Article Type : Research Article
Authors : BoBouassida I, Ayed AB*, Abdennadher M, Zribi H and Marghli A uassida I, Ayed AB*, Abdennadher M, Zribi H and Marghli A
Keywords : Bouassida I, Ayed AB, Abdennadher M, Zribi H and Marghli A
Breast
cancer (BC) is the most common cancer in women. Sternal metastasis usually
occurs in an isolated setting. Sternal metastasis of BC has rarely been
reported in the literature. We report the case of a women, with history of
right mastectomy and axillary node dissection for breast cancer, who was
presented pain overlying the sternum 3 years after completion of adjuvant
systemic therapy. A computed tomography of the chest revealed a 53 mm tissue
mass with sternal destruction. Transparietal biopsy of the sternal mass was
performed and pathology revealed a carcinoma difficult to type. Sternectomy with
node dissection was done. The sternum was reconstructed by Mersilene mesh and a
titanium bar. A bilateral pectoralis advancement flap was then used to close
the defect. Pathology revealed an invasive ductal carcinoma. Postoperative
course was uneventful. Appropriate surgical technique for a well selected case
maintains functional status and improves survival.
Breast
cancer (BC) is the most common cancer in women. Bone is the most common
metastatic site of BC and sternal metastasis usually occurs in an isolated
setting. Sternal metastasis of BC has rarely been reported in the literature.
We present here a case of solitary bone metastasis to the sternum as a
recurrent presentation of breast cancer in a 57-year-old woman.
A
57 year old woman was diagnosed to have invasive ductal carcinoma of the right
breast since 5 years. She underwent right mastectomy and axillary node
dissection after 1 month of 12 lymph nodes, 3 were involved. Margins were
negative. Immunohistochemistry was negative for estrogen and progesterone, and
positive for human epidermal growth factor (HER2). This patient received
adjuvant chemotherapy and locoregional radiation treatment. Three years after
completion of adjuvant systemic therapy, this woman presented pain overlying
the sternum. A computed tomography (CT) of the chest revealed a 47 X 44 X 53 mm
tissue mass with sternal destruction without metastasis in the lung or the
mediastinum (Figure 1). The tumour is eroding the sternal bone and surrounding
soft-tissue. Bone scan found no other bone invasion except in the sternum.
Transparietal biopsy of the sternal mass was performed and pathology revealed a
carcinoma difficult to type. Surgical treatment for sternal tumour was indicated
by oncologic multidisciplinary team. Sternotomy with node dissection through
median sternotomy skin incision was done. The sternum was reconstructed by
using Mersilene mesh and a titanium bar fixed to the 4 th ribs. A bilateral
pectoralis advancement flap was then used to close the defect (Figure 2).
Mediastinal and subcutaneous drainage was used. Pathology revealed an invasive
ductal carcinoma infiltrating the sternum. Postoperative course was uneventful
during a 10 –day in- hospital stay. After 15-month follow-up, the patient
denied any shortness of breath, chest pain or limitation on her daily
activities.
Figure
1: Computed
tomography of the thorax shows a soft tissue mass with manubrial destruction.
Figure
2: Intraoperative
photograph showing the tumor tissue (A). The tumor has been completely resected
(B). Sequential sternal resections: the resected specimen (C). Sternal
reconstruction using Mersilene mesh and a titanium bar (D). A bilateral
pectoralis advancement flap was used to close the defect (E).
The
most common site of metastasis in BC is the bones. In patients with BC, the
presence of isolated sternal metastasis is relatively uncommon, with reported
incidence of 1.9% - 2.4% [1]. The surgical treatment is challenging the place
of radiotherapy. Complete resection of solitary metastases from BC is justified
and can contribute to a long-term survival. In addition, sternal metastases are
different from other bony metastases, such as vertebral metastases, in that
their lack of an expansive communicative vasculature. They might remain
solitary for an extended time [2]. Because the sternum is important for
maintaining the integrity of the thoracic bones, sternal resection
significantly affects respiratory and circulatory function. To preserve the
integrity of the chest and protect vital organs, it is important to reconstruct
the thoracic cage [3]. There are many methods for the reconstruction of sternal
defect, include the reconstruction of soft tissue by free flaps, greater
omentum and polyester patch. And the restore of chest wall rigidity with
three-dimensional printing bioscaffold, acrylic cement, metal plate or mesh,
polypropylene or Mersilene mesh and allograft or homograft of bone [4]. But
none have proven to be clearly superior. In our case, Mersilene mesh has been
used because of its solidity, manageability, long-term tolerability, virtual
absence of foreign body reactions or septic complications, and low cost. It
offers the fixation of the thoracic bones and the protection of endothoracic
organs. Titanium bar was successfully added for greater stability. Furthermore,
muscle flaps have replaced other tissues, such as simple skin flaps, for the
coverage of soft tissue defects, because of their safety and long-term
stability. The 5-year survival rates for chest wall or sternal resections are
described between 18 and 71%. Age at sternal resection, mastectomy or
breast-conserving surgery at primary tumour, disease free interval, lymph node
status of the primary tumour, preoperative chemotherapy and the type of sternal
resection had a significant influence on overall survivals [5].