Chest Wall Tumors:

Radiologic Findings
and Pathologic
Correlation

introduction
Primary malignant chest wall tumors typically
manifest as large, palpable, rapidly growing masses
Chest wall pain is a common symptom, and most
patients with malignant chest wall tumors are
symptomatic, unlike patients with benign chest wall
tumors
Malignant chest wall tumors are classifi ed into eight
main diagnostic categories: muscular, vascular, fi
brous and fibrohistiocytic, peripheral nerve, osseous
and cartilaginous, adipose, hematologic, and
cutaneous
Although the imaging features of many
malignant chest wall tumors are nonspecific,
knowledge of the typical radiologic
manifestations of these tumors often enables
their differentiation from benign chest wall
tumors and occasionally allows a specific
diagnosis to be suggested.
Imaging Techniques
and Findings: An Overview
Chest radiography often is performed at initial
evaluation of a clinically suspected malignant
chest wall tumor
Computed tomography (CT) is more sensitive
than chest radiography for detecting calcified
tumor matrix and cortical destruction
magnetic resonance (MR) imaging, which has a
multiplanar capability and offers superior spatial
resolution, can provide additional information
regarding the extent of the tumor, as well as
tissue characterization
Muscular Tumors
Leiomyosarcoma
Cutaneous and subcutaneous
leiomyosarcomas account for less than 5% of
superficial soft-tissue sarcomas
These tumors are frequently painful and
typically occur in adulthood
Most primary leiomyosarcomas are solitary
lesions
CT scans in leiomyosarcoma show a large
mass that frequently includes areas of
necrotic or cystic change.
displacement or distortion of vessels often is
seen.
Typical MR imaging features of the mass
include a spindle shape and long T1 and T2
relaxation times with resultant relatively low
signal intensity on T1-weighted images and
high signal intensity on T2-weighted images
After intravenous administration of contrast
material, tumors typically exhibit an enhanced
rim or periphery and a central area of low
signal intensity or low attenuation
Rhabdomyosarcoma
Rhabdomyosarcomas are high-grade
sarcomas characterized by skeletal muscle
differentiation
They are usually found in patients younger
than 45 years of age, in the abdomen, head,
or neck, chest wall involvement is relatively
uncommon

Rhabdomyosarcomas in the chest wall
typically manifest as rapidly growing masses
and may cause pain and other symptoms due
to nerve compression
Bone invasion by a primary tumor occurs in
more than 20% of patients
There are several histologic subtypes of
rhabdomyosarcoma: embryonal, alveolar, and
pleomorphic .
The alveolar subtype occurs more frequently
than the embryonal subtype in the chest wall
and extremities, and it has the worst prognosis of
all rhabdomyosarcoma subtypes
MR images of pleomorphic and alveolar
rhabdomyosarcomas show areas of necrosis with
low signal intensity that do not enhance after
contrast material administration and that
alternate with ringlike areas of high signal
intensity and marked enhancement

Vascular Tumors
Angiosarcomas
Angiosarcomas are malignant endothelial
neoplasms characterized by vasoformative
architecture
Angiosarcomas frequently manifest as large,
painful, and rapidly growing masses and are
often mistaken for chronic hematomas
Angiosarcomas occasionally are associated
with hemorrhage, anemia, or coagulopathy
MR images of angiosarcoma show a
heterogeneous mass that sharply enhances
after intravenous administration of
gadolinium-based contrast material
Feeding vessels often are seen in the
periphery of the tumor.
Fibrous thickening, soft-tissue nodules,
increased attenuation in fatty tissue, and fluid
collections around muscle characterize
angiosarcoma.
Fibrous and Fibrohistiocytic
Tumors
Malignant Fibrous Histiocytoma
MFH, a soft-tissue sarcoma most often found
in older adults, rarely occurs in the chest wall
The tumor typically originates in deep fascia
or skeletal muscle and only rarely originates in
bone, although involvement of adjacent bone
is common
MFH initially was described as having a
histiocytic origin, but histogenesis of this
tumor type is now uncertain
Storiform-pleomorphic MFH is the most
common form, accounting for more than two-
thirds of all cases
MFH manifests on CT scans as a nonspecifi c
heterogeneously enhancing mass in muscle
and fascia planes
Myxoid MFH is the second most common
type, with a characteristic CT appearance of
low attenuation in the myxoid matrix at the
center of the lesion and nodular peripheral
enhancement of the more cellular tumor
components
On T1- and T2-weighted MR images, MFH may
appear either homogeneous or heterogeneous.
On T1-weighted images, most tumors have a
signal intensity equal to that of muscle, and on
T2-weighted images, they have a signal intensity
equal to or greater than that of fat
Tumors often show heterogeneous enhancement
on MR images obtained with gadolinium-based
contrast material
Aggressive Fibromatosis
Aggressive fibromatosis or desmoid tumor is
an infiltrative lesion with an intermediate
proliferative tendency
although not as aggressive as the exuberantly
proliferative adult fibrosarcoma, it is more
aggressive than infantile or congenital
fibrosarcoma
Lesions in aggressive fibromatosis do not
metastasize, and they may even undergo
spontaneous regression
Their exact pathogenesis is unknown;
however, trauma, endocrine disorders, and
genetic factors have been implicated
Aggressive fi bromatosis is a common
neoplastic disease and accounts for 54% of
low-grade sarcomas of the chest wall
A chest wall site of origin has been reported
in 10% 28% of patients, with shoulder
involvement being the most common
complication
Aggressive fibromatosis of the chest wall
often affects adolescents and young adults
but also may occur in older patients
CT scans show variable degrees of
attenuation and enhancement in accordance
with variations in tumor composition.
An infiltrative pattern is more common in
young patients, whereas a nodular pattern is
more frequent in adults
On T1-weighted MR images, tumors have
signal intensity less than or equal to that of
muscle, whereas on T2-weighted images they
have mostly intermediate signal intensity,
although very low and extremely high signal
intensities also have been observed
occasionally.