CHEST WALL,PlEURA AND MEDIASTINAL TUMOURS• The chest wall plays host to a variety of tumours, some of which are found most often in this region. They can be divided into benign and malignant tumours and into those which arise in the rib cage and those of soft tissue density.
SALIENT POINTS• Primary Chest wall tumors are rare• Metastases to the chest wall from a variety of primaries( including– Breast, Thyroid, Renal, Lung and Prostate) are common place.• Malignant tumors can arise from any of the elements of chest wall, but most arise from bone or cartilage• Benign disorders occur as often as Primary Malignant Tumors, the commonest being Chondro -Sarcoma
PRESENTATION• Tumors of the Chest wall usually present with pain and a palpable mass , although some are found incidentally on chest radiography• Most require further imaging with CT and/or MRI• These can be combined with per cutaneous biopsy but often the diagnosis is made from an open Biopsy
• For small tumours an excision Biopsy can be both diagnostic and curative• Larger tumors may need to have the diagnosis confirmed by an incision biopsy before an radical excision is undertaken
• The incision biopsy site should be fully excised at subsequent surgery to avoid the risk of tumor seeding.• If the incision biopsy is inconclusive a radical resection is performed, because this is the only effective method of treating those tumors that ultimately turn out to be malignant.
BENIGN TUMOURS• Chondromas develop in ribs and costal cartilages, occasionally becoming huge( giant chondromas)• They usually appear as rounded homogenous masses on chest x ray, although they can contain stippled calcification• All chondromas should be excised, because differentiation from a chondro sarcoma is rarely possible
FIBROUS DYSPLASIA• Fibrous Dysplasia affects the ribs , producing typical radiological appearances of an expanded thin bone cortex with a trabeculated radioluscent core . Exscisional biopsy is however almost always indicated because percutaneous needle biopsy is unreliable and resection is usually warranted to alleviate symptoms• Recurrence is extremely rare
MALIGNANT TUMOURS• Chondrosarcoma is the commonest primary chest wall tumours• Its clinical,radiological,and incision biopsy features are often identical to those of benign cartilaginous tumours• Treatment is by Surgical Resection, because the tumour is not radiosensitive• The prognosis is dependent primarily upon the histological grade and its completeness of resection
FIBROSARCOMAS• Often produce radiolucent erosions of the ribs.• Per cutaneous or incision biopsy is diagnostic when the characteristic features of disorganized collagen formation are present• The prognosis is poor, but reasonable survival can follow wide excision of a low grade tumour.• Post operative irradiation may be given to try and provide local control of the tumour.
EWING’S SARCOMA• Ewing Sarcoma of chest wall is rare• It is a radiosensitive tumor, and the best management probably combines wide excision and a histologically clear margin with radiotherapy and multi agent chemotherapy.• All malignant tumors should be widely excised and this will often include the whole of the involved ribs and one further rib on either side., because these tumors may extend through the inter costal space
• Frozen section may be sent to confirm tumor free margins.• Sternal tumors should be treated by excision of the whole sternum and its attached costal cartilages• The method of reconstruction depends on the size and site of the defect and the chest wall vascularity, because this may be affected by previous surgery or radiotherapy.
• Small defects dont usually need to be reconstructed , especially those that underlie the scapula.• Larger defects should be closed to protect the underlying structures and to maintain the chest wall mechanics and correct shape.
• POLYPROPYLENE mesh is often used and this can be constucted in two layers with methyl methacrylate cement between.• The bone cement is shaped to the contour of the chest wall and the marlesh mesh is sutured to the surrounding structures.• The soft tissue defect can be closedby pectoralis major, latissimus dorsi or rectus abdominis myocutaneous flaps.• Peducled greater omentum or microvascular flaps have been used for this purpose.
TUMOURS OF PLEURA• BENIGN TUMOURS• Benign fibrous tumors of the pleura are sometimes called solitary fibrous tumors. They make up approximately 78% to 88% of non-mesothelioma tumors of the pleura. Fibrous tumors of the pleura are much less common than mesothelioma tumors of the pleura.• Benign fibrous tumors of the pleura are confined to the surface of the lung, where they start.
MALIGNANT TUMOURS OF PLEURA• PRIMARY• MALIGNANT MESOTHELIOMA• SECONDARY• DIFFUSE SEEDLING OF THE PARIETAL AND VISCERAL PLEURA IS A COMMON PATTERN OF DISSEMINATION OF CANCERS , PARTICULARLY ADENOCARCINOMA OF ANY ORIGION
MEDIASTINAL TUMOURS• The mediastinum is divided into three sections:• The anterior (front)• The middle• The posterior (back)• Mediastinal tumors are benign or cancerous growths that form in the area of the chest that separates the lungs. This area, called the mediastinum, is surrounded by the breastbone in front, the spine in back, and the lungs on each side. The mediastinum contains the heart, aorta, esophagus, thymus and trachea.•
• Mediastinum tumors are mostly made of reproductive (germ) cells or develop in thymic, neurogenic (nerve), lymphatic or mesenchymal (soft) tissue.• In general, mediastinal tumors are rare. Mediastinal tumors are usually diagnosed in patients aged 30 to 50 years, but they can develop at any age and form from any tissue that exists in or passes through the chest cavity.
• Anterior (front) mediastinum• Germ cell - The majority of germ cell neoplasms (60 to 70%) are benign and are found in both males and females.• Lymphoma – Malignant tumors that include both Hodgkin’s disease and non Hodgkin’s lymphoma.• Thymoma - The most common cause of a thymic mass, the majority of thymomas are benign lesions that are contained within a fibrous capsule.
• However, about 30% of these may be more aggressive and become invasive through the fibrous capsule.• Thyroid mass mediastinal – Usually a benign growth, such as a goiter, these can occasionally be cancerous.
• Middle mediastinum• Lymphadenopathy mediastinal – An enlargement of the lymph nodes.• Pericardial cyst – A benign growth that results from an "out- pouching" of the pericardium (the heart’s lining).• Thyroid mass mediastinal – Usually a benign growth, such as a goiter.
• These types of tumors can occasionally be cancerous.• Tracheal tumors – These include tracheal neoplasms and non-neplastic masses, such as tracheobronchopathia osteochondroplastica (benign tumors).
• Posterior (back) mediastinum• Lymphadenopathy mediastinal – An enlargement of the lymph nodes.• Neurogenic neoplasm mediastinal – The most common cause of posterior mediastinal tumors, these are classified as nerve sheath neoplasms, ganglion cell neoplasms, and paraganglionic cell neoplasms.• Approximately 70% of neurogenic neoplasms are benign. Oesophageal neoplasm can be there
• Paravertebral abnormalities including infectious, malignant and traumatic abnormalities of the thoracic spine.• Thyroid mass mediastinal – Usually a benign growth, such as a goiter, which can occasionally be cancerous.• Vascular abnormalities – Includes aortic aneurysm