Chest Wall Tumors part2.pdf
Chest Wall Tumors part2.pdf
EDUCATION EXHIBIT 1491
Chest Wall Tumors:
Radiologic Findings
and Pathologic
Correlation
Part 2. Malignant Tumors1
ONLINE-ONLY
CME
See www.rsna
.org/education
/rg_cme.html.
LEARNING
OBJECTIVES
After reading this
article and taking
the test, the reader
will be able to:
Recognize the im-
aging signs that may
be helpful in achiev-
ing differential diag-
nosis of malignant
chest wall tumors.
Describe the indi-
vidual pathologic
entities and processes
involved in the most
frequently occurring
malignant chest wall
tumors.
Identify the charac-
teristic imaging find-
ings in major malig-
nant chest wall tu-
mors.
Ukihide Tateishi, MD, PhD ● Gregory W. Gladish, MD ● Masahiko
Kusumoto, MD, PhD ● Tadashi Hasegawa, MD, PhD ● Ryohei
Yokoyama, MD ● Ryosuke Tsuchiya, MD, PhD ● Noriyuki
Moriyama, MD, PhD
Malignant chest wall tumors are classified into eight main diagnostic
categories: muscular, vascular, fibrous and fibrohistiocytic, peripheral
nerve, osseous and cartilaginous, adipose, hematologic, and cutaneous.
However, there are malignant tumors that arise in the chest wall and
that do not fit well in any of these categories (eg, Ewing sarcoma and
synovial sarcoma). Malignant chest wall tumors typically manifest as
painful, rapidly growing, large palpable masses. Chest radiography, the
technique most often used for initial evaluation, can be helpful for de-
tecting cortical destruction. However, computed tomography is more
sensitive than chest radiography for detecting calcified tumor matrix
and cortical destruction. Magnetic resonance imaging often allows
more accurate delineation and localization of the tumor and is helpful
for determining the presence and extent of tumor invasion and for tis-
sue characterization. Although the imaging features of many malignant
chest wall tumors are nonspecific, knowledge of the typical radiologic
manifestations of these tumors often enables their differentiation from
benign chest wall tumors and occasionally allows a specific diagnosis to
be suggested. The article reviews the clinical and imaging features of
the most common malignant chest wall tumors and presents images
collected at a single cancer referral center.
©RSNA, 2003
Abbreviations: AIDS acquired immune deficiency syndrome, MFH malignant fibrous histiocytoma
Index terms: Thorax, CT, 470.1211 ● Thorax, MR, 470.12141, 470.12143 ● Thorax, neoplasms, 470.32, 470.34, 470.37 ● Thorax, radiography,
470.11
RadioGraphics 2003; 23:1491–1508 ● Published online 10.1148/rg.236015527
1From the Divisions of Diagnostic Radiology (U.T., M.K., N.M.), Pathology (T.H.), Orthopedics (R.Y.), and Thoracic Surgery (R.T.), National
Cancer Center Hospital and Institute, 5–1-1, Tsukiji, Chuo-Ku, 104-0045 Tokyo, Japan; Division of Diagnostic Imaging, M. D. Anderson Cancer
Center, Houston, Tex (G.W.G.); and Division of Orthopedics, National Kyushu Cancer Center, Fukuoka, Japan (R.Y.). Recipient of a Cum Laude
award for an education exhibit at the 2001 RSNA scientific assembly. Received December 20, 2001; revision requested February 22, 2002; revision
received April 22, 2003 and accepted April 25. Supported in part by grant for Scientific Research Expenses for Health and Welfare Programs, the
Foundation for the Promotion of Cancer Research, and 2nd-term Comprehensive 10-year Strategy for Cancer Control. Address correspondence to
U.T. (e-mail: utateish@ncc.go.jp).
