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Chondrosarcoma from the sternum: reconstruction with titanium mesh and a transverse rectus abdominis myocutaneous flap after subtotal sternal excision.
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MedLine Citation:
PMID:  23018358     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Chondrosarcoma arising from the sternum is extremely rare and is often untreatable. Removal of the sternum for malignant tumor results in large defects in bone and soft tissue, causing deformity and paradoxical movement of the chest wall and making subsequent repair of the thorax very important. We report a very rare patient with a chondrosarcoma of the sternum who underwent case chest wall resection, followed by reconstruction using a titanium mesh covered with a transverse rectus abdominis myocutaneous (TRAM) flap.
CASE REPORT: A 63-year-old man was referred to our hospital with progressively enlarged swelling of his anterior chest wall. Physical examination showed a 2.5×2.0 cm mass fixed to the sternum, which was diagnosed as a chondrosarcoma based on clinical findings, imaging characteristics and incision biopsy results. The patient underwent a subtotal sternal and chest wall resection to remove the tumor, followed by reconstruction with a titanium mesh and a TRAM flap. There were no complications associated with surgery.
CONCLUSIONS: We report an extremely rare case of a patient who underwent subtotal sternal resection, followed by reconstruction, for a large chondrosarcoma. The elasticity and rigidity provided by the titanium mesh and the complete coverage of the surgical wound by a TRAM flap suggest that these procedures may be useful in reconstructing large defects in the chest wall.
Kazutaka Koto; Tomoya Sakabe; Naoyuki Horie; Kazuteru Ryu; Hiroaki Murata; Shinichiro Nakamura; Toshihiro Ishida; Eiichi Konishi; Toshikazu Kubo
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Publication Detail:
Type:  Case Reports; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Medical science monitor : international medical journal of experimental and clinical research     Volume:  18     ISSN:  1643-3750     ISO Abbreviation:  Med. Sci. Monit.     Publication Date:  2012 Oct 
Date Detail:
Created Date:  2012-09-28     Completed Date:  2013-02-19     Revised Date:  2013-07-11    
Medline Journal Info:
Nlm Unique ID:  9609063     Medline TA:  Med Sci Monit     Country:  Poland    
Other Details:
Languages:  eng     Pagination:  CS77-81     Citation Subset:  IM    
Department of Orthopedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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MeSH Terms
Chondrosarcoma / radiography,  surgery*
Magnetic Resonance Imaging
Middle Aged
Reconstructive Surgical Procedures / methods*
Rectus Abdominis / radiography,  surgery*
Sternum / pathology,  radiography,  surgery*
Surgical Flaps*
Surgical Mesh*
Titanium / pharmacology*
Reg. No./Substance:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-ta): Med Sci Monit
Journal ID (iso-abbrev): Med. Sci. Monit
Journal ID (publisher-id): Medical Science Monitor
ISSN: 1234-1010
ISSN: 1643-3750
Publisher: International Scientific Literature, Inc.
Article Information
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© Med Sci Monit, 2012
Received Day: 30 Month: 5 Year: 2012
Accepted Day: 21 Month: 9 Year: 2012
collection publication date: Year: 2012
Electronic publication date: Day: 01 Month: 10 Year: 2012
Volume: 18 Issue: 10
First Page: CS77 Last Page: CS81
PubMed Id: 23018358
ID: 3560565
Publisher Id: 883471

Chondrosarcoma from the sternum: Reconstruction with titanium mesh and a transverse rectus abdominis myocutaneous flap after subtotal sternal excision
Kazutaka Koto1BCDEF
Tomoya Sakabe1ABDF
Naoyuki Horie1B
Kazuteru Ryu1B
Hiroaki Murata1AC
Shinichiro Nakamura1AB
Toshihiro Ishida1B
Eiichi Konishi2B
Toshikazu Kubo1G
1Department of Orthopedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
2Division of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
Correspondence: Tomoya Sakabe, Department of Orthopedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan, e-mail:
AStudy Design
BData Collection
CStatistical Analysis
DData Interpretation
EManuscript Preparation
FLiterature Search
GFunds Collection


Primary tumors of the sternum are very rare, accounting for <1% of primary bone tumors [1]. In particular, chondrosarcoma arising from the sternum is extremely rare, observed in only 86 of 49,768 (0.17%) of patients diagnosed with bone tumors in Japan from 1972–2003. Removal of the sternum for a malignant tumor results in a large defects in bone and soft tissue, causing deformity and paradoxical movement of the chest wall. The chest wall may be reconstructed, using methods such as musculocutaneous flaps and alloplastic materials. Although these techniques have enabled wide resection and relieved troublesome complaints, such as a frail chest, each has advantages and disadvantages. We describe here a patient with a chondrosarcoma arising from the sternum, who underwent resection of the sternum and chest wall, followed by thoracic reconstruction with the combination of a titanium mesh and a transverse rectus abdominis myocutaneous (TRAM) flap.

