The British Journal of Radiology, 80 (2007), 574–580

PICTORIAL REVIEW

Soft tissue tumours and mass-like lesions of the chest wall: a

pictorial review of CT and MR findings
1 1
P O’SULLIVAN, FFR, RCSI, H O’DWYER, 2J FLINT, 1P L MUNK, MDCM, FRCPC and 1N MULLER, MD, PhD,
FRCP(C)

Departments of 1Radiology and 2Anatomical Pathology, University of British Columbia, Vancouver General Hospital,
Vancouver, BC, Canada

ABSTRACT. Soft tissue tumours and tumour-like lesions of the chest wall are
uncommon. The purpose of this pictorial essay is to describe the imaging findings of
chest wall soft tissue tumours and tumour-like lesions. We searched the radiological
and pathological archive at our institution retrospectively and reviewed the literature Received 4 November 2005
on soft tissue tumours of the chest wall. Common chest wall soft tissue tumours and Revised 16 December 2005
mass-like lesions include peripheral nerve tumours, lipomas, liposarcomas, Accepted 16 January 2006
haemangiomas, elastofibromas, metastases, lymphoma and abscesses. Other lesions
DOI: 10.1259/bjr/16591964
encountered include desmoid tumours and malignant fibrous histiocytoma. Many have
distinctive radiological findings or occur in specific locations, allowing a specific ’ 2007 The British Institute of
radiological diagnosis to be suggested. Radiology

Tumours of the chest wall are uncommon. They can be
benign or malignant [1, 2] and can be divided into those
of bony and those of soft tissue origin. Common soft
tissue neoplasms and non-neoplastic chest wall masses
include peripheral nerve tumours, lipomas, liposarco-
mas, haemangiomas, elastofibromas, lymphoma, metas-
tases from distant tumours, infectious mass lesions,
desmoid tumours and malignant fibrous histiocytoma
(MFH).
The radiological appearance of ‘‘soft tissue’’ chest
wall tumours has not been extensively described. Our
aim was to review the imaging and histological features
of 44 soft tissue tumours and mass-like lesions of the
chest wall identified during a retrospective archive
search.
The 44 identified tumours included 12 (27.7%)
neurogenic tumours (including 1 (2%) plexiform neuro-
fibroma, 5 (11%) neurofibromas and 6 (13%) schwanno-
mas, all benign), 8 (18%) lipomas, 5 (11%) metastases, 4
(9%) abscesses, 4 (9%) liposarcomas, 3 (6.8%) elastofi-
bromas, 3 (6.8%) lymphomas, 2 (4.5%) haemangiomas, 2
(4.5%) desmoid tumours and 1 (2%) malignant fibrous
histiocytoma. Tumours occurring within bone and
cartilage of the chest wall are not discussed in this
pictorial review.
Peripheral nerve tumours
Neurogenic tumours are slow-growing lesions ori-
ginating within a nerve (neurofibroma; plexiform or
Address correspondence to: Paul O’Sullivan, Department of
Radiology, Vancouver General Hospital, 899 West 12th Avenue,
Vancouver V5Z IM9, Canada. E-mail: sullypos@yahoo.com
non-plexiform), nerve sheath (schwannoma/neurile-
moma) or ganglia (ganglioneuroma). They occur more
frequently in the mediastinum than in the chest wall.
One series of 60 patients identified 63% of tumours
occurring in the mediastinum and 27% in the chest
wall [3], the most common being a schwannoma,
representing 85% of lesions in the series. Most
neurogenic tumours are benign, only one (a schwan-
noma) malignant tumour was identified in the same 60
patients [3].
Schwannoma
Schwannomas on non-contrast CT appear as smooth,
round lesions, either isodense or hypodense to chest wall
muscle [4]. Post contrast administration various patterns
are seen, including a diffuse inhomogeneous pattern,
multiple hypodense or cystic areas, radial enhancement,
peripheral enhancement with low attenuation centre,
diffuse low attenuation or central enhancement with
peripheral hypodensity [4].
At MR schwannomas have signal intensity equal to or
greater than muscle on T1 weighted images. T2 weighted
imaging reveals a higher signal than T1 often hetero-
geneous (Figure 1), intermediate to high signal intensity
when compared with adipose tissue [4]. Avid contrast
enhancement is often seen (Figure 2).
Malignant schwannomas have similar CT findings, but
often have associated abnormalities including pleural
effusions, pleural nodules and metastatic pulmonary
nodules [5]. A rapid size increase, especially in neurofi-
bromatosis should raise suspicion for malignancy [6].
Schwannomas have also been described as having a
‘‘bead-like’’ appearance (Figure 3) [7].

574 The British Journal of Radiology, July 2007

Pictorial review: Soft tissue tumours of the chest wall

Figure 3. 40-year-old male with right intercostal schwan-

noma. Axial T1 image (non-contrast) shows a ‘‘bead-like’’
appearance of schwannoma.
Figure 1. 35-year-old male with intercostal nerve schwan-
noma. T2 coronal MR image shows round, smooth, hetero-
geneous intermediate and high signal intensity.

