Diagnosis & Treatments of Chest Wall Tumors/Sarcomas | Mount Sinai

The chest wall plays an important role in keeping our organs safe. It is the bone-and-tissue framework that forms a cage around vital organs such as the heart and lungs. The chest wall includes the spine, sternum, and ribs. Many types of tumors can grow in this structure. Some are primary tumors, which originate in the chest wall; these can be either benign or malignant. Others are secondary tumors, which spread (metastasize) to the chest wall from another site in the body. When tumors metastasize, they are almost always malignant.

When a tumor forms in the bones, soft tissue, or cartilage, and is malignant, we call it a sarcoma. Malignant chest wall tumors include many types of sarcoma. Symptoms of chest wall sarcomas vary with the tumor’s classification and severity. You might experience difficulty breathing as well as pain and swelling surrounding the tumor.

Types of Chest Wall Sarcomas

The following types of sarcomas could grow in the chest wall:

• Chondrosarcoma: Forms in cartilage and is the most common type of primary chest wall bone cancer. It usually presents as a slowly enlarging, painful mass.
• Osteosarcoma: Forms in bone, typically during a period of accelerated growth, such as adolescence. It typically presents as a rapidly enlarging, painful mass.
• Ewing’s sarcoma: Forms in bone, and most often affects children and young adults. It usually presents as a painful mass with fever and fatigue.
• Plasmacytoma: Arises from plasma cells and is an isolated form of multiple myeloma. You may feel pain but not see a mass. This is one of the few chest wall tumors that we rarely treat surgically.
• Malignant fibrous histiocytoma: The most common soft tissue sarcoma, this often occurs in adults. These usually present as a slowly growing, painless mass.
• Rhabdomyosarcoma: Forms in striated muscle, and most often affects children and young adults. These usually present as a rapidly growing, painless mass.

Diagnosis and Treatment

The process of diagnosing a chest wall tumor typically begins with a physical exam, followed by an imaging test, such as an X-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI). If we need additional information, we may do a biopsy. This involves taking a tissue sample from the tumor and testing it in the lab.   

We design a treatment plan based on the type and stage of tumor you have. Surgical resection is the mainstay of treatment for most early stage chest wall tumors. Additional treatment can include radiation and chemotherapy.

Why Mount Sinai

At Mount Sinai, your thoracic surgeon coordinates a team of specialists to manage your disease. Our goal is to remove the entire tumor without affecting your ability to breathe. We also protect your underlying chest structures, including your heart and lungs. We strive to cure your disease while maintaining your quality of life.

Septic arthritis of the manubriosternal joint presenting as a chest-wall swelling in an immunocompetent patient | Journal of Surgical Case Reports

Journal Article

Adam O’Connor,

Adam O’Connor

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Sanjay Furtado

Sanjay Furtado

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Journal of Surgical Case Reports, Volume 2019, Issue 11, November 2019, rjz261, https://doi. org/10.1093/jscr/rjz261

Published:

15 November 2019

Article history

Received:

22 July 2019

Revision received:

26 July 2019

Accepted:

24 August 2019

Published:

15 November 2019

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Abstract

Septic arthritis of the manubriosternal joint is a rare pathology, often mistaken for other disease processes given its location and chest pain symptoms. We present a case of a 58-year-old man presenting with a dull ache in his chest after returning from a holiday. Initially under the care of the physicians locally, he was investigated for respiratory and cardiac causes of chest pain with no findings. Eventually, a lump was noted on examination of the chest prompting further imaging, which confirmed a diagnosis of manubriosternal septic arthritis. He was discussed and referred to tertiary cardiothoracics, who recommended conservative treatment with 6 weeks of antibiotics. To date, there has been a good recovery. We present this case alongside a discussion of the limited literature, in particular highlighting how difficult a diagnosis it is to make but one that surgeons and medics alike should be aware of.

INTRODUCTION

Septic arthritis of the manubriosternal joint is a rare pathology with only nine cases identified in the literature. Being so rare, it is often mistaken for another disease process such as abscess and often presents with symptoms of chest pain, which undergoes extensive diagnostic work up to exclude more immediate problems such as cardiac or pulmonary causes of chest pain. The chest-wall swelling can be easy to miss and sometimes not even noticed by the patient, as in our case initially. We present the case of a 58-year-old man presenting initially with chest pain, but no significant past medical history. Ultimately, his diagnosis emerged as septic arthritis of the manubriosternal joint, which we attempt to explore in this article.

