1. Chest Wall Tumors

2. 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

3. 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.

4. Table 45-2 Primary chest wall tumors
Malignant
myeloma, malignant fibrous histiocytoma, chondrosarcoma, rhbdomyosarcoma, Ewing’s sarcoma, liposarcoma, lymphoma, leiomyosarcoma, hemangiosarcoma
Benign
osteochondroma, chondroma, desmoids, fibrous dysplasia,
lipoma, fibroma, neurilemoma

5. 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

6. 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( tumor> 5 cm ) or excisional( tumor 3 –5 cm ) biopsy.
Needle aspiration biopsy should be only for patients with a known primary tumor elsewhere.

7. 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.

8. 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

9. 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 Ewing’s sarcoma.

10. 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.

11. 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.

12. 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) Albright’s syndrome( multiple bone
cysts, skin pigmentation and precocious
sex maturity in girls ) should be suspected if
multiple lesions occurs.

13. 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.

14. 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.

15. 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.

16. 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 people< 30 years.
(4) Punched-out lesion with cortical thinning
presents radiographically.

17. 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 %.

18. 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 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.

19. A-2 Malignant Rib Tumors
A-2-3. Ewing’s 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.

20. 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.

21. 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%.

22. 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.

23. 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. .

24. 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.

25. 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.

26. 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.

27. 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 %.

28. 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%.

29. 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.

30. 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
Recklinghausen’s disease.
(4) Treatment is wide excision.

31. 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.