Clavicular Malignancies: A Borderline Surgical Management

Abstract

Nearly 1% of all bone cancers are primary clavicular tumors and because of their rarity, treating clinicians are unfamiliar with their diagnosis, classification, treatment options, and prognosis. In terms of preserving function and avoiding complications, clavicle reconstruction seems logical; however, further studies are needed to support this measure. Reconstruction techniques are difficult taking into account the anatomical structures surrounding the clavicle. When chest wall defects are present, a multidisciplinary team, including an orthopedist and thoracic and plastic surgeons, is of paramount importance for optimal surgical management. Malignant clavicle tumors may include primary and secondary malignancies and neighboring tumors with clavicular invasion. Surgical resection of complex thoracic tumors invading the clavicles can result in larger defects, requiring chest wall reconstruction, which is a substantial challenge for surgeons. Correct diagnosis with proper preoperative planning is essential for limiting complications. Post-resection reconstruction of the partial or total claviculectomy is important for several reasons, including maintaining the biomechanics of the scapular girdle, protecting the vessels and nerves, reducing pain, and maintaining the anatomical appearance of the shoulder. The chest wall resection and reconstruction techniques can involve either partial or full chest wall thickness, influencing the choice of reconstructive technique and materials. In the present paper, we aimed to synthesize the anatomical and physiopathological aspects and the small number of therapeutic surgical options that are currently available for these patients.

Keywords: clavicular malignancies; clavicular metastasis; clavicular resection and reconstruction; claviculectomy; complex thoracic tumors.

Figure 1

Plain radiograph (A) and tomography (B) revealing extensive locoregional clavicle metastasis in a 60-year-old female, secondary to cervix adenocarcinoma. The patient presented with multiple metastases at diagnosis.

Figure 2

(A) Preoperative tomography of a 66-year-old male diagnosed with clavicle condrosarcoma. (B) Preoperative angiography and embolization of the tumor were performed prior to resection to limit intraoperative blood loss. (C) Postoperative image of acrylic cement reinforced with Kirschner brooches reconstruction used after tumoral resection.

Figure 3

Intraoperative aspect of a 64-year-old patient diagnosed with a manubrial tumor. A Gigli wire saw (A) was used for en bloc bilateral resection of the medial third of the clavicles, the cartilaginous portion of the first rib, and the manubrium (B). (C) Polypropylene mesh and Kryptonite cementum were used for rigid anterior chest wall reconstruction. (D) A 3D-CT scan reconstruction at three months after surgery shows the neo-sternum.

Figure 4

(A) Preoperative CT scan of a 55-year-old patient diagnosed with a manubrial tumor. (B) A large resection of the tumor was performed, within oncological limits. (C) After resection, rigid reconstruction was performed using a Stratos titanium bar on the upper side of the operative field. The medial part of the clavicle is shown. (D) Next, a polypropylene mesh was utilized in the left upper corner. The incision used for sectioning of the deltoid tuberosity insertion of the left pectoralis major is shown. (E) For soft-tissue reconstruction, a pectoralis major flap was harvested (main pedicle at the tip of the clamp). (F) The intraoperative aspect with the pectoralis major flap was secured over the polypropylene mesh.