Being told that a lung cancer has grown into the chest wall or the ribs is not the same as being told it cannot be removed. Published surgical series are consistent: survival after resection is determined by whether the tumour can be taken out completely and by the state of the lymph nodes — and much less by how deeply it has grown into the chest wall. Where ribs must be removed, they are taken with the lung as one specimen and the resulting gap is reconstructed. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), performs chest wall resection and reconstruction for lung cancer, and provides second opinions at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days. Self-referrals welcome.
Last reviewed: August 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Chest wall involvement makes the operation larger and more demanding. It does not, by itself, place a cancer beyond surgery. That judgement rests on the nodes and on whether everything can be removed.
Rib resection is not the default. Where the tumour is adherent but has not breached the lining of the chest wall, dissecting behind it can leave the ribs intact. The plane is often tested at the operation itself.
Where reconstruction is needed, it is moulded during the operation to the shape of that patient’s own rib cage and stitched to the surrounding ribs — not an off-the-shelf implant bolted into the chest.
No. This is the single most common misunderstanding patients arrive with, and it matters because it changes what people believe is available to them. Chest wall involvement makes an operation bigger, longer and more demanding. It is a statement about the difficulty of the surgery, not about whether the cancer can be cured.
What decides whether surgery is worth doing is different, and it is set out in the section below: whether the whole tumour can be removed with clear margins, and what the lymph nodes in the centre of the chest are doing. Those are the two questions. Where they can be answered favourably, the fact that some ribs must come out is a technical problem with a technical solution — and one that thoracic surgeons deal with as routine practice. A second opinion is a reasonable step if you have been told otherwise.
Two things, and neither of them is the depth of the invasion. The first is whether the tumour can be removed completely, with clear margins. The second is the state of the lymph nodes in the centre of the chest.
A large series from Memorial Sloan Kettering put it directly: survival after resection of lung cancer involving the chest wall is significantly related to the completeness of resection and to the presence of nodal metastases, and much less so to the degree of chest wall invasion [1].
The numbers behind that carry the same message. In one series, five-year survival after complete resection was 24%, against 13% where resection was incomplete; nodal involvement, depth of invasion and age emerged as the independent prognostic factors, and the authors concluded explicitly that N2 nodal disease should not be considered a contraindication to surgery [2]. The Memorial Sloan Kettering group reported 15% five-year survival in patients with N2 disease whose resection was complete, and argued that complete resection should still be attempted in that group [1]. A more recent analysis of patients undergoing R0 resection confirmed pathological nodal status and pathological stage as reproducible determinants of disease-free and overall survival [3].
Read together, those findings do something useful for a patient facing this decision. They move the question away from how far has it grown into my chest wall — which is what the scan report emphasises and what frightens people — and towards can it all be removed, and what are the nodes doing. Those are the questions worth asking the team.
Lung tissue itself has no pain fibres. The lining of the chest wall and the structures between the ribs do. That anatomical fact is why a cancer sitting at the edge of the lung can be entirely painless until it reaches the chest wall — and why significant, localised pain at the side of the chest, at the site of the tumour, is a meaningful sign that the cancer has extended into the chest wall.
It is worth being precise about how far that sign goes. It is specific rather than sensitive: its presence points strongly towards invasion, but its absence does not rule invasion out. Plenty of patients with chest wall involvement have no pain at all. A 2025 imaging study of chest wall infiltration found chest pain significantly more frequent among patients whose tumours had invaded the chest wall [4], which is the finding most surgeons would recognise from clinic.
If you have a lung cancer diagnosis and new or worsening pain that stays fixed to one place on the chest wall — rather than moving, or varying with position — it is worth raising that specifically with your team, and asking whether the chest wall has been assessed. It changes the operation that is planned, and occasionally it changes whether an operation is offered at all.
Each test answers a slightly different question, and none of them settles it on its own. That is the honest position, and it has a direct consequence for anyone who has been told an operation is impossible on the strength of a scan.
The main test, examined for specific features: erosion of the rib, thinning of the hard outer layer of the bone, and reaction in the bone adjacent to the tumour. It is better at answering whether the bone is destroyed than whether the tumour has crossed the lining. Reported sensitivity for chest wall invasion ranges from roughly 42% to 68% [5], and one long-standing study reported sensitivity of 38% and specificity of 40% [6].
Used selectively rather than routinely. It can add detail about soft tissue and about involvement at the top of the chest, and it is occasionally requested where the CT is equivocal and the answer would change the plan.
Can show whether the lung glides over the chest wall during breathing. Some published series report high accuracy for it [7], but it is markedly operator-dependent, it is not part of routine practice in the UK, and its central limitation is conceptual: loss of gliding shows that the tumour is attached, and attachment is not the same as invasion. A tumour can be stuck to the chest wall without having grown through it — and that distinction is precisely the one that decides whether ribs need to be removed.
