None. Everyone, especially Dr. Mitchell for helping me find cases!
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- Brian Stuart Hall
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2 None. Everyone, especially Dr. Mitchell for helping me find cases!
3
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5 Sagittal T1
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7 Coronal T1
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9 Axial T1
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11 Sagital T1, Axial T1+, Axial T2
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13 Axial CT +, thorax
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15 Axial T1
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17 Within the muscle, not connected to a nerve or vessel Faint internal enhancement on T1+ (not shown) Axial T1 Axial T2
18
19 Review a systematic approach for work up of a soft tissue mass. Highlight key points of some of the more common entities.
20 Soft tissue arises from the mesenchyme. Which differentiates to: fat skeletal muscle peripheral nerves Blood vessels Fibrous tissue Figure 1: Soft tissue layers. <
21 1. Adipocytic 2. Fibroblastic/myofibroblastic 3. Fibrohistiocytic 4. Smooth muscle 5. Pericystic (perivascular) 6. Skeletal Muscle 7. Vascular 8. Chondro-osseous 9. Uncertain differentiaion
22 Review a systematic approach for work up of a soft tissue mass. Highlight key points of some of the more common entities.
23
24 Characterization of these soft-tissue lesions remains problematic, despite advances in imaging. Let s go over an approach, while highlighting some of these lesions.
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26 Chan WP. Magnetic resonance imaging of soft-tissue tumors of the extremities: A practical approach. World Journal of Radiology. 2013;5(12): doi: /wjr.v5.i
27 Chan WP. Magnetic resonance imaging of soft-tissue tumors of the extremities: A practical approach. World Journal of Radiology. 2013;5(12): doi: /wjr.v5.i Determinate Lesions imaging features allowing a diagnosis without biopsy Indeterminate Lesions one that must be biopsied to ensure an accurate diagnosis
28 Chhabra and Soldatos. Soft-Tissue Lesions: When Can We Exclude Sarcoma? American Journal of Roentgenology. 2012;199: /AJR
29 Chhabra and Soldatos. Soft-Tissue Lesions: When Can We Exclude Sarcoma? American Journal of Roentgenology. 2012;199: /AJR
30 Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic imaging approach. Radiology 2009; 253:
31 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
32 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
33 Important information: Age (eg: liposarcomas are rare in children) Hx of trauma (hematoma, myositis ossificans) History of malignancy or familial syndromes (metastasis, radiation induced sarcoma, NF type 1) Mass characteristics (rapid growth, size fluctuation, mobile,etc).
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35
36 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
37 Some masses occur in specific locations. You just have to know them. - Let s look at some!
38 Axial CT +, thorax
39 Axial CT +, thorax
40 Axial CT +, thorax
41 Axial CT +, thorax
42 Axial CT +, thorax
43 Axial CT +, thorax
44 Axial CT +, thorax
45 Axial CT +, thorax
46 Axial CT +, thorax
47 Axial CT +, thorax
48 Axial CT +, thorax
49 Axial CT +, thorax
50 Axial CT +, thorax
51 Axial CT +, thorax
52 Axial CT +, thorax
53 Axial CT +, thorax
54 Axial CT +, thorax
55 Axial CT +, thorax
56 Axial CT +, thorax
57 Axial CT +, thorax
58 Axial CT +, thorax
59 Axial CT +, thorax
60 Axial CT +, thorax
61 Subscapular mass deep to serratus anterior. 99% in subscapular region % bilateral Mean age: years. F > M Slow growth, no malignant degeneration CT imaging findings: Poorly defined, lenticular, heterogeneous soft tissue mass Linear low-attenuation streaks from internal fat Majority of lesion has attenuation similar to muscle
