Chest Wall Tumors part1.pdf
Chest Wall Tumors part1.pdf
EDUCATION EXHIBIT 1477
Chest Wall Tumors:
Radiologic Findings
and Pathologic
Correlation
Part 1. Benign 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:
Identify the imag-
ing techniques that
are most useful for
localizing and char-
acterizing benign tu-
mors of the chest
wall.
Describe the char-
acteristic imaging
findings in the most
prevalent benign
chest wall tumors.
Recognize imaging
signs that facilitate
differential diagnosis
and appropriate
management of be-
nign 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
Benign chest wall tumors are uncommon lesions that originate from
blood vessels, nerves, bone, cartilage, or fat. Chest radiography is an
important technique for evaluation of such tumors, especially those
that originate from bone, because it can depict mineralization and thus
indicate the diagnosis. Computed tomography (CT) and magnetic
resonance (MR) imaging are helpful in further delineating the location
and extent of the tumor and in identifying tumor tissues and types. Al-
though the radiologic manifestations of benign and malignant chest
wall tumors frequently overlap, differences in characteristic location
and appearance occasionally allow a differential diagnosis to be made
with confidence. Such features include the presence of mature fat tis-
sue with little or no septation (lipoma), the presence of phleboliths and
characteristic vascular enhancement (cavernous hemangioma), evi-
dence of neural origin combined with a targetlike appearance on MR
images (neurofibroma), well-defined continuity of cortical and medul-
lary bone with the site of origin (osteochondroma), or fusiform expan-
sion and ground-glass matrix (fibrous dysplasia). Both aneurysmal
bone cysts and giant cell tumors typically manifest as expansile osteo-
lytic lesions and occasionally show fluid-fluid levels suggestive of diag-
nosis.
©RSNA, 2003
Index terms: Ribs, neoplasms, 471.30 ● Thorax, CT, 470.1211 ● Thorax, MR, 470.12141, 470.12143 ● Thorax, neoplasms, 470.31, 470.36, 470.85
Thorax, radiography, 470.11
RadioGraphics 2003; 23:1477–1490 ● Published online 10.1148/rg.236015526
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; final revi-
sion 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
Benign chest wall tumors, which may be of vascu-
lar, peripheral nerve, osseous, cartilaginous, or
adipose tissue origin, are relatively uncommon,
and few research studies of this group of tumors
have been reported. Radiologic imaging is impor-
tant in the assessment of these tumors, particu-
larly for determining anatomic origin and extent,
response to therapy, and recurrence (1). Al-
though the imaging features of many of these le-
sions are nonspecific, the combination of imaging
appearance, location, and clinical information
also may suggest a diagnosis (Tables 1, 2). In this
article, we survey the clinical manifestations and
imaging appearances of the most frequently oc-
curring tumor types, including cavernous heman-
gioma, glomus tumor, schwannoma, neurofi-
broma, ganglioneuroma, paraganglioma, osteo-
chondroma, aneurysmal bone cyst, fibrous
dysplasia, ossifying fibromyxoid tumor, chondro-
myxoid fibroma, lipoma, and spindle cell lipoma.
We describe the imaging techniques that are most
widely used for evaluating and localizing these
tumors and detail the imaging findings common
to tumors of each type, giving particular attention
to findings that may contribute to differential di-
agnosis.
Overview of Imaging
Techniques and Findings
Benign chest wall tumors typically manifest as
slow-growing, palpable masses in asymptomatic
patients. The slow growth rate that typifies most
benign chest wall tumors is evidenced on radio-
logic images by well-defined tissue planes and
sometimes by pressure erosions on adjacent bone.
Chest radiography can be used to determine
the location, size, and growth rate of the mass, as
well as to detect calcification, ossification, or bone
involvement (2). However, the high-kilovoltage
radiographic technique used at chest imaging is
not optimal for assessing soft-tissue calcification,
bone, or tumor matrix. The low-kilovoltage tech-
nique used for bone radiography can more accu-
rately define soft-tissue planes, particularly in fat-
containing tumors such as lipomas. Low-kilovolt-
age radiographs also more accurately delineate
calcifications.
Computed tomography (CT) enables more
accurate assessment of tumor morphology, com-
position, location, and extent (1,3). When used
with contrast material, CT also can provide an
indication of the vascularity of a tumor. When the
relevant anatomy is poorly depicted on axial im-
ages—as occurs, for example, in lesions that are
located parallel to the ribs or in the supraclavic-
ular region—the CT scan may be acquired with
an angled gantry or a thin-section breath-hold
technique and multiplanar reformations to clarify
anatomic relationships.
