Reconstruction of the chest wall after resection of a locally advanced poorly differentiated thyroid carcinoma with sternal infiltration: case report and literature review

Introduction

We present the case of a 52-year-old male with a progressive, painful anterior chest mass that led to the diagnosis of bone-infiltrating poorly differentiated thyroid carcinoma (PDTC). Initial evaluation included clinical examination, imaging, and biopsy, revealing extensive sternal and rib infiltration originating from the thyroid gland. Following interdisciplinary tumour board discussions, the patient underwent an en bloc resection of the thyroid gland, sternum, parts of adjacent muscles and ribs, with simultaneous reconstruction using a human acellular dermis and stabilization systems. Postoperatively, he received radioactive iodine therapy. Six-month follow-up revealed bone metastases, especially in the thoracic spine. Therefore, an external beam radiation and a systemic therapy with tyrosine kinase inhibitor was recommended to the patient. This case highlights the diagnostic challenges and therapeutic complexities of advanced thyroid malignancies with rare bone involvement. It underscores the importance of multidisciplinary care and timely surgical intervention in ensuring optimal outcomes. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-73/rc).

Case presentation

A 52-year-old male presented to our outpatient clinic with a painful progressive mass on the anterior chest, which first became apparent about ten months earlier (Figure 1). The patient did not suffer from any comorbidities, had no history of previous surgeries and did not require long-term medication. The patient denied fever, night sweats and weight loss. The patient’s medical history revealed that thyroid nodules had been detected by ultrasound. However, the nodules had not been considered malignant. Clinically, Tietze’s syndrome, a benign painful inflammation of the costal cartilages with associated anterior chest swelling, could not be ruled out, which is why an orthopaedic consultation was carried out (1). Symptomatic therapy with pain medication hardly led to any relief of the symptoms, so a magnetic resonance imaging (MRI) scan was performed. The MRI scan revealed a tumourous process most likely originating from the thyroid gland with infiltration of the entire sternum and the sternoclavicular joints on both sides (Figure 1). At the time of presentation to our clinic in March 2024, the patient had no evidence of distant metastases. Ultrasound-guided punch biopsies of the sternal mass confirmed the clinically apparent diagnosis of tumour tissue derived from thyroid follicular epithelium with a Ki-67 proliferation index of approximately 20%. Laboratory findings including thyroid function tests were unremarkable except for a massively elevated thyroglobulin level of 47,433.75 µg/L. The patient’s case was discussed in our interdisciplinary tumour board, where the recommendation for complete surgical resection was made, not least to enable the option of subsequent radioiodine therapy. The possibility of neoadjuvant therapy with tyrosine kinase inhibitors was discussed but not prioritized due to the unclear prospects of success, with possible irresectability after unsuccessful treatment.

Figure 1 Preoperative contrast-enhanced magnetic resonance imaging scan of the chest showing a retrosternal mass that infiltrates the sternum per continuitatem (sagittal and axial view).

Notably, all procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Therapeutic intervention

In April 2024, the patient underwent en bloc resection of the thyroid gland and sternum, thymus, the infrahyoid muscles on both sides, the sternal part of both sternocleidomastoid muscles, medial part of both clavicles and part of the ribs I–V. Furthermore, central, mediastinal and left lateral lymphadenectomy was performed (Figure 2). Both left-sided parathyroid glands as well as the right caudal one were reimplanted in the left brachioradialis muscle. Both current laryngeal nerves were protected during the whole surgical procedure. We used continuous intraoperative neuromonitoring (cIONM) to ensure monitoring of the recurrent laryngeal nerve. The chest wall defect was reconstructed using a human acellular dermis (Epiflex^® from the German Institute for Cell and Tissue Replacement) for the soft covering and the Strasbourg Thoracic Osteosynthesis System (STRATOS^®) for stabilization of ribs II and IV (Figure 2). The fixation principle in this system consists of a rib-to-rib bridging with titanium bars anchored via clamp-based fixation. Pleural drainage on both sides were placed. The patient could be extubated immediately after surgery. His general condition was good. On the third postoperative day, the thyroglobulin value was only one-third of the preoperative value. The patient had a prolonged postoperative course due to a fluid collection in the area of the ventral chest wall reconstruction, which was removed by a computed tomography (CT)-guided percutaneous drainage. With the help of a suction drain, it was possible to remove the fluid and close the remaining fluid cavity using the applied negative pressure. The suction was also necessary to avoid rocking breathing due to the complete lack of bony stability of the ventral chest. The patient was discharged four weeks after surgery, and after removal of all the drains.

