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Ann Thorac Surg 1995;60:1353-1358
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Resection of Sternal Tumors: Extent, Reconstruction, and Survival

Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Resection of sternal tumors may be tailored to the patient and the location of the malignancy.

Methods. We reviewed our results of sternectomy (typically 5-cm margins) performed in 30 patients over a 10-year period.

Results. Thirteen patients had primary sternal sarcoma (six chondrosarcoma, five osteosarcoma, two other); 10 patients had local recurrence from breast cancer; 4 patients had metastases; 3 patients had other (two osteoradionecrosis, one malignant fibrous histiocytoma). Morbidity occurred in 8 patients (26.7%): wound dehiscence, 2; wound infection, 1; hemorrhage, 1; pneumonia, 1; prolonged air leak, 1; empyema, 1; and bronchopleural fistula, 1. One patient, with multiple metastases, died from adult respiratory distress syndrome on day 25 (overall mortality, 3.3%; 1 of 30). The area of reconstruction ranged from 35 to 264 cm². The technique of reconstruction included muscle flap alone in 13 patients; muscle flap and mesh, 9; muscle flap and rigid prosthesis (Marlex methylmethacrylate), 7; or other, 1 patient. Nineteen patients (63%) were extubated within 24 hours after operation. Median intensive care unit stay was 2 days; median hospitalization, 6 days. Late local recurrence after resection occurred in 6 patients; 4 from breast cancer (3 patients had concurrent distant metastases). Five-year actuarial survival after primary tumor resection was 73% and 33% after resection of recurrent breast cancer (median, 21 months).

Conclusions. Partial sternectomy may be performed for primary sternal tumors with short hospitalization and good local control. Wider local excision or total sternectomy may minimize local re-recurrence of breast carcinoma to the sternum.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also pages 1358.

Sternal resection is commonly performed for primary and metastatic chest wall tumors involving the sternum or the ribs near the sternum. Chest wall resection for tumors, and sternal resection for both infections and tumors have been described in the past, yet the indications, extent of resection, reconstruction considerations, and results of operation have been infrequently described. Chest wall resection for breast cancer began with Schede in 1866 and Sauerbruch in 1907 [1]. Holden first described partial sternectomy for a primary sarcoma in 1878 [2] and the first complete sternectomy was performed by Brodin and Linden in 1959 [3]Au: check Ref 3; from 1913, yet text mentions operation done in 1959. Modern techniques in reconstruction allow sternal resection for primary and metastatic tumor, and for infections with good local control of tumor or infection, minimal respiratory impairment, and good cosmesis [4–6].

Sternal resection is an extension of anterior chest wall resection. Conventionally a wide local excision with a 5-cm margin is obtained, followed by reconstruction of the defect. Resection of the entire sternum without reconstruction may cause a paradoxical movement of the thorax and impair ventilation. Skin, soft tissue or muscle, or prosthetic material, are available to fill any size of chest wall defect. Reconstruction of bony and soft tissue defects of the sternum after resection protects the underlying mediastinal structures.

We retrospectively reviewed our experience with sternal resections in 30 patients during a 10-year period. The results of reconstruction, local tumor recurrence, and survival were examined.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Thirty patients (20 women, 10 men) underwent sternal resection and reconstruction for tumor between 1984 and 1993. The average age was 51 years (range, 20 to 75 years). We excluded patients who underwent resection of the normal manubrium (commonly performed for anterior mediastinal tracheostomy) in conjunction with gastric interposition for hypopharynx/laryngeal or cervical esophageal tumors.

Most patients presented with a sternal mass. Patients with metastatic sternal tumors or breast cancer (BCA) recurrences were diagnosed on follow-up visits. Nineteen patients had a palpable mass, 3 had purulent drainage with or without an ulcer, and 1 had sternal deformity resulting from neurofibroma of the sternum. Evaluation consisted of plain chest roentgenogram (posteroanterior and lateral), computed tomography of the chest, bone scan, and pulmonary functions tests. Computed tomography of the chest revealed the mass itself or the lytic lesion, and the extent of the tumor in all 30 patients. Bone scan was performed for extent of bony involvement and for detection of metastasis to other sites and to determine the extent of bony sternal involvement. Pulmonary functions tests included simple spirometry for all patients, and as needed xenon-131 ventilation perfusion scans to assist in the determination of respiratory reserve. Aortic arch angiography was performed in 1 patient with mediastinal malignant fibrous histiocytoma. Patients who had previously received doxorubicin underwent echocardiography to evaluate ventricular function.

