Apparent diffusion coefficient values in differentiating benign and malignant thoracic masses in children and young adults

BackgroundIn children and young adults, tumors in the chest and thoracic wall exhibit a wide variety of types, making it challenging to differentiate between benign and malignant cases before invasive histopathological examination.PurposeTo evaluate the utility of apparent diffusion coefficient (ADC) for discriminating malignant thoracic masses in children and young adults.Material and MethodsThis retrospective study included chest magnetic resonance imaging (MRI) scans in patients aged <30 years. Patients' age and sex, tumor location (mediastinum or thoracic wall), tumor size, MR characteristics including necrosis or hemorrhage, and ADC values were assessed.ResultsMalignant masses were found in older patients (mean age = 18.0 ± 8.1 vs. 10.6, ± 9.1 years; P = 0.008), had lower mean ADC values (0.765 ± 0.298 vs. 2.051 ± 0.855 × 10-3 mm2/s; P < 0.001), and showed more internal hemorrhage (6/12 vs. 17/86; P = 0.031) compared to benign masses. Univariate and multivariate regression analyses also showed significant differences in age, tumor size, and ADC values. In the diagnostic performance analysis, age (area under the receiver operating characteristic curve [AUC] = 0.723, 95% confidence interval [CI] = 0.624-0.809; P = 0.004) and ADC mean value (AUC = 0.941, 95% CI = 0.874-0.978, P < 0.001) were significant. The optimal cutoff values were 13 years for age (sensitivity = 83.3%, specificity = 61.6%) and an ADC mean of 1.196 × 10-3 mm²/s (sensitivity = 100%, specificity = 86.1%) for discriminating malignant from benign thoracic masses.ConclusionWhen evaluating thoracic masses in children and young adults, older age and lower ADC values help identify malignancy.

Pediatric Ribs at Chest Radiography: Normal Variants and Abnormalities

Normal variants and abnormalities of the ribs are frequently encountered on chest radiographs. Accurate identification of normal variants is crucial to avoid unnecessary investigations. A meticulous evaluation of rib abnormalities can provide valuable insights into the patient's symptoms, and even when no osseous condition is suspected, rib abnormalities may offer critical clues to underlying conditions. Rib abnormalities are associated with various conditions, including benign tumors, malignant tumors, infectious and inflammatory conditions, vascular abnormalities, metabolic disorders, nonaccidental injuries, malformation syndromes, and bone dysplasias. Abnormalities of the ribs are classified into three groups based on their radiographic patterns: focal, multifocal, and diffuse changes. Focal lesions are further subdivided into nonaggressive lesions, aggressive lesions, and infectious and inflammatory disorders. Radiologists should be aware of individual disorders of the pediatric ribs, including their imaging findings, relevant clinical information, and underlying pathogenesis. Differential diagnoses are addressed as appropriate. Since chest radiographs can suffice for diagnosis in certain cases, the authors emphasize a pattern recognition approach to radiographic interpretation. However, additional cross-sectional imaging may be necessary for focal lesions such as tumors or inflammatory conditions. Awareness of disease-specific imaging findings helps ascertain the nature of the lesion and directs appropriate management. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Carbon-Assisted Minimally Invasive Transtubular Approach for Intercostal Nerve Schwannoma

BACKGROUND AND OBJECTIVES

The intraoperative localization of an intercostal nerve schwannoma (INS) is extremely difficult because the lesion is generally not palpable, and the fluoroscopic visualization of anatomic landmarks in the ribs is unsatisfactory. Using activated carbon suspension to mark the soft-tissue approach could improve INS localization. We present a novel, simple, reproducible carbon-assisted minimally invasive transtubular approach for an INS.

METHODS

The patient was a 57-year-old man with a painful 12th left INS arising below the floating rib. A computed tomography image-guided, tumor-to-skin marking with aqueous carbon suspension was performed 48 hours before surgery. A minimally invasive transtubular approach following the carbon path allowed a precise tumor location.

RESULTS

The INS was completely removed. The patient's thoracic radicular pain was immediately relieved after surgery. He was discharged the following day with residual numbness on the left thoracic side. At the 5-year follow-up, no tumor recurrence was noted in the control MRI.

