Patient Information: Chest Wall Tumours and their Management

 

This information sheet is designed to help you understand more about tumours that can occur in the chest wall, how they are diagnosed, and the different ways they can be treated.

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What is the Chest Wall?

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The chest wall is the structure that surrounds and protects your lungs and heart. It includes:

• Ribs: The bones that form the main framework.

• Sternum (Breastbone): The flat bone in the middle of your chest where most ribs connect.

• Muscles: Layers of muscle between and overlying the ribs.

• Cartilage: Flexible tissue that connects the ribs to the sternum.

• Skin and Soft Tissues: Including fat and connective tissue.

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What are Chest Wall Tumours?

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A chest wall tumour is an abnormal growth of cells that develops in any of the tissues that make up the chest wall. These tumours can be:

• Benign (Non-cancerous): These tumours do not spread to other parts of the body and are usually not life-threatening. However, they can sometimes grow large and cause problems by pressing on nearby structures.

• Malignant (Cancerous): These tumours can invade nearby tissues and organs, and can spread (metastasize) to other parts of the body.

 

Chest wall tumours can be:

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• Primary: Meaning they originate in the chest wall itself.

• Secondary (Metastatic): Meaning cancer cells have spread to the chest wall from a primary cancer elsewhere in the body (e.g., lung cancer, breast cancer, kidney cancer). This information sheet focuses primarily on primary chest wall tumours.

 

Types of Chest Wall Tumours

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There are many different types of chest wall tumours, depending on the tissue they arise from.

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Common Benign Chest Wall Tumours:

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• Lipoma: A tumour made of fat cells.

• Fibrous Dysplasia: A bone disorder where normal bone is replaced with fibrous tissue.

• Chondroma: A benign tumour of cartilage.

• Osteochondroma: A benign growth containing both bone and cartilage, often near the ends of ribs.

• Neurofibroma/Schwannoma: Benign tumours arising from nerve tissue.

 

Common Malignant Chest Wall Tumours (Sarcomas are common primary malignant types):

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• Chondrosarcoma: Cancer arising from cartilage cells; the most common primary malignant chest wall tumour in adults.

• Osteosarcoma: Cancer arising from bone cells.

• Ewing's Sarcoma: A type of bone or soft tissue cancer, more common in children and young adults.

• Fibrosarcoma/Malignant Fibrous Histiocytoma (MFH)/Undifferentiated Pleomorphic Sarcoma: Cancers arising from fibrous connective tissue.

• Rhabdomyosarcoma: Cancer arising from muscle cells.

• Plasmacytoma/Multiple Myeloma: Cancers of plasma cells (a type of white blood cell) that can affect the bones of the chest wall.

• Lymphoma: Cancer of the lymphatic system that can sometimes involve the chest wall.

 

What are the Symptoms?

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Symptoms can vary depending on the type, size, and location of the tumour. Some people may have no symptoms, and the tumour is found incidentally on an imaging test. Common symptoms include:

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• A lump or swelling on the chest wall: This is often the first sign. It may or may not be painful.

• Pain: Can be localised to the area of the tumour, or may radiate. It can be a dull ache or a sharp pain, sometimes worse at night or with movement/breathing.

• Restricted movement.

• Changes in the shape of the chest.

• Difficulty breathing (less common unless the tumour is very large or involves the lungs).

• General symptoms (more common with malignant tumours): Unexplained weight loss, fatigue, fever.

 

How are Chest Wall Tumours Diagnosed?

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1. Medical History and Physical Examination: Your doctor will ask about your symptoms, medical history, and family history. They will perform a physical examination, including feeling the lump and assessing your general health.

2. Imaging Tests:

   • Chest X-ray: Can often show a mass or abnormality in the chest wall bones or soft tissues.

   • CT Scan (Computed Tomography): Provides detailed cross-sectional images of the chest wall, showing the size, location, and extent of the tumour, and whether it involves nearby structures like the lungs or ribs. Contrast dye may be used.

   • MRI Scan (Magnetic Resonance Imaging): Excellent for looking at soft tissues, muscles, nerves, and bone marrow. It can help determine the type of tissue the tumour is made of and its relationship to surrounding structures.

   • PET Scan (Positron Emission Tomography): Often combined with a CT scan (PET-CT). It can help determine if a tumour is cancerous, if cancer has spread, and how the tumour is responding to treatment.

   • Bone Scan: May be used to see if a tumour involves bone or if cancer has spread to other bones.

