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InternationalJournalofSurgeryCaseReports63(2019)125–128
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International
Journal
of
Surgery
Case
Reports
j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m
Can
surgery
relieve
pain
and
act
as
first-line
treatment
for
a
large
metastasis
of
the
sternum?
Beatrice
Manfredini
a,
Uliano
Morandi
a,
Giorgio
De
Santis
b,
Fabio
Catani
c,
Alessandro
Stefani
a,
Massimo
Pinelli
b,
Alessio
Baccarani
b,
Marta
Starnoni
b,
Fabrizio
Artioli
d,
Beatrice
Aramini
a,∗aDivisionofThoracicSurgery,DepartmentofMedicalandSurgicalSciencesforChildren&Adults,UniversityofModenaandReggioEmilia,Modena,Italy bDivisionofPlasticSurgery,DepartmentofMedicalandSurgicalSciencesforChildren&Adults,UniversityofModenaandReggioEmilia,Modena,Italy cOrthopaedicsandTraumatologyDepartment,UniversityofModenaandReggioEmilia,Modena,Italy
dDivisionofMedicalOncology,RamazziniHospital,Carpi,Modena,Italy
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received19August2019 Accepted19September2019 Availableonline24September2019 Keywords:
Clear-cellrenalcarcinomametastasis Sternalmetastasis
Gore-texmesh
a
b
s
t
r
a
c
t
BACKGROUND:Therearefewpaperspublishedonsternalmetastasisfromrenalcellcarcinoma.The unifyingelementistheoperabilityofthesternalmetastasisifitistheonlysiteofmetastasis,onthe operabilityoftheprimarysiteofthetumorandonthepatient’shealthconditions.
PRESENTATIONOFTHECASE:Wepresentacaseofa66-years-oldmanundergonesternalresectionfor alargepainfulmetastasis.Hewaspreviouslyundergoneleftnephrectomyforclearcellscarcinoma. Enblocresectionofthesternalmanubriumandrightclaviclewasperformed,aGore-Texmeshwas placed.Histologyconfirmedmetastasisofkidneyclearcellscarcinoma.Patientwasdischargedwithno complicationsandnopain.ChestCTatsixmonthsfollowupwasnegativeforrecurrence.
DISCUSSIONANDCONCLUSION:Wehighlightedtheimportanceofsurgeryaspossiblefirst-linetreatment insymptomaticlargesternummetastasis.Therefore,prospectivestudiesshouldbeconsideredtoconfirm ourstrategy.
©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
1. Introduction
Renalcellcarcinoma(RCC)isthemostfrequenttypeofrenal tumorinadultsand isderivedfromtheepitheliumoftherenal tubules[1–3].Thesternummetastasisisarelativelyraresiteandit oftenmanifestsasswellingofthesternalregion,painorasensation oftension[4,5].Therearefewpaperspublishedonsternal metas-tasisofrenalcellcarcinoma[1–8].Aimofourreportistodescribe acase ofalargeand painfultumormassinfiltratingthesternal manubrium,undergoneradiotherapy forreducing pain withno resolution.Hewasthenundergonesurgery.Norecurrenceafter 6monthsaftersurgerywasnoted.Wehighlightedthepossibility toconsidersurgeryaspossiblefirstlinetreatmentinpatientswith symptomaticmetastaticcancerofthesternum.
∗ Correspondingauthorat:DivisionofThoracicSurgery,Departmentof Medi-calandSurgicalSciencesforChildren&Adults,UniversityHospitalofModenaand ReggioEmilia,ViaLargodelPozzo,71,ZIP:41124,Modena,Italy.
E-mailaddresses:beatrice.manfredini91@gmail.com(B.Manfredini),
uliano.morandi@unimore.it(U.Morandi),giorgio.desantis@unimore.it
(G.DeSantis),fabio.catani@unimore.it(F.Catani),alessandro.stefani@unimore.it
(A.Stefani),massimo.pinelli@unimore.it(M.Pinelli),alessio.baccarani@unimore.it
(A.Baccarani),martastarn@unimore.it(M.Starnoni),f.artioli@ausl.mo.it(F.Artioli),
beatrice.aramini@unimore.it(B.Aramini).
2. Clinicalcase
A 66-year-oldmale patient wasexamined in July2018 due topainful swelling withincreasedconsistencyin theleft para-median sternum at the level of the manubrium. In November 2018a chest-abdominalcomputed tomographydocumentedan infiltrating neoformation of the manubrium of the sternum of 54×40mm(Fig.1A–C),andan8mmneoformationintheleft kid-ney.Abiopsyofthekidneyconfirmedthemalignancyofthemass, anda leftnephrectomywasperformed.InDecember2018,due totheincreasingofsizeofthesternalmass(Fig.2AandB)and morepain,anecho-guided needlebiopsyconfirmedthe metas-tasisofclearcellrenalcarcinoma.Firstly,thepatientunderwent 30Gytranscutaneousradiotherapy.Afterradiation,18FFGDPET-CT
showedahypermetabolicpositivityonlyatthelevelofthesternal massandanincreasedsize(108×80×90mm).Duetopersistent pain,amultidisciplinaryteamrecommendedsurgerytoremove thesterno-costo-clavicularmetastasis.
