Chest wall tumors: radiologic findings and pathologic correlation: part 2. Malignant tumors

The Breast Imager's Approach to Nonmammary Masses at Breast and Axillary US: Imaging Technique, Clues to Origin, and Management

Ultrasonography (US) of the breast and axilla is primarily used to evaluate a symptomatic patient or to further investigate findings identified with other imaging modalities. Breast imagers are generally familiar with US evaluation of level I, II, and III axillary lymph nodes in the diagnosis and staging of breast cancer. However, the axilla contains nonlymphatic tissue as well, including muscle, fat, and vascular and neurologic structures, and anatomically the breast lies on the chest wall. Therefore, lesions of nonmammary and non-lymph node origin in the axilla or chest wall are not infrequently encountered during US evaluation of the breast or axilla. In fact, such lesions may be the reason that the patient presents to the breast imaging department for evaluation. Understanding the anatomy of the chest wall and axilla and using a systematic US approach will help radiologists expedite accurate diagnosis, suggest optimal additional imaging, and streamline appropriate clinical referral. Key imaging features of nonmammary non-lymph node masses are highlighted, and case examples are provided to illustrate these features. Appropriate patient management is critical in these cases because referral to a breast surgeon may not be the best next step. Depending on institutional referral patterns, other subspecialty surgeons will be involved. Online supplemental material is available for this article.

Primary Pulmonary Angiosarcoma Presenting with Hemoptysis and Ground-Glass Opacity: A Case Report and Literature Review

Angiosarcoma originates from the vascular endothelium and accounts for only 1-2% of all sarcomatous malignancies. The skin is one of the most common primary sites. However, primary pulmonary angiosarcoma is rare, and only 31 cases of primary pulmonary angiosarcoma have been reported. A 79-year-old Japanese female developed bloody sputum, and chest X-ray and chest computed tomography (CT) showed consolidation with ground-glass opacity (GGO) on the right middle and lower lung fields. The bronchoscopic findings demonstrated bleeding from the right B(4) and B(5), and bronchial arterial embolization was subsequently performed. However, the CT findings demonstrated new pulmonary nodules with GGO in the left lung, and she presented with hemosputum and a progression of anemia. Right hemothorax also occurred, and surgical lung resection was performed to control the bleeding. The pathological analysis of the resected lung revealed the focal growth of atypical alveolar epithelioid-like cells that were positive for CD31 and negative for epithelial membrane antigen, and these atypical cells were replacing the endothelium of the pulmonary artery. Based on these findings, the patient was diagnosed with pulmonary angiosarcoma, which might originate from the endothelium of the pulmonary artery. No abnormal findings were observed except for the pulmonary involvement on systemic CT scanning. However, the patient passed away due to respiratory failure with compression of the brainstem caused by brain metastasis three months after the first visit. Early surgical resection is the important treatment for patients with angiosarcoma. In addition, we review the literature reporting the patients with primary pulmonary angiosarcoma.

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.

Sonography of the chest wall: A pictorial essay

Ultrasound (US) is increasingly being used as the first-line imaging modality for investigating the chest wall for soft tissue and bony lesions. This article describes the technique used for the US examination, the relevant chest-wall anatomy, and the appearances on US scanning of pathologic entities either unique to or common in the region of the chest wall.

Thoracic Wall Reconstruction after Tumor Resection

Introduction

Surgical treatment of malignant thoracic wall tumors represents a formidable challenge. In particular, locally advanced tumors that have already infiltrated critical anatomic structures are associated with a high surgical morbidity and can result in full-thickness defects of the thoracic wall. Plastic surgery can reduce this surgical morbidity by reconstructing the thoracic wall through various tissue transfer techniques. Sufficient soft-tissue reconstruction of the thoracic wall improves quality of life and mitigates functional impairment after extensive resection. The aim of this article is to illustrate the various plastic surgery treatment options in the multimodal therapy of patients with malignant thoracic wall tumors.

Materials and methods

This article is based on a review of the current literature and the evaluation of a patient database.

