Sternal resection for primary or secondary tumors

Ultrasound-guided percutaneous screw fixation of sternal metastasis

Sternal metastasis often result in disabling pain, significant functional limitations, with potential consequences for the thoracic spine. This case report suggests a new approach combining ultrasound for initial guidance and fluoroscopy with cone-beam CT (CBCT) for screw fixation. The patient experienced immediate pain relief, a better mobility, and improved quality of life. This approach demonstrates a minimally invasive, radiation-sparing and time saving strategy for sternal screwing.

Sternal Reconstruction with a Custom-Made 3D-Printed Titanium Neo-sternum Prosthesis After Resection for Primary Malignant Sternal Tumour

Primary sternal tumours are rare. Most of them are malignant in nature. When localized, cure can be achieved by radical resection. However, it leaves a large bony defect in front of the heart that makes reconstruction a challenge. In this report, we describe our experience of sternal reconstruction using a custom-made 3D-printed titanium neo-sternum after en-bloc resection of sternal body and anterior ends of bilateral second to fifth ribs for chondrosarcoma.

Synchronous Whole Sternal Metastasis from Primary Malignant Mediastinal Germ Cell Tumor in a Teenager

Naveena A.N. KumarPrimary malignant germ cell tumor (GCT) of the mediastinum is a rare entity with an incidence ranging from 1 to 2% of all childhood cancers. Though a few cases of bone metastasis from mediastinal GCTs have been reported, synchronous whole sternal metastasis from primary malignant mediastinal GCTs is very rare. We report such a rare manifestation in a teenager, emphasizing the need for a multidisciplinary treatment approach with neoadjuvant chemotherapy, surgical expertise for en bloc excision of the mediastinal mass along with whole sternal resection, and reconstruction in a dedicated cancer care center for better oncological outcomes.

The application of three-dimensional custom-made prostheses in chest wall reconstruction after oncologic sternal resection

BACKGROUND AND OBJECTIVES

As one of the cutting-edge advances in the field of reconstruction, three-dimensional (3D) printing technology has been constantly being attempted to assist in the reconstruction of complicated large chest wall defects. However, there is little literature assessing the treatment outcomes of 3D printed prostheses for chest wall reconstruction. This study aimed to analyze the surgical outcomes of 3D custom-made prostheses for the reconstruction of oncologic sternal defects and to share our experience in the surgical management of these rare and complex cases.

METHODS

We summarized the clinical features of the sternal tumor in our center, described the surgical techniques of the application of 3D customized prosthesis for chest wall reconstruction, and analyzed the perioperative characteristics, complications, overall survival (OS), and recurrence-free survival of patients.

RESULTS

Thirty-two patients with the sternal tumor who underwent chest wall resection were identified, among which 13 patients used 3D custom-made titanium implants and 13 patients used titanium mesh for sternal reconstruction. 22 cases were malignant, and chondrosarcoma is the most common type. The mean age was 46.9 years, and 53% (17/32) of the patients were male. The average size of tumor was 6.4 cm, and the mean defect area was 76.4 cm2. 97% (31/32) patients received R0 resection. Complications were observed in 29% (9/32) of patients, of which wound infection (22%, 7/32) was the most common. The OS of the patients was 72% at 5 years.

CONCLUSION

We demonstrated that with careful preoperative assessment, 3D customized prostheses could be a viable alternative for complex sternal reconstruction.

Reconstruction of massive chest wall defect after malignant chest wall mass excision in resource limited setting, a case report

INTRODUCTION AND IMPORTANCE

Chest wall tumors, rare but impactful, constitute less than 2 % of the population and 5 % of thoracic neoplasms. Wide-margin resection is vital, often causing substantial defects necessitating reconstruction. However, in resource-limited settings like sub-Saharan Africa, access to reconstruction materials is limited. We present a successful case of managing a massive chest wall defect using flexible wire and polypropylene mesh in such a context.

CASE PRESENTATION

A 40-year-old male presented with a gradually enlarging anterolateral chest wall mass, diagnosed as low-grade synovial sarcoma. Imaging revealed involvement of the 6th to 11th ribs with compression of the diaphragm and liver. A multidisciplinary team planned wide-margin excision, chest wall reconstruction, and adjuvant chemoradiation. Using a sternal wire bridge and polypropylene mesh, the 25 cm by 15 cm defect was reconstructed, covered with a latissimus dorsi flap. The patient recovered well postoperatively, highlighting the feasibility of innovative approaches in resource-limited settings.

CLINICAL DISCUSSION

Defects larger than 5 cm or involving over 4 ribs require reconstruction to prevent lung herniation and respiratory issues, especially for anteriorolateral defects. Our case featured a 25 by 15 cm anteriorolateral chest wall defect, necessitating rigid reconstruction. Due to resource constraints, we utilized flexible wires and polypropylene mesh, offering a cost-effective solution for managing massive chest wall defects.

CONCLUSION

This case underscores the challenges faced in managing chest wall tumors in resource-constrained regions and emphasizes the importance of innovative solutions for achieving successful outcomes in chest wall reconstruction.

Rare case of chondrosarcoma of the manubrium sterni: Management challenges and insights (a surgical case report)

INTRODUCTION AND IMPORTANCE

Chondrosarcoma of the manubrium sterni is an exceedingly rare localization of chondrosarcoma. Its treatment poses a significant therapeutic challenge due to the tumor's proximity to the mediastinal organs and the clavicles. This challenge is magnified when the inner ends need to be resected due to tumor contact with the sternoclavicular joints and, more critically, during the reconstruction of the thoracic wall.

CASE PRESENTATION

We present the case of a 71-year-old female with a 45x42x51 mm chondrosarcoma of the manubrium sterni, extending to both sternoclavicular joints. The diagnosis was confirmed cytologically and histologically after an ultrasound-guided biopsy. A surgical strategy involving en bloc resection of the manubrium sterni, the internal ends of both clavicles, and the first two ribs, followed by sternal reconstruction using a synthetic manubrial plate and titanium costal staples without clavicular bridging, was indicated and executed.

CLINICAL DISCUSSION

This case outlines the surgical considerations and techniques adopted for this complex procedure, emphasizing the operative planning and interdisciplinary collaboration required for a successful outcome.

CONCLUSION

At 18 months post-surgery, the patient demonstrated favorable clinical and radiological progress, indicating a positive response to the treatment strategy employed.

Resection of Renal Cell and Prostate Carcinoma Sternum Metastases with Long-Term Follow-Up: A Report of 2 Cases

Introduction

Rarely solitary sternum metastases are addressed by resection. Two additional cases are presented as they are interesting because of their long-term follow-up.

