Rib Lesions Research Articles

The Evaluation of Pathologic Alterations of Juxtaosseous Soft Tissue by Xeroradiography

Xeroradiography proved extremely helpful in (a) evaluation of soft-tissue masses of both the axial and appendicular skeleton; (b) quantifying soft-tissue changes in advanced rheumatoid arthritis; (c) evaluation of bony involvement by an adjacent soft-tissue tumor or infection; (d) evaluation of rib lesions or rib integrity; and (e) assessment of bones in casted extremities. The technique was not helpful in the following conditions: early soft-tissue changes of rheumatoid arthritis; detection of minimal skeletal trauma; arthrography of the knee; evaluation of any portion of the vertebral column; evaluation of submandibular neck masses; or assessment of abdominal films for visceral structures.

Giant-cell tumors and aneurysmal bone cystsof ribs in childhood

Cystic or solid lesions of ribs containing giant cells are rarely seen in children. Three cases are presented which are uncommon with regard to the age of the patients (5-14 yr old) as well as the site. These lesions were diagnosed late and exclusively by X-ray. Radiographically it was impossible to distinguish between a giant cell tumor and an aneurysmal bone cyst. Although the distinction of aneurysmal bone cysts and giant cell tumors sensu strictiori is justified from a clinical point of view, the two may be variants of the same pathologic growth process, i.e. growth of angiogribous tissue with giant cells in excess of that generally observed in the course of a "reactive" process.

CHEST WALL TUMORS

There are two important considerations the radiologist must make in the approach to chest wall tumors. The first is whether a rib or sternal lesion is a primary solitary tumor or a local manifestation of a systemic disease, i.e., myeloma or metastatic disease. Other examinations may be indicated prior to direct surgical intervention if the latter is the case. The second important consideration in evaluation of a chest wall tumor is whether the lesion is cartilaginous. If indeed it is suspected of being cartilaginous, it must be considered malignant and a recommendation of complete surgical excision made. In many cases only a differential diagnosis can be rendered. Truly destructive rib lesions are most commonly metastatic disease but eosinophilic granuloma, lymphoma, myeloma, and the sarcomas should be considered. If the rib lesion is associated with an extrapleural mass, metastatic disease and myeloma are the most common causes, but one should also include lymphoma and fibrous dysplasia. The differential diagnosis of an expansile rib lesion includes plasmacytoma, fibrous dysplasia, chondroma, and less commonly eosinophilic granuloma, giant cell tumor, hemangioma, aneurysmal bone cyst, chondromyxoid fibroma, and lymphoma. Most sternal tumors are metastatic lesions and all sternal tumors should be considered malignant until proven otherwise. Soft tissue tumors are rare and radio-graphically nonspecific in most cases. Phleboliths, associated bony changes, and the presence of fat are clues which may help in establishing the diagnosis.

Rib lesions in rheumatoid disease.

Extra-articular osseous manifestations of rheumatoid disease have been described in the vertebral bodies (Seaman and Wells, 1961), in the femoral necks (Mather, 1954; Slocumb, Ferguson, Mayne and Hunder, 1967), and in the vault of the skull (Schlesinger, Forsyth, White, Smellie and Stroud, 1961). Bone biopsy in all these cases showed evidence of granulomatous necrosis and the lesions were considered to be true rheumatoid granulomata arising in bone. In addition, Kreel and Urquhart (1963) described surface erosions of bone in relation to adjacent rheumatoid skin nodules. These authors considered the bone erosions in their cases to be the result of pressure from the skin nodule. Alpert and Feldman (1964) described eight cases of rib erosions occurring in patients with long standing rheumatoid disease. Symmetrical involvement of the superior surfaces of the posterior aspects of the 3rd, 4th and 5th ribs was the most common manifestation. The lesions took the form of deep notches with a maximum width of 9 mm ...

Two Cases of Tumor of the Left 1st Rib.

