such as partial sternotomy with clavicular resection, to obtain safe vascular control and permit en bloc resection with vascular reconstruction (49). When anatomic constraints preclude wide clearance, palliative resection with postoperative radiotherapy may be considered for local control (45).

While open thoracotomy remains standard, minimally invasive techniques—including VATS and robotic thoracic surgery—offer reduced morbidity and pain (50,51). VATS allows excellent visualization but remains technically demanding; tools such as pneumatic high-speed drills facilitate precise rib resection while minimizing soft-tissue injury (51). The EndoClose device (Medtronic, Minneapolis, MN) enables safe thoracoscopic mesh anchoring for reconstruction (51). Robotic approaches further enhance precision through 3D visualization and wristed instruments, enabling deep or apical tumor resection without rib spreading. Preserving overlying musculature often eliminates the need for prosthetic reconstruction and leads to shorter hospital stays (median 3 days) with excellent functional outcomes (50). In the largest reported series to date, Verm et al. demonstrated that robotic chest wall resection is feasible and increasingly utilized nationally, with excellent perioperative outcomes including low conversion rates, minimal blood loss, and short hospital length of stay (median 3 days in institutional cases) (50). Preservation of extrathoracic muscles frequently obviated the need for prosthetic reconstruction, without evidence of paradoxical chest wall motion or functional deficits on follow-up. Importantly, the robotic platform facilitated precise rib division, reliable hemostasis, and en bloc resection when required, while maintaining acceptable oncologic principles in carefully selected patients. Although tumors involving the sternum, major vascular structures, or exceeding 10 cm were generally excluded, these data support a growing role for robotic techniques in select chest wall tumors to reduce morbidity while preserving functional outcomes.

While minimally invasive approaches such as VATS and robotic-assisted resection can reduce surgical morbidity in carefully selected patients, they are not appropriate for all chest wall tumors (52,53). Large anterior defects, tumors involving the sternum or major vascular structures, and cases anticipated to require rigid reconstruction or complex composite reconstruction generally remain better suited for open approaches to ensure oncologic clearance, chest wall stability, and safe reconstruction (15,54). Similarly, extensive full-thickness resections and defects requiring complex flap coverage often necessitate open exposure to facilitate en bloc resection and coordinated reconstruction (35,55). Therefore, patient selection for minimally invasive chest wall resection should be guided by tumor size, location, extent of involvement, and anticipated reconstructive needs to avoid overgeneralization of these techniques (56,57).

In summary, surgical management of chest wall sarcoma demands a careful balance between oncologic radicality and functional preservation. R0 resection remains essential for cure, though margin width should be tailored to tumor biology and anatomic limitations. When critical structures limit resection, R1 resection with adjuvant radiotherapy may be considered for local control. Full-thickness excision of involved tissues ensures durable local control, while advances in minimally invasive and robotic techniques now enable precise, function-preserving resections without compromising oncologic principles.

Reconstruction strategies

Chest wall defect reconstruction following oncologic resection aims to maintain respiratory mechanics, protect vital intrathoracic organs, stabilize the shoulder girdle, and enhance the patients’ bridge to functional recovery (58,59). Currently, there are no validated predictive models to ascertain risk profile and determine success. The decision to pursue reconstruction depends primarily on the size and location of the defect (Figure 1) (60). In general, anterior defects larger than 5 cm in diameter or those involving four or more ribs warrant reconstruction because of the high risk of lung herniation and respiratory compromise associated with paradoxical motion of the chest wall (58,60). Rigid reconstruction is typically recommended for defects exceeding 4–5 cm, while smaller defects usually do not require reinforcement (61,62). Posterior defects are generally reconstructed only when they are greater than 10 cm, as the scapula and adjacent musculature provide inherent support and stability (60,62). Conversely, large anterolateral defects and complete sternectomies necessitate rigid reconstruction to preserve chest wall mechanics and prevent paradoxical motion (62).