Figure 2 Intraoperative overview of the surgical situs at key steps of the procedure. (A) Intraoperative anterior view of sternal tumour mass. (B) Resected en bloc specimen from the front. (C) Intraoperative surgical site after resection showing the defect in the chest wall (black arrow: left brachiocephalic vein, blue arrow: internal jugular vein, red arrow: internal carotid artery interna, green arrow: thyroid cartilage). (D) Repair of the chest wall defect using human acellular dermis covering the mediastinum and the Stratos system for stabilization of ribs II and IV.

Histological findings

After sectioning, a 16 cm tumor to was visible. The right thyroid lobe was completely occupied by a centrally partly brownish disintegrating, partly also whitish indurated tumour with spread to the thymus, infiltration of the perithyroid soft tissue with close approach to the dorsal soft tissue preparation margin as well as infiltration of the bony sternum and ribs (Figure 3). Tumour formations reached the resection margin of the rib III on the left, the clavicular rim on the right and the soft tissue at the insertion of rib 4 on the left. Haemangiosis carcinomatosa was detected. In the left thyroid lobe, there was another 0.5 cm measuring focus as well as multiple soft tissue metastases measuring up to 1.8 cm. Seven lymph node metastases were identified.

Figure 3 Carcinoma with reference to normal thyroid tissue (top left of the image) in reference to poorly differentiated thyroid carcinoma with loss of differentiated architecture with solid growth as well as necrosis (H&E staining). H&E staining, hematoxylin and eosin staining.

Immunohistochemically the tumour cells showed a partly weak, partly strong expression of PAX8, TTF-1 with complete negativity for p53 (Figure 4). The proliferation rate (Ki-67) was up to 30% (Figure 5). The histomorphological and immunohistochemical findings corresponded to a PDTC.

Figure 4 Immunohistochemistry (magnification ×40) showing positive nuclear staining for TTF-1.

Figure 5 Poorly differentiated thyroid carcinoma with high proliferation rate (increased mitoses) (H&E staining, magnification ×200). H&E staining, hematoxylin and eosin staining.

Follow-up

Following discharge from the hospital, radioactive iodine ablation was given approximately 12 weeks after the surgery. The serum thyroglobulin levels were 11,300 ng/mL. The patient has been followed up regularly. Six months postoperatively, the PET-CT scan showed disseminated intense glucose metabolism bone metastases in the skeletal frame. External beam radiation has been initiated to provide the patient with symptomatic relief from these painful osseous lesions. Systemic therapy with tyrosine kinase inhibitor was recommended to the patient.

Discussion

Our case of a 52-year-old male with a progressive and painful anterior chest mass illustrates the diagnostic and therapeutic challenges associated with advanced tumours of the chest. The punch biopsy of the sternum was necessary to confirm the diagnosis of thyroid carcinoma, but also to determine the type of thyroid carcinoma.

