chest wall soft tissue tumor
Introduction
Brief introduction of chest wall soft tissue tumor Thoracic soft tissue tumors are more common and less common. The soft tissue tumors of the chest wall in children and the elderly are mostly malignant, and the tumors that grow faster are more likely to be malignant. basic knowledge The proportion of sickness: 0.1% - 0.4% Susceptible people: no special people Mode of infection: non-infectious Complications: lung abscess
Cause
Chest wall soft tissue tumor cause
Associated with traumatic estrogen inheritance and other factors, histologically well-differentiated fibroblasts and collagen-rich are manifested as benign tumors but infiltrating surrounding tissue may be multiple lesions (called invasive fibromatosis). Located in the abdomen on the chest and more in the shoulders or shoulders, young people are most common, especially young pregnant women.
Prevention
Chest wall soft tissue tumor prevention
Attention to rest, work and rest, life order, high disease prognosis is worse than low-grade lesions. The best prognosis of rhabdomyosarcoma is the worst.
Complication
Chest wall soft tissue tumor complications Complications lung abscess
Abscess, ulcer.
Symptom
Chest wall soft tissue tumor symptoms Common symptoms Leukocytosis Coffee spot calcification Growth slow abscess Trauma rheumatoid arthritis Hypertension Calcified chest wall infiltration
The performance of benign and malignant tumors is not the same, and the clinical manifestations of tumors of different tissue types are also different, as follows:
Benign chest wall tumor
(1) lipoma: a common benign tumor of the chest wall, composed of mature adipocytes, with a complete capsule, a fibrous bundle in the tumor, adhesion to the skin and fascia, which occurs in the skin and can also be seen in the muscles. Often occurs in the back, neck and shoulders, usually asymptomatic, mostly single, divided into hard and soft, the latter can grow into a large tumor, the general tumor is oval or lobulated, more outward Growth can form an exogenous mass; it can also grow into the thoracic cavity, or grow in both the inward and outward directions to form a dumbbell shape; some can be extracted from the chest to the supraclavicular fossa, and the tangential X-ray film and the body slice can be seen. The lipoma body is in a translucent area, and there is occasional calcification in the tumor. MRI or CT shows a clear and uniform fat density of the tumor edge; if the tumor penetrates the entire chest wall, the local intercostal space is widened and painlessly grown; And clear radiological diagnosis, no need to deal with; if the tumor grows or has symptoms, it can be completely resected along the edge; rare recurrence; small tumor resection without difficulty, huge into the chest, need to do thoracotomy.
(2) Schwannomas: benign nerve sheath tumors occur in young and middle-aged people; often asymptomatic; MRI shows eccentric tumors originating from peripheral nerves; histology includes: Antoni A or Antoni B cells; Antoni A: small Spindle cells, distorted nucleus, cytoplasmic unclear, transparent vacuoles; Antoni B: few cellular components, treatment: tumor resection to preserve nerves.
(3) Neurofibromatosis: single or multiple (see neurofibromatosis); most tumors are superficial, slow-growing, painless; when involving large nerves, they may be dumbbell-shaped; histology: distorted, prolonged The cell bundle has a wavy deep-stained nucleus; treatment: resection along the periphery; in neurofibromatosis, 5% to 30% of patients have malignant changes.
(4) Hemangioma: found in children and adults; can be located in the skin, subcutaneous, intramuscular; common with cavernous hemangioma and cavernous hemangioma, capillary cavernous hemangioma is capillary and cavernous hemangioma Hybrid, soft, higher than the skin, blue-red, easy to break bleeding, infection, necrosis and scar formation, can grow into a larger volume, small tumors should be surgically removed early, a larger range, surgical resection is difficult It is highly destructive. At present, hormone and laser therapy are used. Spongiform hemangioma is more common. The appearance of the skin is normal. The tumor is mainly located under the skin. It is slightly elevated, subcutaneous and intramuscular. The former is more limited and higher than the skin. Hemispherical, with a slightly cyan surface, is formed by a large number of blood-filled cysts. It is soft like a sponge. The palpation is sexy. The tumor is compressed by the palm of the hand. After decompression, it expands. The former has a complete capsule. Asymptomatic, can be surgically removed, the latter has no obvious boundaries, often irregularly extended to the intercostal and thoracic and other deep tissues, surgical resection of more bleeding, difficult to remove clean, easy to relapse after surgery You can try urea injection therapy, huge capillary hemangioma or cavernous hemangioma, which can seriously deplete platelets, blood coagulation factors II, V, VII and fibrinogen due to massive blood retention, resulting in anemia and abnormal blood coagulation mechanism. After the control is very difficult, it is necessary to correct the platelets and blood coagulation factors before tumor resection.