Fine needle aspiration or biopsy of the tumor was performed in 27 patients before resection. Six primary tumors were chondrosarcoma. Two patients received preoperative chemotherapy. All 5 patients with primary osteosarcomas received preoperative chemotherapy (doxorubicin plus cisplatin or doxorubicin plus ifosfamide). Two patients had radiation-induced osteosarcomas. The other two primary sternal tumors were clear cell sarcoma and neurofibroma. Ten patients had local recurrence from BCA. Eight BCA patients had adenocarcinoma, and 2, angiosarcoma. All received chemotherapy before the sternal resection. Five BCA patients had received radiation therapy to the chest wall after breast operations.

Four patients had metastases to the sternum: 2 patients had renal cell carcinoma, 1 liposarcoma, and 1 melanoma. Two patients developed osteoradionecrosis of the sternum. One had an inoperable squamous cell carcinoma of the lung 1 year previously and was treated with radiotherapy (58 Gy). The other patient had a radical mastectomy and radiation therapy 27 years previously and resection of mandibular lymphadenopathy and radiation therapy 18 years previously. One patient with mediastinal radiation-induced sarcoma (malignant fibrous histiocytoma) had local extension into the upper half of the sternum with bony destruction and invasion into the left anterolateral wall of the transverse aortic arch.

Sternal resection was begun from the periphery to encompass all tumor or necrotic tissue plus a 5-cm margin beyond the tumor. The intercostal muscles were divided 2 to 3 cm to expose the ribs. The ribs were divided laterally, and the intercostal neurovascular bundle was ligated with absorbable suture. The sternum was usually divided with a Gigli saw. When needed, the medial third to half of the clavicles were divided bilaterally; this provided excellent exposure of the first and second ribs, which may be divided with angled rib shears. A small portion of normal mediastinal tissue was resected if required to provide a negative ``deep'' margin. The internal mammary artery was preserved when possible. The pleural space was not intentionally entered; however, if pleural entry occurred, the lungs were explored and the extent of the tumor in the upper or lower mediastinum was assessed. If tumor invasion into the lung was identified, the adherent lung was resected and removed en bloc with the specimen. Occult metastases were rare. Complete or total sternectomy was performed only when the entire sternum was involved with tumor or when the total sternum was located within the area defined by the margins of resection.

Reconstruction was accomplished by myocutaneous flap alone, woven mesh, or with a rigid prothesis, typically a custom-fashioned Marlex Au: manufacturer, city & statemesh–methylmethacrylate–Marlex mesh ``sandwich'' to minimize the paradoxical chest wall movement. If the instability of the chest wall was not anticipated to compromise ventilation, prosthetic material was not used to repair the defect. Patients with wider defects after resection and without infection were selected for rigid prosthesis reconstruction.

Outcome was evaluated by operative morbidity, local recurrence of tumor or distant metastases, and survival. Survival was calculated by the Kaplan-Meier method.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Thirty patients underwent 30 operations for resection of the sternum (Tables 1–3). Only 1 patient required total sternectomy.

Morbidity occurred in 8 patients (26.7%). Infections occurred in 5 patients. Two patients had wound dehiscence; 1, a wound infection that required excision of half of the flap and 6 months to heal completely; 1, empyema; and 1 patient, pneumonia with intraabdominal sepsis from pseudomembranous colitis. One patient with postoperative anemia required blood transfusion. An esophageal fistula developed in 1 patient after sternal resection. The esophageal fistula occurred before operation from dilation and after operation was complicated with bronchopleurocutaneous fistula that healed spontaneously. One patient had prolonged air leak. The hospital stay of patients with complications was 14 to 27 days.

Overall mortality was 3.3%. One patient died with metastatic renal cell carcinoma. The patient underwent embolization of sacral metastasis for palliation of back pain and renal artery embolization for the primary neoplasm. Sternal resection for local control of a metastasis was performed after chemotherapy. After discharge (postoperative day 8), rectal bleeding occurred. The subsequent hospital course was complicated with sepsis and adult respiratory distress syndrome and the patient died 25 days after sternal resection.

