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Allogenic Sternal Transplant After Sternectomy for Metastasis of Ovarian Carcinoma
Allogenic Sternal Transplant After Sternectomy for Metastasis of Ovarian Carcinoma Franco Stella, MD, PhD, Andrea Dell’Amore, MD, Giampiero Dolci, MD, Nicola Cassanelli, MD, Guido Caroli, MD, Claudio Zamagni, MD, and Alessandro Bini, MD Thoracic Surgery Unit and Oncology Department, Sant’ Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible. (Ann Thorac Surg 2012;93:e71–2) © 2012 by The Society of Thoracic Surgeons
S
ternal localization of secondary tumors is a rare event. Surgical treatment is indicated in the case of controlled primary disease, absence of other metastases, or severe comorbidities limiting the patient’s life expectancy [1]. For curative surgery with a safety margin, an extensive resection of the chest wall is required. The reconstruction of the thorax, to prevent respiratory insufficiency, local infection, and injuries of mediastinal structures, is the most challenging part of the operation. We report the case of a young woman who underwent allograft sternal transplantation after subtotal upper sternectomy for metastasis of ovarian carcinoma.
A 39-year-old woman with history of ovarian carcinoma was treated in March 2009 by bilateral oophorectomy, hysterectomy, pelvic posterior exenteration, rectosigmoidectomy with colorectal anastomosis, and resection of the pelvic peritoneum. The Lynch syndrome was diagnosed based on family history and was confirmed by genomic study. The pathologic staging was pIIIc, G3 serous ovarian carcinoma. Resection was followed by six cycles of adjuvant chemotherapy. In April 2010, chest positron emission tomography showed a single osteolytic lesion in the manubrium sterni with 5.9 standardized uptake value. The computed tomography (CT)– guided bone biopsy was positive for metastasis of ovarian carcinoma. Preoperative CT scan and echography showed a mass of 2.3 ⫻ 3.1 ⫻ 2.7 cm diameter in the manubrium just a few centimeters below the right sternoclavicular joint (SCJ) with destruction of the posterior bony cortex and an initial tumor extension in the soft tissue behind the sternum (Fig 1A). Other metastases of the tumor were Accepted for publication Oct 3, 2011. Address correspondence to Dr Dell’Amore, Thoracic Surgery Unit, Sant’ Orsola Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna 40026, Italy; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
excluded. Before surgery, a high epidural catheter was placed for postoperative analgesia. A longitudinal skin incision in the midline of the sternum was performed from the suprasternal notch to the level of the fourth intercostal space. The anterior surface of the sternum, both SCJs, and the first four ribs were freed from the surrounding soft tissue and the pectoral major muscles bilaterally. The intercostal spaces were dissected without opening the pleural spaces, and both mammary arteries and veins were preserved. At the level of the third intercostals space, the sternum was divided transversally. The left clavicle was disjointed from the sternum, and the cartilage of the first rib was transected. On the right side, because of the continuity between the metastasis and the SCJ, the clavicle and the first rib were transected in the middle third and removed en bloc with the sternum. The second sternochondral rib joints were cut bilaterally with a scalpel. By lifting the excised portion of the sternum, the posterior soft tissue was removed with the bone (Fig 1B). The tissue defect was filled using an allogenic cryopreserved sternum with four pairs of costal segments. The techniques used for retrieval, conservation, and handling of the bone graft were previously reported [2]. The bone graft was tailored to fit perfectly with the remaining recipient sternum and rib stumps (Fig 1C). The allograft was fixed with titanium plates and screws (Synthes, Solothurn, Switzerland). To stabilize the left SCJ, hightension polyethylene sutures (Hi-Fi; ConMed Linvatec, Largo, FL) were passed transosseously between the clavicle and the neomanubrium. A further suture was passed between the clavicle and the body of the first rib. On the right side, the high-tension sutures were passed through the clavicle and the titanium plates connecting the neosternum with the first rib stump. The major pectoral muscles were then completely freed and used as an advancement muscle flap to cover the transplanted graft. The postoperative period was uneventful, and the patient was discharged on the 12th postoperative day.
