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C a r d i o p u l m o n a r y I m a g i n g R ev i ew

Mullan et al.
Imaging of Chest Wall Masses

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Cardiopulmonary Imaging
Review

Radiology of Chest Wall Masses


Charles P. Mullan1
Rachna Madan2
Beatrice Trotman-Dickenson2
Xiaohua Qian 3
Francine L. Jacobson2
Andetta Hunsaker 2
Mullan CP, Madan R, Trotman-Dickenson B,
Qian X, Jacobson FL, Hunsaker A

Keywords: biopsy, cardiopulmonary imaging, CT, MRI,


PET/CT, thorax
DOI:10.2214/AJR.10.7259
Received July 6, 2010; accepted after revision
October 4, 2010.
1Department of Radiology, Altnagelvin Hospital,

Londonderry BT46 5QR, Northern Ireland. Address


correspondence to C. P. Mullan
(cpmullan@hotmail.com).
2
Department of Radiology, Brigham & Womens Hospital,
Boston, MA.
3
Department of Pathology, Brigham & Womens Hospital,
Boston, MA.

CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2011; 197:W460W470
0361803X/11/1973W460
American Roentgen Ray Society

W460

OBJECTIVE. The purpose of this article is to highlight the role of radiography, CT, PET/
CT, and MRI in the diagnosis and management of chest wall lesions. Chest wall masses are
caused by a spectrum of clinical entities. The lesions highlighted in this selection of case scenarios include neoplastic, inflammatory, and vascular lesions.
CONCLUSION. Imaging evaluation with radiography, CT, MRI, and PET/CT plays an
important role in the accurate diagnosis of chest wall lesions. It can also facilitate percutaneous biopsy, when it is indicated. Imaging enables accurate staging and is a key component of
treatment planning for chest wall masses.
Choosing an Imaging Technique
Radiography
Chest radiographs and dedicated views of
the ribs and sternoclavicular joints provide
basic information regarding the site of the
lesion and reveal osseous changes. Radiographs are especially useful in the setting of
trauma, infection, and osseous tumors.

PET/CT
FDG activity provides information regarding the metabolic status of chest wall
masses but only limited additional diagnostic information regarding the primary lesion.
It is most useful in providing data on regional and distant metastases and in choosing the
most metabolically active area for biopsy.

Ultrasound
Superficial chest wall lesions can be characterized with ultrasound imaging, and these
lesions are amenable to biopsy with ultrasound guidance.

Imaging-Guided Biopsy
Chest wall lesions are usually amenable
to imaging-guided percutaneous biopsy with
CT or ultrasound. Review of CT, MRI, and
PET/CT findings allows the percutaneous approach to be formulated. Directing biopsy toward areas of enhancing or metabolically active soft tissue within the lesion will avoid an
inadequate specimen resulting from tumor
necrosis. PET/CT can be particularly helpful
in confirming areas of viable tumor with FDG
uptake in a large chest wall lesion or nodal
metastases, which may be easier to access.

CT
CT is the workhorse of diagnostic imaging for chest wall lesions and provides good
spatial resolution, including depiction of osseous and soft-tissue structures. MDCT enables imaging of a large tissue volume in a
short acquisition time, reducing the effect of
respiratory motion in the thorax. CT reveals
mineralization and bony involvement and
helps in narrowing the differential diagnosis.
MRI
MRI has superior soft-tissue resolution
and is invaluable for local assessment of primary tumors. It enables accurate tissue characterization and assessment of enhancement
patterns. It plays a key role in preoperative
staging to assess for multispatial and multicompartment involvement and involvement
of neurovascular structures.

Scenario 1
Clinical History
A 76-year-old man with a remote history of
aortic and mitral valve replacement presented
with acute left chest wall pain. There was no history of significant trauma. ECG showed no evidence of an acute myocardial event. On clinical
examination, the patient had pain, tenderness,
and swelling in the left anterolateral chest wall.
There were no systemic symptoms or history
of fever, and serum WBC count was normal. A
chest radiograph and MRI were obtained.

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Imaging of Chest Wall Masses

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Fig. 176-year-old man with acute left chest wall


pain.
A, Posteroanterior chest radiograph.
B, Sagittal T2-weighted image of thorax.
C, Axial T1-weighted image of thorax.
D, Axial STIR image of thorax.

