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

Cardiopulmonary Imaging
Review
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Radiology of Chest Wall Masses

Charles P. Mullan1 OBJECTIVE. The purpose of this article is to highlight the role of radiography, CT, PET/
Rachna Madan2 CT, and MRI in the diagnosis and management of chest wall lesions. Chest wall masses are
Beatrice Trotman-Dickenson2 caused by a spectrum of clinical entities. The lesions highlighted in this selection of case sce-
Xiaohua Qian 3 narios include neoplastic, inflammatory, and vascular lesions.
Francine L. Jacobson2 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 percutane-
Andetta Hunsaker 2
ous biopsy, when it is indicated. Imaging enables accurate staging and is a key component of
Mullan CP, Madan R, Trotman-Dickenson B, treatment planning for chest wall masses.
Qian X, Jacobson FL, Hunsaker A
Choosing an Imaging Technique PET/CT
Radiography FDG activity provides information re-
Chest radiographs and dedicated views of garding the metabolic status of chest wall
the ribs and sternoclavicular joints provide masses but only limited additional diagnos-
basic information regarding the site of the tic information regarding the primary lesion.
lesion and reveal osseous changes. Radio- It is most useful in providing data on region-
graphs are especially useful in the setting of al and distant metastases and in choosing the
trauma, infection, and osseous tumors. most metabolically active area for biopsy.

Ultrasound Imaging-Guided Biopsy

Keywords: biopsy, cardiopulmonary imaging, CT, MRI,
PET/CT, thorax Superficial chest wall lesions can be char- Chest wall lesions are usually amenable
acterized with ultrasound imaging, and these to imaging-guided percutaneous biopsy with
DOI:10.2214/AJR.10.7259 lesions are amenable to biopsy with ultra- CT or ultrasound. Review of CT, MRI, and
sound guidance. PET/CT findings allows the percutaneous ap-
Received July 6, 2010; accepted after revision
October 4, 2010.
proach to be formulated. Directing biopsy to-
CT ward areas of enhancing or metabolically ac-
1Department of Radiology, Altnagelvin Hospital,
CT is the workhorse of diagnostic imag- tive soft tissue within the lesion will avoid an
Londonderry BT46 5QR, Northern Ireland.  Address ing for chest wall lesions and provides good inadequate specimen resulting from tumor
correspondence to C. P. Mullan
(cpmullan@hotmail.com).
spatial resolution, including depiction of os- necrosis. PET/CT can be particularly helpful
seous and soft-tissue structures. MDCT en- in confirming areas of viable tumor with FDG
2
Department of Radiology, Brigham & Women’s Hospital, ables imaging of a large tissue volume in a uptake in a large chest wall lesion or nodal
Boston, MA. short acquisition time, reducing the effect of metastases, which may be easier to access.
3 respiratory motion in the thorax. CT reveals
Department of Pathology, Brigham & Women’s Hospital,
Boston, MA. mineralization and bony involvement and Scenario 1
helps in narrowing the differential diagnosis. Clinical History
CME A 76-year-old man with a remote history of
This article is available for CME credit. MRI aortic and mitral valve replacement presented
See www.arrs.org for more information.
MRI has superior soft-tissue resolution with acute left chest wall pain. There was no his-
WEB and is invaluable for local assessment of pri- tory of significant trauma. ECG showed no evi-
This is a Web exclusive article. mary tumors. It enables accurate tissue char- dence of an acute myocardial event. On clinical
acterization and assessment of enhancement examination, the patient had pain, tenderness,
AJR 2011; 197:W460–W470
patterns. It plays a key role in preoperative and swelling in the left anterolateral chest wall.
0361–803X/11/1973–W460 staging to assess for multispatial and multi- There were no systemic symptoms or history
compartment involvement and involvement of fever, and serum WBC count was normal. A
© American Roentgen Ray Society of neurovascular structures. chest radiograph and MRI were obtained.

