By Amr Osman Osman. M.B.B.Ch. Tanta university. Supervisors Dr.Ahmed Mohamed Wafaie. Assistant Professor of radiology.

Transcription

1 Role of ultrasound and color Doppler in evaluation of musculoskeletal soft tissue masses Essay Submitted for partial fulfillment of Master Degree in radiodiagnosis By Amr Osman Osman M.B.B.Ch Tanta university Supervisors Dr.Ahmed Mohamed Wafaie Assistant Professor of radiology Cairo university Dr. Nevien Ezzat El Liethy Lecturer of radiology Cairo university Faculty of medicine Cairo university 2012

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3 Acknowledgment I Acknowledgment merciful. First and foremost I feel always indepted to god the most kind and the most I would like to express my sincere thanks and deep gratitude to professor Dr. Ahmed Mohamed Wafaie Assistant Professor of diagnostic radiology, Cairo university, for his help, guidance, unlimited cooperation, constructive criticism and deep support. My special thanks and deep gratitude to professor Dr. Nevien Ezzat El Liethy Professor of diagnostic radiology, Cairo university, for his sincere help and guidance to bring this work to reality. Finally, I would like to express my deep gratitude to all my family members especially my parents for their unwavering support and love and their ability to instill within me a thirst for knowledge without which this effort would not be possible., my wife (my much better half, a fact that anybody who knows me will thoroughly agree with) for her unlimited cooperation, patience and deep support. They provide my foundation and strength through their love and support.

4 List of content II List of contents Title Acknowledgement List of content List of abbreviations List of Tables & charts List of figures Pages I II III IV V-VII Abstract VIII Introduction 1-3 Aim of the work 4-5 Technique and sonographic anatomy of the musculoskeletal 6-21 system Pathology of soft tissue tumor of the musculoskeletal system Ultrasound and color Doppler appearance of most common musculoskeletal soft tissue tumors: I. Subcutaneous II. Inter and intramuscular III. Interarticular/juxta-articular IV. Tumor like masses Cases demonstration Summary & conclusion References Arabic Summary

5 List of abbreviations III List of abbreviations: Abbreviation US Ultrasound RI resistive index SD standard deviation CD Color Doppler HRUS High resolution ultrasound CDUS Color Doppler ultrasound PDUS Power Doppler US GCTTS Giant cell tumor of tendon sheath DFSP Dermato-fibrosarcoma protuberance MHZ Mega hertz CT Computerized tomography NF1 Neurofibromatosis type 1 MRI Magnetic resonance images

6 List of tables and charts IV List of tables and charts Table 1 : Locations of inflamed bursae evaluated by Ultrasound. Chart 1: Simple algorithm for worrying and un worrying features for soft tissue lump diagnosis. Chart 2: An algorithm for investigating a patient with soft tissue tumor. Pages

