Tumor invasion of the chest wall and mediastinum in lung cancer: evaluation with pneumothorax CT

For preoperative evaluation of chest wall and mediastinal invasion by lung cancer, computed tomography (CT), combined with artificial pneumothorax (pneumothorax CT), was performed in 43 patients with lung cancer in whom conventional CT scans showed that the mass was contiguous to the chest wall (n = 30) and/or mediastinum (n = 25) but without evidence of definite tumor invasion. Invasion was diagnosed on the basis of whether an air space existed between the mass and the adjacent structures. In three patients pneumothorax was not produced. After the procedure, four patients developed symptomatic pneumothorax, and one, subcutaneous emphysema. Comparison of diagnoses based on findings at pneumothorax CT, surgery, and pathologic examination showed that pneumothorax CT is 100% accurate for chest wall invasion and 76% accurate for mediastinal invasion. The authors conclude that this procedure is helpful in accurate evaluation of the T criterion in lung cancer, especially for patients in whom findings at conventional CT suggest tumor invasion of the chest wall and mediastinum.     

Pleural and chest wall invasion in bronchogenic carcinoma: CT evaluation

CT scans of 47 patients who had peripheral bronchogenic carcinoma contiguous to the pleural surface and who had undergone thoracotomy were retrospectively reviewed. The CT features of the primary neoplasm that were analyzed included the angle and amount of contact with the adjacent pleural surface, associated pleural thickening, fat plane between the tumor and chest wall, rib destruction, and chest wall mass. CT was of limited predictive value in separating those patients who had parietal pleural/chest wall involvement from those who did not. The combination of two or three CT findings (obtuse angle, greater than 3 cm contact with pleural surface, associated pleural thickening) resulted in a sensitivity of 87% and a specificity of 59%. The clinical symptom of focal chest pain, while not as sensitive (67%) as CT, was much more specific (94%) for parietal pleura/chest wall invasion.     

Imaging of chest wall infections

A wide variety of infections can affect the chest wall including pyogenic, tuberculous, fungal, and some other unusual infections. These potentially life-threatening disorders are frequent especially among immunocompromised patients but often misdiagnosed by physical examination and radiographs. The purpose of this article is to describe the clinical and imaging features of these different chest wall infections according to the different imaging modalities with emphasis on ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The outcome of chest wall infection depends on early diagnosis, severity of the immunosuppression, offending organism, and extent of infection. Because clinical findings and laboratory tests may be not contributive in immunocompromised patients, imaging plays an important role in the early detection and precise assessment of the disease. US, CT, and MRI are all useful: bone destruction is more accurately detected with CT whereas soft tissue involvement are better visualized with US and MRI. CT and US are also used to guide percutaneous biopsy and drainage procedures. MR images are helpful in pre-operative planning of extensive chest wall infections.     

Limitations of CT in evaluation of neoplasms involving chest wall

We reviewed the CT of 20 patients with peripheral lung malignancies in which CT appearance suggested chest wall invasion on the basis of extension of mass around ribs into fat or muscle of the chest wall, or definite bone destruction. We correlated these findings with other radiographic studies and surgical and autopsy results. All 11 cases in which CT indicated chest wall involvement on the basis of definite bone destruction were confirmed. Tumor extension into the chest wall was disproven in six of the remaining nine cases in which invasion was suggested on the basis of tumor infiltration between ribs or extension of tumor into fat or soft tissue planes. Our findings confirm the lack of reliability of CT findings in determining the extension of malignancy into the chest wall, except when definite bone destruction is present.     

Detection of minute pleural fluid in the pleural retracted space associated with peripheral lung cancer: evaluation with MR imaging

PURPOSE: To evaluate the efficacy of magnetic resonance imaging (MRI) in detecting minute pleural fluid in the pleural retracted space (PRS) associated with peripheral lung cancer. MATERIALS AND METHODS: Our subjects were 20 patients with peripheral lung cancer in whom thin-section CT in the lung window setting demonstrated lesions adjacent to the pleural surface, and who were referred for MR imaging. The imaging findings were retrospectively evaluated and correlated with the histopathologic specimens. Pleural fluid was aspirated for cytology under ultrasound (US) guidance in six patients. RESULTS: STIR MR images revealed water SI areas beneath the chest wall associated with the lung cancer, whereas, on CT images, lung cancer and minute pleural fluid in the PRS showed similar soft-tissue density without enabling easy differentiation. Two of the six patients who underwent aspiration cytology showed malignancy. All histopathologic specimens obtained from 18 patients who underwent surgery showed pleural retraction corresponding to the water SI areas on STIR images. Histopathological study revealed that the fibrotic focus of the tumor tended to occur more intensively when the shape of pleural retraction was thinner and deeper. CONCLUSION: Water SI areas on STIR images were thought to suggest pleural fluid retention in the PRS. MRI was sensitive in detecting minute pleural fluid in the PRS and may help to avoid overdiagnosis of chest wall invasion induced from peripheral lung cancers.     

