Intratendinous Ganglion Cyst: Depiction on MR images

Transcription

1 Intratendinous Ganglion Cyst: Depiction on MR images Poster No.: C-0853 Congress: ECR 2014 Type: Educational Exhibit Authors: R. Prost, J. T. Bencardino, Z. S. Rosenberg ; Cagliari, Cagliari/ IT, New York, NY/US Keywords: Trauma, Education and training, Cysts, Education, MR, Musculoskeletal joint, Musculoskeletal soft tissue, Musculoskeletal system DOI: /ecr2014/C-0853 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Learning objectives Intratendinous Ganglion Cysts (IGC) are rare intrasubstance lesions confined by the tendon's margins, sheath or paratenon. A ganglion cyst is a common tumour-like lesion arising from various soft tissues that is generated by mucoid degeneration of the joint capsule, tendon or tendon sheath [1]. It can occur in any part of the extremities including the hand, wrist and foot. Page 2 of 20

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4 Fig. 12: MRI and US are highly sensitive, specific and effective methods for delineating the nature of cysts, including their size, location and relationship to the surrounding structures [1], but MRI provides a better anatomical overview. References: Department of Radiology, NYU Langone Medical Center The focus of this exhibit is to describe the pathophysiology and MRI appearance of intratendinous ganglion cyst. Images for this section: Page 4 of 20

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6 Fig. 12: MRI and US are highly sensitive, specific and effective methods for delineating the nature of cysts, including their size, location and relationship to the surrounding structures [1], but MRI provides a better anatomical overview. Page 6 of 20

7 Background Definition Intratendinous ganglion cyst (IGC) is an uncommon lesion that originates within the tendon substance itself and causes soft-tissue swelling [2, 3]. In 1959, Robertson [13] reported the 1st case of an intratendinous ganglion cyst arising in the peroneus brevis tendon. Few references to intratendinous ganglion cysts appear in the literature, and most of these concern cysts that arise from the extensor tendons of the wrist, hand, foot, and ankle [3, 4, 8, 9]. Aetiology The aetiology of intratendinous ganglion cysts is unclear. It is probably related to post-traumatic mucoid degeneration of connective tissue within the tendon. It is postulated that intratendinous ganglion may arise due to fluid accumulation in the setting of tenosynovitis[9], possibly via a uniderctional ball valve mechanism. It may also occur due to acute [13] or repetitive [17, 18, 20] mechanical trauma to the tendon by an impinging sturcture such as an adjacent bony prominence. Mucoid degeneration of the collagen fibers of the tendon and cellular hyperplasia associated with active secretion of mucin are thought to be one of the main pathologic pathways that precede the development of these ganglion cysts [13, 20] A congenital anomaly may be responsible in patients with no history of trauma [14]. Histology The wall of a ganglion is composed of randomly oriented sheets of collagen arranged in loose layers. There are focal areas of mucinous degeneration in the cyst wall. Since no synovial lining exists in these structures, they cannot be classified as true cysts [19]. A histologic examination reveals characteristic fibrous tissue wall without a synovial lining [6] Page 7 of 20

8 Fig. 1: Pathologic findings of resected ganglion. The specimen consists of a thickened collagenous wall (arrows) containing mucoid substance (arrow head) (hematoxylin and eosin) [6] References: Kishimoto K et al. Skeletal Radiol 2008;37: Images for this section: Page 8 of 20

9 Fig. 1: Pathologic findings of resected ganglion. The specimen consists of a thickened collagenous wall (arrows) containing mucoid substance (arrow head) (hematoxylin and eosin) [6] Page 9 of 20