Case 1.Age: 40. Sex: Female. The patient complained of pain in the left shoulder and radiating pain to the left upper arm for two months before admission. Chest x-ray showed an expanding lesion of the left 1st rib. Resection was carried out July 24-1969. The resection specimen microscopically revealed at fibrous dysplasia of bone.Case 2.Age: 59. Sex: Male. The patient first noticed pain in the left shoulder on December 1968, and the pain gradually increased in intensity, radiating to the left upper arm. He was admitted to Nagasaki Atomic Bomb Hospital June 25-1969. Chest x-ray showed an osteolytic lesion of the left 1st rib. Surgical resection of the tumor was carried out July 10-1969. Section of the tumor mass revealed metastatic adenocarcinoma.

Chloroma. Report of a patient with unusual rib lesions.

Chloroma is a manifestation of myelogenous leukemia in which leukemic tumors are colored green. The original description by King (10) in 1853 led to the belief that chloroma represented a separate disease entity. In 1937, however, Kandel (9) reviewed 58 cases reported in the literature and found that the chloroma without exception had been associated with myelogenous leukemia. The green color is attributed to reduced breakdown products of hemoglobin (8). In 1966 Filip and Bednář (3) showed in a series of 24 patients marked erythrophagocytosis by tumor cells. Chloroma occurs mainly in children, with predilection for the long bones, calvarium, and periorbital tissues. Roentgenographic descriptions are few, but periosteal elevation was prominent in the patients reported (1, 12). In the original roentgenographic description Gould and LeWald (5) noted underlying new bone at right angles to the shaft. No reports include roentgenographic reproductions of rib chloromas, although isolated rib lesions have been described (11). The present case report is prompted by an unusual roentgenographic appearance resembling the rachitic rosary, with symmetric involvement of the ribs anteriorly by multiple chloromas. Case Report A 10-month-old Caucasian female was admitted with the diagnosis of acute myelogenous leukemia. The child was normal at birth and well until the age of eight months when mild pallor appeared. Three weeks before admission she became anorectic and febrile with rapid respirations. The white blood cell count was 288,000, and many myelocytic blast forms were present. Hemoglobin was 6.4 g per 100 ml. Examination of bone marrow showed diffusely infiltrating acute promyelocytic cells. Treatment with 6-mercaptopurine had been instituted at another hospital. The patient did not improve, and she was transferred to the University of California Medical Center at San Francisco for further therapy. There was no family history of hematologic disease. A maternal grandmother had died of carcinoma of the uterus. Examination revealed an acutely ill female infant in severe respiratory distress. The conjunctivae were pale and the eyes were moderately proptotic. Shotty anterior and posterior cervical lymph nodes were palpable. Intercostal retractions and occasional rhonchi were noted in the chest; no rib masses could be palpated. The liver and spleen were moderately enlarged. The skin contained numerous ecchymoses. Laboratory Data: White blood cell count was 145,000; platelets, 1,000, hematocrit, 21 mm. Aspiration of bone marrow five days after onset of therapy revealed a pronounced hypocellularity with immature blast cells and erythrophagocytosis. Roentgenograms of the chest showed bilateral bulbous expansion of the anterior ends of the second through seventh ribs with periosteal elevation (Fig. 1). Patchy infiltrates were scattered throughout the lungs. Transverse radiolucent bands were seen in the proximal humeral metaphyses.

Rib Lesions—Two of a Kind

Rib Lesions—Two of a Kind

Myeloma and carcinoma metastatic to bone

In three equal groups of cases (57 each of myeloma, carcinoma of the breast, and other carcinoma) with bone lesions, the radiographs were scrutinized for the prevalence of various diagnostic signs. No sign pathognomonic of myeloma was found. Preservation of pedicles, despite erosion or collapse in vertebral bodies; significant expansion of bone; and well-defined areas of destruction in the skull; are all strongly suggestive of myeloma. A soft-tissue mass associated with a rib lesion is uncommon when the primary tumour is in the breast but with other carcinomas is as common as in myeloma. Increased bone density is less common in myeloma than in carcinoma but is occasionally seen.

Bone changes in adult acute leukaemia.

