Chest Wall Mass P.

665
 Fibrous dysplasia
young adults
may be associated with trauma
posterolateral aspect of the rib cage

Diagnostic
Radiographically
expansile mass present,
cortical thinning
no calcification

Treatment:
Local excision with a 2-cm margin
curative
P. 666
 Osteochondroma
Incidental finding solitary lesion on radiograph,
most common benign bone tumor
first two decades of life
arise at or near the growth plate of bones

Thorax: arise from the rib cortex

hereditary multiple exostoses
autosomal dominant syndrome
high rate of degeneration into
chondrosarcomas

Treatment:
benign osteochondroma local excision
malignancy wide excision with a 4-cm margin
P. 666
 Primary Malignant Chest Wall Tumors:
Chondrosarcoma

most common primary chest wall malignancy

arise anteriorly from the costochondral arches
CT scan
radiolucent lesion with stippled calcifications
pathognomonic for chondrosarcomas
involved bony structures destroyed
slow-growing, low- grade tumors
painful masses can reach massive proportions.
Treatment
low-grade chondrosarcoma
wide (4-cm) resection
Not sensitive to radiation or chemotherapy.
Prognosis
determined by tumor grade and extent of resection
P. 667
 Primary Malignant Chest Wall Tumors:
Osteosarcoma
most common bone malignancy
only 10% to 15% of all malignant chest wall tumors.
young adults
rapidly enlarging, painful masses
older patients
association with previous radiation
Paget’s disease
chemotherapy
Radiographically
spicules of new periosteal bone formation producing
a sunburst appearance
Metastasis
propensity to spread to the lungs
1/3 with metastatic disease

P. 667
 Primary Malignant Chest Wall Tumors:
Osteosarcoma

Treatment
sensitive to chemotherapy
followed by complete resection with wide (4-cm) margins
followed by reconstruction
lung metastases
amenable to surgical resection
induction chemotherapy
followed by surgical resection of the primary tumor
pulmonary metastasectomy
post op chemotherapy
 Chest wall Reconstruction
Coverage
Gore-Tex
(a) impervious to fluid
prevents pleural fluid from entering the
chest wall
minimizes seroma formation
(b) provides excellent rigidity and stability when
secured taut to surrounding bony structure
(c) provides a firm platform for
myocutaneous flap reconstruction:
latissimus dorsi
serratus anterior
rectus abdominis
pectoralis major muscles
Mediastinum
 Mediastinal Neoplasm
Thymoma

Radical Thymectomy
Inferior border thyroid
gland
1cm ant phrenic nerve
Diaphragm
Pericardium
Mediastinal Neoplasm
Thymoma
Malignant Pleural Effusion
 Empyema
Thoracic empyema
defined by a purulent pleural effusion
Para pneumonic effusion
most common cause
Causative Organism
Pneumococci and staphylococci
most frequent
gram-negative aerobic bacteria and
anaerobes becoming more prevalent
Pleural fluid
pH <7.2
glucose level <40 mg/dL
Treatment
Antibiotic +
CTT
VATS deloculation, decortication
Instillation fibrinolytic t-PA & DNAse
 Chylothorax
Lymphatic (Chyle) fluid accumulation
in the pleural cavity

Indication for Surgery

leak persists for >1L/day x 1 week or
leak lasting > 2 weeks

Early Surgery
considered
leak > 500ml/day
 Chylothorax Diagnosis
• Triglycerides >100mg/dl
• Triglycerides/cholesterol ratio >1
• Presence of leukocytes in lymph
• Chylomicrons in microscopic
evaluation