Reconstruction technique applicable in the surgery of sternal primary malignancy
Samil Gunay1 (samilgunay at yahoo dot com) #, Aydemir Kocarslan2, Irfan Eser1, M Salih Aydin2
1 Harran University Medical Faculty Department of Thoracic Surgery, Turkey. 2 Harran University Medical Faculty Department of Cardiovascular Surgery, Turkey
# : corresponding author
DOI
//dx.doi.org/10.13070/rs.en.2.1466
Date
2015-11-07
Cite as
Research 2015;2:1466
License
Abstract

Objective: Chondrosarcoma is the most frequent type of tumour in the sternum. Its treatments are resection and reconstruction. Myocutaneous flaps, synthetic, soft and metal, hard mesh are used for reconstruction. Here, we present a technique that merges all techniques in one patient. Method: A 50-year old female was admitted to our department for surgery. Computed tomography scan revealed a 5x5x4-cm mass on the corpus sternum. The patient was proposed for excisional surgery of the sternal mass. Titanium mesh, dual mesh and pectoral muscle mesh reconstructions were implemented after the sternum resection using a new method for this 50-year old female patient diagnosed with sternal chondrosarcoma. Result: No recurrence of sternal chondrosarcoma, infection, sterna dehiscence, rejection or dyspnea occurred after surgery, with a follow-up of 12 months. Pathological examination showed a chondrosarcoma. Conclusion: This new method can be used readily and easily in the surgery of sternal resection and reconstruction.

Introduction

The sternum is a 17 cm long organ that forms the front part of the ribcage. It protects the mediastinum and contributes to respiration [1]. Sternum tumours are quite rare. They form only 0.5% of all bone tumours. The most frequent of these is chondrosarcoma (CS). Chondrosarcoma arises from the medullar part of the bone and destroys the cortex [2]. A hard and pimple-like bulk is determined on examination and computed tomography (CT) scan is used for determining the anatomic situation. Magnetic resonance (MR) is suggested in cases where there is a question of invasion of the pericardium, heart or major vessels [3]. This must be carried out with needle or incisional biopsy in the first stage for histopathologic sampling [4]. Treatment of patients diagnosed with CS is always compelling. It requires curative treatment and radical resection to prevent relapse, and an optimum reconstruction (RC) for healing the defect and preventing complications that may occur [4]. If the defect is smaller than 5cm in RC, then only muscular flaps can be used [5]. If the defect is larger than 5cm, then there are RC options such as myocutaneous flaps (e.g., pectoralis major, serratus anterior and omentum), synthetic soft graft (e.g., prolene mesh, polytetrafluoroethylene mesh and marlex mesh) or metal, hard mesh (e.g., titanium and methyl methacrylate). In pertinent RC surgery, good protection of intrathoracic and mediastinal organs, prevention of paradoxical respiration, protection from infection, keeping dead space minimal and easy practicability of use are very important [4, 6].

Reconstruction technique applicable in the surgery of sternal primary malignancy  figure 1
Figure 1. A: Lateral view sternum mass after skin incision. B: Chest tomography view of the corpus sternum mass

We implemented dual mesh, titanium mesh and pectoralis major mesh reconstruction successfully in our patient with a diagnosis of primary sternal CS, with whom we performed subtotal sternal resection. We therefore wanted to share this experience.

Case

In the examination of a 50 year-old female patient with swelling and sensitivity on her chest, a hard pimple-like painful bulk of 4x4x5 cm was palpated on the front side of her sternum (Figure 1A). Her other examinations were normal. It was determined that this swelling was present for 3 years, grew continually and ached for the last month. Her blood tests were normal. A protruded opacity on the sternum face was observed in chest radiography. There was a lobulated contour contrast 5x5x4 cm bulk, which destroyed the sternum frontal cortex in CT (Figure 1B). An incisional biopsy was carried out on this bulk under local anaesthesia. Upon notification of the pathological result as CS, a total bulk excision was implemented on the patient.

Reconstruction technique applicable in the surgery of sternal primary malignancy  figure 2
Figure 2. A: Rib resection for sternum resection approximately 3 cm to mass. B: Sternum resection ended and substernal tissue viewed. C: Sternal mass macroscopic view after surgery

A standard sternotomy skin incision was performed. The anterior sternal fascia was incised from the middle line, reaching to the sternum cortex. The connections of pectoral and serratus anterior muscles to the sternum and to the right and left 3rd, 4th, and 5th costals were freed (Figure 2A). The bulk was dissected from the skin and subcutaneous tissues through sharp and obtuse dissection. Crackling costals were incised from the costal-control part while protecting the underlying parietal pleura. The sternum subsection was separated from the pericardium with obtuse dissection. Three cm of clean tissue remained in the proximal and distal part of the bulk and it was incised with the help of a sternum Gigli wire and the bulk was totally excised (Figure 2B-2C). The periosts propping up the right and left 3rd, 4th and 5th costals were peeled for mounting the legs of titanium mesh and minimizing pain (Figure 3A). The sternal defect was ascertained and the sizes of dual mesh were measured. The slippery underside of the dual mesh was placed in a way to be in the mediastinum. Mesh sternum was used with 0 number prolene to the left and right of the 3rd, 4th and 5th bone costals. Titanium bars were cut to proper sizes and fixed to the previously fastened titanium legs (Figure 3B). Both pectoral muscle flaps were hardened and sutured to each other on the anterior thoracic wall in a way that the veins were protected and all mesh covered. We received permission to document this patient.

Reconstruction technique applicable in the surgery of sternal primary malignancy  figure 3
Figure 3. A: Titanium mesh bridge pillar applied to bone rib. B: Titanium and Dual mesh reconstruction finished. C: Post-op AP chest radiography after 12 months
Discussion

While sternum tumours are quite rare, they are found most frequently in CS.2 If CT is necessary for the diagnosis, then MR is needed [3]. Incisional biopsy should certainly be carried out on the bulk in a patient with a CS provisional diagnosis [3]. While the curative treatment for CS is surgical, the tumour should be removed totally and the tumour margin should be at least 3 cm [3]. Our patient was evaluated as having pain and bulk in the sternum, was CT tested, and an incisional biopsy was carried out for histopathology. The surgical limits were excised in a way to have 3 cm in total.

He et al. laid stress on the RC method to be simple and easy to use, offer good protection of intrathoracic and mediastinal organs after surgery, prevent paradoxical respiration, protect from infection and keep dead spaces minimal [7]. For this purpose, we also deemed suitable the implementation of triple RC surgery using titanium, dual mesh and pectoral muscle flap.

Hiraiet al. emphasized that the materials used in RC surgery should be hard, not cause adhesion in soft tissues, and be natural [8]. From our searches, a material could not be found that met these three properties. Therefore, we used dual mesh for the subgrade, which is non-stick and does not damage mediastinal tissues, hard titanium mesh for ensuring stabilization of the breast wall, and pectoral muscle flap in the top layer to prevent tissue reactions and provide a supportive tissue. There were no complications in the respiratory functions of the patient and we obtained exceptional results cosmetically as well. At twelve months follow-up of our case, no sternal chondrosarcoma, infection, sterna dehiscence, rejection or dyspnea had occurred (Figure 3C).

Conclusion

With the method we adopted, chest and mediastinal organs were well protected and no complications were experienced in pulmonary function. This is a new method that can be easily and readily used in RC surgery.

References
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