Vol 15 ppt
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This document describes various types of benign soft tissue tumors, including several variants of lipomas. Superficial lipomas are the most common soft tissue tumor seen in orthopedic oncology, typically occurring in older patients on the back, shoulders, and neck. Intramuscular lipomas occur deeper in larger muscle groups between ages 30-60. Spindle cell lipomas are seen more in men ages 45-65 in the neck or shoulder. Angiolipomas occur in younger adults and are often painful due to increased vascularity. Ossifying lipomas are rare, with bone and cartilage present within the lipoma tissue. Imaging and histologic features of each variant are provided.
Vol 15 ppt
- 1. Volume 15 Lipid Soft Tissue Tumors Superficial lipomas-------------Case 1183 Intramuscular lipomas----------Case 270-274 & 1184-1190 Spindle cell lipomas------------Case 275-276 Angiolipomas--------------------Case 277-278 & 1191-1196 Ossifying lipoma----------------Case 1196.1-1196.3 Myxolipomas--------------------Case 279 Diffuse lipomatosis-------------Case 280 Lumbosacral lipoma------------Case 281 Hibernoma-----------------------Case 1197 Liposarcoma Well differentiated------------Case 283 & 1198 Myxoid-------------------------Case 285-289 & 1199-1201 Round cell---------------------Case 290 Pleomorphic-------------------Case 291 & 1202-1203
- 2. Vascular Soft Tissue Tumors Hemangioma---------------------Case 292-298 & 1204-1211 Hemangiomatosis---------------Case 299-300 & 1212 Lymphangioma------------------Case 301-304 & 1213 Glomus tumor-------------------Case 305-307 Hemangiopericytoma-----------Case 308-311 Kaposi’s sarcoma----------------Case 312-313 Angiosarcoma--------------------Case 314
- 3. Lipid Tumors
- 5. Superficial Lipomas Lipomas are by far the most common soft tissue tumor encountered in orthopedic oncology. There is a large number of variants, the most common being the superficial subcutaneous lipoma that occurs in both males and females in an older age group, the 5th and 6th decade of life. Typical lesions are seen in the back, shoulder and neck. On palpation, these tumors have a soft non-tender characteristic. They occur more commonly in obese patients, however, when patients lose weight dramatically, the size of the lipoma will not vary. In older patients they grow quite rapidly at first but then stop. They never convert into a malignant tumor at some later date. Surgical treatment usually consists of a cosmetic resection and the recurrence rate is less than 5%.
- 6. Case #1183 Coronal T-1 MRI 51 year male with superficial lipoma arm
- 7. Another coronal T-1 MRI tumor
- 8. tumor Axial T-1 MRI
- 10. Photomic
- 11. Case #1183.1 Superficial lipoma 71 year female with recent shoulder dislocation and history of a soft tissue lump over back of shoulder for years
- 12. Axial T-1 Gad
- 13. Case #1183.2 Superficial lipoma Axial T-1 PD FS 42 yr male with one yr history of painless lump on shoulder
- 14. Intramuscular Lipomas
- 15. Intramuscular Lipoma The intramuscular lipoma occurs in adults between the ages of 30 and 60 years, and is usually found in the larger muscle groups. The tumor occurs quite gradually, without symptoms of pain, and does not cause disability when left untreated. It is usually recognizable on routine radiographic exam, showing a well- marginated lesion with a radiodensity less than that of the surrounding muscle. However, the best imaging study for a lipoma of muscle is the MRI which shows a diagnostic high signal, lobulated lesion on the T-1 weighted image that has the exact same appearance as the subcutaneous fat. On the T-2 image, the lesion will be an intermediate signal and again have the exact appearance of subcutaneous fat. Histologically, the intramuscular lipoma demonstrates large lipocytes with very small pyknotic nuclei. The pathologist must be very careful to look for evidence of atypical lipoblasts that would suggest the diagnosis of a well- differentiated liposarcoma that can coexist with a benign lipoma.
- 16. On rare occasion, lipomas can have coexistent chondroid or osseous hamartomatous elements that in the past had been classified as mesenchymomas. Surgical treatment for the intramuscular lipoma is a marginal resection, being careful to avoid damage to the neuro- vascular structures that might pass through the lipoma. The recurrence rate is higher than for subcutaneous lipomas and range between 15 and 60%.