©RSNA, 2003
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Introduction
Primary malignant chest wall tumors typically
manifest as large, palpable, rapidly growing
masses (1). Chest wall pain is a common symp-
tom, and most patients with malignant chest wall
tumors are symptomatic, unlike patients with be-
nign chest wall tumors (1–3). Malignant chest
wall tumors are classified into eight main diagnos-
tic categories: muscular, vascular, fibrous and
fibrohistiocytic, peripheral nerve, osseous and
cartilaginous, adipose, hematologic, and cutane-
ous. Although the imaging features of many ma-
lignant chest wall tumors are nonspecific, knowl-
edge of the typical radiologic manifestations of
these tumors often enables their differentiation
from benign chest wall tumors and occasionally
allows a specific diagnosis to be suggested. This
article reviews the clinical and imaging features of
the most frequently occurring malignant chest
wall tumors, emphasizing the features that can be
most useful in suggesting a specific diagnosis and
differentiating benign from malignant tumors
(Tables 1, 2).
Imaging Techniques
and Findings: An Overview
Chest radiography often is performed at initial
evaluation of a clinically suspected malignant
chest wall tumor. Although this technique is use-
ful for detecting cortical destruction—a finding
indicative of extracompartmental extension—it
does not allow comprehensive assessment of the
tumor. Computed tomography (CT) is more sen-
sitive than chest radiography for detecting calci-
fied tumor matrix and cortical destruction. Fur-
thermore, magnetic resonance (MR) imaging,
which has a multiplanar capability and offers su-
perior spatial resolution, can provide additional
information regarding the extent of the tumor, as
well as tissue characterization.
Muscular Tumors
Leiomyosarcoma
Cutaneous and subcutaneous leiomyosarcomas
account for less than 5% of superficial soft-tissue
sarcomas. These tumors are frequently painful
and typically occur in adulthood, most commonly
Table 1
Radiologic Differentiation of Malignant Chest Wall Tumors
Imaging Finding Tumor Type
Fat component Liposarcoma
Calcification
Skeletal
Rings and arcs Chondrosarcoma
Flocculent or stippled Chondrosarcoma
Centrally dense Osteosarcoma
Extraskeletal
Heterogeneous Ganglioneuroblastoma or neuroblastoma
Speckled Proximal-type epithelioid sarcoma
Diffuse osteolytic change Myeloma
Ill-defined mass
Eccentric growth, in children and
young adults
Ewing sarcoma
Fluid-fluid levels and calcification,