A surgical resection would not be useful for example in the case of anaplastic thyroid carcinoma or lymphoma. In this case, the diagnosis was bone-infiltrating PDTC, for which a more aggressive surgical approach for local control was chosen. The case report presents the multidisciplinary approach required for the treatment of such a complex case, from clinical assessment and imaging to surgical intervention and postoperative care. The case is rare because thyroid carcinomas, even PDTC, do not tend to grow locally into the neighbouring bones, except at a very advanced stage. So far, only a handful of cases of sternal infiltration due to thyroid cancer have been published. More than 10 years ago, Moraitis et al. reported a case of a 70-year-old woman with sternal infiltration by follicular thyroid carcinoma (FTC) (2). The patient reported a progressive enlargement of a multinodular goitre that had been present for 20 years. As in our case, the tumour was completely removed by extensive chest resection and reconstruction. Fortunately, the patient remained tumour-free until her death from a stroke 8 years later. A case report by Demirer et al. illustrates the palliative treatment of a 52-year-old woman with an unresectable locally advanced and sternal infiltrating FTC (3). The patient was treated with external beam radiotherapy prior to radioiodine therapy. Radiotherapy led to a reduction of the tumour, but nothing is known about the long-term survival of the patient. In 2012, Luna-Ortiz et al. reported two cases of sternectomy due to thyroid cancer (4). Unlike our case, both patients had metastatic disease, and the sternal infiltration was due to metastases rather than infiltration per continuitatem. The respective primary tumours were rather small (about 4 cm) compared to the 16 cm tumour in our patient. Thyroid cancer metastases to the sternum can occur synchronously or metachronously, even years after initial diagnosis, and the long-term survival rate after extensive resections appears promising (5-7). In general, bone metastases of thyroid cancers are rare and are often associated with FTC (8,9). Our case is worthy of discussion for another reason as most of the thyroid carcinomas in Western countries, even if they are undifferentiated, are diagnosed earlier, as the patient reported suffering from symptoms for about 10 months. Obviously, the diagnosis of the patient was delayed, which led to advanced-stage thyroid cancer. The diagnosis of pain and swelling of the anterior thoracic wall can be challenging due to a variety of benign and malignant differential diagnoses (10). Interestingly, the patient was suspected of having Tietze’s syndrome, a very rare syndrome affecting mostly younger women (1). Further differential diagnoses, which should be evaluated in case of anterior chest wall pain and swelling are for example lymphoma, lipofibroadenoma, thymic cysts, thymic hyperplasia and thymic tumours as well as other rare diseases such as sternocostoclavicular hyperostosis and sternoclavicular tuberculosis (10-12). After diagnosis, the therapy is also challenging and needs experienced surgeons, especially if malignancy is suspected. Given the extent of tumour invasion, the curative treatment strategy in our case was necessarily aggressive. The resection is associated with a high risk of flail chest, which is why the thorax must be reconstructed (13). Our initial thought on this matter was the use of 3D printing technology to plan and reconstruct the sternum. However, we quickly dismissed this idea due to the costs and the necessary waiting time for the material. So we decided to achieve chest wall stabilization using the STRATOS, a modular titanium implant designed for rigid thoracic stabilization. STRATOS employs rib-to-rib bridging with titanium bars anchored via clamp-based fixation, avoiding screw insertion and thus preserving rib integrity – an advantage in oncologic resections with fragile or shortened rib stumps (14). Compared to other commercially available rigid reconstruction systems—such as the MatrixRIB^® Fixation System (DePuy Synthes), conventional titanium plate-and-screw systems, or patient-specific 3D-printed titanium meshes—STRATOS offers intraoperative flexibility, dynamic biomechanical behavior, and reduced risk of implant loosening (15,16). In a multicenter experience, STRATOS provided stable thoracic reconstruction with low complication rates in both adult and pediatric populations (17). In this case, the STRATOS system was chosen due to its intraoperative flexibility, preservation of rib structure, and dynamic biomechanical properties, all of which were critical for achieving functional and stable reconstruction following an extensive en bloc resection. The reconstruction of the chest was not only technically demanding, but the patient first had to get used to his new body image. In order to provide the patient with good postoperative care, a multidisciplinary team of specialist nurses, surgeons and anaesthetists was necessary.

Conclusions

This case illustrates the diagnostic complexities and aggressive treatment required for advanced thyroid malignancies with rare bone involvement. Highlighting the importance of a timely and collaborative approach, it emphasizes that surgical intervention, while challenging, can still offer potential for local control in carefully selected patients. However, the case also serves as a reminder of the necessity for ongoing surveillance and the readiness to adapt treatment strategies in response to emerging metastatic disease, contributing to our understanding of management protocols for similar cases in clinical practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-73/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-73/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-73/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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