Brian Blades, 1949
Primary chest wall tumors are rare.
Statistical data remains inaccurate.
Primary malignancy ranges from 13 to 50%.
They should be considered malignant until proved otherwise by detailed analysis by and experienced surgical pathologist.
Chest wall tumors are 5 % of all thoracic malignant.
They originates in bone, cartilage, soft tissue of chest wall.
Most arise in ribs (85%).
Most often clinical manifestations are either pain, palpable mass or an abnormality detected on a CXR.
Pain occurs when normal struture are compressed or periosteal invasion (more common with malignant tumors).
Patients may be only relatively mild discomfort.
Chest x-rays, CT, bone scan to rule out multiple lesion.
CT : Used to map the local extent of invasion and to plan resection and reconstruction
Biopsy the mass is necessary for tissue diagnosis.
Tumor size < 5 cm. à excisional biopsy.
Inadequate biopsies are untrustworthy.
Pulmonary function and Pt’s ability to tolerate physiologic deficit must be included.
Chest wall reconstruction must be concerned.
required for proper treatment : multimodality or resection
Requires adequate tissue
FNA should be avoided
Frozen sections should be performed
Primary Chest Wall Tumor
Benign Tumor of Chest Wall
Incidence : 30 % of benign chest wall tumors.
Ribs are the most common site of solitary fibrous dysplasia especially at posterior or lateral portion of a rib.
Age : 20 - 40 years old, Male = Female
It usually presents as slowly enlarging nonpainful mass
Pain can occur when large and pathologic fracture can develop.
Chest x-rays :
Soap bubble or ground glass appearance.
Expansion and thinning of the bony cortex with a central trabeculated
Fibrous dysplasia forms part of Albright syndrome (precocious puberty & skin pigmentation in girls).
Incidence : 15 - 20 % of benign chest wall tumors.
Age : 10 - 30 years old., Male = Female
It usually occurs at costochondral junction anteriorly.
It’s usually symptomatic & slow growing tumor
It’s divided into 2 type
Chest X-Ray :
Lytic lesions with sclerotic margins
Expansion of bone with thinned but intact cortex
Difficult to distinguish from chondrosarcoma
Excisional biopsy is always recommended.
Osteochondroma always present as a painless mass in young males ( Male : Female = 3:1 )
It origins from cortex of rib
Chest x-rays :
A pedunculated bony mass capped with viable cartilage
Resection is only for symptomatic & enlarging lesion.
The recurrence is rare.
Multiple lesions of rib are common.
It may be a part of Histiocytosis X or eosinophilic granuloma of lung.
It’s associated with pain & localized tenderness.
Pathologic fracture can developed.
Chest x-rays : punched-out osteolytic lesion
Microscopic : consists of chronic granuloma.
Osteoid Osteoma is a rare tumor.
It arises from bony cortex of rib or vertebral arches.
Symptoms occur especially at night
Chest x-rays : small, radiolucent nidus encircled by sclerotic margin
Treatment : Resection of entire rib for relief of symptom.
Tumors are a form of benign fibromatosis or low-grade fibrosarcoma.
They arise from deep fascia & connective tissue of muscles.
They’re slowly enlarging masses that invade locally.
Pain is caused by pressure (common presenting symptom).
Local recurrence is very high.
Treatment : wide local excision
Additional radiotherapy (external beam or brachytherapy) after resection is recommended.
Lipoma is well circumscribed, thin wall and very soft.
It composes of mature adipose tissue.
Deeper lipomas may infiltrate muscle.
Recurrence is common.
Wide excision is required.
Resection is for cosmetic reason or if true nature of tumor is in doubt.
Malignant Tumors of Chest Wall
Prognosis is ralated to the histologic grade rather than cell classification.
Factors that influence prognosis include age, size of tumor, histologic grade and stage.
Staging plays a central role in planning the therapeutic approach.
In all but stage I : Preoperative and/or postoperative radiotherapy is increase recommended
Stage III & IV : Adjuvant chemotherapy
Chondrosarcoma is the most common chest wall malignant tumors (20%)
Age : >40 years old.
It arises after local trauma to chest or secondary to malignant degeneration of benign chondromas or osteochondromas
It usually involves anterior costochondral junction of sternum.
Chest x-rays : Similar appearance to benign chondroma
Treatment : Resection with wide margins of greater than 4 cm.
5 year survival rate is 70 %.
Incidence : 10-15 % of malignant tumors.
Chest x-rays : Sunburst pattern
It enlarges rapidly. Metastasis is often present.
Investigation : Chest and abdominal CT scan & bone scan for assessment metastasis
Treatment : Surgery and adjuvant chemotherapy
5-year survival rate is 60%.
Ewing’s sarcoma is the third most common (5-10 %).
It frequently occurs in children & young man
Male :Female = 2:1
Intermittent pain & inflammatory response with fever and leukocytosis may be found.
Chest x-rays : Onion peel appearance
Metastasis is common (Lung, CNS).
Treatment : Multimodality therapy
5-year survival rate is 50%.
Hematologic dissemination is most common : Thyroid, Breast, Kidney.
Radiation therapy is used for palliation.
Breast and lung cancers are direct extension.
5 % of non small cell lung cancers invade the chest wall.
5 years survival rate is about 60% for pt. with chest wall invasion without LN involvement, but with N1 ~ 35% and N2 ~ 7-16%.
Chest Wall Reconstruction
Surgical guideline includes a 2-3 cm. soft tissue clear margin & removal of one normal rib above & below the involved ribs, a 2 cm. margin on the sternum is sufficient.
Principle goal : “Protection of the intrathoracic organ, support of respiration by preventing paradoxical movement, and an acceptable cosmetic result without compromising an indicated cancer operation”
No reconstruction in the defect size < 5 cm.
Ideal chest wall replacement
Prosthetic materials ;
Summarized By Thirayost Nimmanon
ÊÃØ»â´Â ¸ÕÃÂÊ¶ì ¹ÔÁÁÒ¹¹·ì
ä´éÃÑº¡ÒÃÊ¹ÑºÊ¹Ø¹ Web Hosting ¨Ò¡ SPAComputer.com, ThaWang.com