62 (distal fingers) Coronal T2 Coronal T1
63 Mesenchymal neoplasm of smooth muscle cells similar to glomus body cells Propensity to subungual region. Fingers and toes most common 99% benign, but often painful. MR imaging findings: Isointense to nail bed or muscle on T1 Hyperintense on T2
64 Case reports of other locations:
65 (Metatarsals) Coronal T1 Coronal T1 post gad Coronal T2
66 Painful, benign fibrosing process of plantar digital nerve between 3rd and 4th metatarsal heads. most common. F>M MR imaging findings: Hypo to Isointense on T1 Iso to Hyperintense on T2 Variable enhancement
67 Sagittal T1
68 Benign discrete nodule along plantar fascia. Ages years M:F = 1:1 MR imaging findings: Isointense on T1 Hypo to isointense on T2
69 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
70 Only a few things arise from a nerve: PNSTs (schwannomas and neurofibromas) If fat, consider Neural fibrolipoma/fibrolipomatous hamartoma
71 Sagital T2, elbow
72 Sagital T2, elbow
73 Sagital T2, elbow
74 Sagital T2, elbow
75 Sagital T2, elbow
76 Sagital T2, elbow
77 Sagital T2, elbow
78 Sagital T2, elbow
79
80 Neurofibromas Schwannoma Malignant Peripheral Nerve Sheath Tumors
81 Benign PNST with neoplastic tissue inseparable from normal nerve Localized NF: 90% of cases, primarily affect superficial cutaneous nerves, can affect larger deeper nerves Diffuse NF: Ill-defined plaque-like in the subcutaneous tissue Plexiform NF: Long segments of diffusely and irregularly enlarged nerves. Multilobulated. Pathgonomic for NF1.
82 Arises in 2nd to 3rd decade of life Low risk of malignant transformation (though higher risk with the deeper lesions). Painless, slowly growing nodule
83 Iso to mildly hyperintense (Hypointense also possible) on T1 Split-fat sign = peripheral rim of fat Hyperintense on T2 Variable heterogeneity Target sign = central low signal focus Fascicular sign = multiple small ring-like structures + enhancement, most prominent centrally
84 Coronal T1 Coronal T2 Coronal T1+
85 In contrast to schwanomas, neurofibromas incorporate many cell types in addition to Schwann cells May be impossible to differentiate from a neurofibroma from a schwanoma via imaging.
86 Encapsulated benign peripheral nerve sheath tumor typically located eccentrically on normal nerve Upper and lower extremity flexor surface nerves Well-defined, solitary fusiform mass Most common in 2nd to 5th decades of life Painless, slowly growing
87 Iso to hyperintense on T1 Split-fat sign = thin peripheral rim of fat May have subtle muscle atrophy distal to lesion Hyperintense on T2 Target sign = central low signal region Fascicular sign = multiple small ring-like structures Diffuse enhancement (often greater than neurofibroma) is typical.
88 Sagital T1, Axial T1+, Axial T2
89 Infiltrative, often invasive, fusiform mass > 5 cm Large to medium deep nerves (Sciatic nerve > brachial plexus, sacral plexus) Proximal extremities, retroperitoneum, posterior mediastinum Malignant spindle cell sarcoma of neural origin % associated with NF % radiation-induced 5-year survival rate: 23-44%
90 Heterogeneously hypo- to hyperintense on T1WI MR Heterogeneously hyperintense on fluidsensitive MR ± hemorrhagic fluid-fluid levels Intense heterogeneous enhancement Diffuse, peripheral or nodular patterns
91 Sagittal T2 and Axial T1.
92 Does it arrive from a vessel? Hemangioma would be the most common Other possibilities include lymphangiomas and angiosarcomas. If there is a Hx of trauma, consider a pseudoaneurysm.
93 Does it arrive from a tendon sheath? Most commonly would be a Giant Cell Tumor of the tendon sheath. Nonetheless, ganglia, lipomas and fibromas can all arise from tendon sheaths.