7 List of figures V List of Figures Figure Title Page Figure 1,2 &3 : Commonly used ultrasound transducers in musculoskeletal ultrasound. 8 Figure 4: Color Doppler showing a large serpiginous feeding vessel. 10 Figure 5: Simple Doppler ultrasound instruments 11 Figure 6&7: The angle of insonation changes. 11 Figure 8: Normal skin and subcutaneous tissu photography and US 14 Figure 9: Subcutaneous veins and nerves diagram and US 15 Figure 10: Intramuscular aponeuroses & perimysium Figure 12 : Normal quadriceps muscle (A) Longitudinal (B) Panoramic veiw 17 Figure 13: Normal nerve echotexture. 19 Figure 14: cuboid bone cartilage and bone by US. 23 Figure 15&16: US appearance of normal bone surface echotexture. 20 Figure 17-20: Hemangioma of the elbow, foot, thigh, leg, subcutaneous hemangioma Figure 21: Subcutaneous hemangioma of the leg, 34 Figure 22: Cavernous hemangioma of the foot. 34 Figure 23: Intramuscular hemangioma of thelower extremity.photgraphy 35 Figure 24: Cystic lymphangioma (A) Grayscale ultrasonography (B) Color Doppler 36 ultrasonography. Figure 25: Glomus tumor in index finger. (A) Grayscale ultrasonography (B) Color 36 Doppler ultrasonography Figure 26: Dermatofibrosarcoma over the left abdominal wall (A&B) Grayscale 37 ultrasonography (C) CDUS (D): Photograph Figure 27: Dermatofibrosarcoma protuberans of the abdominal wall (A), extended 38 view long axis (B), Doppler examination Figure 28: Granuloma annulare focused ultrasound over the dorsum of the foot. 38 Figure 29: Leiomyosarcoma of the upper thigh mass A: Ultrasound. B: Color 40 Doppler Figure 30-32: Superficial (subcutaneous) lipoma over the abdominal wall, the buttock, left medial arm (grayscale ultrasonography) Figure 33: lymphoma cell infiltration to the subcutaneous fat lobule of the right 43 proximal tibial region (A) Grayscale ultrasonography (B) CDUS. Figure 34: Infantile fibrosarcoma of the forearm. A: Radiograph. (B) Grayscale 44 ultrasonography (C) CDUS Figure 35: Malignant fibrohistiocytoma in right lateral thigh. (A) Longitudinal 45 ultrasound section (B) Color Doppler ultrasonography. Figure 36: Fibrosarcoma in the upper leg. (A) Grayscale ultrasonography (B) CDUS 45. Figure 37: Low-grade sarcoma posterolateral thigh. (A) Grayscale ultrasonography 46 (B) CDUS. Figure 38: Loco-regional spread of malignant cutaneous melanoma. 46 Figure 39: Subcutaneous metastasis of the abdominal wall CDUS. 47 Figure 40: metastasis from thyroid carcinoma in the left pelvic region with iliac bone 47 destruction (A) Grayscale ultrasonography (B) CDUS. Figure 41: Subcutaneous metastasis of the thigh, Grayscale ultrasonography 48 Figure 42: Myxoma. in the plane between the rectus femoris and vastus intermedius muscles (extended field of veiw) 49

8 List of figures VI Figure 43: Nodular fasciitis in the wrist & upper arm, Grayscale ultrasonography. 49 Figure 44-45: Epidermoid cyst., Grayscale ultrasonography Figure 46: Fibroma on back. (A) Grayscale ultrasonography (B) CDUS. 51 Figure : Liposarcoma on left elbow &,the thigh. Grayscale ultrasonography- MRI intraoperative view - extended field of view Figure 50: Palmar fibromatosis. of the third finger, Grayscale ultrasonography 57 Figure 51: Superficial fibromatosis in right thigh. (A) Grayscale ultrasonography (B) 57 Color Doppler Figure 52: Plantar fibromatosis. of the plantar aspect of the foot Grayscale 58 ultrasonography Figure 53: Calcifying Aponeurotic Fibroma A. High-resolution US of the phalanx (A) 59 Grayscale ultrasonography (B) Color Doppler Figure 54: Fibromatosis colli of sternocleudomastoid muscle, Grayscale 60 ultrasonography Figure 55: Fibrous Hamartoma of Infancy: A.Grayscale ultrasonography B. color 62 Doppler image. C. Non-enhanced CT scan. D. Sagittal reconstructed contrast enhanced CT Figure 56-57: Desmoid. Tumor (A) Grayscale ultrasonography (B) Color Doppler 63 Figure 58-59: Stump neuromas, Grayscale ultrasonography & Color Doppler Figure 60: Third web space Morton s neuroma. (A) Grayscale ultrasonography (B) 65 Color Doppler Figure 61: Schwannoma of the median nerve Grayscale ultrasonography. 66 Figure 62: Neurofibroma in left medial arm. (A) Grayscale ultrasonography (B) 67 Color Doppler Figure 63: Neurinoma of the leg. (A) Color Doppler (B). 3D CT reconstruction. 67 Figure 64: Benign nerve sheath tumor. (A) Grayscale ultrasonography (B) Color 67 Doppler Figure 65: Malignant schwannoma of the forearm.,grayscale ultrasonography 68 Figure 66: Plexiform neurofibroma, Grayscale ultrasonography 69 Figure 67-68: Intramuscular hemangioma of the lower extremity. (A) Grayscale 70 ultrasonography (B) Color Doppler Figure 69-70: intermuscular lipoma, Grayscale ultrasonography, extended field of veiw Figure 71: rhabdomyosarcoma in the right thigh, Grayscale ultrasonography & 73 Color Doppler. Figure 72-73: Lipoma arborescens of the knee: Microscopic and gross features, & Grayscale ultrasonography Figure 74: Pigmented villonodular synovitis over her right lower leg(a) Grayscale 76 ultrasonography (B) Color Doppler Figure 75-76: Giant cell tumor of the tendon sheath in right thumb. (A) Grayscale 77 ultrasonography (B) Color Doppler Figure 77: A C. Giant cell tumor of the tendon sheath. (A) Grayscale 78 ultrasonography (B) Color Doppler.(C) Corresponding anteroposterior standard radiograph. Figure 78: A d. Synovial chondromatosis. A Plain radiograph of the index finger. B 79 Grayscale ultrasonography. C Axial CT imaging. D Surgical specimen Figure 79: a d. Intra-articular bodies: spectrum of US appearances.- MRI 80 correlation Figure 80-81: Baker s cyst., Grayscale ultrasonography. 81