Pulmonary Aspergillus chest wall involvement in chronic granulomatous disease: CT and MRI findings

Pulmonary Aspergillus infection in patients with chronic granulomatous disease tends to involve the chest wall and consequently carries a high mortality rate. We report the findings of computed tomography (CT) and magnetic resonance imaging (MRI) in three such cases. One patient underwent both CT and MRI, one, CT only, and one, MRI only. In all three, both CT and MRI demonstrated pulmonary consolidations with direct extension to the adjacent chest wall. In both patients who were examined by CT, scans revealed permeative osteolytic changes of adjacent rib or spine compatible with osteomyelitis. In both patients who were examined by MRI, adjacent chest wall involvement was depicted on T1-weighted images and showed increased signal intensity on T2-weighted images. In one of these patients, the chest wall lesion was well defined on T2-weighted images, an appearance compatible with abscess. Epidural extension was demonstrated on MRI in the other patient, who later developed paraparesis. We suggest that CT and MRI have a complementary role in evaluating chest wall invasion by pulmonary Aspergillus infection in chronic granulomatous disease.     

Chest wall invasion by lung cancer: limitations of CT evaluation

Thirty-three patients with peripheral pulmonary malignancies contiguous with a pleural surface were evaluated for chest wall invasion by computed tomography (CT). CT criteria included pleural thickening adjacent to the tumor, encroachment on or increased density of the extrapleural fat, asymmetry of the extrapleural soft tissues adjacent to the tumor, apparent mass invading the chest wall, and rib destruction. The CT scans were classified as positive, negative, or equivocal for invasion, and a decision matrix was constructed comparing CT results with pathologic data. The sensitivity of CT was 38%, specificity was 40%, and accuracy was 39% for evaluation of invasion if equivocal CT results were counted as radiologic errors. CT scanning has low accuracy in assessing chest wall invasion in patients with peripheral lung cancers.     

The use of computed tomography in evaluating chest wall pathology

Forty-nine patients with chest wall lesions were evaluated by computed tomography (CT) and conventional radiography. Computed tomography was found to be indispensable for detecting and precisely localizing these lesions. It revealed unsuspected bone destruction and lung, pleural, and mediastinal involvement, as well as invasion of the spinal canal. In more than two thirds of the patients, CT provided additional information of clinical importance in management and, in one third, treatment was altered or the surgical approach modified because of the CT findings. Computed tomography is an essential diagnostic modality in evaluating chest wall lesions.     

Anterior chest wall: frequency of anatomic variations in children.

PURPOSE: To evaluate the frequency of anterior chest wall variations in children. MATERIALS AND METHODS: The computed tomographic (CT) images of 200 consecutive infants and children (114 boys and 86 girls; mean age, 10.5 years; age range, 3 months to 19 years) who underwent chest CT during a 20-month period were evaluated for chest wall variations. Children who had undergone chest wall surgery or were suspected of having a chest wall abnormality were excluded. The frequency of chest wall anomalies was compared with age and sex (Fisher exact test). RESULTS: The CT scans of 65 children (33%) depicted one or more variations in the anterior chest wall: titled sternum (n = 29), prominent convexity of anterior rib or costal cartilage (n = 19), prominent asymmetric costal cartilage (n = 20), well-defined paracostal subcutaneous nodule (n = 4), mild pectus excavatum (n = 4), or mild pectus carinatum (n = 4). The frequency of these findings did not vary significantly with age (P = .96) or sex (P = .36). CONCLUSION: Variations in the anterior chest wall are common, occurring in one-third of children, and should be considered normal. These asymptomatic variations should not be considered alarming when palpated at physical examination.     

Pitfalls in CT evaluation of chest wall invasion by lung cancer

Computed tomography in a patient with a peripheral lung cancer in the right upper lobe revealed obliteration of the extrapleural fat and direct connection of the tumor with an intercostal soft tissue mass of similar density. The findings were suggestive of chest wall invasion by the cancer which was, however, proven to be false after en bloc resection of the tumor and the contiguous chest wall. Such a diagnostic pitfall could be avoided if special attention were paid to the asymmetry of the CT image at the level of upper thoracic outlet due to improper positioning of the patient.     

