(Radiographics. 1999;19:617-637.)
© RSNA, 1999
Imaging of Chest Wall Disorders1
Mi-Young Jeung, MD,
Afshin Gangi, MD, PhD,
Bernard Gasser, MD,
Cornelia Vasilescu, MD,
Gilbert Massard, MD,
Jean-Michel Wihlm, MD and
Catherine Roy, MD
1 From the Departments of Radiology B (M.Y.J., A.G., C.V., C.R.), Pathology (B.G.), and Thoracic Surgery (G.M., J.M.W.), University Hospital of Strasbourg, 1 place de l'Hôpital, 67091 Strasbourg, France. Recipient of a Certificate of Merit award for a scientific exhibit at the 1997 RSNA scientific assembly. Received April 21, 1998; revision requested May 13 and received July 10; accepted July 10. Address reprint requests to M.Y.J.
 |
Abstract
|
|---|
Pathologic processes that may involve the chest wall include congenital and developmental anomalies, inflammatory and infectious diseases, and soft-tissue and bone tumors. Many of these processes have characteristic radiologic appearances that allow definitive diagnosis. Sternal deformities can be visualized at radiography and their severity quantified with computed tomography (CT). In cervical rib, CT with multiplanar reconstruction may demonstrate relevant anatomic detail and the relationship between bone deformity and arterial compression. In Poland syndrome, radiography reveals an area of hyperlucency on the affected side, whereas CT demonstrates the absence of the greater pectoral muscle and clearly depicts associated musculoskeletal anomalies. Tuberculosis typically manifests at radiography and CT as osseous and cartilaginous destruc-tion and soft-tissue masses with calcification and rim enhancement. Aspergillosis involving the chest wall manifests as pulmonary consolidations and permeative osteolytic changes of the rib and spine at CT and as an area of increased signal intensity at T2-weighted magnetic resonance (MR) imaging. Neurogenic tumors and hemangiomas also typically have high signal intensity at T2-weighted MR imaging. Apparent mass extension or unequivocal bone destruction seen at CT or MR imaging may indicate chest wall involvement by lymphoma. Radiologically, soft-tissue sarcomas typically appear as areas of soft-tissue density or attenuation, often associated with necrotic areas of low density or attenuation. At radiography, plasmacytoma typically manifests as well-defined, "punched-out" lytic lesions with associated extrapleural soft-tissue masses. Chondrosarcoma frequently appears as a large, lobulated excrescent mass arising from a rib with scattered flocculent calcifications characteristic of its cartilaginous mix. Familiarity with these radiologic features facilitates accurate diagnosis and optimal patient treatment.
Index Terms: Thorax, diseases, 47.14, 47.1621, 47.20, 47.21, 47.23, 47.85 • Thorax, neoplasms, 47.30
|
INTRODUCTION
|
|---|
A wide variety of disease processes affect the chest wall. Radiologists and clinicians often have difficulty detecting, localizing, characterizing, and treating these disorders. The advent of cross-sectional imaging techniques such as computed tomography (CT) and magnetic resonance (MR) imaging has enabled precise localization of chest wall lesions and, in some cases, definitive diagnosis. In this article, we discuss and illustrate the radiologic features of a wide spectrum of chest wall disorders, including congenital and developmental anomalies (eg, funnel chest, pigeon breast, cervical rib, cleidocranial dysostosis, Poland syndrome), inflammatory and infectious diseases (eg, pyogenic infection, tuberculosis, actinomycosis, aspergillosis), soft-tissue tumors (eg, lipomas, neurogenic tumors, hemangiomas, desmoid tumors, hemangiopericytomas, lymphomas, soft-tissue sarcomas), and bone tumors (eg, fibrous dysplasia, plasmacytomas, chondrosarcomas, osteosarcomas). In addition, we correlate characteristic radiographic, CT, and MR imaging findings with pathologic findings when appropriate.
|
CONGENITAL AND DEVELOPMENTAL ANOMALIES
|
|---|
Funnel Chest
Funnel chest (pectus excavatum) is the most common congenital deformity of the sternum. In funnel chest, the sternum is depressed so that the ribs on each side protrude anteriorly more than the sternum itself. The currently accepted and most plausible cause of funnel chest is excessive misdirected growth of the lowermost cartilages, resulting in various types of concave deformities and an inwardly forced lower sternal segment (1).
This sternal and cartilaginous depression reduces the prevertebral space, resulting in leftward displacement and axial rotation of the heart (seen at posteroanterior chest radiography) as well as reduction in the space occupied by the left lung. Posteroanterior radiography also depicts parasternal soft tissues of the anterior chest wall as an area of increased density in the inferomedial portion of the right hemithorax (Fig 1a). The degree of sternal depression is easily appreciated at lateral radiography (Fig 1b) (2). The severity of the deformity is best quantified with CT (Fig 1c); this is especially important when surgical correction is being contemplated (3). The "pectus index" can be derived by dividing the transverse diameter of the chest by the anteroposterior diameter. Haller et al (4) found the normal value of this index to be 2.56 (±0.35 SD) and suggested that a pectus index greater than 3.25 necessitated surgical correction. Similar indices (depression, asymmetry, flatness) derived from CT measurements have been used to evaluate surgical outcome (5).
View larger version (139K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1a. Funnel chest in a 21-year-old man admitted for surgical correction. (a) Posteroanterior chest radiograph shows leftward displacement of the heart. (b) Lateral chest radiograph demonstrates severe depression of the sternum. (c) CT scan clearly demonstrates compression of the heart by the depressed sternum and allows quantification of the severity of sternal deformity.
