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

Extraskeletal Ewing sarcoma presenting as an axillary mass with pulmonary metastases

Extraskeletal Ewing sarcoma (EES) is a tumour of rare variant of the Ewing sarcoma family of tumours. This family of tumours can have different features; however, these tumours are categorised on the basis of genetic translocation, specific molecular and immunohistochemical features. EES is seen commonly affecting young adults with poor prognosis and high mortality rates. It can be detected in various locations making its diagnosis more difficult. It can present with varied imaging features, often non-specific. However, imaging plays a vital role in the primary tumour assessment, local staging, preoperative management and surveillance. Management involves surgery with chemotherapy. Long-term prognosis in cases of metastatic disease is very poor. In literature, only three cases of axillary EES have been reported so far. Here, we report the fourth case of large EES originating in the left axillary region in a woman in her 20s. The patient was given neoadjuvant chemotherapy; however, the size of the tumour increased, which was later surgically treated with complete excision of the tumour. Unfortunately, the tumour metastasised to the lung for which the patient was irradiated. Afterwards, the patient presented to the emergency room with respiratory distress for which she was on ventilator support; sadly, the patient died after 1 week.

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.

Non-glandular findings on breast ultrasound. Part II: a pictorial review of chest wall lesions

The breast ultrasound (US) field-of-view (FOV) includes glandular parenchyma as well as tissues located anterior to and posterior to it, up to pleural line. For that, it is possible to incidentally identify lesions unrelated to breast parenchyma during screening or diagnostic US; sometimes a palpable lump may be the reason of the imaging exam. Furthermore, abnormality related to chest wall are easier and more accurate detected after mastectomy. Hence, radiologists should know the US appearance of lesions which may develop from all tissues present in this region and displayed in the US FOV, without focusing only on glandular abnormalities while performing the exam. This is the second of a two-part series on non-glandular breast lesions; in detail, part two provide an overview of US appearance, differential diagnosis, and pitfalls of chest wall lesions. They may have an infectious, traumatic, inflammatory etiology or be benign or malignant neoplasms. The US role in the assessment of chest wall abnormalities is limited, usually computed tomography and/or magnetic resonance are requested as second-level imaging exams to characterize and to assess better their relationship with surrounding structures because of larger and panoramic view. Finally, US could be useful to guide biopsy.

Metastatic pulmonary synovial sarcoma: A double coincidence: Case report

Synovial sarcomas are considered as one of the most aggressive neoplasms that account for approximately 8% of all soft tissue sarcomas; they are mainly localized in soft tissues of the extremities and joints and rarely occur in the thorax. In this case report, we describe a 34-year-old woman presenting a chest pain with a chest radiography showing a mass lesion occupying two-thirds of the right hemi-thorax. A malignant pulmonary tumor was suspected after CT imaging revealing a bilateral renal metastasis, and then a spindle-cell carcinoma was thought-about. The post-operative pathological analysis of the main mass confirmed the diagnosis of a pulmonary synovial sarcoma.

Hondrosarcoma of the chest with intraabdominal distribution (case report)

A rare clinical observation of chondrosarcoma metastasis into the abdominal cavity with a specific metastatic ascitic fluid is presented. Chondrosarcomas that occur as a result of malignant transformation of benign chondroma are quite rare. Even less often in the literature, cases of chondrosarcoma metastases are described, especially in a peritoneum with the presence of metastatic ascites. The article describes a case of metastatic ascites in a 38-year old patient with chondrosarcoma, which developed against the background of previously resected rib chords. The article describes the cytological signs of chondrosarcoma in ascitic fluid.