Case Report

A 63-year-old man was referred to our hospital with progressively enlarging swelling of his anterior chest wall. He had no significant past medical or surgical history. A physical examination showed a 2.5×2.0 cm mass fixed to the sternum. No pulsation was noted. All laboratory tests at admission, including for tumor markers, were within normal limits. A roentgenogram of the sternum showed no apparent shadow of the tumor. Computed tomography showed a tumor shadow on the cancellous bone, which expanded across the destroyed cortex to the parietal and visceral soft parts. The lesion involved some parts of the costal cartilage and most of the sternum body (Figure 1). MR imaging showed a relatively well-defined and heterogeneous mass, primarily in the body of the sternum, but expanded into the soft tissues. The mass was isointense to the adjacent skeletal muscles on T1-weighted images and highly intense with slight heterogeneity on T2-weighted images (Figure 2A, B). On Gd-DTPA images, some parts of the mass were well-defined and contrasted (Figure 2B). A bone scintigram showed a slightly abnormal accumulation, whereas positron emission tomography showed no evidence of abnormal accumulation.

Based on clinical findings and imaging characteristics, the tumor was diagnosed as being either a primary bone tumor arising from the body of the sternum or a metastatic bone tumor. An incisional biopsy was therefore performed. Microscopically, the tumor was composed of sheets of cartilaginous cells, with a lobulated growth pattern. We also observe cells permeating between preexisting bony trabeculae. The tumor cells varied in size and shape, and contained a greater degree of nuclear atypia, hyperchromasia and nuclear size. Myxoid changes in the matrix were also seen. We therefore diagnosed this tumor as a grade II chondrosarcoma (Figure 3A, B). To remove the tumor and obtain wide surgical margins, we performed a subtotal sternal excision, resecting four-fifths of the sternum body and the right third, fourth and fifth ribs with involved soft tissues at a position 2 cm lateral to the right sternal edge. This excision resulted in a huge defect (14.0×8.0 cm) in the anterior chest wall. Macroscopically, the tumor had expanded across the destroyed cortex to the visceral soft parts (Figure 4).

To reconstruct the thorax, titanium mesh was placed over the defect and fixed with screws to the bony rib (Figure 5). A musculocutaneous flap was harvested from the rectus abdominis muscle to close the resultant soft tissue defect. Immediately after surgery, the patient had good respiratory condition and immediate chest wall stability. In addition, the TRAM flap was taken up successfully. Although some fixed screws had dropped off, paradoxical movement of the chest wall was not observed. At the present time, 64 months after the surgery, the patient is physically active with a stable chest wall, and computed tomography has shown no evidence of local recurrence or distant metastasis.


A chondrosarcoma is a malignant tumor with pure hyaline cartilage differentiation that may be accompanied by myxoid changes, calcification or ossification. Primary chondrosarcoma is the second most common primary malignancy of bone after osteosarcoma, accounting for approximately 20% of malignant bone tumors in one large series [2]. The most common skeletal sites of chondrosarcoma are the bones of the pelvis, especially the ilium, followed by the proximal humerus, the distal femur and the ribs. Most patients are older than 50 years, and there is a slight male preponderance [3].

Primary malignant tumors of the sternum are very rare, accounting for only nine of 2004 (0.45%) primary bone tumors in the Leeds Bone Tumor Registry [4]. Although chondrosarcoma is the most common malignant bone tumor of the sternum [59], its frequency was less than 0.2% [2].

Current therapy for chondrosarcoma requires adequate surgical excision; radiation therapy and chemotherapy have not been shown effective [1020]. The goal of surgery is to resect the tumor with a wide margin of normal tissue, ensuring that all tumor cells have been excised and resulting in local disease control. Inadequately tumor resection is associated with a high incidence of recurrence (69% compared with 6% in adequately treated patients) [15]. The exact surgical procedure depends on the location of the tumor, the extent of the disease, and the grade of the lesion.

Sternal tumors are difficult to treat because of the anatomic proximity of vital neurovascular structures and the limited surgical margins that can be achieved. The adequacy of surgical resection is of paramount importance in determining clinical outcome [18,21]. Although it has been recommended that the incision be placed 2 to 6 cm from the margin of the tumor to minimize the risk of local recurrence [6,2224], this requirement is not always fulfilled. Total sternectomy also has drawbacks, including chest wall instability, exposure of thoracic organs and possible paradoxical respiration.