All sternal resections but one were partial resections and ranged from 20% to 90% of the vertical dimension of the sternum. One total sternectomy was required. The operations were generally performed by a team composed of thoracic and plastic surgeons. The size of the resection ranged from 35 to 264 cm² (average, 100 cm²). Four methods of reconstruction were used: (1) muscle flap alone (n = 13); (2) muscle flap plus a woven mesh prosthesis (n = 9); (3) muscle flap plus rigid Marlex methylmethacrylate ``sandwich'' (n = 7); and (4) fascia lata plus muscle flap (n = 1).

Marlex mesh was used in 8 patients, DexonAu: manufacturer, city & state mesh in 1 patient, and a Marlex methylmethacrylate ``sandwich'' in 7 patients. For reconstruction of lower sternal defects, synthetic mesh with muscle flap with or without use of methylmethacrylate was used [5]. A 1- to 2-cm cuff of Marlex, beyond the dimensions of the rigid prothesis, secured the prothesis to the adjacent ribs surrounding the defect.

The most common muscle flap used was pectoralis major (unilateral or bilateral, n = 22) or rectus abdominous muscle (n = 7). One patient had a transverse rectus abdominis muscle flap used in a previous breast reconstruction; and 1 patient required a free transverse rectus abdominis muscle flap. Latissimus dorsi muscle flap was used in 2 patients. Combination muscle flaps were also used. In 2 patients with osteoradionecrosis of the sternum, extensive debridement was required. The defect was reconstructed by myocutaneous flaps of rectus abdominis and pectoralis major (1 patient each). Permanent prosthetic material was not used for reconstruction of infected lesions.

Late local recurrence after sternal resection occurred in 6 patients. Four late local recurrences occurred after partial sternectomy for BCA for a late local recurrence rate of 40% in these patients. Distant metastasis developed in 7 of 10 BCA patients. Three of these distant metastases occurred synchronous with local recurrences. One patient had a late local recurrence after partial sternectomy for angiosarcoma of the breast. One patient had a late local recurrence after resection of a radiation-induced sarcoma. This patient had been treated with radical mastectomy and radiation therapy for BCA 18 years ago. Local recurrence of tumor along the aortic arch distal to the area of resection developed in 1 patient with a mediastinal malignant fibrous histiocytoma with extension into and destruction of the sternum 2 years after tumor resection.

Five-year survival after sternal resection for primary sarcoma was 73% (Fig 1) and 33% after resection of recurrent BCA (Fig 2)

View larger version (12K): [in this window] [in a new window]   Fig 1. . Survival after sternal resection of primary sarcomas in 13 patients. Five-year survival was 73%.

View larger version (13K): [in this window] [in a new window]   Fig 2. . Survival after sternal resection of locally recurrent breast carcinoma in 10 patients. Five-year survival was 33%.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Chest roentgenograms, plain radiographs of the sternum, and computed tomography of the chest/sternum provide a simple means of diagnosis for an experienced bone radiologist or bone pathologist. If questions persist, a needle aspiration (fine-needle aspiration or cutting needle) or an incisional biopsy should be performed. If performed, the biopsy procedure should be planned so that the tract may be excised at the time of operation. A biopsy may also be performed to identify histology that may be susceptible to perioperative chemotherapy [4]. In our patients, most primary sternal tumors had histologic diagnosis before surgical extirpation. Twenty-seven patients underwent biopsy before resection: 17 patients underwent fine-needle aspiration and 10 patients underwent incisional biopsy. Of these patients, 21 had chemotherapy before operation: 7 patients with primary tumors (osteosarcoma, 5; chondrosarcoma, 2); 10 patients with BCA; and 3 patients with metastases (renal cell, 2; melanoma, 1; and mediastinal malignant fibrous histiocytoma, 1)Au: this totals 4 patients. Local seeding or difficulty with the resection as a result of the previous biopsy was not identified. We found little evidence to suggest that biopsy harms patients and it may provide valuable information to modify treatment in those individuals without a definitive radiologic diagnosis.

All patients had good to excellent functional results after resection. One patient had a small hernia with cough; 1 patient with a bronchopleural fistula before operation with a chest wall ulcer had persistent bronchopleural fistula after operation.