Radiographic findings useful for diagnosis of primary chest wall lymphoma without preceding pleural disease: A case report

A 70‐year‐old man with no history of pleural diseases had a dumbbell‐shaped chest wall mass extending from the thoracic cavity to the spinal canal at the intervertebral foramen without bone destruction. Computed tomography revealed a positive a ‘pleural sandwich sign’, where the intercostal artery was enveloped by the mass. A high maximum standard uptake value was noted on fluorodeoxyglucose‐positron emission tomography. No lesions were found in areas other than the chest wall. CT‐guided biopsy was performed and he was diagnosed with primary chest wall lymphoma. This case report suggests that these radiographic findings may be helpful for diagnosing chest wall lymphomas even in patients without prior pleural disease.

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.

Incidental osseous lesions on chest CT: an algorithmic approach for radiologists

Numerous osseous findings are commonly discovered incidentally at chest CTs in daily practice. A broad spectrum of these findings ranges from benign and do not touch lesions to ominous conditions requiring further imaging evaluation and/or intervention. Interpretation of these incidental musculoskeletal findings may constitute a diagnostic challenge to radiologists. This review provides a systematic, algorithmic approach to common osseous lesions on chest CT based on imaging findings with recommendations for proper next step management.

Chest Wall Mass as the Dominant Presentation of Low-Grade B-Cell Non-Hodgkin's Lymphoma: A Case Report

Low-grade B cell non-Hodgkin's lymphoma with dominant presentation of chest wall mass is presented in this report. The patient, a 65-year-old woman, presented with pain, rising skin temperature and redness, and swelling on the right lower chest wall. The histopathological examination revealed non-Hodgkin's lymphoma; the staging fluorodeoxyglucose-positron emission tomography/computed tomography demonstrated stage IVE disease, with hypermetabolic active disease in the right anterolateral chest wall in the form of large soft tissue mass and subcutaneous tissue with underlying bony erosion with extension into right anterior cardiophrenic space and superiorly up to right second costosternal region along the right internal mammary vessels. This was along with hypermetabolic active right axillary, right supraclavicular and left inguinal lymphadenopathy, and thickened hypermetabolic posterior right pleura with ametabolic right-sided pleural effusion. Bone marrow biopsy revealed uninvolved bone marrow. On follow-up after eight cycles of R-CHOP chemotherapy, the mass had completely resolved on contrast-enhanced computed tomography.

Retroperitoneal blue cell round tumor (Ewing sarcoma in a 35 years old male)- case report

Introduction

Ewing sarcoma is a highly aggressive tumor. It's common presentation is primary bone tumor, but very rarely as soft tissue sarcoma both of which are under the spectrum of Ewing sarcoma family of tumors (EFT).

Case presentation

A 35 years old male who presented with advanced locally spreading tumor. He was diagnosed after presenting with epigastric pain and melena, CT abdomen revealed the retroperitoneal mass. CT guided core biopsy taken and was diagnosed as Ewing sarcoma. The patient presented with mass already grown so he was not a surgical candidate. Patient was managed symptomatically till he was sent for palliative care in a Sarcoma centre in Jordon and passed away on October 2021.

Discussion

Ewing Sarcoma family of tumors are group of small round blue cell tumors that are histogenetically related. The better known is Ewing ‘s sarcoma (EWS). It is a malignant small blue round cell tumor with variable degree of neuroectodermal differentiation. Retroperitoneal tumor are mostly malignant and accounts for one third of soft tissue sarcoma. They usually present as large masses at the time of the diagnosis. So they do not produce symptoms until they grow large enough to compress or invade contagious structures.

Conclusion

ES-EWS is an aggressive tumor with high incidence of local recurrence and distant metastasis that's why is was given its poor prognosis characteristic. Multimodality treatment including surgical resection, chemotherapy and High dose radiotherapy will help in better survival rate.

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Extraskeletal Ewing sarcoma is an aggreesive tumor with high incidence of local recurrence and distant metastasis.

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They usully present as large masses at time of the disgnosis so they do not produce symptoms unitil they grow large to compress on adjacent organs

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Multimodality treatment is recommended in terms of surgical resection, chemotherapy and high dose radiotherapy.