Description of Images
The chest radiograph (Fig. 1A) shows evidence of cardiomegaly, left atrial enlargement, and prior sternotomy, consistent with
a history of valvular heart disease. There
is diffuse opacity overlying the left lateral
chest wall and axilla. Figure 1B is a sagittal
T2-weighted image from the MRI study of
the thorax showing a large well-defined lesion in the left anterolateral chest wall containing high-signal material, with layering
of intermediate-to-high-signal material in
the dependent portion. There is also diffusely increased signal intensity in the left
pectoralis major muscle, extending across
the anterior chest wall. Figure 1C shows
low signal within the anterior portion of
the lesion on axial T1-weighted imaging
and intermediate-to-high signal in the dependent portion. An axial STIR image (Fig.
1D) confirms that the lesion contains fluid,
and diffuse high signal in the left pectoralis
major muscle and adjacent fat are consistent
with inflammatory change.

Differential Diagnosis
The most likely diagnosis is a hematoma, consistent with the acute onset of the
pain and location within the chest wall musculature. The patient has prosthetic cardiac
valves and was therefore receiving oral anticoagulants. A relatively minor muscle injury could precipitate a significant hematoma.
Although, to our knowledge, there are limited published data about spontaneous chest
wall bleeding, hematoma in the thoracic
wall is a described complication in patients
receiving anticoagulants who undergo thoracic or shoulder surgery [1]. The fluid-fluid
level within the lesion on MRI is consistent
with layering of hemorrhage, with the moredependent hemorrhagic contents showing
higher signal on T1-weighted imaging. The
increased T2-weighted signal extending
across the left pectoralis muscle is suggestive of pectoralis muscle injury and tear. A
chest wall abscess would also be consistent
with the presentation of chest pain. However, an infective lesion of this size would be

expected to cause systemic symptoms, including fever, which were absent in this case.
Although the MRI scans reveal a large fluid
collection with inflammatory change in adjacent tissues, the lack of a discernible wall is
consistent with hematoma rather than an abscess. The history of acute chest pain does
not suggest a primary neoplastic process, but
hemorrhage occurring within a tumor could
cause these features. Hemorrhage may occur
in soft-tissue metastases, such as those secondary to melanoma. However, the lack of a
solid component within the lesion makes this
diagnosis unlikely. A primary tumor in this
region would most likely be a rhabdomyosarcoma arising in the left pectoralis major
muscle. The appearance of the lesion in this
case is unusual for rhabdomyosarcoma.
Diagnosis: Chest Wall Hematoma
The diagnosis of chest wall hematoma in
this case is suggested by the acute clinical
presentation and the patients valvular heart
disease requiring anticoagulants. The patient

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Mullan et al.
tends through the superior sulcus to encase
the right subclavian artery and the brachial
plexus (Fig. 2A). The mass is predominantly
of fat attenuation, with components of mildly
enhancing soft-tissue attenuation at the anteroinferior portion of the right hemithorax
(Fig. 2B). Septations are identified within the
fat component, especially inferiorly. Figure
2C is a coronal T2-weighted image showing
the extent of abnormal high-signal tissue involving the right hemithorax and invasion of
the hepatic dome through the right hemidiaphragm. Axial T1-weighted imaging shows
high signal in the lipomatous components of
the lesion (Fig. 2D). The soft-tissue components of the lesion in the right lower hemithorax exhibit low signal on unenhanced T1weighted images (Fig. 2D) and high signal
on T2-weighted images (Fig. 2E).

had an international normalized ratio of 3.0


and a low hematocrit on admission. The use
of cross-sectional imaging with CT or MRI
enables the lesion to be localized within the
pectoralis major muscle, helping to define
the differential diagnosis. If there is clinical concern of an abscess or an underlying
chest wall neoplasm, the use of IV contrast
agent should be considered. The presence of
an enhancing soft-tissue component is not an
expected feature of acute chest wall hematoma and should raise suspicion of hemorrhage within a neoplastic lesion. Granulation
tissue surrounding an abscess often exhibits
enhancement. Mild wall enhancement may
be seen in chronic hematomas [2].
Reversal of anticoagulation therapy in this
patient with prosthetic cardiac valves could
precipitate a thromboembolic event, but temporary reversal may be required before undertaking a drainage procedure. A hematoma of
this size would require a prolonged period to
resolve with conservative measures. As well
as causing patient discomfort and localized
mass effect on the adjacent structures in the
chest wall, there is a significant risk that the
hematoma will become infected. The superficial location of the lesion makes it suitable for
imaging-guided percutaneous drainage with
ultrasound. Surgical evacuation would be
more invasive and would expose this patient
with valvular heart disease to increased peri-

operative risks. However, surgical drainage


and dbridement would be required if the hematoma became infected and could not be adequately treated with percutaneous drainage.
Chronic expanding hematoma of the thorax is a clinical entity of uncertain cause that
can present as a slowly growing chest wall
mass [2, 3]. Surgical excision and drainage
is usually required in these patients because
of formation of granulation tissue and calcification. IV antibiotics would be indicated if
there are clinical and radiologic features of
infection but would not be effective alone in
treating the hematoma.