Case Presentation

Case 1: A renal cell carcinoma was treated by transabdominal nephrectomy at age 64. Right iliac bone and sternum metastases were diagnosed 7 months later and treated by internal hemipelvectomy followed by sternum metastasectomy 6 weeks after the internal hemipelvectomy. At 12-year follow-up, the patient appears disease free. Case 2: Prostate cancer was treated by prostatectomy at age 67. A subsequent solitary sternum metastasis was resected 10 years later for persistent PSA-activity despite repeated radiotherapy. The patient remains asymptomatic for 3 years now.

Conclusion

Resection of sternum metastases may have curative potential and should be considered in tumours known to be rather resistant to chemo- and/or radiotherapy.

Anterior Chest Wall Reconstruction After Separation of Thoraco-Omphalopagus Conjoined Twins With Cadaveric Rib Grafts and Omental Flap

BACKGROUND

Anterior chest wall defects have a wide range of etiologies in the pediatric population, ranging from infection, tumor, and trauma to congenital diseases. The reconstructive goals include restoring skeletal stability, obliterating dead space, preserving cardiopulmonary mechanics, and protecting vital underlying mediastinal organs. Although various reconstructive methods have been described in the literature, selecting the optimal method is challenging for the growing pediatric skeleton. Here, we report a case of previously thoraco-omphalopagus twins who underwent successful separation and reconstruction and presented for definitive anterior chest wall reconstruction.

METHODS

A pair of previously thoraco-omphalopagus conjoined twins underwent definitive anterior chest wall defect reconstruction using cadaveric ribs and omental flap. Twin A received 2 cadaveric ribs, whereas twin B had a much larger sternal defect that required 3 cadaveric ribs combined with an omental flap for soft tissue chest coverage. Both twins were followed up for 8 months.

RESULTS

Twin A's postoperative course was uneventful, and she was discharged on postoperative day 6. Twin B's course was complicated, and she was discharged on supported ventilation on postoperative day 10. At 8 months postoperatively, both twins healed well, and chest radiographs confirmed the stability of the chest reconstructions. The rib grafts in the twin with a tracheostomy were not mobile, and the patient had a solid sternum with adequate pulmonary expansion. The construct initially did not facilitate pulmonary functioning, but after a healing process, it eventually allowed for the twin with the tracheostomy who required pulmonary assistance to no longer need this device.

CONCLUSIONS

Cryopreserved cadaveric ribs and omental flaps offer safe and reliable reconstructive methods to successfully reconstruct congenital anterior chest wall skeletal defects in the growing pediatric population. The involvement of multidisciplinary team care is key to optimizing the outcomes.

Interdisciplinary Treatment of Malignant Chest Wall Tumors

BACKGROUND

Chest wall resections for malignant chest wall tumors (MCWTs), particularly those with full-thickness chest wall involvement requiring reconstruction, present a therapeutic challenge for thoracic and plastic reconstructive surgeons. The purpose of this study was to review our experience with chest wall resection for primary and metastatic MCWTs, with a focus on perioperative outcomes and postoperative overall survival (OS).

METHODS

All patients who underwent surgical resection for primary and secondary MCWTs at our single institution between 2000 and 2019 were retrospectively analyzed.

RESULTS

A total of 42 patients (25 male, median age 60 years) operated upon with curative (n = 37, 88.1%) or palliative (n = 5, 11.9%) intent were reviewed. Some 33 (78%) MCWTs were of secondary origin. Chest wall reconstruction was required in 40 (95%) cases. A total of 13 (31%) patients had postoperative complications and one (2.3%) died perioperatively. The 5-year postoperative overall survival rate was 51.9%. The postoperative 5-year survival rate of 42.6% in patients with secondary MCWTs was significantly lower compared to the figure of 87.5% in patients with primary MCWTs.

CONCLUSIONS

In well-selected patients, chest wall resections for primary and secondary MCWTs are feasible and associated with good perioperative outcomes. For secondary MCWTs, surgery can also be performed with palliative intent.

New perspectives in prosthetic reconstruction in chest wall resection

The extension of chest wall resection for the treatment of primary and secondary tumours is still widely debated. The reconstructive strategy after extensive surgery is challenging as well as chest wall demolition itself. Reconstructive surgery aims to avoid respiratory failure and to guarantee intra-thoracic organs protection. The purpose of this review is to analyse the literature on this issue focusing on the planning strategy for chest wall reconstruction. This is a narrative review, reporting data from the most interesting studies on chest wall demolition and reconstruction. Representative surgical series on chest wall thoracic surgery were selected and described. We focused to identify the best reconstructive strategies analyzing employed materials, techniques of reconstruction, morbidity and mortality. Nowadays the new "bio-mimetic" materials in "rigid" and "non-rigid" chest wall systems reconstructive represent new horizons for the treatment of challenging thoracic diseases. Further prospective studies are warranted to identify new materials enhancing thoracic function after major thoracic excisions.

Oligometastatic breast cancer and metastasis-directed treatment: an aggressive multimodal approach to reach the cure

Metastatic breast cancer (BC) is considered an incurable disease and is usually treated with palliative intent. However, about 50% of metastatic BCs present with only a few metastatic lesions and are characterized by longer overall survival. These patients, defined as oligometastatic, could benefit from a multimodal approach, which combines systemic therapy with metastasis-directed treatment (stereotactic ablative therapy or surgery). The current definition of oligometastatic seems incomplete since it is based only on imaging findings and does not include biological features, and the majority of relevant data supporting this strategy comes from retrospective or non-randomized studies. However, the chance of reaching long-term complete remission or even a cure has led to the development of randomized trials investigating the impact of combined treatment in oligometastatic BC (OMBC). The SABR-COMET trial, the first randomized study to include BC patients, showed promising results from a combination of stereotactic ablative radiotherapy and systemic therapy. Considering the randomized trial's results, multidisciplinary teams should be set up to select OMBC patients who could achieve long-term survival with aggressive multimodal treatment.

Giant Sternal Chondrosarcoma in a 50-Year-Old Patient

Chondrosarcomas represent approximately 20% of primary malignant bone cancers, being known as the most frequent neoplasia of the anterior thoracic wall. In our case, we present a case of a primary sternal chondrosarcoma in a 50-year-old female patient that has been polychemiotherapy and radiotherapy treated for breast cancer. Despite the initial treated malignancy of breast cancer in the personal pathologic history of the patient, it was discovered that the sternal tumor was not a metastatic disease from the breast neoplasm. After multiple investigations, the patient was successfully treated for the sternal chondrosarcoma after a radical sternal resection with a chest wall reconstruction completed with two titanium plates that were anchored on the ribs and with the placement of methyl methacrylate mesh.