94 nodular tenosynovitis, tenosynovial giant cell tumor, Benign synovial proliferation within tendon sheath same pathologic entity as pigmented villonodular synovitis (PVNS)
95 85% in fingers. Hand > wrist > ankle/foot > knee > elbow > hip years. M:F = 2:1 Local recurrence in 4-44% Radiographs: Nonspecific soft tissue fullness. Cortical erosion in 10-28%
96 Inhomogeneous low to intermediate signal intensity on T1 and T2 "bloom" on gradient-echo imaging Intense enhancement ± inhomogeneity
97 Axial T1, Axial T2 and Gradient Echo
98 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
99 They should be assessed for: distortion of tissue planes, radiolucent fat indolent or aggressive remodeling of the bone soft-tissue calcifications or ossification.
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101
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104 Heterotopic formation of bone and cartilage in soft tissue At the site of injured muscle (quads/arms most common). Classic appearance: Mature bone formation within soft tissues. Early stages can be confusing and non specific.
105 Myositis is misleading May also be found in fascia, tendons, & fat. "Heterotopic ossification" is more correct term
106 0-2 weeks: Soft tissue mass with indistinct surrounding soft tissue planes 3-4 weeks: Amorphous osteoid forms within mass; adjacent periosteal reaction may be seen 6-8 weeks: Sharper cortex begins to form about lacy central osseous mass 5-6 months: Mature bone formation
107 Axial T2, Radiograph and Sagittal CT
108 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
109 MRI is the most effective for tissue characterization. As usual, the signal intensity of T1 and T2 weighted images are compared to muscle
110
111 This isn t useful, too many lesions with these signal characteristics.
112 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
113 Consider this flow chart:
114
115
116 Benign adipocytic tumors Intermediate adipocytic tumors Malignant adipocytic tumors
117 Lipoma Lipomatosis Nerve Lipomatosis Lipoma Arborescens, Knee Lipoblastoma (pediatrics) Hibernoma Parosteal Lipoma
118 Benign Adipocytic tumors Same signal as fat Only thin septa (< 2mm) No nodules While calcification can occur, it should raise suspicion. Axial T1
119 Benign Adipocytic tumors Same signal as fat Disorganized and poorly circumscribed fat overgrowth Associated with various syndromes Axial T1
120 Benign Adipocytic tumors 78-96% in upper extremity (80% in median nerve distribution) Collection of enlarged cylindrical fascicles along course of nerve, like a coaxial cable Axial T1
121 Benign Adipocytic tumors Most common in suprapatellar recess of knee joint Frond-like or globular pattern of fat proliferating from synovial membrane Treat w/synovectomy Sagital T2
122 Benign Adipocytic tumors Rare, benign tumor of brown adipose tissue Needs biopsy, because imaging alone can t exclude non benign lipomatous lesions More complex then a lipoma, multiple septa and prominent vascularity Axial T1
123 Benign Adipocytic tumors Fatty lesion arising from bone surface Approximately 33% adjacent to femur Internal calcifications, septa, ossifications Adjacent bone shows osseous excrescence and bone cortex changes, such as thicknening
124 Atypical lipomatous tumor or Well-differentiated liposarcoma
125 Intermediate Adipocytic tumors or Intermediate, locally aggressive neoplasm predominantly composed of fat typically composed of > 75% fat with septa and variable nodularity Does not metastasize. 0% mortality for lesions in extremities 80% mortality for retroperitoneal lesions
126 Intermediate Adipocytic tumors or Axial T1
127 Liposarcoma
128 Malignant Adipocytic tumors Typically ages In extremities or retroperitoneum. 5 types: Well-differentiated commonest, low grade, Myxoid - intermediate grade Round Cell/de-differentiated, high grade Pleomorphic, high grade Mixed
129 Malignant Adipocytic tumors Low grade lesions are almost entirely fat signal with thick septa, nodules +/- evidence of local invasion. The higher grade lesions are often devoid of macroscopic fat and have appearances similar to other sarcomas.