Osseous involvement in acute leukaemia is common in children, and occurs in about two-thirds of all cases; but it is rare in adults (Dameshek and Gunz, 1964). A case of lymphoblastic aleukaemic leukaemia in an adult with osteolytic lesions of the skull ribs, iliac and long bones has recently been reported (Don Michael, Parvaresh, Galoostian and Bidari, 1966). The following is a further case of acute leukaemia in an adult with radiological bone changes. A 35-year-old man presented in April, 1966 with a six-month history of pain in the left shoulder and an abrupt onset of haematuria and haematemesis five days previously. On examination, he was pyrexial with extensive purpura and a left retinal haemorrhage. Generalised lymphadenopathy and splenomegaly were also present. Pain was produced by the slightest movement of the left shoulder. The haematological findings were: haemoglobin = 45 per cent, W.B.C. = 19,200/mm3 with 55 per cent blasts; plate-lets = 22,000/mm3. Examination of the marrow revealed pleomorphic blasts and a diagnosis of undifferentiated acute leukaemia was made. The serum calcium level was 8·6 mg/100 ml. and the alkaline phosphatase was 15 K.A. units/100 ml. A radiograph of the left shoulder and arm showed extensive patchy osteolytic changes of the glenoid and spine of the scapula, the outer third of the clavicle and the head and shaft of the humerus (Fig. 1). The chest radiograph showed a pathological fracture of the 6th left rib.

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL. CASE 19-1965.

Presentation of Case First admission. A sixty-eight-year-old man was admitted to the hospital because of anemia.He had been well until one year previously, when a routine physical examination disclosed anemia. Four months before entry studies performed in another hospital disclosed Bence-Jones protein in the urine and a destructive lesion of the right fifth rib in addition to anemia; iron was prescribed. During the three months before admission his appetite diminished, and he lost 5 pounds in weight. Six weeks before admission pain and swelling developed in both hands. There was a past history of occasional nocturia, without dysuria or . . .

Lytic lesions of ribs.

Lytic lesions of ribs.

Erosive rib lesions in paralytic poliomyelitis.

A previously undescribed erosive rib lesion has been observed in chest films of paralytic poliomyelitis patients being studied at a respirator center. Localization of this lesion to the ribs is the unique factor in comparison to other reported orthopedic complications following injury to the central nervous system resulting in paralysis. Material Adequate radiological studies were available on 28 paralytic poliomyelitis patients admitted successively to the respirator center. Fourteen of these showed erosive rib changes of varying degree during the course of the follow-up. Table I presents in summary the pertinent data on these cases. Roentgen Findings The earliest involvement appeared as a shallow indentation and narrowing of the upper cortical margin of the rib (Fig. 2, B), usually approximately 1 cm. long when first seen, but extending to as much as 4 cm. in some instances. With progression, the rib cortex became successively thinner. Localized osteoporosis and trabecular thinning then became evident throughout the involved rib segment (Fig. 1, B). Occasionally slight and similar indentation of the inferior cortical margin occurred, with consequent hourglass formation, although in each instance the uppermost portion of the rib was more severely affected than the lower cortical margin. In the most severe involvement there was almost total disappearance of bone structure throughout the area of the lesion (Fig. 3, B). Periosteal reaction on either side of the involved rib segment was present in the case showing the most severe erosion. In another case, a narrow zone of sclerosis was evident along the lowermost margin of the indented rib segment. The distribution of the lesions was primarily symmetrical, involving the third rib bilaterally in 10 of the 14 positive cases, the eighth rib bilaterally in 1 instance (with concomitant third rib lesions), and the second, fifth, and seventh ribs unilaterally in some cases (see Table I). The extent of the bone changes was also basically equal in degree bilaterally, although one or the other side might show slightly more erosion during the period of observation. In each instance, the eroded rib segment lay in relation to the medial margin of the scapula, although no abnormality of these portions of the scapulae was noted at any time. No regeneration or other sign of healing appeared in the area of the rib lesions throughout the follow-up. On the contrary, there was continued progression of erosion at each successive roentgen examination, although the degree of involvement in any single case did not directly correlate with the total duration of immobilization. The uninvolved portions of the ribs and the remainder of the thoracic cage showed no unusual osteoporosis or other abnormality, and the adjacent soft tissues were not remarkable.

