Radiation-induced Osteomyelitis/Osteonecrosis of the Rib: SPECT/CT Imaging for Successful Surgical Management

Chronic radiation-induced osteomyelitis/necrosis of the rib was rarely encountered in breast cancer patients even before the era of breast-conserving therapy. Few studies have focused on how to evaluate the extent of rib osteomyelitis for surgical management. A 78-year-old woman who had received radiation therapy after a radical mastectomy due to breast cancer 30 years ago manifested a rib pain and chest skin ulcers. Because chest magnetic resonance imaging failed to visualize osteomyelitis of the rib, a wide-ranged rib resection was initially planned considering her radiation field. An additional imaging, 3-dimensional (3D) single-photon emission computed tomography (SPECT)/computed tomography (CT), was performed to obtain 3D virtual chest images highlighting the areas of inflammatory or necrotic bone tissues; her osteomyelitis was localized in the left anterior chest. A chest wall reconstruction was performed using a vascularized pedicled latissimus dorsi myocutaneous flap on the left side after the resection of the ribs, part of the sternum, and costal cartilage with radical debridement of all necrotic tissues. The 3D SPECT/CT contributed to a safe chest wall reconstruction with a 40% reduction in resected bone and soft tissues when compared to the magnetic resonance imaging-based surgical plan. Pathology results showed no evidence of inflammation or necrosis in the surgical margin. No complication related to the reconstruction or no recurrence was observed during a postoperative 12-month follow-up. The present case suggested that 3D SPECT/CT can be applied to preoperative surgical planning related to bone diseases including osteomyelitis, traumas, bone tumors, and diabetic foot. The appropriate application of 3D SPECT/CT requires full validation through significant clinical experience.