Sternal Lesions Research Articles

6918 A Unique Case of Oncocytic Thyroid Cancer with an NBN Gene Pathogenic Variant

Abstract Disclosure: A. Grover: None. S. Jhawar: None. S. Shekhar: None. S.A. Avadhanula: None. G. Al-Naqeeb: None. G. Thota: None. P. Veeraraghavan: None. C. Cochran: None. M.Y. Kao-Hsieh: None. A. Gharib: None. F.E. Escorcia: None. J. Del Rivero: None. J. Klubo-Gwiezdzinska: None. S. Gubbi: None. Introduction: Oncocytic thyroid carcinoma (OTC), previously known as “Hürthle cell” carcinoma, makes up less than 5% of all thyroid cancers. OTCs are often aggressive with a high risk of metastasis, and a poorer prognosis compared to other forms of differentiated thyroid carcinoma (DTC). Molecular drivers of OTC include pathogenic variants (PVs) in NRAS, DAXX, CDKN1A, the mitochondrial genome and chromosomal alterations. PVs in the NBN gene in OTC have not been previously reported. Case: A 53-year-old male was noted to have a thyroid nodule on a routine physical examination. Patient denied any hyper/hypothyroid or compressive symptoms, and family history was unremarkable. Cytopathologic analysis of the fine needle aspiration biopsy of the nodule was consistent with a thyroid follicular neoplasm (Bethesda IV). A total thyroidectomy with central compartment neck dissection was performed. Histopathologic examination demonstrated a 7 cm x 4 cm x 4 cm OTC with capsular and lymphovascular invasion, but without extra-thyroidal extension or lymph node metastasis (pT3aN0Mx). Subsequently, adjuvant radioiodine (RAI) I131 therapy with 165 mCi was administered and post-therapy scan revealed neck uptake. One-year post-therapy RAI diagnostic scan was negative. Three years following the initial thyroid surgery, elevated serum thyroglobulin (Tg) levels were noted. A computed tomogram of the chest revealed multiple bilateral lung nodules. Further imaging ruled out involvement of other distant sites. A diagnostic lower lung wedge resection demonstrated metastatic OTC. The tumor stained positive for CK7, PAX8, TG, TTF-1 and negative for CK20 on immunohistochemistry. Next-generation sequencing of the tumor tissue (Oncomine Comprehensive Assay v3) revealed a PV in the NBN gene (c.2166_2167delGCinsAT; p.Trp722Ter). A year later, the serum Tg levels continued to rise, and the lung nodules had increased in size. Due to disease progression, lenvatinib was initiated. A [F18]-fluorodeoxyglucose positron emission tomography performed one year later demonstrated persistent pulmonary tumor burden with new osseous metastasis in the right scapula, left acetabulum, and the sternum. Zoledronic acid was initiated for the treatment of the skeletal metastases, and palliative external beam radiation (2000 cGy in 5 fractions) was administered to the sternal lesion to alleviate the bone pain. Conclusion: The NBN gene encodes for the protein nibrin, a member of the MRE11/RAD50 complex that is involved in DNA repair. PVs in NBN are commonly identified in non-thyroidal malignancies such as breast and lung carcinomas. While NBN PVs are rarely reported in DTCs, as per our knowledge, this is the first described case of OTC with a PV in NBN as the molecular driver, manifesting with an aggressive disease course. Identification of this novel PV therefore adds to the current knowledge of the molecular landscape of OTC. Presentation: 6/3/2024

EBV positive plasmacytoma in immunocompetent patients: A diagnostically challenging rare entity