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1b. Funnel chest in a 21-year-old man admitted for surgical correction. (a) Posteroanterior chest radiograph shows leftward displacement of the heart. (b) Lateral chest radiograph demonstrates severe depression of the sternum. (c) CT scan clearly demonstrates compression of the heart by the depressed sternum and allows quantification of the severity of sternal deformity.
|
|
View larger version (91K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1c. Funnel chest in a 21-year-old man admitted for surgical correction. (a) Posteroanterior chest radiograph shows leftward displacement of the heart. (b) Lateral chest radiograph demonstrates severe depression of the sternum. (c) CT scan clearly demonstrates compression of the heart by the depressed sternum and allows quantification of the severity of sternal deformity.
|
|
Pigeon Breast
Pigeon breast (pectus carinatum) is a deformity of the chest wall in which the sternum exhibits abnormal protrusion anteriorly (Fig 2). Pigeon breast is less common than the excavation deformities. Although it can occur in isolation, pigeon breast is also frequently seen in patients with cyanotic congenital heart disease (6,7).
View larger version (148K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Pigeon breast in a 25-year-old woman. (a) Lateral chest radiograph shows a bulging sternum. (b) CT scan reveals the degree of sternal protrusion and asymmetry of the chest wall.
|
|
View larger version (115K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Pigeon breast in a 25-year-old woman. (a) Lateral chest radiograph shows a bulging sternum. (b) CT scan reveals the degree of sternal protrusion and asymmetry of the chest wall.
|
|
Cervical Rib
Cervical rib, also known as anomalous accessory rib or "Eve's rib," usually arises from the seventh cervical vertebra. The criterion for diagnosis is the presence of a supernumerary rib that articulates with a cervical-type transverse process (ie, a horizontal transverse process, as opposed to the upward-sloping thoracic transverse processes). This anomaly may vary from full size to a mere riblet and can be perceived as supernumerary by identifying the true second rib, which always articulates anteriorly at the manubriosternal junction (8). Cervical rib occurs in about 0.5% of the population (8). In about 90% of cases, cervical ribs are asymptomatic.
The diagnosis of cervical rib syndrome is certain when there is radiographic evidence of a cervical rib associated with typical signs and symptoms (ie, pain and weakness of the arm, swelling of the hand, variation in pulse intensity in the two arms when the affected extremity is in certain positions) (Fig 3) (2). Bone deformity can cause bilateral thoracic outlet obstruction and compression of the main arterial vessels (9). Arteriography may be useful for diagnosis and preoperative evaluation. CT with multiplanar reconstruction may demonstrate relevant anatomic detail and the relationship between bone deformity and compression of the main arterial vessels (Fig 3).
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Cervical rib syndrome in a 17-year-old girl with pain and weakness of the right arm in certain positions. (a) Coned-down radiograph demonstrates a left cervical rib and pseudoarthrosis between a right cervical rib and the first rib. (b) Contrast material–enhanced CT scan shows compression of the right subclavian artery by the clavicle and cervical rib (arrow).
|
|
View larger version (119K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Cervical rib syndrome in a 17-year-old girl with pain and weakness of the right arm in certain positions. (a) Coned-down radiograph demonstrates a left cervical rib and pseudoarthrosis between a right cervical rib and the first rib. (b) Contrast material–enhanced CT scan shows compression of the right subclavian artery by the clavicle and cervical rib (arrow).
|
|
Cleidocranial Dysostosis
Cleidocranial dysostosis is characterized by incomplete ossification of the clavicle and defective development of the pubic bones, vertebral column, and long bones. The clavicles may be absent or may demonstrate minimal hypoplasia. Most often, the clavicle is underdeveloped and frequently appears as two separate hypoplastic segments (Fig 4) (6).
Poland Syndrome
Poland syndrome is an uncommon congenital aberration of the chest wall characterized by partial or total absence of the greater pectoral muscle and ipsilateral syndactyly (10). Other associated anomalies include absence or atrophy of the ipsilateral second to fifth ribs, absence of the smaller pectoral muscle, aplasia of the ipsilateral breast or nipple, and simian crease of the affected extremity (6,11). Chest radiography reveals an area of hyperlucency on the affected side that mimics a radical mastectomy (Fig 5a) (12). CT more clearly depicts the absence of the greater pectoral muscle and allows better appreciation of other nearby associated musculoskeletal anomalies (Fig 5b).
View larger version (163K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5a. Poland syndrome in a 17-year-old boy with syndactyly of the left hand. (a) Chest radiograph shows diffuse hyperlucency on the left side. (b) CT scan obtained at the level of the sternoclavicular junction demonstrates aplasia of the greater pectoral muscle.
|
|
View larger version (91K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5b. Poland syndrome in a 17-year-old boy with syndactyly of the left hand. (a) Chest radiograph shows diffuse hyperlucency on the left side. (b) CT scan obtained at the level of the sternoclavicular junction demonstrates aplasia of the greater pectoral muscle.
|
|
|
INFLAMMATORY AND INFECTIOUS DISEASES
|
|---|
Although primary infection of the chest wall is rare, it can occur spontaneously or in association with diabetes mellitus, immunosuppression, or trauma (including surgical trauma). Heroin addicts are unusually prone to develop septic arthritis of the sternoclavicular and sternochondral joints. More commonly, osteomyelitis occurs secondary to infectious processes in the lung (usually of tuberculous or fungal origin) or to pleural empyema (empyema necessitatis).
