This document provides information on evaluating and managing chest wall masses. It discusses: 1) Performing a thorough history, physical exam, and imaging to determine if the mass is primary or secondary. 2) Obtaining a biopsy for masses ≥3cm or if resection would be extensive to determine if the mass is benign or malignant. 3) For benign primary masses, complete resection is usually curative. For malignant primary masses, radical resection with reconstruction is required.

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4 THORAX 3 CHEST WALL MASS — 1
3 CHEST WALL MASS
John C. Kucharczuk, M.D., F.A.C.S.
Evaluation of Chest Wall Mass
Chest wall masses arise from a variety of different causes. The a stand-alone test, it cannot differentiate between benign and
chest wall contains a number of distinct tissues, including skin, fat, malignant chest wall lesions.
muscle, bone, cartilage, lymphatic vessels, and fascia. Each of In general, given that neither physical examination nor diag-
these component tissues can give rise to either a benign or a malig- nostic imaging can reliably distinguish benign from malignant
nant primary chest wall mass. In addition, the chest wall is also in chest wall masses, it is important to move quickly to tissue diag-
intimate proximity to a number of organs (e.g., the breast, the nosis.With very unusual tumors, it is often necessary to consult a
lung, the mediastinum, and the pleura) that may give rise to a highly specialized pathologist to make the diagnosis and an oncol-
chest wall mass through extension of a malignancy or infection. ogist to assist in treatment planning.
Finally, because of its large surface area, the chest wall can be the
BIOPSY
site of a secondary mass caused by metastasis from a distant
malignancy (e.g., carcinoma or sarcoma) [see Table 1]. Whether a tissue diagnosis is needed
Chest wall masses, whether primary or secondary, are relative- before initiation of definitive therapy de-
ly uncommon in clinical practice. Accordingly, many surgeons pends on the size and characteristics of the
lack a solid working knowledge of the causes, evaluation, treat- lesion. If the lesion is small (< 3 cm),
ment, and natural history of these lesions. Often, this unfamiliari- regardless of whether it is believed to be
ty leads to inappropriate selection of diagnostic studies, unneces- benign or malignant, excisional biopsy is
sary delays in treatment, and considerable frustration for patient performed as both diagnosis and treat-
and surgeon alike. In what follows, I outline a focused clinical ap- ment. If the lesion is larger (≥ 3 cm) and its resection will lead to
proach aimed at streamlining the evaluation and treatment of pa- significant morbidity and necessitate extensive reconstruction, a
tients with chest wall masses. Appropriate diagnostic studies and preoperative tissue diagnosis is obtained.
operative planning are discussed, and specific causes of chest wall Whether fine-needle aspiration (FNA) is useful for tissue
masses are reviewed. diagnosis in this setting remains a subject of debate. FNA is a
simple procedure that can be performed in the office during the
initial patient evaluation, and several studies suggest that it is an
Clinical Evaluation effective technique for assessing chest wall masses.2 Never-
theless, in routine clinical practice, cytologic analysis of a fine-
HISTORY AND PHYSICAL EXAMINATION
needle aspirate from a primary chest wall mass frequently yields
Initial evaluation of a patient with a chest nondiagnostic results, and additional tissue is often requested.
wall mass begins with a careful history that In such cases, a core-needle biopsy or an incisional biopsy is
notes the symptoms associated with the performed. Both techniques provide tissue for histologic evalu-
mass and records the history of its growth. ation, and both must be performed in such a way that the biop-
Previously obtained radiographs, if available, are reviewed to sy tract will be completely excised at the time of definitive sur-
determine how rapidly the mass has been growing. A complete gical treatment. As a rule, in patients with a known primary
physical examination is performed to rule out other sites of disease malignancy and a secondary chest wall mass, I perform FNA.
and to identify any comorbid medical conditions that may affect In patients with a primary chest wall mass larger than 3 cm and
the patient’s candidacy for resection. If the mass is palpable, its size no underlying diagnosis, I proceed directly to incisional biopsy
and its salient characteristics (i.e., hard versus soft and fixed ver- for diagnosis.