Arguably more important than the chest wall assessment itself, because nodal status is one of the two factors that determines outcome. PET-CT, and where indicated EBUS sampling of the mediastinal nodes, are done before any decision about surgery is finalised.
Which leaves the definitive answer where it usually sits: at the operation. The extrapleural plane behind the tumour either opens or it does not. That is a finding made under direct vision, with the tumour in front of the surgeon. It is the reason an inoperable verdict reached from imaging alone is a verdict reached early — and the reason a second surgical opinion is a reasonable thing to seek.
No — and it is worth saying clearly that removing ribs is not the default assumption. There are two possibilities, and which one applies is decided by the anatomy.
Where the tumour is stuck to the chest wall but has not breached the parietal pleura — the lining on the inside of the ribs — it is often possible to work behind the tumour, lifting it away together with that lining. The ribs stay where they are. There is no defect and no reconstruction. For patients whose tumour is adherent rather than invasive, this is the operation.
Where the tumour is genuinely fixed to the rib and to the intercostal muscles between the ribs, those structures are removed as part of the operation, along with an uninvolved rib above and below. This is what guarantees a margin of normal tissue around the tumour.
The decision between the two is frequently not final until the operation. The surgeon tests the plane: if it opens cleanly and there is no breach through the lining into the bone, the ribs are spared. If the tumour will not separate, the chest wall comes out with it. Being told in advance that ribs will definitely be removed — or definitely not — is over-promising in either direction. What can be promised is that the smaller operation is taken wherever the anatomy allows it, and that completeness is never traded for a smaller operation.
Because the involved ribs and the affected lobe are removed as a single specimen, still joined — an en bloc resection, usually combined with a lobectomy. It is not simply a matter of convenience or sequence. There are two reasons, and both bear directly on whether the operation succeeds.
The first is that separating the tumour from the chest wall during the operation means cutting somewhere close to it — and potentially through it. Removing lung and chest wall together avoids ever dividing that plane.
The second is about what happens afterwards, in the laboratory. When the specimen arrives in one piece, the pathologist can assess the margins in continuity — the relationship between the tumour and the rib is preserved exactly as it was in the chest. When lung and chest wall arrive as separate pieces, that relationship has to be inferred. The completeness of the resection is the single strongest determinant of outcome in this operation, and an en bloc specimen is what allows it to be measured rather than assumed.
Why healthy ribs are taken too. Patients often ask why an uninvolved rib above and below is removed as well. The answer is the margin. Cancer spreads along the tissue planes between and around the ribs in ways that cannot be seen with the naked eye at operation. Taking one clear rib either side is how the surgeon guarantees the tumour has been passed. It is a deliberate over-resection, and it is the reason the operation works.
No. It depends on how big the defect is and — just as importantly — where it is. The chest wall is not equally supported all the way round, and reconstruction is only needed where that support has been lost.
Defects on the side and front of the chest generally need rigid reconstruction. Without it, that part of the chest wall moves in the wrong direction during breathing — sucking in as the rest of the chest expands — and the lung can bulge out through the gap. Both are uncomfortable and both interfere with breathing. The published consensus is that defects larger than about 5 cm, or involving more than four ribs, need skeletal reconstruction [8].
Defects at the back, lying under the shoulder blade, often need no rigid reconstruction at all. The shoulder blade and the thick muscle layer over it provide the support that would otherwise have to be manufactured. Some quite large defects in that position are left unreconstructed for exactly this reason [8].
The recognised exception. A defect that extends below the fourth rib at the back is reconstructed even when it is small, because the tip of the shoulder blade can otherwise catch in the gap as the arm moves. That is an uncomfortable and avoidable problem, and preventing it is a reason to reconstruct in its own right [8].
Bone cement, set between two layers of mesh. Methyl methacrylate — the same material used to fix joint replacements into bone — is prepared during the operation and set between two layers of surgical mesh, forming a firm panel. It is moulded, while it is still soft, to the shape of that patient’s own rib cage as it sits in front of the surgeon. Once set, it is stitched to the surrounding ribs at the edges of the defect, so that it becomes part of the chest wall rather than an object resting against it.
It is then covered by the patient’s own muscle and by the tissue beneath the skin, so nothing is visible or palpable through the skin afterwards. This is a made-to-measure reconstruction produced on the day from the patient’s own anatomy — not an off-the-shelf implant selected from a range of sizes.
Titanium plates have a proper place in chest surgery — they are used to fix broken ribs, where continuous bone runs underneath and the plate sits on top of it, sharing the load with the rib. A chest wall resection is a different mechanical problem. There is no bone beneath the plate: it spans an empty gap, it is the only thing bridging that gap, and every breath loads it. In Dr Okiror’s experience that is where titanium fails — the plates fracture, and a fractured plate then has to be taken out at a second operation. He moved away from them for that reason.