Pyogenic Infection
The most common causative organisms in pyogenic infection are Staphylococcus aureus and Pseudomonas aeruginosa (13). Pyogenic osteomyelitis of the ribs and sternum is generally associated with an adjacent soft-tissue mass, loss of deep soft-tissue planes, and periosteal elevation. However, these findings may be difficult to visualize at radiography until bone destruction is advanced. Bone destruction in pyogenic osteomyelitis may not be visible for 1–2 weeks after the onset of symptoms (3). However, CT and MR imaging can easily help detect soft-tissue masses surrounding the infected bone and can help evaluate adjacent pulmonary, pleural, and mediastinal structures (Figs 6, 7). CT appears to be the modality of choice whenever percutaneous biopsy or drainage is required (14).
View larger version (146K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6. Figures 6, 7. (6) Sternal osteomyelitis caused by ß-hemolytic Streptococcus organisms in a 46-year-old diabetic woman with fever and presternal swelling. CT scan shows pneumonia in the right upper lobe, bone destruction of the sternum, and a peristernal fluid collection with air bubbles. (7) Costal chondritis caused by Staphylococcus aureus in a 54-year-old man who presented with cutaneous fistula and swelling of a thoracic wall scar 1 month after undergoing resection of a mouth carcinoma. Contrast-enhanced CT scan reveals destruction of the fourth cartilage associated with soft-tissue infiltration.
|
|
View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7. Figures 6, 7. (6) Sternal osteomyelitis caused by ß-hemolytic Streptococcus organisms in a 46-year-old diabetic woman with fever and presternal swelling. CT scan shows pneumonia in the right upper lobe, bone destruction of the sternum, and a peristernal fluid collection with air bubbles. (7) Costal chondritis caused by Staphylococcus aureus in a 54-year-old man who presented with cutaneous fistula and swelling of a thoracic wall scar 1 month after undergoing resection of a mouth carcinoma. Contrast-enhanced CT scan reveals destruction of the fourth cartilage associated with soft-tissue infiltration.
|
|
Median sternotomy has become the principal surgical approach to the coronary vessels, heart, mediastinum, and lungs. Poststernotomy complications—most notably sternal dehiscence, mediastinitis, and osteomyelitis (Fig 8)—occur in less than 5% of cases (15). The overall mortality rate of patients with these complications exceeds 50% (15). Complications usually manifest 1–2 weeks after surgery. Conventional radiography plays a limited role in the evaluation of poststernotomy complications. CT is the most useful method for detecting and localizing a retrosternal abscess (15). The presence of air in the retrosternal tissues associated with a mass is highly suspicious for an abscess. At CT, acute mediastinitis manifests as diffuse widening and replacement of mediastinal fat by higher-attenuation inflammatory tissue (Fig 8). Artifacts from sternal wires make MR imaging less useful than CT in the evaluation of sternal infection.
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8. Poststernotomy infection from Staphylococcus aureus in a 65-year-old man who developed a cutaneous fistula of a sternotomy scar 3 weeks after undergoing coronary bypass surgery. Contrast-enhanced CT scan shows a sternal dehiscence and diffuse mediastinal fat infiltration (arrows).
|
|
Open-window thoracostomy or modified Eloesser procedure is a surgical treatment for chronic pleural empyema in which a relatively permanent drainage opening is created in the thoracic wall, eliminating the need for indwelling tubes. In a study by Shapiro et al (16), the Eloesser window appeared at chest radiography as an elliptic or crescent-shaped area of radiolucency with sharp superior margins and ill-defined inferior margins en face and as a downward-sloping chest wall defect with round superior margins and straight inferior margins in profile (Fig 9).
View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9a. Surgically created fistula from open-window thoracostomy performed in a 60-year-old man who had developed a chronically infected empyema following double lobectomy of the right middle and lower lobes for bronchogenic carcinoma. Drainage procedures and antibiotic therapy proved ineffective. (a) Chest radiograph shows a surgically created fistula between the pleural cavity and the skin (arrows). (b) CT scan reveals an opening in the thoracic wall. The interposed muscle flap contains fat (arrows). The right side of the pleural cavity is filled with fluid.
|
|
View larger version (127K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9b. Surgically created fistula from open-window thoracostomy performed in a 60-year-old man who had developed a chronically infected empyema following double lobectomy of the right middle and lower lobes for bronchogenic carcinoma. Drainage procedures and antibiotic therapy proved ineffective. (a) Chest radiograph shows a surgically created fistula between the pleural cavity and the skin (arrows). (b) CT scan reveals an opening in the thoracic wall. The interposed muscle flap contains fat (arrows). The right side of the pleural cavity is filled with fluid.
|
|
Tuberculosis
Chest wall involvement is an uncommon manifestation of tuberculosis (17) that may be due to contiguous spread from underlying pleural or pulmonary lesions, although hematogenous seeding without active pulmonary disease is more common. Chest wall abscess and sinus tract formation occur in about 25% of cases (3). At radiography and CT, tuberculous chest wall involvement typically manifests as osseous and cartilaginous destruction and soft-tissue masses with calcification and rim enhancement following intravenous administration of contrast material (Fig 10) (18).