Comment Neoplastic involvement of the sternum is a challenging situation. Wide resection margins are needed for a radical operation, and reconstruction of the thoracic cage is important to ensure a good respiratory function. In addition, the SCJs are involved in the correct motility of the shoulder girdles and support of the axial skeleton [3,4]. Our goal was to achieve a radical resection of the tumor and an optimal reconstruction of the chest, preserving the respiratory function and good movement of the shoulder girdle and upper limbs. We carefully chose the most suitable materials to fill the tissue defect created by resection of the upper part of the sternum. Synthetic materials have been extensively used in clinical practice with good results. The advocated disadvantages of their application are the excessive rigidity with risk of erosion of the adjacent structures, the risk of infection, insufficient strength, immunologic reaction, impossibility of incorporation into the host tissue, and suboptimal radiologic window [2, 5]. Biological materials have been used with good results in chest wall reconstruction. Various muscle flaps are also able to fill large defects. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.004
e72
CASE REPORT STELLA ET AL ALLOGENIC STERNAL TRANSPLANT
Ann Thorac Surg 2012;93:e71–2
Fig 1. (A) Computed tomography scan showing an osteolytic lesion involving the manubrium sterni (white arrow). (B) Surgical specimen. (C) The sternal allograft before tailoring. (D) Postoperative chest roentgenogram showing the new sternum and the correct positioning of titanium plates and clavicles.
Bone autografts have optimal biomechanical characteristics and are fully compatible. Bone grafts also act as a scaffold for osteoprogenitor cells and bone formation [2, 5, 6]. Various authors have reported the use of bone allografts for chest wall reconstruction with excellent results [2, 6]. Bone allografts have the same advantage as bone autografts in terms of infection risk, compatibility, and host tissue incorporation. Bone allografts do not require additional incision or tissue resection for harvesting, and they are readily available from tissue banks [2, 5–7]. In 2009, the Padua group [2] reported the first case of allograft sternochondral replacement. We found this technique to be simple and reproducible. The allograft fitted perfectly with the remaining sternum (Fig 1D). The preoperative CT scan was used to measure the longitudinal and transverse diameters of the patient’s sternum at the level of the SCJs, the manubrium, and the sterna body to guarantee the correct matching between the donor and recipient sterni. A quick, safe, and efficient stabilization of the transplanted bone was achieved with titanium plates and screws [2]. Owing to the complete removal of the manubrium sterni in our case, both SCJs were disarticulated. In contrast to sternal excision, clavicular resection often requires no specific reconstruction or stabilization. Nevertheless, SCJ instability may cause pain, functional impairment of the shoulder girdles and upper limbs, and cosmetic discomfort [3, 4]. In our opinion, a correct reconstruction of the SCJs is very important in a young and socially active patient to guarantee good quality of life and esthetic results. Various surgical stabilization techniques have been reported [3, 4,]. Titanium plates achieve a stable joint fixation but do not restore normal SCJ mobility. Following the techniques published by Rontini and colleagues [3], we used transosseous high-
tension sutures to stabilize and reconstruct the continuity between the neosternum and the clavicles. The patient started passive and assisted active motion without pain or discomfort the day after surgery. Three months later, she started strengthening of the scapular girdle with no limitation to elevation, abduction, or intrarotation and extrarotation. In conclusion, we confirm that the use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.
References 1. Lequaglie C, Massone PB, Giudice G, Conti B. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms. Ann Surg Oncol 2002;9:472–9. 2. Marulli G, Hamad AM, Cogliati E, Breda C, Zuin A, Rea F. Allograft sternochondral replacement after resection of large sternal chondrosarcoma. J Thorac Cardiovasc Surg 2010;139: 69 –70. 3. Rontini R, Guerra E, Bettelli G, Marinelli A, Frisoni T. Sternoclavicular joint dislocation: a case report of a surgical stabilization technique. Musculoskel Surg 2010;94:91– 4. 4. Lee SU, Park IJ, Kim YD, Kim YC, Jeong C. Stabilization for chronic sternoclavicular joint instability. Knee Surg Sports Traumatol Arthrosc 2010;18:1795–7. 5. Tuncozgur B, Elbeyli L, Gungor A, Isik F, Akay H. Chest wall reconstruction with autologous rib grafts in dogs and reports of a clinical case. Eur J Cardiothorac Surg 1999;16:292–5. 6. Aranda JL, Varela G, Benito P, Juan A. Donor cryopreserved rib allograft for chest wall reconstruction. Interact Cardiovasc Thorac Surg 2008;7:858 – 60. 7. Piotrowski JA, Fischer M, Klaes W, Splittgerber F. Autologous bone transplant after sternal resection. J Cardiovasc Surg (Torino) 1996;37:179 – 81.
Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible. (Ann Thorac Surg 2012;93:e71–2) © 2012 by The Society of Thoracic Surgeons
S
ternal localization of secondary tumors is a rare event. Surgical treatment is indicated in the case of controlled primary disease, absence of other metastases, or severe comorbidities limiting the patient’s life expectancy [1]. For curative surgery with a safety margin, an extensive resection of the chest wall is required. The reconstruction of the thorax, to prevent respiratory insufficiency, local infection, and injuries of mediastinal structures, is the most challenging part of the operation. We report the case of a young woman who underwent allograft sternal transplantation after subtotal upper sternectomy for metastasis of ovarian carcinoma.
A 39-year-old woman with history of ovarian carcinoma was treated in March 2009 by bilateral oophorectomy, hysterectomy, pelvic posterior exenteration, rectosigmoidectomy with colorectal anastomosis, and resection of the pelvic peritoneum. The Lynch syndrome was diagnosed based on family history and was confirmed by genomic study. The pathologic staging was pIIIc, G3 serous ovarian carcinoma. Resection was followed by six cycles of adjuvant chemotherapy. In April 2010, chest positron emission tomography showed a single osteolytic lesion in the manubrium sterni with 5.9 standardized uptake value. The computed tomography (CT)– guided bone biopsy was positive for metastasis of ovarian carcinoma. Preoperative CT scan and echography showed a mass of 2.3 ⫻ 3.1 ⫻ 2.7 cm diameter in the manubrium just a few centimeters below the right sternoclavicular joint (SCJ) with destruction of the posterior bony cortex and an initial tumor extension in the soft tissue behind the sternum (Fig 1A). Other metastases of the tumor were Accepted for publication Oct 3, 2011. Address correspondence to Dr Dell’Amore, Thoracic Surgery Unit, Sant’ Orsola Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna 40026, Italy; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
excluded. Before surgery, a high epidural catheter was placed for postoperative analgesia. A longitudinal skin incision in the midline of the sternum was performed from the suprasternal notch to the level of the fourth intercostal space. The anterior surface of the sternum, both SCJs, and the first four ribs were freed from the surrounding soft tissue and the pectoral major muscles bilaterally. The intercostal spaces were dissected without opening the pleural spaces, and both mammary arteries and veins were preserved. At the level of the third intercostals space, the sternum was divided transversally. The left clavicle was disjointed from the sternum, and the cartilage of the first rib was transected. On the right side, because of the continuity between the metastasis and the SCJ, the clavicle and the first rib were transected in the middle third and removed en bloc with the sternum. The second sternochondral rib joints were cut bilaterally with a scalpel. By lifting the excised portion of the sternum, the posterior soft tissue was removed with the bone (Fig 1B). The tissue defect was filled using an allogenic cryopreserved sternum with four pairs of costal segments. The techniques used for retrieval, conservation, and handling of the bone graft were previously reported [2]. The bone graft was tailored to fit perfectly with the remaining recipient sternum and rib stumps (Fig 1C). The allograft was fixed with titanium plates and screws (Synthes, Solothurn, Switzerland). To stabilize the left SCJ, hightension polyethylene sutures (Hi-Fi; ConMed Linvatec, Largo, FL) were passed transosseously between the clavicle and the neomanubrium. A further suture was passed between the clavicle and the body of the first rib. On the right side, the high-tension sutures were passed through the clavicle and the titanium plates connecting the neosternum with the first rib stump. The major pectoral muscles were then completely freed and used as an advancement muscle flap to cover the transplanted graft. The postoperative period was uneventful, and the patient was discharged on the 12th postoperative day.