Results

Several plastic surgical treatment options can be implemented in the curative and palliative therapy of patients with malignant solid tumors of the chest wall. Large soft-tissue defects after tumor resection can be covered by local, pedicled, or free flaps. In cases of large full-thickness defects, flaps can be combined with polypropylene mesh to improve chest wall stability and to maintain pulmonary function. The success of modern medicine has resulted in an increasing number of patients with prolonged survival suffering from locally advanced tumors that can be painful, malodorous, or prone to bleeding. Resection of these tumors followed by thoracic wall reconstruction with viable tissue can substantially enhance the quality of life of these patients.

Discussion

In curative treatment regimens, chest wall reconstruction enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. In palliative disease treatment, plastic surgical techniques of thoracic wall reconstruction provide palliation of tumor-associated morbidity and can therefore improve patients’ quality of life.

Imaging characteristics of pleural tumours

Abstract

Malignant mesothelioma is doubtless the more known pleural tumour. However, according to the morphology code of the International Classification of Diseases for Oncology (ICD-O), there are several histological types of pleural neoplasms, divided into mesothelial, mesenchymal and lymphoproliferative tumours, that may be misdiagnosed. In this paper we summarise and illustrate the incidence aspects and the clinical, pathological and radiological features of these neoplasms.

Teaching Points

• According to the ICD-O, there are 11 different histological types of pleural neoplasm.

• Imaging, clinical and histopathological aspects of these neoplasms may be overlapping.

• Knowledge of different pleural tumours plays an important role for diagnosis orientation.

Advances in the diagnosis, treatment and prognosis of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare cancer originated from pleural mesothelial cells. MPM has been associated with long-term exposure to asbestos. The prognosis of MPM is poor due to the difficulty of making diagnosis in the early stage, the rapid progression, the high invasiveness and the lack of effective treatment. Although the incidence of MPM is low in China to date, it has a tendency to increase in the coming years. The variety of clinical features may cause the delay of diagnosis and high rate of misdiagnosis. The diagnosis of MPM is based on biopsy of the pleura and immunohistochemistry. As China has become the largest country in the consumption of asbestos, it would give rise to a new surge of MPM in the future. The current treatment of MPM is multimodality therapy including surgery, radiotherapy, chemotherapy and immunotherapy. Two surgical procedures are commonly applied: extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D). Three dimensional conformal radiotherapy is used to denote a spectrum of radiation planning and delivery techniques that rely on the 3D imaging to define the tumor. Cisplatin combined with pemetrexed (PEM) is the first-line chemotherapy for MPM. The principal targets in immunotherapy include T cells (Treg), CTLA-4 and PD-1. The diagnosis, treatment and prognosis still remain a major challenge for clinical research and will do so for years to come.

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.

Chondrosarcoma of a rib

Chondrosarcoma of a rib is a very rare malignant tumor of the bone. Most patients were present with an enlarging painful anterior chest wall tumor. We present a case of an asymptomatic 29-years old female with a tumor size of 10 cm × 12 cm on the left anterior chest wall involving the 8th rib. CT scan with intravenous contrast is the gold standard for radiological imaging and planning for surgery. Since chondrosarcoma is less sensitive to chemotherapy and radiotherapy, surgical treatment with extensive resection with a sufficient margin is considered first line treatment.

Chest wall tumors: Diagnosis, treatment and reconstruction

The aim of the present study was to determine a suitable procedure for the treatment of chest wall neoplasms with less potential risk and an increased rate of survival. Fifty patients with suspected chest wall malignancies were analyzed using various preliminary investigation tools. Whole-chest scanning was performed in all the patients. The patients were subsequently subjected to biopsies for further confirmation of the neoplasm. All such patients were then treated with a surgical approach and radiation therapy, with a follow-up period lasting up to six years. The majority of the patients showed improved survival rates relative to conventional therapies. The survival rates of patients suffering from osteosarcoma (78%) were higher those of patients with rhabdomyosarcoma (73%) and malignant small round cell tumors (64%). The survival and the mortality rates of the patients with synovial sarcoma and fibrosarcoma were the same. This study, which was conducted on a small group of patients, has provided guidance for further studies on tumors of the chest wall, which may, in turn, increase the longevity of affected patients.