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Early diagnosis of such rare tumor will help targeting it at early stage

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[1], [2], [3], [4]

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.

Primary thoracic synovial sarcomas: A case report

Primary pulmonary synovial sarcoma (SS) is a rare neoplasm. Its clinicoradiologic attributes are not yet well defined. We report the observation of a patient followed for primary pulmonary synovial sarcoma. We report the radio‐clinical features of this rare tumor.

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.

Benign rib tumors: a case series from tertiary care Centre of Nepal and review of literature

Rib tumors are rare. They can present with wide varieties of symptoms and differentiating benign from malignant lesions is challenging. A careful history and supporting investigations can help to reach the definite diagnosis. Surgical resection is the treatment of choice with excellent prognosis. A total of four patients were operated for the management of rib tumors over a period of 5 years at our institution. All four were benign lesions and included simple bone cyst, fibrous dysplasia with aneurysmal bone cyst, aneurysmal bone cyst and enchondroma. There were three male and one female. None of them is having recurrence till now. Surgical resection is the treatment of choice for benign rib tumors as it provides diagnostic and curative treatment.

Chest wall and diaphragm reconstruction; a technique not well established in literature - case report

INTRODUCTION

Regardless of its rarity, and indolent clinical course, chest wall tumor places high morbidity and burden on patients especially when invasion to a neighboring structure is found. Once detected, surgery is the cornerstone for treatment of such etiology combined with chemo-radiotherapy. In order to maintain intact respiratory function, chest wall reconstruction must be performed whenever resection is done. Herein, we present a case of chest wall tumor that necessitated three ribs and part of hemidiaphragm resection and reconstruction with optimal post-operative results.

CASE PRESENTATION

A 27-year-old male patient who had chest wall and diaphragm reconstruction for a chest wall Ewing sarcoma, using a single patch of expanded polytetrafluoroethylene (ePTFE) mesh with diaphragm implanted into the middle of the mesh. There were no immediate nor post-operative complications. The patient received post-operative radiotherapy with good functional and cosmetic results.

CONCLUSION

We present a novel and safe technique for combined chest wall and diaphragmatic resection following excision of an invading tumor while ensuring cosmesis and functionality of the ribcage as well as the diaphragm.

A 22-Year-Old Man With Back Pain, Dilated Veins Over Chest, and Mass in Right Atrium

CASE PRESENTATION

A 22-year-old nonsmoker male, without any previous comorbidity, presented with 4 months' history of right upper back pain. Pain was constant dull aching type, nonpleuritic, aggravated by lying on the right lateral side and partially relieved on taking analgesics. He then developed progressive dyspnea over 2 months and noticed dilated veins over his neck and front of chest. There was associated unintentional weight loss of 6 kg. There was no history of cough, expectoration, wheeze, or hemoptysis, nor any episodes of night sweats or fever.

Paraganglioma with highly malignant potential involving the rib - Case report and review of the literature

Paragangliomas are rare neuroendocrine tumors arising from paraganglion cells in sympathetic or parasympathetic chains, which may develop in the abdomen, chest, skull base, and neck. As paragangliomas have a wide range of imaging features, the diagnosis often requires tissue sampling. We present a unique case of a paraganglioma which originally presented as a rib tumor.

A 64-year-old male with right flank pain for 2 months’ was referred for a noncontrast renal colic CT. He was found to have a 3.7 × 3.5 cm soft tissue mass invading the left posterior 9th rib and paraspinal muscle. This was fluorodeoxyglucose F 18, (¹⁸F-FDG) avid, with no other distant metabolic activity. He underwent ultrasound-guided core biopsy which revealed a diagnosis of paraganglioma. A right thoracotomy with chest wall resection of 8, 9, and 10 ribs were subsequently performed. The tumor was removed along with a small portion of adherent lung. The tumor was positive for CD56, synaptophysin and chromogranin. S-100 highlighted occasional sustentacular cells, consistent with a pathologic diagnosis of a paraganglioma. The patient remains symptom free for 6 months’ after the operation.

