Surg Today (2001) 31:799–802

Case Reports

Surgical Treatment of Sternal Metastases From Thyroid Carcinoma:Report of Two Cases

Anjali Mishra1, Saroj Kanta Mishra

1, Amit Agarwal1, Gaurav Agarwal

1, and Surendra Kumar Agarwal2

1 Department of Endocrine Surgery and 2 Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute ofMedical Sciences, Raebareli Road, Lucknow 226 014, India

ablation of the metastasis is one option, but it is re-ported to cure only 7% of patients with bone me-tastases.4 Complete surgical resection of metastasesoffers the best chance for prolonged survival and isrecommended by most authorities.5,6 This report de-scribes two patients with sternal metastases from DTC,successfully managed by partial sternal resection fol-lowed by chest wall reconstruction with polypropylene(Marlex) mesh. These two cases serve to demonstratethe effectiveness of resection in the management ofmetastatic thyroid cancer.

Case Reports

Case 1

A 35-year-old woman presented to our hospital with along history of a goiter which had enlarged rapidly overthe past year. She had also noticed a progressive swell-ing in the upper part of the sternum. There was nohistory of compressive or toxic symptoms. On examina-tion, the patient had a grade III multinodular goiter anda 7 � 7-cm bony swelling involving the manubriumsterni. Fine-needle aspiration cytology from the goiterand sternal swelling revealed findings suggestive of afollicular neoplasm with sternal metastases. Thyroidfunction test results were in the euthyroid range. Acomputed tomography scan of the neck and thoraxshowed soft tissue swelling with destruction of the un-derlying sternum and invasion of the anterior mediasti-num by the swelling. No lymph node enlargement wasnoticed either in the neck or mediastinum, and no pul-monary metastases were found. A total thyroidectomywas performed initially and histopathological examina-tion confirmed a diagnosis of poorly differentiated thy-roid carcinoma. Since the patient had exruciating painwith impending compression of vital structures in thethoracic inlet and anterior mediastinum, we performed

Abstract Radioiodine therapy is currently the treatmentof choice for metastasizing differentiated thyroid cancer(DTC); however, skeletal metastases are resistant tothis form of therapy. The surgical removal of distantmetastases from DTC offers the best chance for pro-longed survival and improved quality of life. Fur-thermore, the surgical removal of a resectable skeletalmetastasis can be a valuable complement to radioiodinetherapy. This report describes two cases of sternal me-tastases from thyroid carcinoma that were managedsuccessfully by surgery involving partial excision of thesternum followed by reconstruction of the chest wallwith Marlex mesh. Both patients recovered unevent-fully. Sternal resection with Marlex mesh reconstruc-tion of the chest wall defect proved a simple andeffective method for managing sternal metastasis. Thus,the surgical resection of distant bony metastases in pa-tients with DTC is recommended as it can be curative,provide symptomatic palliation, or allow for more effec-tive radioiodine treatment.

Key words Thyroid cancer · Radioiodine ·Thyroidectomy

Introduction

Bony metastases have been reported to occur in1%–4%1–3 of all cases of differentiated thyroid cancer(DTC). Although distant metastasis usually signifies anunfavorable outcome for patients with carcinoma, be-cause thyroid cancer is a relatively slow-growing malig-nancy a patient can have several years of palliation, oreven cure, if radical treatment is initiated. Radioiodine

Reprint requests to: S.K. MishraReceived: July 3, 2000 / Accepted: March 6, 2001

800 A. Mishra et al.: Treatment of Metastatic Thyroid Carcinoma

sternal resection followed by reconstruction usingMarlex mesh. A midline skin incision was made, meet-ing the previous cervical incision at the midpoint. Thesternum was cut horizontally at the level of the thirdcostochondral junction and on both sides, the medial2cm of clavicle and the first and second ribs were re-moved with the tumor. The mediastinal and both pleu-ral cavities were drained and the defect was thencovered with Marlex mesh, which was fixed to themargins with 1/0 prolene stitches. A suction drain wasplaced over the mesh and the skin was approximatedover the mesh with interrupted silk sutures. The patienthad excessive drainage in the early postoperative pe-riod, but otherwise her postoperative course was un-eventful. There was no component of flail chest and thepatient maintained normal oxygen saturation during thepostoperative period. Histopathologic examination ofthe resected specimen showed metastatic poorly dif-ferentiated thyroid carcinoma. The patient was com-menced on Levothyroxine and also advised to have apostoperative radioiodine scan. However, she declineddue to financial constraints and left against medical ad-vice on the 14th postoperative day.

