Asian Cardiovasc Thorac Ann 1998;6:212-215
© 1998 Asia Publishing EXchange Pte Ltd
Chest Wall Tumors
B Ali Özuslu, MD,
Onur Genç, MD,
Sedat Gürkök, MD,
Kunter Balkanli, MD
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Department of Thoracic Surgery Gülhane Military Medical Academy Ankara, Turkey
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For reprint information contact: B Ali Özuslu, MD GATA Gö üs Cerr. ABD Etlik, Ankara 06018, Turkey Tel: 90 312 321 2055 Fax: 90 312 321 2055 Email: ozuslu{at}obs.gata.edu.tr
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ABSTRACT
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We reviewed 94 consecutive patients who underwent resection of soft tissue or bone tumors of the chest wall between September 1989 and December 1996. There were 3 females and 91 males ranging in age from 12 to 69 years (median, 22.85 years); 16 had a primary malignant tumor, 11 had a metastatic tumor, and 67 had a benign tumor. Sixty-four patients underwent resection of the chest wall skeleton. Overlying soft tissue was resected en bloc in 15 patients. Chest wall defects were not reconstructed with prosthetic material or autogenous grafts because the defects were not large. Soft tissue reconstructive procedures were predominantly muscle transposition. There were no early postoperative complications and the median hospitalization was 14.2 days (range, 6 to 47 days). Follow-up was complete in all patients and ranged from 2 to 36 months (median, 24.5 months). All patients with benign tumors are currently alive. Recurrent chest wall tumors developed in 5 patients and they underwent a second operation. Nine patients died from distant metastases. There were no early or late deaths related to either resection or reconstruction of the chest wall. We conclude that wide or adequate chest wall resection, depending on histopathologic type of tumor, is the key to successful management of chest wall tumors. In general, this procedure can be performed in one operation with a short hospital stay and low operative mortality.
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INTRODUCTION
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Chest wall tumors comprise those of bone and soft tissues and include both benign and malignant primary neoplasms of the bony skeleton, chest wall metastases, neoplasms that invade the chest wall from the lung, pleura, mediastinum, muscle, and breast, as well as benign non-neoplastic conditions.1 Most present as painful enlarging masses and may be tumors that have recurred or persisted following previous resection or irradiation. Surgical extirpation is frequently the only remaining modality of treatment.2
Advances in chest wall reconstruction, primarily through refinement in muscle transposition and clarification of the functional anatomy and blood supply of trunk muscles, has resulted in more aggressive resection of these tumors.3 Relatively few series of patients with chest wall neoplasms have been reported in the medical literature and the number of patients has been small since such lesions are rare.4–6 To extend the data on treatment and survival for primary malignancies and other tumors of the chest wall, a retrospective analysis was conducted on patients treated in the thoracic surgery department of Gülhane Military Medical Academy.
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PATIENTS AND METHODS
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Between September 1989 and December 1996, we performed resections on 94 patients with chest wall tumors. This experience represents all soft tissue and bone tumors of the chest wall. There were 3 female and 91 male patients with ages ranging from 12 to 69 years (median, 22.85 years). Sixteen patients had primary malignant tumors, 11 had metastatic tumors, and 67 had benign tumors (Tables 1, 2, and 3
). Benign tumors were located in bones in 35 patients and in soft tissues in 18 patients. Primary malignant tumors were located in the ribs in 13 patients and in soft tissues in 3 patients. The metastatic tumors were located in bones in 10 patients and in soft tissue in only 1 patient. Eight of the remaining tumors were cysts in soft tissue and 6 of these were osteochondritis (Table 4).
Twenty-four of 27 patients with either primary malignant (n = 16) or metastatic (n = 11) tumors had a palpable mass that was painful; 3 patients were asymptomatic and presented with a mass visible on chest radiography and whole-body bone scanning. Sixty of 67 patients with benign tumors presented with a palpable mass that was painful in 47.
Sixty-four patients underwent resection of the chest wall skeleton. Overlying soft tissue was resected en bloc in 15 patients. Fifty-four patients underwent one to three rib resections (median, 2.2). Partial sternotomy was performed in 6 patients. Chest wall defects were not reconstructed with prosthetic material or autogenous grafts because the defects were not large. Soft tissue reconstructive procedures were predominantly muscle transpositions. Fifteen patients underwent 21 muscle transpositions comprising 11 latissimus dorsi, 6 pectoralis major, and 4 serratus anterior muscle transpositions. In 5 patients with Ewing's sarcoma, additional chemotherapy and radiotherapy was used. Radiotherapy was applied to 4 patients with myeloma after surgical resection.
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RESULTS
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Median duration of hospitalization was 14.2 days (range, 6 to 47 days). No patient had a complication in the early postoperative period. Eighty-nine patients had a single operation. The other 5 patients underwent a second operation.
Follow-up was complete in all patients and ranged 2 to 36 months (median, 24.5 months). All 64 patients with benign tumors are currently alive. All of the patients had a healed wound postoperatively. Recurrent chest wall tumor was the cause of reoperation in 5 patients. Of these, 1 had bronchogenic carcinoma, 2 had malignant fibrous histiocytoma, and 2 had Ewing's sarcoma. Nine patients died as a result of distant metastases. These comprised 4 patients with Ewing's sarcoma (2 had recurrent tumors), 2 with bronchogenic carcinoma (1 had a recurrence), 2 with malignant fibrous histiocytoma, and 1 with osteogenic sarcoma. The median survival of these patients was 1 year. There were no early or late deaths related to either resection or reconstruction of the chest wall.
