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ABTS - Thoracic Surgery Notecards IA > Chest Wall Tumors > Flashcards

Chest Wall Tumors Flashcards

1
Q

Primary malignant chest wall tumors

A
  • Chondrosarcomas (35%)
  • Plasmacytoma (25%)
  • Ewing’s sarcoma (15%)
  • Osteosarcoma (15%)
  • Lymphoma (10%)
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2
Q

Tumors that metastasize to chest wall

A
  • Melanoma
  • Breast carcinoma
  • Lung carcinoma
  • Mesothelioma
  • Renal cell carcinoma
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3
Q

Benign tumors of the chest wall

A
  • Fibrous dysplasia (40%)
  • Chondoroma (30%)
  • Osteochondroma
  • Desmoids
  • Lipoma
  • Neurofibroma
  • Giant cell tumor

*Characterized by slow growth

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4
Q

Most common presentation of chest wall tumors

A

Painful, enlarging lesions (80%)

20% assymptomatic

*May also present with dyspnea, night sweats, fevers, generalized malaise

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5
Q

Imaging modalities used for diagnosis (and staging)

A
  • Diagnosis: chest CT or MRI
  • Staging: PET/CT
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6
Q

Diagnostic algorithm for chest wall tumors

A
  • Imaging/Staging:
    • Chest CT or MRI
    • PET/CT
  • Tissue diagnosis:
    • determine histopathology
    • determine candidate for neoadjuvant therapy
    • Options:
      • core needle biopsy
      • incisional biopsy
      • excisional biopsy (< 5cm)
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7
Q

Most common primary malignant chest wall tumor

A

Chrondrosarcoma

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8
Q

Most common location of chrondrosarcoma

A

Costochondral arches (80%)

Costochondral junction (sternum 20%)

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9
Q

CXR appearance of chrondrosarcoma

A

lobulated mass (medullary portion of the rib or sternum)

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10
Q

Treatment for chondrosarcoma

A

Treatment therefore should be wide local excision with wide margins for malignant lesions. Adjuvant therapy is rarely indicated because these tumors are resistant to chemotherapy and RT.

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11
Q

Prevalence of plasmacytoma

A

(a.k.a solitary plasma cell tumor myeloma)

Accounts for 20-30% of primary malignant chest wall tumors

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12
Q

Most common location of plasmacytoma

A

Ribs and sternum

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13
Q

Primary malignant chest wall tumor associated with progression to multiple myeloma

A

Plasmacytoma

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14
Q

Presentation of plasmacytoma

A

Painful mass with osteolytic CXR appearance

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15
Q

TOC for plasmacytoma

A

Treatment id definitive XRT

  • Surgical resection (wide resection) for refractory cases
  • Chemotherapy used for disease progression
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16
Q

Most common chest wall malignancy in children

A

Ewing’s sarcoma

  • Aggressive, destructive tumors that invade and displace adjacent structures
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17
Q

Cell of origin of Ewing’s sarcoma

A

neural crest cells

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18
Q

Most common presentation of Ewing’s sarcoma

A

Painful mass with fever and malaise

  • May have elevated WBC and ESR
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19
Q

CXR appearance of Ewing’s sarcoma

A

Lytic lesion with surrounding destruction and onion peel appearance (new bone formation)

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20
Q

Treatment of choice for Ewing’s sarcoma?

A

Treatment is wide excision of the lesion. The entire rib is removed along with the adjacent rib above and below the tumor.

This is followed by adjuvant RT.

Chemotherapy is used for patients with systemic disease and has been shown to improve survival.

