Soft tissue chest wall tumors are generally asymptomatic, initially, presenting as slowly enlarging masses. As Gordon and colleagues¹⁶ reported, 73% of patients with primary soft tissue sarcomas of the chest wall presented with a nonpainful mass. With continued growth and tumor involvement of surrounding tissue, pain invariably occurs. The pain is frequently generalized, and the patient commonly is treated for musculoskeletal or neuropathic etiologies. Almost all malignant lesions are likely to become painful, whereas only two-thirds of benign tumors produce pain. Cartilaginous and bony tumors more frequently have pain as one of the first symptoms of disease. Burt⁷ showed that pain with or without a mass was present in 49% of patients with
chondrosarcoma, in 95% with Ewing’s sarcoma, and in 78% with osteosarcoma. In some cases with rib lesions, a radiographic abnormality can be discovered with no mass palpable on physical examination. Occasionally, there may be systemic manifestations, such as fever, leukocytosis, and eosinophilia.

The initial evaluation of any patient suspected of having a chest wall neoplasm begins with a complete history and physical examination. The clinician should pay particular attention to any history of prior malignancy, exposure to ionizing radiation, or presence of familial conditions, such as Gardner’s syndrome or von Recklinghausen’s disease. Standard conventional plain chest radiographs should be obtained and compared with any previous studies if available. Computed tomography (CT) of the chest is the single best radiographic modality to localize and characterize most chest wall tumors in order to generate a differential diagnosis and treatment strategy. In some instances, magnetic resonance imaging (MRI) of the chest can add additional useful information. Compared with CT, MRI can delineate better the extent of muscular invasion, relationship to nearby blood vessels, and/or spinal involvement by chest wall lesions.^13,47 CT, however, is superior in the assessment of calcifications and presence of pulmonary pathology. While specific tumors may have features better elucidated by one or the other modality, it is clear that these techniques are complementary. Moreover, while judicious use of imaging and careful analysis of films can often lead to a correct diagnosis, radiographs tend to be most useful in the planning of tissue biopsy or surgical resection.³⁶

Following history, physical examination, and imaging, if there is doubt whether a chest wall neoplasm is benign or malignant or if the lesion is suspected of being a primary tumor, tissue diagnosis by histologic examination is required. Biopsy should be well planned, minimally traumatic to the primary tumor and surrounding tissue, and diagnostic. There are three options: needle biopsy, excisional biopsy, and incisional biopsy.

The benefits of needle biopsy include minimal soft tissue injury, ease of performance, and low complication rate in an outpatient setting. Fine-needle aspiration alone is best employed in patients who are suspected of having a metastasis from a prior documented malignancy. It is not as good for situations such as a primary bony or cartilaginous chest wall tumor, where a larger amount of tissue is required for pathologic diagnosis. Percutaneous core needle biopsy is a viable option for the diagnosis of primary chest wall tumors and is a well-accepted technique for biopsy of primary bone tumors. Welker and coauthors⁴⁵ demonstrated a diagnostic rate of 92.6% in 161 musculoskeletal tissue masses suspected of being sarcoma.

Excisional biopsy with minimal margins (1 cm) should be employed for small (<5 cm) primary neoplasms. Closure of the chest wall usually can be performed primarily without reconstruction. If the lesion is benign or best treated with non-surgical-therapy (chemotherapy, radiation, or both), no further operation is required. If the lesion is a primary malignant neoplasm, the patient should undergo reoperation with radical excision with wide margins and appropriate reconstruction.

Incisional biopsy should be performed when a needle biopsy is nondiagnostic or for primary lesions >5 cm. It is important to orient the skin incision to facilitate its excision at the time of definitive resection and to promote optimal wound healing, avoiding ulceration and infection that might delay therapy. Skin flaps should not be raised, and the deep plane of the tumor, in particular the pleural space, should be left intact to prevent dissemination of tumor cells.

While advances in surgical technique, anesthesia, and perioperative management have reduced morbidity and mortality, extensive chest wall resection and reconstruction remains a major surgical procedure. As with any other thoracic operation, careful preoperative assessment is critical to minimize the risks to the individual patient. In addition to a detailed history and physical examination, this evaluation should include a thorough investigation of cardiopulmonary comorbidities, smoking history, performance status, and psychosocial support. The presence of cardiovascular disease, such as coronary artery or valvular disease, has important implications for intraoperative and postoperative hemodynamic monitoring and fluid management. The authors are in the practice of routinely obtaining cardiac stress testing in patients over the age of 70, in particular if they have a long history of smoking, hypertension, diabetes mellitus, or other manifestations of atherosclerotic disease (peripheral vascular disease, carotid stenosis, aneurysm). If the patient’s pulmonary reserve is of concern, it should be assessed with pulmonary function tests that include spirometry, diffusion capacity, and arterial blood gas analysis. Patients with chronic obstructive pulmonary disease or other active pulmonary disease should have optimal medical treatment prior to surgery.

Preoperative consultation with a variety of subspecialists is often necessary. For instance, in the case of the “medical malignancies,”
such as Ewing’s sarcoma and plasmacytoma, evaluation by medical and radiation oncologists prior to operation is an integral part of their multimodality treatment. Depending on the size of the lesion, chest wall reconstruction may warrant the use of myocutaneous flaps; these procedures are best performed in conjunction with plastic and reconstructive surgeons. Similarly, neurosurgical consultation is often required for tumors encroaching on the spine.²⁹ When complete resection is limited by proximity of the lesion to vital structures, external beam radiotherapy, either preoperatively or postoperatively, or intraoperative brachytherapy should be considered.⁴²

Primary bone neoplasms of the chest wall are uncommon. Dahlin and Unni¹⁰ summarized a series of 6,034 bone tumors, of which 355 (5.9%) occurred in either the ribs (85%) or the sternum (15%). Nearly all were malignant (89%), with sternal tumors slightly more likely to be malignant than rib tumors (96% versus 88%). The most common benign bone lesions are osteochondromas, chondromas, and fibrous dysplasia. Martini and coworkers²⁵ reported that fibrous dysplasia accounts for 30% of benign tumors of the chest wall. The most common primary malignant bone tumors seen at MSKCC are chondrosarcoma, Ewing’s sarcoma, and osteosarcoma.⁷