CASE REPORT

A previously well 58-year-old man initially presented with chest pain having returned from holiday and was admitted under the care of the physicians. He described a dull ache across the chest, not pleuritic in nature and with no associated dyspnoea, cough or haemoptysis. There was no history of trauma. Physical examination at that time was unremarkable and the patient did not report any swellings of the chest wall. Blood results revealed a C Reactive protein (CRP), of 88 mg/l, a d-dimer of 2137 ng/ml, liver function tests (LFT) derangement but a normal Full blood count (FBC). Given the d-dimer, computed tomography pulmonary angiography (CTPA) was performed to exclude pulmonary embolism. This showed no Pulmonary embolism (PE), pneumothorax or pneumonia. Instead, it showed subcutaneous tissue stranding in the midline anterior to the manubrium and upper sternum with soft tissue thickening inseparable from the medial pectoral muscles. On further examination of the chest, there was a tender, prominent sternum with mild erythema but no warmth. The patient was discharged from the medical team with ibuprofen gel and advised to seek medical attention should he develop any signs of infection.

He then presented 3 weeks later referred by his general practitioner (GP) to the surgical hot clinic with worsening swellings of the sternum and discharge from the inferior aspect of the sternum. He had been given oral flucloxacillin by the GP, but was clinically well and not septic. Physical observations were within normal limits. On examination, there was a 3 × 3 cm swelling overlying the body of the sternum with discharge. Superior to that was another diffuse inflammatory swelling. Blood tests revealed CRP of 86, his LFTs had returned to normal and FBC was normal. Options were considered as to whether to drain under lupus anticoagulant, but given the recent computed tomogramphy (CT) chest showing possible pectoral involvement, the decision was made to admit to hospital for incision and drainage under GA. He was consented as such and admitted. He was then reviewed the next day by the on call consultant surgeon, who felt given the prolonged history of the swelling that an abscess was unlikely. Magnetic resonance imaging (MRI) of the sternum was, therefore, recommended by the radiologists to further characterize the lesion (Fig. 1a–c). MRI of the area revealed fluid within the manubriosternal joint with erosion of the articular margins. A fluid collection 65 × 7 mm was presented within the right pectoralis major, along with a small collection in the medial aspect of left pectoralis major. Also present was surrounding soft tissue thickening and oedema with marrow oedema of the upper body of sternum and manubriosternal joint. No abnormality was demonstrated in the underlying mediastinum. The MRI concluded that this was septic arthritis of the manubriosternal joint with bony erosion and underlying osteomyelitis.

Figure 1

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(a–c) Lateral views of sternal MRI showing varying degrees of inflammation and septic arthritis of manubriosternal joint.

He was subsequently commenced on intravenous flucloxicillin and discussed with the cardiothoracic regional centre on call, who advised conservative management with antibiotics for 6 weeks. This was agreed with the local microbiologists, who advocated metronidazole and clindamycin therapy for the same period of time. To date, his recovery has been excellent and he is progressing well.

DISCUSSION

Septic arthritis of the manubriosternal joint in an immunocompetent patient is rare [1]. Most commonly, it is related to intravenous drug abuse via the transmission of infection in the upper limbs with axillary and subclavian phlebitis but other primary sources such as distant septic arthritis, GI infection and cellulitis have been implicated [2]. Both acute septic responses and more indolent, subacute courses as in our case have been described in the literature with one particular case demonstrating a course of 18 months. [3, 4]. Parity of septic arthritis in the manubriosternal joint is in part due to its anatomy. Being a symphysis, despite case reports of infection of the pubic symphysis, the rates of septic arthritis are massively lower than in synovial joints [5]. Coagulase positive staph aureus is the primary pathogen in 60% of the cases with some suggestions also of the importance in the disease of salmonella and pseudomonas [1]. No positive cultures were identified in our patient.

In terms of diagnosis, the disease process may or may not be present on sternal radiographs [6]. The presence of soft tissue and joint destruction on CT or MRI scans demonstrates a later stage of the disease process [7]. The small incidence of septic arthritis in this location makes the diagnosis challenging, and there is often misdiagnosis of the case as in our case, where more acute, medically orientated diagnosis were considered foremost [1]. Regarding management, in early stages of the disease, intravenous antibiotics are the mainstay with surgical washout indicated in upwards of 60% of cases [4]. Post-washout, large defects in the pectoral area may be treated with pectoralis flap; however, this depends upon factors such as patient’s age, occupation and general functional status [8].

Conflict of interest statement

None declared.

Funding

None.

Patient Consent

Obtained.

References

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© The Author(s) 2019. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2019.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]

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What symptoms accompany swelling of the breast?

Edema compresses the nerve roots, respectively, there is discomfort, in the form of a feeling of heaviness and unpleasant fullness of the gland, and then pain. The intensity of the pain is directly dependent on the swelling of the chest, but the perception of the strength of the pain is very individual.

