Chest Wall Tumors

a) 75% = painless mass 
b) Bone tumors cause pain 

i) Expand cortex and periosteum 
ii) Pathologic fx

c) Cartilaginous rib = incidental CXR finding

a) Determine invasiveness 

i) CT 

a) Cystic vs. solid lesion 
b) Bony invasion

ii) MRI 

a) Also outlines vascular structures 
b) Spinal and great vessel invasion

b) Biopsy (for histology) 

i) Lesions <5cm, when complete resection will not be mutilating, excisional biopsy 
ii) Larger lesions - core needle or incisional biopsy (orient scar)

a) Cutaneous nevus - excision w/margin 
b) Lipoma 

i) Clinical diagnosis sufficient 
ii) Resect for cosmesis or diagnosis 
iii) Intramuscular - can recur, Tx = require larger excision

c) Lymphangioma- extend from neck - complete excision precludes recurrence 
d) Hemangioma 

i) Skin or subcutaneous - Tx for cosmesis 
ii) Cavernous or AVM - Tx = resect in absence of contraindications

a) Fibroma 

i) Slow growth, occurs near joints 
ii) Tx = resect for symptoms or cosmesis

b) Rabdomyoma - rare 

i) Biopsy to confirm benignancy 
ii) Tx = resect for function, cosmesis

c) Neurofibroma 

i) Usually multiple - von Recklinghausen’s 
ii) Near vertebral body, must r/o “dumbbell” tumor (CT or MRI)-extension into spinal canal

d) Desmoid 

i) From deep fascia and connective tissue of muscle 
ii) Most commonly involves anterolateral chest wall 
iii) Some consider it a low-grade fibrosarcoma 
iv) High potential for local recurrence 
v) Tx = extensive local resection - external beam radiation or local brachytherapy recommended to control local recurrence

a) Fibrous dysplasia 

i) Most common tumor of the ribs 
ii) Painless expansion on posterior or lateral aspect of rib 
iii) Malignant change unusual 
iv) Natural hx is continued growth w/pain and deformity 
v) Tx = complete excision = cure

b) Chondroma 

i) 20-40 yo 
ii) Arises in ribs at costochondral jxn or in sternum 
iii) < 4cm = benign (no other clear distinctions) 
iv) Tx = complete resection w/margins (see below)

c) Osteochondroma and osteoblastoma - very rare 

i) Originate from bony cortex of rib, have stalk and cartilaginous covering 
ii) Tx = complete resection

a) Basal cell 
b) Malignant liposarcoma 
c) Angiosarcoma 
d) Fibrosarcoma, rhabdomyosarcoma, neurofibrosarcoma 

i) Tx = complete resection

a) Chondrosarcoma 

i) Most common malignant tumor of sternum and of entire chest wall 
ii) Anterior rather than posterior costal jxn (front of chest) 
iii) Slow-growing 
iv) Histologic grade is of prognostic importance 
v) Tx = excision w/5cm margin w/a normal rib above and below (underlying pleura) 
vi) 10-year survival 

a) Wide excision - 96% 
b) Limited resection - 65% 
c) Palliative resection - 14%

b) Osteogenic sarcoma 

i) Usually in long bones 
ii) Greater virulence and earlier hematogenous spread than chondrosarcoma 
iii) Lung is almost exclusive site of early mets 
iv) Responds to chemo tx and to RT 
v) Tx 

a) Local disease only à radical excision, then chemo tx after wound is healed 
b) Simultaneous primary and lung metsà 

(1) First - chemo tx (vincristine, adriamycin and high-dose methotrexate) 
(2) If no new dz and/or change after several cycles, resect all tumor 

(a) Mets first if 1° requires major resection 
(b) If mets unresectable, palliative tx of 1°

c) Chemotherapy also for distant failure (mets)

vi) 15-25% survival w/surgery and chemo tx

c) Ewing’s sarcoma - rare 

i) Adolescent males 
ii) Rapidly expanding tender mass 
iii) Systemic symptoms common 
iv) Early mets to lung and bone common 
v) Tx 

a) Local control w/surgery or RT 
b) Multiple agent chemotherapy - high incidence of distant mets

d) Myelomatous tumors 

i) Males 60-70 yo 
ii) Tx = chemo tx + RT for painful lesions 
iii) Plasmacytoma (isolated) à resect

a) 5% involve chest wall 
b) T3 - at least stage IIIA (T3, N0-2) 
c) Prognostic criteria 

i) Mediastinal lymph node status 
ii) Distal mets 
iii) Location of tumor w/regard to spine and mediastinum

d) Complete resection in 62% - (no extrathoracic tumor, medically fit) 
e) Invasion of spine precludes resectability 
f) Extent of resection (controversial) 

i) Full thickness of chest wall in every case (of parietal pleural involvement), or… 
ii) Begin extrapleural dissection away from lesion 

a) If pleura separates easily, microscopic invasion is limited to parietal pleura - resect only pleura and tumor 
b) If resistance is met, resect chest wall - a rib above and below, 5cm margin of involved rib + tumor + mediastinal lymph node dissection (always, diagnostic)

g) Adjuvant RT recommended but no trials 
h) Incomplete resection = 9 month median survival 
i) 5-yr survival (table 34-5) [CR=complete resection] 

i) Complete resection - 40% 
ii) Neg regional nodes - 56% 
iii) Pos regional nodes - 21% 
iv) Confined to parietal pleura - 48% (CR 77%) 

a) w/ neg nodes - 62%

v) Invading ribs - 16% (CR 53%) 

a) Neg nodes - 35%

a) Recurrence following RT or resection 
b) Large or deep tumors 
c) Mets to internal mammary nodes 
d) Survival is directly related to stage

a) Carcinoma 

i) Ribs 
ii) Solitary mass à resect 
iii) Multiple (usual case) à systemic tx 
iv) Survival is related to stage

b) Sarcoma 

i) Least common malignant tumor of chest wall 
ii) R/o other dz, then resect 
iii) Survival is related to stage

a) Extent of resection 

i) 2-3cm margin of soft tissue 
ii) 1 normal rib above and 1 normal rib below tumor 
iii) 5cm clear rib margin 
iv) Remove contiguous, involved structures 
v) One normal myofascial plane below skin (i.e., between resection and skin) 
vi) Skin if adherent to tumor or site of previous biopsy

b) Shoulder girdle involvement may necessitate forequarter amputation 
c) Lower rib cage may necessitate diaphragm resection - reconstruct w/PTFE or 1° repair 
d) Consider need for RT - brachytherapy

a) <5cm 

i) Bony defect only 

a) No reconstruction 
b) Mesh (marlex better than Gore-tex)

ii) Soft tissue 

a) Myocutaneous flap +/- mesh 
b) Advancement flap +/- mesh

b) >5cm 

i) Marlex or Gore-tex patch 
ii) Methyl methacrylate “sandwich” - it’s HOT!! 
iii) Sternum- inject methyl methacrylate into cut edge of bone marrow 
iv) Diaphragm - Gore-tex 
v) Omentum - between mesh and myocutaneous flap

a) STSG based on omentum 
b) Delayed flaps 
c) Myocutaneous flaps 

i) Latissimus dorsi - Thoracodorsal artery 
ii) Pectoralis major - Pectoral branch of thoracoacromial, internal mammary, lateral thoracic arteries 
iii) Rectus abdominus - Superior and inferior epigastric arteries 
d) Free flaps

a) Palliation may be the goal, improving quality of life, but not survival 
b) 55% alive w/o dz and 22% live >5 years following resection