Daliakopoulos et al. Journal of Medical Case Reports 2010, 4:75 http://www.jmedicalcasereports.com/content/4/1/75 resistant to all other therapy is a viable alternative for palliation and cure in patients who were carefully selected. Furthermore, Avital et al. [11] presented two patients with isolated sternal metastasis from breast cancer that underwent sternectomy followed by systemic che- motherapy and irradiation. Follow-up examinations con- tinued for 30 and 36 months and they were alive and living a good quality of life during this period. One of them, however, had local recurrence in the axilla, but this was resected successfully. Meanwhile, in a series of 100 patients, Brower et al. [12] observed that the inci- dence of local recurrence after radical chest wall resec- tion was 20%, while the incidence of systemic recurrence after chest wall resection was 60%. The mean survival for the entire group was 17 months after chest wall recurrence and radical resection. On the other hand, Kwai et al. stated that an isolated sternal metastasis should be regarded with caution because it is more likely to herald systemic disease than to develop as solitary sternal disease [2]. The authors demonstrated that 54% of patients with breast cancer and solitary sternal disease developed other foci of distant disease within 20 months. The predomi- nance of pulmonary metastasis and distant skeletal dis- ease found in their study was attributed to the drainage of the internal mammary nodes into the sub- clavian vein. Moreover, Park and Tarver reported 3 cases of solitary sternal metastasis from breast carci- noma that was treated with systemic therapy [13]. Although follow-up results on these patients were not clearly mentioned, the authors stated that single metastasis in the sternum have the unique tendency to remain solitary for longer than metastasis to other sites. According to McKenna et al., even given the advances in the treatment of locally recurrent and advanced breast cancer, 50% to 70% of patients will still succumb to their disease [14]. Mortality after chest wall resection is reported to be 1.6% to 4.5% [15]. The choice of surgical technique depends on a number of factors, of which the most important is the size and site of the lesion. There is a considerable discussion as to whether the missing bony thorax should be reconstructed [16]. The decision not to reconstruct the skeleton depends on the size and location of the defect, the presence of wound infection, and whether or not the tumour had been previously irradiated. Generally, lesions less than 5 cm in size in any location and up to 10 cm in poster- ior size need not require functional reconstruction. Various techniques have been used to repair the defects in the anterior thoracic wall, such as fascia lata, rib grafts, large skin flaps, the contralateral breast, myo- cutaneous flaps, and various types of prosthetic Page 7 of 8 materials (polypropylene and Vicryl nets, Gore-Tex patches). The use of prosthesis has not been reported to increase septic complications or foreign body reactions [17]. The numerous advances in chest wall reconstruc- tion over the years, including the use of muscle transpo- sition and musculocutaneous flaps, have made these techniques the mainstay in chest wall reconstruction [18]. Gore-Tex has the advantage of being impermeable to air and liquids and provides excellent results in terms of stability, intrathoracic organ protection, and pulmon- ary expansion [9]. Conclusions The most important task as a thoracic surgeon assessing a patient with a solitary metastatic carcinoma of the sternum is to determine the tumor’s likelihood of recur- rence after surgery and its amenability to a complete resection. The extensive literature on relapsed breast cancer demonstrates that patients with bone metastasis coincident with the initial presentation of their breast cancer have the best outlook, while histological grade and type are the next most important prognostic factors. Patients with grades I and II ductal or lobular cancers have better prognosis than those with grade III tumors. Estrogen receptor positivity, a long disease-free interval (>3 years versus <3 years) and a pre-menopausal status are other factors that predict a longer survival of patients. In the case of our patient, the recurrence after 9 years following mastectomy, chemotherapy and radio- therapy led us to treat the sternal metastasis aggressively. The localization of the probable defect after resection, its depth, width, convenient tissue flaps, and the tissue amount necessary for reconstruction must be evaluated pre-operatively. The serratus anterior muscle is a reli- able muscle flap with a consistently long pedicle and excellent malleability, thus permitting the coverage of complex three dimensional wounds. It has been success- fully used for flap reconstruction of the lower limps, dorsal surface hand defects, injuries to the head, neck and extremities, as well as bony and soft tissue defects in the face. There are only a few cases of flap recon- struction in relation to anterior thoracic wall defects [18,19]. Metastatic breast cancer confined to the skeletal sys- tem is a complication that can be diagnosed relatively easily. It is highly responsive to treatment and it is fre- quently associated with extended patient survival [20]. As our experience in solid recurrent breast cancer ster- nal metastasis teaches, full thickness chest wall resection remains integral in controlling major complications associated with the chest wall reconstruction because it improves the quality of our patient’s life, may provide patients with durable disease-free remission, and can