sus mobile) are noted. By itself, physical examination will not
establish whether the lesion is benign or malignant. Table 1 Classification of Primary
and Secondary Chest Wall Masses
Investigative Studies
Benign
DIAGNOSTIC IMAGING Infectious masses
Soft tissue neoplasms
At presentation, most patients with Primary masses of Bone and cartilage neoplasms
chest wall masses have already undergone chest wall
Malignant
chest radiography and computed tomog- Soft tissue neoplasms
raphy. In the case of a primary chest wall Bone and cartilage neoplasms
mass, magnetic resonance imaging is useful for further character-
Secondary masses of Tumor invasion from contiguous organs
ization of the lesion. MRI allows precise delineation of tissue chest wall Metastasis from distant organs
planes and major adjacent neurovascular structures1; however, as

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4 THORAX 3 CHEST WALL MASS — 2
Evaluation of Chest Wall Mass
Patient presents with chest wall mass
Obtain clinical history:
• Growth of mass
• Associated symptoms
• Previous chest radiographs (if available)
Perform physical examination:
• Other disease sites or comorbid conditions
• Size and salient characteristics of mass (if palpable)
Determine whether mass is primary or secondary.
Chest wall mass is primary Chest wall mass is secondary
Consider MRI for further Control primary underlying disease process.
characterization of lesion Perform needle biopsy to confirm diagnosis.
if desired.
Consider definitive treatment after primary
Assess size of mass. process is controlled.
Mass is < 3 cm Mass is ≥ 3 cm
Perform excisional biopsy for diagnosis Perform incisional biopsy for diagnosis.
and treatment.
Mass represents benign lesion Mass represents malignant lesion
Consider resection for confirmation of Perform radical resection with reconstruction.
diagnosis or for management of symptoms.

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4 THORAX 3 CHEST WALL MASS — 3
Management
PRIMARY BENIGN MASSES OF
CHEST WALL
Infectious Masses
Sternal infection Primary sternal
osteomyelitis may be seen in intravenous
drug abusers but is otherwise rare. Much
more common is osteomyelitis occurring after median sternoto-
my. Approximately 1% to 3% of median sternotomies for cardiac
procedures are complicated by sternal wound infection.3 Risk fac-
tors include diabetes, the use of bilateral internal mammary arter-
ies, and reoperation.4 Patients with poststernotomy osteomyelitis
present with pain, drainage, and, often, a palpable mass overlying
the incision. In most cases, the infection is not confined to the
sternum but extends deeply into the mediastinum as well. The
diagnostic study of choice is CT scanning of the chest, which will
Figure 2 CT scan shows typical appearance of SCJ infection,
determine the extent of mediastinal soilage.
including fluid collection around the joint and tissue stranding.
After CT, the patient is taken to the operating room for wide
drainage and sternal debridement. A number of different tech-
niques have been employed to treat these infections; of these, aggres-
sive surgical debridement of the infected area with flap closure yields is made on the basis of the history, the physical examination, and
the best overall clinical outcomes [see 4:9 Chest Wall Procedures].5 CT scanning of the chest (with particular attention paid to the
The patient who presents with a pulsating sternal mass after SCJ). Typical CT findings include tissue stranding and a collec-
sternotomy represents a special case. Such patients have a pseu- tion around the joint [see Figure 2].
doaneursym of the underlying aorta and are at risk for exsan- Treatment consists of wide resection of the SCJ and the proxi-
guination.They should undergo an emergency CT angiogram or mal third of the clavicle, as well as debridement of the manubri-
aortogram to confirm the diagnosis and then be taken directly to um [see 4:9 Chest Wall Procedures].6 Often, the proximal portion of
the OR, where they are placed on cardiopulmonary bypass the first rib is involved and also must be resected. Immediate
through femoral cannulation and cooled to a hypothermic state reconstruction is performed by rotating a pectoralis muscle flap
before the sternum is opened. into the resection cavity. After operation, I.V. antibiotics are ad-
ministered for 6 weeks. Most patients require intensive postoper-
Sternoclavicular joint infection Sternoclavicular joint ative physical therapy to restore strength, function, and mobility
(SCJ) infections present as painful palpable masses overlying the in the upper extremity.
joint [see Figure 1]. These infections are often associated with I.V.
drug abuse, infected indwelling subclavian catheters, or trauma. Osteomyelitis of rib Osteomyelitis of a rib presents as a
Most patients also have an underlying risk factor (e.g., diabetes or painful, swollen mass overlying an infected segment of rib. Often,
hepatic or renal insufficiency) or a history of sepsis.The diagnosis a draining sinus tract is present.The diagnosis is made on clinical
grounds. A CT scan of the chest is obtained to rule out an under-
lying intrathoracic condition (e.g., empyema).
