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Malignant chest wall neoplasms of bone and cartilage: a pictorial review of CT and MR findings
P O’SULLIVAN, FFR, RCSI, 1H O’DWYER, N L MULLER, MD, PhD, FRCR(C)
P L MUNK,
Departments of 1Radiology and 2Anatomical Pathology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
ABSTRACT. Malignant tumours of the chest wall are uncommon. The purpose of this pictorial essay is to describe the CT and MRI findings of malignant neoplasms affecting the bony skeleton of the chest wall and the costal cartilages. The most common primary malignant neoplasms involving the bony skeleton of the chest wall are chondrosarcoma, osteosarcoma and Ewing’s sarcoma/primitive neuroectodermal tumour. Metastases, multiple myeloma and invasive primary lung cancer are the most frequent secondary lesions. We performed a retrospective review of the radiology and pathology archive at our institution from 1 July 2000 to 31 December 2004 and identified 31 of these lesions. Several of these tumours have distinctive radiological features, allowing a confident radiological diagnosis to be suggested.
Received 4 November 2005 Revised 11 January 2006 Accepted 19 January 2006 DOI: 10.1259/bjr/82228585
’ 2007 The British Institute of Radiology
Primary tumours involving the bony skeleton of the chest wall are uncommon. The most common primary malignant tumour of the chest wall is chondrosarcoma . Less common primary bony chest wall tumours include osteosarcoma and Ewing’s sarcoma/primitive neuroectodermal tumour (PNET). Multiple myeloma is a malignant tumour of plasmacytes most commonly seen in the bone marrow. It frequently involves the chest wall resulting in lytic lesions and bony expansion. The chest wall may also be involved by direct extension of pulmonary carcinoma and by metastases from extrathoracic malignancy. Imaging plays an important role in the diagnosis and management of neoplasms involving the bony skeleton of the chest wall. The radiological appearance of these tumours in the chest wall has not been extensively described. Our aim was to review the imaging features of neoplasms affecting the bony skeleton of the chest wall and the costal cartilages. During the review of our radiology and pathology archive we encountered 31 malignant tumours affecting the bone or cartilage of the chest wall. This included 10 (32%) metastatic chest wall lesions, 7 (22.5%) invasive lung primary tumours, 5 (16%) chondrosarcomas, 4 (13%) multiple myeloma chest wall tumours, 3 (9%) osteosarcomas and 2 (6.4%) Ewing’s sarcomas of the chest wall.
occur more commonly in men and affect patients greater than 50 years of age. Chondrosarcomas are most commonly found in the anterior chest wall, in the superior five ribs and adjacent to the costochondral junction , or in the paravertebral regions. The majority of chondrosarcomas are seen to originate within bone; occasionally they may originate in the soft tissue . The characteristic CT appearance of chondrosarcomas consists of a well-defined, lobulated mass of soft tissue attenuation with foci of dense chondroid matrix calcification (Figure 1). ‘‘Ring-like’’ or ‘‘arcs’’ of calcification can also be seen (Figure 2) . The pattern of calcification has been described as nodular (Figure 3a) or peripheral in nature . Bone destruction and invasion of the overlying soft tissue to varying degrees is also seen
Chondrosarcomas may occur de novo or arise from bony exostosis or following radiotherapy [2, 3]. They
Figure 1. 28-year-old female with a chondrosarcoma. CT
Address correspondence to: P O’Sullivan, Department of Radiology, Vancouver General Hospital, 899 West 12th Avenue, Vancouver V5Z 1M9, Canada. E-mail: firstname.lastname@example.org
image photographed on bone windows demonstrates dense amorphous matrix calcification within the tumour arising from the inferior angle of the scapula.
