3/21/15
1
Disorders of the Chest Wall
Ramesh S. Iyer, M.D.
Associate Professor Department of Radiology SeaCle Children’s Hospital University of Washington
School of Medicine
Disclosures • I have no financial disclosures
IniJal ModaliJes • Radiographs
– Usually iniJal study – Good for “big picture,” parJcularly for diffuse/global abnormaliJes
• US
– Great iniJal study for focal abnormaliJes, beCer for non-‐osseous pathology
– Solid vs cysJc, vascularity Restrepo R, Lee EY. Updates on imaging of chest wall lesions in pediatric paJents. Semin Roentgenol 2012 Jan; 47(1):79-‐89.
3/21/15
2
Secondary ModaliJes • CT
– Characterizing osseous pathology – Usually follow-‐up to XR or US – Assessing intrathoracic involvement including lungs
• MR
– Problem-‐solving modality – Great for suspected mulJcompartmental pathology – malignancy or vascular malformaJon
Restrepo R, Lee EY. Updates on imaging of chest wall lesions in pediatric paJents. Semin Roentgenol 2012 Jan; 47(1):79-‐89.
Congenital
Pectus Excavatum • Most common congenital
chest wall deformity • Posterior, mild ledward
Jlt of the sternum • Oden cosmesis, though
pain, dyspnea and restricJve lung disease possible
Koumbourlis AC. Pectus deformiJes and their impact on pulmonary physiology. Paediatr Respir Rev 2015 Jan; 16(1):18-‐24.
3/21/15
3
Pectus Excavatum • Lateral XR – posterior Jlt of sternum
• AP – obscured right heart margin may mimic PNA
Pectus Excavatum • Low-‐dose CT with limited
slices for characterizaJon
• Haller Index: Transverse / AP • <2.6 is normal • >3.2 requires surgery
Pectus Excavatum • Typically repaired by Nuss procedure – convex retrosternal bar (Nuss bar)
• ComplicaJons: Pneumothorax (most common), infecJon, hardware displacement
3/21/15
4
InfecJon
OsteomyeliJs • Rare in children
• S. aureus most common, fungal in immunocomp
• MR usually best, CT for corJcal destrucJon
• MR: T1 hypo, T2/STIR hyper, enhancement, +/-‐ abscess Baez JC, Lee EY, Restrepo R, Eisenberg RL. Chest wall lesions in children. AJR 2013; 200(5):W402-‐419.
OsteomyeliJs – 11 yo F
3/21/15
5
OsteomyeliJs – 11 yo F
Axial and Sag STIR
Focal Bone Lesions -‐ Fundamentals • Age of paJent • Unifocal vs mulJfocal • Margins/zone of transiJon • CalcificaJons – chondroid? osteoid? • CorJcal breach, periosJJs, sod Jssue component, etc…
Benign Bone Lesions
3/21/15
6
Osteochondroma • Most common benign
bone tumor of chest wall • Exostosis or osseous
protuberance • XR usually enough • CT/MR – corJcomedullary
conJnuity, carJlage cap
Enchondroma • Benign carJlaginous, most
common in hands/feet
• XR/CT – lyJc, well-‐defined, chondroid calcs (rings/arcs, dense, punctate)
• MR – T2 hyper with hypo
calcs
Atypical Enchondroma
3/21/15
7
Fibrous Dysplasia • Replaced medullary cavity by
immature fibro-‐osseous stroma
• ~80% monostoJc, ribs common
• PolyostoJc – one side of body, syndromes (McCune-‐Albright)
• “Ground-‐glass” classic, oden variable lucent/scleroJc on XR/CT – CT usually needed
Malignancy
Ewing Sarcoma Family • Malignant small round cell tumors: Ewing, PNET, Askin
• Share 11;22 translocaJon • Most common chest wall malignancy • XR/CT – large mass, aggressive osteolysis • MR – T2 bright, hetero enhancement (necrosis) Dang NC, Siegel SE, Phillips JD. Malignant chest wall tumors in children and young adults. J Pediatr Surg 1999; 34(12):1773-‐1778.
3/21/15
8
Ewing Sarcoma Family
5 yo M with PNET
Ewing Sarcoma Family
14 yo M with led 4th rib Ewing sarcoma
Other Malignancies Rhabdomyosarcoma Osteosarcoma
www.orthopaedicsone.com
3/21/15
9
Summary • Pectus excavatum – Posterior sternal Jlt, mimics RML PNA – Haller index >3.2 needs surgery – Nuss bar, PTX
• OsteomyeliJs – MR – edema, enhancement, +/-‐ abscess/phlegmon
Summary • Benign – Osteochondroma – exostosis with carJlage cap – Enchondroma – well-‐defined lyJc lesion with chondroid calcs
– Fibrous dysplasia – monostoJc or polyostoJc, ground-‐glass density classic but variable lysis/sclerosis
• Malignant – Ewing/PNET, Rhabdo, Osteosarc
Thank you!
Top Related