W460 AJR:197, September 2011


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A B
Description of Images
The chest radiograph (Fig. 1A) shows ev-
idence of cardiomegaly, left atrial enlarge-
ment, 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 le-
sion in the left anterolateral chest wall con-
taining high-signal material, with layering
of intermediate-to-high-signal material in
the dependent portion. There is also dif-
fusely 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 de-
pendent 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.
AJR:197, September 2011 W461
Imaging of Chest Wall Masses
C D
Differential Diagnosis
The most likely diagnosis is a hemato-
ma, consistent with the acute onset of the
pain and location within the chest wall mus-
culature. The patient has prosthetic cardiac
valves and was therefore receiving oral an-
ticoagulants. A relatively minor muscle inju-
ry could precipitate a significant hematoma.
Although, to our knowledge, there are lim-
ited published data about spontaneous chest
wall bleeding, hematoma in the thoracic
wall is a described complication in patients
receiving anticoagulants who undergo tho-
racic or shoulder surgery [1]. The fluid-fluid
level within the lesion on MRI is consistent
with layering of hemorrhage, with the more-
dependent hemorrhagic contents showing
higher signal on T1-weighted imaging. The
increased T2-weighted signal extending
across the left pectoralis muscle is sugges-
tive of pectoralis muscle injury and tear. A
chest wall abscess would also be consistent
with the presentation of chest pain. Howev-
er, an infective lesion of this size would be
Fig. 1—76-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.
expected to cause systemic symptoms, in-
cluding fever, which were absent in this case.
Although the MRI scans reveal a large fluid
collection with inflammatory change in adja-
cent tissues, the lack of a discernible wall is
consistent with hematoma rather than an ab-
scess. 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 sec-
ondary 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 rhabdomyo-
sarcoma 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 patient’s valvular heart
disease requiring anticoagulants. The patient

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 clini-
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cal 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 hema-
toma and should raise suspicion of hemor-
rhage 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 tem-
porary reversal may be required before under-
taking 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 superfi-
cial 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-
A B
Fig. 2—53-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.
W462 AJR:197, September 2011
Mullan et al.
operative risks. However, surgical drainage
and débridement would be required if the he-
matoma became infected and could not be ad-
equately treated with percutaneous drainage.
Chronic expanding hematoma of the tho-
rax 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 calci-
fication. IV antibiotics would be indicated if
there are clinical and radiologic features of
infection but would not be effective alone in
treating the hematoma.
Scenario 2
Clinical History
A 53-year-old man presented with a his-
tory of progressive dyspnea and altered sen-
sation in the right upper limb. There was
no significant medical history. A chest ra-
diograph showed diffuse abnormality in
the right hemithorax, and the patient subse-
quently underwent CT of the thorax.
Description of the Images
Selected axial images from a contrast-en-
hanced CT performed in the arterial phase
show a large mass lesion in the right hemi-
thorax, causing significant compressive atel-
ectasis in the right lung. Although the largest
component of the mass is intrathoracic, it ex-
D E
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 an-
teroinferior 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 in-
volving the right hemithorax and invasion of
the hepatic dome through the right hemidia-
phragm. Axial T1-weighted imaging shows
high signal in the lipomatous components of
the lesion (Fig. 2D). The soft-tissue compo-
nents of the lesion in the right lower hemi-
thorax exhibit low signal on unenhanced T1-
weighted images (Fig. 2D) and high signal
on T2-weighted images (Fig. 2E).
Differential Diagnosis
The differential diagnosis includes lipo-
sarcoma and atypical lipoma. The extension
of the mass outside the right hemithorax, in-
volvement of the superior sulcus, and inva-
sion of the hepatic dome are consistent with
an aggressive malignancy. The lesion extends
along the right side of the mediastinum. Be-
cause fat comprises the greatest component of
the mass, it is difficult to determine the ex-
tent of mediastinal invasion. Well-differenti-
ated liposarcoma may contain large amounts
C
 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 li-
pomas and liposarcomas do not contain areas
of calcification. When calcification is present,
it is not a reliable determinant of malignan-
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and amorphous enhancement on contrast-
enhanced CT, suggesting a myxoid compo-
nent. 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.
wall on a chest radiograph performed at rou-
tine follow-up. The patient had sustained mi-
nor injuries following a motor vehicle acci-
dent 2 years previously and was otherwise
asymptomatic.

