Chest wall tumors are benign or malignant tumors that arise within the chest wall (but outside the lung parenchyma) that can interfere with pulmonary function. Symptoms are due to obstruction. Diagnosis is made by chest imaging and biopsy for identification of histological type. Treatment often depends on cancer type. General approaches include observation for small lesions and surgical resection with reconstruction for malignant lesions, if possible. Some tumors require surgery with or without chemotherapy and radiation therapy.
Primary chest wall tumors account for 5% of all thoracic tumors and 1 to 2% of all primary tumors (1). More than 50% are malignant.
The most common benign chest wall tumors are:
Osteochondroma
Chondroma
Fibrous dysplasia
A wide range of malignant chest wall tumors exist. Over half are metastases from distant organs or direct invasions from adjacent structures (breast, lung, pleura, mediastinum).
The most common malignant primary tumors arising from the chest wall are:
Sarcomas: Approximately 55% originate from cartilaginous tissue or bone (2, 3), and 45% originate from soft tissue
Chondrosarcomas are the most common primary chest wall sarcoma (2) and arise from the anterior tract of ribs and less commonly from the sternum, scapula, or clavicle. Bone tumors include osteosarcoma and small-cell malignant tumors (eg, Ewing sarcoma, Askin tumor).
The most common soft-tissue primary malignant tumors are fibrosarcomas (desmoids, neurofibrosarcomas) and liposarcomas (4). Other primary tumors include chondroblastomas, osteoblastomas, melanomas, lymphomas, rhabdomyosarcomas, lymphangiosarcomas, multiple myeloma, and plasmacytomas.
General references
1. Carter BW, Benveniste MF, Betancourt SL, et al. Imaging Evaluation of Malignant Chest Wall Neoplasms. Radiographics. 2016;36(5):1285-1306. doi:10.1148/rg.2016150208
2. Crowley TP, Atkinson K, Bayliss CD, Barnard S, Milner RH, Ragbir M. The surgical management of sarcomas of the chest wall: A 13-year single institution experience. J Plast Reconstr Aesthet Surg. 2020;73(8):1448-1455. doi:10.1016/j.bjps.2020.02.036
3. van Roozendaal LM, Bosmans JWAM, Daemen JHT, et al. Management of soft tissue sarcomas of the chest wall: a comprehensive overview. J Thorac Dis. 2024;16(5):3484-3492. doi:10.21037/jtd-23-1149
4. Gross JL, Younes RN, Haddad FJ, Deheinzelin D, Pinto CA, Costa ML. Soft-tissue sarcomas of the chest wall: prognostic factors. Chest. 2005;127(3):902-908
Symptoms and Signs of Chest Wall Tumors
Soft-tissue chest wall tumors often manifest as a localized mass without other symptoms. Approximately 20% of patients with benign chest tumors are asymptomatic (1). Some chest wall tumors are detected incidentally when imaging studies are done for another clinical reason. Some patients may have constitutional symptoms such as weight loss, fatigue, and fever. Patients usually do not have pain until the tumor is advanced. In contrast, primary cartilaginous tumors and bone tumors are often painful.
Symptoms and signs reference
1. Minervini F, Sergi CM, Scarci M, et al. Benign tumors of the chest wall. J Thorac Dis. 2024;16(1):722-736. doi:10.21037/jtd-23-464
Diagnosis of Chest Wall Tumors
Imaging
Biopsy
Patients with chest wall tumors require chest radiography, CT, MRI, and sometimes positron emission tomography (PET)–CT to determine the original site and extent of the tumor and whether it is a primary chest wall tumor or a metastasis.
Biopsy and histologic evaluation confirm the diagnosis.
Treatment of Chest Wall Tumors
Surgery
Sometimes combination chemotherapy, radiation therapy, and surgery
Benign tumors are usually managed with surgical excision, although observation may be appropriate for small, asymptomatic lesions (1).
Malignant tumors are usually treated with wide surgical resection and reconstruction (2). Some tumors may also require further adjuvant chemotherapy or radiation therapy. Reconstruction often uses a combination of myocutaneous flaps and prosthetic materials. The presence of a malignant pleural effusion is a contraindication to surgical resection.
In cases of multiple myeloma or isolated plasmacytoma, chemotherapy and radiation therapy should be the primary therapy.
Small-cell malignant tumors such as Ewing sarcoma and Askin tumor should be treated with a multimodality approach, combining chemotherapy, radiation therapy, and surgery.
In cases of chest wall metastasis from distant tumors, a palliative chest wall resection is recommended only when nonsurgical options do not alleviate symptoms.
Treatment references
1. Minervini F, Sergi CM, Scarci M, et al. Benign tumors of the chest wall. J Thorac Dis. 2024;16(1):722-736. doi:10.21037/jtd-23-464
2. Sharma J, Deo SVS, Kumar S, et al. Malignant Chest Wall Tumors: Complex Defects and Their Management-A Review of 181 Cases. Ann Surg Oncol. 2024;31(6):3675-3683. doi:10.1245/s10434-023-14765-w
Prognosis for Chest Wall Tumors
Prognosis varies by cancer type, cell differentiation, and stage; firm conclusions are limited by the low incidence of any given tumor. Sarcomas have been the most well studied, and primary chest wall sarcomas have a reported 5-year overall survival of approximately 50% and recurrence-free survival of 72% (1). Survival is better with early-stage disease.
Prognosis reference
1. Sarvan M, Etienne H, Bankel L, Brown ML, Schneiter D, Opitz I. Outcome Analysis of Treatment Modalities for Thoracic Sarcomas. Cancers (Basel). 2023;15(21):5154. doi:10.3390/cancers15215154
Key Points
Almost half of chest wall tumors are benign.
Less than half of malignant chest wall tumors are primary.
Consider the diagnosis if patients have a chest mass or unexplained chest wall pain, with or without fever.
Diagnose chest wall tumors with imaging, followed by biopsy.
Treat most with surgical resection and reconstruction (unless malignant pleural effusion is present), and sometimes chemotherapy and/or radiation therapy.