CONCLUSION

This article presents an alternative novel technique for resecting an intercostal schwannoma. Using a transtubular approach with carbon-marking assistance allowed a tumor gross total resection with immediate pain relief and a successful outcome.

High-Grade Surface Osteosarcoma of the Rib Mimicking a Neurogenic Tumor: Radiologic and Pathologic Findings

Osteosarcoma commonly occurs in the intramedullary cavity of long bones such as the femur, tibia, and humerus in children and adolescents. Osteosarcoma occurring as a primary tumor in the chest wall is rare. Only a limited number of such cases have been documented in the existing literature. Herein, we present radiologic and pathologic findings of a high-grade surface osteosarcoma of the rib mimicking a neurogenic tumor in a 44-year-old woman.

Solitary osteochondroma of the rib: An unusual chest wall tumor in the pediatric age group

Pediatric chest wall tumors are unusual and can arise from bone structures or from adjacent soft tissues. Osteochondroma is a benign cartilaginous tumor arising from the metaphysis of bone; however, it is more common in extremity rather than in membranous bone. Although benign, osteochondroma of the rib may lead to fatal complications such as pneumothorax, hemothorax, fractures, and pleural or pericardial effusion. Therefore, some form of surgical management becomes necessary to treat these lesions. We present a case of 7-year-old female child with solitary osteochondroma of the rib. The tumor was surgically excised and the child is asymptomatic on follow-up.

CT features of primary bone neoplasia of the thoracic wall in dogs

Primary thoracic wall neoplasia is uncommon in dogs and the prognosis depends on tumor type. The aims of this retrospective, multi-center, observational study were to describe CT features of primary thoracic wall neoplasia in dogs and to test the hypothesis that CT features would differ among tumor types. Dogs with a diagnosis of primary thoracic wall bone neoplasia and thoracic CT study were included. CT findings recorded were as follows: dimensions, location, invasiveness, grade and type of mineral attenuation, periosteal reaction, contrast enhancement, and presence of presumed pulmonary metastases, pleural effusion, and sternal lymphadenopathy. Fifty-eight cases were included (54 ribs and four sternum). Fifty-six were malignant (sarcomas - SARC) and two were benign (chondromas - CHO). Out of the 56 malignant tumors, 41 had histological confirmation of the tumor type: 23 (56%) osteosarcomas (OSA), 10 (24%) chondrosarcomas (CSA), and eight (20%) hemangiosarcomas (HSA). The majority of rib tumors were right-sided (59%) and ventrally located (72%). Malignant masses showed severe invasiveness, mild/moderate contrast enhancement, and different grades of mineral attenuation. Sternal lymphadenopathy was significantly more frequent in dogs with OSA and HSA compared to dogs with CSA (p = 0.004 and p = 0.023). Dogs with HSA showed significantly lower mineral attenuation grades compared to dogs with OSA (p = 0.043). Primary thoracic wall bone neoplasias were more frequently arising from the ribs, with only a few cases of sternal masses. Findings can be used to help prioritize differential diagnoses for CT studies of dogs with thoracic wall neoplasia.

Hemothorax caused by costal exostosis injuring diaphragm: a case report and literature review

Background

Osteochondromas, also known as exostoses, are the most common benign tumors of bone and can be classified into isolated and multiple osteochondromas. A great majority of osteochondromas is asymptomatic, painless, slow-growing mass, and incidentally found. However, osteochondromas occurring in adolescence or in adult patients can grow in size and become symptomatic as a result of mechanical irritation of the surrounding soft tissues or peripheral nerves, spinal cord compression, or vascular injury.

Case presentation

We present a case of a 13-year-old girl with spontaneous hemothorax, the cause of which was identified by limited thoracotomy with the aid of video-assisted thoracic surgery to be bleeding from a diaphragmatic laceration incurred by a costal exostosis on the left sixth rib. Preoperative chest computed tomography (CT) depicted a bony projection arising from the rib and bloody effusion in the intrathoracic cavity, but was unable to discern the bleeding cause from the lung or the diaphragm. This case will highlight our awareness that costal exostosis possibly results in bloody pleural effusion. Meanwhile, English literatures about solitary costal exostosis associated with hemothorax were searched in PubMed and nineteen case reports were obtained. Combined our present case with available literature, a comprehensive understanding of this rare disease entity will further be strengthened.

