Pneumothorax caused by costal exostosis

Pneumothorax as the first presentation of multiple exostosis

This article underscores the critical importance of thorough physical examinations and the need to investigate secondary causes in cases of refractory pneumothorax. The identification of hereditary multiple exostoses (HME) as the underlying condition highlights the necessity of considering rare etiologies, particularly in atypical presentations. While exostoses typically affect long bones, they can also involve the ribs and scapulae, leading to complications such as pneumothorax. In pediatric patients, where multiple symptoms may arise from a single condition, a multidisciplinary approach is essential for accurate diagnosis and effective management.

Osteochondroma of the Rib: A Potentially Life-Threatening Benign Tumor

Osteochondroma is the most common benign bone tumor. It can be classified as isolated or multiple. While the majority of osteochondromas are asymptomatic and found incidentally, they can become symptomatic during adolescence or adulthood due to mechanical irritation, nerve compression, spinal cord compression, or vascular injury. In this article, we present a case of a 14-year-old patient who experienced spontaneous hemothorax caused by bleeding from a diaphragmatic laceration incurred by a costal exostosis on the right eighth rib. A preoperative chest CT scan revealed a bony projection from the rib and bloody effusion in the thoracic cavity, highlighting the possibility of bloody pleural effusion due to costal exostosis. It is important to note that costal osteochondromas are a rare cause of thoracic injury and can lead to laceration of the lung, diaphragm, and/or pericardium. Surgical intervention should be considered for symptomatic rib osteochondroma, and we advocate for prophylactic surgical removal of intrathoracic exostosis even in asymptomatic patients, in order to prevent potential complications.

Spontaneous pneumothorax in a 17-year-old male patient with multiple exostoses: A case report and review of the literature

BACKGROUND

Multiple exostoses generally develop in the first decade of life. They most frequently arise from the distal femur, proximal tibia, fibula, and proximal humerus. Costal exostoses are rare, contributing to 1%–2% of all exostoses in hereditary multiple exostoses (HME). They are usually asymptomatic, but a few cases have resulted in severe thoracic injuries. Pneumothorax caused by costal exostoses is rare, with only 13 previously reported cases. We report a new case of pneumothorax caused by costal exostoses.

CASE SUMMARY

A 17-year-old male with HME underwent surgery for removal of exostoses around his right knee. Four months following the operation, he felt chest pain when he was playing the trumpet; however, he did not stop playing for a week. He was referred to our hospital with a chief complaint of chest pain. The computed tomography (CT) scan revealed right pneumothorax and multiple exostoses in his right ribs. The CT scan also revealed visceral pleura thickness and damaged lung tissues facing the exostosis of the seventh rib. We diagnosed that exostosis of the seventh rib induced pneumothorax. Costal exostosis resection was performed by video-assisted thoracoscopic surgery (VATS) 2 wk after the onset. The patient’s postoperative course was uneventful, and there was no recurrence of pneumothorax for 2 years.

CONCLUSION

Costal exostoses causing thoracic injuries should be resected regardless of age. VATS must be considered in cases with apparently benign and relatively small exostoses or HME.

Hemothorax and Pneumothorax Secondary to Costal Involvement in Hereditary Multiple Exostoses: A Systematic Review of Reported Cases in the Literature

Hereditary multiple exostoses (HME) are an autosomal dominant skeletal disorder characterized by the development of multiple benign osteochondromas (exostoses) that frequently involve long bones of the body. Less commonly, the ribs are a site of involvement, and long-term friction between an exostosis and pleura can produce a hemothorax or pneumothorax. The purpose of this study is to provide a comprehensive review of existing literature on pneumothorax or hemothorax secondary to costal exostosis in HME patients. We reviewed the databases of PubMed and Embase and included data as current as of February 15, 2021. All case reports included cases of hemothorax or pneumothorax in patients with a known personal or family history of HME. After evaluation for inclusion based on eligibility criteria, 18 cases were included. The average age at presentation was 11.7 years (range: 3-32), and most patients were male (83%). Hemothoraces occurred in 15 cases, while pneumothoraces occurred in three cases. All cases were evaluated using chest X-ray and CT scan, and the majority of the cases were treated with surgical resection of the exostosis, either with video-assisted thoracoscopic surgery (VATS; 61%) or thoracotomy (22%). Outcomes were successful with no cases of recurrence after surgical intervention. Although rare, costal exostosis should be considered as a differential in patients presenting with pneumothorax or hemothorax and past medical history or physical exam findings suggestive of HME. Immediate evaluation and surgical intervention to resect costal exostosis are essential to reduce the risk of recurrent life-threatening injury.