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10. Tuberculous abscess in a 27-year-old woman with acquired immunodeficiency syndrome who complained of right lower chest pain and swelling. The patient had been treated for pulmonary tuberculosis 2 month earlier. Contrast-enhanced CT scan demonstrates a well-defined, multiloculated abscess in the right lower thoracic wall (arrows).
|
|
Collapse therapy was an important aspect of treatment for pulmonary tuberculosis before the advent of chemotherapy. Various surgical methods have been designed to collapse the excavated lung and include intra- and extrapleural pneumothorax; extrapleural plombage with Lucite balls (Fig 11), paraffin cellophane packets, polystan sponges, or fiberglass; and thoracoplasty. These treatments often lead to stabilization and sometimes to permanent cure of the lesions (19,20). However, the complication rate of collapse therapy is very high (up to 16%) (19) and primarily involves infection of the plombage space (Fig 11), hemorrhage through vascular erosion, and breach of the underlying parenchymal cavitation leading to extrapleural spread of tuberculosis with pleurocutaneous fistula (Fig 12).
View larger version (150K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11a. Infected extraperiosteal plombage space in a 56-year-old man who presented with fever and chest pain. The patient had undergone extraperiosteal plombage with Lucite balls 15 years earlier. (a) Posteroanterior chest radiograph shows the dispersed Lucite balls in the right apex. (b, c) CT scan (b) and sagittal T1-weighted MR image (c) show an abundant collection of fluid in the extraperiosteal plombage space and migration of some Lucite balls to the subpleural and paravertebral subcutaneous regions.
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11b. Infected extraperiosteal plombage space in a 56-year-old man who presented with fever and chest pain. The patient had undergone extraperiosteal plombage with Lucite balls 15 years earlier. (a) Posteroanterior chest radiograph shows the dispersed Lucite balls in the right apex. (b, c) CT scan (b) and sagittal T1-weighted MR image (c) show an abundant collection of fluid in the extraperiosteal plombage space and migration of some Lucite balls to the subpleural and paravertebral subcutaneous regions.
|
|
View larger version (142K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11c. Infected extraperiosteal plombage space in a 56-year-old man who presented with fever and chest pain. The patient had undergone extraperiosteal plombage with Lucite balls 15 years earlier. (a) Posteroanterior chest radiograph shows the dispersed Lucite balls in the right apex. (b, c) CT scan (b) and sagittal T1-weighted MR image (c) show an abundant collection of fluid in the extraperiosteal plombage space and migration of some Lucite balls to the subpleural and paravertebral subcutaneous regions.
|
|
View larger version (115K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12. Tuberculous pleurocutaneous fistula in a 61-year-old woman who presented with fever and a cutaneous fistula in the left paravertebral area. The patient had undergone collapse therapy for tuberculosis 44 years earlier and thoracoplasty for infection of a plombage space 5 years afterward. CT scan shows an abscess collection in the chest wall (arrowhead) and pleural effusion. Results of biopsy of the cutaneous fistula confirmed the recurrence of tuberculosis.
|
|
Actinomycosis
Thoracic actinomycosis is an uncommon bacterial infection reported to occur in about 15% of cases of actinomycosis (21). Actinomycosis is well known for its tendency to involve the chest wall from the lung and pleura, often creating fistulas without regard for tissue planes by producing proteolytic enzymes (22). Empyema necessitatis is a collection of fluid in the extra-pleural space resulting from direct extension from pulmonary or pleural lesions following dissection of the parietal pleura and chest wall (Fig 13). The disease may remain indolent for long periods of time. Important radiographic findings in actinomycosis include chest wall involvement in the form of abnormal thickening of the soft tissue, draining sinus, wavy periostitis, and rib destruction (21,23).
View larger version (139K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13a. Actinomycosis with empyema necessitatis in a 61-year-old woman who presented with fever and a fluctuant mass of the left chest wall. The patient had been treated for multiple pelvic fractures sustained in a motor vehicle accident 1 month earlier. (a) Collimated radiograph shows irregular destruction and fractures of the sixth and seventh left ribs (arrows). (b) Contrast-enhanced CT scan reveals a well-defined, fluid-filled mass with marked rim enhancement (arrowheads) in the thoracic wall and airspace consolidation in the adjacent lung parenchyma. (c) Low-power photomicrograph (original magnification, x50; hematoxylin-eosin stain) of resected tissue shows a typical sulfur granule surrounded by numerous polynuclear leukocytes.
|
|
View larger version (128K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13b. Actinomycosis with empyema necessitatis in a 61-year-old woman who presented with fever and a fluctuant mass of the left chest wall. The patient had been treated for multiple pelvic fractures sustained in a motor vehicle accident 1 month earlier. (a) Collimated radiograph shows irregular destruction and fractures of the sixth and seventh left ribs (arrows). (b) Contrast-enhanced CT scan reveals a well-defined, fluid-filled mass with marked rim enhancement (arrowheads) in the thoracic wall and airspace consolidation in the adjacent lung parenchyma. (c) Low-power photomicrograph (original magnification, x50; hematoxylin-eosin stain) of resected tissue shows a typical sulfur granule surrounded by numerous polynuclear leukocytes.