10 Findings and procedure details MRI and US are highly sensitive, specific and effective methods for delineating the nature of cysts, including their size, location and relationship to the surrounding structures [1]. MRI, however, may provide a better anatomical overview of the surrounding bony and soft tissue structures. Retrospective review of our database rendered 25 cases of IGC diagnosed between January 2007 and March Location Intratendinous ganglion cysts were found in the following locations: Shoulder: Rotator cuff tendons (5), Long head of biceps tendon (5) Fig. 2 on page 11, Fig. 3 on page 11. Wrist: Extensor digitorum (2) Fig. 4 on page 12, Fig. 5 on page 13. Knee: Patellar tendon(5) Fig. 6 on page 15, Fig. 7 on page 15. Semimembranosus tendon (1); Foot/Ankle: Peroneus brevis tendon (5) Fig. 8 on page 15, Fig. 9 on page 17. Peroneus longus tendon (1) Fig. 10 on page 17. Achilles tendon (1). Tibialis anterior (1) Fig. 11 on page 18. MRI Appearance A ganglion is typically a well-defined, lobulated mass located adjacent to a tendon, ligament or a joint. A fluid-filled stalk or pedicle that connects to the adjacent joint or tendon sheath is a reliable sign of a ganglion [13, 2]. MRI signal characteristics of intratendinous ganglion are typical of other ganglions, depicting homogenous, low signal intensity on T1-weighted images and a high signal intensity on T2-weighted images. Thin peripheral wall enhancement is seen after gadolinum injection. Since IGC originates within the tendon substance it typically has no continuity to the tendon sheath or joint capsule [6]. Thus, a lobulated, homogenous cystic mass occupying the characteristic location within a tendon and displaying thin rim enhancement should suggest an IGC [2]. Differential diagnosis of a ganglion Differential diagnosis based on MRI findings includes: Page 10 of 20

11 Mucoid degenerative tendinopathy Tenosynovitis Tendon tear Intramuscular ganglia Bursa Epidermal cyst Abscess Giant cell tumor of the tendon sheath Myxoma Nerve sheath tumor Synovial chondromatosis lesion Malignant lesions which should be considered in the differential diagnosis of a ganglion are: synovial sarcoma, malignant nerve sheath tumor, myxoid chondrosarcoma, myxoid liposarcoma, and metastasis [21]. Images for this section: Fig. 2: Intra-articular biceps tendinosis and a ganglion cyst in the extra-articular tendon. A, An oblique coronal T2W Fat Sat. and B, Axial PD Fat Sat images show an elongated area of linear bright signal in the extra-articular biceps tendon (arrows) consistent with an IGC. Page 11 of 20

12 Fig. 3: A, B, Oblique coronal T2W Fat Sat. C, Oblique coronal PD Fat Sat. D, Axial PD Fat Sat. The extra-articular component of the long head biceps tendon is markedly degenerated and shows longitudinal split tearing with intratendinous cyst formation (arrows). Page 12 of 20

13 Fig. 4: A, B, Axial and Sagittal T1W. and C, D Axial and Sagittal T2W images show oval, homogenous, low T1, high T2 signal mass, asymmetrically expanding the extensor digitorum tendon in the fourth dorsal compartment of the wrist. Page 13 of 20

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15 Fig. 5: A, Axial PD. B, Axial PD Fat Sat. Mild tenosynovitis of the fourth extensor compartment of the wrist (arrow), with an intratendinous ganglion of the third digital extensor tendon in the fourth extensor compartment (arrowhead). Fig. 6: Patellar tendon intratendinous ganglion. A, B, Sagittal proton density and fatsuppressed T2; C, Axial fat suppressed T2 show a mass containing fluid signal within the mid patellar tendon. An ossific body located near the distal insertion of the patellar tendon, likely reflects prior Osgood-Schlatter's disease (arrow). Fig. 7: A, B, Sagittal proton density and fat-suppressed T2; C, Axial fat suppressed T2, show large ganglion within the lateral aspect of the patellar tendon Page 15 of 20

16 Fig. 8: Peroneus brevis intratendinous ganglion. A, short axis STIR images and B, short axis T1; C long axis fat suppressed T2-weighted and D sagittal STIR images show Page 16 of 20

17 split longitudinal tear of the peroneus brevis tendon associated with an intratendinous ganglion cyst formation (arrows). Fig. 9: A, long axis STIR; B, short axis T1W. Acute on chronic peroneus brevis tendinosis associated with intratendinous cyst (arrow) and longitudinal split tear of the subfibular tendon (arrow head). Fig. 10: Peroneus longus intratendinous ganglion. A, B, Short axis T2w fat sat; a large complex multiseptated intratendinous ganglion, is noted (arrows). Page 17 of 20

