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Dr. Alfredo M. Igama

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CHEST WALLChest Wall Mass

Clinical Approach-All chest wall tumors should be considered

malignant until proven otherwise -50-80%Presentation

1. Mass Slow, growing, 50-70%2. Chest wall pain - localized

- more intense in malignant- 25-50%

3. Fever & malaise Ewings sarcoma4. Younger (26 yrs old) Benign5. Older (40 yrs old) - Malignant

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CHEST WALLEvaluation and Management

1. Laboratory exams -limited advantage-Plasmacytoma - monoclonality

- normal in other immunoglobulins

-Osteosarcoma Alkaline PO4 elevated-Ewings Sarcoma ESR elevated

2. Radiographya. Chest X-ray - Rib destruction

- Metastatic lesions- Extra osseous bone formation and

bone destructionb. MRI - Better definition

- Neurovascular structures well defined- Better pre-op planning- Can distinguish benign from malignant

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CHEST WALL3. Biopsy- First step in the management of all chest wall tumors.

-Avoid seeding surrounding tissues and pleural space.

Methods1. Needle Biopsy CT-guided, FNA or core biopsy.2. Incisional Biopsy3. Excisional Biopsy

Advantages of Excisional Biopsy1. Entire mass is removed, accurate sampling anddiagnosis.2. Seeding is avoided.3. Adjuvant chemo can be given.

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CHEST WALL NEOPLASMSA. Benign:

1. Chondroma - Occur at costochondral junction.- Mass without pain in contrast to

costochondritis.

- Radiologically- Lobulate, Radiodense, diffuse orfocal calcifications- Displace bony cortex without penetration.- Can grow to huge sizes.- Surgical resection with2 cm margin.

2. Fibrous Dysplasia-Pain is located at the Postero lateral aspect of the rib cage.

- Ribs are a frequent site of origin.-Young adults-Associated with trauma-Xray expansile mass is present, with cortical thinning and nocalcification.- Local excision of2 cm margin.

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CHEST WALL NEOPLASMS3. Osteochondroma

- Most common benign bone tumors- Most are solitary. Multiple are malignant-Arise at or near growth plate of bones

- Becomes malignant after completionof skeletal growth- Chondrosarcoma-Arise from rib cortex- Local excision

4. Eosinophilic Granuloma- Osteolytic Lesions

- Destructive lesions with large numbers of eosinophilic cells- Maybe part of Langerhans Cell histiocytosis- Can recur in ribs, skull, pelvis, mandible, humerus- Seen in children 5-15 yrs old- Surgical excision with2 cm margin

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CHEST WALL NEOPLASMS5. Desmoid Tumors

-Arise from fascial or musculoaponeurotic

structure- consists of fibroblastic cells, abundant collagenand few mitoses

-A form of fibrosarcoma

-Seen at or near incision sites- Fixed to chest wall not on skin

- Do not metastasize but high in recurrence rates

-Wide local excision of2-4 cm margin

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CHEST WALL NEOPLASMSB. Malignant Chest Wall Bone Tumors

1. Chondrosarcoma- Most common primary chest wall malignancy.-Arise at costochondral arches.

- Slowly enlarging huge painful mass.- CT scan Radiolucent with stippled calcification-Wide resection 4 cm- Not sensitive to chemotherapy and RT.

2. Osteosarcoma- Most common bone malignancy but uncommon on the chest

wall.-Rapidly enlarging painful mass in young adults.-X-ray: -Sunburst appearance spicules of new periosteal

bone formation.-Lung metastasis is common.

-Sensitive to chemotherapy.

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CHEST WALL NEOPLASMS3. Primitive Neuroectodermal Tumors (PNET)

- Derived from primordial neural crest cells that migrate from the mantle layer ofthe developing spinal cord.

- Includes : -Neuroblastomas-Ganglioneuroblastomas-Ganglioneuroma

4. Ewings Sarcoma- Seen in adolescents and young adults- Progressive chest wall pain without the presence of a mass.- Malaise and fever- Elevated ESR and WBC

-X-ray: -Onion peel appearance multiple layers of periosteum inthe bone formation.-Bone destruction

-Strong propensity to spread to lungs and skeleton-50% survival rates for 3 years.- Improved survival with chemotherapy, radiation therapy and surgery.

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CHEST WALL NEOPLASMSC. Malignant Chest Soft Tissue Sarcomas

- Fibrosarcomas-Liposarcomas

-Malignant Fibrohistiocytomas-Rhabdomyosarcomas-Angiosarcomas

Treatment:

-Wide surgical resection with 4 cm margins andreconstructions.- Rhabdomyosarcomas Pre-operation chemotherapy

prior to wide surgical resection.*Propensity to spread to the lungs.

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