Description of the Images


Selected axial images from a contrast-enhanced CT performed in the arterial phase
show a large mass lesion in the right hemithorax, causing significant compressive atelectasis in the right lung. Although the largest
component of the mass is intrathoracic, it ex-

Differential Diagnosis
The differential diagnosis includes liposarcoma and atypical lipoma. The extension
of the mass outside the right hemithorax, involvement of the superior sulcus, and invasion of the hepatic dome are consistent with
an aggressive malignancy. The lesion extends
along the right side of the mediastinum. Because fat comprises the greatest component of
the mass, it is difficult to determine the extent of mediastinal invasion. Well-differentiated liposarcoma may contain large amounts

Fig. 253-year-old man with progressive dyspnea


and altered sensation in right upper limb.
A and B, Selected axial images from CT of thorax
performed with IV contrast agent.
C, Coronal T2-weighted image of thorax.
D and E, Axial T1-weighted (D) and T2-weighted (E)
images of lower thorax.

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Scenario 2
Clinical History
A 53-year-old man presented with a history of progressive dyspnea and altered sensation in the right upper limb. There was
no significant medical history. A chest radiograph showed diffuse abnormality in
the right hemithorax, and the patient subsequently underwent CT of the thorax.

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Imaging of Chest Wall Masses


of fatty tissue [4] and can therefore be difficult
to distinguish from atypical lipoma in cases
without overt signs of local invasion. Most lipomas and liposarcomas do not contain areas
of calcification. When calcification is present,
it is not a reliable determinant of malignancy [4]. Large thickened septations in a lipomatous lesion are suggestive of liposarcoma.
However, thin septations such as those seen in
this case are frequently seen in lipomas. Primary liposarcoma in the mediastinum is rare,
but reported findings include invasion of the
pericardium and great vessels [5]. In this case,
there is clear invasion through the diaphragm
and into the dome of the liver. Nonadipose
components are much more frequent in welldifferentiated liposarcomas than in lipomas.
However, up to 31% of lipomas may exhibit
nonadipose components [4], so the presence
of higher attenuation portions within the mass
is not reliable in determining malignancy.
Diagnosis: Liposarcoma
Distinguishing well-differentiated liposarcoma from lipoma can be a diagnostic challenge with radiologic imaging. Although lesions composed entirely of adipose
tissue can be reliably identified as lipomas,
the presence of nonadipose components does
not definitively indicate malignancy. Imaging-guided biopsy targeting the nonadipose
component of the lesion is an invasive procedure but is the best way to prove the diagnosis. This is a less invasive option than surgical biopsy. The extensive nature of the lesion
in this patient means that accurate diagnosis and staging are required before deciding
whether surgical excision is appropriate. Although MRI is the best imaging technique
to provide information on local staging, liposarcoma cannot be reliably diagnosed
by MRI features alone. Ultrasound may be
helpful in distinguishing cystic lesions from
myxoid elements of liposarcoma [6]. However, CT was performed with IV contrast agent
in this case, and ultrasound is therefore unlikely to provide further information to aid in
characterization of the lesion. PET/CT may
be useful in the pretreatment assessment of
liposarcoma [7]. However, FDG uptake by
liposarcomas is variable [7, 8], and the absence of significant FDG activity will not reliably exclude malignancy. The liposarcoma in this scenario exhibits a heterogeneous
signal intensity pattern. There are large focal areas in the right lower hemithorax
with low signal on unenhanced T1-weighted MRI, high signal on T2-weighted MRI,

and amorphous enhancement on contrastenhanced CT, suggesting a myxoid component. There are also larger areas of fat signal
seen throughout the rest of the mass without
significant contrast enhancement, consistent
with well-differentiated fatty component.
This appearance of variable signal intensity
on MRI is commonly seen in larger liposarcomas, which can have multiple histologic
subtypes within the same lesion [9]. Patients
with well-differentiated liposarcoma have a
much better prognosis after therapy than do
patients with pleomorphic histologic subtype
[6]. Myxoid liposarcoma has an intermediate
prognosis [5, 6]. On histopathologic analysis, the tumor in this scenario had both welldifferentiated and myxoid components. The
patient subsequently developed metastatic
disease a few years later, with histology indicating high-grade pleomorphic liposarcoma.

wall on a chest radiograph performed at routine follow-up. The patient had sustained minor injuries following a motor vehicle accident 2 years previously and was otherwise
asymptomatic.