cy [4]. Large thickened septations in a lipo- This appearance of variable signal intensity Description of Images
matous lesion are suggestive of liposarcoma. on MRI is commonly seen in larger liposar- Selected axial (Fig. 3A) and sagittal (Fig.
However, thin septations such as those seen in comas, which can have multiple histologic 3B) images of CT examination are displayed
this case are frequently seen in lipomas. Pri- subtypes within the same lesion [9]. Patients in bone window. An abnormal osseous ex-
mary liposarcoma in the mediastinum is rare, with well-differentiated liposarcoma have a crescence is seen arising from the region of
but reported findings include invasion of the much better prognosis after therapy than do the left sternoclavicular joint, without evi-
pericardium and great vessels [5]. In this case, patients with pleomorphic histologic subtype dence of osteolysis in the bones adjacent to
there is clear invasion through the diaphragm [6]. Myxoid liposarcoma has an intermediate the lesion. The lesion extends into the left
and into the dome of the liver. Nonadipose prognosis [5, 6]. On histopathologic analy- chest wall, causing anterior displacement of
components are much more frequent in well- sis, the tumor in this scenario had both well- the left pectoralis major muscle. Periosteal
differentiated liposarcomas than in lipomas. differentiated and myxoid components. The reaction is identified at the anterior aspect
However, up to 31% of lipomas may exhibit patient subsequently developed metastatic of the articular surfaces of both the manu-
nonadipose components [4], so the presence disease a few years later, with histology indi- brium and the clavicle. The margins of the
of higher attenuation portions within the mass cating high-grade pleomorphic liposarcoma. lesion are well defined, and no inflammato-
is not reliable in determining malignancy. ry changes are seen in the adjacent muscle
Scenario 3 or fat of the chest wall. On the sagittal view,
Diagnosis: Liposarcoma Clinical History bone proliferation can be seen on both sides
Distinguishing well-differentiated li- A 64-year-old woman with a history of of the sternoclavicular joint. Intraarticular
posarcoma from lipoma can be a diagnos- left breast carcinoma was found to have an gas is identified within the slightly widened
tic challenge with radiologic imaging. Al- osseous abnormality in the left anterior chest left sternoclavicular joint. A reformatted cor-
though lesions composed entirely of adipose
tissue can be reliably identified as lipomas,
the presence of nonadipose components does
not definitively indicate malignancy. Imag-
ing-guided biopsy targeting the nonadipose
component of the lesion is an invasive proce-
dure but is the best way to prove the diagno-
sis. This is a less invasive option than surgi-
cal biopsy. The extensive nature of the lesion
in this patient means that accurate diagno-
sis and staging are required before deciding
whether surgical excision is appropriate. Al-
though MRI is the best imaging technique
to provide information on local staging, li- A B
posarcoma cannot be reliably diagnosed
by MRI features alone. Ultrasound may be
helpful in distinguishing cystic lesions from
myxoid elements of liposarcoma [6]. Howev-
er, CT was performed with IV contrast agent
in this case, and ultrasound is therefore un-
likely 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 ab-
sence of significant FDG activity will not re-
liably exclude malignancy. The liposarco- C D
ma in this scenario exhibits a heterogeneous Fig. 3—64-year-old woman with history of left breast carcinoma and osseous abnormality in left anterior chest
signal intensity pattern. There are large fo- wall on chest radiograph.
cal areas in the right lower hemithorax A, Axial CT image of thorax in bone window.
B, Sagittal CT image of thorax in bone window.
with low signal on unenhanced T1-weight- C, Reformatted coronal image of sternoclavicular joints.
ed MRI, high signal on T2-weighted MRI, D, Axial CT image of thorax obtained 3 years before images in A–C were obtained.

AJR:197, September 2011 W463

 Mullan et al.

onal image (Fig. 3C) also shows the osseous
abnormality involving both sides of the ster-
noclavicular 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.
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a result of degenerative processes. The vac-
uum phenomenon is rarely seen in infec-
tions but occurs in osteoarthropathy, crystal
deposition disease, and trauma [11]. Al-
though the right sternoclavicular joint is not
affected in this patient, published literature
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 in-
termediate signal intensity on proton-den-
sity imaging (Fig. 4A) and fat-suppressed

