대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Angiosarcoma of the chest wall

Radiologic Findings

Fig 1. Ultrasonography shows a 2.4 cm, oval, hypoechoic mass with small internal anechoic foci in the subcutaneous layer of the right anterior chest wall.
Fig 2-4. The mass is markedly hyperintense on STIR (Fig 2), demonstrates restricted diffusion (Fig 3), and shows vivid enhancement on contrast-enhanced MRI (Fig4).
Fig 5. Axial contrast-enhanced CT shows vivid enhancement of the mass.
Fig 6. FDG PET/CT shows hypermetabolism in the mass.

Brief Review

Chest wall neoplasms are uncommon lesions that represent approximately 5% of all thoracic malignancies and are encountered less frequently than are osseous and soft-tissue tumors that occur elsewhere in the body. More than 50% of chest wall neoplasms are malignant and typically result from direct invasion by or metastasis from thoracic tumors; however, these lesions may also arise from the chest wall as primary tumors. Most of these rare lesions are malignant, and because they are uncommon, radiologists may be unfamiliar with their typical clinical manifestations and imaging features. As malignant chest wall tumors represent a heterogeneous group of lesions, several different classification schemes have been proposed and may be used in clinical practice. In most schemes, malignant chest wall neoplasms are divided into categories that are based on their site of origin (bone and cartilage, or soft tissue) and tissue composition.
Angiosarcoma is the most common primary malignant neoplasm of vascular origin and demonstrates a vasoformative architecture histologically. These tumors manifest as large, painful, rapidly enlarging chest wall lesions, and affected patients may present with clinical signs and symptoms such as hemorrhage, anemia, and/or coagulopathy. Angiosarcoma is most strongly associated with chronic lymphedema, especially after mastectomy for breast cancer, although this association exists in only 10% of cases. When angiosarcomas arise from the chest wall, the most common location is the breast in patients with a history of breast cancer.
The imaging features of angiosarcoma depend on the lesion’s location and whether it is superficial or deep. Most superficial lesions manifest as a focal soft-tissue mass with associated skin thickening and subcutaneous edema. In contrast, deep lesions tend to manifest as a focal mass without these associated features. At multidetector CT, angiosarcomas are heterogeneous with internal regions of necrosis, hemorrhage, and vascularity. After intravenous administration of contrast material, enhancement of the vascular tissue may be seen. At MR imaging, the typical finding is a soft-tissue mass with heterogeneous signal intensity on T1- and T2-weighted images. Intense enhancement following the intravenous administration of gadolinium-based contrast material is common. Discrete vessels may be identified at the tumor periphery. Features such as fibrous thickening, soft-tissue nodules, and fluid collections adjacent to chest wall muscles are often present owing to the association with lymphedema. At FDG PET/CT, angiosarcoma demonstrates increased FDG uptake, although the uptake pattern may be heterogeneous owing to the presence of hemorrhage and/or necrosis.

References

1. Carter BW, Benveniste MF, Betancourt SL, de Groot PM, Lichtenberger JP 3rd, Amini B, Abbott GF. Imaging Evaluation of Malignant Chest Wall Neoplasms. Radiographics. 2016 Sep-Oct;36(5):1285-306.

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