Treatment consists of resection of the infected bone and soft
tissue coverage of the defect [see 4:9 Chest Wall Procedures]. Care
must be taken to avoid contamination of the underlying pleural
cavity during rib resection.
In children, the diagnosis is made on clinical grounds and may
be facilitated by the use of ultrasonography, which demonstrates
obliteration of the intermuscular planes adjacent to the infected
rib and pericostal edema.7 Again, a CT scan is usually obtained to
rule out other underlying pleura-based abnormalities. As with
adults, the range of pathologic organisms that may be recovered is
quite wide.
Benign Neoplasms
Benign neoplasms of the chest wall may be divided into those
arising from soft tissue and those arising from bone and cartilage
[see Table 2].
Soft tissue neoplasms Benign soft tissue neoplasms of the
chest wall usually present as slowly growing, painless masses. On
Figure 1 Sternoclavicular joint infections present as painful pal- examination, the lesions usually are soft and freely movable. Plain
pable masses overlying the joint. radiographs and a CT scan of the chest are obtained. The CT

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4 THORAX 3 CHEST WALL MASS — 4
Table 2 Primary Benign Chest Wall PRIMARY MALIGNANT MASSES OF
CHEST WALL
Neoplasms by Tissue of Origin
Like benign chest wall neoplasms, malig-
Lipoma nant chest wall neoplasms may be divid-
Fibroma ed into those arising from soft tissue and
Hemangioma those arising from bone and cartilage [see
Benign soft tissue neoplasms Granuloma Table 3].
Neurofibroma
Elastoma Soft Tissue Neoplasms
Desmoid
Sarcomas are the primary malignant soft tissue neoplasms of
Osteochondroma the chest wall. Most of the published series addressing soft tissue
Benign bone and cartilage neoplasms
Chondroma sarcoma of the chest wall have included small numbers of patients
Fibrous dysplasia and have also addressed lesions arising in bone and cartilage.The
Eosinophilic granuloma largest surgical series of patients with soft tissue sarcomas of the
chest wall was published in 1991.10 This study included 149
patients who had undergone resection at the Memorial Sloan-
Kettering Cancer Center in New York.The overall 5-year survival
scan shows a homogeneous mass, with no necrosis and no infil- rate was 66%. Unfortunately, the study also included 32 patients
tration of associated soft tissue or destruction of associated bone. with desmoid tumors, which are not histologically classified either
Small soft tissue lesions (< 3 cm) are completely removed by as sarcomas or as malignant neoplasms. In 2005, a large retro-
means of excisional biopsy, which provides definitive diagnosis spective study from a single institution in Brazil reported on 55
and treatment. Larger lesions (≥ 3 cm) undergo incisional biopsy patients who underwent surgical treatment of soft tissue sarcomas
first to rule out a malignant soft tissue neoplasm. If the lesion is of the chest wall.11 Nearly 53% of the lesions were fibrosarcomas.
confirmed as benign, it is resected with close negative margins to With wide surgical resection, the disease-free survival rate was
minimize the size of the surgical defect. If it is determined to be 75% at 5 years and 64% at 10 years. The histologic grade of the
malignant, an aggressive wide excision is performed with immedi- tumor and the type of surgical resection performed were found to
ate reconstruction [see 4:9 Chest Wall Procedures]. be independent prognostic factors for disease-free survival. These
Desmoid tumors deserve special mention, in that they are bor- findings are consistent with those of other studies that suggest that
derline neoplasms.8 These tumors generally arise in the muscle age, gender, symptoms, and lesion size do not have a significant
and fascia around the shoulder. Although they are histologically impact on survival.12
benign, they can infiltrate adjacent structures and exhibit a high Sarcomas of the chest wall can be quite sizable [see Figure 3].