Preoperative planning is essential and includes optimization of nutritional status, cardiopulmonary function, and overall conditioning, given that extensive reconstructions are associated with postoperative ventilatory dysfunction (58). The overarching surgical goal is to restore chest wall stability and re-establish physiologic negative intrathoracic pressure, both of which are crucial for adequate pulmonary expansion (58,60). Failure to reconstruct large defects can result in acute and chronic restrictive respiratory failure. Non-rigid reconstructions have been associated with pulmonary complication rates approaching 36%, whereas rigid reconstruction yields more favorable respiratory mechanics and reduces complications such as lung herniation and scapular entrapment (63). Reconstruction is particularly important following sternectomy, as it prevents chest wall hypomobility and paradoxical motion that may significantly impair respiration (60).

Reconstruction following manubrial resection requires particular attention to restoration of the thoracic inlet and stabilization of the shoulder girdle (60,64). Isolated manubriectomy without clavicular involvement may be managed with rigid anterior reconstruction using titanium plates or mesh anchored to the residual sternum and adjacent ribs, combined with well-vascularized soft-tissue coverage [most commonly pectoralis major (PM) or latissimus dorsi (LD) flaps] to protect mediastinal structures (45). When the manubrium is resected in conjunction with partial clavicular excision, reconstruction should prioritize prevention of shoulder droop and mediastinal instability; selective clavicular fixation to the remaining sternum or first rib using titanium systems may be considered in high-demand patients, although routine bony reconstruction is not universally required (45).

Bilateral claviculectomy presents a distinct functional problem rather than a respiratory one and typically does not require rigid chest wall reconstruction (65). Because chest wall stability and pulmonary mechanics are usually preserved, reconstruction focuses on soft-tissue coverage and protection of underlying vessels and mediastinal contents (61,62). Vascularized muscle flaps (PM, LD, or omentum in contaminated fields) are generally sufficient. While clavicular reconstruction can be considered in select patients to mitigate shoulder girdle collapse or improve upper-extremity biomechanics, many patients tolerate bilateral claviculectomy with acceptable long-term function when robust soft-tissue support is provided.

The choice of reconstructive material depends on the defect’s size, location, and risk of contamination, and options include prosthetic, synthetic, biologic, or composite materials (15,59,63). Among prosthetic techniques, the methyl methacrylate (MMA)/Marlex sandwich provides excellent rigidity and allows restoration of normal thoracic contour. However, MMA is impermeable to fluids, predisposing to infection rates as high as 80%, and can result in chronic pain, rigidity, and deformity; infected prostheses typically require removal. Polytetrafluoroethylene (PTFE) and polypropylene (Prolene or Marlex) meshes are widely used alternatives that provide flexibility and conformability, although they lack sufficient rigidity to maintain chest wall contour. PTFE, in particular, exhibits poor tissue incorporation, leading to seroma formation and infection rates of 10–25%; removal is usually advised 6–8 weeks after infection to allow the development of supportive scar tissue. Titanium mesh and plate systems have gained favor because they combine high strength, low weight, and biocompatibility, while permitting postoperative imaging. Titanium meshes are easily contoured, demonstrate low infection rates, and incorporate well into adjacent tissues. Although mesh fracture has been observed following surgery (median range: nine months), this rarely leads to adverse sequelae, likely because of rapid integration into the chest wall (59-61,63,66).

Biologic reconstruction options have advanced considerably. Porcine-derived acellular cross-linked dermal matrix (PACLIDEM) represents a notable innovation, offering an extracellular scaffold that supports native tissue healing (67). Its use is particularly advantageous in contaminated or high-risk surgical fields, as studies have demonstrated excellent long-term stability and a low incidence of infection, even when used in combination with rigid titanium frameworks. Allografts and autografts have also been employed; cryopreserved sternal allografts from cadaveric donors can achieve favorable cosmetic and functional results, while autologous reconstruction—such as rigid anterior chest wall repair using a double-barrel free fibula flap—provides durable stability with biologic incorporation and minimal long-term infection risk (59-61,63,66).

