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.

A Schwannoma-Hemangioma Composite Tumor as a Very Uncommon Cause of a Chest Wall Tumor in a Teenage Patient: A Case Report

Schwannoma-hemangioma composite tumors are extremely rare, with most cases described in the head and neck of adult patients. Pediatric cases involving the chest wall have not been widely reported and, therefore, present diagnostic and therapeutic challenges. We describe the case of a 14-year-old male patient who presented with a painless nodular lesion on the chest wall. After imaging studies and laboratory analysis, the consulting oncologist recommended the surgical removal of the tumor due to the indeterminate nature of the lesion. Histopathologic analysis of the excised tissue confirmed a composite schwannoma-hemangioma tumor. The patient recovered uneventfully postoperatively with no recurrence or complications at the three-month follow-up. This case highlights the importance of considering rare composite tumors in the differential diagnosis of pediatric chest wall lesions. Accurate histopathologic evaluation is essential for optimal management. Further case reports are needed to improve the understanding of the etiology and clinical behavior of such tumors.

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.

Imaging palpable tumors in pediatrics: Part 2

Palpable tumors in children are a common reason for consulting a radiologist. The origin of these lesions varies widely, and although they are common, classic radiology books do not cover some of them. This series of two articles aims to review the clinical and radiological characteristics of a selection of palpable tumors in children that radiologists need to be familiar with.

Spectrum of anatomical variants, normal findings and pathology in and around the paediatric sternum

Abnormalities of the sternum and adjacent structures are an uncommon presentation in the paediatric population and can have a variety of benign and malignant causes, including normal and developmental variants of the chest wall. Although there is overlap with adults, many sternal abnormalities are unique to the paediatric population. Following clinical examination, radiography is usually the first type of imaging used; however, it is limited and often ultrasound and cross-sectional imaging are needed for further assessment. An understanding of the normal anatomy is important; however, this can be challenging due to the varied appearances of age-related changes of the sternum. The purpose of this article is to familiarize the general paediatric radiologist with the expected anatomy and imaging findings of the developing sternum, anatomical variants and pathology of the sternum and adjacent structures encountered in this group of patients.

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.

Silent anatomic variations of the pediatric chest: They might not be congenital

AIM

We aimed to evaluate the prevalence of silent anatomic variations of the chest wall, to estimate frequency in different age groups, and to answer are these variations more prominent with age?

MATERIALS AND METHODS

Thorax CT scans of 592 children were retrospectively reviewed. 82 children who underwent CT for evaluation of the suspected chest wall deformities, chest wall lesions, prominent scoliosis, and who had chest wall surgery, thoracotomy, or trauma causing chest wall or clavicular fracture were excluded from the study. The frequency of silent anatomic variations was evaluated and compared with age subgroups and sex.

RESULTS

118 of 510 patients had variations of the chest wall (23.1%). The most common silent variation was the prominent convexity of the costal cartilage (n = 36, 30.5% of the variations). A significant difference existed in the frequency of variations between age subgroups (p < 0.001).

CONCLUSION

A high rate of silent variations indicates that asymptomatic asymmetries of the chest wall are mostly benign and there is no need for further imaging. An increase in the frequency of the variations with age supports the hypothesis that these findings are mostly developmental instead of congenital and become more prominent with growth.

Mesenchymal Hamartoma of the Chest Wall in an Infant - A Benign Entity Masquerading as Malignancy

Mesenchymal hamartoma of the chest wall is a rare tumor-like lesion encountered in neonates and infants. Although typically benign with no metastatic potential, it has alarming imaging and pathological features that mimic malignancy. We describe the imaging, surgical, and pathological features of this rare entity in a 1-month-old infant.

Looking for the "connection": A clinical vignette on pediatric chest wall masses

Chest wall masses in the pediatric population are relatively rare, and the differential diagnosis predominantly includes neoplastic soft tissue or osseous tumours, either benign or malignant in etiology, although local infectious processes represent additional diagnostic possibilities. Among recent immigrants, a more diverse array of less commonly observed pathogens warrant consideration. Here, we present a case of a chest wall mass in an immunocompetent child who had recently immigrated from the Philippines.

Extra-skeletal Ewing Sarcoma of the chest wall in a child

Chest wall or pleural-based tumours represent a heterogeneous group of lesions that are infrequent in children and infants; however, a large proportion of these lesions are malignant in nature. Categorising them on the basis of primary versus secondary, site of origin (osseous and cartilage, or soft tissue) and tissue composition may assist in narrowing the differential diagnosis. We present a case of a 7-year-old boy with a progressive history of dyspnoea. The initial chest radiograph (CXR) demonstrated complete opacification of the left hemithorax with no air bronchograms. This was associated with the cut-off of the left main bronchus and mediastinal shift to the right. The post-contrast computed tomography (CT) of the chest showed multiple left-sided enhancing pleural-based masses with collapse of the left lung. These lesions were locally invasive as demonstrated by the intra and extra-thoracic extension. There were no associated erosions of the adjacent ribs or intra-tumoural calcifications. Based on the imaging findings, the diagnosis of extra-skeletal Ewing sarcoma (ES-EWS) of the chest wall was made with a differential diagnosis of rhabdomyosarcoma. A core biopsy was performed of the pleural-based mass, and histology with immunohistochemistry confirmed the diagnosis of a malignant small round blue cell tumour; subtype Ewing sarcoma family tumour (ESFT). The child was subsequently commenced on chemotherapy. The diagnosis of ES-EWS should be considered when a child or adolescent presents with an ill-defined, eccentric, chest wall mass in the absence of a lesion with a primary osseous origin. Imaging plays a key role in tumour staging, therapeutic planning and follow-up of patients.

Thoracic Bone Tumors Every Radiologist Should Know

The thoracic cage provides the structural support that makes respiration possible, provides protection to vital organs such as the lungs, heart, liver, and spleen, and serves as an anchor point for the upper extremities. Neoplasms of the bony thorax are not an uncommon incidental finding at both radiography and cross-sectional imaging. Some tumors have a characteristic appearance and it is important that an accurate differential diagnosis be provided. Misidentification could lead to unnecessary imaging or procedures with associated cost, morbidity, and mortality. The purpose of this article is to serve as a quick review of bone tumors commonly encountered in the thorax and that every radiologist should know. Please note that there are also several non-neoplastic osseous lesions that may mimic bone tumors such as osteomyelitis and eosinophilic granuloma; however, these entities are beyond the scope of this review and would not be discussed.