Oncological Outcome of Surgically Resected Sternal Tumors, 16 Years’ Experience

BACKGROUND: Tumors of the sternum are rare and can develop from primary bone pathology or through metastatic spread. Sternal resection with immediate reconstruction of the anterior chest wall defect was recommended for both primary and secondary sternal tumors as curative treatment. AIM: The purpose of our study was to examine the perioperative outcomes, recurrence rate, and OS in patients undergoing partial, subtotal, and total sternectomy. METHODS: We retrospectively reviewed our experience with sternal resections in 29 patients during a 16-year period. The purpose of our study was to examine the perioperative outcomes, recurrence rate, and overall survival (OS) in patients undergoing partial, subtotal, and total sternectomy. RESULTS: We found that 5-year OS was 26.0%, Univariate analysis of predictors of survival revealed that, there was a trend toward prolonged 5-year survival at R0 resection (35.5% vs. 0%, p = 0.058). Post resection defect size associated with prolonged 5-year OS (42.1% vs. 0%, p < 0.001). The absence of post-operative complications associated with prolonged 5-year OS (40.4% vs. 0%, p = 0.012), with special attention to absence of post-operative flail chest which was associated with prolonged 5-year OS (36.2% vs. 0%, p < 0.001). On multivariable analysis, R0 resection (HR, 3.692 [95% CI, 1.190–11.456], p = 0.024) and absence of post-operative flail chest (HR, 52.204 [95% CI, 5.908–461.289], p < 0.001) were associated with improved OS. CONCLUSIONS: We have shown that sternal resection of benign and primary malignant tumors can yield long-term survival. The completeness of resection and absence of postoperative flail chest are the strongest predictors of survival.

Treatment Strategies for Oligometastatic Breast Cancer

OPINION STATEMENT

Oligometastatic breast cancer, typically defined as the presence of 1-5 metastases, represents an intermediate state between locally advanced and widely metastatic disease. Emerging research suggests that oligometastatic cancer has a unique molecular signature distinct from widely metastatic disease, and that it carries a superior prognosis. Owing to its more limited capacity for widespread progression, oligometastatic disease may benefit from aggressive ablative therapy to known metastases. Options for ablation include surgical excision, radiofrequency ablation, and hypofractionated image-guided radiotherapy (HIGRT). The phase II SABR-COMET trial, which enrolled patients with oligometastatic disease of multiple histologies and randomized them to HIGRT vs. standard of care, found a notable survival advantage in favor of HIGRT. Other data suggest that HIGRT may synergize with immunotherapy by releasing powerful cytokines that increase anti-tumor immune surveillance and by recruiting tumor infiltrating lymphocytes, helping to overcome resistance to therapy. There are many ongoing trials exploring the role of ablative therapy, most notably HIGRT, with or without immunotherapy, for the treatment of oligometastatic breast cancer.We believe that patients with oligometastatic breast cancer should be offered enrollment on prospective clinical trials when possible. Outside the context of a clinical trial, we recommend that select patients with oligometastatic breast cancer be offered treatment with a curative approach, including ablative therapy to all sites of disease if it can be safely accomplished. Currently, selection criteria to consider for ablative therapy include longer disease-free interval from diagnosis to metastasis (>2 years), fewer metastases, and fewer involved organs. Undoubtedly, new data will refine or even upend our understanding of the definition and optimal management of oligometastatic disease.

Indications and Results of Sternal Allograft Transplantation: Learning From a Worldwide Experience

BACKGROUND

Reconstruction of the anterior chest wall defect after sternectomy is a challenge for cardiothoracic surgeons. In 2010, the Padua group published the first case of cadaveric sternum transplantation after sternectomy. This multicenter study reports the clinical indications and early and long-term results of sternal chondral allograft transplantation.

METHODS

This is a retrospective multicenter study from 7 academic centers. We collected demographic data, surgical indications, technical details, and early postoperative results. The complications, long-term stability, and tolerance of the allografts were also analyzed.

RESULTS

Between January 2008 and December 2019, 58 patients underwent sternectomy followed by reconstruction using cadaveric-cryopreserved sternochondral allografts. Thirty-two patients were male, median age 63.5 years (interquartile range, 50-72 years). Indications for sternectomy were secondary sternal tumors (n = 13), primary sternal tumors (n = 15), and nonneoplastic disease (n = 30). Thirty patients underwent total sternectomy, 16 lower-body sternectomy, and 12 upper-body manubrium resection. The 30-day mortality was 5%; overall morbidity was 31%. Six early reoperations were necessary because of bleeding (n = 1), titanium plate dislocation (n = 1), and resuture of the skin in the lower part of the incision (n = 4). Overall, 5-year survival was 74%. In all the survived patients, the reconstructions were stable and free from mechanical or infective complications.

CONCLUSIONS

The main indications for sternal allograft implantation were complex poststernotomy dehiscence followed by primary or secondary tumor involvement of the sternum. The collected results demonstrate that sternochondral allograft transplantation is a safe and effective method in reconstructing the anterior chest wall after sternectomy. Further studies to demonstrate the integration of the bone grafts into the patients' sternal wall will be made.

Percutaneous image-guided sternal biopsy: a cross-institutional retrospective review of diagnostic yield and safety in 50 cases

OBJECTIVE

Image-guided sternal biopsy may be technically daunting given the immediately subjacent critical structures. There is a paucity of literature describing technique, safety, and efficacy. This study aims to quantify the diagnostic yield and safety of image-guided sternal biopsies. Secondary aims include (1) describing the preferred approach/technique and (2) identifying imaging features and disease entities associated with higher and lower diagnostic yields.

MATERIALS AND METHODS

A retrospective review of 50 image-guided sternal biopsies performed at two quaternary care centers from 2000 to 2019 was performed. Recorded lesion-related variables included as follows: location, density, extraosseous extension, and size. Recorded variables from electronic medical records included as follows: patient demographics, histologic or microbiological diagnosis, and complications. Recorded technique-related variables included as follows: needle obliquity, type, and gauge; biopsy core number and length; and modality.

