CARTILAGINOUS TUMORS OF RIBS AND STERNUM

Cardiac and Non-Cardiac Chest Wall Pain

The various causes of anterior chest wall pain are reviewed with particular reference to the clinical manifestations of coronary artery disease (CAD), costochondritis and the myofascial pain syndrome.

Attention is drawn to the manner in which myofascial pain syndrome in the anterior chest wall may arise as a result of primary trauma or anxiety-induced activation of myofascial trigger point (MTrP) nociceptors and also as a result of the secondary activation of MTrPs situated in a zone of cardiac pain referral, and how myofascial pain syndrome may develop in patients with mitral valve prolapse.

It is explained that, because of an appreciable incidence of concomitant costochondritis and CAD pain and of MTrP and CAD pain, and because dry needling in both myofascial pain syndrome and costochondritis may relieve underlying CAD pain, it is not infrequently necessary in cases of anterior chest wall pain to carry out a detailed cardiological assessment including electrocardiographic exercise testing and radionuclide cineangiography.

Chondroma and chondrosarcoma

A chondrosarcoma is the most common primary malignant tumor of the chest wall. It usually presents on the anterior chest wall arising from the costochondral arches or sternum. It may occur as the result of malignant degeneration of a benign chondroma. Both chondrosarcomas and benign chondromas present as painful, slow-growing, hard, fixed, and nontender anterior chest wall masses. Microscopic differentiation between the two tumors is difficult and the treatment for both tumors is wide excision with a margin of at least 4 cm. Chemotherapy is ineffective and radiation therapy is used only for patients with tumors that are either not amenable to surgical resection or have positive resection margins.

Tumors of the ribs: experience with 47 cases

OBJECTIVES

To emphasise the existing difficulties in differentiating benign from malignant rib tumours, and especially the problems that a clinical doctor encounters when dealing with a hyperplastic rib.

METHODS

Forty-seven patients with rib tumour underwent surgery in a period of 12 years (1984-1996). In 40 cases (85%), the lesion was benign and in seven (15%) was malignant. Twenty-one benign tumours originated from cartilage and bone, seven were inflammatory, six originated from the bone marrow, and minor percentages (2.5-5%) had vascular, neurogenous, degenerative or miscellaneous origin. Three of the malignant tumours were primary chondrosarcomas and two were metastatic from kidney. The rest were metastatic from stomach (adeno-Ca), and skin (melanoma). The mean age in the benign group was 25.2 years and in the primary malignant group was 20.7 years. Related symptoms were pain (47%) and swelling (42.5%). One-third (32%) of the patients were asymptomatic and the lesion was accidentally found during routine chest radiography. All patients were treated surgically with wide excision of the tumour and the diagnosis was established histologically.

RESULTS

Resection was complete and curative in all cases without recurrence.

CONCLUSIONS

Since the likelihood of malignancy cannot be excluded, all rib tumours should be considered malignant until proven otherwise. Therefore, prompt intervention is necessary and wide and radical initial excision of the involved rib is advocated.

Histological grading and morphometric analysis of cartilaginous tumours

Morphometric analysis of cartilaginous tumours was performed on 25 chondrosarcomas, 9 cases of enchondroma (ENCH), and 2 chondroblastic osteosarcomas (CBOS). The chondrosarcomas were classified into three grades of malignancy according to Evans' histological classification and were further divided into low and high grades of malignancy. Cellularity, nuclear area, binucleate cells and mitotic figures were examined using formalin-fixed and paraffin-embedded specimens. The cellularity was significantly higher in high-grade chondrosarcoma (HGCS) than in low-grade chondrosarcoma (LGCS) (P less than 0.005). The nuclear area was larger in more malignant lesions. Significant differences in the nuclear area were found between ENCH and LGCS (P less than 0.005) and between LGCS and HGCS (P less than 0.01). Binucleate cells were found more frequently in LGCS than in ENCH (P less than 0.005). Although a few mitotic figures were found in HGCS, they were extremely rare in chondrosarcomas. Mitotic figures, however, were easily found in CBOS when compared with HGCS (P less than 0.05). These results suggest that nuclear area and binucleate cells are useful for differentiation between benign and malignant cartilaginous lesions and that easily detectable mitotic figures are a reliable marker for neoplastic cartilage in osteosarcoma.

Primary bone tumours of the thoracic skeleton: an audit of the Leeds regional bone tumour registry

An audit of the Leeds regional bone tumour registry found that primary bone tumours of the thoracic skeleton constituted 90 of the 2004 cases (4.5%). Thirty seven per cent occurred in the ribs, 32% in the scapulae, 11% in the thoracic vertebrae, 11% in the sternum, and 9% in the clavicles. Malignant tumours were more common than benign (54 v 36) and occurred in an older population (mean ages 47 and 31 years). The scapula was the most common site for malignant lesions and the ribs the most common site for benign tumours. Chondrosarcoma was the commonest tumour in older patients, fibrous dysplasia and plasmacytoma in the middle age group, and eosinophilic granuloma in children. Presenting symptoms were a poor guide to whether the lesion was malignant or not. This and the small proportion of correct preoperative diagnoses indicate the need for early biopsy. Bone tumour registries provide a valuable source of cumulative information about uncommon tumours and facilitate accurate diagnosis, teaching, and research.

Giant chondroma of the sternum mimicking a mediastinal mass

A 64 year old man with a giant benign sternal chondroma presented with cough as his sole complaint.