9 List of figures VII Figure 82-83: Iliopectineal and olecranon bursitis (A) Grayscale ultrasonography (B) Color Doppler Figure 84: a f. Synovial hemangioma. A,B,C Grayscale ultrasonography & Color 84 Doppler over the suprapatellar region D Sagittal T2-weighted and E fatsuppressed postcontrast T1-weighted MR imaging F Lateral radiograph Figure 85-86: Synovial sarcoma of theknee and foot. Grayscale ultrasonography,color 85 Doppler and MRI image correlation Figure 87: Volar wrist ganglion cyst. (A) Grayscale ultrasonography (B) Color 86 Doppler Figure 88: Ganglion of the dorsal wrist Grayscale ultrasonography 87 Figure 89: Atypical digital ganglion in the thumb (A) Grayscale ultrasonography (B) 87 Color Doppler Figure 90: Rectus femoris muscle tear., Grayscale ultrasonography 88 Figure 91: Muscle hernia. a Photograph showing the examination technique for 90 detecting muscle hernias. b,c Schematic drawings illustrate the mechanism of hernia. d g Grayscale ultrasonography Figure 92: Muscle hernia with a defect in the muscle fascia 91 Figure 93: Pseudoaneurysm (A) Grayscale ultrasonography (B) Color Doppler 92 Figure 94: Acute Vastus intermedius intramuscular ill-defined muscle hematoma, 92 Grayscale ultrasonography Figure 95: Intramuscular hematoma of the leg in various stages. (A) Grayscale 93 ultrasonography (B) Color Doppler (C) liquefied hematoma. Figure 96-98: Muscle abscess.,grayscale ultrasonography & Color Doppler Figure 99: Idiopathic myositis with torticollis (A) Grayscale ultrasonography (B) Color Doppler 96 Figure : Foreign body in right palm and in the superficial tissues of the thigh Grayscale ultrasonography & Color Doppler Figure 102: Myositis ossificans in left anterior thigh. 97 Figure 103: Tumoral calcinosis on shoulder, Grayscale ultrasonography & Color Doppler 98

10 Abstract VIII ABSTRACT Musculoskeletal sonography is a rapidly growing technique that is gaining popularity for the evaluation and treatment of joint and soft tissue diseases. It can be intimidating due to the vast array of anatomy that is present and the different techniques and dynamic maneuvers required for a complete study. It is reliable, expedient and readily accessible alternative to other more costly techniques such as MR imaging. In the detection of musculo-skeletal masses especially soft tissue masses, ultrasonography is a readily available, inexpensive and non invasive modality,color Doppler can be also used in assessment of lesion vascularity and detection of neurovascular bundle involvement. Key word:mr- musculoskeletal- ultrasound- radiodiagnosis