Additionally, long-term durability and prosthesis-related complications are important considerations in chest wall reconstruction. Reported complication rates vary by material and are influenced by defect size, site, and soft tissue coverage. In series involving MMA prostheses, overall complication rates have been reported in the range of approximately 10% to 20%, with infection as the most common complication and occasional prosthesis displacement (68,69). Synthetic mesh materials, including polypropylene and PTFE, have documented infection rates ranging from approximately 10% to 25%, and the need for implant removal due to infection has been described in a subset of patients (70,71). Rigid metallic implants such as titanium bars or plates generally show favorable long-term strength, but hardware-related complications such as implant failure or loosening have been reported in small proportions of patients, and chronic pain has been described on long-term follow-up (62,72). Fracture or displacement of rigid prosthetic elements has also been described on follow-up imaging (72). These data underscore the importance of balancing rigidity and biocompatibility when selecting prosthetic materials and highlight the role of meticulous coverage and surveillance to mitigate long-term complications.

An equally critical component of chest wall reconstruction is soft-tissue coverage, which is especially important when prosthetic materials are used. Adequate coverage protects implants, reduces infection risk, and obliterates dead space (60,66). Options for soft-tissue reconstruction include local, regional, and free flaps, selected according to defect size, location, and the presence of contamination or prior irradiation. Commonly used regional flaps include the LD, PM, vertical rectus abdominis myocutaneous (VRAM), and cranially pedicled transverse rectus abdominis myocutaneous (TRAM) flaps, each with distinct anatomic advantages.

The LD flap, often referred to as the “workhorse” of chest wall reconstruction, is favored for its large surface area, robust thoracodorsal blood supply, and wide arc of rotation. It can adequately cover most thoracic defects, including primarily the sternal body with limited reach to the manubrium region, and was utilized in 66.3% of patients in one large series of malignant chest wall reconstructions (73). The PM flap is most useful for small or moderate defects in the upper sternum and anterior chest, functioning as an advancement or rotation flap. The VRAM flap is well suited for extensive longitudinal anterior or inferior sternal defects but carries a reported risk of abdominal wall bulging or hernia formation in approximately 13% of cases (66). The cranially pedicled TRAM flap offers broad coverage for large anterolateral thoracic defects and provides durable, well-vascularized soft tissue for these challenging reconstructions. The role of flap coverage following robotically resected chest wall disease is generally limited and highly selective. Because robotic approaches emphasize muscle-sparing access, preservation of overlying soft tissue, and avoidance of rib spreading, most robotic chest wall resections do not require formal flap reconstruction. In these cases, intact musculature provides sufficient soft-tissue coverage, and primary closure or limited prosthetic reinforcement is often adequate (50).

A free flap is indicated when local or regional options are insufficient due to size or volume limitations, prior surgery or radiation, or tension on the flap (58). Advances in microsurgical technique have made free flaps a safe and reliable option for large or complex reconstructions. The anterolateral thigh (ALT) flap, often harvested with the vastus lateralis muscle, has shown excellent outcomes, offering long vascular pedicles, substantial tissue volume, and favorable aesthetic results while avoiding the morbidity of previously irradiated fields (58).

The choice between pedicled and free flaps depends on patient-specific factors, prior treatments, and surgeon expertise. While free-flap reconstruction may be associated with lower complication rates, it generally entails longer operative times (370.2 vs. 232.9 minutes in one series) (58). Regardless of technique, optimal outcomes rely on a multidisciplinary approach. Collaboration between thoracic and plastic surgeons ensures comprehensive planning to meet functional requirements, address anatomic complexity, and minimize postoperative morbidity.

Despite their versatility, each flap option carries important anatomic and treatment-related limitations that must be considered during reconstructive planning (Table 2). Prior non-muscle-sparing thoracotomy or division of the thoracodorsal pedicle represents a contraindication to LD flap harvest, while extensive prior radiation may compromise flap perfusion and wound healing (65,74). The PM flap has limited reach to the lower sternum and xiphoid and may result in functional shoulder morbidity, particularly in active patients. VRAM and TRAM flaps provide substantial tissue volume but are associated with donor-site morbidity, including abdominal wall bulging or hernia, and may be unreliable if internal mammary vessels have been sacrificed (70). Trapezius and serratus anterior flaps are constrained by smaller tissue volume and risk of shoulder dysfunction or scapular winging. Finally, free-flap reconstruction may be limited by poor recipient vessel quality, prior radiation, medical comorbidity, or prolonged operative time tolerance. These constraints underscore the importance of individualized flap selection within a multidisciplinary framework that integrates prior treatments, defect characteristics, and patient functional goals.

