First published online May 25, 2006
British Journal of Radiology (2007) 80, 574-580
© 2007 British Institute of Radiology
doi: 10.1259/bjr/16591964
Soft tissue tumours and mass-like lesions of the chest wall: a pictorial review of CT and MR findings
P O'Sullivan, FFR, RCSI1,
H O'Dwyer1,
J Flint2,
P L Munk, MDCM, FRCPC1 and
N Muller, MD, PhD, FRCP(C)1
Departments of 1 Radiology and 2 Anatomical Pathology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
Correspondence: Paul O'Sullivan, Department of Radiology, Vancouver General Hospital, 899 West 12th Avenue, Vancouver V5Z IM9, Canada. E-mail: sullypos{at}yahoo.com
 |
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 on soft tissue tumours of the chest wall. Common chest wall soft tissue tumours and mass-like lesions include peripheral nerve tumours, lipomas, liposarcomas, haemangiomas, elastofibromas, metastases, lymphoma and abscesses. Other lesions encountered include desmoid tumours and malignant fibrous histiocytoma. Many have distinctive radiological findings or occur in specific locations, allowing a specific radiological diagnosis to be suggested.
|
Introduction
|
|---|
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, liposarcomas, haemangiomas, elastofibromas, lymphoma, metastases 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 neurofibroma, 5 (11%) neurofibromas and 6 (13%) schwannomas, all benign), 8 (18%) lipomas, 5 (11%) metastases, 4 (9%) abscesses, 4 (9%) liposarcomas, 3 (6.8%) elastofibromas, 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 originating within a nerve (neurofibroma; plexiform or non-plexiform), nerve sheath (schwannoma/neurilemoma) 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 schwannoma) 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 heterogeneous (Figure 1
), intermediate to high signal intensity when compared with adipose tissue [4]. Avid contrast enhancement is often seen (Figure 2).
View larger version (142K):
[in this window]
[in a new window]
|
Figure 1. 35-year-old male with intercostal nerve schwannoma. T2 coronal MR image shows round, smooth, heterogeneous intermediate and high signal intensity.
|
|
View larger version (150K):
[in this window]
[in a new window]
|
Figure 2. 62-year-old-male with right axillary plexiform neuroma. Coronal T1 fat-saturated MR post gadolinium shows uniform tumour enhancement.
|
|
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 neurofibromatosis should raise suspicion for malignancy [6]. Schwannomas have also been described as having a "bead-like" appearance (Figure 3) [7].
View larger version (90K):
[in this window]
[in a new window]
|
Figure 3. 40-year-old male with right intercostal schwannoma. Axial T1 image (non-contrast) shows a "bead-like" appearance of schwannoma.
|
|
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 administration of gadolinium (Figure 4).
View larger version (106K):
[in this window]
[in a new window]
|
Figure 4. 56-year-old female with hepatitis C and metastatic hepatocellular carcinoma. CT shows enhancing chest wall metastases (arrow) and similar enhancing nodular hepatocellular carcinoma.
|
|
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].
View larger version (103K):
[in this window]
[in a new window]
|
Figure 5. 68-year-old female with metastatic breast carcinoma. CT image shows multiple soft tissue attenuation mass lesions in the chest wall and subcutaneous tissues.
|
|
Lipoma and liposarcomas
Fatty chest wall tumours are relatively common. Most are lipomas. Lipomas are sharply circumscribed tumours 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.
View larger version (82K):
[in this window]
[in a new window]
|
Figure 6. 42-year-old male with right anterior chest wall lipoma. CT image shows fatty lobulated tumour with a few thin internal septations.
|
|
View larger version (114K):
[in this window]
[in a new window]
|
Figure 7. 26-year-old female with well-differentiated liposarcoma. Coronal T1 fat-saturated post-gadolinium MR shows incomplete fat saturation within a large encapsulated fatty-appearing tumour in the right lateral chest wall.
|
|
Imaging features that favour a diagnosis of liposarcoma (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].
View larger version (129K):
[in this window]
[in a new window]
|
Figure 8. 56-year-old male with intermediate-grade liposarcoma deep to left pectoralis minor muscle. T2 weighted MR image shows oval mass of heterogeneous high signal intensity lower than fat.
|
|
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 lymphoma identified 22 patients (6.7%) with chest wall invasion. These patients have significantly poorer outcome 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.
View larger version (160K):
[in this window]
[in a new window]
|
Figure 9. 82-year-old female also with non-Hodgkin lymphoma. CT image shows extensive anterior chest wall spread of lymphoma, with bilateral pleural effusions, pericardial effusion and right lung consolidation.
|
|
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 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 features 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 necessitans" (Figure 11). Bone destruction may or may not occur. The imaging findings are suggestive of infection, but microbacterial identification is required to direct appropriate anti-microbial therapy [13].
View larger version (113K):
[in this window]
[in a new window]
|
Figure 10. 32-year-old male with anterior chest wall TB abscess. CT image shows fluid collection with a thick enhancing rim.
|
|
View larger version (132K):
[in this window]
[in a new window]
|
Figure 11. 36-year-old male intravenous drug user with "empyema necessitans". CT image shows empyema and draining chest wall abscess.
|
|
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 prevalence 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].
View larger version (108K):
[in this window]
[in a new window]
|
Figure 12. 78-year-old male with right infrascapular elastofibroma. T2 MR shows low signal mass similar to muscle with internal "layered" appearance (arrow) due to adipose tissue.
|
|
|
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 haemangiomas 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].
View larger version (45K):
[in this window]
[in a new window]
|
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.
|
|
View larger version (146K):
[in this window]
[in a new window]
|
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).
|
|
Fibromatosis/desmoid
Aggressive fibromatosis/desmoid tumours are fibromatous tumours, which are often seen in the chest wall. They are locally aggressive, produce large exuberant 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.