130 Malignant Adipocytic tumors Axial CT Sagital T1
131 Axial PD FatSat
132 Axial PD FatSat
133 Axial PD FatSat
134 Axial PD FatSat
135 Axial PD FatSat
136 Axial PD FatSat
137 Axial PD FatSat
138 Axial PD FatSat
139 Axial PD FatSat
140 Axial PD FatSat
141 Axial PD FatSat
142 Axial PD FatSat
143 Axial PD FatSat
144 Axial PD FatSat
145 Axial PD FatSat
146 Axial PD FatSat
147 Axial PD FatSat
148 Axial PD FatSat
149 Axial PD FatSat
150 Axial PD FatSat
151 Axial PD FatSat
152 Axial PD FatSat
153 Axial PD FatSat
154 Axial PD FatSat
155 Axial PD FatSat
156 Axial PD FatSat
157 Axial PD FatSat
158 Axial PD FatSat
159 Axial PD FatSat
160 Axial PD FatSat
161 Axial PD FatSat
162 Axial PD FatSat
163 Axial PD FatSat
164 Axial PD FatSat
165 Axial PD FatSat
166 Axial PD FatSat
167 Axial PD FatSat
168 Axial PD Fatsat Axial T1 Axial T1 FatSat Axial T1 FatSat +
169 Axial PD Fatsat Axial T1 Axial T1 FatSat Axial T1 FatSat +
170
171
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174
175 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
176 Divide the differential into 3 categories: 1. Fibrosis 2. Hemosiderin 3. Calcification
177
178
179 Can still be hyperintense on T2!
180 Benign neoplasm originating from smooth muscle Punctate, plaque-like, or "popcorn" calcifications Iso to slightly hyperintense T1 Hypo to hyperintense on T2. Excision, rare recurrence Subcutaneous lesions are small <2cm Deep lesions are larger
181 Axial T1 Axial T2 Axial T1+
182 Malignant fibroblastic/myofibroblastic neoplasm Often in deep soft tissues of extremities Commonly 3-8 cm at presentation Variable appearance depending on cellular content. Thus heterogenous appearance that can be low to high signal intensity on T1 and T2 Estimated 39-54% 5-year survival Metastases in 9-63%
183 Axial T2 Axial T1+
184 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
185 Look at the enhancement pattern. Is it rim enhancing, or demonstrate internal enhancing components?
186
187
188 Axial T1 Axial T2 Rare benign type of soft tissue myxoma 40 to 70 years. F>M homogeneous low T1, high T2, mild internal enhancement Simple excision is curative
189 Fibroblastic soft tissue sarcoma involving elderly patients years. Low grade: homogeneous low T1, high T2, mild internal enhancement High Grade: heterogeneous intermediate T1, high T2, intense enhancement ± hemorrhage, necrosis High local recurrence rate (38-79%). Even with lowgrade tumors
190
191 Malignant soft tissue tumor of uncertain differentiation. 95% in the extremities, Often in the knees years of age Does not arise from synovium. 5-year survival rate: 27-76% Metastases in up to 41%
192 Imaging findings are not pathognomonic. Iso to slightly hyperintense on T1 and heterogeneous Mostly hyperintense on T2. Markedly heterogeneous. Calcification in 1/3 but extent variable "Triple" sign = multiple signal intensities due to hemorrhage, necrosis, solid tissue, and calcification "Bowl of grapes" sign = multiloculated appearance of mass with internal septa Fluid Fluid levels = Intra-tumoral hemorrhage Enhancement is usually prominent and can be diffuse, heterogeneous or peripheral.
193 Due to variable appearance any soft tissue mass near a joint, especially containing calcification, should not be dismissed as being benign.
194 Coronal T1 Coronal T2 Fatsat
195 Axial PD Axial T1+
196 Sagittal and Axial T2 Fluid Fluid levels and Triple Sign Coronal T2 Bowl of Grapes sign
197 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
198 While a systematic approach can narrow a differential, it is not comprehensive. If a lesion can not be confidently diagnosed then it is an intermediate lesion.
199 According to WHO soft tissue masses that do not demonstrate tumor-specific features on MR images should be considered indeterminate and biopsy should always be obtained to exclude malignancy.