11 INTRODUCTION Introduction 1

12 Introduction 2 Introduction Soft tissue masses in the extremities and trunk are common presentations to physicians and surgeons. These growths range from benign neoplasms and cystic structures based in the epidermis and dermis to malignant neoplasms arising within the structures below the deep fascia. (Frassica et al., 1996). There are a number of useful applications and advantages of diagnostic ultrasound in the assessment of musculoskeletal pathology. Ultrasonography (U/S) may be used to assess superficial tendons and ligaments that traverse a joint. It can demonstrate the presence and characteristics of joint effusions, bursae, or cysts, and it also can detect loose bodies in joints. The advantages lie in the cost-efficiency, shorter examination time, (Kelvin Chew etal., 2008 ) Ultrasound is generally unaffected by metallic artifacts (eg, metatarsal plate in the foot, suture anchors) and delivers no radiation to the patient or the user, an important consideration when evaluating females of childbearing age. Unlike radiographs, CT, and MRI, ultrasound can be readily used to complete a comparative examination of the contralateral extremity when clinically indicated. Finally, ultrasound can provide precise, real-time guidance for interventional procedures. Compared with radiographs and CT scans, ultrasound can demonstrate soft tissues with great detail, enabling safe and accurate needle guidance for interventional procedures. Similar to ultrasound, MRI provides excellent soft tissue visualization, but the requirement for nonferromagnetic instrumentation coupled equipment size and expense currently limit MRI use for real-time interventional procedures. (Smith etal., 2009) Dynamic assessment during contraction and relaxation of the structure of interest is essential. This helps in establishing the exact relationship of the mass with the muscle and or the tendon. Soft tissue masses in the anterior abdominal wall should also be evaluated during deep inspiration and

13 Introduction 3 expiration to define the relationship of the mass with the peritoneum. (Kinare etal., 2007) Physicians should recognize several clinically relevant limitations of musculoskeletal ultrasound. Perhaps the most important limitations pertain to field of view and penetration. Ultrasound provides a very high quality picture of a relatively small area. Clinicians should use ultrasound to confirm or characterize pathological changes within a defined body region. ultrasound s limited resolution at greater depths and inability to penetrate bone limit its ability to adequately image deep body regions, morbidly obese patients, areas deep to bones, and central intra-articular regions. Finally, as an interactive and technologically intensive examination, musculoskeletal ultrasound is also limited by both the ultrasound machine and the skill of the examiner using it. (Smith etal., 2009) Combining grayscale ultrasound with Doppler imaging allows unique real-time evaluation of regional blood flow, which may be altered in a variety of disease processes. The presence of Doppler signal can also help differentiate solid from cystic lesions. (James., 2006). US have a high sensitivity when detecting tumors, but it has not proven to be useful in differentiating benign from malignant conditions. Power Doppler US (PDUS) or color Doppler US (CDUS) and spectral analysis can depict the vascular irregularities in malignant tumor, but the reported criteria for malignancy vary widely. (Chiou et al., 2009). HRUS does have a high sensitivity in detecting tumors. Recent advances in ultrasound technology have enabled the echotexture of soft tissue tumors to be presented in greater detail. (Chiou et al., 2007). Using split-screen technology (which basically allows combining two images from two adjacent areas) the field of view can be doubled to 12 cm. Extended field of view enable panoramic imaging with real time probes.

14 AIM OF WORK Aim of the work 4

15 Aim of the work 5 Aim of the work: To evaluate the usefulness and high light the indications, advantages and disadvantages of high-resolution grayscale and color Doppler ultrasound evaluation in musculo-skeletal soft tissue masses and to differentiate benign from malignant masses.