|
|
View larger version (179K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13c. Actinomycosis with empyema necessitatis in a 61-year-old woman who presented with fever and a fluctuant mass of the left chest wall. The patient had been treated for multiple pelvic fractures sustained in a motor vehicle accident 1 month earlier. (a) Collimated radiograph shows irregular destruction and fractures of the sixth and seventh left ribs (arrows). (b) Contrast-enhanced CT scan reveals a well-defined, fluid-filled mass with marked rim enhancement (arrowheads) in the thoracic wall and airspace consolidation in the adjacent lung parenchyma. (c) Low-power photomicrograph (original magnification, x50; hematoxylin-eosin stain) of resected tissue shows a typical sulfur granule surrounded by numerous polynuclear leukocytes.
|
|
Aspergillosis
Aspergillosis is a disease of worldwide proportions caused by species of the dimorphic fungus Aspergillus. These organisms are opportunistic invaders that chiefly affect immunocompromised hosts, most commonly as a result of cancer and related therapy but occasionally following organ transplantation or cardiac surgery. Rare cases of postoperative or de novo aspergillosis have been reported in apparently healthy hosts (24,25). The organisms grow in association with underlying systemic or pulmonary disease as saprophytes (a mycetoma) or as invasive organisms that cause tissue destruction. Invasive pulmonary aspergillosis can take several forms including tracheobronchitis and necrotizing bronchopneumonia with or without cavity formation. Hemorrhagic infarction, miliary disease, and interstitial pneumonitis have also been reported (2). Invasion of the chest wall and pleura can create fistulas (26–29). Detection of chest wall invasion is difficult with conventional radiography, but extension can be identified and monitored effectively with CT and MR imaging (Fig 14). CT can demonstrate pulmonary consolidations and permeative osteolytic changes of the rib and spine. MR imaging can depict chest wall involvement, which has increased signal intensity on T2-weighted images, and decreased signal intensity from fat planes on T1-weighted images (26).
View larger version (169K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Invasive aspergillosis mimicking a superior sulcus tumor in a 37-year-old man with a 2-month history of right arm and shoulder pain. (a) Contrast-enhanced CT scan demonstrates an irregular cavitary subpleural-based lesion infiltrating extrapleural fatty tissue (arrowheads). (b) Sagittal T1-weighted MR image shows a poorly marginated lesion extending superiorly into the chest wall (arrows). (c) Low-power photomicrograph (original magnification, x12; hematoxylin-eosin stain) of resected tissue shows multiple conglomerations of interwoven fungal hyphae (arrows) surrounded by necrotic lung parenchyma.
|
|
View larger version (170K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Invasive aspergillosis mimicking a superior sulcus tumor in a 37-year-old man with a 2-month history of right arm and shoulder pain. (a) Contrast-enhanced CT scan demonstrates an irregular cavitary subpleural-based lesion infiltrating extrapleural fatty tissue (arrowheads). (b) Sagittal T1-weighted MR image shows a poorly marginated lesion extending superiorly into the chest wall (arrows). (c) Low-power photomicrograph (original magnification, x12; hematoxylin-eosin stain) of resected tissue shows multiple conglomerations of interwoven fungal hyphae (arrows) surrounded by necrotic lung parenchyma.
|
|
View larger version (182K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14c. Invasive aspergillosis mimicking a superior sulcus tumor in a 37-year-old man with a 2-month history of right arm and shoulder pain. (a) Contrast-enhanced CT scan demonstrates an irregular cavitary subpleural-based lesion infiltrating extrapleural fatty tissue (arrowheads). (b) Sagittal T1-weighted MR image shows a poorly marginated lesion extending superiorly into the chest wall (arrows). (c) Low-power photomicrograph (original magnification, x12; hematoxylin-eosin stain) of resected tissue shows multiple conglomerations of interwoven fungal hyphae (arrows) surrounded by necrotic lung parenchyma.
|
|
|
TUMORS OF THE CHEST WALL
|
|---|
The thoracic wall consists of muscles, bone, cartilage, fat, fibrous connective tissue, nerves, breast tissue, blood, and lymphatic vessels. Tumors may arise from any of these tissues and produce chest wall masses. When such masses expand into the lung, they usually displace the pleura and form an obtuse angle with the chest wall on radiographs, CT scans, and MR images. Masses associated with rib bone changes are unequivocally extrapleural in location.
Soft-Tissue Tumors
Primary soft-tissue neoplasms of the thoracic wall are rare. In adults, the most common benign soft-tissue neoplasm is lipoma and the most common malignant neoplasms are fibrosarcoma and malignant fibrohistiocytoma. In children, primitive neuroectodermal tumor (Askin tumor), rhabdomyosarcoma, and extraosseous Ewing sarcoma are the most common malignant soft-tissue tumors (2). Other soft-tissue lesions involving the chest wall include neurogenic tumors, hemangiomas, desmoid tumors, hemangiopericytomas, lymphomas, and other soft-tissue sarcomas.
Lipomas.—Lipomas of the chest wall are benign and do not require treatment until they become large. Some of these lesions are dumbbell-shaped, having both intrathoracic and extrathoracic components (30). CT and MR imaging demonstrate the lesion as a well-circumscribed mass with the imaging characteristics of fat (Fig 15). At times, CT and MR imaging may help distinguish lipomas from liposarcomas, which almost always have inhomogeneous nonfatty elements.