Excess fluid causes breast enlargement and deformity. With inflammatory edema, the temperature of the skin rises and its color changes. With a very pronounced accumulation of fluid in the tissues, redness is replaced by cyanosis and even marbled pallor of the skin due to blockade of venous vessels by blood clots.

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Under what diseases does benign edema develop?

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When is edema malignant?

Due to thrombosis of the lymphatic vessels by tumor cells, a slight pastosity of the skin occurs when there is a tumor node in the glandular tissue of more than 5 cm. At the same time, there are no tumor cells in the skin of the gland itself, fluid retention is mechanical in nature – the presence of an obstacle, and non-specific edema – not cancerous , secondary.

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ᐈ First aid for pulmonary edema ~【Kyiv】

Pulmonary edema is a pathological condition in which fluid begins to accumulate in the alveoli. The situation occurs when the heart cannot pump blood normally from the blood vessels of the lungs to other organs. This prevents effective gas exchange and leads to hypoxia of the body. Pulmonary edema occurs suddenly and rapidly increases. The condition can be fatal.

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Classification of pulmonary edema

There are several forms of the disease according to the rate of development:

• Fulminant – the process grows rapidly, and within a few minutes the patient dies.
• Acute – the clinical picture develops over 4 hours. The probability of death is quite high and occurs against the background of a heart attack or brain injury.
• Subacute – characterized by alternating active and calm stages. The cause is liver failure.
• Protracted – symptoms increase within 12 hours without clear signs. The basis is heart failure or diseases of the respiratory system.

Various causes form separate types of pulmonary edema. Most often there are cardiogenic, neurological or allergic variants.

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Acute etiology

The most common cause of pulmonary edema is left ventricular failure.

Pathology occurs against the background of such diseases as:

• heart attack;
• arrhythmia;
• valve defects;
• hypertension.

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In addition, there are non-cardiac causes of pulmonary edema:

• trauma;
• toxic substances;
• inhalation of smoke;
• altitude sickness;
• influenza;
• pneumonia;
• COVID-19;
• inflammation of the pancreas;
• allergic reactions;
• kidney disease.

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The administration of some intravenous drugs can also cause a pathological condition.

Pathogenesis

Alveoli are the structural elements of the lungs where gas exchange takes place. They are usually filled with air. When fluid accumulates in the alveoli, normal gas exchange processes are disrupted. For various reasons, the heart does not pump blood from the lungs. As a result, blood accumulates in the blood vessels of the lungs and then seeps into the lumen of the alveoli. There are signs of pulmonary edema. The probability of a favorable or unfavorable outcome is dependent on the form of pathology and qualified care for the patient. According to statistics, approximately 25% of patients die from pulmonary edema.

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Clinical manifestations

Symptoms of pulmonary edema occur suddenly. The patient is usually pale, perspiring, and assumes a sitting position in which he breathes best. Also, the patient may experience severe anxiety. Breathing is fast and shallow and can be described as “wheezing”.

Additional symptoms of pulmonary edema include:

• pale skin or cyanosis;
• palpitations;
• dry cough, eventually turning into a wet one;
• difficult, rapid breathing, shallow breaths and short exhalations;
• foamy yellow discharge with a hint of blood may appear;
• low or high CD.

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Features of the manifestation of the condition during pregnancy

During pregnancy, pulmonary edema can occur both against the background of heart problems and with initially normal physiological changes in the female body. The most common causes are multiple pregnancies and manifestations of preeclampsia. With an increase in symptoms, it is required to plant the patient and call an ambulance. In the hospital, oxygen therapy, diuretics and antihypertensives are prescribed. If the therapy does not bring results, the pregnant woman is connected to an artificial respiration apparatus.

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Peculiarities of the disease in children

In childhood, heart problems are much less common than in adults. Therefore, the main causes of pulmonary edema are diseases of the respiratory system or severe injuries. A dangerous pathology can be suspected if the child becomes restless, feels short of breath and complains of fear of death. In this case, it is required to immediately deliver the patient to the hospital, where resuscitation will be carried out.

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Complications

Pathology itself is a threatening complication. At the same time, failure to comply with the deadlines and proper medical care can lead to death. The consequences of pulmonary edema, even with successful relief, sometimes lead to congestive pneumonia, the formation of signs of pneumosclerosis and disruption of the internal organs.

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First aid for pulmonary edema

With timely and effective intervention, the pathological condition quickly resolves. Reduce shortness of breath and improve blood oxygenation as soon as possible.

Emergency care for pulmonary edema includes:

• first call an ambulance and indicate the patient’s condition;
• while waiting for the arrival of an ambulance, it is necessary to keep the patient in a sitting position;
• open a window and provide the patient with fresh air.