Scenario 3
Clinical History
A 64-year-old woman with a history of
left breast carcinoma was found to have an
osseous abnormality in the left anterior chest

Description of Images
Selected axial (Fig. 3A) and sagittal (Fig.
3B) images of CT examination are displayed
in bone window. An abnormal osseous excrescence is seen arising from the region of
the left sternoclavicular joint, without evidence of osteolysis in the bones adjacent to
the lesion. The lesion extends into the left
chest wall, causing anterior displacement of
the left pectoralis major muscle. Periosteal
reaction is identified at the anterior aspect
of the articular surfaces of both the manubrium and the clavicle. The margins of the
lesion are well defined, and no inflammatory changes are seen in the adjacent muscle
or fat of the chest wall. On the sagittal view,
bone proliferation can be seen on both sides
of the sternoclavicular joint. Intraarticular
gas is identified within the slightly widened
left sternoclavicular joint. A reformatted cor-

Fig. 364-year-old woman with history of left breast carcinoma and osseous abnormality in left anterior chest
wall on chest radiograph.
A, Axial CT image of thorax in bone window.
B, Sagittal CT image of thorax in bone window.
C, Reformatted coronal image of sternoclavicular joints.
D, Axial CT image of thorax obtained 3 years before images in AC were obtained.

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Mullan et al.
onal image (Fig. 3C) also shows the osseous
abnormality involving both sides of the sternoclavicular joint. Figure 3D shows an axial
image from CT performed 3 years earlier at
an outside hospital, with a stable appearance
at the left sternoclavicular joint.
Differential Diagnosis
A bony outgrowth is identified at the medial end of the left clavicle and the adjacent
portion of the sternal manubrium and appears to be centered on the left sternoclavicular joint. This patient has no symptoms to
suggest septic arthritis and no evidence of
periarticular bone resorption or inflammatory changes in the adjacent soft tissues. Although chondrosarcoma can extend across
joint spaces [10], the symmetric involvement of both articular surfaces and lack of
osseous destruction is not suggestive of a
primary bone neoplasm. Also, no chondroid
matrix is visualized. The patient has a history of treated breast cancer, and the possibility of an osseous metastasis has to be considered. However, the joint-based nature of
the lesion, lack of other osseous lesions, and
stability over a 3-year period does not suggest metastatic disease. The imaging findings are consistent with hyperostosis of the
sternoclavicular joint, with exuberant new
bone formation centered around the joint
and the presence of intraarticular gas. The
vacuum phenomenon is seen as gas accumulation (mostly nitrogen) within synovial
joints due to distraction of the articular surfaces. This radiologic feature is also commonly found within intervertebral disks as

a result of degenerative processes. The vacuum phenomenon is rarely seen in infections but occurs in osteoarthropathy, crystal
deposition disease, and trauma [11]. Although the right sternoclavicular joint is not
affected in this patient, published literature
has described cases of bilateral hyperostosis associated with cutaneous symptoms
[12, 13]. The SAPHO syndrome is a clinical entity consisting of synovitis, acne, pustulosis, hyperostosis, and osteitis. However,
this patient does not have bilateral sternoclavicular hyperostosis or palmar cutaneous
lesions to suggest SAPHO syndrome.

Description of Images
Selected axial images of MRI of the area
of clinical interest in the right posterior chest
wall are displayed. A soft-tissue mass of intermediate signal intensity on proton-density imaging (Fig. 4A) and fat-suppressed
T1-weighted (Fig. 4B) imaging is identified
adjacent to the inferior tip of the right scapula. The lesion is more heterogeneous than the
neighboring skeletal muscle on all sequences, exhibiting alternating high and intermediate signal areas. The mass exhibits avid
enhancement on the contrast-enhanced sequence (Fig. 4C).

