Chest Wall Resection For Chest Wall Tumors

Introduction:

Chest wall tumor comprises neoplasms of various origins, including bone, cartilage, soft tissue, and hematologic origin. However, they are mostly bony or cartilaginous in origin. There are two basic groups of chest wall tumors - primary and secondary. It has been challenging because of the high rate of misdiagnosis, incomplete resection, and inability to reconstruct chest wall defects after extensive damage successfully. Chest wall resection may be necessary for various reasons, such as malignancies, radio necrosis, infection, or trauma. Malignancies may be either a primary chest wall in origin or may arise from a direct extension of a primary lung tumor or metastatic lesion.

What Are the Chest Wall Tumors?

Primary chest wall tumors are uncommon or rare. They originate in the chest wall itself. They can be either malignant or benign. Secondary chest wall tumors originate somewhere else in the body and spread to the chest wall. They can spread from the breast, lungs, thyroid, stomach, colon, kidneys, prostate, and uterus. Approximately 80 percent of secondary chest wall tumors are malignant. Soft tissues are the most common source of chest wall tumors. These tumors can affect individuals of all ages. A few tumors are more prevalent in young, whereas a few others are more prevalent in adults. There is no gender predilection.

The most common malignant chest wall tumor in adults is chondrosarcoma, whereas Ewing's sarcoma is the most common malignancy in small children.

The common malignant chest wall tumors are

• Chondrosarcoma.

• Ewing’s sarcoma.

• Fibrosarcoma.

• Liposarcoma.

• Myeloma.

• Malignant fibrous histiocytoma.

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• Rhabdomyosarcoma.

• Osteosarcoma.

The most common benign chest wall tumors are

• Osteochondroma.

• Chondroma.

• Eosinophilic granuloma.

• Lipoma.

• Lymphangioma.

• Desmoid tumor.

• Cavernous hemangioma.

• Fibrous dysplasia.

• Myxochondroma.

What Are the Signs and Symptoms of Chest Wall Tumors?

Most chest wall tumors are diagnosed incidentally on radiographic investigations. Patients are usually asymptomatic until and unless the tumor has advanced.

The signs and symptoms include

• Localized mass in the chest.

• Fever.

• Malaise.

• Abrupt weight loss.

• Chest pain.

• Muscle atrophy.

• Tenderness.

• Inflammation.

• Restricted movement with chest expansion.

What Causes Chest Wall Tumors?

The exact etiology is unknown, but genetics and lifestyle play the most significant role in developing these tumors. For example, cigarette smoking increases the risk of developing lung cancer. Lung cancer may metastasize to the chest wall, resulting in chest wall tumors.

What Are the Diagnostic Tests That Can Be Carried Out?

Diagnostic tests that can be carried out are

Imaging Tests:

• Chest X-Ray: It is most commonly used for the initial evaluation of the tumor and is also helpful in detecting cortical destruction.

• Computed Tomography (CT) Scan: It is more sensitive than a chest X-ray for detecting calcified tumor matrix and cortical destruction.

• Magnetic Resonance Imaging (MRI): It helps in the accurate delineation and localization of the tumor and helps determine the presence and the extent of the tumor invasion. It also helps in tissue characterization.

Biopsy:

A biopsy of the abnormal tissue is usually performed to diagnose the tumor and determine the nature of the tumor, whether it is benign or malignant. An excisional biopsy is performed for a small lesion of less than 4 cm. A larger lesion may require a fine needle aspiration cytology (FNAC) in which a needle of 26 gauge is inserted into the tumor, and cells are removed for further investigations. Even an incisional biopsy may be recommended in case FNAC is not possible. A small surgical incision is placed to remove the tissues.

What Is the Management of Chest Wall Tumors?

Chest wall tumors are usually managed as resection or excision of the tumor, followed by reconstructive surgery to repair the extensive damage the tumor has caused. If the tumor is malignant, resection, radiotherapy, and chemotherapy are indicated. The main goal in any chest wall resection and reconstruction should be removing the area of interest, obliterating the dead space, restoring the chest wall rigidity, preserving ventilatory mechanics, and protecting the intrathoracic organs.

For any malignant tumor, radical resection is required. At least a 4 cm lateral margin and resection of ribs above and below the tumor are recommended. Using electrocautery, the upper and lower intercostal spaces are opened. This allows finger-palpation of the actual extent of the tumor, and if this is not enough, a thoracoscope may be required to localize the tumor. The underlying intercostal muscles and nerves are ligated. The lateral rib margins are usually divided.

A frozen section can be done if resection margins are to be expanded. Sternectomy is the removal of the sternum that may be required to achieve adequate osseous margins. This involves performing costochondral release maneuvers to at least one rib space above and below the tumor margins.

The sternomanubrial joint may be divided if there is no involvement of the manubrium. If the tumor has extended posteriorly, the ribs may be dissected from the vertebrae with the help of electrocautery or blunt dissection. This requires identifying the joint between the posterior rib, the transverse process, and the division of the three costotransverse attaching ligaments.

What Is the Importance of Chest Wall Reconstruction?

Any resection of more than 5 cm or involving more than three consecutive ribs should be reconstructed to avoid respiratory compromise. It is also recommended in cases of defects extending below the fourth rib posteriorly, where there are chances of entrapment of the tip of the scapula with arm movement.

Usually, the overlying skin and the soft tissues are well preserved for reconstruction. Reconstruction plays a significant role in restoring the chest wall's structural and functional rigidity and ensuring adequate coverage of the defect with viable tissue.

A custom-made methyl methacrylate cast occupies the defect wall. Methyl methacrylate is poured over polypropylene mesh and cured till the resin becomes rigid. Another layer of mesh is applied to create a sandwich. The implant size should be less than the defect size by 1 to 2 cm, allowing for a rim of mesh to be sutured circumferentially to the adjacent tissues. Various homografts and allografts are also available and can be implanted similarly. These materials can be used along with bridging titanium plates to provide further structural support and stability.

Conclusion:

Chest wall tumors may be benign or malignant. They are usually asymptomatic; malignant tumors may present with chest pain, abrupt weight loss, and muscle atrophy. The diagnosis is based on a chest radiograph, CT scan, and MRI. A biopsy may be required to determine the nature of the tumor. Usually, the chest wall tumors are resected, followed by reconstruction to restore the chest wall's structural integrity and functional rigidity. An early diagnosis, intervention, and treatment are the key to preventing the spread of the tumor.