Chondrosarcoma: Among malignant skeletal tumors of the chest wall, chondrosarcoma is one of the more common ones, with the highest incidence between the ages of 30 and 50, and less common before the age of 20. It is mostly seen in men. It occurs in the ribs, rib cartilage junction and rib corners, and also in the sternum, mostly in the sternal stalk. It is often thought to be malignant on the basis of osteochondroma or chondrosarcoma, but most people believe that the disease is malignant from the beginning. The interstitial matrix of the tumor cells is formed by collagen fibers and cartilage matrix. The tumor is usually round or dumbbell-shaped, partly within the bone cortex and cancellous bone, and partly outside the bone cortex. The mass is mostly palpable locally, but some tumors grow inward and are not palpable on the chest wall. When the tumor compresses the intercostal nerve and pleura, it produces local pain symptoms. Some of them may recur after a long time after local excision. More than 90% of the masses are larger than 4 cm in diameter and often have a lobulated shape. Therefore, it is believed that if the tumor is larger than 4 cm in diameter, there are osteolytic changes and destructive translucent areas in the ribs, and there are dotted or speckled calcifications in the tumor, it can be identified as chondrosarcoma and should be extensively resected, not necessarily in the preoperative X-ray chest film and CT film. It is not necessary to perform puncture biopsy before surgery. Chondrosarcoma often invades adjacent tissues, but rarely metastasizes to distant places, and local excision is not enough to easily recur. Therefore, complete resection must be performed during surgery, and the extent of rib removal should be more than 5 cm from the edge of the tumor. If the tumor recurs after surgery, it can be resected again and some of them can survive for a long time. Sternal chondrosarcoma mostly occurs in the sternal stalk and often needs to be removed together with a part of the clavicle on both sides during surgery. Generally, the chest wall defect of chondrosarcoma surgery is large, so the chest wall repair and reconstruction materials should be properly designed and prepared before surgery. Osteosarcoma: It used to be called osteogenic sarcoma or osteogenic sarcoma. The age of prevalence is 10 to 30 years old, and it is rare over 50 years old. Most of them occur in the long bones of the limbs, but also in the sternum, ribs and scapula. It is highly malignant, with bone-like tissue in its malignant stroma, and the tumor cells can directly produce tumor-like bone. Most osteosarcomas penetrate the bone cortex and invade the adjacent soft tissues, which can spread hemorrhagically at an early stage and easily metastasize to the lungs. The main clinical symptoms are pain and swelling, which start as intermittent vague pain and rapidly turn into continuous severe pain, with unbearable pain at night, followed by local swelling. When the tumor enlarges and invades the spine or brachial plexus, spinal cord compression and upper limb neuralgia may appear. The pain is obvious, the tumor is soft and hard, the skin is often hot and red, and there is pathological fracture occasionally. Systemic symptoms may appear early, including wasting, anemia, weakness, loss of appetite, low hemoglobin, rapid sedimentation, leukocytosis, and increased serum alkaline phosphatase. There may be “jumping” lesions. Osteolysis type: The bone trabeculae are destroyed and disappeared, the erosion penetrates the bone cortex and continues to grow under the periosteum, forming Codman’s triangle and soft tissue mass shadow, but the bone shadow of needle-like tumor is less. 2.Osteogenic type: extensive dense shadow, no bone trabecular structure, no boundary, can invade soft tissue, there is obvious periosteal reaction, from the periosteum to the surface of the tumor, there is a radial arrangement of new needle-like bone trabeculae. 3.Mixed type: osteolysis and osteogenesis are mixed, periosteal reaction is obvious, and there may be soft tissue shadow. The prognosis of osteosarcoma is not good. It should be treated with extensive chest wall resection and high-dose methotrexate and adriamycin, which can achieve certain efficacy. Ewing sarcoma: A kind of sarcoma composed of round cells in bone marrow, also called “malignant small round cell tumor”, usually occurs in adolescents before 25 years old, but rare above 30 years old, more men than women. It mostly invades long bones, but also occurs in ribs, scapula, pelvis and other bones. The tumor starts from the bone marrow cavity of the bone cadre, destroys the bone cancellous, infiltrates and penetrates the bone cortex, stimulates periosteal hyperplasia and forms a soft group of masses, which grows rapidly and has pain, fever, secondary anemia and increased sedimentation, and the symptoms are similar to osteomyelitis, which is often misdiagnosed as osteomyelitis. “This tumor is highly malignant. This tumor is highly malignant and can have metastasis in early stage. It is sensitive to radiotherapy, similar to lymphoma, and with 20-30Gy irradiation, the tumor can shrink quickly and osteosclerotic changes can occur, and the pain can subside, and the X-ray can see that the lesion is repaired. The prognosis is also poor, with a 5-year survival rate of only 3% to 16%. Myeloma: malignant tumor from plasma cells in bone marrow, also known as plasma cell myeloma. It is mostly seen in 50-70 years old. It occurs in the skull, ribs, sternum, spine and pelvis. Lesions of the chest wall are often part of a systemic disease. It is twice as common in men as in women. The tumor forms nodules or a diffuse infiltrate in the bone marrow cavity. Patients have symptoms of anemia and bone pain. Bone destruction and dissolution and invasion of the periosteum may cause oncotic fractures, mostly in multiple