Primary tumours of the ribs

Thirty-four primary rib tumours (24 benign, 10 malignant) were surgically treated in 1966-1985. The mean age was higher and the tumour diameter was greater in the patients with malignant, than in those with benign neoplasm. The benign tumours were excised without operative death. At follow-up after a mean of 12.3 years there was no recurrence of benign growth, but in two cases with initial diagnosis of chondroma a regrowth at the same site proved to be chondrosarcoma. Among the cases of malignant tumour there was one operative death from pulmonary embolism, after radical resection of sarcoma. None of the four patients with chondrosarcoma had recurrence 6-13 years after surgery. There was no long-term survival among the patients with other forms of sarcoma or malignant tumour of the reticuloendothelial system.

Osteoblastoma of the sternum

Osteoblastoma has become a well defined bone tumor since its first description by Jaffe and Mayer in 1932. This tumor was considered to occur in almost any bone of the skeleton. Only one previous case of sternal osteoblastoma was described in the literature. Herein we report, as far as we know, the second reported case of osteoblastoma in the sternum, as an isolated tumor.

Chondrosarcoma of the chest wall: factors affecting survival

The cases of 96 patients (55 male and 41 female) with primary chondrosarcoma of the chest wall were reviewed. Ages ranged from 17 to 78 years (median, 53.5 years). The tumor involved the rib in 78 patients and the sternum in 18. Seventy-two patients had treatment at the Mayo Clinic, 28 by wide resection, 25 by local excision, and 19 by palliative excision. There was 1 operative death. Follow-up ranged from 1 to 46 years. Recurrent chondrosarcoma developed in 37 patients. All had local recurrence, and 14 also had metastases. Within 10 years, recurrence had developed in 50% of patients who had local excision and in 17% of patients who had wide resection. Ten-year chondrosarcoma survival (Kaplan-Meier) for patients treated by wide resection was 96%; by local excision, 65%; and by palliative excision, 14% (p less than 0.0001). Tumor grade, tumor diameter, tumor location, and date of operation all had a significant influence on survival. This report documents the natural history of chest wall chondrosarcoma and demonstrates that early wide resection is the treatment of choice.

Solitary rib lesions

Solitary rib lesions are not uncommon. They are frequently asymptomatic and usually benign. Virtually all of the malignant tumors are associated with an obvious soft tissue mass which merits further investigation. However, should any of the benign appearing lesions either become symptomatic, change appearance or start growing then they too should be biopsied.

Primary chest wall tumors

A retrospective study of 53 primary chest wall tumors, 26 benign and 27 malignant, was carried out to review their clinical radiological and pathological features. Forty-nine of the 53 lesions presented in the ribs and the remaining 4, in the sternum. The overall 5-year survival for patients with primary malignant neoplasms of the chest wall was 33.3%, and the 10-year survival was 18.5%. All of the deaths were disease related. All of the patients with benign tumors were treated by excision without recurrence or death. Distinction between benign and malignant chest wall tumors was not possible using radiographic criteria unless cortical destruction and involvement of soft tissues were visualized. On the basis of our analysis, we believe that all tumors of the chest wall should be considered malignant until proven otherwise and that wide excision should be carried out. This is necessary not only to obtain an adequate diagnosis but also to provide the best chance for cure in both benign and malignant lesions.

Tumors of the chest wall

Primary tumors of the chest wall are uncommon but should be considered in the evaluation of patients with persistent chest wall pain or the presence of a chest wall mass, especially when this is near the costal cartilages. Special radiographic techniques may help to define the diagnostic possibilities and the extent of local involvement. Since at least half of the primary rib tumors and virtually all of the sternal tumors are malignant, these problems demand prompt investigation, accurate tissue diagnosis, and, usually, generous surgical excision. With appropriate attention to skin, soft tissue, and skeletal involvement, resection of major chest wall tumors can be done safely, and there are a variety of reconstructive techniques available to deal with the resulting defects. Radiotherapy has little role in the treatment of chest wall tumors except for the myeloproliferative disorders and possibly some cases of Ewing's sarcoma. Chemotherapy has similarly been ineffective for the cartilaginous tumors but shows some promise in the multidisciplinary approach to osteogenic sarcoma. Surgical resection, however, remains the mainstay for the treatment of most tumors of the chest wall. Even in instances of recurrent disease there are many whose long-term survival has been achieved by multiple operative procedures.

Aneurysmal bone cyst mimicking Ewing's sarcoma of the rib

A cantaloupe-sized intrathoracic tumor destroying the eighth rib with a pleural effusion is ominous. This case of an aneurysmal bone cyst of a rib mimicking a malignant chest wall tumor was both interesting and instructive.

Tumori Della Gabbia Toracica

The pathological and clinical problems related to the tumours of the thoracic bones are surveyed. 34 cases of such tumours (27 of the ribs and 7 of the sternum) observed at the Cancer Institute of Milan are reported. These tumours are nearly always of malignant type, and the chondromatous forms are prevailing in the ribs whereas plasmocytomas are more frequent at the level of the sternum. Symptomatology is often moderate also in very malignant lesions, and in many cases a precise diagnosis is possible only after histological examination.

The therapy of choice is the surgical treatment and consists in wide removal of the affected rib, and often also of the adjoining ones with the intervening tissues. Suitable repairs of the residual gap are necessary in order to maintain the function of the thoracic wall.

Radiotherapy must be confined to ablastic tumours and reticulosarcomas, to all cases non susceptible of radical treatment and to recurrencies from previous interventions.