[03.16] SUR - Disorders of the Pleura, Mediastinum, & Chest Wall V2.1.pdf

Pectus excavatum

What is the most common congenital deformity of the anterior chest wall?

Posteriorly

In which direction is the sternum displaced in pectus excavatum, resulting in a sunken chest appearance?

Three times

How many times more frequently does pectus excavatum occur in males compared to females?

Uncertain

What is the established etiology of pectus excavatum?

Chest CT scan

What is the preferred imaging modality usually requested to evaluate pectus excavatum?

Two-D Echocardiography

What diagnostic test is indicated in pectus excavatum if there is clinical concern regarding compression of the heart or underlying cardiac structures?

To repair the first-degree cosmetic defect and relieve developing symptoms from organ compression

What are the two primary indications for surgical repair of pectus excavatum?

Once with growth spurt

At what developmental milestone is surgical repair of pectus excavatum ideal to minimize the chance of recurrence?

Ravitch procedure

What classical open surgical repair for pectus excavatum involves making a sternal incision, excising the breastplate, and inverting it to restore a natural contour?

Nuss bar procedure

What minimally invasive surgical repair for pectus excavatum involves inserting a temporary metal bar under the depressed sternum and flipping it to push the chest wall anteriorly?

Two hours

Approximately how long does the first surgery for Nuss bar insertion take to complete?

General anesthesia and a thoracic epidural

What two forms of anesthesia and pain management are administered to a patient undergoing a Nuss bar procedure to block postoperative recovery pain?

Three

How many total incisions are created during a Nuss bar procedure?

Two one-inch incisions for the bar and one quarter-inch incision for the camera

What are the sizes and purposes of the three incisions made during a Nuss bar procedure?

Ribs

Between what anatomical structures is the Nuss bar threaded before being brought in front of the heart and lungs?

Thin area of connective tissue under the sternum

Through what specific tissue plane is the Nuss bar passed before being rotated into position?

Two

How many metal bars may be required in severe cases of pectus excavatum during a Nuss procedure?

Metal stabilizer

What device is placed on one side of the chest wall to secure the Nuss bar in place before closing?

Absorbable sutures

What type of sutures are used on both sides of the chest wall to secure the Nuss bar construct?

Pectus carinatum

What congenital chest wall deformity is characterized by an anterior protrusion of the sternum?

Bird chest

What is the common colloquial name for pectus carinatum?

Ten percent

What percentage of congenital chest wall deformities are represented by pectus carinatum?

Less symptomatic

How does the severity of symptoms in pectus carinatum compare to pectus excavatum due to the lack of underlying organ compression?

Cosmetic reasons

What is the primary indication for surgical correction of pectus carinatum?

Collapse the breastplate to a straight line

What is the surgical objective when correcting pectus carinatum?

Fifty percent to eighty percent

What is the estimated incidence of malignancy among chest wall tumors?

Consider all chest wall tumors malignant until proven otherwise

What is the core clinical tenet that must guide a surgeon's initial approach to any chest wall mass?

Older than forty years

In what patient age cohort are malignant chest wall tumors most commonly found?

Twenty-six years old

What is the average age of patients presenting with benign chest wall tumors?

Placement of the biopsy incision

What initial diagnostic step can significantly impact the success of subsequent complete chest wall resection and reconstruction?

Complete surgical resection

What is imperative to achieve in chest wall tumors if there is any hope for a cure or long-term survival?

Growing or slowly enlarging palpable mass

What classic clinical history presentation of chest wall tumors often results in late medical evaluation or consultation?

Localized or intense pain

What characteristic of pain associated with a chest wall mass typically signifies a malignant process?

Consistency, location, size, and mobility

What four physical characteristics must be detailed when examining a chest wall mass?

Palpable mass is fixed to the underlying chest wall

What does it signify during physical examination of a chest wall tumor if the patient moves when the mass is wiggled?