Surgical resection provided local control for sternal tumors. Partial sternectomy was most often performed (29 of 30 patients) as the potential for recurrence by spread in the bone marrow or along the periosteum into the neighboring tissue was deemed unlikely [6–8]. Negative margins were obtained in the operating room. Four to 5-cm gross margins, from the edge of the tumor, were planned consistently.

Modern techniques facilitate complete or partial sternectomy [5, 6] and minimize paradoxical movement of the chest wall after operation [9]. Preventing ``flail chest'' and ventilatory impairment and protecting underlying mediastinal structures must be considered in planning sternal resection. With a portion of the bony sternum intact, even without rigid reconstruction, pulmonary dysfunction is minimized [10, 11]; mesh may be added for enhanced cosmesis. If only the upper sternum (breast plate) is resected (manubrium with ribs 1 to 3), muscle flaps may be used alone. In contrast, resection of the lower sternum frequently requires rigid reconstruction to protect the heart and stabilize the bony thorax.

Reconstruction was planned and performed routinely with plastic surgeons. Pectoralis major muscle and myocutaneous flaps were frequently used to reconstruct defects of the upper sternum/chest wall [12]. Single or bilateral pectoralis major muscle flaps were used in 22 patients. Rectus abdominis muscles for reconstruction of lower sternal defects may also be used [13]. Latissimus dorsi myocutaneous flap or muscle was used for 2 patients. Previous radiation therapy does not compromise the viability of these flaps. Marlex mesh (as a single or as a double layer) was used in 15 patients: alone in 8 patients and with methylmethacrylate in 7 patients. All 15 patients with Marlex had muscle interposed between the mesh and the skin. Dexon mesh was used in 1 patient with an infected tumor to minimize risks of prosthesis infection.

Local regional control for primary and metastatic tumors was good. Six patients recurred locally: 4 with BCA, 1 with primary sarcoma, and 1 with malignant fibrous histiocytoma. Three of the 4 locally re-recurrent BCA patients had synchronous distant metastases. Local recurrence after breast surgery does not consistently represent systemic metastases [14], although it is a negative prognostic indicator [15]. Survival may exceed 40% following treatment of isolated local recurrence [12] 14Au: spell out LR; what is 14?. Although many investigators [16, 17] consider that distant metastases occur concomitantly with local recurrence, one series of 36 patients achieved local control after chest wall resection with a median survival of 50 months [18]. Radiation therapy may not produce a better or more durable local control [19].

No local recurrence occurred in 4 patients with metastatic sternal tumors. A local recurrence developed in only 1 patient after resection of a primary sternal sarcoma (1 of 13; median follow-up, 17 months). That patient had a radiation-induced osteosarcoma. After resection, the tumor recurred as a parasternal nodule, which was excised. One patient with a malignant fibrous histiocytoma originating within the anterior mediastinum, destroyed the sternum by local extension and after resection and radiation, recurred along the transverse aortic arch. The tumor was resected completely en bloc with sternum and a portion of aortic arch.

Overall 5-year survival after sternal resection of recurrent BCA was 33%. Four patients recurred and 3 had concurrent distant metastases with multiple negative prognostic indicator factors (positive axillary lymph nodes, late stage of the primary BCA, and large size of the recurrences). The remaining patient had re-recurrence of angiosarcoma of the breast involving the sternum. The higher re-recurrence of BCA in this series may reflect the systemic nature of the disease and the presence of micrometastases. Despite ``adequate'' 5-cm margins, wider margins or total sternectomy may be of greater value in controlling local disease, although the additional wider local resection may yield little additional value to affect the biology of the systemic metastases.

Partial resection of the sternum appears to be well tolerated with short hospitalization, minimal morbidity, and good local control for primary and metastatic sternal tumors. In patients with recurrent BCA, partial sternectomy provides good local control, although prolonged recurrence-free survival is poor with this systemic disease.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

Address reprint requests to Dr Putnam, Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 109, Houston, TX 77030.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Garrett L. Walsh Jonathan C. Nesbitt Jack A. Roth Joe B. Putnam, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Soysal, O. Articles by Putnam, J. B. Search for Related Content PubMed PubMed Citation Articles by Soysal, O. Articles by Putnam, J. B., Jr Related Collections Related Article