Frequency and treatment outcomes of chest wall masses: a 10-year report

Introduction

Cancer is a prominent cause of global mortality, with an estimated 18 million new cases documented in 2018, affecting both genders [1]. Cancer manifests as a genetic disease characterized by aberrant cellular growth due to mutations affecting growth-regulating genes, leading to oncogene activation and tumor suppressor gene inactivation [2, 3].

Chest wall tumors, albeit rare, represent a significant subset of thoracic neoplasms, accounting for approximately 5% of thoracic and 2% of overall body neoplasms [4]. These tumors encompass primary, adjacent with local invasion, metastatic, or non-neoplastic masses [5]. Notably, a considerable proportion of chest wall malignancies are metastatic or locally invasive [6].

Research from leading institutions such as Memorial Sloan Kettering Cancer Center and Mayo Clinic has shed light on the distribution and characteristics of chest wall tumors. A significant portion, often exceeding 30%, of these tumors are secondary, with breast and lung cancers being the most frequent primary sources [7, 8]. Among metastatic tumors, sarcomas such as chondrosarcoma and osteosarcoma are particularly prevalent [7]. The average age at presentation differs between benign and malignant lesions, with benign lesions typically diagnosed at a younger age compared to malignant ones [9, 10]. Historically, the management of chest wall tumors posed challenges for surgeons, often resulting in misdiagnosis, incomplete resection, and high complication rates [11]. However, recent advancements in surgical techniques, coupled with a better understanding of tumor biology, have improved treatment outcomes.

Surgical resection with adequate margins remains the cornerstone of treatment for primary chest wall tumors and selected secondary tumors [9]. The individualized surgical approach should take into account the specific characteristics of the disease to optimize outcomes.

Aim

This study aims to report on the various tumor types, examine their pathological features, and evaluate the efficacy of surgical interventions, thus providing valuable insights into the management of chest wall tumors and their impact on disease recurrence.

Material and methods

The present study used a descriptive, analytical, retrospective approach, which was approved by the ethics committee of Mashhad University (code IR.MUMS.MEDICAL REC.1401.161), and was conducted at Ghaem Hospital, Mashhad, Iran, between 2011 and 2021. Patients with incomplete medical records (missing specific criteria) were excluded. Data on demographics (age, sex), pre-operative pathology (tumor type, stage, grade), post-operative pathology, type of surgical procedure, duration of hospitalization, need for post-surgical rehabilitation, and history of pre-operative chemotherapy/radiotherapy were collected using a standardized data collection tool. A total of 131 patients were included in the analysis.

Results

This study involved the examination of 131 patients, of whom 38.2% were female and 61.8% were male, as shown in Table I. The mean age of the patients was 38.5 ±17.35 years, ranging from 6 to 78 years.

The mean length of hospital stay for the patients was 3.3 ±87.29 days, with durations ranging from one to 26 days. Patients undergoing surgery and reconstruction had a significantly longer hospital stay compared to those without reconstruction, with respective averages of 5.43 ±3.59 days and 1.91 ±1.18 days. The mean age of patients undergoing surgery and reconstruction was 36.65 ±17.03 years, which was lower than the mean age of 40.84 ±17.61 years for those undergoing surgery without reconstruction. Of the total, 54.2% of cases were diagnosed with benign tumors. Gender distribution in the surgery groups showed that 64.4% of patients undergoing surgery and reconstruction were male, while 58.6% of those undergoing surgery without reconstruction were male. There was no significant relationship between gender and the type of surgery performed (p > 0.05). A significant relationship was found between preoperative tumor pathology and the type of surgery performed (p < 0.05). Patients diagnosed with benign tumors had a lower likelihood of requiring reconstruction surgery compared to those with malignant tumors (14.8% vs. 85.2%).