Differential Diagnosis
A bony outgrowth is identified at the me-
dial end of the left clavicle and the adjacent
portion of the sternal manubrium and ap-
pears to be centered on the left sternoclavic-
ular joint. This patient has no symptoms to
suggest septic arthritis and no evidence of
periarticular bone resorption or inflamma-
tory changes in the adjacent soft tissues. Al-
though chondrosarcoma can extend across
joint spaces [10], the symmetric involve-
ment 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 histo-
ry of treated breast cancer, and the possibil-
ity of an osseous metastasis has to be con-
sidered. However, the joint-based nature of
the lesion, lack of other osseous lesions, and
stability over a 3-year period does not sug-
gest metastatic disease. The imaging find-
ings 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 accu-
mulation (mostly nitrogen) within synovial
joints due to distraction of the articular sur-
faces. This radiologic feature is also com-
monly found within intervertebral disks as
has described cases of bilateral hyperos-
tosis associated with cutaneous symptoms
[12, 13]. The SAPHO syndrome is a clini-
cal entity consisting of synovitis, acne, pus-
tulosis, hyperostosis, and osteitis. However,
this patient does not have bilateral sterno-
clavicular hyperostosis or palmar cutaneous
lesions to suggest SAPHO syndrome.
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 arthropa-
thy. The presence of intraarticular gas is sug-
gestive of osteoarthropathy, although it may
also be seen with trauma and crystal deposi-
tion disease [11]. The remote history of mi-
nor chest trauma indicates a possible caus-
ative factor for osteoarthropathy.
Scenario 4
Clinical History
A 60-year-old man presented with increas-
ing discomfort in the right posterior chest wall
over a 3-month period. The patient had no sig-
nificant medical history. On examination,
there was an ill-defined palpable swelling ad-
jacent to the inferior pole of the right scapula.
T1-weighted (Fig. 4B) imaging is identified
adjacent to the inferior tip of the right scapu-
la. The lesion is more heterogeneous than the
neighboring skeletal muscle on all sequenc-
es, exhibiting alternating high and interme-
diate signal areas. The mass exhibits avid
enhancement on the contrast-enhanced se-
quence (Fig. 4C).
Differential Diagnosis
The clinical features of progressive dis-
comfort in the chest wall over 3 months with-
out significant history are not suggestive of an
infective cause. The signal characteristics in-
dicate an enhancing soft-tissue lesion, with-
out 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 pre-
sentation, 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 hypoin-
tensity on T2-weighted imaging due to fibro-
collagenous material [15], which is not pres-
ent in this case. Plexiform neurofibromas can
be infiltrative with variable signal pattern on

A B C
Fig. 4—60-year-old man with 3-month history of right posterior chest wall pain.
A, Axial proton density–weighted 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.

W464 AJR:197, September 2011


T1-weighted, T2-weighted, and contrast-en-
hanced imaging. However, these lesions are
almost exclusively seen in patients with neuro-
fibromatosis type 1, in conjunction with mul-
tiple cutaneous manifestations [16]. Elastofi-
broma dorsi essentially always occurs in the
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subscapular area, is nonencapsulated, and has
alternating fibrous and fatty tissue bands that
produce a striated appearance on T1-weight-
ed 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 elasto-
fibromas usually exhibit only faint enhance-
ment, more marked enhancement occasional-
ly occurs in these lesions [18].
Diagnosis: Elastofibroma Dorsi
The infrascapular location, striated ap-
pearance, and absence of invasion are strong-
ly 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 tu-
mor. Imaging-guided biopsy confirmed that
this patient had an elastofibroma. Asymp-
tomatic patients with more typical imaging
characteristics may not require biopsy or ex-
cision [17]. Elastofibroma dorsi is a benign
soft-tissue pseudotumor characterized by ac-
cumulation of collagenized tissue with elas-
tic fibers. These lesions are most common in
elderly women and are an important differ-
ential diagnosis to consider when an infra-
scapular soft-tissue lesion is present. Elas-
tofibroma dorsi often presents as bilateral
subscapular masses [17, 18]. The presence of
A B
Fig. 5—50-year-old man with right posterior rib pain.
A, Axial CT image of thorax.
B and C, Axial T2-weighted MRI scans of thorax.
AJR:197, September 2011 W465
Imaging of Chest Wall Masses
bilateral lesions with typical imaging char-
acteristics is essentially diagnostic, obviat-
ing 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 fi-
bers in collagenized fibrofatty tissue [18]. If
the results of percutaneous biopsy are equiv-
ocal or the lesion is causing significant func-
tional impairment, surgical biopsy or exci-
sion will be required [18].
Scenario 5
Clinical History
A 50-year-old man presented with right
posterior rib pain. The patient had no signifi-
cant 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 T2-
weighted 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 sig-
nal 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 lo-
cation. Although the lesion may arise from
the pleura, mesothelioma usually progresses
in a circumferential pattern around the hemi-
thorax, 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. Al-
though chondrosarcoma is the most common
primary malignancy of the chest wall, it usu-
ally occurs more anteriorly than the lesion in
this scenario. Chondrosarcoma is often cen-
tered on the sternum or costochondral carti-
lage [14]. Stippled areas of calcification due
to chondroid matrix are often seen in chon-
drosarcoma, 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 plasmacy-
toma or multiple myeloma or osseous metas-
tases. Myeloma is the most common prima-
ry bone marrow malignancy in adults [20].
Most plasmacytomas arising from bone are
osteolytic in nature and usually do not con-
tain 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 pe-
ripheral nerve sheath tumors such as neuro-
fibroma and schwannoma. However, other
neoplasms, including plasmacytoma and in-
fectious diseases, can cause this finding [22].
Diagnosis: Plasmacytoma
Most patients with solitary myeloma (plas-
macytoma) are male and older than 50 years
C
 Mullan et al.