View larger version (151K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 15. Transthoracic lipoma in a 75-year-old man. CT scan shows a low-attenuation mass (arrows) surrounding the transverse muscle of the thorax at the anterior chest wall and invaginating the lung.
|
|
Neurogenic Tumors.—Neurogenic tumors may originate from the intercostal nerves of the thoracic cage (Fig 16) or from the paraspinal ganglion of the sympathetic chain. Tumors that arise from nerve roots include neurilemmoma (benign schwannoma, neurinoma), neurofibroma, neurofibrosarcoma, and neuroma. Tumors that affect the sympathetic ganglion include neuroblastoma, ganglioneuroma, and ganglioneuroblastoma (31). Neurofibromas develop as multiple tumors located throughout the body and associated with the pigmented "café-au-lait" skin lesions of von Recklinghausen disease (neurofibromatosis) (Fig 17). Neurofibromas from von Recklinghausen disease become malignant in 10%–20% of cases (32). The extent of chest wall involvement is easily evaluated with MR imaging because neurofibromas and other neurogenic tumors have high signal intensity on T2-weighted images. A characteristic imaging feature of neurofibroma on T2-weighted MR images is the target sign, a central focus of low signal intensity within the bright tumor (31).
View larger version (159K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16a. Intercostal schwannoma in a 72-year-old woman with a known area of increased opaci-ty in the left upper lobe. (a) Contrast-enhanced CT scan shows a well-defined, heterogeneous solid mass attached to the thoracic wall. (b) Photograph of the gross specimen shows a regular, white-yellow mass containing focal areas of necrosis and hemorrhage. Scale is in millimeters.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 16b. Intercostal schwannoma in a 72-year-old woman with a known area of increased opaci-ty in the left upper lobe. (a) Contrast-enhanced CT scan shows a well-defined, heterogeneous solid mass attached to the thoracic wall. (b) Photograph of the gross specimen shows a regular, white-yellow mass containing focal areas of necrosis and hemorrhage. Scale is in millimeters.
|
|
View larger version (70K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17a. Neurofibroma in a 43-year-old man with known neurofibromatosis who presented with a large axillary mass and a 3-month history of right arm pain. (a) Contrast-enhanced CT scan with coronal two-dimensional reconstruction demonstrates a well-defined mass with central necrosis displacing the right subclavian artery. (b) Sagittal T2-weighted fast spin-echo MR image shows a regular mass with a high-signal-intensity area of necrosis.
|
|
View larger version (145K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 17b. Neurofibroma in a 43-year-old man with known neurofibromatosis who presented with a large axillary mass and a 3-month history of right arm pain. (a) Contrast-enhanced CT scan with coronal two-dimensional reconstruction demonstrates a well-defined mass with central necrosis displacing the right subclavian artery. (b) Sagittal T2-weighted fast spin-echo MR image shows a regular mass with a high-signal-intensity area of necrosis.
|
|
Hemangiomas.—Hemangiomas are occasionally found in the soft tissues of the chest wall. They are usually cavernous and may contain a significant amount of fat. Hemangiomas may be visible at radiography if they contain phleboliths. CT demonstrates a poorly defined mass with an attenuation approximating that of skeletal muscle, along with phleboliths and underlying bone remodeling (Fig 18a) (33). MR imaging best demonstrates the extent of hemangiomas in soft tissue: The lesion characteristically demonstrates intermediate signal intensity on T1-weighted images and marked hyperintensity on T2-weighted images, indicating a prolonged T2 relaxation time (Fig 18b, 18c) (33,34).
View larger version (164K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18a. Hemangioma in a 33-year-old man with a slow-growing thoracic wall mass of 20 years duration. (a) Contrast-enhanced CT scan demonstrates complex nodular masses with phleboliths in the chest wall (arrowheads). (b) Coronal T1-weighted MR image shows multiple low-signal-intensity masses deforming the lower chest wall (arrowheads). (c) On an axial T2-weighted MR image, the extremely high-signal-intensity hemangiomas can be clearly differentiated from adjacent chest wall structures.
|
|
View larger version (153K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18b. Hemangioma in a 33-year-old man with a slow-growing thoracic wall mass of 20 years duration. (a) Contrast-enhanced CT scan demonstrates complex nodular masses with phleboliths in the chest wall (arrowheads). (b) Coronal T1-weighted MR image shows multiple low-signal-intensity masses deforming the lower chest wall (arrowheads). (c) On an axial T2-weighted MR image, the extremely high-signal-intensity hemangiomas can be clearly differentiated from adjacent chest wall structures.
|
|
View larger version (131K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 18c. Hemangioma in a 33-year-old man with a slow-growing thoracic wall mass of 20 years duration. (a) Contrast-enhanced CT scan demonstrates complex nodular masses with phleboliths in the chest wall (arrowheads). (b) Coronal T1-weighted MR image shows multiple low-signal-intensity masses deforming the lower chest wall (arrowheads). (c) On an axial T2-weighted MR image, the extremely high-signal-intensity hemangiomas can be clearly differentiated from adjacent chest wall structures.
|
|
Desmoid Tumors.—Desmoid tumors are distinctly uncommon lesions and may involve the chest wall. Although they can be locally aggressive and tend to recur after resection, these firm, fibroblastic tumors are considered benign and do not metastasize. Desmoid tumors occur most frequently in the intercostal musculature and around the shoulder girdle, usually after trauma (35), and are seen more frequently in women than in men. At CT, desmoid tumors generally appear as ill-defined, nonenhancing soft-tissue masses. At MR imaging, the masses are hypointense on T1-weighted images and iso- or moderately hyperintense on T2-weighted images (Fig 19).