Diagnosis: Sternoclavicular Hyperostosis


The large amount of bone proliferation in
this case might initially raise the suspicion of
a primary osseous neoplasm. However, the
joint-centered nature of the lesion, the intact
cortical margins, and lack of involvement of
adjacent soft tissues point toward arthropathy. The presence of intraarticular gas is suggestive of osteoarthropathy, although it may
also be seen with trauma and crystal deposition disease [11]. The remote history of minor chest trauma indicates a possible causative factor for osteoarthropathy.
Scenario 4
Clinical History
A 60-year-old man presented with increasing discomfort in the right posterior chest wall
over a 3-month period. The patient had no significant medical history. On examination,
there was an ill-defined palpable swelling adjacent to the inferior pole of the right scapula.

Differential Diagnosis
The clinical features of progressive discomfort in the chest wall over 3 months without significant history are not suggestive of an
infective cause. The signal characteristics indicate an enhancing soft-tissue lesion, without areas of fluid signal to suggest an abscess.
The lesion has ill-defined margins and shows
prominent enhancement after contrast agent
administration. Primary sarcoma of the chest
wall is relatively uncommon. However, with
the imaging characteristics and clinical presentation, sarcoma should be considered in
the differential diagnosis [14]. Neurofibromas
typically have well-circumscribed margins
and higher signal on T2-weighted imaging
than seen in this lesion. Neurofibromas may
also show a target sign, with central hypointensity on T2-weighted imaging due to fibrocollagenous material [15], which is not present in this case. Plexiform neurofibromas can
be infiltrative with variable signal pattern on

A
Fig. 460-year-old man with 3-month history of right posterior chest wall pain.
A, Axial proton densityweighted image of thorax.
B, Axial T1-weighted image of thorax with fat suppression.
C, Axial T1-weighted image of thorax obtained after IV administration of gadolinium-based contrast agent.

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Imaging of Chest Wall Masses


T1-weighted, T2-weighted, and contrast-enhanced imaging. However, these lesions are
almost exclusively seen in patients with neurofibromatosis type 1, in conjunction with multiple cutaneous manifestations [16]. Elastofibroma dorsi essentially always occurs in the
subscapular area, is nonencapsulated, and has
alternating fibrous and fatty tissue bands that
produce a striated appearance on T1-weighted MRI in comparison with adjacent skeletal
muscle [17]. Elastofibroma dorsi is a benign
proliferation of fibrofatty tissue containing
elastin fibers and therefore does not infiltrate
adjacent osseous structures. Although elastofibromas usually exhibit only faint enhancement, more marked enhancement occasionally occurs in these lesions [18].
Diagnosis: Elastofibroma Dorsi
The infrascapular location, striated appearance, and absence of invasion are strongly suggestive of elastofibroma [19]. However,
the intense enhancement identified in this
case is an atypical finding that necessitates
further workup to exclude a soft-tissue tumor. Imaging-guided biopsy confirmed that
this patient had an elastofibroma. Asymptomatic patients with more typical imaging
characteristics may not require biopsy or excision [17]. Elastofibroma dorsi is a benign
soft-tissue pseudotumor characterized by accumulation of collagenized tissue with elastic fibers. These lesions are most common in
elderly women and are an important differential diagnosis to consider when an infrascapular soft-tissue lesion is present. Elastofibroma dorsi often presents as bilateral
subscapular masses [17, 18]. The presence of

bilateral lesions with typical imaging characteristics is essentially diagnostic, obviating tissue diagnosis. Imaging-guided biopsy
is the least invasive option when pathologic
diagnosis is required. A core biopsy should
distinguish between malignant lesions and
elastofibroma, which will exhibit elastic fibers in collagenized fibrofatty tissue [18]. If
the results of percutaneous biopsy are equivocal or the lesion is causing significant functional impairment, surgical biopsy or excision will be required [18].
Scenario 5
Clinical History
A 50-year-old man presented with right
posterior rib pain. The patient had no significant medical history and there was no history
of trauma. Selected images of CT and MRI
examinations of the thorax are displayed.
Description of Images
The axial CT image (Fig. 5A) shows a
large soft-tissue lesion in the posterior right
chest wall, causing osseous destruction of
the adjacent rib. Figure 5B is an axial T2weighted MRI scan revealing invasion of
the right lamina and right pedicle of the T5
vertebra. The mass extends into and widens
the right neural foramen (Fig. 5C), abutting
the right side of the spinal canal. The lesion
is homogeneous in attenuation on CT (Fig.
5A). It is of intermediate-to-high signal on
T2-weighted MRI (Figs. 5B and 5C), with no
evidence of central heterogeneity or fluid signal to suggest necrosis. The lesion forms an
obtuse angle with the chest wall and has both
chest wall and intrathoracic components.