The British Journal of Radiology, August 2007
Ewing’s sarcoma and primitive neuroectodermal tumour Ewing’s sarcoma is a rare aggressive malignant tumour of bone. with ‘‘arcs’’ of central calcification. and a high signal periphery may be seen. (b) Coronal T2 MRI shows high signal multilobulated anterior chest wall tumour (arrow). Axial CT image demonstrates large tumour arising from the right 6th rib. 62-year-old male with a chondrosarcoma. weighted images . Chest wall osteosarcomas are most commonly found in the ribs. scapula and clavicle . bone or marrow are present in 25% of patients at the time of presentation . Signal void is also seen when dense matrix mineralization is present (Figure 6). Instead. 56-year-old female with a chondrosarcoma. Metastases to lungs. Figure 2. Contrast enhancement is often patchy. PNET. It occurs most commonly in the diaphysial and metadiaphysial regions of the lower extremities .Pictorial review: Malignant chest wall neoplasms of bone and cartilage Osteosarcoma Osteosarcomas are high-grade malignant bone tumours. arising from the posterior aspect of the left 5th costo-chondral junction. Two age peaks are seen for chest wall osteosarcomas: the osseous form is seen in younger adult patients. previously classed as a separate tumour. (Figure 4). (a) CT shows the tumour with nodular calcification. MRI usually reveals intensity higher than muscle on T1. is now thought to be an aggressive form of Ewing’s sarcoma . Ewing’s and PNET are the most common malignant tumour of the chest wall in children and both (a) (b) Figure 3. Some authors have suggested that it is possible to differentiate osteosarcoma from chondrosarcoma based these findings . and mixed to higher signal than muscle on T2. with areas of signal void due to calcification. The most frequent site of origin is the distal femur. a predominantly myxoid matrix of uniform low soft tissue attenuation is seen. The chondroid matrix calcification produces a signal void on MRI (Figure 5). Chondrosarcomas may present without any visible matrix calcification. The typical CT presentation of osteosarcomas consists of matrix mineralization greatest at the centre of the lesion and decreasing towards the periphery. more commonly seen in children and adolescents . The MRI features include signal intensity similar to muscle on T1 weighted imaging and signal intensity greater than adipose tissue on T2 weighted images (Figure 3b). Osteosarcomas contain neoplastic new bone or disorganized ossification. August 2007 679 . while the less common extraosseous type is seen in patients over 50 years. The British Journal of Radiology.
Figure 5. Chest wall invasion is clinically important (Figure 12). Both CT and MRI have demonstrated a varying degree of success . the sclerotic pattern of prostate or breast (Figure 13) or the expansile nature of renal cell carcinoma. and uniform high signal on T2 weighted imaging. August 2007 Lung carcinoma Aggressive primary lung carcinoma may extend directly into the bony chest wall.P O’Sullivan. In one review of 432 patients with multiple myeloma. as when involved the lesion will be classed as a T3 lesion. The pathological tissue appears as soft tissue attenuation similar to muscle at CT. Other findings such as apparent soft tissue extension have a low specificity. which may not be considered for surgery. with a degree of enhancement post contrast. Axial CT shows a large mass arising from the anterior left 4th rib. At MRI these lesions are usually low signal on T1 weighted imaging. When occurring in bone these characteristics are best evaluated on CT. 70-year-old male with a chondrosaroma. Soft tissue tumours (e. sternum. H O’Dwyer. clavicle or paravertebral regions . the new 16 and 64 track multislice CT scanners with multiplanar reconstructions are demonstrating an increasing sensitivity in this area . On MRI. has a relatively low sensitivity. They tend to be large in size and have an inhomogeneous appearance due to rapid growth. CT is superior to MRI in depicting early cortical breaches. producing masses in the surrounding soft tissues. MM often produces gross sternal expansion and distortion (Figure 9) and vertebral body destruction (Figures 10 and 11). composed of malignant plasmacytes.4%) were identified as having extramedullary multiple myeloma . and a high signal tumour margin. These cells grow in the bone marrow. 11]. however. Various patterns of metastatic disease to the bony chest wall can be seen. 72-year-old male with chondrosarcoma.g. these tumours usually have a pattern of heterogeneous high signal on T1 and T2 weighted images. Metastatic disease Metastatic disease to the chest wall is not unusual. lymphoma) when they spread to the bony chest wall (Figure14) also produce tissue of similar appearance and attenuation to the primary tumour. MRI typically reveals masses of uniform low signal on T1 weighted imaging. such as the lytic pattern of myeloma. J Flint et al Figure 4. It is associated with a poorer outcome. with a marked periosteal reaction. scapula. due to extensive haemorrhage and necrosis (Figure 8b) . The accurate identification of locally advanced lung cancer spreading through to the chest 680 . Later in the disease cortical breaches occur. inhomogeneous mass with poorly defined margins. are highly aggressive in nature [8. or earlier in presentation with particularly aggressive disease. and high signal on T2 weighted imaging. displacing surrounding tissues (Figure 8a) and mixed internal attenuation. CT or MRI demonstration of bony destruction is the most reliable method to identify chest wall invasion by lung cancer. and further spread from bone is seen. MRI appears the superior modality in relation to superior sulcus (Pancoast) tumours. This finding. Extramedullary disease (outside the marrow) is uncommon. They can also be seen in young adults. The imaging characteristics of the primary lesion may be observed within the bony metastatic deposit to the chest wall. (a) Axial T2 MRI shows paraspinal tumour with extensive central signal loss due to matrix calcification. CT findings include a large. However. Primary chest wall Ewing’s sarcoma and PNET tumours usually develop as solitary lesions centred on the ribs (Figure 7). The British Journal of Radiology. Multiple myeloma Multiple myeloma (MM) is a tumour of the bone marrow. only 19 (4. similar to muscle tissue with necrosis and/or calcification. It is often seen at the terminal stages of malignant disease. and cause expansion and remodelling of bones within the chest wall. wall is often difficult.