AI currently plays an adjunctive but expanding role in chest wall reconstruction planning, primarily through advanced imaging analysis, 3D reconstruction, and patient-specific modeling rather than autonomous decision-making (75). AI-assisted segmentation of CT and MRI datasets enables precise delineation of osseous defects, soft-tissue involvement, and adjacent vital structures, facilitating accurate defect quantification and preoperative planning. When combined with 3D reconstruction and virtual surgical planning, these tools support selection of reconstructive materials, optimization of implant geometry, and anticipation of chest wall biomechanics, particularly for large or complex defects. AI-driven workflows increasingly inform the design of custom 3D-printed titanium implants and prostheses by automating contouring, predicting implant fit, and reducing intraoperative modification and operative time (60,76). In parallel, machine learning-based image analysis has shown promise in estimating postoperative chest wall stability, respiratory mechanics, and reconstruction feasibility by integrating defect size, location, and patient-specific anatomic variables, although these applications remain investigational. At present, AI and 3D mapping function primarily as decision-support tools within multidisciplinary planning rather than as validated predictive models, but ongoing advances in imaging analytics, biomechanical simulation, and outcome prediction suggest a growing future role in personalized chest wall reconstruction (76,77).

Furthermore, MDT discussions facilitate optimal material selection, flap coverage, and restoration of both functional and aesthetic outcomes. Emerging technologies are further expanding reconstructive options. 3D-printed titanium implants, custom-modeled prostheses, and bioprinted scaffolds tailored to patient-specific anatomy offer improved fit, reduced operative time, and enhanced cosmetic results. This has been shown through single-center case series and institutional experiences (15,48,60,64,78). In parallel, advances in regenerative medicine—including stem-cell-seeded biomaterials and vascularized tissue engineering—represent promising future directions for personalized chest wall reconstruction (63,66).

Complications and outcomes

Complications

Surgical morbidity primarily includes surgical site and respiratory complications at rates of 40–77% as indicated by several reports (41,71,79). The size of the resection, reconstruction strategy, and the operation’s impact on pulmonary function each affect the complication rate. A 2021 retrospective cohort study of chest wall resections for sarcomas followed by reconstruction using rigid and non-rigid materials, demonstrated the highest complication rate of 77% (20/26 patients) (41). The reported 90-day mortality rate following massive chest wall resection and reconstruction was 8.5% in a 20-year experience at a single center (80). Surgical site complications include infection, dehiscence, hematoma, and flap complications (partial/complete loss, need for re-operation). The risk of surgical site infection is increased by patient risk factors such as smoking, diabetes, obesity, and prior radiation exposure (71). Wound complications appear to have a dose-response relationship with radiation. Several studies suggest that higher cumulative dose and larger field size worsen tissue healing, with reports that 50 Gy preoperatively is associated with worse healing (81,82).

When considering reconstruction strategy, the evidence comparing biologic and prosthetic mesh complications is variable. A systematic review reports that there are fewer wound infections, mesh explantations, and re-operations with biologic mesh in contaminated fields (83). However, a single-center study shows no difference in overall surgical-site complications or respiratory complications comparing biologic and prosthetics in chest wall reconstruction (84).

Respiratory complications are the most common complication following chest wall resection and include pneumonia, acute respiratory distress syndrome, and atelectasis. A study examining complications after chest wall reconstruction found that respiratory complications occurred more frequently in patients who were older, had smoking history, had lower forced expiratory volume in one second (FEV₁), and had a wider area of skin resected (85). In an effort to reduce complications, similar to other surgical specialties that rely on the “enhanced recovery after surgery” pathways, thoracic surgery has increasingly adopted these pathways, which may include a preoperative appointment for optimization (86,87). Preoperative optimization with smoking cessation, appropriate glucose control, and mobilization to maximize the patient’s pulmonary status can reduce postoperative complications (86,87).