Abstract Introduction/Objective Epstein-Barr Virus (EBV)-positive plasmacytoma is a rare entity that shows morphological and immunophenotypic overlap with plasmablastic lymphoma and can cause a diagnostic dilemma. Here we discuss a unique case of EBER-positive plasmacytoma arising from nasal polyps. Methods/Case Report A 61-year-old immunocompetent male presented with nasal polyps, right maxillary sinus lesions, and an enlarging sternal lesion. Multiple biopsies were obtained which revealed a diffuse infiltration by atypical plasma cells, that were positive for CD138, MUM1, CD79a, CD56, lambda-in situ hybridization, and Ki67- proliferation index of 20-30%. In situ, hybridization for EBV-encoded viral RNA (EBER) was positive in the neoplastic cells. B- and T- cell markers were negative. The flow cytometry studies detected monotypic lambda-restricted CD38/CD138 positive plasma cells with an aberrant expression of CD56 and CD117. Molecular studies for B-and T- cell gene rearrangement were also negative. A final diagnosis of EBER-positive plasmacytoma was made. The patient was treated with cyclophosphamide, vincristine, doxorubicin, and carboplatin followed by four cycles of RVD, and is doing well. Results (if a Case Study enter NA) NA Conclusion EBER-positive plasmacytoma poses a diagnostic challenge with plasmablastic lymphoma, specifically in immunocompetent individuals. The useful differentiating clues pointing towards EBER positive plasmacytoma could be a spectrum of morphology ranging from mature to anaplastic, low Ki67 proliferation index, aberrant CD56 and CD117 positivity, and high M- spike on protein studies. Comprehensive clinical, morphologic phenotypic, and genetic investigations are necessary to make a specific diagnosis as the two entities differ in their management.

Wide Composite Resection of Sternal Metastasis & Reconstruction Using Titanium Mesh Implant and Myocutaneous Flap in Differentiated Thyroid Carcinoma: Case Report of Two Cases.

Differentiated Thyroid carcinoma (DTC) with distant skeletal metastases is associated with a very poor prognosis and are unfortunately resistant to radioiodine therapy (RIT). Surgical removal of the metastases in such selected cases is a beneficial adjunct to RIT. We report two cases of DTC with sternal metastases whom we successfully managed with surgical resection of the sternal lesion with reconstruction of the chest wall defect using titanium mesh implant and myocutaneous flap.

A Retrospective Analysis of Sternal Lesions Detected on Breast MRI in Patients Without History of Cancer.

To determine the imaging characteristics and stability over time of sternal lesions identified on breast MRI in patients without history of cancer. An IRB-approved retrospective analysis of all breast MRIs performed at our institution from September 1, 2017 to December 1, 2021 that included one of several key words related to the sternum. Studies with history of non-dermatologic malignancy including breast cancer, absence of a true sternal lesion, or presence of symptoms during the examination were excluded. Imaging was reviewed for size, distribution, signal characteristics, and presence of contrast enhancement, perilesional edema, periosteal edema, or intralesional fat. Available comparison imaging, clinical history, and follow-up recommendations were reviewed. Descriptive statistics were used to summarize lesion data. Of 60 lesions included from 60 patients, 40 lesions with more than two years of comparison imaging were either stable or decreased in size and none demonstrated change in signal characteristics. The majority of these presumed benign lesions demonstrated hypointense signal on T1-weighted sequences (21/40, 52.5%), hyperintense signal on fluid-sensitive sequences (33/40, 82.5%), contrast enhancement (32/40, 80.0%), and absence of clear intralesional fat (29/40, 72.5%). One patient who did not have comparison imaging was diagnosed with malignancy (multiple myeloma) eight months following their MRI. This lesion demonstrated uniquely diffuse and heterogeneous enhancement but did not undergo biopsy. Sternal lesions in women without history of non-dermatologic malignancy have a very low likelihood of malignancy. Common imaging characteristics of the presumed benign lesions can inform imaging recommendations when incidental sternal lesions are discovered.

Surgical treatment of patients with chest wall metastases

To evaluate postoperative outcomes in patients with chest wall metastases. We analyzed 40 patients who underwent surgery for chest wall metastatic lesions. Fourteen (35%) patients had sternal lesion, 26 (65%) ones - rib metastases. We used implants for chest wall defect closure in 15 (37.5%) patients. Chest wall repair with autologous tissues was performed in 19 (47.5%) patients. Median survival was 17 months. Most patients (n=30, 75%) showed improvement in the quality of life according to Karnofsky and EGOG scale after surgery. Continued tumor growth occurred in 4 (10%) patients within 8-16 months after surgery. There were 2 patients who suffered from tumor recurrence accompanied by other metastatic foci (progression). Complications were diagnosed in 5 (12.5%) patients. Tactical errors were identified in 4 (10%) patients and they were associated with progression of cancer in the form of new metastatic foci within 6 months after surgery. Active surgical approach for bone metastases in patients with favorable cancer-related prognosis can improve quality of life and survival at least in case of solitary lesions. New program for treatment strategy selection based on prognosis of life expectancy and algorithms of surgical treatment will reduce the risk of erroneous management and increase its effectiveness.

