Ann Thorac Surg 2011;91:584-586. doi:10.1016/j.athoracsur.2010.08.029
© 2011 The Society of Thoracic Surgeons
Case Reports
Sternal Metastasis of Breast Cancer: Ex Vivo Hypothermia and Reimplantation
Moisés Rosenberg, PhDa,*,
Aldo Castagno, MDb,
Jorge Nadal, MDc,
Adolfo Rosales, MDa,
Erik Pebe Pueyrredon, MDb,
Ana K. Patané, MDa
a Department of Thoracic Surgery, Instituto Fleming, Buenos Aires, Argentina
b Department of Traumatology and Orthopedic Surgery, Instituto Fleming, Buenos Aires, Argentina
c Department of Oncology, Instituto Fleming, Buenos Aires, Argentina
Accepted for publication August 16, 2010.
* Address correspondence to Dr Rosenberg, Department of Thoracic Surgery, Instituto Fleming, Cramer 1180, 1453 AMZ Buenos Aires, Argentina (Email: mrosenberg{at}arnet.com.ar).
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Abstract
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Breast cancer frequently metastasizes to the bone. When the sternum is involved, it usually presents as a solitary lesion. In such cases, resection is indicated, including with the intention to cure. This case report describes a technique for a complete exeresis of the sternum, ex vivo repair under hypothermia, and reimplantation. Cryosurgery is a well-known technique to resect bone metastases and was the procedure used in our patient. The follow-up after 2 years shows no evidence of tumor recurrence, with excellent results on aesthetic levels.
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Introduction
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Breast cancer commonly metastasizes to bone [1]. When the sternum is involved, the metastasis is usually single and evolves along extended periods of time. When the disease is stable, there are no other metastases, and no other disease is present, sternal resection is a reasonable option [2]. Multiple techniques are available to reconstruct the chest wall after sternal resection. However, when the sternal manubrium or the whole sternum is involved, there is concern about the extent of the resection because the stability of the shoulder girdle may be compromised.
Cryosurgery is a well-known technique to resect bone metastases [3] and was the procedure used in the patient presented in this report. We performed complete resection of the sternum, the ex vivo curettage of the metastasis, and its treatment by immersion in liquid nitrogen, followed by reimplantation.
A 58-year-old woman with a history of stage IIb breast carcinoma was initially treated with a left radical mastectomy on April 2002. The histopathology revealed a 4.5-cm Nottingham grade II, estrogen receptor- and progesterone receptor-positive, ductal invasive carcinoma with 1 of 13 lymph nodes involved. Adjuvant chemotherapy was with six cycles of cyclophosphamide, doxorubicin, and 5-fluorouracil, followed by tamoxifen, for 5 years.
In February 2008, she complained of mild sternal pain. A technetium 99 radionuclide bone scan and an integrated positron emission tomography–computed tomography scan confirmed a lytic lesion involving manubrium and body of the sternum, without other lesions. A needle biopsy specimen was positive for ductal carcinoma (Fig 1).
The patient was informed of the resection technique and that it was our first case. She provided written consent, and we also received approval from the institutional ethics committee.
The procedure took place in April 2008, during which:
- 1 A horizontal incision was made along the clavicles and a vertical incision from the manubrium to the xiphoid.
- 2 The anterior wall of the sternum, the costal cartilages, and the medial segments of the ribs were exposed. The internal mammary arteries were preserved. The pleural space was not entered.
- 3 The entire sternum was removed, along with the medial segments of 4 ribs on the right and 3 on the left to allow for subsequent reattachment.
- 4 The site of the metastasis was curetted ex vivo, but the preserved bone was left intact (Fig 2).
- 5 The entire specimen was immersed in liquid nitrogen for 20 minutes. Then, it was kept at room temperature and immersed in saline solution for 20 minutes. The bone defect created after curettage was filled with bank bone consisting of trabecular bone from femur heads with HA-BOND (Baumer S.A., Sao Paulo, Brasil) alloplastic composites.
- 6 The sternum was reimplanted and fixed to the clavicles with stainless steel and to the ribs with titanium plaques (Fig 3).
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Fig 3. The repaired sternum was reimplanted to the clavicles with stainless steel and to the ribs with titanium plaque.