Malignant phyllodes tumor with chondrosarcomatous differentiation: radiological-pathological correlation

We present a case of a 63-year-old woman with malignant phyllodes tumor in her left breast. On imaging, a large, dumbbell-shaped, predominantly cystic mass with thin peripheral enhancement was noted. The lesion was causing rib destruction, chest wall invasion, and intrathoracic extension. These aggressive imaging features were considered highly suspicious of a malignant chest wall tumor. Subsequent chest wall resection of the tumor showed breast tissue with a biphasic lesion composed of proliferated spindle cells in loose sheets with extensive islands of atypical cartilage and a scanty epithelial component, including compressed ducts in the periphery of the lesion. A diagnosis of a malignant phyllodes tumor with stromal overgrowth and chondrosarcomatous differentiation was made in view of the presence of a benign epithelial component and negative reaction of the stromal component with a pancytokeratin. To the best of our knowledge, a phyllodes tumor with the radiological features of chest wall invasion and intrathoracic extension has not been described in the literature until now. Malignant phyllodes should be included in the list of differentials along with sarcomas on encountering lesions with such aggressive imaging features.

Rib tumors: a 15-year experience

OBJECTIVE

A retrospective study of rib tumors was conducted to review their clinical, radiological, and pathological features, the difficulties in differentiating benign from malignant tumors, as well as the early and long-term results of surgical management.

METHODS

All patients with rib lesions evaluated by the Thoracic Surgery Department from 1998 to 2012 were studied. The patient's age, sex, symptoms, radiologic evaluation, surgical procedure, pathologic diagnosis and follow-up were assessed.

RESULTS

Ninety-one patients (81 male, 10 female, age range 16-80) with rib tumors underwent surgery in a period of 15 years (1998-2012). 64 patients (70.33 %) had benign lesions and 27 patients (29.67 %) had malignant tumors. In the group with malignant tumors, the main symptom was pain, and in the group with benign tumors the main symptom was swelling. Ten patients with benign rib tumor and two with malignant tumor were detected during routine chest radiograph. All patients were treated surgically with wide excision of the tumor and the diagnosis was established histologically. In the benign cohort, osteochondromas, fibrous dysplasia, enchondroma, eosinophilic granuloma and posttraumatic fibro-osseous lesion/dysplasia were among the most customary diagnoses. In the malignant cohort, 13 patients (48.15 %) had metastatic lesions, with the remaining 14 patients having primary malignant rib tumor.

CONCLUSIONS

Although radiographic imaging has evolved, all rib lesions must be considered as potentially malignant until proven otherwise. Prompt intervention is necessary and surgery must consist of wide resection with tumor-free margins to provide the best chance for cure in both benign and malignant lesions.

Primary intrathoracic malignant mesenchymal tumours: computed tomography features of a rare group of chest neoplasms

Objectives

To describe the computed tomography (CT) features in a case series of primary intrathoracic extracardiac malignant mesenchymal tumours (sarcomas).

Methods

A 5-year retrospective research was conducted, and 18 patients were selected. CT exams were reviewed by two chest radiologists, blinded to tumour pathological type, origin and grade. Lesions were described in relation to location, size, shape, margins, enhancement, presence of cavitation, calcifications, ground glass component, intratumoural enhanced vessels, pleural effusion, pleural tags, lymphangitis, chest wall/rib involvement and pathological lymph nodes.

Results

The readers described five pulmonary, six mediastinal and seven pleural/wall based lesions. Mean largest diameter was 103 mm. The most frequent shape was irregular (n = 12), most predominant margin was smooth (n = 12) and enhancement was mostly heterogeneous (n = 8). Intratumoural vessels and pleural effusion were seen in 11 patients. Pathological lymph nodes were present in four cases and calcifications in two cases.

Conclusions

Some frequent radiological features were described independently of tumour location and subtype. A sarcoma should be included as a major differential diagnosis when the radiologist faces an intrathoracic mass of large size (>70 mm) but with well defined smooth or lobulated margins, especially if presenting intratumoural vessels, associated pleural effusion but no significant lymphadenopathy.

