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  • • Chondrosarcomas, osteosarcomas, myelomas, Ewing sarcoma, lymphoma, and metastatic cancer

Chondrosarcoma

  • • Most common primary malignancy of chest wall (30%)

    • Commonly develop at costochondral junction

    • First 4 ribs commonly affected; spreads locally

    • More malignant than chondrosarcoma

    • Propensity to metastasize to lung or bone

    • < 5% arise in chest wall

    • Majority present on extremity

Myeloma

  • • Rare lesions, causing 5-20% of chest wall tumors

    • 75% of the time solitary chest wall plasmacytomas are harbingers of diffuse disease

Ewing Sarcoma

  • • 10-15% of primary chest wall tumors

    • < 15% present in chest

    • Kidney, thyroid, lung, breast, prostate, stomach, uterus, or colon

    • Renal and thyroid high propensity to metastasize to sternum

    • Direct extension occurs with breast and lung cancers

Epidemiology

Chondrosarcomas

  • • Patients are 20- to 40-years-old

Osteosarcoma

  • • Patients are 20- to 40-years-old

    • 60% of cases occur in men;40% in women

Myeloma

  • • Patients are 40- to 60-years-old

    • More common in men

Ewing Sarcoma

  • • Disease of childhood/adolescence

Symptoms and Signs

  • • Pain is rare

    • Mass

    • Ewing sarcoma

    • -Large, warm, painful, soft-tissue mass

      -Systemic symptoms common, including fever, malaise, weight loss

    • Metastatic disease may present as pulsatile mass due to vascularity

Imaging Findings

Chondrosarcoma

  • Radiography

    • -Destruction of cortical bone with ossification

      -Tumor border indistinct

Osteosarcoma

  • Radiography

    • -Bone destruction and recalcification at right angles causing characteristic "sunburst" appearance

Myeloma

  • Radiography

    • -Classic "punched-out" lytic lesion without new bone formation

  • Ewing sarcoma

    • -Fine-needle aspiration cytology or incisional biopsy to diagnose

      -Histology reveals broad sheets of small polyhedral cells with pale cytoplasm staining periodic acid-Schiff-positive

Rule Out

  • • Aortic aneurysm before obtaining biopsy specimen of any lesion, especially if pulsatile

  • • Physical exam

    • Chest x-ray

    • Chest CT scan

    • Incisional or excisional biopsy depending on size and configuration

  • • Wide excision, en bloc

    • Negative margins is goal

    • Postoperative chemotherapy for osteosarcoma

Surgery

Indications

  • • Large tumors (> 20 cm) can be cured surgically

    • Important in diagnosis of myeloma

Medications

  • • Radiation therapy is useful in myeloma to control pain

    • Chemotherapy is primary treatment for myeloma

    • Chemotherapy followed by radiation therapy or surgery for Ewing sarcoma

Treatment Monitoring

  • • Local recurrence portends future metastatic disease

Prognosis

Chondrosarcoma

  • • Positive margins much worse prognosis

    • Histologic grade clear predictor

    • -Low grade: 5-year, 60-80%

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