16 Technique &Sonographic anatomy of the musculoskeletal system 6 TECHNIQUE & SONOGRAPHIC ANATOMY OF THE MUSKULOSKELETAL SYSTEM

17 Ultrasound technique 7 MUSCULOSKELETAL ULTRASOUND THE PREREQUISITES Musculoskeletal ultrasound is perhaps the most operator dependent imaging modality currently available. The primary reason for this is the need to physically acquire an acceptable image, using appropriately adjusted equipment, with specific attention to transducer positioning, all within the context of an in-depth understanding of neurological and musculoskeletal anatomy (Bates, 2004). To successfully integrate diagnostic or interventional musculoskeletal ultrasound into clinical practice, the practitioner must therefore acquire the necessary equipment, education, and scanning skills (Bates, 2004). Ultrasound Equipment Types of probes used in musculoskeletal examinations (John et al.,2007): Linear Array Probes Linear array probes have a flat face along which a sequence of crystals is arranged. The sector size of the linear probe is identical to the footprint of the probe itself and the resulting image is rectangular or square (Fig. 1). Linear probes are generally used to view superficial structures and are therefore constructed to produce higher frequencies. Linear probes are used for various musculoskeletal applications (John et al.,2007). Convex Array Probes The crystals in convex arrays are arranged along a curved face. The resulting image has a sector size larger than the footprint of the probe. The range of frequencies and overall construction of curved array probes are important

18 Ultrasound technique 8 determinants regarding where they are most beneficial. Larger footprint probes with less curvature typically provide greater lateral resolution at a given frequency in the far fields. However, smaller footprint probes with a tighter curvature allow for easier access through the intercostal spaces. (Fig.1, 2 &3 ) (John et al.,2007). Figure 2: Linear probe, linear image. The linear probe with high frequency provides excellent superficial resolution (John et al., 2007). Figure 1: Curved probe, provides curved image and for powerful penetration( John et al.,2007) Figure 3: Commonly used ultrasound transducers in musculoskeletal ultrasound. Left, Highfrequency (15-7 MHz), small footprint, linear array transducer, also called a hockey stick transducer. Center, High-frequency (17-5 MHz) linear array transducer. Right, Low- to medium-frequency (5-2 MHz) curvilinear array transducer. Both linear transducers are used for superficial imaging, whereas the curvilinear transducer s lower frequency facilitates examination of deeper regions such as the hip (Philips iu22 Ultrasound Machine; Philips Medical Systems, Bothell, WA) (Bates, 2004).

19 Ultrasound technique 9 Protocol for ultrasound of superficial lumps Equipment selection and technique : (Martino et al., 2006) Use of a high resolution probe (7-15 MHZ) is essential when assessing superficial structures. Careful scanning technique to avoid anisotropy (and possible misdiagnosis). Use panoramic to get both edges in the same image May need to use a curved linear array probe if it travels deep or it is a high attenuating lesion with calcification etc Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. Good color / power / Doppler capabilities when assessing vessels or vascularity of a structure. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures. (Martino et al., 2006) I. Role of grey scale ultrasound : (Chiou etal.,2009). Location : Label surrounding anatomy; use a body marker on the film. Compare to the other side Measure in 3 planes: 1. Anterior-posterior. 2. Longitudinal 3. Transverse. Tumor size was defined as large (> 5 cm), medium (1 5 cm) or small (< 1 cm). Volume Echogenicity: Hypo, hyper, isoechoic,anechoic, calcified compared to the surrounding tissue and its composition was solid, cystic, necrotic content or septate. Texture: Homogenous, heterogeneous, simple or complex.

20 Ultrasound technique 10 Margins : Were assessed as well-defined (clear-cut and thin capsule-like), ill-defined (uncertain margin with respect to adjacent normal tissue) or infiltrated (certain irregular margin with adjacent normal tissue and wider transitional zone) Shape : Was defined as round, ovoid, lobulated or scalloped Check the lump for spread into the muscle: Has it broken the fascia, the skin or invasion anywhere else Is it compressing any vessels or ducts Shadowing,posterior enhancement or no change. (Chiou,etal,2009). II. Role of spectral,color & power Doppler ultrasound : Use the Spectral Doppler Trace The use of a spectral Doppler trace can confirm if the Doppler signal is artifactual, as a phasic waveform should be obtained if there is true flow. Furthermore the spectral trace allows differentiation of arterial from venous flow and allows measurement of parameters such as the resistive index (Fig. 4) (James, 2006). Figure 4: Arteriovenous malformation of the thigh. (A) Color Doppler showing a large serpiginous feeding vessel. (B) Spectral Doppler trace confirms phasic, arterial flow. (James, 2006).