Rib osteochondroma causing cardiac compression in a pediatric patient

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Osteochondromas are considered the most common benign tumors of bony origin.

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Exostosis are slow growing masses usually diagnosed before the third decade of life.

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A computed tomography scan offers a more accurate tool in the diagnosis of this type of condition.

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Rib exostosis occurs more frequently in males than females with a ratio of 1.5:1.

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Costal osteochondromas mostly occur as a part of hereditary multiple osteochondromas.

Introduction and importance

Rib osteochondromas are rare genetic disorders, which can present as bony exostosis causing compression, impingement and damage to surrounding vessels, organs and structures within the thoracic cavity. The objective of this study was to clearly describe a rare presentation of rib osteochondromas in a pediatric patient along with managing techniques.

Case

A 9-year-old girl was admitted to the hospital due to shortness of breath on exertion. Physical examination did not reveal any abnormalities except for small bony projections over the left 5th rib. Computed tomography (CT) scan showed a bony lesion on the left fifth rib causing cardiac compression. Video-assisted thoracoscopy (VAT) was done, which showed a bony exostosis compressing the left ventricle, the lesion was resected without any complications. Final pathology confirmed the diagnosis of osteochondroma measuring 2.0 cm × 2.0 cm × 1.5 cm, along with a thickness of 0.4 cm. Post-operative recovery was well, with no morbidities and the patient was discharged without any complications. On the post-operative follow up, the patient showed significant improvement in her symptoms.

Clinical discussion

Our reported case is a rare example of a solitary costal osteochondroma leading to serious complications because of its shape, size, and location. Previous reports have not addressed any significant traumatic event or impact prior to the occurrence of symptoms related to the cases, including the case of our patient. Cases of rib exostosis were surgically approached using different techniques most often through thoracotomy.

Conclusions

Rib osteochondromas are rare benign bony lesions which can cause cardiac symptoms secondary to direct compression. They can be resected safely via video assisted thoracoscopy (VAT) or limited thoracotomy.

Chondrogenic Bone Tumors: The Importance of Imaging Characteristics

BACKGROUND

 Chondrogenic tumors are the most frequent primary bone tumors. Malignant chondrogenic tumors represent about one quarter of malignant bone tumors. Benign chondrogenic bone tumors are frequent incidental findings at imaging. Radiological parameters may be helpful for identification, characterization, and differential diagnosis.

METHODS

 Systematic PubMed literature research. Identification and review of studies analyzing and describing imaging characteristics of chondrogenic bone tumors.

RESULTS AND CONCLUSIONS

 The 2020 World Health Organization (WHO) classification system differentiates between benign, intermediate (locally aggressive or rarely metastasizing), and malignant chondrogenic tumors. On imaging, typical findings of differentiated chondrogenic tumors are lobulated patterns with a high signal on T2-weighted magnetic resonance imaging (MRI) and ring- and arc-like calcifications on conventional radiography and computed tomography (CT). Depending on the entity, the prevalence of this chondrogenic pattern differs. While high grade tumors may be identified due to aggressive imaging patterns, the differentiation between benign and intermediate grade chondrogenic tumors is challenging, even in an interdisciplinary approach.

KEY POINTS

  · The WHO defines benign, intermediate, and malignant chondrogenic bone tumors. · Frequent benign tumors: osteochondroma and enchondroma; Frequent malignant tumor: conventional chondrosarcoma. · Differentiation between enchondroma versus low-grade chondrosarcoma is challenging for radiologists and pathologists. · Pain, deep scalloping, cortical destruction, bone expansion, soft tissue component: favor chondrosarcoma. · Potential malignant transformation of osteochondroma: progression after skeletal maturity, cartilage cap thickness (> 2 cm adult; > 3 cm child). · Potentially helpful advanced imaging methods: Dynamic MRI, texture analysis, FDG-PET/CT.

CITATION FORMAT

· Engel H, Herget GW, Füllgraf H et al. Chondrogenic Bone Tumors: The Importance of Imaging Characteristics. Fortschr Röntgenstr 2021; 193: 262 - 274.

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.

Hereditary multiple exostoses of the ribs as an uncommon cause of pneumothorax: A case report

RATIONALE

Hereditary multiple exostoses (HME) is a genetic musculoskeletal condition causing multiple exostoses. Rib location of exostosis can be complicated by thoracic injuries.

PATIENT CONCERNS AND DIAGNOSES

We report a case of pneumothorax in a 32-year-old man with a partial left-sided pneumothorax caused by an exostosis of the fourth and fifth ribs.