(5) Vascular cutaneous tumor: a rare tumor derived from the vascular epithelial cells, which may be located in various parts of the body, may be benign or malignant, and may be from a middle to a high, slow-growing painless mass. Treatment: lesion-based Differentiation.
(6) Nodular fasciitis: seen in young people, pain, rapid increase in lesions; 50% in the upper limbs, histology: short irregular banding, only a small amount of mature collagen, treatment: along the lesion Edge resection.
(7) Synovial cyst: The synovial membrane is a fibrous tissue sheath attached to the joint. It is an extension of the periosteum. The inner layer is covered with the synovial membrane. The synovial cyst is derived from the intima, while the ganglion cyst is not slippery. Periarticular cysts of the endometrial structure. These mucinous pseudocysts are derived from the aponeurosis or tendons. Synovial cysts are common in the knee joints, occasionally on the shoulders, elbows, hips and ankles. Some shoulder synovial cysts may appear as Asymptomatic chest wall tumors, tumors may grow faster, there may be recurrence after surgery, synovial cysts are asymptomatic, depending on their size and location, there may be mild discomfort or limited joint activity, compression of nerves, blood vessels Rarely, the vast majority of cases have no clear cause. They are considered to be spontaneous cysts, trauma, rheumatoid arthritis, synovitis or Charcot joints may be associated with cysts. Neurosynthesis cysts may originate from the phrenic nerve, median nerve, and ulnar nerve. Or phrenic nerve, chest wall synovial cyst may be located in the shoulder joint or intercostal nerve, but there may be no clear source, surgical resection should be performed to exclude malignant possibility.
(8) fibroids: Hard fibroma occurs in the deep fascia of the chest wall, tendon or periosteum, relatively rare, more common in the scapula, the causes are related to trauma, familial colon polyps, hormones, etc., due to more matrix, fewer cells, Therefore, the texture is hard, fixed with the long axis of the muscle, movable in the direction of the horizontal axis, and the growth is slow. It is a painless round or elliptical solid mass, and the size is uncertain. Once the brachial plexus or the iliac vein is violated, neurological symptoms may occur. Symptoms of vascular obstruction, soft tissue mass shadow on the X-ray film, occasionally the rib is compressed and eroded, although the pathological cell morphology is benign, but the tumor cells tend to infiltrate into the surrounding tissue, the naked eye appears to have a realm and capsule, but Histological examination does not have a true capsule. The extent of resection is often insufficient during surgery, resulting in easy recurrence after surgery. The recurrence rate is 25% to 65%. Therefore, the resection range should exceed the tumor itself, at least 3 cm away from the boundary seen by the naked eye. The site is removed.
2. Malignant chest wall tumor
(1) Malignant fibrous histiocytoma: similar to malignant fibrosarcoma. Treatment: extensive local excision, if > 5cm, can be supplemented by radiotherapy before, during and after surgery.
(2) extra-abdominal fibroma: fibroma is a rare fibroid tumor that originates from the tendon membrane tissue. It is characterized by the formation of fibroblasts and myofibroblasts. It is a low-grade malignant tumor with unclear etiology. May be related to trauma, estrogen, genetics, etc., histologically well-differentiated fibroblasts, and rich in collagen, mostly manifested as benign tumor appearance, but infiltrating surrounding tissue growth, may be multiple lesions (called Invasive fibromatosis), the tumor is mostly located in the abdomen, and the chest is mostly located in the shoulder or shoulder. It is most common in young people, especially young pregnant women. The palpation tumor has rock-like hardness. CT, MRI and biopsy can help diagnose. The principle of treatment is early diagnosis, extensive resection, such as anti-estrogen receptor-positive, resectable, anti-estrogen or non-steroidal anti-inflammatory drugs. It is currently believed that anti-estrogen can prevent the growth of hard fibroblast cells. Non-steroidal anti-inflammatory drugs play a certain therapeutic role by interfering with the metabolism of prostaglandins. They have the longest survival time in soft tissue sarcoma and more common local recurrence after surgery.
