Chest Wall Tumors Flashcards
Primary malignant chest wall tumors
- Chondrosarcomas (35%)
- Plasmacytoma (25%)
- Ewing’s sarcoma (15%)
- Osteosarcoma (15%)
- Lymphoma (10%)
Tumors that metastasize to chest wall
- Melanoma
- Breast carcinoma
- Lung carcinoma
- Mesothelioma
- Renal cell carcinoma
Benign tumors of the chest wall
- Fibrous dysplasia (40%)
- Chondoroma (30%)
- Osteochondroma
- Desmoids
- Lipoma
- Neurofibroma
- Giant cell tumor
*Characterized by slow growth
MC presentation of chest wall tumors
Painful, enlarging lesions (80%)
20% assymptomatic
*May also present with dyspnea, night sweats, fevers, generalized malaise
Imaging modalities used for diagnosis (and staging)
- Diagnosis: chest CT or MRI
- Staging: PET/CT
Diagnostic algorithm for chest wall tumors
- 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)
MC primary malignant chest wall tumor
Chrondrosarcoma
MC location of chrondrosarcoma
Costochondral arches (80%)
(sternum 20%)
CXR appearance of chrondrosarcoma
lobulated mass (medullary portion of the rib or sternum)
TOC for chondrosarcoma
Wide resection
Prevalence of plasmacytoma
(a.k.a solitary plasma cell tumor myeloma)
Accounts for 20-30% of primary malignant chest wall tumors
MC location of plasmacytoma
Ribs and sternum
Primary malignant chest wall tumor associated with progression to multiple myeloma
Plasmacytoma
Presentation of plasmacytoma
Painless mass with osteolytic CXR appearance
TOC for plasmacytoma
XRT
- Surgical resection (wide resection) for refractory cases
- Chemotherapy used for disease progression
MC malignant lesion of the ribs in children
Ewing’s sarcoma
- Aggressive, destructive tumors that invade and displace adjacent structures
Cell of origin of Ewing’s sarcoma
neural crest cells
MC presentation of Ewing’s sarcoma
Painful mass with fever and malaise
- May have elevated WBC and ESR
CXR appearance of Ewing’s sarcoma
Lytic lesion with surrounding destruction and onion peel appearance (new bone formation)
TOC Ewing’s sarcoma
Wide resection + XRT
Neoadjuvant chemotherapy may be used to shrink tumor preoperatively
MC location of osteosarcoma
Ribs, scapula, clavicle (young adults)
Unique featurs of osteosarcoma of the chest wall compared to osteosarcoma of the extremity
More prone to recurrence and metastasis
MC presentation of osteosarcoma
Painful mass with elevated ALP
CXR appearance of osteosarcoma
Sunburst pattern with elevation of periosteum (Codman’s triangle) due to new bone formation
Prognosis for osteosarcoma determined by
response to chemotherapy
Role of XRT for osteosarcoma
None to minimal (usually ineffective)
Codman’s triangle
Osteosarcoma
Elevation of periosteum due to new bone formation
MC type of chest wall lymphoma
Extranodal diffuse large B-cell lymphoma
Demographics of chest wall lymphoma
Immunocompromised patients
(transplant, HIV)
TOC chest wall lymphoma
CRT and chemotherapy (CHOP)
MC chemotherapy for chest wall lymphoma
CHOP
- Cytoxan (cycolphosphamide)
- Adriamycin (doxarubicin)
- Vincristine
- Prednisone
Workup for soft tissue sarcoma of the chest wall
- CT: evalute for pulmonary mets
- MRI: evaluate infiltration and relation to adjacent vital structures
TOC for soft tissue sarcoma of chest wall
WLE ( 1 cm margin)
*include biopsy site in WLE
Role of XRT for soft tissue sarcoma of the chest wall
- Residual disease
- Inadequate margins
- Tumors > 5 cm
- Highly invasive tumors (high-grade)
TOC for local recurrence of soft tissue sarcoma of chest wall
Resection (WLE)
Solitary pulmonary lesions = resection
TOC for XRT-induced sarcomas
WLE
(very aggressive tumors)
Painless, slowly enlarging, violaceous chest wall mass that is associated with a history of XRT
Angiosarcoma
TOC = WLE
TOC for solitary metastatic tumors to chest wall
Resection +/- XRT
- Melanoma
- Breast carcinoma
- Lung carcinoma
- Mesothelioma
- Renal cell carcinoma
MC benign rib lesion in children
Fibrous dysplasia of the bone
- Maturation defect
- May be associated with trauma
- Painless mass
CXR appearance of fibrous dysplasia of the bone
Fusiform mass with thinning of the cortex an no calcifications
TOC for fibrous dysplasia of the bone
Resection whtere the deformity has occurred
MC benign tumor of chest wall cartilage
Chondroma
- Appear similar to chondrosarcoma (requires biopsy or resection to r/o malignancy)
Benign chest wall tumor that typically presents as mass associated wtih rib fractures
Osteochondroma
- Resection is performed to prevent further tissue displacement
Benign tumor develooping from muscula aponeurosis
Desmoid tumor
Demographics of desmoid tumors
- MC in females
- FAP association
- Sites of prior trauma or scarring
Histologic appearance of Desmoid tumors
Sheets of fibroblasts with abundant collagen
MC presentation of Desmoid tumors
Painful mass fixed to deep tissues (but not skin)
TOC Desmoid tumors
WLE with 2-4 cm margin
Incidence of recurrence of Desmoid tumors following resection
25-50%
Role of XRT and/or chemotherapy for Desmoid tumors of the chest wall
- XRT: margin-positive resections
- Chemotherapy: none to minimal (not supported by trials)
Other less common benign chest wall tumors
- Lipoma
- Fibroma
- Neurofibroma
- Gangioneuroma
- Schwannoma
- Giant cell tumor
Oveall treatment strategy for chest wall tumors
Multidisciplinary, multimodality approach
(primarily due to the infrequency with with most practitioners encounter them)
- Most chest wall lesions are resected (including benign lesions)
Chest wall reconstruction technique used for resection defects < 5 cm or posterior resections covered by scapula
None required
Indications for chest wall reconstruction
- Defects > 5 cm
- Defects involving 2 or more adjacent ribs
Surgical options for chest wall reconstruction
- Methyl methacrylate/non-absorbable mesh “sandwich”
- Tissue flaps (latissimus, rectus, pectoralis, myocutaneous)
- Particularly useful in irradiated tissue beds
- Plastic surgery consultation
Sites of metastasis for primary malignant chest wall tumors
Lungs
Liver
- Long-term surveillance warranted (serial chest CT)