Our case highlights that, when paragangliomas occur within the chest wall, they may present as a rib tumor and can mimic metastasis, myeloma or other primary neoplastic etiologies originating from ribs. Both imaging and pathologic diagnosis can be challenging.

Palpable Lumps after Mastectomy: Radiologic-Pathologic Review of Benign and Malignant Masses

Patients who have undergone mastectomy, with or without reconstruction, are not universally screened with mammography or US. Therefore, clinical breast examination by the physician and patient-detected palpable abnormalities are crucial for detecting breast cancer or recurrence. Diagnostic US is the first-line modality for evaluation of postmastectomy palpable masses, with occasional adjunct use of diagnostic mammography for confirming certain benign masses. In the setting of a negative initial imaging evaluation with continued clinical concern, diagnostic MRI may aid in improving sensitivity. Knowledge of the typical multimodality imaging appearances and locations of malignant palpable abnormalities-such as invasive carcinoma recurrence, cancer in residual breast tissue, radiation-induced sarcoma, and metastatic disease-is crucial in diagnosis and treatment of these entities. In addition, familiarity with the range of benign palpable postmastectomy processes-including fat necrosis, fat graft, seroma, granuloma, neuroma, fibrosis, and infection-may help avoid unnecessary biopsies and reassure patients. The authors review common and rare benign and malignant palpable masses in mastectomy patients, describe multimodality diagnostic imaging evaluation of each entity, review radiologic and pathologic correlation, and acquaint the radiologist with management when these findings are encountered. ^©RSNA, 2021.

"Multimodality imaging of the extrapleural space lesions"

Extrapleural space (EPS) is a potential space between the outer layer of the parietal pleura and the inner layer of the chest wall and the diaphragm. Many different pathologies including chronic inflammatory conditions, infections, trauma, neoplastic disease (both benign and malignant) as well as many infiltrative disorders can involve the EPS. It is one of the frequently overlooked entity on imaging due to relative lack of understanding of the anatomy and the imaging appearances of the diseases localized to this space. The knowledge of the EPS is essential for the radiologists as the pathologies which involve the EPS may require different treatment approach compared to pleural or parenchymal lung disease. Additionally, the EPS involvement may influence the staging and treatment planning for chest malignancies. In this review, we give an overview of the anatomy and various pathologies involving EPS, utility of different imaging modalities in the evaluation of EPS lesions with emphasis on cross sectional imaging and emerging technologies like spectral CT and its role in recognizing the imaging features which enable specific diagnosis of various pathologies.

Application of Polarization Sensitive-Optical Coherence Tomography to the Assessment of Phase Retardation in Subpleural Cancer in Rabbits

BACKGROUND

Polarization sensitive-optical coherence tomography (PS-OCT) provides the unique advantage of being able to measure the optical characteristics of tissues by using polarized light. Although the well-organized fibers of healthy muscle can change the polarization states of passing light, damaged tissue has different behaviors. There are studies on optical imaging methods applied to the respiratory organs; however, they are restricted to structural imaging. In particular, the intercostal muscle situated under the pleura is very challenging to visualize due to the difficulty of access.

METHOD

In this study, PS-OCT was used to identify subpleural cancer in male New Zealand white rabbits (3.2-3.4 kg) and to assess the phase retardation changes in normal and cancerous chest walls. VX2 cell suspension was injected between the intercostal muscle and parietal pleura and a tented area was observed by thoracic scope. A group of rabbits (n = 3) were sacrificed at day 7 after injection and another group (n = 3) at day 14.

RESULTS

In the PS-OCT images, pleura thickness changes and muscle damage were criteria to understand the stages of the disease. The results of image and phase retardation analysis matched well with the pathologic examinations.