Main messages

• Malignant mesenchymal tumours (sarcomas) are rare and can arise from any structure in the chest.

• Intrathoracic sarcomas show some frequent radiological features, independent of location and type.

• Some CT features may help the radiologist suspect for a sarcoma instead of other more common tumours.

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.

Malignant peripheral nerve sheath tumor of the chest wall associated with neurofibromatosis: a case report

Primary chest wall tumors are relatively rare and represent approximately 5% of all thoracic neoplasms. Malignant peripheral nerve sheath tumor (MPNST) is highly aggressive and occurs in the second or third decade of patients with neurofibromatosis type 1 (NF-1). The estimated incidence of MPNST in patients with NF-1 is 2-5% (general population, 0.001%). This neoplasm usually affects the extremities and rarely the thoracic cavity. We present a case of MPNST of the chest wall in a patient with NF-1 who developed local recurrence 5 months after complete surgical resection and postoperative adjuvant radiotherapy.

Scapular bone destruction: do not forget to think of tuberculosis in endemic areas

Tuberculosis is an endemic disease of worldwide concern. The most common involvement is in the form of pulmonary tuberculosis. Musculoskeletal system is involved in 20-30% of cases of extrapulmonary tuberculosis. Among these cases of musculoskeletal tuberculosis, vertebral column is most commonly involved followed by long bones. However, tuberculosis of flat bones like scapula is very rare. We present a case of a 56-year-old woman with painless swelling in the right lower back of chest. Ultrasonography suggested abscess formation. A chest X-ray and CT scan suggested coexisting pulmonary tuberculosis. CT revealed abscess with osteomyelitis of inferior angle of scapula. The abscess was aspirated and histopathological examination confirmed tubercular pathology. A 6-month course of antitubercular treatment resulted in complete resolution of symptoms.

Percutaneous image-guided needle biopsy of rib lesions: a retrospective study of diagnostic outcome in 51 cases

OBJECTIVE

To assess the diagnostic yield and diagnostic accuracy of image-guided percutaneous needle biopsy of rib lesions and to analyse the diagnostic spectrum of rib lesions referred to a tertiary musculoskeletal oncology centre.

MATERIALS AND METHODS

A retrospective review of all patients that underwent image-guided rib biopsy and/or excision during the period from 1 January 2003 to 31 July 2011. A total of 51 consecutive subjects were identified and included in this study. Image-guided percutaneous biopsy was performed using either CT (n = 43) or ultrasound (n = 8).

RESULTS

There were 28 males and 23 females, with a mean age of 49.9 years (range 10-84 years). Forty-five of the 51 biopsies (88%) yielded a diagnostic sample, and 6 (12%) were non-diagnostic. Thirty-one of 45 (69%) lesions were malignant, and 14 (31%) were benign. The commonest malignant lesions were metastases, 16 of 31 (51.6%), and primary bone or cartilaginous tumours, 15 of 31 (48.4%). The commonest benign lesion was fibrous dysplasia (6 of 14, 43%) followed by infection (5 of 14, 36%). All non-diagnostic samples were from lesions which had no extra-osseous component, and all were subsequently confirmed as benign on rib resection. There was complete agreement between needle and surgical resection in 18 of 19 subjects (96%).

CONCLUSION

Image-guided percutaneous rib biopsy has high diagnostic yield and accuracy. Intra-osseous lesions which have no associated extra-osseous component have a lower biopsy success rate.

Review of chest wall tumors: a diagnostic, therapeutic, and reconstructive challenge

Chest wall tumors are a heterogeneous group of lesions that provide an interesting diagnostic and therapeutic challenge for surgeons. They make up less than 5% of thoracic malignancies and vary widely in pathology as they arise from all anatomic structures of the chest wall. In general, treatment is wide local excision, the margins for malignant disease are necessarily wider, and adjuvant radiation is typically given for those with positive margins. Chemotherapy is rarely effective. Local control is the most important prognostic factor. Disease-free survival for malignant disease is limited by positive margins; therefore full oncologic resection with 4-cm margins should be attempted. For small lesions, the resection and reconstruction is usually straightforward. For more advanced disease or those lesions that require significant functional loss, preoperative planning using a multidisciplinary approach, incorporating thoracic surgery, plastic surgery, neurosurgery, radiation medicine, oncology, and physical medicine and rehabilitation, may be essential.

