Chest wall tumors are uncommon malignancies, whether primary or secondary in nature. Nevertheless, nearly every thoracic surgeon eventually will be asked to evaluate one of these tumors in clinical practice. It is estimated that only 500 index cases of primary malignant chest wall tumors occur in the United States annually,1 in addition to secondary chest wall tumors, which are, most notably, those related to recurrent breast cancer. Given this relatively low incidence, no one surgeon or surgical group could be expected to have an extensive experience with this tumor type. Having a working knowledge of the surgical principles underlying the management of uncommon chest wall tumors therefore is all the more relevant.
The more common primary chest wall tumors are listed in Table 115-1. Although most of these tumors in the pediatric population are malignant, only approximately half of these tumors are malignant in adults.
Table 115-1. Primary Chest Wall Tumors |Favorite Table|Download (.pdf)
Table 115-1. Primary Chest Wall Tumors
Malignant fibrous histiocytoma
Primitive neuroectodermal tumors (Askin's tumor of chest wall, Ewing's sarcoma of bone)
Desmoid tumor (low-grade fibrosarcoma)
The overriding technical principle of chest wall surgery is similar to that of tracheal surgery. Specifically, the procedure consists of two separate but equally important parts—resection and reconstruction—and the technical considerations of each must be assessed independently.
With regard to resection, it is imperative to establish first whether the tumor is primary or metastatic, and if primary, whether it is malignant or benign. This determination may be clear from the patient's history and certain radiographic characteristics of the tumor, but a tissue diagnosis is important for several reasons. If the tumor is benign, an overly aggressive resection and complex reconstruction may not be needed. Alternatively, if the tumor is malignant, one of several different treatment strategies may be required. For example, some of these tumors (e.g., osteosarcoma and plasmacytoma) are best treated nonoperatively initially. Other primary malignant chest wall tumors (e.g., primitive neuroectodermal tumors and some sarcomas) may benefit from induction therapy before a planned surgical resection. Thus, establishing a tissue diagnosis is the first important step in the treatment algorithm for chest wall tumors.
The diagnostic technique selected for biopsy also must adhere to standard oncologic principles. The biopsy site must be placed in a location that can be incorporated into the planned resection specimen. Most chest wall lesions that arise from bone, cartilage, or soft tissues of the chest wall are amenable to diagnosis by core needle biopsy. On the rare occasion that core needle biopsy is not possible or is nondiagnostic, incisional biopsy can be performed, provided that the incision is placed within the margins of the resection specimen, as mentioned earlier. Excisional biopsy also can be used for smaller lesions (<3 cm), and if such lesions are later determined to be malignant, a wider local excision that incorporates the old surgical scar can be performed as a separate procedure.