The American Journal of Medicine
Volume 123, Issue 2 , Pages e7-e8, February 2010

Sarcoma of the Chest Wall: A Rare Tumor

  • Matthew J. Czarny, BS

      Affiliations

    • Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
    • ,
  • Grant V. Chow, MD

      Affiliations

    • Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
    • Corresponding Author InformationRequests for reprints should be addressed to Grant V. Chow, MD, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave, Baltimore, MD 21224-2780
    • ,
  • Daniel S. Rhee, MD

      Affiliations

    • Department of Surgery, Saint Joseph Mercy Health System, Ann Arbor, Mich
    • ,
  • Joel Fradin, MD

      Affiliations

    • Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Md
    • ,
  • Jessica Colburn, MD

      Affiliations

    • Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
    • ,
  • Mehran Habibi, MD

      Affiliations

    • Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
    • ,
  • Ilene Browner, MD

      Affiliations

    • Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Md

Article Outline

 

To the Editor:

A 44-year-old construction worker presented with pain and swelling of the right anterior chest, first noticed 8 months previously as a quarter-sized induration. The mass had gradually enlarged and become tender and was producing an exertion-related aching pain. On the day of arrival, the pain became excruciating and was associated with new numbness and tingling of the entire right arm. There also were several weeks of fatigue, night sweats, generalized muscle aches, dyspnea, and dizziness. Past medical and family history were unremarkable; social history was significant for 45 pack-years of smoking.

On evaluation, the patient was afebrile with stable vital signs. Chest examination demonstrated a large, tender, ill-defined, immobile mass approximately 5 cm superior to the right nipple. There was no discharge or nipple retraction, and no palpable cervical, submandibular, supraclavicular, or axillary lymphadenopathy. Neurologic examination revealed intact sensation and 5/5 strength in both upper extremities. Laboratory study, chest x-ray, and electrocardiogram results were unremarkable.

Imaging studies were performed, and chest computed tomography scan with contrast demonstrated a 9.4×6.2-cm mass in the right pectoralis muscles with ipsilateral axillary and internal mammary lymphadenopathy (Figure 1A). Ultrasound characterized the mass as heterogeneously echogenic (Figure 1B), and several core needle biopsies were successfully obtained to yield a pathologic diagnosis of high-grade sarcoma with rhabdoid features. Magnetic resonance imaging subsequently demonstrated the heterogeneous, lobulated, infiltrative nature (Figure 1C) of the mass, as well as involvement of the chest wall.

  • View full-size image.
  • Figure 1. 

    Chest computed tomography with contrast (transverse image, A) demonstrated a 9.4×6.2-cm right chest mass (arrows) involving both ipsilateral pectoralis muscles. Subsequent diagnostic right thoracic ultrasound (B) and T2-weighted magnetic resonance imaging (C) revealed the lobulated, heterogeneous, infiltrative nature of the mass, suggestive of sarcoma.

Soft-tissue sarcomas are a group of malignant mesenchymal tumors that are relatively rare in the United States, accounting for less than 1% of incident solid tumors yearly.1 Although usually presenting as a painless, gradually enlarging mass, soft-tissue sarcoma can infiltrate surrounding tissues and organs. Sequelae from local compression are common with large sarcomas and yield site-specific symptoms. Invasion of the shoulder girdle (as was later identified in our patient) might produce limb paresthesias, pain, reduced range of motion, or distal swelling. Tumor growth and mortality rates are highly variable, with rapidly growing masses associated with higher grade and worse prognosis.2, 3

In the absence of metastatic disease, wide local excision of the tumor offers the best prognosis and is first-line therapy.4 Radiation therapy should be considered in cases with large or highly invasive tumors, narrow (<1 cm) margins, or positive margins with residual disease.4, 5 When soft-tissue sarcoma presents with a large tumor burden or lies in the vicinity of important neurovascular structures, neoadjuvant chemotherapy can be given before surgery to improve resectability. It also might assist in determining the response of a tumor to chemotherapeutic agents, thus providing an advantage when selecting drugs for adjuvant chemotherapy.5 First-line chemotherapy includes doxorubicin with or without ifosfamide, but response rates under the best of circumstances remain less than 40%.6

Our patient received mesna, doxorubicin, ifosfamide, and dacarbazine neoadjuvant chemotherapy with interdigitated radiotherapy, and surgical excision with chest wall reconstruction was planned. However, serial imaging of the chest revealed multiple, rapidly growing foci of metastatic disease in both lungs, as well as probable right shoulder joint and vascular involvement. Given the markedly increased risk involved with resection, palliative treatment with radiation and chemotherapy was chosen.

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References 

  1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–96
  2. Clark MA, Fisher C, Judson I, Thomas JM. Soft-tissue sarcomas in adults. N Engl J Med. 2005;353:701–711
  3. In:  Greene FL,  Page DL,  Fleming ID, et al. editor. AJCC Cancer Staging Manual. 6th ed.. New York: Springer-Verlag; 2002;
  4. Thornton K, Pesce C, Choti M. Multidisciplinary management of metastatic sarcoma. Surg Clin North Am. 2008;88:661–672
  5. Casali PG, Jost L, Sleijfer S, et al. Soft tissue sarcomas: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2008;19(Suppl 2):ii89–ii93
  6. Thornton K. Chemotherapeutic management of soft tissue sarcoma. Surg Clin North Am. 2008;88:647–660

 Funding: none

 Conflict of Interest: The authors state that they have no conflict of interest regarding the content of the article.

 Authorship: All authors meet the criteria for authorship, including acceptance of responsibility for the scientific content of the article. All authors had access to the data and a role in writing the article.

PII: S0002-9343(09)01010-9

doi:10.1016/j.amjmed.2009.07.030

The American Journal of Medicine
Volume 123, Issue 2 , Pages e7-e8, February 2010

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