Treatment of chest wall osteosarcoma presenting as second primary after treatment of neuroblastoma

Only 2 cases of osteosarcoma as a second primary malignancy after neuroblastoma have been reported in the literature. We present a case of chest wall osteosarcoma that developed in a 14-year-old boy 7 years after completion of chemotherapy, autologous peripheral blood stem cell transplantation, radiation, and resection for stage 3, high-risk neuroblastoma. A biopsy of a painful chest wall mass arising from the right third rib diagnosed osteosarcoma. He went on to have preoperative chemotherapy followed by wide local excision and chest wall reconstruction. He then received additional chemotherapy. This case highlights the importance of close observation for second malignancies in this patient population.

Primary burkitt lymphoma of the chest wall

Burkitt lymphoma (BL) originating in the skin and soft tissue at any site is exceedingly rare. This paper is about a case of primary sporadic BL that presented as an isolated, rapidly enlarging chest wall mass arising from skin and/or soft tissue in an adult. As with other BL presentations, this patient was treated with aggressive chemotherapy with central nervous system (CNS) chemoprophylaxis, but he later died because of sepsis.

Prediction of treatment outcomes in patients with chest wall sarcoma: evaluation with PET/CT

OBJECTIVE

The aim of this study was to investigate the prognostic implications of (18)F-2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography in patients with chest wall sarcoma.

METHODS

Positron emission tomography/computed tomography scans of 42 patients (mean age: 46 years) with chest wall sarcomas were analyzed. Pathologic confirmation was obtained by surgical specimens in all patients. Tumor grade assessed by Ki-67 (MIB-1) immunohistochemical analysis and expression of glucose transporter protein 1 were compared with a maximum standardized uptake value. Univariate and multivariate analyses were conducted for estimates of overall and event-free survivals.

RESULTS

The median maximum standardized uptake value of the tumor was 10.2 and the median MIB-1 index of the tumor was 32.5%. Glucose transporter protein 1 expression was found in 29 patients (69%). Univariate analyses revealed that surgery, chemotherapy, MIB-1 labeling index (cut-off 32.5%), MIB-1 grade, glucose transporter protein 1 expression and maximum standardized uptake value were possible predictors for overall and event-free survival. Multivariate analysis revealed that surgery (hazard ratio, 4.852; P = 0.017), maximum standardized uptake value (hazard ratio, 3.077; P = 0.037) and MIB-1 labeling index (hazard ratio, 6.549; P = 0.003) were independent predictors of event-free survival. In addition, surgery (hazard ratio, 4.092; P = 0.021) and maximum standardized uptake value (hazard ratio, 2.968; P = 0.027) were independent predictors of overall survival.

CONCLUSIONS

(18)F-2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography allows the prediction of prognosis after treatment in patients with chest wall sarcoma and may be useful in selecting high-risk patients for more risk-adapted treatments.

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.

[Multifocal epithelioid angiosarcoma of bone with lung metastases]

Angiosarcoma is a rare mesenchymal neoplasm that may arise from vascular or lymphatic tissue. Bone primary angiosarcoma is extremely rare, representing less than 1% of all angiosarcomas. It́s a very aggressive neoplasm and patients have metastatic disease at initial diagnosis in a large percentage of cases. On radiographs, these lesions are usually aggressive osteolytic lesions, commonly with soft-tissue mass extension, and tumoral enhancement on CT or MR imaging. The appearance of the bone scan is variable, describing studies with tracer uptake or low uptake. These tumours are more often found in the long bones, but spinal involvement has been reported in 10% of patients. There are a few reports in the literature of bone angiosarcoma with lung metastases. We present a patient with multifocal epithelioid angiosarcoma (spine and ribs) and multiple lung metastasis, evidenced by CT and conventional bone scintigraphy, with a fast growth.