- 17. CLASSIC Case #270 72 year male with an intramuscular lipoma quadriceps muscle
- 18. Coronal T-1 MRI
- 19. Another coronal T-1 MRI
- 20. Axial T-1 MRI
- 21. Gross specimen
- 22. Photomic
- 23. Case #270.1 Intramuscular lipoma Axial T-1 T-1 STIR 72 year female with painless mass in anterior thigh for years
- 24. Coronal T-1 Sagittal T-1 Coronal STIR
- 25. Case #270.2 Axial T-1 T-2 Gad 56 year male with painless soft mass in anterior thigh for 2 years
- 26. Sag T-1 T-2 FS
- 27. Case #270.3 Intraneural lipoma sciatic nerve 65 year old female with 3 yr history of large painless mass in posterior thigh
- 28. Sag T-1 T-2
- 29. Axial T-1 PD
- 31. Case #271 74 year female with intramuscular lipoma hand
- 32. Coronal T-1 MRI
- 33. Axial T-1 MRI
- 35. Photomic
- 36. Case #272 Sagittal T-1 MRI 47 year female with intramuscular lipoma foot
- 37. Axial T-1 MRI
- 38. Coronal T-1 MRI
- 39. Case #273 Axial T-1 MRI 11 year male lipoma deltoid muscle
- 40. Coronal T-1 MRI
- 41. Case #273.1 Axial T-1 T-2 43 year female with soft painless mass in axilla
- 42. Sag T-1 T-2 Cor T-1
- 43. Case #274 67 year male calcifying necrotic lipoma
- 44. calcification Resected specimen cut in path lab
- 45. Case #1184 58 year female with intramuscular lipoma buttock area
- 46. Axial T-1 MRI showing lipoma extruding thru the sciatic notch
- 47. Coronal T-1 MRI showing lipoma extrusion thru the notch
- 49. Case #1184.1 Lipoma CT scan 51 year old male with soft painless mass in buttocks for 5 yrs
- 50. Axial T-1 T-2 Gad
- 51. Cor T-1 T-2 Gad
- 52. Sag gad
- 53. Case #1185 59 year female with intramuscular lipoma anterior proximal thigh Coronal T-1 MRI
- 54. Axial T-2 MRI
- 55. Axial T-2 MRI at lower level
- 56. Fat subtraction MRI showing signal void in lipoma
- 57. Case #1186 51 year male with intramuscular lipoma posterior compartment thigh
- 58. Axial T-1 MRI
- 59. Case #1187 62 year female with intramuscular lipoma adductor compartment thigh Coronal T-1 MRI
- 60. Surgical exposure of tumor
- 61. Case #1188 72 year female with intramuscular lipoma mid arm
- 62. Axial T-1 MRI
- 63. Case #1189 2 year male with intramuscular lipoma posterior thigh
- 64. AP view
- 65. Case #1190 66 year female with intramuscular lipoma forearm
- 66. tumor CT scan
- 67. Case #1190.1 Intramuscular lipoma 55 year female with painless mass in forearm over 1 yr
- 68. Sagittal MRI T-1 T-1 PD-FS Gad
- 69. Axial T-1 Gad
- 71. Case #1190.2 33 year old female with painless lump at ankle for 1 year
- 72. Sag T-1 PD Gad
- 73. Axial T-1 Gad
- 76. Spindle Cell Lipoma The spindle cell lipoma is seen more commonly in men between the ages of 45 and 65 years and is typically located in the posterior neck or shoulder area. MRI imaging demonstrates the high signal features of a lipoma on the T-1 weighted image but with areas of lower signal streaking seen throughout the high signal areas where the fibrous tissue is located. Histologically, the spindle cell lipoma looks like any other lipoma except for the presence of benign- appearing fibrous tissue with occasional areas of gelatinous break- down in the fibrous tissue. The treatment for this variant is a marginal resection and carries a minimal chance for local recurrence.
- 77. CLASSIC Case #275 CT scan 59 year male with spindle cell lipoma thigh
- 78. Case #276 64 year male with spindle cell lipoma proximal forearm
- 79. Sagittal T-1 MRI
- 80. Axial T-1 MRI
- 81. Axial proton density MRI
- 82. Angiolipomas
- 83. Angiolipoma The angiolipoma is another variant of the lipoma occurring usually in subcutaneous locations in young adult patients. It is seen most commonly in the forearm. These lesions may be multiple and can be painful because of their increased vascularity. These lesion can be seen on routine radiographs when phleboliths are present in the vascular component, but the most diagnostic imaging study is the MRI that will show the high signal features of a lipoma on the T-1 weighted image with the additional serpinginous low signal pattern of vascular tissue streaking throughout the high signal lipomatous tissue. Treatment for this variant is a simple marginal resection from which one can expect a relatively low recurrence rate.
- 84. CLASSIC Case #277 phleboliths 27 year female with angiolipoma forearm showing phleboliths and hypertrophic subadjacent radius
- 85. Sagittal T-1 MRI showing low signal serpinginous vessels running thru high signal lipoma tissue
- 86. Resection specimen showing serpinginous vessels in fat
- 87. Case #278 Coronal T-1 MRI 16 year female with angiolipoma quadriceps muscle
- 88. Axial T-1 MRI
- 89. Case #1191 24 year female with angiolipoma anterior thigh Sagittal T-1 MRI
- 90. Axial T-1 MRI
- 91. Coronal T-2 MRI
- 93. Case #1192 23 year female with angiolipoma anterior to hip joint
- 94. Axial T-1 MRI
- 95. Sagittal T-1 MRI
- 96. Coronal T-1 MRI
- 97. Case #1194 41 year male with angiolipoma thigh Coronal T-1 MRI
- 98. Axial T-1 MRI
- 99. Case #1194.1 Axial T-1 MRI 33 year female with painless mass in anterior thigh 1 year
- 100. Axial Gad Contrast Axial T-2
- 101. Sagittal T-2 Sagittal Gad
- 102. Case #1195 17 year female with angiolipoma forearm Sagittal T-1 MRI
- 103. Coronal T-1 MRI
- 104. Axial T-2 MRI
- 105. Case #1196 33 year male with angiolipoma calf
- 106. Axial T-1 MRI
- 107. Sagittal T-1 MRI
- 108. Ossifying Lipoma The ossifying lipoma is a very rare variant of the lipoma with only 12 cases in the literature most of which were located in the head and neck area. Four extremity cases were located in the shoulder, thigh and hand in middle aged patients. Bone and cartilage may be found in the central area of the lipoma and is thought to be a dysplastic or hamart- omatous process similar to the mesenchymoma. They are not attached to bone as in the case of the parosteal lipoma. They are painless lesions that grow slowly over years and are easy to resect with little chance of recurrence.