Used mainly for reconstructing the diaphragm, and for smaller chest wall defects where the gap needs closing but no rigid support is required. These are soft rather than structural, and the choice between soft and rigid reconstruction follows the same logic as the decision to reconstruct at all — size and location.
Occasionally, where a very large defect leaves insufficient tissue to cover the reconstruction, muscle is moved from elsewhere on the chest or back to provide that cover, working jointly with a plastic surgeon. In lung cancer resections this is very rare indeed. The great majority of chest wall reconstructions after lung cancer surgery are covered with the patient’s own local muscle without any such procedure.
A full-thickness chest wall resection with en bloc lobectomy is performed through an open incision, not by keyhole or robotic access. Patients who have read about minimally invasive surgery sometimes hear this as a step backwards. It is not.
The access is chosen to fit the operation. Most lung cancer resections are done robotically because that access suits them — it gives better visualisation of the mediastinum for lymph node dissection and a faster recovery for the patient. Chest wall resection is done openly for the same kind of reason: it allows the lung and the chest wall to be removed together, in one specimen, under direct vision, with the margins controlled. Matching the access to the disease is the same judgement in both directions. A robotic operation that compromised the completeness of the resection would be the wrong operation, and completeness is the factor that determines the outcome here.
Frequently, though not always. Many patients with chest wall involvement now receive chemotherapy combined with immunotherapy before surgery, with the operation following a restaging scan. Others proceed directly to surgery. Which sequence applies depends on the stage, the nodal status, and the molecular profile of the tumour, and the decision is made at a multidisciplinary team meeting rather than by any single clinician.
If treatment before surgery has been recommended to you, the sequence, the scans, and what the restaging appointment involves are set out in detail on the surgery after chemotherapy and immunotherapy page. For the wider picture of Stage III disease and how the treatment decisions are made, see locally advanced lung cancer.
It is a bigger operation than a standard lung resection and the recovery reflects that. The hospital stay is longer than for a keyhole lobectomy, and the return to full activity is measured in weeks to a few months rather than weeks. Pain control is planned deliberately from the outset, because an open chest wall operation is painful and because breathing well afterwards depends on being comfortable enough to do it. Approaches to pain relief after thoracic surgery are discussed before the operation, not improvised after it.
Some patients have lasting altered sensation or nerve pain in the area of the chest wall that was removed, because the nerves running under those ribs are taken with them. This is worth knowing in advance rather than discovering afterwards, and it is treatable.
The reconstruction itself is permanent and needs no maintenance. It does not set off airport scanners, it does not restrict movement once healed, and it is not visible under the skin. On subsequent CT scans it is clearly identifiable, which is worth knowing if you have scans reported elsewhere. General guidance on the weeks after chest surgery is set out on the recovery after lung surgery page.
Judgements about resectability in tumours involving the chest wall vary between centres, and they vary for understandable reasons: they depend on the imaging, on how the nodal staging is interpreted, on the patient’s fitness, and on the surgical experience available locally. A tumour considered unresectable in one unit may be considered operable in another. That is not a criticism of anyone — it is a description of how a difficult judgement behaves.
Circumstances in which a further surgical opinion is reasonable:
Appointments are typically available within 2–3 working days at London Bridge Hospital or The Lister Hospital Chelsea, with virtual consultations often available sooner for patients travelling from outside London. Bring your CT, PET-CT, any MRI, the histology report, and the MDT outcome if you have it. Dr Okiror reviews the imaging personally and gives a clear view at the first appointment — including, where that is the answer, that the original recommendation was right. Lung cancer second opinion service →
Questions most commonly asked by patients and families told that a lung cancer involves the chest wall or the ribs.
Request a Second Opinion →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Second opinion appointments at London Bridge Hospital and The Lister Hospital Chelsea within 2–3 days, with virtual consultations often available sooner. Dr Okiror reviews the imaging personally and gives a clear view at the first appointment.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas’ Hospital #1 UK · Guy’s Hospital #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
Deposits in the breastbone or ribs from breast cancer — when removal is considered and who decides
Locally Advanced Lung CancerStage III disease, nodal staging, and how the treatment sequence is decided — the wider context for chest wall involvement. Surgery After ChemoimmunotherapyThe treatment journey where chemotherapy and immunotherapy come before the operation — scans, restaging, and what to expect. Lung Cancer Second OpinionIndependent review of imaging, staging and the surgical recommendation — within 2–3 days, before any commitment. LobectomyThe lung resection performed alongside chest wall removal — what a lobectomy involves and why the lymph node dissection matters. Surgery After RadiotherapyWhere radiotherapy has not fully worked and surgery remains the radical option — including for chest wall disease. Rare Lung and Chest TumoursTumours other than lung cancer that may require chest wall resection — including solitary fibrous tumour of the pleura. Rib Fracture FixationWhere titanium plates are the right answer — fixing broken ribs, with continuous bone beneath the plate. Recovery After Lung SurgeryThe weeks after chest surgery — breathing, activity, driving, and returning to normal life.