A routine chest radiograph in a 40-year-old asymptomatic man reveals an abnormality in the 9th rib 
posteriorly. The appropriate next step is

A. aspiration fine needle biopsy.
B. biopsy with further surgical resection dictated by frozen section results.
C. excisional biopsy.
D. observation with repeat CT scan in three months.
E. wide surgical excision. 

Answer C

It is appropriate to biopsy all rib tumors unless there are characteristic radiographic 
findings of a benign lesion. Occasionally in a young female with fibrous dysplasia of the rib 
the radiographic picture is so characteristic that the lesion can be observed. 

Fine needle 
aspiration can be helpful, but resection may still be necessary because of the risk of 
interpretation error or a false negative diagnosis from limited sampling. Frozen section of a 
biopsy from a bone lesion is often not possible because the lesion is calcified. Decalcification 
requires 10-12 hours and thus the final pathologic interpretation may differ from the frozen 
section result. 

Excisional biopsy is readily performed for lesions under 3 cm located in the 
lateral chest wall. Further resection can then be based on the permanent pathologic report. If 
the lesion is larger than 3 cm or in an area where excisional biopsy is difficult, such as the 
first rib, then an incisional biopsy is the next best alternative. An initial wide surgical 
excision has too much associated morbidity for a lesion that may turn out to be benign.


Anderson BO, Burt ME. Chest wall neoplasms and their management. Ann 
Thorac Surg 1994;58:1774-1781
Although uncommon, primary and metastatic neoplasms can occur in the chest wall. For 
malignant neoplasms, the potential for cure depends on the completeness of resection, histologic 
type, and tumor stage. Each patient warrants individual evaluation for chest wall resection. 
Operative selection is based on the potential benefits, operative feasibility, patient health, 
and anticipated tumor biology. The choice of reconstruction techniques is based on the tumor's 
location, the size of the remaining defect, and the availability of autogenous graft materials. 
Skeletal and soft tissue reconstruction can be performed safely in a single stage.