Thoracic surgeons successfully performed a total sternal resection and rigid chest wall reconstruction using a prosthetic sandwich technique in an elderly patient diagnosed with primary undifferentiated pleomorphic sarcoma of the sternum. Primary undifferentiated pleomorphic sarcoma of the bone is an exceptionally uncommon malignancy for which wide surgical resection represents the principal curative approach. When extensive disease involves the sternum, complete excision is essential to achieve negative margins, yet radical removal presents substantial physiological hazards. The sternum serves as a critical mechanical anchor for respiratory dynamics, shields vital mediastinal organs, and provides indispensable structural stability for shoulder girdle and upper limb movement. Developing a reconstructive strategy capable of restoring chest wall integrity while minimizing surgical trauma remains a formidable challenge, particularly in older patients with underlying systemic conditions.
The clinical case involved a seventy-nine-year-old male who presented for medical evaluation with a painful mass located over the anterior chest wall. The patient had a complex medical history marked by multiple chronic comorbidities, including a prior cerebral infarction managed with ongoing antiplatelet aspirin therapy, type two diabetes mellitus, systemic hypertension, and hyperlipidemia. Diagnostic computed tomography imaging identified a three-centimeter osteolytic lesion confined within the sternum. A subsequent core needle biopsy revealed an undifferentiated malignant neoplasm, prompting systemic staging evaluations. Whole-body positron emission tomography combined with computed tomography revealed intense fluorodeoxyglucose avidity localized strictly to the sternal mass, registering a maximum standardized uptake value of 13.3 without evidence of distant metabolic abnormalities. Magnetic resonance imaging demonstrated that the tumor invaded both the manubrium and the sternal body, raising concern for longitudinal intramedullary spread.
Because the primary tumor involved both the manubrial and corporal segments of the sternum, surgical specialists determined that a total sternal resection was required to establish wide, oncologically secure margins. Serum tumor markers remained entirely within normal physiological ranges. Given the complexity of the presentation, the clinical details were reviewed by a multidisciplinary cancer board comprising thoracic surgeons, orthopedic oncologists, medical oncologists, and diagnostic radiologists. Multimodal therapeutic pathways were evaluated, including the potential administration of perioperative systemic chemotherapy. However, in light of the patient’s advanced age, impaired physiological reserve, and notable cardiovascular and metabolic comorbidities, the multidisciplinary team recommended upfront surgical resection alone, avoiding the potential toxicities associated with aggressive cytotoxic regimens.
Operative intervention was carried out under general anesthesia with the patient positioned supine. Surgical dissection commenced through the cutaneous and subcutaneous layers, maintaining a gross soft-tissue clearance margin of at least two centimeters around the neoplasm. To ensure autologous tissue was available for secondary defect coverage, the left pectoralis major muscle was meticulously preserved during initial exposure. Following comprehensive thoracoscopic inspection of the pleural cavities, surgical teams transected the bilateral third, fourth, and fifth ribs. The sternal framework was divided at the caudal margin of the fifth intercostal space and carefully mobilized cranially. Subsequent sequential division of the bilateral second ribs, first ribs, and sternoclavicular joints enabled complete en bloc excision of the sternum and adjacent articulations without intraoperative disruption of the tumor capsule.
Skeletal stabilization was accomplished immediately following tumor resection using a composite sandwich construct designed to provide rigid yet lightweight structural support. Thoracic surgeons molded polymethyl methacrylate into a prosthetic plate measuring approximately one centimeter in thickness, shaped to match the resected anatomical contour of the sternum. This methyl methacrylate core was then enclosed between two one-millimeter-thick polytetrafluoroethylene sheets, establishing a dual-layer synthetic barrier. The fabricated prosthetic sternum was positioned across the anterior thoracic defect and secured directly to the bilateral residual rib stumps using heavy nonabsorbable 2-0 Ethibond sutures. To complete the thoracic closure and insulate the synthetic hardware, surgeons mobilized a pedicled left pectoralis major musculocutaneous flap, transposing the vascularized tissue over the reconstructed chest wall to provide durable soft-tissue coverage.
Pathological analysis of the resected specimen confirmed complete macroscopic and microscopic eradication of the malignant disease with clear surgical margins. Microscopic evaluation of hematoxylin and eosin sections showed marked proliferation of pleomorphic spindle cells characteristic of high-grade sarcoma. Focal positive immunoreactivity was observed for alpha-smooth muscle actin, establishing a definitive diagnosis of primary undifferentiated pleomorphic sarcoma of the sternum.
The patient experienced an uneventful intraoperative and early postoperative course, undergoing successful endotracheal extubation in the operating room immediately following wound closure. The patient avoided mechanical ventilation complications and exhibited no clinical signs of chest wall instability, paradoxical breathing patterns, or prosthetic dislocation during his hospital stay. Surgical incisions healed without wound dehiscence or deep space surgical site infection, and the patient was discharged in a stable condition on postoperative day sixteen. Longitudinal functional assessments confirmed that the patient achieved independent performance in all activities of daily living without requiring ambulatory assistance.
