Abstract
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.
Keywords: Primary malignant sternal tumour, Titanium neo-sternum, Sternal reconstruction 3D printing
Introduction
Primary malignant sternal tumours are rare, and most of them are sarcomas [1]. Radical resection offers a possibility of cure; however, it leaves a large bony defect, where reconstruction is a great challenge. Numerous materials and techniques have been previously used with varying degrees of success [2]. However, we performed a sternal reconstruction using a custom-made 3D-printed titanium neo-sternum prosthesis after sternal resection for primary malignant sternal tumour.
Case Report
A 43-year-old male presented with incidentally detected expansile lytic lesion in the body of sternum detected on CT chest done for Covid-19 illness. (Fig. 1A, B). FDG PET revealed localised disease. The resection margins (3 cm) were planned pre-operatively, and a 3D-printed titanium neo-sternum prosthesis was designed and created by Jajal Medical Pvt. Ltd., Vadodara, Gujrat, India, based on the patient’s high-resolution CT images. It was made of multi-perforated titanium plate with bilateral projections simulating the sternochondral junctions. These projections were designed to be fixed to the stumps of second to fifth ribs bilaterally (Fig. 1C, D).
Fig. 1.
A Preoperative CT showing sternal tumour axial view. B Sagittal view. C Planning of surgical implant placement on 3-D reconstruction. D 3-D printed neo-sternum prosthesis
A midline skin incision was given; bilateral pectoralis major muscles were mobilised exposing the sternum and bilateral anterior chest wall. A sterilised 3D-printed replica of the neo-sternum made of medical grade nylon polyamide (PA2200) was used to mark the resection margin, to ensure proper fit of the prosthesis. An en-bloc resection of body of sternum, along with the costochondral junction of the bilateral second to fifth ribs was performed. The defect was first covered with a composite mesh (Proceed™) in a sublay fashion. Custom-made titanium neo-sternum prosthesis was fixed carefully to the manubrium and bilateral second to fifth ribs using sternal wires and screws to cover the defect completely (Fig. 2A). The patient was extubated immediately and showed no paradoxical chest wall movements. Postoperative course was uneventful. Histopathology was chondrosarcoma with clear margins. On 6-month follow-up, patient had no active complaints and had no limitations in his daily activities. Chest X-ray revealed no evidence of prosthesis displacement or fracture. (Fig. 2B).
Fig. 2.
A Intraoperative view of the implanted neo-sternum prosthesis. B Postoperative chest X-ray
Discussion
Various prosthetic materials such as PTFE, polypropylene mesh (PPM), and PPM–methyl methacrylate composites were used for sternal reconstruction which has been described in large series [3, 4]. However, these are prone to displacement and fractures and often not able to precisely restore the anatomical contouring of the sternum. Use of custom-made 3D-printed titanium prosthesis solves these issues to a great extent.
Titanium is an inert, biocompatible material that integrates well with the bone, has a high strength-to-weight ratio, and does not flex with movements at joints. The use of single-piece customised sternal prosthesis with preformed sternochondral joints will lead to minimal movements at fixation points reducing the risk of fatigue fractures. On follow-up at 3 and 6 months on both clinical examination and imaging, there was no evidence of dislocation or paradoxical movement. The customised implant not only helped preserve the anatomical shape and physiological function of the chest wall but also had a positive psychological impact on the patient because of adequate restoration of form and function.
The cost and the time associated with procuring customized implants in our country are limiting factors making its wide use, particularly in patients with malignant tumour a concerning issue.
Conclusion
Use of 3D-printed customised titanium prosthesis for sternal reconstruction after surgery for malignant sternal tumours is safe and feasible. It helps in preservation of form and function along with high degree of patient satisfaction. However, prospective studies in a larger cohort of patients with long-term follow-up are required to truly establish long-term safety and efficacy.
Declarations
Conflict of Interest
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Incarbone M, Nava M, Lequaglie C, Ravasi G, Pastorino U (1997) Sternal resection for primary or secondary tumors. J Thorac Cardiovasc Surg 114:93–99 [DOI] [PubMed] [Google Scholar]
- 2.Kamel M, Port J, Altorki NK (2015) Sternal resections: New materials for reconstruction. Curr Surg Rep 3:16. 10.1007/s40137-015-0094-1 [Google Scholar]
- 3.Weyant M, Bains M, Venkatraman E, Downey R, Park B, Flores R et al (2006) Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 81:279–285 [DOI] [PubMed] [Google Scholar]
- 4.Aghajanzadeh M, Alavy A, Taskindost M, Pourrasouly Z, Aghajanzadeh G, Massahnia S (2010) Results of chest wall resection and reconstruction in 162 patients with benign and malignant chest wall disease. J Thorac Dis 2:81–5 [PMC free article] [PubMed] [Google Scholar]