(3) epithelioid sarcoma: good for young people's hands, thighs, feet, knee nodular masses, ulcers and similar granulomas or rheumatoid nodules, lymph node metastasis, histology: oval or Polygonal cells, cytoplasmic eosin, extensive surgical resection.
(4) acinar soft tissue sarcoma: formerly known as malignant organosomal granulosa cell myoblastoma and malignant non-chromophobic paragangaroma, although it is difficult to confirm its exact source, but currently the pathology community believes it is striated muscle A subtype of sarcoma, most commonly found on the anterior side of the thigh, is rare in the chest wall, and occasionally reports of the anterior or posterior mediastinum. Unlike other soft tissue sarcomas, the blood is transferred to the lungs, but more is seen in the brain. Sometimes it can take up to 30 years to change, women, children are more common, treatment: extensive resection and radiotherapy.
(5) angiosarcoma: tumor tissue resembles vascular endothelium, which may be primary or secondary. The latter is more common in breast cancer after radiotherapy, which is rare, accounting for 1% to 2% of all soft tissue tumors and 0.7% of malignant tumors. Located in the soft tissue or bone tissue of the chest wall, it is often manifested as a chest wall tumor in the pleural cavity of the human body, which can cause hemothorax. CT shows that the tumor is a dense and uniform or uneven shadow, showing calcification and invasive growth. The characteristics (such as: invading the ribs), the tumor is not enhanced, MRI shows that the T1 and T2 windows are images of uneven density, this image is characterized by intratumoral hemorrhage, the degree of differentiation of the treatment depends on the tumor and its location At the site, it is generally believed that the angiosarcoma of the chest wall should be extensively resected after adjuvant radiotherapy, and the prognosis is poor.
(6) decidual clear cell sarcoma: young people with good hair, chronic growth, painless, occur in the tendon or aponeurosis area, treatment: extensive resection, and adjuvant radiotherapy.
(7) skin fibrous tissue cell sarcoma: skin fibrous tissue sarcoma, rare nodular skin tumor; young onset; moderate differentiation; local recurrence, but rare metastasis, treatment: extensive resection.
(8) liposarcoma: a malignant tumor differentiated from adipose tissue; mostly located in the adipose tissue of the extremities, the tumor cells are similar to the signet ring cells (adipocytes), the degree of differentiation is from low to high, low-grade liposarcoma: Tumor cells and benign lipoma are difficult to identify, treatment of low-grade liposarcoma: extensive resection or radiotherapy; treatment of high-grade liposarcoma: extensive resection plus radiotherapy.
(9) Fibrosarcoma: the most common soft tissue sarcoma. Gradually increasing painless mass. More common in the limbs, chest wall is rare. The age of onset is between 30 and 80 years old. In the case of symptoms, its size is often around 10cm. X-ray films are often normal unless there is bone attack. MRI showed uneven density of the tumor. Histology: cluster or fusiform cell shape, sparse cytoplasm, unclear boundaries, etc. Treatment: extensive local excision, if > 5cm, can be supplemented by radiotherapy before, during and after surgery.
(10) leiomyosarcoma: can be high or low tumor; may be related to blood vessels; extensive, radical surgical resection, plus radiotherapy.
(11) Neurofibrosarcoma: rare, may be neonatal or derived from neurofibromatosis; tends to be highly malignant, so the treatment needs extensive resection, or supplemented with radiotherapy.