18 Fig. 11: Anterior tibial intratendinous ganglion. A, short axis T2W fat sat; B, long axis PD fat sat. There is a split longitudinal tear of the distal anterior tibial tendon with intrasubstance fluid collection (arrows). Page 18 of 20

19 Conclusion Intratendinous ganglion cysts are uncommon lintrasubstance lesions confined by the tendon's margins, sheath or paratenon demonstrating MRI appearance and signal characteristics similar to ganglions elsewhere in the body. MRI allows delineation of these cysts and provides excellent characterization regarding their intratendinous location and size. This information may influence treatment strategy and surgical planning. Personal information Roberto Prost P.O. Marino ASLCagliari, Viale Poetto, Cagliari Italy J.T. Bencardino, Z.S. Rosenberg NYU Hospital for Joint Diseases Department of Radiology 301 East 17th Street - Sixth Floor New York, NY References 1. McCarthy CL, McNally EG. The MRI appearance of cystic lesions around the knee. Skeletal Radiol 2004;33: Costa CR, Morrison WB, Carrino JA, Raiken SM. MRI of an intratendinous ganglion cyst of the peroneus brevis tendon. AJR Am J Roentgenol 2003;181: Rayan GM. Intratendinous ganglion. A case report. Orthop Rev 1989;18: Page 19 of 20

20 4. Ikeda K, Tomita K, Matsumoto H. Intratendinous ganglion in the extensor tendon of a finger: A case report. J Orthop Surg (Hong Kong) 2001;9: Steiner E, Steinbach LS, Schnarkowski P, Tirman PF, Genant HK. Ganglia and cysts around joints. Radiol Clin North Am1996;34: , xi-xii. 6. Kishimoto K, Akisue T, Fujimoto T, Kawamoto T, Hara H, Hitora T, et al. Intra-tendinous ganglion in the long head of the biceps humeri. Skeletal Radiol 2008;37: Lece ne MP. Three cases of pseudocystic gelatinous degeneration of juxta-articular connective tissue and tendon tissue. Bull Mem Soc Nat Chir 1927;53:2. 8. Young SC, Freiberg A. A case of an intratendinous ganglion. J Hand Surg Am 1985;10: Seidman GD, Margles SW. Intratendinous ganglia of the hand. J Hand Surg Am 1993;18: Graves FT. A ganglion in the muscle belly of peroneus longus. Br J Surg 1956;43: Siebert CH, Kaufmann A, Niedhart C, Heller KD. The quadriceps tendon cyst: an uncommon cause of chronic anterior knee pain. Knee Surg Sports Traumatol Arthrosc 1999;7: Schram AJ, Kirschenbaum SE. Presentation of a unique ganglionic cyst. J Foot Surg 1988;27: Robertson DE. Cystic degeneration of the peroneus brevis tendon. J Bone Joint Surg Br 1959;41-B: Pedrinelli A, Castellana FB, Braganca devasconcellos Fontes R, Coelho RF, Alvaro demenezes LA. Anterior cruciate ligament ganglion: case report. Sao Paulo Med J 2002;120: Rozbruch SR, Chang V, Bohne WH, Deland JT. Ganglion cysts of the lower extremity: an analysis of 54 cases and review of the literature. Orthopedics 1998;21: Pontious J, Good J, Maxian SH. Ganglions of the foot and ankle. A retrospective analysis of 63 procedures. J Am Podiatr Med Assoc 1999;89: Thornburg LE (1999) Ganglions of the hand and wrist. J Am Acad Orthop Surg 7: Chen WS (1992) Intratendinous ganglion and carpometacarpal boss. A report of two cases. Ital J Orthop Traumatol 18: Psaila JV, Mansel RE (1978) The surface ultrastructure of ganglia. J Bone Joint Surg 60-B: Kannus P, Józsa L (1991) Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. J Bone Joint Surg Am 73: Kransdorf MJ (1995) Malignant soft tissue tumors in a large referral population: distribution of diagnoses by age, sex, and location. AJR Am J Roentgenol 164: Page 20 of 20