Surgical treatment in patients with a sternal metastatic lesion

Surgical treatment in patients with a sternal metastatic lesion

802 Preservation of a Reconstructed Breast Whilst Undertaking Total Sternal Resection for Metastatic Breast Cancer with a Pedicled Latissimus Dorsi Flap and a Methyl Methacrylate Mesh Sandwich

Abstract Background Sternal resection and reconstruction are a complex and challenging procedure that requires a multidisciplinary approach and input from both thoracic and plastic surgeons. Limited data exist on sternal resection and reconstruction for secondary breast malignancies. The goals of sternal and anterior chest wall reconstruction are to maintain chest wall integrity, rigidity, and the negative pressure necessary for respiratory and cardiac functions, protect intrathoracic contents, and restore the chest wall contour. Case Presentation A 40-year-old lady developed a solitary sternal metastatic lesion three years after her initial diagnosis with BRCA2 positive breast cancer. She had previously undergone left mastectomy, axillary clearance and implant reconstruction followed by right prophylactic mastectomy and implant reconstruction. She also had neoadjuvant chemotherapy and adjuvant chest wall radiotherapy. Her solitary sternal metastasis was managed with curative intent by complete sternal resection and a combined alloplastic and autologous sternal reconstruction with methyl methacrylate sandwiched between a polypropylene mesh and covered with a pedicled latissimus dorsi flap. The flap was successfully tunnelled under the previous implant-based breast reconstruction capsule. The surgical margins were clear, there were no post-operative complications and no further disease. The patient achieved good cosmetic outcomes. Conclusions We describe the first case of breast implant preservation whilst undertaking total sternal resection for an isolated sternal metastasise and reconstruction with a pedicle latissimus dorsi flap and methyl methacrylate mesh sandwich. We advocate combined approach with thoracic and plastic surgery, which allows a safe single stage procedure.

Self-limiting sternal tumors of childhood (SELSTOC): A diagnostic challenge

IntroductionSelf-limiting sternal tumors of childhood (SELSTOC) are rapidly growing sternal lesions that tend to resolve spontaneously. Patients have no history of infection, trauma, or neoplasms, and the most likely etiologyis an aseptic inflammatory reaction of unknown origin. The differential diagnosis includes a wide spectrum of lesions such as tumors, infections, malformations, or anatomic variants. Material and methodsWe analyzed all cases of sternal masses in pediatric patients seen between 2012 and 2019; five of these had findings compatible with SELSTOC. We retrospectively recorded patients’ race, sex, age, clinical presentation, laboratory findings, imaging tests, treatment, and follow-up. ResultsWe present five cases of rapidly growing sternal lesions whose clinical and radiological features are compatible with SELSTOC. In the absence of alarming symptoms and laboratory markers, watchful waiting could be an appropriate therapeutic approach. However, patients with some findings such as fever, elevated acute phase reactants, and/or comorbidities could require therapeutic interventions such as antibiotics or percutaneous drainage. In our series, depending on the clinical presentation and the patient’s comorbidities, different therapeutic approaches were adopted (a conservative approach in two patients, antibiotics in three patients, and percutaneous drainage in one patient). In all cases, the sternal lesion was absent at discharge and/or at later follow-up visits. ConclusionRadiologists and pediatricians must be aware of this entity and the different diagnostic and therapeutic approaches to rapidly growing sternal lesions in pediatricpatients because recognizing SELSTOC can avoid unnecessary diagnostic tests and/or disproportionate therapeutic strategies.

Tumores esternales autolimitados en la edad pediátrica (SELSTOC): un reto diagnóstico