Neurofibroma
Neurofibromas are typically smoothly marginated,
round or oval-shaped masses. Displacement of adjacent
structures rather than invasion is seen. Neurofibromas
have a low muscle-like attenuation on non-contrast CT
and show heterogeneous enhancement post contrast. The
MR features include uniform low signal similar to
muscle on T1, and a high signal rim-like pattern with a
low signal centre on T2 weighted images [1]. Uniform
avid enhancement is seen following intravenous admini-
stration of gadolinium (Figure 4).

Figure 4. 56-year-old female with hepatitis C and metastatic

hepatocellular carcinoma. CT shows enhancing chest wall
metastases (arrow) and similar enhancing nodular hepato-
cellular carcinoma.

Figure 2. 62-year-old-male with right axillary plexiform Figure 5. 68-year-old female with metastatic breast carci-
neuroma. Coronal T1 fat-saturated MR post gadolinium noma. CT image shows multiple soft tissue attenuation mass
shows uniform tumour enhancement. lesions in the chest wall and subcutaneous tissues.

The British Journal of Radiology, July 2007 575

 P O’Sullivan, H O’Dwyer, J Flint et al

Figure 6. 42-year-old male with right anterior chest wall

lipoma. CT image shows fatty lobulated tumour with a few
thin internal septations.

Figure 9. 82-year-old female also with non-Hodgkin lym-

phoma. CT image shows extensive anterior chest wall spread
of lymphoma, with bilateral pleural effusions, pericardial
effusion and right lung consolidation.

Metastases
Metastatic lesions to the chest wall are uncommon and
usually only seen in patients with extensive metastases
elsewhere (Figure 4). Breast carcinoma has reported rates
of recurrence in the chest wall from 5% to 20% (Figure 5)
[8, 9]. Breast carcinoma may recur in the chest wall, in
scars, close to margin edges or in adjacent axillary lymph
nodes. The occurrence of chest wall metastases is a poor
prognostic indicator, associated with decreased survival
rates [8].

Figure 7. 26-year-old female with well-differentiated lipo-

sarcoma. Coronal T1 fat-saturated post-gadolinium MR
shows incomplete fat saturation within a large encapsulated
Lipoma and liposarcomas
fatty-appearing tumour in the right lateral chest wall. Fatty chest wall tumours are relatively common. Most
are lipomas. Lipomas are sharply circumscribed tumours

Figure 8. 56-year-old male with intermediate-grade liposar-

coma deep to left pectoralis minor muscle. T2 weighted MR Figure 10. 32-year-old male with anterior chest wall TB
image shows oval mass of heterogeneous high signal abscess. CT image shows fluid collection with a thick
intensity lower than fat. enhancing rim.

576 The British Journal of Radiology, July 2007

Pictorial review: Soft tissue tumours of the chest wall
Figure 11. 36-year-old male intravenous drug user with
‘‘empyema necessitans’’. CT image shows empyema and
draining chest wall abscess.
Figure 12. 78-year-old male with right infrascapular elasto-
fibroma. T2 MR shows low signal mass similar to muscle with
internal ‘‘layered’’ appearance (arrow) due to adipose tissue.
(a)
Figure 13. 32-year-old female with sclerosing haemangioma of the chest wall. (a) CT image shows round soft tissue mass in
anterior chest wall. A phlebolith is seen on the pre-contrast images (arrow). (b) CT image shows marked vascular ‘‘blush’’
enhancement pattern following intravenous contrast administration.
The British Journal of Radiology, July 2007
with uniform fat attenuation on CT and homogeneous fat
signal characteristics on MRI. They may contain a few
thin internal septations (Figure 6). There is uniform
signal loss on fat-suppressed MRI. Subtle failure of fat
suppression is seen in well-differentiated (Figure 7)
liposarcomas. Poorly differentiated liposarcomas may
exhibit patchy, little or no fat suppression.
Imaging features that favour a diagnosis of liposar-
coma (Figure 8) include size greater than 10 cm, thick
internal septations, nodular non-adipose areas and
lesions with less than 75% fat signal characteristics
[10].
Lymphoma
Chest wall lymphoma is rare; usually the tumour
extends directly into the anterior chest wall from the
mediastinum in patients with aggressive disease. One
study of 324 patients with Stage 1–2 Hodgkin’s lym-
phoma identified 22 patients (6.7%) with chest wall
invasion. These patients have significantly poorer out-
come when compared with those without chest wall
invasion [11].
Tumour tissue from lymphoma is usually of soft
tissue attenuation at CT, occasionally with central areas
of necrosis. The margins are usually well defined.
Lymphoma tends to spread around bone and cartilage
and to spare these structures. A variable degree of
enhancement is seen post contrast (Figure 9). MRI
usually shows masses of isointense to mildly increased
signal on T1 imaging, with hyperintensity on T2
imaging.
Abscess
Chest wall abscess formation is seen most commonly
in intravenous drug users (IVDU) and following trauma.
Accurate identification is important, as chest wall
abscesses usually require surgical drainage for definitive
(b)
577