myeloma. Plasma cells have the function of producing globulin, and the proliferation of large number of plasma cells will cause elevated whole serum protein, unchanged serum albumin, inverted albumin-globulin ratio, increased phosphatase and blood calcium, positive urine periprotein, abnormal proteinuria leading to tubular formation, renal impairment, and finally the patient dies from pneumonia and uremia. X-ray manifestations: The early stage of transition from plasmacytoma to polyosteomyelitis is characterized by generalized osteoporosis, with small, faintly bounded translucent areas visible in the bone marrow cavity, followed by sharp-edged speckled, granular, or chisel-like bone destruction defects with trabecular septa and soap bubble-like changes, which are not easily distinguished from giant cell tumors. In advanced stages, multiple lesions appear, each of which may exhibit isolated plasmacytoma changes. Isolated solitary lesions without systemic symptoms can be resected and treated with radiotherapy and chemotherapy after surgery. In multiple myeloma, surgical resection is not effective, and radiotherapy and chemotherapy are mainly used. Hodgkin’s disease: It is a malignant lymphoma, more than half of which invade the bones, including the spine, pelvis, ribs and sternum, etc. It is rare, and can develop from children to the elderly. X-ray manifestations: bone shows osteolytic destruction, either by direct invasion from adjacent lymph nodes or by bone marrow infiltration. Bone marrow infiltration may cause thickening and sclerosis of bone trabeculae, and some of these changes are a mixture of partial sclerosis and partial destruction, with some sclerotic lesions being osteolytic in nature. Osteolytic lesions erode the bone cortex, causing it to thin outward and form soft tissue masses, while sclerotic bone infiltrates generally do not thicken the involved bone. The diagnosis of this disease is difficult and should be differentiated from osteosarcoma, metastatic carcinoma of bone and eosinophilic granuloma. Treatment can be combined with radiotherapy, chemotherapy and surgery. The scope of radiotherapy should be wide, because the tumor often involves a wider range than estimated. 45-50 Gy can be used, irradiated within 4-5 weeks, and after combining with chemotherapy, extensive local excision can be made. Usually the bone has been invaded and the prognosis is poor. Reticulocytic sarcoma of bone: It starts from reticulocytes in the bone marrow, has a slow course, is less malignant, and rarely metastasizes. It occurs mostly in adults under 40 years of age, often with a history of trauma, 3 or 4 times more often in men than in women, mostly in the long bones, but also in the ribs and scapulae. The main symptoms are local swelling and pain, but the pain is not serious, and the temperature rarely exceeds 38’C. It is characteristic that although the tumor has been very large and the lesioned bone has been extensively destroyed, the patient is in good general condition and the systemic symptoms are not obvious. It should be distinguished from soft tissue reticulocytic sarcoma, which has an extremely malignant prognosis and is widely distributed from the beginning and invades the bone from outside. Pathologically, the shape is the same as that of Ewing’s tumor, but the cells are larger than those of Ewing’s tumor, and the shape is not as simple as that of Ewing’s tumor, including round, star-shaped and unconventional shapes, and there is a lot of cytoplasm. X-ray manifestation: In the early stage, there is extensive destruction of medullary bone, showing lamellar bone destruction area with unclear boundary, and periosteal reactive bone proliferation is not obvious. The disease is sensitive to radiation, and the primary tumor can regress after radiation therapy, but later it can develop systemic spread again. Early surgical resection with radiotherapy has a better prognosis than other malignant bone tumors, and the 5-year survival rate can reach 5%. Other rare malignant skeletal tumors: There are various rare malignant skeletal tumors in the ribs, sternum and clavicle, such as malignant osteoblastoma, malignant eosinophilic granuloma, malignant giant cell tumor, etc. In addition to X-ray and CT film, biopsy can be performed if necessary. For single and limited tumors, surgical resection should be performed as much as possible. Some tumors should be considered for surgery after radiotherapy or chemotherapy, when the tumor is reduced in size. Secondary chest wall tumor: Almost all of them are metastases from other parts of cancer. The common primary cancers include lung cancer, thyroid cancer, breast cancer, kidney and adrenal cancer, prostate cancer, nasopharyngeal cancer and so on. However, various sarcomas and Ewing’s tumor from other parts may also metastasize to the bones of chest wall, mainly hematogenous metastasis. If there is a clear history of primary cancer, multiple skeletal tumors in the chest, or the same lesions in other parts of the body, the diagnosis is easily confirmed. Sometimes, if the primary cancer is not obvious and the chest wall tumor is solitary, it is not easy to distinguish from primary chest wall tumor, and often the patient can only be clearly identified as metastatic cancer after surgery. Pulsatile metastases can also occur in the sternum and rib cage, often metastasized from thyroid cancer or Grawuz tumor, and some of them can be heard as vascular murmurs due to the abundant small blood vessels inside the tumor. Pathological fractures often occur in rib metastases. Treatment of chest wall metastases can depend on the condition of the primary tumor and whether there are other metastases in other parts of the body. If the primary tumor has been controlled, some single metastases can still be considered for surgical resection, but the prognosis is mostly poor in terms of overall outcome.