Chest Wall Tumors

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Chest Wall Tumors
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Table 45-1 Classification of Chest Wall Tumors

• __________________________________________
• Primary neoplasm of chest wall malignant, benign
• Metastatic neoplasms to chest wall sarcoma,
  carcinoma
• Adjacent neoplasms with local invasion
• lung, breast, pleura
• Nonneoplastic disaease cyst, inflammation
• __________________________________________

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INCIDENCE

• Primary chest wall tumors are uncommon.
• 50-80 of these tumors are malignant.
• Soft tissues are major sources of chest wall
  tumors.
• The most common primary malignant chest wall
  tumors are malignant fibrous histiocytoma,
  rhabdomyosarcoma and chondrsarcoma.
• The most common primary benign chest wall tumors
  cartilaginous tumors, desmoids and fibrous
  dysplasia.

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Table 45-2 Primary chest wall tumors

• Malignant
• myeloma, malignant fibrous histiocytoma,
  chondrosarcoma, rhbdomyosarcoma, Ewings sarcoma,
  liposarcoma, lymphoma, leiomyosarcoma,
  hemangiosarcoma
• Benign
• osteochondroma, chondroma, desmoids, fibrous
  dysplasia,
• lipoma, fibroma, neurilemoma

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BASIC PRINCUPLES

• Signs and Symptoms
• 1. Chest wall tumors grow slowly.
• 2. Most patients have no symptoms initially.
• 3. Pain may occurs in nearly all malignant
• tumors and 2/3 of benign tumors.
• 4. Fever, leukocytosis and eosinophilia may
• accompany some chest wall tumors

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Diagnosis

• History, PE and lab exams
• Chest plain film and CT scan
• MRI can distinguish tumor from vessels and
  nerves, but does not assess lung nodules and
  calcification in the lung.
• Chest wall tumors must be diagnosed with
  incisional biopsy( tumorgt 5 cm ) or excisional(
  tumor 3 5 cm ) biopsy.
• Needle aspiration biopsy should be only for
  patients with a known primary tumor elsewhere.

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Treatment(1)

• Wide resection is essential for malignant chest
  wall tumors.
• The margin of normal tissue is 4 cm.
• For tumors of rib cage, involved ribs, partial
  ribs above and below the tumor must be removed.

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Treatment(2)

• For tumors of the sternum, manubrium, resection
  of the involved bone and corresponding costal
  arches is indicated.
• Any attached structures, such as lung, thymus,
  chest wall muscle or pericardium must be removed.
• The role of resection of chest wall metastasis
  and recurrent breast cancer is controversial

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SPECIFIC TUMORS

• A. Primary Bone Tumors
• Primary bone neoplasms involving chest
  wall
• are uncommon.
• The most common benign bone tumors are
• cartilaginous in origin-osteochondroma
  and
• chondroma.
• The most common malignant bone tumors are
  
• myeloma, chondrosarcoma, malignant
• lymphoma and Ewings sarcoma.

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A-1 Benign Rib Tumors

• A-1-1. Osteochondroma
• (1) It is the most common benign bone
  
• tumor( 50 of benign rib tumors ).
• (2) It arises from the metaphyseal region of
  
• the rib and present a bony protuberance
• with a cartilaginous cap.
• (3) Rarely, it can involves the diaphragm and
  
• induce hemothorax.

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A-1 Benign Rib Tumors

• A-1-2. Chondroma
• (1) It occurs anteriorly at costochondral
• junction.
• (2) It presents thinning of the cortex
• radiographically.
• (3) Differentiation of chondroma and
• chondrosarcoma is difficult.
• (4) It should be treated as malignancy.

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A-1 Benign Rib Tumors

• A-1-3. Fibrous dysplasia
• (1) It is a cystic, nonneoplastic lesion with
• fibrous replacement of medullay cavity
  
• of the rib.
• (2) Albrights syndrome( multiple bone
• cysts, skin pigmentation and precocious
  
• sex maturity in girls ) should be
  suspected if
• multiple lesions occurs.

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A-1 Benign Rib Tumors

• A-1-3 Fibrous dysplasia
• (3) Treatment should be conservative.
• (4) Many lesions stop growing at puberty.
• (5) Resection is indicated if pain and
• enlarging lesions occurs.

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A-1 Benign Rib Tumors

• A-1-4. Histiocytosis X
• (1) It is not a neoplasm.
• (2) It is a part of the spectrum of disease
• involving the reticuloendothelial system
• , including eosinophilic granuloma,
• Letterer-Siwe disease and Hand-
• Schuller-Christian disease.
• (3) Histiocytosis X occurs in patients
• younger than 50 years.

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A-1 Benign Rib Tumors

• A-1- 4. Histiocytosis X
• (4) Eosinophilic granuloma is limited only
• bone involvement.
• (5) Bone lesions may occurs in all types of
• histiocytosis X and skull is the most
  common.
• (6) For patients of solitary eosinophilic
• granuloma , excision can result in cure.
• (7) For patients of multiple eosinophilic
• granulomas, radiation is helpful.

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A-2 Malignant Rib Tumors

• A-2-1 Myeloma
• (1) It is the most common malignant rib
• tumor.
• (2) Most myelomas involving chest wall
  
• are systemic myeloma.
• (3) Most myeloma occurs in people of
  40-60
• years and rare in peoplelt 30 years.
• (4) Punched-out lesion with cortical
  thinning
• presents radiographically.