Calcification of the mandibular third molar and its relation to skeletal and chronological age in children: By Arthur Demisch and Peter Wartmann. Child Development 27: 459–473, December, 1956

The La Ferrassie 1 (LF1) skeleton, discovered over a century ago, is one of the most important Neandertal individuals both for its completeness and due to the role it has played historically in the interpretation of Neandertal anatomy and lifeways. Here we present new skeletal remains from this individual, which include a complete right middle ear ossicular chain (malleus, incus, and stapes), three vertebral fragments, and two costal remains. Additionally, the study of the skeleton has allowed us to identify new pathological lesions, including a congenital variant in the atlas, a greenstick fracture of the left clavicle, and a lesion in a mid-thoracic rib of unknown etiology. In addition, we have quantified the amount of vertebral pathology, which is greater than previously appreciated. We have complemented the paleopathological analysis with a taphonomic analysis to identify any potential perimortem fractures. The taphonomic analysis indicates that no surface alteration is present in the LF1 skeleton and that the breakage pattern is that of bone that has lost collagen, which would be consistent with the intentional burial of this individual proposed by previous researchers. In this study, we used CT and microCT scans in order to discover new skeletal elements to better characterize the pathological lesions and to quantify the fracture orientation of those bones in which the current plaster reconstruction did not allow its direct visualization, which underlines the broad potential of imaging technologies in paleoanthropological research. A century after its discovery, LF1 is still providing new insights into Neandertal anatomy and behavior.

Spinal cord compression caused by vertebral myelomas

Os autores apresentam 4 casos de mieloma vertebral, com invasão do espaço epidural, provocando compressão medular ou radículo-medular. Em um caso havia lesões em vários ossos; noutro foi verificada apenas osteólise costal, além da lesão vertebral; nos demais tratava-se, provavelmente, de formas solitárias. A lesão se localizou entre C7 e T9, nos 4 casos. Em nenhum deles se verificou invasão do espaço subdural. Em 3 casos a sintomatologia era representada por paraplegia crural sensitivo-motora; em 1 caso prevaleciam sintomas radiculálgicos. Dos exames complementares destacam-se: presença de proteinuria de Bence-Jones e anormalidade do mielograma só verificadas no caso de mielo-matose generalizada; neste caso foi observada também redução da colesterolemia, hiperuricemia e positividade de algumas provas de função hepática; a eletroforese das proteínas plasmáticas, efetuada no caso 4, revelou diminuição da albumina e discreto aumento das taxas de globulina α1 e α2; o exame do liqüido cefalorraqueano, por punção lombar, revelou sempre a síndrome de compressão medular; o bloqueio do canal raqueano e seu nível foram comprovados por perimielografia, que confirmou os elementos clínicos de localização, sendo, entretanto, sugestiva de tumor intramedular em um caso. O tratamento consistiu em laminectomia, com extirpação do tecido tumoral peridural, seguida de radioterapia em altas doses. Os resultados obtidos foram altamente satisfatórios em 3 casos, porém o paciente com mielo-matose múltipla não se beneficiou, vindo a falecer um ano após a operação.

Fibrous dysplasia of rib

Summary Two cases of fibrous dysplasia of rib are described. The possibilities of endocrine traumatic and congenital factors in the etiology of the condition are discussed. The histological and radiological appearances are described, and it is suggested that awareness of the existence of this lesion in rib is the mainstay of the diagnosis. Excision of the lesion is recommended in view of the necessity of a histological diagnosis and also because of the possibility of malignant change.

The Development of Rib Notching After Surgical Intervention in Congenital Heart Disease

Reference is made to those conditions which may be associated with notching of the ribs. In Fallot's tetralogy a mechanism is known to exist by which such changes rarely occur. An account is given of two cases of congenital heart disease in which the rib lesions were produced by an entirely different mechanism. The feature of these cases is that the rib notching, absent before operation, appeared only on the side of thoracotomy after division of the subclavian artery, a step in the Blalock pulmonary-systemic anastomosis. It is concluded that the erosions developed as a result of the participation by the intercostal arteries in a collateral circulation to the arm. Angiocardiographic studies in Case 1 support this conclusion. Although no similar observations have apparently been reported it seems unlikely that these cases are unique.