Comment Neoplastic involvement of the sternum is a challenging situation. Wide resection margins are needed for a radical operation, and reconstruction of the thoracic cage is important to ensure a good respiratory function. In addition, the SCJs are involved in the correct motility of the shoulder girdles and support of the axial skeleton [3,4]. Our goal was to achieve a radical resection of the tumor and an optimal reconstruction of the chest, preserving the respiratory function and good movement of the shoulder girdle and upper limbs. We carefully chose the most suitable materials to fill the tissue defect created by resection of the upper part of the sternum. Synthetic materials have been extensively used in clinical practice with good results. The advocated disadvantages of their application are the excessive rigidity with risk of erosion of the adjacent structures, the risk of infection, insufficient strength, immunologic reaction, impossibility of incorporation into the host tissue, and suboptimal radiologic window [2, 5]. Biological materials have been used with good results in chest wall reconstruction. Various muscle flaps are also able to fill large defects. 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.004
e72
CASE REPORT STELLA ET AL ALLOGENIC STERNAL TRANSPLANT
Ann Thorac Surg 2012;93:e71–2
Fig 1. (A) Computed tomography scan showing an osteolytic lesion involving the manubrium sterni (white arrow). (B) Surgical specimen. (C) The sternal allograft before tailoring. (D) Postoperative chest roentgenogram showing the new sternum and the correct positioning of titanium plates and clavicles.
Bone autografts have optimal biomechanical characteristics and are fully compatible. Bone grafts also act as a scaffold for osteoprogenitor cells and bone formation [2, 5, 6]. Various authors have reported the use of bone allografts for chest wall reconstruction with excellent results [2, 6]. Bone allografts have the same advantage as bone autografts in terms of infection risk, compatibility, and host tissue incorporation. Bone allografts do not require additional incision or tissue resection for harvesting, and they are readily available from tissue banks [2, 5–7]. In 2009, the Padua group [2] reported the first case of allograft sternochondral replacement. We found this technique to be simple and reproducible. The allograft fitted perfectly with the remaining sternum (Fig 1D). The preoperative CT scan was used to measure the longitudinal and transverse diameters of the patient’s sternum at the level of the SCJs, the manubrium, and the sterna body to guarantee the correct matching between the donor and recipient sterni. A quick, safe, and efficient stabilization of the transplanted bone was achieved with titanium plates and screws [2]. Owing to the complete removal of the manubrium sterni in our case, both SCJs were disarticulated. In contrast to sternal excision, clavicular resection often requires no specific reconstruction or stabilization. Nevertheless, SCJ instability may cause pain, functional impairment of the shoulder girdles and upper limbs, and cosmetic discomfort [3, 4]. In our opinion, a correct reconstruction of the SCJs is very important in a young and socially active patient to guarantee good quality of life and esthetic results. Various surgical stabilization techniques have been reported [3, 4,]. Titanium plates achieve a stable joint fixation but do not restore normal SCJ mobility. Following the techniques published by Rontini and colleagues [3], we used transosseous high-
tension sutures to stabilize and reconstruct the continuity between the neosternum and the clavicles. The patient started passive and assisted active motion without pain or discomfort the day after surgery. Three months later, she started strengthening of the scapular girdle with no limitation to elevation, abduction, or intrarotation and extrarotation. In conclusion, we confirm that the use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.
References 1. Lequaglie C, Massone PB, Giudice G, Conti B. Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms. Ann Surg Oncol 2002;9:472–9. 2. Marulli G, Hamad AM, Cogliati E, Breda C, Zuin A, Rea F. Allograft sternochondral replacement after resection of large sternal chondrosarcoma. J Thorac Cardiovasc Surg 2010;139: 69 –70. 3. Rontini R, Guerra E, Bettelli G, Marinelli A, Frisoni T. Sternoclavicular joint dislocation: a case report of a surgical stabilization technique. Musculoskel Surg 2010;94:91– 4. 4. Lee SU, Park IJ, Kim YD, Kim YC, Jeong C. Stabilization for chronic sternoclavicular joint instability. Knee Surg Sports Traumatol Arthrosc 2010;18:1795–7. 5. Tuncozgur B, Elbeyli L, Gungor A, Isik F, Akay H. Chest wall reconstruction with autologous rib grafts in dogs and reports of a clinical case. Eur J Cardiothorac Surg 1999;16:292–5. 6. Aranda JL, Varela G, Benito P, Juan A. Donor cryopreserved rib allograft for chest wall reconstruction. Interact Cardiovasc Thorac Surg 2008;7:858 – 60. 7. Piotrowski JA, Fischer M, Klaes W, Splittgerber F. Autologous bone transplant after sternal resection. J Cardiovasc Surg (Torino) 1996;37:179 – 81.