3. Operationtechnique
Acervicotomyandamedialsuprasternallongitudinalincisionto thedistalthirdofthesternalbodywereperformed.Thesofttissue flapsweredetachedstartingwithacervicotomyandprogressing
https://doi.org/10.1016/j.ijscr.2019.09.022
2210-2612/©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.
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126 B.Manfredini,U.Morandi,G.DeSantisetal./InternationalJournalofSurgeryCaseReports63(2019)125–128
Fig.1.Radiologicalassessmentbeforeandaftersurgery.A-B-C.ChestCTofthesternalmetastasis.Fig.1Bshowsaclearinfiltrationofthemanubrium.Fig.1D.Chestx-ray after2daysfromsurgery.Fig.1E.Chestx-rayafter6monthsfromsurgery.
toasternotomytoexposethemassivesternocostoclavicularlesion (Fig.3AandB).Oncethesternumwasisolated,weproceededto thecross-sectionatthebodylevelcorrespondingtotheinsertion oftherightthirdribwithaGiglisawandthesamemaneuverwas performedattheinsertionofthesecondandthirdleftribs(Fig.3B). Weperformedadigitalisolationofthesternalinsertionofboth theclavicleandfirstrib,protectingthemediastinalvascularplane, proceedingwiththeinitialsectionoftheleftfirstribandclavicula. Aspecularmaneuverontherightside.
Afterenblocresectionofthelesion(Fig.3C),aGore-Texdual meshwaspositionedtocovertheunderlyingstructuresandfixed withnon-absorbablesutures.Arightpectoralismuscleflapwas harvestedincludingaskinislandlocatedatitsdistalportion(Fig.3D andE).Thehumeralinsertionofthepectoralismusclewas dev-idedtoallowforrotation-transpositionofthecompositeflapto thedefect.Aleftpectoralismuscleflapwasalsoharvestedwitha similarapproach,butwithoutincludingaskincomponent.With bilateralmobilizationofpectoralisflapavascularized andthick soft-tissuelayerwasobtainedtofullyprotectthemesh.Theskin wasthensuturedwithouttension.Achestx-raywasperformed immediatelyaftersurgeryandaftertwodaysfromsurgery(Fig.1D). The postoperative course was characterized by meta-hemorrhagic anemia with 4 units of concentrated red blood cells transfused. Thepatient wasdischarged onthenineteenth postoperativeday.Thehistologywaspositiveforclear-cellrenal carcinomawithfullpositivityforPAX8andmildpositivityforTFE3. Atsixmonths fromsurgery,the patientwasin goodcondition withnosignsofdiseaserecurrence(Figs.1Eand2B).
4. Discussionandconclusion
RCCisatypeoftumorpoorlyresponsivetoradiotherapyand chemotherapytreatment;moreover,bonemetastasesfromRCCare oftenrichlyvascularizedanddestructive.
Surgicaltreatmentoftheselesions,whentheprimarytumorcan beremovedandtheoperationisallowedbythepatient’sgeneral condition,canbeconsideredasafirst-linetreatmentbecausethis istheonlyprocedurethatcanimprovethequalityoflifeintermsof survivaltimeandpainreliefforthesepatients.Radiationtherapy canbeusedtoreducethepaincausedbymetastasisbone infiltra-tion,however,theresultsonthesesymptomsarenotguarantee,as inourcase.
ReconstructionofthethoracicwallwithGore-Texor polypropy-lene mesh or withmethylacrylate is currentlythe mostoften usedand mosteffective methodtoensureeffective respiratory mechanicsandadequateprotectionoftheunderlyingmediastinal structures[9].
Mostofthepublishedstudiesdescribethepossibilityofaradical treatmentinselectedpatientswhoaregenerallyingood condi-tions,withtheonlysternalmetastasis[2–6].Althoughweshowed alargemassofthesternumtreatedwithsurgerybecauseofthe fail-ureofradiationtreatment,norecurrencewasnotedafter6months. We areconsciousof thefactthat thefollowupperiod is quite limited;however,webelievethatit representsagoodproposal forfutureprospectivestudiesinalargercohortofpatients.This willbenecessarytoallowthisproceduretobeusedasfirst-line treatment.
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B.Manfredini,U.Morandi,G.DeSantisetal./InternationalJournalofSurgeryCaseReports63(2019)125–128 127
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128 B.Manfredini,U.Morandi,G.DeSantisetal./InternationalJournalofSurgeryCaseReports63(2019)125–128
Fig.3.Stepsduringtheoperation.A.Viewofthemassbeforestartingtheoperation.B.Sternalmassremoval.C.Drainplacement.D.Largepectoralismusclemobilization beforemuscleflaptransposition.E.Gore-Texdualmeshplacement.F.Sternalmassaftersurgery.
Sourcesoffunding Nofunding. Ethicalapproval
ForsinglecasereportNOethicalapprovalneeds.Patientsigned aconsentforpublishingthecasereport.
Consent
Patientsignedaconsentforthepublicationofthiscasereport. Author’scontribution
BMandBAwrotethecasereport.TheotherAuthorsreadand revisedthecasereport.
Registrationofresearchstudies
EthicalBoardapprovalisnotrequiredforcase reportsinour Center.
Guarantor
Prof.UlianoMorandiistheGuarantorofthiscasereport. Availabilityofsupportingdata
Yes.
Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed. DeclarationofCompetingInterest
TheAuthorshavenofinancialandpersonalrelationshipsto dis-close.
Acknowledgements Notapplicable. References
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