- 109. Case #1196.1 Ossifying Lipoma 75 yr female with painless soft mass in thigh for 10 yrs
- 110. Axial T-1
- 111. Sag T-1 Axial T-2
- 112. Surgical removal of the large mass from the quadriceps muscle Necrotic tumor bone fat
- 113. Photomics show typical lipoma tissue covering necrotic ossifying tissue
- 114. Post op appearance following resection
- 115. Case #1196.2 Ossifying Lipoma Cor T-1 Axial T-2 53 yr male with painless mass in knee for 3 yrs
- 116. Case #1196.3 Ossifying lipoma 60 yr female with painless forearm mass for 2 years
- 117. Sag T-1 T-2 FS Gad
- 118. Axial T-1 T-2 FS Gad
- 119. Myxolipoma
- 120. CLASSIC Case #279 Sagittal T-1 MRI 63 year female with myxolipoma knee
- 121. Sagittal T-2 MRI
- 122. Axial T-1 MRI
- 123. Diffuse Lipomatosis
- 124. Diffuse Lipomatosis An extremely rare variant of the lipoma is the diffuse lipomatosis form seen during the first two years of life. It may involve one entire extremity or the trunk, demonstrating both superficial and deep intramuscular, multifocal lesions. Histologically, these lesions are identical to that of a benign lipoma and because of the massive involvement of the extremity in some cases, amputation may be indicated.
- 125. CLASSIC Case #280 20 year male with diffuse lipomatosis lower extremities
- 126. CT scan
- 127. Another CT cut
- 128. Lumbosacral Lipoma
- 129. Lumbosacral Lipoma The lumbosacral lipoma variant is frequently associated with a spinabifida defect in the spine and can be seen in both the pediatric and adult age group. These lesions can be associated with both intra- dural and extradural lipomas and can result in neurological deficiency. The MRI image will show the characteristic high signal response on the T-1 weighed image, like all other forms of lipomas. Treatment consists of a marginal surgical resection, including the lesions within the vertebral canal. A low recurrence rate is anticipated.
- 130. CLASSIC Case #281 Sagittal T-1 MRI lumbosacral lipoma 61 year male
- 131. Axial T-1 MRI
- 132. Synovial Lipoma
- 133. Case #281.1 Synovial lipoma 26 year male with injury to shoulder 6 years ago
- 134. Axial T-1 Axial T-2
- 135. Cor T-1 Cor T-2
- 136. Sag T-2
- 137. Case #281.2 Synovial lipoma knee Axial T-1 T-2 Gad 48 year old female with tender lump over medial retinaculum for l year
- 138. Coronal T-1 T-2 Gad
- 139. Sagittal T-1 T-2 Gad C+
- 140. Hibernoma
- 141. Hibernoma The hibernoma is a very rare lipoma variant seen usually in young adults in the intrascapular area of the back. It is painless and slow growing and ranges between 10 and 15 cm in diameter. Histolo- logically, the hibernoma demonstrates fine granular or vaculated cells consisting of brown fat and large amounts of glycogen. The treatment for this lesion is simple marginal resection with a very low potential for local recurrence.
- 142. Case #1197 CLASSIC 37 year female with hibernoma triceps m Sagittal T-1 MRI
- 143. Axial T-1 MRI
- 144. Axial T-2 MRI
- 147. Surgical specimen showing tan color
- 148. Photomic
- 149. Photomic
- 150. Case #1197.1 Sag T-1 MRI Cor T-1 MRI Axial T-1 MRI 38 year female with painless hibernoma anterior thigh
- 151. Sagittal T-2 MRI Sagittal Gad MRI
- 152. Case #1197.2 hibernoma 28 yr male with fullness in groin area for 1 yr
- 153. T-1 Axial PD Gad
- 154. Sag PD Sag Gad
- 155. Case #1197.3 Axial T-1 Axial T-2 MRI 2.5 yr male with painless buttock lump for 1 year with tissue diagnosis of lipoblastoma
- 156. Coronal T-1 MRI Coronal T-2 MRI
- 157. Sagittal T-1 MRI Sagittal T-2 MRI
- 158. Liposarcoma
- 159. Liposarcoma Second to the MFH, the liposarcoma is the most common soft tissue tumor seen in the musculoskeletal system. These tumors are seen typically in an older population group (over the age of forty) and are slightly more common in males than females. They are typically located in large muscle groups, especially in the lower extremity where 70% of these tumors will be found. There are four subtypes of liposarcoma, including the well-differentiated form and the myxoid form that are low grade, and the round cell and pleomorphic forms that are high grade.