RESULTS

Of the 50 biopsies, 88.0% resulted in a definitive histologic diagnosis. Six biopsies were non-diagnostic. The majority of biopsies were performed under computed tomography (88.0%), followed by ultrasound (12.0%). Tumor was the most common biopsy indication (90.0%), followed by infection (10.0%). Of the diagnostic biopsies indicated for tumor, 88.9% were malignant. Seventy-four percent of the lesions were predominantly lytic. Fifty percent of lesions had extraosseous extension. Lesion locations were as follows: manubrium (48.0%), sternal body (48.0%), and sternomanubrial joint (4.0%). No minor or major, acute, or delayed procedure-related complications were encountered.

CONCLUSION

Image-guided sternal biopsy is an efficacious and safe method of obtaining a definitive histologic diagnosis regardless of lesion-specific features or location.

Excision of metastatic breast cancer from sternum and reconstruction in two patients with solitary metastatic spread

Metastatic breast carcinoma is a relatively common clinical entity. However, the prognosis of oligometastatic and polygometastatic disease differs considerably pertaining to five-year survival. Metastatic breast carcinoma to the sternum has been described as early as 1988. We describe two cases in our institution who presented with solitary sternal metastases with a previous history of treated breast cancer. In both cases, there had been a history of previous left breast cancer treated aggressively with surgical resection and adjuvant oncological therapy and maintenance hormonal therapy. Partial sternectomy or total sternectomy for solitary metastatic sternal deposits is well established with relatively low morbidity and mortality and improvement in quality of life and possible improvement in long-term survival. Furthermore, reconstructive options are inherently dependent on extent of resection performed. These techniques can incorporate the use of sternal plates in order to approximate defects and reinforce the sternum in the setting of partial sternectomy.

Sternal reconstruction with bone cement block using the rigid plate fixation technique

Chest computed tomography demonstrated a suspected primary tumor in the upper sternal body of a 48‐year‐old woman who presented with sternal pain. After being diagnosed with chondrosarcoma, she underwent sternal resection. Subsequent chest wall reconstruction was performed after careful planning using a bone cement block made of polypropylene mesh and polymethylmethacrylate. The block was fixed to the manubrium and ribs using the SternaLock System. She was discharged following an uneventful postoperative recovery, and is currently undergoing follow‐up.

Outcomes of Curative-Intent Treatment for Patients With Breast Cancer Presenting With Sternal or Mediastinal Involvement

PURPOSE

Optimal treatment of patients diagnosed with de novo metastatic breast cancer limited to the mediastinum or sternum has never been delineated. Herein, we sought to determine the efficacy of multimodality treatment, including metastasis-directed radiation therapy, in curing patients with this presentation.

METHODS AND MATERIALS

This is a single-institution retrospective cohort study of patients with de novo metastatic breast cancer treated from 2005 to 2014, with a 50-month median follow-up for the primary cohort. The primary patient cohort had metastasis limited to the mediastinum/sternum treated with curative intent (n = 35). We also included a cohort of patients with stage IIIC disease treated with curative intent (n = 244). Additional groups included a mediastinal/sternal palliative cohort (treatment did not include metastasis-directed radiation therapy; n = 14) and all other patients with de novo stage IV disease (palliative cohort; n = 1185). The primary study outcomes included locoregional recurrence-free survival (LRRFS), recurrence-free survival (RFS), and overall survival (OS), which were calculated using the Kaplan-Meier method. Cox multivariable models compared survival outcomes across treatment cohorts adjusted for molecular subtype, age, and race.

RESULTS

For the mediastinal/sternal curative-intent cohort, 5-year LRRFS was 85%, RFS was 52%, and OS was 63%. After adjustment, there was no statistically significant difference in LRRFS (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.13-1.13; P = .08), RFS (HR, 0.87; 95% CI 0.50-1.49; P = .61), or OS (HR, 0.79; 95% CI 0.44-1.43; P = .44) between the stage IIIC cohort and the mediastinal/sternal curative-intent cohort (referent). In contrast, RFS was worse for the mediastinal/sternal palliative cohort (HR, 2.29; 95% CI 1.05-5.00; P = .04). OS was worst for the de novo stage IV palliative cohort (HR, 2.61; 95% CI 1.50-4.53; P < .001).

CONCLUSIONS

For select patients presenting with breast cancer metastatic to the sternum and/or mediastinum, curative-intent treatment with chemotherapy, surgery, and radiation yields outcomes similar to those of stage IIIC disease and superior to de novo stage IV breast cancer treated with palliative intent.

Chest Wall Mechanics In Vivo With a New Custom-Made Three-Dimensional-Printed Sternal Prosthesis

PURPOSE

Reconstruction after sternal resection is performed according to surgeon intuition; physiologic evidence for selection of prostheses is lacking. We present our experience of the in vivo function of a novel device for sternal reconstruction.

DESCRIPTION

A three-dimensional-printed titanium and porous polyethylene sternal prosthesis was made according to the patient's computed tomographic scan. The titanium arms slot over adjacent ribs and are fixed in place with screws. The porous element allows ingrowth of native tissue while preventing lung herniation around the narrow titanium bars.

EVALUATION

We performed optoelectronic plethysmography to assess the physiologic function of the device compared with a muscle flap reconstruction. Asynchronous and paradoxical movements of the thoracoabdominal surface were apparent with the muscle flap reconstruction but not with the new device. Considerably higher tidal volumes and a lower respiratory rate achieved the same minute volume with the new device compared with the muscle flap.

CONCLUSIONS

Rigid sternal reconstruction with a three-dimensional-printed prosthesis demonstrated superior respiratory mechanics compared with reconstruction with an autologous muscle flap.

Sternal resection and reconstruction for metastasis due to breast cancer: the Marlex sandwich technique and implantation of a pedicled latissimus dorsi musculocutaneous flap

Background

The treatment of hemotogenous solitary sternal metastases by breast cancer remains a controversial issue. Sternal resection for select patients might provide good long-term local control.

Case presentation

A 63-year-old woman was admitted to our hospital with a mass at the sternum and right second to third costochondral cartilage. She had undergone bilateral mastectomy for breast cancer 13 years earlier. A percutaneous biopsy was performed, and the mass was diagnosed as solitary metastasis due to breast cancer. She received two courses of weekly paclitaxel and bevacizumab, and computed tomography (CT) revealed shrinking of the mass in the sternum. We performed surgical resection with curative intent for a multimodality approach. Parasternectomy and removal of the right second and third costochondral cartilage was performed. A prosthesis was created to fill the defect by sandwiching molded methylmethacrylate between polypropylene mesh. The prosthesis was fixed to the cut ends of the costochondral cartilage and the residual sternum. Finally, a harvested latissimus dorsi myoctaneous flap was transpositioned to cover the chest midline wound. Negative surgical margins at the stump of the sternum and costochondral cartilage were revealed.

