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

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.

A bump: what to do next? Ultrasound imaging of superficial soft-tissue palpable lesions

Soft-tissue palpable lesions are common in clinical practice, and ultrasound (US) represents the first imaging option in the evaluation of a patient with a soft-tissue swelling. A full and systematic US assessment is necessary, however. This includes grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities, as well as a trained operator. Several lesions showing characteristic US features can be diagnosed confidently, without any further work-up, and the high spatial resolution of ultrasound in the superficial layers can be a powerful tool to discriminate their etiologies. Second-level options, to be reserved for indeterminate cases or those suspected malignant at initial ultrasound, include magnetic resonance imaging, percutaneous fine-needle aspiration or biopsy, and surgical-excision biopsy. In this article, we discuss the proper US approach for addressing superficial soft-tissue lesions.

Benign and Malignant Male Breast Diseases: Radiologic and Pathologic Correlation

Male breast disease comprises a wide spectrum of benign and malignant processes. We present the spectrum of diseases encountered at our institution over the past 7 years (2007-2013) and correlate their radiological and histopathological appearances. Gynaecomastia is the most frequently encountered disease due to its association with a variety of causes. Male breast malignancies, though rare, must be considered. The most frequently encountered pathological characteristic is invasive and the predominant histologic subtypes are infiltrating ductal carcinomas.

From the radiologic pathology archives: diseases of the male breast: radiologic-pathologic correlation

Male breast disease includes a variety of benign and malignant conditions, many of which are hormonally influenced. Gynecomastia and skin lesions account for the majority of conditions in symptomatic men with a palpable abnormality, and these conditions should be accurately recognized. Imaging patterns of gynecomastia include nodular, dendritic, and diffuse patterns. Histopathologically, the nodular and dendritic patterns correlate with the florid and quiescent (fibrotic) phases of gynecomastia, respectively. The diffuse pattern may have features of both phases and is associated with exposure to exogenous estrogen. Benign-appearing palpable masses in male patients should be approached cautiously, given the overlapping morphologic features of benign and malignant tumors. In addition to gynecomastia, other benign male breast tumors include lipoma, pseudoangiomatous stromal hyperplasia, granular cell tumor, fibromatosis, myofibroblastoma, schwannoma, and hemangioma. Male breast cancer accounts for 1% of all breast carcinomas. Invasive ductal carcinoma accounts for the majority of cases in adult males and typically appears as a subareolar mass without calcifications that is eccentric to the nipple. Other epithelial and mesenchymal tumors that may occur, albeit not as commonly as in women, include papillary carcinoma, invasive lobular carcinoma, adenoid cystic carcinoma, liposarcoma, dermatofibrosarcoma, pleomorphic hyalinizing angiectatic tumor, basal cell carcinoma of the nipple, hematopoietic malignancies, and secondary tumors. Knowledge of the natural history, clinical characteristics, and imaging features of tumors that occur in the male breast will help narrow the radiologic differential diagnosis and optimize treatment.

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTION

Chondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.

PRESENTATION OF CASE

A 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.

DISCUSSION

The outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.

CONCLUSION

This case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.