The role of imaging for the surgeon in primary malignant bone tumors of the chest wall

Primary malignant chest wall tumors are rare. The most frequent primary malignant tumor of the chest wall is chondrosarcoma, less common are primary bone tumors belonging to the Ewing Family Bone Tumors (EFBT), or even rarer are osteosarcomas. They represent a challenging clinical entities for surgeons as the treatment of choice for these neoplasms is surgical resection, excluding EFBT which are normally treated by a multidisciplinary approach. Positive margins after surgical procedure are the principal risk factor of local recurrence, therefore to perform adequate surgery a correct preoperative staging is mandatory. Imaging techniques are used for diagnosis, to determine anatomic site and extension, to perform a guided biopsy, for local and general staging, to evaluate chemotherapy response, to detect the presence of a recurrence. This article will focus on the role of imaging in guiding this often difficult surgery and the different technical possibilities adopted in our department to restore the mechanics of the thoracic cage after wide resections.

Radiology of chest wall masses

OBJECTIVE

The purpose of this article is to highlight the role of radiography, CT, PET/CT, and MRI in the diagnosis and management of chest wall lesions. Chest wall masses are caused by a spectrum of clinical entities. The lesions highlighted in this selection of case scenarios include neoplastic, inflammatory, and vascular lesions.

CONCLUSION

Imaging evaluation with radiography, CT, MRI, and PET/CT plays an important role in the accurate diagnosis of chest wall lesions. It can also facilitate percutaneous biopsy, when it is indicated. Imaging enables accurate staging and is a key component of treatment planning for chest wall masses.

Hodgkin lymphoma presenting with chest wall involvement: a case series

Chest wall tumors in the pediatric population can have a variety of etiologies, malignancy being the most worrisome. Hodgkin lymphoma (HL) rarely presents as a chest wall mass in the pediatric population. In this report, we describe 3 male pediatric patients, all of whom had chest wall masses present at the initial diagnosis of HL. We also discuss the literature on this topic. We conclude that malignancy and, more specifically, HL should always be considered when evaluating a pediatric patient who presents with a chest wall mass.

Giant submental lipoma: Case report and review of the literature

Lipomas may be located in all parts of the body and may be confused clinically with other soft tissue masses. They infrequently occur in the head and neck. A large neck mass (greater than 10 cm) with a rapid growth rate should raise concerns about a possible malignancy. Failure to distinguish a liposarcoma from a lipoma may represent a medicolegal pitfall. Surgical excision of a lipoma is often used as the definitive treatment modality, and alternative treatments described for lipomas range from liposuction to steroid injections. In the present study, a 60-year-old man who presented with a rapidly enlarging submental mass is described. A 15 cm x 12 cm mass was successfully removed. The surgery produced excellent cosmetic results and no functional impairment. An integrated review of the literature regarding etiology, epidemiology, diagnostic and treatment modalities of submental lipomas follows.

Review of Physiologic and Pathophysiologic Sources of Fluorodeoxyglucose Uptake in the Chest Wall on PET

The chest wall can be defined as the osseous and soft tissue structures that form the outer framework of the thorax and move during breathing. Topics discussed in this article include physiologic uptake of fluorodeoxyglucose, benign diseases of the chest wall, and malignant tumors of the chest wall.

Clinical utility of image-guided chest wall mass biopsy: results in 28 patients

The purpose of our study was to determine the clinical usefulness of percutaneous image-guided biopsy of chest wall masses. A retrospective study of 28 patients who underwent image-guided biopsy of chest wall masses from 2005 to 2007 was performed. In 19 (68%) patients, the mass was detected as part of a staging evaluation in patients with known malignancy; 9 (32%) patients had no known malignancy. Biopsy results were classified as diagnostic (malignant or benign) or non-diagnostic (atypical and insufficient). Sensitivity, specificity and negative predictive value were calculated for all patients, and the Fisher–Freeman–Halton exact test was used to determine if test characteristics varied in patients with and without a history of cancer, masses smaller and greater than 5 cm, or according to needle size. The overall diagnostic rate was 71%. Of these, there were 20 true-positives, 3 true-negatives, 5 false-negatives and no false-positive results (sensitivity 80% (20/25), specificity 100% (3/3) and negative predictive value 37.5% (3/8)). There were no differences between patients with and without cancer. Among 19 patients with known cancer, 10 had metastatic disease from their known primary. Biopsy test characteristics did not differ with respect to mass or needle size. Minor complications were seen in 7% of patients. Image-guided chest wall mass biopsy is a sensitive and specific procedure, which is clinically important in the care of patients both with and without a known primary cancer.