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A-2 Malignant Rib Tumors

• A-2-1 Myeloma
• (5) Pathologic fracture is common.
• (6) Local excision is for diagnosis.
• (7) Radiation is for a solitary lesion and
• both radiation and chemotherapy for
  
• multiple lesion.
• (8) 5-year survival is 20 .

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A-2 Malignant Rib Tumors

• A-2-2 Chondrosarcoma
• (1) It is almost a tumor of the anterior
  chest
• wall.
• (2) Most chondrosarcoma occurs in people
• of 20-30 years and male.
• (3) All tumors from costal cartilages should
  be
• considered malignancy.
• (4) Pathological fracture is uncommon.
• (5) Chest wall chondrosarcoma grows slowly
  and
• metastases occur late if it is left.

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A-2 Malignant Rib Tumors

• A-2-3. Ewings sarcoma
• (1) 2/3 patients is younger than 20 years.
• (2) An onion-skin appearance of the surface
• of the bone may be seen.
• (3) Pathological fracture is rare.
• (4) Radiation is the treatment of choice and
• adjuvant chemotherapy is also used.

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A-2 Malignant Rib Tumors

• A-2-4. Osteogenic sarcoma
• (1) It is more malignant and less common
• than chondrosarcoma.
• (2) It is more common in teenagers and
• young adults. The male is more common
• than the female.
• (3) Serum ALP is frequently elevated.

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A-2 Malignant Rib Tumors

• A-2-4 Osteogenic sarcoma
• (4) Pathologic fracture is rare.
• (5) The treatment is wide excision.
• (6) Radiation is not valuable and
• chemotherapy is controversial.
• (7) 5-year survival is 20.

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A-2 Malignant Rib Tumors

• A-2-5 Radiation-Associated Malignant Tumors
• 1. Those tumors are uncommon.
• 2. Osteosarcoma and soft tissue sarcoma are
• the most common.
• 3. The initial radiation is most common for
• breast cancer and lymphoma.
• 4. The treatment is similar to tumors arising
• de novo.

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A-3 Tumors of the manubrium , Sternum , Scapula
and Clavicle

• 1. Primary tumors of the manubrium and the
  sternum constitute 15 of the chest wall tumors,
  but nearly all are malignant.
• 2. The sternum is a frequent site metastasis from
  the
• breast, thyroid and kidney.
• 3. The scapula is not a frequent site of
  metastasis.
• 4. Primary tumors of the clavicle are uncommon,
  but 90 are malignant.
• 5. The clavicle is more a site of a metastasis
  than a primary tumor.
• .

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SPECIFIC TUMORS

• B. Primary Soft Tissue Tumors
• B-1 Benign Soft Tumors
• Predominant tumors are fibroma,
• lipoma, giant cell tumors, vascular
  
• tumors and neurogenic tumors.
• Malignant degeneration is uncommon.
• Local excision is the choice.

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B-1 Benign Soft Tissue Tumor

• B-1-1 Desmoid
• (1) 40 of all demoids occur in the chest
  wall
• and the shoulder.
• (2) Encapsulation of vessels and brachial
• plexus in arms and neck is common.
• (3) The tumor may extend into the pleural
• cavity and displace mediastinal
  structure.

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B-1 Benign Soft Tissue Tumor

• B-1-1 Desmoid
• (4) Desmoid is most common in people of
  between
• puberty and 40 years of age. Men and
  women
• was affected equally.
• (5) The tumor originates in muscle
• and fascia.
• (6) The tumor must be treated with wide
• excision. Recurrence may occur if
• inadequate excision.

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B-2 Malignant Soft Tissue Tumors

• B-2-1 Malignant Fibrous Histiocytoma
• (1) It is the most common chest wall tumor
• that the thoracic surgeon was asked.
• (2) It is most common in people of 50-70
• years of age. 2/3 of patients are male.
• (3) The tumor was unresponsive to radiation and
  
• chemotherapy, so wide resection is the
  choice.
• (4) 5-year survival is 38 .

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B-2 Malignant Soft Tissue Tumors

• B-2-2 Rhabdomyosarcoma
• (1) It is the most second common malignant
  soft
• tissue tumor.
• (2) It is most common in children and young
  adults.
• (3) The tumor is neither pain nor tender,
• despite rapid growth.
• (4) Wide excision with postoperative
• chemotherapy and radiotherapy results in
  5-year
• survival of 70.

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B-2 Malignant Soft Tissue Tumors

• B-2-3 Liposarcoma
• (1) It is most common in people of 40-60
• years of age.
• (2) Most patients are men.
• (3) Treatment is wide excision. 5-year survival
  is
• 60 .
• (4) Chemotherapy and radiotherapy have
• little to offer.

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B-2 Malignant Soft Tissue Tumors

• B-2-4 Neurofibrosarcoma
• (1) Chest wall neurofibrosarcoma occurs
• along the intercostal nerve.
• (2) It is most common in people of 20-50
• years of age. Most patients are male.
• (3) Half of patients are associated with von
• Recklinghausens disease.
• (4) Treatment is wide excision.

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B-2 Malignant Soft Tissue Tumors

• B-2-5 Leimyosarcoma
• (1) It is most common in adults.
• (2) Most patients are female.
• (3) Most tumors present enlarging slowly but
• painful.
• (4) Treatment is wide excision.