200 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
201
202
203 Sagittal T1
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205 Sagittal T1
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207 Coronal T1
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209 Coronal T1
210
211 Axial T1
212
213 Axial T1
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215 Sagital T1, Axial T1+, Axial T2
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217 Sagital T1, Axial T1+, Axial T2
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219 Axial CT +, thorax
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221 Axial CT +, thorax
222
223 Axial T1
224
225 Axial T1
226 Axial T1 or
227
228 Within the muscle, not connected to a nerve or vessel Faint internal enhancement on T1+ (not shown) Axial T1 Axial T2
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230 Axial T1 Axial T2
231
232 1. Clinical History 2. Location 3. Does it arise from something? 4. What does the radiograph show? 5. Is it hyperintense on T1? 6. Is it hypointense on T2? 7. Is it hyperintense on T2?
233 Question 5 quiz: Walker, C. Elastofibroma Slide 62: Roberts, C. Glomus Tumor Slide 65: Blankenbaker, D. Morton Neuroma Slide 67: Unknown author. Plantar Fibroma Slide 88: Roberts, C. Schwannoma Slide 91: Chen, K., Zhou, M., Yang, H., Qian, Z., Wang, G., Wu, G.... Sun, Z. (2013). Pre-operative embolization facilitating a posterior approach for the surgical resection of giant sacral neurogenic tumors. Oncology Letters, 6, Slide 95: Roberts, C. Giant Cell Tumor of the Tendon Sheath Slide 97: Wan, J., Magarelli, N., Peh, W. et al. Giant Cell Tumor of the Tendon Sheath Radiol med (2010) 115: 141. doi: /s
234 Slide 101: Roberts, C. Hemangioma Slide 103 and 107: Banaster, M. Myositis Ossificans Slide 118: Roberts, C, Lipoma Slide 119: Roberts, C. Lipomatosis Slide 120: Roberts C. Lipomatosis of a nerve b759d6caf025 Slide 121: Weerakkody et al. Lipoma Arborescens Slide 122: Goel, A at al. Hibernoma Slide 123: Lawson, A. Parosteal lipoma Slide 126: Nicoletti, D. Atypical lipomatous tumor Slide 130: Di Muzio, B. and Gaillard et Al. Liposarcoma Slide 181: Roberts, C. Leiomyoma Slide 183: Roberts, C. Fibrosarcoma, Soft Tissue f5e?searchTerm=fibrosarcoma
235 Slide 188: Weerakkody et al. Intramuscular Myxoma Slide 190: Roberts, C. Myxofibrosarcoma Slide : Di Muzio, B. and Gaillard, F. et al. Synovial Sarcoma
236 Chan WP. Magnetic resonance imaging of soft-tissue tumors of the extremities: A practical approach. World Journal of Radiology. 2013;5(12): doi: /wjr.v5.i Chen, K., Zhou, M., Yang, H., Qian, Z., Wang, G., Wu, G.... Sun, Z. (2013). Pre-operative embolization facilitating a posterior approach for the surgical resection of giant sacral neurogenic tumors. Oncology Letters, 6, Chhabra and Soldatos. Soft-Tissue Lesions: When Can We Exclude Sarcoma? American Journal of Roentgenology. 2012;199: /AJR Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic imaging approach. Radiology 2009; 253: Wan, J., Magarelli, N., Peh, W. et al. Giant Cell Tumor of the Tendon Sheath Radiol med (2010) 115: 141. doi: /s Roberts, C. Glomus Tumor 26a9-43eb-8d97-98fdcc9330cd Roberts, C. Neurofibroma Roberts, C. Giant Cell Tumor of the Tendon Sheath Roberts, C, Lipoma Roberts, C. Lipomatosis Roberts C. Lipomatosis of a nerve
237 Roberts, C. Leiomyoma Roberts, C. Fibrosarcoma, Soft Tissue Roberts, C. Myxofibrosarcoma Walker, C. Elastofibroma Di Muzio, B. and Gaillard, F. et al. Synovial Sarcoma Banaster, M. Myositis Ossificans
238
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