Conclusions

Injury to the diaphragm is the primary cause of hemothorax caused by costal osteochondroma, including the present case. Thoracic CT scan can help establish a diagnosis of preoperative diagnosis of costal osteochondroma. Surgical intervention should be considered for those patients with symptomatic osteochondroma of the rib. Combined with our case and literature, prophylactic surgical removal of intrathoracic exostosis should be advocated even in asymptomatic patients with the presentation of an inward bony spiculation.

Palpable pediatric chest wall masses

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Diagnostic value of 18F-FDG PET/CT in discriminating between benign and malignant lesions of the ribs

PURPOSE

Imaging biomarkers for rib mass are needed to optimize treatment plan. We investigated the diagnostic value of metabolic and volumetric parameters from 18F-fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) in discriminating between benign and malignant lesions of the ribs.

PATIENTS AND METHODS

Fifty-seven patients with pathologically proven diagnosis of rib lesions were retrospectively enrolled. The size of rib lesions, the maximum, mean, and peak standardized uptake value (SUVmax, SUVmean, SUVpeak), tumor-to-background ratio (TBR), metabolic tumor volume (MTV), and total lesions glycolysis (TLG) were measured. The FDG uptake patterns (segmental and discrete) and CT findings (soft tissue involvement and fracture) were also reviewed.

RESULTS

Among the multiple parameters extracted from PET/CT, the MTV of malignant lesions was significantly higher than that of benign lesions (median; 4.7 vs 0.2, respectively, P = .041). In receiver operating characteristics curve analysis, MTV had the largest area under curve of 0.672 for differentiating malignant from benign lesions. For identifying malignant lesions, an MTV threshold of 0.5 had a sensitivity of 85.0%, specificity of 47.1%, positive predictive value of 79.1%, negative predictive value of 57.1%, and accuracy of 73.7%. The presence of adjacent soft tissue involvement around rib lesions showed a significant association with malignancy (odds ratio = 6.750; 95% CI, 1.837-24.802, P = .003).

CONCLUSIONS

The MTV is a useful PET/CT parameter for assisting in the differential diagnosis of suspected malignant lesions of the ribs. CT finding of adjacent soft tissue involvement around rib was significantly associated with malignant lesions of the ribs.

Incidental posterior rib hyperostosis on chest CT: incidence and etiology

OBJECTIVE

Incidental rib hyperostosis is defined as asymmetric cortical thickening and sclerosis of the medial posterior ribs and is important because it may lead to unnecessary laboratory testing, additional imaging and occasionally biopsy. The purpose of this study is to identify the incidence of rib hyperostosis within different patient groups known to have an increased propensity towards osteophyte formation and ankylosis.

METHODS

This study was a retrospective cohort study reviewing chest CT examinations in a control group of patients over 50 years old and three different patient populations: psoriatic arthritis, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis (DISH). Each CT was evaluated by an attending musculoskeletal and cardiothoracic radiologist to identify rib hyperostosis, osteophyte formation, ankylosis, and spinal curvature. Two senior radiology residents also performed consensus reads and inter-reader reliability was calculated between the two groups.

RESULTS

Two hundred eighty-two individuals were included in the study of which 38 (13.5%) had at least one hyperostotic rib. The ankylosing spondylitis population and the DISH population had the highest incidence of rib hyperostosis with a relative risk of 5.6 (p = 0.012) and 5.3 (p =  < 0.001) when compared to the control group. There was good inter-reader reliability for the presence of rib hyperostosis with a kappa estimate of 0.739.

CONCLUSION

Incidentally detected rib hyperostosis is most likely the sequela of abnormal stress on the ribs secondary to rib hypomobility from fusion at the costovertebral joint. The incidence of rib hyperostosis is markedly increased in the DISH and ankylosis spondylitis study populations.

