134: Overview of Chest Wall and Sternal Tumors

Introduction

Chest wall tumors reflect a wide range of the various musculoskeletal diseases. Their infrequency in this unique location generates a diagnostic and therapeutic challenge to the thoracic surgeon. More than half the malignant tumors of the chest wall represent either metastatic lesions from distant organs (i.e., carcinoma or sarcoma) or invasion from contiguous structures such as the breast, lung, pleura, or mediastinum.¹ Primary malignant neoplasms include tumors that arise from soft, cartilaginous, or bony tissues. The most common pathology is sarcoma and, less frequently, solitary plasmacytoma or lymphoma. In many series, the number of patients reported is small because of the rarity of primary chest wall malignant tumors; thus the data on these cases are limited. From these data it can be concluded that approximately 45% of primary malignant chest wall tumors arise from soft tissue sarcomas and 55% appear in cartilaginous or bony tissue.²

Presenting Signs and Symptoms

The soft tissue chest wall tumor commonly presents as an enlarging mass without pain. Conversely, patients with bone tumors most often have pain as their initial complaint secondary to periosteal damage or expansion. Rapidly expanding lesions more often produce pain and favor a malignant diagnosis. The character of the pain is a persistent, dull aching sensation that is likely related to stretching of the pericostal sheath.

Constitutional complaints such as fever and malaise may accompany Ewing sarcoma. Rarely, a benign bony lesion such as osteomyelitis or eosinophilic granuloma may present as a painful bony mass with fever and malaise. Other clinical signs and symptoms produced by chest wall and sternal malignancies are related to invasion or pressure effects that the tumor exerts on adjacent structures.

Differential Diagnosis

Chest wall masses can be divided into three main categories: malignant, benign, and nonneoplastic. More than half of all chest wall tumors represent metastases from different sites or local invasion of adjacent tumors. Primary chest wall tumors are relatively uncommon and represent only 1% to 2% of all primary neoplasms. Table 134-1 classifies the malignant neoplasms of the chest wall.

Benign tumors comprise approximately half the primary neoplasms of the chest wall. The most common benign neoplasms in the chest wall are osteochondroma and chondroma. Osteochondroma is the most common benign rib neoplasm and accounts for nearly 50% of this group. It is usually asymptomatic and does not mandate removal. Chondromas usually occur anteriorly at the costochondral junction. ...