Conclusion

Parasternal resection and reconstruction by the Marlex sandwich technique and implantation of a pedicled latissimus dorsi myocutaneous flap for metastasis due to breast cancer was safely performed.

Chest Wall Resection for Recurrent Breast Cancer in the Modern Era: A Systematic Review and Meta-analysis

OBJECTIVE

To review the literature on chest wall resection for recurrent breast cancer and evaluate overall survival (OS) and quality-of-life (QOL) outcomes.

BACKGROUND

Full-thickness chest wall resection for recurrent breast cancer is controversial, as historically these recurrences have been thought of as a harbinger of systemic disease.

METHODS

A systematic search in MEDLINE, EMBASE, and Cochrane CENTRAL identified 48 eligible studies, all retrospective, accounting for 1305 patients. The review is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary end points were patient-centered QOL outcomes and OS; secondary outcomes included disease-free survival (DFS) and 30-day morbidity. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies instrument and the Oxford Centre for Evidence-Based Medicine's levels of evidence tool. Random-effects meta-analysis was used to create pooled estimates. Meta-regressions and sensitivity analyses were used to explore study heterogeneity by age, year of publication, risk of bias, and surgical intent (curative vs palliative).

RESULTS

Studies consistently reported excellent OS and DFS in properly selected patients. Pooled estimates for 5-year OS in all studies and those from the past 15 years were 40.8% [95% confidence interval (CI) 35.2-46.7) and 43.1% (95% CI 35.8-50.7), whereas pooled 5-year DFS was 27.1% (95% CI 16.6-41.0). Eight studies reported excellent outcomes related to QOL. Mortality was consistently low (<1%) and 30-day pooled morbidity was 20.2% (95% CI 15.3%-26.3%). Study quality varied, and risk of selection bias in included studies was high.

CONCLUSIONS

Full-thickness chest wall resection can be performed with excellent survival and low morbidity. Few studies report on QOL; prospective studies should focus on patient-centered outcomes in this population.

Bone Metastasis of Breast Cancer

Bone is the most common site of metastasis for breast cancer. Bone metastasis significantly affects both quality of life and survival of the breast cancer patient. Clinically, complications secondary to bone metastasis include pain, pathologic fractures, spinal cord compression, and hypercalcemia of malignancy. Because bone metastasis is extremely common in patients with metastatic breast cancer, clinical management of bone metastases is an important and challenging aspect of treatment in the metastatic setting.The skeleton is a metabolically active organ system that undergoes continuous remodeling throughout life. A delicate balance of the bone-forming osteoblasts and bone-resorbing osteoclasts in the dynamic microenvironment of the skeleton maintains normal bone remodeling and integrity. The presence of metastatic lesions in bone disrupts the normal bone microenvironment and upsets the fine balance between the key components. The changes in the bone microenvironment then create a vicious cycle that further promotes bone destruction and tumor progression.Various therapeutic options are available for bone metastases of breast cancer. Treatment can be tailored for each patient and, often requires multiple therapeutic interventions. Commonly used modalities include local therapies such as surgery, radiation therapy and radiofrequency ablation (RFA) together with systemic therapies such as endocrine therapy, chemotherapy, monoclonal antibody-based therapy, bone-enhancing therapy and radioisotope therapy. Despite the use of various therapeutic modalities, bone metastases eventually become resistant to therapy, and disease progresses.In this chapter, we describe the clinical picture and biological mechanism of bone metastases in breast cancer. We also discuss known risk factors as well as detection and assessment of bone metastases. We present therapeutic options for bone metastasis using a multidisciplinary approach. Further, we describe future directions for bone metastasis management, focusing on novel bone-specific targeted therapies.

Sternal resection and reconstruction for secondary malignancies

Background

Limited data on sternal and/or anterior chest wall resections for secondary malignancies exist. The purpose of this study was to examine the perioperative outcomes and postoperative overall survival (OS) in patients who underwent sternal and/or anterior chest wall resections for secondary sternal tumors (SSTs).

Methods

A retrospective analysis of all patients who underwent resection of SSTs at single institution between 2000 and 2016 has been performed. OS was estimated using the Kaplan-Meier method.

Results

Ten patients underwent sternal and/or anterior chest wall resection for SSTs with curative (70%) or palliative (30%) intent. Two (20%) patients underwent complete and 8 (80%) partial sternal and/or anterior chest wall resection. There were no perioperative deaths, major complications occurred in 3 (30%) patients. Tumor resection was complete (R0) in 5 (50%) patients. The 5-year OS rate was 40%. No OS difference in R0 vs. R1 resections was observed.

Conclusions

Sternal and/or anterior chest wall resections for SSTs can be performed with low morbidity and mortality. Complete SST resection does not assure favorable OS. Sternal resections can be considered palliative treatment option in patients with stable stage IV disease with isolated sternal involvement.

Mechanical behavior of a total chest wall prosthesis with rib-like features

The Department of Thoracic Surgery of the National Institute of Cancer in Milan developed a new rib-cage prosthesis which tries to combine flexibility, protection and bio-compatibility. This new replacement concept has been implanted in many patients, showing cheering results in term of reconstructions simplicity, postoperative complications reduction and patients comfort. This paper investigates and discusses in detail the mechanical behavior of the innovative rib cage prosthesis. Mechanical strength and stiffness are numerically evaluated in order to asses its limits and if it is fully compatible with patients 'normal' life.

Short and long-term results of sternectomy for sternal tumours

Background

We analyzed our experience in sternal resections (SRs) for primary or secondary neoplasm focusing on technical aspects of reconstruction, post-operative outcomes and long term survival.

Methods

From January 2005 to December 2015, 36 patients (24 males, 67%) underwent surgical excision of primary (chondrosarcoma n=18 patients, 50%; osteosarcoma n=2, 6%; Ewing sarcoma n=1, 3%; other n=2, 6%) or secondary (breast cancer n=7, 19%; kidney carcinoma n=2, 6%) sternal tumour. We performed n=30 partial sternectomy and n=6 total sternectomy with en-bloc resection of the sternocostal cartilages in all patient and extended resection in 7 patients. Stability was obtained with prosthetic material, rigid and non-rigid and a muscular flap: rigid material [Strasbourg Thoracic Osteosynthesis System (STRATOS), MedXpert GmbH] and muscle flap n=11 (30.6%); polytetrafluoroethylene patch and muscle flap n=6 (16.7%); muscle flap alone n=19 (52.8%).