3. Biopsy: This is the most important step to get a definitive diagnosis, especially to determine if a tumour is benign or malignant, and its specific type. A small sample of the tumour tissue is removed and examined under a microscope by a pathologist.

   • Needle Biopsy: A thin needle is inserted into the tumour to get a sample. This can be done using CT or ultrasound guidance (Image-Guided Biopsy).

     • Fine Needle Aspiration (FNA): Uses a very thin needle to draw out cells.

     • Core Needle Biopsy: Uses a slightly larger needle to get a small cylinder of tissue. This is often preferred as it provides more tissue for diagnosis.

   • Incisional Biopsy: A small surgical procedure where a piece of the tumour is removed.

   • Excisional Biopsy: The entire lump is removed surgically. This may be done if the tumour is small and thought to be benign, or if a needle biopsy is not conclusive.

 

How are Chest Wall Tumours Managed?

 

Treatment depends on many factors, including:

• Whether the tumour is benign or malignant.

• The specific type and grade of the tumour (how aggressive it looks under the microscope).

• The size and location of the tumour.

• Whether the tumour has spread.

• Your overall health and preferences.

Treatment often involves a team of specialists (Multidisciplinary Team - MDT), including surgeons, oncologists (cancer specialists), radiologists, and pathologists.

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1. Surgery

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Surgery is the main treatment for most primary chest wall tumours, both benign and malignant.

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• For Benign Tumours: Surgery is often done to remove the tumour if it is causing symptoms, growing, or if there's any uncertainty about the diagnosis. The goal is complete removal.

• For Malignant Tumours: The goal is to completely remove the tumour along with a margin (a border) of healthy tissue around it (wide local excision). This is to reduce the risk of the cancer coming back.

  • Chest Wall Resection: This involves removing the part of the chest wall affected by the tumour. This may include ribs, muscle, and sometimes part of the sternum or other tissues.

  • Chest Wall Reconstruction: If a large part of the chest wall is removed, reconstruction is usually necessary to protect the internal organs, maintain chest stability, and ensure proper breathing mechanics. Reconstruction can involve:

    • Synthetic materials: Such as mesh (e.g., Prolene, Gore-Tex) or bone cement to bridge the defect.

    • Muscle flaps: Using nearby muscles (e.g., latissimus dorsi, pectoralis major) rotated to cover the defect.

    • Bone grafts: Less commonly, bone from another part of the body might be used.

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2. Radiotherapy (Radiation Therapy)

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Radiotherapy uses high-energy X-rays or other types of radiation to kill cancer cells or stop them from growing. It may be used for malignant chest wall tumours:

• After surgery (Adjuvant Radiotherapy): To kill any remaining cancer cells and reduce the risk of the cancer coming back, especially if the tumour was large, high-grade, or the surgical margins were close.

• Before surgery (Neoadjuvant Radiotherapy): To shrink a large tumour to make it easier to remove surgically.

• As the main treatment: If surgery is not possible, or for certain types of tumours that respond well to radiation (e.g., Ewing's sarcoma, lymphoma).

• For Palliative Care: To relieve symptoms like pain if the cancer has spread or cannot be cured.

Radiotherapy is carefully planned to target the tumour while minimising damage to surrounding healthy tissues. Treatment is usually given in a series of daily sessions over several weeks.

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3. Chemotherapy

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Chemotherapy uses anti-cancer drugs to kill cancer cells. The drugs are usually given intravenously (into a vein) or sometimes as tablets. They travel throughout the body, so chemotherapy can treat cancer cells that may have spread.

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Chemotherapy may be used for malignant chest wall tumours:

• Before surgery (Neoadjuvant Chemotherapy): To shrink the tumour.

• After surgery (Adjuvant Chemotherapy): To kill any remaining cancer cells and reduce the risk of spread.

• As the main treatment: For certain types of tumours that are very sensitive to chemotherapy (e.g., Ewing's sarcoma, lymphoma, osteosarcoma, rhabdomyosarcoma).

• For metastatic disease: If the cancer has spread to other parts of the body.

• In combination with radiotherapy.

 

The type of chemotherapy drugs used depends on the specific type of cancer. Side effects are common and vary depending on the drugs used but can include fatigue, nausea, hair loss, and increased risk of infection.

 

4. Other Treatments

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• Targeted Therapy: These are newer drugs that target specific molecules involved in cancer cell growth. They may be an option for certain types of chest wall sarcomas or metastatic cancers.