Eosinophilic Granuloma of Bone

A 25-year-old white soldier stationed in the South Pacific was in good health until the latter part of May 1944. At that time, upon lifting a heavy airplane engine part, he first experienced sharp, stabbing pain in the right axilla and beneath the right scapula. Motion of the right arm and shoulder, coughing, sneezing, and deep inspiration reproduced the pain. On occasions he was awakened at night by a heavy, dull aching sensation high in the right axilla. Physiotherapy produced only moderate relief, and on June 3, 1944, the patient was admitted to a numbered station hospital. The only finding of significance on physical examination was sharp pain at the medial and inferior border of the right scapula when the arm was abducted beyond 90°. Roentgen examination of the right shoulder disclosed what was described as a localized osteolytic lesion of the 2nd right rib, containing remnants of normal bone. The remaining long bones, skull, and vertebrae showed no similar lesions. Urinalysis gave normal findings, and tests for Bence-Jones protein were negative. Blood studies showed: hemoglobin 17.5 gm., white cells 10,650, with a normal differential count (3 per cent eosinophils), blood calcium 13.5 mg. and 13.0 mg. on two occasions, blood phosphorus 2.9 mg., sedimentation rate 8 mm. per hour (Cutler). A smear for malaria was negative, as was the Kahn reaction. The patient was evacuated to the continental United States and admitted to a General Hospital on July 21, 1944. Physical examination was entirely negative at this time; range of motion of the right shoulder was normal, and there was neither pain nor tenderness in the axilla or shoulder girdle. Laboratory findings were essentially the same as previously reported, except that the blood calcium was now 12.3 and 12.6 mg. on two occasions, the blood phosphorus was 3.9 and 4.7 mg., and phosphatase 9.2 units (Bodansky). Serum albumin was 4.88 gm. and serum globulin 2.42 gm. The patient was referred to the roentgenological service for examination of the right shoulder, and the following opinion was given on July 27, 1944: “The 2nd right rib at the mid point of its shaft in the mid-axillary line presents an eccentric, oval-shaped area of infiltrative destruction with cortical erosion on the medullary side and moderate subperiosteal new bone formation. The lesion has grown in the axial plane of the rib, and though there is subperiosteal new bone formation, there is no soft-tissue mass surrounding the rib to give it a spherical shape. The area of destruction is fairly sharply demarcated, but at the margins the destructive process has infiltrated between the bony trabeculae, leaving small islands of normal bone between areas of destruction. Similarly, in the center of the lesion, where destruction has been most severe, a coarse reticulum of bone remains, giving a faintly honeycombed appearance.

Tumors of the thoracic cage

Tumors of the chest wall comprise all growths affecting tissues of a similar character elsewhere in the body. While they do not present any special pathological characters they do, because of their location, present special surgical problems. The differentiation between benign and malignant growths in the fibrous and cartilage groups is, as elsewhere, difficult and cannot be done on histologic appearances only. When operated upon by a surgeon unaccustomed to treating thoracic lesions, these tumors are perhaps likely to be removed incompletely because the surgeon fears to open the chest widely. They should be operated upon always with a closed type of anesthesia, preferably of the intralaryngeal or intratracheal type. The anesthetist as well as the surgeon should be accustomed to handling thoracic cases. Radiotherapy cannot be expected to have much effect on most of the primary conditions and should be used as a rule, only when surgical removal is impossible. Because they occur rather infrequently and are the most interesting of the group, case reports of the primary lesions of ribs and cartilages have been given in some detail. ∗ ∗ Cases I, II, III, IV, V, XIII and XV were reported previously in The Journal of Tboracic Surgery, 9: 145–159 December, 1939.

Some points in the X-ray diagnosis of pulmonary tuberculosis

Tumors of the chest wall comprise all growths affecting tissues of a similar character elsewhere in the body. While they do not present any special pathological characters they do, because of their location, present special surgical problems. The differentiation between benign and malignant growths in the fibrous and cartilage groups is, as elsewhere, difficult and cannot be done on histologic appearances only. When operated upon by a surgeon unaccustomed to treating thoracic lesions, these tumors are perhaps likely to be removed incompletely because the surgeon fears to open the chest widely. They should be operated upon always with a closed type of anesthesia, preferably of the intralaryngeal or intratracheal type. The anesthetist as well as the surgeon should be accustomed to handling thoracic cases. Radiotherapy cannot be expected to have much effect on most of the primary conditions and should be used as a rule, only when surgical removal is impossible.Because they occur rather infrequently and are the most interesting of the group, case reports of the primary lesions of ribs and cartilages have been given in some detail.∗