IntroductionSelf-limiting sternal tumors of childhood (SELSTOC) are rapidly growing sternal lesions that tend to resolve spontaneously. Patients have no history of infection, trauma, or neoplasms, and the most likely etiology is an aseptic inflammatory reaction of unknown origin. The differential diagnosis includes a wide spectrum of lesions such as tumors, infections, malformations, or anatomic variants. Material and methodsWe analyzed all cases of sternal masses in pediatric patients seen between 2012 and 2019; five of these had findings compatible with SELSTOC. We retrospectively recorded patients’ race, sex, age, clinical presentation, laboratory findings, imaging tests, treatment, and follow-up. ResultsWe present five cases of rapidly growing sternal lesions whose clinical and radiological features are compatible with SELSTOC. In the absence of alarming symptoms and laboratory markers, watchful waiting could be an appropriate therapeutic approach. However, patients with some findings such as fever, elevated acute phase reactants, and/or comorbidities could require therapeutic interventions such as antibiotics or percutaneous drainage. In our series, depending on the clinical presentation and the patient's comorbidities, different therapeutic approaches were adopted (a conservative approach in two patients, antibiotics in three patients, and percutaneous drainage in one patient). In all cases, the sternal lesion was absent at discharge and/or at later follow-up visits. ConclusionRadiologists and pediatricians must be aware of this entity and the different diagnostic and therapeutic approaches to rapidly growing sternal lesions in pediatric patients because recognizing SELSTOC can avoid unnecessary diagnostic tests and/or disproportionate therapeutic strategies.

Every Breath You Take – Evaluating Respiratory Motion of the Bony Thorax in the Context of Bone SBRT

Stereotactic Body Radiation Therapy (SBRT) delivers highly conformal treatment in a single or few fractions of high-dose radiation yielding excellent local control rates with minimal toxicity. There is growing interest in using SBRT to treat oligometastases, which potentially includes any anatomical site where metastases can occur. Bone is one of the most common sites of metastatic disease and although methodology to treat SBRT spine is well established, very little is known about the technical considerations of bone SBRT, particularly regarding respiratory motion in the bony thorax. The purpose of this study was to evaluate respiratory motion in thoracic bone metastases and to determine if the motion differs based on anatomic location. The first 70 patients treated with thoracic bone SBRT planned with four-dimensional computed tomography (4DCT) were identified from a prospective institutional database. To quantify motion, a region of interest representative of the treatment target was contoured by a single user in Pinnacle on the 0% (inhale) and 50% (exhale) datasets using fixed autocontour threshold values to eliminate subjectivity. A point of interest was automatically placed in the centroid of each volume and the relative positional difference of these points was calculated to measure the lateral (LR), anterior/posterior (AP) and superior/inferior (SI) motion. A total linear distance (LD) vector was calculated from these values. Rib lesions were further categorized as anterior, lateral or posterior based on axial position as well as superior (1-4), middle (5-7) and inferior (8-12) depending on rib location. Rib motion was analyzed using analysis of variance (ANOVA), if it was significant (p<0.05) a post hoc analysis was done to evaluate pairwise comparisons amongst the rib location groups. There were 15/16 sternal lesions assessed as 1 patient had significant bone destruction and could not be reliably contoured. Mean (range) LR, AP and SI sternum motion was 0.2 mm (0-0.7), 1.2 mm (0-2.6) and 0.1 mm (0-0.3) respectively and the LD was 1.2 mm (0-2.6). Forty-seven rib lesions were assessed for motion; 7 were excluded due to bone destruction preventing use of auto contour tool. The mean (range) LR, AP and SI motion for all rib lesions was 1.1 mm (0-4.0), 2.4 mm (0-8.4) and 0.1 mm (0-0.8) respectively and LD was 2.8 mm (0.1-8.5). When categorized by rib location, there were 9 superiorly, 22 middle and 16 inferior located rib lesions. The mean LD was 3.2 mm, 3.5 mm and 1.6 mm for superior, middle and inferior lesions respectively. There was a significant difference between the groups, with the inferiorly located moving less in terms of AP motion (p=0.02) and LD (p=0.04). In terms of axial position, there were 6 anterior lesions, 27 lateral lesions and 14 posterior lesions. The mean LD was 3.6 mm, 3.3 mm and 1.3 mm for anterior, lateral and posterior lesions respectively. There was a significantly less motion for posteriorly located lesions in terms of AP motion (p=0.005) and LD (p=0.02). This data suggests that the respiratory motion of the bony thorax is variable but not trivial in the context of high precision radiation therapy techniques with small margins. It appears that lesions located in the sternum and posterior and/or inferior aspect of the ribs move less; however, contouring guidelines, margins and image guidance technique need to be strongly considered before eliminating motion assessment when planning thoracic bone SBRT.