tendency for local recurrence. Desmoid tumors are best treated by They are painless in about 50% of patients. The typical clinical
means of radical surgical excision. In patients with positive surgi- finding is a hard, fixed mass. No calcifications are visible on CT
cal margins, the recurrence rate is 89%, whereas in those with neg- chest scans, but bone invasion is common.The standard treatment
ative margins, the recurrence rate is less than 20%.9 is wide surgical excision. Currently, the data are not sufficient to
warrant recommendation of neoadjuvant therapy, which has
Bone and cartilage neoplasms Osteochondromas are the become routine in managing soft tissue sarcomas of the extremi-
most common bone tumors overall. These lesions are benign car- ties. In 2001, the University of Texas M. D. Anderson Cancer
tilaginous neoplasms that may occur in any bone that undergoes Center reported its multidisciplinary experience with primary chest
enchondral bone formation; essentially, they are hamartomas of wall sarcomas.13 The retrospective review included patients with
the growth plate.The knee is the most common site of occurrence. sarcomas of soft tissue, cartilage, and bone, as well as desmoid
In the chest, osteochondromas arise in the metaphyseal regions of tumors. Nevertheless, the cumulative 5-year survival rate was 64%,
the anterior ribs. Most are asymptomatic and are found when which is about the rate to be expected from surgery alone.
screening chest radiographs reveal an eccentric growth pattern at
the costochondral junction. The diagnosis is made on the basis of Bone and Cartilage Neoplasms
a characteristic pattern on plain x-rays. In children, osteochondro- A solitary plasmacytoma is a unique chest wall mass that is
mas are followed; in postpubescent and adult patients, they are caused by a localized collection of monoclonal plasma cells. His-
resected to confirm the diagnosis and rule out malignancy.
Chondromas are the next most common benign neoplasms of
the chest wall. They occur along the costochondral junctions Table 3 Primary Malignant Chest Wall
between the anterior ribs and the sternum. Unfortunately, it is not
possible to distinguish between benign and malignant cartilage neo- Neoplasms by Tissue of Origin
plasms on the basis of clinical or radiographic findings; therefore,
Liposarcoma
excision is required for diagnosis. Excision results in a significant
Leiomyosarcoma
surgical defect that usually necessitates complex reconstruction,
Malignant soft tissue neoplasms Rhabdomyosarcoma
including the use of prosthetic material to provide rigid structure Malignant fibrous histiocytoma
and soft tissue coverage [see 4:9 Chest Wall Procedures]. Angiosarcoma
Fibrous dysplasia usually presents as a painless cystic bone
lesion that is found incidentally on a screening chest x-ray. Re- Solitary plasmacytoma
Chondrosarcoma
placement of the medulla by fibrous tissue creates a characteristic
Malignant bone and cartilage neoplasms Osteosarcoma
radiolucent appearance. These lesions are treated conservatively
Ewing sarcoma
and are simply followed. Local resection is indicated if pain devel- Synovial cell sarcoma
ops or if the lesion is seen to be enlarging on serial x-rays.

