Asian Journal of Surgery (2013) 36, 130e133

Available online at www.sciencedirect.com

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CASE REPORT

Wide composite resection of follicular thyroidcarcinoma with metastases to sternum: Reportof two cases

Yen-Chou Chen a,y, Ngian-Chye Tan a,y, Hung-I. Lu b, Shun-Chen Huang c,Fong-Fu Chou d, Yur-Ren Kuo a,*

aDepartment of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung UniversityCollege of Medicine, Kaohsiung, TaiwanbDepartment of Cardiovascular and Thoracic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung UniversityCollege of Medicine, Kaohsiung, TaiwancDepartment of Anatomic Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University Collegeof Medicine, Kaohsiung, TaiwandDepartment of General Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University Collegeof Medicine, Kaohsiung, Taiwan

Received 26 April 2011; received in revised form 4 February 2012; accepted 1 May 2012Available online 15 July 2012

KEYWORDSfollicular thyroidcarcinoma;

pectoralis majormyoadipofascialflap;

sternum metastasis

* Corresponding author. DepartmenUniversity College of Medicine, 123, T

E-mail addresses: t1207816@ms22y These authors contribute equally t

1015-9584/$36 Copyright ª 2012, Asiahttp://dx.doi.org/10.1016/j.asjsur.20

Summary Follicular thyroid carcinoma (FTC) with sternum metastasis is rarely reported.Conservative treatments always result in a poor prognosis.We report two cases of FTC presentingwitha large symptomatic solitarymetastatic lesion in the sternum. Surgical intervention includedtotal thyroidectomy, combined with wide composite resection of the sternal manubrium, as wellas the adjacent clavicular head and ribs. A large defect with exposed pericardium and greatvessels was found post resection in both cases. Because the ipsilateral vessels were sacrificed,a contralateral extended pedicled pectoralis major adipofascial flap was designed and trans-posed to cover the underlying vital organs. The patients received both adjuvant I-131 and radio-therapy postoperatively. The treatment was uneventful, and the patients are well andasymptomatic 5 years after the treatment. Wide composite resection and appropriate adjuvanttherapies may offer a survival benefit in patients with advanced FTC with sternum metastasis.Copyright ª 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rightsreserved.

t of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gunga-Pei Road, Niao-Sung Hsiang, Kaohsiung, Taiwan..hinet.net, kuoyr@adm.cgmh.org.tw (Y.-R. Kuo).o this article and are considered co-first authors.

n Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.12.05.001

Resection of sternal metastases 131

1. Introduction

Well-differentiated thyroid carcinoma with direct invasionor bone metastasis to the sternum is uncommon. Patientswith metastatic disease, in general, have a poorer prog-nosis. However, additional treatments may reduce theburden of tumor for some of these patients and thus offerthem a survival or palliative benefit. Treatment modalitiesfor patients with metastatic thyroid cancer include surgicalexcision, radioactive iodine (RAI) therapy with I-131,external-beam radiotherapy, and recruitment to clinicaltrials. Large tumors and bone metastases are factors thatpredict a poor response to RAI therapy.1 Complete surgicalresection of isolated symptomatic metastases has beenassociated with improved survival and should be consid-ered, especially, for patients <45 years old with slowlyprogressive diseases. For skeletal metastases in particular,surgery is recommended for symptomatic or asymptomatictumors in weight-bearing extremities. However, metastasisof thyroid carcinoma to the sternum is uncommon and hasbeen reported only rarely. Herein, we present two cases ofthyroid follicular carcinoma with metastases to the sternumand demonstrate how surgical intervention, together withappropriate adjuvant therapy, can result in long-termsurvival.

Figure 1 (A) A 56-year-old male patient presenting with a painfutomography of head and neck revealed right thyroid tumor withexamination illustrated sternal metastases from follicular thyroidand chest wall soft-tissue defect was reconstruction by pectoralisadipofascial tissue; m Z pectoralis major muscle.

2. Case reports

2.1. Case 1

A 56-year-old male patient presented to our center witha painful, progressively enlarging mass over his anteriorchest that had been present for the previous 6 months(Fig. 1A). On physical examination, an 8 � 6 cm2 sized masswas noted in the sternal manubrium, involving the leftclavicle head. A computed tomography scan revealed thepresence of a right thyroid tumor with bone metastases tohis sternum as well as the T9 and L2 vertebral bodies(Fig. 1B). There was also a palpable right thyroid nodule.The sternal mass biopsy revealed metastatic follicularcarcinoma (Fig. 1C). Total thyroidectomy and a widecomposite resection of his sternum, including the bilateralsternoclavicular joint and partial resection of bilateralsecond and left third ribs, were performed. No surgery wasperformed for his other bone metastases, as he wasasymptomatic. The wide composite resection revealeda large soft-tissue defect with exposed pericardium, greatvessels, and a pleural apex. Because of the absence of thepedicle of the ipsilateral pectoralis major (PM) flap aftertumor composite ablation, we harvested the extended PMmyoadipofascial flap from the contralateral side. This flap

l enlarged mass over his upper part of sternum. (B) Computedsternum and parasternal tissue metastases. (C) Histological

carcinoma. (D) After wide composite resection, large sternummajor myoadipofascial flap, 18 � 25 cm2 in size. ad Z distal