[23]. Although these lesions are relative-
ly common, the imaging features are non-
specific. 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
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erosion of adjacent cortical bone and dumb-
bell shape of the mass are recognized fea-
tures of a benign peripheral nerve sheath tu-
mors, such as schwannoma or neurofibroma.
It is often difficult to differentiate schwan-
noma from neurofibroma on radiologic im-
component, the absence of any areas of fat
attenuation within the lesion is not consistent
with lipoma.
Diagnosis: Schwannoma
Schwannomas are peripheral nerve sheath

may also originate in extraosseous soft tis- aging. An eccentric location relative to the tumors that most often present in adults as
sues [25]. Biopsy of this lesion confirmed a parent nerve and areas of cystic degeneration asymptomatic slow-growing lesions [22].
plasmacytoma. No other sites of bone dis- are more suggestive of schwannoma [22, 26]. They typically have a well-defined encapsu-
ease were identified on skeletal survey. The However, these imaging features are not lated appearance and commonly cause ero-
extraosseous soft-tissue component may pre- present in the current scenario. Although sion of adjacent bony structures as a result
dominate, as in this case. Expansile osteolyt- atypical lipomas may have a large soft-tissue of a pressure effect. Benign peripheral nerve
ic metastases, such as those resulting from
primary renal or thyroid malignancy, could
cause a similar appearance. Radiologic im-
aging plays an important role in determin-
ing the disease burden in patients with my-
elomatous disease, including complications
such as pathologic factors [25]. Eighty-five
percent of patients with solitary plasmacy-
toma will develop multiple myeloma within
several years of initial diagnosis [23].

Scenario 6
Clinical History
A 48-year-old man underwent CT examina-
tion 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 homoge- A B
neous well-circumscribed right subclavicu-
lar soft-tissue mass, which is slightly hypoat-
tenuating in comparison with the adjacent
skeletal muscle (Figs. 6A–6C). The lesion
extends into the first intercostal space and
has a dumbbell shape (Fig. 6B). There is
mild scalloping and erosion of the right later-
al second rib adjacent to the mass lesion (Fig.
6A). The mass is mildly FDG avid on PET/
CT examination (Fig. 6D). No other FDG-
positive disease is seen in the chest.

Differential Diagnosis
The dumbbell shape of the mass and exten-
sion into the intercostal space is unusual for a
lymph node. There is no evidence of central ne-
crosis on PET, which would be expected with a
lymph node lesion of this size. The asymptom-
atic nature of the lesion does not suggest an in-
fective cause. Also, there is no central low at-
tenuation within the lesion to indicate fluid, and
no inflammatory change is seen in the adjacent C D
fat of the right chest wall to an abscess. The Fig. 6—48-year-old man with incidental finding of upper right chest wall lesion on CT.
well-defined margins, homogeneous appear- 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.
ance, and asymptomatic nature of the lesion C, Contrast-enhanced coronal CT image of thorax.
are suggestive of a slow-growing entity. The D, Coronal FDG PET image.