Local and wound-related complications: rigid vs. non-rigid reconstruction

In addition to pulmonary complications, local and wound-related complications are common after chest wall reconstruction and vary by reconstructive strategy (71,85). Wound infection, dehiscence, seroma, and flap necrosis are among the most frequently reported local complications (71,85). Rigid reconstruction constructs, including MMA sandwiches or titanium bars and plates, can provide superior stability for large defects but may be associated with higher rates of hardware exposure or wound breakdown if soft-tissue coverage is inadequate (85). In contrast, non-rigid techniques using synthetic mesh alone may have lower rates of structural complications but may be more prone to mesh infection and herniation in the setting of large full-thickness defects (83,84). Optimal soft-tissue coverage and meticulous closure remain critical to minimizing local complications regardless of the reconstructive material used (71).

The role of palliative surgery

Palliative chest wall surgery may be appropriate in select patients with advanced disease and intractable local symptoms. Indications include severe pain refractory to medical management, uncontrolled wound infection including fungal superinfection, or fungating tumors causing bleeding or odor (66). Extended palliative procedures such as forequarter amputation have been described in select cases of locally advanced chest wall malignancy with reported improvement in functional status (88,89). The primary goals of palliation are symptom relief and improvement in quality of life (QoL), recognizing that complete oncologic resection may not be achievable (90,91). Careful patient selection and multidisciplinary assessment are essential to align surgical intervention with overall goals of care.

Desmoid tumors

Desmoid tumors (aggressive fibromatosis) represent a distinct subgroup of chest wall tumors characterized by local aggressiveness and a high risk of local recurrence despite benign histology (92). Management options include active surveillance for asymptomatic or stable disease, medical therapy with nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, tamoxifen, or low-dose chemotherapy for progressive or symptomatic tumors, and surgical resection for select cases with refractory or rapidly enlarging disease (92). The choice of therapy should be individualized, and contemporary approaches often favor initial non-operative management when feasible given the morbidity associated with resection (92).

Functional outcomes and QoL

Beyond surgical complications, functional outcomes and QoL metrics are critical for patient care following major thoracic surgery such as chest wall resection. Surgical QoL can be captured by outcome metrics such as pain, mobility, patient-perceived function, and patient satisfaction. There have been several studies on QoL following chest wall resection for oncologic thoracic surgery; however, many studies are limited by small sample size (93-96). Liu et al. reported a study of 135 case-matched patients following operable non-small lung cancer with and without chest wall resection, and found that chest wall resection does not significantly reduce overall pulmonary function or QoL and does not significantly affect postoperative chest wall pain (96). Functionally, when comparing the groups with and without chest wall resection, they found that the chest wall resection group did have significantly decreased functional capacity of ventilation and restrictive ventilation defects but had no effect on functional capacity of gas exchange (96). In a smaller QoL study of 23 long-term (>36 months) survivors of chest wall resection, patients reported moderate impairment in several QoL subscales, most notably in the subjective assessment of dyspnea, although its impact on overall QoL was mixed. In this same study, there was a 15% reduction in FEV₁ postoperatively (94). Functionally, after chest wall resection, the FEV₁ decline has been reported to be 12–18% (93,94).

Local recurrence remains a major challenge for chest wall sarcomas despite advances in surgical resection and reconstruction. Recurrences often occur early, many within the first two years and are reported at rates ranging from 20% to 40% (97,98). Local recurrence is associated with poor overall survival (99). Risk factors for local recurrence include positive surgical margins, high histological grade, larger tumor size, deep location, histologic type (undifferentiated pleomorphic sarcoma, high grade fibroblastic sarcomas, high-grade myxofibrosarcoma) (97-99). In a study by McMillan et al. of 192 patients with chest wall sarcomas, 23% had recurrences with a median time to event of 11.6 months for local recurrences and 13.5 months for distant recurrences (97).

Surveillance is a critical component to monitor for local recurrence and metastasis after primary oncologic resection. It is most critical in the first 2–3 years as local recurrences often occur in this timeframe and the ability to intervene is available. Surveillance largely depends on the resection as well as the histological type and grade of the sarcoma. The ESMO guidelines suggest intermediate-/high-grade (G2, G3, G4) sarcomas are followed every 3–4 months in the first 2–3 years, then twice a year up to the fifth year, and once a year after (92). While there is no standardized imaging schedule for chest wall sarcoma follow-up, it is recommended that clinical examinations focus on history with chest X-ray and CT to investigate any new concerns, and MRI to investigate for local recurrence (100). Surveillance and follow-up with oncology teams (ideally, a sarcoma-focused clinic) as well as thoracic surgery teams are necessary to keep patients on the pathway for consistent care and facilitate early detection of recurrence.