CONCLUSION

We were able to visualize and analyze subpleural cancer by PS-OCT, which provided structural and functional information. The measured phase retardation could help to identify the margin of the tumor. For further studies, various approaches into other diseases using polarization light are expected to have positive results.

18F-FDG PET/CT of Double Expressor High-Grade B-Cell Lymphoma in an Isolated Chest Wall Mass

F-FDG PET/CT is now an integral part of management of high-grade B-cell lymphoma. It is used for staging, response evaluation, restaging, and surveillance. Although high-grade B-cell lymphoma most commonly presents with involvement of the lymph nodes, spleen, liver, and bone marrow, chest wall involvement is very rare. We present the staging F-FDG PET/CT findings in a case of an 82-year-old woman with double expressor high-grade B-cell lymphoma of isolated presternal anterior chest wall mass.

Primary Intrathoracic Sarcomas: A Review of Cross-sectional Imaging and Pathology

The most common sarcomas in the thorax are metastasis from an extrathoracic primary malignancy. Primary intrathoracic sarcomas are rare albeit aggressive malignancies that are diagnosed on histopathology. Although a few imaging characteristics have been described that are common to sarcomas, it is still a diagnosis of exclusion as other tumors are much more common. Like elsewhere, primary thoracic sarcomas are also classified according to their histologic features. They are a rare group of tumors that can arise from the mediastinal structures, lung, pleura, or chest wall. On imaging, differentiating these from more common malignancies like lung cancer is difficult and often requires multimodality workup and tissue sampling. A few sarcomas are very specific to their locations, such as angiosarcoma in the right atrium, leiomyosarcoma in the pulmonary artery, where imaging has high accuracy for the diagnosis. Despite being nonspecific in a majority of cases, imaging plays a pivotal role in determining the organ of origin, tumor extent, invasion of adjacent structures, and thus help to assess the surgical resectability. Although sarcomas arising from chest wall are the most common primary sarcomas in the chest, they are excluded from this review to focus only on primary intrathoracic sarcomas. The article provides a comprehensive imaging and pathology review of the rare primary intrathoracic sarcomas, including but not limited to angiosarcoma, Kaposi sarcoma, fibrosarcoma, malignant transformation of fibrous tumor of pleura, sarcomatoid mesothelioma, leiomyosarcoma, and malignant small round blue cell tumors.Key points:Primary intrathoracic sarcomas are rare but clinically important.Imaging helps to determine local extent, invasion, metastases and appropriate site/mode of biopsy.Role of pathology is paramount in diagnosis and guiding treatment based on immunogenetic/molecular typing.

Smooth Muscle Conditions of the Chest: A Clinical, Radiologic, and Pathologic Review

Smooth muscle conditions of the chest have diverse clinical and imaging manifestations and may involve nearly every thoracic structure. Differentiation among these conditions requires the integration of clinical, radiologic, and histopathologic data. Histologic examination in conjunction with immunohistochemistry is essential for differentiation from other spindle cell neoplastic mimics. Familiarity with these entities will ensure the inclusion of smooth muscle conditions in the differential diagnosis of thoracic soft tissue lesions and potentially guide the clinician in appropriate management. We review the clinical, imaging, and histopathologic features of thoracic smooth muscle-related conditions organized by the anatomic structures affected.

Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician

INTRODUCTION

Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics.

AREAS COVERED

Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years.

EXPERT OPINION

As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.

Chondrosarcoma of the Ribs

Chondrosarcoma is a unique kind of tumor that originates from the cartilage-producing neoplastic mesenchymal cells and appears in both the appendicular and atlantoaxial skeleton. It is the second most prevalent neoplastic bone tumor, with an occurrence of 0.79/100,000/year. The biological presentation of this cancer fluctuates extensively, depending on the grade and anatomical location. Since chondrosarcoma is predominantly resistant to conventional chemo- and radiation therapy, surgical resection remains the sole curative treatment, although at present new treatment modalities are under investigation.

