대한흉부영상의학회 Weekly Chest Cases

Case No : 677 Date 2010-10-18

Courtesy of Chang Hyun Lee / Seoul National University Hospital
Age/Sex 27 / F
Chief ComplaintC/C chest wall mass PHx) Breast augmentation surgery, 1 year ago

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Diagnosis With Brief Discussion

Diagnosis: Fibromatosis involving chest wall
Radiologic Findings: There is a well-defined mass, 7.7 x4.3 cm,located at the medial side of the breast implant and in the Rt. 2nd intercostal space. The mass shows intrathoracic extension and associated minimal bony erosion is noted at the Rt 2nd rib anterior arch. On T2 weighted axial and sagittal images, this mass demonstrates heterogenous high SI with inner striated pattern low SI portion. Sagittal T2 weighted image clearly reveals that this mass extends to the intrathoracic cavity and compresses the adjacent pleura and augmatation mammoplasty bag. After Gd administration, this mass shows strong enhancement.
Brief Review: Radiographs may be normal or may show a nonspecific soft-tissue mass. Calcification is uncommon. Underlying bone involvement is seen in 6%?7% of patients, typically with pressure erosion and cortical scalloping but without invasion of the medullary canal. Bone scintigraphy usually demonstrates increased uptake on blood pool and static images. Angiograms are variable in appearance, often showing marked hypervascularity, although some lesions demonstrate no vascular blush. CT scans of the deep fibromatoses are also usually nonspecific. Lesions may be hypoattenuating relative to skeletal muscle but are typically isoattenuating or even hyperattenuating. The latter finding may be related to lesions with more extensive collagen. Lesions usually demonstrate enhancement after intravenous administration of iodinated contrast material; the enhancement is sometimes marked. Owing to the infiltrative growth pattern and the attenuation similar to that of skeletal muscle, the margins of the lesion are often indistinct at CT unless it is separated from normal tissue by a fat plane. Subtle pressure erosions of bone are often better evaluated on radiographs owing to beam-hardening artifact at CT.
The best imaging modality for evaluation and staging of the deep fibromatoses is MR imaging. Extraabdominal desmoid tumors are typically intermuscular lesions, although muscle invasion is common. In addition, linear extension along fascial planes is a frequent manifestation and is uncommon with other soft-tissue neoplasms. Initial reports suggested that the lesions have decreased signal intensity on both T1- and T2-weighted spin-echo images. The MR imaging pattern of the deep fibromatoses has been highly variable. The most common signal intensity pattern is heterogeneous, with intermediate signal intensity (similar to that of fat on T2-weighted images and similar to that of skeletal muscle on T1-weighted images) seen with standard pulse sequences. The heterogeneous signal intensity pattern likely corresponds to the varying proportions of cellular tissue, myxoid tissue (high water content and high signal intensity on T2-weighted images), and collagen (low signal intensity with all pulse sequences) in the lesion. Prominent low-signal-intensity bands are often seen with all pulse sequences and are likely related to the dense areas of collagen. Areas of low signal intensity with all pulse sequences are characteristic of fibromatosis but not specific for it. Other types of soft-tissue masses with prominent low signal intensity on T2-weighted images include giant cell tumor of tendon sheath (a localized form of pigmented villonodular synovitis), calcified masses, and malignancies such as fibrosarcoma or malignant fibrous histiocytoma. The deep fibromatoses typically demonstrate moderate to marked enhancement after administration of gadolinium contrast material particularly in less collagenized and more cellular regions. Only 10% of lesions lack significant enhancement at MR imaging. Lesion margins at MR imaging may be well defined or infiltrative.
References: 1. Robbin MR et al. Imaging of musculoskelectal fibromatosis. Radiographics. 2001;21:585-600.
2. Aaron AD, et al. Chest wall fibromatosis associated with silicone breast implants. Surg Oncol.1996;5(2):93-99.
3. Dale PS et al. Desmoid tumor occurring after reconstruction mammaplasty for breast carcinoma. Ann Plast Surg. 1995;35:515-518.
Keywords: Chest wall, Benign tumor,

No. of Applicants : 80

▶ Correct Answer : 15/80, 18.8%

- Osaka University , Japan Osamu Honda
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Radnet Teleradiology , Turkey Murat Ulusoy
- DFCI/BWH , United States jyothi Priya jagannathan
- seoul national university hospital , Korea (South) Ijin Joo
- Song-do Hospital , Korea (South) Ji-young Yun
- clinique medipole toulouse , France delaunay francois
- vims , India akhila d
- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- Asan Medial center , Korea (South) Chae Lim
- Kobe City Medical Center General Hospital , Japan Hitomi Nagano
- Youngdong Hospital , Korea (South) Sang Min Lee
- IRSA La Rochelle France , France Denis Chabassiere
- Mallinckrodt Institute of Radiology , United States Naganathan Mani
- IRCCS Istituto Oncologico - Bari , Italy Carlo Florio

▶ Correct Answer as Differential Diagnosis : 14/80, 17.5%

- radiologist, aditya imaging centre , India vivek patel
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Siirt Devlet Hastanesi , Turkey Armagan Sarac
- Doctors Hospital , Bahamas muneesh sharma
- McGill University , Canada Ben Smith
- Montreal , Canada D J
- clinique de SAVOIE , France, Metropolitan gay-depassier philippe
- aarthi scans , India abirami mahadevan
- Bundang CHA hospital , Korea (South) Jung Jin Young
- Hotel-Dieu Montreal , Canada nicolas gautier
- Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
- All India Institute of medical sciences , India Justin Moses
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- Okayama university , Japan Mayu Uka

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 677 Date 2010-10-18

Discussion

No. of Applicants : 80