Malignant bone tumors of the chest wall

Grade 1 and 2 Chondrosarcomas of the Chest Wall: CT Imaging Features and Review of the Literature

The purpose of our retrospective article is to review the CT imaging features of chondrosarcomas of the chest wall with pathologic correlation. For 26 subjects with biopsy-proven chondrosarcomas of the chest wall, two musculoskeletal radiologists retrospectively reviewed 26 CT scans in consensus. Descriptive statistics were performed. The mean tumor size was 57 mm. Twenty (20/26, 77%) chondrosarcomas were located in the ribs and six (6/26, 23%) in the sternum. The majority were lytic (19/26, 73%) with <25% calcification (15/26, 58%), and with a soft tissue mass (22/27, 85%). In this study CT features of grade 1 chondrosarcoma overlapped with those of grade 2 tumors. In conclusion, chondrosarcomas of the chest wall are generally lytic with an associated soft tissue mass, showing little calcified matrix and low-to-intermediate grade.

Outcomes of chest wall resections in pediatric sarcoma patients

PURPOSE

Chest wall tumors in pediatric patients are rare. This study evaluates outcomes in pediatric patients who have undergone chest wall resections secondary to sarcomas.

METHODS

A retrospective review was performed for patients <19years old who underwent chest wall resections for sarcoma 1999-2014 at the University of Texas MD Anderson Cancer Center.

RESULTS

Of 44 patients, Ewing's sarcoma (n=18) and osteosarcoma (n=16) were most common. Other sarcomas included synovial sarcoma, chondrosarcoma, and rhabdomyosarcoma. Gore-Tex® or a Marlex™ mesh and methyl methacrylate sandwich was used in 22 patients, and 9 children did not require reconstruction. Twenty-four (54.5%) patients had normal activity, 3 (6.8%) had occasional discomfort, 2 (4.5%) had pain impairing function, 7 (15.9%) required medication or physical therapy for impairment, and 8 (18.2%) needed additional surgery. Five children (11.4%) developed scoliosis, and all of these patients had posterior rib tumors. Median overall survival for the entire cohort was 41.9±11.82months. Histology (p=0.003), location of tumor on the ribs (p=0.007), and surgical margins (p=0.011) were significantly associated with overall survival. Tumors on the middle and posterior (p=0.003) portions of the ribs had a lower chance of death.

CONCLUSION

Scoliosis is more common in posterior rib resections. Histology, location of the tumor, and surgical margins impact survival, but, type of reconstruction does not.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Treatment Study.

Chest wall reconstruction after oncological resections

Most chest wall defects requiring reconstruction result from tumor resection. Bone and soft tissue sarcomas and recurrent mammary cancer are the most common tumors. Careful preoperative evaluation, meticulous surgical technique and active postoperative treatment are important. The selection of reconstruction is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient. The goals of the reconstruction are adequate stability, water- and airtight closure of the chest cavity, and acceptable cosmetic appearance. The pedicled muscular or musculocutaneous flaps are usually the first choice for tis-sue coverage. These include flaps such as latissimus dorsi, vertical or transverse rectus abdominis and pectoralis. In certain cases also the breast flap or omental flap can be used. In selected cases, a free flap reconstruction is indicated if the local options for reconstruction have been used, or if they are unreliable due to earlier scars or radiotherapy. The free flaps to be used for chest wall can be harvested from the thigh (tensor fascia latae flap, anterolateral thigh flap), from the abdomen (transverse rectus abdominis flaps, deep epigastric perforator flaps) or from the chest wall (latissimus dorsi flap and other flaps based on the subscapular artery). Sometimes a fillet forearm can be used as a flap to cover a defect after extended forequarter amputation. Artificial meshes are commonly used to give stability in the defect and to give a platform for the flap. Methylmethacrylate embedded between the two layers of a mesh, or one or two rib grafts fixed to the mesh, can be used to give additional stability in extensive defects to prevent paradoxical movement.

Primary chest wall tumors

The differential diagnosis of chest wall tumors is diverse, including both benign and malignant lesions (primary and malignant), local extension of adjacent disease, and local manifestations of infectious and inflammatory processes. Primary chest wall tumors are best classified by their primary component: soft tissue or bone. Work-up consists of a thorough history, physical examination and imaging to best assess location, size, composition, association with surrounding structures, and evidence of any soft tissue component. Biopsies are often required, especially for soft tissue masses. Treatment depends on histological subtype and location, but may include chemotherapy and radiotherapy in addition to surgical resection.