Furthermore, postoperative tumor pathology was significantly associated with the type of surgery performed, with 67.2% of patients undergoing surgery without reconstruction having benign tumors compared to 32.8% with malignant tumors. Conversely, 43.8% of patients undergoing surgery and reconstruction had benign tumors, while 56.2% had malignant tumors (p < 0.05). There was no significant relationship between the patients’ history of chemotherapy and radiotherapy and the type of surgery performed (p > 0.05).

Table II shows a significant relationship between tumor histology and the type of surgery, whether with or without reconstruction (p < 0.05). According to the findings, 32.9% of patients undergoing surgery with reconstruction had sarcoma tumors, whereas 17.8% of them had fibrosis tumors. In contrast, 17.2% of patients undergoing surgery without reconstruction had sarcoma tumors, while 25.5% had fibrosis tumors.

Out of 131 patients, it was observed that 19 (14.5%) patients experienced post-surgery disease recurrence, necessitating further excision and reconstruction. Among the relapsed cases, 16 (84.3%) were malignant and 3 (15.7%) were benign. Specifically, among the malignant cases, 3 (18.8%) were metastases and 13 (81.2%) were sarcomas. Additionally, during hospitalization, 2 (1.5%) cases resulted in death, and 2 cases of complications were reported among hospitalized patients. One patient, who underwent surgery due to an extensive skin defect, experienced skin graft necrosis, which was managed by graft replacement. Another case involved skin inflammation at the cement placement site.

Discussion

Numerous studies have investigated the treatment of chest wall masses and associated methods across various academic centers. However, none of these studies have provided detailed surgical recommendations or specific surgical approaches for patients with such masses. Therefore, this study aimed to investigate the frequency of surgical chest wall tumors and their respective treatments at Ghaem Hospital in Mashhad from 2011 to 2021.

Primary malignant tumors of the chest wall are typically categorized into two main types: primary bone tumors and primary soft tissue tumors [12]. The most common primary malignant tumors include malignant fibrous histiocytoma (MFH), chondrosarcoma, and leiomyosarcoma. Additionally, common benign tumors comprise chondroma, desmoid tumor, fibrous dysplasia, and osteochondrodysplasia [13]. Desmoid tumor, a soft tissue tumor, is considered an intermediate neoplasm, posing diagnostic challenges. Some pathologists classify it as benign fibromatosis, while others classify it as a low-grade fibrosarcoma [4, 5, 9].

More than half of malignant chest wall tumors are metastatic lesions originating from distant organs, including carcinoma or metastatic sarcoma, or due to invasion from adjacent structures such as breast, lung, pleura, or mediastinum [8]. The predominant tumor histologies are sarcoma at 26%, fibromatosis at 21.4%, inflammatory lesions at 9.2%, and osteochondroma at 2%. Among sarcoma cases, chondrosarcoma is the most common subtype. Research by Fatahi et al. suggests that wide resection of the chest wall for primary or secondary tumors, followed by reconstruction, is an effective and safe treatment method, offering promising long-term outcomes [12].

Another study in Iran conducted by Tabatabai et al. reported that benign tumors accounted for 41.1% and malignant tumors for 58.9% of cases. Among the study population, malignancy prevalence was 56.5% in males and 62% in females. Osteosarcoma was the most common malignant tumor, while inflammatory lesions were the predominant histological subtype of benign tumors. Tabatabai et al. also concluded that therapeutic and surgical interventions to remove the mass are the most effective treatments for patients [7]. Benign tumors typically manifest around 15 years earlier than malignant lesions, with an average age of onset at 26 years for benign and 40 years for malignant lesions. The male-to-female incidence ratio is approximately 2.1 [14, 15].

In this study, 131 patients were examined, comprising 50 (38.2%) women and 81 (61.8%) men. Our results indicate a higher prevalence of chest wall tumors in men compared to women. This finding aligns with the study conducted by Tabatabai et al., where the prevalence of chest wall tumors was also higher in men [16]. The average age of the patients in our study was 38.51 ±17.35 years, ranging from 6 to 78 years. Fatahi et al. reported a similar trend in their study involving 61 patients, with ages ranging from 13 to 80 years and an average age of 40.19 years [7]. Like previous studies, we found a higher prevalence of tumors in men, with a male-to-female incidence ratio of 2 : 1 [7].

