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J Thorac Cardiovasc Surg 1997;114:684-685
© 1997 Mosby, Inc.
BRIEF COMMUNICATIONS |
Bronx,. N.Y.
Received for publication Feb. 25, 1997 accepted for publication Feb. 26, 1997. Address for reprints: Peter L. Faries, MD, Department of Surgery, First Floor Gold Zone, Montefiore Medical Center, 111 East 210th St., Bronx, NY 10467.
A 38-year-old man was referred to us with a painful sternal mass. On examination a firm, fixed, tender 3 x 3 cm sternal mass was present at the level of the third rib. Roentgenographic and computed tomographic studies of the chest demonstrated a 2.5 x 3 x 3 cm lytic mass originating in the right side of the sternum at the level of the third rib (Fig. 1) . No extension into the mediastinum and no mediastinal or hilar adenopathy were present. The lung fields were clear and the large airways were without compromise. Computed tomographic scans of the head, abdomen, and pelvis, a radionuclide bone scan, and bronchoscopic examination demonstrated no evidence of malignant disease at other sites.
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Pathologic examination of the specimen demonstrated a soft pink-tan lesion originating in the sternum, replacing the trabecular bone and thinning the cortical bone. The tumor did not extend to the mediastinum. Microscopic evaluation demonstrated sheets of malignant, highly pleomorphic lymphocytes within the sternal mass (Fig. 2). Extensive necrosis and a high mitotic rate were present, and plasmacytoid and polymorphous immunoblastic features of lymphoma were seen. Immunohistochemical analysis was positive for lymphocyte (LCA) and B-cell (L26) markers and negative for T-cell (UCHL1) and neuroendocrine (S100, chromogranin) markers, confirming the diagnosis of a non-Hodgkin's immunoblastic B-cell lymphoma originating in the sternum. The patient received six cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone and is well with no evidence of active disease 2 years after the operation.
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1
Both Hodgkin's disease and non-Hodgkin's lymphoma involving the sternum and chest wall have been described. Frequently the malignancy originates within lymph nodes of the mediastinum or internal thoracic chain and invades the chest wall through direct extension. Mediastinal adenopathy occurs frequently in Hodgkin's disease but is unusual in non-Hodgkin's lymphoma, in which endobronchial and diffuse interstitial involvement occur. Isolated chest wall masses are distinctly uncommon and are usually a manifestation of large cell non-Hodgkin's lymphoma. One case of localized Hodgkin's disease that was detected as a sternal tumor and required total sternectomy plus reconstruction with a Marlex mesh prosthesis (Bard Implants, Billerica, Mass.) has been reported. 2 A case of non-Hodgkin's lymphoma of lymphoid progenitor cell origin appearing as a lytic sternal lesion has also been described. 3 That patient was treated with radiation and chemotherapy but died 7 months after the initial diagnosis. Six cases of high-grade malignant lymphoma of the sternum have also been reported. Two of the patients were treated with sternectomy, three with radiation, and one with chemotherapy, with an overall 10-year survival of 83%. 1 Non-Hodgkin's lymphoma of the anterior mediastinum with evidence of B-cell origin has also been seen, 4 but no case of B-cell immunoblastic non-Hodgkin's lymphoma originating in the sternum has been reported previously.
Resection of sternal tumors with adequate surgical margins of 4 cm may result in substantial bony and soft tissue defects. Loss of the upper sternal body and the costal cartilages, as in this case, produces a defect that is not physiologically significant. More extensive resections including the entire sternal body or manubrium with the adjacent ribs and clavicles produce more severe deficits. Reconstruction is therefore necessary to avoid prolonged ventilatory support. 1 Reconstruction after sternal resection can be performed with a variety of materials. Skin defects are frequently small and are most often covered primarily by advancing skin flaps. Larger defects may require split-thickness skin grafting or closure as part of a myocutaneous tissue flap. Underlying soft tissue defects may be closed by advancing pectoralis muscle flaps, by transposition of a free tissue graft, or by an omental flap. Prosthetic materials including polytetrafluoroethylene, methyl methacrylate, polypropylene, polyethylene, and steel mesh have all been used successfully in reconstructing sternal defects. 5
Footnotes
From the Departments of Surgerya and Thoracic Surgery,b Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y. 
References
This article has been cited by other articles:
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  S. Zareifar, M. R. Bordbar, M. Karim, B. Geramizadeh, and A. R. Rasekhi T-Cell Lymphoblastic Lymphoma of the Sternum J. Clin. Oncol., February 1, 2010; 28(4): e51 - e53. [Full Text] [PDF]
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 K. Mohan, F. Simeone, and N. Parada A 79-Year-Old Man With Chest Wall Pain and a Rapidly Growing Mass Chest, January 1, 2009; 135(1): 221 - 224. [Full Text] [PDF]
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 P.-K. Hsu, H.-S. Hsu, A. F.-Y. Li, L.-S. Wang, B.-S. Huang, M.-H. Huang, and W.-H. Hsu Non-Hodgkin's Lymphoma Presenting as a Large Chest Wall Mass Ann. Thorac. Surg., April 1, 2006; 81(4): 1214 - 1218. [Abstract] [Full Text] [PDF]
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