132 Y.-C. Chen et al.

included PM muscle (18 � 20 cm2) with adjoining adipo-fascial tissue (15 � 10 cm2) and was about 18 � 25 cm2 intotal size. The flap was used to abolish the dead space nextto the pericardium and apex of the left lung (Fig. 1D). Acombination of three courses of RAI (I-131) ablation therapyand external-beam radiotherapy was administered post-operatively. The patient recovered uneventfully, and hasbeen well and pain free for the 5 years since surgery.

2.2. Case 2

A 55-year-old lady presented to our center with a largepainful solitary tumor over the upper part of her sternum,which had been present for 2 months. She also has a historyof a thyroid goiter. A physical examination revealeda 4 � 5 cm2 mass located in the sternum and right claviclehead (Fig. 2A). Fine-needle aspiration cytology of thesternal masses revealed metastatic follicular carcinoma.The head and neck computed tomography revealeda 4.3 � 2.5 � 5.5 cm3 tumor in the right thyroid gland andanother 5.0 � 4.0 cm2 upper sternal osteolytic mass(Fig. 2B). The patient received a total thyroidectomy andunderwent a wide composite resection of the anteriormediastinal tumor as well as of the manubrium, sternum,and bilateral partial first and second ribs. After the wideresection, a large soft-tissue defect exposing the pericar-dium and the great vessels was found. As the pedicle of theipsilateral PM flap had already been sacrificed during the

Figure 2 (A) A 55-year-old lady presenting with a painful solittomography angiogram revealed a 4.3 � 2.5 � 5.5 cm3 tumor in rigosteolytic feature (arrowheads). (C) After wide composite resectioexposure was found. The defect was reconstructed by a pectora(D) Patient showed good results without recurrence postoperativel

composite wide resection, we used a contralateral PMmuscle flap (12 � 18 cm2) with adjoining adipofascial flaptissue (10 � 8 cm2), which was about 12 � 22 cm2 in totalsize, to abolish the dead space and cover the soft-tissuedefect adjacent to the pericardium (Fig. 2C). After theoperation, the patient received RAI (I-131) therapy andradiotherapy. The aesthetic result was good except for mildbreast asymmetry (Fig. 2D). No paradoxical chest wallmovement or impaired ventilation was observed. Noevidence of cancer recurrence or distant metastasis wasdetected during the follow-up over the last 5 years.

3. Discussion

Distant metastases are the principal cause of death frompapillary and follicular carcinomas. Almost 10% of patientswith papillary carcinoma and up to 25% of those withfollicular carcinoma develop distant metastases. About 50%of these metastases are present at the time of diagnosis. Inmanaging patients with bone metastases, the key criteriafor therapeutic decisions include the following: (1) thepresence of or the risk for pathologic fracture, particularlyin a weight-bearing structure; (2) the risk of neurologiccompromise from vertebral lesions; (3) the presence ofpain; (4) the avidity of RAI uptake; and (5) the potential forsignificant marrow exposure from radiation arising fromRAI-avid pelvic metastases. Surgical palliation is recom-mended for symptomatic bone metastases or asymptomatic

ary mass over the upper part of her sternum. (B) Computedht thyroid gland and another 5 � 4 cm2 upper sternal mass withn, a huge soft-tissue defect with pericardium, and great vessellis major myoadipofascial flap 10 � 22 cm2 in size (arrow).y.

Table 1 Reported cases of thyroid cancer with metastases to sternum.

Caseno.