Chest wall tumors in childhood and adolescence

Chest wall tumors in childhood and adolescence can be very heterogeneous and may appear at any age from infancy to late adolescence. They can be benign or malignant and secondary or primary. A careful history and physical examination should be followed by adequate imaging studies to delineate the primary tumor and identify possible sites of dissemination. Diagnosis usually requires either a needle or open biopsy which minimizes dissection so that a complete resection can be done later. Most neoplastic lesions require a complete resection, whereas secondary and infectious processes are treated with chemotherapy or antibiotics. Rigid chest wall re-construction has the advantage of eliminating paradoxical respiration and obviating the need for postoperative ventilation. Another advantage is maintenance of chest wall contour.

International Classification of Childhood Cancer, third edition

BACKGROUND

The third edition of the International Classification of Diseases for Oncology (ICD-O-3), which was published in 2000, introduced major changes in coding and classification of neoplasms, notably for leukemias and lymphomas, which are important groups of cancer types that occur in childhood. This necessitated a third revision of the 1996 International Classification of Childhood Cancer (ICCC-3).

METHODS

The tumor categories for the ICCC-3 were designed to respect several principles: agreement with current international standards, integration of the entities defined by newly developed diagnostic techniques, continuity with previous childhood classifications, and exhaustiveness.

RESULTS

The ICCC-3 classifies tumors coded according to the ICD-O-3 into 12 main groups, which are split further into 47 subgroups. These 2 levels of the ICCC-3 allow standardized comparisons of the broad categories of childhood neoplasms in continuity with the previous classifications. The 16 most heterogeneous subgroups are broken down further into 2-11 divisions to allow study of important entities or homogeneous collections of tumors characterized at the cytogenetic or molecular level. Some divisions may be combined across the higher-level categories, such as the B-cell neoplasms within leukemias and lymphomas.

CONCLUSIONS

The ICCC-3 respects currently existing international standards and was designed for use in international, population-based, epidemiological studies and cancer registries. The use of an international classification system is especially important in the field of pediatric oncology, in which the low frequency of cases requires rigorous procedures to ensure data comparability.

Prereferral evaluation of patients with suspected bone and soft tissue tumors

One hundred consecutive patients referred to an orthopaedic oncology practice for evaluation of suspected bone or soft tissue tumors were studied prospectively. There were 76 patients with bone lesions and 24 patients with soft tissue lesions. At the time of initial consultation, information regarding the referring diagnosis, number of prior physician office visits, and prereferral imaging studies obtained was collected. There were 50 patients with benign tumors, 17 patients with primary malignant tumors, 11 patients with metastatic tumors, and 22 patients with nonneoplastic conditions. The average number of physician visits before referral for the entire group was 4.8 visits and was highest for patients with malignant bone tumors (6.2 visits). Imaging studies obtained before referral included plain radiographs, magnetic resonance imaging, bone scans, computed tomography scans, and ultrasound. None of the plain radiographs were thought to be unnecessary; however, 26 of 76 (34.2%) magnetic resonance imaging scans, 17 of 40 (42.5%) bone scans, and 13 of 36 (36.1%) computed tomography scans were excessive and did not contribute to the evaluation of the lesion. Although only 58% of the study group included patients with benign bone tumors and nonneoplastic bone lesions, they accounted for the majority (79%) of unnecessary imaging studies. Primary care physicians and general orthopaedic physicians were equally likely to order unnecessary imaging studies (48% and 52%, respectively).

Cytologic spectrum of 227 fine-needle aspiration cases of chest-wall lesions

This study was carried out with the objective of studying the cytomorphology of the wide variety of chest-wall lesions. Two hundred twenty-seven chest-wall lesions were studied over a period of 4 yr. Routine May-Grünwald-Giemsa (MGG) and hematoxylin-eosin (H&E) slides were studied along with special stains, whenever required. The malignant lesions comprised 36.13% of all cases (81/227). Of the 126 benign lesions, the majority were inflammatory in nature (68/126), the next commonest lesion being lipoma (38/126). Rare cases of tuberculosis involving the sternum, epithelioid leiomyosarcoma, and neuroendocrine tumors involving ribs, malignant nerve sheath tumors involving the chest wall, metastatic carcinoma of the stomach and prostate, and papillary carcinoma thyroid are reported in this series. Histopathology was available in 24 cases, and hematological correlation in one case. A 100% cytohistological and cytohematological correlation was found, with no false positives or false negatives. In conclusion, fine-needle aspiration cytology is a rapid, diagnostic tool, eliciting many interesting lesions in the chest wall. It is useful not only in detecting primary and metastatic lesions, but also in follow-up of tumor recurrence.

[Costal chondroma and chondrosarcoma]

The aim of this study was to report two cases of chondrosarcoma located on the chest wall, in order to emphasize the difficulty encountered by the pathologist to differentiate a chondrosarcoma from a chondroma and the importance, in our opinion, of performing a large resection with wide margins in all cases.