Figure 14. 57-year-old male with massive haemangioma of
the chest wall. T1 weighted MR image shows large soft tissue
mass, with low signal vascular channels (arrow).
treatment [12]. In IVDU chest wall infection is often seen
at or near the sterno-clavicular joint, perhaps due to
attempts by the drug abuser to inject into adjacent
vascular structures.
Staph. aureus and M. tuberculosis are the most common
organisms encountered [12]. The typical imaging fea-
tures consist of a focal mass-like lesion with enhancing
walls and central necrosis resulting in fluid attenuation
on CT, and high signal intensity on T2 weighted MR
images. There is usually thickening of surrounding soft
tissue due to inflammation (Figure 10). The formation of
a chest wall abscess via direct communication with a
pneumonia or empyema is termed ‘‘empyema necessi-
tans’’ (Figure 11). Bone destruction may or may not
Figure 15. 28-year-old male with aggressive fibromatosis/
desmoid tumour. Coronal T1 weighted image shows a large
tumour (arrow) of similar attenuation to muscle arising from
the right chest wall.
578
P O’Sullivan, H O’Dwyer, J Flint et al
Figure 16. 65-year-old male with aggressive fibromatosis/
desmoid tumour. T2 weighted image shows high signal
intensity large exuberant tumour growth from the right
chest wall.
occur. The imaging findings are suggestive of infection,
but microbacterial identification is required to direct
appropriate anti-microbial therapy [13].
Elastofibroma dorsi
Elastofibroma dorsi are muscular tumours of the
posterior chest wall. They characteristically occur at the
inferior angle of the scapula and have a reported pre-
valence of 2% in the elderly population. Elastofibroma
typically appears as a tumourous soft tissue mass with a
layered appearance on CT (Figure 12) [14]. On MR, a
mass of low signal similar to muscle is seen, interspersed
with linear high signal on T1 and T2 weighted images.
Only mild enhancement is seen post administration of
contrast in these typically benign tumours [15].
Haemangioma
Haemangiomas are rare benign lesions, composed of
multiple dilated, thin walled tortuous vessels. They are
seen most commonly in children and young adults [1].
On CT haemangiomas usually appear as soft tissue
masses with poorly defined margins. Phleboliths may be
identified at non-contrast CT imaging in ‘‘sclerosing
haemangiomas’’. They usually have heterogeneous low
attenuation on CT pre-contrast, and show marked
enhancement post contrast (Figure 13). Typical haeman-
giomas may show a similar signal to fat on T1 and T2
imaging due to overgrowth of adipose tissue within
them. This may be accompanied by patchy areas of low
signal similar to muscle (Figure 14). Irregular swirled
areas of high signal are seen internally corresponding to
stagnant blood in vascular spaces. Signal void may also
be noted in larger feeding vessels (Figure 14) [1].
Fibromatosis/desmoid
Aggressive fibromatosis/desmoid tumours are fibro-
matous tumours, which are often seen in the chest wall.
They are locally aggressive, produce large exuberant
The British Journal of Radiology, July 2007
Pictorial review: Soft tissue tumours of the chest wall
(a)
Figure 17. 52-year-old female with malignant fibrous histiocytoma (MFH) of the right chest wall, behind a breast prosthesis. (a)
Cross-sectional T1 weighted image shows low signal tumour similar to muscle (arrow). (b) Sagittal T2 image shows high signal
tumour periphery with dark centre (arrow).
tumour growth patterns but rarely metastasize [16, 17].
Extensive chest wall resection is usually required for
adequate treatment. Recurrence rates up to 50% have
been reported in the chest wall [17]. The shoulder is the
most frequently affected area. These tumours are most
commonly seen in young patients less than 25 years of
age.
The CT findings of these lesions are variable and
depend on the tumour composition, including the
collagen content and amount of solid or necrotic tissue
present (Figure 15) [2]. Lesions with a higher solid tissue
component have greater attenuation and enhancement.
Most lesions are confined by the surrounding fascia.
They may surround or displace adjacent structures but
overt tissue invasion is uncommon.
These lesions have similar signal to muscle on T1, with
very high signal on T2 weighted images (Figure 16).
Central areas of low signal are also seen on T2 weighted
images, thought to be due to high collagen content
[2].
Malignant fibrous histiocytoma (MFH)
MFH is a neoplasm that occurs commonly in the chest
wall. It is most frequently seen in elderly patients,
tending to be centred on muscle or surrounding fascial
planes. These tumours tend to be invasive and spread
into adjacent muscle groups. Involvement of under-
lying bone is also not unusual in MFH. Storiform-
pleomorphic MFH is the most common histological
form.
On CT, these tumours present as a heterogeneous
enhancing mass found in the muscle fascial planes. The
MR characteristics include signal intensity similar to or
lower than muscle on T1 weighted images, often
inhomogeneous, and T2 weighted signal equal to or
greater than adipose tissue (Figure 17) [2, 20]. Although
the above features are seen, MFH tumours of long bones
The British Journal of Radiology, July 2007
(b)
and in the chest wall have been shown to have a wide
range of MR signal characteristics [18–20].
Conclusion
‘‘Soft tissue’’ tumours of the chest wall often have a
characteristic appearance or occur in a typical position.
This coupled with a clinical history can often lead to an
accurate radiological diagnosis.
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