Differential Diagnosis
The obtuse angle between the chest wall
and the mass suggests an extrapulmonary location. Although the lesion may arise from
the pleura, mesothelioma usually progresses
in a circumferential pattern around the hemithorax, rather than the focal expansile manner
seen in this case. No pleural plaques are seen
to indicate prior asbestos exposure, which is
the primary risk factor for mesothelioma. Although chondrosarcoma is the most common
primary malignancy of the chest wall, it usually occurs more anteriorly than the lesion in
this scenario. Chondrosarcoma is often centered on the sternum or costochondral cartilage [14]. Stippled areas of calcification due
to chondroid matrix are often seen in chondrosarcoma, but no calcification is observed
in this scenario. The most likely causes of an
expansile soft-tissue mass with rib osteolysis
in a patient of this age group are plasmacytoma or multiple myeloma or osseous metastases. Myeloma is the most common primary bone marrow malignancy in adults [20].
Most plasmacytomas arising from bone are
osteolytic in nature and usually do not contain intralesional calcifications [21]. In this
case, there is widening of the right neural
foramen caused by infiltration of the lesion.
Neuroforaminal widening is typical of peripheral nerve sheath tumors such as neurofibroma and schwannoma. However, other
neoplasms, including plasmacytoma and infectious diseases, can cause this finding [22].
Diagnosis: Plasmacytoma
Most patients with solitary myeloma (plasmacytoma) are male and older than 50 years

Fig. 550-year-old man with right posterior rib pain.


A, Axial CT image of thorax.
B and C, Axial T2-weighted MRI scans of thorax.

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Mullan et al.
[23]. Although these lesions are relatively common, the imaging features are nonspecific. Plasmacytomas usually arise from
bone and are often expansile in nature [24].
The most frequent sites include the vertebral
column and ribs [23, 24]. Solitary myeloma
may also originate in extraosseous soft tissues [25]. Biopsy of this lesion confirmed a
plasmacytoma. No other sites of bone disease were identified on skeletal survey. The
extraosseous soft-tissue component may predominate, as in this case. Expansile osteolytic metastases, such as those resulting from
primary renal or thyroid malignancy, could
cause a similar appearance. Radiologic imaging plays an important role in determining the disease burden in patients with myelomatous disease, including complications
such as pathologic factors [25]. Eighty-five
percent of patients with solitary plasmacytoma will develop multiple myeloma within
several years of initial diagnosis [23].

erosion of adjacent cortical bone and dumbbell shape of the mass are recognized features of a benign peripheral nerve sheath tumors, such as schwannoma or neurofibroma.
It is often difficult to differentiate schwannoma from neurofibroma on radiologic imaging. An eccentric location relative to the
parent nerve and areas of cystic degeneration
are more suggestive of schwannoma [22, 26].
However, these imaging features are not
present in the current scenario. Although
atypical lipomas may have a large soft-tissue

component, the absence of any areas of fat


attenuation within the lesion is not consistent
with lipoma.

Diagnosis: Schwannoma
Schwannomas are peripheral nerve sheath
tumors that most often present in adults as
asymptomatic slow-growing lesions [22].
They typically have a well-defined encapsulated appearance and commonly cause erosion of adjacent bony structures as a result
of a pressure effect. Benign peripheral nerve

Scenario 6
Clinical History
A 48-year-old man underwent CT examination of the thorax, which revealed an incidental
finding of an upper right chest wall mass. The
patient had no symptoms related to the mass.
Description of Images
Contrast-enhanced CT shows a homogeneous well-circumscribed right subclavicular soft-tissue mass, which is slightly hypoattenuating in comparison with the adjacent
skeletal muscle (Figs. 6A6C). The lesion
extends into the first intercostal space and
has a dumbbell shape (Fig. 6B). There is
mild scalloping and erosion of the right lateral second rib adjacent to the mass lesion (Fig.
6A). The mass is mildly FDG avid on PET/
CT examination (Fig. 6D). No other FDGpositive disease is seen in the chest.
Differential Diagnosis
The dumbbell shape of the mass and extension into the intercostal space is unusual for a
lymph node. There is no evidence of central necrosis on PET, which would be expected with a
lymph node lesion of this size. The asymptomatic nature of the lesion does not suggest an infective cause. Also, there is no central low attenuation within the lesion to indicate fluid, and
no inflammatory change is seen in the adjacent
fat of the right chest wall to an abscess. The
well-defined margins, homogeneous appearance, and asymptomatic nature of the lesion
are suggestive of a slow-growing entity. The

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Fig. 648-year-old man with incidental finding of upper right chest wall lesion on CT.
A, Contrast-enhanced axial CT image of upper right hemithorax in bone window.
B, Contrast-enhanced axial CT image of upper right hemithorax in soft-tissue window.
C, Contrast-enhanced coronal CT image of thorax.
D, Coronal FDG PET image.