Cervical, axillary, and femoral areas

What three regional lymph node groups must be systematically palpated when evaluating a chest wall mass?

Skin involvement and discoloration

What superficial changes should be documented during physical examination of a chest wall mass?

Signs of superior vena cava compression

What may a right-sided chest wall mass near the SVC present with on physical examination?

Spinal cord involvement

What complication must be evaluated if a patient presents with a posteriorly located chest wall mass?

Complete staging workup

What must be performed once a chest wall tumor has a clear diagnosis to rule out metastasis or organ involvement?

Surgical resection

What primary treatment is offered for chest wall lesions less than two centimeters in size?

Wide surgical excision

What surgical technique involves excising a tumor with a specified normal margin of tissue around it to address microscopic invasion rather than simple enucleation?

Needle biopsy or incision biopsy

What two diagnostic sampling options are indicated for chest wall tumors when the diagnosis is unclear after initial imaging?

Determine histopathology to guide preoperative chemotherapy or adjunct procedures

What is the clinical purpose of performing a partial biopsy on an unclear chest wall mass before definitive wide excision?

Chondroma

What benign chest wall tumor is more often seen in children and young adults, typically presenting as a painless mass at the costochondral junction?

Costochondral junction in the anterior chest wall

Where do benign chondromas of the chest wall most commonly originate?

Lobulation

What characteristic radiological finding is seen on a plain film X-ray of a chest wall chondroma?

Fibrous dysplasia

What slowly growing benign chest wall tumor is usually seen in young adults and may be associated with a previous history of trauma?

Posterior or lateral ribs

From what specific anatomical region of the rib cage does fibrous dysplasia typically originate?

Two-centimeter margin

What is the minimum normal surgical margin required when excising a benign fibrous dysplasia of the chest wall?

Expansion of the mass and cortical thinning of the bone without calcification

What two radiological features are visible on an X-ray of a patient with fibrous dysplasia?

Osteochondroma

What is the most common benign chest wall tumor, which is typically discovered as an incidental radiographic finding?

Growth plate of bones or rib cortex

Where is an osteochondroma typically located?

First and second decades of life

In what decades of life is osteochondroma most commonly diagnosed?

Hereditary exostoses

What autosomal dominant syndrome is associated with multiple chest wall osteochondromas?

Degenerate into chondrosarcoma

What malignant transformation potential is associated with benign osteochondromas?

Four-centimeter margin

What is the required surgical margin for a chest wall osteochondroma if malignancy is clinically suspected?

Eosinophilic granuloma

What solitary, destructive chest wall lesion presents as a painful, tender mass in the ribs?

Punched-out osteolytic lesion

What classic radiological bone feature is visualized on an X-ray of an eosinophilic granuloma?

Two-centimeter margin

What is the required surgical margin for exisiting a painful eosinophilic granuloma of the chest wall?

Desmoid tumors

What benign but locally aggressive chest wall tumors involve fascial or musculoaponeurotic structures?

Gardner syndrome

What familial polyposis syndrome is clinically associated with desmoid tumors?

Increased estrogen production during pregnancy

What hormonal state is associated with a higher incidence of desmoid tumors in female patients?

Fixed to the chest wall but not to the skin

What is the characteristic mobility of a desmoid tumor on physical examination?

Wide local excision with a two-to-four-centimeter margin including the rib above and below

What is the required surgical management for desmoid tumors due to their strong propensity to recur locally?

Histologic grade

What is the most important prognostic factor for a chest wall sarcoma, which directly determines its aggressiveness?

Chondrosarcoma

What is the most common primary chest wall malignancy?

Anterior costochondral arches

What anatomical site is most commonly involved in primary chondrosarcoma of the chest wall?

Painful mass

How do malignant chondrosarcomas of the anterior chest wall classically present clinically?

Resistant to chemotherapy and radiotherapy

What key therapeutic resistance characteristic defines malignant chondrosarcomas of the chest wall?