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The patient had an uneventful recovery and was discharged on postoperative day 8. As adjuvant treatment, she received six cycles of docetaxel, followed by exemestane. Two years after resection, the patient remains free of disease and maintains her normal activities, with only minor discomfort in the anterior chest wall that does not require any medication. Present images of the sternum are similar to those taken shortly after the operation.
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Comment
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Breast cancer tends to metastasize to bones, and multiple metastases are frequent [1]. The isolated sternum involvement can be explained by the lack of blood vessel communication with the paravertebral plexus, venous drainage of the sternal area is not through the paravertebral plexus, or as a locoregional recurrence. The lesion can be resected with curative intent or to effectively palliate the symptoms.
The procedure, consisting of sternal removal, ex vivo tumor excision, immersion in liquid nitrogen, and further reimplantation, has two main advantages over other techniques: it preserves the uninvolved sternal bone, which is used to restore the function and the aesthetics of the chest wall with no additional prosthetic material or muscle flaps, and it eliminates the potential residual cancer cells at the resection margins or scattered in the remaining bone.
In cryosurgery, extreme cold is applied to the tissue. The most common fast cooling solution is liquid nitrogen. Cellular damage occurs when ice crystals form inside the cells and tear their membrane and organelles apart. When freezing is fast, it occurs inside and outside simultaneously.
Tanzawa and colleagues [4] published an experience for reconstruction of large bone defects after tumor excision. Several methods have been developed. Freezing by liquid nitrogen has a number of advantages for biologic reconstruction, and they show a case report in which a frozen autograft was removed 6 years after resection. Histologic studies showed no tumor cells in any of the sections, most parts had osteocytes and microvessels, and fibrovascular tissue was present between the cortex and medullary space.
They concluded that frozen autograft might be considered one of the most useful materials for biologic reconstructions.
Systemic therapy was added in our patient, assuming that treatment might eliminate micrometastases, like adjuvant chemotherapy. This rationale, which was evaluated by the M. D. Anderson Cancer Center [5], suggests substantial advantages compared with historical controls. However, no randomized data are available to support this argument.
The purpose of reporting this case is to arouse interest for further research. The very low frequency of single metastasis involving the sternum makes the evaluation of the reported procedure difficult. Sternal resection and repair with prosthetic materials or muscle flaps, has been reported with a high percentage of complications (ie, infections, wound dehiscence, and anemia) and prolonged hospitalization [6–8]. These large operations should be reserved for those patients with good performance status, a reasonable disease-free survival before the single sternal metastasis, no evidence of metastases in other sites, and no other disease present.
In conclusion, this case showed that the ex vivo curettage of a single sternal metastasis, and the immersion of the costosternal specimen into liquid nitrogen, followed by reimplantation, is feasible and could be considered an alternative treatment.
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References
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- Lee YT. Breast carcinoma: pattern of metastases at autopsy J Surg Oncol 1983;23:175-180.[Medline]
- Noguchi S, Miyauchi K, Nishizawa Y, Imaoka S, Koyama H, Iwanaga T. Results of surgical treatment for sternal metastasis of breast cancer Cancer 1988;62:1397-1401.[Medline]
- Marcove RC. A 17-year review of cryosurgery in the treatment of bone tumors Clin Orthop Relat Res 1982;163:231-233.[Medline]
- Tanzawa Y, Tsuchiya H, Shirai T, Hayashi K, Yo Z, Tomita K. Histological examination of frozen autograft treated by liquid nitrogen removed after implantation J Orthop Sci 2009;14:761-768.[Medline]
- Rivera E, Holmes FA, Buzdar AU, et al. Fluorouracil, doxorubicin and cyclophosphamide followed by tamoxifen as adjuvant treatment for patients with stage IV breast cancer and no evidence of disease Breast J 2002;8:2-9.[Medline]
- Durr HR, Muller PE, Lenz T, Baur A, Jansson V, Refior HJ. Surgical treatment of bone metastases in patients with breast cancer Clin Orthop Relat Res 2002;396:191-196.[Medline]
- 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;9:472-479.[Medline]
- Shimizu J, Nakamura Y, Tsuchida K, et al. Complete sternectomy for metastatic carcinoma with reconstruction using a latissimus dorsi musculocutaneous flap Eur J Cardiothorac Surg 1995;9:342-344.[Abstract/Free Full Text]
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Abstract
Introduction
