Chest Wall Tumours: A Lump on the Ribs and What It Means

What the chest wall contains

The chest wall is more than ribs. It comprises bone and cartilage, muscle, fat, nerves, blood vessels and connective tissue — and a tumour can arise from any of these, or spread to the chest wall from elsewhere.

Because these lesions are uncommon and the tissues involved are varied, the approach is different from most surgical problems: the diagnosis comes first, and the operation is designed around it, not the reverse.

How they present

Most commonly as a lump that the patient or a doctor notices. Pain is an important feature: a chest wall lesion that is painful, particularly one that aches at night or at rest, is more concerning than a painless one. Growth over weeks to months, size above about five centimetres, and a lesion that is fixed to underlying bone rather than freely mobile all raise concern.

Some are discovered incidentally on imaging performed for another reason.

Benign or malignant

Benign

Lipomas, fibrous lesions, osteochondroma, chondroma, fibrous dysplasia, and inflammatory swellings including costochondritis, which is common and causes tenderness without a true mass.

Malignant

  • Primary bone and cartilage tumours — chondrosarcoma is the commonest primary malignant chest wall tumour, along with osteosarcoma and Ewing sarcoma, which particularly affects children and young adults.
  • Soft tissue sarcomas arising from muscle, fat or connective tissue.
  • Secondary tumours — spread from breast, lung, kidney, thyroid or prostate cancer, or myeloma. These are more common than primary chest wall malignancy, which is why a known cancer history changes the whole assessment.
  • Direct invasion from an adjacent lung or breast cancer.

Investigation

CT of the chest defines the lesion, its relationship to ribs, pleura and lung, and detects other disease. MRI is superior for soft tissue detail and for planning how far a resection must extend. PET-CT assists in staging and in identifying a primary tumour when a secondary is suspected.

Why the biopsy must be planned, not improvised

This is the single most important practical point in this article.

In suspected sarcoma, the biopsy track itself can seed tumour cells. That track must therefore be positioned so it can be removed along with the tumour at definitive surgery. A biopsy taken through a poorly chosen approach — or an attempted "quick excision" of an unrecognised sarcoma — can convert a straightforward resection into a far larger one, or compromise the chance of cure.

For that reason, biopsy of a suspicious chest wall mass should be planned by the team who will perform the definitive operation, ideally with sarcoma expertise. A lump on the ribs that is growing or painful should be referred rather than removed locally.

Treatment

Treatment depends entirely on the diagnosis:

  • Benign, asymptomatic lesions — often simply observed.
  • Benign but symptomatic or enlarging — local excision.
  • Chondrosarcoma — wide surgical resection with clear margins is the mainstay, as it responds poorly to chemotherapy and radiotherapy.
  • Ewing sarcoma and osteosarcoma — chemotherapy first, then surgery, with radiotherapy where indicated. Operating before chemotherapy in these tumours is a significant error.
  • Secondary deposits — treatment follows the primary cancer; surgery is usually for symptom control.

Reconstruction

Removing a segment of chest wall creates two problems: a hole in a structure that must remain airtight and stable enough to support breathing, and a soft tissue defect that must be covered.

Small defects, and those tucked beneath the shoulder blade, may need no reconstruction. Larger ones are reconstructed with synthetic mesh, sometimes reinforced with bone cement or a titanium plate system, and covered with muscle flaps — latissimus dorsi, pectoralis major, serratus anterior or rectus abdominis — often in collaboration with plastic surgery.

The aim is not cosmetic. An unsupported chest wall segment moves paradoxically with breathing, exactly as in flail chest described in our article on chest trauma, which impairs ventilation. Reconstruction restores mechanical stability.

Recovery

Pain control and breathing physiotherapy dominate the early period, for the same reasons they matter after any chest operation. Recovery is generally longer than for lung resection alone, because the chest wall itself has been reconstructed.

Further reading

MedlinePlus: bone cancer and the US National Cancer Institute on soft tissue sarcoma.

On this site: thoracic surgery and mediastinal tumours.

General education, not advice about a specific lump. A growing or painful chest wall mass should be assessed by a specialist before any attempt at removal.