Diagnostic and Imaging Approaches to Chest Wall Lesions

Chest wall lesions are relatively uncommon and may be challenging once they are encountered on images. Radiologists may detect these lesions incidentally at examinations performed for other indications, or they may be asked specifically to evaluate a suspicious lesion. While many chest wall lesions have characteristic imaging findings that can result in an accurate diagnosis with use of imaging alone, other entities are difficult to distinguish at imaging because there is significant overlap among them. The interpreting radiologist should be familiar with the imaging features of both "do not touch" benign entities (which can be confidently diagnosed with imaging only, with no need for biopsy or resection unless the patient is symptomatic) and lesions that cannot be confidently characterized and thus require further workup. CT and MRI are the main imaging modalities used to assess the chest wall, with each having different benefits and drawbacks. Chest wall lesions can be classified according to their predominant composition: fat, calcification and ossification, soft tissue, or fluid. The identification or predominance of signal intensities or attenuation for these findings, along with the patient age, clinical history, and lesion location, can help establish the appropriate differential diagnosis. In addition, imaging findings in other organs, such as the lungs or upper abdomen, can at times provide clues to the underlying diagnosis. The authors review different chest wall lesions classified on the basis of their composition and highlight the imaging findings that can assist the radiologist in narrowing the differential diagnosis and guiding management. ^©RSNA, 2022.

A Review of Posteromedial Lesions of the Chest Wall: What Should a Chest Radiologist Know?

A heterogeneous group of tumors can affect the posteromedial chest wall. They form diverse groups of benign and malignant (primary or secondary) pathologies that can arise from different chest wall structures, i.e., fat, muscular, vascular, osseous, or neurogenic tissues. Chest radiography is very nonspecific for the characterization of chest wall lesions. The modality of choice for the initial assessment of the chest wall lesions is computed tomography (CT). More advanced cross-sectional modalities such as magnetic resonance imaging (MRI) and positron emission tomography (PET) with fluorodeoxyglucose are usually used for further characterization, staging, treatment response, and assessment of recurrence. A systematic approach based on age, clinical history, and radiologic findings is required for correct diagnosis. It is essential for radiologists to be familiar with the spectrum of lesions that might affect the posteromedial chest wall and their characteristic imaging features. Although the imaging findings of these tumors can be nonspecific, cross-sectional imaging helps to limit the differential diagnosis and determine the further diagnostic investigation (e.g., image-guided biopsy). Specific imaging findings, e.g., location, mineralization, enhancement pattern, and local invasion, occasionally allow a particular diagnosis. This article reviews the posteromedial chest wall anatomy and different pathologies. We provide a combination of location and imaging features of each pathology. We will also explore the role of imaging and its strengths and limitations for diagnosing posteromedial chest wall lesions.

Grade 1 and 2 Chondrosarcomas of the Chest Wall: CT Imaging Features and Review of the Literature

The purpose of our retrospective article is to review the CT imaging features of chondrosarcomas of the chest wall with pathologic correlation. For 26 subjects with biopsy-proven chondrosarcomas of the chest wall, two musculoskeletal radiologists retrospectively reviewed 26 CT scans in consensus. Descriptive statistics were performed. The mean tumor size was 57 mm. Twenty (20/26, 77%) chondrosarcomas were located in the ribs and six (6/26, 23%) in the sternum. The majority were lytic (19/26, 73%) with <25% calcification (15/26, 58%), and with a soft tissue mass (22/27, 85%). In this study CT features of grade 1 chondrosarcoma overlapped with those of grade 2 tumors. In conclusion, chondrosarcomas of the chest wall are generally lytic with an associated soft tissue mass, showing little calcified matrix and low-to-intermediate grade.

ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain

Chest pain is a common reason that patients may present for evaluation in both ambulatory and emergency department settings, and is often of musculoskeletal origin in the former. Chest wall syndrome collectively describes the various entities that can contribute to chest wall pain of musculoskeletal origin and may affect any chest wall structure. Various imaging modalities may be employed for the diagnosis of nontraumatic chest wall conditions, each with variable utility depending on the clinical scenario. We review the evidence for or against use of various imaging modalities for the diagnosis of nontraumatic chest wall pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.

Tumor and tumorlike conditions of the pleura and juxtapleural region: review of imaging findings

Pleural lesions form a diagnostic challenge for the radiologist. Whereas lesions can be initially detected on chest radiographs, CT and MRI imaging are the imaging modalities of choice for further characterization. In a number of cases, imaging findings can be relatively specific. In general unfortunately, imaging findings are rather aspecific. Evolution and extrathoracic imaging findings are important clues toward the diagnosis.

