iyer sprpostgrad2015 chestwall - pedrad 405 - (iyer, ramesh).pdf ·...

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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.  

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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.  

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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  

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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  

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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  

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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  

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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.  

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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  

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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!