Furthermore, objective assessment of postoperative functional outcomes after chest wall resection and reconstruction commonly includes pulmonary function testing, CT-based lung volume evaluation, and patient-reported outcome measures. Pulmonary function testing has been used in clinical series to document changes after resection and reconstruction. In one study, long-term survivors after extensive chest wall resection showed reduced FEV₁ and forced vital capacity (FVC) compared with baseline measurements, and subjective dyspnea scores correlated with QoL more closely than objective lung function parameters (94). CT-based lung volume measurement has been reported as a tool to quantify thoracic cavity and regional lung expansion, allowing anatomic correlation with functional changes following resection (101). Patient-reported outcome measures have been obtained using validated instruments such as the Short Form-36 QoL questionnaire and dyspnea scales. Additionally, studies examining long-term pulmonary function after chest wall resection have noted significant decreases in FEV₁ and FVC, particularly with larger resections, reinforcing the importance of objective testing in follow-up (102). Incorporation of these tools into routine postoperative evaluation may support objective benchmarking and patient-centered outcome assessment after complex chest wall reconstruction.

Multimodal therapy

Neoadjuvant therapy plays an important role in high-risk, radiosensitive sarcomas when there is concern for positive margins or inability to achieve an R0 resection, with the goal of reducing local recurrence risk. Radiation sensitivity varies by histologic subtype, with some sarcomas demonstrating greater radiosensitivity than others. Among sarcomas, myxoid liposarcoma (MLPS), Ewing sarcoma, angiosarcoma, and chondrosarcoma are considered radiosensitive (103).

The role of neoadjuvant therapy in chest wall sarcomas is histology dependent. In osteosarcoma and Ewing sarcoma family tumors, including primitive neuroectodermal tumor, neoadjuvant multi-agent chemotherapy is standard of care to treat micrometastatic disease and facilitate margin-negative resection, followed by definitive surgery with or without radiotherapy (92). In contrast, undifferentiated pleomorphic sarcoma shows variable chemosensitivity, and neoadjuvant therapy is used selectively for large, high-grade, or borderline resectable tumors, while upfront surgery remains appropriate for clearly resectable disease (92). In patients with metastatic disease at presentation, systemic therapy is generally favored prior to surgery when there is widespread metastatic burden or a need for downstaging. Upfront resection of the primary chest wall tumor may be considered in carefully selected patients with limited metastatic disease, good performance status, and the ability to achieve complete resection, particularly when local symptoms compromise QoL. Multidisciplinary evaluation is essential to guide treatment sequencing (92).

The decision between neoadjuvant and adjuvant radiation therapy is particularly important when reconstruction is anticipated, given concerns about postoperative radiation to flap-based reconstructions (92). In a single-institution study spanning over 20 years and including 65 patients with chest wall sarcoma, the addition of chemotherapy, radiation therapy, or a combination of both in addition to surgery was associated with improved 5- and 10-year disease-free survival (DFS) (9). However, neoadjuvant and adjuvant therapies, including chemotherapy and radiotherapy, are still not routinely used in patients with chest wall sarcoma except in cases of unresectable, metastatic, or recurrent disease.

Systemic immunotherapy has demonstrated promise for improving long-term survival in some malignancies, such as melanoma and lymphoma; however, its benefit in sarcoma therapy has not been proven to be as effective (104,105). Immunotherapy utilizing targets such as anti-angiogenesis therapy and inhibitors targeting cyclin-dependent kinase 4/6, poly-ADP-ribose polymerase, insulin-like growth factor-1 receptor, and mammalian target of rapamycin pathways modulators have shown some success in sarcoma subtypes (106,107). However, most sarcomas are considered “immune cold” with limited response (106,107). Ongoing research into additional strategies to combine pathways may improve response rates, and further trials are needed to determine whether patients with unresectable or advanced chest wall sarcoma may benefit.