• Immunotherapy: This type of treatment helps your own immune system to fight cancer. Its role in primary chest wall tumours is still evolving but may be used for certain metastatic cancers.

 

What to Expect (General Points)

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• Before Treatment: You will have detailed discussions with your medical team about the proposed treatment, benefits, risks, and expected outcomes. You may need further tests to plan treatment.

• During Treatment: This will vary greatly depending on the treatment type. Surgery involves a hospital stay and recovery period. Radiotherapy and chemotherapy are often given as outpatient treatments over weeks or months.

• After Treatment: Regular follow-up appointments are crucial.

 

Recovery and Follow-Up

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• After Surgery: Recovery depends on the extent of the surgery and reconstruction. You will have pain, which will be managed with medication. You will likely have chest drains initially. Physiotherapy is important to help with breathing, movement, and regaining strength.

• Follow-up Care: After treatment for a malignant tumour, you will need regular follow-up appointments for many years. These appointments may include physical examinations, blood tests, and imaging scans (e.g., CT, MRI, X-ray) to monitor for any signs of the cancer returning or spreading.

• Living with Changes: Depending on the treatment, you may have long-term changes to your chest appearance or function. Support services and rehabilitation can help you adapt.

 

When to Contact Your Doctor

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Contact your doctor or specialist nurse if you experience any of the following after treatment:

• New or worsening pain.

• A new lump or swelling.

• Signs of infection around a surgical wound (redness, warmth, swelling, pus, fever).

• Increasing shortness of breath or cough.

• Unexplained weight loss or persistent fatigue.

• Any new or concerning symptoms.

 

Support

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Dealing with a chest wall tumour can be challenging. Don't hesitate to seek support from your healthcare team, family, friends, and patient support groups.

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Disclaimer: This information sheet provides general guidance and is not a substitute for professional medical advice, diagnosis, or treatment. The management of chest wall tumours is complex and depends on your individual circumstances. Always discuss your specific condition, treatment options, risks, and benefits thoroughly with your medical team.

Rib and Sternal Fractures :
Management, Complications, and Surgical Treatment
 

This information sheet is designed to help you understand rib and sternal (breastbone) fractures, potential complications like malunion and pseudarthrosis, and how they are managed, including surgical options and pain control.
 

What are Rib and Sternal Fractures?
 

• Rib Fractures: A rib fracture is a crack or break in one or more of the bones that form your rib cage. The rib cage protects your lungs, heart, and other internal organs. You have 12 pairs of ribs.

• Sternal Fracture: A sternal fracture is a break in your sternum (breastbone), the long, flat bone located in the center of your chest.

These fractures can range from a simple crack to a complete break, and sometimes multiple ribs or parts of the sternum can be affected.

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What Causes Rib and Sternal Fractures?
 

These fractures are most commonly caused by trauma to the chest:

• Blunt Force Trauma: This is the most common cause. Examples include:

  • Car accidents (e.g., impact from a steering wheel or seatbelt).

  • Falls, especially in older adults.

  • Direct blows to the chest during sports or assaults.

  • Crush injuries.

• Severe Coughing: Rarely, prolonged and forceful coughing (e.g., due to a severe chest infection) can lead to stress fractures of the ribs, especially in people with weaker bones.

• Cardiopulmonary Resuscitation (CPR): Rib or sternal fractures can sometimes occur during CPR.

• Underlying Bone Conditions: Conditions like osteoporosis or cancer that has spread to the bones can make them weaker and more prone to fracture with less force.
   

What are the Symptoms?
 

Symptoms can vary depending on the severity and location of the fracture(s):

• Chest Pain: This is the most common symptom. The pain is often sharp and worsens with:

  • Deep breathing.

  • Coughing or sneezing.

  • Twisting or moving the torso.

  • Pressing on the injured area.

• Tenderness and Swelling: Over the fractured area.

• Bruising: On the chest wall.

• Shortness of Breath or Difficulty Breathing: Especially if multiple ribs are broken or if there's an associated lung injury (like a pneumothorax - collapsed lung).

• A "Crunching" or "Grinding" Sensation (Crepitus): When you move or breathe, if the broken bone ends rub together.

• Deformity: In severe cases, there might be a visible change in the shape of the chest.

• Pain Radiating to the Shoulder or Arm.
   

How are Rib and Sternal Fractures Diagnosed?
 