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4 THORAX 3 CHEST WALL MASS — 5
multimodality approach that includes preoperative chemothera-
py followed by complete resection of residual disease.20 A 2003
review of three multi-institutional trials from the Pediatric
Oncology Group suggests that in patients with Ewing sarcoma
and closely related primitive neuroectodermal tumors of the
chest wall, the likelihood of achieving a complete resection is
improved by employing neoadjuvant chemotherapy followed by
delayed resection.21 The definitive resection is undertaken after
four cycles of chemotherapy. If the resection is complete and the
pathologic margins are negative, no radiation therapy is adminis-
tered. Avoidance of radiation therapy may be particularly impor-
tant in pediatric and adolescent patients, who are at significant
(10% to 30%) risk for a radiation-induced malignancy over their
lifetime.22
Askin tumors are members of the Ewing family of tumors.They
are small round cell tumors of the thoracopulmonary region that
arise from the same primordial stem cell. They are best managed
by means of diagnostic biopsy, preoperative chemotherapy, and
Figure 3 Shown is the appearance of a chest wall sarcoma on complete surgical resection.23
physical examination. Such lesions can be quite large. Synovial sarcomas are very uncommon, but they occasionally
arise on the trunk, where they present as palpable chest wall
masses. Although these tumors are referred to as synovial cell
tologically, the plasma cells are identical to those seen in patients sarcomas, this term is a misnomer, in that the lesions do not
with multiple myeloma; however, in a plasmacytoma, unlike mul- arise from synovial cells or joint cavities. The name originally
tiple myeloma, these cells are confined to a single site. Patients derived from the tumors’ resemblance to developing synovial tis-
generally present with pain and often have pathologic rib frac- sue under light microscopy; however, synovial sarcomas are now
tures. When soft tissue becomes involved, a palpable mass be- known to arise from primitive mesenchymal cells.24 The most
comes evident. The role of surgery is limited to obtaining tissue important prognostic factor is tumor size.25 The limited data
for diagnosis via FNA, core-needle biopsy, or a small incisional available at present suggest that although neoadjuvant chemo-
biopsy. Tissue is sent for analysis by flow cytometry, which con- therapy may elicit an objective response, it apparently has no de-
firms the clonal nature of the cells.14 Definitive local radiother- tectable beneficial effect on survival.26 The current therapeutic
apy is the treatment of choice for solitary bone plasmacytoma.15 recommendation is aggressive surgical resection. If the tumor is
Although local control is achieved in more than 90% of patients very large or margins are positive, postoperative adjuvant treat-
with radiation therapy alone, about 50% of patients progress ment is indicated.
to multiple myeloma within 2 years and require systemic
SECONDARY MASSES OF CHEST WALL
treatment.16
Chondrosarcomas are the most common primary malignant The secondary chest wall masses of sur-
tumors of the chest wall. They are found along the anterior ster- gical interest arise as direct extensions of a
nal boarder or the costochondral arches and are substantially malignancy in a contiguous organ. The
more common in males than in females. Pain is typically a pre- breast and the lung are the most common
senting complaint. CT scanning is the primary imaging study; primary sites. The initial evaluation centers
however, there are no distinguishing radiographic characteristics on the underlying disease, not the chest wall
that establish a definitive diagnosis.17 Complete surgical resection mass. For example, a patient with a chest
with adequate surgical margins and immediate reconstruction is wall mass resulting from direct invasion by a primary lung cancer
the treatment of choice [see 4:9 Chest Wall Procedures]. A 2004 should undergo a staging workup to determine the extent of the
study from the Mayo Clinic reported a 5-year survival rate of disease. If the patient is a stage-appropriate candidate for resection
100% and a recurrence rate of less than 10% in patients with ade- and is medically fit for surgery, he or she should undergo pul-
quate surgical margins.18 In contrast, patients with inadequate monary resection with en bloc chest wall resection.27 After resec-
surgical margins had a 50% 5-year survival rate and a 75% local tion, the patient should be referred for four cycles of postoperative
recurrence rate. chemotherapy.The interventional intent is cure, and the outcomes
Ewing sarcoma is an aggressive primary malignant bone tumor are stage specific.
that occurs in children and adolescents. It is more common in Unfortunately, most women who present with a chest wall
boys than in girls and usually develops between the ages of 10 and mass arising from a breast neoplasm have a local recurrence.
20 years. Ewing sarcoma was initially distinguished from osteosar- From a technical standpoint, resection with reconstruction is
coma on the basis of its sensitivity to radiation. The origin of feasible in this setting; however, it is unclear whether it offers any
Ewing sarcoma remains unclear, but there appear to be several real benefit. In a study from the Memorial Sloan-Kettering
tumors that share the same genetic translocation; these lesions are Cancer Center, 38 women underwent extensive chest wall resec-
referred to as the Ewing family of tumors.19 tion for recurrent breast cancer.28 The operative mortality was
The initial role of surgery in managing primary Ewing sarco- 0%, but the 5-year survival rate was only 18%, and by 5 years,
ma of the chest wall consists of obtaining tissue for diagnosis. 87% of the patients had local recurrences. Currently, chest wall
With smaller rib lesions, this may be done by means of an exci- resection for locally recurrent breast cancer must be considered
sional biopsy. Generally, Ewing sarcoma is best managed with a on a case-by-case basis.

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4 THORAX 3 CHEST WALL MASS — 6
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