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Chest Wall Resection For Chest Wall Tumors

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Chest wall tumors are resected, followed by reconstruction to restore the structural integrity of the chest wall. Read the article below to know more.

Medically reviewed by

Dr. Pandian. P

Published At February 20, 2023
Reviewed AtJune 27, 2023

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.

  • 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.

Frequently Asked Questions

1.

Where Is the Location of a Chest Wall Tumor?

Chest wall tumors can be located on the surface of the chest, often involving the area's ribs, muscles, or connective tissues.

2.

How Do Chest Wall Tumors Feel?

Chest wall tumors may feel like a lump or mass under the skin, sometimes causing pain or discomfort, and can be detected during self-examination or clinical evaluations.

3.

What Are the Implications of Having a Tumor in the Chest Wall?

Implications of having a tumor in the chest wall can include pain, limited mobility, possible compression of nearby structures, and, in some cases, the potential for the tumor to be cancerous.

4.

Why Might a Breast Tumor Be Near the Chest Wall?

A breast tumor near the chest wall may occur due to the invasive nature of some breast cancers, where cancer cells grow beyond the milk ducts and into surrounding tissues, including the chest wall.

5.

What Are Chest Wall Tumors, and What Do They Feel Like?

Chest wall tumors can be abnormal growths or masses occurring in the chest wall, potentially causing localized symptoms such as pain, swelling, or changes in the contour of the chest, and they may require medical evaluation for diagnosis and appropriate management.

6.

What Is the CPT Code for Excising a Chest Wall Tumor?

The specific CPT code for excising a chest wall tumor can vary depending on factors such as the exact procedure performed, the size of the tumor, and the approach used (open surgery, minimally invasive, etc.). Consulting with a medical coding professional for the accurate CPT code is crucial.

7.

Are All Chest Wall Tumors Cancerous?

Not all chest wall tumors are cancerous. They can be either benign (non-cancerous) or malignant (cancerous). Accurate diagnosis is crucial for understanding the characteristics of the tumor.

8.

Can Chest Wall Cancer Be Treated and Cured?

The treatment and potential for a cure for chest wall cancer depend on several factors, including the type of cancer, its stage, location, and the patient's overall health. Certain cases of chest wall cancer are manageable and potentially curable, whereas continuous care and monitoring might be necessary in other cases.

9.

How Are Chest Wall Tumors Detected?

Chest wall tumors can be detected through various methods, including physical examination, imaging studies (like X-rays, CT scans, or MRI), biopsy (removing a small sample for analysis), and other diagnostic tests as recommended by a healthcare provider.

10.

When Do Chest Wall Tumors Typically Develop in Life?

Chest wall tumors can develop at any age, but the timing can vary. Some may occur in childhood, while others are more common in adults. The development of chest wall tumors depends on genetics, environmental exposures, and underlying health conditions.

11.

Can Chest Pain Indicate a Chest Wall Tumor?

Chest discomfort may arise as a potential indicator of a chest wall tumor, particularly if the tumor is exerting pressure on the chest wall or nearby structures. However, chest pain can have various causes, so a medical evaluation is crucial for an accurate diagnosis.

12.

What Factors Contribute to Chest Tumor Development?

Factors contributing to chest tumor development may include:
- Genetic predisposition.
- Exposure to carcinogens.
- Certain medical conditions.
- Lifestyle factors. 

13.

How Can Someone Determine if They Have a Chest Wall Tumor?

To determine if they have a chest wall tumor, someone should seek medical attention if they experience persistent chest pain, palpable lumps or masses on the chest, changes in chest contour, or other concerning symptoms. A healthcare professional can conduct appropriate tests for diagnosis.

14.

What Is the Survival Rate for Chest Wall Cancer?

Survival rates for chest wall cancer depend on various factors like the type, stage of cancer, treatment effectiveness, and the individual's overall health. Specific survival rates can vary widely, and prognosis is best discussed with a medical oncologist.

15.

Is Chest Wall Cancer the Same As Lung Cancer, or Are They Separate Conditions?

Chest wall cancer is separate from lung cancer. While both involve the chest region, chest wall cancer originates in the chest wall structures (such as muscles, ribs, and connective tissues), while lung cancer originates in the lungs. They are distinct conditions with different characteristics, treatments, and implications.
Dr. Pandian. P
Dr. Pandian. P

General Surgery

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chest wall cancer
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