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CHEST WALL CANCER

Primary chest wall cancers are a large group of benign or malignant tumors, which are originated from cortex, bone, cartilage and soft tissues in thorax. Spreads in the chest wall can stem from lungs, pleura, muscles or breast cancer. These might be distant spreading or more often local involvement.

Various non-cancer diseases might also spread to the chest wall. Primary chest wall tumors are less than 1-2% of all cancers. In children and adults, all primary chest wall tumors are malignant tumors of more than 50% soft tissue origin. Patients might have various complaints such as pain and swelling. Yet, some of them might not have any complaints at all.
The main treatments of all chest cancers are surgical removal and reconstruction of the chest wall. Most of the time; thoracic surgeons, plastic surgeons and neurosurgeons need to perform a joint surgery.

Chest wall surgery has four main reasons:

1) Chest wall inflammation,

2) Benign and Malignant cancers,

3) Beam (radiation) damage,

4) Accidents.

Chest wall cancers are rare. The keys to their successful treatments are early diagnosis, extensive surgery and reconstruction of the chest wall. According to some studies, 60% of chest wall tumors are malignant. Chest wall tumors are required to be studied in three distinct sections: Primary, regional (breast and lung) involvement and distant spread.

Most commonly, primary chest wall cancers occur in bone and cartilaginous and the common formations are in ribs. Primary sternum involvements are seen by 1% and most of them are malignant tumors.

Primary chest wall cancers are divided into two as benign and malignant. Benign tumors can originate from soft tissue or bone cartilage. Soft tissue tumors include adipose tissue tumor, connective tissue tumor, lymphatic duct tumor, blood vessel tumors, striated muscle tumor; and those originating from the bone cartilage tissue are connective tissue dysplasia, cartilage tumor, osteochondroma, bone cyst and giant cell tumor. The connective tissue (fibrous) dysplasia of the bone constitutes 30% of all benign tumors. It originates from the side and back ribs. They are tumors growing slowly. Cartilage tumors (chondromas) are the most common and slowly growing tumors in the 20-30 age ranges. Most commonly, they occur at the cartilaginous junction of the rump. Benign tumors are usually painless, slow growing cancers.

In malignant primary tumors, the cancer has a soft tissue and a cartilage bone origin. Soft tissue originated ones are soft tissue sarcoma,desmoid tumor, PNET; cartilage bone originated ones are chondrosarcoma, bone sarcoma, single plasmocytoma, malignant fibrosis histiocytoma and Ewing sarcoma. Malignant tumors are rapidly growing tumors with lots of pain and swelling, which can be measured by bare hands. The duration of complaints is rather short when compared to the benign tumors. All cancers arising from the bone tissue stem from the ribs. If malignant cancers start to make severe pain in patients, it is the sign of deterioration.  The pain due to the bone involvement indicates regional deterioration. The pain in the soft tissue sarcomas is usually absent and follows a better process (5-year survival = 60%) than other malignant breast cancers. Ewing sarcoma in 47%, bone sarcoma in 15% and plasmocytoma in 20% are the rates of 5-year survival. Primary cartilage-sarcoma is the most common cancer of the sternum and occurs in ages of 30-40.

Radiologically, it affects the crustal part of the bone (cortical).  It also affects the junction of the anterior ribs and spreads to the tissues next to it. The five year of survival rate after complete surgical removal of the tumor is 70%. Bone sarcoma is common in the long bones of pubes and young adults. 5-Year survival rate is 20%. In 68% of the patients, the spread of the cancer is from distant areas and most commonly, it is a metastasis in lungs. Single plasmocytoma is associated with multiple myeloma, a common silent disease in older men. It is usually accompanied by pain, mass or both complaints.

Chest wall cancers with the distant spread are rare. Thyroid glands, prostate, breasts, lungs and kidneys are the places of this distant spread. In these cases, there are chances of surgical removal of the cancer, the control of the first tumor, the absence of further spread in the field and the possibility of complete removal of the mass.

In radiological examinations; an attention must be given to diameter and growth rate of the mass, the destruction of the bone capsule (cortical), the involvement of the soft tissue and the presence of metastasis which creates the possibilities of malignant tumors in other areas. Chest tomography (CT) is sufficient to evaluate these findings. In a patient with involvement of the sternum, a bone scintigraphy must be taken in order to see if there is any other metastasis.

The most important condition is to perform a full surgical removal procedure, if chest wall is removed by surgery.

a. Resection

b. Restoration of skeletal stability

c. Soft tissue coverage

 

Recurrence occurs in a short time when the mass is not fully resected. The least amount of 4 cm of macroscopic tumor-free tissue must be removed around the cancer area. It can also be performed in the form of an upper and lower sturgeon of the mass.

Providing chest wall stability and normal function to reconstruct the chest wall after the removal of it, closing the opening with the appropriate soft tissue and providing the cosmetic appearance are the ways to perform the operation according to its procedure. Various chest wall stabilizers are available for this purpose. Such as Synthetic materials (Gore-Tex Grafts- PTFE, prolene mesh, composite prosthesis, marlex mesh and methyl methacrylate) and the tissues of the patient

(autologous materials, bone grafts, muscles, etc.).

Preliminary limited longitudinal left parasternal incision: The sternocostal joints of the second, third, and fourth ribs are interrupted and nonabsorbable stitches are placed on the peristernal tissues and temporarily abandoned inside the chest cavity.

References:

  • Athanassiadi K, Kalavrouziotis G, Rondogianni D, et al. Primary chest wall tumors: Early and long term results of surgical treatment. Eur J Cardiothorac Surg 2001;19:589-93.
  • Sabanathan S, Salama FD, Morgan WE, et al. Primary chest wall tumors. Ann Thorac Surg 1985;39:4-15.
  • Liptay MJ, Fry WA. Malignant bone tumors of the chest wall. Semin Thorac Cardiovasc Surg 1999;11:278-84.
  • Anderson BO, Burt ME. Chest wall neoplasms and their management. Ann Thorac Surg 1994;58:1774-81.
  • King RM, Pairolero PC, Trastek VF, et al. Primary chest wall tumors: Factors affecting survival. Ann Thorac Surg 1986;41:597-601.
  • Pass HI. Primary and metastatic chest wall tumors. In: Roth JA, Ruckdeschel JC, Weisenburger TH, eds. Thoracic Oncology. Philaelphia: WB Saunders, 1995:519-37.
  • Graeber GM. Chest wall resection and reconstruction. Semin Thorac Cardiovasc Surg 1999;11:251-63.
  • Burt M. Primary malignant tumors of the chest wall: The Memorial Sloan-Kettering Cancer Center experience. Chest Surg Clin N Am 1994;49:363-9.

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