Year : 2006 | Volume
: 1 | Issue : 2 | Page : 84--86
Unusual sternal mass: Adenocarcinoma with unknown primary site
Anshuman Darbari, Shekhar Tandon
C. T. V. S. Department, K. G. Medical University, Lucknow - 226 003, India
C. T. V. S. Department, K. G. Medical University, Lucknow - 226 003
We are reporting a case of sternal mass-histologically proven high-grade adenocarcinoma. Despite exhaustive investigations, no other primary site was detected. It was difficult to differentiate from metastasis or from primary skin adnexa, but whatever diagnosis is made, wide surgical excision with reconstruction is recommended for improvement of life quality.
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Darbari A, Tandon S. Unusual sternal mass: Adenocarcinoma with unknown primary site.Ann Thorac Med 2006;1:84-86
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Darbari A, Tandon S. Unusual sternal mass: Adenocarcinoma with unknown primary site. Ann Thorac Med [serial online] 2006 [cited 2020 Aug 4 ];1:84-86
Available from: http://www.thoracicmedicine.org/text.asp?2006/1/2/84/27108
Sternal tumors encompass a kaleidoscopic panorama of bone and soft tissue tumors; included among these are benign and malignant primary neoplasms; invading neoplasms from breast, lung, pleura or mediastinum; and neoplasms by metastasis. From a practical standpoint, treatment for cure is most often limited to resection of tumor, but inability to reconstruct large chest wall defects may compromise this.
A 60-year-old man was admitted to our institute with complaints of slow-growing, painless growth on midline anterior chest wall for the last 3 years. On clinical examination, a firm to hard swelling over manubrium and upper part of the body of sternum bone - with ill-defined margins, of size approx. 6 x 4 cm and without any ulcer, sinus and pulsations - was noticed. Bilateral breasts were normal. On clinical examination, cardiorespiratory, abdominal and neurological systems were normal. Routine hematological and coagulation studies were within normal ranges. Blood sugar, liver function tests and renal function tests were also within normal ranges.
Chest X-rays PA (posteroanterior) and lateral views [Figure 1] showed that manubrium and upper part of the body of sternum were irregular with destroyed bone and soft tissue mass in presternal and retrosternal area. Fine needle aspiration cytology and incisional biopsy reports were inconclusive. Contrast-enhanced computerized tomographic scan of thorax [Figure 2] showed irregularity and sclerosis of manubrium and upper part of body of sternum with presternal and retrosternal soft tissue mass with streaky attenuation of anterior and superior mediastinal fat. Ultrasound abdomen study was normal. Preoperatively, his FEV 1 = 4.0 L (Predicted 4.10 L), FVC = 5.6 L (Predicted 5.3 L), PaO 2 = 96 mmHg and PaCO 2 = 42 mmHg were found.
Under general endotracheal anesthesia, subtotal sternectomy with removal of bilateral costochondral junctions of 2, 3, 4 ribs was done. On visual inspection and manual palpation, lungs, pleura and mediastinal structures were normal. By the help of prosthetic prolene mesh, skin closed per primam. Removed specimen of bone and soft tissue was approximately 12 x 7 x 4 cm. In postoperative phase, no ventilatory support was needed.
Final biopsy showed high-grade adenocarcinoma [Figure 3] involving and destroying the sternum bone, with extension into surrounding soft tissue and into the overlying skin. Pleural fluid was negative for cancer cells. Postoperatively, no primary site of adenocarcinoma was detected in spite of repeat meticulous clinical examination, ultrasound abdomen, prostate-specific antigen, proctosigmoidoscopy and esophagogas-troduodenoscopy (EGD).
Patient recovered well and did not have any respiratory difficulty on regular follow-up [Figure 4]. Two years after operation, no local or distant pathology has developed and also, till now there is no other symptomatology suggestive of any other primary site. In our opinion, it is an unusual case of high-grade adenocarcinoma of sternum bone with unknown primary site.
Primary bone tumors involving sternum are very rare (only 0.6%). Dhlin and Unni (1986) reported that primary neoplasm of the manubrium and sternum constitutes 15% of all primary chest wall bone tumors. Two-thirds of sternal tumors are metastatic. Most frequently, these are breast cancer invasion, lung or pleural malignancy invasion or rarely, solitary metastasis from kidney and thyroid - the last two often present as pulsating tumor mass. It is also not uncommon for patients to present with a postradiation necrotic chest wall neoplasm. Metastatic tumor present symptomatically earlier because of their increased doubling time.,,,
The approach to a sternal tumor is made in two steps. First, the size and invasiveness is determined, followed by the histology. Careful radiological investigations are necessary to assess the extent of the tumor. The mass evident on examination is often part of a much larger tumor invading the sternum. CT scanning has enhanced the ability to distinguish into cystic or solid mass and to demonstrate invasion. In large tumors, a core needle biopsy or an incisional biopsy is done first. Care must be taken to plan the biopsy incision so that the subsequent excision can include the biopsy scar. In metastasis, needle biopsy generally confirms the diagnosis. A complete search for primary site is carried out. If none are found, excision should be done. Preoperative diagnosis is able to identify those patients whose primary treatment consists of chemotherapy or radiation or distinguish primary from metastatic or inflammatory conditions.,
Surgery to perform wide resection and simultaneous reconstruction safely is the best treatment and basic step of multimodality approach. In 1978, Holder was the first to describe a partial sternectomy for a primary sternal sarcoma. Now the guidelines for resection are to get 5 cm of clear margin of tissue. Violation of tumor should be avoided and a full thickness chest wall resection carried out, including parietal pleura. Invaded contiguous structure should also be removed. Overlying skin should always be taken, if adherent or from site of previous biopsy.,,
Our case also represents the adenocarcinoma of sternum, but after resection, no primary site was detected. This surgical resection, initially done with palliative or diagnostic intent, has proved to be curative, giving patient a near-normal life.
In the analysis of survival data in malignant sternal tumors, two major considerations merit attention. First, removal of a fungating, painful or bleeding tumor mass will give the patient an improved quality of survival, although it may not prolong life. Second, the group of patients in whom symptoms are directly related to compression or invasion of lung and/or neurovascular or underlying structures will show marked improvement in symptoms and well being with resection of these tumors. Result in these cases are not measured by survival rates but by improved quality of life after resection.,,
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