Solitary osteochondroma affecting the rib and adjacent vertebral body: a case with atypical radiology features

Costal osteochondroma is an uncommon primary benign tumor. Thorough radiological and pathological examinations should be performed to avoid misdiagnosis. Herein, we describe a case of a surgically resected costal osteochondroma in 23-year-old man. The aim of this report is the value of cartilage cap on imaging, leading to a correct preoperative impression. We also present a brief review of existing literature on costal osteochondroma.

Intercostal Muscle Cavernous Haemangioma: A Chest Wall Pandora's Box

Background

Haemangiomas are uncommon chest wall tumours arising outside the rib cage. Their occurrence in intercostal muscle is extremely rare.

Aim

We describe a case of intercostal muscle cavernous haemangioma as a differential diagnosis for chest wall swelling.

Case description

We describe an 18-year-old male patient with an asymptomatic left-sided chest wall swelling. Contrast-enhanced computed tomography revealed a well-defined homogenously non-enhancing mass lesion arising from the seventh intercostal muscle with differential diagnoses of various chest wall tumours. Clinical presentation and imaging findings were inconclusive, but histopathological examination following excision biopsy revealed a cavernous haemangioma. The present case emphasizes the importance of histopathological diagnosis when clinical and radiological examination is inconclusive. Hence, it is necessary to consider intercostal muscle haemangiomas as a differential diagnosis for chest wall tumours in the absence of a feeding vessel.

Conclusion

Despite its rare occurrence, intercostal muscle haemangioma must be considered as a differential diagnosis in chest wall tumours even in the absence of a feeding vessel. We believe that histopathology can provide a definitive diagnosis when most investigative procedures are inconclusive.

LEARNING POINTS

Haemangiomas are rare chest wall tumours and even rarer when they originate from intercostal muscle.Intercostal muscle haemangiomas should be included in the differential diagnosis of chest wall tumours even in the absence of a feeding vessel.The present case emphasizes the importance of histopathological diagnosis when clinical and radiological examinations are inconclusive.

Non-traumatic complications of a solitary rib osteochondroma; an unusual cause of hemoptysis and pneumothorax

Osteochondromas are a very common and usually asymptomatic entity which may originate anywhere in the appendicular and axial skeleton. However, the ribs are a rare site of origin and here they may prove symptomatic for mechanical reasons. In this case report, we describe an unusual case of a symptomatic osteochondroma of the rib secondary to its location and unique shape, ultimately requiring surgical intervention.

Metastatic prostate carcinoma: A rare presentation initially misdiagnosed as a rib fracture

Metastatic prostate carcinoma mainly occurs in bone as an osteoblastic lesion or lesions in the pelvis, spine, or chest wall. We present a unique case of a singular metastatic osteolytic lesion in the rib initially misdiagnosed as a fracture in a 61-year-old male. A single rib fracture in a patient with no history of trauma should raise suspicion for metastatic disease. We would encourage prostate cancer to be included in the differential diagnosis for an osteolytic lesion in a male over the age of 40. We review the current literature on this rare presentation of bone metastasis as well as the pathogenesis of metastatic prostate carcinoma as it relates to a solitary metastatic osteolytic lesion.

Neoplastic pathology at the crossroads between neck imaging and cardiothoracic imaging

The thoracic inlet is located at the crossroads between imaging of the neck and the chest. Its location is an important anatomic landmark, serving as the central conducting pathway for many vital structures extending from the neck into the chest and vice versa. Many critical body systems, including the respiratory, lymphatic, neurologic, enteric, musculoskeletal, endocrine, and vascular systems, are located within this region. Neoplasms, both benign and malignant, can arise in any of the body systems located in this area. Due to the small size of this anatomic location, pathology is easily overlooked and imagers should be aware of the imaging appearance of these neoplasms, as well as which imaging modality is the most appropriate for neoplasm evaluation. This article will present an image rich, system-based discussion of the neoplastic pathology that can occur in this region. The anatomy of the thoracic inlet and the non-neoplastic pathology of the thoracic inlet have been covered in our companion article.

