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Chest Wall and Pleura
Chest Wall: Bony and Soft Tissue Lesions
Rib Lesions
Benign
Congenital abnormalities
The upper ribs are commonly bifid, splayed, fused, or hypoplastic ▸ they are occasionally associated with syndromes (e.g. basal cell naevus syndrome) or other anomalies (e.g. Sprengel's deformity)
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Cervical rib: this arises from C7 (affecting 1–2% of the population) and consists of an initially downward sloping rib just lateral to the spine (cf. an initially upward sloping normal rib) ▸ it can cause a thoracic outlet syndrome and is often bilateral and asymmetrical
Callus
Post fracture this can mimic an intrapulmonary opacity
Rib notching
This is due to external pressure on a rib (e.g. coarctation of the aorta, neurofibromatosis type I (NF2))
Benign primary tumours
These are infrequent ▸ they are most commonly cartilaginous tumours (e.g. a chondroma or osteochondroma) ▸ they are predominantly found in an anterior location and may show characteristic cartilaginous calcification
Other benign rib lesions
Fibrous dysplasia ▸ histiocytosis X ▸ haemangioma ▸ aneurysmal bone cyst
Aggressive
Destructive rib lesions
These are most commonly an osteomyelitis or a neoplastic disease
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Malignant rib tumours: these are commonly metastatic deposits or myeloma ▸ primary malignant tumours are rare (but usually a chondrosarcoma)
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Osteomyelitis: this is uncommon ▸ it may be due to haematogenous spread (e.g. staphylococcal or tuberculous), or it may be caused by direct spread from the lung or pleural space (e.g. actinomycosis)
Bronchial carcinoma (including pancoast's tumours)
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These can spread from the lung to a rib ▸ MRI can determine the extent of a Pancoast's tumour (and assess the relationship between the tumour and the plexus brachialis)
Differential of Rib Notching
| Inferior rib notching | Arterial: Coarctation of the aorta, aortic thrombosis, subclavian obstruction, any cause of pulmonary oligaemia Venous: Superior vena cava obstruction Arteriovenous: Pulmonary arteriovenous malformation, chest wall arterial malformation Neurogenic: Neurofibromatosis (ribbon ribs) |
| Superior rib notching | Connective tissue diseases: Rheumatoid arthritis, SLE, Sjögren's, scleroderma Metabolic: Hyperparathyroidism Miscellaneous: Neurofibromatosis, restrictive lung disease, poliomyelitis, Marfan's syndrome, osteogenesis imperfecta, progeria |
Clavicles
Definition
Together with the spine the medial clavicular heads can assess rotation ▸ the joints at both ends are synovial and may be eroded in any synovitis appearing more ill defined (e.g. rheumatoid arthritis, hyperparathyroidism)
Pearl
Neoplasms of the clavicle are usually malignant (myeloma or metastatic)
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Other primary tumours/tumour-like conditions:
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Osteosarcoma ▸ Ewing's sarcoma ▸ post radiation sarcoma ▸ aneurysmal bone cyst ▸ histiocytosis X ▸ intersternocostoclavicular hyperostosis
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Chest Wall: Bony and Soft Tissue Lesions
Soft Tissue Lesions
Poland's Syndrome
Definition
An autosomal condition where there is unilateral absence or hypoplasia of the pectoralis major muscle ▸ it is accompanied by ipsilateral hand and arm anomalies (particularly syndactyly), rib anomalies and hypoplasia of the breast and nipple
CXR
Unilateral lung transradiancy and an abnormal anterior axillary fold
Soft Tissue Tumours
Benign (rib separation or notch-like remodelling from pressure erosion)
Lipoma
The most common benign chest wall tumour
CT
A low-density well-demarcated homogeneous mass (−90 to −150HU) ▸ soft tissue components suggest a liposarcoma
MRI
T1WI: high SI ▸ T2WI: intermediate SI (and low SI with fat suppression)
Neurofibroma
Rib splaying and pressure erosion ▸ widened intervertebral foramina
CT
Lower density than muscle before and after IV contrast medium
MRI
T1WI: low to intermediate SI ▸ T2WI: high SI ▸ T1WI + Gad: marked contrast enhancement
Haemangiomas
An uncommon anterior mediastinal lesion (± phleboliths)
CT
A smooth, sharp, lobulated mass with central heterogeneous enhancement ▸ there may be bone remodelling and hypertrophy
MRI
The best investigation for delineating its extent ▸ there are signal inhomogeneities generated by vessels, soft tissue and haemorrhage
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T1WI: intermediate SI ▸ T2WI: high SI
Lymphangiomas
CT
Fluid-filled cyst ± septation
MRI
Features of a cyst with a low protein content
Malignant (bony destruction)
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Malignant primary chest wall tumours are rare ▸ the most common are lipo- or fibrosarcomas
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Secondary tumours of the chest wall are common, particularly if there is local tumour spread (e.g. carcinoma of the breast and lung)
Sternal Lesions
Pectus Excavatum
Definition
A depressed sternum resulting in the anterior ribs projecting more anteriorly than the sternum (funnel chest) ▸ it may be an isolated abnormality or associated with other disorders such as Marfan's syndrome or congenital heart disease (particularly an ASD)
CXR
The condition is best assessed on a lateral CXR ▸ PA CXR: leftward shift of the heart ▸ straightening of the left heart border with prominence of the main pulmonary artery segment ▸ an indistinct right heart border simulating middle lobe disease (the sternum replaces aerated lung at the right heart border) ▸ a steep inferior slope of the anterior ribs ▸ undue clarity of the lower dorsal spine seen through the heart
Pearl
Pigeon chest (pectus carinatum): the reverse deformity, which may be congenital or acquired
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