in adolescents and adults
Synovial sarcoma
Chronic lymphedema Angiosarcoma
Infiltrative growth Malignant lymphoma
Nonspecific findings Leiomyosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma,
aggressive fibromatosis, malignant peripheral nerve sheath tumor, or
dermatofibrosarcoma protuberans
1492 November-December 2003 RG f Volume 23 ● Number 6
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RG f Volume 23 ● Number 6 Tateishi et al 1493
R
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ed
iff
er
en
tia
te
d
Sp
in
dl
e
ce
ll
sa
rc
om
a
co
m
-
bi
ne
d
w
ith
w
el
l-
di
ff
er
en
ti-
at
ed
lip
os
ar
co
m
a
So
ft
-t
is
su
e
an
d
fa
tc
om
po
-
ne
nt
s
T
1-
w
ei
gh
te
d
im
ag
es
:a
re
as
of
hi
gh
si
gn
al
in
te
ns
ity
in
te
rs
pe
rs
ed
w
ith
lo
w
si
gn
al
in
te
ns
ity
;T
2-
w
ei
gh
te
d
im
ag
es
:a
re
as
of
lo
w
si
gn
al
in
te
ns
ity
in
te
rs
pe
rs
ed
w
ith
ar
ea
s
of
hi
gh
si
gn
al
in
te
ns
ity
H
et
er
og
en
eo
us
en
ha
nc
e-
m
en
t
H
em
at
ol
og
ic
M
al
ig
na
nt
ly
m
-
ph
om
a
A
du
lth
oo
d
U
nc
om
m
on
A
ss
oc
ia
tio
n
w
ith
A
ID
S,
m
et
al
-
lic
im
pl
an
t,
im
m
un
os
up
-
pr
es
si
on
N
o
ca
lc
ifi
ca
tio
n
T
1-
w
ei
gh
te
d
im
ag
es
:l
ow
si
gn
al
in
te
ns
ity
;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
n-
si
ty
Il
l-
de
fin
ed
co
nt
ou
rs
;i
nfi
l-
tr
at
iv
e
gr
ow
th
pa
tt
er
n;
va
ri
ab
le
en
ha
nc
em
en
t
(c
on
tin
ue
d)
1494 November-December 2003 RG f Volume 23 ● Number 6
R
a
d
io
G
ra
p
h
ic
s
T
ab
le
2
Im
ag
in
g
F
in
d
in
gs
w
it
h
C
li
n
ic
al
an
d
P
at
h
ol
og
ic
C
or
re
la
ti
on
in
M
al
ig
n
an
t
C
h
es
t
W
al
lT
u
m
or
s
T
um
or
T
is
su
e
an
d
T
yp
e
P
at
ie
nt
A
ge
F
re
qu
en
cy
of
O
cc
ur
re
nc
e
C
lin
ic
al
an
d
L
ab
or
at
or
y
F
in
di
ng
s
Im
ag
in
g
F
in
di
ng
s
C
T
M
R
Im
ag
in
g
G
en
er
al
So
lit
ar
y
m
ye
lo
m
a
O
ss
eo
us
A
du
lth
oo
d
C
om
m
on
M
ay
pr
og
re
ss
to
m
ul
tip
le
m
y-
el
om
a
C
al
ci
fic
at
io
n;
ra
re
sc
le
ro
si
s
(c
au
se
d
by
fr
ac
tu
re
,i
r-
ra
di
at
io
n,
or
ch
em
o-
th
er
ap
y)
T
1-
w
ei
gh
te
d
im
ag
es
:l
ow
si
gn
al
in
te
ns
ity
;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
n-
si
ty
M
ul
tic
ys
tic
ex
pa
ns
ile
m
as
s
or
os
te
ol
yt
ic
fo
cu
s
w
ith
ou
te
xp
an
si
on
;l
o-
ca
tio
n
in
ve
rt
eb
ra
lc
ol
-
um
n,
ri
bs
,o
r
cl
av
ic
le
s
E
xt
ra
os
se
ou
s
A
du
lth
oo
d
C
om
m
on
P
ro
gr
es
se
s
le
ss
fr
eq
ue
nt
ly
to
m
ul
tip
le
m
ye
lo
m
a
N
o
ca
lc
ifi
ca
tio
n
T
1-
w
ei
gh
te
d
im
ag
es
:l
ow
si
gn
al
in
te
ns
ity
;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
n-
si
ty
N
on
sp
ec
ifi
c
so
ft
-t
is
su
