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Chest wall tumours and resection with reconstruction
A primary malignant chest wall tumour in an adult is usually a chondrosarcoma at the costochondral junction, and in a child or young adult — Ewing sarcoma; the goal is wide resection with a 4 cm margin and reconstruction of the wall when the defect is large, and in Ewing sarcoma surgery follows chemotherapy.
Why it matters in the exam
Most chest wall masses are not primary tumours: metastases, invasion by lung or breast cancer, and infectious processes are more common. Among primary tumours, the commonest benign rib tumour is fibrous dysplasia, followed by osteochondroma and chondroma. The commonest primary malignant tumour in adults is chondrosarcoma — a hard, slow-growing anterior chest mass near the costochondral junction; it is resistant to chemotherapy and radiotherapy, so treatment is surgery. An important rule: every cartilaginous mass in the anterior chest is treated as malignant until proven otherwise, because a chondroma is hard to distinguish from a low-grade chondrosarcoma on biopsy, so it is excised with wide margins. Ewing sarcoma appears in children and young adults (sometimes called an Askin tumour when in the chest wall), with pain, a mass and sometimes fever; treatment combines neoadjuvant chemotherapy, resection and sometimes radiotherapy.
Biopsy is planned with the surgeon: a core needle biopsy, so that the biopsy tract is excised with the tumour. In resection of a malignant tumour a 4 cm margin is the aim, usually including one normal rib above and one below. Rigid or semi-rigid reconstruction (mesh, mesh with bone cement or titanium bars) is needed for a large anterior or lateral defect — usually above 5 cm or more than 4 ribs — to prevent paradoxical movement and impaired breathing. A posterior defect covered by the scapula does not always need reconstruction, but a defect near the scapular tip requires it so the scapula does not "catch" in the defect. Soft-tissue cover uses a muscle flap (latissimus dorsi or pectoralis major). A desmoid tumour is a benign but aggressive tumour that tends to recur; observation or medical treatment precedes surgery in many cases.
For a lung tumour invading the wall (T3) the lung and chest wall are resected en bloc.
Key points
- The commonest primary malignant tumour in an adult — chondrosarcoma.
- In a child — Ewing sarcoma.
- A 4 cm margin.
- Reconstruction for a defect above 5 cm or more than 4 ribs.
- Cover with a muscle flap.
Summary table
| Tumour | Age and features | Treatment |
|---|---|---|
| Fibrous dysplasia | Commonest benign rib tumour | Observation or excision if painful |
| Chondrosarcoma | Adults, anterior chest, costochondral junction | Wide resection with a 4 cm margin |
| Ewing sarcoma | Children and young adults, pain and fever | Chemotherapy then resection, sometimes radiotherapy |
| Desmoid | Benign but aggressive, recurs | Observation, medical treatment or resection |
| Metastasis or invasion from the lung | The commonest | By the primary tumour; en bloc resection in T3 |
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Bone Cancer, 2025 — Chondrosarcoma and Ewing sarcoma
- Shields' General Thoracic Surgery, 8th edition (2019) — Chest wall tumors and reconstruction
- ESMO–EURACAN–GENTURIS Clinical Practice Guideline: Bone sarcomas, 2021 — Diagnosis and treatment
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.