Primary chest wall tumors

The differential diagnosis of chest wall tumors is diverse, including both benign and malignant lesions (primary and malignant), local extension of adjacent disease, and local manifestations of infectious and inflammatory processes. Primary chest wall tumors are best classified by their primary component: soft tissue or bone. Work-up consists of a thorough history, physical examination and imaging to best assess location, size, composition, association with surrounding structures, and evidence of any soft tissue component. Biopsies are often required, especially for soft tissue masses. Treatment depends on histological subtype and location, but may include chemotherapy and radiotherapy in addition to surgical resection.

Intercostal myositis ossificans misdiagnosed as osteosarcoma in a 10-year-old child

Myositis ossificans (MO) is a rare benign cause of heterotopic bone formation within soft tissue. It most commonly affects adolescents and young adults, typically in the limbs and following trauma. Very few cases have been reported in children. We report here a case of nontraumatic MO occurring in a 10-year-old girl with an uncommon location in the 5th right intercostal space; it was initially misdiagnosed and treated as osteosarcoma. Imaging findings including plain radiographs, CT, MRI, bone scintigraphy and PET-CT are described. This case highlights the central role played by imaging in diagnosis, thus avoiding biopsy that can erroneously suggest osteosarcoma as the diagnosis, as occurred in this case.

Cardiac metastasis of osteosarcoma

Cardiac osteosarcoma metastasis is extremely rare and is documented in several case reports in the literature. The behaviour of osteosarcoma metastases is similar to the primary tumour. Thoracic non-enhanced computed tomography (CT) examination is beneficial in the detection of calcific cardiac metastases. In this case report, we describe a 29-year-old woman with cardiac osteosarcoma metastasis after 7 years of follow-up, compare the demographic features with previous cases and discuss the imaging findings.

Tumors of the mediastinum and chest wall

Primary tumors of the mediastinum and chest wall comprise a diverse group of conditions with a wide range of presentations. A thorough knowledge of thoracic anatomy is essential for appropriate diagnosis and treatment. Given their proximity to critical structures, treatment of these tumors is often challenging. Although surgery is the mainstay of therapy for most mediastinal and chest wall tumors, a multidisciplinary approach is valuable in many cases.

Soft tissue tumours: imaging strategy

Vascular tumours and malformations, fibrous and fibrohistiocytic tumours and pseudotumours are the most common benign soft-tissue masses observed in children, and can be treated conservatively. Rhabdomyosarcomas are the most frequent malignant tumours, accounting for about half of soft tissue sarcomas. A child referred for a soft-tissue mass should ideally be managed by a multidisciplinary team and primary excision should be proscribed until a definite diagnosis has been established. Clinical examination, conventional radiography and US with Doppler represent the first-line examinations and are sometimes sufficient to make a diagnosis. In all other situations, MRI is mandatory to establish the aggressiveness and extension of the tumour. This technique provides the relevant data to guide the decision regarding tissue sampling.

Case report. PET/CT appearance of desmoid tumour of the chest wall

Desmoid tumours are rare, poorly circumscribed tumours that have a firm consistency and, although benign, have a remarkable tendency to infiltrate into surrounding structures. Extra-abdominal desmoid tumours involve mainly the extremities or the chest wall and are usually managed by wide radical resection. Moreover, desmoid tumours involving the chest wall are locally aggressive tumours with a high recurrence rate. We report a case of a pathologically proven desmoid tumour of the chest wall in a patient with a history of bilateral breast cancer and oesophageal cancer. We discuss the imaging appearances of this tumour on positron emission tomography combined with computed tomography (PET/CT) and magnetic resonance imaging.