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      Sternal resection and reconstruction for metastasis due to breast cancer: the Marlex sandwich technique and implantation of a pedicled latissimus dorsi musculocutaneous flap

      case-report

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          Abstract

          Background

          The treatment of hemotogenous solitary sternal metastases by breast cancer remains a controversial issue. Sternal resection for select patients might provide good long-term local control.

          Case presentation

          A 63-year-old woman was admitted to our hospital with a mass at the sternum and right second to third costochondral cartilage. She had undergone bilateral mastectomy for breast cancer 13 years earlier. A percutaneous biopsy was performed, and the mass was diagnosed as solitary metastasis due to breast cancer. She received two courses of weekly paclitaxel and bevacizumab, and computed tomography (CT) revealed shrinking of the mass in the sternum. We performed surgical resection with curative intent for a multimodality approach. Parasternectomy and removal of the right second and third costochondral cartilage was performed. A prosthesis was created to fill the defect by sandwiching molded methylmethacrylate between polypropylene mesh. The prosthesis was fixed to the cut ends of the costochondral cartilage and the residual sternum. Finally, a harvested latissimus dorsi myoctaneous flap was transpositioned to cover the chest midline wound. Negative surgical margins at the stump of the sternum and costochondral cartilage were revealed.

          Conclusion

          Parasternal resection and reconstruction by the Marlex sandwich technique and implantation of a pedicled latissimus dorsi myocutaneous flap for metastasis due to breast cancer was safely performed.

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          Most cited references13

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          Chest wall recurrence after mastectomy does not always portend a dismal outcome.

          Chest wall recurrence (CWR) after mastectomy often forecasts a grim prognosis. Predictors of outcome after CWR, however, are not clear. From 1988 to 1998, 130 patients with isolated CWRs were seen at our center. Clinicopathologic factors were studied by univariate and multivariate analyses for distant metastasis-free survival after CWR. The median post-CWR follow-up was 37 months. Initial nodal status was the strongest predictor of outcome by univariate analysis. Other significant factors included initial T4 disease, primary lymphovascular invasion, treatment of the primary tumor with neoadjuvant therapy or radiation, time to CWR >24 months, and treatment for CWR (surgery, radiation, or multimodality therapy). Multivariate analysis also found initial nodal status to have the greatest effect; time to CWR and use of radiation for CWR were also independent predictors. Three groups of patients were identified. Low risk was defined by initial node-negative disease, time to CWR >24 months, and radiation for CWR; intermediate risk had one or two favorable features; and high risk had none. The median distant metastasis-free survival after CWR was significantly different among these groups (P <.0001). Patients with CWR are a heterogeneous population. Patients with initial node-negative disease who develop CWR after 24 months have an optimistic prognosis, especially if they are treated with radiation.
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            Predictors of survival in malignant tumors of the sternum.

            From 1930 to 1994, 54 patients with primary malignant tumors of the sternum were seen. Fifty patients were first seen with a mass, and one half of them also had pain in the sternal region. Two patients had no symptoms at presentation. Among 39 solid tumors were 26 chondrosarcomas, 10 osteosarcomas, 1 fibrosarcoma, 1 angiosarcoma, and 1 malignant fibrous histiocytoma. Of these, 25 were low-grade and 14 were high-grade tumors. Among 15 small cell tumors were 8 plasmacytomas, 6 malignant lymphomas, and 1 Ewing's sarcoma. Partial or subtotal sternectomy was done in 37 patients and total sternectomy in 3. Of the remaining 14 patients, 3 had local excision; 10 had external radiation or chemotherapy without operation, or both; and 1 had no treatment. All but one patient treated by wide resection (N = 40) had some form of skeletal reconstruction of the chest wall defect. Thirty-one (78%) underwent repair with Marlex mesh, and in 25 this was combined with methyl methacrylate. The skin edges were closed per primum in 32 patients; 8 required muscle, omentum, or skin flaps. Resection in chondrosarcomas yielded a 5-year survival (Kaplan-Meier) of 80% (median follow-up, 17 years). The 5-year survival in osteosarcomas was 14%. Resection was curative in 64% of low-grade sarcomas but in only 7% of high-grade sarcomas. In small cell tumors, resection and radiation were helpful for local control; all failures were a result of distant metastases. We conclude that primary sarcomas of the sternum though uncommon are potentially curable by wide surgical excision. With rigid prostheses to repair the skeletal defects, the surgical complication rates are low. Overall survival after complete surgical resection is related to tumor histologic type and grade.
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              Results of surgical treatment for sternal metastasis of breast cancer.

              Nine patients with solitary sternal metastasis of breast carcinoma were treated aggressively, with partial (n = 8) or total (n = 1) resection of the sternum. Parasternal and mediastinal lymph node dissection also was performed concomitantly for every patient. Chest wall defects were reconstructed with acrylic resin plate (n = 3) or rectus abdominus myocutaneous flap (n = 6). All patients received chemoendocrine therapy postoperatively. The median survival of these nine patients was 30 months. The prognosis of the patients (n = 4) with the mediastinal or parasternal lymph node metastasis were poor and all of them died of second relapse within 30 months. The prognosis of those (n = 5) without the lymph node metastasis, however, was quite favorable; three survived more than 6 years. These results suggest that sternectomy should be indicated for the solitary sternal metastasis when no evidence of systemic spread is noted since it can improve the quality of life and occasionally may result in long-term survival.
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                Author and article information

                Contributors
                motono@kanazawa-med.ac.jp
                shimaken@kanazawa-med.ac.jp
                torukama@lily.ocn.ne.jp
                hidetaka@kanazawa-med.ac.jp
                Journal
                J Cardiothorac Surg
                J Cardiothorac Surg
                Journal of Cardiothoracic Surgery
                BioMed Central (London )
                1749-8090
                18 April 2019
                18 April 2019
                2019
                : 14
                : 79
                Affiliations
                [1 ]ISNI 0000 0001 0265 5359, GRID grid.411998.c, Department of Thoracic Surgery, , Kanazawa Medical University, ; 1-1 Daigaku, Uchinada, Ishikawa 920-0293 Japan
                [2 ]ISNI 0000 0001 0265 5359, GRID grid.411998.c, Department of Plastic and Reconstructive Surgery, , Kanazawa Medical University, ; 1-1 Daigaku, Uchinada, Ishikawa 920-0293 Japan
                [3 ]GRID grid.440095.c, Department of Breast Surgery, , Keiju Medical Center, ; 64 Tomioka, Nanao, Ishikawa 926-8605 Japan
                Author information
                http://orcid.org/0000-0001-5407-5479
                Article
                905
                10.1186/s13019-019-0905-z
                6471832
                30999925
                6a8b4377-3a41-43fa-a974-3e81ac96a732
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 30 January 2019
                : 3 April 2019
                Categories
                Case Report
                Custom metadata
                © The Author(s) 2019

                Surgery
                sternal resection,metastasis,breast cancer,reconstruction
                Surgery
                sternal resection, metastasis, breast cancer, reconstruction

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