The sternum reconstruction: Present and future perspectives

Sternal resection and reconstruction: a review

Sternal resection and reconstruction is a rare but sometimes challenging procedure due to its profound anatomical and functional implications. For these reasons, an adequate preoperative evaluation is crucial in each patient, especially when we are faced with malignant lesions that sometimes require extensive radical resections, thus demanding an integrated reconstructive strategy that allows stabilizing the chest wall, protecting the underlying mediastinum and minimize resulting deformity. The large number of available reconstruction techniques and the lack of quality studies for their analysis mean that sternal reconstruction depends to a great extent on the consensus of experts or, more frequently, on the simple preference of each surgical team. This article aims to provide an overview of sternal resection and reconstruction. Indications for partial versus total or subtotal sternectomy are suggested and their surgical and oncological outcomes are presented. The use of rigid or semi-rigid prostheses is an ongoing debate, although recent functional data advise reserving rigid reconstructions for extensive defects. Sternectomy for primary tumors or local tumor involvement has a good prognosis with an overall survival of 5 and 10 years: 67% and 58%, respectively, provided that a radical resection with free surgical margins is performed. Breast cancer is the most common secondary sternal tumor, and surgery can offer 5-year overall survival ranging from 20% to 50% provided an R0 resection is achieved, although radical surgery does not appear to decrease rates. of recurrence. Metastases of origin other than the breast give the worst results (less than 40% at 36 months and 0% at 5 years) and although the data available on these cases are limited, the radicality of the resection does not seem to modify the survival or recurrence rates, so a conservative approach is probably more appropriate.

Sternum Metastases: From Case-Identifying Strategy to Multidisciplinary Management

We aimed to overview the most recent data on sternal metastases from a multidisciplinary approach (diagnosis strategies, outcome, and histological reports). This narrative review based on a PubMed search (between January 2020 and 22 July 2023) using key words such as "sternal", "manubrium", and "metastasis" within the title and/or abstract only included original papers that specifically addressed secondary sternal spreading of cancer in adults, for a total of 48 original articles (14 studies and 34 single case reports). A prior unpublished case in point is also introduced (percutaneous incisional biopsy was used to address a 10 cm sternal tumour upon first admission on an apparently healthy male). The studies (n = 14) may be classified into one of three groups: studies addressing the incidence of bone metastases (including sternum) amid different primary cancers, such as prostate cancer (N = 122 with bone metastases, 83% of them with chest wall metastases), head and neck cancers (N = 3620, 0.8% with bone metastases, and 10.34% of this subgroup with sternum involvement); and glioblastoma (N = 92 with bone metastases, 37% of them with non-vertebral metastases, including the sternum); assessment cohorts, including breast cancer (N = 410; accuracy and sensitivity of PET/CT vs. bone scintigraphy is superior with concern to sternum spreading) and bone metastases of unknown origin (N = 83, including a subgroup with sternum metastases; some features of PET/CT help the differentiation with multiple myeloma); and cohorts with various therapeutic approaches, such as palliative arterial embolization (N = 10), thymic neuroendocrine neoplasia (1/5 detected with sternum metastases), survival rates for sternum metastases vs. non-sternum chest wall involvement (N = 87), oligo-metastatic (sternal) breast cancer (3 studies, N = 16 for all of them), oligo-metastatic head and neck cancer (N = 81), conformal radiotherapy (N = 24,215, including an analysis on sternum spreading), and EBRT followed by MR-HIFU (N = 6). Core data coming from the isolated case reports (N = 34) showed a female to male ratio of 1.6; the females' ages were between 34 and 80 (mean of 57.28) and the males' ages varied between 33 and 79 (average of 58.78) years. The originating tumour profile revealed that the most frequent types were mammary (N = 8, all females) and thyroid (N = 9, both women and men), followed by bladder (N = 3), lung (N = 2), and kidney (N = 2). There was also one case for each of the following: adenoid cystic carcinoma of the jaw, malignant melanoma, caecum MiNEN, a brain and an extracranial meningioma, tongue carcinoma, cholangiocarcinoma, osteosarcoma, and hepatocellular carcinoma. To our knowledge, this is the most complex and the largest analysis of prior published data within the time frame of our methods. These data open up new perspectives of this intricate, dynamic, and challenging domain of sternum metastases. Awareness is a mandatory factor since the patients may have a complex multidisciplinary medical and/or surgical background or they are admitted for the first time with this condition; thus, the convolute puzzle will start from this newly detected sternal lump. Abbreviations: N = number of patients; n = number of studies; PET/CT = positron emission tomography/computed tomography; EVRT = external beam radiotherapy; MR-HIFU = magnetic resonance-guided high-intensity focused ultrasound; MiNEN = mixed neuroendocrine-non-neuroendocrine tumour.