MR imaging of the chest: Mediastinum and chest wall

This review presents the options and limitations of MRI in non-vascular diseases of the mediastinum and the chest wall. In numerous thoracic pathologies, MRI is a useful supplement to spiral CT. This imaging procedure also allows a contrast-media-free differentiation of solid tumors and vascular lesions (e. g., aortic aneurysms). The advantages of MRI over CT are particularly useful when multiplanar tumor imaging is required prior to surgery to establish the exact spatial relationship between tumor and the other mediastinal structures. Primary indications for MRI in diseases of the mediastinum and chest wall are therefore: (a) tumors of the posterior mediastinum for determining their position in relation to the neural foramina and the spinal canal; (b) chest wall tumors; (c) preoperative multiplanar imaging of primary mediastinal tumors; and (d) contraindications against CT exams with iodine contrast media.     

胸壁肿块的CT诊断

目的分析胸壁肿块的CT表现,提高其诊断水平。方法 30例临床证实的胸壁肿块患者均经CT平扫,10例又经增强扫描。对所有患者的CT表现进行了回顾性分析。结果在CT像上,胸壁结核(5例)表现为胸壁内软组织密度肿块影;细菌性脓肿(4例),表现为局限性软组织肿块影,密度不均匀;脂肪瘤(4例)表现为胸壁内局限性脂肪密度肿块影;神经源性肿瘤(5例)表现为胸壁内密度均匀、边界清楚的软组织肿块影;血管瘤(1例)表现为左侧胸壁散在条状迂曲的软组织密度肿块影,增强后明显强化;胸膜间皮瘤(3例),其中良性者(2例)表现为局限性胸膜增厚,恶性者(1例)表现为弥漫性胸膜增厚伴胸腔积液;胸膜转移瘤(3例)表现为胸膜结节状增厚;肋骨转移瘤(4例)表现为胸膜结节状增厚;Askin瘤(1例)表现为右侧胸壁内及胸膜处软组织肿块影伴邻近肋骨骨质破坏。结论 CT对胸壁肿块的定位及良、恶性鉴别具有重要价值,尤其64排螺旋CT及其后处理技术更有利于其诊断与鉴别诊断。     

Thin-section multiplanar reformats from multidetector-row CT data: utility for assessment of regional tumor extent in non-small cell lung cancer

PURPOSE: To determine the clinical utility of thin-section multiplanar reformats (MPRs) from multidetector-row CT (MDCT) data sets for assessing the extent of regional tumors in non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS: Sixty consecutive NSCLC patients, who were considered candidates for surgical treatment, underwent contrast-enhanced MDCT examinations, surgical resection and pathological examinations. All MDCT examinations were performed with a 4-detector row computed tomography (CT). From each raw CT data set, 5mm section thickness CT images (routine CT), 1.25 mm section thickness CT images (thin-section CT) and 1.25 mm section thickness sagittal (thin-section sagittal MPR) and coronal images (thin-section coronal MPR) were reconstructed. A 4-point visual score was used to assess mediastinal, interlobar and chest wall invasions on each image set. For assessment of utility in routine clinical practice, mean reading times for each image set were compared by means of Fisher's protected least significant difference (PLSD) test. A receiver operator characteristic (ROC) analysis was performed to determine the diagnostic capability of each of the image data sets. Finally, sensitivity, specificity and accuracy of the reconstructed images were compared by McNemar test. RESULTS: Mean reading times for thin-section sagittal and coronal MPRs were significantly shorter than those for routine CT and thin-section CT (p<0.05). Areas under the curve (Azs) showing interlobar invasion on thin-section sagittal and coronal MPRs were significantly larger than that on routine CT (p=0.03), and the Az on thin-section sagittal MPR was also significantly larger than that on routine CT (p=0.02). Accuracy of chest wall invasion by thin-section sagittal MPR was significantly higher than that by routine CT (p=0.04). CONCLUSION: Thin-section multiplanar reformats from multidetector-row CT data sets are useful for assessing the extent of regional tumors in non-small cell lung cancer patients.     