Case 2

A 43-year-old man who had been aware of a thyroidswelling for the last 5 years presented to a local hospitalabout 1 year after first noticing the development ofswelling over the upper sternum. A total thyroidectomywas performed and histopathological examinationrevealed follicular carcinoma thyroid. The surgeonreferred the patient to our hospital for radioiodine abla-tion of metastases. Radioiodine scan revealed increasedtracer concentration in the sternum and sacrum, as wellas bilateral diffuse uptake in the lungs with an area ofincreased tracer uptake in the right lung. Since thenuclear physician believed that resection of the bonymetastasis would enable more effective radioiodinetreatment of pulmonary metastasis, the patient was re-ferred to our department. On physical examination, thethyroidectomy scar was evident, and a 7 � 10-cm swell-ing involving the manubrium sterni and upper part ofthe body of the sternum was also seen (Fig. 1). A mag-netic resonance imaging scan showed a heterogeneoussoft tissue swelling involving the upper part of sternumand extending to the anterior mediastinum; however,the major vessels were not involved (Fig. 2). Smallnodular lesions were also seen in peripheries of bothlungs. An X-ray of the spine revealed an obliteratedintervertebral space between L5 and S1 vertebrae.Since the patient did not have any abnormal neurologi-cal signs, a decision was made to resect the sternalmetastases followed by resection of the spinal lesion.Through a transverse incision, resection and reconstruc-

tion of the sternum was done using the same techniqueas described in case 1 (Fig. 3). The resected specimenincluded the manubrium sterni, the upper part of thesternal body up to the fourth costochondral junction,the medial 2.5 cm of clavicle, and the anterior part of theupper three ribs on both sides. The patient had an un-eventful postoperative course. Histopathologic exami-nation revealed metastatic follicular carcinoma. He wasdischarged on the 11th postoperative day and advised toundergo radioiodine ablation as he had declined anyfurther surgery. At the time of writing, the patient hadreceived a total 350mCi of 131I therapy.

Fig. 1. Clinical photograph of case 2 showing a large mass,later revealed to be metastatic follicular carcinoma, in theupper part of the sternum

Fig. 2. Magnetic resonance image of the thorax of case 2revealed a metastatic lesion in the sternum

801A. Mishra et al.: Treatment of Metastatic Thyroid Carcinoma

Discussion

According to our review of the literature, less than1% of patients with papillary carcinoma and 3%–4% ofthose with follicular thyroid carcinoma had distant me-tastasis at the time of presentation.1–3 In a series re-ported by Niederle et al.,5 46 (80%) of the 54 metastaseswere located in bones, of which approximately 20%were sternal metastases. Ozaki et al.7 reported two casesof sternal metastases; however, in a series by Marcocciet al.8 there were no metastases to the sternum.

The occurrence of bone metastases, either alone orin combination with other metastases, significantlyworsens the prognosis,1,9–11 as bone metastases do notrespond effectively to radioiodine ablation. This may bedue to reduced sensitivity to radioiodine, possibly at-tributable to a lower capacity of absorption9,13–16 whichcould be related to the expression of a higher percent-age of poorly differentiated tumor cells.13 According tothe series by Niederle et al.,5 27% of the tumors re-moved exhibited solid tumor formation and all hadbone metastases.

The indications for surgery to treat bone metastasesare mentioned only in relation to individual cases.10,17–21

Surgical resection is recommended if the metastasis issolitary and amenable to resection; however, even ifthere are multiple metastases, resection of bone me-tastases can allow more efficient radioiodine treatmentof visceral metastasis and has a favorable effect on prog-nosis and the patient’s quality of life.5 Considering theradioiodine insensitivity of bone metastases, surgicaltreatment has been recommended by many surgeons.5,6,8

We support this approach and always try to resect me-tastases whenever feasible. Complete remission hasonly been reported in a few isolated cases of bone me-tastases of small size, detected by whole body iodinescan, but not by radiography.5,8 The main indications forresection of metastatic lesions at our center are: cura-

tive intent for patients with a solitary metastasis;symptomatic palliation, for example to relieve spinalcompression in patients with paraplegia; and to allowradioiodine therapy to more effectively be delivered tolung metastases, for example, if a patient has large bonymetastases with lung metastases.

There are two main ways of reconstructing the chestwall after sternal resection, namely, by direct coveringwhen the defect is limited to the manubrium, or bysubstitution for a wider defect, using either autologustissue or an artificial substitute. A foreign body reactionis not seen when autologus material is used, but there isa limitation to the extent of substitution and strength ofthe tissue being used. Marlex mesh is now widely usedfor its convenience as it has good tissue affinity and iseasy to handle. Ozaki et al.7 showed that reconstructionwith an acrylic resin plate sandwiched between layers ofMarlex mesh gave a superior result compared with re-construction with an acrylic resin plate alone. However,both of our patients underwent partial sternum resec-tion and fared well with Marlex mesh reconstructionalone.

For patients with DTC and bony metastases, we rec-ommend surgical resection of the distant metastases,not only as curative or palliative measure but also toallow more effective radioiodine treatment to be deliv-ered. We believe that sternal resection with Marlexmesh reconstruction of the chest wall defect is a simpleand effective method of surgically managing sternalmetastases.

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Fig. 3. Perioperative photograph of case 2 showing theMarlex mesh sutured to the margins of the defect in the ante-rior chest wall

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