Metastatic Squamous Cell Carcinoma of Sternum: An Oncological Curiosity

Skeletal metastasis is a frequent complication of cancer resulting in significant morbidity as well as mortality. We highlight a case of a 73-year-old gentleman with metastatic squamous cell carcinoma of the sternum. He denied dysphagia, shortness of breath, goitre, and presence of chronic non-healing ulcer. He was anaemic and carcinoembryonic antigen (CEA) was 18.7. Chest radiograph on lateral view showed a suspicious cortical irregularity. Computed tomography (CT) scan of thorax revealed an aggressive sternal lesion with soft tissue component. Ultrasound-guided biopsy was performed and the biopsy was consistent with metastatic squamous cell carcinoma. Squamous cell carcinoma has a predilection to metastasize via haematogenous spread, but direct extension of tumour into the bone is not frequently seen. Finding the primary cause is utmost importance either via imaging modalities or invasive procedures. Isolated secondary lesion is extremely rare but unfortunate among defaulters. We discuss its diagnostic work-up and treatment options conserved to manage this condition.

Characterization of Metastatic Sternal Lesions on Dynamic Contrast-Enhanced Breast MRI in Women with Invasive Breast Cancer

Detecting sternal lesions is not the purpose of breast MRI, but diagnosing metastasis has major clinical implications. Our purpose was to determine the breast MRI features of sternal metastases detected on PET-CT and bone-scan. Between 01/2010-09/2018, 379 patients with breast cancer had sternal findings on PET-CT or bone-scan, 21 of which underwent breast MRI within 100 days. Sternal lesions were considered metastatic if (1) biopsy demonstrated metastasis, (2) the lesion had similar appearance to synchronous sites of biopsy-proven osseous metastases, or (3) there were numerous suspicious lesions in which widespread osseous metastasis was presumed. Four radiologists reviewed the MR images to determine if metastases were retrospectively detectable. MRI reports were reviewed to determine if lesions were prospectively described. MRI features of metastatic sternal lesions were compared to benign controls. Fourteen sternal metastases met inclusion criteria. Lesions were retrospectively detectable on breast MRI by all radiologists in 86% (12/14) of cases, but prospectively reported in 57%. Of the 12 MRI-detectable metastases, mean maximum dimension was 33 mm, 7 had >1 lesion, all were T1-hypointense, 11 were T2-hyperintense, 11 were noncircumscribed, 6 extended beyond cortex, 11 enhanced heterogeneously, and 11 demonstrated washout. Heterogeneous enhancement (p = 0.002), noncircumscribed margins (p < 0.001), multiplicity (p = 0.005), and size >1 cm (p < 0.001) were more frequent with metastatic compared to benign sternal lesions. Most sternal metastases (86%) were retrospectively detectable on breast MRI, but only 57% were prospectively reported, emphasizing the importance evaluating the sternum on breast MRI. Certain MRI features may raise suspicion for metastasis.

Anaplastic large cell lymphoma presenting as sternal swelling

Lymphomas involving the sternum are very rare. We report a case of lymphoma presenting as lytic sternal lesion. A 14-year-old girl presented with history of painless swelling of central chest (sternum) of 3 months duration. Fine needle aspiration cytology from the site revealed anaplastic large cell lymphoma. It was confirmed by histopathology and immunohistochemistry. She underwent treatment with chemotherapy but succumbed to her illness after six months of treatment.

Malignant tumors of the sternum in pediatric patients: report of two cases and literature review

Destructive changes in the bones are rarely observed in daily practice of pediatric orthopedic surgeons. Clinical and X-ray signs of destructive changes in the bone tissue are characteristic of tumoral, infectious, and inflammatory damages of bones. These signs do not always correspond to a specific disease, and differential diagnostics without histological evaluation is difficult. This is especially true for tumors of the sternum, 85% of which are malignant.&#x0D; Two rare clinical cases of primary malignant sternal neoplastic lesions in pediatric patients, and a detailed analysis of their clinical, radiologic, and morphologic data are presented. The importance of early histological verification for determining the choice of treatment is demonstrated. A short literature review is also presented.