Reconstruction after resection is necessary to prevent respiratory deficits and to protect mediastinal structures. Various reconstruction techniques using prosthetic or homologous material have been described, including synthetic and metallic grafts, pedicled skin and muscle flaps, free skin grafts, fascia lata and autologous bone transplants, with the choice of reconstruction technique dependent on the size and site of the defect, minimizing any deleterious effects. Skeletal reconstruction is not necessary for defects less than 5 cm in diameter [25]. If only the upper sternum is resected (i.e. the manubrium with ribs 1 to 3), muscle flaps alone may be sufficient for reconstruction. In contrast, resection of the lower sternum frequently requires rigid structures to protect the heart and stabilize the bony thorax [24].

The ideal characteristics of a prosthetic material include rigidity, reducing paradoxical chest motion; inertness, to allow in-growth of fibrous tissue and decrease the likelihood of infection; malleability, to enable the material to be fashioned to the appropriate size and shape at the time of surgery; and radiolucency to allow radiographic follow-up of the underlying problem [26]. Polypropylene mesh (Marlex mesh,R) is used most frequently for the reconstruction of chest wall defects. Although this mesh is relatively easy to handle and has a high affinity for tissues [27], its lack of rigidity in patients with large defects may result in paradoxical chest wall motion [28]. In contrast, methyl methacrylate and titanium plates are highly rigid but insufficiently malleable. Titanium mesh may be complicated by infection or fragmentation of the graft, but it is more rigid and osteoconductive than polypropylene mesh, easy to handle and mold to the shape of the defect, appropriately elastic, less visible on MR imaging than stainless steel, and assimilates well with surrounding soft tissues [29]. Since the protection of visceral organs after wide resection was the most important consideration in our patient, we used titanium mesh. We observed no change in postoperative pulmonary function, providing further evidence for the effectiveness of our procedure for large chest wall reconstruction.

Artificial materials are prone to infection and induce allergic reactions, factors not observed with autologous tissues [30]. TRAM flaps, based on the superior epigastric artery, are elegantly designed musculocutaneous flaps that have become the mainstay for breast reconstruction. Moreover, these flaps have been used in reconstruction of the chest wall, such as in patients with sternal wound infections and chest wall ulcers after irradiation [31]. One advantage of the TRAM flap is that the patient does not have to be moved throughout the procedure [32]. In addition, the graft survival rate is high because it TRAM flaps can be used as pedicle flaps in chest wall reconstruction. The size of the defect in our patient required a large volume of tissue, such as a TRAM flap, to reconstruct the chest wall. Since the tumor was located in the precordia, surgery was performed with the patient in the supine position, allowing the TRAM flap to be collected while the patient is in the same supine position.


We have described an extremely rare case of subtotal sternal resection and reconstruction of the sternum for a chondrosarcoma. Chest wall resection, followed by reconstruction with titanium mesh and a TRAM flap can be safely and effectively performed as a one-stage surgical procedure on patients with large chondrosarcomas arising from the sternum. The postoperative course of our patient was good, without infection, because the titanium mesh and TRAM flap provided appropriate rigidity and elasticity and covered the surgical wound fully. Our findings suggest that these procedures may be useful for reconstructing large defects in the chest wall.