The Spectrum of Rib Neoplasms in Adults: A Practical Approach and Multimodal Imaging Review

OBJECTIVE. Adult neoplasms of the ribs are a heterogeneous group consisting of both benign and aggressive entities. Rib neoplasms have a variety of overlapping imaging features, with much of the imaging data disjointed across the musculoskeletal, thoracic, and oncologic imaging literature. Arrival at accurate diagnosis can therefore be quite challenging. This article consolidates this information and introduces the reader to an algorithmic approach to rib lesion evaluation based on imaging. CONCLUSION. Rib neoplasms are a diverse group of benign and malignant entities, which often makes determining an accurate diagnosis challenging. Evaluation requires a multipronged approach that incorporates radiographic imaging features, nonradiographic imaging findings, lesion location, and clinical data.

Chest Wall Schwannoma: Case Report and a Review of Imaging Findings

A chest wall schwannoma arises from peripheral nerve sheath Schwann cells of the intercostal nerves. We describe the presentation and imaging findings of a patient who presented with a chest wall swelling. The imaging findings were highly suspicious for a chest wall schwannoma and the histopathology confirmed the diagnosis following surgical excision. Imaging findings are reviewed in detail.

A confounding rib variation: bilateral symmetric aberrant posterior rib articulations and bridgings

INTRODUCTION

Although mild bone angulation with osseous enlargement often suggests fractures with callus formation, in some cases the diagnosis is synchondrosis.

CASE REPORT

We present a rare variation of the chest wall in a 15-year-old male with a history of lymphoma. Bilateral multi-level posterior rib enlargements revealing mild ¹⁸F-fluorodeoxyglucose uptake were detected via positron-emission tomography/computed tomography. The variations were identified as healing fractures, although the more accurate diagnosis was determined to be multi-level posterior rib synchondroses with consecutive bridgings. Although variant bone anatomies are commonly seen in radiological practice, such multiple symmetrical posterior rib synchondroses associated with consecutive bridgings and articulations have not been clearly demonstrated before.

CONCLUSION

Awareness of such a rare combination of a well-known variation is crucial for radiologists to exclude malignancies, possibility of fracture and suspicion of child abuse.

Role of Cross Sectional Imaging in Isolated Chest Wall Tuberculosis

INTRODUCTION

Isolated chest wall tuberculosis though a rare entity, the incidence of it has been on rise among immunocompromised population making it an important challenging diagnosis for the physicians. Its clinical presentation may resemble pyogenic chest wall abscess or chest wall soft tissue tumour. Sometimes it is difficult to detect clinically or on plain radiograph.

AIM

The present study was conducted with an aim to evaluate the common sites and varying appearances of isolated chest wall tuberculosis.

MATERIALS AND METHODS

A hospital based cross-sectional retrospective study was conducted in Assam Medical College and Hospital, a tertiary care centre in North East India. The study group comprise of 21 patients (n=15 male and n=6 females) with isolated chest wall tuberculosis without associated pulmonary or spinal involvement who were subjected to Computed Tomography/Magnetic Resonance Imaging (CT/MRI) of the thorax following initial Ultrasonogram (USG) evaluation of the local site. Pathological correlation was done from imaging guided sampling of the aspirate or surgery.

RESULTS

Variable sites of involvement were seen in the chest wall in our patients (n=21), with chest wall abscess formation being the most common presentation and rib being the most common bony site affected in the thoracic cage. Bony sclerosis was noted in 11 patients (52.4%), periosteal reaction in 10 patients (47.6%) and sequestration in five patients (23.8%). CT/MRI not only localized the exact site and extent of the abscesses which facilitated guided aspirations, but also helped in detecting typical bony lesions thereby, differentiating from pyogenic osteomyelitis besides ruling out associated pulmonary or pleural involvement in such patients.

CONCLUSION

Cross-sectional imaging plays an important role by giving a wholesome picture of both soft tissue and bony pathology. It is important to have adequate understanding of the radiologic manifestations of the chest wall involvement and complications of tuberculosis to facilitate diagnosis and in assessing response to treatment on follow up in patients.

