Sternal resection and reconstruction for primary malignant tumors

BACKGROUND: Primary malignant sternal tumors (PMST) are locally aggressive and their optimal surgical management still continues to evolve. METHODS: From 1986 to 2002, 38 patients (25 females/13 males) underwent radical resection of PMST. This series included 33 sarcomas, 17 of which had been radiation-induced, 3 hematologic tumors, and 2 carcinomas. Seventeen were high-grade tumors. Nine patients had received preoperative chemotherapy. Twelve patients required extensive skin excision. Eight total, seven subtotal, and 23 partial sternectomies were performed. Resection was extended to the anterior chest-wall in 4 patients, lung in 4, brachiocephalic vein in 3, superior vena cava in 2, and pericardium in 1. In 36 patients, chest wall stability was obtained by Marlex (n = 21) or Vicryl (n = 2) mesh and polytetrafluoroethylene patch (n = 13), with methylmethacrylate reinforcement in 12 patients. Soft tissue coverage was done by the pectoralis major muscles with skin advancement in 25 patients, a myocutaneous flap in 11, a breast transposition in 1, and a skin flap in 1. Omentoplasty was performed in 3 patients. RESULTS: One patient died from pneumonia. Two patients needed a tracheostomy after total sternectomy. No flap-related complication was observed. Four local septic complications required removal of the composite prosthesis with reoperations. Local recurrence occurred in 9 patients, 7 patients having a repeat resection. Metastases developed in eight. The 5-year overall and disease-free survival was 66% and 53%, respectively. The histologic grade of sarcomas was a survival predictor (high grade versus others p = 0.035). CONCLUSIONS: Wide resection of PMST is necessary to minimize local recurrence. Large sternal defects are safely reconstructed with a musculocutaneous flap. We suggest that the use of methylmethacrylate should be limited to reconstruction after total sternectomy.