View larger version (95K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19a. Desmoid tumor in a 53-year-old woman with a parasternal mass. (a) CT scan demonstrates a homogeneous soft-tissue mass of the parasternum without adjacent bone destruction. (b) Photograph of a cut specimen shows a firm, whitish mass with an irregularly whorled surface. Scale is in centimeters. (c) Axial short-inversion-time inversion recovery MR image obtained 2 years after surgery reveals the recurrence of two high-signal-intensity masses in the anterior chest wall and axillary region (arrows).
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19b. Desmoid tumor in a 53-year-old woman with a parasternal mass. (a) CT scan demonstrates a homogeneous soft-tissue mass of the parasternum without adjacent bone destruction. (b) Photograph of a cut specimen shows a firm, whitish mass with an irregularly whorled surface. Scale is in centimeters. (c) Axial short-inversion-time inversion recovery MR image obtained 2 years after surgery reveals the recurrence of two high-signal-intensity masses in the anterior chest wall and axillary region (arrows).
|
|
View larger version (121K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 19c. Desmoid tumor in a 53-year-old woman with a parasternal mass. (a) CT scan demonstrates a homogeneous soft-tissue mass of the parasternum without adjacent bone destruction. (b) Photograph of a cut specimen shows a firm, whitish mass with an irregularly whorled surface. Scale is in centimeters. (c) Axial short-inversion-time inversion recovery MR image obtained 2 years after surgery reveals the recurrence of two high-signal-intensity masses in the anterior chest wall and axillary region (arrows).
|
|
Hemangiopericytomas.—Hemangiopericytomas are slow-growing vascular tumors of the soft tissue that are believed to be derived from the pericytes of Zimmerman, which surround the capillary wall (36). Hemangiopericytomas occur most frequently in adults and are usually located in the soft tissues of the upper and lower extremities, the pelvis, and the retroperitoneal space. Although some hemangiopericytomas behave in a benign fashion, many are locally invasive at the time of diagnosis or recur following removal, then metastasize and cause death (37). Radiography and CT demonstrate a nonspecific soft-tissue mass (Fig 20). Occasionally, hemangiopericytomas may exhibit calcification and bone erosion (36).
View larger version (135K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20a. Hemangiopericytoma in an 82-year-old woman with a 2-month history of severe resting dyspnea. (a) Posteroanterior chest radiograph shows a large area of increased opacity in the right hemithorax mimicking an elevated diaphragm. (b) CT scan obtained with the patient in the lateral decubitus position reveals a large, heterogeneous solid mass with pleural effusion. The 2.1-kg mass was resected with a portion of the chest wall. Hemangiopericytoma was diagnosed at histologic analysis.
|
|
View larger version (175K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 20b. Hemangiopericytoma in an 82-year-old woman with a 2-month history of severe resting dyspnea. (a) Posteroanterior chest radiograph shows a large area of increased opacity in the right hemithorax mimicking an elevated diaphragm. (b) CT scan obtained with the patient in the lateral decubitus position reveals a large, heterogeneous solid mass with pleural effusion. The 2.1-kg mass was resected with a portion of the chest wall. Hemangiopericytoma was diagnosed at histologic analysis.
|
|
Lymphomas.—Hodgkin and non-Hodgkin lymphomas may occasionally involve the chest wall with or without mediastinal or lung parenchymal disease. In a study by Press et al (38) of 250 patients with newly diagnosed or recurrent lymphoma, CT revealed chest wall involvement in 24 patients (9.6%); in 17 of these 24 cases, there was no evidence of direct extension from contiguous mediastinal or parenchymal disease. In four patients, the thoracic wall was the only site of disease.
Patients with Hodgkin or non-Hodgkin lymphoma undergo a variety of radiologic procedures that are performed to define the extent of disease for staging, follow up the effects of treatment, and monitor for relapse. CT and MR imaging have proved sensitive in the evaluation of possible chest wall involvement by lymphoma on the basis of (a) apparent extension of the mass into fat or muscle of the chest wall or around the ribs, or (b) unequivocal bone destruction (Fig 21) (39,40). Chest wall involvement by lymphoma may be extensive. Pericardial involvement should be carefully assessed. Stage, prognosis, and choice of therapy depend on the depth of mediastinal invasion.
View larger version (145K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 21. Lymphoma in a 62-year-old man with a lower thoracic wall mass and a 3-month history of vague discomfort. Contrast-enhanced CT scan demonstrates diffuse thickening of the left thoracic wall and diaphragm (arrowheads).
|
|
Soft-Tissue Sarcomas.—Fibrosarcoma and malignant fibrohistiocytoma are the most common malignant tumors arising from the soft tissues of the chest wall in adult patients. Rhabdomyosarcoma (Fig 22), malignant schwannoma, and synovial sarcoma are less common. All these tumors have a similar radiologic appearance. At radiography, CT, and MR imaging, they appear as areas of soft-tissue density or attenuation, often associated with necrotic areas of low density or attenuation (Fig 22). Calcification within the tumor may also be seen (3).
View larger version (118K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22a. Rhabdomyosarcoma in a 23-year-old woman who presented with a mass below the right breast that had been growing rapidly since she gave birth 2 months earlier. (a) Contrast-enhanced CT scan demonstrates a heterogeneous mass in the chest wall behind the breast. (b) Coronal T1-weighted MR image shows the well-defined mass as nearly isointense relative to muscle. (c) Axial T2-weighted spin-echo MR image shows the homogeneous high-signal-intensity mass.
|
|
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22b. Rhabdomyosarcoma in a 23-year-old woman who presented with a mass below the right breast that had been growing rapidly since she gave birth 2 months earlier. (a) Contrast-enhanced CT scan demonstrates a heterogeneous mass in the chest wall behind the breast. (b) Coronal T1-weighted MR image shows the well-defined mass as nearly isointense relative to muscle. (c) Axial T2-weighted spin-echo MR image shows the homogeneous high-signal-intensity mass.