Imaging Evaluation of Malignant Chest Wall Neoplasms

Neoplasms of the chest wall are uncommon lesions that represent approximately 5% of all thoracic malignancies. These tumors comprise a heterogeneous group of neoplasms that may arise from osseous structures or soft tissues, and they may be malignant or benign. More than 50% of chest wall neoplasms are malignancies and include tumors that may arise as primary malignancies or secondarily involve the chest wall by way of direct invasion or metastasis from intrathoracic or extrathoracic neoplasms. Although 20% of chest wall tumors may be detected at chest radiography, chest wall malignancies are best evaluated with cross-sectional imaging, principally multidetector computed tomography (CT) and magnetic resonance (MR) imaging, each of which has distinct strengths and limitations. Multidetector CT is optimal for depicting bone, muscle, and vascular structures, whereas MR imaging renders superior soft-tissue contrast and spatial resolution and is better for delineating the full extent of disease. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is not routinely performed to evaluate chest wall malignancies. The primary functions of PET/CT in this setting include staging of disease, evaluation of treatment response, and detection of recurrent disease. Ultrasonography has a limited role in the evaluation and characterization of superficial chest wall lesions; however, it can be used to guide biopsy and has been shown to depict chest wall invasion by lung cancer more accurately than CT. It is important that radiologists be able to identify the key multidetector CT and MR imaging features that can be used to differentiate malignant from benign chest lesions, suggest specific histologic tumor types, and ultimately guide patient treatment. (©)RSNA, 2016.

Imaging findings of various talus bone tumors-clinico-radiologic features of talus bone tumors

Osseous neoplasms of the foot are uncommon, accounting for only 3.3% of all primary bone tumors. Bone tumors of the talus are even rarer, and there are not many publications that comprehensively evaluate the imaging findings of talus tumors. The purpose of this article is to review the benign and malignant bone tumors affecting this uncommon site and to describe the clinical and radiologic features of each tumor.

Combined posterior hemiosteotomies and stabilization with lateral thoracotomy for en bloc resection of thoracic paraspinal primary bone tumors: technical note

Primary bone tumors of the spine are rare entities with a poor prognosis if left untreated. En bloc excision is the preferred surgical approach to minimize the rate of recurrence. Paraspinal primary bone tumors are even less common. In this technical note the authors present an approach to the en bloc resection of primary bone tumors of the paraspinal thoracic region with posterior vertebral body hemiosteotomies and lateral thoracotomy. They also describe 2 illustrative cases.

Sonographic appearance of an intramuscular myxoma of the pectoralis major muscle

Intramuscular myxomas are benign soft tissue tumors that usually involve skeletal muscle of the extremities; occurrence in the chest wall is extremely rare. We describe a case of intramuscular myxoma in the pectoralis major muscle of a 55-year-old woman. The patient presented with a palpable lump in her right breast. Mammography showed a circumscribed, oval, hyperdense mass within the pectoralis muscle. Ultrasonography showed a circumscribed, oval, complex mass within the pectoralis muscle.

Value of porous titanium alloy plates for chest wall reconstruction after resection of chest wall tumors

OBJECTIVE

To explore the value of porous titanium alloy plates for chest wall reconstruction after resection of chest wall tumors.

MATERIALS AND METHODS

A total of 8 patients with chest wall tumors admitted in our hospital from Jan. 2006 to Jan. 2009 were selected and underwent tumor resection, then chest wall repair and reconstruction with porous titanium alloy plates for massive chest wall defects.

RESULTS

All patients completed surgery successfully with tumor resection-induced chest wall defects being 6.5 x 7 cm ~ 12 x 15.5 cm in size. Two weeks after chest wall reconstruction, only 1 patient had subcutaneous fluidify which healed itself after pressure bandaging following fluid drainage. Postoperative pathological reports showed 2 patients with costicartilage tumors, 1 with squamous cell carcinoma of lung, 1 with lung adeno-carcinoma, 1 with malignant lymphoma of chest wall, 2 with chest wall metastasis of breast cancers and 1 with chest wall neurofibrosarcoma. All patients had more than 2 ~ 5 years of follow-up, during which time 1 patient with breast cancer had surgical treatment due to local recurrence after 7 months and none had chest wall reconstruction associated complications. The mean survival time of patients with malignant tumors was (37.3 ± 5.67) months.

