Diagnostic Approach for Chest Wall Lumps

Primary Diagnostic Categories

The American College of Radiology suggests that nerve sheath tumors can present as palpable axillary or chest wall masses 1
The American College of Radiology recommends considering vascular lesions, including hemangiomas and arteriovenous malformations, in the differential diagnosis of chest wall lumps 1
The American College of Radiology notes that infectious/inflammatory processes, including abscesses and inflammatory lymphadenopathy, should be considered in the differential diagnosis of chest wall lumps 1
The American College of Radiology suggests that autoimmune disease manifestations can present as chest wall lumps 1
Hamartomas are characterized by intranodular fat and popcorn calcification on imaging, according to the American Thoracic Society 2
Primary breast malignancy, particularly in women with axillary presentation, should be considered in the differential diagnosis of chest wall lumps, according to the American College of Radiology 1
Metastatic disease from non-breast malignancies should be considered in the differential diagnosis of chest wall lumps, according to the American College of Radiology 1
Lymphoma should be considered in the differential diagnosis of chest wall lumps, according to the American College of Radiology 1

The risk of malignancy is low (7%) in women without a personal history of breast cancer, but increases with age, according to the American College of Radiology 1
The American College of Radiology notes that primary breast cancer presenting as isolated axillary adenopathy occurs in less than 1% of cases 1
The risk of malignancy increases with an odds ratio of 1.04-2.2 for every 10-year increase in age, according to the American College of Radiology 3

Spiculated or irregular margins increase the likelihood of malignancy more than 5-fold (LR 5.5), according to the American College of Radiology 3
A size greater than 8 mm is associated with approximately 1.1-fold increased odds per 1 mm diameter increase, according to the American College of Radiology 3
Pleural retraction increases the likelihood of malignancy 1.9-fold, according to the American College of Radiology 3
The vascular sign (vessels leading into mass) increases the likelihood of malignancy 1.7-fold, according to the American College of Radiology 3
Rapid growth, with a volume doubling time less than 400 days, is suspicious for malignancy, according to the American College of Radiology 3
Diffuse, central, laminated, or "popcorn" calcification is associated with a low odds ratio for malignancy (0.07-0.20), according to the American Thoracic Society 2
Smooth or polygonal margins make malignancy 5 times less likely (LR 0.2), according to the American College of Radiology 3
Intranodular fat with popcorn calcification is pathognomonic for hamartoma, according to the American Thoracic Society 2
Stability for at least 2 years is characteristic of benign nodules, according to the American College of Radiology 3

The American College of Radiology recommends obtaining a thorough history, including duration, associated symptoms, smoking history, personal/family cancer history, and risk factors, in the initial evaluation of chest wall lumps 3
The American College of Radiology suggests that physical examination should include visualization of deeper structures if malignancy risk is elevated 5
Ultrasound is the first-line imaging modality for superficial chest wall masses, according to the American College of Radiology 5
Diagnostic mammogram/digital breast tomosynthesis plus axillary ultrasound should be used to evaluate axillary lumps in women, according to the American College of Radiology 1
CT chest should be used to determine bony involvement, chest wall invasion, or pleural space involvement in suspected chest wall invasion or deeper involvement, according to the American College of Radiology 1
Image-guided core biopsy is preferred over fine-needle aspiration when diagnosis remains uncertain, according to the American College of Radiology 5
US-guided biopsy can be performed for accessible axillary or chest wall masses, according to the American College of Radiology 1