(12) Rhabdomyosarcoma: the most common sarcoma for children, young people, accounting for 2/3 of children's soft tissue sarcoma, rapid growth, high malignancy, sensitive to multi-drug chemotherapy, histology: spindle cells, multinucleated giant cells and racket Cell and other manifestations are divided into 3 main types: 1 embryonic type is more common in infants and young children, mostly in the head and neck or genitourinary system (especially testicles, prostate, vagina and bladder), chest wall is rare; 2 acinar type is more common in young people More common in peripheral muscle tissue, sensitive to radiotherapy; 3 pleomorphism occurs in the elderly, common in the limbs of the muscle tissue, chest wall is rare, although not sensitive to radiotherapy, chemotherapy, but the best prognosis of the above 3 types, treatment: surgery Extensive surgical resection after chemotherapy, and radiotherapy.
(13) synovial sarcoma: highly malignant; occurs in the proximal joint, but rarely intra-articular lesions; X-ray will show intra-cranial calcification; histology: tumor has the dual characteristics of fusiform components and epithelial components, treatment: Extensive resection, supplemented by radiotherapy.
3. Neoplastic disease
(1) Synovial chondromatosis: mainly young people with disease, with pain, stiffness and swelling as the main manifestations, X-ray showed small punctate calcification, histological manifestations of synovial tissue or cartilage induration, treatment : Synovial resection and removal of the free body.
(2) multiple neurofibromatosis: also known as neurofibromatosis, first described by Von Recklinghausen in 1882, it is also known as Ray's phenomenon (syndrome), is a neurocutaneous syndrome, mainly expressed as skin The pigmentation (milk coffee spot) and the neurofibroma of the skin and the body, about 30% of the mediastinal neurofibromatosis is a manifestation of neurofibromatosis.
It is divided into at least 2 types, namely: 1 "traditional type": marked by skin lesions, accompanied by different degrees of other parts of the lesion; 2 "central type": skin lesions are not obvious, but bilateral acoustic neuroma mainly.
Its characteristics are: the incidence of newborn live birth is about 1 / 3000; important diagnostic indications are accompanied by Crowe's sign, namely: underarms, and even skin freckles; except for the primary subcutaneous, the most involved skeletal system, 15 % involving the lungs, neurofibroma is very common in the posterior mediastinum, originating in the vertebral roots may be in the spinal canal, forming a dumbbell shape, the primary neurofibroma in the lung parenchyma is rare.
Multiple neurofibromatosis can be complicated by the following diseases: 1 About 20% of patients over the age of 35 can develop diffuse interstitial fibrosis and bullous bullae of unknown origin. Some people think that pulmonary fibrosis and mesenchymal defects lead to Primary collagen deposition; 2 endothelial system abnormalities (pheochromocytoma); 3 renal abnormalities (renal artery stenosis with malignant hypertension); 4 about 5% can develop neurofibrosarcoma, more metastasis to the lungs; 5 other malignant tumors that may be associated with are: angiosarcoma, lymphoma, rhabdomyosarcoma and the like.
Examine
Examination of chest wall soft tissue tumors
1. X-ray plain film: all soft tissue tumors should be taken before the treatment of chest radiographs; lipoma and other can be expressed as fat density lesions; synovial sarcoma, chondrosarcoma or hemangioma can be seen punctate calcification; osteosarcoma or bone Osteomyelitis can be seen in ossification; osteomyelitis, primary bone disease or periosteal reaction caused by soft tissue tumors and other skeletal abnormalities.
2. CT scan: showing the extent of bone involvement and destruction, which is helpful for diagnosing subcortical destruction and fracture, calcification and ossification. It is not as good as MRI for soft tissue lesions, but soft tissue masses with diameter 5mm can be found for tumor staging, such as : Secondary lesions in the lungs.
3. MRI: is the most valuable imaging examination, but it is limited to large lesions or localized lesions; can clearly identify (malignant) bone lesions caused by a wide range of soft tissue lesions, or primary soft tissue tumors; T1 phase and Lesions with low T2 phase density, suggesting hard fibroma, extensive scar tissue, cortical or bone dense, or foreign bodies, such as: bone glue or gas; T1 phase is high, T2 phase is also high, suggesting that it may be lipoma, low Differentiated liposarcoma can be characterized by a low T1 phase and a high T2 phase. This image is also seen in any chest wall lesion, tumor or other benign or malignant disease.