- 160. Well-differentiated Liposarcoma (Atypical Lipoma)
- 161. Well-differentiated Liposarcoma The well-differentiated liposarcoma is a very low grade variant of the liposarcoma that looks almost like a benign lipoma. It occurs in people past the age of 45 years and is commonly seen in the lower extremity, especially in the buttock and thigh area, but can also be found in the retroperitoneal portions of the body. On gross examination, the well-differentiated form looks like a routine intra- muscular lipoma, but microscopically the pathologist must find a few areas of low grade lipoblasts with a signet ring appearance to make this diagnosis. This lesion is sometimes referred to as an atypical lipoma because its gross appearance is similar to the benign lipoma. The prognosis for this variant is extremely good but with a fairly high potential for local recurrence in about 30-50% of cases. There is essentially no chance of this lesion metastasizing to distant parts. If located in the retroperitoneal area, it can be fatal because of the difficulty in removing the tumor.
- 162. CLASSIC Case #283 Coronal T-1 MRI 63 year female Well-differentiated liposarcoma thigh
- 164. Case #283.1 Well Differentiated Liposarcoma Thigh Cor T-1 STIR Gad 68 yr old male with three time recurrence of soft mass in thigh
- 165. Axial T-1 STIR Gad
- 166. Case #284 Coronal T-1 MRI 49 year male with well-differentiated liposarcoma (atypical lipoma) distal thigh
- 167. Sagittal T-1 MRI
- 168. Axial T-2 MRI
- 169. Case #1198 Axial T-2 MRI 62 year male with well-differentiated liposarcoma thigh
- 170. Coronal T-2 MRI
- 171. Case #1198.1 Atypical Lipoma Sag T-1 PD 47 yr old female with mild intermittent pain in thigh 2 yrs
- 172. Axial T-1 PD Gad
- 173. Case #1198.2 Dedifferentiated lipsosarcoma Coronal T-1 MRI of the thigh of a 41 year male with prior history of partially resected atypical lipoma 3 yrs before
- 174. Axial PD Axial Gad
- 175. Sagittal Gad
- 176. Case #1198.3 CT scan 4/06 71 year old male with painless soft mass in adductor compartment in 06 which became painful with recent growth in 09
- 177. 09 Sag T-1 Gad
- 178. Axial T-1 upper T-2 upper T-2 lower Cor STIR
- 179. Surgical removal
- 180. Case #1198.4 Sag T-1 T-2 FS Gad 45 yr female with atypical lipoma resected from calf 3 yrs ago
- 181. Axial T-1 Gad
- 182. nerve Tumor resection off the posterior tibial nerve
- 183. Myxoid Liposarcoma
- 184. Myxoid Liposarcoma The myxoid variant is the most common variant of the lipo- sarcoma and it is seen in a slightly younger age group between 40 and 50 years of age. It occurs in the lower extremities in 75% of cases, especially in the popliteal area. These lesions are slow growing and frequently asymptomatic in the early stages. On imaging studies, the MRI is the best method for visualizing these tumors that will have a mixed high and low signal on the T-1 weighted image because of the high percentage of fatty tissue in the tumor. Histologically, there will be evidence of malignant lipoblasts and it is common to find a plexiform network of small capillary tubes running thru the fatty tumor, similar to the capillary hemangioma. The prognosis for this variant is quite good after a wide local surgical resection, followed in most cases by local radiation therapy. The chance of pulmonary metastases runs as high as 20% and occasionally there will be multifocal myxoid
- 185. liposarcomas occurring in the extremities as well as in retro- peritoneal locations. Occasionally, one will see a transitional form of myxoid converting into a higher grade round cell lipo- sarcoma which carries a more guarded prognosis.