This is practically all that relatives can do in this situation. Everything else is done by a team of doctors, starting with the supply of oxygen, the installation of an intravenous catheter and the provision of medical care. The decision is immediately made to transport the patient to the hospital, but at the same time, medications are constantly administered and his vital activity is monitored. Only in a specialized institution are optimal conditions created to bring the patient out of a serious condition.

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Diagnosis of the disease

The doctor diagnoses the condition based on the history and typical changes observed during the examination. When examining a patient with pulmonary edema, the doctor hears typical auscultatory changes. The tonometer readings determine high or too low blood pressure. On palpation, swelling of the lower extremities is determined (in people with exacerbation of chronic heart failure).

Instrumental diagnosis of pulmonary edema:

• chest x-ray;
• ECG;
• cardiac echocardiography;
• laboratory blood tests;
• blood test for oxygen and carbon dioxide.

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Treatment of pulmonary edema

The first priority in the treatment of pulmonary edema is emergency medical care. Immediate intensive treatment is required. The patient is given oxygen at a high flow rate and diuretics are administered intravenously. Depending on the values ​​of blood pressure, appropriate drugs are prescribed to stabilize it. Sometimes, despite taking medication, the patient’s condition does not improve due to insufficient oxygenation of the blood. In this case, the treatment of pulmonary edema requires intubation (placement of a plastic tube in the patient’s trachea to secure the airway) and temporary support of breathing with a ventilator.

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Control of cure

Timely treatment usually relieves signs of pulmonary edema. A disease that provokes a pathology requires careful diagnosis and treatment in order to prevent a threat to life. The patient should be under constant supervision of a family doctor and a cardiologist.

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Prevention of pulmonary edema

The main prevention of pulmonary edema is to prevent this condition by treating the underlying disease. Regular intake of prescribed drugs, regular measurement of blood pressure and its stabilization during jumps are necessary. Weight loss is of paramount importance. Regular visits to the doctor will help to avoid a serious condition.

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Tips and tricks

Pulmonary edema cannot be cured with traditional medicine. In this case, self-medication will lead to death. Only qualified medical care can prevent the consequences of a pathological condition.

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Q&A

What is the difference between pulmonary edema and cardiac asthma?

The main similarities between pulmonary edema and cardiac asthma are shortness of breath, choking, dry cough and forced sitting. The main symptoms of cardiac asthma include cyanosis, coughing, dry rales and crepitus. With pulmonary edema, shortness of breath is more pronounced (30-35 per minute), often accompanied by severe attacks of suffocation. Signs of developing pulmonary edema include frothy sputum and moist rales. The main differences between pulmonary edema and cardiac asthma: bubbling breathing, moist rales, which are well audible at a distance, blood may be present in the sputum. Only a pulmonologist and a cardiologist can establish an accurate diagnosis and the severity of the disease.

What is morphine used for in pulmonary edema?

The use of intravenous morphine for pulmonary edema helps to relieve psycho-emotional arousal, reduce shortness of breath, and also has a vasodilating effect. The drug treats tachycardia, anesthetizes, relieves severe pain. In the treatment of pulmonary edema, morphine is administered only intravenously.

How long do people live with pulmonary edema?

Life expectancy with pulmonary edema directly depends on the general condition of the patient’s body and the type of edema. The most favorable prognosis for non-cardiogenic edema. According to statistics, up to 50% of patients survive after cardiogenic edema. With a fulminant and toxic form, in the absence of emergency care, it is almost impossible to save a person.

How to recognize pulmonary edema at home?

The beginning of pulmonary edema can be judged by the following signs: shortness of breath and suffocation, a feeling of lack of air, accompanied by increasing anxiety and agitation; increased sweating; cyanosis of the skin; cough with expectoration of frothy sputum. As edema develops, symptoms such as an increase in heart rate and a drop in blood pressure join the above manifestations, wheezing appears, heard at a distance. Psycho-emotional arousal is replaced by apathy and depression. The patient gets some relief from a sitting position with emphasis on the arms and legs down. A chest X-ray can reliably indicate the presence of pulmonary edema.

How to relieve allergic pulmonary edema?

To relieve allergic pulmonary edema, it is necessary to avoid contact with the allergen and call for emergency help. Treatment of pulmonary edema in allergies includes stopping the pathological process and prescribing drugs (morphine, cardiac glycosides, antihistamines, antihypertensives, arrhythmic drugs, etc.). After the condition improves, be sure to seek advice from an allergist.

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The article is for informational purposes only. Please remember: self-medication can harm your health.

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Expert in the direction:

Pionova Elena Nikolaevna

Therapist of the highest category, pulmonologist, Ph.D.

Which doctor treats pulmonary edema?

Consultation of an experienced cardiologist or pulmonologist of the MEDICOM clinic and special equipment will help to quickly stop an acute condition.