Physical therapy and musculoskeletal evaluations demonstrated substantial preservation of upper extremity mobility despite the radical resection of the sternoclavicular joints and surrounding muscular attachments. Postoperative examination documented that range of motion in both shoulders reached one hundred sixty degrees of active flexion and one hundred sixty degrees of abduction. Serial spirometric monitoring was performed preoperatively and repeated at three and six months following surgery to quantify respiratory mechanics. Although forced vital capacity, total vital capacity, and forced expiratory volume in one second exhibited transient declines at three months, pulmonary mechanics showed marked recovery by six months. Forced vital capacity and vital capacity returned to near-baseline preoperative measurements, while forced expiratory volume in one second displayed only a mild persistent decrease, confirming that the rigid sandwich prosthesis effectively preserved ventilatory capacity.
Surveillance imaging conducted eight months following the initial sternal resection identified an isolated solitary metastatic lesion in the left supraclavicular lymph node basin. Because lymphatic dissemination in bone sarcomas is historically documented to be rare, elective regional nodal lymphadenectomy had not been performed at the time of primary sternal excision. Sternal tumors possess unique lymphovascular drainage pathways distinct from long bone neoplasms, which likely mediated this atypical lymphatic spread. To address the regional recurrence while minimizing local treatment morbidity, the patient received targeted external beam radiotherapy delivering a total dose of 60 Gray across twenty fractions, utilizing precise planning to spare the adjacent brachial plexus. The patient tolerated radiotherapy without significant toxicity and remained alive without systemic disease progression at eighteen months of follow-up.
The published case highlights key technical and oncological considerations surrounding chest wall reconstruction in geriatric oncology. Soft-tissue clearance margins of at least two centimeters are recommended by clinical guidelines to restrict local recurrence rates below ten percent in high-grade sarcomas. While alternative reconstructive strategies such as autologous bone grafts, titanium plating systems, and custom three-dimensional printed prostheses offer structural rigidity, each entails drawbacks including donor-site trauma, high material expense, long manufacturing lead times, and radiation beam attenuation. The polymethyl methacrylate and polytetrafluoroethylene sandwich technique provides a versatile, cost-effective, and rapidly adaptable intraoperative alternative that achieves reliable thoracic stability, maintains pulmonary and upper extremity function, and minimizes hardware-related morbidity in high-risk patients undergoing extensive sternal resection.
The sandwich reconstruction technique was first described by McCormack and colleagues in 1981 to achieve durable thoracic wall restoration while preserving ventilatory mechanics. Although the method provides substantial intraoperative adaptability without requiring complex fixation hardware, published clinical series evaluating large polymethyl methacrylate prostheses have established clear baseline complication benchmarks. These historical investigations document postoperative infection rates between 5 and 6 percent and respiratory failure rates between 3 and 4 percent, along with infrequent instances of prosthesis displacement or adjacent rib fractures. Furthermore, incorporating a rigid prosthetic core overcomes the physiological hazards of utilizing soft-tissue flaps alone, which clinical reports have directly linked to postoperative respiratory collapse.
The reconstructive strategy also addresses critical surgical dilemmas associated with alternative rigid materials. Although titanium-based plating systems restore thoracic contour, they remain vulnerable to persistent seroma formation, deep infection, adjacent rib fractures, and hardware fatigue, while also attenuating radiotherapy beams. Custom three-dimensional printed prostheses offer precise anatomical matching but involve substantial production expenses and prolonged manufacturing turnaround. More critically, three-dimensional printed implants require exact preoperative definition of resection boundaries, creating potential conflict with intraoperative oncologic decision-making when wider surgical margins become necessary. Autologous bone grafting provides biological integration and osteogenic potential, yet donor-site trauma and constrained graft availability limit its feasibility in medically compromised patients.
The clinical course also reflects significant oncological patterns identified in comprehensive sarcoma registries. A retrospective investigation encompassing 5,064 patients from a Japanese bone sarcoma registry revealed that regional lymph node metastasis occurs in 5.2 percent of patients with undifferentiated pleomorphic sarcoma. Crucially, that analysis demonstrated that isolated regional nodal metastasis confers disease survival outcomes equivalent to distant metastasis, establishing that lymphatic spread represents a grave prognostic event requiring vigilant long-term surveillance. Because the majority of bone sarcomas arise in extremity long bones and spread hematogenously to the lungs, the localized lymphatic recurrence observed in this patient underscores the unique lymphovascular drainage of the sternum and reinforces the importance of sustained oncological monitoring.
Subject of Research: Sternal resection and sandwich technique chest wall reconstruction for primary undifferentiated pleomorphic sarcoma
Article Title: Wide resection and reconstruction using the sandwich technique for primary undifferentiated pleomorphic sarcoma of the sternum: a case report
Article References: Kobayashi, M., Takenaka, S., Shinyashiki, K., Kanzaki, R., Maniwa, T., Satomi, H., Honma, K., & Okami, J. (2026). Wide resection and reconstruction using the sandwich technique for primary undifferentiated pleomorphic sarcoma of the sternum: a case report. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 17. https://doi.org/10.1186/s44215-026-00251-8
Image Credits: AI Generated
DOI: 10.1186/s44215-026-00251-8
Keywords: undifferentiated pleomorphic sarcoma, sternal resection, sandwich technique, polymethyl methacrylate, polytetrafluoroethylene, chest wall reconstruction, pectoralis major flap, supraclavicular metastasis, radiation therapy, thoracic oncology, pulmonary function, bone sarcoma, surgical margins, forced expiratory volume, rib fixation, osteolytic lesion, multidisciplinary cancer board
News Source: Nathaniel Bowman. (November 13, 2026). Sandwich Sternal Reconstruction Preserves Chest Function After Extensive Sarcoma Resection. Scienmag.