Tabatabai et al. examined 112 patients, with 62 (55.4%) men and 50 (44.6%) women. There was no significant difference in the average age between men and women. However, the average age of patients with malignant tumors was significantly higher compared to those with benign tumors. The average age for benign cases was 32.19 ±9.6 years, whereas for malignant cases, it was 44.7 ±22.4 years.

In our study, no significant relationship was found between gender and the type of surgery, whether reconstructive or non-reconstructive. Diagnosis of chest wall masses typically relies on biopsy and pathological examination. Excisional biopsy is used for small tumors (3–5 cm), while larger lesions undergo biopsy before initiating treatment [17–19].

Surgical treatment is preferred for primary malignant sarcomas of the chest wall, with wide resection being feasible even in cases involving multiple ribs, the sternum, or the clavicle. In cases of lung cancer invading the chest wall, radical resection may offer long-term survival. However, surgery for secondary chest wall tumors is primarily palliative and considered after failure of conservative treatments. Pleurisy with malignant cells is an absolute contraindication for surgery in these tumors [20].

Magnetic resonance imaging (MRI) is effective for evaluating soft tissue tumors involving the spine, spinal cord, or apex of the lung, while computed tomography (CT) scan is preferred for assessing lung parenchyma and identifying pulmonary nodules or calcifications [21–23].

In conclusion, surgical treatment remains the preferred option for primary malignant sarcomas of the chest wall, with wide resection being technically feasible even in cases involving multiple ribs, the sternum, or the clavicle. A report from the Mayo Clinic assessed the impact of wide resection on the long-term survival of patients with primary chest wall malignancies. The study found that among tumors completely resected with a margin of 4 cm, 56 patients had a 5-year life expectancy, compared to 29 patients whose tumors were resected with less than 2 cm margins [8, 24, 25].

Regarding chemotherapy before surgery for chest wall sarcoma, it is noted that some tumors, including osteochondrodysplasia, rhabdomyosarcoma, and PENT sarcoma, are sensitive to chemotherapy. However, tumors such as fibrosarcoma, lip sarcoma, desmoid tumor, synovial sarcoma, and malignant fibrotic histiocytoma may not necessarily require preoperative chemotherapy. The role of adjuvant chemotherapy in primary sarcomas of the chest wall remains unclear.

In our study, 112 (85.5%) patients had no history of chemoradiotherapy (CRT), while 19 (14.5%) patients had a history of CRT. Our investigations revealed no significant relationship between a history of CRT and the type of surgery (with or without reconstruction).

Currently, the most effective treatment strategy for malignancies often involves a combination of radiotherapy, chemotherapy, and surgery. The goal of chemotherapy and other treatments is to reduce the risk of cancer recurrence following surgery [26, 27].

In surgical treatment of chest tumors, wide surgical resection with adequate margins and subsequent reconstruction of the chest wall defect is crucial. This requires specialized experience and skill. Wide resection without surgical limitations is considered the best approach for primary malignant tumors. The decision to reconstruct depends on the location and size of the lesion. Lesions smaller than 5 cm in any area of the chest wall may not require reconstruction, but the defect must be adequately covered with soft tissue. Lesions larger than 5 cm in other areas of the chest wall typically require reconstruction [5, 7–9, 28].

When the skin is involved, a 0.75 cm margin of normal skin around the lesion is typically removed [25]. In cases where the tumor has not infiltrated the skin and subcutaneous tissue, an incision is made on the skin over the tumor area. Skin flaps can then be utilized for primary closure, with any scar tissue on the tumor removed. Additionally, any skin exposed to radiation should be excised due to decreased healing capacity and increased risk of local infection [29].