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Imaging of Chest Wall Masses


sheath tumors often exhibit prominent enhancement on contrast-enhanced images [15,
26] and may be mildly FDG avid on PET, as
in this case [27]. Although these lesions are
generally benign, malignant transformation
can occur. Imaging features suggestive of a
malignant peripheral nerve sheath tumor include indistinct margins and myxoid stroma,
but these findings are nonspecific [28].
Scenario 7
Clinical History
A 39-year-old woman presented with persistent left anterior chest wall pain over a
3-month period. There was no significant
medical history.
Description of Images
The posteroanterior chest radiograph (Fig.
7A) shows opacity centered on the anterior
aspect of the left fifth rib. The axial CT image in bone window shows that the lesion is
expansile, with fine bony spicules radiating
from the central portion and loss of the normal cortical rib margins (Fig. 7B). The mass
exhibits high signal on T2-weighted imaging
with fat suppression with lower signal in the
central portion of the lesion (Fig. 7C). There
is prominent peripheral enhancement on the
axial contrast-enhanced MRI (Fig. 7D) and
peripheral uptake of FDG on the axial PET
image (Fig. 7E). Figure 7F shows the gross
pathologic appearance of the lesion after surgical resection, with central fibrous stroma-

Diagnosis: Rib Hemangioma


The expansile nature of the mass with radiating bony spicules made definitive diagnosis on the basis of radiologic imaging alone
difficult. Preoperatively, a primary malignant
tumor of the rib, such as low-grade chondrosarcoma or, less likely, osteosarcoma, was
suspected. PET/CT did not reveal any other

lesions. Primary intraosseous hemangioma


most frequently occurs in the vertebrae and
skull. However, there are published case reports describing rib hemangiomas with radiologic features similar to those in this scenario
[31, 32]. Patients with rib hemangioma usually present with a solitary expansile rib lesion, which may cause pain or a palpable chest
wall mass [33]. These lesions usually enhance
on contrast-enhanced CT or MRI. Some hemangiomas have a spiculated or sunburst appearance due to fine linear calcifications, as
seen in this patient. This scenario highlights
the limitations of imaging alone and the importance of definite histologic diagnosis in the
management of chest wall tumors. Chest wall
tumors may be sampled using fine-needle aspiration biopsy, excisional biopsy, and incisional biopsy. In general, fine-needle aspiration biopsy is not recommended unless there
is a strong suspicion of myeloma or metastatic
disease. Excisional biopsy is performed for lesions less than 23 cm in diameter, and larger
lesions usually undergo incisional biopsy. In
this case, the PET/CT scan showing prominent FDG activity in the periphery of the lesion would have provided useful information
to direct needle biopsy or incisional biopsy.
However, because the preoperative working
differential diagnosis was low-grade primary
malignant tumor of the chest wall, no preoperative biopsy was done. Therefore, resection
was performed for both definitive diagnosis
and treatment.

containing areas of calcification and a highly


vascular peripheral component.
Differential Diagnosis
The lesion has indeterminate radiologic
features. The expansile nature and prominent
enhancement suggest an aggressive process.
No other lesions are identified in the visualized bony skeleton on the chest radiograph or
PET/CT examination. Although metastases
are the most common neoplastic rib lesion,
primary malignant lesions (e.g., chondrosarcoma) or benign lesions (e.g., fibrous dysplasia) must be considered in the differential diagnosis of a solitary expansile rib lesion [29].
Further investigation should be performed
to secure a diagnosis unless there are clinical contraindications to further workup. As in
this scenario, expansile rib lesions may lack
definitive radiologic features, necessitating
tissue diagnosis [30]. Excisional biopsy could
be considered as the next step for this patient,
but securing the diagnosis with imaging-guided biopsy would probably be preferable so
that the surgical approach can be optimized.

A
Fig. 739-year-old woman with 3-month history of persistent left anterior chest wall pain.
A, Posteroanterior chest radiograph.
B, Axial CT image of thorax in bone window.
C, Axial T2-weighted image of thorax with fat suppression.