- 186. CLASSIC Case #285 Sagittal T-1 MRI 67 year female with myxoid liposarcoma knee
- 187. Sagittal T-2 MRI
- 188. Axial T-2 MRI
- 189. Resection specimen
- 190. Photomic showing lipoblasts and vascular channels
- 191. Case #286 Sagittal T-2 MRI tumor 43 year male with myxoid liposarcoma behind knee
- 193. tumor Axial T-1 MRI
- 194. Surgical resection
- 195. Cut specimen
- 196. lipoblasts vessel Photomic
- 197. Case #287 tumor Coronal T-1 MRI 29 year male with myxoid liposarcoma posterior thigh
- 198. tumor Axial PD MRI
- 199. Axial T-2 MRI
- 201. Photomic showing numerous vascular channels
- 202. Case #288 Coronal T-1 MRI 34 year female with myxoid liposarcoma thigh
- 203. Coronal T-2 MRI
- 204. tumor Axial T-1 MRI
- 205. Axial T-2 MRI tumor
- 206. Photomic
- 207. tumor kidney Axial T-2 MRI showing multifocal involvement in abdomen
- 208. Case #289 Sagittal T-1 MRI 32 year male with tumor myxoid liposarcoma distal thigh
- 209. tumor Axial T-1 MRI
- 210. Resected specimen
- 211. fat myxoid Specimen cut in path lab
- 212. Photomic
- 213. Case #1199 30 year male with myxoid liposarcoma posterior thigh Sagittal T-1 MRI
- 214. Sagittal T-2 MRI
- 215. tumor Axial T-1 MRI
- 216. Axial Gad contrast MRI
- 218. Surgical specimen
- 219. Photomic
- 220. Case #1200 Sagittal T-1 MRI 75 year male with myxoid liposarcoma foot
- 221. Another sagittal T-1 MRI
- 222. tumor Axial T-1 MRI
- 223. Sagittal T-2 MRI
- 224. Another sagittal T-2 MRI
- 225. Sagittal Gad contrast MRI
- 227. Case #1201 CT scan tumor 69 year male with myxoid liposarc pelvis
- 228. Axial T-2 MRI
- 229. Photomic showing lipoblasts and vessels
- 230. Case #1201.1 27 year male with myxoid liposarcoma vastus intermedius m. Axial T-1 MRI
- 231. Coronal T-1 MRI
- 232. Coronal Gad contrast MRI showing femoral artery
- 233. Surgical incision including biopsy site
- 234. biopsy Surgical exposure of tumor contained in muscle fascia
- 235. Tumor excised including periosteum
- 236. biopsy site Excised tumor mass contained in muscle fascia
- 237. Wound closure
- 238. Case #1201.2 Axial T-1 STIR Gad 70 yr female with slightly tender mass above elbow for 1 year Myxoid Liposarcoma Triceps
- 239. Sag T-1 STIR Gad
- 242. Round cell and Pleomorphic Liposarcoma The round cell and pleomorphic liposarcomas are high grade liposarcomas seen in the same locations as other liposarcomas in a slightly older age group. They account for about 10% of all liposarcomas. Because these are high grade they act more like a high grade MFH with increased pain and rapid growth. On imaging studies, the higher grade lesions take on the appearance of a more aggressive sarcoma without the high signal appearance of fat on the T-1 weighted image. Histologically, there will be evidence of severe atypicism and bizarre-appearing giant cells with only occasional areas of lipoblastic signet ring cells that are necessary to make the ultimate diagnosis. These high grade lesions are treated by wide surgical resection, followed by postoperative radiation therapy and occasionally chemotherapy will be indicated for aggressive lesions in a younger age group. The chance of pulmonary metastases runs as high as 80% in these high grade variants.
- 243. CLASSIC Case #290 38 year male with high grade round cell liposarcoma thigh
- 244. Sagittal T-1 MRI tumor
- 245. Sagittal T-2 MRI tumor
- 246. tumor Axial proton density MRI
- 247. Photomic showing round cells and lipoblasts
- 249. CLASSIC Case #291 Sagittal T-2 MRI tumor 44 year male with pleomorphic liposarcoma knee
- 251. tumor Axial gad contrast MRI
- 252. Photomic showing bizarre pleomorphic giant cells
- 253. Close up of pleomorphic lipoblasts
- 254. Case #1202 80 year male with pleomorphic liposarcoma Sagittal T-1 MRI
- 255. Sagittal T-2 MRI
- 256. Surgical specimen
- 257. Photomic
- 258. Case #1203 61 year male with pleomorphic liposarcoma biceps muscle Sagittal T-1 MRI
- 259. Sagittal T-2 MRI
- 260. Case #1203.1 Pleomorphic liposarcoma Axial CT scan 65 year male with recent onset buttock tumor mass in area of previous resected large benign lipoma 6 years ago
- 261. Sag CT scan Cor CT
- 262. Axial T-1 T-2 fluid tumor Gad
- 263. Sag T-2 Surgical specimen
- 264. Vascular Tumors
- 265. Hemangioma