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 22c. Rhabdomyosarcoma in a 23-year-old woman who presented with a mass below the right breast that had been growing rapidly since she gave birth 2 months earlier. (a) Contrast-enhanced CT scan demonstrates a heterogeneous mass in the chest wall behind the breast. (b) Coronal T1-weighted MR image shows the well-defined mass as nearly isointense relative to muscle. (c) Axial T2-weighted spin-echo MR image shows the homogeneous high-signal-intensity mass.
|
|
Osseous Tumors
Primary neoplasms of the thoracic skeleton are uncommon. Ochsner et al (41) reported 134 cases of thoracic skeletal neoplasms, which represented only 5% of all bone and joint neoplasms. Of these 134 cases, 84 (63%) were primary. The majority of osseous neoplasms were seen in the ribs. These rib lesions were usually metastatic, typically from the lung and breast. The majority of lesions arising in the sternum were malignant and most often represented chondrosarcoma. Lesions of the thoracic vertebrae were almost invariably metastatic (41).
Osteochondroma is the most common benign tumor of the cartilage and bone; enchondroma and osteoblastoma are less common. The most common malignant neoplasm is chondrosarcoma (42), with hemangiopericytoma, fibrosarcoma, malignant fibrohistiocytoma, and osteosarcoma seen less frequently (32,41). The most common nonneoplastic tumor of the thoracic skeleton is fibrous dysplasia, although eosinophilic granuloma, hemangioma, Paget disease, giant cell tumor, and aneurysmal bone cyst may also occur (41). Myeloma and solitary plasmacytoma are the most common malignant neoplasms of reticuloendothelial origin, followed by Hodgkin disease and large cell lymphoma (41).
Fibrous Dysplasia.—Fibrous dysplasia is the most common nonneoplastic tumor of the rib, accounting for approximately 30% of benign bone tumors of the chest wall (32). Fibrous dysplasia probably originates as a developmental abnormality of bone-forming mesenchyme in which osteoblasts fail to undergo normal morphologic differentiation and maturation (36). These slow-growing tumors are seen in the lateral or posterior aspect of a rib and are asymptomatic until they become sufficiently large to cause pressure symptoms, pathologic fractures, or both. Fibrous dysplasia manifests as an expanding lytic area with a ground-glass appearance (Fig 23).
View larger version (168K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23a. Fibrous dysplasia in a 36-year-old man with a chest wall mass. (a) Chest radiograph reveals expansion and distortion of the left third rib (arrow). (b) Thin-section CT scan shows a multiloculated, sharply marginated, expanding lytic area surrounded by a thin cortex. (c) Radiograph of the resected specimen demonstrates lytic areas with a characteristic hazy, ground-glass appearance.
|
|
View larger version (136K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23b. Fibrous dysplasia in a 36-year-old man with a chest wall mass. (a) Chest radiograph reveals expansion and distortion of the left third rib (arrow). (b) Thin-section CT scan shows a multiloculated, sharply marginated, expanding lytic area surrounded by a thin cortex. (c) Radiograph of the resected specimen demonstrates lytic areas with a characteristic hazy, ground-glass appearance.
|
|
View larger version (57K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 23c. Fibrous dysplasia in a 36-year-old man with a chest wall mass. (a) Chest radiograph reveals expansion and distortion of the left third rib (arrow). (b) Thin-section CT scan shows a multiloculated, sharply marginated, expanding lytic area surrounded by a thin cortex. (c) Radiograph of the resected specimen demonstrates lytic areas with a characteristic hazy, ground-glass appearance.
|
|
Plasmacytomas.—Solitary plasmacytoma is a rare tumor that is associated with latent systemic disease in the majority of affected patients. It usually occurs in patients between 40 and 80 years of age. The presence of systemic disease (multiple myeloma) is confirmed by the presence of an abnormal plasma immunoelectrophoretic pattern, Bence-Jones proteinuria, or plasmacytosis at bone marrow examination (32). Plasmacytoma and multiple myeloma are typically seen as well-defined, "punched-out" lytic lesions with associated extrapleural soft-tissue masses, similar in appearance to most metastatic lesions (Fig 24). In advanced plasmacytoma, there is often marked erosion, expansion, and destruction of bone cortex, sometimes with thick ridging around the periphery, creating a "soap bubble" appearance. CT may demonstrate subtle lytic lesions or small soft-tissue masses, particularly of the sternum, that are not visible at radiography (3). Use of short-inversion-time inversion recovery and contrast-enhanced fat suppression techniques may improve the sensitivity of MR imaging (36).
View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 24a. Rib plasmacytoma in a 50-year-old man with a mass of the chest wall and left iliac crest. (a) Posteroanterior chest radiograph shows a large mass protruding into the thorax along the lower axillary lung zone with a destructive rib lesion. (b) Photograph of a cut specimen of the rib shows the soft, expansile, crumbled hemorrhagic mass with yellowish necrotic areas (arrows). Scale is in centimeters.
|
|
View larger version (68K):
| |
Top
Abstract
INTRODUCTION
