Surgical Management of Chest Wall Tumors: An Overview

Introduction:

The chest wall is a vital organ that protects the heart, lungs, and liver. It plays a crucial role in keeping vital organs safe. The chest wall is made of sternum and ribs. Chest wall tumors are sometimes primary tumors originating from the chest or secondary tumors spreading (metastasizing) to the chest from other sites.

Primary tumors can be either benign or malignant. However, the secondary is malignant and needs surgical excision to prevent further spread and damage to other organs. Generally, bones, soft tissue, or cartilage tumors are called sarcomas. These sarcomas are malignant, and patients might experience swelling, pain, and difficulty breathing depending on the severity of the tumor.

How Common Are Chest Wall Tumors?

• Chest walls are generally rare and difficult to treat.

• Chest walls are usually less than five percent of all malignancies.

Who Is Affected By Chest Wall Tumors ?

• It is common in all age groups.

• Few sarcomas are more common in children when compared to adults.

• Treating chest walls is comparatively easy at a young age compared to adults.

What Are Different Types of Chest Wall Tumors?

Different types of tumors that grow in the chest wall are-

• Chondrosarcoma- Usually occurs in cartilage and is the most common type of chest wall. It is generally painful and keeps enlarging.

• Osteosarcoma- Usually occurs in the bone and is typically seen in young children. It is painful and a rapidly enlarging tumor.

• Rhabdomyosarcoma- Usually affects muscles, especially striated muscles affecting children and young adults. It is a painless growing tumor.

• Ewing's Sarcoma- Usually affects bone and soft tissue. It is common in children and young adults and is very painful. Often the ribs are involved.

• Malignant Fibrous Histiocytoma- Usually affects the soft tissues and is common in individuals aged 40 to 60. They are slow growing and generally painless.

• Plasmacytoma- It is a type of multiple melanomas affecting the plasma cells. It is usually painful and can be treated without surgical intervention. Common in individuals of age 40 and above.

• Fibrous Dysplasia- It commonly affects the bones, mainly in the ribs. It is an excruciating and most common type of chest wall tumor.

What Are the Common Symptoms of Chest Wall Tumors ?

Symptoms are rarely seen in the initial stages, and individuals experience few common symptoms in advanced stages. These include-

• Fever and continuous tiredness.

• Pain and swelling.

• A feeling of a lump in the chest.

• Atrophy of muscles.

• Loss of appetite.

• Experiencing drastic weight loss.

• Sluggish body movement.

How to Diagnose the Chest Wall Tumors ?

The doctor will suggest a series of investigations to achieve a proper diagnosis and to know the severity of the tumor. These include:

• Chest X-ray.

• Magnetic resonance imaging (MRI) helps to provide information on soft tissues.

• Computed tomography (CT) helps access calcification, bone destruction, and tumor severity.

• Positron emission tomography (PET) scan along with CT scan.

• Biopsy of a tumor (generally, a needle biopsy is done to assess the tumor).

How Are Chest Wall Tumors Managed?

After the preoperative evaluation, the surgeons advocate the following procedures to manage the chest wall.

Radiation And Chemotherapy-

• Once the diagnosis is established, the surgeon may start chemotherapy, where different drugs are used to kill the cancer cell, and radiotherapy, which utilizes high-intensity rays to kill the cancer cells.

• The disadvantage of radiation therapy is it kills even the normally growing cells. This procedure is helpful in the initial stages of the tumor.

Resection-

• Resection is advocated in the advanced stages of the tumor.

• Complete resection of the tumor is advocated without any compromise.

• Chest walls are often challenging for thoracic and reconstructive surgeons as they have high chances of pulmonary dysfunction.

• It is best to have a multidisciplinary approach to prevent postoperative complications.

Reconstruction-

• After the resection, partial or full-thickness thoracic wall defects will need to be addressed.

• Full-thickness wall defects involve soft tissues, muscles, and bone and should be reconstructed immediately after the resection.

• Following are some of the options that facilitate the reconstruction and achieve a quick recovery.

Reconstruction With Mesh-

• Different synthetic nets are available to increase the rigidity of the chest wall and protect the internal organs. These are durable, pliable, and radiolucent and help to achieve quick coverage.

Reconstruction With Implants-

• Composite implants are generally used for reconstruction. These implants help to achieve the original contours of the chest and are usually indicated for anterior and lateral chest wall defects. They are found to produce good results with minimal chances of infection.

Osteosynthesis-

• This procedure is recommended when a direct approximation of sternal edges is possible. In this procedure, the bony edges are stabilized using mechanical devices that help a proper union and adequate fixation.
  • Once the rebuilding is complete, the wound is covered with a skin flap-like pectoralis major flap taken from the lower breast fold along with muscle. Thoracoepigastric flap from the abdominal region and latissimus doris muscular flap from the lateral side of the upper body helps in extensive coverage of the chest wall.

  • Sore throat caused due to the tube placed in the windpipe for breathing during surgery.

  • Nausea and vomiting from general anesthesia.

  • Pain, swelling, and soreness around the reconstruction site.

  • Increased thirst.

  • Sleeplessness and restlessness.

  • Tingling and numbness at the surgical site.

  • Lethargy.

  • Patients should continue the medications and should not miss follow-up appointments.

  • Restrict physical activities.

  • Continue the physiotherapy exercises to improve the flexibility of the chest.

  • Adapting healthy lifestyle habits and quitting smoking and tobacco products if the practice is present.

  • Screening tests should be performed yearly as suggested by the surgeon or health care provider.

Reconstruction With Flaps-

Once the rebuilding is complete, the wound is covered with a skin flap-like pectoralis major flap taken from the lower breast fold along with muscle. Thoracoepigastric flap from the abdominal region and Latissimus Doris muscular flap from the lateral side of the upper body helps in extensive coverage of the chest wall.

What Happens After Surgery?

After the surgery, the patient may experience the following symptoms

• Sore throat caused due to the tube placed in the windpipe for breathing during surgery.

• Nausea and vomiting from general anesthesia.

• Pain, swelling, and soreness around the reconstruction site.

• Increased thirst.

• Sleeplessness and restlessness.

• Tingling and numbness at the surgical site.

• Lethargy.

These symptoms usually reduce once the healing starts, and the patient can resume normal activities recommended by the surgeon.

What Are the Post-Operative Instructions Given to a Patient?

• Patients should continue the medications and should not miss follow-up appointments.

• Restrict physical activities.

• Continue the physiotherapy exercises to improve the flexibility of the chest.

• Adapting healthy lifestyle habits and quitting smoking and tobacco products if the practice is present.

• Screening tests should be performed yearly as suggested by the surgeon or health care provider.

Conclusion:

Surgical management of the chest wall varies from patient to patient, depending on the severity of the tumor. Early detection always helps to achieve more significant results with minimal resection. The earlier the detection greater the chances of success