- 266. Hemangioma After the benign lipoma, the benign vascular tumor is the second most common soft tissue lesion seen in the human body. Hemangiomas are developmentally dysplastic neoplasms of the endothelial tube. They occur most commonly during childhood, more commonly in females than males, and account for 70% of all benign tumors. The most common type of hemangioma is the solitary capillary hem- angioma that appears as an elevated red to purple cutaneous lesion, usually in the head and neck area. It is usually seen during the first few weeks after birth. The lesion will grow rapidly for a period of several months and then disappear spontaneously over a period of seven years in about 80% of cases. These lesions are essentially cosmetic and do not deserve any aggressive form of treatment. However, in the past, attempts at injecting them with sclerosing agents or liquid nitrogen, or using radiation therapy, made the situation more disabling than the original lesion. A less common
- 267. form of hemangioma is the so-called cavernous hemangioma that has a purplish-gray appearance and can look similar to varicosities in the extremities but in a younger age group. They can involve large muscle groups in the extremity and can even involve synovial membranes in joints. Radiographically, the hemangioma may present with small, punctate, calcific deposits within the tumor that is almost diagnostic of this condition. These are referred to as phleboliths. The use of MRI technology is very helpful in making the diagnosis of a hem- angioma and the characteristic sharp mixed signal serpinginous pattern is seen clearly on the T-1 weighted images. As with the cutaneous hemangioma, the larger intramuscular hemangiomas in children are not very disabling but can create symptoms of pain caused by spontaneous hemorrhage into the lesion with minimal blunt trauma. The pain symptoms can usually be treated with icing down for the first 24 hours, followed by compressive dressings for a period of two weeks, after which the patient returns to normal
- 268. activity. There may be a recurrence of these clinical symptoms once or twice a year. Sometimes repeated hemorrhage into an intra- muscular hemangioma can result in fibrotic contracture with deformity of the adjacent joint that might require a surgical release to correct the deformity. An example of this is equinous deformity of the foot caused by a hemangioma of the gastroc muscle. In the past, attempts have been made to eradicate these larger tumors in muscle with embolization technique, attempting to occlude the feeder vessels. This can lead to compartment syndrome, severe contractures and loss of muscle strength that can be more severe a disability than the original lesion. Wide surgical resection is extremely difficult because of the poorly defined margin to the hemangioma and, as a result, local recurrence is common, followed by intramuscular hemorrhage and associated pain. In some cases with very large hemangiomas, amputation is indicated when severe loss of function occurs. It is extremely rare for a malignant conversion to occur within a benign vascular dysplasia.
- 269. CLASSIC Case #292 14 year female hemangioma foot
- 271. Lateral x-ray showing more phleboliths
- 272. tumor Axial T-1 MRI
- 273. tumor Axial T-2 MRI
- 274. Gross specimen with hemorrhagic cysts
- 275. Photomic
- 276. Case #293 36 year female hemangioma hand
- 277. X-ray showing calcifying mass
- 278. AP and oblique views
- 279. Surgical removal
- 280. Photomic showing cavernous vascular spaces
- 281. Case #293.1 Hemagioma of hand 57 year female with tender mass under volar aspect of 3rd MP joint for years
- 282. Axial T-1 prox phalanges T-2 Gad PD metacarpal heads
- 283. Cor T-1 T-2 Gad
- 284. Cor T-1 T-2 Gad
- 285. Case #293.2 Hemagioma hand 52 year old female with tender lump beneath 2nd MP joint for years
- 286. Cor T-1 T-2 FS Gad
- 287. Axial T-1 T-2 FS Gad
- 288. Case #293.3 Tenosynovial Hemangioma Hand T-2 Cor T-1 47 year old male with long history intermittent painful swelling palm of hand Gad
- 289. Axial T-1 Gad
- 290. Case #294 30 year female with hemangioma hand
- 291. Case #295 phlebolith 8 year female with hemangioma distal arm
- 292. Lateral view
- 293. Coronal T-1 MRI Coronal T-2 MRI
- 294. Sagittal T-1 MRI Sagittal T-2 MRI
- 295. Axial T-1 MRI Axial T-2 MRI
- 296. bone Photomic showing large vascular spaces
- 297. Case #295.1 Recurrent hemangioma phleboliths 24 year female with recurrent hemangioma triceps
- 298. Coronal T-1 T-2
- 299. Sagittal T-1 T-2
- 300. Axial T-2 T-1 Gad
- 301. Case #295.2 Hemagioma triceps m Cor CT Axial CT 16 year female with tender mass in posterior arm for years
- 302. Cor T-1 T-2 Gad
- 303. Axial PD Gad
- 304. Sag PD Gad