Results

The 30-day mortality rate was 0, overall complication rate was 19%. The median ICU stay was 1.5 days and mean hospital stay was 10.6±5.9 days. We obtained a complete (R0) resection in all patients. Overall survival (OS) at 5 and 10 years were 59% and 40%; in the group of primary neoplasm OS rate at 5 and 10 years was 79% and 54%. Disease free survival (DFS) rate at 5 years was 61%. Higher grading was identified as negative prognostic factor.

Conclusions

Wide radical resections of anterior chest wall are basilar in a multimodality treatment for primary or metastatic neoplasm of the sternum. Stabilization with titanium bars and clips provides rigidity of chest wall with good functional results.

Percutaneous CT-guided sternal biopsy: factors affecting the diagnostic yield

Background Sternal lesions are occasionally seen in clinical practice and their diagnosis can be important, especially for oncologic patients. However, percutaneous computed tomography (CT)-guided biopsy of sternal lesions is rarely performed. Purpose To assess the diagnostic yield of percutaneous CT-guided sternal biopsies and to analyze the factors that affect diagnostic yield. Material and Methods A retrospective review of 34 patients who underwent CT-guided sternal biopsy was carried out at a single institution. Pre-biopsy CT density, location, penetration length of biopsy needle, number of biopsy attempts, angle of needle approach, final diagnosis, and operator experience level were recorded. A biopsy was considered as diagnostic if it provided a confident pathologic result. All variables were compared using Chi-square tests. Results Twenty-two of the 34 (64.7%) biopsy procedures yielded a diagnostic sample and 12 (35.3%) were non-diagnostic. Eight participants in the non-diagnostic group were clinically diagnosed with inflammatory arthritis of the manubriosternal or costosternal joints. Longer penetration distance of the tumor by the biopsy needle showed higher diagnostic yield ( P = 0.031). Osteoblastic lesions ( P < 0.001), lesions in the manubriosternal joint ( P = 0.018) and approaches using more obtuse angles ( P = 0.009) were associated with significantly lower diagnostic yields. Malignancy in the final diagnosis led to a higher diagnostic yield than benign lesions ( P < 0.001). Conclusion CT-guided percutaneous sternal biopsy has a relatively lower diagnostic yield. However, acute angle of needle approach may help increase biopsy success rate. Osteoblastic lesions and lesions in the manubriosternal joint tend to have lower diagnostic yield.

Massive chest wall resection and reconstruction for malignant disease

Objective

Malignant chest wall tumors are rare neoplasms. Resection with wide-free margins is an important prognostic factor, and massive chest wall resection and reconstruction are often necessary. A recent case series of 20 consecutive patients is reported in order to find any possible correlation between tumor histology, extent of resection, type of reconstruction, and adjuvant treatment with short- and long-term outcomes.

Methods

Twenty patients were submitted to chest wall resection and reconstruction for malignant chest wall neoplasms between 2006 and 2014. The mean age (ten males) was 59±4 years. The size and histology of the tumor, the technique of reconstruction, and the short- and long-term follow-up records were noted.

Results

The median maximum diameter of tumors was 10 cm (5.4–32 cm). Subtotal sternal resection was performed in nine cases, and the resection of multiple ribs was performed in eleven cases. The median area of chest wall defect was 108 cm² (60–340 cm²). Histology revealed soft tissue, bone, and cartilage sarcomas in 16 cases (80%), most of them chondrosarcomas. The rest of the tumors was metastatic tumors in two cases and localized malignant pleural mesothelioma and non-Hodgkin lymphoma in one case. The chest wall defect was reconstructed by using the “sandwich technique” (propylene mesh/methyl methacrylate/propylene mesh) in nine cases of large anterior defects or by using a 2 mm polytetrafluoroethylene (e-PTFE) mesh in nine cases of lateral or posterior defects. Support from a plastic surgeon was necessary to cover the full-thickness chest wall defects in seven cases. Adjuvant oncologic treatment was administered in 13 patients. Local recurrences were observed in five cases where surgical reintervention was finally necessary in two cases. Recurrences were associated with larger tumors, histology of malignant fibrous histiocytoma, and initial incomplete resection or misdiagnosis made by nonthoracic surgeons. Three patients died during the study period because of recurrent disease or complications of treatment for recurrent disease.

Conclusion

Chest wall tumors are in their majority mesenchymal neoplasms, which often require major chest wall resection for their eradication. Long-term survival is expected in low-grade tumors where a radical resection is achieved, while big tumors and histology of malignant fibrous histiocytoma are connected with the increase rate of recurrence.

Post-operative pulmonary and shoulder function after sternal reconstruction for patients with chest wall sarcomas

BACKGROUND

Sternal resection is occasionally required for patients with malignant tumors, particularly sarcomas, in the sternal region. Few reports have described post-operative respiratory and shoulder function after sternal resection for patients with bone and soft-tissue sarcomas.

METHODS

Eight consecutive patients with bone and soft tissue sarcomas requiring sternal resection were the focus of this study. Chest wall was reconstructed with a non-rigid or semi-rigid prosthesis combined, in most cases, with soft tissue flap reconstruction. Clinical outcomes investigated included complications, shoulder function, evaluated with Musculoskeletal Tumor Society-International Symposium of Limb Salvage system, and respiratory function, evaluated by use of spirometry.

RESULTS

The anterior chest wall was reconstructed with non-rigid strings for 3 patients and with polypropylene mesh for 5. There were no severe post-operative complications, for example surgical site infection or pneumonia. All 3 patients with non-rigid reconstruction experienced paradoxical breathing, whereas none with polypropylene mesh did so. Post-operatively, FEV(1)% was unchanged but %VC was significantly reduced (p = 0.01), irrespective of the reconstruction method used (strings or polypropylene mesh). Shoulder function was not impaired.

CONCLUSIONS

Among patients undergoing sternal resection, post-operative shoulder function was excellent. Pulmonary function was slightly restricted, but not sufficiently so to interfere with the activities of daily living (ADL). Paradoxical breathing is a slight concern for non-rigid reconstruction.

En bloc spondylectomy combined with chest wall excision for spinal tumor via a modified posterior approach: a retrospective study on 21 patients

OBJECTIVE

This study was to investigate the feasibility and efficacy of total en bloc spondylectomy (TES) combined with chest wall excision through a modified posterior approach in treating the patients with thoracic spinal tumor and posterior chest wall invasion.