Special considerations

Notable considerations in sarcoma surgery include the management of positive margins and the selection of re-resection candidates. If there are positive margins, re-resection should be pursued if it is technically feasible from a surgical perspective as well as from the standpoint of patient survival and QoL benefit. In patients who have not received prior radiation, adjuvant radiation treatment or repeat radiation therapy can also be a consideration. The ideal candidate for surgical treatment of a local recurrence would be an isolated recurrence of the chest wall with no distant metastasis and the ability to achieve an additional R0 resection (90). Flap coverage may limit re-resection based on vascular compromise and donor site limitations. In large defects due to flap coverage, vacuum-assisted closure therapy as a bridge to re-reconstruction is a consideration (90). In these cases, a multidisciplinary approach involving thoracic and plastic surgery teams can aid in complex chest wall closure.

In a retrospective review of patients with recurrence requiring re-resection, radical resection was achieved in 80% of the primary chest wall sarcomas and 64% of the recurrences, demonstrating that aggressive surgery remains an option for local control. Median follow-up was 73 months, showing DFS after surgery for recurrences was 18 months versus 36 months for primary sarcomas, with 5-year survival rates of 50% and 63%, respectively (91). In a similar retrospective single-center study of 38 patients reporting R0 resection in 95% soft tissue and 94% of bone chest wall sarcomas, many patients still experienced recurrences, including 40% in the soft tissue group, emphasizing the high rate of local recurrence and need for additional adjuvant therapies (108).

Future directions

Despite advances in multidisciplinary care, local recurrence rates for chest wall sarcomas remain high, reported at 20–40% (97,98). Additional work is needed to optimize the management of recurrent disease. Surgical resection remains the cornerstone of treatment with the goal of achieving an R0 margin, while adjuvant chemotherapy, radiation therapy, and emerging immunotherapeutic approaches are selectively employed to reduce recurrence risk in high-risk sarcomas. Continued innovation in chest wall reconstruction is also critically needed, particularly for patients undergoing re-resection after recurrence.

Advances in AI, 3D imaging, and patient-specific modeling may create new opportunities to improve prosthetic design, durability, and functional outcomes following complex chest wall reconstruction. AI has significant potential to transform chest wall reconstruction by enabling data-driven, personalized surgical planning and reconstruction strategies as we have outlined above. Machine learning models can further integrate imaging, oncologic, and patient-specific data to optimize resection margins for more precise R0 resections, predict reconstructive needs and assist in the selection of prosthetic materials based on the tensile strengths and forces of the proposed models. In the future, AI predictive analytics may improve outcomes, reduce complications, and potentially expand its role in the field of complex oncologic chest wall surgery.

Multi-institutional prospective registries are needed to better characterize the long-term outcomes of these rare tumors. Additionally, clinical trials looking at immunotherapy and neoadjuvant strategies’ roles in converting immunologically “cold” sarcomas into more immune-responsive or “hot” targets must be further studied in this patient population.

Limitations

The limitations of this clinical practice review include its reliance on predominantly retrospective studies, potential publication bias, and the absence of systematic search criteria and a formal appraisal process. As such, this review has the potential for selection bias and incomplete representation of the available evidence. Nevertheless, the authors selected from a broad range of reviews, clinical trials, single-center studies, and case series to provide a comprehensive clinical practice review of chest wall sarcomas.

Conclusions

Chest wall sarcomas are rare and aggressive tumors that require a coordinated and individualized treatment approach based on the histologic subtype. Herein, we present a clinical practice review summarizing the diagnosis, assessment, treatment strategies, prognosis, and outcomes of chest wall sarcomas. The decision-making flowchart presented in this article may serve as a reference for clinicians (Figure 1). Management at specialty surgical centers with multidisciplinary tumor board input from pathology, radiology, oncology, and surgical teams including thoracic, cardiac, orthopedic, and plastic surgery can aid in decision-making for these rare tumors. After resection, the reconstruction of the chest wall remains a challenge and involves extensive coordination between multiple surgical teams to restore function and respiratory mechanics.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-62/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-62/coif). C.N.E. received speaker honoraria from AtriCure and Ethicon (Johnson & Johnson) and consulting fees from AtriCure, Ethicon (Johnson & Johnson), and Cook Medical (expired). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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