Diagnostic accuracy of thin-section CT and chest radiography of pediatric interstitial lung disease

OBJECTIVE: We assessed the accuracy of thin-section CT and chest radiography to diagnose pediatric interstitial lung disease. MATERIALS AND METHODS: We identified 20 infants, boys, and girls (age range, 1 month to 14 years) with histopathologic confirmation of interstitial lung disease. Six boys and girls without interstitial lung disease were also included. Two observers independently assessed chest radiograph and CT images. The observers stated the most likely diagnosis and a differential diagnosis. We evaluated individual CT features and their distribution. RESULTS: Observers' diagnoses on CT images were correct (first choice or differential) in 66% of observations versus 45% on chest radiographs (p < 0.025). Correct diagnoses were made on first choice in 61% of CT observations versus 34% on chest radiographs (p < 0.005). Observers were confident (versus uncertain) in 42% of the CT observations versus 18% on chest radiographs; of the confident diagnoses made on CT, 91% were correct. CT interpretations were most accurate in the diagnosis of pulmonary alveolar proteinosis, congenital lymphangiectasia, and idiopathic pulmonary hemosiderosis. All healthy patients examined with CT were correctly identified as such. We noted a distinctive CT pattern in three patients with nonspecific interstitial pneumonitis and one patient with desquamative interstitial pneumonitis; the CT pattern consisted of upper zone predominant honeycombing on a background of ground-glass attenuation. CONCLUSION: A higher proportion of pediatric interstitial lung diseases can be diagnosed on thin-section CT than on chest radiographs. In our study, confident and correct diagnoses were made more frequently with CT than with chest radiographs.     

Pulmonary lymphangioleiomyomatosis: correlation of ventilation-perfusion scintigraphy, chest radiography, and CT with pulmonary function tests

PURPOSE: To determine the findings on ventilation-perfusion (V-P) scintigrams, computed tomographic (CT) scans, and chest radiographs and correlate them with pulmonary function test results in patients with lymphangioleiomyomatosis. MATERIALS AND METHODS: V-P scintigraphy, chest radiography, conventional and thin-section CT, and pulmonary function tests were performed in 39 patients. The images were graded on a scale of 0 (normal) to 3 (severely abnormal). RESULTS: Imaging abnormalities were found on 92% of ventilation scintigrams, 92% of perfusion scintigrams, 79% of chest radiographs, 100% of CT scans, and 100% of thin-section CT scans. On ventilation scintigrams, 28 (72%) patients demonstrated a speckling pattern. On CT scans, all patients had pulmonary cysts. Univariate analysis showed that extent of disease on chest radiographs and CT scans, cyst size, V-P abnormalities, and degree of speckling were inversely correlated with forced expiratory volume in one second (FEV(1)), diffusing capacity of lung for carbon monoxide, and the ratio of FEV(1) to forced vital capacity (FVC) (P <.01) but not with FVC and total lung capacity. Larger cyst size correlated with extent of disease at CT, but not significantly (P =.056). CONCLUSION: Scintigraphic and radiologic abnormalities are seen in a majority of patients with lymphangioleiomyomatosis. On ventilation scintigrams, a frequently seen speckling pattern may be related to accumulation of radionuclide in pulmonary cysts-a hallmark of the disease at CT. Findings with each imaging modality correlate with certain pulmonary functions.     

Magnetic resonance imaging in the evaluation of lung cancer

MRI is used most efficaciously in the evaluation of patients with bronchogenic carcinoma when employed as a tailored examination designed to answer specific questions relevant to patient management. CT continues to be used more generally in staging lung cancer when imaging beyond conventional chest radiography is required. Specific areas in which MRI can provide important and unique information (which may supplement a CT study) include the following: (1) evaluation of the local extent of superior sulcus tumors, and (2) distinction between stage IIIA (resectable) and stage IIIB (unresectable) tumors. Confirmation of tumor invasion of major mediastinal structures is necessary before depriving a patient of potential curative resection. MRI may contribute important information when CT findings are indefinite, particularly with regard to invasion of major cardiovascular structures (eg, superior vena cava, pulmonary artery, pericardium, and heart); invasion of the tracheal carina or bilateral involvement of main bronchi; and the presence of contralateral mediastinal or hilar lymphadenopathy. MRI should be considered as a primary imaging modality to evaluate central tumors in patients for whom intravenous contrast agents are contraindicated, and as a problem-solving modality when CT is inconclusive in the detection of a possible hilar or mediastinal mass. Other specific applications of MRI include the identification of tumor recurrence in the presence of radiation fibrosis, assessment of the extent of chest wall invasion of peripheral lung tumors, and the noninvasive characterization of adrenal masses. The scope of these MRI applications in patients with lung cancer may expand in the future with refinements in motion suppression techniques, implementation of ultrafast MRI (using variations of the echoplanar method), and further development of MRI spectroscopy and MRI contrast agents.     

