Chest wall resection and reconstruction using titanium micromesh covered with Marlex mesh for metastatic follicular thyroid carcinoma: a case report
© Suganuma et al; licensee Cases Network Ltd. 2009
Received: 29 September 2008
Accepted: 22 January 2009
Published: 8 June 2009
The distant metastases from differentiated thyroid carcinomas are often untreatable. In particular, bone metastasis is significantly related to poor prognosis since radioactive iodine therapy is generally less effective. Therefore, surgical resection is considered one of the treatments for patients with bone metastases. We report chest wall resection and reconstruction using titanium micromesh covered with polypropylene mesh (Marlex mesh) for metastatic rib bones as a result of follicular thyroid carcinoma.
A 51-year-old man was referred to our institution with a painful chest wall tumor. He presented with a 15 × 10 cm bony swelling on the left chest wall and multiple small lung nodules from follicular thyroid carcinoma. Completion total thyroidectomy, chest wall resection and reconstruction using titanium micromesh covered with Marlex mesh were performed. There were no critical complications associated with surgical treatments and tumor pain disappeared during the postoperative period. Then, he received radioactive iodine therapy and the uptake of radioactive iodine was well observed in bilateral lung fields.
Reconstruction using titanium micromesh covered with Marlex mesh is possible for repairing the wide chest wall resection required for thyroid carcinoma metastasis. This technique would help to enhance treatment efficacy in the combination therapy of radioactive iodine and surgery in patients with large thyroid carcinoma metastasis in the chest wall.
Differentiated thyroid carcinomas (DTC) are usually curable, but the distant metastases are often untreatable. Lungs and bones are the major metastatic sites for DTC and radioactive iodine (RI) therapy is important in the treatment of such distant metastases. RI therapy is generally less effective in bone metastasis due to the low uptake of RI  and the occurrence of bone metastases is significantly related to poor prognosis [2, 3]. Therefore, if possible, surgical resection should be considered one of the treatments of choice for patients with bone metastases. Solitary sternal metastasis can be a good indicator for surgical resection and reconstruction and these treatments have been successfully performed in clinical practice [4–6]. In addition, elimination of large bone metastases is considered to facilitate other distant metastases, mainly lung metastases, to uptake RI effectively. Such an enhancement effect is expected in RI treatment for DTC patients with multiple metastases. Thus, surgical resection of bone metastases contributes to the efficacy of RI therapy and is associated with favorable prognosis and improved quality-of-life (QOL) .
To our knowledge, this is the first report of chest wall resection and reconstruction using titanium micromesh covered with polypropylene mesh (Marlex mesh) for metastatic rib bones as a result of follicular thyroid carcinoma (FTC). There were no critical complications such as flail chest, dyspnea, or infection. Chest wall pain as the chief complaint disappeared after surgery and this procedure improved the patient's QOL.
Distant metastases,mainly in the lung and bone, occur in 10% to 20% of patients with DTC. RI therapy is essential to treat such metastatic disease. Lung metastases usually respond to RI treatment, however bone metastases uncommonly respond to RI therapy and are associated with poor prognosis [1–3, 8]. Casara et al. reported that less than 5% of patients with bone metastases achieve complete remission despite the fact that RI uptake was observed in 60% of patients, whereas more than 35% of patients with lung metastases were considered to achieve complete remission after RI therapy. The 10-year survival rates for patients with bone and lung metastases were 15% and 53%, respectively. Because of the low remission rate in RI therapy and poor prognosis in patients with bone metastases, the surgical approach should be considered as one of the treatments of choice for bone metastasis, if possible. Curative resection of solitary bone metastasis is associated with improved survival, especially in younger patients [7, 9–11]. Moreover, patients' QOL is often improved by surgical removal of the metastases due to the rapid relief of symptoms. Thus, surgical resection of bone metastases is considered valuable. In addition, external beam radiotherapy or embolization has been reported to be effective as palliative therapy for unresectable or multiple bone metastases .
Our patient had large bone metastases at the left chest wall and multiple small lung nodules. We considered that it was not enough to treat these advanced lesions with RI therapy alone because of the decreased effectiveness of RI therapy to large bone metastases and the decreased RI delivery to lung metastases. Therefore, we performed chest wall resection followed by reconstruction. Removal of large bone metastases was expected to facilitate other distant metastases to uptake RI efficiently. In fact, RI was well concentrated to lung metastases after surgery. Furthermore, this patient became free from left chest wall pain with limited analgesics after surgery. Thus, such surgical treatment is considered to contribute to both the efficacy of RI uptake and better patients' QOL, although just in restricted cases.
There are some reports on the surgical methods used for reconstruction after sternal resection [4–6]. Marlex mesh is reported to be easy to handle, has a high affinity for tissues and is resistant to infections, but it may have a paradoxical chest wall motion because of the lack of rigidity when the defect is large. On the other hand, a metal plate can retain the rigidity and prevent a flail chest, but its affinity to tissue is insufficient and lung injury may occur. Briccoli et al. reported that sternal reconstruction with Marlex mesh and a titanium plate after sternotomy resulted in satisfactory surgical treatment without a flail chest. We used a titanium micromesh, which has many holes on a titanium plate, moderate malleability and sufficient rigidity, and covered with Marlex mesh for reconstruction of the wide defect after thoracic wall resection. This procedure showed good affinity to tissues, prevention of paradoxical respiration and an acceptable level of radiolucency. To our knowledge, this is the first report using titanium micromesh covered with Marlex mesh for reconstruction after the resection of chest wall metastases from thyroid carcinoma.
Reconstruction using a titanium micromesh covered with Marlex mesh is possible for repairing the wide chest wall resection from thyroid carcinoma metastasis. This technique could help to enhance the treatment efficacy in the combination therapy of RI and surgery in patients with large thyroid carcinoma metastases in the chest wall.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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