PMC6968258_01
Axial T2-weighted MR-image (A) shows an area of abnormal signal intensity (bone involvement) in the sternum with associated right parasternal soft tissue component. The soft tissue mass has a lobulated morphology, is well defined and has a high signal intensity. Axial T1-weighted images after intravenous gadolinium contrast administration (B) show a heterogeneous lesion with peripheral enhancement and central areas of low signal intensity, corresponding to areas of necrosis. Axial CT-images at the time of diagnosis (C) show an abnormal density in the sternum with large soft tissue component. Follow-up CT after neoadjuvant chemotherapy (D) shows prominent shrinkage of the mass. Follow-up CT after surgery (E) shows normal postoperative findings after partial sternal resection and reconstruction.
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After initial assessment with ultrasound (not shown), CT and Magnetic Resonance Imaging (MRI) showed a parasternal mass with both an intraosseous and a large soft tissue component (Figure 1(A-C)). The patient was treated with three series cycles of neo-adjuvant VIDE (Vincristine, Ifosfamide, Doxorubicin and Etoposide) chemotherapy with very good response on CT (Figure 1(D)).
Sternal biopsy. HE stain (4x magnification) shows tumour cell infiltration between muscle fibres (A). HE stain (40x magnification) shows a high-grade population of 'small blue round cells', compatible with Ewing's sarcoma (B).
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Sternal biopsy revealed a high-grade population of 'small blue round cells', compatible with Ewing's sarcoma (Figure 2).
Cross section scheme of the sternal reconstruction with coronal plane (A), and axial plane (B). A layer of methyl methacrylate was sandwiched between two layers of a polypropylene mesh and sutured to the remaining ribs and muscles with polypropylene 3-0.
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Cross section schemas of the reconstruction are shown in Figure 3.
Intraoperative images of the resected sternal body incorporating the major pectoral muscles (A), the large defect of the anterior chest wall after resection (B), sternal reconstruction by a methyl methacrylate sandwich graft (C).
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Intraoperative images are shown in Figure 4.
Comparison of the preoperative situation, which shows a small scar from the sternal biopsy at the presternal area (A), to the result four months after sternum resection and reconstruction by a polypropylene - methyl methacrylate sandwich graft and a pedicled myocutaneous latissimus dorsi flap (B).
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Figure 5 shows a comparison of the preoperative situation of the patient (Figure 5(A)) and the result four months postoperatively (Figure 5(B)).