Titanium Mesh Reconstruction after Solitary Sternal Plasmacytoma Surgery-A Case report

We present chest wall reconstruction with titanium mesh in a patient who underwent sternal resection due to solitary plasmacytoma (SP). A 35 year old female was admitted to The Thoracic Surgery Department of University Clinical Center Tuzla with pain and tender upper-sternal swelling. Thoracic magnetic resonance imaging (MRI) revealed hypo dense wll-shaped rounded mass involving manubrium streni which was 40mmx40mm in size measured by two right angle perpendicular diameters. Affected part was resected together with removal of sternoclavicular and costochondral junctions and reconstruction with titanium mesh was performed. Case report Titanium Mesh Reconstruction after Solitary Sternal Plasmacytoma Surgery-A Case report Krdzalic G1*, Mujagic H2, Musanovic N1 and Krdzalic A3 1Department of Thoracic Surgery, Surgery Clinic, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina 2Former Scholar and Professor, Massachusetts General Hospital Cancer Center, 55 Fruit St.02114 Boston, USA 3Clinic for Cardiovascular Diseases, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina Dates: Received: 23 November, 2017; Accepted: 28 December, 2017; Published: 29 December, 2017 *Corresponding author: Krdzalic G, Department of Thoracic Surgery, Surgery Clinic, University Clinical Centre Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina, Tel: 003876164555; E-mail: https://www.peertechz.com


Introduction
Primary sternal tumors are very rare and account for only ~ 1% of primary bone neoplasms [1]. The most common lesion is chondrosarcoma (33%) followed by mayeloma and plasmacytoma (30%), than (21%) lymphoma and occasional lesions like osteosarcoma, fobrosarcoma and Ewing sarcoma [2]. Surgical treatment requires adequate, wide margin resections and reconstruction of the anterior chest wall [3].
Resonstruction is essential for maintenance of respiratory function and for protection of mediastinal organs [4]. Here we report reconstruction of anterior chest wall with titanium mesh inserted between two polypropylene mesh sheets. We performed wide manubrial resection including right and left sternocalvicular joints and upper sternal part. Complete specimen was sent to surgical pathology for rapid frozen section diagnosis and pathologist recommended to wait until fi nal analysis. However, considering that all primary sternal tumors are malignant [5] we didn´t wait for fi nal diagnosis but Ewing tumors [2].

Case report
The most common site of SP is vertebral column. The involvement of ribs and sternum accounts for 10-15% of cases. Males are two times more frequently affected than females which makes sternal plasmacytoma being very rare. [5]. Radiological examination of sternal solitary plasmacytoma usually presents as an osteolytic expansive lesion or a typical 'punched-out' lytic lesion. Plasmacytoma destroys bone cortex in several places and invades soft tissues. On MR imaging, these tumors exhibit a low signal intensity on T1 and a high signal intensity on T2-weighted images [7].
Although radiotherapy is recommended for sternal SP, extensive wide resection and reconstruction of anterior chest wall is still treatment of choice [5,8,9]. The goal of wide resection is to ensure that all malignant tissue has been excised resulting in local control.
Reconstruction of strenal defect is essential to maintain original respiratory function and to protect mediastinal organs.
The choice of reconstruction technique depends on the extent and localization of the defect using various prosthetic and homologous materials, including synthetic and metallic grafts, pedicled skin and muscle fl aps, free skin grafts, fascia lata and autologous bone transplants [10].
Recently, titanium mesh has emerged as promising material for sternal reconstruction in cases of sternal defect larger than 5 cm without using additional autologous tissue.
Due to its biocompability and fl exibility titanium mesh has been acknowledged as versatile and easy to implement [11]. Polypropilene mesh is used more frequently for the reconstruction of sternal defects but its lack of rigidity may result in paradoxical chest wall motion [10]. Titanium mesh is may be complicated by infection or fragmentation of the graft, but it is more rigid and osteconductive than polypropilene mesh and mold to shape of the defect. It is easy to handle, minimally elastic, less visible on MRI than stainless steel and adapts well to surrounding soft tissues [10][11][12]. Our patient was extubated in the early postoperative period, and paradoxical respiration was not observed during 12 months postoperatively. In the present case the titanium mesh, embedded between two polypropylene meshes, was used for anterior chest reconstruction without use of musculocutaneous fl ap. The benefi ts for patients are simplifying the procedure, ideal rigidity and biocompability.
Further advantages include minimal trauma, no infection and no change in pulmonary function [13].
In conclusion, we presented a wide manubrial resection and reconstruction with titanium mesh between two polypropylene meshes for a solitary plasmacytoma. This resection and reconstruction can be performed successfully and effectively in patients with large sternal tumors. We suggest that titanium mesh may be highly benefi cial material for sternal reconstruction.