(a) Chest radiograph shows a large densely calcified mass overlying the left upper chest wall. 65-year-old female with an osteosarcoma. situated on the ribs and displacing overlying pectoralis muscles.Pictorial review: Malignant chest wall neoplasms of bone and cartilage (a) (b) (c) Figure 6. August 2007 681 . (c) Coronal T1 MRI shows large chest wall mass with extensive central signal loss (arrow) due to tumour calcification. The British Journal of Radiology. (b) Axial CT shows a large densely calcified left chest wall mass.
(b) Axial T2 MRI shows large high signal chest wall mass. 32-year-old male with Ewing’s sarcoma. (a) Axial CT shows large soft tissue tumour (arrow) with well-defined margins. H O’Dwyer. 30-year-old female with Ewing’s sarcoma. with intra-abdominal extension and liver compression. Axial CT demonstrates a large soft tissue attenuation mass arising from the left 4th rib. The ribs exhibit a marked periosteal reaction. August 2007 .P O’Sullivan. which is irregular and sclerotic. Figure 9. (a) (b) Figure 8. 52-year-old female with multiple myeloma. J Flint et al Figure 7. and extending into the anterior and posterior soft tissues. Axial CT shows a large enhancing soft tissue tumour expanding the sternum. Note compression of the brachiocephalic vein and superior vena cava. 682 The British Journal of Radiology.
88-year-old male with multiple myeloma. MM produces lytic. expansile lesions in the sternum and vertebrae. A large right side chest wall recurrence is seen originating from the sclerotic expanded right 6th rib. CT image shows marked sternal expansion and deformity.Pictorial review: Malignant chest wall neoplasms of bone and cartilage Figure 10. 56-year-old male with multiple myeloma. Breast carcinoma has reported rates of ‘‘local recurrence’’ in the chest wall ranging from 5% to 20% [15. The British Journal of Radiology. and vertebral destruction with paravertebral soft tissue masses from myeloma. Sarcomas. are seen in the chest wall post radiation treatment for lung and breast malignancies. 16]. Recurrent disease Local recurrence of malignant disease is not uncommon in the chest wall. CT shows superior sulcus tumour extending into the ribs and right axilla. 52-year-old female with previous left mastectomy for breast carcinoma (note prosthesis). Figure 13. Ewing’s tumour is seen in the paediatric population. Matrix mineralization is seen in both chondrosarcomas and osteosarcomas. In adults the most common chest wall tumour without calcification is a plasmacytoma or metastatic deposit from a distant primary. August 2007 683 . such as chondrosarcoma and fibrosarcoma. In elderly patients a calcified primary tumour is likely to be a chondrosarcoma. Figure 11. Patient’s age is an important factor. 71-year-old male with right apical adenocarcinoma (Pancoast’s tumour). Figure 12. Conclusions Several chest wall tumours have characteristic features that suggest a particular diagnosis. Other lesions have characteristic locations. CT shows diffuse infiltration of vertebrae and extensive bilateral extramedullary soft tissue extension.
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