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DISCUSSION
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Primary tumors of the chest wall are uncommon. Of 2000 primary bone tumors in a series at the Mayo Clinic reported by Pascuzzi and colleagues7 in 1957, only 126 (6%) occurred in the ribs and 18 (1%) were in the sternum. Nearly half of all chest wall tumors originate in cartilaginous tissue.8 In our series, the tumors were located in bone structures in 35 of 67 patients (50.2%) with benign tumors and they were located in ribs in 13 of 16 patients (80.1%) with primary malignant tumors. The main location of primary tumors was also the cartilaginous tissue in our patients.
Metastatic malignancy must always be considered when a patient presents with a chest wall tumor, particularly if multiple sites of involvement are noted. Malignancies of the breast or lung can involve the chest wall by direct extension as well as by the metastatic route. Other tumors likely to metastasize to ribs and sternum include those arising in the kidney or prostate. A renal or thyroid malignant tumor in the sternum may even mimic aortic aneurysm by presenting as a pulsatile mass. As far as solitary lesions of the chest wall are concerned, metastatic lesions occur with about the same frequency as primary tumors.4,8 In our series, the metastatic lesions were seen with approximately the same frequency as primary malignant tumors.
Pain and the presence of a mass were the most common symptoms of patients with chest wall tumors and many patients experienced both. Nearly 75% of our patients had these signs and those with malignant tumors were more likely to present with them. Approximately 80% of our patients with malignancy had symptoms compared with only 65% of patients with benign tumors. The location of the pain or mass is sometimes helpful since the majority of tumors of cartilaginous origin occur along the costochondral junctions, whereas fibrous dysplasia tends to occur over the posterior chest wall. Tumors of the sternum are almost always malignant and should be assumed so until proved otherwise.9,10 In our series, 6 patients had a sternal tumor; 4 of these were benign and 2 were metastatic.
Although there is a tendency for malignant tumors to occur in older patients, age per se is of little prognostic significance. Ewing's sarcoma is more likely to occur in the adolescent age group and myeloma is more common in persons over 50 but primary chest wall tumors can occur in all age groups. Both benign and malignant tumors of the chest wall are twice as frequent in males as in females.11 Because our center is a military medical academy, most of our patients were young males. All of the patients with Ewing's sarcoma were young and only 1 of the 4 patients with myeloma was over 50 years old.
The diagnostic evaluation of patients with suspected primary chest wall tumors should include a careful history and physical examination followed by conventional plain and tomographic chest radiography. Computed tomography should also be performed to delineate soft tissue, pleural, mediastinal, and pulmonary involvement.12 This method was used especially in the evaluation of our patients whose lesions were suspected of being metastatic or primary malignant tumors.
Chest wall tumors suspected of being primary neoplasms should be diagnosed by excision rather than incision or needle biopsy. Patients with tumors diagnosed as malignant should then undergo wide excision. However, the extent of resection should not be compromised because of an inability to close the chest wall defect.4,13,14 Opinions differ as to what constitutes wide resection.2,4,13,14 All of our patients, with malignant tumors had at least a 2-cm margin resected around the tumor (range, 2 to 4 cm; median, 2.8 cm). The extent of the resected margin in our study did not influence survival. Similarly, King and colleagues10 reported that the extent of the margin resected did not influence survival but may have affected the rate of tumor recurrence. They could not demonstrate a significant difference in survival because all of their patients had a margin of resection of at least 2 cm. Many surgeons are of the opinion that a margin grossly free from tumor by several centimeters would be adequate resection. Although this may be sufficient for benign and low-grade malignant primary tumors such as chondrosarcoma, higher-grade tumors such as malignant fibrous histiocytoma, rhabdomyosarcoma, and osteosarcoma have the potential to spread within the marrow cavity, along the periosteum, or along the parietal pleura. Consequently, excision of these higher-grade tumors with a 2-cm margin would not be adequate resection.15
Large chest wall defects frequently result from treatment of primary tumors. Chest wall reconstruction should include stabilization of the bony thorax and coverage of any soft tissue defect. Defects with a maximum diameter less than 5 cm anywhere on the thorax are usually not reconstructed. Posterior defects of less than 10 cm do not require reconstruction because the overlying scapula provides support.9,11,16 In our patients, the defects were under these limits and did not require chest wall reconstruction with prosthetic materials. Soft tissue reconstruction is best accomplished by muscle transplantation. The pectoralis major, serratus anterior, latissimus dorsi, and rectus abdominis muscles all have an axial blood supply that permits substantial elevation and rotation of the muscle with or without the overlying skin.5,6 Because of the nature of our institution and the fact that army personnel are required to undergo periodic medical check-ups, it is likely that the tumors were detected at an earlier stage than in other series. Early diagnosis probably reduces the extent of resection necessary for adequate removal of malignant tissue.
Our experience indicates that accurate diagnosis is the first step in successful management of any chest wall tumor. Wide or adequate chest wall resection, depending on histopathologic type of tumor, is the key to successful management of chest wall tumors. In general, this procedure can be performed in one operation with a short hospitalization and low operative mortality.
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REFERENCES
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ABSTRACT
INTRODUCTION