View larger version (125K):
[in this window]
[in a new window]
|
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.
|
|
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].
View larger version (109K):
[in this window]
[in a new window]
|
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.
|
|
|
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 underlying 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 and in the chest wall have been shown to have a wide range of MR signal characteristics [18–20].
View larger version (66K):
[in this window]
[in a new window]
|
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).
|
|
|
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.
Received for publication November 4, 2005.
Revision received December 16, 2005.
Accepted for publication January 16, 2006.
|
References
|
|---|
- Tateishi U, Gladish GW, Kusumoto M, Hasegawa T, Tsuchiya R, Moriyama N, et al. Chest wall tumors: radiologic findings and pathologic correlation: part 1. Benign tumors. Radiographics 2003;23:1477–90.[Abstract/Free Full Text]
- Tateishi U, Gladish GW, Kusumoto M, Hasegawa T, Tsuchiya R, Moriyama N, et al. Chest wall tumors: radiologic findings and pathologic correlation: part 2. Malignant tumors. Radiographics 2003;23:1491–508.[Abstract/Free Full Text]
- Yamaguchi M, Yoshino I, Fukuyama S, Osoegawa A, Kameyama T, Maehara Y. Surgical treatment of neurogenic tumors of the chest. Ann Thorac Cardiovasc Surg 2004;10:148–51.[Medline]
- Ko SF, Lee TY, Lin JW, Ng SH, Chen WJ, Hsieh MJ, et al. Thoracic neurilemomas: an analysis of computed tomography findings in 36 patients. J Thorac Imaging 1998;13:21–6.[Medline]
- Moon WK, Im JG, Han MC. Malignant schwannomas of the thorax: CT findings. J Comput Assist Tomogr 1993;17:274–6.[Medline]
- Verstraete KL, Achten E, De Schepper A, Ramon F, Parizel P, Degryse H, et al. Nerve sheath tumors: evaluation with CT and MR imaging. J Belge Radiol 1992;75:311–20.[Medline]
- Tsuzuki E, Kamimura M, Kobayashi N, Kudo K, Morita T, Hasuo K, et al. [A case of schwannoma of the chest wall showing a bead-like appearance in MRI] [Article in Japanese]. Nihon Kokyuki Gakkai Zasshi 2003;41:766–70.[Medline]
- Haffty BG, Hauser A, Choi DH, Parisot N, Rimm D, King B, et al. Molecular markers for prognosis after isolated postmastectomy chest wall recurrence. Cancer 2004;100:252–63.[CrossRef][Medline]
- Cuenca RE, Allison RR, Sibata C, Downie GH. Breast cancer with chest wall progression: treatment with photodynamic therapy. Ann Surg Oncol 2004;11:322–7.[Abstract/Free Full Text]
- Kransdorf MJ, Bancroft LW, Peterson JJ, Murphey MD, Foster WC, Temple HT, et al. Imaging of fatty tumors: distinction of lipoma and well-differentiated liposarcoma. Radiology 2002;224:99–104.[Abstract/Free Full Text]
- Hodgson DC, Tsang RW, Pintilie M, Sun A, Wells W, Crump M, et al. Impact of chest wall and lung invasion on outcome of stage 1–2 Hodgkin's lymphoma after combined modality therapy. Int J Radiat Oncol Biol Phys 2003;57:1374–81.[CrossRef][Medline]
- Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore) 2004;83:139–48.[CrossRef][Medline]
- Arslan A, Ciftci E, Yildiz F, Cetin A, Demirci A. Multifocal bone tuberculosis presenting as a breast mass. Eur Radiol 1999;9:1117–19.[CrossRef][Medline]
- Brandser EA, Goree JC, El-Khoury GY. Elastofibroma dorsi: prevalence in an elderly patient population as revealed by CT. AJR Am J Roentgenol 1998;171:977–80.[Abstract/Free Full Text]
- Zembsch A, Schick S, Trattnig S, Walter J, Amann G, Ritschl P. Elastofibroma dorsi. Study of two cases and magnetic resonance imaging findings. Clin Orthop Relat Res 1999;364:213–19.[CrossRef][Medline]
- Kabiri EH, Al Aziz S, El Maslout A, Benosman A. Desmoid tumors of the chest wall. Eur J Cardiothoracic Surg 2001;19:580–3.[Abstract/Free Full Text]
- Allen PJ, Schriver CD. Desmoid tumors of the chest wall. Semin Thorac Cardiovasc Surg 1999;11:264–9.[Medline]
- Tateishi U, Kusumoto M, Hasegawa T, Yokoyama R, Moriyama N. Primary malignant fibrous histiocytoma of the chest wall: CT and MR appearance. J Comput Assist Tomogr 2002;26:558–63.[CrossRef][Medline]
- Link TM, Haeussler MD, Popek S, Woertler K, Rummeny EJ. Malignant fibrous histiocytoma of bone: conventional X-ray and MR imaging features. Skeletal Radiol 1998;27:552–8.[CrossRef][Medline]
- Mahajan H, Kim E, Wallace S, Abello R, Benjamin R, Evans HL. Magnetic resonance imaging of malignant fibrous histiocytoma. Magn Reson Imaging 1989;7:283–8.[CrossRef][Medline]
This article has been cited by other articles:
|
|
|
|
 
J. H. Youk, E.-K. Kim, M. J. Kim, and K. K. Oh
Imaging Findings of Chest Wall Lesions on Breast Sonography
J. Ultrasound Med.,
January 1, 2008;
27(1):
125 - 138.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