(Fig. 7 continues on next page)

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Mullan et al.

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Fig. 7 (continued)39-year-old woman with 3-month history of persistent left anterior chest wall pain.
D, Axial contrast-enhanced T1-weighted image of thorax with fat suppression.
E, Axial FDG PET image.
F, Gross pathologic specimen of rib lesion after surgical excision.

Scenario 8
Clinical History
A 31-year-old man presented with a
1-month history of persistent left upper chest
wall pain. He had no significant medical history and no systemic clinical features.

soft tissues of the left chest wall, indicating


an aggressive lesion. The patients age and
absence of any prior clinical history of malignancy makes a bone metastasis less likely.
The mass has an enhancing soft-tissue component with cortical breakthrough. In the absence of fat stranding, these findings are more
suggestive of a primary bone tumor rather
than osteomyelitis. Although osteomyelitis
has aggressive radiologic features, bony destruction and fat stranding are usually the predominant features, and a soft-tissue phlegmon
is generally minimal. Also the areas of amorphous calcification and lack of systemic clinical features do not favor an infective process.
The finding of a chest wall lesion with aggressive features including bone destruction and
amorphous calcification in a young adult is
most consistent with a primary osseous neoplasm. Chondrosarcoma is the most common
primary malignant tumor of the chest wall
[24]. It is usually osseous in origin [34] and
most frequently occurs in the costochondral
region or sternum, as in this case [24]. However, osteosarcoma may contain areas of mineralization and must also be considered in the
differential diagnosis.

neoplasm arising from the sternum. Differentiating between chondrosarcoma and osteosarcoma according to imaging features
alone may be difficult. Both tumors typically
exhibit enhancement on contrast-enhanced
imaging and cause osseous destruction [24,
35]. Chondrosarcomas typically have stippled and arclike calcifications, whereas osteosarcomas tend to have dense foci of calcification located predominantly in the central
portion of the tumor [24]. Osteosarcoma is
less common than chondrosarcoma of the
chest wall and typically has a rib, scapular,
or clavicular location [14]. Biopsy of the lesion in this patient confirmed that it was a
chondrosarcoma. Radiation-induced chondrosarcoma and osteosarcoma of the chest
wall have been reported in some patients
who undergo radiation therapy for Hodgkin
disease and breast cancer [36]. However, as
in this case scenario, most patients with primary chondrosarcoma of the chest wall have
no history of prior irradiation.

Description of Images
Axial CT shows a soft-tissue mass with
osseous destruction involving the left sternal manubrium (Fig. 8A). The lesion has a
large soft-tissue component that extends into
the extraosseous tissues (Fig. 8B). The lesion extends into the anterior mediastinal
fat but appears to maintain a narrow plane
of separation from the aortic arch. There are
amorphous areas of irregular and arclike
calcification within the mass. Axial contrastenhanced MRI (Fig. 8C) shows peripheral enhancement of the lesion and delineates
its extension into adjacent soft-tissue structures. The central portion of the mass is heterogeneous, with relative hypoenhancement.
A coronal STIR image (Fig. 8D) shows high
signal throughout the lesion on T2-weighted
imaging with fat suppression.
Differential Diagnosis
The lesion is centered on the left side of the
manubrium, with associated osseous destruction. The mass also extends into the adjacent

W468

Diagnosis: Chondrosarcoma
The clinical and radiologic features in this
case are consistent with a primary malignant

Conclusion
The clinical case scenarios presented here
illustrate the utility of radiologic imaging in
the management of chest wall masses. A systematic problem-based approach is required
to define the differential diagnosis and to determine the most appropriate investigation to

AJR:197, September 2011

Imaging of Chest Wall Masses

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Fig. 831-year-old man with left upper chest wall


pain for 1 month.
A, Axial CT image of thorax in bone window.
B, Axial CT image of thorax in soft-tissue window.
C, Axial contrast-enhanced T1-weighted image of
thorax with fat suppression.
D, Coronal STIR image.

characterize the lesion. In situations where it


is not possible to secure a diagnosis by imaging features alone, chest wall masses are often amenable to percutaneous biopsy under
CT or ultrasound guidance. PET/CT may be
helpful in targeting biopsy toward metabolically active areas, which are likely to have a
greater diagnostic yield. The correlation of
clinical, radiologic, and pathologic data is
required for optimal treatment planning of
chest wall masses.

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