gms | German Medical Science

18. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie

Deutsche Gesellschaft für Thoraxchirurgie

08.10. bis 10.10.2009, Augsburg

Personal experience with 120 sternal resections

Meeting Abstract

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  • Cosimo Lequaglie - National Cancer Institute Rionero in Vulture, Department of Thoracic Surgery, Rionero in Vulture, Italien
  • Gabriella Giudice - National Cancer Institute Rionero in Vulture, Department of Thoracic Surgery, Rionero in Vulture, Italien

Deutsche Gesellschaft für Thoraxchirurgie. 18. Jahrestagung der Deutschen Gesellschaft für Thoraxchirurgie. Augsburg, 08.-10.10.2009. Düsseldorf: German Medical Science GMS Publishing House; 2009. DocHS3.4

DOI: 10.3205/09dgt20, URN: urn:nbn:de:0183-09dgt201

Published: November 20, 2009

© 2009 Lequaglie et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

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Objective: To target the gold standard to sternal resections for cancer even in extreme situations.

Methods: We review our experience during last 25 years, 112 patients (37 males with a mean age of 49 years: range 16–82, and 75 females with a mean age of 52 years: range 22–78) underwent the surgical resection of sternal tumors: 37 primary tumors, 38 local relapses or metastases from breast cancers, 22 other tumors and 15 radionecroses. All of the patients were evaluated by functional tests, CT and/or MR, and then completely staged (including WB or PET scan) in order to exclude the presence of extra-thoracic metastatic lesions. We adopted the usual pre-operative evaluation criteria and considered a resection possible if lobe FEV1 was ≥1L and lung FEV1 ≥2L, or if the expected post-resection residual FEV1 was not less than 800 mL.

Fine needle aspiration or open biopsies were positive in 99 cases, and the diagnosis allowed an adequate resection; in the remaining 13 cases, the clinical and radiological findings clearly indicated the presence of a primary malignant sternal tumor or radionecrosis, and so it was possible to perform an en bloc radical resection without a previous biopsy.

The surgical resection begins with a vertical elliptical incision including the mass. Mobilization is then begun first on one side of the sternum, with exposure and section of the ribs. We attack the sternum from the periphery, leaving any critical point of bone attachment to the heart and great vessels to the last. Sometimes a Gigli saw is used to transect the sternum in its upper free margin. Both internal thoracic vessels by this time would have been identified, dissected out, and ligated before division.

There were 15 total sternectomies, 45 subtotal (>50%), and 52 partial (<50%). The average size of the sternal resection (including the ribs) was 161.7 cm2 (15.4 x 10.5 cm), the largest being 682 cm2 (31 x 22 cm). The procedure was associated to 78 rib resections, 19 of the clavicles, 31 of the lung, 20 of the pericardium. The breaches in the soft tissue and bone were repaired using: prosthetic materials covered by myocutaneous or muscle tissue in 98 patients, prosthetic material in 98, myocutaneous or muscle flaps in 73, and other in 38. A radical resection (3–4 cm margins macroscopically free of disease at both cutaneous and underlying tissue level and proved by microscopy) was in 102 cases and palliative in 10 ones.

Indications: The choice of surgical technique depends on the size and site of the lesion, but its success depends on the full-thickness resection of the thoracic wall and the personal experience of the surgeon. Another problem is the restoration of ventilatory mechanics and the need to protect the intrathoracic organs. Broad full-thickness resections are possible because the use of myocutaneous flaps and synthetic prostheses allow the simultaneous repair of breaches in the chest wall.

The role of surgical treatment in the case of local relapses or distant breast cancer metastases has not been debate. To-day surgery gives an improvement in survival; sternal resections as a means of removing the metastases of tumors located in other sites is not exclusively palliative and is therefore feasible as a means of improving the quality of life. The same is true in the case of post-actinic necrosis and often leads to a good cosmetic result.

Results: There were 2 peri-operative deaths due to multi-organ failure, and morbidity was limited to 16 cases. Fiftheen patients presented complications at the site of the surgical wound. The last patient developed bilateral pulmonary aspergillosis successfully treated with antifungal therapy.

Seventy-two patients after radical surgery were alive and disease free at the end of the follow-up. Kaplan-Meier survival percentage calculated at 10 years was 86% of survival percentage in primary tumors, 11.6 versus 0% in secondary tumors and 42.7% in breast cancer relapses, respectively.

Conclusions: The treatment of sternal tumors by means of a broad sternal resection followed by a reconstruction based on the use of prosthetic materials is an efficacious and safe solution that improves the quality of life and makes it possible to perform curative broad radical resections in the case of primary tumors.

Major en bloc resections including the pericardium, lung or diaphragm can be performed with zero mortality, minimal morbidity and acceptable hospitalisation times provided that all of the steps are standardised. Resection offers a significant and permanent palliative solution even in breast cancer relapse and radionecroses.