W466 AJR:197, September 2011


sheath tumors often exhibit prominent en-
hancement 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
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malignant peripheral nerve sheath tumor in-
clude indistinct margins and myxoid stroma,
but these findings are nonspecific [28].
Scenario 7
Clinical History
A 39-year-old woman presented with per-
sistent 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 im-
age in bone window shows that the lesion is
expansile, with fine bony spicules radiating
from the central portion and loss of the nor-
mal 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 sur-
gical resection, with central fibrous stroma-
A B
Fig. 7—39-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.
AJR:197, September 2011 W467
Imaging of Chest Wall Masses
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 visual-
ized bony skeleton on the chest radiograph or
PET/CT examination. Although metastases
are the most common neoplastic rib lesion,
primary malignant lesions (e.g., chondrosar-
coma) or benign lesions (e.g., fibrous dyspla-
sia) must be considered in the differential di-
agnosis of a solitary expansile rib lesion [29].
Further investigation should be performed
to secure a diagnosis unless there are clini-
cal 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-guid-
ed biopsy would probably be preferable so
that the surgical approach can be optimized.
Diagnosis: Rib Hemangioma
The expansile nature of the mass with ra-
diating bony spicules made definitive diagno-
sis on the basis of radiologic imaging alone
difficult. Preoperatively, a primary malignant
tumor of the rib, such as low-grade chondro-
sarcoma 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 re-
ports describing rib hemangiomas with radio-
logic features similar to those in this scenario
[31, 32]. Patients with rib hemangioma usu-
ally present with a solitary expansile rib le-
sion, which may cause pain or a palpable chest
wall mass [33]. These lesions usually enhance
on contrast-enhanced CT or MRI. Some hem-
angiomas have a spiculated or sunburst ap-
pearance due to fine linear calcifications, as
seen in this patient. This scenario highlights
the limitations of imaging alone and the im-
portance of definite histologic diagnosis in the
management of chest wall tumors. Chest wall
tumors may be sampled using fine-needle as-
piration biopsy, excisional biopsy, and inci-
sional biopsy. In general, fine-needle aspira-
tion biopsy is not recommended unless there
is a strong suspicion of myeloma or metastatic
disease. Excisional biopsy is performed for le-
sions less than 2–3 cm in diameter, and larger
lesions usually undergo incisional biopsy. In
this case, the PET/CT scan showing promi-
nent FDG activity in the periphery of the le-
sion 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 preop-
erative biopsy was done. Therefore, resection
was performed for both definitive diagnosis
and treatment.
C
(Fig. 7 continues on next page)
 Mullan et al.

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.
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D E
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 his-
tory and no systemic clinical features.
Description of Images
Axial CT shows a soft-tissue mass with
osseous destruction involving the left ster-
nal manubrium (Fig. 8A). The lesion has a
large soft-tissue component that extends into
the extraosseous tissues (Fig. 8B). The le-
sion 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 contrast-
enhanced MRI (Fig. 8C) shows peripher-
al enhancement of the lesion and delineates
its extension into adjacent soft-tissue struc-
tures. The central portion of the mass is het-
erogeneous, 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 destruc-
tion. The mass also extends into the adjacent
soft tissues of the left chest wall, indicating
an aggressive lesion. The patient’s age and
absence of any prior clinical history of ma-
lignancy makes a bone metastasis less likely.
The mass has an enhancing soft-tissue com-
ponent with cortical breakthrough. In the ab-
sence of fat stranding, these findings are more
suggestive of a primary bone tumor rather
than osteomyelitis. Although osteomyelitis
has aggressive radiologic features, bony de-
struction and fat stranding are usually the pre-
dominant features, and a soft-tissue phlegmon
is generally minimal. Also the areas of amor-
phous calcification and lack of systemic clini-
cal features do not favor an infective process.
The finding of a chest wall lesion with aggres-
sive features including bone destruction and
amorphous calcification in a young adult is
most consistent with a primary osseous neo-
plasm. 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]. How-
ever, osteosarcoma may contain areas of min-
eralization and must also be considered in the
differential diagnosis.
Diagnosis: Chondrosarcoma
The clinical and radiologic features in this
case are consistent with a primary malignant
F
neoplasm arising from the sternum. Differ-
entiating between chondrosarcoma and os-
teosarcoma 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 stip-
pled and arclike calcifications, whereas os-
teosarcomas tend to have dense foci of calci-
fication 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 le-
sion in this patient confirmed that it was a
chondrosarcoma. Radiation-induced chon-
drosarcoma 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 pri-
mary chondrosarcoma of the chest wall have
no history of prior irradiation.
Conclusion
The clinical case scenarios presented here
illustrate the utility of radiologic imaging in
the management of chest wall masses. A sys-
tematic problem-based approach is required
to define the differential diagnosis and to de-
termine the most appropriate investigation to

W468 AJR:197, September 2011

 Imaging of Chest Wall Masses

Fig. 8—31-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.
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A B

C D

characterize the lesion. In situations where it
is not possible to secure a diagnosis by imag-
ing features alone, chest wall masses are of-
ten amenable to percutaneous biopsy under
CT or ultrasound guidance. PET/CT may be
helpful in targeting biopsy toward metaboli-
cally 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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W470 AJR:197, September 2011