CONCLUSIONS

Porous titanium alloy plates are safe and effective in the chest wall reconstruction after resection of chest tumors.

Ultrasound evaluation of costochondral abnormalities in children presenting with anterior chest wall mass

OBJECTIVE

The purpose of this article is to summarize our experience with the use of ultrasound for evaluation of costochondral cartilage deformity in patients presenting with an anterior chest wall mass.

MATERIALS AND METHODS

From 2007 to 2012, we identified all patients at our tertiary care children's hospital younger than 18 years old who underwent ultrasound for a clinical indication of anterior chest wall mass of unknown cause. A pediatric radiologist reviewed all ultrasound examinations and other pertinent radiology examinations as well as prior and follow-up clinical history and determined the final clinical cause of the mass.

RESULTS

We identified 16 patients (nine girls and seven boys; age range, 11 months to 16.1 years; mean, 7.5 years). All patients presented with a firm anterior chest wall mass. Three patients had pain. Thirteen patients had prior imaging studies, including chest radiography (n = 13), CT of the chest (n = 1), MRI of the breast (n = 1), and ultrasound of the chest wall (n = 1). In all prior studies the cause of the anterior chest wall mass was missed. Ultrasound showed an angular deformity of a single-level (n = 13) or multilevel (n = 1) costal cartilage, hypertrophy and elongation with mild angulation of the costal cartilage (n = 1), and osteochondroma (n = 1).

CONCLUSION

Targeted chest ultrasound is a useful diagnostic tool in the evaluation of costochondral cartilage deformities and should be considered in children with a firm anterior chest wall mass and negative radiography.

Imaging-pathologic correlation of diseases in the axilla

OBJECTIVE

This article reviews the imaging and histopathologic findings of various axillary diseases and suggests management guidelines for radiologists based on imaging findings with clinical correlation.

CONCLUSION

Although axillary diseases may reveal nonspecific imaging findings, a knowledge of the characteristic radiologic manifestations of specific diseases according to anatomic origin (nodal, accessory breast, adipocytic, fibrous, nerve, vascular, stromal, and dermal) and postsurgical lesions aids in establishing an appropriate differential diagnosis and determining whether intervention is necessary.

Primary dedifferentiated liposarcoma of the axilla arising in a mixed, well-differentiated and myxoid liposarcoma

We describe a case of mixed liposarcoma of the axilla presenting as a high grade undifferentiated sarcoma with areas of well-differentiated and myxoid liposarcoma. MRI demonstrated a lobulated, septated intermuscular mass with marked heterogeneous gadolinium enhancement. A small focus of the tumor demonstrated fat suppressed signal more characteristic of well-differentiated liposarcoma. Pathologic analysis following wide local excision revealed a large, high grade sarcomatous component with highly pleomorphic cells with a thin rim of well-differentiated and myxoid liposarcoma on histologic examination. Dedifferentiated liposarcomas arising outside of the retroperitoneum are very rare, as are dedifferentiated liposarcomas arising from a histologically mixed liposarcoma. In this regard, this case illustrates an unusual combination of tumor location and histology which, to our knowledge, has not previously been reported.

Malignant primary chest wall neoplasms: a pictorial review of imaging findings

Malignant primary chest wall neoplasms (MCWN) are uncommon. Although benign chest wall neoplasms are most commonly asymptomatic, MCWN typically manifest as painful, fast growing masses. While the imaging features of malignant masses can be nonspecific, knowledge of the typical radiologic manifestations of MCWN may suggest a specific diagnosis. We review imaging features of the most common MCWN with images collected at an outpatient academic oncologic center.

OBJECTIVE

While the imaging features of patients with malignant masses can be nonspecific, knowledge of the typical radiologic manifestations of MCWN may suggest a specific diagnosis. We review distinguishing imaging features of the most common MCWN, including epithelial and mesenchymal malignancies, with images collected at an outpatient oncologic center.

CONCLUSION

Chest wall neoplasms encompass 5% of all thoracic tumors, with nearly half of chest wall neoplasms being malignant. Out of these malignant neoplasms, 50% are primary and the commonest one is chondrosarcoma. Although distinguishing imaging features may suggest a specific diagnosis in the majority of MCWN, most affected patients undergo biopsy for a definitive diagnosis.