Mr. Sohail Akhter (name changed), 50 years of age from Bangladesh was suffering from a rare and complex form of cancer where a large mass of tumour affected his chest bone (sternum) with first 8 ribs on both left and the right side being involved. The tumour also impacted the pericardium-the outer layer of the heart and the lungs. He roamed from country to country, one cancer hospital to another only to be turned down because there was no possible solution to his problem. The case was complex because even if the cancer was removed through surgery, there was no feasible solution to fix the chest bone (sternum) and the ribs, which were essential for breathing normally. Without it, the patient would be dependent on mechanical ventilation permanently.
When the patient approached Manipal Hospitals, the oncologist team of Dr. Somashekhar S P, Dr. Rohit Kumar C along with Dr. Ashwin Rajagopal evaluated the patient and held a joint meeting with the plastic surgeons, Dr. Ashok B C, Dr. Srikanth V and Dr. Anantheshwar to manage this challenging case, determined to save his life.
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The patient had a history of swelling in front of the chest for 6 years with no complaints of breathlessness or palpitations. He was managed conservatively in Bangladesh 6 years back. When the swelling in the front chest returned, he came to India for further treatment.
Medical Examination and Diagnosis
His biopsy reports were suggestive of a malignant tumour.
An MRI of the chest showed a tumour mass measuring about 15×12.7 cm sitting on the lung and heart that had completely destructed the entire length of the middle portion of the sternum or the chest bone (sternum is the long flat bone present at the centre of the chest that connects the ribs to form the ribcage). The tumour was bulging into the retrosternal space (inside the ribcage) and indenting the heart. Anteriorly, the mass was bulging to the subcutaneous space (the deepest layer of the skin) and was displacing the muscles of the chest wall around it and laterally bulging in the muscle planes.
Management: Tumour resection and sternum reconstruction surgery
After taking informed consent and thorough preoperative evaluation, he underwent tumour removal surgery under general anaesthesia. The entire chest bone (sternum) and ribs were removed without much blood loss. After tumour resection, the entire sternum and all the ribs on either side were reconstructed with an advanced 3D printed custom-made titanium implant. The new implant was fixed with a new drilling technique and titanium wire. The implant was a replica of the original chest bone and ribs that were removed during the surgery. It was custom-made before the surgery with the help of CT scan images of the patient’s sternum and ribcages and 3D printing technology.
Elaborating on this new technology, Dr. Somashekhar SP, Chairman & HOD – Surgical Oncology, Manipal Comprehensive Cancer Center, Manipal Hospitals, Bangalore, said, “The entire chest bone (sternum) and the costosternal junction was printed with titanium powder and liquid titanium and a new titanium chest bone (sternum) was formed, custom-made for this patient according to his size, height, weight and the portion of the skeleton to be removed. Multiple meetings were held with the company technologists, engineers and Manipal onco surgery and plastic surgery team for the same. However, such implants are usually very heavy upto 5 kgs. In this case, this would be too heavy for the patient to carry such weight on the chest. To rectify the same, a modified honeycomb technology was used to make the chest bone (sternum) and sternum weighing <250 grams.“
“Such implants are strong, durable and at the same time light in weight. Moreover, they are well-accepted by the body and less prone to immune reactions and implant rejection. Such implants reduce the risk of osteoporosis and fractures around the implant that may arise due to uneven stress transfer between the implant and the surrounding bone tissue. The implant itself was covered with muscle flaps taken from the front of the chest before closing the skin,” added Dr Ashok B C, Consultant – Plastic, Reconstructive and Cosmetic Surgery, Manipal Hospital, Old Airport Road.
Patient recovery and discharge
The patient recovered smoothly and was out of the ICU on the third-day post-surgery. He was started with chest physiotherapy and was gradually mobilized. During his discharge from the hospital, he was feeding, breathing and walking normally without any complications. He returned to living a healthy normal life.
“Advanced technology can be used nowadays to offer treatment in complicated cancer cases, which otherwise is thought to be incurable by many. The credit for this case goes to Excellent coordination between Manipal Comprehensive Cancer Centre and Dept. Of Plastic and Reconstructive Surgery which boasts modern technology coupled with experts in the field of medicine which offer hope to millions of cancer patients across the globe,” said Dr. Somashekhar SP.
“New age technology and materials are helping patients with complex problems to be solved and recover fast. This patient is a perfect example with the combination of excellent medical care and technology coming together,” added Dr. Ashok B C.
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