- 305. Case #296 24 year female with hemangioma forearm with phleboliths
- 306. Case #297 phlebolith 6 year female hemangioma forearm
- 307. Case #297.1 Hemangioma forearm Cor T-1 Gad 18 year old female with forearm mass for years
- 308. Axial T-1 Axial Gad
- 309. Case #297.2 Hemangioma forearm 46 yr male with tender soft mass forearm for years
- 310. Cor T-1 T-2 Gad
- 311. Sag T-1 T-2 Gad
- 312. Axial T-1 T-2 Gad
- 313. Case #298 10 year female with a hemangioma distal leg and foot Sagittal T-2 MRI
- 314. Axial T-2 MRI
- 315. Sagittal T-1 MRI foot
- 316. Sagittal T-2 MRI
- 317. Axial T-2 MRI
- 318. Case #298.1 Hemangioma Ankle Sag Gad 52 yr female with 30 year history of intermittent pain in ankle
- 319. Cor T-1 T-2 FS Gad
- 320. Axial T-1 T-2 FS Gad
- 321. Surgical resection
- 322. Hemangioma Case #298.1 15 year male with tender mass lateral side of forefoot for many years
- 323. Axial T-1 T-2
- 324. Sag T-1 T-2
- 325. Cor T-2
- 326. Case #1204 22 year male with hemangioma anterior compartment leg with subadjacent cortical hypertrophy of tibia
- 328. Coronal T-1 MRI
- 329. Case #1204.1 31 year female with soft swelling in leg for many years
- 330. Axial CT Cor Ct
- 331. Cor T-2 Sag Gad Sag Gad
- 332. Axial Gad Axial Gad
- 333. Case #1205 38 year female with hemangioma forearm with hypertrophic response in subadjacent ulna
- 334. Bone scan
- 335. bone hypertrophy Axial PD MRI
- 336. Axial gad contrast MRI
- 337. Sagittal T-2 MRI
- 338. Case #1206 31 year female with hemangioma leg with hypertrophic response in adjacent fibula
- 339. Axial T-2 MRI
- 340. Coronal T-1 MRI
- 341. Case #1207 tumor calcification 25 year female with hemangioma buttock area
- 342. Coronal T-1 MRI
- 343. Sagittal T-2 MRI
- 344. Case #1207.1 Axial T-1 T-2 Hemangioma buttock Gad 65 year old female with tender lump in buttock for 1 year
- 345. Cor T-2 Sag T-2
- 346. Pet scan CT scan
- 347. Case #1208 tumor calcification 28 year female with hemangioma gastroc muscle
- 348. Sagittal T-1 MRI
- 349. Axial T-1 MRI
- 350. Case #1208.1 Axial CT scan Sag 43 year old female with tender lump in medial gastroc for years
- 351. Axial T-2 Gad
- 352. Sag T-1 Gad
- 353. Case #1208.2 Sag T-1 PD FS Gad 16 year female with intermittent pain and swelling in calf for years second to hemagioma of the gastroc muscle
- 354. Axial T-1 T-2 Gad
- 355. Case #1209 17 year male with hemangioma in quadriceps muscle Axial T-2 MRI
- 356. Case #1210 14 year female with hemangioma hind foot Axial T-2 MRI
- 357. Case #1211 67 year female with synovial hemangioma hip joint with secondary erosion of femoral head and neck
- 358. Synovial biopsy showing numerous vascular spaces
- 359. Case #1211.1 Synovial hemangioma knee 4 year male with painless mass below the patella 1 yr
- 360. Sagittal T-1 Sagittal T-2
- 361. Axial T-1 Axial T-2 Axial Gad
- 362. Case #1211.2 Synovial hemagioma knee 15 year male with knee pain for 6 months
- 363. Coronal T-1 Coronal T-2
- 364. Axial T-2
- 365. Surgical exposure at time of excisional biopsy
- 366. Case #1211.3 Synovial hemangioma knee 68 year old female with soft mass medial knee for years
- 367. Cor T-1 T-2 Gad
- 368. Sag PD Gad
- 369. Axial T-2 Gad
- 370. Hemangiomatosis
- 371. CLASSIC Case #299 Stillborn with extensive hemangiomatosis
- 372. Upper body showing disappearing bones
- 373. Lower half of body
- 374. Lower extremity with disappearing bones in hemangiomatosis
- 375. Case #300 25 year female hemangiomatosis upper extremity with disappearing bones phleboliths
- 376. Case #1212 phleboliths 34 year female with hemagiomatosis forearm
- 377. Case #1212.1 39 year male with extensive hemangiomatosis thigh
- 379. Coronal T-1
- 380. MRI arteriogram
- 381. Lymphangiomas
- 382. Lymphangioma The Lymphangioma, like the hemangioma, is a hamartomatous dysplastic lesion of soft tissue that arises from the endothelial tube. Instead of being filled with blood like in the hemangioma, the lymph- angioma is filled with lymphatic fluid, but otherwise it has a very similar histological appearance. 90% of these lesions will occur before the age of two years. There is no sex predominance and the most common locations are the head and neck, axilla, inguinal area and, in some cases, the abdominal viscera including the liver and spleen. Lymphangiomas can be classified as either the capillary type or simplex type which are considered cutaneous lesions. Larger, deeper lesions are usually cavernous or cystic in nature and referred to as cystic hygromas.