Recognition of pulmonary pathology in a patient presenting with shoulder pain

BACKGROUND

. Shoulder pain is a common symptom of musculoskeletal disorder about the shoulder. However, shoulder pain can also be symptomatic of other non- musculoskeletal disease. Careful assessment of the clinical presentation is essential in differential diagnosis and decisions to treat or refer.

CASE DESCRIPTION

. A 56-year-old male preseted with shoulder pain and a previous diagnosis of subacromial impingement of the left shoulder. The shoulder pain increased with effort, was present at night making it difficult to sleep and became disabling for the patient in work and activities of daily living. In addition, the patient reported left thoracic pain and increasing episodes of dry coughing, shortness of breath, fever and unusual generalized fatigue. Physical examination did not reveal a musculoskeletal concern about the patient's shoulder. An increased body temperature was detected and when combined with auscultation and thorax percussion led the physiotherapist to hypothesize pulmonary involvement, later reinforced by the evocation of the patient's symptoms while measuring his peak expiratory flow.

DISCUSSION

. An underlyng serious pathology can be easily masked by shoulder pain. Physiotherapists need to consider that when a patient presents with a cluster of history and physical examination findings that are negative for mechanical shoulder pain, other systems must be considered as the source of presenting symptoms. Through the identification of risk factors and red flag findings, the physiotherapist can identify the need for referral.

Evaluation of a two-image technique consisting of an axial and a coronal image generated by using the rib-flattening application: effect on reading time and diagnostic validity

Background/aim

When reading a chest CT, a radiologist needs to evaluate each rib one by one due to complex curvy shape, which makes reporting a tiresome and time-consuming task. A new curved planar reformat application that flattens ribs on a single plane may find a place in the radiology reporting room. This study aimed to evaluate the effect of a two-image set created by using the rib-flattening application on the performance of a radiologist in detecting sclerotic rib lesions in cancer patients.

Materials and methods

The local Institutional Review Board approved this retrospective study. Two radiologists with different experience levels reviewed chest CT examinations of 106 patients (76 men, 30 women). We divided the patients into group A (n = 54), reviewed by a standard method, and group B (n = 52), reviewed by a standard method and the two-image set created on the rib-flattening application. Reading times, validity indices, and agreement levels with reference data were evaluated for both readers.

Results

The median reading time of the junior examiner significantly decreased with the rib-flattening method (160.5 s vs. 70.0 s; P < 0.001). Diagnostic indices of the senior reader were improved significantly at per patient level (group A, AUC: 0.867; group B, AUC: 0.982; P = 0.046). The new method showed better agreement levels (kappa: 0.69 to 0.96) than the general method (kappa: 0.53 to 0.91).

Conclusion

Based on improved agreement levels, reading times, and diagnostic validity indices we conclude that a two-image set consisting of an axial and a coronal flattened-rib image may be used in conjunction with an ordinary exam.

Vascular chest wall lesion mimicking a breast tumor on screening mammograms: Report of a case

Vascular lesions in the chest wall muscles are extremely rare and can cause diagnostic difficulties on screening mammograms. We describe a case of venous malformation of the pectoralis muscle, diagnosed during routine screening, in a 60-year-old woman. The mammograms showed a mass over the chest wall, projecting in the breast parenchyma. The ultrasound was not diagnostic. The definite diagnosis was made using MRI, and to our knowledge, only 1 similar case has been reported so far, but this is the only asymptomatic case depicted during screening services.

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.

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.

MR Imaging of Primary Chest Wall Neoplasms

Primary chest wall neoplasms are uncommon and comprise a heterogeneous group of lesions that may be challenging to classify and diagnose. These tumors may be primary or secondary, malignant or benign, and arise from cartilaginous/osseous structures or soft tissues. The role of magnetic resonance (MR) imaging in the evaluation of chest wall tumors continues to expand given its superior soft tissue contrast relative to computed tomography. MR imaging can facilitate differentiation of neoplasms from normal chest wall structures and other disease processes due to infection and inflammation, and can fully characterize abnormalities by demonstrating the various internal components of complex lesions. It is important that radiologists be able to identify key features of primary chest wall neoplasms on MR imaging to provide focused differential diagnoses and guide patient management.