4. Bone scan: 99Tc labeled bisphosphonate, commonly used dose is 500 ~ 600mBq; bone tumors show high density shadow, and image delay; inflammatory lesions can also show high density shadow; also used 99Ga.
5. Angiography: Defining the relationship between blood vessels and tumors adjacent to large blood vessels; vascular displacement caused by tumors, assessing the possibility of surgical removal of tumors; tumor vascular embolization before surgery; intra-arterial chemotherapy.
Diagnosis
Diagnosis and diagnosis of chest wall soft tissue tumor
According to the medical history: age, gender, location, past history, combined with palpation and auxiliary examination of tumors and lymph nodes.
1. Size: Smaller tumors, at least 20% of tumors with a maximum diameter of 5 cm are soft tissue sarcomas. If the tumor is located under the skin, it is easy to palpate, the size can be determined by physical examination, and ultrasound, CT or MRI can also be used.
2. Clear depth: superficial disease changes tend to be benign, even if malignant, prognosis is better than deep tumors, the depth of the tumor is best based on physical examination, ultrasound or MRI, any part of the chest wall can occur, women need to be differentiated from breast tumors.
3. Tumor hardness: soft tissue sarcoma is harder in texture, and it causes pain when it is large in volume and affects blood supply or compression nerve. Lipoma often has no tenderness, soft touch, deep lipoma (such as intramuscular or infiltration) When the muscles contract, the touch is hard, but when the muscles are slack, the tumor will become "soft", the infection or inflammation of the tumor will be painful, the surface will be hot, and the pseudoaneurysm will occasionally be larger due to the larger image. It looks like a sarcoma during the examination, but the physical examination can detect pulsations and can smell murmurs.
4. Tumor properties: Several cystic tumors are inflammatory or benign lesions, such as: synovial cyst or soft tissue abscess, but the scapular glial cyst is often misdiagnosed as a solid lesion due to high tension, benign and malignant lesions can be expressed as Solid lesions, light transmission test is a traditional, simple identification method, deep ultrasound or MRI can also help identify.
5. Course of disease: Rapid tumor growth for more than 2 months is likely to be a sarcoma, while tumors that grow slowly for more than 20 years are rarely malignant. The volume of the tumor is large and small, often cystic, but care must be taken. Long-standing tumors, soft tissue sarcoma occasionally manifested as a history of several years, soft tissue sarcoma before the diagnosis of the longest disease can reach 30 years.
6. Special attention should also be paid to the following organs: thyroid, breast, chest, liver, kidney, rectum (prostate and rectal tumor), blood items including: FBC (leukocytosis, etc.), ESR (often elevated), biochemistry ( Calcium, phosphorus, liver function and alkaline phosphatase and other abnormal metastasis), acid phosphatase (prostate lesions and elevated metastases), thyroid function test, PSA, serum protein electrophoresis (myeloma), etc., urine routine: urine Bence-Jones (myeloma), tissue biopsy is the only way to confirm the diagnosis.
7. Chest wall tumor staging
(1) Benign tumor staging.
(2) Malignant tumor staging: based on histological grade (G), site (tumor size) (T) and metastasis (M), this staging helps to assess prognosis and develop a treatment plan for primary connective tissue Tumors, excluding primary tumors of non-circular cell origin (eg, leukemia, lymphoma, myeloma or Ewing).
Grading (evaluating the invasiveness of biology):
G0: Good histology (differentiated).
G1: low malignancy (occasionally mitosis, moderate differentiation and local dissemination); there is a very low metastatic potential.
G2: Highly malignant (more mitotic, poorly differentiated) with high metastatic rate.
Characteristics of invasive tumors: atypical cell structure, common mitosis, extensive necrosis, abundant blood supply, immature cells.
The location (the anatomy where the lesion is located):
T0: carcinoma in situ
T1: localized in the cortical joint capsule or fascia
T2: spread out of the fascia
Metastasis (lymph node or blood source tumor metastasis):
M0: no regional or distant evidence of transfer
M1: Evidence of regional or distant transfer