fn8-medscimonit-18-10-cs77Source of support: Departmental sources

1. Sharma RK,Mehrotra S,Dhaliwal RS. :Extended deep inferior epigastric artery flaps’ for reconstruction after excision of chondrosarcoma sternumBr J Plast SurgYear: 2005581004616039634
2. Unii KK,Inwards CY. Dahlin’s bone tumors: General Aspects and Data on 10,165 Cases6th edLippincott-RavenPhiladelphiaYear: 2010
3. Christopher DM,Fletcher K,Unni K,Mertens F. Pathology and Genetics of Tumours of Soft Tissue and BoneWorld Health Organization classification of tumoursKleihues Paul,Sobin Leslie HLyonIARC PressYear: 200224751
4. Waller DA,Newman RJ. Primary bone tumours of the thoracic skeleton: an audit of the Leeds regional bone tumour registryThoraxYear: 199045850552256013
5. Eng J,Sabanathan S,Pradhan GN,Mearns AJ. Primary bony chest wall tumoursJ R Coll Surg EdinbYear: 19903544472342012
6. Martini N,Huvos AG,Burt ME,et al. Predictors of survival in malignant tumors of the sternumJ Thorac Cardiovasc SurgYear: 1996111961068551793
7. McAfee MK,Pairolero PC,Bergstralh EJ,et al. Chondrosarcoma of the chest wall: factors affecting survivalAnn Thorac SurgYear: 198540535412416278
8. Sabanathan S,Salama FD,Morgan WE,Harvey JA. Primary chest wall tumorsAnn Thorac SurgYear: 1985394153966836
9. Sabanathan S,Shah R,Mearns AJ. Surgical treatment of primary malignant chest wall tumoursEur J Cardiothorac SurgYear: 1997111011169237580
10. Bjornsson J,McLeod RA,Unni KK,et al. Primary chondrosarcoma of long bones and limb girdlesCancerYear: 1998832105199827715
11. Bruns J,Elbracht M,Niggemeyer O. Chondrosarcoma of bone: an oncological and functional follow-up studyAnn OncolYear: 2001128596411484965
12. Enneking WF. Musculoskeletal tumor surgeryNew YorkChurchill LivingstoneYear: 1983
13. Evans HL,Ayala AG,Romsdahl MM. Prognostic factors in chondrosarcoma of bone: a clinicopathologic analysis with emphasis on histologic gradingCancerYear: 19774081831890662
14. Fiorenza F,Abudu A,Grimer RJ,et al. Risk factors for survival and local control in chondrosarcoma of boneJ Bone Joint Surg BrYear: 200284939911837841
15. Gitelis S,Bertoni F,Picci P,Campanacci M. Chondrosarcoma of bone. The experience at the Istituto Ortopedico RizzoliJ Bone Joint Surg AmYear: 1981631248577287795
16. Lee FY,Mankin HJ,Fondren G,et al. Chondrosarcoma of bone: an assessment of outcomeJ Bone Joint Surg AmYear: 1999813263810199270
17. Lichtenstein L,Jaffe HL. Chondrosarcoma of BoneAm J PatholYear: 1943195538919970709
18. Pritchard DJ,Lunke RJ,Taylor WF,et al. Chondrosarcoma: a clinicopathologic and statistical analysisCancerYear: 198045149577350999
19. Rizzo M,Ghert MA,Harrelson JM,Scully SP. Chondrosarcoma of bone: analysis of 108 cases and evaluation for predictors of outcomeClin Orthop Relat ResYear: 20013912243311603673
20. Springfield DS,Gebhardt MC,McGuire MH. Chondrosarcoma: a reviewInstr Course LectYear: 199645417248727760
21. Sheth DS,Yasko AW,Johnson ME,et al. Chondrosarcoma of the pelvis. Prognostic factors for 67 patients treated with definitive surgeryCancerYear: 199678745508756367
22. Incarbone M,Nava M,Lequaglie C,et al. Sternal resection for primary or secondary tumorsJ Thorac Cardiovasc SurgYear: 199711493999240298
23. King RM,Pairolero PC,Trastek VF,et al. Primary chest wall tumors: factors affecting survivalAnn Thorac SurgYear: 1986415976013013106
24. Soysal O,Walsh GL,Nesbitt JC,et al. Resection of sternal tumors: extent, reconstruction, and survivalAnn Thorac SurgYear: 1995601353598526626
25. Carbognani P,Vagliasindi A,Costa P,et al. Surgical treatment of primary and metastatic sternal tumoursJ Cardiovasc Surg (Torino)Year: 20014241114
26. le Roux BT,Shama DM. Resection of tumors of the chest wallCurr Probl SurgYear: 198320345866851629
27. Haraguchi S,Hioki M,Hisayoshi T,et al. Resection of sternal tumors and reconstruction of the thorax: a review of 15 patientsSurg TodayYear: 2006362252916493530
28. Briccoli A,Manfrini M,Rocca M,et al. Sternal reconstruction with synthetic mesh and metallic plates for high grade tumours of the chest wallEur J SurgYear: 20021684949912549692
29. Horio H,Ohtsuka T,Kubota Y,et al. Large chest wall reconstruction using titanium micromesh and a pedicled latissimus dorsi musculocutaneous flap: report of a caseSurg TodayYear: 200535737515622468
30. Suzuki K,Takahashi T,Itou Y,et al. Reconstruction of diaphragm using autologous fascia lata: an experimental study in dogsAnn Thorac SurgYear: 2002742091212118760
31. Yoshino N,Yamauchi S,Akimoto M,et al. A case report on a full-thickness chest wall reconstruction with polypropylene mesh and stainless steel mesh concurrently using a transverse rectus abdominis myocutaneous flapAnn Thorac Cardiovasc SurgYear: 2006124454817228288
32. Nagashima A,Tashima Y,Yoshimatsu T,Osaki T. A Case of Chest Wall Reconstruction After Resection of a Desmoid TumorJournal of Japan Surgical AssociationYear: 20036427058

Article Categories:
  • Case Study

Keywords: chondrosarcoma, sternum, transverse rectus abdominis myocutaneous frap, titanium mesh, reconstruction, bone tumors.

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