Age(y)

Sex Size (cm) Histology Symptom Other metastases Yearreported

References

1. 75 F 14 � 8 � 7 Poorly Differentiated Pain Pulmonary 2008 Yanagawa et al1

2. 35 F 7 � 7 Poorly Differentiated Pain None 2000 Mishra et al2

3. 43 M 7 � 10 Follicular None Pulmonary, vertebral 2000 Mishra et al2

4. 61 F 6 � 5 � 4.5 Follicular Pain None 2006 Eroglu et al3

5. 69 F 8 � 4.5 Papillary Pain None 2004 Haraguchi et al4

6. 54 F 4 � 4 Follicular Pain Pulmonary 1995 Ozaki et al5

7. 48 F 8 6 Papillary Pain None 1995 Ozaki et al5

8. 59 F NR Follicular NR Neck 2005 Meyer and Behrend6

9. 62 F NR Poorly differentiated NR Lymph nodes 2001 Kinoglou et al7

10. 75 F 12 � 9 Follicular None None 1998 Muthuphei and Mabua8

11. 57 M 6 � 7 � 7 Follicular Pain Vertebral12. 55 F 5 � 4 Follicular Pain None

F Z female; M Z male; NR Z not reported.

Resection of sternal metastases 133

tumors in weight-bearing extremities. Other therapeuticoptions include 131-I treatment (if the whole-body scan ispositive), considering dosimetry to maximize dosing and/orexternal-beam radiotherapy. However, patients with largemetastases and bone metastases are unlikely to benefitfrom RAI treatment.1

Metastasis of thyroid carcinoma to the sternum is rarelyreported.2 To date, we found only 10 such cases reported inEnglish when we conducted a search on PubMed. Table 11e8

presents a summary of these cases, including the twopatients from our center. Consequences of large sternalmetastases include pain, ulceration, and dyspnea. Inaddition to these morbidities, large sternal metastaseshave been specifically documented as a cause of immediatedeath because of the compression of the superior vena cavaand circulatory arrest.1 As large metastases and bonemetastases are unlikely to benefit from RAI treatment,sternal resection is an important palliative option forpatients with large thyroid cancer metastases to thesternum.1 In our series, the patients suffered significantpain from the sternal metastases. To achieve optimalresults, total thyroidectomy with a composite resection ofthe metastatic sternal lesion is warranted. Radical removalof the metastatic sternum, including the adjacent clavicleand ribs, is necessary to obtain clear margins.

Nevertheless, exposed pericardium, great vessels, andexistence of a pleural apex after the wide compositeresection always pose a challenge. For soft-tissue recon-struction, loco-regional flaps, such as the PM muscle flap,are most commonly used because they provide adequatesoft-tissue volume and are easy to harvest. However, in ourseries, the main pedicle of the ipsilateral PM flap wassacrificed during wide composite resection, and no otherlocal flaps were suitable for reconstruction. The contra-lateral traditional PM muscle flap could not completelycover the distal part of the pericardium and lung apex.Nevertheless, we designed and used the contralateral PMmuscle flap with distal adjoining adipofascial tissue asa myoadipofascial flap to increase the distal flap length and

volume for coverage of the pericardium and lung apex.Postoperatively, both patients received adjuvant I-131therapy and radiotherapy. Since the completing treatment5 years ago, these patients have remained asymptomaticand well. Moreover, there have been no respiratorycomplications or chest wall instability related to ourreconstruction.

In summary, wide composite resection with appropriatereconstruction for patients with advanced follicular thyroidcancer with sternal metastases can be performed safelyand may offer these patients a palliative or survivalbenefit.

References

1. Yanagawa J, Abtin F, Lai CK, et al. Resection of thyroid cancermetastases to the sternum. J Thorac Oncol. 2009;4:1022e1025.

2. Mishra A, Mishra SK, Agarwal A, et al. Surgical treatment ofsternal metastases from thyroid carcinoma: report of two cases.Surg Today. 2001;31:799e802.

3. Eroglu A, Karaoglanglu N, Bilen H, et al. Follicular thyroidcarcinoma: metastasis to the sternum, 13 years after totalthyroidectomy. Int J Clin Pract. 2006;60:1506e1508.

4. Haraguchi S, Yamashita Y, Yamashita K, et al. Sternal resectionfor metastasis from thyroid carcinoma and reconstruction withthe sandwiched Marlex and stainless steel mesh. Jpn J ThoracCardiovasc Surg. 2004;52:209e212.

5. Ozaki O, Kitagawa W, Koshiishi H, et al. Thyroid carcinomametastasized to the sternum: resection of the sternum andreconstruction with acrylic resin. J Surg Oncol. 1995;60:282e285.

6. Meyer A, Behrend M. Partial resection of the sternum forosseous metastasis of differentiated thyroid cancer: casereport. Anticancer Res. 2005;25:4389e4392.

7. Kinoglou G, Vandeweyer E, Lothaire P, et al. Thyroid carcinomametastasis to the sternum: resection and reconstruction. ActaChir Belg. 2001;101:253e255.

8. Muthuphei MN, Mabua MP. Retrosternal thyroid carcinomametastatic to the sternum: a case report. Cent Afr J Med. 1998;44:292e293.