METHODS

Clinical data of 21 consecutive patients (7 males, 14 females; average age: 41.5, range: 20-69) who underwent the combined TES and chest wall excision through a modified posterior approach from 08/2005 to 01/2014 were retrospectively analyzed. Reconstruction of the spinal defect following TES was accomplished by dorsal stabilization and carbon cage interposition. All resected specimens were examined histologically. Radiotherapy and chemotherapy were performed according to the results of the surgery and histological examination. All patients were followed up on a regular basis.

RESULTS

The surgery was successfully performed in all patients. Histological analysis revealed primary malignant tumors in 16 patients and solitary vertebral metastases in 5 patients. Three patients with preoperative neurologic deficits of Frankel D recovered to Frankel E 1-3 weeks postoperatively. After the mean follow-up of 31 months (9-70), the 16 patients (16/21, 76.2%) with primary bone tumors were free of recurrence and present no evidence of disease. Four cases (4/21, 19%) with metastatic tumor developed recurrence or distant metastases. Three patients presented with cerebrospinal fluid leakage and one patient suffered pneumonia; they were soon recovered after treatment. No other complications were observed.

CONCLUSION

The results suggest that the combined TES with chest wall excision via a modified posterior approach seems feasible and effective for treating patients with thoracic spinal tumor and posterior chest wall invasion.

Resection of Primary and Secondary Tumors of the Sternum: An Analysis of Prognostic Variables

BACKGROUND

We sought to determine the prognostic variables associated with overall survival (OS) and recurrence-free probability (RFP) in patients with primary and secondary sternal tumors treated with surgical resection.

METHODS

A retrospective analysis of patients who underwent resection of primary or secondary sternal tumors at 2 cancer institutes between 1995 and 2013 was performed. OS and RFP were estimated using the Kaplan-Meier method, and predictors of OS and RFP were analyzed using the Cox proportional hazards model.

RESULTS

Sternal resection was performed in 78 patients with curative (67 [86%]) or palliative (6 [8%]) intent. Seventy-three patients (94%) had malignant tumors, of which 28 (36%) were primary and 45 (57%) were secondary malignancies. Sternal resections were complete in 13 patients (17%) and partial in 65 (83%). There were no perioperative deaths, and grade III/IV complications were noted in 17 patients (22%). The 5-year OS was 80% for patients with primary malignant tumors, 73% for patients with nonbreast secondary malignant tumors, and 58% for patients with breast tumors (p = 0.85). In the overall cohort, R0 resection was associated with prolonged 5-year OS (84% vs 20%) on univariate (p = 0.004) and multivariate (adjusted hazard ratio, 3.37; p = 0.029) analysis. On subgroup analysis, R0 resection was associated with improved OS and RFP only for patients with primary malignant tumors.

CONCLUSIONS

Sternal resection can achieve favorable OS for patients with primary and secondary sternal tumors. R0 resection is associated with improved 5-year OS and RFP in patients with primary malignant tumors. We did not detect a similar effect in patients with breast or nonbreast secondary tumors.

Autogenous rib grafts for reconstruction of the manubrium after resection: technical refinements and outcomes

OBJECTIVE

Sternal reconstruction after resection is essential for restoring the rigidity of the chest cavity. However, no consensus has been reached regarding the most physiologic or efficacious material for this procedure. We present our clinical experience with autogenous rib grafts for reconstruction of the manubrium after resection and discuss the refinements in this procedure.

METHODS

Twelve consecutive patients with a confirmed diagnosis of a primary neoplasm in the manubrium between March 2003 and August 2013 were analyzed retrospectively. All patients underwent manubrium resection and immediate reconstruction with autogenous rib grafts.

RESULTS

No cases of perioperative mortality were noted. The median operation time was 129 minutes. One patient experienced mild paradoxical movement; the other patients recovered well without any complications. The median follow-up period after surgery was 69 months. Two patients died. One patient with chondrosarcoma died as a result of cardiac disease 26 months after surgery and another patient with non-Hodgkin lymphoma died as a result of local recurrence 6 months after surgery. Computed tomographic scans for the other 10 patients have shown neither dislocation nor abnormality of the transplanted ribs; moreover, no absorption of the grafts or recurrence was noted. None of the patients required prescription analgesics for the pain at the donor site at the 3-month follow-up visit.

CONCLUSIONS

This case series demonstrates the successful use of autogenous rib grafts in the reconstruction of the manubrium after resection. We consider that the reconstruction technique is a safe and effective alternative to a complex problem.

Stable construction of the sternum after broad radical resection of malignant tumours

Radical resection of primary or solitary secondary malignant sternal tumours is indicated in patients without metastases. Sternal reconstruction may be indicated in large defects to prevent pulmonary complications, to achieve protection of intra-thoracic organs and to obtain a good aesthetic result. In this article, a modified surgical technique is described to fill and reconstruct large defects after radical resection of a primary or secondary malignant sternal tumour. The technique makes use of a methyl methacrylate composite within two layers of polypropylene mesh enforced by steel wires through the sternal ends of the defect enhancing stability. This modified technique can be easily applied, making curative broad radical resections of the sternum feasible.

Chondrosarcoma from the sternum: reconstruction with titanium mesh and a transverse rectus abdominis myocutaneous flap after subtotal sternal excision

BACKGROUND

Chondrosarcoma arising from the sternum is extremely rare and is often untreatable. Removal of the sternum for malignant tumor results in large defects in bone and soft tissue, causing deformity and paradoxical movement of the chest wall and making subsequent repair of the thorax very important. We report a very rare patient with a chondrosarcoma of the sternum who underwent case chest wall resection, followed by reconstruction using a titanium mesh covered with a transverse rectus abdominis myocutaneous (TRAM) flap.

CASE REPORT

A 63-year-old man was referred to our hospital with progressively enlarged swelling of his anterior chest wall. Physical examination showed a 2.5×2.0 cm mass fixed to the sternum, which was diagnosed as a chondrosarcoma based on clinical findings, imaging characteristics and incision biopsy results. The patient underwent a subtotal sternal and chest wall resection to remove the tumor, followed by reconstruction with a titanium mesh and a TRAM flap. There were no complications associated with surgery.

CONCLUSIONS

We report an extremely rare case of a patient who underwent subtotal sternal resection, followed by reconstruction, for a large chondrosarcoma. The elasticity and rigidity provided by the titanium mesh and the complete coverage of the surgical wound by a TRAM flap suggest that these procedures may be useful in reconstructing large defects in the chest wall.