Primary angiosarcoma of the chest wall: CT and MR findings

A surgically confirmed primary angiosarcoma of the chest wall is described. CT showed a right chest wall mass projecting into the thoracic cavity from the right axilla. The tumor was a high density, inhomogeneous-density mass. Invasion to the rib was noted, and calcified foci were demonstrated. A homogenous high-density mass ventral to the chest wall mass was shown. Contrast-enhanced CT did not demonstrate any enhancement. MRI demonstrated a large heterogeneous mass on both T1-weighted images (T1WI) and T2-weighted images (T2WI). Contrast-enhanced axial T1-weighted MR images did not show any enhancement of the mass, but the homogenous mass ventral to the chest wall mass was shown. MRI demonstrated certain characteristic findings of angiosarcoma of the chest wall. Intratumoral hemorrhage with juxtaposed hematoma and aggressive invasion to the surrounding tissue suggest angiosarcoma.     

Primary malignant fibrous histiocytoma of the chest wall: CT and MR appearance

PURPOSE: The purpose of this work is to describe the CT and MR appearance of primary malignant fibrous histiocytoma (MFH) of the chest wall. METHOD: Eleven men and eight women (45-76 years old) with primary MFH of the chest wall who underwent both CT and MRI were enrolled, and the imaging interpretation was retrospectively compared to the pathologic specimen. RESULTS: All tumors were inhomogeneous in appearance on CT scans. All tumors showed high signal intensity on T2-weighted images. On T1-weighted MR images, tumors displayed inhomogeneous isosignal intensity in 15 cases (79%) and low signal intensity in 5 (21%) compared with the surrounding muscle. Tumors exhibited inhomogeneous enhancement in all except three localized tumors on enhanced CT and MRI. Invasion of intercostal muscle was noted on MR images in 18 patients (95%) and on CT in 11 patients (58%). CONCLUSION: There might be various radiologic appearances of MFH. However, CT and MRI are able to demonstrate the exact localization and disease extent of MFH arising in the chest wall.     

鼻咽癌颅底侵犯的CT与MRI征象对比分析

目的:探讨CT及MRI在鼻咽癌颅底侵犯诊断中的应用价值.方法:回顾性分析经病理证实的52例鼻咽癌的CT及MRI图像,并以放疗后6个月的影像资料和临床资料为参考依据,比较CT与MRI在鼻咽癌颅底受侵诊断中的应用价值.结果:52例放疗6个月后定性诊断结果为颅底受侵41例,其中颅底骨质受侵39例,颅底肌肉受侵41例.52例中...     

Pulmonary embolism: comprehensive diagnosis by using electron-beam CT for detection of emboli and assessment of pulmonary blood flow

P:URPOSE: To comprehensively assess thoracic anatomy and pulmonary microcirculation in pulmonary embolism by using computed tomographic (CT) angiography of the pulmonary arteries combined with functional CT imaging of blood flow. MATERIALS AND METHODS: Twenty-two patients suspected of having acute pulmonary embolism underwent contrast material-enhanced thin-section electron-beam CT angiography of the pulmonary arteries. In addition, in each patient, a dynamic multisection blood flow CT study was performed on a 7.6-cm lung volume with electrocardiographic gating. Pulmonary blood flow was calculated, and perfusion parameters were visualized on color-coded maps. The color-coded maps and CT angiograms were independently evaluated, segment by segment, by two readers for perfusion deficits and the presence of clots, respectively. The results were compared. RESULTS: Mean pulmonary blood flow was 0.63 mL/min/mL in the occluded segments versus 2.27 mL/min/mL in the nonoccluded segments (P: =.001). The sensitivity and specificity of perfusion maps for the presence of segmental pulmonary embolism compared with those of CT angiography were 75.4% and 82.3%, respectively, with positive and negative predictive values of 79.6% and 84.7%, respectively. The false-negative findings were caused mainly by partial occlusion of vessels. In eight patients, a substantial alternative or additional pathologic entity was diagnosed. CONCLUSION: By combining CT angiography and dynamic CT imaging, a comprehensive and noninvasive diagnosis of thoracic structure and function is feasible with a single modality.