e
m
as
s
M
ul
tip
le
m
y-
el
om
a
A
du
lth
oo
d
C
om
m
on
M
ul
tip
le
ar
ea
s
of
os
te
ol
ys
is
an
d
pl
as
m
a
ce
ll
pr
ol
ife
ra
tio
n
V
ar
ia
bl
e
ca
lc
ifi
ca
tio
n
T
1-
w
ei
gh
te
d
im
ag
es
:l
ow
si
gn
al
in
te
ns
ity
;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
n-
si
ty
M
ul
tip
le
os
te
ol
yt
ic
fo
ci
w
ith
di
sc
re
te
m
ar
gi
ns
C
ut
an
eo
us
D
er
m
at
ofi
br
os
ar
-
co
m
a
pr
ot
ub
er
an
s
A
do
le
sc
en
ce
U
nc
om
m
on
P
al
pa
bl
e
m
as
s;
fr
eq
ue
nt
re
cu
r-
re
nc
e
w
ith
in
3
ye
ar
s
of
in
iti
al
tr
ea
tm
en
t
W
el
l-
de
fin
ed
su
bc
ut
an
e-
ou
s
no
du
le
w
ith
at
te
nu
-
at
io
n
of
m
us
cl
e
or
sl
ig
ht
ly
hi
gh
er
;m
od
er
-
at
e
en
ha
nc
em
en
t
T
1-
w
ei
gh
te
d
im
ag
es
:l
ow
si
gn
al
in
te
ns
ity
;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
n-
si
ty
V
ar
ia
bl
e
co
nt
ou
rs
;m
ay
be
lo
ca
lly
in
va
si
ve
;m
ay
in
cl
ud
e
he
te
ro
ge
ne
ou
s
fo
ci
du
e
to
he
m
or
rh
ag
e,
m
yx
oi
d
ch
an
ge
,o
r
ne
-
cr
os
is
O
th
er
tu
m
or
s
E
w
in
g
sa
rc
om
a
C
hi
ld
ho
od
to
ea
rl
y
ad
ul
th
oo
d
R
ar
e
11
;2
2
ch
ro
m
os
om
al
tr
an
sl
oc
a-
tio
n
R
ar
e
ca
lc
ifi
ca
tio
n
T
1-
w
ei
gh
te
d
im
ag
es
:s
ig
na
li
nt
en
si
ty
of
m
us
cl
e
or
hi
gh
er
;T
2-
w
ei
gh
te
d
im
ag
es
:
hi
gh
si
gn
al
in
te
ns
ity
Il
l-
de
fin
ed
co
nt
ou
rs
;e
c-
ce
nt
ri
c
gr
ow
th
;h
et
er
o-
ge
ne
ou
s
en
ha
nc
em
en
t
Sy
no
vi
al
sa
rc
om
a
A
do
le
sc
en
ce
to
ea
rl
y
ad
ul
th
oo
d
R
ar
e
X
;1
8
ch
ro
m
os
om
al
tr
an
sl
oc
a-
tio
n
C
al
ci
fic
at
io
n
(i
n
20
%
–
30
%
of
pa
tie
nt
s)
T
1-
w
ei
gh
te
d
im
ag
es
:s
ig
na
li
nt
en
si
ty
of
m
us
cl
e;
T
2-
w
ei
gh
te
d
im
ag
es
:t
ri
pl
e-
si
gn
al
-i
nt
en
si
ty
pa
tt
er
n
in
la
rg
e
tu
m
or
s
(3
3%
of
pa
tie
nt
s)
;fl
ui
d-
flu
id
le
ve
ls
(1
5%
–2
5%
of
pa
tie
nt
s)
Il
l-
de
fin
ed
co
nt
ou
rs
;l
oc
a-
tio
n
ne
ar
jo
in
t;
se
pt
a-
tio
n
in
la
rg
e
tu
m
or
s
P
ro
xi
m
al
-t
yp
e
ep
i-
th
el
io
id
sa
rc
om
a
A
do
le
sc
en
ce
to
ea
rl
y
ad
ul
th
oo
d
R
ar
e
L
es
io
n
m
ay
be
su
bc
ut
an
eo
us
or
de
ep
se
at
ed
O
ss
ifi
ca
tio
n
or
sp
ec
kl
ed
ca
lc
ifi
ca
tio
n
(i
n
20
%
–
30
%
of
pa
tie
nt
s)
T
1-
w
ei
gh
te
d
im
ag
es
:s
ig
na
li
nt
en
si
ty
of
m
us
cl
e;
T
2-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
g-
na
li
nt
en
si
ty
M
ul
tin
od
ul
ar
so
ft
-t
is
su
e
le
si
on
;h
et
er
og
en
eo
us
en
ha
nc
em
en
t;
no
da
l
m
et
as
ta
si
s;
at
ta
ch
m
en
t
to
te
nd
on
or
fa
sc
ia
N
ot
e.
—
N
D
no
da
ta
av
ai
la
bl
e.
*T
yp
ic
al
pa
ti
en
t
ag
e
at
di
ag
no
si
s.
RG f Volume 23 ● Number 6 Tateishi et al 1495
R
a
d
io
G
ra
p
h
ic
s
...