Table 1
Radiologic Differentiation of Benign Chest Wall Tumors
Imaging Finding Tumor Type
Attenuation or signal intensity of fat Lipoma
Calcification
Skeletal
Amorphous contours Fibrous dysplasia
Cartilaginous apical cap Osteochondroma
Extraskeletal, punctate Cavernous hemangioma
Cortical thinning, fluid-fluid levels Aneurysmal bone cyst or giant cell tumor
Cortical expansion, sclerotic band Ossifying fibromyxoid tumor or chondro-
myxoid fibroma
Rib erosion, well-defined contours,
extraskeletal location
Schwannoma or neurofibroma
Location at costochondral junction Osteochondroma
Location in paravertebral region Ganglioneuroma or paraganglioma
Location in shoulder region Spindle cell lipoma
1478 November-December 2003 RG f Volume 23 ● Number 6
R
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RG f Volume 23 ● Number 6 Tateishi et al 1479
R
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T
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xp
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G
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ar
ly
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oo
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om
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or
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la
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or
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ca
lt
hi
nn
in
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te
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te
ns
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2-
w
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gh
te
d
im
ag
es
:
hi
gh
si
gn
al
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te
ns
it
y;
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id
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ui
d
le
ve
ls
(l
es
s
co
m
m
on
th
an
in
an
-
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ry
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al
bo
ne
cy
st
)
E
cc
en
tr
ic
gr
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th
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su
al
ly
so
lit
ar
y
bu
t
m
ay
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cu
r
in
m
ul
ti
pl
es
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ho
nd
ro
m
yx
oi
d
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ro
m
a
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ar
ly
ad
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t-
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ar
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at
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ri
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in
e,
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ap
ul
a
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ba
nd
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2-
w
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gh
te
d
im
ag
es
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ig
h
si
gn
al
in
te
ns
it
y
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xp
an
si
le
;d
if
fu
se
or
he
te
r-
og
en
eo
us
en
ha
nc
em
en
t
A
di
po
se
L
ip
om
a
A
du
lt
ho
od
C
om
m
on
D
ee
p
so
ft
-t
is
su
e
le
si
on
;
m
os
t
fr
eq
ue
nt
in
th
e
ob
es
e
A
tt
en
ua
ti
on
of
fa
t;
sl
ig
ht
ly
en
ha
nc
-
in
g
se
pt
a
T
1-
w
ei
gh
te
d
im
ag
es
:h
ig
h
si
gn
al
in
te
ns
it
y
(l
ow
-s
ig
na
l-
in
te
ns
it
y
se
pt
a)
;T
2-
w
ei
gh
te
d
im
ag
es
:
hi
gh
si
gn
al
in
te
ns
it
y
W
el
l-
de
fin
ed
co
nt
ou
rs
;
in
te
rn
al
ho
m
og
en
ei
ty
an
d
no
en
ha
nc
em
en
t
un
le
ss
se
pt
a
ar
e
pr
es
en
t
S
pi
nd
le
ce
ll
li-
po
m
a
A
du
lt
ho
od
U
nc
om
m
on
S
ub
cu
ta
ne
ou
s
lo
ca
ti
on
in
ne
ck
or
sh
ou
ld
er
re
-
gi
on
;s
lo
w
gr
ow
th
;
m
os
t
fr
eq
ue
nt
in
m
en
N
A
T
1-
w
ei
gh
te
d
im
ag
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1480 November-December 2003 RG f Volume 23 ● Number 6
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Magnetic resonance (MR) imaging is the pre-
ferred modality for the evaluation of chest wall
tumors. The superior spatial resolution afforded
by MR imaging with the administration of con-
trast material often enables accurate characteriza-
tion of the tumor tissue and extent, including dif-
ferentiation from adjacent areas of inflammation.
Meticulous attention to technique is necessary for
optimal MR imaging. Standard spin-echo and
fast spin-echo sequences are satisfactory for most
evaluations, but the use of peripheral cardiac gat-
ing and respiratory compensation can reduce mo-
tion artifacts that often degrade MR images of the
thorax. Prone positioning of the patient can lessen
the occurrence of respiratory artifacts on images
of anterior chest wall tumors. Surface coils are
useful for obtaining detailed images of superficial
chest wall lesions, whereas a dedicated torso coil
should be used to optimize image quality for tu-
mors with greater intrathoracic extent.
Vascular Tumors
Cavernous Hemangioma
Cavernous hemangiomas, which are among the
least common benign chest wall masses, consist of
dilated, tortuous, thin-walled vessels. They are
typically cutaneous in location, large, and poorly
circumscribed, and they can be locally destruc-
tive. Noncutaneous location is uncommon, with a
reported frequency of 0.8% among all benign vas-
cular lesions (4) (Fig 1).
Cavernous hemangiomas typically manifest at
birth or before the age of 30 years. Plain chest
radiographs may show a soft-tissue mass, which
occasionally is associated with pressure erosion on
adjacent bone. CT is more sensitive than plain
radiography in detecting phleboliths, which are
present in approximately 30% of cavernous hem-
angiomas (5). CT scans show a soft-tissue mass
with heterogeneous low levels of attenuation due
to the fatty, fibrous, and vascular tissue elements
of the mass. T1- and T2-weighted MR images
typically reveal areas of high signal intensity in the
mass. On T1-weighted images, intramuscular
cavernous hemangiomas manifest as poorly mar-
ginated masses with signal intensity similar to that
of skeletal muscle. Wispy or coarse linear areas of
high signal intensity are common and thought to
be caused in part by the presence of stagnant
Figure 1. Cavernous hemangioma in a 46-year-old man. (a) Axial T1-weighted (repeti-
tion time msec/echo time msec 600/12) magnetic resonance (MR) image obtained with a
surface coil at the level of the liver (L) shows an ill-defined soft-tissue mass in the right chest
wall. The tumor appears as an area of heterogeneous hyperintense signal relative to the signal
intensity of adjacent muscle (arrows). (b) Axial gadolinium-enhanced T1-weighted (600/12)
fat-suppressed MR image shows heterogeneous enhancement and distended vessels (arrow)
in the tumor.
RG f Volume 23 ● Number 6 Tateishi et al 1481
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