INTERVENTIONS AND OUTCOMES

Clinical and radiological presentations allowed a conservative management. A video-assisted thoracoscopic surgery was performed a few weeks later to avoid any recurrence.

LESSONS

Rib exostosis represents an unusual cause of pneumothorax. Any local modification of symptoms or size of the exostosis should lead to investigations in regard to chondrosarcoma transformation.

Chest pain caused by multiple exostoses of the ribs: A case report and a review of literature

The aim of this paper is to report an exceptional case of multiple internal exostoses of the ribs in a young patient affected by multiple hereditary exostoses (MHE) coming to our observation for chest pain as the only symptom of an intra-thoracic localization. A 16 years old patient with familiar history of MHE came to our observation complaining a left-sided chest pain. This pain had increased in the last months with no correlation to a traumatic event. The computed tomography (CT) scan revealed the presence of three exostoses located on the left third, fourth and sixth ribs, all protruding into the thoracic cavity, directly in contact with visceral pleura. Moreover, the apex of the one located on the sixth rib revealed to be only 12 mm away from pericardium. Patient underwent video-assisted thoracoscopy with an additional 4-cm mini toracotomy approach. At the last 1-year follow-up, patient was very satisfied and no signs of recurrence or major complication had occured. In conclusion, chest pain could be the only symptom of an intra-thoracic exostoses localization, possibly leading to serious complications. Thoracic localization in MHE must be suspected when patients complain chest pain. A chest CT scan is indicated to confirm exostoses and to clarify relationship with surrounding structures. Video-assisted thoracoscopic surgery can be considered a valuable option for exostoses removal, alone or in addiction to a mini-thoracotomy approach, in order to reduce thoracotomy morbidity.

Bilateral Scapulothoracic Osteochondromas in a Patient With Hereditary Multiple Exostosis: A Case Report and Review of the Literature

Hereditary multiple exostosis (HME) is an autosomal dominant disorder characterized by two or more benign growing, cartilage capped tumors of long bones called osteochondromas. If abnormal growth and clinical symptoms of osteochondromas newly appear in adults, malignant transformation of the usually benign growing tumors should be suspected and diagnostic testing should be initiated. Against the background of hypothesized higher malignant transformation of osteochondromas into chondrosarcoma in individuals with shoulder exostoses, we report a case of bilateral scapulothoracic osteochondromas in a patient suffering from HME. A 60-year-old female with HME complained of chest pain while being hospitalized for bilateral femoral fractures. A computed tomography scan of the chest was performed to rule out pulmonary embolism. However, bilateral osteochondromas in the scapulothoracic spaces were detected. Due to absence of radiographic evidences for malignant transformation in the patient, invasive diagnostic procedures such as biopsy and histological examination were recommended in order to exclude malignant transformation of both osteochondromas. Physicians should be aware that patients with HME who present with shoulder pain should be examined for osteochondromas in the scapulothoracic space. Due to possible sarcomatous transformation, regular follow-ups are necessary for adolescents and adults.

Asymptomatic costal exostosis with thickening in the pericardium: a case report

Background

Costal exostosis is a benign condition that sometimes requires emergent surgery because of associated hemothorax; in addition, there have been cases with malignant transformation to chondrosarcoma. Here, we describe an asymptomatic patient who underwent thoracoscopic resection for primary costal exostosis.

Case presentation

A 16-year-old male was found to have a bow-shaped shadow on a chest X-ray. Chest computed tomography revealed a rod-like mass with a soft tissue shadow adjacent to the left fifth rib. A thoracoscopic partial resection of the left fifth rib was performed. Intraoperative findings included thickening of the pericardium near the tip of the growth and erosion of the visceral pleura of the left lung. The resected specimen was diagnosed as a primary costal exostosis based on histopathological findings.

Conclusions

We review the published literature on costal exostosis and discuss the surgical indications of asymptomatic cases.

Osteochondroma of the Hyoid Bone: A Previously Unrecognized Location and Review of the Literature

Osteochondroma is a benign cartilaginous neoplasm and the most common benign tumor of bone. Osteochondromas occur primarily in the axial skeleton with a predilection for the distal femur, and relatively few cases occur in the head and neck region. The majority of cases of osteochondromas in the head and neck region affect the mandibular condyle, with fewer cases reported in the skull base and the neck. To our knowledge, there is no reported case of osteochondroma of the hyoid bone documented in the English literature. We thus report the first case of a hyoid bone osteochondroma, presenting as an asymptomatic mass in a young woman.