In some studies, surgeons performed wide surgical resections involving tumor-affected ribs with a resection margin of at least 3 cm. They also removed the rib above and below the tumor to ensure an adequate margin [30].

It is worth mentioning that in our study, we performed tumor resections with a margin of 4 cm without removing the adjacent unaffected ribs.

In the past, various materials such as fascia lata, rib osteal grafts, and metal prostheses were used for chest wall reconstruction. However, the use of fiberglass can cause stiffness in the chest, leading to injury and tissue destruction with continuous movement. Nowadays, synthetic materials such as Marlex mesh, Vicryl mesh, Gore-Tex polytetrafluoroethylene, and Prolene mesh are preferred due to their better tolerance and ease of use [30].

Muscles from the chest wall and omentum can be utilized to reconstruct soft tissue defects. Skin-muscular flaps offer several advantages, including long-term reliability and versatility in their usage. Muscles such as the pectoralis major, latissimus dorsi, and rectus abdominis are commonly used for this purpose. Skin-muscle flaps can also be employed individually or in combination, depending on the extent of the chest wall defect. The presence of perforating arteries under the muscle provides blood supply to the tissue, allowing large skin flaps to be moved along with the muscle [12].

In recent investigations, it was found that 58 (44.3%) patients underwent resection without reconstruction, while 73 (55.7%) underwent resection with reconstruction. A significant relationship was detected between post-surgery tumor pathology and the type of surgery with or without reconstruction. In patients undergoing surgery without reconstruction, 67.2% had benign tumors and 32.8% had malignant tumors. Conversely, among patients undergoing surgery with reconstruction, 43.8% had benign tumors and 56.2% had malignant tumors. These findings suggest that patients with benign tumors are less likely to require reconstruction, possibly due to the need for less tissue resection in malignant tumor surgery, reducing the spread of malignant cells [31–33].

The new frontiers in chest-wall reconstruction involve using 3D porous scaffolds that can recreate the ensemble of cell-instructive physicochemical and structural signals, inducing the formation and remodeling of bone tissue. However, the currently available devices fail to fully replicate the anatomical and functional characteristics of bone tissue due to its structural complexity and mechanical properties [34].

Of the patients who underwent resection with reconstruction, 38 (29%) received muscle skin flap reconstruction, 27 (20.6%) received mesh reconstruction, and 8 (6.1%) received mesh and cement reconstruction. There was a significant relationship between tumor histology and tumor type and the type of surgery without or with reconstruction. Among patients undergoing surgery with reconstruction, 32.9% had sarcoma tumors and 17.8% had fibrosis tumors. In contrast, among patients undergoing non-reconstructive surgery, 17.2% had sarcoma tumors, with chondrosarcoma being the most common subtype at 57.6%, and 25.9% had fibromatosis tumors.

Conclusions

The results of this research indicate that sarcoma and fibromatosis were the most common chest wall tumors among patients, with chondrosarcoma being the predominant subtype among sarcomas. Gender and history of chemoradiotherapy did not show a significant relationship with surgery and reconstruction outcomes. Patients with benign tumors were less likely to require surgery and reconstruction, with the most common reconstructive procedure being resection and reconstruction using a skin-muscular flap. Reconstruction was most frequently performed in patients with sarcoma tumors.

Among the studied patients, 19 underwent re-resection surgery due to tumor recurrence, primarily in cases of malignant tumors, particularly sarcoma. Additionally, two deaths occurred during hospitalization, one involving a woman with advanced breast cancer and recurrence at the mastectomy site and chest wall involvement, and the other involving a person with osteosarcoma of the sternum requiring wide resection of the lesion.

Furthermore, 2 cases of complications during hospitalization were reported: skin graft necrosis in a patient requiring a graft due to the extent of the skin defect, and skin inflammation at the cement placement site.

These findings, along with a review of medical publications, affirm that wide resection of the chest wall for primary or secondary tumors followed by reconstruction is an effective and safe treatment option.