Chest wall tumors
Basic knowledge
The thoracic wall is made up of all the structures that surround and protect the lungs, heart, great vessels, esophagus, and trachea forming what we know as thorax. It starts at the bottom of the neck and ends at the level of the inferior ribs and the diaphragm. Its integrity is essential to carry out a normal respiratory cycle.
Because the chest wall is composed of different types of tissues, each tissue can develop a specific type of tumor. There are tumors arising from the muscles (myosarcoma), from the bones (osteosarcoma), from the cartilages (chondrosarcoma), from the body fat (lipoma or liposarcoma), etc. Chondrosarcoma is the most frequent tumor in adults and Ewing´s sarcoma the most common tumor in infants.
Although most tumors in adults over 40 years of age arising from the chest wall should be considered as malignant tumors, there are also benign conditions to be taken into account. For most of these tumors’ surgery is the most appropriate treatment.
Diagnosis
Most patients’ initial consultation is related to localized pain or to a newly detected chest wall mass. However, not all chest tumors are painful, and the size of the tumor does not relate to the intensity of the pain.
Mass growth is another important factor that should prompt medical consultation. The presence of changes in the skin such as redness, violet color or the presence of an open wound are reasons to ask for urgent medical evaluation.
Your doctor will evaluate the problem through a dedicated physical examination. He / she will ask for radiological tests such as CT scan, magnetic resonance and or a positron emission tomography (PET-CT) to evaluate the tumor and the extension of the disease. These images will also help your surgeon to plan the most suitable surgical resection to ensure adequate margins and the most functional chest wall reconstruction.
In some tumors, radiological findings are so specific that not even a biopsy is needed to proceed with surgical resection. However, if other treatments are considered or the image findings are not conclusive, a biopsy should be taken. Normally samples are obtained in outpatient settings under local anesthesia and radiological control.
Treatment
For most tumors, surgical resection is the initial appropriated treatment. Depending on the size, the position of the lesion and its relationship with intrathoracic structures, surgery will require multidisciplinary collaboration of different specialties (such as plastic and reconstructive surgery, orthopedic surgery, etc.) for a successful outcome.
Reconstruction of the chest wall integrity can be more difficult than removing the lesion. This integrity is mandatory to assure adequate functionality (from breathing to movements) after the procedure. Therefore, every procedure needs a careful planning. Depending on the size and position of the tumor and the size of the defect, prosthetic material may be necessary to create the solid support for the respiratory excursion. Muscles should cover the prosthesis to avoid its contact with the skin. When they are local or near-by muscles available, they become the first choice and they should be used. However, sometimes there are not tissues available, and they should be mobilized or brought in from distant sites. Don´t be surprised if your doctor comments on the use of abdominal muscles or the omentum to cover the prosthesis. Omentum will be retrieved from the abdomen. It is a mantle of internal fat with great wound-healing capacity. Finally, the skin must be closed directly, using nearby skin or a free graft obtained from distant sites.
After the pathological study of the surgical specimen, normally a long follow-up period starts. Sometimes an adjuvant treatment will be proposed. Your surgeon will refer you to the Oncology specialist for further assessment.
Surgery
Your surgeon will explain you the specific procedure and the possible multidisciplinary collaborations required, especially with plastic surgeons. Other specialists involved may need to evaluate you in order to assure the most esthetic and functional reconstruction.
Preparation for the procedure should follow a standard pathway.
Postoperative period
After surgery, depending on the surgical procedure you will receive specific recommendations regarding wound care, the need to wear a corset and, possibly, movement limitations. They will be specific according to the performed procedure.
However, chest physiotherapy will always be recommended to avoid pulmonary complications.