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21
Q

Most common location of osteosarcoma

A

Ribs, scapula, clavicle (young adults)

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22
Q

Unique featurs of osteosarcoma of the chest wall compared to osteosarcoma of the extremity

A

More prone to recurrence and metastasis

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23
Q

MC presentation of osteosarcoma

A

Painful mass with elevated ALP

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24
Q

CXR appearance of osteosarcoma

A

Sunburst pattern with elevation of periosteum (Codman’s triangle) due to new bone formation

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25
Q

Prognosis for osteosarcoma determined by

A

response to chemotherapy

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26
Q

Role of XRT for osteosarcoma

A

None to minimal (usually ineffective)

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27
Q

Codman’s triangle

A

Osteosarcoma

Elevation of periosteum due to new bone formation

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28
Q

MC type of chest wall lymphoma

A

Extranodal diffuse large B-cell lymphoma

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29
Q

Demographics of chest wall lymphoma

A

Immunocompromised patients

(transplant, HIV)

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30
Q

TOC chest wall lymphoma

A

CRT and chemotherapy (CHOP)

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31
Q

MC chemotherapy for chest wall lymphoma

A

CHOP

  • Cytoxan (cycolphosphamide)
  • Adriamycin (doxarubicin)
  • Vincristine
  • Prednisone
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32
Q

Workup for soft tissue sarcoma of the chest wall

A
  • CT: evalute for pulmonary mets
  • MRI: evaluate infiltration and relation to adjacent vital structures
33
Q

TOC for soft tissue sarcoma of chest wall

A

WLE ( 1 cm margin)

*include biopsy site in WLE

34
Q

Role of XRT for soft tissue sarcoma of the chest wall

A
  • Residual disease
  • Inadequate margins
  • Tumors > 5 cm
  • Highly invasive tumors (high-grade)
35
Q

TOC for local recurrence of soft tissue sarcoma of chest wall

A

Resection (WLE)

Solitary pulmonary lesions = resection

36
Q

TOC for XRT-induced sarcomas

A

WLE

(very aggressive tumors)

37
Q

Painless, slowly enlarging, violaceous chest wall mass that is associated with a history of XRT

A

Angiosarcoma

TOC = WLE

38
Q

TOC for solitary metastatic tumors to chest wall

A

Resection +/- XRT

  • Melanoma
  • Breast carcinoma
  • Lung carcinoma
  • Mesothelioma
  • Renal cell carcinoma
39
Q

MC benign rib lesion in children

A

Fibrous dysplasia of the bone

  • Maturation defect
  • May be associated with trauma
  • Painless mass
40
Q

CXR appearance of fibrous dysplasia of the bone

A

Fusiform mass with thinning of the cortex an no calcifications

41
Q

TOC for fibrous dysplasia of the bone

A

Resection whtere the deformity has occurred

42
Q

MC benign tumor of chest wall cartilage

A

Chondroma

  • Appear similar to chondrosarcoma (requires biopsy or resection to r/o malignancy)
43
Q

Benign chest wall tumor that typically presents as mass associated wtih rib fractures

A

Osteochondroma

  • Resection is performed to prevent further tissue displacement
44
Q

Benign tumor develooping from muscula aponeurosis

A

Desmoid tumor

45
Q

Demographics of desmoid tumors

A
  • Most common in females (2:1)
  • Familial adenomatous polyposis association
  • Sites of prior trauma or scarring

Gardner’s syndrome is a genetic disorder characterized by multiple colonic polyps and tumors outside the colon. The extracolonic tumors may include osteomas of the skull, thyroid cancer, epidermoid cysts, fibromas and sebaceous cysts. The multiple colon polyps predispose to development of colon cancer. Gardner’s syndrome is caused by mutation in the APC gene located in chromosome 5q21 and is recognized as a phenotypic variant of FAP.

46
Q

Histologic appearance of Desmoid tumors

A

Sheets of fibroblasts with abundant collagen

47
Q

MC presentation of Desmoid tumors

A

Painful mass fixed to deep tissues (but not skin)

48
Q

TOC Desmoid tumors

A

WLE with 2-4 cm margin

49
Q

Incidence of recurrence of Desmoid tumors following resection

A

25-50%

50
Q

Role of XRT and/or chemotherapy for Desmoid tumors of the chest wall

A
  • XRT: margin-positive resections
  • Chemotherapy: none to minimal (not supported by trials)
51
Q

Other less common benign chest wall tumors

A
  • Lipoma
  • Fibroma
  • Neurofibroma
  • Gangioneuroma
  • Schwannoma
  • Giant cell tumor
52
Q