Abstract P3-13-19: Isolated sternal metastases: The place of surgical resection

Abstract Background: Solitary sternal metastases from breast cancer are found in approximately 1.9 to 2.5 % of all advanced breast cancer cases. According to the latest AJCC classification, they are still considered as stage IV disease, but their prognosis is better in the absence of other foci of metastatic disease. Their treatment still remains controversial. Material and methods: This is a monocentric retrospective study performed in our breast clinic and approved by our ethics committee. Twelve patients were included in this study between 2010 and 2015; 11 had a metachronous solitary sternal metastasis and 1 had a synchronous metastatic sternal lesion. Complete restaging was negative in all patients for other metastatic lesions. The extent of resection (different parts of the sternum and frequently also adjacent rib cartilages) necessary to obtain free margins was estimated preoperatively on MRI images focused with adequate sequences. All the patients underwent a large sternal resection and a chest wall reconstruction integrated in a multimodal approach. Characteristics of the patients and of the tumors were studied. The major outcomes studied were disease-free (DFS) and overall survival (OS). Results: The mean interval between the initial diagnosis of breast cancer and the discovery of sternal metastasis was 115 months. After surgical resection, free margins were obtained in 10 patients. No post-operative complications were observed except for persistent thoracic pain in one patient with a medical history of chronic pain. Excellent cosmetic and functional outcomes were obtained without significant impairment of respiratory function. Ten patients received chemotherapy pre- or postoperatively. All the tumors expressed ER and /or PgR receptors, and endocrine therapy was administered in all patients. Mean duration of follow-up was 25 months (9-51 months). Three patients presented distant recurrences: 2 liver lesions and 1 cervical nodal recurrence with pericardic effusion. Out of these 3 patients, 1 died after 51 months. Currently the DFS of this small study is 75 % and the OS is 91.6 %. Conclusion: Treatment of isolated sternal metastases of breast cancer must be based on a multidisciplinary strategy. Sternectomy and multilayered chest wall reconstruction (with different types of meshes and flaps) could be a curative approach in highly selected patients with no other metastatic lesions. In this group of patients, the good prognosis observed could be due to a different mechanism of dissemination, based on lymphatic rather than hematogenic diffusion. Longer follow-up and prospective studies are needed to confirm these encouraging results. Citation Format: Berliere M, Taburiaux L, Lacroix V, Gerday A, Coyette M, Lecouvet F, Piette P, Galant C, Duhoux F, Lengele B. Isolated sternal metastases: The place of surgical resection [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-19.

Percutaneous CT-guided sternal biopsy: factors affecting the diagnostic yield.

Background Sternal lesions are occasionally seen in clinical practice and their diagnosis can be important, especially for oncologic patients. However, percutaneous computed tomography (CT)-guided biopsy of sternal lesions is rarely performed. Purpose To assess the diagnostic yield of percutaneous CT-guided sternal biopsies and to analyze the factors that affect diagnostic yield. Material and Methods A retrospective review of 34 patients who underwent CT-guided sternal biopsy was carried out at a single institution. Pre-biopsy CT density, location, penetration length of biopsy needle, number of biopsy attempts, angle of needle approach, final diagnosis, and operator experience level were recorded. A biopsy was considered as diagnostic if it provided a confident pathologic result. All variables were compared using Chi-square tests. Results Twenty-two of the 34 (64.7%) biopsy procedures yielded a diagnostic sample and 12 (35.3%) were non-diagnostic. Eight participants in the non-diagnostic group were clinically diagnosed with inflammatory arthritis of the manubriosternal or costosternal joints. Longer penetration distance of the tumor by the biopsy needle showed higher diagnostic yield ( P = 0.031). Osteoblastic lesions ( P < 0.001), lesions in the manubriosternal joint ( P = 0.018) and approaches using more obtuse angles ( P = 0.009) were associated with significantly lower diagnostic yields. Malignancy in the final diagnosis led to a higher diagnostic yield than benign lesions ( P < 0.001). Conclusion CT-guided percutaneous sternal biopsy has a relatively lower diagnostic yield. However, acute angle of needle approach may help increase biopsy success rate. Osteoblastic lesions and lesions in the manubriosternal joint tend to have lower diagnostic yield.