Malignant pleural mesothelioma: diagnostic value of medical thoracoscopy and long-term prognostic analysis

BACKGROUND

Malignant pleural mesothelioma (MPM) is marked by its difficult diagnosis and poor prognosis. Medical thoracoscopy (MT) is an effective and safe procedure for the diagnosis of exudative pleural effusions and many factors associated with poor prognosis of MPM. We conducted this study to investigate the value of MT for diagnosing of MPM and to identify prognostic factors for MPM patients.

METHODS

From July 2005 through June 2014, a total of 833 patients with undiagnosed pleural effusions underwent MT and pleural biopsies were taken. Clinical data of all patients with MPM were retrospectively analyzed, and those with complete follow-up data were analyzed for prognostic factors.

RESULTS

Eventually, MPM was the final diagnosis in 40 patients. Diagnostic efficiency of MT for MPM was 87.5%, since diagnosis of MPM failed to be established in 5 patients during the initial MT. Median survival was 17.1 mo (95% confidence interval: 13.6-20.7 mo). MT findings of pleural adhesion and plaques were adverse prognostic factors for MPM. In addition, old age, male gender, smoking history, histological type, poor staging, no treatment, low total protein level in pleural fluid, and computed tomographic findings such as pulmonary consolidation or infiltration, mediastinal lymphopathy, pulmonary mass or nodules, and pleural nodularity were also poor prognostic factors for MPM.

CONCLUSIONS

MT is safe with a high positive rate in the diagnosis of MPM, and pleural adhesion and plaques seen under MT may be the adverse prognostic factors for MPM. Multiple clinical characteristics can affect the survival of MPM patients.

Chest wall - a structure underestimated in ultrasonography. Part III: Neoplastic lesions

Chest wall neoplasms mainly include malignancies, metastatic in particular. Differential diagnosis should include clinical data; tumor location, extent, delineation; the degree of homogeneity; the presence of calcifications; the nature of bone destruction and the degree of vascularization. The aim of the paper is to present both the benefits and limitations of ultrasound for the diagnosis of chest wall neoplasms. The neoplastic process may be limited to the chest wall; it may spread from the chest wall into the intrathoracic structures or spread from the inside of the chest towards the chest wall. Benign tumors basically originate from vessels, nerves, bones, cartilage and soft tissues. In this paper, we briefly discuss malformations of blood and lymphatic vessels, glomus tumor as well as neurogenic tumors originating in the thoracic branches of the spinal nerves and the autonomic visceral system. Metastases, particularly lung, breast, kidney cancer, melanoma and prostate cancer, are predominant tumors of the osteocartilaginous structures of the chest wall. Plasma cell myeloma is also relatively common. The vast majority of these lesions are osteolytic, which is reflected in ultrasound as irregular cortical defects. Osteoblastic foci result only in irregular outline of the bone surface. Lipomas are the most common neoplasms of the chest wall soft tissue. Elastofibroma is another tumor with characteristic echostructure. Desmoid fibromatosis, which is considered to be a benign lesion with local aggressivity and recurrences after surgical resection, represents an interesting tumor form the clinical point of view. Ultrasonography represents an optimal tool for the monitoring of different biopsies of pathological lesions located in the chest wall. Based on our experiences and literature data, this method should be considered as a preliminary diagnosis of patients with chest wall tumors.