Oveall treatment strategy for chest wall tumors

A

Multidisciplinary, multimodality approach

(primarily due to the infrequency with with most practitioners encounter them)

  • Most chest wall lesions are resected (including benign lesions)
53
Q

Chest wall reconstruction technique used for resection defects < 5 cm or posterior resections covered by scapula

A

None required

54
Q

Indications for chest wall reconstruction

A
  • Defects > 5 cm
  • Defects involving 2 or more adjacent ribs
55
Q

Surgical options for chest wall reconstruction

A
  • Methyl methacrylate/non-absorbable mesh “sandwich”
  • Tissue flaps (latissimus, rectus, pectoralis, myocutaneous)
    • Particularly useful in irradiated tissue beds
    • Plastic surgery consultation
56
Q

Sites of metastasis for primary malignant chest wall tumors

A

Lungs

Liver

  • Long-term surveillance warranted (serial chest CT)
57
Q
A

Aneurysmal Bone Cyst

58
Q
A

Cavernous Hemangioma

59
Q
A
60
Q
A

Chondromyxoid fibroma

61
Q
A

Chondrosarcoma

62
Q
A

Ewing Sarcoma

63
Q
A

fibrous dysplasia

64
Q
A

Ganglioneuroma

65
Q
A

Giant cell tumor

66
Q
A

Lipoma

67
Q
A

Osteochondroma

68
Q
A

Osteosarcoma

69
Q
A

Paraganglioma

70
Q
A

plasmacytoma

71
Q
A

Spindle cell lipoma

72
Q

The most common presentation is that of a slow-growing painful mass. Imaging demonstrates a lobulated mass arising in the medullary portion of the rib or sternum often with cortical bone destruction. These are often missed on standard chest radiography but CT scan of the chest will easily identify a lesion and help characterize both local and metastatic extent of disease.

A

Chondrosarcoma

73
Q

Name that chest wall Mass?

  • Arises in the ribs near the chostochondral junction anteriorly.
  • lobulated radiodense, displaces bony cortex but does not penetrate it.
  • Diffuse calcification or focal with a stippled pattern.
  • Histology: mature hyaline cartilagewith foci of myxoid degeneration and calcification.
A

Chondroma

74
Q

Name that chest wall Mass?

  • Origin: anywhere, frequently in the posterior ribs
  • Radiographic appearance: central fusiform expanded mass with thinning of cortex, cortical bone erosion can be present.
  • Calcifiction: none
  • Histology: fish-hook configuration of trabeculae and lack of transformation of the coarse bony fibers to lamellar bone, represents a maturation defect.
  • Young adults, in association with trauma.
A

Fibrous dysplasia

75
Q

Name that chest wall Mass?

  • Origin: metaphysis, grows in a direction opposite to that of the adjacent bone.
  • Radiographic appearance: can have a focal radiolucent area surrounded by osteosclerotic tissue.
  • Histology: Mature bone trabeculae covered by a cartilaginous cap.
  • Occurs in the first or second decade of life.
A

Osteochondroma
(Most common benign bone lesion)

76
Q

Name that chest wall Mass?

  • Origin:Lymphoreticular system, not a true tumor; occurs in metaphysis of diaphysis
  • Radiographic appearance: osteolytic activity with adjacent osteosclerosis
  • Histology:abundance of Langerhans cells, giant cells, eosinophils and neutrophils.
  • 5-15yo, frequently confused with Ewing’s sarcoma or osteomyelitis.
A

Eosinophilic granuloma
(histiocytosis X)

77
Q

Name that chest wall Mass?

  • Origin:
  • Radiographic appearance:
  • Calcifiction:
  • Histology:
A
78
Q

Name that chest wall Mass?

  • Origin:
  • Radiographic appearance:
  • Calcifiction:
  • Histology:
A
79
Q

Name that chest wall Mass?

  • Origin:
  • Radiographic appearance:
  • Calcifiction:
  • Histology:
A

ABTS - Thoracic Surgery Notecards IA (48 decks)

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