Non-neoplastic variants of the sternum detected on bone scintigraphy using a hybrid SPECT/CT machine

PurposeTo identify the non-neoplastic variants of the sternal uptake in patients known to have a primary tumor, referred for detection of metastases elsewhere. Materials and methodsThis retrospective study was approved by the Institutional Review Board. Fifty eligible patients (17 males & 33 females) known to have a primary tumor underwent 99mTc-MDP-bone scan for detection of metastases. All patients underwent SPECT/CT of the chest region.For each patient, 10 subsites were evaluated (right & left sternoclavicular joints, right and left first costo-sternal articulation, manubrium sterni, manubriosternal junction, body of the sternum, xiphisternal junction, xiphoid process and other sub-sites (e.g. chondro-sternal articulations)). The uptake was described as normal or abnormal. CT findings were categorized as normal/abnormal (arthritis, degenerative, developmental & congenital). Any patient with suspicious metastatic sternal lesion based on CT findings or abnormal tracer uptake was excluded. ResultsA total of 500 sub-sites were analyzed. Increased uptake was seen in 189 sub-sites. Of them, 133 showed abnormal CT findings (95 arthritis, 33 degenerative, 3 developmental & 2 congenital) and 56 sites were unremarkable. Of the 311 with normal uptake, only 18 showed abnormal CT findings (8 arthritis & 10 degenerative). The association was statistically significant (P<0.001). ConclusionIncreased sternal uptake is significantly associated with CT structural abnormalities and knowledge of these non-neoplastic variants is essential for correct interpretation of SPECT/CT bone scans especially in patients with known cancers.

Intercostal Nerve Schwannoma Encountered during a Rib-Latissimus Dorsi Osteomyocutaneous Flap Operation.

Schwannomas are benign, slow-growing tumors that arise from the Schwann cells of peripheral nerve sheaths and are also known as neurilemmomas or neurinomas. These tumors are covered with a well-demarcated capsule and commonly measure 2-4 cm in diameter. They frequently occur in the head and neck or in the extremities. The lesions themselves do not cause an inflammatory reaction, and patients usually present when these lesions compress the associated peripheral nerve and cause sensory or motor issues secondary to neuropathy. Schwannomas do not have a predilection for sex or ethnicity, but tend to develop between the second and fifth decades of life. Surgical resection is curative, and the possibility of recurrence or malignant transformation is considered extremely low [1,2]. Schwannomas of the intercostal nerve are extremely rare with few cases of large or symptomatic lesions reported in the literature. No intercostal schwannomas have been reported as an incidental finding. Here, we report a small intercostal schwannoma found during a chest wall reconstruction. A 58-year-old male patient with a sternal mass underwent excisional biopsy of a sternal lesion. The mass was found to be a chondrosarcoma on histopathology, and the patient subsequently underwent a secondary operation for wide resection and reconstruction of the chest wall defect. In the operating room, the sternal mass was resected en bloc with a wide surgical margin. In order to restore the resulting chest wall defect, a composite island flap was elevated, including the left tenth rib and the latissimus dorsi muscle. During this process, a 1-cm×1-cm mass was incidentally found along the subcostal groove of the tenth rib (Fig. 1). This well demarcated mass was excised. The remainder of the operation was uneventful. The results of the histologic examination of this lesion were consistent with a schwannoma (Fig. 2). Upon inquiry, the patient did report occasional bouts of pain in the area, which was described as sharp stabbing pain that worsened with coughing and exercise. However, the preoperative chest computed tomography images did not indicate the presence of the intercostal schwannoma. He did not report any paresthesia or hypoesthesia in the area innervated by the tenth intercostal nerve. The patient was discharged 14 days after the operation without any complications. The patient did not report any subsequent episodes of the pain. Fig. 1 (A, B) Intraoperative photographs. A 1-cm×1-cm mass was incidentally found under the left tenth rib. Fig. 2 Histopathologic images of the specimen. (A) The low-power view shows a biphasic pattern with a cellular Antoni A area (black arrow) and a hypocellular Antoni B area (white arrow) (H&E, ×40). (B) The high-power view shows tumor cells forming ... The most common presentation of schwannomas is a palpable mass, the percussion of which result in a painful paresthesia along the involved peripheral nerve [3]. In the case described here, the patient recalled a sharp shooting pain along the tenth intercostal nerve distribution of the left chest wall that worsened with coughing and exercise. While uncommon, schwannomas of the intercostal nerve can grow to compress the nerve against the subcostal groove, causing intercostal neuralgia, including pain, tenderness, paresthesia, and hypoesthesia. Chronic intercostal neuralgia is relatively common among adults, and is caused by herpes zoster infection, diabetic polyneuropathy, vertebral facet joint hypertrophy or arthritis, and malposition of the costovertebral joint (slipping rib syndrome) [3]. Intercostal neuralgia can also be caused by tumors and/or inflammation in the mediastinal, paravertebral, and costal areas [4]. The intercostal schwannoma and neuralgia in our case did not cause significant disability to the patient, which was most likely due to the fact that the lesion was smaller than most intercostal schwannomas (1 cm×1 cm compared to the usual size of 2-4 cm). The intercostal nerves are a part of the somatic nervous system, and originate from the anterior root of the thoracic spinal nerve (T1-T12). Each intercostal nerve is responsible for the sensation of the skin and parietal pleura and the motor activation of the intercostal muscle at its respective level. Since the tenth intercostal nerve is not responsible for significant sensory or motor function, we were able to completely excise the schwannoma in our patient without any morbidities or complications. This patient was a very rare case of intercostal schwannoma. The small tumor was responsible for intercostal neuralgia. Such small intercostal schwannomas are difficult to detect clinically because the intercostal nerve is located deep in the chest wall and may not be apparent in radiologic studies. However, larger lesions may involve the surrounding tissue and cause symptoms such as pleural effusion, dyspnea, and Horner's syndrome [5]. Therefore, incidentally found intercostal schwannomas, although generally benign and asymptomatic, should be excised to prevent the development of symptoms or complications from further growth.