1. Medical History and Physical Examination: Your doctor will ask about how the injury occurred, your symptoms, and your medical history. They will examine your chest, listen to your breathing, and gently press on your chest to identify tender areas.

2. Imaging Tests:

   • Chest X-ray: This is often the first imaging test to look for rib and sternal fractures and to check for related lung injuries like a pneumothorax or lung contusion (bruising). However, some fractures, especially non-displaced ones (where the bone ends are still aligned), may not be easily visible.

   • CT Scan (Computed Tomography): This provides more detailed images and is better at detecting subtle fractures, multiple fractures, the exact position of broken bones, and associated injuries to internal organs. It's often used for more significant trauma.

   • Ultrasound: Can sometimes be used, particularly at the bedside in emergency settings, to detect rib fractures or associated pleural fluid/pneumothorax.

   • Bone Scan: Rarely needed for acute fractures but might be used if stress fractures or underlying bone disease is suspected.
      

How are Rib and Sternal Fractures Initially Managed?
 

Most rib and sternal fractures heal on their own with time (usually 6-8 weeks). The main focus of initial management is pain control and preventing complications like chest infections.

1. Pain Management: This is crucial.

   • Oral Painkillers: Such as paracetamol, anti-inflammatory drugs (e.g., ibuprofen – if appropriate for you), and sometimes stronger opioid painkillers for a short period if the pain is severe.

   • Nerve Blocks: In some cases, an injection of local anaesthetic around the nerves supplying the injured area (e.g., intercostal nerve block, paravertebral block, erector spinae plane block) can provide significant pain relief. This might be done as a one-off injection or via a catheter for continuous relief in hospital.

   • Ice Packs: Applied to the injured area (wrapped in a cloth) for 15-20 minutes at a time, several times a day, can help reduce pain and swelling, especially in the first few days.

   • Avoiding Restrictive Bandaging: Strapping the chest tightly is generally NOT recommended as it restricts breathing and can increase the risk of lung complications.

2. Breathing Exercises and Coughing:

   • It's important to take deep breaths and cough regularly, even if it's uncomfortable. This helps keep your lungs clear and prevents pneumonia. Your doctor or a physiotherapist can teach you techniques (e.g., "huffing," splinting the injured area with a pillow when you cough).

3. Rest and Activity Modification:

   • Avoid activities that worsen your pain or could re-injure your chest.

   • Gradually increase your activity as your pain allows.

4. Managing Associated Injuries: If there are other injuries, such as a pneumothorax or lung contusion, these will be managed appropriately (e.g., with a chest drain).
    

Complications: Malunion and Pseudarthrosis
 

Sometimes, rib or sternal fractures do not heal properly, leading to complications:

• Malunion: This means the fractured bone has healed, but in an abnormal or misaligned position. This can lead to:

  • Chronic pain.

  • Noticeable deformity of the chest wall.

  • Restricted movement or difficulty breathing.

  • Clicking or popping sensations.

• Pseudarthrosis (Non-union): This means the fractured bone fails to heal completely, and a "false joint" forms at the fracture site. This results in persistent movement at the fracture site, causing:

  • Chronic pain, often worse with movement or breathing.

  • Instability of the chest wall.

  • A persistent clicking or grinding sensation.

  • Difficulty with daily activities.

These complications are more common with multiple displaced fractures, severe trauma, or if there are factors that impair bone healing (e.g., smoking, poor nutrition, certain medical conditions).

Drawing Placeholder: Illustrations showing a normal healed fracture, a malunion (healed in a bad position), and a pseudarthrosis (non-healed with a false joint).
 

When is Surgery Considered for Rib and Sternal Fractures, Malunion, or Pseudarthrosis?
 

Surgery is not usually needed for most rib and sternal fractures. However, it may be recommended in specific situations:
 

• Flail Chest: This is a serious condition where multiple adjacent ribs are broken in more than one place, causing a segment of the chest wall to become unstable and move paradoxically (inward during inhalation, outward during exhalation). This severely impairs breathing and often requires surgical fixation.

• Significant Displacement of Fractures: If the broken ends of the bones are far apart or severely angled, which could lead to poor healing, chronic pain, or risk of injury to internal organs.

• Severe Pain Uncontrolled by Other Means: If pain remains debilitating despite optimal non-surgical pain management.

• Progressive Decline in Lung Function: Due to pain and inability to breathe deeply.

