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Radiology of Chest Wall Masses

Journal Reading

Nurul Hidayati Syarah

Preceptor : dr. Dessy Wimelda, Sp.Rad

American Roentgen Ray Society


Charles P. Mullan; Rachna Madan; Beatrice Trotman-Dickenson;
Xiaohua Qian; Francine L. Jacobson; Andetta Hunsaker
Radiography
01 Site of lesion, osseous hanges; infection, tumors, trauma

Ultrasound
02 Guidancance for biopsy

Choosing 03 CT
Spatial resolution, mineralization, bony involvement

an Imaging MRI
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Technique Superior soft tissue resolution

PET/CT
05 Metabolic status of chest wall massess

Imaging Guided Biopsy


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Clinical History Description of Images
A 76 year old man with remote history of aortic and mitral valve - Chest radiograph: cardiomegaly, left atrial enlargement, prior
replacement presented with acute chest wall pain: sternotomy
- ECG within normal - Large well defined lesion in the left anterolateral chest wall
- Pain, tenderness, and swelling in the left anterolateral chest containing high signal material, with layering of intermediate
wall
to high signal material in depdendent portion
- No symptoms or history of fever
- STIR: lesion containing fluid
- WBC normal

Scenario 1
Differential Diagnosis Diagnosis:
- Hematoma Chest wall hematoma
- Pectoralis muscle injury and tear - Acute clinical presentation
- Chest wall abscess - Lesion localized within muscle
- Neoplasic proces - Soft tissue enhancement
- Treatment: surgical or conservative

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Chest wall hematoma

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Clinical History Description of Images
A 53 years old man presented with a history of progressive dyspnea - Large mass lesion in right hemithorax;
and alered sensation in the right upper limb:
compressing lung
- No significant medical history
- Predominantly Fat attenuation
- Chest radiograph showed diffuse abnormality in the right hemithorax
- CT obtained - Septations within fat component
- Invasion of hepatic dome

Scenario 2
Differential Diagnosis Diagnosis:
- Liposarcoma Liposarcoma
- Atypical lipoma - Large focal areas in the right hemithorax with low
signal on unenchaned T1-weighted MRI, high
signal on T2-weighted MRI, and amorphous
enhancement on contrast-enchaned CT

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Liposarcoma

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Clinical History Description of Images
A 64 old woman with history of left breast carcinoma: - An abnormal osseous excresscence
- Osseous abnormality in the left anterior chest wall
- Periosteal reation
- Sustaining minor injuries following a motor vehicle accident 2 years
- Margins of lesions are well defined, no
previously
- Asymptomatic inflammatory changes
- Bone proliferation
- Intraarticular gas

Scenario 3
Differential Diagnosis Diagnosis:
- Chondrosarcoma Sternoclavicular Hyperostosis
- Osseous metastases - Large amount of proliferation
- Hyperostosis
- Join centered nature of the lesion
- Degenerative processes
- Intact cortical margins
- Osteoarthropaty, trauma
- Lact of involvement of adjacent soft tissue
- SAPHO syndrome
- Intraartiular gas
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Sternoclavicular
Hyperostosis

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Clinical History Description of Images
A 60 year old man with increasing discomfort in the right posterior - Soft tissue mass with intermediate signal on
chestwall over 3 month period:
proton density imaging
- No significant medical history
- Lesion more heterogenous than neighboring
- Ill defined palpable swelling adjacent to the inferior pole of the right
scapula skeletal muscle
- Alternating high and intermediate signal
areas

Scenario 4
Differential Diagnosis Diagnosis:
- Infective cause Elastofibroma Dorsi
- Abscess - Infrascapular location
- Primary sarcoma of chest wall
- Striated appearance
- Neurofibromas
- Absence of invasion
- Plexiform neurofibromas
- Elastofibroma Dorsi

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Elastofibroma Dorsi

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Clinical History Description of Images
A 50 year old man with right posterior rib pain: - Large soft tissue lesion in posterior right chest wall;
- No significant medical history causing desctruction of ribs
- No history of trauma - Invasion of right lamina and right pedicle of T5 vertebra,
and abutting right side of spinal canal
- Lesion is homogenous
- Obtuse angle with chest wall

Scenario 5
Differential Diagnosis Diagnosis:
- Extrapulmonary Plasmacytoma
- Mesothelioma - Male, older than 50 years old
- Primary malignancy of the chest wall:
- Arise from bone and expansile
chondrosarcoma
- The most frequent site: vertebral column and ribs
- Multiple myeloma
- Osseous metastatis
- Plasmacytoma
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Plasmacytoma

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Clinical History Description of Images
A 48 year old man with no symptoms related to the mass: - Homogenous well circumscribed right subclavicular soft
- Incidental finding of an upper right chest wall mass tissue mass, slightly hypoattenuation
- Lesion has dumbbell shape and extends into first
intercostal space
- Mildly avid on PET/CT examination

Scenario 6
Differential Diagnosis Diagnosis:
- Lymph node Schwannoma
- Infective vause - Well defined encapsulated appearance
- Abscess - Omonly cause erosion of adjacent bony structure
- Benign peripheral nerve sheath tumor: - Prominent enchancement on contrast enhanced
shwannoma or neurofibroma images
- Atypical lipoma - Midly FDG avid on PET
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Schwannoma

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Clinical History Description of Images
A 39 year old woman with persistent left anterior chest wall - Opacity centered on the anterior aspect of the left fifth
pain over 3 month period: rib
- No significant medical history - Expansile, with bony spicules radiating from central
portion and loss of normal cortical rib margins
- Central fibrous stroma containing areas of calcification
and highly vascular peripheral component

Scenario 7
Differential Diagnosis Diagnosis:
- Agressive process Rib hemangioma
- Metastasis: chondrosarcoma - Imaging play a limited value in this scenario
- Benign: fibrous dysplasia - PET/CT  prominent FDG activity in the periphery
of the lesion
- Low grade primary malignant tumor of the chest
wall
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Rib hemangioma
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Clinical History Description of Images
A 31 year old man with 1 month history of persistent left - Soft tissue mass with osseous destruction involving the
upper chest wall pain: left sternal manubrium
- No significant medical history - Extending into extraosseous tissue
- No systemic clinical feature - Amorphous areas of irregular and arclike calcification
within the mass
- Central porsion of the mass is heterogenous

Scenario 8
Differential Diagnosis Diagnosis:
- Osseous manubrium Chondrosarcoma
- Bone metastasis - Stippled and arclike calcification
- Primary tumor - But patients has no history of prior irradioation
- Osteomyelitis
- Osseous neoplasma; Chondrosarcoma,
osteosarcoma
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Chondrosarcoma

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 A systematic problem-based approach is required to
define the differential diagnosis and to determine the
most appropriate investigation to characterize the lesions

 Inf it is not possible to secure a diagnosis by imaging


alone, biopsy will be necessary under CT or ultrasound

Conclusion guidane

 PET/CT will targeting biopsy toward metabolically active


area

 The correlation of clinical, radiologic, and pathologic data


is required for optimal treatment planning of chest wall
masses

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Thank you!

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