- 383. CLASSIC Case #301 23 year female lymphangioma forearm and hand with thumb gigantism
- 384. Surgical specimen from forearm
- 385. Photomic showing lymphatic channels
- 386. Case #302 7 month male lymphangioma elbow
- 387. Coronal T-1 MRI
- 388. Axial T-2 MRI
- 389. Case #303 10 year female with lymphangioma forearm
- 390. fluid cyst Axial proton density MRI
- 391. Axial T-2 MRI
- 392. Case #304 Axial T-1 MRI 21 year female with lymphangioma inguinal area
- 393. Axial T-1 MRI more distal
- 394. Axial T-1 MRI even more distal
- 395. Surgical specimen cut in path lab
- 396. Photomic with lymphatic channels
- 397. Case #304.1 Lymphangioma Buttock Cor T-1 T-2 8 yr old male with soft mass over buttock for years with Gad intermittent clear serous fluid drainage
- 398. Axial T-1 Axial T-2 Axial Gad Sag T-2
- 399. Case #1213 46 year male with lymphangioma arm Axial PD MRI
- 400. Another T-2 MRI showing 2 lesions
- 401. Coronal T-2 MRI vein showing lymphangioma next to cephalic vein
- 402. Sagittal T-2 MRI vessels showing hygroma next to brachial vessels
- 404. Glomus Tumor
- 405. Glomus Tumor The glomus tumor and the hemangiopericytoma are vascular tumors that arise from the hemangiopericyte which is a cell at the periphery of the capillary vascular network whose normal function is to regulate the flow of blood thru the capillary tube system. There- fore, these are tumors that arise from cells outside the endothelial tube where hemangiomas originate from endothelial cells. The glomus tumor is a small and usually subcutaneous tumor measuring less than 1 cm in diameter and represents 1.6% of all soft tissue tumors. It occurs equally in men and women between the ages of 20 and 40 years. The most common location for the glomus tumor is in the subungual area of a digit where it is readily visible, exquisitely tender on palpation and has a reddish-purple color. Subcutaneous glomus tumors that occur in the hand, wrist, forearm and foot area are invisible to physical diagnosis and characteristically present with localized lancinating pain that persists in the exact location of origin until treated by minimal wide surgical resection.
- 406. CLASSIC Case #305 50 year male with glomus tumor thumb
- 407. AP x-ray
- 408. Surgical removal
- 410. Case #306 45 year female with glomus tumor web space hand
- 411. Case #307 Surgical exposue subcutaneous glomus tumor forearm 45 year female
- 412. Hemangiopericytoma
- 413. Hemangiopericytoma The hemangiopericytoma arises from the same hemangiopericytes in the capillary system but is a larger tumor seen in more proximal areas, usually a deep tumor in muscle bellies about the thigh or retroperitoneal area of the pelvis. The smaller tumors are usually benign but the larger, more aggressive pericytomas can be malignant and therefore deserve more aggressive treatment with wide resection followed by postoperative radiation therapy because of the chance of local recurrence.
- 414. CLASSIC Case #308 Sagittal T-1 MRI 87 year female with hemangiopericytoma below groin
- 416. Axial proton density MRI
- 417. Cut specimen in path lab
- 418. Photomic
- 419. Case #309 Coronal T-1 MRI 45 year male with hemangiopericytoma thigh
- 420. Axial T-1 MRI
- 421. Axial proton density MRI
- 422. tumor Axial T-2 MRI
- 423. Case #310 Axial T-1 MRI 44 year female with hemgiopericytoma thigh
- 424. tumor Axial T-2 MRI
- 426. Case #311 58 year female malignant hemangiopericytoma arm
- 428. Coronal proton density MRI tumor
- 429. Axial proton density MRI tumor
- 430. Kaposi’s Sarcoma
- 431. Kaposi’s Sarcoma Kaposi’s sarcoma is considered to be the most common of all soft tissue malignant vascular tumors and can be divided into the chronic, lymphadenopathic, transplant associated type, and the AIDS-related type. It is a cutaneous angiosarcoma seen just beneath the skin, presenting with a characteristic purplish-blue appearance, similar to a cutaneous hemangioma. It occurs most commonly in men and is endemic in Central Africa where AIDS is very prevalent. The most frequent location for the Kaposi’s sarcoma is in the foot and ankle area. Microscopically, the tumor has an aggressive vascular pattern but with rare mitoses. However, over a period of years the tumor can develop into a high grade angiosarcoma or even fibrosarcoma. The overall mortality runs between 10 and 20%. The treatment usually consists of local radiation therapy or surgical resection if the lesion is localized.
- 432. Case #312 75 year female with Kaposi’s sarcoma foot
- 433. Plantar view
- 435. Photomic
- 436. Case #313 65 year male with Kaposi’s sarcoma foot
- 437. Photomic
- 438. Angiosarcoma
- 439. Angiosarcoma The soft tissue angiosarcoma is an extremely rare soft tissue tumor, accounting for less than 1% of all sarcomas. It is usually a cutaneous lesion that affects males more often than females. It can be deeply located, seen typically in the upper extremities of women who have had chronic lymphedema following radical breast surgery and radiation therapy. The high grade angiosarcoma is not a very bloody tumor and does not have the typical vascular spaces seen in benign vascular tumors or low grade intermediate angiosarcomas. The prognosis for the high grade angiosarcoma is very poor, especially for older people, and the treatment usually consists of wide local resection and postoperative radiation therapy.
- 440. CLASSIC Case #314 Sagittal proton density MRI 30 year male with high grade angiosarcoma heel
- 441. Coronal T-2 MRI
- 442. Sagittal proton density MRI Metastasis to inguinal lymph node
- 443. Sagittal T-2 MRI of positive lymph node
- 444. Low power photomic
- 445. Higher power showing pleomorphic giant cells around vascular spaces
- 446. Case #314.1 Angiosarcoma Thigh 52 yr old male with tender mass in proximal anterior thigh area 3 mos
- 447. Axial T-1 STIR
- 448. Cor STIR Sag STIR