• Symptomatic Malunion or Pseudarthrosis: If these complications are causing significant chronic pain, deformity, or functional impairment.

• Need for Prolonged Mechanical Ventilation: In trauma patients, fixing the fractures can sometimes help with weaning from a ventilator.

• Cosmetic Deformity: In some cases, if the deformity is significant and bothersome.
   

Surgical Management
 

The goal of surgery is to stabilise the fractured bones in their correct position (fixation), promote healing, relieve pain, and improve chest wall mechanics and lung function. This is often called Surgical Stabilisation of Rib Fractures (SSRF) or sternal fixation.
 

• Procedure:

  • Surgery is performed under general anaesthesia.

  • Incisions are made over the fractured ribs or sternum.

  • The surgeon carefully realigns the broken bone fragments.

  • Specialized metal plates and screws, designed for ribs or the sternum, are used to hold the bones in place while they heal. These are usually made of titanium.

  • For malunions or pseudarthrosis, the surgeon may need to remove any fibrous tissue from the "false joint," reshape the bone ends, and sometimes use bone graft (taken from your own body, e.g., rib or pelvis, or a synthetic bone substitute) to encourage healing, before applying plates and screws.

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• Benefits of Surgery Can Include:

  • Better pain control.

  • Improved breathing mechanics.

  • Shorter time on a ventilator (in trauma patients).

  • Reduced risk of pneumonia.

  • Earlier return to normal activities.

  • Correction of deformity and prevention/treatment of malunion/pseudarthrosis.
     

• Risks of Surgery Include:

  • General risks of anaesthesia.

  • Infection (wound infection or infection around the plates/screws).

  • Bleeding.

  • Pain (though usually less than the fracture pain over time).

  • Nerve injury causing numbness or persistent pain.

  • Injury to underlying structures (lungs, heart, blood vessels) – rare with experienced surgeons.

  • Hardware problems (e.g., plate loosening or breaking, though uncommon with modern implants).

  • Failure of the bone to heal despite surgery (non-union).

  • Blood clots (DVT/PE).
     

Your surgeon will discuss the specific procedure, benefits, and risks relevant to your situation.
 

Management of Pain After Surgery
 

Effective pain management is crucial for recovery:

• Intravenous or Oral Painkillers: Stronger painkillers are often needed initially, then tapered down.

• Nerve Blocks/Regional Anaesthesia: Techniques used before or during surgery (e.g., paravertebral block, epidural) can provide excellent pain relief for the first few days.

• Patient-Controlled Analgesia (PCA): A pump that allows you to self-administer small doses of pain medication as needed.

• Ice Packs.

• Physiotherapy: Early mobilisation and breathing exercises are important.
   

Recovery and Follow-Up
 

• Hospital Stay: Varies from a few days to over a week, depending on the extent of your injuries and surgery.

• At Home:

  • You will be given instructions on wound care, pain management, and activity.

  • Avoid strenuous activities and heavy lifting for several weeks to months, as advised by your surgeon.

  • Gradually increase your activity.

  • Physiotherapy will be important for regaining movement, strength, and lung function.

• Follow-up: You will have regular follow-up appointments with your surgeon, including X-rays or CT scans to check bone healing and the position of any implants.

• Implants: The metal plates and screws are usually left in place permanently unless they cause problems (e.g., irritation, infection).
   

When to Seek Medical Attention
 

Contact your doctor or seek medical attention if you experience:

• After initial injury (non-surgical management): Worsening shortness of breath, severe uncontrolled pain, fever, coughing up blood or greenish/yellow phlegm.

• After surgery: Increasing pain not relieved by medication, signs of infection (redness, swelling, warmth, discharge from the wound, fever), new or worsening shortness of breath, calf pain or swelling (possible DVT).
   

Key Points to Remember
 

• Most rib and sternal fractures heal without surgery, with a focus on pain control and breathing exercises.

• Malunion (healing in a bad position) or pseudarthrosis (non-healing) can cause chronic pain and may require surgery.

• Surgery involves fixing the broken bones with plates and screws and is considered for specific situations like flail chest, severe pain, or symptomatic non-healing.

• Effective pain management is key to recovery, both with and without surgery.
   

Disclaimer: This information sheet provides general guidance and is not a substitute for professional medical advice, diagnosis, or treatment. The management of rib and sternal fractures is complex and depends on your individual circumstances. Always discuss your specific condition, treatment options, risks, and benefits thoroughly with your medical team.