thoracic surgery

1. CHEST WALL TUMOR
TUMMARAT RUANGPRATYAKUL, MD

2. Incidence
majority are metastatic or local invasive
primary chest wall tumor 5% of all thoracic tumor
1% of all primary tumor
40-60% of primary chest wall tumor is malignancy
Rib cage is the most common site

3. Bone
Malignant
osteochondroma
fibrous dysplasia
chondroma
Desmoid tumor
Liposarcoma
Soft tissue
Bone
Rhabdomyosarcoma
Chondrosarcoma
Osteosarcoman
Ewing’s sarcoma
Most COMMON
Benign

4. Presentation
slowly enlarging mass
painless/painful
systemic manifestations; fever, leukocytosis,
eosinophilia

5. Diagnosis
CT (Gold standard)
MRI
PET-CT
Tissue diagnosis: Needle biopsy, Excisional
biopsy, Incisional biopsy

6. Surgical Management
Surgical resection for cure is appropriate for Primary chest
wall neoplasms
En bloc resection
Margin for excision depended on type of neoplasms (at
least 4cm)
Reconstruction when defect >5cm, exposed vulnerable
structures
Aim of reconstruction are recreate stable, non-
paradoxically functioning chest wall during respiration

7. SPECIFIC TUMORS

8. Primary bone tumor
Benign
• Osteochondroma
• Chondroma
• Fibrous Dysplasia
• Eosinophilic
Granuloma
Malignant
• Chondrosarcoma
• Ewing’s Sarcoma
• Osteosarcoma
• Solitary
Plasmacytoma

9. Primary soft tissue tumor
Benign
• Hemangioma
• Neurofibroma
• Lipoma
• Fibroma
Malignant
• Desmoid
• Soft tissue sarcoma

10. Osteochondroma
most common benign bone neoplasm
(50% all benign rib tumors)
painless mass
arise from metaphyseal region of rib and
develops as stalked mass with
cartilaginous cap
male x3 > female
complete surgical resection of treatment of
choice

11. Chondroma
15% of all benign rib neoplasms
20-30 years, equal both sexes
costochondral junction
slowly enlarging a symptomatic mass
expansile medullary mass causes thinning of cortex
difficult to ddx chondroma and low grade chondrosarcoma
all chondroma must managed as malignant lesion, with wide
excision

13. Fibrous Dysplasia
benign, cystic lesions
30% of all benign chest wall tumor
most common present as a solitary mass in lateral of posterior
rib cage
male and female are equally
asymptomatic slow growing mass
multiple lesion can occur in Albright’s syndrome
a trabeculated, expansile lesion with a ground glass center and
thinning of the cortex
conservative
Albright’s syndrome
1multiple bone cyst,
2skin pigmentation, cafe au lait spot
3precocious sexual maturity in
females

15. Eosinophilic Granuloma
lymphoreticular system disease, not a true bone
tumor
fever, malaise, wright loss, lymphadenopathy,
splenomegaly, leukocytosis, eosinophilia, anemia
expansile lesion with periosteal new bone
formation and uneven destruction of cortex
radiation, chemotherapy and corticosteroid

17. Chondrosarcoma
most common primary chest wall bone neoplasm
60% arises in costochondral arches or sternum
30-40 years old
cause is unknown
slow enlarging mass become painful
lobulated mass arising in medullary portion with
destruction of cortex and mineralization of tumor
matrix(mottled type of calcification)
treatment is complete resection, 5-yr survival of 64%

19. Ewing’s sarcoma
small round cell sarcoma
15% presented at chest wall, 17% all primary chest wall tumor
age >40 years old, male x2> female
painfull, enlarging mass associated with fever, malaise,
leukocytosis, anemia, increase ESR
mottled destruction containing lytic and blastic area, onion skin
appearance
medical treatment, surgical role to biopsy
5-year survival 48%

20. Osteosarcoma
10% of all primary chest wall tumor, poor prognosis
teenagers, and young adults
rapidly enlarging, painful mass, high ALP
bone destruction with indistinct borders merge into
adjacent normal bone, sunbrust appearance
chemotherapy with wide resection
5-year survival 15%

23. Solitary Plasmacytoma
6% of all primary chest wall tumor
50-70 years old
pain often without associated mass, anemia, high
ESR, abnormal protein electrophoresis, Bence
Jones protein and hypercalcemia
ostolytic lesion with cortical thinning
chemotherapy and radiation
5-year survival 38%

24. Desmoid
locally invasive tumors
most common chest wall sarcoma 21%
adolescence - 40yrs old, male=female
associated with Gardner’s syndrome
asymptomatic, paresthesia, hyperesthesia, motor
weakness, progressive neural encasement
homogenous mass with indistinct border
treat with wide resection, radiation used in recurrent
5-year survival 93%, 5-year recurrent rate 29%
Gardner’s syndrome
familial colorectal polyposis, desmoid
osteoma, fibroma

26. Soft tissue sarcoma
one-half of primary malignant chest wall
adult life except rhabdomyosarcoma(child and
young adult <45)
painless mass
wide surgical resection, multimodality therapy
overall 5-year survival 60%

28. Metastatic disease and
Recurrent breast carcinoma
metastatic disease 20-30% of all chest wall neoplasm
role of surgical resection is controversy
criteria for curative resection:
1. chest wall is the only site of disease
2. locoregional disease is controlled
3. complete resection with negative margin is possible
5-year survival for chest wall metastasectomy 20%
10-12% stage II CA breast recur locally after mastectomy

29. THANK YOU