An alternative technique for anterior chest wall reconstruction: the sternal allograft transplantation

OBJECTIVES

Sternal resection is indicated for a variety of pathological conditions, mainly neoplastic or related to sternotomy complications. Resection of the sternum generally leaves a large chest-wall defect, and reconstruction is thus the most difficult part of the operation. Correct stabilization of the anterior chest wall is very important to avoid secondary complications and respiratory failure. In the last few years, different technical solutions have been used to reconstruct the sternum. We describe our technique using a sternal allograft to reconstruct the anterior chest wall after partial or complete sternal resection.

METHODS

Between June 2010 and February 2012, four patients underwent sternectomy followed by anterior chest wall reconstruction using sternal allograft. The sternal allograft was harvested from a multitissue donor following Italian legislation for tissue donation. Three patients had neoplastic involvement of the sternum, and one had a complete sternal defect as a complication of a cardiac operation.

RESULTS

We had no operative mortality. Three patients underwent partial sternal transplantation, and one underwent total sternal replacement. We had no postoperative respiratory insufficiency, infections or mechanical failure of the reconstructions. The respiratory function was preserved in all patients. The follow-up period was free from complications related to the sternal allograft implantation.

CONCLUSIONS

The technique of sternal allograft transplantation is simple, reproducible and provides excellent functional and cosmetic results. Further studies including a larger number of patients are needed to understand the biology of the allograft and the long-term results of this technique.

The "rib-like" technique for surgical treatment of sternal tumors: lessons learned from 101 consecutive cases

BACKGROUND

Sternal tumors represent a rare subgroup of chest wall neoplasms in which indication, surgical issues, and long-term results are rarely reported. Thus, in this study we reevaluated our experience in sternal replacement from a series of 101 consecutive cases during the last 30 years.

METHODS

Clinical records of patients who underwent sternal resection between January 1980 and December 2008 were reviewed. The technique of reconstruction after sternectomy varied over time, including mesh replacement in 52 patients (group A), rigid prosthesis in 27 patients (group B), and the "rib-like" technique, a semi-rigid tridimensional prosthesis reproducing the shape of native ribs, in 22 patients (group C). Postoperative outcomes and long-term survival were analyzed.

RESULTS

Of 101 patients, 42 underwent resection for primary chest wall tumors, 30 for breast cancer, 15 for locally advanced tumors, 11 for metastatic disease, and 3 for benign disease. One patient died postoperatively. The overall major complications rate was similar between groups. Local infection required prosthetic removal in 7 patients of groups A and B (9%). No infection occurred in group C (p = 0.02). Median survival exceeded 60 months for primary sternal tumors and 22 months for other cancer (p = 0.01). The worst survival was recorded in radioinduced sarcoma (17 months) and in patients who underwent previous resection before salvage sternectomy (18 months).

CONCLUSIONS

Results from this study showed that an adequate sternal resection should be done at the first operation and that improving prosthetic integration with surrounding tissues may reduce the local complication rate.

Improvement of survival and prospect of cure in patients with metastatic breast cancer

Patients with metastatic breast cancer have traditionally been considered incurable with conventional treatment. However, 5-10% of those patients survive more than 5 years, and 2-5% survive more than 10 years. Recent studies suggest that the survival of patients with metastatic breast cancer has been slowly improving. In this review, we examine the possible curative approach for a certain group of patients with metastatic breast cancer. We identify that patients most likely to benefit from such an aggressive approach are young and have good performance status, adequate body functional reserve, long disease-free interval before recurrence, oligometastatic disease, and low systemic tumor load. An aggressive multidisciplinary approach including both local treatment of macroscopic disease and systemic treatment of microscopic disease can result in prolonged disease control in certain patients with metastatic breast cancer. Whether patients with prolonged disease control are "cured" remains controversial.

Isolated sternal involvement in breast cancer: is it truly stage IV disease?

PURPOSE

There is no consensus regarding treatment for patients with breast cancer and isolated sternal involvement. Though classified as AJCC stage IV, this group of patients may have prolonged distant disease free survival.

PATIENTS AND METHODS

Retrospective case series of 8 patients with isolated sternal recurrence. Information regarding age, menopausal status, hormonal receptor status, HER2 status, initial treatment, time to sternal recurrence, treatment of sternal involvement, and outcome was obtained.

RESULTS

Median follow-up, 6 years. Seven of 8 diagnosed with metachronous sternal recurrence at a median of 3 years from initial breast cancer diagnosis, 1 with sternal involvement at initial diagnosis. Seven of 8 are alive, with one death from metastatic breast cancer 10 years after sternal recurrence. Six of 8 are without evidence of distant spread, 2 in continuous complete remission (CR) at 7 and 14 years from sternal recurrence.

CONCLUSION

While a small cohort, the excellent survival of the group identifies this as a distinct subset of metastatic disease, requiring special treatment considerations. Isolated sternal involvement could represent direct local-regional extension rather than systemic spread.

The prognostic factors of chest wall metastasis resection

OBJECTIVE

Limited data exist regarding the outcomes after resection of pure hematogenous chest wall (CW) metastases. Therefore, we reviewed our 17 years' experience to determine clinically relevant factors.

METHODS

A retrospective review of all patients who underwent CW metastasectomy (other than breast cancer) from October 1991 to August 2008 at a single institution was performed. Post-CW metastasectomy survival curves were estimated by the Kaplan-Meier method and compared using log-rank test. Factors predictive of improved survival were determined by univariable and multivariable Cox proportional hazard regression analysis.

RESULTS

A total of 90 CW metastasectomies were performed on 79 patients (33 females and 46 males). The median follow-up period was 25.6 months. Operative mortality was 1.1%. The 5-year survival was 40%. Significant factors after multivariable analysis were margin status, histology, and a history of heavy smoking (≥ 20 pack years). Microscopically positive margin (P=0.01; hazard ratio (HR) 2.85; 95% confidence interval (CI) 1.28-6.35) and grossly positive margin (P<0.01; HR 9.55; 95% CI 2.60-35.1) fared worse. Compared with carcinoma, sarcoma (P<0.01; HR 3.9; 95% CI 1.7-9.2) and melanoma (P<0.01; HR 6.4; 95% CI 1.7-24) had worse survival. A history of heavy smoking diminished survival (P<0.01; HR 3.7; 95% CI 1.6-8.4).

CONCLUSIONS

The resection of CW metastases in highly selected patients as a part of multimodality treatment has low risk and is associated with prolonged survival. The margin status and histology are significant factors in the survival after CW metastasectomy. In addition, heavy smoking history also has a significant negative impact on survival.