Imaging in Sternal Tumours: A Pictorial Review

The sternum is an uncommon site for neoplastic involvement and metastases are far commoner than primary neoplasms. Of the primary tumours, malignant lesions are more frequent than the benign lesions. Early diagnosis and treatment is prudent in such neoplasms not only to halt disease progression but also to prevent circulatory compromise resulting from the mass effect on the mediastinum. Sound knowledge of neoplasms affecting the sternum and their imaging appearance is essential to arrive at an early diagnosis and also to obviate biopsy in cases with classical imaging findings. Neoplastic involvement of the sternum is extremely unusual and should be considered malignant unless proven otherwise. Imaging may help in arriving at the diagnosis of these lesions, together with other factors such as patient's age, type of lesion (lytic/sclerotic or mixed), matrix mineralization, multiplicity and involvement of other sites.

Nodular Fasciitis of the Posterior Chest Wall With Bone Invasion Mimicking a Malignant Neoplasm

Nodular fasciitis is a self-limiting benign fibroblastic/myofibroblastic proliferation, which typically presents as a rapidly growing mass resembling an aggressive lesion clinically. It can also mimic a sarcoma histologically, hence the frequent characterization as "pseudosarcoma." We describe a case of a 53-year-old man who presented with a posterior chest wall mass that on imaging showed erosion into the adjacent ribs. After resection, the diagnosis of nodular fasciitis was rendered. Bone erosion by nodular fasciitis is extremely rare and can resemble a malignant neoplasm radiologically.

Solitary Fibrous Tumors of Chest: Another Look with the Oncologic Perspective

Solitary fibrous tumors are mesenchymal lesions that arise at a variety of sites, most commonly the pleura. Most patients are asymptomatic at diagnosis, with lesions being detected incidentally. Nevertheless, some patients present due to symptoms from local tumor compression (eg. of the airways and pulmonary parenchyma). Furthermore, radiological methods are not always conclusive in making a diagnosis, and thus, pathological analysis is often required. In the past three decades, immunohistochemical techniques have provided a gold standard in solitary fibrous tumor diagnosis. The signature marker of solitary fibrous tumor is the presence of the NAB2-STAT6 fusion that can be reliably detected with a STAT6 antibody. While solitary fibrous tumors are most often benign, they can be malignant in 10-20% of the cases. Unfortunately, histological parameters are not always predictive of benign vs malignant solitary fibrous tumors. As solitary fibrous tumors are generally regarded as relatively chemoresistant tumors; treatment is often limited to localized treatment modalities. The optimal treatment of solitary fibrous tumors appears to be complete surgical resection for both primary and local recurrent disease. However, in cases of suboptimal resection, large disease burden, or advanced recurrence, a multidisciplinary approach may be preferable. Specifically, radiotherapy for inoperable local disease can provide palliation/shrinkage. Given their sometimes -unpredictable and often- protracted clinical course, long-term follow-up post-resection is recommended.

Mini review: surgical management of primary chest wall tumors

Primary chest wall tumors (PCWTs) are relatively rare entities, and their clinical characteristics as well as appropriate treatments are not fully known. Previously reported studies, including ours, are reviewed here, taking into account the clinical approach and findings in Japan for the diagnosis, distribution of histological types, surgical procedures, and prognosis of these entities. Surgery for PCWTs comprised that approximately 0.7 % of surgeries in 2012 in Japan and 28.3 % of PCWTs were malignant with an extremely low rate of mortality within 30 days from surgery. Surgical biopsy is recommended for the differential diagnosis of chest wall tumors to determine if they are primary, metastatic, benign, or malignant lesions. Of the 297 PCWT cases reported in nine published studies, neurogenic tumors were the most common benign PCWT, and chondrosarcoma was the most common malignant PCWT. Reconstruction of the resected chest wall was performed for 41.3 % of cases, and the materials used were e-PTFE or polypropylene. The prognosis of patients with benign tumors is usually good if complete resection is achieved; however, the 5-year recurrence rate and disease-related mortality were approximately 22.5 and 18.1 %, respectively, for patients with malignant tumors. Surgery for PCWTs is safe; however, surgical treatment for patients with malignant PCWTs remains challenging, and multimodal treatments for each histological tumor type should be considered.