Four-centimeter margin

What is the mandatory wide surgical margin required for a primary chondrosarcoma resection?

Osteosarcoma

What primary bone tumor is highly common in extremity bones but rare in the chest wall, presenting as a rapidly enlarging, painful mass?

Adults older than forty years with a history of prior radiotherapy, Paget's disease, or previous chemotherapy

What older adult cohort is at risk for developing chest wall osteosarcoma?

Alkaline phosphatase

What serum enzyme biomarker may be elevated in a patient with active osteosarcoma of the chest wall?

Sunburst appearance

What classic bone reaction pattern is seen on a plain film X-ray of chest wall osteosarcoma?

Highly sensitive to chemotherapy and neoadjuvant therapy

How does the treatment sensitivity of osteosarcoma compare to chondrosarcoma?

Malignant fibrous histiocytoma

What is the most common soft tissue sarcoma of the chest wall in late adult life, typically presenting in patients aged fifty to seventy?

Mass with surrounding destruction

What does a plain film X-ray reveal in a patient with malignant fibrous histiocytoma of the chest wall?

Lungs

To what organ does malignant fibrous histiocytoma have a strong propensity to metastasize?

Four-centimeter margin with chest wall reconstruction

What is the standard surgical management plan for malignant fibrous histiocytoma?

Liposarcoma

What low-grade chest wall tumor presents as a painless, soft mass that is often clinically mistaken for a benign lipoma?

Wide resection with frozen section to confirm clear margins followed by chest wall reconstruction

What is the recommended surgical management for a suspected chest wall liposarcoma?

Frozen section

What rapid pathological technique is performed during active surgery to confirm that surgical margins are microscopically clear before proceeding with chest wall reconstruction?

Fibrosarcoma

What large, painful soft tissue sarcoma of the chest wall presents with surrounding bone destruction on X-ray and has a high rate of local and systemic recurrence?

Rhabdomyosarcoma

What rare malignant soft tissue tumor of the chest wall presents microscopically as a spindle cell tumor?

Immunohistochemical staining or muscle markers

What diagnostic testing is required to confirm a pathological diagnosis of chest wall rhabdomyosarcoma?

Preoperative chemotherapy followed by subsequent surgical resection

What is the established treatment paradigm for chest wall rhabdomyosarcoma?

Primitive neuroectodermal tumors and plasmacytoma

What are two examples of other rare primary tumors of the chest wall?

Single monoclonal spike on serum protein electrophoresis

What diagnostic laboratory finding confirms a diagnosis of chest wall plasmacytoma?

Ewing's sarcoma

What chest wall malignancy is most commonly seen in adolescents and young adults, presenting with progressive pain, fever, and malaise?

Onion-peel appearance

What classic radiographic bone finding on X-ray is associated with Ewing's sarcoma?

Erythrocyte sedimentation rate

What inflammatory laboratory marker may be elevated in a patient with active Ewing's sarcoma?

Multimodality therapy consisting of chemotherapy, radiotherapy, and surgery

What type of treatment regimen is required to manage Ewing's sarcoma?

Reconstruction of the chest wall

What is planned and executed using multiple disciplines when a chest wall resection involves skin, muscles, and bones?

Sternectomy

What surgical procedure involves wide excision of the sternal wall for malignancy?

Omentum

What abdominal structure is mobilized through the diaphragm and placed over a sternal wall defect during reconstruction?

Pectoralis major muscle flap

What muscle is laid over the mobilized omentum during sternal wall reconstruction before skin closure?

Metal plates, wires, methacrylate, or bone cement

What are four examples of hard construction materials used to restore bony structural stability to the chest wall during reconstruction?

Hemangioendothelioma

What vascular chest wall malignancy was diagnosed in the case of the male patient presenting with a breast mass involving the underlying ribs?

Visceral pleura

What layer of the pleura directly covers the outer surface of the lungs?