A rare case of eccrine spiradenoma-treatment and management.

A young male patient presented with multiple swellings on his chest and the nape of his neck. Physical examination revealed multiple small papulonodular swellings measuring 0.5 × 0.5 cm to 2 × 2 cm, that were soft without discharge with no surrounding skin changes or induration. Skin biopsy samples were diagnosed as benign adnexal neoplasm consistent with eccrine spiradenoma, trichoepithelioma, and cylindroma, i.e., Brooke–Spiegler syndrome. Having confirmed this to be a case of eccrine spiradenoma, surgical excision was performed and the raw area was covered with a split thickness skin graft taken from the right thigh and sutured over the raw area. The sternal lesion was circumferentially excised and the wound was primarily closed by Z-plasty. Surgical excision is considered the gold standard for the treatment of these cases, with low rates of recurrence. Around 50 such cases have been reported in the literature to date. Although eccrine spiradenomas are usually solitary and small, the findings in our case underscore the fact that a variety of presentations are possible. With strict clinical suspicion and histological criteria, the correct diagnosis can be achieved, especially when combined with pertinent clinical information and laboratory studies.Level of Evidence: Level V, therapeutic study.

Detection and Clinical Significance of Sternal Lesions on Breast MRI.

The purpose of this study is to characterize sternal lesions detected on breast magnetic resonance imaging (MRI), compare MRI detection of sternal lesions with other imaging modalities (bone scan, positron emission tomography/computed tomography (PET/CT) and chest CT), and ascertain how often patient management is altered by discovery of sternal lesions. Retrospective review of 1143 breast MRIs between 2007 and 2012 identified 17 patients with sternal lesions including 15 patients with newly diagnosed breast cancer and two patients with remote history of breast cancer. Tumor size, histopathology, receptor status, nodal and distant metastasis, and images of breast MRI, and other modalities were reviewed. Sternal lesions in 9 of the 17 patients were determined to be malignant (metastasis) either by biopsy or presence of widespread metastases. Sternal lesions in 8 of the 17 were benign, confirmed by biopsy or presumed benign as not detected by other modalities. The malignant group had statistically significant larger breast cancer size (malignant: 6.4 cm; benign: 2.3 cm), a higher percentage of diffuse sternal lesions (malignant: 56%; benign: 0%), and more frequently showed rapid initial enhancing (malignant: 100%; benign: 63%) and delayed washout curves (malignant: 67%; benign: 13%). Although not statistically significant, the malignant group had a higher frequency of invasive lobular carcinoma (malignant: 44%; benign: 13%) and more lymph node involvement (malignant: 78%; benign: 50%). Breast MRI detected more sternal lesions than did bone scan, PET/CT and chest CT. Four of the 17 (24%) patients were upgraded to stage 4 due to unsuspected metastatic sternal lesions on breast MRI. In conclusion, breast MRI is more sensitive than other modalities in detecting sternal lesions. Sternal metastases occur more frequently in aggressive breast cancer and exhibit malignant-type dynamics on breast MRI. Detection of unsuspected sternal metastasis alters staging and improves patient management with more appropriate treatment.